I recently answered four interesting questions about my clinical work for a Danish publication:
1) What is the most unusual or odd form of therapy/method you’ve ever had to go about to ensure an effective therapy and a good alliance with a client?
The client that comes to mind is Natalie. Natalie told me she’d been a multiple personality since childhood when her different alters provided protection from a brutally abusive environment. She felt she had already dealt with the abuse and didn’t want to become integrated into a single self, but rather wanted “co-consciousness,” a state in which the alters would be aware of each other’s experience without losing their separate identities. Natalie entered therapy because she had lost access to some of her most intuitive subselves.

I didn’t have any idea of how to help Natalie recontact her missing alters or promote co-consciousness. I shared my lack of experience in these matters and Natalie responded that her doctor had referred her, had said good things about me, and that she trusted her completely. Besides, she added, the previous therapist, a dissociative identity expert, had all but demanded that Natalie give up her alters in service of an integrated personality. Natalie wanted nothing to do with that. Natalie told me that she didn’t fit the mold of how that therapist thought about multiples, and added, “I can’t help that!”

But I was willing to not know—to explore her world, to find out how her system worked, to validate it, and try to discover a way to help her re-access her alters. Natalie was quite remarkable: witty, obviously bright, and very artistic. She worked as a copy editor for a magazine by day and by night was an accomplished oil painter. Over the next few sessions, Natalie and others in her system explained to me that her alters lived in various rooms in a visualized house. Some were practical, others intuitive, and others tough as nails. She would visualize the pathway to the different alters’ rooms to access them; whoever had the best skills then emerged to deal with whatever life dished out. Except for now, when some of them had mysteriously gone missing. I sincerely told Natalie—an extremely intuitive woman, or collection of women—that I thought she had a “wonderful system,” and suggested she think of all the ways she had gained access to her alters before.

A possible source to the problem was finally discovered. Natalie said she thought that the alters were hiding because her boyfriend, Joe, was embroiled in extreme, ongoing arguments with a brother and sister over the impending sale of their grandparents’ farm. Natalie believed that the alters were frightened and hiding much like they did when she was a child. Once Joe became less unpredictably volatile, Natalie thought, access to her missing alters would return. With this discovery made, we focused on ways to address Joe’s anger, and otherwise, in Natalie’s words, “deflect it” and diminish its impact on her alters. Natalie implemented our ideas and Joe responded by calming down and becoming more attentive to Natalie’s needs. Subsequently, over the next days, several others “came home.”

But my confusion didn’t stop there. With the crisis with Joe abated, Natalie identified a new goal of addressing her Epstein-Barr virus. In the next session, a wise, spiritually centered, martial artist alter named “Nora” showed up. Since Natalie was already adept at visualization, I had planned to suggest that we fine tune her skills to rally her resources against the virus. I suggested this to Nora instead and we worked on various martial arts images to combat the virus. I wondered aloud if it was possible to teach the others the same skills and Nora said she would try.

Perhaps in my most speechless encounter with a client, Natalie appeared in the next session and with great enthusiasm exclaimed, “I’m a me! My experienced and tempered empathic therapeutic response: “Say what?” This video sequence has brought down the house in my trainings. I am so dumbfounded, so confused—I clearly don’t know what the hell is going on. But as I always say, at least I was authentically stupid!

Then Natalie explained: Nora had called a meeting in a visualized library to communicate to the alters what she had learned about Epstein Barr. It was the first time they had all been in the same room together. Natalie reported that each alter had come forward, naming her special gifts to the overall system. After praying together, each alter had said, “I belong.”

Then Natalie told me, “Now I’m a ‘me,’ and I’m different. I am the collage of their gifts. Everybody’s there. And if they want, they could still come out, but I’m a me. This me is finding out a lot of things. I’m articulate. I have movement. I definitely have a temper, and I can express it. It’s like I’m looking through a pair of new eyes that have never been touched or scarred.” Again, I was dumbstruck! She had gone beyond “co-consciousness” to a form of integration that she welcomed. I sat stunned for some time before Natalie asked me if she could give me a hug. I am not sure, in retrospect, whether it was celebratory hug or one designed to comfort me and reel my confusion in.

Natalie stands out to me because I never have felt more cast adrift. I didn’t have a clue about what to do—no theoretical or technical training prepared me for this client and how therapy progressed over time. In reality, that’s the way it always is. But I was there hunting for what could work, adding something when I could—the anger suggestions and the imagery to help combat the virus—until the unexpected occurred. I believe it is best described, for me, as a collaborative expedition for the magic of the moment. Not the magic of the sweeping, dramatic gesture or an isolated technique or any other novelty, but rather the magic that grows out of exploring the client’s world, validating their experiences, and discovering what works.

2) Have you ever had to make use of a method, technique or a theory in a therapy session, where you have found it necessary to compromise your ethics or values in life, to create or retain a good alliance and effectiveness in therapy?
No. I have experienced many encounters with clients in which I challenged my values and ethics, and perhaps stretched them, but not compromised them. Here is one example. This is a bit of tawdry tale. Richard, a 29-year-old systems analyst, was referred by his company doctor because of Richard’s increasing distress and frequent absences. When I greeted Richard in the waiting room, he jumped out of his chair, got right in my face—not 3 inches away—and demanded “What are you going to do for me?”

Richard didn’t look too good. The 60 cent therapy words would be agitated and disheveled. I tried to stay calm and just invited him to accompany me to my office, whereupon Richard raised his voice another notch and repeated his question, and was once again, too close for comfort.

I was definitely freaked at this point but I simply replied that I didn’t know if I could do anything for him but that I would try my very best. Richard finally sat down on my couch and told his story, and the flood gates opened. Richard began suspecting his wife, Justine, of having an affair after he discovered footprints in the snow in his backyard. Consequently, he followed her, searched her belongings, and kept track of her whereabouts. But he could not find the incontrovertible evidence that he was sure existed. Throughout Richard’s growing mistrust, Justine emphatically denied the affair and told him he needed help. Perhaps in desperation, Richard began to secretly check Justine’s underwear for signs of semen, which would provide ironclad evidence of her unfaithfulness (given there was no sex with him).

Finally, Richard found stains on her underwear and took it to a laboratory which confirmed the presence of semen. Justine still denied his accusations and insisted the semen was his. She stepped up her efforts to involve others, telling friends, family, his employer, and their own children, that Richard was sick and in need of hospitalization. Justine rallied many to her cause and filed for divorce. The company doctor concurred with her assessment, as did the first provider that Richard saw, a psychiatrist who offered an antipsychotic to ease Richard’s pain.

After Richard’s first unsuccessful encounter with the psychiatrist, the company doctor was peeved. Perhaps hoping to admonish Richard into sanity, he had yelled “Cut the crap!” Richard didn’t do much to disconfirm everyone’s assessment of his sanity. He was doing some pretty whacky things, and looked more distressed and haggard with each passing day.

Richard told me that he was obtaining a DNA analysis of the semen to see if it was a match with his. While scrutinizing my every reaction, not in a threatening way but rather like a condemned man waiting for a sentence, he nervously asked me if I believed him.

So was Richard psychotic or was Justine a liar? Subsequently, I talked with Justine and invited her to therapy but she declined. She was very persuasive and pulled out all the stops to describe Richard as a hopelessly psychotic and in need of medical help, noting that Richard’s sister was also schizophrenic and lived in a group home. What would you say to Richard?

I told Richard that I did believe him. Richard allowed himself a moment of relief, but pressed on and told me that the DNA test was going to cost a lot of money. He then leaned forward, stared uncomfortably, and asked me the big question: did I think he was crazy for spending all that money?

I responded that peace of mind is cheap at any price. Richard broke down and cried long and hard. He had been through a lot, and was starting to believe what many had told him—that he was paranoid and needed medication. After a while, we started talking about what he needed to do to stop looking crazy while he waited on the DNA results. If we took the affair as a given, and that her intent was to make him look crazy as a loon, then everything he was doing was playing right into her hands. Richard and I worked out a plan to get normalcy back in his life: return to work, start spending time with his kids, and taking better care of himself. He did all of those things and continued to bide his time as best he could.

Finally the results came in. Although Richard was greatly saddened when the DNA results confirmed that the semen was not his, he was not surprised. Ultimately, the whole seamy business came to light, and Richard went about rebuilding his life.

I was so moved by Richard’s response, the depth of his wailing, to my simple act of believing him and understanding his desire to know what was going on that I have never forgotten it. Richard taught me that I have to believe my clients, pure and simple. Honestly, while Richard told me his story, I struggled with believing him, which I knew was risky to our alliance. But I ultimately made a conscious choice, during that session, to believe Richard—that it didn’t matter how bizarre it seemed or how classically paranoid it looked. I decided, at the very least, that my clients deserve to be believed. That was a significant event in my development as a therapist. From that day on, I no longer struggled with being a reality police officer And while it’s true that sometimes people do lie, even maliciously, like Justine, I am willing to suspend disbelief until the “facts” appear or maybe into perpetuity.

3) What is the most fun part of working with clients within a frame of reference which contains no fixed techniques, theory or method?

The most fun part is never knowing what is going to happen when you put two resourceful, unique individuals in a room who engage each another in this beautiful interpersonal event we call psychotherapy. The magnificently inexplicable is always lingering, and the joy of discovery ever present. The uncertainty within a frame of reference with no fixed ideas ore methods creates unlimited possibilities for change. It is this indeterminacy that gives therapy its texture and infuses it with the excitement of discovery. This allows for the “heretofore unsaid,” the “aha moments,” and all the spontaneous ideas, connections, conclusions, plans, insights, resolves, and new identities that emerge when you put two people together and call it therapy. This doesn’t mean, of course, that it’s all fireworks (just watch an entire session rather than edited video clips), it just means that tolerance for uncertainty creates the space for new directions and insights to occur to both the client and the therapist.

The tolerance for uncertainty, however, requires faith—faith in the client, faith in yourself, and faith in psychotherapy. But I am certain of one thing: uncertainty is the key that unlocks the potential for discovery. It is hard to discover something if you already know what it is that you are looking for and where it is. Because CDOI is unencumbered by any particular theoretical or explanatory concepts, there is a freedom to speculate. Some ideas grow into relevant discussion, while others fade away as it becomes apparent they are not helpful to pursue. This process seeks to chart a different course—connections, conclusions, solutions, etc.—in any form, that permits a way to address the client’s goals, to encourage an increase on the Outcome Rating Scale (available in Danish, free for personal use at www.heartandsoulofchange.com).

From a discovery-oriented perspective, the word “intervention” does not adequately describe the collaborative process that emerges. To intervene is “to come into or between by way of hindrance or modification.” It implies something done to clients rather than with them, and consequently overemphasizes the technical expertise of the therapist, inaccurately portraying what makes therapy successful. The word intervention does not capture the interdependence of technique on the client’s resources and ideas or how technique is successful to the extent that it emerges from the client’s positive evaluation of the alliance. The words “invent” and “invention” seems more apropos to discovery. To invent is to “find or discover, to produce for the first time through imagination or ingenious thinking and experiment.” Every technique is used for the first time, invented by clients and therapists to fit the client’s unique attributes and circumstance.

The therapist and client are co-explorers, searching the client’s world for the map that provides a route of restoration. As co-adventurers, you encounter multiple opportunities for sharing your respective vantage points while crossing the terrain of the client’s world, periodically stopping to consult your ORS/SRS compass to ensure you are headed in the right direction. When lost along the way, you regroup to look for alternate routes on your maps, as well as the maps of others you encounter on the journey. Such expeditions often uncover trails that we never dreamed existed.

4. If you at one point in your life was to seek therapy (of course depending on why) how would I as a therapist manage to obtain a good alliance between us and ensure effectiveness?

I have consulted a therapist twice in my life and I had a good experience both times. I don’t think I would want anything different than most clients who make their way into our offices. I want to be heard, understood, and respected. I want you to see me as transcending my problems, that my humanity is not represented by the problem, that I am not my problem. I want validation of my experience and for you to believe that I have good reason to think, feel, and behave the way I do, even if it doesn’t fit your experience. Finally, I would want my ideas about how I might change to remain central, and that your interest in your own ideas would fade if they did not resonate with me.

The best way to secure a good alliance with me and ensure effectiveness would be to monitor both the alliance and outcome in each session. This would not leave either the alliance or effectiveness to chance. By creating a culture of feedback, and aspiring to transparency and collaboration, together we could make sure that we were on the right track regarding my benefit from your services and that you were fitting my expectations about how therapy was conducted. If things were not going well, your non-defensive response would be critical along with your wiliness to explore options, including referring me on to someone else.

And don’t forget this month’s free webinar about my book, On Becoming a Better Therapist. This month’s webinar covers Chapter 3 and will be on September 28th, 6-7:30PM Central. Register now at: https://www2.gotomeeting.com/register/945596986  I’ll start our discussion with a 25 minute overview and then I’ll turn it over to you for your questions, comments, and reflections. It should be fun. For those of you who can’t attend live, I’ll record the sessions and post them on the website so you can access the discussions at your leisure.

Clients are indeed the best teachers. The following client, Peter, taught me about the importance of soliciting client ideas about what might be helpful or what I later called “the client’s theory of change.” This is an excerpt from On Becoming a Better Therapist:

When I was an intern, I worked in an outpatient unit euphemistically called the “Specialized Adult Services” unit. While about a fifth of my referrals came from a stress management program, it was really an aftercare facility devoted to working with clients with the moniker “severely mentally ill.” By that time, I had acquired experiences in two CMHCs and an assessment/therapy stint in the state hospital. But the hospital experience lingered, leaving me with a bad taste in my mouth. I saw firsthand the facial grimaces and tongue wagging that characterize the neurological damage caused by antipsychotics and sadly realized that these young adults would be forever branded as grotesquely different, as “mental patients.” I witnessed the dehumanization of people reduced to drooling, shuffling zombies, spoken to like children and treated like cattle. I barely kept my head above water as hopelessness flooded the halls of the hospital, drowning staff and clients alike in an ocean of lost causes. I could not even imagine what it would have been like to live there in the revolving door fashion that many were forced to endure. Now, in my internship position, my charge was to help people stay out of the hospital, and I took that charge quite seriously.

One of my first clients was Peter. Peter was not very liked at the SAS unit. He sometimes said ominous things to other clients in the waiting room, or often spoke in a boisterous way about how the florescent lights controlled his thinking through a hole in his head. When he wasn’t speaking, he grunted and squealed and made other sounds like a pig. As a new intern, I was put under considerable pressure to address Peter’s less than endearing behaviors, particularly because he sometimes offended the stress management clients, who were seen as coveted treasures not to be messed with. Actually, I found Peter to be a terrific guy with a very dry sense of humor, but a man of little hope who lived in constant dread of returning to the state hospital. His behaviors were mostly his efforts to distract himself from tormenting voices that told him that people were trying to kill him and other scary things.

Peter’s unfortunate routine was that he was terrorized by these voices until he started taking actions that would ultimately wind him up in the state hospital. He might empty his refrigerator for fear that someone had poisoned his food, creating a stench that would soon bring in the landlord and ultimately the authorities. Or, occasionally he would start threatening or menacing others, those he believed were trying to kill him. One time he took an empty rifle and perched on an overpass trying to figure out who was on their way to kill him, thinking he could ward them off. Once hospitalized, his medications were changed, usually increased in dose, and he essentially slept out the crisis. These cycles occurred about every four to six months and had so for the last eight years. Peter’s treatment brought with it tardive dyskinesia and about a hundred pounds of extra weight.

Peter hated the state hospital and I could truly commiserate, after my less than inspiring experience there. I felt profoundly sad for this young man, who was about the same age as me. I also felt completely helpless. Nothing in my training provided any guidance. I had no clue about what to do to be helpful to him. I was trying to apply strategies I learned from my supervisor about addressing the voices, which were helpful to others, but not with Peter. I knew he was ramping up for another admission—he told me that he had already emptied his refrigerator and left it on the kitchen floor. I hit a brick wall. It seemed that nothing I said could convince Peter to get off the merry go round to the state hospital. The anguish in his eyes about his impending hospitalization haunted me.

Only because I had no clue about what to do, I asked Peter what he thought it would take to get a little relief from his situation—what might give him just a glimpse of a break from the torment of the voices and the revolving door hospitalizations. After a long pause, Peter said something very curious—he said that it would help if he would start riding his bike again. This led to my inquiry about the word “again.” Peter told me about what his life was like before the bottom fell out. Peter had been quite the competitive cyclist in college and was physically fit as only world class cyclists can be. I heard the story of a young man away from home for the first time, overwhelmed by life, training day and night to keep his spot on the racing team, and topped off by falling in love for the first time. When the inevitable came to pass and the relationship ended, it was too much for Peter, and he was hospitalized, and then hospitalized again, then hospitalized again, and so on until there was no more money or insurance—then the state hospitalization cycles ensued.

On a roll now and enjoying a level of conversation not achieved before, I asked Peter what it would take to get him going again on his bike. He said that his bike was in need of parts and what he needed was for me to accompany him to the bike shop. Peter was afraid to go out in public alone for fear of threatening someone and ending up in the hospital. I immediately consulted with my supervisor who had the good sense here (and on many occasions) to give me an enthusiastic green light. The next day, I went with Peter to the bike shop, where I, bought a bike as well. Peter and I started having our sessions biking together. Peter still struggled with the voices at times, but he stayed out of the hospital and they never kept him from biking. He eventually joined a bike club and moved into an unsupervised living arrangement.

You can read a lot of books about schizophrenia and its treatment but you’ll never find one that recommends biking as a cure. And you can read a lot of books about treatments in general, and you’ll never read a better idea about a client dilemma than will emerge from a client in conversation with you—a person who cares and wants to be helpful.

The first Discussion Webinar covering Chapter One of On Becoming a Better Therapist is history. It was a great discussion and lots of fun. Over a hundred folks joined me for a lively Q and A.  Watch the video of the Chapter One Discussion and enjoy some great comments and questions.

Here is the description of the free webinar series and the details of the Chapter Two Webinar on August 26.

Most of us became therapists because we wanted to be helpful to other human beings, and most of us carry an inextinguishable passion to become better at it. But how do we get better? The truth is that although we are painfully aware that some clients clearly don’t benefit while others inexplicably end therapy, we don’t know how effective we really are or what we can do to improve our outcomes. Despite our hard work and good intentions, unfruitful encounters with clients combined with the confusing cacophony of “latest” developments can weigh on us, steer us into ruts, and make us forget why we became therapists to begin with. How can we remember our original aspirations, continue to develop as therapists, and achieve better results, more often, with a wider variety of clients? In short: how can you become a better therapist?

On Becoming answers that question in a pragmatic and clinically nuanced way, presenting a five-step method of integrating outcome management with therapists’ long-term professional development. In this second of seven webinars corresponding to the seven chapters of the book, I will present a 15 minute overview of the second chapter followed by your questions, comments, and reflections. My hope is that the book and these discussions will inspire you to rediscover purpose in your work and become a better therapist.

Hope you can make the next one: August 26, 6-7:30PM. Register now at: https://www2.gotomeeting.com/register/525541291

Remember, it’s free! If you can’t make the live event, each discussion will be posted for your anytime watching pleasure at: http://heartandsoulofchange.com/on-becoming-a-better-therapist-free-discussion-webinars/

Here is an excerpt from On Becoming a Better Therapist:

While I often don’t remember where I leave my glasses, I still vividly recall my first client, Tina. A long time ago in a galaxy far way, I was in my initial clinical placement in graduate school at the Dayton Mental Health and Developmental Center, a euphemism for the state hospital. Tina was like a lot of the clients: young, poor, disenfranchised, heavily medicated, and on the merry-go-round of hospitalizations—and, at the ripe old age of 22, a “chronic schizophrenic.”

I gathered up the battery of tests I was attempting to gain competence with, and was on my merry but nervous way to the assessment office, a stark, run-down room in a long past its prime, barrack-style building that reeked of cleaning fluids over-used to cover up some other worse smell, the institutional stench. But on the way I couldn’t help but notice all the looks I was getting—a smirk from an orderly, a wink from a nurse, and funny looking smiles from nearly everyone else. My curiosity piqued, I was just about to ask what was going on when the chief psychologist, a kindly old guy, put his hand on my shoulder and said, “Barry, you might want to leave the door open.” And I did.

I greeted Tina, a young, extremely pale woman with short brown, cropped hair, who might have looked a bit like Mia Farrow in the Rosemary’s Baby era had Tina lived in friendlier circumstances, and introduced myself in my most professional voice. And before I could sit down and open up my test kit, Tina started to take off her clothes, mumbling something indiscernible. I just stared in disbelief. Tina was undaunted by my dismay and quickly was down to her bra and underwear when I finally broke my silence and said, “Tina, what are you doing? Tina responded not with words but with actions, removing her bra like it had suddenly become made of wool and very uncomfortable. So there we were, a graduate student, speechless, in his first professional encounter, and a client sitting nearly naked, mumbling now quite loudly but still nothing I could understand, and contemplating whether to stand up to take her underwear off or simply continue her mission while sitting.

In desperation, I pleaded, “Tina, would you please do me a big favor? She looked at me for the first time, and said, “What?” I replied, “I would really be grateful if you could put your clothes back on and help me get through this assessment. I’ve done them before, but never with a client, and I am kinda freaked out about it.” Tina whispered, “Sure,” and put her clothes back on. And although Tina struggled with the testing and clearly was not enjoying herself, she completed it. I was so genuinely appreciate of Tina’s help that I told her she really pulled me through my first real assessment. She smiled proudly, and ultimately smiled at me every time she saw me from then on.

So Tina started my psychotherapy journey and offered up my first lessons for consideration: authenticity matters and when in doubt or in need of help, ask the client. Those lessons have served me well.

On Becoming demonstrates how systematic client feedback provides the means for clients to teach you how to do good work. It embodies the lessons I learned from Tina, providing for a transparent interpersonal process that solicits the clients help in ensuring a positive outcome.

Please join me this July 22 at 6PM Central for a free webinar discussion of my book. Each month will cover a different chapter. I’ll start our discussion with a 15 minute overview and then I’ll turn it over to you for your questions, comments, and reflections. It should be fun. For those of you who can’t attend live, I’ll record the sessions and post them on the website so you can access the discussions at your leisure. In addition, right after the webinar, I’ll be hosting a two-hour discussion about each chapter of the book on the heroicagencies list .

July 22: 6PM Central to 7:30 It’s free! Every month a free webinar!

Reserve your Webinar seat now at:
https://www2.gotomeeting.com/register/863269466

I am excited to announce a seven month series starting in July of webinars and discussions about my new book, On Becoming a Better Therapist.  First here is a brief review of the book:

Drawing on many years of clinical experience and research on evidence-based practice, Duncan argues with conviction and humor that systematically monitoring client outcomes is advantageous to therapists as well as to clients. He offers lessons learned about clients being the best teachers and guidelines for what works in therapy. The guide includes a foreword by Michael J. Lambert, other pearls of wisdom, findings of the Norway Feedback Project, excerpts of therapy sessions, and information on career development tracking software (ASIST, MyOutcomes). –Reference & Research Book News (May 2010)

This will be a three-pronged effort to disseminate the ideas in the book, two of which are free. First, for those who subscribe to CDOI Members (join here for just $120 a year), beginning July 22 at noon Central, I will conduct monthly webinars on each of the seven chapters of the book, adding to the already over $400 of training materials. And stay tuned: Client videos are coming soon to CDOI Members so you will be able to learn CDOI by watching me with actual clients.

And now for the free stuff: Have you ever wanted to ask a question or engage in a conversation with an author when you were reading a book? I know I have. Starting also on July 22 at 6PM Central, I will offer a free monthly webinar discussion of my book. Each month will cover a different chapter. I’ll start our discussion with a 15 minute overview and then I’ll turn it over to you for your questions, comments, and reflections. It should be fun. For those of you who can’t attend live, I’ll record the sessions and post them on the website so you can access the discussions at your leisure. In addition, right after the webinar, I’ll be hosting a two-hour discussion about each chapter of the book on the heroicagencies list (join now). I hope you can join me. I am anxious to hear your impressions and questions about the book.

Here is the free webinar announcement:

On Becoming a Better Therapist: Chapter One Discussion
Most of us became therapists because we wanted to be helpful to other human beings, and most of us carry an inextinguishable passion to become better at it. But how do we get better? The truth is that although we are painfully aware that some clients clearly don’t benefit while others inexplicably end therapy, we don’t know how effective we really are or what we can do to improve our outcomes. Despite our hard work and good intentions, unfruitful encounters with clients combined with the confusing cacophony of “latest” developments can weigh on us, steer us into ruts, and make us forget why we became therapists to begin with. How can we remember our original aspirations, continue to develop as therapists, and achieve better results, more often, with a wider variety of clients? In short: how can you become a better therapist?

On Becoming answers that question in a pragmatic and clinically nuanced way, presenting a five-step method of integrating outcome management with therapists’ long-term professional development. In this first of seven webinars corresponding to the seven chapters of the book, I will present a 15 minute overview of the first chapter followed by your questions, comments, and reflections. My hope is that the book and these discussions will inspire you to rediscover purpose in your work and help you become a better therapist.

Join us for a Webinar on July 22: 6PM Central to 7:30 It’s free! Every month a free webinar!

Space is limited.
Reserve your Webinar seat now at:
https://www2.gotomeeting.com/register/863269466

Hope you join me!

I recently did a training in Colorado Springs and was asked by talented young therapist, Andrew Van Dyke to address four questions for the Psych Society newsletter:

1. Do you have any tips on how to motivate resistant clients, i.e., non-compliant, court-ordered, or mandated clients to positive change? Clients may not share our motivations, but they certainly hold strong motivations of their own. Research has now established that the critical process-outcome link in successful therapy is the quality of the client’s participation. Clients who collaborate in therapy, are engaged with the therapist, and involve themselves with a receptive and open mind will likely profit. Owing to the importance of clients’ positive involvement for outcome, their motivation—not only just for being in therapy, but also for achieving their own goals—has to be understood, respected, and actively incorporated into the treatment. To do less or to impose agendas motivated by theoretical prerogatives, personal bias, and perhaps some sense of what would be good for the client, invites “resistance.”What we come to call resistance may sometimes reflect the client’s attempt to salvage a small portion of self-respect.

Important findings regarding court-ordered or mandated clients emerged from Project Match, the largest study of substance abuse ever done. First, there was no difference in outcome between mandated and non-mandated clients; and second, the only predictor of outcome, whether the client was voluntary or involuntary, was the therapeutic alliance. Whether clients are “resistant” or mandated, job one is the therapeutic alliance. It’s not always easy. But you didn’t think that “therapeutic work” business only applied to clients—did you?

2. As students, we often get overwhelmed with a plethora of theoretical models and techniques. How important is technique delivery in being an effective therapist who creates positive results in the majority of our clients? Sometimes our altruistic desire to be helpful hoodwinks us into believing that if we were just smart enough or trained correctly, clients would not remain inured to our best efforts—if we found the Holy Grail, that special model or technique, we could once and for all defeat the psychic dragons that terrorize clients. Amid explanations and remedies aplenty, therapists courageously continue the search for designer explanations and brand name miracles—disconnected from the power for change that resides in the pairing of two unique persons, the application of strategies that resonate with both, and the impact of a quality partnership.

Don’t get me wrong. There is nothing wrong with learning about models and techniques—in fact, it is a good thing because it allows you to fit more client preferences. But becoming beholden to one is folly as is the belief that any model represents the way that people can be helped. Technique is important but it is only effective to the extent that it engages the client in purposeful work. If it does not pass that fundamental test, it has no value regardless of its evidentiary support. Moreover, a particular technique is only important to the client in your office now if it results in measureable benefit. The proof of the pudding is in the eating.

3. What is the history of the use of outcome measures in psychotherapy and what do you think its future role will ultimately be in managed care? Ken Howard first advocated for the evaluation of client response to treatment during the course of therapy, but feedback pioneer Michael Lambert really brought the idea to fruition. He has conducted six RCTs that have demonstrated significant gains for feedback groups over treatment as usual (TAU) for clients at-risk for a negative outcome. The addition of client feedback alone enabled over two times the amount of at- risk clients to benefit from psychotherapy. Our recent RCT of couple therapy found that feedback clients reached clinically significant change nearly four times more than non-feedback couples.

Collecting data and managing outcomes can allow therapists, agencies, and professional organizations to become “players” at the reimbursement table with managed care. The advantages in effectiveness and efficiency that outcome management brings can be bargaining chips that increase the value of our services. We should support managed care systems that collect data and provide immediate feedback about results so that we can adjust quickly to benefit clients. On the other side, we should oppose data collection for the purpose of provider profiling and incentive practices without feedback. Such policies risk killing the spirit of outcome management—to help as many clients as possible—and turning therapists against measuring outcomes.

4. What changes in thinking and practicing are you hoping that participants walk away with from your trainings? There are two things I would love for folks to walk away with. First is that regardless of one’s preferences regarding theory or technique, outcomes can be improved by paying more attention to the heart and soul of change: Rallying the client and his or her resources to the cause, their participation, is the heart of the work; and proactively securing that tried and true but taken for granted old friend, the therapeutic alliance—the soul of change is the alliance. The second change that I hope for is that folks will give client feedback a shot, not some time, not next month or even next week, but with the next client. Client-based feedback substantially increases the effectiveness and efficiency of services—more than anything in the history of our field. It enhances the benefit of any psychotherapy regardless of the model practiced. Nine of ten therapists in our large RCT improved their outcomes with feedback; in fact a therapist in the lowest tier of effectiveness without feedback became the most effective therapist in the study with feedback.

And two announcements: One is that pdfs of all the Heart and Soul of Change Conference presentations are now available at: http://heartandsoulofchange.com/heart-and-soul-of-change-conference-new-orleans-slide-presentations/

And the next webinar is scheduled: our own Bob Bohanske presenting “Implementing CDOI in Public Agencies: Is it Mission Impossible?”

Many of you have asked me for a Vatican Update. Sorry it has been so long but this has been and will likely continue to be a long term process that requires a sustained effort to reach success. As you know, Jacqueline Sparks and I continue our efforts (see our chapter in the new Heart and Soul) to encourage folks to consider the risk/benefits of psychiatric drugs and our conclusion that the data do not support drugs as a first line intervention or rising prescription rates. This of course does not mean that we are anti drug or anti psychiatry but rather that we challenge automatic prescription, and believe that clients should have access to information, informed consent, and a range of alternatives that honor their preferences—and have the ability to monitor the results.

And many of you know that I did a radio show on Voice America about this same issue with Marcia Barbacki and David Cohen (many episodes available at http://heartandsoulofchange.com/resources/audio-presentations/ ). Marcia is the most persistent and selfless person I know. She works tirelessly at her own expense to bring this controversial topic to mainstream awareness and her efforts over the past three years have focused on enlisting the Catholic Church to help stem the tide of rising prescriptions, especially to kids given they have little voice in such decisions. I was intrigued and inspired by the idea that the Church and her vessels could counter the forces of corporate power and greed. Few institutions or even governmental entities seem to be able to stand up to economic tsunami of the pharmaceuticals…over 40 billion in sales last year and more spent on marketing than on research and development; and there is a pharmaceutical lobbyist assigned to every member of congress. Remember that good marketing, and unlimited lobbying, can overcome bad data every single day of week. Knowing that, I couldn’t help but be smitten by the idea that if the Church could be persuaded that the evidence does not support the prescription rates especially with children, considering the risks, then, through all the channels available—religious communities, churches, and schools—they might promote a cautionary, no first line use stance , and call for each professional to look at the evidence him or herself as well as a more defined separation between the pharmaceutical industry and research/education. For a great article about the negative effects of blurring this distinction as well as recommendations to fix the influence of drug companies on research and education, see Marcia Angell’s excellent article at: http://bostonreview.net/BR35.3/angell.php. This is not a wide eyed anti drug zealot but rather a former editor of the New England Journal of Medicine. I hope that this article might convince you that we are not just conspiracy theorists!

Marcia Barbacki and I recently did a presentation in Lourdes, France—a place that is inspiring on many levels—to an international group of Catholic physicians, nurses, pharmacists, and other health care professionals. Check out this presentation available in PowerPoint for your free download as well as the narrative summary at a new page of articles about psychotropics: http://heartandsoulofchange.com/resources/psychiatric-drugs/. The video from the presentation will be available soon. It will at the least be entertaining because I am wearing a suit and look like a fish out of water or perhaps like Gomer Pyle in his Sunday best. Golly! Marcia’s efforts and the presentation paid off. I am presenting at the Vatican’s annual conference in November. This could lead to an international conference on this important topic. Keep your fingers crossed.

And speaking of kids and drugs, Jacqueline just sent me this music video on ADHD:

And now for something completely different: I also wanted to remind you about the CDOI Directory. The benefits of listing will only increase over time as it becomes more known. Traffic to the site is increasing and will continue as other things develop including upcoming press releases about the alliance article as well as Networker and Psychotherapy in Australia articles. Besides allowing others to find you and know that you aspire to CDOI ideas and practices, it will allow you to network with folks holding similar values about practice, perhaps allowing you to find a local community. It can also provide additional exposure of your practice and let potential funders, interns, volunteers, etc, know of you and your interests. Over time, I hope to let funders know of our list and the benefits that members can offer because of their attention to client benefit and the alliance. And Rebecca just added another feature. You can download the CDOI Registered Provider icon from your listing and place it on your website to inform your visitors of your membership in the directory and what it means.

I am hoping for 100 members by the time of the Heart and Soul of Change Conference so I can show it to folks. I would appreciate your consideration. And while you are considering that, consider coming to the conference!

I am doing a free webinar about CDOI. Here is a teaser:

And here is info about the webinar:

“Dr. Barry Duncan – What in the heck is CDOI? Client Directed, Outcome Informed Ideas and Practices”

You might hear folks say CDOI this or CDOI that, and wonder, what in the heck is CDOI?! Client directed, outcome informed services contain no fixed techniques or causal theories regarding the concerns that bring people to treatment. Any interaction can be client-directed and outcome-informed when the consumer’s voice is privileged, social justice is embraced, recovery is expected, and helpers purposefully form partnerships to: (1) enhance the factors across theories that account for success—especially the heart and soul of change; (2) use client’s ideas and preferences (theories) to guide choice of technique and model; and (3) inform the work with reliable and valid measures of the consumer’s experience of the alliance and outcome. This webinar covers the waterfront, from recovery to the common factors to the ORS and SRS—an all in one place description of this thing we call CDOI.

Date: Tuesday, December 22, 2009

Time: 12:00 PM – 1:00 PM CDT

Register now by clicking the link below:

https://www2.gotomeeting.com/register/326593746  

BTW, check out the new resources added to the handouts page: CDOI Fact Sheet, Youth Outcome Management, and Evidence Based Practice Talking Points: http://heartandsoulofchange.com/resources/handouts/

And I wanted to let you know about all the publicity the Norway Feedback Study has received after a press release was sent out by the University of Rhode Island—a co-investigator of the study was Dr. Jacqueline Sparks, faculty in the Department of Human Development and Family Studies.

5 Questions with Dr. Sparks http://www.pbn.com/detail.html?sub_id=46289

New Therapy Technique Reduces Divorce Rates http://ow.ly/162i0O

Professor finds strong link between counseling approach and relationship success: http://www.medicalnewstoday.com/articles/171024.php  

Finally, the Norway Feedback Study also made the Clinician Digest by Garry Cooper in the November edition of the Psychotherapy Networker. Check it out:

http://www.psychotherapynetworker.org/magazine/currentissue/689-clinicians-digest?start=3

I hope you join me for the free webinar.