1. Is this an unrealized potential to inform practice?
Without question it is an unrealized potential, although more and more people are getting on board all the time. When you consider that outcome informed practice improves outcomes more than anything in our field since its inception (sounds like hyperbole but it isn’t), it is really a wonder that everyone isn’t doing it. But many are. The outcome system of the Heart and Soul of Change Project or the Partners for Change Outcome Management System (PCOMS) is recognized by two states (Arizona and Colorado) as an evidence based treatment and it is currently under review by SAMHSA for national evidence based treatment designation. PCOMS has been implemented by hundreds of organizations, public and private, by thousands of behavioral healthcare professionals in all 50 states and 20 countries serving over 100,000 clients a year. Norway is currently implementing nationally in their family counselling offices. Given that now 9 RCTs (Lamberts and ours) demonstrate the significant advantages of outcome informed practice, I think it is only a matter of time until it is considered standard practice.

2. Why, given all the time, money, and other resources dedicated to assessing outcomes in behavioral health, is there not a widespread adoption and implementation of outcome measurement?
There are a few reasons. First it hasn’t been a part of the vernacular of our field at the clinician level. For anyone in the field for a few years, it is a totally foreign concept and most folks assume the best regarding effectiveness. It is critical that graduate education step up to plate here and groom a new generation of mental health/substance abuse professionals that are savvy about outcome informed practice. Second, the field has not provided clinicians with any feasible, clinician friendly way to manage outcomes until recently. Some have been turned off by cumbersome and lengthy measures designed by researchers that don’t appear to be related to the day-to-day work of the front line therapist. Finally, many are afraid because of all the talk about P4P and other ideas that suggest that some will be punished who do not measure up to some arbitrary standard. The whole process of outcome measurement and management need to makes sense to front line therapists and appeal to their nearly universal desire to do good work and get better over the course of their careers. That is why the implementation process of the Project emphasizes both a top down and bottom process. It includes attention to things that makes sense to therapists: 1) common factors; 2) a nuanced clinical process; 3) and therapist development.

The common factors, those elements of psychotherapy running across all models that account for change (Duncan, 2010; Duncan et al., 2010), provide an overarching framework for the PCOMS intervention. Integrating the use of PCOMS within the larger literature about what works in therapy promotes therapist understanding of the feedback process and adherence to the feedback protocol. PCOMS is presented as the tie that binds these healing components together, allowing the factors to be expressed one client at a time. Soliciting systematic feedback is a living, ongoing process that engages clients in the collaborative monitoring of outcome, heightens hope for improvement, fits client preferences, maximizes chances for a strong alliance, and is itself a core feature of therapeutic change (Duncan, 2010).

Although the over 300,000 administrations of the measures has yielded invaluable information regarding the psychometrics of the measures, trajectories, algorithms, etc., PCOMS remains a clinical intervention embedded in the complex interpersonal process called psychotherapy. For successful implementation and ongoing adherence, PCOMS must appeal to therapists at a clinical level in ways that the numbers or data or even the research never can. Consequently, PCOMS is described as the clinical process that it is—one that requires skill and nuance to achieve the maximum feedback effect. PCOMS speaks to therapists “where they live” by providing a methodology to address those clients who do not benefit from their services.

Similarly, a focus on therapist development provides a positive motivation for therapists to invest time and energy in PCOMS. There will always be organizational motivations for PCOMS in terms of improved outcomes and reduced costs–the language of “return on investment” and “proof of value.” But there is also the personal motivation of the therapist, the very reason most got into this business in the first place: to make a difference in the lives of those served. The groundbreaking research by Orlinsky and Rønnestad (2005) about therapist development (now over 11,000 therapists included) demonstrates that nearly all therapists want to continue to improve throughout their careers and harnessing this motivation is part and parcel to successful implementation. PCOMS appeals to the best of therapist intentions and encourages therapists to collect ORS data so that they can track their development and implement strategies to improve their effectiveness (Duncan, 2010).

Including these larger themes allows therapists to see that the intentions of PCOMS go well beyond management or funder’s cost or efficiency objectives—client based outcome feedback is about client privilege and benefit, and helping therapists get better at what they do. In addition, it is also critical that therapists know that management only intends to use data to improve the quality of care that clients receive, that there will be no punitive use of the data in any way, shape, or form. Given that most therapists improve their outcomes with feedback ( 9 of 10 therapists improved in the Anker et al. trial), a positive, non-competitive approach goes a long way to assuage therapists’ fears.

3. We go to the doctor and expect that our blood pressure will be taken, we will be weighed, and our heart rate monitored. But when we go see a behavioral health professional there is no such standard measures. Is this patient preference? Clinician Preference? Both?
It is definitely not client preference. Consumers want to be involved in their own care. However, they don’t want to do meaningless paperwork that takes away from their time with the therapist. Consumer involvement in all decisions that affect care is the foundation of the PCOMS intervention, including persons not of the dominant culture as well as the traditionally disenfranchised. We have found that when people understand the purpose of the measures (keeping their voice central and making sure they are getting what they want), refusal rates are about one in a hundred. This is far more of an issue for therapists as discussed above.

4. Where do you see the field going in the near term?
Given that there are now nine RCTs supporting it, the time for client-based outcome feedback seems to have arrived (Lambert, 2010). I think that within 5 years, it will be standard practice. My optimism comes from several recent events. For example, the American Psychological Association (APA) Presidential Task Force (hereafter Task Force) on Evidence-Based Practice in Psychology (EBPP) defined EBPP as “the integration of the best available research with clinical expertise in the context of patient (sic) characteristics, culture, and preferences” (Task Force 2006, p. 273). Two parts of this definition draw attention to client feedback and to tailoring services to the individual client. First, regarding clinical expertise, the Task Force submitted:
Clinical expertise also entails the monitoring of patient progress… If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate. (APA, 2006, p. 276-277)

And second, “in the context of patient characteristics, culture, and preferences,” emphasizes what the client brings to the therapeutic stage as well as the acceptability of any intervention to the client’s expectations. The Task Force said:
The application of research evidence to a given patient always involves probabilistic inferences. Therefore, ongoing monitoring of patient progress and adjustment of treatment as needed are essential (Task Force, 2006, p. 280).
Outcome, in other words, is not guaranteed regardless of evidentiary support of a given technique or the expertise of the therapist. Client-based outcome feedback must become routine.

Further support comes from APA’s Division 29 Task Force on Empirically Supported Relationships who advised practitioners “…to routinely monitor patients’ responses to the therapy relationship and ongoing treatment. Such monitoring leads to increased opportunities to repair alliance ruptures, to improve the relationship, and to avoid premature termination” (Ackerman et al., 2001, p. 496). Finally, two other recent endorsements of outcome management by APA have emerged. First the APA Commission on Accreditation (2011) states that students and interns: “Be provided with supervised experience in collecting quantitative outcome data on the psychological services they provide…”(2011, C-24). And second, APA recently created a new outcome measurement database to encourage practitioners to select outcome measures for practice ((http://practiceoutcomes.apa.org).

So change is on the horizon.

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I was recently asked by the magazine, The New Therapist (Issue 74) to addresss the following question:
How important is attention to, and/or interpretation of, transference and countertransference dynamics for successful outcomes in psychotherapy, and why?

My response: Attention to and/or interpretation of transference/countertransference is no more important, and no less, than any other therapist action derived from theory, model, or technique. All approaches tend to work equally well, a finding referred to as the “dodo verdict.” Moreover, model differences or “specific effects” (those aspects unique to a given approach) account for a small amount of the variance of change with an effect size (ES) of only .2. Putting this into perspective, a meta-analysis of the client’s perception of empathy found an ES of .32. This is not meant to denigrate transference/countertransference or any other model-based idea or technique but rather to suggest what Saul Rosenzweig concluded 75 years ago–given that all approaches appear to work about the same, there must be common factors that account for therapeutic change.

One such factor (originating from psychodynamic thinking) holds far more sway over outcome–the therapeutic alliance. There are over 1000 studies that support the association between a strong alliance and positive outcome. The alliance accounts for five to seven times the amount of variance attributed to model and technique. It transcends any specific therapist behavior and is a property of all. It functions to engage the client in purposive work and includes both a relational connection and an agreement about the goals and tasks of therapy. Importantly, the alliance is dependent on the delivery of some particular treatment—a framework for understanding and solving the problem. Technique–whether interpreting transference or challenging dysfunctional thoughts–is the alliance in action.

While there is no differential efficacy among approaches on aggregate, there is with the client in your office now. The question is: does it resonate or not? Does its application help or hinder the alliance? Does the client engage in the work and make meaningful changes when you attend to or make transference/countertransference interpretations?

The only way to answer this question is to risk our romance with our theories and secure client-based feedback about outcome and the alliance–a process now shown in nine RCTs to significantly improve outcomes regardless of the treatment administered. For example, the largest trial of couples therapy ever done found that clients who gave their therapists feedback about the outcome and alliance on two brief, four-item forms reached clinically significant change nearly four times more than non-feedback couples did .

The constructs of transference/countertransference have a storied history steeped in the tradition of psychoanalytic thinking. Approaches that hold these ideas dear are just as effective as those that don’t. Regardless of model, however, most therapists can increase their effectiveness substantially through identification of those clients who are not responding and addressing the lack of change in a way that keeps clients engaged and forges new directions. The evidence calls for a “new therapist,” a more sophisticated clinician who chooses from a variety of orientations and methods to best fit client preferences and cultural values based on feedback about the benefit and fit of services.

The Training of Trainers event is coming up quick.  Learn how to train others in CDOI and PCOMS! Escape the cold this winter and attend the Training of Trainers Conference in sunny Florida, January 30-February 3.

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I just returned a few weeks ago from Europe which included training in The Netherlands, Switzerland, and Belgium which I did for Korzybski International. They run an extensive multiyear post graduate training program in Solution Focused Cognitive Therapy, which in Europe is called the Bruges Model as well as many other useful therapeutic ideas and practices. This was my second trip for them and the more I get to know them the more I have come to like what they are doing. This trip cemented my involvement in their training program and now CDOI and PCOMS will be a fixed feature of their training. There is now a formal affiliation between the Korzybski Institute and the Heart and Soul of Change Project. This is important because it will help spread the word to many who would have otherwise never heard of CDOI or PCOMS because of language differences. While many Europeans speak English, many do not as well. French speaking folks, for example, have had little exposure to the ideas (the first edition of Heroic Client was translated but it did not include the ORS/SRS) but no longer. There is a translation of the Heart and Soul of Change in the works and I am hopeful that On Becoming a Better Therapist will be next. And, I will be conducting training in France next year which hopefully inspire interest as well.

I am pleased to announce that Luc Isebaert will join The Heart and Soul of Change Project as a Project Leader. I don’t know if you have seen the Dos Equis commercials about the “most interesting man in the world” but since meeting Luc, I beg to differ. Luc is truly a renaissance man, and a walking encyclopedia of art, music, wine, beer (his family ran a brewery and if you know anything about Belgium, you know that beer is a national treasure), history, and of course psychotherapy. Luc is also a gourmet chef and I had an amazing dinner at his home and his partner Sophie (a concert pianist who played for us over a glass of incredible Riesling wine on a piano that Franz Liszt played at the Paris World Fair in 1878). Luc and I share a common heritage in Ericksonian and systemic thinking (hence the name, Korzybski Institute) as well as many perspectives of therapy and training therapists. He co-founded the Korzybski Institute in 1982. His previous position was Chief of the Dept of Psychiatry and Psychosomatics at St John’s Hospital in Bruges. Luc was taken by CDOI’s attention to the common factors as well as the importance of monitoring outcomes.

On a more content related note, Jesse Owen just turned me on to a great alliance article: Crits-Christoph, P., Connolly Gibbons, M, , Hamilton, J., Ring-Kurtz, S., Gallop, R. (2011). The dependability of alliance assessments: The alliance-outcome correlation is larger than you think. Journal of Consulting and Clinical Psychology, 79, 267-278. Once again, a very sophisticated study validates the focus of CDOI and PCOMS. 

This study found that session 3 alliance ratings accounted for 4.7% of the variance but the average of sessions 3-9 explained a whopping 14.7% of outcome variance. This study suggests that a single session view of the relationship between the alliance and outcome very likely underestimates its impact on ultimate treatment outcome. Bottom line: Don’t underestimate the power of the alliance! In addition they recommended ongoing alliance assessment with alliance measures that don’t put too much burden on clients but that are reliable and valid. Do you know of any?

Don’t forget the upcoming webinar on supervision (Supervision Matters: Tapping into Therapist Aspirations to Get Better) coming up this Thursday, June 30 at noon Central. Join the CDOI member site to catch this one and many others.

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A special issue of the Journal of Clinical Psychology: In Session (February, 2011) addressed a topic near and dear to the hearts of CDOI therapists: Adapting Psychotherapy to the Individual Patient (sic). Here are some highlights.

Preferences: In this meta-analysis, we summarize results from 35 studies that have examined the preference effect with adult clients. Overall, clients who were matched to their preferred therapy conditions were less likely to drop out of therapy prematurely (OR=.59, p<.001) and showed greater improvements in treatment outcomes (d=.31, p<.001). Type of preference (role, therapist, or treatment type) was not found to moderate the preference effect. These results underscore the centrality of incorporating patient preferences when making treatment decisions. Swift, J.K., Callahan, J.L. & Vollmer, B.M. Preferences. Journal of Clinical Psychology: In Session, 67, 155–165.

Matching client preferences or privileging client ideas is what CDOI is all about in general, and what exploring the client’s theory is about specifically–the client’s view of the problem and how it may be best addressed including the role of therapist and the choice of any given explanation of and remedy to the problem.

Expectations: Patients’ expectations have long been considered a contributory factor to successful psychotherapy. Expectations come in different guises, with outcome expectations centered on prognostic beliefs about the consequences of engaging in treatment. Our research review includes a comprehensive meta-analysis (N =8,016 patients across 46 independent samples) of the association between pretherapy or early-therapy outcome expectations and posttreatment outcomes. The overall weighted effect size was d=.24, p<.001, indicating a small but significant positive effect of outcome expectations on adaptive treatment outcomes. Constantino, M.J., Arnkoff, D.B., Glass, C.R., Ametrano, R.M., & Smith, J.Z. (2011). Expectations. Journal of Clinical Psychology: In Session 67, 184–192.

Enhancing client expectations for success is part and parcel to CDOI clinical work. Monitoring outcome and conveying that the therapy is about change builds on expectancy effects as does matching client preferences about intervention. The alliance, expectancy, and model/technique are interdependent and overlapping. Technique is the alliance in action, carrying an explanation for the client’s difficulties and a remedy for them—an expression of the therapist’s belief that it could be helpful in hopes of engendering the same response in the client. Indeed, you cannot have an alliance without a treatment, an agreement between the client and therapist about how therapy will address the client’s goals. Similarly, you cannot have a positive expectation for change without a credible way for both the client and therapist to understand how change can happen. Soliciting systematic feedback is a living, ongoing process that engages clients in the collaborative monitoring of outcome, heightens hope for improvement, fits client preferences, maximizes therapist-client fit and client participation, and is itself a core feature of therapeutic change

Culture: We present an original meta-analysis of 65 experimental and quasi-experimental studies involving 8,620 participants. The omnibus effect size of d = .46 indicates that treatments specifically adapted for clients of color were moderately more effective with that clientele than traditional treatments. The most effective treatments tended to be those with greater numbers of cultural adaptations. Mental health services targeted to a specific cultural group were several times more effective than those provided to clients from a variety of cultural backgrounds. We recommend a series of research-supported therapeutic practices that account for clients’ culture, with culture-specific treatments being more effective than generally culture-sensitive treatments.  Smith, T.B., Domenech Rodríguez, M., & Bernal, G. (2011). Culture. Journal of Clinical Psychology:In Session, 67, 166–175.

And of course, we believe that being outcome informed allows one to be more culturally sensitive. Privileging the client via practice based evidence levels the counseling process by inviting collaborative decision making, honoring client diversity with multiple language availability, valuing local cultural and contextual knowledge, and amplifying the voice of the disenfranchised.

Don’t forget the upcoming webinar: Become a CDOI Member!
Title: Barry Duncan – Therapeutic Work: It’s Not Just for Clients Anymore; Date: Monday, March 28, 2011;  Time: 12:00 PM – 1:00 PM CDT

The trend toward describing, researching, teaching, practicing, and regulating psychotherapy in the terms of the medical model (simplified by the equation: diagnosis plus prescriptive treatment = cure or symptom amelioration) began long ago. George Albee (2000) suggested that psychology made a Faustian deal with the medical model over fifty years ago. The deal was sealed, he asserted, at the famed Boulder conference in 1949, where psychology’s bible of training was developed with a fatal flaw:
[The fatal flaw]…was the uncritical acceptance of the medical model, the organic explanation of mental disorders, with psychiatric hegemony, medical concepts, and language (Albee, 2000, p. 247).

Later, in the 1970’s, with the passing of freedom of choice legislation guaranteeing parity with psychiatrists, psychologists (and later others) learned to collect from third-party payers using only a psychiatric diagnosis for reimbursement. Thereafter, drowning any possibilities for other psychosocial systems of understanding human challenges, the National Institute of Mental Health (NIMH), the leading source of research funding for psychotherapy, decided to apply the same methodology used in drug research to evaluate psychotherapy (Goldfried & Wolfe, 1996)—the randomized clinical trial (RCT) requiring both diagnosis and manualized treatments. Diagnosis reached its pinnacle. Now both reimbursement and research funding depended on it. Funding for studies not related to specific treatments for specific disorders precipitously dropped as both research and psychotherapy itself became more and more medicalized, and dependent on diagnosis, manualization, and RCTs for credibility.

Diagnosis is the beginning point, the foundation of the both the medical model’s simple equation as well as the RCT. Unlike with medical treatments, diagnosis is an ill-advised starting point for psychotherapy. Diagnosis simply lacks reliability. In an interview, Robert Spitzer, the architect of the DSM III, admitted:
“To say that we’ve solved the reliability problem is just not true…It’s been improved. But if you’re in a situation with a general clinician it’s certainly not very good. There’s still a real problem, and it’s not clear how to solve the problem” (Spiegel, 2005, p. 63).

In addition to underwhelming reliability, psychiatric diagnosis lacks validity. Allen Frances, lead editor of the fourth edition of the DSM, recently confessed, “there is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it” (Greenberg, 2010, p. 1). Psychiatric diagnoses fail the most basic definition of validity—they lack empirical standards to distinguish the hypothesized pathological states from normal human variation or other disorders. Consequently, diagnosis always begs numerous, unanswered questions concerning cultural expectations and the role that power, privilege, gender, and race play in the identifying, cataloguing, and addressing client distress. The result is a set of murky over-inclusive criteria, often disadvantaging those who are racially or ethnically different, for an ever growing list of disorders (Duncan et al., 2004).

Finally and particularly germane to practitioners, diagnosis tells little about a person that is relevant to therapeutic change. Diagnosis in mental health is not correlated with outcome or length of stay (Brown et al., 1999; Wampold & Brown, 2005), and given the dodo verdict (see below) cannot provide reliable guidance to clinicians or clients regarding the best approach to resolving a problem. Diagnosis does not address what is most relevant to the helping process, namely the impact of the “disorder” in the client’s life and what can be done about it. Diagnosis also does not cover the range of reasons for which people seek therapy—relational, situational, and quality of life related, not symptom oriented. Nevertheless, the DSM, in spite of a long history of detailed critique (Carson, 1997; Duncan et al., 2004; Kirk & Kutchins, 1992), poor reliability and validity, and limited power to predict treatment outcome, lives on. It remains a fixed part of graduate training programs, a prominent feature of ESTs, and a prerequisite for funding in most mental health and substance abuse delivery systems—all engendering an illusion of scientific aura and clinical utility that far overreaches the DSM’s deeply flawed infrastructure.

Turning to the second part of the equation, that psychotherapists might possess the psychological equivalent of a “pill” for emotional distress resonates strongly with many, and is nothing if not seductive as it teases the desire to be helpful as possible to clients. A treatment for a specific “disorder,” from this perspective, is like a silver bullet, potent and transferable from research setting to clinical practice. Any therapist need only to load the silver bullet into any psychotherapy revolver and shoot the psychic werewolf stalking the client. Perhaps in its most unfortunate interpretation, clients are reduced to a diagnosis and therapists defined by a treatment technology—both interchangeable and insignificant to the procedure at hand

Consider the RCT. It was designed to compare the effects of a drug (an active compound) to a placebo (a therapeutically inert or inactive substance) for a specific illness. The basic assumption of the RCT is that the specific (unique) ingredients of different drugs (or psychotherapies) will produce different effects, superior over placebo, with different disorders. In effect, this assumption likens psychotherapy to a pill, with discernable unique ingredients that can be shown to have more potency than other active ingredients of other drugs.

There are three empirical arguments that cast doubt upon this assumption. First is the dodo bird verdict, which colorfully summarizes the robust finding that specific therapy approaches do not show specific effects or relative efficacy. In 1936, Saul Rosenzweig first invoked the dodo’s words from Alice’s Adventures in Wonderland, “Everybody has won and all must have prizes,” to illustrate his observation of the equivalent success of diverse psychotherapies. Almost 40 years later, Luborsky, Singer, and Luborsky (1975) empirically validated Rozenzweig’s conclusion in their now classic review of comparative clinical trials. The dodo bird verdict has since become the most replicated finding in the psychological literature, encompassing a broad array of research designs, problems, and clinical settings.

Three classic comparative clinical trials illustrate the dodo verdict. Ushering in the RCT in psychotherapy research was the Treatment of Depression Collaborative Research Program (TDCRP) (Elkin et al., 1989). The TDCRP randomly assigned 250 depressed participants to four different conditions: CBT, interpersonal therapy (IPT), antidepressants plus clinical management (IMI), and a pill placebo plus clinical management. The four conditions—including placebo—achieved about the same results, although both IPT and IMI surpassed placebo (but not the other treatments) on the recovery criterion. Project MATCH is the “largest and most statistically powerful clinical trial” in the history of alcohol and drug treatment (Project MATCH Research Group, 1997). Three widely divergent approaches were included: motivational enhancement therapy (MET), 12-Step facilitation (TSF), and CBT. The results revealed considerable improvement, but no differences in outcome emerged among the three approaches. Follow up ten years later (Tonigan et al, 2003) found no support for differential outcomes among the three therapies on percent days abstinent, drinks per drinking day, and total standard drink measures. In the Cannabis Youth Treatment (CYT) Study (Dennis et al., 2004), considered by many to be the largest and most methodologically sound investigation of adolescents to date, 600 adolescents were assigned either to treatment with MET plus CBT ( 5 or 12 sessions), family education and therapy, Adolescent Community Reinforcement Approach, or Multidimensional Family Therapy (MDFT). Comparisons between conditions found roughly equivalent significant pre-post treatment effects that were stable in terms of days of abstinence and percent in recovery by the end of the study.

Meta-analyses have yield similar results. A meta-analysis, designed specifically to test the dodo bird verdict (Wampold et al., 1997), included some 277 studies conducted from 1970 to 1995. This analysis verified that no approach has reliably demonstrated superiority over any other. At most, the effect size (ES) of treatment differences was a weak .2. “Why,” Wampold et al. ask, “[do] researchers persist in attempts to find treatment differences, when they know that these effects are small?” (p. 211).

The preponderance of the data, therefore, indicate a lack of specific effects and refute any claim of superiority when two or more bona fide treatments fully intended to be therapeutic are compared. If there are no specific technical operations that can be reliably shown to produce a specific effect, then prescriptive treatments in psychotherapy (i.e., mandating specific models and techniques for particular disorders) seems to make little sense.

The second argument shining a light on the specific ingredients assumption comes from component studies. Component studies, which dismantle approaches to tease out unique ingredients, have similarly found little evidence to support any specific effects of therapy. For example, a meta-analytic investigation of component studies (Ahn & Wampold, 2001) located 27 comparisons in the literature between 1970 and 1998 that tested an approach against that same approach without a specific component. The results revealed no differences. These studies have shown that it doesn’t matter what component you leave out—the approach still works as well as the treatment containing all of its parts.

A final empirical argument challenging the assumption comes from estimates regarding the impact of specific technique on outcome. After an extensive, but non-statistical analysis of decades of outcome research, Lambert (1986, 1992) suggests that model/technique factors account for about 15% of outcome variance. An even smaller role for specific technical operations of various psychotherapy approaches is proposed by Wampold (2001). His meta-analysis assigns only a 13% (derived from a .8 ES) contribution to the impact of therapy, both general and specific factors combined. Of that 13%, a mere 8% is portioned to the contribution of model effects. Of the total variance of change, only 1% can be assigned to specific technique. A consideration of Lambert’s and Wampold’s estimates of variance reveals that specific treatments do not account for 85% and 99%, respectively, of the variance of outcome. Other variables–the client, the therapist, and their relationship–account for far more of outcome variance. When taken in total–the equivalent results of comparative clinical trials and meta-analytic investigations, component studies, and analyses of the amount of variance attributed to specific effects –the evidence points in the same direction. There are no significant unique ingredients to therapy approaches and therefore little justification for basing psychotherapy on prescriptive or empirically supported treatments. Psychotherapy, therefore, has been shoehorned into the medical model.

But The Medical Model is not the Borg, nor am I Captain Picard fighting for the survival of therapists. Psychotherapy, however, is not a medical endeavor, it is a relational one. There is nothing wrong with the medical model. But it is not empirically supported nor an apt description of our work.

On another note, the last free webinar about my book, On Becoming a Better Therapist is coming up on January 21. Of course you can catch all the free webinars anytime here, but attending live allows you to ask that question you always wanted to ask or make a comment that occurred to you while you were reading the book. In any event, I hope you join me. Here is the info:

Dr. Barry Duncan – On Becoming a Better Therapist: Chapter Seven Discussion
On Becoming presents a five-step method of integrating outcome management with therapists’ long-term professional development. In this seventh of seven webinars corresponding to the seven chapters of the book, I present the fifth step to keep your development on the front burner, the Treasure Chest. I’ll also discuss the controversial issues of the day as they pertain to your identity as a therapist: managed care, evidence based practice, psychiatric drugs, and the medical model. We’ll begin with a 25 minute overview 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.
Friday, January 21, 2011, 6:00 to 7:30 PM
Reserve your Webinar seat now at: https://www2.gotomeeting.com/register/595664219

Do you think you have ever been duped in therapy? I had the opportunity to contribute to the Kottler and Carlson book, Duped, which was great fun because it allowed me to talk about two clients who taught me a lot about what is important in therapy. The first one really stretched my ability to believe clients, taught me that being a reality police officer is not likely to help form a strong alliance, and convinced me that the least I can do is believe my clients. The second client taught me that sometimes a lie can be therapeutic, perhaps just what is needed to allow resolution to occur. Check it out:

And don’t forget the new free webinar on December 29th 6:00 to 7:30 Central (and the previous one for Chapter Five is posted): On Becoming a Better Therapist: Chapter Six Discussion. This chapter keeps the focus on you, encouraging you to envision your identity as a helper and further contemplate this unpredictable and complexly human enterprise called therapy. It takes a whimsical look at therapist identity using the classic fable, The Wizard of Oz, to illustrate three different therapist personas. Concomitant to reflection about your identity is your personal description of what therapy means to you. This chapter encourages you to define and continually edit your personal rendition of what you do as a therapist. Psychotherapy is presented as a discovery-oriented process, a non-cookie cutter search for what works for each unique client. Feedback provides a comforting compass, a way to manage the uncertainty that is just as characteristic of therapy as it is of life.

Register now at: https://www2.gotomeeting.com/register/537803827

The alliance study is now published in the prestigious Journal of Consulting and Clinical Psychology (if I can boast a bit!): Anker, M., Owen, J., Duncan, B., & Sparks, J. (2010). The alliance in couple therapy: Partner influence, early change, and alliance patterns in a naturalistic sample. Journal of Consulting and Clinical Psychology, 78, 635–645. Congrats again to the crew!

A quick and dirty summary: N = 500 (total sample) n = 236 (subsample attending 4 or more sessions).  This study further supports both the feasibility and the importance of the feedback (PCOMS) intervention. The alliance significantly predicted outcome over and above early change, demonstrating that the alliance is not merely an artifact of client improvement but rather a force for change in and of itself. The study also found that those couples whose alliance scores ascended attained significantly better outcomes than those whose alliances scores did not improve. Together these findings suggest that therapists should not leave the alliance to chance but rather routinely assess it and discuss it with clients in each session.

Here is a discussion I had with the principal and onsite investigator, my friend, colleague, and partner in crime here at the Project, Morten Anker:

This study is significant for several reasons. First, as the Norway Feedback Study, it brings academic credibility to the use of the measures. Next it offers an antidote to the alliance nay-sayers who dismiss the alliance as only correlational despite the over 1000 studies that support the association between the alliance and outcome (this is like dismissing the association between cigarette smoking and lung cancer!) and often assert that the alliance is merely an artifact of early change. In other words, they argue that the alliance is confounded with early change and does not make any contribution beyond the client’s experience of improvement (clients experience positive alliances because they experience change). It is worthy question but it is often wielded in a way that undermines the importance of the alliance and the fact that it is second most replicated finding in the literature (the dodo bird verdict is first). This is one of only 6 studies that systematically examine this issue. Noteworthy is that we took a very stringent perspective of change. We looked at the clients who experienced reliable change so it was significant change, not just a little change. The alliance was predictive of outcome over and above early change even when that change exceeded 5 points on the ORS. Finally, the study, as mentioned, demonstrated the feasibility and benefit of routine alliance assessment.

On another note, a very interesting blog was sent to me by the author, a consumer. If you ever have any doubts about why collaborative monitoring of outcome and the alliance is a good idea, check this out from a consumer who says: “I’ve had a number of conversations with those harmed by therapy. A common thread is how resistant the profession seems to be to feedback from clients. To that end is my modest entry into the fray:” http://disequilibrium1.wordpress.com/2010/10/10/a-disgruntled-ex-psychotherapy-client-speaks-her-piece/

I recently did an exchange with a reviewer of The Heart and Soul of Change: Delivering What Works (2nd Ed.):

The Heart and Soul of the Dodo: A Review of The Heart and Soul of Change (2nd Ed.)

Thomas L. Rodebaugh

“The time has come,” the Walrus said, “To talk of many things.”

In The Heart and Soul of Change: Delivering What Works in Therapy, considerable attention is paid to establishing that Saul Rosenzweig was the original articulator of the dodo bird hypothesis: All psychotherapies work about equally effectively. Let us look closer at the source of the quotation, found in Alice in Wonderland, “Everyone has won, and all must have prizes!” (Carroll, 1865 and 1871/1998, p. 49).

In the story, an assortment of animals and the protagonist, Alice, have become drenched in a sea of Alice’s own tears. The ensuing “Caucus-race” (Carroll, 1865 and 1871/1998, p. 48) is the dodo’s invention to motivate the creatures to dry themselves off. It is not actually a race to be won, which is also demonstrated by the pitiful prizes: Each animal receives a single comfit (a candied, dried fruit). Because the animals eat all of those, Alice herself receives a thimble. More precisely, she keeps a thimble, because the comfits and the thimble were her own to begin with.

The dodo bird’s statement is not meant to be a hypothesis: It is meant to quiet the animals. Taken literally, the declaration regarding winners and prizes is clearly intended as nonsensical. The dodo, otherwise best known as a dead bird, is thereby made immortal as a purveyor of nonsense. Rosenzweig’s use of the dodo as a witty epigram some 74 years ago was inspired; that the dodo should live on as a metaphor for psychotherapy research so many years later strikes me as truly strange.

The dodo is a strong force in The Heart and Soul of Change. The book is a series of chapters by different authors but maintains a structure largely focused on the dodo bird hypothesis, its historical context, the research that can be taken to support it, and its implications for practice. Much of the rest of the book consists of further demonstrations that the dodo bird hypothesis is the most sensible interpretation of the data, set alongside critiques of empirically supported therapies (ESTs) and policies that support their adoption. Some later chapters focus primarily on what should be the next steps given that the dodo bird’s viewpoint is better supported than is a viewpoint that emphasizes ESTs.

Any adherents to ESTs who stumble upon the book might be forgiven for thinking they had accidentally landed in the mirror world described in Lewis Carroll’s other famous adventure for Alice: They are likely to cry foul, that evidence has been distorted and conclusions have been drawn contrariwise. Most (but not all) of the authors opine that ESTs offer no advantage and have been massively overblown and overpromoted.

Yet supporters of ESTs will probably already have to hand several recent challenges to the dodo (e.g., Ehlers et al., 2010). Among these counterpoints, I find particularly lucid Siev and Chambless’s (2007) demonstration that one must examine specific treatments for specific disorders to uncover differences between treatments. Supporters of ESTs might question why such findings are not responded to in this book. Certainly at least Siev and Chambless’s meta-analysis was available at the time of the writing of the chapters. Such apparent stacking of the deck does little to persuade people already inclined to support ESTs.

This book is clearly not aimed at such readers; neither is it, despite the title, primarily aimed at individuals looking for a how-to book regarding common factors in therapy. Although a chapter by Norcross, “The Therapeutic Relationship,” presents an excellent summary of these factors and the research that has investigated them, very little evidence is given as to how these factors can be better brought to bear in therapy. That is, although it seems clear that (for example) a stronger therapeutic alliance is desirable, there appears to be little systematic research available to establish that any particular intervention (e.g., a type of therapist training) necessarily improves alliance (although feedback, dealt with below, is held up as an exception to this general rule).

In fact, in another chapter, Wampold indicates that piecemeal investigations of one of the common factors cannot be conducted successfully: “The presence or absence of a common factor cannot be manipulated” (pp. 72–73). If this were accurate, then true experiments regarding common factors would be impossible and their causal role would remain unclear to the many researchers and clinicians who rely upon strong causal inference to understand the nature of treatment (cf. Borkovec & Miranda, 1999).

For whom, then, is the book intended? People who are amenable to the dodo bird hypothesis or find support of ESTs misguided are most likely to find the book palatable, and presumably this is the target audience. It seems likely that many of the authors would like policy makers to read the book, although I am not sure how likely that outcome is. Although it might seem a curious recommendation, I suggest that those who most strongly believe that ESTs are valuable could benefit from reading this book. I do not think this book will likely sway many such readers, but I do think it will be very helpful in illuminating the concerns of the researchers and clinicians who find adherence to ESTs misguided.

As most readers will have probably already guessed, I myself am convinced of the value of ESTs, at least for some disorders. Nevertheless, I can see many of the authors’ points. Although the repetitive dismissal of ESTs and related research, found chapter after chapter, seems excessive (like beating a dead dodo), my primary disappointment in the book is that it contains so little information regarding what changes an individual practitioner could make that are known to improve outcomes. In short, readers looking for guidance in employing the common factors (aside from feedback) might do better to read the Norcross chapter and follow it with seminal work by previous authors (I have my own favorites: Rogers, 1961; Wachtel, 1993) rather than read the entire book.

The major concept put forward for improving the common factors is gathering systematic feedback from clients, focusing on avoiding or mending ruptures in the therapeutic relationship; two full chapters (and additional space in other chapters) are devoted to demonstrating that such feedback is valuable and can have effects in community mental health organizations. These chapters appear longer on promise than on specific guidelines on what works and what does not.
Much additional research needs to be done, but the point regarding the general value of feedback is well taken and should be well considered by any practicing clinician. Devotees of cognitive therapy might nevertheless find perplexing the news that “of course, one need not choose between giving feedback and using empirically supported treatments. They can work in concert” (see Lambert’s chapter, “‘Yes, It Is Time for Clinicians to Routinely Monitor Treatment Outcome,” p. 249). Feedback from clients in each session has long been emphasized by cognitive therapists (Beck, 1995).

Such verbal feedback does not match the technical and statistical sophistication of the processes reviewed in this book, but the same intent is there. That Lambert needs to point out that ESTs and feedback are, in fact, compatible speaks to a very strange disconnect, the fissures of which seem to run throughout the book.

Perhaps my underwhelmed reaction to this book speaks merely to the effects of my allegiances. Of course, the authors and editors have allegiances of their own, although I wonder if they are as uniform in those allegiances as it might seem at first glance. Upon a closer inspection, it seems to me that a range of understandings of the dodo hypothesis is expressed across chapters.

In the weakest form, the argument seems to assert merely that ESTs may have been overemphasized by some and that common factors deserve more research. In its strongest form, the argument seems to assert that (a) anything that therapists and clients can believe is a therapy will work as well as any other such treatment; (b) common factors explain virtually everything about the way therapy works, yet there is probably little that could be mandated that could improve their effects; and (c) naturalistic tracking of outcomes is perhaps the sole exception to (b) and can also conclusively demonstrate that therapy is useful. In the strongest form, then, therapy and therapists are treated as a set of black boxes: There is no way to systematically alter the functions of these boxes, yet one can select therapists and therapist/client dyads on the basis of results.

I find myself concerned that some readers, perhaps most particularly those who see ESTs as a magnifier of the bureaucratic nightmare of insurance company requirements, might too easily endorse the strong dodo hypothesis. The position might seem attractive because it basically implies that therapists should be allowed to do whatever it is they do.

However, this position strikes me as pregnant with unwanted consequences. If good therapy entails a special quality (in the therapist, client, or both) that cannot be systematically varied (that is, caused to be present in some courses of therapy but not others), then one might wonder why anyone should research psychotherapy at all.

It seems to me that rather than the (strong) dodo hypothesis, we would be better off listening, but just for a moment, to the walrus hypothesis: The time has come to talk of many things. The field of psychotherapy needs more research, using many approaches, at all levels; it does not need an excuse to leave well enough alone.

However, research is not the only consequence of the strong dodo hypothesis. Practice, too, could suffer. If being a good therapist cannot be systematically taught, who would want to pay for years of training? One might wonder: Why not let anyone, with any level of training, try out being a therapist? One could simply select those people who are able to get the best results while accepting a minimum wage (perhaps the minimum wage) as payment.

It seems to me that the strong dodo hypothesis supports a form of essentialism that will not do science, practice, or policy any good at all. Neither supporters of ESTs nor their detractors want to see the therapeutic practice of clinical psychology go the way of the dodo.

Some Therapies Are More Equal than Others? A response to the review of The Heart and Soul of Change: Delivering What Works in Therapy (2nd ed.)

Barry L. Duncan

Rodebaugh (2010) candidly admits his allegiance to empirically supported treatments (EST), which perhaps explains the myopic lens used to examine the book. The dodo verdict (“Everybody has won and all must have prizes.”) still perfectly describes the state of affairs in psychotherapy—all bona fide approaches, in spite of vociferously argued differences, appear to work equally well. It is the most replicated finding in the outcome literature. Commenting on the dodo verdict’s ubiquity is hardly “stacking of the deck” when the findings that contradict it are less than would be attributable to chance alone. Importantly, saying that the dodo verdict persists in no way suggests that specific treatments for particular problems are not helpful.

While we take a critical stance toward claims of model superiority and confirm the veracity of the dodo verdict across modalities and populations, we do not denigrate model and technique nor specific effects, but rather propose that model/technique are essential components of a common factors perspective. We offered a way to understand how the alliance, expectancy, and model/technique are interdependent and overlapping. Technique is the alliance in action, carrying an explanation for the client’s difficulties and a remedy for them—an expression of the therapist’s belief that it could be helpful in hopes of engendering the same response in the client. Indeed, you cannot have an alliance without a treatment, an agreement between the client and therapist about how therapy will address the client’s goals. Similarly, you cannot have a positive expectation for change without a credible way for both the client and therapist to understand how change can happen.

We attempted to unite the warring factions via a more sophisticated understanding of change (interconnected factors, not disembodied parts or a tiresome specific v common factors polemic) as well as APA’s more contextual definition of evidence based practice. As the APA Task Force noted, the response of the client is variable and therefore must be monitored and treatment tailored accordingly to ensure a positive outcome. Proponents from both sides of the common versus specific factors aisle have recognized that outcome is not guaranteed, regardless of evidentiary support of a given technique or the expertise of the therapist. Monitoring outcome with clients, what has been called practice based evidence, has been shown to significantly improve outcomes regardless of the treatment administered. There are now nine RCTs showing the significant benefits of feedback (Duncan, 2010).

Rodebaugh’s assertion that one must examine specific treatments for specific disorders to uncover differences between treatments ignores the many direct comparisons that have not yielded any differences for specific disorders, like the TDCRP, Project Match, the Youth Cannabis Project, to mention a few (see Duncan et al., 2010). Consider the study we didn’t cite (Siev & Chambless, 2007). Although it is hard to imagine many therapists who would solely do relaxation training with panic, CBT beat relaxation alone on primary measures (although a closer look at the five studies reveals that one was significantly more positive than the other four, and two found very little difference). But even accepting this investigation at face value, that CBT is better than relaxation for panic (but not GAD) on primary measures only, hardly seems like any definitive overturn of the dodo verdict.

Nowhere in the book is there any suggestion that the dodo verdict implies that we should “leave well enough alone” regarding research, or perhaps the most egregious comment, that anything goes in the consulting room—or that there is little point to training. Quite the contrary, the book advocates for a shift toward research and training about what works and how to deliver it, and away from a sole reliance on comparative, “battle of the brands,” clinical trials. For example, my colleagues and I recently explored the relationship of the alliance to outcome and found that it predicted outcome above early treatment change and that ascending alliance scores were associated with better outcomes (Anker, Owen, Duncan, & Sparks, 2010), a strong argument for continuous alliance assessment. The book also calls for a more sophisticated clinician who chooses from a variety of orientations and methods to best fit client preferences and cultural values. Although there has not been convincing evidence for differential efficacy among approaches, there is indeed differential efficacy for the client in the room now—therapists need expertise in a broad range of intervention options, including ESTs, a point made by several authors.

Dismissing the book on the basis that some therapies are more equal than others is reminiscent of another set of animals in another classic story. It’s time to transcend the polemics and instead focus on what works with the client in my office now.

A Response to Barry L. Duncan

Thomas L. Rodebaugh

Let me emphasize that my reaction to The Heart and Soul of Change: Delivering What Works in Therapy was not uniformly negative. Further, I did not intend my review to be completely negative. I found the book useful overall; some chapters were particularly helpful. It would be a shame if the current debate were to overshadow that point.

The current format demands brevity. A point-by-point response to Barry L. Duncan (all the way down to Animal Farm) is untenable. The interested reader might re-examine my original review; my answers to some of Duncan’s statements are already implied there.

Allow me to focus on the term bona fide, upon which the current version of the dodo bird hypothesis rests. Bona fide treatments are treatments that are intended to be therapeutic. Intended by whom? Duncan expresses doubt that “many psychologists” would use relaxation treatment alone to treat panic disorder. I know one psychologist who would do so. I have informally polled my colleagues, who state that they have encountered others. Perhaps it is important that many psychologists believe that a treatment should work before it be considered bona fide. How many?

Without precise definition, whether something is bona fide is a subjective judgment. Studies could be dismissed because particular authors believe a treatment not to be bona fide or because they believe the researchers probably did not believe them to be bona fide, even if the researchers actually thought otherwise. I have had only modest experiences with clinical trials, but even I have seen many variations in level of belief at different levels of study teams. Sometimes therapists seemed to clearly believe more or less in particular conditions than did the principal investigator(s). Is it the therapists, investigators, or psychologists at large who count? Unless we define what level of belief is needed in the individual clinician or researcher, or how many psychologists must have such belief, our resulting decisions cannot be consistent (cf. Ehlers et al., 2010, for similar concerns).

Duncan seems to dismiss the idea that his argument indicates that “anything goes” in treatment. I can see his point, if bona fide means that “many psychologists” believe a treatment should work. We could thus be saved from endorsing ludicrous, fringe treatments. All the more reason to stringently define bona fide and thus reduce confusion among psychologists interpreting this literature.

Yet ineffective treatments sometimes have a popular following. As Ehlers et al. (2010) have pointed out, critical incident stress debriefing is certainly one example of a treatment that psychologists intended to be therapeutic but seems, upon investigation, possibly worse than useless. The hypothesis is that all (bona fide) treatments have won. To disprove it requires only one that has lost.

And don’t forget to register for the free webinars covering each chapter of 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 have been thinking about and writing about the common factors and their operationalization for many years. Research continues to build a compelling case for the presence of pantheoretical factors in operation that overshadow any perceived or presumed differences among approaches. For example, our alliance article soon to be published in the Journal of Consulting and Clincal Psychology found the alliance to be predictive of outcome over and above early treatment change and our in preparation investigation of therapist effects found that differences among therapists were best explained by their alliance abilities–over gender, discipline, or experience (more on both of these studies later). Some of you may have seen my depiction of the factors shown below:

I am always striving to describe the factors in a way that illustrates their interdependence. Here is my latest effort: Five factors comprise this perspective: client, therapist, alliance, the model/technique delivered, and feedback—all interdependent and overlapping. Technique is the alliance in action, carrying an explanation for the client’s difficulties and a remedy for them—an expression of the therapist’s belief that it could be helpful in hopes of engendering the same response in the client. Indeed, you cannot have an alliance without a treatment, an agreement between the client and therapist about how therapy will address the client’s goals. Similarly, you cannot have a positive expectation for change without a credible way for both the client and therapist to understand how change can happen. And the only way to know whether the common factors are in operation is to obtain real time client feedback about the benefit and fit of services. Feedback overlaps with and affects all the factors—it is the tie that binds them together—allowing the common factors to be delivered one client at a time. Soliciting systematic feedback is a living, ongoing process that engages clients in the collaborative monitoring of outcome, heightens hope for improvement, fits client preferences, maximizes therapist-client fit, and is itself a core feature of therapeutic change.

And I believe the only way to fully understand the importance of the common factors, including feedback, is to see them in action with real clients. Consequently, a new feature has been added to CDOI Members: actual client videos (client idenities are protected) are now available to Members for anytime viewing and learning.

Also, please check out the free webinars about my new book, On Becomng a Better Therapist. They are posted as they occur on the Video page, and the pdf of the slides as well as the videos are posted on the discussion page.

Finally, check out the following video made by Robyn Pope, a certified CDOI trainer of the Heart and Soul of Change Project, of staff at Wesley Community Action.  Wesley is a broad based social service agency that provides culturally sensitive and socially just services in non traditional settings. Robyn solicits staff reactions about the use of the Outcome Rating Scale and Session Rating Scale, including how they have grown professionally and personally as well as the challenges they have faced in implementation.

I just had the great privilege to meet Nora Bateson, the daughter of Gregory Bateson, and Betty Alice Erickson, the daughter of Milton Erickson in Bruges. It was quite an incredible experience to say the least—these two very profoundly insightful and talented women of two of the most influential people of their generation. Betty Alice (named after Alice in Alice in Wonderland) is a masterful story teller in own right. She picked up her father’s trade 20 years ago after raising her family and now does training in hypnosis, storytelling, etc. She also just completed an edited book about her father called “An American Healer.” In addition to her great accounts of her father, she told a couple of metaphoric stories at the end of the day and there was not a dry eye in the room. Besides all that, she was quite delightful and full of fun.

Nora Bateson just completed a documentary film about her father which is not only a beautiful honoring of a father by a devoted daughter, an invaluable account of his impact on many fields, but also a magnificent statement of the interconnectedness of all living things—all embedded in a finely crafted cinematic experience. Nora is a truly gifted speaker and filmmaker, as well as an articulate spokesperson for systemic ideas. She was also was full of life and had a sparkling sense of humor. Check out the film at: http://www.anecologyofmind.com/Home_Page.php

This all came about via my association with the Korzybski Institute (a largely solution focused group with a decided existential twist called the Bruges model) which trains many therapists across Europe but mainly in the Netherlands, Switzerland, and Belgium. A fascinating man, Luc Isabaert, is the director. Luc is a wise and very knowledgeable person about almost everything from Bateson to Belgium Beer (which I capitalize because it is a national treasure)! I am now a trainer for Luc and Korzybski which led to my invitation to this “think tank” session following my kick off training course in Amsterdam which will continue in Bruges and other training sites in May. The theme of the think tank was my old friend, the therapeutic alliance, and the participants ranged from anthropologists, logicians, and organizational consultants to psychiatrists and family therapists. The discussion was fascinating although it was a bit outside of the pragmatic world in which I live and therefore a bit more academic at times than my taste. It brought back make many memories for me because my dissertation was a theoretical one (an option in my program) about systems theory and paradox. I had not thought about these ideas for some time and it was particularly fun to see how they still influence my thinking. And of course, the participants were brilliant and interesting so I spent much of time marveling at it all. And Bruges is absolutely unbelievable, a very well preserved 14th century crown jewel of Belgium. Check out the Institute at: http://www.korzybski.com/index.php?lang=en

Here is my presentation at the think tank about the alliance: