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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As I have said before, the reason that we are called the Heart and Soul of Change Project is because we are committed to both creating and disseminating research from naturalistic sites that operationalize our mission to privilege the client’s voice and enter true partnerships with those we serve. That is our ongoing project. Besides the ones I mentioned in the “Bob Bohankse Land” blog, there is another project well underway in one site and beginning in another and a completed one that just made the light of day in the Journal of Family Psychotherapy. The first randomized clinical trial of feedback ever done with children and adolescents in the schools (or anywhere else) has been underway for some time in Mary Haynes Land, otherwise known as Maine and Community Health and Counseling Services. This project has been a collaborative effort of Mary Haynes (who is also a Project Leader of the HSCP) and Liam Shaw, a supervisor of the Skowhegan office (and several dedicated therapists) with the ongoing support of Executive Director Dale Hamilton. Another site has just signed on, thanks to the leadership of Bob Bohanske and the support of the President of Southwest Behavioral Health, Jeff Jorde. Also part of the Phoenix team are Vice President Ed McClelland and Clinical Supervisor Alysson Zatarga, who will really be the ones making it happen. This study could really make a difference in how services are delivered in the schools, ensuring that kids and adolescents have a voice in decisions about their care. This study is an collaborative of Barry, Project Leader and UCA Professor John Murphy, and Art Gillaspy, Associate Professor at UCA. Considering the impact the Norway Couple Feedback Trial had on how couple services are delivered in Norway, this study could change the way services are provided in the schools.

And the completed and published project: Anker, M., Sparks, J., Duncan, B., & Stapnes, A. (2011). Footprints of couple therapy: Client reflections at follow up using a mixed method design in routine care. Journal of Family Psychotherapy, 22, 22-45. In this study, we explored client experiences of couple therapy using their written responses to questions at 6-month follow-up. We did a qualitative thematic analysis and a number of themes emerged along with client evaluations of those themes. We analyzed these with respect to the overall sample, gender, and the feedback/no-feedback groups in the original Norway Feedback Trial (Anker, Duncan, & Sparks, 2009). There were two general domains—relationship and tasks, that neatly fit Bordin’s definition of the alliance. Respondents were generally satisfied with the relationship domain, but there were more dissatisfied responses in the tasks domain. Basically, clients indicated that they liked therapists who were friendly, warm, and able to be neutral. There were more negative assessments of therapists not giving enough concrete suggestions, not challenging when appropriate, or not structuring the session. These findings did not differ significantly by gender and supported other the findings from similar studies. What was interesting had to do with the category “service delivery.” This category had the most statements in the tasks domain and there were more negative than positive. Clients were not happy with how the scheduling of therapy happened, the frequency of meetings, and lack of therapist follow-through on contacting clients between sessions and being flexible about scheduling. This was very interesting as this element of our work is rarely discussed in the literature, or training for that matter. But it is an important aspect of the alliance. Even more interesting, this was the one category that differed between the feedback and no-feedback groups, with no-feedback clients more dissatisfied with service delivery. We weren’t exactly sure what this meant, but speculated that therapists routinely getting and responding to feedback somehow were more attentive to their clients in these areas. We also asked couples what they thought of the feedback process. Over 60% of clients found it useful while less than 30% didn’t find it helpful. But the client’s goal for the relationship was important here. Of those clients who indicated that his or her goal was to improve the relationship, over 80% found the feedback process helpful.

Here is the article:

Finally, don’t forget this month’s webinar: Tuesday, May 31 at Noon Central: George Braucht and Neil Kaltenecker present: “Stand by Me: Recovery-Oriented, Person-Directed & Outcome Informed Peer Services”

This webinar highlights an application of CDOI skills and tools that blend the alcohol and other drug use recovery-oriented (RO) systems of care model with person (instead of client)-directed (PD) and outcome-informed (OI) peer-delivered services. As empirically demonstrated, transforming acute care models and techniques into CDOI services achieves improved efficiencies and outcomes that can contribute significantly to reaching the enhanced service goals fostered by the Parity and Affordable Healthcare laws. A key takeaway of this webinar is an example of how to integrate into existing services the experience, strength and hope of ROPDOI-trained people in long-term recovery along with the pervasive, culturally-diverse community resources for initiating and sustaining recovery. Building on Georgia’s seminal work on mental health peer specialists, the webinar focuses on the service delivery tools used by peer recovery coaches who have completed the Certified Addiction Recovery Empowerment Specialist (CARES) Academy. This webinar is suitable for behavioral, healthcare and social service providers and administrators; recovery community members; and others who are seeking or in long-term recovery. Participants who have not already seen Dr. Bob Bohanske’s webinar Operationalizing recovery: The Consensus Statement in Action are encouraged to view it before this webinar.

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The Heart and Soul of Change Project (HSCP) is a practice-driven, training and research initiative that focuses on what works in therapy, and more importantly, how to deliver it on the front lines via client based outcome feedback, or what is called the Partners for Change Outcome Management System (PCOMS). Consequently we are not just interested in capitalizing on what others do; rather the HSCP team produces research and directly translates it to clinical practice in the real world. The Norway Feedback Trial and Alliance Study is a case in point–these studies led to national implementation of PCOMS in Norway. And the hits just keep coming. First, the third randomized clinical trial (RCT) demonstrating the dramatic improvement in outcomes provided by merely adding feedback to therapeutic mix via the ORS and SRS is now in print. This is the replication study of the Norway Feedback Trial and it is an uncanny replication. This study found almost identical findings: four times as many couples achieved clinically significant change and the effect size for feedback was .49. Congratulations to Jeff Reese, Project Leader of the HSCP, and his research team for helping put CDOI and PCOMS on the map. This study culminated in our submission to SAMSHA for evidenced based treatment status (more on that later as well as the important distinction between evidence based treatment and evidence based practice).
Here is the study:

We have three RCTs in progress: one with returning veterans, one with kids in the schools, and one study seeking to ferret out what really causes the feedback effect, or what is called a component study. Stay tuned.

Next in print is the “Footprints” article to appear next month the in Journal of Family Psychotherapy. This article looked at 6 month follow up data from the Norway Feedback Trial. As just a teaser of a study that reaffirms the importance of the alliance plus throws in a few curves, we found that clients in the non-feedback group were significantly more likely to complain about the therapy service delivery than feedback clients. More on this next month.

And a soon to be published (in the 2nd edition of the John Norcross book, Psychotherapy Relationships that Work) meta-analysis of PCOMS studies conducted by feedback pioneer Michael Lambert and K. Shimokawa found that those in feedback group had 3.5 higher odds of experiencing reliable change and less than half the odds of experiencing deterioration.

Finally, check out the next webinar by Dr. Mary Haynes: Creative Applications: CDOI in Case Managment
This workshop explores the ground-breaking expansion of the use of feedback to case management services. Based on her eight years of experience in extending the use of outcome management to settings other than traditional therapy, Mary will address the unique benefits and challenges of incorporating client feedback in community-based work with adults.

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Call me cynical but it seems that the field is not really sure what professional development means or how we can accomplish it. First up to bat, of course, were the psychodynamic folks who told us that developing ourselves as psychotherapists required that we become more self-aware through personal therapy. This makes a lot of intuitive sense and gaining an appreciation of what it is like to sit in the client’s chair seems invaluable. But the cold hard truth is that personal therapy and “self awareness” has nothing to do with outcome—it neither helps nor hinders. Strike one.

Then along came family therapy, the antiestablishment poster kids who rejected analysis and decided to train therapists differently: watch the moves of the masters, they said, and replicate them. It took these renegades, the family therapists, to bring intervention and training to its highest art form. What swashbuckling enactments, what breathtaking chair moving, what heartrending sculpting! From falling off chairs to invariant prescriptions, to symptom prescription, to washing floors at 3:00 A.M., family therapy training rose to new heights of . . . of entertainment. Audiences thrilled, readers gasped. Therapists did their best impersonations of the masters. But that didn’t help outcomes either.

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. The “right approach,” however, evidenced based treatments or the everyday variety, doesn’t matter much to outcome. No one approach has ever shown it is better than any other. This, of course, is the famous dodo bird verdict (“All have won and all must have prizes.”), taken from the classic Lewis Carroll tale, Alice in Wonderland, first invoked by Saul Rosenzweig way back in 1936 to illustrate the equivalence of outcome among approaches.

And, although the need and value of training seems obvious, it has long been known that training doesn’t seem to matter much to outcome. And a just published study just adds to this less than inspiring fact. In the Journal of Counseling and Development, researchers Nyman and Nafziger reported that it didn’t matter if the client was “seen by a licensed doctoral–level counselor, a pre-doctoral intern, or a practicum student,” concluding that “It may be that researchers are loathe to face the possibility that the extensive efforts involved in educating graduate students to become licensed professionals result in no observable differences in client outcome.” As for continuing professional education, there is no research about it. The bottom line is the professional training, continuing education, and the search for the right approach result in no observable differences in outcome. Strike two.

So what about experience? Surely, years of clinical encounters make a significance difference in outcome. But are we getting better, or are we having the same experience year after year? More bad news here: Experience just doesn’t seem to matter much. A look at the bible (Garfield and Bergin’s Handbook of Psychotherapy and Behavior Change) reveals that in large measure, experienced and inexperienced therapists achieve about the same outcomes. So, personal awareness, training, and experience don’t make us better. Strike three, yer out!

And finally, regardless of our methods of getting better, we are quite self-delusional about our effectiveness. Consider a study reported by Vanderbilt researcher Len Bickman and associates: Clinicians were asked to rate their job performance from A+ to F. Two-thirds considered themselves A or better. Not one therapist rated him or herself as below average. If you remember that thing called the Bell curve, you know this is not possible. But it’s not their fault! In the absence of reliable information, how could they know? How can you know?

Does this mean that you should take your bat, glove, and ball and go home and forget the whole thing? Nope. Whether you are a novice or a seasoned veteran, becoming a better therapist requires you to be proactive about your growth as a helper In spite of oppressive paperwork, daunting productivity requirements, and funder mandates, you must take your development personally to remain a vital force in client lives. And contrary to my cynical portrayal the state of the field’s efforts to help you get better, there is an empirically-based method arising from the most extensive investigation of therapist development ever conducted. The findings of that study, combined with advantages of tracking outcome with clients provide just the ticket to making you a better therapist. Read about it here:

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?”

Practice based evidence, or the systematic collection of client based outcome feedback, will likely become the rage of the next decade—and for good reason: Feedback pioneer Michael Lambert in his chapter in the just published second edition of the Heart and Soul of Change (2010) reports that effect sizes (ES; a statistical measurement of change) for the difference between feedback and TAU ranges from .34 to .92, unusually large considering that the estimates of the ES of the difference between empirically supported and comparison treatments are about .20. Putting this in perspective, feedback has two to four times the impact of model differences.

Where did this great idea of feedback come from? Howard, Moras, Brill, Matinovich, and Lutz (1996) were the first to advocate for the systematic evaluation of client response to treatment during the course of therapy. When this occurs—when client feedback is systematically collected and used to tailor treatment—good things happen.

For example, using the Outcome Questionnaire 45.2, Michael Lambert really brought this great idea to fruition. He has conducted five RCTs and all five demonstrated significant gains for feedback groups over treatment as usual (TAU) for clients at-risk for a negative outcome. Twenty two percent of TAU at-risk cases reached reliable improvement and clinically significant change compared with 33% for feedback to therapist groups, 39% for feedback to therapists and clients, and 45% when feedback was supplemented with support tools such as measures of the alliance. The addition of client feedback alone, without new techniques or models of treatment and leaving therapists to practice as they saw fit, enabled over two times the amount of at- risk clients to benefit from psychotherapy. Think of the advantage this brings to clinical practice. Systematic feedback allows good outcomes with many of those clients who would otherwise not benefit. 

I am very happy to announce that Michael Lambert, the person most responsible for bringing the power of client feedback to the forefront, will be conducting the next webinar to set the stage for his Heart and Soul of Change conference presentations:

“Yes, It Is Time for Clinicians to Track Outcomes”

Wednesday, January 27, noon to 1:00 Central

Join the person most responsible for the greatest innovation in clinical effectiveness since the beginning of psychotherapy. Register now by joining the CDOI membersite, now over a $400 value for a one year $120 subscription at http://www.cdoimembers.com/

Michael Lambert also inspired our client feedback process, The Partners for Change Outcome Management System’s (PCOMS). PCOMS appeal rests on the brevity of the measures and therefore its feasibility for everyday use in the demanding schedules of front-line clinicians. PCOMS was based on Lambert’s continuous assessment model using the Outcome Questionnaire 45.2, but there are differences beyond the measures. First, PCOMS is integrated into the ongoing psychotherapy process and routinely includes a transparent discussion of the feedback with the client (The Heroic Client). Session by session interaction is focused by client feedback about the benefits or lack thereof of psychotherapy. Second, PCOMS assesses the therapeutic alliance every session and includes a discussion of any potential problems. Lambert’s system includes alliance assessment only when there is a lack of progress. 

Three studies have demonstrated the benefits of client feedback with the ORS and SRS. Miller, Duncan, Brown, Sorrell, and Chalk (2006) explored the impact of feedback in a large culturally diverse sample utilizing a telephonic employee assistance program (EAP). Although the study’s quasi-experimental design qualifies the results, the use of outcome feedback doubled overall effectiveness and significantly increased retention. Two recent RCTs used PCOMS to investigate the effects of feedback versus TAU. First, in an independent investigation, Reese, Norsworthy, & Rowlands (2009) found that clients who attended therapy at a university counseling center or a graduate training clinic demonstrated significant treatment gains for feedback when compared to TAU. Finally, our recent study in Norway (Anker, Duncan, & Sparks, 2009), the largest RCT of couple therapy ever done, found that feedback clients reached clinically significant change nearly four times more than non-feedback couples. The feedback condition maintained its advantage at 6 month follow-up and achieved nearly a 50% lower separation/divorce rate.

A fourth study, a replication of the Norway Feedback Study by Jeff Reese has been submitted and a fifth study addressing feedback in an acute inpatient unit is about to get underway.

Read more on the resources page at http://heartandsoulofchange.com/resources/

Four simple questions on well-being asked at the start of each session of ongoing couple therapy can greatly increase chances for reconciliation and improved relationships, according to a newly published study. The largest clinical trial with couples to date, it shows that divorce and separation rates for couples that used this feedback technique were 46.2 percent less than that of couples who received therapy as usual. The findings, published in the August 1, 2009, Journal of Consulting and Clinical Psychology, are the results of a 2-year study conducted at the Vestfold Family Counseling Center in Norway by a U.S.-Norwegian team of researchers.

From October 2005 to December 2007, 205 randomly selected couples receiving therapy in southern Norway participated in the study, which investigated the effects of providing ongoing feedback regarding the progress of treatment to both clients and therapists. The couples had problems typical of struggling relationships: communication difficulties, loss of feeling for partner, jealousy/infidelity, conflict, and coping with partner’s physical or psychological problems. Half of the study group had feedback incorporated into their therapy while the other half did not.

Couples who used the feedback method rated their well-being on an individual, interpersonal, social, and overall basis by using a visual scale called the Outcome Rating Scale (ORS) at the beginning of each session. The results were used to guide each session: if progress was not noted, new directions for therapy were discussed and implemented. Therapists participating in the study received training on how to integrate the findings of the ORS and collaborate with couples to find new solutions.

“Adding feedback can truly boost effectiveness in couples therapy,” said Dr. Barry Duncan, one of the authors of the study. “It encourages couples to honestly evaluate their progress and enables therapists to adjust therapy before it’s too late.” Although feedback has been demonstrated to improve individual psychotherapy outcomes, no studies until now have examined couples therapy.

Participants were contacted 6 months after the last therapy session. Respondents answered questions about their experience in treatment, including whether the couple remained together. The feedback couples were not only more satisfied with their relationships but also reported significantly lower rates of separation or divorce: a 18.4 percent separation/divorce rate for ORS couples versus 34.2 percent for non-ORS couples.

This study adds to growing evidence that ongoing client feedback in psychotherapy can significantly improve outcomes.

For more information on the ORS, see this website and www.myoutcomes.com .

Media Relations Contact: Barry L. Duncan, Psy.D., barrylduncan@comcast.net, (954) 721-2981, or (561) 239-3640.

Co-authors on the study were Morten G. Anker, Ph. D., the Family Counseling Office in Vestfold, Norway; Barry L. Duncan, Psy.D., the Heart and Soul of Change Project; and Jacqueline A. Sparks, Ph.D., the University of Rhode Island.

Worldwide, there are more than 20,000 registered users of the Outcome Rating Scale. The ORS is available in a variety of formats, including MyOutcomes, a Web-based software application that provides quick and easy administration and interpretation of the ORS.