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/

One of the great controversies in psychotherapy has been the common v. specific factors debate. On one hand, the common factors, or the notion that it is the pantheoretical aspects of providing psychotherapy, those elements common to all (like the alliance) that account for change. On the other hand, the specific factors side argues that there are unique ingredients to particular models of practice that explain how people change in therapy. The common factors side of things enjoys far more empirical support given that no approach has every shown superiority over another, have not ever demonstrated the proposed specific effects, and model differences only account for 1% of the overall variance. It would be great, however, to move beyond the common v specific factors polemics because of course, the factors are intimately intertwined in all ways imaginable. But it is tough when various orientations continue to argue for specific factors in somewhat deceptive attempts to privilege different models. Fact of the matter is you can’t really separate the specific elements of a given model from the context it occurs in (not to mention who is delivering the treatment), or the general effects of delivering any treatment.

Here is how I am writing about the interdependence (excerpted from my new book, On Becoming a Better Therapist): The specific factors (the differences between models) have a relatively small impact but the general effects of delivering a treatment are far more potent. As Jerome Frank (1973) seminally noted, all models include a rationale or myth, an explanation for the client’s difficulties, and a procedure or ritual, strategies to follow for resolving them. Models achieve their effects, in large part, if not completely through the activation of placebo, hope, and expectancy, combined with the therapist’s belief in (allegiance to) the treatment administered. As long as a treatment makes sense to, is accepted by, and fosters the active engagement of the client, the particular approach used is unimportant. Said another way, therapeutic techniques are placebo-delivery devices (Kirsch, 2005).

Allegiance and expectancy are two sides of the same coin—the belief by both the therapist and the client in the restorative power and credibility of the therapy’s rationale and related rituals. When a placebo or technically “inert” condition is offered in a manner that fosters positive expectations for improvement, it reliably produces effects almost as large as a bona fide treatment (Baskin, Tierney, Minami, & Wampold, 2003). The TDCRP is again instructive. First, across all conditions, client expectation of improvement predicted outcome (Sotsky et al., 1991). And second, an inspection of the Beck Depression Inventory scores of those who completed the study (see Elkin et al., 1989) reveals that the placebo plus clinical management condition accounted for nearly 93% of the average response to the active treatments. The act of administering treatment—the model/technique delivered—is the vehicle that carries allegiance and placebo effects in addition to the specific effects of the given approach.

It pays, therefore, to have several rationales and remedies at your disposal that you believe in, as well as believing in the possibility of the client’s ideas about change. Finally, it is important to note that suggesting specific effects are small in comparison to general effects, and that psychotherapy approaches achieve about the same results does not mean that models and techniques are not important. On the contrary, a particular orientation or method may be just the ticket for a given client—while there is no differential efficacy on aggregate, there are approaches that are likely better or worse for the client in your office now.
Bottom Line: The specifics of any approach, either unique to the client or of a particular orientation, are not as important as the cogency of the rationale and ritual to both the client and the therapist, and most importantly, the client’s response to the delivered treatment.

And then there is the alliance context of delivering any specific treatment. The alliance is an all-encompassing framework for psychotherapy—it transcends any specific therapist behavior and is a property of all aspects of providing services (Hatcher & Barends, 2006). The alliance is evident in anything and everything you do—from offering an explanation or technique to address the client’s situation to scheduling the next appointment—to engage the client in purposive work. In an important way, the alliance is dependent on the delivery of some particular treatment—a framework for understanding and solving the problem. The alliance cannot happen without technique (Hatcher & Barends, 2006). If technique fails to engage the client in purposive work, it is not working properly and a change is needed. Think of it this way: Technique is an activity—the alliance is a way to characterize that activity; the alliance is the purpose of the activity (Hatcher & Barends, 2006). Although it is possible for a strong relationship to develop between you and the client, there can be no agreement about the tasks of therapy, a critical aspect of the alliance, without some discussion and negotiation of what “treatment” will be used (Wampold, 2010)—be it some specific approach, the client’s own ideas and cultural preferences, or some unique blend.

The overlapping components of the Venn diagram below depicts the interdependent common factors. There can be no alliance without a treatment, and on the other hand, technique is only as effective as its delivery system—the client-therapist relationship. So you can’t have a good alliance without some agreement about how therapy is going to address the issues at hand. You can’t have purposeful work without collaboration about what that work will entail.

Here is where the incredible variety of models and techniques pays off. While there is no differential efficacy among approaches in general, there is differential efficacy among approaches with the client in your office now. The question is: does it resonate or not? Does it fit client preferences? Does its application help or hinder the alliance? Is it something that both you and the client can get behind? You matter here too. If you don’t believe in the potential restorative or healing power of any selected approach—i.e., don’t have allegiance to it—then not much good will come of it. Can you get on board with the client’s notions about how he or she can be helped? Or perhaps some idiosyncratic blend of client ideas, yours, and theoretical/technical ones might ultimately be just the ticket. Your alliance skills are truly at play here: your interpersonal ability to explore the client’s ideas, discuss options, collaboratively form a plan, and negotiate any changes when benefit to the client is not forthcoming. Technique, its selection and application, in other words, are instances of the alliance in action.

So it doesn’t make a whole lot of sense to think of things separately. That is what my hallucinogenic figure tries to portray. BTW, see a full explanation of the common factors diagram on the handouts page:
http://heartandsoulofchange.com/resources/handouts/

And don’t forget to register for the free webinar!

Title: “Dr. Barry Duncan– What in the heck is CDOI? Client Directed, Outcome Informed Ideas and Practices
Date: Tuesday, December 22, 2009
Time: 12:00 PM – 1:00 PM CDT
Register now by clicking the link below:
https://www2.gotomeeting.com/register/326593746

Here are the slides:

Coming soon: People have asked me about my Oprah appearance for years. On my next blog, I will post the video. The deal is that I am posting it but you are not allowed to laugh about it, at least not to my face!

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.