Project Leader Dave Claud, an addiction specialist and all around good guy, asked me to take a look at a recent article extolling the virtues of Suboxine for opioid addiction.

Weiss, R., et al. (2012). Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence. Archives of General Psychiatry, 68 (12), 1238-1246.

This is an interesting article and on first pass, it seems like a reasonable look at the relative merits of medication management with buprenorphine-naloxone (Suboxone) v. the same with an additional counseling component. But on further inspection, the spin on the results is an unabashed marketing of Suboxone to primary care docs. First, and foremost, the results are simply atrocious. The study had 2 phases: a two week “treatment lite” version (2 weeks of meds with a 2 week taper off the med followed by a 7 week follow up) and an up to 24 week more intensive regimen (12 weeks of meds followed by a 3 week taper and a 7 week follow up). In the first phase, only 6.6% of participants achieved successful outcomes; in the second phase, only 8.6% achieved a successful outcome. Holy Cow! The additional counseling mattered not: no differences in outcome between conditions. But before I get to that, and there is likely a pretty good reason for it, let’s address the spin on this study.

In the second phase, following 12 weeks of the meds (of course you know this an opioid agonist that approximates but does not offer the full package of actual opioid use because of the addition of a one quarter antagonist), there was a 49.2% successful outcome which all but evaporated after the med was tapered off. So the spin is that as long as you keep prescribing the Suboxone, nearly half of patients will successfully stay off prescription opioids. But if you stop, nearly all of those who benefit will ultimately start using again. So Suboxone, in essence, and without saying it directly, is promoted as a life-long treatment for opioid addiction that any physician can do in primary practice. A scary thought to be sure, and certainly a conclusion that benefits you know who. That’s the spin. But what won’t be in the sound bites here is that the medication management condition included weekly appointments with docs and weekly discussion of addiction, abstinence, and other psychiatric and substance abuse issues as well as the recommendation of self help groups. So the medication management condition already included a counseling component, although a less intensive one—a 20 minute meeting as opposed to the 60 minute meetings in the counseling condition. It is not likely that primary care physicians in the real world would every do the medication management component of the treatment and would wind up just prescribing the Suboxone, which is likely the bottom line message here.

Now, I am not saying that counseling added anything better because it didn’t. It seems like the counseling was pretty much the traditional, psychoeducational medical model, 12 step variety with a skill building component around life skills and relapse prevention. It just didn’t add much to what the doc provided and perhaps was seen as superfluous by the patient after talking to the doc and getting the drug. In essence it was counseling lite (by a doc who is giving you drugs) vs. a more intensive counseling experience. I wonder what giving the drug v. therapy would have done. I don’t think it was a very good effort to show what therapy can provide a person with an opioid addiction .

Several take home points: first of all opioid addiction (oxycodone, hydrocodone, hydromorphone, morphine, codeine, propoxyphene, etc), virtually created by free prescribing practices of primary care docs and anesthesiologists for pain etc, promoted heavily by drug companies is perhaps the mother of all addictions in terms of difficulty to treat. It exceeds heroin addiction in scope by at least 20 times. Perhaps it is the ultimate irony that the treatment advocated is to be administered by the same primary care docs who got us into this mess to start with. So the pharmaceutical industry has created this monster problem and now has a solution for it. I hope that we can figure out a better way than keeping a person on Suboxone. Because, besides the less than exemplary results, 83% experienced 1 or more adverse events in Phase 1 and 60% in Phase 2 (most common were headache and constipation). It is interesting that percentages of all the side effects are presented until we get to the “serious adverse events (SAE).” In Phase1, there were 12 SAEs (just 2 weeks of med treatment) or 1.8% experienced an SAE but when the med treatment continued for 12 weeks, 6.7% of patients experienced a severe adverse reaction. So the risks increase as time on the meds increase.

It is a complicated picture of a very difficult problem. Call me jaded but it is hard for me to not to see this article (whose authors have many ties to pharmaceuticals) as purely a marketing effort.

That’s my take.

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Some of you, given my previous critiques of EBT may be surprised by my answer, which is “yes.” EBT, however, must be taught within several larger contexts. First, EBTs should be taught within the context of what models and techniques bring to the table in therapy: namely, as Jerome Frank so eloquently noted, all models bring an explanation for the client problem and a remedy or solution for it. The important stuff that models offer is not their inherent truth across clients, but rather a rationale for the client’s problem and a ritual to solve it. In addition, as Rønnestad and Orlinsky so aptly argue from their research of now nearly 11,000 therapists, having theoretical breadth is a good thing—the breadth of our theoretical understandings enhances both our ability to attain healing involvement (the pinnacle of therapist development) and long term career growth—important reasons to take the theoretical plunge in many conceptual pools. There is a summary of Rønnestad and Orlinsky’s research in this article:

So I think students need to understand the value of treatment models within a developmental context and an understanding of the general aspects that models bring to the table.

The next larger context is the alliance. 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. If technique fails to engage the client in purposive work, it is not working properly and a change is needed. Technique is an activity—the alliance is a way to characterize that activity; the alliance is the purpose of the activity. Although it is possible for a strong relationship to develop, 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—be it some specific approach, the client’s own ideas and cultural preferences, or some unique blend.

The issue of resonance and the agreement about tasks—finding a framework for therapy that both the therapist and the client can believe in—is why it makes a lot of sense to ask clients about their ideas about how to proceed, or at the very least getting client approval of any intervention plan. Not surprisingly, Frank and Frank (1991) said it best: “Ideally, therapists should select for each patient the therapy that accords, or can be brought to accord, with the patient’s personal characteristics and view of the problem’’ (p. xv). But Frank was not the first and in fact the idea of matching client preferences and worldview goes back to Paul Hoch, Milton Erickson, and the MRI. Traditionally, such a process has not been the case—the search has been for interventions that promote change by validating the therapist’s favored theory. Serving the alliance requires taking a different angle—the search for ideas that promote change by validating the client’s view of what is helpful—or what I have called, based on the work of Erickson and the MRI, the client’s theory of change (Duncan et al., 1992; Duncan & Moynihan, 1994). Here is an article about the client’s theory of change:

Finally, the third context is regarding evidence based treatment itself and the difference between evidence based treatments and evidence based practice as defined by APA. Jeff Reese and I recently wrote a chapter about this and I will post it after it is published. They are two fundamentally different approaches to defining and disseminating evidence (Littell, 2010; see her chapter in Heart and Soul of Change)—one that seeks to improve clinical practice via the dissemination of treatments meeting a minimum standard of empirical support (EBT) and another that describes a process of research application to practice that includes clinical judgment and client preferences (EBP). 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 as 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 load the silver bullet into any psychotherapy revolver and shoot the psychic werewolf stalking the client. This is the essence of an EBT approach, characterized by Division 12, depicting confidence in the available evidence and appealing to those who believe that more structure and consistency and less clinician judgment is needed to bring about positive outcomes in mental health and substance abuse services. On the other hand, EBP reflects the understanding that scientific evidence is tentative and that outcome is dependent not only on applying the various types of empirical research but also on the participants. EBP appeals to those who value clinician autonomy and individualized treatment decisions based on unique presentations of clients. The APA Task Force definition on EBP exemplifies this approach to the evidence: “the integration of the best available research with clinical expertise in the context of patient [sic] characteristics, culture, and preferences” (APA Task Force 2006, p. 273).
The first part, “the integration of the best available research,” includes the consideration of EBTs without privileging them, as well as the wide range of findings regarding the alliance and other common factors. Next, “with clinical expertise,” in contrast to the EBT mentality of the therapist as an interchangeable part, brings the therapist into the equation—highlighting what therapists bring is consistent with emerging research about the importance of clinician variability to outcome. Moreover, the Task Force submitted: “Clinical expertise also entails the monitoring of patient progress…” (APA, 2006, p. 276–277). Finally, “in the context of patient characteristics, culture, and preferences” rightfully emphasizes what the client brings to the therapeutic stage as well as the acceptability of any intervention to the client’s expectations, how well any model or technique resonates. In short, EBP accommodates the common factors, reinforces the importance of the therapist and client, and includes client feedback as a necessary component.

So if these larger contexts of understanding EBTs are included, I believe that EBTs should be taught in graduate training programs. Graduate training should call for a more sophisticated and empirically informed 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 effectiveness for the client in the room now—therapists need expertise in a broad range of intervention options, including evidence based treatments, but must remember that the proof of the pudding is in the taste.

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Consider the reach of CDOI/PCOMS: PCOMS and/or CDOI are recognized by two states (Arizona and Colorado) as an evidence based treatment and PCOMS 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. I think it is safe to say that CDOI and PCOMS are becoming a part of the vernacular of providing mental health and substance abuse services.

The Norwegian-American research team (Jesse Owen, Morten Anker, Jacqueline Sparks and Barry Duncan) has scored again, our fourth article based on the massive Norway Couple Feedback Study. Our article, “Initial Relationship Goal and Couple Therapy Outcomes at Post and Six Month Follow Up” has been accepted for publication in the Journal of Family Psychology. This study shows the benefits of knowing what couples want to accomplish in therapy at the outset as well as how couple therapy can help folks regardless of their goals of wanting to improve the relationship or get out of it. It is based on the scale developed by Morten Anker as well as his experience with couples wanting a variety of different things from therapy. Most if not all research in couple therapy deals with couples who desire to improve their relationship but that only covers a portion of the couples we see in real life. This study addresses that reality. It confirms the common sense notion that couples wanting to improve their relationship get better outcomes and are more likely to be together at follow up than couples in which one or both individuals are seeking clarification regarding the viability of the relationship. Moreover, it also demonstrates that couple therapy can benefit clients regardless of their initial goal. We conclude that therapist awareness of each individual’s relationship goal prior to couple therapy could enhance outcomes and treatment tailored according to initial goals could set the stage for positive outcomes however defined.

Jesse Owen, who is now a Project Leader, is doing a webinar via the member site on January 27 about these issues (Become a CDOI Member to participate):

The Couple Therapy that Nobody Talks About: Ambivalence, Commitment, and Change
This webinar discusses couple therapy in which at least one partner is ambivalent about the viability of the relationship. Commitment is vital for couples to successfully develop a secure emotional base and maintain a healthy relationship. When commitment wavers it affects nearly all aspects of the relationship, such as communication, couple identity, willingness to sacrifice, as well as respect, trust, and safety. Treating couples with wavering commitment is rarely discussed in either the theoretical or empirical literature. This webinar covers: (a) cutting-edge research on the importance of assessing couples’ initial relationship goals as a facet of the working alliance; (b) a theoretical framework to understand couples’ commitment; and (c) treatment guidelines for treating couples when at least one partner desires to clarify the viability relationship.

Two other items of interest: A brief video about On Becoming a Better Therapist that I did at APA: http://www.apa.org/pubs/books/interviews/4317217-duncan.aspx

And an interview I did with an old friend from graduate school who hosts a radio show:
http://www.clientdirectedoutcomeinformed.com/media/mp3/Wake_Up_Call_2011-11-20.mp3

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International Society for Ethical Psychology and Psychiatry Position Paper By Dr. Jacqueline Sparks, Project Leader, Heart and Soul of Change Project

The American Academy of Pediatrics (AAP) recently updated their guidelines for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) to include preschool children (www.pediatrics.org/cgi/doi/10.1542/peds.2011-2654 ). The lowered age limit for treatment in the new AAP guidelines inevitably will increase the use of stimulant medications for this vulnerable age group. The use of these drugs and diagnoses of ADHD continue to rise (http://psychiatryonline.org/cgi/content/abstract/appi.ajp.2011.1103038). The numbers are sure to swell as pediatricians are given the green light to prescribe psychostimulants for very young patients.

Treatment related evidence for the AAP clinical ADHD practice guidelines relied on a recent review prepared by the Agency for Healthcare Research and Quality (AHRQ) (Charach, 2011). This review examined 15 reports representing 11 investigations of the use of psychostimulants by preschoolers and claimed that studies found the drugs to be safe and efficacious. However, the review acknowledges that “the evidence comes primarily from short-term trials lasting days to weeks with small samples” (p. Es-8). When comparing methylphenidate with parent behavior training (PBT), the review concludes that the strength of evidence for use of PBT was high due to number of studies and consistency of results but low for methylphenidate because of only one good-quality study (The Preschool ADHD Treatment Study, PATS). While PATS found modest differences on endpoint measures between the drug and placebo, only 21% of best-dose methylphenidate achieved defined criterion for remission set for school-age children diagnosed with ADHD. Moreover, 30% of parents spontaneously reported moderate to severe adverse events in all phases of the study, including irritability, repetitive behaviors, tics, and emotional outbursts (Wigal et al., 2006). For those children who remained on medication, annual growth rates were 20.3% less than expected for height and 55.2% for weight (Swanson et al., 2006).

In 2006, the Drug Safety and Risk Management Advisory Committee of the FDA urged stronger warnings on ADHD drugs, citing reports of serious cardiac risks, psychosis or mania, and suicidality for children taking them. A review of past studies on the effect of ADHD drugs on children’s growth found that the drugs suppress both height and weight for the duration of the trials that were studied (Drappatz et al., 2006). Height and weight effects were noted by the AHRQ review. Moreover, the AHRQ review cites that “Evidence that psychostimulant use in childhood improves long-term outcomes was inconclusive” (p. vii). . . [and] the majority of studies examining the long-term safety and efficacy of ADHD drugs are industry-funded and may result in “enhanced representations of efficacy and safety” (p. ES-9). The report concludes: “The increasing use of off-label prescriptions [of ADHD drugs] for very young children is concerning . . . “There is one primary implication from the review . . . the first line intervention for young children [at risk of ADHD] is evidence-based PBT” (p. 171).

Based on their own investigation, opening the floodgates for ADHD medications for children under the age of 6 is not justified. In light of current evidence, the International Society for Ethical Psychology and Psychiatry (ISEPP) strongly opposes the new AAP Guidelines and urges the AAP to reconsider the implications for lowering the age for which ADHD drugs may be recommended. The ISEPP further urges the AAP to retract their new guidelines until such evidence surfaces that ADHD drugs provide an acceptable risk relative to their benefit for children under the age of 6.

For references, see full position paper at: http://heartandsoulofchange.com/resources/psychiatric-drugs/

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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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I usually don’t write on this blog about the places I visit to do training because I don’t really want the blog to be a twitter accounting of my travels to exotic and not so exotic places. But I have to talk about my travels this week to Bob Bohankse land, otherwise known as Phoenix, Arizona. I conducted a two-day training: one day was an overview of CDOI for the new folks and the second day covered the clinical nuances of getting the max out of the measures and the four steps of CDOI supervision for the seasoned staff members and supervisors. But I went a day early and stayed an extra day so Bob and I could work on and prioritize the many projects (that is the reason that we are called the Heart and Soul of Change Project because we are committed to doing things to both create and disseminate research from naturalistic sites that operationalize our mission to privilege the client’s voice) that would advance the state of knowledge about CDOI and PCOMS and therefore further help to spread the word. Although there are several, two in particular deserve special mention. First is an article to discuss the incredible data that Bob’s agency, Southwest Behavioral Health has collected. Bob has data on over 6000 clients and the results are nothing short of phenomenal, both for kids and adults. As a teaser, here is a piece of the data offering a comparison to services delivered without CDOI and PCOMS:

Children with CDOI: Achieved reliable change on average (including caretakers) and 47% achieved all goals (v. 32%) in 128 less days.
Adults with CDOI: Achieved reliable change on average and 33% achieved all goals (v. 19%) in 138 less days.

The article also proposes that that CDOI and PCOMS not only offer a way to improve outcomes while increasing productivity and saving money, it also operationalizes the vision of “recovery” as described by the SAMSHA and the Consensus Statement of Recovery. Bob will be presenting a webinar about Operationalizing Recovery and his data on April 22. Sign up for the members site now!

The second project is joint project of Southwest Behavioral Health, the Erikson Foundation, and the Heart and Soul of Change Project, and it is redo of the “Impossible” Case Project I did way back in the early to middle 90’s that culminated in the book Psychotherapy with “Impossible” Clients. This was an inspiring project that really changed the way that I did psychotherapy. I am very proud of that project and what we found but I really didn’t know what I was doing, research wise. There were no quantitative findings and no systematic assessment of outcome or of the chart review process. Further, although I conducted interviews with all the clients at termination, it was not a systematic qualitative inquiry and therefore didn’t mine all the golden data that was there. But this project will. It will repeat the study of clients who have had multiple treatment failures and pursue their experience and perceptions of why those failures occurred as well as why the current round produced a different outcome (hopefully). The project will include Bob, me, and Jacqueline Sparks (our qualitative consultant), as well as Lynette Small and Heath Kilgore (Southwest Behavioral folks).

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 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.

Join the member site now!

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