Two recent articles highlight the amazing fact that good marketing overcomes bad data every single day of the week. As Jacqueline Sparks (Project Leader) and I and our colleagues say in the new Heart and Soul of Change:

The fact that a for-profit industry plays a role in fashioning what counts as evidence may no longer surprise many. The former editor of the New England Journal of Medicine called attention to the problem of “ubiquitous and manifold . . . financial associations” authors of drug trials had to the companies whose drugs were being studied (Angell, 2000, p. 1516). The result is a direct correlation between who funds the study and its outcome. For example, Heres et al. (2006) looked at published comparisons of five antipsychotic medications. In 9 out of 10 studies, the drug made by the company that sponsored the study was found to be superior…Antonuccio, Danton, and McClanahan, (2003) detail the vast reach of the pharmaceutical industry—from Internet, print, and broadcast media, direct-to consumer-advertising, “grassroots” consumer-advocacy organizations, and professional guilds to medical schools, prescribing physicians, and research—even into the board rooms of the FDA. They conclude, “It is difficult to think of any arena involving information about medications that does not have significant industry financial or marketing influences” (p. 1030). Given the infiltration of industry influence, reliance on press reports, web pages, and even the academic literature as a basis for sound decision-making is unwise. Discerning good science from good marketing requires a willingness to engage primary source material.

Think this is overkill? Think twice. Check out the embedded article “From Evidence-based Medicine to Marketing-based Medicine: Evidence from Internal Industry Documents” written by Glen Spielmans & Peter Parry. Here is the abstract:

While much excitement has been generated surrounding evidence-based medicine, internal documents from the pharmaceutical industry suggest that the publicly available evidence base may not accurately represent the underlying data regarding its products. The industry and its associated medical communication firms state that publications in the medical literature primarily serve marketing interests. Suppression and spinning of negative data and ghostwriting have emerged as tools to help manage medical journal publications to best suit product sales, while disease mongering and market segmentation of physicians are also used to efficiently maximize profits. We propose that while evidence-based medicine is a noble ideal, marketing-based medicine is the current reality.

Here is the article:

And, as a case in point, consider this is true nowhere more than with antidepressants. The slightly better than placebo efficacy of antidepressants has been know for many years. Roger Greenberg and Seymour Fisher exposed antidepressants in their classic 1997 book, From Placebo to Panacea and we reviewed the subsequent literature and reported it (along with several others) as far back as 2000 and 2004 in The Heroic Client as well as the 2000 article, “Exposing the Mythmakers,” which received the All Time Top Ten Award for one of the most influential articles in the Psychotherapy Networker’s history. But yet millions are still prescribed and millions still take them as a first line of defense (nothing against folks who do and surely some benefit). Irving Kirsch, the person who meta-analyzed FDA trials and reported that the antidepressant emperor wore no clothes, has a new book. Check out this article in Newsweek about it: http://www.newsweek.com/id/232781  

Here is a brief summary of Kirsch’s research that we (Sparks, Duncan, Cohen, & Antonuccio) summarize in the new Heart and Soul of Change:

Kirsch and Sapirstein (1998), in a meta-analytic review of nineteen studies involving 2,318 people, showed that 75 percent of the response to antidepressants was duplicated by placebo. They speculated that the remaining 25 percent of the positive antidepressant effect may be attributable to the un-blinding power of side effects. Adding to the critique, Kirsch, Moore, Scoboria, and Nichols (2002) analyzed the efficacy data submitted to the US Food and Drug Administration (FDA) for the six most widely prescribed antidepressants approved between 1987 and 1999. Approximately 82% of the response to medication was duplicated by placebo control groups—57% of the studies failed to show a drug-placebo difference. When a difference was found, the drug/placebo difference was only, on average, 1.8 points on the clinician-rated Hamilton Depression Rating Scale (HDRS). FDA memoranda intimated that the clinical significance of such a small difference was questionable (Laughren, 1998).

In a review of antidepressant trials involving 12,564 persons (Turner, Matthews, Eftihia Linardatos, Tell, & Rosenthal, 2008), 94% of published trials had favorable results whereas the percentage of positive results for published and unpublished trials together drops to 51%. The authors warn that publication bias of this magnitude dramatically distorts reported effect sizes and has serious implications for researchers, health care professionals, and clients. Kirsch et al. (2008) provide further evidence that the belief in antidepressant efficacy is scientifically unfounded. Meta-analytically examining all trials submitted to the FDA for the licensing of four popular SSRIs, the authors found no clinically significant differences between placebo and the drugs, with the exception of the most distressed in the severely depressed group. Even this negligible difference was found to be due not to the drug, but to a decreased response to placebo.

Regarding taking a critical stance about psychiatric drugs, check out the new webiste of the International Critical Psychiatry Network: http://www.criticalpsychiatry.net/  The Heart and Soul Project’s own Certifed Trainer and psychiatrist, Sami Timimi, is a key member. 

On another note, a new webinar by our own John Murphy has been scheduled for February 17:
Respect, Resources, and Recovery: Putting the 3 Rs into Action with Children, Adolescents, and Schools
Wednesday, February 17, 2010, 1:30 to 2:30 Central
Based on the persistent belief that young people and their caregivers are capable of remarkable changes when invited to actively participate in services and to apply their “natural resources” toward solutions, this webinar describes practical ways to put the principles of CDOI and recovery into action in schools, counseling agencies, and other child/youth settings. Real-world examples are used to illustrate the power of partnership and the benefits of client-driven/strength-based practice.

John Murphy, Ph.D., professor of psychology at the University of Central Arkansas, has extensive experience implementing collaborative approaches with young people and school problems (www.drjohnmurphy.com). He recently authored (with Barry Duncan) the book, Brief Intervention for School Problems (2nd ed.) (Guilford, 2007) and Solution-Focused Counseling in Schools (2nd ed.) (2008, American Counseling Association.

John is also a Project Leader of the Heart and Soul of Change Project and a featured speaker at the Heart and Soul of Change Conference in New Orleans. Join John and Barry for this timely discussion of kids and school at: http://www.cdoimembers.com/Default.aspx?pageId=199866

People have asked me about my appearance on Oprah for many years. It was way back in 1992 just after I published my first book (with my best friend Joe Rock), a self help book called Overcoming Relationship Impasses. (That book, now called “The Lone Changer,” is available as a download at http://heartandsoulofchange.com/resources/bookstore/)

It has always been a source of amusement for me that people are so interested in my brief moment in the spotlight. No matter what I put in my bio, the first thing that is commented on is my Oprah appearance. So in deference to an interest that has mightily stood the test of time, here are snippets of my Oprah debut in the world of TV media. But before you look at it let me say a few words in my defense. I was a full time private practitioner with zero media experience, and I was scared half out of my wits. They called on a Monday and asked me to be there for a Wednesday taping. So I flew up after my last client on Tuesday and checked into a very fancy Chicago hotel, The Drake. I didn’t have a clue about what I was doing. I knew a lot about the book, and a fair amount about working with couples, but nothing about how to handle this situation. The producers for the show, a young and extremely talented  group, were exceptionally helpful and had really done their homework. They really knew the book and asked me very good questions to prepare me for what might happen.  They told me that I had to be very assertive, even aggressive at times (not exactly my style!) and the last thing they wanted me to be was a wallflower. They noted that Oprah would intentionally provoke me, in a nice way, to comment on the action as it unfolded. I was freaked to say the least and rued the day that I ever thought to write a self help book! So here’s the deal: feel free to laugh but not in my face; and please don’t tell me how young I looked (the subtext being how old I look now!)

And one more thing: People often ask me about Oprah. What was she like? She was warm, friendly, and the consumate professional. I have nothing but good things to say about her and her staff. BTW, I have improved (thank goodness) on the TV front. Check out my TV interviews regarding the book What’s Right With You, including a friendly debate with a psychiatrist, at http://www.whatsrightwithyou.com/resources.htm

The bookstore is now open and has all my books including the just published 2nd Edition of The Heart and Soul of Change. More books of interest to the mission of the Project will be added periodically. Full length videos will also soon be featured. Webinars and slideshows are avaliable too. If you have been following the blog and this site, you know that the concept of “recovery” is thematic and a vital part of client directed, outcome informed (CDOI) ideas and practices (http://heartandsoulofchange.com/training/cdoi-members/what-is-cdoi/). I am very happy to say that the theme of recovery also applies to the bookstore. Folks in recovery are running the bookstore and the more products that are sold, the more hours can be offerred. Thanks to Mary Haynes for making this happen and for her ongoing commitment to the values of recovery.

Finally, I am very happy to announce that Anne-Grethe Tuseth is joining our team as a Project Leader. Anne-Grethe is the Leader of the KOR (CDOI) network in Norway and is a long time advocate of CDOI. She first brought me to Norway ten years ago and has been a mover and shaker of the ideas ever since. She orchestrated the first book written about CDOI by others than the developers, was instrumental in translating the Heroic Clients, Heroic Agencies manual into Norwegian, and has been a leader in training others and disseminating  the ideas. In short, Anne-Grethe is a powerful addition to an already incredible group. Find out more about the Project Leaders as well as the CDOI community at http://heartandsoulofchange.com/community/

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

And here is info about the webinar:

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

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

Date: Tuesday, December 22, 2009

Time: 12:00 PM – 1:00 PM CDT

Register now by clicking the link below:

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

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

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

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

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

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

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

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

I hope you join me for the free webinar.

Just back from an incredible conference of consumers and providers, the 20th annual Children Come First event with the wonderful name: Ready, Set, Relationship! This was the continuing efforts of a group of dedicated individuals, called Wisconsin Family Ties, almost all of whom are parents of special needs children, to give families the support, encouragement, and resources they need to survive and thrive in tough times. They embrace the values of consumer strengths and wisdom as well as the power of change that resides in human relationships. I can’t really say enough about them nor can I express how moved I was to experience their commitment to what they are doing. The director, Hugh Davis, was nothing short of inspirational. He gave up a lucrative career in corporate America to try to make a difference with families who are under exceptional pressures from within because of a special needs child and from without from a system oriented more toward investigation and punishment than helping folks succeed. Constantly fighting an uphill battle for funding, they are making a significant difference in the lives of hundreds of children and families.

Check them out at: http://www.wifamilyties.org/

This is one of the great gifts that I am privileged to receive in my travels, the inspiration of meeting people who have been called to try to make a difference for others. It is heartening to say to least, that people like Family Ties exist. If I become jaundiced at times in my thoughts about we do, these experiences quickly remind me of not only the goodness of people, but also the good of what psychosocial services can accomplish.

On another note, I am doing a workshop in the Twin Cities on February 5th hosted by Rebecca Chesin, another person trying to make a difference in the community. If you are in the Twin Cities area, I would appreciate your support of Rebecca’s efforts. Rebecca recently compiled a list of individuals and agencies who are using client directed, outcome informed practices and is going to expand this idea into an online directory soon. Check out the workshop and the list at:

http://www.timeforclarity.com/cdoitest.html

Finally, another mover and shaker of these ideas is Eric Kueler of Mental Health Pros. Mental Health Pros offers therapists “21st Century tools to optimize psychotherapy for clients.” The 21st Century tools include MyOutcomes, online articles, assessments, multimedia workshops, videos, Lunch and Learn teleseminars, as well as online journaling for clients, practice newsletters, and more.

Check out Mental Health Pros out at: http://mentalhealthpros.com/mhp/ An e-brochure is available at http://mentalhealthpros.com/mhp/pdf/MHPbrochure.pdf

Eric recently interviewed me about the evolution of CDOI ideas and research.

Check it out: Interview with Eric (Download)

Please let me know what you thinking about the blogs. I appreciate your feedback.

Many exciting things are happening in Norway with CDOI. First I was there to help kick off the Bufetat (Child and Family Services Directorate) pilot implementation of 5 family counseling offices which will begin the nationwide rollout of CDOI (called KOR in Norway) in all 64 agencies across Norway. This massive implementation is in great hands with project leader Marianne Bie, and with the able help of Morten Anker, a Heart and Soul of Change Project (HSCP) Certified Trainer, and Geir Skauli a long time CDOIer. This all began back in 2006 when I did a tour of all the family counseling agencies to introduce CDOI (under the visionary leadership of Berger Hareide and Geir Skauli), but the decision to implement was likely cemented by the Norway Feedback Project. Speaking of the Norway Feedback Project, check out this conversation with principle investigator, Morten Anker.

Get the Norway Feedback Article here: http://heartandsoulofchange.com/resources/articles/

Another very cool thing is what RBUP (Child and Adolescent Psychiatric Services) is doing with CDOI training. Under the leadership of Anne-Grethe Tuseth (the person who brought CDOI to Norway), and with the help of Tor Fjeldstad (another HSCP Certified Trainer), a new training program will soon be launched addressing both academic and clinical training. If you have been following this Blog you know that this is part of the mission of the HSCP, to encourage formal inclusion of CDOI in academic and training programs to promote learning of the ideas and practices early in professional careers. This, in a sense, “institutionalizes” the values of client/consumer privilege and true partnerships via outcome and alliance feedback.

Speaking of academia, I was also privileged to share CDOI ideas as well as their integration with therapist development as presented in my upcoming book On Becoming A Better Therapist to a very esteemed group of faculty/practitioners at the University of Oslo. This was arranged by the famous Norwegian Researcher Helge Rønnestad, who along with David Orlinksy, are the premier researchers investigating therapist development and what it means to be therapist. It was quite a thrill for me to present my integration of these ideas before one of the originators. BTW, Professor Rønnestad called the clinical use of the ORS and SRS “operationalized collaboration,” and noted the likely alliance effects of using the measures the way we do with clients.

And of course, that is why I believe that the Norway Feedback Project and Jeff Reese’s feedback article (to be published in December in Psychotherapy) achieved a positive effect with all clients instead of just those clients at risk, as Lambert’s studies mostly do. I believe the way we clinically use the measures in collaboration with clients makes the difference.

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

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

Those of you who are CDOI Members: http://heartandsoulofchange.com/training/cdoi-members/  know that I just did a webinar of the same title as this blog. For the first time, members were able to download the actual PowerPoint slides from the presentation so that they could influence the decision makers where they work. Here are the slides in pdf format: 

GoodBadUglyWebinarSlides

Here is a brief video I did that covers the main points:

And here is a narrative account excerpted from new book, On Becoming a Better Therapist:
The good news is that the efficacy of psychotherapy is very good—the average treated person is better off than about 80% of the untreated sample (Duncan, Miller, Wampold, & Hubble, 2010), translating to an effect size (ES) of about 0.8. Moreover, these substantial benefits apparently extend from the laboratory to everyday practice. For example, a real world study in the UK (Stiles, Barkham, Twigg, Mellor-Clark, & Cooper, 2006) comparing cognitive behavioral therapy (CBT), psychodynamic therapy (PDT), and person centered therapy (PCT) as routinely practiced reported a pre-post ES of around 1.30. In short, there is a lot to feel proud about our profession: psychotherapy works.

But there’s more to the story. The bad news is two-fold: First, drop outs are a significant problem in the delivery of mental health and substance abuse services, averaging at least 47% (Wierzbicki & Pekarik, 1993). When drops outs are considered, a hard rain falls on psychotherapy’s efficacy parade, both in randomized clinical trials (RCT) and in clinical settings. Second, despite the fact that the general efficacy is consistently good, not everyone benefits. Hansen, Lambert, and Foreman (2002), using a national data base of over 6000 clients, reported a sobering picture of routine clinical care in which only 20% of clients improved as compared to the 57-67% rates typical of RCTs. Whichever rate is accepted as more representative of actual practice, the fact remains that a substantial portion of clients go home without help.

And the ugly: Explaining part of the volatile results, variability among therapists is the rule rather than the exception. Not surprisingly, although rarely discussed, some therapists are much better at securing positive results than others. In fact, therapist effectiveness ranges from 20-70%! Moreover, even very effective clinicians seem to be poor at identifying deteriorating clients. Hannan et al. (2005) compared therapist predictions of client deterioration to actuarial methods. Though therapists were aware of the study’s purpose, familiar with the outcome measure used, and informed that the base rate was likely to be 8%, they accurately predicted deterioration in only one out of 550 cases; psychotherapists did not identify 39 out of the 40 clients who deteriorated. In contrast, the actuarial method correctly predicted 36 of the 40.

So despite the overall efficacy and effectiveness of psychotherapy, drop outs are a substantial problem, many clients do not benefit, therapists vary significantly in effectiveness, and are poor judges of client deterioration. Most of us provide an invaluable service to our clients, but sadly most of us don’t know how effective we really are—we don’t know who will drop out or who will ultimately not benefit or even deteriorate. Do you know how effective you are? With drop outs considered, how many of your clients leave your office absent of benefit? Which clients in your practice now are at risk for drop out or negative outcome?

And what is the answer to these problems? You know! Practice based evidence. Continuous client feedback individualizes psychotherapy based on treatment response, provides an early warning system that identifies at risk clients thereby preventing drop-outs and negative outcomes, and suggests a tried and true solution to the problem of therapist variability—namely that feedback necessarily improves performance and quickens the pace of your development.

I just did a brief video (see below) for the Louisiana Counseling Association’s Annual Conference to invite folks to the Heart and Soul of Change Conference occurring June 17-19 in perhaps the most exciting city in North American, New Orleans. http://heartandsoulofchange.com/training/heart-and-soul-of-change-conference/  That reminded me to blog more about the details.

Heart and Soul of Change, New Orleans

The conference will be just a stone’s throw away from the French Quarter at the InterContinental Hotel http://www.ichotelsgroup.com/intercontinental/en/gb/locations/neworleans and I am very happy to say that the room rate was negotiated to be a very reasonable $119 per night. Check out the video tour of the hotel and what New Orleans has to offer. We want you to get the most out of your visit, not only with regard to the quality of the presenters and the stellar training opportunity this conference offers, but also your experience of this spectacular city. Consequently, lunch breaks will be a full two hours so that you can explore the amazing culinary experiences awaiting you in the French Quarter. New Orleans is such an historical, festive, musical, culinary, cultural place that you have to experience firsthand to appreciate it.

Another reason this conference is exciting for me is that I will be presenting my five steps to accelerate your development as a therapist that I detail in my new book, On Becoming a Better Therapist due out in March. Here is a brief description. The five steps build on the lessons I’ve learned from incorporating feedback in my work and helping others do it, but also integrates research about therapist development. A pre-requisite is your understanding that you are a primary figure in each client’s ultimate outcome—the client is certainly central, but as the old saying goes, it takes two to tango. Your view of your growth impacts your ability to be vitally involved in the therapeutic process. Collecting outcome feedback begins the process. The first step is to track your cumulative career development and take it on as a project. Proactively monitor your effectiveness in service of implementing strategies to improve your outcomes. Practice the skills of your craft and monitor your results.

Next, deliberately expand your theoretical repertoire and loosen your grip on the inherent truth value of any given approach. Take multiple vantage points on your journeys with clients while you search out different understandings of client dilemmas. Plurality of perspective serves you and your clients. Theoretical breadth enriches the therapeutic process while simultaneously increasing your involvement in and satisfaction with the work. Third and most importantly, pay close attention to your currently experienced growth. Take a step back, review your current clients and consider the lessons you are learning. Empower yourself, like you would your clients, to enable the lessons to take hold and add meaning to your development as a therapist. Articulate how client lessons have changed you and your work, and what it means to both your identity as a helper and how you describe what it is that you do.

Fourth, continuing that theme, reflect about your identity and construct a story of your work that captures what you do as a helper. Continue to edit and refine your identity and accounts of what constitutes the essence of your work—evolve a description that you can have allegiance to but that doesn’t lead to dead ends. Finally, accumulate the gems of your experiences with clients and the gifts of their feedback, and secure them safely in your Treasure Chest. The Treasure Chest is the place to go to escape tough times and reconnect to the work, to why you become a therapist in the first place. It is also the place to record, through your clients and your own narrative accounts, your development as a therapist. To learn more about the five steps, subscribe to CDOIMembers at http://heartandsoulofchange.com/training/cdoi-members/

Bottom Line: If you got into this business, like me and the majority of therapists I meet, because you wanted to help people, you already have what it takes to become a better therapist. It boils down to two things: One is your commitment to forming partnership with clients to monitor the alliance you have with them and the outcome of the services you are providing. The second is your investment in yourself, your own growth and development. Systematic client feedback provides the method for both.

Rebecca just posted this article on the Heroicagency Listserv, and as she said, it begged a response.

Ignoring the Evidence
Why do psychologists reject science?
By Sharon Begley | NEWSWEEK

Published Oct 2, 2009

From the magazine issue dated Oct 12, 2009

It’s a good thing couches are too heavy to throw, because the fight brewing among therapists is getting ugly. For years, psychologists who conduct research have lamented what they see as an antiscience bias among clinicians, who treat patients. But now the gloves have come off. In a two-years-in-the-making analysis to be published in November in Perspectives on Psychological Science, psychologists led by Timothy B. Baker of the University of Wisconsin charge that many clinicians fail to “use the interventions for which there is the strongest evidence of efficacy” and “give more weight to their personal experiences than to science.” As a result, patients have no assurance that their “treatment will be informed by science.” Walter Mischel of Columbia University, who wrote an accompanying editorial, is even more scathing. “The disconnect between what clinicians do and what science has discovered is an unconscionable embarrassment,” he told me, and there is a “widening gulf between clinical practice and science.”

The “widening” reflects the substantial progress that psycho-logical research has made in identifying the most effective treatments. Thanks to clinical trials as rigorous as those for, say, cardiology, we now know that cognitive and cognitive-behavior therapy (teaching patients to think about their thoughts in new, healthier ways and to act on those new ways of thinking) are effective against depression, panic disorder, bulimia nervosa, obsessive-compulsive disorder, and -posttraumatic-stress disorder, with multiple trials showing that these treatments—the tools of psychology—bring more durable benefits with lower relapse rates than drugs, which non-M.D. psychologists cannot prescribe. Studies have also shown that behavioral couples therapy helps alcoholics stay on the wagon, and that family therapy can help schizophrenics function. Neuroscience has identified the brain mechanisms by which these interventions work, giving them added credibility.

You wouldn’t know this if you sought help from a typical psychologist. Millions of patients are instead receiving chaotic meditation therapy, facilitated communication, dolphin-assisted therapy, eye-movement desensitization, and well, “someone once stopped counting at 1,000 forms of psychotherapy in use,” says Baker. Although many treatments are effective, they “are used infrequently,” he and his coauthors point out. “Relatively few psychologists learn or practice” them.

Why in the world not? Earlier this year I wrote a column asking, facetiously, why doctors “hate science,” meaning why do many resist evidence-based medicine. The problem is even worse in psychology. For one thing, says Baker, clinical psychologists are “deeply ambivalent about the role of science” and “lack solid science training”—a result of science-lite curricula, especially in Psy.D. programs. Also, one third of patients get better no matter what therapy (if any) they have, “and psychologists remember these successes, attributing them, wrongly, to the treatment. It’s very threatening to think our profession is a charade.”

When confronted with evidence that treatments they offer are not supported by science, clinicians argue that they know better than some study what works. In surveys, they admit they value personal experience over research evidence, and a 2006 Presidential Task Force of the American Psychological Association—the 150,000-strong group dominated by clinicians—gave equal weight to the personal experiences of the clinician and to scientific evidence, a stance they defend as a way to avoid “cookbook medicine.” A 2008 survey of 591 psychologists in private practice found that they rely more on their own and colleagues’ experience than on science when deciding how to treat a patient. (This is less true of psychiatrists, since these M.D.s receive extensive scientific training.) If they keep on this path as insurers demand evidence-based medicine, warns Mischel, psychology will “discredit and marginalize itself.”

If public shaming doesn’t help, Baker’s team suggests a new accreditation system to “stigmatize ascientific training programs and practitioners.” (The APA says its current system does require scientific training and competence.) Two years ago the Association for Psychological Science launched such a system to compete with the APA’s.

That may produce a new generation of therapists who apply science, but it won’t do a thing about those now in practice.

Find this article at
http://www.newsweek.com/id/216506

My Response
There are many inaccuracies in this story—not the least of which is the distortion of APA’s definition of evidence based practice, which unequivocally does not give equal weight to the personal experiences of the clinician and scientific evidence—but I will focus here on the “evidence” claiming that the noted approaches are the most effective. Perhaps clinicians are ignoring the researchers quoted in the article because the brand of evidence they are selling is not credible or relevant to their work. They fail to mention the most replicated piece of evidence in the psychological literature: Namely, that no one treatment model, including the cognitive and cognitive behavioral models canonized in the article, have reliably shown any superiority over other treatments. Moreover, treatment models account for a very small amount of the variance of change. As just one example of these robustly demonstrated findings, consider the landmark NIMH study of depression in which cognitive behavioral therapy was compared to interpersonal therapy and antidepressants. No differences emerged between the treatments—they all worked about the same (although the talk therapies did better at follow-up). Treatment model differences accounted for only 2% of variance of change. What did explain the changes achieved by the clients? The quality of the relationship/alliance between the clinician and the client accounted for 21% of the variance. The person of the clinician, not what treatment was delivered explained another 8%. This is why clinicians don’t rally around the flag of different treatments making false claims about superior effectiveness. They know that other factors are far more important—psychotherapy is a richly nuanced interpersonal event that defies being reduced to a diagnosis and treatment model.

The much ballyhooed models have only shown themselves to be better than sham treatments or no treatment at all, which is not exactly news to write home to mom about. Think about it. What if one of your friends went out on a date with a new person, and when you asked about the guy, your friend replied, “He was better than nothing—he was unequivocally better than watching TV or washing my hair.” (Or, if your friend was a researcher: “…he was significantly better, at a 95% confidence level, than watching TV or washing my hair). How impressed would you be?

Finally, the success of any treatment is not guaranteed regardless of its evidentiary support or the expertise of the therapist. As the APA Task Force noted, the response of the client is variable and therefore must be monitored and treatment tailored accordingly to ensure a positive outcome. Monitoring outcome with clients, what has been called practice based evidence, has been shown to significantly improve treatment outcomes regardless of the treatment administered, a far more powerful influence on outcome that the specific approach administered.

Two things continue to excite me about training folks in CDOI: first is the opportunity to meet people on the front lines who truly value this work and strive to get better at it; and two, being able to experience the application of CDOI well beyond its beginnings in traditional outpatient psychotherapy: for example, like Mary Haynes and case management (and other areas), Bob Bohanske and wrap around (and other areas), Barry Winstead and adult inpatient, Dave Claude and residential “co-occurring disorder” services, just to mention a few. Such applications take quite a commitment to client privilege as well as a large dose of creativity to figure out the logistics involved. Any data that can be collected in such settings will go a long way to support CDOI ideas and practices, and further the mission of bringing clients into the inner circle of decision making about their own care. Because before the measures were validated and long before others and our own RCTs found the power of feedback to improve effectiveness, there was a desire to privilege client voice and provide services that are just.

So I wanted to let you know that we are continuing to get more folks on board in such settings. I was in Jackson, Mississippi a couple of weeks ago and they are gearing up for application in child/adolescent inpatient, residential, foster care, and home-based preservation services. Art Ring is leading a very talented group at Mississippi Children’s Home and I look forward to their success. And Wesley Community Action in New Zealand is also taking CDOI to places I never imagined it could go. David Hanna and Robyn Pope are applying CDOI in walk in community centers, services for the elderly who have just transitioned to assisted living arrangements, foster care, and other social services. Their commitment to social justice continues to inspire me. Their credo:

We are working for a just and caring society
We believe positive change is always possible
We work in partnership with people,
We listen actively
We respond with honesty and openness
We remain open to challenge, change and growth
We work …
As members of communities
Out of compassion
As facilitators of positive change

They are starting a network of CDOI interested folks in New Zealand. New Zealanders should contact Robyn at  RPope@wesleyca.org.nz.

On another note, here are my slides for an upcoming workshop in West Palm Beach that provide the rationale for practive based evidence and CDOI.

PBEUpdateSlides

It is always fun to post good news, to let folks know that CDOI continues to grow and is having an impact. One area that will lead to the expansion of CDOI practices is its inclusion in graduate training programs. This is a major strategic goal of the Heart and Soul of Change Project (HSCP) and we will reach out to professors and researchers to invite them to both conduct research and teach CDOI ideas and practices. The Norway Feedback Project will assist us in this endeavor because it brings academic credibility to the measures and is a nice calling card.

You might already know that Dr. Jacqueline Sparks, Project Leader at the HSCP, has implemented an outcome management protocol with students in her MFT program and clinic at the University of Rhode Island. Jackie’s program uses ASIST and can truly claim to not only train competent clinicians, but also effective ones. It also sets the course for new graduates on a lifelong journey of monitoring their effectiveness and their cumulative career development. Consider the benefits for these budding clinicians and for anyone who decides to monitor outcomes over the course of their career. Such a process allows a strategic trial and error application of new learning as well as the continual refinement of the tried and true mechanisms that we know enhance outcomes. In short, it enables you to take action about your effectiveness. It permits you to learn from your experience, not repeat it. (see below)

Now Jackie’s program is not the only one.

Jeff Reese, the researcher at University of Kentucky who conducted an independent RCT using the ORS and SRS that will soon appear in the prestigious journal Psychotherapy, brought me to UK last week to present to both students and faculty, and the community. After my visit with the Counseling Psychology department, standing on the strong shoulders of Jeff’s work, the program faculty unanimously decided to implement the ORS and SRS as an integral piece of their clinical training. Students will use the measures in their practicum training, and the faculty believes that it will not only strengthen their training, but will also operationalize their commitment to social justice. That’s what I am talking about!

The Heart and Soul of Change Project, like my new book, On Becoming A Better Therapist, suggests that you step up to the plate with two things: attaining systematic client feedback and taking your development as a therapist to heart. Integrating these two critical aspects, I believe, can open new vistas for therapists wishing to rapidly impact the quality of their work with clients. Attaining client feedback is a simple but clinically nuanced process of collaborating with clients, forming true partnerships, and enhancing the factors known to impact outcomes. It helps us know we are on track, enables us to empower change, and it provides an early warning system for clients at risk for drop out or other negative outcomes. Collecting client feedback also paves the way for your development as a therapist.

In a remarkable study, veteran researchers David Orlinsky and Helge Rønnestad (2005) took an in-depth look at therapists’ experience of their work and professional growth. Over a 15 year period, they collected richly detailed reports from nearly 5000 psychotherapists of all career levels, professions, and theoretical orientations from over a dozen countries. From their analyses of many specific aspects of therapeutic work, a mode of therapist participation was identified:

Healing Involvement reflects a mode of participation in which therapists experience themselves as personally committed and affirming to clients, engaging at a high level of basic empathic and communication skills, conscious of Flow-type feelings during sessions, having a sense of efficacy in general, and dealing constructively with difficulties if problems in treatment arose. Healing Involvement represents us at our best—the way we want to be with our clients. Think of it as being “in the zone” akin to how athletes describe their experience when their performance is optimal. Their extensive investigation identified three sources of Healing Involvement, a therapist’s experience of being in the zone: First is the therapist’s sense of cumulative career development—improvement in clinical skills, increasing mastery, and gradual surpassing of past limitations. Second, another important influence on Healing Involvement is the therapist’s sense of theoretical breadth. Orlinsky and Rønnestad suggest that understanding clients from a variety of conceptual contexts enhances therapist’s adaptive flexibility in responding to the challenges of clinical work. Indeed, broad spectrum integrative-eclectic practitioners were more likely to experience Healing Involvement. The third and by far most powerful influence on being in the zone is the therapist’s sense of currently experienced growth. Therapists like to think of themselves as developing now. Your ongoing experience of professional development is therefore critical to becoming a better therapist. In a sense we continually ask ourselves, “What have you done for me lately?” Therapists with the highest levels of current growth showed the highest levels of Healing Involvement. Orlinsky and Rønnestad suggest that the experience of current growth translates to positive work morale and energizes therapists to apply their skills on behalf of clients.

How does all this relate to client feedback? Tracking client responses to therapy provides an accessible route to being in the zone, addressing all three sources identified by Orlinsky and Rønnestad. First, collection of client feedback allows you to monitor your outcomes and plot your career development, so you will know about your effectiveness and whether you are improving. Moreover, charting your outcomes not only permits a more systematic process of planning and implementing strategies to improve your effectiveness, it also permits your evaluation of the strategies and whether or not your time might be better spent elsewhere. Second, tailoring your approach based on client feedback about benefit and the fit of the services will lead you to theoretical breadth as you expand your repertoire to serve more clients. Soliciting client feedback enhances your ability to be tuned to client preferences and encourages your flexibility to try out new ideas in search of what resonates with clients—opening you to a range of theoretical explanations and attending methods. Finally, securing client feedback seats you in the front of the class so you can readily see and hear the lessons of the day—to experience your currently experienced growth. Practice based evidence encourages your continual professional reflection with each client, thereby increasing your learning potential exponentially. Client feedback is the compass that provides direction out of the wilderness of negative outcomes and average therapy—taking the notion of clients as the best teachers of psychotherapy well beyond cliché, significantly accelerating your development as a therapist, and helping you become a better one.

Over the next several months, I’ll blog how you can accelerate your development as a therapist. Stay tuned.