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

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

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

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

I am very pleased to announce that our alliance article from the Norway Feedback Project (Anker, Owen, Duncan, & Sparks, in press) was accepted in the prestigious Journal of Consulting and Clinical Psychology (JCCP). Congrats to the whole team: Morten Anker, Certified Trainer, Jesse Owen, Research Director, and Jacqueline Sparks, Project Leader. Although already well established in terms of its widespread use and validated psychometrics, this is a major step forward for the Session Rating Scale (our alliance measure), bringing it more academic credibility, and importantly, it allows mainstream scientific dissemination of the idea of continuous alliance monitoring. The Outcome Rating Scale/Session Rating Scale combo (or the Partners for Change Outcome Management System or PCOMS), btw, is the only outcome system that includes routine alliance monitoring. And the SRS is the only alliance measure specifically designed for the front line clinician for use with every client in every session.

There’s a lot of talk about what makes some therapists more effective than others, and a lot of claims unsubstantiated by research. But what really makes a difference in outcome is that tried and true but taken granted old friend, the alliance. The most definitive thing we know about what makes some therapists better than others is their ability to secure a good alliance across a variety of client presentations and personalities. This finding was recently confirmed by a sophisticated analysis by Scott Baldwin and colleagues in perhaps the premier psychotherapy research publication, JCCP. It also dispelled common folklore by demonstrating that good alliances were more of a function of what therapists brought to the table than clients; i.e., therapists adept at alliances were able to transcend type of client while other less effective therapists were not. Further, and simply put, the alliance accounts for five to seven times the amount of variance of outcome as model and technique. And, according to the bible of psychotherapy outcome research (Garfield and Bergin’s Handbook of Psychotherapy and Behavior Change, the Orlinsky, Rønnestad, and Willutzki chapter) there are over 1000 process-outcome findings that support the association between a strong alliance and positive outcome.

Despite this, however, naysayers (read model maniacs, I mean proponents) will dismiss the alliance by saying the research is only correlational. Even more damning, they say, is that we don’t know which comes first, client experience of a strong alliance or client report of change or benefit—the classic chicken or the egg question. Enter our just accepted alliance study that involved a total sample of 500 clients. The alliance significantly predicted outcome over and above early change, demonstrating that the alliance is not merely an artifact of client improvement but rather a force to be reckoned with in and of itself. Don’t let anyone tell you that the alliance is anything less than it is—the single greatest impact we can have on client change. We can continually improve our ability to form strong alliances with a broader range of clients, and thereby improve our effectiveness. Don’t leave it to change. Monitor with your clients.

A new feature just added to the website: The Heart and Soul of Change Project Mailing List. This list won’t cover you up in email or leave you hurling harsh language at me—I promise. You will only receive 4-6 updates per year about the latest training opportunities and Project happenings.  Subscribe/unsubscribe or change your profile.

Finally, the next webinar is scheduled:

Have you ever wondered how to present client directed outcome informed (CDOI) ideas and practices to a general rather than professional audience? Wonder no longer, because that is what I did in my self help book, What’s Right With You and that’s what this webinar will do:

We live in a world pervaded by the unspoken attitude that we are all basically flawed, broken, incomplete, scarred or sick: we’re labeled as dysfunctional, codependent, depressed, you name it. Contrary to popular perception and drug company ad campaigns, fifty years of research shows that positive change does not primarily emerge from examining the disorders, diseases, or dysfunctions—all the stuff that’s wrong with us—that allegedly plague the masses. Change, in truth, comes from what’s right with the people attempting it—their strengths, resources, ideas, and relational support—not the labels they are branded with, the special expertise of doctors or the magic methods or potions they peddle.

In this webinar Barry translates CDOI into a six step plan, as detailed in his self help book, What’s Right With You.

Title: What’s Right With You by Barry Duncan
Date: Friday, May 28, 2010
Time: 12:00 PM – 1:00 PM CDT

Join the CDOI Members or wait until this webinar is posted on the bookstore.

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

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

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

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

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

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

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

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

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

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

Here are the slides:

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