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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A quick and dirty summary: N = 500 (total sample) n = 236 (subsample attending 4 or more sessions).  This study further supports both the feasibility and the importance of the feedback (PCOMS) intervention. 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 for change in and of itself. The study also found that those couples whose alliance scores ascended attained significantly better outcomes than those whose alliances scores did not improve. Together these findings suggest that therapists should not leave the alliance to chance but rather routinely assess it and discuss it with clients in each session.

Here is a discussion I had with the principal and onsite investigator, my friend, colleague, and partner in crime here at the Project, Morten Anker:

This study is significant for several reasons. First, as the Norway Feedback Study, it brings academic credibility to the use of the measures. Next it offers an antidote to the alliance nay-sayers who dismiss the alliance as only correlational despite the over 1000 studies that support the association between the alliance and outcome (this is like dismissing the association between cigarette smoking and lung cancer!) and often assert that the alliance is merely an artifact of early change. In other words, they argue that the alliance is confounded with early change and does not make any contribution beyond the client’s experience of improvement (clients experience positive alliances because they experience change). It is worthy question but it is often wielded in a way that undermines the importance of the alliance and the fact that it is second most replicated finding in the literature (the dodo bird verdict is first). This is one of only 6 studies that systematically examine this issue. Noteworthy is that we took a very stringent perspective of change. We looked at the clients who experienced reliable change so it was significant change, not just a little change. The alliance was predictive of outcome over and above early change even when that change exceeded 5 points on the ORS. Finally, the study, as mentioned, demonstrated the feasibility and benefit of routine alliance assessment.

On another note, a very interesting blog was sent to me by the author, a consumer. If you ever have any doubts about why collaborative monitoring of outcome and the alliance is a good idea, check this out from a consumer who says: “I’ve had a number of conversations with those harmed by therapy. A common thread is how resistant the profession seems to be to feedback from clients. To that end is my modest entry into the fray:” http://disequilibrium1.wordpress.com/2010/10/10/a-disgruntled-ex-psychotherapy-client-speaks-her-piece/

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:

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.

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!