1. Is this an unrealized potential to inform practice?
Without question it is an unrealized potential, although more and more people are getting on board all the time. When you consider that outcome informed practice improves outcomes more than anything in our field since its inception (sounds like hyperbole but it isn’t), it is really a wonder that everyone isn’t doing it. But many are. The outcome system of the Heart and Soul of Change Project or the Partners for Change Outcome Management System (PCOMS) is recognized by two states (Arizona and Colorado) as an evidence based treatment and it 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. Norway is currently implementing nationally in their family counselling offices. Given that now 9 RCTs (Lamberts and ours) demonstrate the significant advantages of outcome informed practice, I think it is only a matter of time until it is considered standard practice.

2. Why, given all the time, money, and other resources dedicated to assessing outcomes in behavioral health, is there not a widespread adoption and implementation of outcome measurement?
There are a few reasons. First it hasn’t been a part of the vernacular of our field at the clinician level. For anyone in the field for a few years, it is a totally foreign concept and most folks assume the best regarding effectiveness. It is critical that graduate education step up to plate here and groom a new generation of mental health/substance abuse professionals that are savvy about outcome informed practice. Second, the field has not provided clinicians with any feasible, clinician friendly way to manage outcomes until recently. Some have been turned off by cumbersome and lengthy measures designed by researchers that don’t appear to be related to the day-to-day work of the front line therapist. Finally, many are afraid because of all the talk about P4P and other ideas that suggest that some will be punished who do not measure up to some arbitrary standard. The whole process of outcome measurement and management need to makes sense to front line therapists and appeal to their nearly universal desire to do good work and get better over the course of their careers. That is why the implementation process of the Project emphasizes both a top down and bottom process. It includes attention to things that makes sense to therapists: 1) common factors; 2) a nuanced clinical process; 3) and therapist development.

The common factors, those elements of psychotherapy running across all models that account for change (Duncan, 2010; Duncan et al., 2010), provide an overarching framework for the PCOMS intervention. Integrating the use of PCOMS within the larger literature about what works in therapy promotes therapist understanding of the feedback process and adherence to the feedback protocol. PCOMS is presented as the tie that binds these healing components together, allowing the factors to be expressed one client at a time. 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 chances for a strong alliance, and is itself a core feature of therapeutic change (Duncan, 2010).

Although the over 300,000 administrations of the measures has yielded invaluable information regarding the psychometrics of the measures, trajectories, algorithms, etc., PCOMS remains a clinical intervention embedded in the complex interpersonal process called psychotherapy. For successful implementation and ongoing adherence, PCOMS must appeal to therapists at a clinical level in ways that the numbers or data or even the research never can. Consequently, PCOMS is described as the clinical process that it is—one that requires skill and nuance to achieve the maximum feedback effect. PCOMS speaks to therapists “where they live” by providing a methodology to address those clients who do not benefit from their services.

Similarly, a focus on therapist development provides a positive motivation for therapists to invest time and energy in PCOMS. There will always be organizational motivations for PCOMS in terms of improved outcomes and reduced costs–the language of “return on investment” and “proof of value.” But there is also the personal motivation of the therapist, the very reason most got into this business in the first place: to make a difference in the lives of those served. The groundbreaking research by Orlinsky and Rønnestad (2005) about therapist development (now over 11,000 therapists included) demonstrates that nearly all therapists want to continue to improve throughout their careers and harnessing this motivation is part and parcel to successful implementation. PCOMS appeals to the best of therapist intentions and encourages therapists to collect ORS data so that they can track their development and implement strategies to improve their effectiveness (Duncan, 2010).

Including these larger themes allows therapists to see that the intentions of PCOMS go well beyond management or funder’s cost or efficiency objectives—client based outcome feedback is about client privilege and benefit, and helping therapists get better at what they do. In addition, it is also critical that therapists know that management only intends to use data to improve the quality of care that clients receive, that there will be no punitive use of the data in any way, shape, or form. Given that most therapists improve their outcomes with feedback ( 9 of 10 therapists improved in the Anker et al. trial), a positive, non-competitive approach goes a long way to assuage therapists’ fears.

3. We go to the doctor and expect that our blood pressure will be taken, we will be weighed, and our heart rate monitored. But when we go see a behavioral health professional there is no such standard measures. Is this patient preference? Clinician Preference? Both?
It is definitely not client preference. Consumers want to be involved in their own care. However, they don’t want to do meaningless paperwork that takes away from their time with the therapist. Consumer involvement in all decisions that affect care is the foundation of the PCOMS intervention, including persons not of the dominant culture as well as the traditionally disenfranchised. We have found that when people understand the purpose of the measures (keeping their voice central and making sure they are getting what they want), refusal rates are about one in a hundred. This is far more of an issue for therapists as discussed above.

4. Where do you see the field going in the near term?
Given that there are now nine RCTs supporting it, the time for client-based outcome feedback seems to have arrived (Lambert, 2010). I think that within 5 years, it will be standard practice. My optimism comes from several recent events. For example, the American Psychological Association (APA) Presidential Task Force (hereafter Task Force) on Evidence-Based Practice in Psychology (EBPP) defined EBPP as “the integration of the best available research with clinical expertise in the context of patient (sic) characteristics, culture, and preferences” (Task Force 2006, p. 273). Two parts of this definition draw attention to client feedback and to tailoring services to the individual client. First, regarding clinical expertise, the Task Force submitted:
Clinical expertise also entails the monitoring of patient progress… If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate. (APA, 2006, p. 276-277)

And second, “in the context of patient characteristics, culture, and preferences,” emphasizes what the client brings to the therapeutic stage as well as the acceptability of any intervention to the client’s expectations. The Task Force said:
The application of research evidence to a given patient always involves probabilistic inferences. Therefore, ongoing monitoring of patient progress and adjustment of treatment as needed are essential (Task Force, 2006, p. 280).
Outcome, in other words, is not guaranteed regardless of evidentiary support of a given technique or the expertise of the therapist. Client-based outcome feedback must become routine.

Further support comes from APA’s Division 29 Task Force on Empirically Supported Relationships who advised practitioners “…to routinely monitor patients’ responses to the therapy relationship and ongoing treatment. Such monitoring leads to increased opportunities to repair alliance ruptures, to improve the relationship, and to avoid premature termination” (Ackerman et al., 2001, p. 496). Finally, two other recent endorsements of outcome management by APA have emerged. First the APA Commission on Accreditation (2011) states that students and interns: “Be provided with supervised experience in collecting quantitative outcome data on the psychological services they provide…”(2011, C-24). And second, APA recently created a new outcome measurement database to encourage practitioners to select outcome measures for practice ((http://practiceoutcomes.apa.org).

So change is on the horizon.

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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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There are five features of implementation of client directed, outcome informed (CDOI) clinical work and the Partners for Change Outcome Management System (PCOMS) that distinguish the Heart and Soul of Change Project:

1. Attention to the common factors of change and the evidence demonstrating that most of therapist variability is accounted for by alliance abilities: PCOMS, the feedback intervention, is viewed as an interconnected part of the healing factors of psychotherapeutic intervention and the tie that binds the other factors together allowing the factors to be expressed one client at a time. 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. The natural fit between the common factors research literature and PCOMS is integral to the implementation process of the Heart and Soul of Change Project.

2. A focus on the clinical nuances of using PCOMS as detailed in On Becoming a Better Therapist, addressing how to get the maximum feedback effect. Although the now 300,000 administrations of the measures and all the information that has yielded in terms of the psychometrics of the measures, trajectories, algorithms, etc., has been invaluable, PCOMS remains a clinical intervention embedded in the complex interpersonal process we call psychotherapy. The Heart and Soul of Change Project keeps this in mind and therefore appeals to the clinician in ways the numbers never can.

3. Similarly, a focus on therapist development and how therapists naturally want to get better over the course of their careers provides a positive motivation for therapists to invest time and energy in PCOMS. There will always be organizational motivations for PCOMS in terms of improved outcome and reduced costs–the language of “return on investment” and “proof of value.” But there is also the personal motivation of the therapist, the very reason most of us got into this business in the first place: to make a difference in the lives of those we serve. Research demonstrates that nearly all therapists want to continue to improve over their careers and harnessing this motivation is part and parcel of how the Heart and Soul of Change Project implements PCOMS.

4. Attention to Multiculturalism and Social Justice is a key element of PCOMS (and of the Training of Trainers Conference). Client privilege and voice form the foundation of the PCOMS intervention. Privileging the client via PCOMS 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. We see PCOMS as a way of building cultural proficiency.

5. Attention to the concept of “Recovery” as defined by the National Consensus Statement is core to PCOMS and a natural fit—a journey best directed by the individual in the context of a true partnership providing both hope and accountability. PCOMS offers a vital way to operationalize the Consensus Statement into clinical practice.

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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I just returned a few weeks ago from Europe which included training in The Netherlands, Switzerland, and Belgium which I did for Korzybski International. They run an extensive multiyear post graduate training program in Solution Focused Cognitive Therapy, which in Europe is called the Bruges Model as well as many other useful therapeutic ideas and practices. This was my second trip for them and the more I get to know them the more I have come to like what they are doing. This trip cemented my involvement in their training program and now CDOI and PCOMS will be a fixed feature of their training. There is now a formal affiliation between the Korzybski Institute and the Heart and Soul of Change Project. This is important because it will help spread the word to many who would have otherwise never heard of CDOI or PCOMS because of language differences. While many Europeans speak English, many do not as well. French speaking folks, for example, have had little exposure to the ideas (the first edition of Heroic Client was translated but it did not include the ORS/SRS) but no longer. There is a translation of the Heart and Soul of Change in the works and I am hopeful that On Becoming a Better Therapist will be next. And, I will be conducting training in France next year which hopefully inspire interest as well.

I am pleased to announce that Luc Isebaert will join The Heart and Soul of Change Project as a Project Leader. I don’t know if you have seen the Dos Equis commercials about the “most interesting man in the world” but since meeting Luc, I beg to differ. Luc is truly a renaissance man, and a walking encyclopedia of art, music, wine, beer (his family ran a brewery and if you know anything about Belgium, you know that beer is a national treasure), history, and of course psychotherapy. Luc is also a gourmet chef and I had an amazing dinner at his home and his partner Sophie (a concert pianist who played for us over a glass of incredible Riesling wine on a piano that Franz Liszt played at the Paris World Fair in 1878). Luc and I share a common heritage in Ericksonian and systemic thinking (hence the name, Korzybski Institute) as well as many perspectives of therapy and training therapists. He co-founded the Korzybski Institute in 1982. His previous position was Chief of the Dept of Psychiatry and Psychosomatics at St John’s Hospital in Bruges. Luc was taken by CDOI’s attention to the common factors as well as the importance of monitoring outcomes.

On a more content related note, Jesse Owen just turned me on to a great alliance article: Crits-Christoph, P., Connolly Gibbons, M, , Hamilton, J., Ring-Kurtz, S., Gallop, R. (2011). The dependability of alliance assessments: The alliance-outcome correlation is larger than you think. Journal of Consulting and Clinical Psychology, 79, 267-278. Once again, a very sophisticated study validates the focus of CDOI and PCOMS. 

This study found that session 3 alliance ratings accounted for 4.7% of the variance but the average of sessions 3-9 explained a whopping 14.7% of outcome variance. This study suggests that a single session view of the relationship between the alliance and outcome very likely underestimates its impact on ultimate treatment outcome. Bottom line: Don’t underestimate the power of the alliance! In addition they recommended ongoing alliance assessment with alliance measures that don’t put too much burden on clients but that are reliable and valid. Do you know of any?

Don’t forget the upcoming webinar on supervision (Supervision Matters: Tapping into Therapist Aspirations to Get Better) coming up this Thursday, June 30 at noon Central. Join the CDOI member site to catch this one and many others.

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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

I recently answered four interesting questions about my clinical work for a Danish publication:
1) What is the most unusual or odd form of therapy/method you’ve ever had to go about to ensure an effective therapy and a good alliance with a client?
The client that comes to mind is Natalie. Natalie told me she’d been a multiple personality since childhood when her different alters provided protection from a brutally abusive environment. She felt she had already dealt with the abuse and didn’t want to become integrated into a single self, but rather wanted “co-consciousness,” a state in which the alters would be aware of each other’s experience without losing their separate identities. Natalie entered therapy because she had lost access to some of her most intuitive subselves.

I didn’t have any idea of how to help Natalie recontact her missing alters or promote co-consciousness. I shared my lack of experience in these matters and Natalie responded that her doctor had referred her, had said good things about me, and that she trusted her completely. Besides, she added, the previous therapist, a dissociative identity expert, had all but demanded that Natalie give up her alters in service of an integrated personality. Natalie wanted nothing to do with that. Natalie told me that she didn’t fit the mold of how that therapist thought about multiples, and added, “I can’t help that!”

But I was willing to not know—to explore her world, to find out how her system worked, to validate it, and try to discover a way to help her re-access her alters. Natalie was quite remarkable: witty, obviously bright, and very artistic. She worked as a copy editor for a magazine by day and by night was an accomplished oil painter. Over the next few sessions, Natalie and others in her system explained to me that her alters lived in various rooms in a visualized house. Some were practical, others intuitive, and others tough as nails. She would visualize the pathway to the different alters’ rooms to access them; whoever had the best skills then emerged to deal with whatever life dished out. Except for now, when some of them had mysteriously gone missing. I sincerely told Natalie—an extremely intuitive woman, or collection of women—that I thought she had a “wonderful system,” and suggested she think of all the ways she had gained access to her alters before.

A possible source to the problem was finally discovered. Natalie said she thought that the alters were hiding because her boyfriend, Joe, was embroiled in extreme, ongoing arguments with a brother and sister over the impending sale of their grandparents’ farm. Natalie believed that the alters were frightened and hiding much like they did when she was a child. Once Joe became less unpredictably volatile, Natalie thought, access to her missing alters would return. With this discovery made, we focused on ways to address Joe’s anger, and otherwise, in Natalie’s words, “deflect it” and diminish its impact on her alters. Natalie implemented our ideas and Joe responded by calming down and becoming more attentive to Natalie’s needs. Subsequently, over the next days, several others “came home.”

But my confusion didn’t stop there. With the crisis with Joe abated, Natalie identified a new goal of addressing her Epstein-Barr virus. In the next session, a wise, spiritually centered, martial artist alter named “Nora” showed up. Since Natalie was already adept at visualization, I had planned to suggest that we fine tune her skills to rally her resources against the virus. I suggested this to Nora instead and we worked on various martial arts images to combat the virus. I wondered aloud if it was possible to teach the others the same skills and Nora said she would try.

Perhaps in my most speechless encounter with a client, Natalie appeared in the next session and with great enthusiasm exclaimed, “I’m a me! My experienced and tempered empathic therapeutic response: “Say what?” This video sequence has brought down the house in my trainings. I am so dumbfounded, so confused—I clearly don’t know what the hell is going on. But as I always say, at least I was authentically stupid!

Then Natalie explained: Nora had called a meeting in a visualized library to communicate to the alters what she had learned about Epstein Barr. It was the first time they had all been in the same room together. Natalie reported that each alter had come forward, naming her special gifts to the overall system. After praying together, each alter had said, “I belong.”

Then Natalie told me, “Now I’m a ‘me,’ and I’m different. I am the collage of their gifts. Everybody’s there. And if they want, they could still come out, but I’m a me. This me is finding out a lot of things. I’m articulate. I have movement. I definitely have a temper, and I can express it. It’s like I’m looking through a pair of new eyes that have never been touched or scarred.” Again, I was dumbstruck! She had gone beyond “co-consciousness” to a form of integration that she welcomed. I sat stunned for some time before Natalie asked me if she could give me a hug. I am not sure, in retrospect, whether it was celebratory hug or one designed to comfort me and reel my confusion in.

Natalie stands out to me because I never have felt more cast adrift. I didn’t have a clue about what to do—no theoretical or technical training prepared me for this client and how therapy progressed over time. In reality, that’s the way it always is. But I was there hunting for what could work, adding something when I could—the anger suggestions and the imagery to help combat the virus—until the unexpected occurred. I believe it is best described, for me, as a collaborative expedition for the magic of the moment. Not the magic of the sweeping, dramatic gesture or an isolated technique or any other novelty, but rather the magic that grows out of exploring the client’s world, validating their experiences, and discovering what works.

2) Have you ever had to make use of a method, technique or a theory in a therapy session, where you have found it necessary to compromise your ethics or values in life, to create or retain a good alliance and effectiveness in therapy?
No. I have experienced many encounters with clients in which I challenged my values and ethics, and perhaps stretched them, but not compromised them. Here is one example. This is a bit of tawdry tale. Richard, a 29-year-old systems analyst, was referred by his company doctor because of Richard’s increasing distress and frequent absences. When I greeted Richard in the waiting room, he jumped out of his chair, got right in my face—not 3 inches away—and demanded “What are you going to do for me?”

Richard didn’t look too good. The 60 cent therapy words would be agitated and disheveled. I tried to stay calm and just invited him to accompany me to my office, whereupon Richard raised his voice another notch and repeated his question, and was once again, too close for comfort.

I was definitely freaked at this point but I simply replied that I didn’t know if I could do anything for him but that I would try my very best. Richard finally sat down on my couch and told his story, and the flood gates opened. Richard began suspecting his wife, Justine, of having an affair after he discovered footprints in the snow in his backyard. Consequently, he followed her, searched her belongings, and kept track of her whereabouts. But he could not find the incontrovertible evidence that he was sure existed. Throughout Richard’s growing mistrust, Justine emphatically denied the affair and told him he needed help. Perhaps in desperation, Richard began to secretly check Justine’s underwear for signs of semen, which would provide ironclad evidence of her unfaithfulness (given there was no sex with him).

Finally, Richard found stains on her underwear and took it to a laboratory which confirmed the presence of semen. Justine still denied his accusations and insisted the semen was his. She stepped up her efforts to involve others, telling friends, family, his employer, and their own children, that Richard was sick and in need of hospitalization. Justine rallied many to her cause and filed for divorce. The company doctor concurred with her assessment, as did the first provider that Richard saw, a psychiatrist who offered an antipsychotic to ease Richard’s pain.

After Richard’s first unsuccessful encounter with the psychiatrist, the company doctor was peeved. Perhaps hoping to admonish Richard into sanity, he had yelled “Cut the crap!” Richard didn’t do much to disconfirm everyone’s assessment of his sanity. He was doing some pretty whacky things, and looked more distressed and haggard with each passing day.

Richard told me that he was obtaining a DNA analysis of the semen to see if it was a match with his. While scrutinizing my every reaction, not in a threatening way but rather like a condemned man waiting for a sentence, he nervously asked me if I believed him.

So was Richard psychotic or was Justine a liar? Subsequently, I talked with Justine and invited her to therapy but she declined. She was very persuasive and pulled out all the stops to describe Richard as a hopelessly psychotic and in need of medical help, noting that Richard’s sister was also schizophrenic and lived in a group home. What would you say to Richard?

I told Richard that I did believe him. Richard allowed himself a moment of relief, but pressed on and told me that the DNA test was going to cost a lot of money. He then leaned forward, stared uncomfortably, and asked me the big question: did I think he was crazy for spending all that money?

I responded that peace of mind is cheap at any price. Richard broke down and cried long and hard. He had been through a lot, and was starting to believe what many had told him—that he was paranoid and needed medication. After a while, we started talking about what he needed to do to stop looking crazy while he waited on the DNA results. If we took the affair as a given, and that her intent was to make him look crazy as a loon, then everything he was doing was playing right into her hands. Richard and I worked out a plan to get normalcy back in his life: return to work, start spending time with his kids, and taking better care of himself. He did all of those things and continued to bide his time as best he could.

Finally the results came in. Although Richard was greatly saddened when the DNA results confirmed that the semen was not his, he was not surprised. Ultimately, the whole seamy business came to light, and Richard went about rebuilding his life.

I was so moved by Richard’s response, the depth of his wailing, to my simple act of believing him and understanding his desire to know what was going on that I have never forgotten it. Richard taught me that I have to believe my clients, pure and simple. Honestly, while Richard told me his story, I struggled with believing him, which I knew was risky to our alliance. But I ultimately made a conscious choice, during that session, to believe Richard—that it didn’t matter how bizarre it seemed or how classically paranoid it looked. I decided, at the very least, that my clients deserve to be believed. That was a significant event in my development as a therapist. From that day on, I no longer struggled with being a reality police officer And while it’s true that sometimes people do lie, even maliciously, like Justine, I am willing to suspend disbelief until the “facts” appear or maybe into perpetuity.

3) What is the most fun part of working with clients within a frame of reference which contains no fixed techniques, theory or method?

The most fun part is never knowing what is going to happen when you put two resourceful, unique individuals in a room who engage each another in this beautiful interpersonal event we call psychotherapy. The magnificently inexplicable is always lingering, and the joy of discovery ever present. The uncertainty within a frame of reference with no fixed ideas ore methods creates unlimited possibilities for change. It is this indeterminacy that gives therapy its texture and infuses it with the excitement of discovery. This allows for the “heretofore unsaid,” the “aha moments,” and all the spontaneous ideas, connections, conclusions, plans, insights, resolves, and new identities that emerge when you put two people together and call it therapy. This doesn’t mean, of course, that it’s all fireworks (just watch an entire session rather than edited video clips), it just means that tolerance for uncertainty creates the space for new directions and insights to occur to both the client and the therapist.

The tolerance for uncertainty, however, requires faith—faith in the client, faith in yourself, and faith in psychotherapy. But I am certain of one thing: uncertainty is the key that unlocks the potential for discovery. It is hard to discover something if you already know what it is that you are looking for and where it is. Because CDOI is unencumbered by any particular theoretical or explanatory concepts, there is a freedom to speculate. Some ideas grow into relevant discussion, while others fade away as it becomes apparent they are not helpful to pursue. This process seeks to chart a different course—connections, conclusions, solutions, etc.—in any form, that permits a way to address the client’s goals, to encourage an increase on the Outcome Rating Scale (available in Danish, free for personal use at www.heartandsoulofchange.com).

From a discovery-oriented perspective, the word “intervention” does not adequately describe the collaborative process that emerges. To intervene is “to come into or between by way of hindrance or modification.” It implies something done to clients rather than with them, and consequently overemphasizes the technical expertise of the therapist, inaccurately portraying what makes therapy successful. The word intervention does not capture the interdependence of technique on the client’s resources and ideas or how technique is successful to the extent that it emerges from the client’s positive evaluation of the alliance. The words “invent” and “invention” seems more apropos to discovery. To invent is to “find or discover, to produce for the first time through imagination or ingenious thinking and experiment.” Every technique is used for the first time, invented by clients and therapists to fit the client’s unique attributes and circumstance.

The therapist and client are co-explorers, searching the client’s world for the map that provides a route of restoration. As co-adventurers, you encounter multiple opportunities for sharing your respective vantage points while crossing the terrain of the client’s world, periodically stopping to consult your ORS/SRS compass to ensure you are headed in the right direction. When lost along the way, you regroup to look for alternate routes on your maps, as well as the maps of others you encounter on the journey. Such expeditions often uncover trails that we never dreamed existed.

4. If you at one point in your life was to seek therapy (of course depending on why) how would I as a therapist manage to obtain a good alliance between us and ensure effectiveness?

I have consulted a therapist twice in my life and I had a good experience both times. I don’t think I would want anything different than most clients who make their way into our offices. I want to be heard, understood, and respected. I want you to see me as transcending my problems, that my humanity is not represented by the problem, that I am not my problem. I want validation of my experience and for you to believe that I have good reason to think, feel, and behave the way I do, even if it doesn’t fit your experience. Finally, I would want my ideas about how I might change to remain central, and that your interest in your own ideas would fade if they did not resonate with me.

The best way to secure a good alliance with me and ensure effectiveness would be to monitor both the alliance and outcome in each session. This would not leave either the alliance or effectiveness to chance. By creating a culture of feedback, and aspiring to transparency and collaboration, together we could make sure that we were on the right track regarding my benefit from your services and that you were fitting my expectations about how therapy was conducted. If things were not going well, your non-defensive response would be critical along with your wiliness to explore options, including referring me on to someone else.

And don’t forget this month’s free webinar about my book, On Becoming a Better Therapist. This month’s webinar covers Chapter 3 and will be on September 28th, 6-7:30PM Central. Register now at: https://www2.gotomeeting.com/register/945596986  I’ll start our discussion with a 25 minute overview and then I’ll turn it over to you for your questions, comments, and reflections. It should be fun. For those of you who can’t attend live, I’ll record the sessions and post them on the website so you can access the discussions at your leisure.

I am excited to announce a seven month series starting in July of webinars and discussions about my new book, On Becoming a Better Therapist.  First here is a brief review of the book:

Drawing on many years of clinical experience and research on evidence-based practice, Duncan argues with conviction and humor that systematically monitoring client outcomes is advantageous to therapists as well as to clients. He offers lessons learned about clients being the best teachers and guidelines for what works in therapy. The guide includes a foreword by Michael J. Lambert, other pearls of wisdom, findings of the Norway Feedback Project, excerpts of therapy sessions, and information on career development tracking software (ASIST, MyOutcomes). –Reference & Research Book News (May 2010)

This will be a three-pronged effort to disseminate the ideas in the book, two of which are free. First, for those who subscribe to CDOI Members (join here for just $120 a year), beginning July 22 at noon Central, I will conduct monthly webinars on each of the seven chapters of the book, adding to the already over $400 of training materials. And stay tuned: Client videos are coming soon to CDOI Members so you will be able to learn CDOI by watching me with actual clients.

And now for the free stuff: Have you ever wanted to ask a question or engage in a conversation with an author when you were reading a book? I know I have. Starting also on July 22 at 6PM Central, I will offer a free monthly webinar discussion of my book. Each month will cover a different chapter. I’ll start our discussion with a 15 minute overview and then I’ll turn it over to you for your questions, comments, and reflections. It should be fun. For those of you who can’t attend live, I’ll record the sessions and post them on the website so you can access the discussions at your leisure. In addition, right after the webinar, I’ll be hosting a two-hour discussion about each chapter of the book on the heroicagencies list (join now). I hope you can join me. I am anxious to hear your impressions and questions about the book.

Here is the free webinar announcement:

On Becoming a Better Therapist: Chapter One Discussion
Most of us became therapists because we wanted to be helpful to other human beings, and most of us carry an inextinguishable passion to become better at it. But how do we get better? The truth is that although we are painfully aware that some clients clearly don’t benefit while others inexplicably end therapy, we don’t know how effective we really are or what we can do to improve our outcomes. Despite our hard work and good intentions, unfruitful encounters with clients combined with the confusing cacophony of “latest” developments can weigh on us, steer us into ruts, and make us forget why we became therapists to begin with. How can we remember our original aspirations, continue to develop as therapists, and achieve better results, more often, with a wider variety of clients? In short: how can you become a better therapist?

On Becoming answers that question in a pragmatic and clinically nuanced way, presenting a five-step method of integrating outcome management with therapists’ long-term professional development. In this first of seven webinars corresponding to the seven chapters of the book, I will present a 15 minute overview of the first chapter 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 help you become a better therapist.

Join us for a Webinar on July 22: 6PM Central to 7:30 It’s free! Every month a free webinar!

Space is limited.
Reserve your Webinar seat now at:
https://www2.gotomeeting.com/register/863269466

Hope you join me!

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.

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

Four simple questions on well-being asked at the start of each session of ongoing couple therapy can greatly increase chances for reconciliation and improved relationships, according to a newly published study. The largest clinical trial with couples to date, it shows that divorce and separation rates for couples that used this feedback technique were 46.2 percent less than that of couples who received therapy as usual. The findings, published in the August 1, 2009, Journal of Consulting and Clinical Psychology, are the results of a 2-year study conducted at the Vestfold Family Counseling Center in Norway by a U.S.-Norwegian team of researchers.

From October 2005 to December 2007, 205 randomly selected couples receiving therapy in southern Norway participated in the study, which investigated the effects of providing ongoing feedback regarding the progress of treatment to both clients and therapists. The couples had problems typical of struggling relationships: communication difficulties, loss of feeling for partner, jealousy/infidelity, conflict, and coping with partner’s physical or psychological problems. Half of the study group had feedback incorporated into their therapy while the other half did not.

Couples who used the feedback method rated their well-being on an individual, interpersonal, social, and overall basis by using a visual scale called the Outcome Rating Scale (ORS) at the beginning of each session. The results were used to guide each session: if progress was not noted, new directions for therapy were discussed and implemented. Therapists participating in the study received training on how to integrate the findings of the ORS and collaborate with couples to find new solutions.

“Adding feedback can truly boost effectiveness in couples therapy,” said Dr. Barry Duncan, one of the authors of the study. “It encourages couples to honestly evaluate their progress and enables therapists to adjust therapy before it’s too late.” Although feedback has been demonstrated to improve individual psychotherapy outcomes, no studies until now have examined couples therapy.

Participants were contacted 6 months after the last therapy session. Respondents answered questions about their experience in treatment, including whether the couple remained together. The feedback couples were not only more satisfied with their relationships but also reported significantly lower rates of separation or divorce: a 18.4 percent separation/divorce rate for ORS couples versus 34.2 percent for non-ORS couples.

This study adds to growing evidence that ongoing client feedback in psychotherapy can significantly improve outcomes.

For more information on the ORS, see this website and www.myoutcomes.com .

Media Relations Contact: Barry L. Duncan, Psy.D., barrylduncan@comcast.net, (954) 721-2981, or (561) 239-3640.

Co-authors on the study were Morten G. Anker, Ph. D., the Family Counseling Office in Vestfold, Norway; Barry L. Duncan, Psy.D., the Heart and Soul of Change Project; and Jacqueline A. Sparks, Ph.D., the University of Rhode Island.

Worldwide, there are more than 20,000 registered users of the Outcome Rating Scale. The ORS is available in a variety of formats, including MyOutcomes, a Web-based software application that provides quick and easy administration and interpretation of the ORS.