The trend toward describing, researching, teaching, practicing, and regulating psychotherapy in the terms of the medical model (simplified by the equation: diagnosis plus prescriptive treatment = cure or symptom amelioration) began long ago. George Albee (2000) suggested that psychology made a Faustian deal with the medical model over fifty years ago. The deal was sealed, he asserted, at the famed Boulder conference in 1949, where psychology’s bible of training was developed with a fatal flaw:
[The fatal flaw]…was the uncritical acceptance of the medical model, the organic explanation of mental disorders, with psychiatric hegemony, medical concepts, and language (Albee, 2000, p. 247).

Later, in the 1970’s, with the passing of freedom of choice legislation guaranteeing parity with psychiatrists, psychologists (and later others) learned to collect from third-party payers using only a psychiatric diagnosis for reimbursement. Thereafter, drowning any possibilities for other psychosocial systems of understanding human challenges, the National Institute of Mental Health (NIMH), the leading source of research funding for psychotherapy, decided to apply the same methodology used in drug research to evaluate psychotherapy (Goldfried & Wolfe, 1996)—the randomized clinical trial (RCT) requiring both diagnosis and manualized treatments. Diagnosis reached its pinnacle. Now both reimbursement and research funding depended on it. Funding for studies not related to specific treatments for specific disorders precipitously dropped as both research and psychotherapy itself became more and more medicalized, and dependent on diagnosis, manualization, and RCTs for credibility.

Diagnosis is the beginning point, the foundation of the both the medical model’s simple equation as well as the RCT. Unlike with medical treatments, diagnosis is an ill-advised starting point for psychotherapy. Diagnosis simply lacks reliability. In an interview, Robert Spitzer, the architect of the DSM III, admitted:
“To say that we’ve solved the reliability problem is just not true…It’s been improved. But if you’re in a situation with a general clinician it’s certainly not very good. There’s still a real problem, and it’s not clear how to solve the problem” (Spiegel, 2005, p. 63).

In addition to underwhelming reliability, psychiatric diagnosis lacks validity. Allen Frances, lead editor of the fourth edition of the DSM, recently confessed, “there is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it” (Greenberg, 2010, p. 1). Psychiatric diagnoses fail the most basic definition of validity—they lack empirical standards to distinguish the hypothesized pathological states from normal human variation or other disorders. Consequently, diagnosis always begs numerous, unanswered questions concerning cultural expectations and the role that power, privilege, gender, and race play in the identifying, cataloguing, and addressing client distress. The result is a set of murky over-inclusive criteria, often disadvantaging those who are racially or ethnically different, for an ever growing list of disorders (Duncan et al., 2004).

Finally and particularly germane to practitioners, diagnosis tells little about a person that is relevant to therapeutic change. Diagnosis in mental health is not correlated with outcome or length of stay (Brown et al., 1999; Wampold & Brown, 2005), and given the dodo verdict (see below) cannot provide reliable guidance to clinicians or clients regarding the best approach to resolving a problem. Diagnosis does not address what is most relevant to the helping process, namely the impact of the “disorder” in the client’s life and what can be done about it. Diagnosis also does not cover the range of reasons for which people seek therapy—relational, situational, and quality of life related, not symptom oriented. Nevertheless, the DSM, in spite of a long history of detailed critique (Carson, 1997; Duncan et al., 2004; Kirk & Kutchins, 1992), poor reliability and validity, and limited power to predict treatment outcome, lives on. It remains a fixed part of graduate training programs, a prominent feature of ESTs, and a prerequisite for funding in most mental health and substance abuse delivery systems—all engendering an illusion of scientific aura and clinical utility that far overreaches the DSM’s deeply flawed infrastructure.

Turning to the second part of the equation, that psychotherapists might possess the psychological equivalent of a “pill” for emotional distress resonates strongly with many, and is nothing if not seductive as it teases the desire to be helpful as possible to clients. A treatment for a specific “disorder,” from this perspective, is like a silver bullet, potent and transferable from research setting to clinical practice. Any therapist need only to load the silver bullet into any psychotherapy revolver and shoot the psychic werewolf stalking the client. Perhaps in its most unfortunate interpretation, clients are reduced to a diagnosis and therapists defined by a treatment technology—both interchangeable and insignificant to the procedure at hand

Consider the RCT. It was designed to compare the effects of a drug (an active compound) to a placebo (a therapeutically inert or inactive substance) for a specific illness. The basic assumption of the RCT is that the specific (unique) ingredients of different drugs (or psychotherapies) will produce different effects, superior over placebo, with different disorders. In effect, this assumption likens psychotherapy to a pill, with discernable unique ingredients that can be shown to have more potency than other active ingredients of other drugs.

There are three empirical arguments that cast doubt upon this assumption. First is the dodo bird verdict, which colorfully summarizes the robust finding that specific therapy approaches do not show specific effects or relative efficacy. In 1936, Saul Rosenzweig first invoked the dodo’s words from Alice’s Adventures in Wonderland, “Everybody has won and all must have prizes,” to illustrate his observation of the equivalent success of diverse psychotherapies. Almost 40 years later, Luborsky, Singer, and Luborsky (1975) empirically validated Rozenzweig’s conclusion in their now classic review of comparative clinical trials. The dodo bird verdict has since become the most replicated finding in the psychological literature, encompassing a broad array of research designs, problems, and clinical settings.

Three classic comparative clinical trials illustrate the dodo verdict. Ushering in the RCT in psychotherapy research was the Treatment of Depression Collaborative Research Program (TDCRP) (Elkin et al., 1989). The TDCRP randomly assigned 250 depressed participants to four different conditions: CBT, interpersonal therapy (IPT), antidepressants plus clinical management (IMI), and a pill placebo plus clinical management. The four conditions—including placebo—achieved about the same results, although both IPT and IMI surpassed placebo (but not the other treatments) on the recovery criterion. Project MATCH is the “largest and most statistically powerful clinical trial” in the history of alcohol and drug treatment (Project MATCH Research Group, 1997). Three widely divergent approaches were included: motivational enhancement therapy (MET), 12-Step facilitation (TSF), and CBT. The results revealed considerable improvement, but no differences in outcome emerged among the three approaches. Follow up ten years later (Tonigan et al, 2003) found no support for differential outcomes among the three therapies on percent days abstinent, drinks per drinking day, and total standard drink measures. In the Cannabis Youth Treatment (CYT) Study (Dennis et al., 2004), considered by many to be the largest and most methodologically sound investigation of adolescents to date, 600 adolescents were assigned either to treatment with MET plus CBT ( 5 or 12 sessions), family education and therapy, Adolescent Community Reinforcement Approach, or Multidimensional Family Therapy (MDFT). Comparisons between conditions found roughly equivalent significant pre-post treatment effects that were stable in terms of days of abstinence and percent in recovery by the end of the study.

Meta-analyses have yield similar results. A meta-analysis, designed specifically to test the dodo bird verdict (Wampold et al., 1997), included some 277 studies conducted from 1970 to 1995. This analysis verified that no approach has reliably demonstrated superiority over any other. At most, the effect size (ES) of treatment differences was a weak .2. “Why,” Wampold et al. ask, “[do] researchers persist in attempts to find treatment differences, when they know that these effects are small?” (p. 211).

The preponderance of the data, therefore, indicate a lack of specific effects and refute any claim of superiority when two or more bona fide treatments fully intended to be therapeutic are compared. If there are no specific technical operations that can be reliably shown to produce a specific effect, then prescriptive treatments in psychotherapy (i.e., mandating specific models and techniques for particular disorders) seems to make little sense.

The second argument shining a light on the specific ingredients assumption comes from component studies. Component studies, which dismantle approaches to tease out unique ingredients, have similarly found little evidence to support any specific effects of therapy. For example, a meta-analytic investigation of component studies (Ahn & Wampold, 2001) located 27 comparisons in the literature between 1970 and 1998 that tested an approach against that same approach without a specific component. The results revealed no differences. These studies have shown that it doesn’t matter what component you leave out—the approach still works as well as the treatment containing all of its parts.

A final empirical argument challenging the assumption comes from estimates regarding the impact of specific technique on outcome. After an extensive, but non-statistical analysis of decades of outcome research, Lambert (1986, 1992) suggests that model/technique factors account for about 15% of outcome variance. An even smaller role for specific technical operations of various psychotherapy approaches is proposed by Wampold (2001). His meta-analysis assigns only a 13% (derived from a .8 ES) contribution to the impact of therapy, both general and specific factors combined. Of that 13%, a mere 8% is portioned to the contribution of model effects. Of the total variance of change, only 1% can be assigned to specific technique. A consideration of Lambert’s and Wampold’s estimates of variance reveals that specific treatments do not account for 85% and 99%, respectively, of the variance of outcome. Other variables–the client, the therapist, and their relationship–account for far more of outcome variance. When taken in total–the equivalent results of comparative clinical trials and meta-analytic investigations, component studies, and analyses of the amount of variance attributed to specific effects –the evidence points in the same direction. There are no significant unique ingredients to therapy approaches and therefore little justification for basing psychotherapy on prescriptive or empirically supported treatments. Psychotherapy, therefore, has been shoehorned into the medical model.

But The Medical Model is not the Borg, nor am I Captain Picard fighting for the survival of therapists. Psychotherapy, however, is not a medical endeavor, it is a relational one. There is nothing wrong with the medical model. But it is not empirically supported nor an apt description of our work.

On another note, the last free webinar about my book, On Becoming a Better Therapist is coming up on January 21. Of course you can catch all the free webinars anytime here, but attending live allows you to ask that question you always wanted to ask or make a comment that occurred to you while you were reading the book. In any event, I hope you join me. Here is the info:

Dr. Barry Duncan – On Becoming a Better Therapist: Chapter Seven Discussion
On Becoming presents a five-step method of integrating outcome management with therapists’ long-term professional development. In this seventh of seven webinars corresponding to the seven chapters of the book, I present the fifth step to keep your development on the front burner, the Treasure Chest. I’ll also discuss the controversial issues of the day as they pertain to your identity as a therapist: managed care, evidence based practice, psychiatric drugs, and the medical model. We’ll begin with a 25 minute overview followed by your questions, comments, and reflections. My hope is that the book and these discussions will inspire you to rediscover purpose in your work and become a better therapist.
Friday, January 21, 2011, 6:00 to 7:30 PM
Reserve your Webinar seat now at: https://www2.gotomeeting.com/register/595664219

I am back from Rome and it was quite an inspiring experience on many levels. Rome is an enchanting and spiritual city. As many of you know who have read the preface to Heroic Client, I have been following the kid and psychiatric drug issue for the duration of my career. And as much as the data doesn’t support the prescription of psychiatric drugs to children, the practice has skyrocketed. It has at times been a very disheartening experience when the concerns are so quickly discounted, not only by psychiatrists but also by almost everyone else. I can’t tell you how many times people just dismiss it out of hand and have thought I was a fruitcake (or anti drug or anti psychiatry or even anti science) for even bringing it up. Keep in mind that this attitude persists despite the fact the data clearly show that drugs should never be a first line treatment, especially for kids. This doesn’t mean that they are never helpful.

But most did not dismiss us in Rome, esppecially the people that can make a difference. The presentation was very well received and got some very good publicity (http://www.catholicreview.org/subpages/storyworldnew-new.aspx?action=9117) Furthermore, we received strong support from various Vatican officials and there is hope for doing an international, multi-religion conference in Rome about this. The implications here are quite exciting.

Here is the text of presentation:

Here are the slides from my presentation. 

And I also made three short videos from around Rome about my presentation which will be up in a couple of days.

A final note about Rome. This would have never happened without the persistence and dedication of Marcia Barbacki. She has selflessly worked on this project for several years and doesn’t know how to take no for an answer. Long after I held little hope for getting the Vatican involved in this issue, Marcia continued to lobby until she succeeded in getting me on this recent program which led to many opportunities for further meetings.

On another note, the next free webinar is scheduled on December 29th 6:00 to 7:30 Central (and the previous one for Chapter Five is posted): On Becoming a Better Therapist: Chapter Six Discussion. This chapter keeps the focus on you, encouraging you to envision your identity as a helper and further contemplate this unpredictable and complexly human enterprise called therapy. It takes a whimsical look at therapist identity using the classic fable, The Wizard of Oz, to illustrate three different therapist personas. Concomitant to reflection about your identity is your personal description of what therapy means to you. This chapter encourages you to define and continually edit your personal rendition of what you do as a therapist. Psychotherapy is presented as a discovery-oriented process, a non-cookie cutter search for what works for each unique client. Feedback provides a comforting compass, a way to manage the uncertainty that is just as characteristic of therapy as it is of life.

Register now at: https://www2.gotomeeting.com/register/537803827

I recently did an exchange with a reviewer of The Heart and Soul of Change: Delivering What Works (2nd Ed.):

The Heart and Soul of the Dodo: A Review of The Heart and Soul of Change (2nd Ed.)

Thomas L. Rodebaugh

“The time has come,” the Walrus said, “To talk of many things.”

In The Heart and Soul of Change: Delivering What Works in Therapy, considerable attention is paid to establishing that Saul Rosenzweig was the original articulator of the dodo bird hypothesis: All psychotherapies work about equally effectively. Let us look closer at the source of the quotation, found in Alice in Wonderland, “Everyone has won, and all must have prizes!” (Carroll, 1865 and 1871/1998, p. 49).

In the story, an assortment of animals and the protagonist, Alice, have become drenched in a sea of Alice’s own tears. The ensuing “Caucus-race” (Carroll, 1865 and 1871/1998, p. 48) is the dodo’s invention to motivate the creatures to dry themselves off. It is not actually a race to be won, which is also demonstrated by the pitiful prizes: Each animal receives a single comfit (a candied, dried fruit). Because the animals eat all of those, Alice herself receives a thimble. More precisely, she keeps a thimble, because the comfits and the thimble were her own to begin with.

The dodo bird’s statement is not meant to be a hypothesis: It is meant to quiet the animals. Taken literally, the declaration regarding winners and prizes is clearly intended as nonsensical. The dodo, otherwise best known as a dead bird, is thereby made immortal as a purveyor of nonsense. Rosenzweig’s use of the dodo as a witty epigram some 74 years ago was inspired; that the dodo should live on as a metaphor for psychotherapy research so many years later strikes me as truly strange.

The dodo is a strong force in The Heart and Soul of Change. The book is a series of chapters by different authors but maintains a structure largely focused on the dodo bird hypothesis, its historical context, the research that can be taken to support it, and its implications for practice. Much of the rest of the book consists of further demonstrations that the dodo bird hypothesis is the most sensible interpretation of the data, set alongside critiques of empirically supported therapies (ESTs) and policies that support their adoption. Some later chapters focus primarily on what should be the next steps given that the dodo bird’s viewpoint is better supported than is a viewpoint that emphasizes ESTs.

Any adherents to ESTs who stumble upon the book might be forgiven for thinking they had accidentally landed in the mirror world described in Lewis Carroll’s other famous adventure for Alice: They are likely to cry foul, that evidence has been distorted and conclusions have been drawn contrariwise. Most (but not all) of the authors opine that ESTs offer no advantage and have been massively overblown and overpromoted.

Yet supporters of ESTs will probably already have to hand several recent challenges to the dodo (e.g., Ehlers et al., 2010). Among these counterpoints, I find particularly lucid Siev and Chambless’s (2007) demonstration that one must examine specific treatments for specific disorders to uncover differences between treatments. Supporters of ESTs might question why such findings are not responded to in this book. Certainly at least Siev and Chambless’s meta-analysis was available at the time of the writing of the chapters. Such apparent stacking of the deck does little to persuade people already inclined to support ESTs.

This book is clearly not aimed at such readers; neither is it, despite the title, primarily aimed at individuals looking for a how-to book regarding common factors in therapy. Although a chapter by Norcross, “The Therapeutic Relationship,” presents an excellent summary of these factors and the research that has investigated them, very little evidence is given as to how these factors can be better brought to bear in therapy. That is, although it seems clear that (for example) a stronger therapeutic alliance is desirable, there appears to be little systematic research available to establish that any particular intervention (e.g., a type of therapist training) necessarily improves alliance (although feedback, dealt with below, is held up as an exception to this general rule).

In fact, in another chapter, Wampold indicates that piecemeal investigations of one of the common factors cannot be conducted successfully: “The presence or absence of a common factor cannot be manipulated” (pp. 72–73). If this were accurate, then true experiments regarding common factors would be impossible and their causal role would remain unclear to the many researchers and clinicians who rely upon strong causal inference to understand the nature of treatment (cf. Borkovec & Miranda, 1999).

For whom, then, is the book intended? People who are amenable to the dodo bird hypothesis or find support of ESTs misguided are most likely to find the book palatable, and presumably this is the target audience. It seems likely that many of the authors would like policy makers to read the book, although I am not sure how likely that outcome is. Although it might seem a curious recommendation, I suggest that those who most strongly believe that ESTs are valuable could benefit from reading this book. I do not think this book will likely sway many such readers, but I do think it will be very helpful in illuminating the concerns of the researchers and clinicians who find adherence to ESTs misguided.

As most readers will have probably already guessed, I myself am convinced of the value of ESTs, at least for some disorders. Nevertheless, I can see many of the authors’ points. Although the repetitive dismissal of ESTs and related research, found chapter after chapter, seems excessive (like beating a dead dodo), my primary disappointment in the book is that it contains so little information regarding what changes an individual practitioner could make that are known to improve outcomes. In short, readers looking for guidance in employing the common factors (aside from feedback) might do better to read the Norcross chapter and follow it with seminal work by previous authors (I have my own favorites: Rogers, 1961; Wachtel, 1993) rather than read the entire book.

The major concept put forward for improving the common factors is gathering systematic feedback from clients, focusing on avoiding or mending ruptures in the therapeutic relationship; two full chapters (and additional space in other chapters) are devoted to demonstrating that such feedback is valuable and can have effects in community mental health organizations. These chapters appear longer on promise than on specific guidelines on what works and what does not.
Much additional research needs to be done, but the point regarding the general value of feedback is well taken and should be well considered by any practicing clinician. Devotees of cognitive therapy might nevertheless find perplexing the news that “of course, one need not choose between giving feedback and using empirically supported treatments. They can work in concert” (see Lambert’s chapter, “‘Yes, It Is Time for Clinicians to Routinely Monitor Treatment Outcome,” p. 249). Feedback from clients in each session has long been emphasized by cognitive therapists (Beck, 1995).

Such verbal feedback does not match the technical and statistical sophistication of the processes reviewed in this book, but the same intent is there. That Lambert needs to point out that ESTs and feedback are, in fact, compatible speaks to a very strange disconnect, the fissures of which seem to run throughout the book.

Perhaps my underwhelmed reaction to this book speaks merely to the effects of my allegiances. Of course, the authors and editors have allegiances of their own, although I wonder if they are as uniform in those allegiances as it might seem at first glance. Upon a closer inspection, it seems to me that a range of understandings of the dodo hypothesis is expressed across chapters.

In the weakest form, the argument seems to assert merely that ESTs may have been overemphasized by some and that common factors deserve more research. In its strongest form, the argument seems to assert that (a) anything that therapists and clients can believe is a therapy will work as well as any other such treatment; (b) common factors explain virtually everything about the way therapy works, yet there is probably little that could be mandated that could improve their effects; and (c) naturalistic tracking of outcomes is perhaps the sole exception to (b) and can also conclusively demonstrate that therapy is useful. In the strongest form, then, therapy and therapists are treated as a set of black boxes: There is no way to systematically alter the functions of these boxes, yet one can select therapists and therapist/client dyads on the basis of results.

I find myself concerned that some readers, perhaps most particularly those who see ESTs as a magnifier of the bureaucratic nightmare of insurance company requirements, might too easily endorse the strong dodo hypothesis. The position might seem attractive because it basically implies that therapists should be allowed to do whatever it is they do.

However, this position strikes me as pregnant with unwanted consequences. If good therapy entails a special quality (in the therapist, client, or both) that cannot be systematically varied (that is, caused to be present in some courses of therapy but not others), then one might wonder why anyone should research psychotherapy at all.

It seems to me that rather than the (strong) dodo hypothesis, we would be better off listening, but just for a moment, to the walrus hypothesis: The time has come to talk of many things. The field of psychotherapy needs more research, using many approaches, at all levels; it does not need an excuse to leave well enough alone.

However, research is not the only consequence of the strong dodo hypothesis. Practice, too, could suffer. If being a good therapist cannot be systematically taught, who would want to pay for years of training? One might wonder: Why not let anyone, with any level of training, try out being a therapist? One could simply select those people who are able to get the best results while accepting a minimum wage (perhaps the minimum wage) as payment.

It seems to me that the strong dodo hypothesis supports a form of essentialism that will not do science, practice, or policy any good at all. Neither supporters of ESTs nor their detractors want to see the therapeutic practice of clinical psychology go the way of the dodo.

Some Therapies Are More Equal than Others? A response to the review of The Heart and Soul of Change: Delivering What Works in Therapy (2nd ed.)

Barry L. Duncan

Rodebaugh (2010) candidly admits his allegiance to empirically supported treatments (EST), which perhaps explains the myopic lens used to examine the book. The dodo verdict (“Everybody has won and all must have prizes.”) still perfectly describes the state of affairs in psychotherapy—all bona fide approaches, in spite of vociferously argued differences, appear to work equally well. It is the most replicated finding in the outcome literature. Commenting on the dodo verdict’s ubiquity is hardly “stacking of the deck” when the findings that contradict it are less than would be attributable to chance alone. Importantly, saying that the dodo verdict persists in no way suggests that specific treatments for particular problems are not helpful.

While we take a critical stance toward claims of model superiority and confirm the veracity of the dodo verdict across modalities and populations, we do not denigrate model and technique nor specific effects, but rather propose that model/technique are essential components of a common factors perspective. We offered a way to understand how 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.

We attempted to unite the warring factions via a more sophisticated understanding of change (interconnected factors, not disembodied parts or a tiresome specific v common factors polemic) as well as APA’s more contextual definition of evidence based practice. 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. Proponents from both sides of the common versus specific factors aisle have recognized that outcome is not guaranteed, regardless of evidentiary support of a given technique or the expertise of the therapist. Monitoring outcome with clients, what has been called practice based evidence, has been shown to significantly improve outcomes regardless of the treatment administered. There are now nine RCTs showing the significant benefits of feedback (Duncan, 2010).

Rodebaugh’s assertion that one must examine specific treatments for specific disorders to uncover differences between treatments ignores the many direct comparisons that have not yielded any differences for specific disorders, like the TDCRP, Project Match, the Youth Cannabis Project, to mention a few (see Duncan et al., 2010). Consider the study we didn’t cite (Siev & Chambless, 2007). Although it is hard to imagine many therapists who would solely do relaxation training with panic, CBT beat relaxation alone on primary measures (although a closer look at the five studies reveals that one was significantly more positive than the other four, and two found very little difference). But even accepting this investigation at face value, that CBT is better than relaxation for panic (but not GAD) on primary measures only, hardly seems like any definitive overturn of the dodo verdict.

Nowhere in the book is there any suggestion that the dodo verdict implies that we should “leave well enough alone” regarding research, or perhaps the most egregious comment, that anything goes in the consulting room—or that there is little point to training. Quite the contrary, the book advocates for a shift toward research and training about what works and how to deliver it, and away from a sole reliance on comparative, “battle of the brands,” clinical trials. For example, my colleagues and I recently explored the relationship of the alliance to outcome and found that it predicted outcome above early treatment change and that ascending alliance scores were associated with better outcomes (Anker, Owen, Duncan, & Sparks, 2010), a strong argument for continuous alliance assessment. The book also calls for a more sophisticated clinician who chooses from a variety of orientations and methods to best fit client preferences and cultural values. Although there has not been convincing evidence for differential efficacy among approaches, there is indeed differential efficacy for the client in the room now—therapists need expertise in a broad range of intervention options, including ESTs, a point made by several authors.

Dismissing the book on the basis that some therapies are more equal than others is reminiscent of another set of animals in another classic story. It’s time to transcend the polemics and instead focus on what works with the client in my office now.

A Response to Barry L. Duncan

Thomas L. Rodebaugh

Let me emphasize that my reaction to The Heart and Soul of Change: Delivering What Works in Therapy was not uniformly negative. Further, I did not intend my review to be completely negative. I found the book useful overall; some chapters were particularly helpful. It would be a shame if the current debate were to overshadow that point.

The current format demands brevity. A point-by-point response to Barry L. Duncan (all the way down to Animal Farm) is untenable. The interested reader might re-examine my original review; my answers to some of Duncan’s statements are already implied there.

Allow me to focus on the term bona fide, upon which the current version of the dodo bird hypothesis rests. Bona fide treatments are treatments that are intended to be therapeutic. Intended by whom? Duncan expresses doubt that “many psychologists” would use relaxation treatment alone to treat panic disorder. I know one psychologist who would do so. I have informally polled my colleagues, who state that they have encountered others. Perhaps it is important that many psychologists believe that a treatment should work before it be considered bona fide. How many?

Without precise definition, whether something is bona fide is a subjective judgment. Studies could be dismissed because particular authors believe a treatment not to be bona fide or because they believe the researchers probably did not believe them to be bona fide, even if the researchers actually thought otherwise. I have had only modest experiences with clinical trials, but even I have seen many variations in level of belief at different levels of study teams. Sometimes therapists seemed to clearly believe more or less in particular conditions than did the principal investigator(s). Is it the therapists, investigators, or psychologists at large who count? Unless we define what level of belief is needed in the individual clinician or researcher, or how many psychologists must have such belief, our resulting decisions cannot be consistent (cf. Ehlers et al., 2010, for similar concerns).

Duncan seems to dismiss the idea that his argument indicates that “anything goes” in treatment. I can see his point, if bona fide means that “many psychologists” believe a treatment should work. We could thus be saved from endorsing ludicrous, fringe treatments. All the more reason to stringently define bona fide and thus reduce confusion among psychologists interpreting this literature.

Yet ineffective treatments sometimes have a popular following. As Ehlers et al. (2010) have pointed out, critical incident stress debriefing is certainly one example of a treatment that psychologists intended to be therapeutic but seems, upon investigation, possibly worse than useless. The hypothesis is that all (bona fide) treatments have won. To disprove it requires only one that has lost.

And don’t forget to register for the free webinars covering each chapter of 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 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 have been thinking about and writing about the common factors and their operationalization for many years. Research continues to build a compelling case for the presence of pantheoretical factors in operation that overshadow any perceived or presumed differences among approaches. For example, our alliance article soon to be published in the Journal of Consulting and Clincal Psychology found the alliance to be predictive of outcome over and above early treatment change and our in preparation investigation of therapist effects found that differences among therapists were best explained by their alliance abilities–over gender, discipline, or experience (more on both of these studies later). Some of you may have seen my depiction of the factors shown below:

I am always striving to describe the factors in a way that illustrates their interdependence. Here is my latest effort: Five factors comprise this perspective: client, therapist, alliance, the model/technique delivered, and feedback—all 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. And the only way to know whether the common factors are in operation is to obtain real time client feedback about the benefit and fit of services. Feedback overlaps with and affects all the factors—it is the tie that binds them together—allowing the common factors to be delivered 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 is itself a core feature of therapeutic change.

And I believe the only way to fully understand the importance of the common factors, including feedback, is to see them in action with real clients. Consequently, a new feature has been added to CDOI Members: actual client videos (client idenities are protected) are now available to Members for anytime viewing and learning.

Also, please check out the free webinars about my new book, On Becomng a Better Therapist. They are posted as they occur on the Video page, and the pdf of the slides as well as the videos are posted on the discussion page.

Finally, check out the following video made by Robyn Pope, a certified CDOI trainer of the Heart and Soul of Change Project, of staff at Wesley Community Action.  Wesley is a broad based social service agency that provides culturally sensitive and socially just services in non traditional settings. Robyn solicits staff reactions about the use of the Outcome Rating Scale and Session Rating Scale, including how they have grown professionally and personally as well as the challenges they have faced in implementation.

Clients are indeed the best teachers. The following client, Peter, taught me about the importance of soliciting client ideas about what might be helpful or what I later called “the client’s theory of change.” This is an excerpt from On Becoming a Better Therapist:

When I was an intern, I worked in an outpatient unit euphemistically called the “Specialized Adult Services” unit. While about a fifth of my referrals came from a stress management program, it was really an aftercare facility devoted to working with clients with the moniker “severely mentally ill.” By that time, I had acquired experiences in two CMHCs and an assessment/therapy stint in the state hospital. But the hospital experience lingered, leaving me with a bad taste in my mouth. I saw firsthand the facial grimaces and tongue wagging that characterize the neurological damage caused by antipsychotics and sadly realized that these young adults would be forever branded as grotesquely different, as “mental patients.” I witnessed the dehumanization of people reduced to drooling, shuffling zombies, spoken to like children and treated like cattle. I barely kept my head above water as hopelessness flooded the halls of the hospital, drowning staff and clients alike in an ocean of lost causes. I could not even imagine what it would have been like to live there in the revolving door fashion that many were forced to endure. Now, in my internship position, my charge was to help people stay out of the hospital, and I took that charge quite seriously.

One of my first clients was Peter. Peter was not very liked at the SAS unit. He sometimes said ominous things to other clients in the waiting room, or often spoke in a boisterous way about how the florescent lights controlled his thinking through a hole in his head. When he wasn’t speaking, he grunted and squealed and made other sounds like a pig. As a new intern, I was put under considerable pressure to address Peter’s less than endearing behaviors, particularly because he sometimes offended the stress management clients, who were seen as coveted treasures not to be messed with. Actually, I found Peter to be a terrific guy with a very dry sense of humor, but a man of little hope who lived in constant dread of returning to the state hospital. His behaviors were mostly his efforts to distract himself from tormenting voices that told him that people were trying to kill him and other scary things.

Peter’s unfortunate routine was that he was terrorized by these voices until he started taking actions that would ultimately wind him up in the state hospital. He might empty his refrigerator for fear that someone had poisoned his food, creating a stench that would soon bring in the landlord and ultimately the authorities. Or, occasionally he would start threatening or menacing others, those he believed were trying to kill him. One time he took an empty rifle and perched on an overpass trying to figure out who was on their way to kill him, thinking he could ward them off. Once hospitalized, his medications were changed, usually increased in dose, and he essentially slept out the crisis. These cycles occurred about every four to six months and had so for the last eight years. Peter’s treatment brought with it tardive dyskinesia and about a hundred pounds of extra weight.

Peter hated the state hospital and I could truly commiserate, after my less than inspiring experience there. I felt profoundly sad for this young man, who was about the same age as me. I also felt completely helpless. Nothing in my training provided any guidance. I had no clue about what to do to be helpful to him. I was trying to apply strategies I learned from my supervisor about addressing the voices, which were helpful to others, but not with Peter. I knew he was ramping up for another admission—he told me that he had already emptied his refrigerator and left it on the kitchen floor. I hit a brick wall. It seemed that nothing I said could convince Peter to get off the merry go round to the state hospital. The anguish in his eyes about his impending hospitalization haunted me.

Only because I had no clue about what to do, I asked Peter what he thought it would take to get a little relief from his situation—what might give him just a glimpse of a break from the torment of the voices and the revolving door hospitalizations. After a long pause, Peter said something very curious—he said that it would help if he would start riding his bike again. This led to my inquiry about the word “again.” Peter told me about what his life was like before the bottom fell out. Peter had been quite the competitive cyclist in college and was physically fit as only world class cyclists can be. I heard the story of a young man away from home for the first time, overwhelmed by life, training day and night to keep his spot on the racing team, and topped off by falling in love for the first time. When the inevitable came to pass and the relationship ended, it was too much for Peter, and he was hospitalized, and then hospitalized again, then hospitalized again, and so on until there was no more money or insurance—then the state hospitalization cycles ensued.

On a roll now and enjoying a level of conversation not achieved before, I asked Peter what it would take to get him going again on his bike. He said that his bike was in need of parts and what he needed was for me to accompany him to the bike shop. Peter was afraid to go out in public alone for fear of threatening someone and ending up in the hospital. I immediately consulted with my supervisor who had the good sense here (and on many occasions) to give me an enthusiastic green light. The next day, I went with Peter to the bike shop, where I, bought a bike as well. Peter and I started having our sessions biking together. Peter still struggled with the voices at times, but he stayed out of the hospital and they never kept him from biking. He eventually joined a bike club and moved into an unsupervised living arrangement.

You can read a lot of books about schizophrenia and its treatment but you’ll never find one that recommends biking as a cure. And you can read a lot of books about treatments in general, and you’ll never read a better idea about a client dilemma than will emerge from a client in conversation with you—a person who cares and wants to be helpful.

The first Discussion Webinar covering Chapter One of On Becoming a Better Therapist is history. It was a great discussion and lots of fun. Over a hundred folks joined me for a lively Q and A.  Watch the video of the Chapter One Discussion and enjoy some great comments and questions.

Here is the description of the free webinar series and the details of the Chapter Two Webinar on August 26.

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 second of seven webinars corresponding to the seven chapters of the book, I will present a 15 minute overview of the second 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 become a better therapist.

Hope you can make the next one: August 26, 6-7:30PM. Register now at: https://www2.gotomeeting.com/register/525541291

Remember, it’s free! If you can’t make the live event, each discussion will be posted for your anytime watching pleasure at: http://heartandsoulofchange.com/on-becoming-a-better-therapist-free-discussion-webinars/

Here is an excerpt from On Becoming a Better Therapist:

While I often don’t remember where I leave my glasses, I still vividly recall my first client, Tina. A long time ago in a galaxy far way, I was in my initial clinical placement in graduate school at the Dayton Mental Health and Developmental Center, a euphemism for the state hospital. Tina was like a lot of the clients: young, poor, disenfranchised, heavily medicated, and on the merry-go-round of hospitalizations—and, at the ripe old age of 22, a “chronic schizophrenic.”

I gathered up the battery of tests I was attempting to gain competence with, and was on my merry but nervous way to the assessment office, a stark, run-down room in a long past its prime, barrack-style building that reeked of cleaning fluids over-used to cover up some other worse smell, the institutional stench. But on the way I couldn’t help but notice all the looks I was getting—a smirk from an orderly, a wink from a nurse, and funny looking smiles from nearly everyone else. My curiosity piqued, I was just about to ask what was going on when the chief psychologist, a kindly old guy, put his hand on my shoulder and said, “Barry, you might want to leave the door open.” And I did.

I greeted Tina, a young, extremely pale woman with short brown, cropped hair, who might have looked a bit like Mia Farrow in the Rosemary’s Baby era had Tina lived in friendlier circumstances, and introduced myself in my most professional voice. And before I could sit down and open up my test kit, Tina started to take off her clothes, mumbling something indiscernible. I just stared in disbelief. Tina was undaunted by my dismay and quickly was down to her bra and underwear when I finally broke my silence and said, “Tina, what are you doing? Tina responded not with words but with actions, removing her bra like it had suddenly become made of wool and very uncomfortable. So there we were, a graduate student, speechless, in his first professional encounter, and a client sitting nearly naked, mumbling now quite loudly but still nothing I could understand, and contemplating whether to stand up to take her underwear off or simply continue her mission while sitting.

In desperation, I pleaded, “Tina, would you please do me a big favor? She looked at me for the first time, and said, “What?” I replied, “I would really be grateful if you could put your clothes back on and help me get through this assessment. I’ve done them before, but never with a client, and I am kinda freaked out about it.” Tina whispered, “Sure,” and put her clothes back on. And although Tina struggled with the testing and clearly was not enjoying herself, she completed it. I was so genuinely appreciate of Tina’s help that I told her she really pulled me through my first real assessment. She smiled proudly, and ultimately smiled at me every time she saw me from then on.

So Tina started my psychotherapy journey and offered up my first lessons for consideration: authenticity matters and when in doubt or in need of help, ask the client. Those lessons have served me well.

On Becoming demonstrates how systematic client feedback provides the means for clients to teach you how to do good work. It embodies the lessons I learned from Tina, providing for a transparent interpersonal process that solicits the clients help in ensuring a positive outcome.

Please join me this July 22 at 6PM Central for a free 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 .

July 22: 6PM Central to 7:30 It’s free! Every month a free webinar!

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

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!