So I think students need to understand the value of treatment models within a developmental context and an understanding of the general aspects that models bring to the table.

The next larger context is the alliance. In an important way, the alliance is dependent on the delivery of some particular treatment—a framework for understanding and solving the problem. The alliance cannot happen without technique. If technique fails to engage the client in purposive work, it is not working properly and a change is needed. Technique is an activity—the alliance is a way to characterize that activity; the alliance is the purpose of the activity. Although it is possible for a strong relationship to develop, there can be no agreement about the tasks of therapy, a critical aspect of the alliance, without some discussion and negotiation of what “treatment” will be used—be it some specific approach, the client’s own ideas and cultural preferences, or some unique blend.

The issue of resonance and the agreement about tasks—finding a framework for therapy that both the therapist and the client can believe in—is why it makes a lot of sense to ask clients about their ideas about how to proceed, or at the very least getting client approval of any intervention plan. Not surprisingly, Frank and Frank (1991) said it best: “Ideally, therapists should select for each patient the therapy that accords, or can be brought to accord, with the patient’s personal characteristics and view of the problem’’ (p. xv). But Frank was not the first and in fact the idea of matching client preferences and worldview goes back to Paul Hoch, Milton Erickson, and the MRI. Traditionally, such a process has not been the case—the search has been for interventions that promote change by validating the therapist’s favored theory. Serving the alliance requires taking a different angle—the search for ideas that promote change by validating the client’s view of what is helpful—or what I have called, based on the work of Erickson and the MRI, the client’s theory of change (Duncan et al., 1992; Duncan & Moynihan, 1994). Here is an article about the client’s theory of change:

Finally, the third context is regarding evidence based treatment itself and the difference between evidence based treatments and evidence based practice as defined by APA. Jeff Reese and I recently wrote a chapter about this and I will post it after it is published. They are two fundamentally different approaches to defining and disseminating evidence (Littell, 2010; see her chapter in Heart and Soul of Change)—one that seeks to improve clinical practice via the dissemination of treatments meeting a minimum standard of empirical support (EBT) and another that describes a process of research application to practice that includes clinical judgment and client preferences (EBP). 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 as 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 load the silver bullet into any psychotherapy revolver and shoot the psychic werewolf stalking the client. This is the essence of an EBT approach, characterized by Division 12, depicting confidence in the available evidence and appealing to those who believe that more structure and consistency and less clinician judgment is needed to bring about positive outcomes in mental health and substance abuse services. On the other hand, EBP reflects the understanding that scientific evidence is tentative and that outcome is dependent not only on applying the various types of empirical research but also on the participants. EBP appeals to those who value clinician autonomy and individualized treatment decisions based on unique presentations of clients. The APA Task Force definition on EBP exemplifies this approach to the evidence: “the integration of the best available research with clinical expertise in the context of patient [sic] characteristics, culture, and preferences” (APA Task Force 2006, p. 273).
The first part, “the integration of the best available research,” includes the consideration of EBTs without privileging them, as well as the wide range of findings regarding the alliance and other common factors. Next, “with clinical expertise,” in contrast to the EBT mentality of the therapist as an interchangeable part, brings the therapist into the equation—highlighting what therapists bring is consistent with emerging research about the importance of clinician variability to outcome. Moreover, the Task Force submitted: “Clinical expertise also entails the monitoring of patient progress…” (APA, 2006, p. 276–277). Finally, “in the context of patient characteristics, culture, and preferences” rightfully emphasizes what the client brings to the therapeutic stage as well as the acceptability of any intervention to the client’s expectations, how well any model or technique resonates. In short, EBP accommodates the common factors, reinforces the importance of the therapist and client, and includes client feedback as a necessary component.

So if these larger contexts of understanding EBTs are included, I believe that EBTs should be taught in graduate training programs. Graduate training should call for a more sophisticated and empirically informed 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 effectiveness for the client in the room now—therapists need expertise in a broad range of intervention options, including evidence based treatments, but must remember that the proof of the pudding is in the taste.

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

Now Jackie’s program is not the only one.

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

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

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

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

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

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