heartandsoulofchangeslides

www.heartandsoulofchange.com 11/23/2010

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On Becominga Better Therapist

The Heart and Soul of Change

Barry Duncan,Barry Duncan, Psy.DPsy.D. www.heartandsoulofchange.com. www.heartandsoulofchange.com954.721.2981 www.whatsrighwithyou.com954.721.2981 www.whatsrighwithyou.com

[email protected]@comcast.net


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Winter Getaway!Training of Trainers

Winter Getaway!Training of Trainers

HSCP Training of Trainers(TOT): Jan. 31- Feb. 4,2011 (24 hours of CEs)This intensive trainingexperience gives you all youneed to train others andimplement CDOI. And itprovides the first step inbecoming an HSCP CertifiedTrainer of CDOI.

HSCP Training of Trainers(TOT): Jan. 31- Feb. 4,2011 (24 hours of CEs)This intensive trainingexperience gives you all youneed to train others andimplement CDOI. And itprovides the first step inbecoming an HSCP CertifiedTrainer of CDOI.


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I Admit ItI’m a SnobI Admit ItI’m a Snob

Not about money,possessions, wine,food, coffee, socialstatus, etc. I am asnob about therapy,the work I love, &about who teachesme about it, and…

Not about money,possessions, wine,food, coffee, socialstatus, etc. I am asnob about therapy,the work I love, &about who teachesme about it, and…

Rock StarsBut Haven’t Done Much Therapy

Rock StarsBut Haven’t Done Much Therapy

Some of the biggestworkshop stars haveminimal therapyexperience…some have notheld one full time therapygig—went from graduateschool to doing workshopsbased on luck of assoc. withfamous folks and/or abilityto put on a good show.

Some of the biggestworkshop stars haveminimal therapyexperience…some have notheld one full time therapygig—went from graduateschool to doing workshopsbased on luck of assoc. withfamous folks and/or abilityto put on a good show.


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And Then.There Are the Researchers

And Then.There Are the Researchers

Should be consumed &translated by clinicians. Goal…

But I get a bit chaffed whenthey presume too much—whattherapists should do. Meta-analysis & HLM only go so far.

Not saying that there isn’tmuch to learn, just that I am asnob about psychotherapy andwho teaches me about it.

Should be consumed &translated by clinicians. Goal…

But I get a bit chaffed whenthey presume too much—whattherapists should do. Meta-analysis & HLM only go so far.

Not saying that there isn’tmuch to learn, just that I am asnob about psychotherapy andwho teaches me about it.

Chapter 5My Voice in Hopeful Harmony

Chapter 5My Voice in Hopeful Harmony

with the best of whatresearch has to offer.This chapter picks upon the discussion ofcumulative careerdevelopment andoffers empirically-based suggestions forimproving your work

with the best of whatresearch has to offer.This chapter picks upon the discussion ofcumulative careerdevelopment andoffers empirically-based suggestions forimproving your work


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Chapter 5 Brings YouThe Heart and Soul of Change

Chapter 5 Brings YouThe Heart and Soul of Change

What the client brings totherapy and the impact of thealliance gave rise to the name Igave the co-edited book aboutthe common factors—the clientis the heart and the alliance isthe soul. Your focus on theseprimary sources, in conjunctionwith attaining client feedback isthe best way to accelerate yourdevelopment—the biggest bangfor your buck.

What the client brings totherapy and the impact of thealliance gave rise to the name Igave the co-edited book aboutthe common factors—the clientis the heart and the alliance isthe soul. Your focus on theseprimary sources, in conjunctionwith attaining client feedback isthe best way to accelerate yourdevelopment—the biggest bangfor your buck.

Client/Extratherapeutic Factors (87%)

Treatment Effects13%

Feedback Effects15-31%

Alliance Effects38-54%

Model/Technique8%

Model/Technique Delivered:Expectancy/AllegianceRationale/Ritual (GeneralEffects)

30-?%

Therapist Effects46-69%

Duncan, B. (2010). On becoming a better therapist.Washington DC: American PsychologicalAssociation


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Becoming BetterBottom Line

Becoming BetterBottom Line

Suggests adifferent focus

Enlist, harvest,rally, recruit clientresources to thecause of change

Suggests adifferent focus

Enlist, harvest,rally, recruit clientresources to thecause of change

“The quality ofthe patient'sparticipation . . .[emerges] asthe mostimportantdeterminant ofoutcome."

Orlinsky, D. E., Rønnestad, M. H., & Willutzki, U. (2004). Fifty years ofprocess -outcome research: In M. J. Lambert (Ed.), Bergin andGarfield’s handbook of psychotherapy and behavior change (5th ed.,pp. 307-390). New York: Wiley.

Until lions have theirUntil lions have theirhistorians, tales ofhistorians, tales ofhunting will alwayshunting will alwaysglorify the hunter.glorify the hunter.

African Proverb

Clients Are the Lions of Change


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Casting the Client in Heroic RolesCasting the Client in Heroic Roles

No formula here, more of an attituderequiring a balance betweenlistening empathically withmindfulness toward resources thatyou know are there.

Identify not what clients need, butwhat they already have in their worldthat can be put to use in reachingtheir goals

No formula here, more of an attituderequiring a balance betweenlistening empathically withmindfulness toward resources thatyou know are there.

Identify not what clients need, butwhat they already have in their worldthat can be put to use in reachingtheir goals

Finding the Heroic ClientFinding the Heroic Client

What are the qualities that describe you when

you are your very best? What were you doing

when these aspects became apparent to you?

What kind of person do these aspects describe?

Or, What kind of person do these aspects show an

aspiration toward?

What are the qualities that others would describe

In you when you are at your very best? What

were you doing when they noticed these aspects?


Or, what kind of person do these aspects show an

aspiration toward?

What are the qualities that describe you when

you are your very best? What were you doing

when these aspects became apparent to you?


Or, What kind of person do these aspects show an

aspiration toward?

What are the qualities that others would describe

In you when you are at your very best? What

were you doing when they noticed these aspects?


Or, what kind of person do these aspects show an

aspiration toward?


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Finding the Heroic ClientFinding the Heroic Client

Who was the first person to tell you that theynoticed the best of you in action? What wereyou doing when they noticed these aspects?

Who was the last person to tell you that theynoticed the best of you in action? What wereyou doing when they noticed these aspects?

Who in your life wouldn’t be surprised to seeyou stand up to these situations and prevail?What experiences would they draw upon tomake these conclusions about you? What“quintessentially you” stories would theytell?...Kim

When I am at my very best, I am_____________.

Who was the first person to tell you that theynoticed the best of you in action? What wereyou doing when they noticed these aspects?

Who was the last person to tell you that theynoticed the best of you in action? What wereyou doing when they noticed these aspects?

Who in your life wouldn’t be surprised to seeyou stand up to these situations and prevail?What experiences would they draw upon tomake these conclusions about you? What“quintessentially you” stories would theytell?...Kim

When I am at my very best, I am_____________.

Telling Heroic StoriesTelling Heroic Stories

What are the obvious and hiddenstrengths, resources, resiliencies,and competences contained in theclient’s story?

What are the competing stories—thestories of clarity, coping, endurance,and desire that exist simultaneouslywith the confusion, pain, suffering,and desperation?

What is already there to be recruitedfor change?

What are the obvious and hiddenstrengths, resources, resiliencies,and competences contained in theclient’s story?

What are the competing stories—thestories of clarity, coping, endurance,and desire that exist simultaneouslywith the confusion, pain, suffering,and desperation?

What is already there to be recruitedfor change? The Heroic Client


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Sam—the Violent Suicidal ManSam—the Violent Suicidal Man

Story of “Threats”

Story of “Suicide”

Story of “StrangeBeliefs”…wants anapocalypse

Story of “Threats”

Story of “Suicide”

Story of “StrangeBeliefs”…wants anapocalypse

Sam’s Heroic StorySam’s Heroic Story

Story of a man with awarrior inside.

Story of a man who controlshis rage.

Story of a natural bornleader wanting to do somegood in the world.

Story of a man with awarrior inside.

Story of a man who controlshis rage.

Story of a natural bornleader wanting to do somegood in the world.


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Client is the of ChangeClient is the of Change

Client’s Resources,Resiliencies, andRelational Support

Client’s View of theAlliance

Client’s View of Progress& Expectation of Success

Many ways to learn toengage client strengths

Client’s Resources,Resiliencies, andRelational Support

Client’s View of theAlliance

Client’s View of Progress& Expectation of Success

Many ways to learn toengage client strengths

ClientsThe Heart of Change

ClientsThe Heart of Change

Client outcome feedbackmakes consumers thehistorians of their ownchange

Partnering w/clients tomonitor outcome engagesmost the potent factor ofchange


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Model/Technique8%


30-?%



Therapists Variables thatPredict Change

Therapists Variables thatPredict Change

Therapists with thebest results:

Are better at thealliance acrossclients; allianceability accounts fortherapist differences

Therapists with thebest results:

Are better at thealliance acrossclients; allianceability accounts fortherapist differences

Baldwin et al. (2007). Untangling the alliance-outcomecorrelation. Journal of Consulting and Clinical Psychology,75(6), 842-852.;Anker, Owen, Duncan, & Sparks (2010). The alliance incouple therapy. Journal of Consulting and ClinicalPsychology.Owen, Duncan, Anker, & Sparks (2010). Therapist variabilityin couple therapy. Manuscript submitted for publication.


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Model/Technique8%


30-?%



The Alliance:The Alliance:OverOver 10001000 Research FindingsResearch Findings

Quality of the alliance morepotent predictor of outcome thanorientation, experience, orprofessional discipline-- recallTDCRP, MATCH, CYT.

Clients rarely report negativereactions before deciding toterminate.

Same holds true for youth andfamily therapy


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Project MATCHProject MATCH

••No difference in outcome between voluntaryNo difference in outcome between voluntaryand mandated clients.and mandated clients.

••The only reliable predictor?The only reliable predictor?••The AllianceThe Alliance

Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 7-29.Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participationand outcome. Journal of Consulting and Clinical Psychology, 65(4), 588-98.

What about theWhat about the mandatedmandated clients?clients?

Model ManiacsArguments Against the Alliance

•Findings only correlational,even though over 1000reported associations…likeargument about smokingcigarettes & cancer!•Don’t know direction of thecorrelation—the chicken orthe egg: does change causehigh alliance ratings or does ahigh alliance cause change


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Alliance

Alliance score at session 3 predicts outcome over and abovethe effects of early symptom change...The alliance createschange and is not just an artifact of it.

Disentangling the Alliance-Outcome Correlation

Anker, Owen,Duncan, & Sparks(2010). The alliancein couple therapy.Journal ofConsulting andClinical Psychology,78(5), 635-645.

••Increasingly, the relationship isIncreasingly, the relationship isviewed as merely “setting the stage”viewed as merely “setting the stage”for the “real” treatment:for the “real” treatment:

••Confronting distorted thoughts;Confronting distorted thoughts;••Recovering forgotten memories;Recovering forgotten memories;••Asking special questions;Asking special questions;••Tapping on or waving fingers in front of theTapping on or waving fingers in front of theface…but the data say:face…but the data say:

••The alliance deserves farThe alliance deserves farmoremore RESPECT…RESPECT…

Research into PracticeThe Alliance

Research into PracticeThe Alliance

Duncan, B. (2010). On becoming a better therapist. Washington, DC: APA.


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Alliance As An Overarching FrameworkThe Alliance is the Soul

Alliance As An Overarching FrameworkThe Alliance is the Soul

Transcends any beh & isa property of all—fromtech. to scheduling appt

Purpose is to engage inpurposive work

Have to earn it each &every time; alliance isour craft; practiceelevates to art

Transcends any beh & isa property of all—fromtech. to scheduling appt

Purpose is to engage inpurposive work

Have to earn it each &every time; alliance isour craft; practiceelevates to art

Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass

Relationship FactorsRelationship Factors

The Alliance:The Alliance:

•• Relational BondRelational Bond•• Agreement onAgreement on goals• Agreement on tasksAgreement on tasks

Seven TimesSeven Times the Impact ofthe Impact ofModel/Technique…AccountsModel/Technique…Accountsfor Most of Therapistfor Most of TherapistVarianceVariance

3838--54%54%


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Means orMeans orMethods:Methods:Theory ofTheory ofChangeChange

Goals,Goals,MeaningMeaning

ororPurposePurpose

The Therapeutic AllianceThe Therapeutic Alliance

The AllianceThe Alliance

Client’s View of theClient’s View of theRelationshipRelationship

RelianceReliance on theon the AllianceAlliance

• Be friendly, responsive, andflexible (like a first date); stayclose to client’s experience.

• Empathy and Positive Regard:Validate. Legitimize the client’sconcerns/basic worth and theimportance of their struggle.

• Work on client’s goals period.

• Fit the client’s theory of change.


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EmpathyCarl Rogers Was On To Something

EmpathyCarl Rogers Was On To Something

Empathy. A meta-analysis of47 studies: r of .26 betweentherapist empathy andpsychotherapy outcome,translating to ES of .32.

ES of model and techniquedifferences is but .20; Client’sperception of empathy morepowerful than any techniqueyou can ever wield.

Empathy. A meta-analysis of47 studies: r of .26 betweentherapist empathy andpsychotherapy outcome,translating to ES of .32.

ES of model and techniquedifferences is but .20; Client’sperception of empathy morepowerful than any techniqueyou can ever wield.

Positive Regard: warm acceptanceof client w/o conditions.

When outcome & positive regardwere both rated by clients, 88%of studies found sig. relationship.Critical that clients think we viewthem positively.

Appreciation: appreciation ofpeople in general, their struggles,and of their humanity and innategoodness…Cary

Positive Regard: warm acceptanceof client w/o conditions.

When outcome & positive regardwere both rated by clients, 88%of studies found sig. relationship.Critical that clients think we viewthem positively.

Appreciation: appreciation ofpeople in general, their struggles,and of their humanity and innategoodness…Cary

Empathy Plus Positive RegardEquals Validation

Empathy Plus Positive RegardEquals Validation


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The Rubber Hose of Doubtand the Bright Light of BlameThe Rubber Hose of Doubt

and the Bright Light of Blame

Validation doesn’t mean you agree withwhat the client has done; means thatyou acknowledge the rest of the story!

Puts client’s actions in a context thatlegitimizes him/her as a human being.No wonder…

Clears a path for change because itdiffuses self doubt and dissipates selfloathing…Sam…Cary

Validation doesn’t mean you agree withwhat the client has done; means thatyou acknowledge the rest of the story!

Puts client’s actions in a context thatlegitimizes him/her as a human being.No wonder…

Clears a path for change because itdiffuses self doubt and dissipates selfloathing…Sam…Cary

You are the problem!You are to blame!

RelianceReliance on theon the AllianceAlliance

• Be friendly, responsive, andflexible (like a first date); stayclose to client’s experience.

• Empathy and Positive Regard:Validate. Legitimize the client’sconcerns/basic worth and theimportance of their struggle.

• Work on client’s goals period.

• Fit the client’s theory of change.


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The Client’s Theory of ChangeThe Client’s Theory of Change

PrePre--existing beliefsexisting beliefsabout the problemabout the problemand changeand change

Source: Duncan, B., Solovey, A., & Rusk, G. (1992). Changing the Rules. NewYork: Guilford.

Plurality Pays OffDifferential Efficacy with Current Client

Plurality Pays OffDifferential Efficacy with Current Client

Q: Does it resonate; does itfit client preferences; canboth get behind it?

Alliance skills: explore clientideas, discuss options,collaboratively plan, andnegotiate changes if benefitnot forthcoming.

Alliance in action. Litmustest: whether it engagesclient in purposive work.

Q: Does it resonate; does itfit client preferences; canboth get behind it?

Alliance skills: explore clientideas, discuss options,collaboratively plan, andnegotiate changes if benefitnot forthcoming.

Alliance in action. Litmustest: whether it engagesclient in purposive work.


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Attitude ImportantAlliance is Central Filter

Attitude ImportantAlliance is Central Filter

Is what I am doing andsaying now building orrisking the alliance?

Doesn’t mean you can’tchallenge but ratherthat you have to earnthe right and, considerthe allianceconsequences

Is what I am doing andsaying now building orrisking the alliance?

Doesn’t mean you can’tchallenge but ratherthat you have to earnthe right and, considerthe allianceconsequences

Bottom LineThere Are Many Ways

Bottom LineThere Are Many Ways

To understand & apply relationship skillsand research offers key guidelinesregarding what is important to outcomefrom the client’s point of view.

Take on your relational skills as a project,the central symbol of your development.Try on the different systems of skills forsize and watch your outcomes improve asyou refine ways to purposefully involveyour clients in the work.

To understand & apply relationship skillsand research offers key guidelinesregarding what is important to outcomefrom the client’s point of view.

Take on your relational skills as a project,the central symbol of your development.Try on the different systems of skills forsize and watch your outcomes improve asyou refine ways to purposefully involveyour clients in the work.


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The AllianceThe of Change

The AllianceThe of Change

Alliance feedback enables a fitbetween client expectations,preferences, and services

Does not leave the alliance tochance—applying over 1000studies showing therelationship of the alliance topositive outcomes

Interdependent & overlapping: Technique is the alliancein action, an explanation for the client’s difficulties & aremedy for them—an expression of the therapist’s beliefthat it could be helpful in hopes of inspiring the sameresponse in the client. Cannot have an alliance w/o a tx,an agreement about how therapy will address clientgoals. Similarly, you can’t have a positive expectation forchange w/o a credible way for both the client & therapistto understand how change can happen.





Model/Technique8%


30-?%



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Feedback As A Common FactorFeedback As A Common Factor

Overlaps with & affects allfactors—tie that binds

Soliciting feedback is aliving, process that engagesclients in monitoringoutcome, heightens hope,fits client preferences,maximizes therapist-clientfit, and is itself a corefeature of change.

Overlaps with & affects allfactors—tie that binds

Soliciting feedback is aliving, process that engagesclients in monitoringoutcome, heightens hope,fits client preferences,maximizes therapist-clientfit, and is itself a corefeature of change.

By focusing on what is known about the commonfactors, especially the heart and soul of change.Working on harvesting client resources andsecuring strong alliances is a great place to start(and continue) to grow as a therapist.

You Can Be Proactive in Other Ways

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