networker2011

www.heartandsoulofchange.com 3/25/11

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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

A Roadmap toProfessional Development

Becoming aBetter Therapist


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How Do We Get Better?How Do We Get Better?


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Question #1:Question #1:

Becoming moreBecoming moreaccurate at diagnosisaccurate at diagnosisimproves treatmentimproves treatmentmatching andmatching andtherefore outcomestherefore outcomes

FalseFalseDiagnosis has noDiagnosis has norelationship torelationship toOutcome in MentalOutcome in MentalHealth/SubstanceHealth/SubstanceAbuse ServicesAbuse Services

How Do We Get BetterPop Quiz


“Psychotherapy is the only form of treatmentwhich, at least to some extent, appears to createthe illness it treats” Jerome Frank (Frank, 1961,p. 7).

Reliability: “To say that we've solved thereliability problem is just not true…It's beenimproved. But if you're in a situation with ageneral clinician it's certainly not very good.There's still a real problem, and it's not clearhow to solve the problem" Robert Spitzer, leadeditor of DSM III (Spiegel, 2005, p. 63).

Validity: “There is no definition of a mentaldisorder. It’s bullshit. I mean, you just can’tdefine it… these concepts are virtuallyimpossible to define precisely with bright lines atthe boundaries.” Allen Francis, lead editor ofDSM IV (Greenberg, 2010, p. 1).

Quotable Quotes about Diagnosis

•Creates the Illness•Reliability not good•It’s BS


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QuestionQuestion #2:#2:

Finding the rightFinding the rightapproach orapproach orselecting evidenceselecting evidencebased treatmentsbased treatmentswill improvewill improveoutcomesoutcomes

FalseFalseStudy after study, andStudy after study, andstudies of studiesstudies of studiesshow that allshow that alltreatments are thetreatments are theright treatmentright treatment——forforsome clients.some clients.



Evidenced Based TreatmentNone Have Shown SuperiorityEvidenced Based Treatment

None Have Shown Superiority

Rosenzweig, S. (1936). Some implicit commonRosenzweig, S. (1936). Some implicit commonfactors in diverse methods in psychotherapy.factors in diverse methods in psychotherapy.Journal of Orthopsychiatry, 6Journal of Orthopsychiatry, 6, 412, 412--15.15.

••Nothing wrong with EBTs but DodoNothing wrong with EBTs but Dodohighlights fatal flaw:highlights fatal flaw: Being betterBeing betterthan placebo/TAU is notthan placebo/TAU is not sayingsayingmuchmuch——ifif a friend went out on adate, you asked about the guy, yourfriend replied, “He was better thannothing—he was unequivocallybetter than watching TV or washingmy hair.” How impressed?How impressed?

••And the conclusion…And the conclusion…


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Personal therapy andPersonal therapy andincreasing our selfincreasing our selfawareness makes us aawareness makes us abetter person andbetter person andimproves our outcomesimproves our outcomes

FalseFalseWhile therapists findWhile therapists findpersonal therapypersonal therapyinvaluable, it neitherinvaluable, it neitherhelps nor hindershelps nor hindersoutcomes.outcomes.

Geller, J.,Geller, J., NorcorssNorcorss, J.,&, J.,& OrlinkskyOrlinksky D. (2005).D. (2005). TheThepsychotherapist’s Own Psychotherapy.psychotherapist’s Own Psychotherapy. New York:New York:Oxford Univ. Press.Oxford Univ. Press.




ProfessionalProfessionalTraining andTraining andContinuingContinuingEducation have aEducation have adirect impact ondirect impact onoutcomesoutcomes..

FALSEFALSENo difference inNo difference inoutcomes betweenoutcomes betweendisciplines, trainingdisciplines, trainingmodels, and not onemodels, and not onestudy supports CE asstudy supports CE ashelping outcomeshelping outcomes


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The Value of TrainingAnother Nail in the Coffin

The Value of TrainingAnother Nail in the Coffin

Didn’t matter tooutcome if theclient was “seen bya lic. doctoral–levelcounselor, a pre-doctoral intern, orpracticum student.”

Didn’t matter tooutcome if theclient was “seen bya lic. doctoral–levelcounselor, a pre-doctoral intern, orpracticum student.” Nyman, S. J., Nafziger, M. A., Smith, T. B. (2010).

Client outcomes across counselor training levelwithin a multi-tiered supervision model. Journal ofCounseling and Development, 88, 204-209.




The accruedThe accruedwisdom of clinicalwisdom of clinicalexperience, years ofexperience, years ofseasoning,seasoning,improves outcomesimproves outcomes

FALSEFALSEThe cold hard realityThe cold hard realityis that experienceis that experiencemakes no difference.makes no difference.


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Experience Is the Best Teacher?Getting Better All the Time?

Experience Is the Best Teacher?Getting Better All the Time?

Less experiencedtherapists achieve aboutthe same results as theirmore seasoned colleagues.

All of us want to think thatwe are getting better.

But are we getting betteror are we having the sameyear of experience overand over? So how do we?

Less experiencedtherapists achieve aboutthe same results as theirmore seasoned colleagues.

All of us want to think thatwe are getting better.

But are we getting betteror are we having the sameyear of experience overand over? So how do we?

There Is No Roadmap! And…How Do We Keep On Keeping On?

There Is No Roadmap! And…How Do We Keep On Keeping On?

Let’s face it…sometimes beinga therapist feelslike the worst jobon earth

Let’s face it…sometimes beinga therapist feelslike the worst jobon earth


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Worse that Tarring Roofsand Draining Septic TanksWorse that Tarring Roofsand Draining Septic Tanks

Or Being the NewCrewmember WhoOr Being the NewCrewmember Who

Justbeameddown to ahostileplanetwith Kirk,Bones,andSpock.

Justbeameddown to ahostileplanetwith Kirk,Bones,andSpock.


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Media DepictionsCast Us as Kooks & Crackpots

Media DepictionsCast Us as Kooks & Crackpots

Often blamed for creating anation of wimps orotherwise causing thedecline of westerncivilization with ourencouragement of selfindulgence, preoccupationwith feelings, and StuartSmalley daily affirmations.

Often blamed for creating anation of wimps orotherwise causing thedecline of westerncivilization with ourencouragement of selfindulgence, preoccupationwith feelings, and StuartSmalley daily affirmations.

Then There Isthe Economic Situation

Then There Isthe Economic Situation

The golden days of privatepractice are over

The typical agencytherapist faces manyhardships—seeminglyunattainable productivity,insurmountable paperwork,more & more intrusivefunder oversight, threat oflayoff

The golden days of privatepractice are over

The typical agencytherapist faces manyhardships—seeminglyunattainable productivity,insurmountable paperwork,more & more intrusivefunder oversight, threat oflayoff


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And Does Not Even Speak ToAnd Does Not Even Speak To

The emotionaldownsides, thesometimesoverwhelmingtragedy of the humancondition that seemsinured to our bestefforts—the stories ofsuffering that arehard to shake.

The emotionaldownsides, thesometimesoverwhelmingtragedy of the humancondition that seemsinured to our bestefforts—the stories ofsuffering that arehard to shake.

Becoming BetterBut

We don’t dothis workbecause wethought wewould acquirethe lifestyles ofthe rich andfamous.


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And We Knew

• at the outsetthat mixing itup in themorass ofhuman miserywould not be awalk in thepark.

Being a Therapist IsMore of a Calling

• That smart, creative indvsmake the sacrifices onlyto earn far less thanothers says something

• Required servitude w/othe promise of rags toriches only makes senseb/c it is more of a callingthan a job—a quest formeaning & fulfillment


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But Many of Us Are Battle Weary

• and in the face of mediaridicule, culturaldevaluation, & financialuncertainty may haveforgotten why we enlisted inthe therapy rank & file inthe first place. How do wekeep going?

• The answer may surpriseyou

How Helpers DevelopOrlinsky & Rønnestad

• Not only the answerbut also captures theheart of our aspirationsand the very soul ofour identity. Massive20 year study of11,000 providers of allstripes and flavorsfrom many countries

Orlinsky, D. E., Rønnestad, M. H. (2005).How psychotherapists develop:Washington, DC: APA.


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What Is Immediately Fascinating

• is the consistency of resultsacross discipline, nationality,gender, and theoreticalorientation. Psychotherapy,in all its variations, seems tobe a unified, despite whatour warring professionalorganizations & theories tellus, toward one, true cause,Healing Involvement.

Becoming BetterHealing Involvement

Committed & affirming, highlevel of empathic skills,conscious of “flow,” feelingeffective, & dealingconstructively w/ difficulties.

We keep on keeping onbecause we really, really likeconnecting deeply with ourclients and helping them getbetter.


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Analysis of a 392 ItemsHealing Involvement

• Healing Involvement represents us at our best—thosetimes when our immersion into our client’s story is socomplete, our attunement so sharp, that the pathrequired for change becomes eminently accessible.Sometimes you feel the texture of your connectionwith clients, an intimate space where you both knowthat there is something very good about thisconversation. This is Healing Involvement—the reasonwe do the work and the intrinsic reward it offers. So,what causes this, and more importantly, how can wemake it happen more often?

Here Is The Psychotherapist’sDistinctive Narrative: Two Ways

• First, it emerges from atherapist’s long-termexperience of cumulativecareer development, improvingclinical skills, increasingmastery, & graduallysurpassing past limitations, aswell as gaining a positivesense of our clinicaldevelopment since we began.


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Cumulative Career Development

• Therapists want to think of themselves aslearning more and getting better at whatthey do over time. As we accrue the hardearned lessons offered by differentsettings, modalities, orientations, andpopulations, we want to come out on thepositive end of any agonizing reappraisalof our experience.

•

But the Most Powerful InfluenceCurrently Experienced Growth

• or what we are learningfrom our real time, dayto day clinical work. Welike to think of ourselvesas developing now. CEGtranslates to positivework morale andenergizes therapists toapply their skills onbehalf of clients.


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How Do We AttainCurrently Experienced Growth

• Beyond cliché, webelieve clients are thebest teachers & ourbest access to CEG

• 97% endorsedpractical learning fromclients; 84% saidinfluence high

We Never Lose the DesireCumulative Career Development

• Even in the arguabledecline, we have aninextinguishable passionto get better

• 86% “highly motivated” topursue prof. dev.

• No profession morecommitted—Therapistswant to continue to getbetter over their careers


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Maybe Not Front Page NewsThink about It

• Consider NetworkerSymposium & the # of latecareer practitioners. This isour unique narrative—ourown professional growth &getting better at what we doappears to be the lifebloodof our identity, & more. Butwhy is it so important?

Currently Experienced Growth

• Enables optimism &openness to the daily grind.Increases likelihood ofHealing Involvement.

• Here & now growthremoralizes us, repairsabrasions & stressors of &fights routinization,disillusionment, & loss ofempathy.


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In Other Words

• CurrentlyExperiencedGrowth buffersagainst burnout.We need to Grow

Currently Experienced GrowthDavid Orlinksy

• “Is the balm that keeps ourpsychological skinpermeable—many believe thatthe constant hearing ofproblems would lead to beingemotionally callused, to a‘thick skin.’ But we need ‘thinskin,’—open, sensitive, &responsive to contact withclients.”


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Currently Experienced Growth

• Reward for doing thework & our greatest allyfor sending the grimreaper of burnoutpacking.

• Most striking aspect ofstudy: our growth is ourprimary way to fend offdisenchantment.

Part and Parcel to Our Identity

• Is a continual retrospectiveevaluation of where we areversus where we havebeen, looking for evidenceof our mastery of the work,& an ongoing filtering of ourhere and now clinicalexperiences, mining for thegolden moments thatreplenishes us.


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But How Do We Know We AreMastering Anything

• You know when a roofis tarred or a tankdrained but how doyou know therapy isbeneficial? Outcomesare hard to define.

• And apparently we arenot very good judgesof it

Poor Judges of OutcomesProviders Don’t Know

Poor Judges of OutcomesProviders Don’t Know

Graded theireffectiveness, A+ toF—67% said A orbetter; none ratedbelow average.

ProvidersProviders don’t knowdon’t knowhow effective they arehow effective they are

Graded theireffectiveness, A+ toF—67% said A orbetter; none ratedbelow average.

ProvidersProviders don’t knowdon’t knowhow effective they arehow effective they are

Sapyta, J., Riemer, M., & Bickman, L. Feedback toclinicians: Theory, research, and practice. Journalof Clinical Psychology: In Session, 61, 145-153


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It is Not thatWe Are Not Naïve or Stupid

It is Not thatWe Are Not Naïve or Stupid

Impossible to know in anyreliable/valid way.

We have to measureoutcomes. “Not that!”

Not about becoming“accountable” for fundingsources or to justify yourexistence via showing“proof of value” or “returnon investment.”

Impossible to know in anyreliable/valid way.

We have to measureoutcomes. “Not that!”

Not about becoming“accountable” for fundingsources or to justify yourexistence via showing“proof of value” or “returnon investment.”

This Time It’s PersonalIt’s About Becoming Better

This Time It’s PersonalIt’s About Becoming Better

It’s part of your identity,about survival. Can’t leavedev. to chance—it’s an ins.policy against burnout.

Measuring outcomesallows you to wade thruthe ambiguity & discernyour growth from aperspective outside of yourown.

It’s part of your identity,about survival. Can’t leavedev. to chance—it’s an ins.policy against burnout.

Measuring outcomesallows you to wade thruthe ambiguity & discernyour growth from aperspective outside of yourown.


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Use Study Findings Without FallingPrey to Own Biases

• Our perceptions areimportant but we need thechecks and balances.

• Collecting data addressesthe most sig. finding of thestudy—the perception ofgetting better & a palpableexperience of currentgrowth enliven therapy &staves off burnout.

• Step One: Measureoutcomes

• Two: Track your cumulativecareer development. Monitoreffectiveness over time inservice of implementingstrategies to improveoutcomes.

• It permits you to learn fromyour experience, not repeatit, and to reflect on yourgrowth in a meaningful way.

TranslatingTranslating Developmental ResearchDevelopmental ResearchFive StepsFive Steps To Accelerate Your DevelopmentTo Accelerate Your DevelopmentTranslatingTranslating Developmental ResearchDevelopmental Research

Five StepsFive Steps To Accelerate Your DevelopmentTo Accelerate Your Development


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First Things FirstWhy You Might Be Reluctant

First Things FirstWhy You Might Be Reluctant

Finding out is risky

What if you find out thatyou are not so good? Whatif you are in the wrongprofession?

The only way we improveis thru feedback. It takescourage. But so doeswalking in a room withsomeone in distress.

Finding out is risky

What if you find out thatyou are not so good? Whatif you are in the wrongprofession?

The only way we improveis thru feedback. It takescourage. But so doeswalking in a room withsomeone in distress.

Feedback v TAU;Both persons reliableor sig. change—50.5% v. 22.6%;ES: .50; 4 xs # ofclin. sig. change

FU: TAU-34.2% v.18.4% Feedbacksep./divorce rate

Feedback v TAU;Both persons reliableor sig. change—50.5% v. 22.6%;ES: .50; 4 xs # ofclin. sig. change

FU: TAU-34.2% v.18.4% Feedbacksep./divorce rate

Anker, M., Duncan, B., & Sparks, J. (2009). Using client feedback toimprove couple therapy outcomes: A randomized clinical trial in anaturalistic setting. Journal of Consulting and Clinical Psychology,77(4), 693-704.

Good Reasons to Take the RiskIsn’t It Good, Norwegian WoodGood Reasons to Take the RiskIsn’t It Good, Norwegian Wood


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Barry Finds the Spot in the Norway Picture

By Coincidence

Norway: 9 of 10 gotbetter outcomes

Feedback raisedeffectiveness of the lowerones to their moresuccessful colleagues.

Therapist in loweffectiveness groupbecame the BEST withfeedback!

Norway: 9 of 10 gotbetter outcomes

Feedback raisedeffectiveness of the lowerones to their moresuccessful colleagues.

Therapist in loweffectiveness groupbecame the BEST withfeedback!

Clients Do BenefitBut So Do We

Clients Do BenefitBut So Do We


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Counselor's Outcomes(n=30 or more case s)

00.20 .4

0 .60 .8

11 .2

1 .41 .61 .8

1(n

=94)

2(n

=74)

3(n

=67)

4(n

=65)

5(n

=59)

6(n

=58)

7(n

=55)

8(n

=50)

9(n

=48)

10(n

=48)

11(n

=47)

12(n

=47)

13(n

=41)

14(n

=41)

15(n

=40)

16(n

=39)

17(n

=37)

18(n

=35)

19(n

=34)

20(n

=31)

21(n

=31)

22(n

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Counselor

Eff

ect

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e

M ean E ffec t S ize for all Cases

Miller, S.D., Duncan, B.L., Sorrell, R., & Brown, G.S. (February, 2005). The Partners for ChangeMiller, S.D., Duncan, B.L., Sorrell, R., & Brown, G.S. (February, 2005). The Partners for ChangeOutcome Management System.Outcome Management System. Journal of Clinical Psychology, 61Journal of Clinical Psychology, 61(2), 199(2), 199--208.208.

Provider VariationFeedback Improves Effectiveness

Provider VariationFeedback Improves Effectiveness

Cumulative Development TrackingDoesn’t have to be Complicated

Start by entering data intoExcel, & tracking outcomewith simple calculations:ave. intake & final sessionscores, ave. change score,& the % of clients whoreach reliable or clinicallysignificant change. Otheroptions available atheartandsoulofchange.com


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Cumulative Career DevelopmentStep Three: Implement Strategies

• Models/techniques, but…

• Practice well the skills ofthe craft—the alliance. Atsome point, craftbecomes art. Relationalrepertoire likely parallelsyour development

Therapists Variables thatPredict Change

Therapists Variables thatPredict Change

Therapists with thebest results:

Are better at thealliance across clients;alliance ability accountsfor therapist differences

Alliance predicts changeover and above earlychange

Therapists with thebest results:

Are better at thealliance across clients;alliance ability accountsfor therapist differences

Alliance predicts changeover and above earlychange

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, 78(5), 635-645..


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Duncan, B. (2010). On Becoming a Better Therapist. Washington, DC: APA

The Alliance: Over 1000 StudiesThe Alliance: Over 1000 Studies

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%

••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…ItRESPECT…Itain’tain’t easy!easy!

Norcross, J. (2010). The Therapeutic Relationship. In B. Duncan et al. (eds.). The Heart and Soul ofChange. Washington, D.C.: APA.

Research into PracticeThe Alliance

Research into PracticeThe Alliance


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My Task, Your TaskYou Know It Ain’t Easy

My Task, Your TaskYou Know It Ain’t Easy

Gotta try and understand theanger; gotta figure out a wayfor it all to make sense(validation)

Gotta find stuff about theclient to like, to appreciate

Gotta work on her goals, andget her involved in purposefulwork

Gotta try and understand theanger; gotta figure out a wayfor it all to make sense(validation)

Gotta find stuff about theclient to like, to appreciate

Gotta work on her goals, andget her involved in purposefulwork

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


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Cumulative Career DevelopmentTake Charge

• Track effectiveness by30 client block.

• Implement ideas,practices, & models, aswell as building skills.

• Will readily seewhether efforts arepaying off.

• But how do I getstarted?

Partners for ChangeOutcome Management System

Partners for ChangeOutcome Management System

3 Skills of PCOMS (TheThree I’s)

Introducing theMeasures

Integrating ClientFeedback into Practice

Informing and TailoringServices Based on ClientFeedback

3 Skills of PCOMS (TheThree I’s)

Introducing theMeasures

Integrating ClientFeedback into Practice

Informing and TailoringServices Based on ClientFeedback


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••Scored to theScored to thenearest millimeter.nearest millimeter.

••Add the fourAdd the fourscales togetherscales togetherfor the total score.for the total score.

••Give at theGive at thebeginning of thebeginning of thevisit; Clientvisit; Clientplaces a markplaces a markon the line.on the line.

••Each line 10Each line 10cm (100 mm) incm (100 mm) inlength.length.

•Reliable, valid,feasible

Becoming BetterMeasuring Outcome

Becoming BetterMeasuring Outcome

•When scheduling, providerationale for seeking feedback;convey commitment to their goalsand highest quality of service…inyour own words•Work a little differently;•If we are going to be helpfulshould see signs sooner ratherthan later; If not helpful, we’ll seekconsultation & consider a referral.•No one has ever said: Bad idea!

Becoming BetterCreating A Culture of Feedback

Becoming BetterCreating A Culture of Feedback


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The Outcome Rating ScaleAn Introduction

The Outcome Rating ScaleAn Introduction

The ORS is an outcome measure that allowsus to track where you’re at, how you’re doing,how things are changing or if they are not. Itallows us to determine whether the therapy isbeing helpful so we can do something differentif it’s not helping. It also is way to make surethat your perspective stays central here, thatwe are addressing what you think is mostimportant. It only takes a minute to fill out andmost clients find it to be very helpful. Wouldyou like to give it a try?

The ORS is an outcome measure that allowsus to track where you’re at, how you’re doing,how things are changing or if they are not. Itallows us to determine whether the therapy isbeing helpful so we can do something differentif it’s not helping. It also is way to make surethat your perspective stays central here, thatwe are addressing what you think is mostimportant. It only takes a minute to fill out andmost clients find it to be very helpful. Wouldyou like to give it a try?

The First SessionWhatever It TakesThe First Session

Whatever It Takes

You can’t over-explain…

Clients get this. Face validity.

Whatever explanation theclient gives is ok. Some willsay: “You mean like poor towell?” or “Like 1 to 10?”

It’s their subjectiveexperience that matters sotheir understanding of themeasure is paramount.

You can’t over-explain…

Clients get this. Face validity.

Whatever explanation theclient gives is ok. Some willsay: “You mean like poor towell?” or “Like 1 to 10?”

It’s their subjectiveexperience that matters sotheir understanding of themeasure is paramount.


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The First MeetingThe “Clinical Cutoff”

The First MeetingThe “Clinical Cutoff”

0

5

1015

2025

30

3540

1st 2nd 3rd 4th

Session Number

Ou

tco

me

Sco

re

Actual Score Line 2 25th % 75th %

••The dividing lineThe dividing linebetween a clinicalbetween a clinical& “non& “non--clinical”clinical”population (25).population (25).••Cutoffs also forCutoffs also foryouth andyouth andcaretakers.caretakers.

The Clinical CutoffOnly 2 Choices

The Clinical CutoffOnly 2 Choices

Either above or below.

Mention client score as itrelates to the cutoff & havethe client make sense of it.

Scores under cutoff:reporting distress similar toothers seeking services—the lower the score, thehigher the distress. Lookingfor a change; in the rightplace!

Either above or below.

Mention client score as itrelates to the cutoff & havethe client make sense of it.

Scores under cutoff:reporting distress similar toothers seeking services—the lower the score, thehigher the distress. Lookingfor a change; in the rightplace!


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••Explore why the client enteredExplore why the client enteredtherapy; twotherapy; two reasonsreasons: specific: specificproblemproblem or mandated/coercedor mandated/coerced••If mandated, ask forIf mandated, ask for referral’sreferral’srating asrating as catalystcatalyst forforconversation; doesn’tconversation; doesn’t mean theymean theyareare lyinglying••Don’t stir the cauldron or pickDon’t stir the cauldron or pickscabs.scabs.

The First MeetingOver the Clinical Cutoff

The First MeetingOver the Clinical Cutoff

First Session: Connect ORS to theClient’s Described Experience

First Session: Connect ORS to theClient’s Described Experience

At some point,connect the client’sdescribed experienceof their lives to themarks on the scales

At some point,connect the client’sdescribed experienceof their lives to themarks on the scales


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The ORSThe Bare Bones

The ORSThe Bare Bones

No specific content—skeletonto which clients add flesh &blood of their experiences.

At the moment clientsconnect the marks with whatthey find distressing, the ORSbecomes a meaningfulmeasure of their progressand potent clinical tool

Get a good rating!

No specific content—skeletonto which clients add flesh &blood of their experiences.

At the moment clientsconnect the marks with whatthey find distressing, the ORSbecomes a meaningfulmeasure of their progressand potent clinical tool

Get a good rating!

Clients drop out for 2reasons: therapy is not helping(monitor outcome) & allianceproblems—not engaged orturned on. Direct way toimprove effectiveness is tokeep people engaged intherapy.

Gotta measure the alliance

PCOMSPrevent Drop Out

PCOMSPrevent Drop Out


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The Session Rating ScaleMeasuring the AllianceThe Session Rating ScaleMeasuring the Alliance

••Give at the endGive at the endof session;of session;

••Each line 10 cmEach line 10 cmin length;in length;

••Reliable, valid,Reliable, valid,feasiblefeasible

••Score in cm toScore in cm tothe nearest mm;the nearest mm;

••Discuss withDiscuss withclient anytimeclient anytimetotal score fallstotal score fallsbelowbelow 3636

Becoming BetterA Culture of Feedback with the SRS

Becoming BetterA Culture of Feedback with the SRS

•When scheduling a firstappointment, provide a rationalefor seeking feedback regarding thealliance.

•Work a little differently;•Want to make sure that you aregetting what you need;

•Take the “temperature” at the end ofeach visit;•Feedback is critical to success.

•Restate the rationale prior toadministering the scale.

•How not to do the SRS


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Make My DayMake My Day


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The Session Rating ScaleAn Introduction

The Session Rating ScaleAn Introduction

Let’s take a minute and have you fill out theother form that asks your opinion about ourwork together. It’s kind of like taking thetemperature of our relationship today. Arewe too hot or too cold? Do I need to adjustthe thermostat? This information helps mestay on track. The ultimate purpose of usingthese forms is to make every possible effortto make our work together beneficial. Ifsomething is amiss, you would be doing methe best favor if you let me know. Can youhelp me out?

Let’s take a minute and have you fill out theother form that asks your opinion about ourwork together. It’s kind of like taking thetemperature of our relationship today. Arewe too hot or too cold? Do I need to adjustthe thermostat? This information helps mestay on track. The ultimate purpose of usingthese forms is to make every possible effortto make our work together beneficial. Ifsomething is amiss, you would be doing methe best favor if you let me know. Can youhelp me out?

The Session Rating ScaleTraditionally

The Session Rating ScaleTraditionally Told us with their feetWill let us know on SRS

before telling/bolting. Takes work for candor.Disparity in power &

socio- economic, ethnic,or racial diff., can makeit tough. When was thelast time you told yourphysician, “You'remaking a big mistake"?

Told us with their feetWill let us know on SRS

before telling/bolting. Takes work for candor.Disparity in power &

socio- economic, ethnic,or racial diff., can makeit tough. When was thelast time you told yourphysician, “You'remaking a big mistake"?


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But Don’t StressIt’s Okay

But Don’t StressIt’s Okay

Keep encouraging client tolet you know…

Have to KNOW: No badnews. Not a measure ofcompetence or anythingnegative about you or theclient. Gift from the clientthat helps you to be better.

Unless you really want it,you are unlikely to get it.

You won’t get it fromeveryone.

Keep encouraging client tolet you know…

Have to KNOW: No badnews. Not a measure ofcompetence or anythingnegative about you or theclient. Gift from the clientthat helps you to be better.

Unless you really want it,you are unlikely to get it.

You won’t get it fromeveryone.

The Session Rating ScaleA Quick Visual Check

The Session Rating ScaleA Quick Visual Check

Scores < 36 or 9cms shouldbe discussed.

SRS is good or its not. Eitherthank the client for thefeedback, & invite them toshare future concerns; orthank client & explore whytheir ratings are lower sothat you can fix the concern.

Building the Alliance

Scores < 36 or 9cms shouldbe discussed.

SRS is good or its not. Eitherthank the client for thefeedback, & invite them toshare future concerns; orthank client & explore whytheir ratings are lower sothat you can fix the concern.

Building the Alliance


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XX

X

X

Now we’re ready to be better therapists,but first we must heed the words of a notedpsychotherapy scholar

Granted, at firstblush, thesehardly seem likewords fortherapists to liveby—but, as itturns out, theyare.

Sage Psychotherapy Scholar:Mae West?

When I’mgood,I’m verygood,but whenI’m bad,I’m better.


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Becoming BetterHelping Every Single Client

Becoming BetterHelping Every Single Client

When clients are notbenefiting provides theopportunity to do yourbest work and learn themost—gives you thepossibility of beinghelpful to everyone yousee. Sound too good tobe true? It’s not.

When clients are notbenefiting provides theopportunity to do yourbest work and learn themost—gives you thepossibility of beinghelpful to everyone yousee. Sound too good tobe true? It’s not.

Becoming BetterPCOMS Identifies Clients Not Responding

Becoming BetterPCOMS Identifies Clients Not Responding

When outcome is badin other words, youcan make it better bychanging somethingabout the therapy toturns things around;and if things don’t turnaround, by moving theclient on to a differentprovider or service

When outcome is badin other words, youcan make it better bychanging somethingabout the therapy toturns things around;and if things don’t turnaround, by moving theclient on to a differentprovider or service


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Becoming BetterTwo Choices: Not Rocket Science

Becoming BetterTwo Choices: Not Rocket Science

Either the client isimproving or not. If not,the client is at risk.

Engage client in discussionabout progress, and whatshould be done differentlyif there isn’t any.

Keeps clients engaged sothat a new direction can beplanned.

Either the client isimproving or not. If not,the client is at risk.

Engage client in discussionabout progress, and whatshould be done differentlyif there isn’t any.

Keeps clients engaged sothat a new direction can beplanned.

Becoming BetterWhen I’m Good, I’m Very Good

Becoming BetterWhen I’m Good, I’m Very Good

When ORS scoresincrease, when you’regood, a crucial step tobe very good is helpclients see gains as aconsequence of theirown efforts and makesense of its meaningso repeat in thefuture.

When ORS scoresincrease, when you’regood, a crucial step tobe very good is helpclients see gains as aconsequence of theirown efforts and makesense of its meaningso repeat in thefuture.


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Involve the client inmonitoring progress & thedecision about what to donext, to elicit his or her ideas& formulate a plan.

The discussion repeated in allmeetings, but later ones gainsignificance and warrantadditional action: Checkpointand Last Chance Discussions.

Involve the client inmonitoring progress & thedecision about what to donext, to elicit his or her ideas& formulate a plan.

The discussion repeated in allmeetings, but later ones gainsignificance and warrantadditional action: Checkpointand Last Chance Discussions.

Becoming BetterWhen I’m Bad, I’m Better

Becoming BetterWhen I’m Bad, I’m Better

Becoming BetterWhen to Say WhenBecoming Better

When to Say When

Stimulates both clientand therapist tostruggle withcontinuing a processthat is yielding little orno benefit.

To support what isworking & challengewhat is not. Urgencyincreases over time

Stimulates both clientand therapist tostruggle withcontinuing a processthat is yielding little orno benefit.

To support what isworking & challengewhat is not. Urgencyincreases over time


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Checkpoint Session:An Opportunity to Be Better

Checkpoint Session:An Opportunity to Be Better

Be transparent—comment about thelack of progress andseek feedback fromthe client about whathe/she thinks it means

Be transparent—comment about thelack of progress andseek feedback fromthe client about whathe/she thinks it means

Becoming BetterFirst, the AllianceBecoming BetterFirst, the Alliance

“It doesn’t look like we aregetting anywhere. Let’s goover the SRS to make sureyou are getting exactlywhat you are looking for.”Going thru SRS and elicitingclient responses in detailcan help you & the clientget a better sense of whatmay not be working.

“It doesn’t look like we aregetting anywhere. Let’s goover the SRS to make sureyou are getting exactlywhat you are looking for.”Going thru SRS and elicitingclient responses in detailcan help you & the clientget a better sense of whatmay not be working.


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Checkpoint ConversationDo Something DifferentCheckpoint ConversationDo Something Different

Nothing may come of talkabout the alliance. Don’tworry. Making effort helps.

Invite others from supportsystem, use a team or co-therapist, a differentapproach; referral to anothertherapist, religious advisor,or self-help group—whateverseems of value.

Any ideas are implemented,and progress is monitored.

Nothing may come of talkabout the alliance. Don’tworry. Making effort helps.

Invite others from supportsystem, use a team or co-therapist, a differentapproach; referral to anothertherapist, religious advisor,or self-help group—whateverseems of value.

Any ideas are implemented,and progress is monitored.

Becoming BetterThe Last Chance Discussion


Driving into desertrunning on empty,“last chance for gas.”

Depicts the necessityof stopping anddiscussing theimplications ofcontinuing w/ochange.

Driving into desertrunning on empty,“last chance for gas.”

Depicts the necessityof stopping anddiscussing theimplications ofcontinuing w/ochange.


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1.What does the client say?2.What have you done

differently?3.What can be done

differently now?4.What other resources can

be rallied?5.Is it time to fail

successfully?

Last Chance ThoughtsThe Longer w/o Change, the Quicker to #5



At the least, consultation

Referral seriously discussed.

Rarely justified to continuepast typical period.

Rarely is not never. Highlyidiosyncratic & uniquelynegotiated. Keeps us honest,addresses the lack of changetransparently—new for me.

At the least, consultation

Referral seriously discussed.

Rarely justified to continuepast typical period.

Rarely is not never. Highlyidiosyncratic & uniquelynegotiated. Keeps us honest,addresses the lack of changetransparently—new for me.


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When I’m Bad, I’m BetterFailing Successfully

When I’m Bad, I’m BetterFailing Successfully

Repeat commitment tohelp them achieve goals.

Failure says nothingabout them or theirpotential.

If client wants, meet untilarrangements are made.

But rarely continue withclients who show noimprovement.

Repeat commitment tohelp them achieve goals.

Failure says nothingabout them or theirpotential.

If client wants, meet untilarrangements are made.

But rarely continue withclients who show noimprovement.

Being BadCan Make You Better

Being BadCan Make You Better

Helps clients you are alreadyeffective with by empoweringchange—helps those notbenefiting by enabling otheroptions and, in absence ofchange, the ability to movethe client on.

When we’re good, we’revery good, but whenwe’re bad, we can beeven better.

Helps clients you are alreadyeffective with by empoweringchange—helps those notbenefiting by enabling otheroptions and, in absence ofchange, the ability to movethe client on.

When we’re good, we’revery good, but whenwe’re bad, we can beeven better.


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Clinical NuancesNot a Perfunctory Piece of Paper

Clinical NuancesNot a Perfunctory Piece of Paper

Administering, But Don’t Get It. Clients mustunderstand purpose (monitoring outcome,privileging their perspective); Therapists mustunderstand same + make them meaningful

Administering, Using Some. But not theclinical cutoff or numbers…Use but nocontinuity; questionable data integrity

Administering, Using Some. But notconnecting to the client’s experience orreasons for service

Administering the SRS. But seeing it asreflective of competence rather than analliance building tool

Administering, But Don’t Get It. Clients mustunderstand purpose (monitoring outcome,privileging their perspective); Therapists mustunderstand same + make them meaningful

Administering, Using Some. But not theclinical cutoff or numbers…Use but nocontinuity; questionable data integrity

Administering, Using Some. But notconnecting to the client’s experience orreasons for service

Administering the SRS. But seeing it asreflective of competence rather than analliance building tool

Back to Currently Experienced GrowthClients Are the Best Teachers

• Impossible to sit with people in disaster,witness journey to a better

place & not be changed.

• Teach us about the humancondition & ways peopletranscend adversity & copew/the unthinkable.

• Tracking outcomes takes this notion to adifferent & more immediately practical level.


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Tracking Outcomes: Keeps Our UtmostAttention on the Here and Now

• Clients teach us with theirresponses about the benefit& fit of service—as well astheir reflections about thenext step. Those clients notresponding to ourtherapeutic business asusual help us step outsideof our comfort zones.

Learning from ClientsOngoing Reflection

• Separate graphs: clientschanging and not

• Articulate changes andlessons

• Note how it was done

• Make before/afterdistinctions

• Reflect about the newchapter in your dev as wellas your identity


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Step Four: Proactively Consider theLessons Clients Teach

• Any difference can be animportant marker thathighlights your CEG.Perhaps you didsomething for the firsttime with a client, or alight went on & now youunderstand something ina different way.

I’ve never done that before!

Learning from ClientsOur Norwegian Colleague

• I became more transparent,more courageous. I felt moresecure and conveyed it.

• Clients and I got moreconcrete about change, how itstarted, and what else wouldbe helpful.

• Feedback sharpened myfocus—pinpointed that wehave a common purpose.


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Our Norwegian Colleague (cont)Be Proactive

• Feedback helped me takerisks and invite negativecomments.

• Made me more secure, Iam far more daring. I amnow more collaborative andallow things to emergerather than following a setway to work.

The Orlinsky and Rønnestad StudySays Something Important

The Orlinsky and Rønnestad StudySays Something Important

About who we are &what we have to doremain a vital force inclients’ lives. Trackingoutcomes enables a bigpicture view of yourcumulative career dev. &a microscopic view ofyour currentlyexperienced growth.

About who we are &what we have to doremain a vital force inclients’ lives. Trackingoutcomes enables a bigpicture view of yourcumulative career dev. &a microscopic view ofyour currentlyexperienced growth.


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Step Five:Continual Professional Reflection

Step Five:Continual Professional Reflection

Both perspectives(CCD and CEG) allowyou to continuallyreflect about yourdevelopment and testyour assumptions,adjust to clientpreferences, masternew tools and learnnew ideas.

Both perspectives(CCD and CEG) allowyou to continuallyreflect about yourdevelopment and testyour assumptions,adjust to clientpreferences, masternew tools and learnnew ideas.

• Reflect about your identity& construct a story of yourwork that captures whatyou do.

• Edit and refine youridentity & accounts—evolve a description thatcaptures you and whatyou do.

ContinualContinual Professional ReflectionProfessional ReflectionIdentities and DescriptionsIdentities and Descriptions

ContinualContinual Professional ReflectionProfessional ReflectionIdentities and DescriptionsIdentities and Descriptions


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You Do WhatLabor or Art

What we do is ameasure of who weare. If we imagineour work as labor, webecome laborers. Ifwe imagine our workas art, we becomeartists.

Jeffrey Patnaude

The Fuel of Our DevelopmentThe Love of the Work

The Fuel of Our DevelopmentThe Love of the Work

Foster parents (actual aunt anduncle) trying to do right thing

Bio parents lost parental rights;dad in jail; both poly substanceaddicted; using while pregnant;many ups and downs; Emilyhad many dx; a real handful

Aunt worried about“attachment” and didn’t know ifshe could do it anymore;struggling

Foster parents (actual aunt anduncle) trying to do right thing

Bio parents lost parental rights;dad in jail; both poly substanceaddicted; using while pregnant;many ups and downs; Emilyhad many dx; a real handful

Aunt worried about“attachment” and didn’t know ifshe could do it anymore;struggling


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Into My Treasure ChestI Felt the Pure Joy

• Of that moment, this decisionthat gave a kid anotherchance. I still do. This wasHealing Involvement, thatintimate space where weconnect with people & theirpain in a way that opens thepath of what can be ratherthan what is. This is thereward for what we do

For the Love of the WorkBecoming Better at What We Do

• Your unique narrative as atherapist says you already havewhat it takes. Two things canhelp: One is your commitment tomonitor the outcome of theservices. The second is yourinvestment in yourself, your owngrowth and development. Clientfeedback provides the methodfor both, the compass for thejourney—your love of the workprovides the rest.

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