Common Factors (Duncan)

On Becoming a Better Therapist (Barry Duncan)

It just doesn't matter:

• Therapist training. Nyman, Nafziger, and Smith (2010): "it didn't matter to outcome if the client was seen by a licensed doctoral-level counselor, a predoctoral intern, or a practicum student; all levels of training achieved about the same outcomes." 
• Continuing education. Neimeyer, Taylor, and Philip (2009): "As far as continuing professional education, despite its requirement in nearly every state, there is no evidence that therapists learn anything from such experiences or that their participate translates to better outcomes." 
• Experience. Beutler et al. (2004), Hill and Knox (2013): "In large measure, generic experience does not improve outcomes -- experienced and inexperienced therapists achieve about the same outcomes." 
• Dodo Bird Verdict ("All have won and all must have prizes"). "None of the heralded models have reliably demonstrated superiority to any other systematically applied psychotherapy." Stiles, Barkham, Mellor-Clark, and Connell (2008): no much difference between CBT, psychodynamic therapy, and person-centered therapy. Benish, Imel, and Wampold (2007): CBT as effective at treating PTSD as EMDR and present-centered therapy.

Mechanisms of Change. Michael Lambert (2013) identified four mechanisms of therapeutic change: client/life variables (40%), relationship factors (30%), hope, expectancy, and placebo (15%), and model/technique (15%). Recent research has shown that Lambert omitted the impact of the therapist. Five mechanisms of change: client/life factors (86%),

1. Client/Life Factors (86%). This refers to everything in the client's life that has nothing to do with the therapist -- e.g., "persistence, faith, a supportive grandmother, depression, membership in a religious community, divorce, a new job, a change encounter with a stranger." These factors, including the extent to which the client participates, are the most important determinant of change (86%). Consequently, "Becoming a better therapist depends on rallying clients and their resources to the cause." 
2. Therapist Effects (5-8%). This refers to who the therapist is, not the model they use. One study found that clients receiving sugar pills from the top third most effective psychiatrists did better than the clients taking antidepressants from the bottom third, least effective psychiatrists. What makes some therapists better than others? (1) Resource activation vs. problem activation: successful therapists spend more time "identifying client resources and channeling them toward achieving client goals." (2) Specific experience: e.g., a therapist with specific experience doing couples therapy will be more effective at couples therapy. (3) The therapist's ability for form a strong alliance.   
3. Alliance (5-7%). Definition of a positive alliance: "an interpersonal partnership between the client and therapist to achieve the client's goals." 
4. Model/Technique (1%). "Models achieve their effects through the activation of placebo, hope, and expectancy, combined with the therapist's belief in (allegiance to) the treatment administered." Placebo: "As long as a treatment makes sense to, is accepted by, and enhances the active engagement of the client, the particular approach is unimportant." Expectancy: "Client expectation of improvement predict[s] outcome." 
5. Feedback Effects. Feedback affects the other factors; "it is the tie that binds them together." "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 alliance quality and client participation."  

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Patient-Focused Research. "Valuing clients as credible sources of their own experiences allows us to critically examine our assumptions and practices -- to support what is working and challenge what is not -- and allows clients to teach us how we can be the most effective with them." The Outcome Questionnaire: clients in the feedback group "had less than half the odds of experiencing deterioration while having 2.6 times higher odds of attaining reliable improvement than the TAU group." Partners for Change Outcome Management System (PCOMS): Outcome Rating Scale (ORS) and Session Rating Scale (SRS) are four-item measures that track outcome and the therapeutic alliance, respectively. PCOMS works in schools (15).

The point of PCOMS: It identifies clients "who aren't responding to your therapeutic business as usual so that you can address the lack of progress in a positive, proactive way that keeps clients engaged while you collaboratively seek new directions." Therapists tend to be bad at identifying deteriorating clients. PCOMS allows therapists to measure their effectiveness.

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Most clients experience the majority of change in the first eight sessions.

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ORS, CORS (6-12) -- Beginning of session. SRS, CSRS -- End of session. No numbers b/c research suggests that numbers influence how people will mark the scale -- people more likely to score on the average side of things and to round off to whole numbers.

Link

Studies confirm reliability and validity. Purpose: To monitor our progress. Measure with centimeter ruler: 10 cm / line. Clinical cutoff: adults 25, adolescents 28, kids 32 >> under 32 for kids indicates a  level of distresses typically associated with being a client >> over 32 indicates that the client is more satisfied with the status quo "and therefore may require a bit more context to understand what they are looking for from therapy."

The area clients mark lowest is probably the area they want to discuss/work on. For mandated clients, ask the referring party to complete the form.

ORS is "designed to measure how things are going in the client's life relative to the reasons for therapy." The client must understand that the marks on the scales are connected to the work in therapy.

SRS scores tend to be rated high whether or not therapist is present and whether or not the client and therapist ever discuss it. None of these affects the score much. You should discuss if score is 36 or less. Some clients will never give honest feedback.

Script: "Let me just take a second here to look at this SRS--it's kind of like a thermometer that takes the temperature of our meeting here today. Wow, great, looks like we are on the same page, that we are talking about what you think is important and you believe today's meeting was right for you. Please let me know if I get off track, b/c letting me know would be the biggest favor you could do for me."

Script: "Let me quickly look at this other form here that lets me know how you think we are doing. Okay, seems like it could have gone better. Thanks very much for your honest and for giving me a chance to address what I can do differently. Was there something else I should have asked you about or should have done to make this meeting work better for you? What was missing here?"

Second and subsequent sessions. Use scores "to engage the client in a discussion about progress, and more importantly, what should be done differently if there isn't any." Reliable change index (RCI) "indicates change that is greater than chance, error, or maturation of the client." The RCI on the ORS is 6. If client is not making change on the ORS, check the SRS. If client's ORS score radically drops, they could just be having a really bad day; ask them to redo ORS and rate their entire week.

Tracking client outcomes gives you the feedback needed to grow as a therapist.

APA Outcome Measurement Database

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How to become a better therapist.

(1) Engage clients and their resources.

(2) Improve your alliance skills.

• Bordin (1979) classically defined the alliance w/ three interacting elements: a) a relational bond b/t you and the client -- the client's perception of your empathy, positive regard, and genuineness; (b) agreement on the goals of therapy; and (c) agreement on the tasks of therapy, which include all the accompanying details -- topics of conversation, frequency of meetings, handling cancellations, payment, etc. The alliance is an all-encompassing framework for psychotherapy. It transcends any specific therapist behavior and is a property of all aspects of providing services. 
• The alliance is the central filter of all your words and actions: Is what I am saying and doing now building or risking the alliance? Few things are worth risking the alliance. This doesn't mean that you can never challenge clients; it just means that you have to earn the right to do so and must always consider the alliance consequences. At the very least, a discussion with the client about the value of challenge and securing permission is advisable. Our behavior should be designed to engage the client in purposeful work. That is what the alliance is supposed to do. 
• Three important ways to improve alliance: Validation -- empathy, unconditional positive regard, authenticity. Empathy is "the therapist's sensitive ability and willingness to understand clients' thoughts, feelings, and struggles from their point of view." Unconditional positive regard is "warm acceptance of the client's experience without conditions, a prizing, an affirmation, and a deep nonpossessive caring or love." Congruence/genuineness: "the therapist is mindfully genuine in the therapy relationship, underscoring present personal awareness, as well as genuineness or authenticity." 
• How to enhance the relational bond: (a) Listen, listen, listen. (b) Be likeable, friendly, and responsive (like on a first date). (c) Carefully monitor the client's reaction to comments, explanations, interpretations, etc. (d) Be flexible: Do whatever it takes to engage the client and ensure his or her experience of empathy, positive regard, and congruence. 
• Validate the client. Legitimize the client's concerns and highlight the importance of the client's struggle. Appreciate your clients. Let them know that you do.