TherapeuticWork

www.heartandsoulofchange.com 3/28/2011

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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

It’s Not Just forClients Anymore

TherapeuticWork


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My Dad Had A Stalwart Responseto any Complaint I ever Made

My Dad Had A Stalwart Responseto any Complaint I ever Made

About any job. w Whetherit was painting or roofinga house, working in a tirefactory, studying for atest, or working in mypractice, his response wasconsistent: “Why do youthink they call it work?”Hold that thought whilewe discuss the alliance.

About any job. w Whetherit was painting or roofinga house, working in a tirefactory, studying for atest, or working in mypractice, his response wasconsistent: “Why do youthink they call it work?”Hold that thought whilewe discuss the alliance.


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Although Often IgnoredThe Fact Is that the Alliance

Although Often IgnoredThe Fact Is that the Alliance

Represents the most influence that we canhave over outcome. Do not underestimate itspower or its endurance—don’t give the allianceshort shrift!

I know this is challenging—you believe in it butit’s hard not to take it for granted when it getssuch little press compared to models andtechniques. How often, for example, is thealliance discussed in client conferences?

Represents the most influence that we canhave over outcome. Do not underestimate itspower or its endurance—don’t give the allianceshort shrift!

I know this is challenging—you believe in it butit’s hard not to take it for granted when it getssuch little press compared to models andtechniques. How often, for example, is thealliance discussed in client conferences?

••Considered most sophisticatedConsidered most sophisticatedcomparative clinical trial ever:comparative clinical trial ever:

••CBT, IPT, Drug, PlaceboCBT, IPT, Drug, Placebo

Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of GeneralPsychiatry, 46, 971-82.

••NoNo differencedifference in outcomein outcome••TheThe client’sclient’s rating of the alliance atrating of the alliance atthe second session the best predictorthe second session the best predictorof outcome across conditions.of outcome across conditions.

TDCRPThe Alliance

TDCRPThe Alliance


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••CBT, 12CBT, 12--step, & Motivationalstep, & MotivationalInterviewingInterviewing

••NONO differencedifference in outcomein outcome••The client’s rating of the allianceThe client’s rating of the alliancethe best predictor of:the best predictor of:

Treatment participation;Treatment participation;Drinking behavior duringDrinking behavior duringtreatment;treatment;Drinking at 12Drinking at 12--month FUmonth FUCOMBINE…same thingCOMBINE…same thing

Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 7-29.Babor, T.F., & Del Boca, F.K. (eds.) (2003). Treatment matching in Alcoholism. Cambridge University Press: Cambridge, UK.Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome. Journalof Consulting and Clinical Psychology, 65(4), 588-98.

Project MATCHThe Alliance

Project MATCHThe Alliance

Anton, S. et al., (2006). Combinedpharmaceutical and behavioralinterventions for alcoholdependence.. JAMA, 295, 203-217.

••600 Adolescents marijuana users:600 Adolescents marijuana users:••Significant coSignificant co--morbidity (3morbidity (3--12 problems).12 problems).

••Two arms (dose, type) and one ofTwo arms (dose, type) and one ofthree types of treatment in each arm:three types of treatment in each arm:

••Dose arm: MET+CBT (5 wks),Dose arm: MET+CBT (5 wks),MET+CBT (12 wks), Family SupportMET+CBT (12 wks), Family SupportNetwork (12 wks)+MET+CBT;Network (12 wks)+MET+CBT;••Type arm: MET/CBT (5 wks), ACRT (12Type arm: MET/CBT (5 wks), ACRT (12weeks), MDFT (12 wks).weeks), MDFT (12 wks).

The Dodo Also Rules Family TherapyThe Dodo Also Rules Family TherapyCannabis Youth Treatment ProjectCannabis Youth Treatment Project

No Difference!No Difference! ApproachApproach accounted for 0% of the variance in outcome.accounted for 0% of the variance in outcome.AllianceAlliance predicted: Premature droppredicted: Premature drop--out; Substance abuseout; Substance abuse symptomssymptoms postpost--treatment, and cannabis use at 3 and 6 month followtreatment, and cannabis use at 3 and 6 month follow--up.up.


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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%

TDCRP: top thirdpsychiatrists giving placebobested bottom third givingmeds; clients of besttherapists improve 50%more & dropped out 50%less; meds useful for clientsof more effective therapists,not for less--What accountsfor the variability?

Wampold, B., & Brown, J. (2006). Estimating variability inoutcomes attributable to therapists: A naturalistic study ofoutcomes in managed care. Journal of Consulting andClinical Psychology, 73 (5), 914-923.

Therapist DifferencesIncredible Variation Among Providers

Therapist DifferencesIncredible Variation Among Providers


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Therapists Variables thatPredict Change

Therapists Variables thatPredict Change

Therapists with thebest results:

Are better at thealliance acrossclients; allianceability accounts fortherapistdifferences

Therapists with thebest results:

Are better at thealliance acrossclients; allianceability accounts fortherapistdifferences

Baldwin et al. (2007). Untangling the alliance-outcomecorrelation. Journal of Consulting and Clinical Psychology,75(6), 842-852.;Owen, Duncan, Anker, & Sparks (2011). Therapist variabilityin couple therapy. Manuscript submitted for publication.

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%


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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%

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


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The Alliance:The Alliance:OverOver 10001000 Research FindingsResearch Findings

Quality of the alliancemore potent predictor ofoutcome than orientation,experience, orprofessional discipline--recall TDCRP, MATCH,CYT. Across modalitiesand populations

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?


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Model Maniacs (I Mean Proponents)Dis the Alliance by saying…

Findings are only correlational,even though there are over 1000reported associations…

Don’t know anything about thedirection of the correlation—thechicken or the egg: does changecause high alliance ratings ordoes a high alliance cause change

Only 6 studies have looked at theissue and they are split down themiddle on findings

Alliance

Alliance score at session 3 predicts outcome over and abovethe effects of early symptom change

Disentangling the Alliance-Outcome Correlation

Anker, Owen, Duncan, &Sparks (2010). The alliancein couple therapy. Journal ofConsulting and ClinicalPsychology, 78, 635–645


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Not the anesthesia tosurgery. Not the stuff youdo until the real therapy.Intervention is not therapy.Better case for the alliancebeing the therapy.

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

Deserves RESPECT

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…Lisbeth

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…Lisbeth

Empathy Plus Positive RegardEquals Validation

Empathy Plus Positive RegardEquals Validation


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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

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…Lisbeth

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…Lisbeth

You are the problem!You are to blame!


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But I Can’t Validate That!Yes You Can

But I Can’t Validate That!Yes You Can

Abuse! No wonder you weretrying to establish parentalcontrol—the kid was over thetop…not agreeing with the abusebut the intent of the behavior.

Crime! No wonder you wound uprobbing that store. You believedthe lies about the life people toldyou, and you didn’t have much ofa family life or anything else good

going on.

Abuse! No wonder you weretrying to establish parentalcontrol—the kid was over thetop…not agreeing with the abusebut the intent of the behavior.

Crime! No wonder you wound uprobbing that store. You believedthe lies about the life people toldyou, and you didn’t have much ofa family life or anything else good

going on.

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.

In the TDCRP, congruence betweenthe clients TOC and tx resulted in:Stronger therapeutic alliances;Longer duration in treatment; andImproved treatment outcomes.

The Client’s Theory of Change:The Client’s Theory of Change:Empirical FindingsEmpirical Findings

Elkin, I. (1999). “Patient-treatment fit" and early engagement in therapy. Psychotherapy Research. 9(4) 437-451.


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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.

PreferencesMeta-Analysis of 35 Studies

PreferencesMeta-Analysis of 35 Studies

Clients matched topreferred conditions wereless likely to drop out &improved more.

Type of preference (role,therapist, or tx) not sig.

Results underscorecentrality of incorporatingclient preferences

Clients matched topreferred conditions wereless likely to drop out &improved more.

Type of preference (role,therapist, or tx) not sig.

Results underscorecentrality of incorporatingclient preferences

Swift, J.K., Callahan, J.L. & Vollmer, B.M. Preferences. Journal of Clinical Psychology: In Session, 67, 155–165.


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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

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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The AllianceBottom LineThe Alliance

Bottom Line

The Alliance Matters—Big Time

TDCRP: allianceaccounted for up to21% of the variance,

Real-time Feedbackabout the AllianceCritical to Success

The Alliance Matters—Big Time

TDCRP: allianceaccounted for up to21% of the variance,

Real-time Feedbackabout the AllianceCritical to Success

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


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••Client’sClient’s rating of therating of thealliancealliance the best predictor ofthe best predictor ofengagement and outcomeengagement and outcome..

40 Years of Data say…40 Years of Data say…

••Client’sClient’s subjective experiencesubjective experienceof change early in the processof change early in the processthe best predictor of successthe best predictor of successfor any particular pairing.for any particular pairing.

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

Quickest WayPrevent Drop Out

Quickest WayPrevent 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

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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Alliance PatternsAlliance Patterns

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.


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The SRSGraceful Acceptance

The SRSGraceful Acceptance

And a willingness to be flexibleusually turn things around.

Clients reporting allianceproblems more likely forsuccess. Lower scores on theSRS should be celebrated.

If clients are comfortableenough to express somethingisn’t right, then you are doingsomething great…example

And a willingness to be flexibleusually turn things around.

Clients reporting allianceproblems more likely forsuccess. Lower scores on theSRS should be celebrated.

If clients are comfortableenough to express somethingisn’t right, then you are doingsomething great…example

No Bad News on theSRS

It’s where you windup that counts

Use SRS to BUILD orMaintain Alliance

No Bad News on theSRS

It’s where you windup that counts

Use SRS to BUILD orMaintain Alliance

The Session Rating ScaleProblems and Challenges

TherapeuticWork

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