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Bar Harbor, Maine A Story about Research

• Three Evidence Based Practice


Researchers

• Went on a hot-air balloon ride

• An unexpected fog rolled


in…hopelessly lost.

• Finally, a small clearing


June 22-24th, 2006 appeared…

The Heroic Client


Translating
What Works Institute for the Study of Therapeutic Change
Barry Duncan, Psy.D. & Scott Miller, Ph.D.

www.talkingcure.com
www.whatsrightwithyou.com

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What Doesn’t Work:
The Medical Model Equation
Diagnosis
+
Prescriptive
Treatment
=
Cure or Symptom
Amelioration

Diagnosis The History of Mental Health

•The quintessential question:


“I have found little
that is good about
human beings. In my
experience, most of •What’s Wrong With You?!
them are trash.”
--Sigmund Freud, M.D. And the key…

© ©

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Educate the People: You Are Sick
Mental Health Screening Test

• Educate people about the nature of mental illness


and to de-stigmatize seeking help. 1. Lift your right foot off the floor
and make clockwise circles.
• Now "free mental health check ups” like National
Depression Day or National Anxiety Day.
2. Now, while doing this, draw the
• Largely funded by drug companies and sponsored number "6" in the air with your
by MH prof. org—should be telling. right hand.
• Cultivated a curious change. Unhappiness not
shaped by diverse forces. No, problems now
publicly defined as illnesses, treatable—thank
heaven—by the miracle drugs and other txs 3. If your foot changes direction,
administered by experts. you need drugs or therapy or
both.

And It Works! The Killer Ds


In truth, we have all been
If drug txs for mental “disorders” were
books, they would be runaway caught in the undertow of a
bestsellers. growing industry seeking to
diagnose us with disorders,
diseases, deficits,
Last year, more than 150 million pres.
were written for anti-dep.—more than dysfunctions, disabilities—
$14 billion spent; 20 million pres. for the Killer Ds—or otherwise
Ritalin, surpassing the amount spent for
antibiotics! diminish our innate
propensities to help
ourselves.

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Diagnostic Dys- Order Diagnoses Portray Clients
9Poor Reliability

9Unknown Validity
As Dim
9Does not predict LOS or outcome Witted
9Little help in treatment selection Plodders…
9Surveys consistently find that
therapists do not like it or find it
Or
useful…
useful…and attribution creep
Kirk, S.A., & Kutchins, H. (1992). The selling of DSM: The rhetoric of science in psychiatry. New York: Aldine
Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass.

Godzilla Personality Disorder


The Medical Model Equation

• As pathological Diagnosis + Prescriptive Treatment


monsters of epic =
proportions Cure or Symptom Amelioration

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•Since the 60’
60’s, the # of models The “Battle” of the Brands
has grown from 60 to over 400,
multiplying like…
like…

•Each claims superiority in


conceptualization and outcome Cognitive Therapy Gestalt Therapy
Cognitive Behavioral Therapy Systemic Therapy
Solution-Focused Therapy Redecision Therapy
Narrative Therapy Adlerian Therapy
The result is a fragmentation along Structural Therapy Jungian Therapy
theoretical and disciplinary lines Strategic Therapy Morita Therapy
Ericksonian Therapy Rogerian Therapy
Now over 100 so called evidence Paradoxical Therapy Person-Centered Therapy
Thought Field Therapy Psychodynamic Therapy
based treatments--
treatments--effectiveness
effectiveness not E.M.D.R. Object-Relations Therapy
increased in 40 years, and…
and… Dialectical Behavior Therapy Pharmacotherapy
©

Evaluations of Treatment Models The Treatment of Depression Collaborative


Research Project (TDCRP)
•With few exceptions, partisan studies
originally designed to prove the The Design
unique effects of a given model have
found no differences—
differences—nor has recent •The largest comparative clinical trial ever
meta-
meta-analyses. conducted:
•Four treatment approaches (CBT, IPT, Drug,
•Termed, the “Dodo Bird Verdict”
Verdict” Placebo).
•Treatment administered at multiple sites.
“Everybody has won and all •Used experienced therapists, treatment
must have prizes.”
prizes.” manuals, supervision, and adherence tests.
Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy.
Journal of Orthopsychiatry, 6, 412-15. Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of
© Wampold, B.E. et al. (1997). A meta-analysis of outcome studies comparing bona fide General Psychiatry, 46, 971-82. ©
psychotherapies: Empirically, "All must have prizes." Psychological Bulletin, 122(3), 203-215.

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The Treatment of Depression Collaborative
Research Project (TDCRP) Project MATCH
The Results
The Design
•No difference in outcome between approaches:
•The client’
client’s rating of the alliance at the second •The largest study ever conducted on the treatment of
session the best predictor of outcome across problem drinking:
conditions. •Three different treatment approaches studied (CBT,
12-
12-step, and Motivational Interviewing).
•The psychotherapies (CBT, IPT) outperformed the drug
conditions on every single outcome measure: •Treatment administered at multiple sites to over
•Those in the drug condition sought more treatment, had 1700 participants.
higher probability of relapse, and had fewer weeks of •Used treatment manuals and adherence tests.
minimal or no symptoms.
Shea, M. et al. (1992). Course of depressive symptoms over follow up: The NIMH TDCRP. Archives © © Project MATCH Group (1997). Matching alcoholism treatment to client
of General Psychiatry, 49(10), 782-87. heterogeneity. Journal of Studies on Alcohol, 58, 7-29.

Project MATCH The Dodo Bird Also Rules in Youth


& Family Therapy
The Results „ Meta-
Meta-analysis found meager
differences (.2 ES) (Varhely
(Varhely,,
•All approaches work equally well with some of Miller, & Wampold,
Wampold, in press)
the people some of the time: „ Behavioral approaches in
•The client’
client’s rating of the therapeutic alliance direct comparison to other
bona-
bona-fide child tx offer no
the best predictor of: advantage. (Spielmans
(Spielmans,, 2005)
•Treatment participation; „ There is little differential
efficacy between approaches
•Drinking behavior during treatment; to marriage and family
•Drinking at 12-
12-month follow-
follow-up. therapy. (Shadish
(Shadish & Baldwin,
Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 2002)
7-29.
© Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation
and outcome. Journal of Consulting and Clinical Psychology, 65(4), 588-98.

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The Wheel of Change:
Factors Accounting for Successful Outcome
If the engine works but has little to do
with its “bells and whistles,”
whistles,” what’
what’s
providing the power? 40.0%

Client/Extratherapeutic
Client/Extratherapeutic

Models/Techniques
Relationship
30.0%
15.0%
Placebo/Hope/Expectancy
© 15.0%
Hubble, M., Duncan, B., & Miller, S. (1999). The Heart and Soul of Change. Washington, D.C.:
APA Press

Meta-Analytic Research
Translating Research into Practice
Treatment:

•7% due to Alliance


factors (or 54% of •How do traditional theories
effects due to tx)
tx) and models marginalize the
role of clients?
•1% due to Model and
13% technique (or 8% of
effects due to tx)
tx) •How can research showing
87% the impact of the client be
•Client factors utilized; how can the client
be recast in heroic roles?
Wampold,
©
Wampold, B. (2001). The Great Psychotherapy Debate.
Debate. New York: Lawrence Erlbaum.

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The Killer D’s of
Client Diminishment

9Diagnosis Until lions have


9Dysfunction their historians,
9Disorder tales of hunting
9Disability will always
9Disease
9Deficit glorify the hunter.
9Damaged African Proverb
9Delinquent
©

Casting the Client in Heroic Roles Finding the Heroic Client


Listening for Heroic Stories What are the qualities that describe you when you are
your very best? What were you doing when these
aspects became apparent to you?

• No formula here, more of an attitude What kind of person do these aspects describe? Or,
requiring a balance between listening What kind of person do these aspects show an
empathically with mindfulness toward aspiration toward?
resources that you know are there.
What are the qualities that others would describe in
you when you are at your very best? What were you
• Identify not what clients need, but what doing when they noticed these aspects?
they already have in their world that can
be put to use in reaching their goals What kind of person do these aspects describe? Or,
what kind of person do these aspects show an
aspiration toward?

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Finding the Heroic Client (cont) Telling Heroic Stories
• Who was the first person to tell you that they • What are the obvious and hidden
noticed the best of you in action? What were you strengths, resources, resiliencies, and
doing when they noticed these aspects? competences contained in the client’s
story?
• Who was the last person to tell you that they
noticed the best of you in action? What were you
doing when they noticed these aspects? • What are the competing stories—the
stories of clarity, coping, endurance, and
• Who in your life wouldn’t be surprised to see you desire that exist simultaneously with the
stand up to these situations and prevail? What confusion, pain, suffering, and
experiences would they draw upon to make these desperation?
conclusions about you? What “quintessentially
you” stories would they tell?...Kim
• What is already there to be recruited for The Heroic Client
• When I am at my very best, I am _____________. change?

Heather Heather’s Heroic Story


• Story of woman who has
• Story of Borderline overcome many obstacles.
Personality Disorder and
long term mental illness • Story of moving into
independent living
• Story of HIV
• Story of going to school
• Story of food addiction
and out of control binge • Story of a person ready to
eating deal with eating problems
based on successes

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Change in Treatment
The Unsung Heroes of Therapy

• The Client:
• Strengths, resources, culture,
world view, existing support
network.

• Chance events:
• Things that simply happen while
the person happens to be in
therapy…
therapy…

Source: Miller, S., Duncan, B., & Hubble, M (1997). Escape from Babel.
© © Source: Howard, et al (1986). The dose effect response in psychotherapy. American Psychologist,
New York: Norton. 41(2), 159-164.

Maintaining Change Translating Research into Practice


•Strong correlation between the maintenance of change
•How have traditional
and the degree to which clients attribute it to their own
efforts. theories and models
minimized the role of
•Participants who attribute changes to a med or therapist are less chance change-
change-producing
likely to maintain gains than those who viewed the improvement events?
resulting from their own efforts.

•Those who attribute changes to their own efforts rather than •How can research showing
chance more likely to maintain gains regardless of the cause. the impact of chance events
Frank, J.D. (1976). Psychotherapy and the sense of mastery. In R.L. Spitzer et al. (eds). Evaluation of on the change process be
Psychotherapies. Baltimore, MD: Johns Hopkins.
Liberman, B. (1978). The maintenance and persistence of change. In J.D. Frank et al. (eds). Effective ingredients of
©
utilized?
effective psychotherapy. New York: Brunner Mazel.
©

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Becoming Change Focused

“Chance favors the • Listen for a change! Ask about


and be curious about change:
prepared mind.” How did you do that? Where
did that idea come from?
Louis Pasteur • Validate the clients
December 7, 1854
contribution to change.
How is (the drug/treatment
program) helping access
strengths and resources that
have always been there but
©
were just beyond your grasp?

Encourage Before and After Distinctions Relationship Factors


• How did you decide that now was the time for • The Therapeutic
action?
• What insights have you gained from your life that Alliance:
you were finally able to put into action?
• What insights have you gained from this change • Relational Bond
that will help you in the future?
• What does this say about you, the kind of person
you are, that you took the bull by the horns at • Agreement on
this time?
• Who in your past would not be surprised to see 30% goals
you making these changes?
• How did you do it? How will you maintain the
gains you have made?
• How are you different now that you have realized • Agreement on
this change? Ponder the difference in your self- tasks
image before you implemented this change and
now.
Hubble, M., Duncan, B., & Miller, S. (1999). The Heart and Soul of Change. Washington, D.C.:
© APA Press

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Relationship Factors
The Therapeutic Alliance
The Therapeutic
Alliance:

•Relational Goals,
Bond Meaning
54% Means or
•Agreement on or Methods
goals Purpose
•Agreement on
tasks Client’
Client’s View of the
Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass
Therapeutic Relationship

Project MATCH The Alliance: Research Findings

z Quality of the alliance more potent


What about the mandated clients? predictor of outcome than orientation,
experience, or professional discipline.
•No difference in outcome between voluntary z Client perception of the alliance a better
and mandated clients. predictor of outcome than therapist’s.
z No correlation between the length of time
spent in tx and strength of the alliance.
•The only reliable predictor? z Clients rarely report negative reactions
•The Alliance before deciding to terminate.
z Same holds true for youth and family
Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58,
7-29.
therapy as Jacqueline will present
© Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation
and outcome. Journal of Consulting and Clinical Psychology, 65(4), 588-98.

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Translating Research into Practice Translating Research into Practice
•Increasingly, the therapeutic
•How have traditional theories relationship is viewed as merely
and models minimized the role “setting the stage”
stage” for the “real”
real” or
of the alliance and client “active”
active” ingredients in treatment:
•Confronting distorted thoughts;
engagement? •Recovering forgotten memories;
•Asking special questions;
•How can research showing the •Tapping on or waving fingers in front of the
face.
importance of the therapeutic
•Research on the power of the
alliance and client engagement
alliance now reflected in over 1000
be utilized?
findings.
© Bachelor, A., & Horvath, A. (1999). The Therapeutic Relationship. In M. Hubble, B. Duncan, & S.
© Miller (eds.). The Heart and Soul of Change. Washington, D.C.: APA Press.

Translating Research into Practice


Serving The Alliance Master Invalidation
• Be friendly, responsive, and
flexible (like a first date). • On the flip side, invalidation
demoralizes and inserts self
doubt and self loathing—
• Validate. Legitimize the client’s significant obstacles to change.
concerns and highlight their
• Most have learned two forms
importance. of invalidating messages:
• Ones that contradict or dismiss
• Work on client’s goals period. our feelings;
• Ones that blame us for life’s
• Fit the client’s theory of change. inevitable pitfalls.

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The Rubber Hose of Doubt and the Validation: Nuts and Bolts
Bright Light of Blame
• What are the invalidations contained in the
You are the problem! client’s story? How is he or she or others,
You are to blame! discounting or contradicting his or her
experiences? How are he or she or others blaming
him or her?
• What other factors have contributed to this
• Validation does not mean you should agree with
everything the client has done; simply means that situation or are extenuating variables? How can I
you acknowledge the rest of the story! place this situation in a context that justifies the
client’s behavior or feelings? How can I give the
client credit for trying to do the right thing?
• Puts the client’s actions in a context that legitimizes
him or her as a human being—explaining the • Format: No wonder you feel or behave this way
situation in a “big picture” way in which actions are (fill in with circumstance) given that (fill in the
part of a larger scenario involving many aspects. ways to justify client responses).
• Now what different conclusions are reached and
courses of action emerge?
• Clears a path for change because it diffuses self
doubt and dissipates self loathing…John

Translating Research into Practice


Serving The Alliance Master The Client’s Theory of Change
• Be friendly, responsive, and
flexible (like a first date).

• Validate. Legitimize the client’s


Pre-
Pre-existing beliefs
concerns and highlight their about the problem
importance. and change
• Work on client’s goals period.

• Fit the client’s theory of change.


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

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The Client’s Theory of Change:
The Therapeutic Alliance Empirical Findings

Client’
Client’s Theory of
Change In the TDCRP, congruence between
Goals,
the clients TOC and tx resulted in:
Meaning Means or 9Stronger therapeutic alliances;
or Methods 9Longer duration in treatment; and
Purpose
9Improved treatment outcomes.

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

Therapeutic Relationship

Learning the Client’s Theory Learning the Client’s Theory

•Explore the client’


client’s ideas about the cause, •Explore the clients usual method of or
maintenance, and resolution of the problem: experience with change:
•Many times people not only have a hunch about •How does change usually happen in your life?
what is causing the problem but also what might help •What (do you do/is your role) in initiating or
to resolve it. What ideas do you have? facilitating change?
•Forget about solving it--
it--what
what could happen that •What (do others do/is the role of others) in
would give you some relief? Scott initiating, facilitating or maintaining change?
•What events usually (precede/ occur
during/follow after) a successful change?
Source: Duncan, B.L. & Miller, S.D. (2000). The Heroic Client. San Francisco: Source: Duncan, B.L. & Miller, S.D. (2000). The Heroic Client. San Francisco:
Jossey-Bass. Jossey-Bass.

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A New Equation: A Relational One
Learning the Client’s Theory
•Explore the ways the client has attempted Client Resources and Resilience

to solve the problem:


•What have you tried so far to resolve this problem? +
•Who (has been most helpful/seems to have a special Client View of Alliance and Theory
of Change
knack) with this problem?
•In what ways have your attempts proven successful
(even if only in part or temporarily)? =
•What are your ideas about why your attempts have Client Perception of Preferred
(worked/not worked)? Outcome

Source: Duncan, B.L. & Miller, S.D. (2000). The Heroic Client. San Francisco:
Jossey-Bass.

Clients Are Indeed

• The Heroic
Ones

• The Lions of
Change

• The Superstars

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