AcceleratingYourDevelopmentSlides

www.heartandsoulofchange.com 10/29/2010

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On Becominga Better Therapist

Accelerating Your Development

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

[email protected]@comcast.net


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Winter Getaway!Training of Trainers

Winter Getaway!Training of Trainers

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

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


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Getting in the ZoneBecoming Better at What We Do

• Two things: One is yourcommitment to monitorthe alliance and theoutcome of the services.The second is yourinvestment in yourself,your own growth anddevelopment. Clientfeedback provides themethod for both, thecompass for the journey.

• Feedback v TAU;Both personsreliable or sig.change—50.5% v.22.6%; ES: .50; 4 xs# of clin. 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.

Becoming BetterIsn’t It Good, Norwegian Wood

Becoming BetterIsn’t It Good, Norwegian Wood


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Regarding Therapist VariabilityFeedback Improves OutcomesRegarding Therapist VariabilityFeedback Improves Outcomes

• Norway: 9 of 10 gotbetter outcomes

• Therapist in loweffectiveness groupbecame the BESTwith feedback!

Blown AwayTherapist Effects and Feedback

• Correlation b/w theeffectiveness of a t withno feedback &feedback effect was r =-.99. Feedback acts asa “leveler,” raisingeffectiveness of lower orave. ts to their moresuccessful colleagues.


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Becoming BetterAccelerating Your Development

• Feedback tailors therapybased on response,provides an early warningsystem to prevents drop-outs & negative outcomes,& solves therapistvariability—feedbackimproves performance andquickens yourdevelopment…

How Therapists DevelopOrlinsky & Rønnestad

• 5000 therapists (11,000)

• The Pinnacle ofDevelopment—HealingInvolvement: committed& affirming, high level ofempathic skills, consciousof “flow,” feeling effective,& dealing constructivelyw/ difficulties.

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


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Immediately FascinatingA Unified Profession

• What is immediatelyfascinating about this study isthe consistency of resultsacross profession, nationality,gender, and theoreticalorientations. Psychotherapy, inall its variations, seems to be aunified profession, despitewhat our professional org. andtheories tell us.

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Healing InvolvementUs at Our Best

• Our immersion into our client’s storyis so complete, our attunement sosharp, that the path required forchange becomes eminentlyaccessible. Sometimes you feel thetexture of your connection withclients, an intimate space where youboth know that there is somethingvery good about this conversation.This is HI—the reason we do the workand the intrinsic reward it offers. Howcan we make it happen more often?


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How Therapists DevelopOrlinsky & Rønnestad

Three Sources ofTherapist Growth:

• Cumulative CareerDevelopment; TheoreticalBreadth, and the mostimportant, CurrentlyExperienced Growth

• Pre-requisite: youare a primaryfigure—the client iscentral, but it takestwo to tango. Yourgrowth impactsyour ability to bevitally involved.

Becoming a Better TherapistAccelerate Your Development


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First Source of AccelerationCumulative Career Development

First Source of AccelerationCumulative Career Development

• Improvement in skills,increasing mastery, &surpassing pastlimitations.

• 86% “highly motivated”to pursue prof. dev.

• Therapists continuallyevaluate where they areversus where theystarted

A Distinctive Narrative

• No profession morecommitted—therapists want tocontinue to get better overtheir careers

• Orlinsky & Rønnestad: Ourdevelopment is just asimportant to us at end of ourcareers as it is in thebeginning.


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Cumulative Career DevelopmentGetting Better All the Time?

• All of us want to think thatwe are getting better.

• But are we getting betteror are we having the sameyear of experience overand over?

• How do we know if we aregetting better or deludingourselves?

Do We Really Know?

• Dew & Reimers hadtherapist grade theireffectiveness, A+ to F—67% said A or better;none rated belowaverage.

•• 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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Measuring OutcomesRemoves Ambiguity

• Allows you to usethe evidence abouttherapist growthwithout falling preyto pitfalls of atherapist-centricview of success.

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Cumulative Development TrackingDoesn’t have to be Complicated

Start by entering datainto Excel, & trackingoutcome with simplecalculations: ave.intake & final sessionscores, ave. changescore, the % of clientswho reach reliable orclinically significantchange, & “drop outs.”


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Client benefit a better way.Trying to avoid client whodiscontinues in an unplannedway, w/o experiencing target.If it's planned, then we havereferred the client on togreener pastures. If it isunplanned but the clientreached target, then that isokay too.

A Brief Word About Drop OutA Brief Word About Drop OutOnus and Blame on ClientOnus and Blame on Client

A Brief Word About Drop OutA Brief Word About Drop OutOnus and Blame on ClientOnus and Blame on Client

•Clinicallysignificantchange is 5 ormore pointson the ORSplus crossingthe clinicalcutoff or 25

•Reliablechange is achange of 5or more:more thanattributableto chance,measurement error ormaturation

Reliable or ClinicallySignificant ChangeReliable or ClinicallySignificant Change


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Cumulative Career DevelopmentASIST and MyOutcomes.com

• The single bit ofinformation that tellsyou the most is the %who reach target—the 50th percentiletrajectory for clientsentering services withthe same intakescore.

Reviewing GraphsFirst Things First


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Becoming BetterConsider Benefits of Tracking Outcome

• Allows a systematic trialand error application of newlearning as well as therefinement of the tried andtrue mechanisms that weknow enhance outcomes.

• Tracking cumulative careerdevelopment enablesreflection and action abouteffectiveness.

Cumulative Career DevelopmentStart with the Common Factors

• Models/techniques, but…

• Focus on the commonfactors.

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


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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%

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

Client is the of Change

• Client’s Resources,Resiliencies, andRelational Support

• Client’s View of theAlliance

• Client’s View ofProgress &Expectationof Success


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Alliance As An Overarching FrameworkThe Alliance is the Soul

• Transcends any beh & is aproperty of all—from tech. toscheduling an appt

• Purpose is to engage inpurposive work

• Have to earn it each & everytime; alliance is our craft;practice elevates to art

Becoming BetterTake Charge

• Track effectiveness byquarter or 30 client block.

• Keeps your dev. front &center; implement ideas,practices, & models, aswell as building skills.

• Will readily see whetherefforts are paying off, ifyour chosen methods ofincreasing effectivenessneed to be tweaked orchanged outright.


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Sources of AccelerationStep 2. Theoretical Breadth

Therapists at everystage who combinedseveral theoreticalperspectives were the“most growing” &more likely to exp.Healing Involvement.

Becoming Better at What We DoExpand Your Theoretical BreadthBecoming Better at What We DoExpand Your Theoretical Breadth

• Loosen your grip onthe “truth” of anyapproach

• Theoretical loyaltybrings certainty(certain failure);theoreticalpromiscuity bringsuncertainty (but fitsmore clients)


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Theoretical BreadthWe All Have Pet Theories

• We all have those thatseem to fit with who weare, that match our ideasof how people can change

• But all approaches havevalidity, all are butmetaphorical accounts ofhow people can change.

• It is the fit that matters, &whether any approachresonates with both theclient and the therapist.

Believing in the TruthNot Rocket Science

• Can hold only 3/4 systems• But far more frames or

structures or explanations.• Open up to Franks

observation that theimportant stuff is thatmodels offer a rationaleand a ritual.

• They don’t require 2 yrs ofsupervision to understandor implement, but keepthat under your hat.


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Becoming BetterTheoretical Breadth

• Stepping outside comfortzones make usvulnerable—cookiecutter therapy is mucheasier to do, but we don’tgrow much.

• Let go a bit, like singingin the shower or dancingwhen no one is looking.

How Do YouBroaden Theoretical Horizons?

• Start with those that fityour views of humannature, problems, andsolutions, & their relatives.

• Set self conscientiousnessto the side—let the client’stheory be your theory withthat client…Claire

• Be proactive. Play “onother hand” games


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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.

Biggest Source of Development

3. Currently Experienced Growth

• “What have you donefor me lately?”

• Our work is a calling,so our dev. isimportant to us—somuch so that we keepa finger on the pulseof it at all times.


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Perhaps the MostSignificant Finding

The perception ofgetting better overtime and a palpableexperience ofcurrent growthenliven therapy andstaves off burnout.

Currently Experienced Growthand Morale

• Closely associated withwork morale. Energizestherapists to apply theirskills & understandings

• Remoralizes, repairsabrasions & stressorsof the work.

• Combats routinization,disillusionment, & lossof empathy.


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Growth is our Primary Way toFend of Disenchantment

• “CEG the balm that keeps ourpsychological skin permeable—manycommonly believe that the constanthearing of problems would lead oneto be emotionally callused anddevelop a ‘thick skin.’ But not fortherapists—we need ‘thin skin,’—open, sensitive, and responsive tocontact with clients.”

Currently Experienced Growth

Both the rewardfor doing our workand our greatestally for sendingthe grim reaper ofburnout packing.


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How Do We AttainCurrently Experienced Growth

• Experiential learningthru clinical work

• Beyond cliché, helpersbelieve that clients arethe best teachers—our primary access toGrowth

Beyond Cliché

• . Impossible to routinely sit with people in thethroes of disaster, then witness their journey toa better place, and not be changed. Lean aboutthe human condition, different cultures andworld views, as well as the myriad of ways thatpeople transcend adversity and cope with theunthinkable. While noteworthy, trackingoutcome takes the notion that “the client is thebest teacher” to a different and perhaps morepractical level.


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Attention to the Here and Now

Clients teach us with theirresponses—whether they arebenefiting & whether ourservice is a good fit—as wellas their reactions &reflections re the next step.

Clients who are not benefitingoffer us the best opportunityfor learning, helping us stepoutside our comfort zones.

Proactively Consider theLessons and Reflect

• Any difference can be animportant marker thathighlights your currentlyexperienced growth.Perhaps you didsomething for the first timewith a client, or a lightwent on and you nowunderstand something in adifferent way.


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Making the Best ofCurrently Experienced Growth

• Review current clients,consider lessons.

• Empower yourself, likeyour clients, to enable thelessons to take hold.

• Articulate how clientlessons have changed yourwork, your identity & howyou describe what youdo…Ann

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.

Study Says Something ImportantAbout Who and What

• Tracking outcomes enablesbig picture view of CCD, anda microscopic view of CEG.

• Both perspectives allow youto continually reflect aboutyour development and testyour assumptions, adjust toclient preferences, masternew tools & learn new ideas


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Getting Better IsPart of Your Identity

• But you have to keep yourhead and heart in the game inspite of all the reasons thatconspire —like fundermandates, unrealisticproductivity requirements,meaningless paperwork, andgut-wrenching clientcircumstances to —for you toaccept monotony and negativeoutcomes.

Ensuring Development withOutcome Feedback

• Client feedback monitorsoutcome & plots cumulativecareer development.

• Tailoring services leads totheoretical breadth to servemore clients.

• Securing client feedback placesproviders in acceleratedcourses of development, in thefront of the class to see andhear the lessons of the day—toexperience currentlyexperienced growth.

Education

AcceleratingYourDevelopmentSlides