On Becoming

a Better
Therapist
On Becoming
a Better
Therapist
Evidence-Based Practice
One Client at a Time
SECOND EDITION

BARRY L. DUNCAN
Forewords by Michael J. Lambert and David N. Elkins

A M E R I C A N PSYC H O LO G I C A L A S S O C I AT I O N • Washington, DC
Copyright © 2014 by the American Psychological Association. All rights reserved. Except
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Library of Congress Cataloging-in-Publication Data

Duncan, Barry L.
On becoming a better therapist : evidence-based practice one client at a time / Barry L.
Duncan. — Second edition.
pages cm
Includes bibliographical references and index.
ISBN-13: 978-1-4338-1745-8
ISBN-10: 1-4338-1745-4
1.  Psychotherapy. 2.  Psychotherapists.  I. American Psychological Association. II. Title.
RC480.D857 2014
616.89'14—dc23
2013048651

British Library Cataloguing-in-Publication Data

A CIP record is available from the British Library.

Printed in the United States of America

Second Edition

http://dx.doi.org/10.1037/14392-000
 CONTENTS

Foreword to the First Edition......................................................................   vii

Michael J. Lambert
Foreword to the Second Edition..................................................................   xi
David N. Elkins
Preface........................................................................................................   xiii
Chapter 1. So You Want to Be a Better Therapist.............................. 3
Chapter 2. Becoming a Better Therapist With PCOMS.................. 35
Chapter 3. How Being Bad Can Make You Better............................ 71
Chapter 4. Getting Better With Couples, Families, and Youth........ 99
Chapter 5. Using PCOMS to Accelerate Your Development........ 127
Chapter 6. The Heart and Soul of Change..................................... 147
Chapter 7. Wizards, Humbugs, or Witches..................................... 175

v
Chapter 8. Becoming a Better Agency............................................ 191
Chapter 9. For the Love of the Work.............................................. 217
References................................................................................................. 237
Index......................................................................................................... 253
About the Author..................................................................................... 269

vi       contents
 FOREWORD to the first edition
MICHAEL J. LAMBERT

Outcome research in the last 2 decades has extensively focused on the

effects of specific treatments for specific disorders, so-called clinical trials.
Researchers employing this methodology typically attend to the individual
therapist as an important factor to be controlled before undertaking their pri-
mary analysis of treatment effects. Such research uses considerable resources to
diminish variability in outcomes that could be attributed to the therapist. This
is typically accomplished through careful selection of therapists, extensive train-
ing, and supervision of therapists who are using treatment manuals to guide their
interventions. The intent of such procedures is to maximize the likelihood of
finding effects due to treatments, independent of the therapists who offer them.
In a field dedicated to the understanding of human behavior, it is a paradox that
half the human element of therapy, the therapist, has largely been relegated to
the category of an extraneous variable in clinical trials. This has resulted in an
“oddly personless” view of psychotherapy (Norcross, 2002, p. 4).
Such designs don’t necessarily ignore the importance of the thera-
pist’s capacity to both build a relationship with the client and flexibly tai-
lor therapeutic treatment (techniques) to meet the needs of the individual
client, but they do reduce variability in these important capacities, which
are so central in service delivery in everyday practice. Considering the

vii
therapist and the client as central elements in the process of therapy does
not detract from psychotherapy itself as having important healing ingre-
dients but expands the possibilities for understanding the human encoun-
ter as connected with, rather than incidental to, therapeutic techniques.
It makes little practical sense in routine care to ignore or minimize the
interpersonal nature of psychotherapy and the therapist’s contribution to
patient improvement.
On Becoming a Better Therapist redirects our attention from specific
treatments to our behaviors and attitudes as therapists, offering a refreshing
look at improving treatment that operates outside the contemporary solution
of providing the “right psychological treatment for the right disorder.” This
book provides simple but elegant solutions for becoming a more effective
therapist.
In On Becoming a Better Therapist, Barry Duncan emphasizes the ther-
apist and the therapist’s contribution to patient well-being, extending the
usual solutions provided in graduate education and challenging therapists
in two important ways. The first requires therapists to systematically moni-
tor their clients’ treatment response and the therapeutic alliance (as rated
by the client) and to discuss these phenomena with the client. The second
challenge is for therapists to examine their effectiveness over time and use
this information to become more effective. The discourse is on the one hand
highly personal, anecdotal, passionate, and persuasive, and on the other,
evidence-based. Barry Duncan is one of a handful of individuals advocating
and implementing client progress information as an integral method of help-
ing while learning from our patients.
Duncan makes improving patient outcomes the private and primary
business of therapists, rather than policymakers and researchers. In this per-
suasive book he shows therapists how they can empower themselves and
change their identities from providers of brand-name treatments to effective
providers. This is truly ambitious and even revolutionary. To quote his words:
In this book I have suggested that you step up to the plate with two things:
attaining systematic client feedback and taking your development as a
therapist to heart. . . . Routine collection of client feedback allows you
to monitor your outcomes and plot your cumulative career development,
so you know about your effectiveness, can determine whether you are
improving, and most important, can reflect about what you can do to
grow as a therapist. Tailoring your services to client feedback and pref-
erences encourages you to let loose of any grip on the certainty of any
particular ideology or practice and stimulates your expansion of your
theoretical breadth.
Thus, On Becoming a Better Therapist provides new goals for our therapeu-
tic efforts. These goals shift our attention from becoming experts in techniques

viii       foreword to the first edition

to becoming knowledgeable about our effects on patients and our effectiveness.
Rather than settling for getting certifications in techniques based on par-
ticipation in workshops, the emphasis is on systematically measuring patient
treatment response.
In fact, substantial evidence exists showing the degree to which track-
ing patient treatment response benefits clients (Lambert, 2010). It is becom-
ing clearer that patients (particularly if they go off track) are advantaged
when their response to treatment is formally measured and viewed by their
therapist. But in this book Duncan goes beyond this reason for implementing
formal tracking and feedback. It is a good idea if we want to understand our
strengths and weaknesses and use this information to help us grow. If readers
find Duncan persuasive and take up his challenge of systematically monitor-
ing treatment response and alliance, it will be possible to estimate the extent
to which we therapists actually become more effective with ongoing cases
and over time. Duncan is confident that practicing with progress and alli-
ance feedback will accelerate movement toward becoming a more effective
therapist, and he provides evidence that this can be the case.
It is surprising that those most likely to instigate systematic monitoring
are system administrators, not therapists. One would think that therapists
would eagerly embrace the collection of important and empowering informa-
tion through the easily applied methods advocated here, but this is not gener-
ally the case. Most investigations of therapist effects (Brown, Jones, Lambert,
& Minami, 2005; Okiishi, Lambert, Eggett, et al., 2006; Okiishi, Lambert,
Nielsen, & Ogles, 2003; Wampold & Brown, 2005) have been conducted by
systems of care that have grasped the advantages of managing outcomes. The
presence of variability in client outcome due to individual therapists allows
systems of care to manage service delivery on the basis of effectiveness, not
just processes. Duncan persuasively argues the advantages of monitoring and
feeding back information for therapists, appealing to the basic motives of
those who enter the helping professions—to make a difference by relieving
suffering and maximizing human potential.
On Becoming a Better Therapist goes a long way toward expanding the
potential of outcome monitoring by arguing that such methods are not only
good for clients but also good for therapists—that such simple methods can
affect the identity and well-being of therapists. This volume is yet another
good read produced by Barry Duncan. Here he emphasizes the contribu-
tions of the therapist to client well-being and what has been learned from
those who practice day-to-day with no fanfare. This book advocates becom-
ing a better therapist by virtue of formally tracking our patients’ treatment
response and discussing progress and problems. The possibility and novelty of
his ideas make this an important and provocative contribution to the field. It
is time to make monitoring the consequences of day-to-day practice routine.

foreword to the first edition      ix

FOREWORD TO THE SECOND EDITION
DAVID N. ELKINS

I first became aware of Barry Duncan’s scholarly work in the field of

psychotherapy more than a decade ago. In recent years I have come to know
him more personally, and I am honored to write this foreword for the second
edition of On Becoming a Better Therapist. Duncan became involved with com-
mon factors as a full-time practitioner who was looking for ways to increase
his effectiveness with clients. Disenchanted by the debates about which
model and techniques were most effective, Duncan came to believe that the
best way to increase effectiveness was to apply what was known about psycho­
therapy outcome. He proposed that clinicians spend time in therapy com-
mensurate to each element’s differential impact on outcome. Because the
outcome research showed that client factors and the therapeutic alliance
were the most potent determinants of outcome, Duncan called on therapists
to spend less time on models and techniques, which had relatively little effect
on outcome, and more time supporting the inherent strengths of clients and
building a positive therapeutic relationship. More specifically, he called for
a “client-directed” approach that focused on clients’ strengths and resources,
clients’ ideas on how they can be helped, clients’ hopes and expectations
about the therapy, and clients’ views on the nature and quality of the thera-
peutic relationship.

xi
 Duncan has published 16 books and dozens of articles, as well as conducting
research on psychotherapy outcome. As a clinician who has spent more than
17,000 hours in direct client contact, Duncan’s major contribution to the field
is his ongoing effort to operationalize the common factors in therapeutic work.
He believes that the client and the alliance are the “heart and soul” of change,
a term he chose to name both the popular book about common factors as well
as the organization he directs (see https://heartandsoulofchange.com).
Duncan’s focus on the importance of the client culminated in the pub-
lication of this book and a client feedback process known as the Partners
for Change Outcome Management System (PCOMS). To identify clients
not responding to therapy, PCOMS solicits client feedback at each session
about the outcome of therapy and the alliance. The feedback system helps
clients, in collaboration with the psychotherapist, to find new and more help-
ful directions when the therapy is not going well. Duncan believes ongoing
client feedback should be a “common factor” in all psychotherapies because
of its proven effectiveness in helping clients to become more actively engaged
in monitoring and improving their therapy experience, thus promoting more
effective outcomes.
For those clinicians who, like Barry Duncan, are committed to becoming
the best therapist possible, this book will be a breath of fresh air. Written in
an accessible yet scholarly style, this updated second edition offers evidence-
based and practical guidance on how to become a more effective therapist.
In fact, the information presented in the following pages is so practical and
“clinician friendly” that therapists can apply it immediately, beginning with
the next client who walks in the door.

xii       foreword to the second edition

 preface

At times our own light goes out and is rekindled by a spark from another
person. Each of us has cause to think with deep gratitude of those who
have lighted the flame within us.
—Albert Schweitzer

I named a previous book The Heroic Client (Duncan, Miller, & Sparks,
2004) to showcase the more noble sides of human nature that accompany
clients to our offices and to recast the drama of therapy, assigning clients
their rightful central roles in therapeutic change. I could have called this one
The Heroic Therapist to spotlight those individuals who are in the trenches,
fighting the good fight with clients to transcend adversity, manage life, and
find meaning in this crazy existence. I truly admire you, and I write this book
for you, regardless of your discipline or whether you call yourself a psycho-
therapist, counselor, case manager, nurse practitioner, addiction specialist, or
student. You are the spark that has rekindled my flame over the years.
I have been in the presence of many great therapists in my life, and
none of them have been workshop stars or authors of definitive works about
psychotherapy. No, these exceptional therapists whom I have been privi-
leged to know are you—the folks who, in spite of downsides of the work that

xiii
lead some to burn out and accept mediocrity, still manage to care deeply
about clients and do incredible work. As I travel in my role as a trainer and
consultant, I am continually inspired not only by the character of individu-
als who do this work but also by their commitment to improve their effec-
tiveness. It seems to be part of their makeup, their very identity, to strive to
be more helpful, to increase the numbers of clients who benefit from their
services.
On Becoming a Better Therapist: Evidence-Based Practice One Client at a
Time intends to help you be better at what you do—to both improve your out-
comes now and accelerate your development—in a pragmatic and measurable
way via the Partners for Change Outcome Management System (PCOMS).
PCOMS solicits the consumer’s real-time feedback about outcome and the
alliance to enable more effective care that is tailored to client preferences.
It allows a clinically friendly method to track outcome, something that has
been sorely missing.
When I was in graduate school, the only discussion of outcome was in
the context of psychotherapy efficacy studies. And that was unbelievably
confusing given all the types of psychometric instruments, not to mention
the complexity of the findings, leaving many of us with our heads reeling and
the idea that measuring outcomes was about research, with no applicabil-
ity to everyday practice. In the late 1990s, a new era was ushered in based
largely on the pioneering work of Michael Lambert and the Outcome Ques-
tionnaire 45.2 (Lambert et al., 1996). Over time Lambert demonstrated that
feedback enhanced client benefit and that outcome management could be a
part of routine clinical work. In other words, measuring outcomes wasn’t just
for researchers anymore. With that inspiration, PCOMS was developed as a
brief and feasible yet psychometrically sound alternative to longer outcome
tools, to encourage routine use and bring the advantages of feedback to the
in-the-trenches therapist. PCOMS is designed for use in everyday practice
as a reliable, valid, and perhaps most important, doable method to partner
with clients to track outcome—to identify at-risk clients while offering a
way for therapists to monitor their effectiveness over the course of their
careers. And just in time, too, because the Affordable Care Act calls for
measurable outcomes, a call that is increasing in volume from many private
and public funders.
Since the first edition of this book was published, PCOMS has been
included in the Substance Abuse and Mental Health Services Administra-
tion’s National Registry of Evidence-Based Programs and Practices. All three
randomized clinical trials (RCTs) that enabled our application for and real-
ization of evidence-based practice (EBP) status were conducted by Partners
(my colleagues and me) of the Heart and Soul of Change Project (see https://
heartandsoulofchange.com). We are committed to the values of consumer

xiv       preface

privilege, partnership, and service accountability, and we put our efforts into
proving that a value-based outcome management system can really make a
difference.
And it does. As demonstrated by the extensive research (including five
RCTs) described in this book, PCOMS has the potential to improve your
outcomes more than anything since the beginning of psychotherapy. Sounds
like hyperbole, but it’s not. PCOMS identifies clients who aren’t responding
so that you can proactively address the lack of progress and collaboratively
develop a new plan. PCOMS allows you to recapture those clients destined
for a negative outcome.
But PCOMS is not a specific treatment model for a particular client
diagnosis; it’s a horse of a different color. It is atheoretical and therefore may
be added to or integrated with any model of practice, and it applies to all diag-
nostic categories. So, in effect, one size does fit all, allowing you to be evidence
based across your clients. And, more important, PCOMS is evidence based
at the individual client–therapist level. Collecting client feedback monitors
whether this therapeutic approach provided by this therapist is benefiting this
client. It provides a seemingly contradictory way to become evidence based
across all your clients while tailoring services to the individual client’s needs,
preferences, and culture—or evidence-based practice one client at a time. Hence,
the new subtitle of this second edition.
This book asserts that getting better at this work we love requires you
to step up to the plate with two things: attain systematic client feedback via
PCOMS and take your development as a therapist to heart. You are a signifi-
cant ingredient of therapeutic change—in fact, in more ways than not, you are
the treatment. Consequently, your perceptions of yourself and the work, your
effectiveness, and your professional development are critical to your ongo-
ing vitality as a helper. Pragmatically integrating the groundbreaking research
about therapist growth of Orlinsky and Rønnestad (2005) with PCOMS, On
Becoming a Better Therapist details a five-step plan to take charge of your develop-
ment and accelerate it, with ways to keep your growth on the front burner, stave
off the grim reaper of burnout and disenchantment, and remain a vital force for
change in clients’ lives. I’ll show you how to track your outcomes and form a stra-
tegic plan that ensures that you learn from your experience and not just repeat it.
Finally, On Becoming a Better Therapist brings the lessons that I have
learned from the best teachers of psychotherapy, my clients, some of whom
were instrumental in shaping my career as well as my identity as therapist. But
more important, this book shows you how to take advantage of the lessons ten-
dered by your clients in a more systematic, session-by-session way. Beyond the
cliché of clients being the best teachers, clients can, in real time, shape your
therapeutic behavior, to create a better fit with their expectations, improve
your outcomes, and enable you to do better work with more people. On

preface       xv
Becoming a Better Therapist demonstrates how harvesting the lessons learned
from clients not only replenishes us but also encourages quantum leaps in
our development.
Speaking of clients, the vignettes in this book are real, but all iden-
tifying information, including specific circumstances, have been removed
or substantially altered to protect client confidentiality. In some, details are
interchanged with other clients just to ensure that no one can be identified.
But the accounts of the clinical process reflect what happened and are accu-
rate depictions of the therapeutic events described.
Those of you familiar with the first edition will notice many changes. In
addition to significant research updates and new clinical examples, the focus
has been broadened with two new chapters, one demonstrating PCOMS
with couples, families, and youth and the other presenting how to implement
PCOMS on an organizational scale. And in writing the second edition, I
quickly realized that, once you repaint one room, then the whole house looks
in need of a new coat. So this edition also includes everything I’ve learned
since the first edition from considering the many thoughtful questions that
have been raised in my trainings and implementations.
Many people deserve special mention for their contributions to this book.
I want to express my deepest gratitude to my partners in crime at the Heart
and Soul of Change Project, for their scholarly contributions and expansions
of my thinking and also for their spirit of collaboration and friendship—it
has been a joy to surround myself with people whom I trust, who are selflessly
committed to the ideals in this book. First, the Project Leaders: Jacqueline
Sparks, Brian DeSantis, John Murphy, Mary Susan Haynes, Bob Bohanske,
Anne-Grethe Tuseth, Jeff Reese, Luc Isebaert, and Sami Timimi. And the Cer-
tified Trainers: Morten Anker, Robyn Pope, Tor Fjeldstad, Pamela Parkinson,
Dave Hanna, Barbara L. Hernandez, Alan Girard, Joan Biever, George Braucht,
Mark DeBord, Geir Skauli, and Don Rogers. In addition to the readers of the
first edition, I owe an incalculable debt to David N. Elkins (who also gra-
ciously wrote the foreword to the second edition), Jeff Reese, Morten Anker,
and especially Jacqueline Sparks (who also substantially contributed to Chap-
ter 4), who generously gave their time to give me feedback about this edition.
Finally, I am appreciative of Susan Reynolds and Tyler Aune of the American
Psychological Association. Susan has remained supportive of my work over
the years and encouraged this second edition, and Tyler contributed expert
editorial advice that significantly improved this book.

xvi       preface

On Becoming
a Better
Therapist
 1
SO YOU WANT TO BE
A BETTER THERAPIST

It’s never too late to be who you might have been.

—George Eliot

A long time ago in a galaxy far way, I was in my initial placement in

graduate school at the Dayton Mental Health and Developmental Center,
the state hospital. While I often don’t remember where I leave my glasses,
I still vividly recall my first client, including her full name, but I’ll call her
“Tina.” Tina was like a lot of the clients: young, poor, disenfranchised, heavily
medicated, and in the revolving door of hospitalizations—and at the ripe old
age of 22, she was called a chronic schizophrenic.
Although this practicum offered some group experience, it was largely
devoted to assessment, and that’s how I met Tina. I gathered up my Wechsler
Adult Intelligence Scale—Revised, the first of the battery of tests I was attempt-
ing to gain competence with, and was on my merry but nervous way to the
assessment office, a stark, run-down room in a long-past-its-prime, barrack-
style building that reeked of cleaning fluids overused to cover up some other
worse smell, the institutional stench. But on the way I couldn’t help noticing
all the looks I was getting—a smirk from an orderly, a wink from a nurse, and

http://dx.doi.org/10.1037/14392-001
On Becoming a Better Therapist, Second Edition: Evidence-Based Practice One Client at a Time, by B. L. Duncan
Copyright © 2014 by the American Psychological Association. All rights reserved.

3
funny-looking smiles from nearly everyone else. My curiosity piqued, I was just
about to ask what was going on when the chief psychologist put his hand on my
shoulder and said, “Barry, you might want to leave the door open.” And I did.
I greeted Tina, a young, extremely pale woman with brown cropped hair
(who might have looked a bit like Mia Farrow in the Rosemary’s Baby era had
Tina lived in friendlier circumstances) and introduced myself in my most pro-
fessional voice. Before I could sit down and open my test kit, Tina started to
take off her clothes, mumbling something indiscernible. I just stared in dis­
belief, in total shock, really. Tina was undaunted by my dismay and quickly was
down to her underwear when I finally broke my silence, hearing laughter in the
distance, and said, “Tina, what are you doing?” Tina responded not with words
but with actions, removing her bra like it had suddenly become very uncom-
fortable. So, there we were, a graduate student, speechless, in his first profes-
sional encounter, and a client sitting nearly naked, mumbling now quite loudly
but still nothing I could understand, and contemplating whether to stand up to
take her underwear off or simply continue her mission while sitting.
Finally, in desperation, I pleaded, “Tina, would you please do me a big
favor? I mean, I would really appreciate it.” She looked at me for the first time,
looked me right in the eye, and said, “What?”
I replied, “I would really be grateful if you could put your clothes back
on and help me get through this assessment. I’ve done them before, but never
with a client, and I am kinda freaked out about it.”
Tina whispered, “Sure,” and put her clothes back on. And although
Tina struggled with the testing and clearly was not enjoying herself, she
completed it.
I was so genuinely appreciative of Tina’s help that I told her she really
pulled me through my first real assessment. She smiled proudly, and ulti-
mately she smiled at me every time she saw me from then on. I wound up
getting to know Tina pretty well and often reminded her of how she helped
me, and I even told her that I thought she looked like Mia Farrow, to her
immense enjoyment. The more I got to know Tina and realized that her
actions, stemming from horrific abuse, were attempts to take control of situ-
ations in which she felt powerless, the angrier I became about her being used
as a rite of passage for the psychology trainees—a practice that I subsequently
put a stop to in that institution.
I’ll never forget the lessons that Tina taught me in the very beginning
of my psychotherapy journey: Authenticity matters, and when in doubt
or in need of help, ask the client, because you are in this thing together.
Wherever you are, Tina, thanks for charting my course toward the power of
real partnerships with clients.
I am a true believer in psychotherapy and in therapists of all stripes and
flavors. In the 34 years and over 17,000 hours of my experience with clients

4       on becoming a better therapist

since I saw Tina, I have been privileged to witness the irrepressible ability
of human beings to transcend adversity—clients troubled by self-loathing
and depression, battling alcohol or drugs, struggling with intolerable mar-
riages, terrorized by inexplicable voices, oppressed by their children’s prob-
lems, traumatized by past or current life circumstances, and tormented with
unwanted thoughts and anxieties—with amazing regularity. As a trainer and
consultant, I have rubbed elbows with thousands of psychotherapists across
the globe, and the thing that strikes me most is their authentic desire to be
helpful. Regardless of discipline, theoretical persuasion, or career level, they
really care about people and strive to do good work. The odds for change
when you combine a resourceful client and caring therapist are worth bet-
ting on, certainly cause for hope, and responsible for my unswerving faith in
psychotherapy as a healing endeavor.
It’s no secret, however, that this is a tough time to be a therapist. In
public agencies, we’re underpaid, overworked, and often held to unattainable
productivity standards. We’re subjected to a continual onslaught of paper-
work and frequently face cutbacks and layoff threats. While some of us still
thrive in private practice, most of us make far less than we did during the
“golden age” of fee-for-service insurance reimbursement, and we endure over-
sight that challenges our patience. Furthermore, the nature of clinical work
itself is sometimes frustrating, even anxiety provoking, exposing us to high
levels of human suffering, stories that are at times tough to shake.
Adding insult to injury, the culture at large doesn’t seem to admire ther-
apists particularly, or understand what we do. This point is clear if you take a
moment to think about popular portrayals of therapists, such as Dr. Marvin
Monroe of The Simpsons or Jack Nicholson in Anger Management or Barbra
Streisand in Meet the Fockers. Sure, good examples of competent clinicians
exist, but they’re far outweighed by those that cast us as self-indulgent crack-
pots endlessly mouthing psychobabble. Perhaps one sobering indication of
how much we are valued is provided by the online salary database PayScale.
com, which reveals that the two worst-paying master’s degrees are in counsel-
ing and social work. It is amazing to think, in these hard economic times, that
smart, creative individuals make the necessary sacrifices to attain advanced
degrees only to earn far less money than those with comparable degrees in
other fields. So, why would anybody choose to enter such a field?
To be sure, most of us didn’t chose this work because we thought we’d
acquire the lifestyles of the rich and famous—and we knew at the outset that
devoting our lives to trying to assuage human misery wouldn’t be a walk in
the park. The fact of the matter is that the overwhelming majority of psycho-
therapists, as corny as it sounds, want to be helpful. Many of us, including me,
even answered in graduate school applications “I want to help people” as the
reason we chose to be therapists (see Figure 1.1). Often, some well-meaning

so you want to be a better therapist      5

 I just want to
help people!

Figure 1.1.  Barry just wanted to help people.

person dissuaded us from that answer because it didn’t sound sophisticated

or appeared too “co-dependent.” Doing the required servitude without the
promise of a rags-to-riches future only makes sense because being a psycho-
therapist is more of a calling than a job—a quest for meaningful activity and
personal fulfillment (Orlinsky et al., 2005) and a desire to make a difference
in the lives of those we serve.
But when the realities of everyday practice set in, answering the call to
the work brings with it an immediate conundrum: We want to build on our
original aspirations and get better over the course of our careers, but how do we
make sense of the cacophony of “latest” developments, all the fully manualized

6       on becoming a better therapist

treatments hot off the press, each promising increased effectiveness with this or
that disorder? Call me cynical, but the field doesn’t seem to know what profes-
sional development means or how we can get better at therapy.
We are often told that developing ourselves as psychotherapists requires
that we become more self-aware through personal therapy. This makes a lot
of intuitive sense, and gaining an appreciation of what it is like to sit in
the client’s chair seems invaluable. But a look at probably the best source,
The Psychotherapist’s Own Psychotherapy (Geller, Norcross, & Orlinsky, 2005)
reveals that the cold, hard truth is that although therapists rave about its
benefits, personal therapy has nothing to do with outcome.
And although the need and value of training seem obvious, it has long
been known that professional training and discipline are not related to posi-
tive outcomes (Beutler et al., 2004). A more recent study only confirmed this
conclusion. Nyman, Nafziger, and Smith (2010) reported that, as strange as it
seems, 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. As for continuing professional education,
despite its requirement in nearly every state, there is no evidence that therapists
learn anything from such experiences or that their participation translates to
better outcomes (Neimeyer, Taylor, & Philip, 2009).
What about experience? Surely, years of clinical encounters make a dif-
ference. But are we getting better, or are we having the same year of experience
over and over? How would we even know whether experience really improved
our outcomes? More bad news here: Experience just doesn’t seem to matter
much (Beutler et al., 2004). Results are mixed at best, with recent studies
suggesting no effects on outcome of experience (Hill & Knox, 2013). In large
measure, generic experience does not improve outcomes—experienced and
inexperienced therapists achieve about the same outcomes. (I revisit the issue
of experience later in the chapter.)
Does this mean that we should forget the whole thing? No, not at all.
But getting better is not about learning the latest and greatest miracle tech-
nique, or a never-before-available way to unravel the mysteries of the human
psyche, or the most recent breakthrough in brain neurochemistry. There will
be no husky voiceover here declaring a winner of the battle of the psycho-
therapy brands or adding yet another fashion to the therapy boutique of tech-
niques. Most of you have already been there and done that. Rather, this book
is about you—this time it’s personal, from one therapist to another. Contrary
to my cynical portrayal of the state of the field’s efforts to help you get better,
this book describes an evidence-based method that will both improve your
outcomes and accelerate your development. On Becoming a Better Therapist
intends to help you answer your calling and remember why you became a
therapist in the first place.

so you want to be a better therapist      7

 This chapter sets the stage. I start with a broad look at the field of psycho­
therapy and its problems, and then I present an evidence-based solution that
provides a seemingly contradictory way to become evidence based across all
your clients while tailoring services to the individual client’s needs, prefer-
ences, and culture—evidence-based practice one client at a time. Two other
relevant topics are addressed: First, those aspects of the work that really mat-
ter in therapeutic change, the so-called, but not so common, common factors,
and the apparently never-ending controversy surrounding evidence-based
treatments and evidence-based practice.

THE GOOD, THE BAD, AND THE UGLY

To exchange one orthodoxy for another is not necessarily an advance.

The enemy is the gramophone mind, whether or not one agrees with the
record that is being played at the moment.
—George Orwell

The good news is that the efficacy of psychotherapy is very good—the

average treated person is better off than about 80% of the untreated sample
(Duncan, Miller, Wampold, & Hubble, 2010; Lambert, 2013), translating to
an effect size (ES) of about 0.8.1 Moreover, these substantial benefits extend
from the laboratory to everyday practice. For example, a large (N = 5,613)
real-world study in the U.K. (Stiles, Barkham, Mellor-Clark, & Connell,
2008) comparing cognitive behavioral therapy (CBT), psychodynamic
therapy (PDT), and person-centered therapy (PCT) as routinely practiced
reported a pre–post ES of around 1.30. Moreover, three benchmarking studies
have demonstrated that observed results in not only managed care (Minami
et al., 2008) and university counseling settings (Minami et al., 2009) are
comparable to those in randomized clinical trials (RCTs), but also to those
attained in a public behavioral health setting (Reese, Duncan, Bohanske,
Owen, & Minami, 2014). In short, there is a lot to feel proud about our
profession: We know that psychotherapy works, even in the trenches.
But there’s more to the story. The bad news is twofold: First, dropouts
are a significant problem in the delivery of mental health and substance abuse
services, averaging at least 47% (Wierzbicki & Pekarik, 1993). When drop-
outs are considered, a hard rain falls on psychotherapy’s efficacy parade, both

1Effect size (ES) refers to the magnitude of change attributable to treatment, compared with an untreated

group. The ES most associated with psychotherapy is 0.8 standard deviations above the mean of the
untreated group. An ES of 1.0 indicates that the mean of the treated group falls at approximately the
84th percentile of the untreated one. Consequently, the average treated person is better off than approxi-
mately 80% of those without the benefit of treatment.

8       on becoming a better therapist

in RCTs and in clinical settings. Second, despite the fact that general efficacy
is consistently good, not everyone benefits. Hansen, Lambert, and Forman
(2002), using a national database of 6,072 clients, reported a sobering picture
of routine clinical care in which only 35% of clients improved as compared
with the 57% to 67% rates typical of RCTs. Whichever rate is accepted as
more representative of actual practice, the fact remains that a substantial
portion of clients go home without help.
And the ugly: Explaining part of the volatile results, variability among
therapists is the rule rather than the exception. Not surprising, although rarely
discussed, some therapists are much better at securing positive results than
others. Moreover, even very effective clinicians seem to be poor at identifying
deteriorating clients. Hannan et al. (2005) compared therapist predictions
of client deterioration to actuarial methods. Though therapists were aware of
the study’s purpose, familiar with the outcome measure used, and informed
that the base rate was likely to be 8%, they did not identify 39 out of the
40 clients who deteriorated. In contrast, the actuarial method correctly pre-
dicted 36 of the 40.
So, despite the overall efficacy and effectiveness of psychotherapy, drop-
outs are a substantial problem, many clients do not benefit, and therapists
vary significantly in effectiveness and are poor judges of client deterioration.
Perhaps the ugliest of the ugly is that most of us don’t know how effective
we really are. Do you know how effective you are? With dropouts considered,
how many of your clients leave your office absent of benefit? Which clients
in your practice now are at risk for dropout or negative outcome?
What is the solution to these problems? Sometimes our altruistic desire
to be helpful hoodwinks us into believing that if we are just smart enough
or trained correctly, clients would not remain inured to our best efforts. If we
found the Holy Grail, that special model or technique, we could once and for
all defeat the psychic dragons that terrorize clients. We come by this belief
honestly. We hear it all the time, constantly reinforced on nearly all fronts.
The warring factions carry on the struggle for alpha dogma status in the
psychotherapy pack and claims of “miracle cures better than the rest” continue
unabated. The subtext is that if we don’t avail ourselves of these approaches
we are doing our clients a reprehensible disservice. But these admonitions
leave out a vital fact: None of the heralded models have reliably demonstrated
superiority to any other systematically applied psychotherapy.
This, of course, is the famous dodo bird verdict (“All have won and all
must have prizes”), taken from the classic Lewis Carroll (1865/1962) tale,
Alice in Wonderland, first invoked by Saul Rosenzweig way back in 1936
to illustrate the equivalence of outcome among approaches (see Duncan,
2010b). The dodo verdict is a much-replicated finding encompassing a broad
array of research designs, problems, populations, and clinical settings. For

so you want to be a better therapist      9

example, the study mentioned previously (Stiles et al., 2008), comparing
CBT, PDT, and PCT as routinely practiced, once again found no differences
among the approaches.
A more controversial illustration is provided by the treatments for the
diagnosis du jour, posttraumatic stress disorder (PTSD). CBT has demonstrated
its efficacy and is widely believed to be the treatment of choice, but several
approaches with diverse rationales and methods have also been shown to be
effective: eye-movement desensitization and reprocessing, cognitive ther-
apy without exposure, hypnotherapy, psychodynamic therapy, and present-
centered therapy (PRCT). A meta-analysis comparing these treatments found
all of them about equally effective (Benish, Imel, & Wampold, 2007). Two of
the treatments, cognitive therapy without exposure and PRCT, were designed
to exclude any therapeutic actions that might involve exposure (clients were
not allowed to discuss their traumas because that invoked imaginal exposure).
Despite the presumed extraordinary benefits of exposure for PTSD, the two
treatments without it, or in which it was incidental (psychodynamic), were just
as effective (Benish et al., 2007).
Unfortunately, the mountain of evidence researchers have amassed has
had little impact on the training of mental health or substance abuse clinicians
or, sad to say, on professional attitudes. We spend thousands of dollars on work-
shops, conferences, and books to learn highly publicized methods of treatment.
Instead of feeling hopeful or validated and experiencing the oft-promised better
outcomes, we often wind up feeling demoralized. Why didn’t the powerful sword
slay the dragon of misery of the client in my office now? The answer all too often
is to blame ourselves—we are just not measuring up. The Holy Grail seems just
out of reach.
Don’t get me wrong. There is nothing wrong with learning about mod-
els and techniques—in fact, it is a good thing, as I’ll discuss throughout the
book. You definitely want to bring the best to your client that the field has
to offer, but becoming beholden to any approach is not a good idea, nor is
believing that salvation will come from any of them. They are indeed false
gods. Why?
First, given the robust findings supporting the dodo verdict, it is impor-
tant to keep in mind that the much ballyhooed models have only shown
themselves to be better than sham treatments or no treatment at all, or to
less than equal opponents, which is not exactly news to write home to mom
about. Think about it. What if one of your friends went out on a date with
a new person, and when you asked about the guy, your friend replied, “He
was better than nothing—he was unequivocally better than watching TV or
washing my hair.” (Or, if your friend was a researcher: “He was significantly
better, at a 95% confidence level, than watching TV or washing my hair”)?
How impressed would you be?

10       on becoming a better therapist

 And second, the idea that change primarily emanates from the model or
techniques you wield is a siren call destined to smash you against the jagged
rocks of ineffective therapy. That therapists might possess the psychological
equivalent of a “pill” for emotional distress resonates strongly with many,
and is nothing if not seductive, because it teases our desires to be helpful. A
treatment for a specific “disorder,” from this perspective, is like a silver bul-
let, potent and transferable from research setting to clinical practice. Any
therapist need only to load the silver bullet into any psychotherapy revolver
and shoot the psychic werewolf stalking the client. In its most unfortunate
interpretation, clients are reduced to a diagnosis and therapists are defined
by a treatment technology—both interchangeable and insignificant to the
procedure at hand. This product or medical view of psychotherapy is most
empirically vacuous because the treatment model itself accounts for so lit-
tle of outcome variance, whereas the client and the therapist—and their
partnership—account for so much more.
Fear is also a potent motivator for the ongoing search for the Holy Grail.
Going well beyond subtext, we are told that not administering the “right” treat-
ment is unethical (Chambless & Crits-Christoph, 2006) and even “prosecut-
able!” A New York Times article reported: “Using vague, unstandardized methods
to assist troubled clients ‘should be prosecutable’ in some cases, said Dr. Marsha
Linehan . . . ” (Carey, 2005, p. 2). Given the lack of demonstrated superiority
of dialectical behavior therapy (DBT) or any other approach and the relative
contribution of model and technique to change (see below), such rhetoric seems
a bit over the top.
Perhaps the most publicized study of DBT (Linehan et al., 2006) com-
pared it with community experts (CE), examining suicidal behavior, emer-
gency room and hospital admissions, and other variables. Results indicated
that DBT led to significantly fewer suicide attempts and emergency room and
hospital admissions, as well as reduced medical risk, but no differences were
found with CE on the rest of the outcome measures: suicidal ideation, the
Reasons for Living Inventory, and the Hamilton Rating Scale for Depression.
DBT therapists received 45 hours of specialized training as well as weekly super-
vision and support; the CE therapists received none. Moreover, in addition to
the individual treatment component of DBT, the DBT therapists administered
38 group therapy sessions of 2.5 hours’ duration largely focused on keeping
people out of the hospital, perhaps accounting for the reduced ER and hospital
admissions. Although the study reports that the dose of treatment was compa-
rable, an examination of the tables revealed that the 2.5-hour group sessions
were counted only as 20 minutes of therapy, a somewhat curious way to record
95 hours of additional treatment. Given the unequal doses of treatment as well
as the differential training and attention that the DBT therapists received, it is
surprising that DBT didn’t outperform CE on all measures.

so you want to be a better therapist      11

 In truth, we are easily smitten by the lure of flashy techniques and mir-
acle cures. Amid explanations and remedies aplenty, therapists courageously
continue the search for designer explanations and brand-name miracles—
disconnected from the power for change that resides in the pairing of two
unique persons, the application of strategies that resonate with both, and the
impact of a quality partnership. Despite our herculean efforts to master the
right approach, we continue to observe that clients drop out or, even worse,
continue without benefit.

TO THE RESCUE: CLIENT FEEDBACK

Great doubt: great awakening. Little doubt: little awakening. No doubt:

no awakening.
—Zen mantra

Dan Ariely (2008) tells a horrendous story of an explosion that left

him with 70% of his body covered with third-degree burns. His treatment
included a much-dreaded daily removal of his bandages. In the absence of
skin, the bandages were attached to raw flesh and their removal was both
harrowing to witness and excruciatingly painful. The nurses removed the
bandages as fast as possible, quickly ripping them off one by one. Believing
that a slower pace would be less painful, Ariely repeatedly asked the nurses
to slow down the removal process. The nurses, however, asserted that finish-
ing fast was the best approach, and continued to do so. This ordeal inspired
Ariely to research the experience of pain as well as other phenomena. His
investigation of pain demonstrated that a slow and less intense experience
of pain over longer periods was far easier to tolerate than more intense pain
over shorter time frames.
Consider this story and its relevance to psychotherapy. It is noteworthy
that the nurses disregarded Ariely’s response to their removal methods—his
experience of his own pain did not hold much weight for them! But the
nurses ignored his response as well as his pleadings to slow down not because
they were evil or had any malevolent intentions—in fact, Ariely reports that
he grew to love the nurses and believed that they loved him as well. Rather,
the nurses assumed they knew more about his pain than he did and went full
steam ahead for his own good! He also later learned that the nurses consid-
ered it easier for them to remove the dressings quickly. Clinical lore about the
rapid removal of bandages, as well as what was convenient for the nurses,
prevailed over Ariely’s experience of his own pain.
When services are provided without intimate connection to those
receiving them and to their responses and preferences, clients become

12       on becoming a better therapist

cardboard cutouts, the object of our professional deliberations and subject to
our whims. 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.
A relatively new research paradigm called patient-focused research
(Howard, Moras, Brill, Martinovich, & Lutz, 1996) rescues us from the
problems noted above (the bad and ugly) as well as Ariely’s unfortunate cir-
cumstance. Howard et al. (1996) advocated for the systematic evaluation of
client response to treatment during the course of therapy and recommended
that such information be used to “determine the appropriateness of the cur-
rent treatment . . . [and] the need for further treatment . . . [and] prompt a
clinical consultation for patients who [were] not progressing at expected
rates” (Howard et al., 1996, p. 1063).
Although several systems have emerged that answer Howard’s origi-
nal call (for a review, see Castonguay, Barkham, Lutz, & McAleavey, 2013;
Lambert, 2010), only two have demonstrated treatment gains in RCTs and
gained evidence-based-practice designation. The pioneering work of Michael
Lambert and colleagues stands out—not only for the development of mea-
surement systems and predictive algorithms but also for their groundbreak-
ing investigations of the effects of providing therapists feedback about client
progress in treatment.
In a meta-analytic review of the Outcome Questionnaire 45.2 (OQ)
system, Shimokawa, Lambert, and Smart (2010) reanalyzed the combined
data set (N = 6,151) from all six of the OQ feedback studies that com-
pared the OQ system with treatment as usual (TAU; Harmon et al., 2007;
Hawkins, Lambert, Vermeersch, Slade, & Tuttle, 2004; Lambert et al., 2001,
2002; Slade, Lambert, Harmon, Smart, & Bailey, 2008; Whipple, Lambert,
Vermeersch, Smart, Nielsen, & Hawkins, 2003).When the odds of deterio-
ration and clinically significant improvement were compared, those in the
feedback (OQ) group had less than half the odds of experiencing deteriora-
tion while having 2.6 times higher odds of attaining reliable improvement
than the TAU group.
The other RCT-supported method of using continuous client feed-
back to improve outcomes is the one presented in this book, the Partners
for Change Outcome Management System (PCOMS; Duncan, 2010a, 2012;
Duncan, Miller, & Sparks, 2004; Duncan & Sparks, 2002). Much of this
system’s appeal rests on the brevity of the measures and therefore its feasi-
bility for everyday use in the demanding schedules of frontline clinicians.
The Outcome Rating Scale (ORS) and the Session Rating Scale (SRS)
are both four-item measures that track outcome and the therapeutic alli-
ance, respectively. PCOMS was based on Lambert and colleagues’ (1996)

so you want to be a better therapist      13

continuous assessment model using the OQ, but there are differences beyond
the measures. First, PCOMS is integrated into the ongoing psychotherapy
process and includes a transparent discussion of the feedback with the cli-
ent (Duncan & Sparks, 2002). Session-by-session interaction is focused by
client feedback about the benefits or lack thereof of psychotherapy. Second,
PCOMS assesses the therapeutic alliance every session and includes a discus-
sion of any potential problems. Lambert’s system includes alliance assessment
only when there is a lack of progress.
Moreover, unlike most other outcome instruments, the ORS is not a
list of symptoms or problems checked by clients or others on a Likert scale.
Rather it is an instrument that evolves from a general framework of client
distress to a specific representation of the client’s idiosyncratic experience
and reasons for service; the ORS is individualized for each client. It there-
fore requires collaboration with clients as well as clinical skill and nuance in
its application; the therapist is intimately involved and inextricably linked
to its success.
Six studies have demonstrated the benefits of client feedback with
PCOMS. The first (Miller, Duncan, Brown, Sorrell, & Chalk, 2006) explored
the impact of feedback in a large (N = 6,424) culturally diverse sample utiliz-
ing a telephonic employee assistant program (EAP). Although the study’s
quasi-experimental design qualifies the results, the use of feedback doubled
overall effectiveness and significantly increased retention. Several RCTs
conducted by those affiliated with my organization, the Heart and Soul
of Change Project (hereafter the Project), used PCOMS to investigate
the effects of feedback versus TAU. Norwegian therapist and researcher
Morten Anker and other colleagues from the Project (Anker, Duncan,
& Sparks, 2009) randomized couples seeking couple therapy (N = 410)
at an outpatient clinic in Norway to PCOMS or TAU; therapists saw both
PCOMS and TAU clients to control for therapist effects. This study, the
largest RCT of couple therapy ever done, found that nearly 4 times more
feedback couples than non-feedback couples reached clinically significant
change, and over doubled the percentage of couples in which both individu-
als reached reliable and/or clinically significant change (50.5% vs. 22.6%). At
6-month follow-up, 47.6% of couples in the feedback condition reported reli-
able and/or significant change versus 18.8% in TAU. The feedback condition
not only maintained its advantage at 6-month follow-up but also achieved a
46% lower separation/divorce rate. Feedback improved the outcomes of 9 of
10 therapists in this study. It is noteworthy that the therapists in this study
were naïve to feedback; they had not used PCOMS in their work prior to the
study and therefore were not “true believers.”
University of Kentucky professor and Project Leader Jeff Reese and col-
leagues (Reese, Norsworthy, & Rowland, 2009) found significant treatment

14       on becoming a better therapist

gains for feedback when compared with TAU. This study was two small trials in
one. Study 1 occurred at a university counseling center (n = 74) and Study 2
at a graduate training clinic (n = 74). Clients in the PCOMS condition in
both studies showed significantly more reliable change versus TAU clients
(80% vs. 54% in Study 1, 67% vs. 41% in Study 2). In addition, clients using
PCOMS achieved reliable change in significantly fewer sessions than TAU.
Reese, Toland, Slone, and Norsworthy (2010) replicated the Anker et al.
(2009) study with couples and found nearly the same results. Finally, a meta-
analysis of PCOMS studies (Lambert & Shimokawa, 2011) found that those
in the feedback group had 3.5 higher odds of experiencing reliable change
and less than half the odds of experiencing deterioration.
The applicability of PCOMS to other modalities and populations was
recently demonstrated. Schuman, Slone, Reese, and Duncan (in press) con-
ducted an RCT (N = 263) of group treatment of returning Iraq and Afghanistan
veterans and active duty soldiers struggling with alcohol and drug problems
that compared a minimal PCOMS intervention (only using the ORS) to TAU.
Soldiers in the feedback condition achieved significantly more improvement
on the ORS, higher rates of clinically significant change, and higher ratings
of success by both clinicians and commanders, and they attended signifi-
cantly more sessions compared to the TAU condition. Similarly, a recent RCT
(N = 85) by Slone, Reese, Mathews-Duvall, and Kodet (2014) of group psycho­
therapy found that clients in the PCOMS condition achieved significantly
higher gain on the ORS compared with TAU. Additionally, significantly more
clients in the feedback condition experienced reliable (feedback: 31.8%;
TAU: 17.0%) and clinically significant (feedback: 40.9%; TAU: 29.3%)
change, attended significantly more sessions (feedback: 8.5 sessions; TAU:
6.0 sessions), and dropped out at a lower rate (feedback: 34%; TAU: 56%)
than clients in the TAU condition.
Regarding children, using a cohort design comparing outcomes in the
schools with 7-to-11-year-olds in Northern Ireland, University of Rhode
Island professor and Project Leader Jacqueline Sparks and University of
Strathclyde professor Mick Cooper and his team from the U.K. (Cooper,
Stewart, Sparks, & Bunting, 2013) found that school-based counseling incor-
porating systematic feedback via PCOMS was associated with large reductions
in psychological distress for children (N = 288). In addition, comparing care-
taker and teacher ratings on the U.K. standardized measure, the Strength and
Difficulties Questionnaire (SDQ) revealed an approximate twofold advantage
in ES on the caretaker-completed SDQ when PCOMS was used and a small
but significant advantage in effect on the teacher-completed SDQ.
These studies collectively support the effectiveness of PCOMS across
various treatment sites, client populations, and therapeutic models, and
they make a strong case for routine outcome management. Because of the

so you want to be a better therapist      15

RCTs conducted by me and my colleagues from the Project, PCOMS is
designated as an evidence-based practice by the Substance Abuse Mental
Health Services Administration and listed in the National Registry of
Evidence-Based Programs and Practices. PCOMS, however, is not your aver-
age evidence-based practice: It is not a specific treatment model for a specific
client diagnosis. First, it is a-theoretical and may be added to or integrated
with any model of practice. PCOMS does not suggest how to understand cli-
ent problems nor does it prescribe a treatment for them. Rather, it provides
a vehicle to partner with clients around their views of benefit and the alli-
ance, and the ability to identify when whatever chosen model is not helping.
Second, PCOMS applies to all diagnostic categories. So, in effect, one size
does fit all, allowing you to be evidence based across your clients in contrast
to the ridiculous notion that you can learn an evidence-based approach for
each of the seemingly ever-growing list of diagnoses. Finally, PCOMS is
“evidence based” at two levels. It is evidence based by virtue of the RCTs
that found significant benefits for both clients and therapists when feedback
was part of the work, regardless of the theoretical orientations of the thera-
pists or the diagnoses of the clients. More important, PCOMS is evidence
based at the individual client–therapist level. Not just relying on the past
evidence of efficacy in RCTs (e.g., Anker et al., 2009), or even past evidence
of effectiveness in real clinical settings (e.g., Reese et al., 2014), PCOMS
focuses you on the present evidence of effectiveness with the client in your
office right now. In other words, it is evidence-based practice one client at a time.
PCOMS has the potential to significantly improve your outcomes, but
it’s not a miracle cure, nor does it explain human behavior. It also doesn’t
make you any smarter or better-looking or serve as a panacea for the complex-
ity and difficulty of the psychotherapy process. It does, however, identify your
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. Think about this for
a minute. Even if you are one of the la crème de la crème now (my looks at
many data sets reveal that the best therapists are effective about two-thirds
of the time), for every cycle of 10 clients you see, three will go home without
benefit. Over the course of a year, this amounts to a lot of unhappy clients.
You can recover a substantial portion of those folks who don’t benefit by first
identifying who they are, keeping them engaged, and tailoring your services
accordingly.
That’s it in a nutshell. PCOMS is your ticket to both better outcomes
and to taking charge of your development. Knowing how effective you really
are sets the stage for you to proactively get better at this work. Unfortunately,
up to now, therapeutic outcomes have been hard to define and even harder
to actually measure in everyday practice, leaving us to our own devices and

16       on becoming a better therapist

judgment—which aren’t so good. Consider a study (Dew & Riemer, 2003) that
asked 143 clinicians to rate their job performance from A+ to F. Two thirds
considered themselves A or better; not one therapist rated him- or herself as
below average. More recently, Walfish, McAlister, O’Donnell, and Lambert
(2012) surveyed practitioners and found that therapists likely inflate their
effectiveness, reporting that 85% of their clients improve and seeing them-
selves as above average in effectiveness (90% saw themselves as above the 75th
percentile). If you know anything about the Bell curve, you know this can’t be
true. We are not all above average—we are not from Lake Woebegon!
But of course it is not that we’re naïve or stupid; it’s simply hard, if not
impossible, to accurately assess your effectiveness without some quantitative
standard as a reference point; you need to measure outcomes. And the field
has not been very useful to us in this regard. Until recently, measures of out-
comes were only for researchers and totally impractical for everyday clinical
use. But that has changed with PCOMS. Measuring outcomes allows you to
cut through the ambiguity of therapy, using objective evidence from your
practice to help you discern your clinical development without falling prey to
that perennial bugaboo of the therapeutic endeavor: wishful thinking.
As this book details, measuring outcomes relates directly to both having
an awareness about our development and doing something about it. PCOMS
can help you survive—indeed thrive—in a profession that is under siege, yet
still compelling; a profession that offers a lifetime training ground for human
connection and growth, and frequently yields small victories that matter in
the lives of those we see.

WHAT WORKS IN THERAPY: GUIDELINES FROM RESEARCH

Whoever acquires knowledge and does not practice it resembles him [sic]
who ploughs his land and leaves it unsown.
—Sa’di, Gulistan

A story illustrates the sentiments that many practitioners feel about

research. Two researchers were attending their annual conference. Although
enjoying the proceedings, they decided to find some diversion to combat the
tedium of sitting all day and absorbing vast amounts of information. They
settled on a hot-air balloon ride and were quite enjoying themselves until a
mysterious fog rolled in. Hopelessly lost, they drifted for hours until, finally,
a clearing in the fog appeared and they saw a man standing in an open field.
Joyfully, they yelled down at the man, “Where are we?” The man looked at
them, and then down at the ground, before turning a full 360 degrees to sur-
vey his surroundings. Finally, after scratching his beard and what seemed to

so you want to be a better therapist      17

be several moments of facial contortions reflecting deep concentration, the
man looked up and said, “You are above my farm.”
The first researcher looked at the second researcher and said, “That
man is a researcher—he is a scientist!” To which the second researcher
replied, “Are you crazy, man? He is a simple farmer!” “No,” answered the first
researcher emphatically, “that man is a researcher and there are three facts
that support my assertion: First, what he said was absolutely 100% accurate;
second, he systematically addressed our question through an examination of
all of the empirical evidence at his disposal, and then carefully deliberated
before delivering his conclusion; and finally, the third reason I know he is a
researcher is that what he told us is absolutely useless to our predicament.”
In this book, I strive to present only research that is useful to conducting
psychotherapy, and the common factors, I believe, represent the best of what
empirical investigation has to offer “our predicament.”
The common factors—what works in therapy—have a storied his-
tory that started with Rosenzweig’s (1936) classic article “Implicit Common
Factors in Diverse Forms of Psychotherapy.” In addition to the original invo-
cation of the dodo bird and seminal explication of the common factors of
change, Rosenzweig also provided the best explanation for the common fac-
tors, still used today: namely, that given that all approaches achieve roughly
similar results, there must be pantheoretical factors accounting for the
observed changes beyond the presumed differences among schools (Duncan,
2010b). Rosenzweig’s four-page article is still well worth the read (and avail-
able at https://heartandsoulofchange.com).
If Rosenzweig penned the first notes of a common factors chorus,
Jerome Frank (1961, 1973; Frank & Frank, 1991) composed an entire sym-
phony. He advanced the idea that psychotherapy orientations (and other
forms of healing) are equivalent in their effectiveness because of factors
shared by all: (a) a healing setting; (b) a rationale, myth, or conceptual
framework that provides an explanation for the client’s complaint and a
method for resolving it; (c) an emotionally charged, confiding relationship
with a helping person; and (d) a ritual or procedure that requires involve-
ment of both the healer and client to bring about “cure” or resolution.
Frank’s work is particularly helpful, as noted below, in understanding the
role of model and technique as the vehicle for providing the other factors.
Several others have identified these elements found in all therapies,
but Brigham Young University’s Michael Lambert deserves special mention.
After an extensive analysis of decades of outcome research, Lambert (1986,
2013) identified four factors—and their estimated percentages of outcome
variance—as the principal elements accounting for improvement: client/life
variables (40%); relationship factors (30%); hope, expectancy, and placebo
(15%); and model/technique (15%). Although these factors are not derived

18       on becoming a better therapist

from a statistical analysis, he suggested that they embody what studies indi-
cated about treatment outcome. Lambert’s portrayal of the common factors
bravely differentiated factors according to their relative contribution to out-
come, opening a new vista of understanding models and their proportional
importance to success—a bold challenge to the reverence many researchers
and therapists feel toward their preferred models.
Inspired by Lambert’s proposal and the integration movement, my col-
leagues and I (Duncan & Moynihan, 1994; Duncan, Solovey, & Rusk, 1992)
proposed a “client directed” perspective to apply the common factors based on
their differential impact on outcome. Client directed spoke to the influence of
clients on outcome: their resources, strengths, and resiliencies, their view of the
alliance, their ideas and theories of how they can be helped, and their hopes
and expectations. The common factors, in other words, make the case that cli-
ents should direct the therapeutic process: Their views should be the privileged
ones in the room. Intervention success was described as dependent on rallying
client resources and as a tangible expression of the quality of the alliance. I
have been attempting to operationalize the factors ever since (e.g., Duncan,
2010a, in press; Duncan et al., 2010; Sparks & Duncan, 2010). The common
factors help us take a step back and get a big-picture view of what really works,
suggesting that we spend our time in therapy commensurate to each element’s
differential impact on outcome.
Recent findings from meta-analytic studies (see below) point to the
biggest omission of Lambert’s portrayal of the common factors, namely, the
profound impact of the therapist, and they paint a more complicated but sat-
isfying representation of the different factors, their effects, and their relation-
ship to each other. The “pie chart” view of the common factors incorrectly
implies that the proportion of outcome attributable to each was static and
could be added up to 100% of therapy effects. This suggested that the factors
were discrete elements and could be distilled into a treatment model and that
techniques could be created and then administered to the client. Any such
formulaic application across clients, however, merely leads to the creation of
another model. On this point, the jury has deliberated and the verdict has
been rendered; model differences ultimately matter little in terms of out-
come. In truth, the factors are interdependent, fluid, dynamic, and depen-
dent on who the players are and what their interactions are like. Five factors
comprise this meta-analytic perspective: client, therapist, alliance, model/
technique (general and specific effects), and feedback.

Client/Life Factors

To understand the common factors, it is first necessary to separate the

variance due to psychotherapy from that attributed to client/life factors,

so you want to be a better therapist      19

those variables incidental to the treatment model, idiosyncratic to the
specific client, and part of the client’s life circumstances that aid in recov-
ery despite participation in therapy (Asay & Lambert, 1999)—everything
about the client that has nothing to do with us. Calculated from the often-
reported 0.80 ES of therapy, the proportion of outcome attributable to treat-
ment (14%) is depicted by the small circle nested within the larger circle at
the lower right side of the left circle in Figure 1.2. The remaining variance
accounted for by client factors (86%), including unexplained and error vari-
ance is represented by the large circle on the left. Even a casual inspection
reveals the disproportionate influence of what the client brings to therapy.
More conservative estimates put the client’s contribution at 40% (Lambert,
2013). As examples, persistence, faith, a supportive grandmother, depres-
sion, membership in a religious community, divorce, a new job, a chance
encounter with a stranger, a crisis successfully managed all may be included.
Although they are hard to research because of their idiosyncratic nature,
these elements are the most powerful of the common factors—the client is
the engine of change (Bohart & Tallman, 2010).
In the absence of compelling evidence for any specific variables that cut
across clients to predict outcome or account for the unexplained variance,
this most potent source remains largely uncharted. Client factors cannot be
generalized because they differ with each client. These unpredictable dif-
ferences can only emerge one client at a time, one alliance at a time, one
therapist at a time, and one treatment at a time.

Client/Life Factors (86%) (includes unexplained and error variance)

Feedback Effects
21-42%
Alliance Effects
Treatment Effects 36-50%
14%
Model/Technique:
Specific Effects
(Model Differences)
7%

Model/Technique:
General Effects (Rational &
Therapist Effects Ritual), Client Expectancy
36-57% (Hope, Placebo), &
Therapist Allegiance
28-?%

Figure 1.2.  The Common Factors.

20       on becoming a better therapist

 But we do know one thing for sure: If we don’t recruit these idiosyn-
cratic contributions to outcome in service of client goals, we are inclined
to fail. Indeed, in a comprehensive review of 50 years of literature for the
5th edition of the Handbook of Psychotherapy and Behavior Change, Orlinsky,
Rønnestad, and Willutzki (2004) observed that “the quality of the patient’s
participation . . . [emerges] as the most important determinant of outcome”
(p. 324; emphasis added).
Bottom Line: Becoming a better therapist depends on rallying clients and their
resources to the cause. PCOMS sets the context for client participation in the
monitoring of therapy outcome and the alliance.

Figure 1.2 also illustrates the second step in understanding the com-
mon factors. The second, larger circle in the center depicts the overlap-
ping elements that form the 14% of variance attributable to treatment.
Visually, the relationship among the common factors, as opposed to a static
pie-chart depicting discreet elements adding to a total of 100%, is more
accurately represented with a Venn diagram, using overlapping circles and
shading to demonstrate mutual and interdependent action. The factors,
in effect, act in concert and cannot be separated into disembodied parts
(Duncan et al., 1992).
To exemplify the various factors and their attending portions of
the variance, the tried-and-true Treatment of Depression Collaborative
Research Program (TDCRP; Elkin et al., 1989) will be enlisted. The
TDCRP randomly assigned 250 depressed participants to four different
conditions: CBT, interpersonal therapy (IPT), antidepressants plus clinical
management (IMI), and a pill placebo plus clinical management. The four
conditions—including placebo—achieved about the same results, although
both IPT and IMI surpassed placebo (but not the other treatments) on the
recovery criterion (yet another example of the dodo verdict). Although
the TDCRP is now over 20 years old, the data continue to be analyzed and
remain relevant.

Therapist Effects

Therapist effects represent the amount of variance attributable not to

the model wielded but rather to who the therapist is—it’s no surprise that the
participants in the therapeutic endeavor account for the lion’s share of how
change occurs. Depending on whether therapist variability is investigated
in efficacy or effectiveness studies, a recent meta-analysis suggested that 5%
to 7% of the overall variance is accounted for by therapist effects (Baldwin
& Imel, 2013). This is a conservative finding, compared with earlier esti-
mates that suggested that at least 8% of the variance is accounted for by

so you want to be a better therapist      21

therapist factors, including the TDCRP (Kim, Wampold, & Bolt, 2006) and
a recent investigation by my Project colleagues and me (Owen, Duncan,
Reese, Anker, & Sparks, in press). Therefore, in Figure 1.2, a 5% to 8% range
is depicted or 36% to 57% of the variance (the 14%) attributed to treatment.2
The amount of variance, therefore, accounted for by therapist factors is about
5 to 8 times more than that of model differences. In many respects, you are
the treatment. This is why attention to your development is important.
The psychiatrists in the TDCRP illustrate—the clients receiving sugar
pills from the top third most effective psychiatrists did better than the cli-
ents taking antidepressants from the bottom third, least effective psychiatrists
(Kim et al., 2006). Who was providing the medication or sugar pill was far
more important than what the pill contained. Although we know that some
therapists are better than others, there is not a lot of research about what spe-
cifically distinguishes the best from the rest. Demographics (gender, ethnicity,
discipline, and experience) don’t seem to matter much (Beutler et al., 2004),
and although a variety of therapist interpersonal variables seem intuitively
important, there is not much empirical support for any particular quality or
attribute (Baldwin & Imel, 2013). So what does matter? There are two pre-
liminary possibilities and one absolute certainty.
One possibility—and building on the Orlinsky et al. (2004) quote
above—is what Gassmann and Grawe (2006) called resource activation v.
problem activation. They conducted minute-by-minute analyses of 120 ses-
sions involving 30 clients treated for a range of psychological problems. They
found that unsuccessful therapists focused more on problems while neglect-
ing client strengths. Successful therapists attended more to identifying client
resources and channeling them toward achieving client goals.
Another possibility is experience, but not the generic kind that we
are often told that will make us better. A criticism often leveled at research
investigating therapist experience is that it is not operationally defined and
that a more sophisticated look may yield more positive findings (Beutler
et al., 2004). For example, Kraus, Castonguay, Boswell, Nordberg, and Hayes
(2011) found that therapist competencies can be domain specific, as some
therapists were better at treating certain “conditions.” Specificity, there-
fore, in the definition of experience may be important. My colleagues and
I put this to the test in our examination of therapist effects in the study men-
tioned above (Owen et al., in press). Similar to other studies, demographics
were not significant, but specific experience in couple therapy explained
25% of the variance accounted for by therapists. So, experienced therapists

2The percentages are best viewed as a defensible way to understand outcome variance but not

as representing any ultimate truths. They are meta-analytic estimates of what each of the factors
contributes to change. Because of the overlap among the common factors, the percentages for the
separate factors will not add to 100%.

22       on becoming a better therapist

can take some solace that getting older does have its advantages—as long
as it is specific to the task at hand.
And the absolute certainty: The client’s view of the alliance is not only
a robust predictor of therapy outcomes, but also is the best avenue to under-
stand therapist differences. Marcus et al. (2009) noted:
High levels of consensus in client ratings of their therapist indicate that
clients of the same therapist tend to agree about the traits or charac-
teristics of their therapist, suggesting that there is something about the
therapist’s manner or behavior that evokes similar response from all of
his or her clients. (p. 538)
Baldwin, Wampold, and Imel (2007) found only modest therapist variability
(2%) compared with other studies but reported that therapist average alli-
ance quality accounted for 97% of that variability. Our study of therapist dif-
ferences found that therapist average alliance quality accounted for 50% of
the variability in outcomes attributed to therapists (Owen et al., in press). In
general, research indicates that clients seen by therapists with higher average
alliance ratings have better outcomes (Crits-Christoph et al., 2009; Zuroff,
Kelly, Leybman, Blatt, & Wampold, 2010). There is really no mystery here.
The answer to the oft-heard question about why some therapists are better
than others is that tried-and-true but taken-for-granted old friend, the thera-
peutic alliance.
Bottom Line: Therapist differences loom large and may be related to the abil-
ity to mobilize client resources and participation and gain specific experience.
More importantly, therapist variability is related to the ability to form strong
alliances across clients. PCOMS by design engages clients in a partnership that
increases participation and resource activation, while not leaving the alliance
to chance.

The Alliance

Researchers repeatedly find that a positive alliance—an interpersonal part-

nership between the client and therapist to achieve the client’s goals (Bordin,
1979)—is one of the best predictors of outcome. Historically, the amount of
variance attributed to the alliance has ranged from 5% to 7% of overall variance
or from 36% to 50% of the variance accounted for by treatment (e.g., Horvath,
& Bedi, 2002). More recently, Horvath, Del Re, Flückiger, and Symonds (2011)
examined 201 studies and found the alliance to account for a slightly higher
7.5% of the variance. Putting this into perspective, the amount of change
attributable to the alliance is about five to seven times that of specific model
or technique. In addition, a recent meta-analytic longitudinal study examin-
ing the alliance outcome relationship found that it remained largely intact

so you want to be a better therapist      23

regardless of the type of investigation or analyses used (Flückiger, Del Re,
Wampold, Symonds, & Horvath, 2012).
Krupnick et al. (1996) analyzed data from the TDCRP and found that
the alliance, from the client’s perspective, was predictive of success for all
conditions; the treatment model was not. Mean alliance scores explained
21% of the overall variance (Wampold, 2001). Keep in mind that treatment
accounts for, on average, 14% of the variance (see Figure 1.2). The alliance in
the TDCRP, therefore, explained more of the variance than typically attrib-
uted to treatment, illustrating how the percentages are not fixed and depend
on the particular context of client, therapist, alliance, and treatment model.
Some have suggested that the relationship between alliance and out-
come could be a consequence of how much clients are benefiting from ther-
apy (e.g., Barber, 2009). However, several recent studies have confirmed that
there appears to be little evidence that controlling for prior change substan-
tially reduces the alliance–outcome correlation (Crits-Cristoph, Connolly
Gibbons, & Mukherjee, 2013; Horvath et al., 2011). Similarly, my colleagues
and I (Anker, Owen, Duncan, & Sparks, 2010) found that the alliance at the
third session significantly predicted outcome over and above early reliable
change. The fact that the alliance is predictive beyond early benefit suggests
a more causal relationship.
Bottom Line: The alliance makes significant contributions to psychotherapy
outcome and therefore should be actively monitored and tailored to the indi-
vidual client.

Model/Technique: Specific and General Effects (Explanation

and Ritual), Client Expectancy (Hope, Placebo),
and Therapist Allegiance

Model/technique factors are the beliefs and procedures unique to any given
treatment. But these specific effects—the impact of the differences among
treatments—are very small, only about 1% of the overall variance (Wampold,
2001), or 7% of that attributable to treatment. But the general effects of pro-
viding a treatment (an explanation of the problem and solution for it) that
harness both client expectancy and therapist allegiance are far more potent.
Models achieve their effects, in large part, if not completely, through the acti-
vation of placebo, hope, and expectancy, combined with the therapist’s belief
in (allegiance to) the treatment administered.
When a placebo or technically “inert” condition is offered in a manner
that fosters positive expectations for improvement, it reliably produces effects
almost as large as a bona fide treatment (Baskin, Tierney, Minami, & Wampold,
2003). (There is some controversy surrounding how potent this effect is, hence
the question mark in Figure 1.2.) As long as a treatment makes sense to, is

24       on becoming a better therapist

accepted by, and enhances the active engagement of the client, the particu-
lar approach used is unimportant. Said another way, therapeutic techniques
are placebo-delivery devices (Kirsch, 2005). Placebo factors are also fueled by
a therapist belief that change occurs naturally and almost universally—the
human organism, shaped by millennia of evolution and survival, tends to heal
and to find a way, even out of the heart of darkness (Sparks & Duncan, 2010).
Allegiance and expectancy are two sides of the same coin—the belief
by both the therapist and the client in the restorative power and credibility
of the therapy’s rationale and related rituals. The TDCRP is again instruc-
tive. First, across all conditions, client expectation of improvement pre-
dicted outcome (Sotsky et al., 1991). And second, an inspection of the Beck
Depression Inventory scores of those who completed the study (see Elkin
et al., 1989) reveals that the placebo plus clinical management condition
accounted for nearly 93% of the average response to the active treatments
(Duncan, 2010a).
To punctuate the point about the more powerful general effects, con-
sider present centered therapy mentioned earlier as a treatment that works
for PTSD (see Wampold, 2007, for a full description). Researchers testing the
efficacy of CBT for PTSD wanted a comparison group that contained curative
factors shared by all treatments (warm, empathic relationship) while exclud-
ing those believed unique to CBT (exposure). This control treatment, PRCT,
contained no treatment rationale and no therapeutic actions. Moreover, to
rule out any possibility of exposure, even covert in nature, clients were not
allowed to talk about the traumatic events that had precipitated therapy.
PRCT was, of course, found to be less effective than CBT—it was really a
sham treatment without “active” ingredients. However, when later a manual
containing a rationale and condition-specific treatment actions was added to
facilitate standardization in training and delivery, few differences in efficacy
were found between PRCT and CBT in the treatment of PTSD (McDonagh
et al., 2005). In fact, significantly fewer clients dropped out of PRCT than
CBT. Thus, when PRCT was made to resemble a bona fide treatment, that
is, it added placebo, expectancy, and allegiance variables, it was not only as
effective but also more acceptable than CBT.
The act of providing treatment is the vehicle that carries allegiance and
placebo effects in addition to the specific effects of the given approach. It
pays, therefore, to have several rationales and remedies at your disposal that
you believe in, as well as believing in the client’s ideas about change. Keep in
mind that the selection of the tasks of therapy, that is, model and technique,
is also a critical component of the alliance, hence the overlap between model
and alliance depicted in Figure 1.2. Finally, it is important to note that, in
suggesting that specific effects are small in comparison with general effects
and that psychotherapy approaches achieve about the same results, I do not

so you want to be a better therapist      25

mean that models and techniques are not important. On the contrary, while
there is no differential efficacy on aggregate, there are approaches that are
likely better or worse for the client in your office now and ones that better fit
or match the client’s view of what could be helpful. Once again, the TDCRP
is helpful. Clients’ perceptions of treatment match with their beliefs about
the origin of their depression and what would be helpful (psychotherapy or
medication) contributed to early engagement, continuation in therapy, and
the development of a positive alliance (Elkin et al., 1999).
Bottom Line: The specifics of any approach are not as important as the
cogency of the rationale and ritual to both the client and the therapist, and,
most important, as the client’s response to the delivered treatment.

Feedback Effects

At first blush, feedback may seem like an odd addition to the list of fac-
tors that cut across all approaches. The process of attaining formal client feed-
back and using that input to tailor services, however, seems a worthy addition
for several reasons. First, the effects of feedback seem largely independent of
the measures used. Second, systematic feedback improves outcome regardless
of the specific process used, whether in collaboration with clients (although
collaboration tends to yield better results) or merely giving the feedback to
therapists—over the phone or face-to-face, paper-and-pencil administrations
versus electronic formats, matters not. Third, feedback increases client ben-
efit across professional discipline, clinical setting, client population, as well as
beginning or experienced therapists. Fourth, feedback significantly improves
outcome regardless of the model practiced—the feedback process does not
dictate what technique is used but, rather, is a vehicle to modify any delivered
treatment for client benefit. Fifth, attaining informal client feedback about
progress and the alliance is common practice among psychotherapists. Any
approach that openly discusses the outcome of services or checks in about the
relationship is incorporating informal client feedback into the therapeutic
mix. Feedback speaks to an interpersonal process of give-and-take between
the clinician and client and, at least to some extent, can be argued to be
characteristic of many therapeutic encounters. Finally, the evidence regard-
ing feedback continues to build. Feedback, then, similar to the concept of the
alliance (see Gaston, 1990), was initially viewed as an important aspect of
conducting effective psychotherapy and is garnering a growing evidence base
that supports a more formal understanding and systematic inclusion.
Common-factors research provides general guidance for enhancing
those elements shown to be most influential to positive outcomes. The spe-
cifics, however, can only be derived from the client’s response to what we
deliver—the client’s feedback regarding progress in therapy and the quality

26       on becoming a better therapist

of the alliance. An inspection of Figure 1.2 shows that feedback overlaps and
affects all the factors; it is the tie that binds them together, allowing the other
common factors to be delivered one client at a time. Soliciting systematic
feedback is a living, ongoing process that engages clients in the collaborative
monitoring of outcome, heightens hope for improvement, fits client prefer-
ences, maximizes alliance quality and client participation, and is itself a core
feature of therapeutic change. Feedback embodies the lessons I learned from
Tina, providing for a transparent interpersonal process that solicits the cli-
ent’s help in ensuring a positive outcome.
Bottom Line: Given its broad applicability, lack of theoretical baggage, and
independence from any specific instrument, feedback can be understood as a
factor that demonstrably contributes to outcome regardless of the model predi-
lection of the clinician.

EVIDENCE-BASED TREATMENTS AND

EVIDENCE-BASED PRACTICE

Seek facts and classify them and you will be the workmen of science.
Conceive or accept theories and you will be their politicians.
—Nicholas Maurice Arthus, De l’Anaphylaxie à l’immunité

All approaches have valid explanations and solutions for the problems
that clients bring us. It only makes good clinical sense to expand our model/
technique horizons and learn multiple ways to serve client goals. Similarly, it
also makes good clinical sense to be evidence based in our work. In truth, no
one says, “Evidence, schmevidence! It means nothing to my work—I fly by the
seat of my pants, meander willy-nilly through sessions, and rely totally on the
wisdom of the stars to show the way.” Saying you don’t believe in the almighty
evidence is tantamount to not believing in Mom or apple pie, or whatever your
sacrosanct cultural icons happen to be. So what is the controversy about?
On the heels of the American Psychiatric Association’s development of
practice guidelines in 1993, to ensure their continued viability in the mar-
ket, psychologists rushed to offer magic bullets to counter psychiatry’s magic
pills—to establish empirically supported treatments or what is now more typi-
cally called evidence-based treatments (EBTs). With all good intentions, a task
force of Division 12 (Society of Clinical Psychology; Task Force on Promotion
and Dissemination of Psychological Procedures, 1995) reviewed the available
research and cataloged treatments of choice for specific diagnoses based on
their demonstrated efficacy in RCTs. On the one hand, the Division 12 task
force effectively increased recognition of the efficacy of psychological inter-
vention among the public, policy makers, and training programs; on the other

so you want to be a better therapist      27

hand, it simultaneously promulgated gross misinterpretations—such as the
idea that EBTs have proven their superiority over other approaches and, there-
fore, should be mandated and/or exclusively reimbursed. Unfortunately many
people, including many state government funders, to paraphrase Orwell, now
believe that some therapies are more equal than others.
The notion, however, that any approach is reliably better than another
and should be exclusively practiced or funded is indefensible in light of the evi-
dence that supports the dodo verdict, as well as the relative influence of factors
other than model and technique. Efficacy over placebo, sham, or no treatment
does not mean efficacy over other approaches. In the minority of studies that
claim superiority over TAU or another approach, you need only to ask one
question of the investigation (see Duncan & Reese, 2012, for a full discussion):
Is it a fair contest? Is the study a comparison of two valid approaches that are
intended to be therapeutic, administered in equal amounts by therapists who
equally believe in what they are doing and are equally supported to do it? Recall
the DBT example: Are the therapists from the same pool with equal caseloads
or is the experimental group special—selected, trained, and supervised by the
researcher/founder of the approach and with reduced caseloads? I have never
seen a purported advantage of any approach over another (or TAU) that wasn’t
a lopsided contest that had its winner predetermined.
In the face of growing criticism, 2005 American Psychological
Association (APA) President Ronald Levant appointed the APA Presidential
Task Force on Evidence-Based Practice (hereafter Task Force). The Task Force
defined evidenced-based practice (EBP) as: “the integration of the best available
research with clinical expertise in the context of patient [sic] characteristics,
culture, and preferences” (APA Task Force, 2006, p. 273). This definition
transcends the “demonstrated efficacy in two RCTs” mentality of EBTs and
makes common clinical sense.
In fact, the Task Force’s EBP definition emphasizes the major themes
of this book: The first part, “the integration of the best available research,”
includes the consideration of EBTs without privileging them, as well as the
wide range of findings regarding the alliance and other common factors.
Next, “with clinical expertise,” in contrast to the EBT mentality of the ther-
apist as an interchangeable part, brings you back into the equation—your
interpersonal skill plus everything about you attained through education,
training, and experience—highlighting what therapists bring is consistent
with the growing research about the importance of clinician variability to
outcome. This part of the EBP definition supports attention to your develop-
ment. Moreover, the Task Force submitted:
Clinical expertise also entails the monitoring of patient progress (and
of changes in the patient’s circumstances—e.g., job loss, major illness)
that may suggest the need to adjust the treatment (Lambert, Bergin, &

28       on becoming a better therapist

 Garfield, 2004). If progress is not proceeding adequately, the psychologist
alters or addresses problematic aspects of the treatment (e.g., problems in
the therapeutic relationship or in the implementation of the goals of the
treatment) as appropriate. (APA Task Force, 2006, pp. 276–277)
So, attaining feedback, as described in this book, on yet another level is
an EBP.
Next, “in the context of patient characteristics, culture, and preferences”
rightfully emphasizes what the client brings to the therapeutic stage, as well
as the acceptability of any intervention to the client’s expectations and how
well any model or technique resonates. In short, EBP now accommodates the
common factors, reinforces the importance of your development of clinical
expertise, and includes client feedback as a necessary component.
The two approaches, EBT and EBP, take radically different stances about
defining and disseminating evidence. One seeks to improve clinical practice via
the dissemination of treatments meeting a minimum standard of empirical sup-
port (EBT), and the other describes a process of research application to practice
that includes clinical judgment and client preferences (EBP; see Littell, 2010,
for a full discussion of the two approaches). In essence an EBT approach, as
characterized by Division 12, depicts confidence in the available evidence and
appeals to those who believe that more structure and consistency and less clini-
cian judgment is needed to bring about positive outcomes. On the other hand,
EBP reflects the understanding that scientific evidence is tentative and that out-
come is dependent not only on applying the various types of empirical research
but also on the participants. EBP appeals to those who value clinician autonomy
and individualized treatment decisions based on unique presentations of clients.
The APA Task Force on EBP exemplifies this approach to the evidence.
Finally, the Task Force (2006) said:
The application of research evidence to a given patient always involves
probabilistic inferences. Therefore, ongoing monitoring of patient progress
and adjustment of treatment as needed are essential. (APA Task Force, p. 280)

Proponents from both sides of the EBT-versus-EBP aisle recognized that out-
come is not guaranteed regardless of evidentiary support of a given technique
or the expertise of the therapist. The APA definition, as does this book, sup-
ports an identity of plurality, essential attention to client preferences, a focus
on therapist expertise, and the importance of feedback.

Bottom Line: APA’s definition brings clinical common sense to the controversy.
There is nothing wrong with EBTs. But the evidence doesn’t justify mandates,
exclusive reimbursement, or dictates about the way to address client problems.
The only way to know what the “right” treatment is to measure the client’s
response to any delivered treatment—to conduct EBP one client at a time.

so you want to be a better therapist      29

 ABOUT THIS BOOK

Feedback is the breakfast of champions.

—Ken Blanchard and Spencer Johnson, The One-Minute Manager

On Becoming a Better Therapist intends to help you remember your origi-

nal aspirations, continue to develop as a therapist, and achieve better out-
comes more often with more clients. It draws on the experiences of the two
most important people to psychotherapy outcome: the client and you: Client
perspectives about the benefit and the alliance and your perceptions of your
professional growth. Regardless of your approach, this book will help you con-
tinue what you are doing well while expanding your influence to those clients
who do not respond to your usual efforts. Through a transparent process of
attaining client feedback, you’ll learn ways to deepen the therapeutic conver-
sation, intensify the power of a collaborative alliance, and more effectively
recruit clients’ resources in the service of change. In short, you’ll accelerate
your development and learn how to become a better therapist—one client
at a time.
Psychotherapy is not an uninhabited landscape of technical procedures.
It is not the sterile, stepwise process of surgery, nor does it follow the predict-
able path of diagnosis, prescription, and cure. It cannot be described without
the client and therapist, co-adventurers in a journey across what is largely
uncharted territory. The common factors provide useful landmarks for this
intensely interpersonal and idiosyncratic trip, and specific models and tech-
niques provide well-traveled routes to consider, but feedback offers a neces-
sary compass to provide bearings of the psychotherapy terrain and guidance
to the desired destination.
This book has nine chapters. Chapter 2, “Becoming a Better Therapist
With PCOMS,” shows you how to get started using PCOMS to help clients
help you do good work—not sometime, next month, or even next week, but
with your next client. It begins with a discussion of the measures and then cov-
ers the first-session pragmatics, detailing all you need to know to start becom-
ing a better therapist. Chapter 3, “How Being Bad Can Make You Better,”
describes how recapturing the clients who are not benefiting will make the
difference between being an average therapist or a better one. Rather than
only learning from failed cases, this chapter details how to turn them around
before a negative outcome ensues. Chapter 4, “Getting Better With Couples,
Families, and Youth,” reviews the lessons from the five published couple
studies that arose from the Norway Feedback Trial and details the clinical
process of using PCOMS with youth, couples, and families. “Using PCOMS
to Accelerate Your Development” is the topic of Chapter 5. Integrating the
groundbreaking work of Orlinsky and Rønnestad (2005) regarding therapist

30       on becoming a better therapist

development, Chapter 5 shows you how to take charge of your professional
growth and ensure that you learn from your experience rather than repeat it.
Building on Chapter 5’s framework to track your development and outcomes,
Chapter 6, “The Heart and Soul of Change,” delineates strategies to improve
your effectiveness based on the most potent common factors—the client
and the therapeutic alliance. Chapter 7, “Wizards, Humbugs, or Witches,”
encourages you to reflect about your identity as a therapist and what it is that
you do—to create a description of your work that you can believe in and that
provides clinical flexibility. Next, Chapter 8 broadens the focus. “Becoming
a Better Agency” addresses implementation of PCOMS in public behavioral
health (PBH) and other organizations, detailing what it takes for success. In
addition, Chapter 8 presents the results of our benchmarking study of a large
PBH agency in Arizona. Contrary to earlier dire accounts of PBH effective-
ness, this agency achieved outcomes comparable to benchmarks from RCTs
of depression and feedback. How? This agency implemented PCOMS.
Each of the first eight chapters concludes with a story that documents key
lessons that clients have taught me over my career—meaningful moments that
reminded me of why I made the choice to become a therapist. These examples
are not intended to depict everyday therapeutic encounters but, rather, the
ones that made the most dramatic impact on my identity as a psychotherapist.
Finally, Chapter 9, “For the Love of the Work,” continues the focus on your
development, exploring ways for continued reflection about the work you
love. It concludes with my parting thoughts about the controversial issues of
the day as they pertain to our identity as therapists, as well as what I think it
takes to become a “master” therapist.

CLIENTS ARE THE BEST TEACHERS: THEIR STORIES

DOCUMENT OUR DEVELOPMENT

At bottom every man [sic] knows well enough that he is a unique

being, only once on this earth; and by no extraordinary chance will
such a marvelously picturesque piece of diversity in unity as he is, ever
be put together a second time.
—Friedrich Nietzsche

When I was an intern, I worked in an outpatient unit euphemistically

called Specialized Adult Services (SAS). While it included a stress man-
agement program, SAS was really an aftercare facility devoted to working
with clients labeled severely mentally ill. By that time, I had acquired expe-
riences in two community mental health centers and an assessment stint
in the state hospital. But the hospital experience lingered, leaving me with

so you want to be a better therapist      31

 a bad taste in my mouth. I saw firsthand the facial grimaces and tongue
wagging that characterize the neurological damage caused by antipsychot-
ics and sadly realized that these young adults would be forever branded as
grotesquely different, as “mental patients.” I witnessed the dehumanization
of people reduced to drooling, shuffling zombies, spoken to like children
and treated like cattle. I barely kept my head above water as hopelessness
flooded the halls of the hospital, drowning staff and clients alike in an
ocean of lost causes. I could not even imagine what it would have been
like to live there in the revolving-door fashion that many endured. Now,
in my internship, my charge was to help people stay out of the hospital,
and I took that charge quite seriously.
One of my first clients was Peter. Peter was not well liked at SAS.
He sometimes said ominous things to other clients in the waiting room,
or spoke in a boisterous way about how the fluorescent lights controlled
his thinking through a hole in his head. When he wasn’t speaking,
he grunted and squealed and made other sounds like a pig. As a new
intern, I was put under considerable pressure to address Peter’s less-
than-endearing behaviors, particularly because he sometimes offended
the stress management clients, who were seen as coveted treasures not
to be messed with. Actually, I found Peter to be a terrific guy with a very
dry sense of humor, but a man of little hope who lived in constant dread
of returning to the state hospital. His behaviors were mostly his efforts
to distract himself from tormenting voices that told him people were
trying to kill him and other scary things.
Peter would be routinely terrorized by these voices until he started
taking actions that led him to ultimately wind up in the state hospital. He
might empty his refrigerator for fear that someone had poisoned his food,
creating a stench that would soon bring in the landlord and ultimately the
authorities. Or, occasionally, he would start threatening or menacing oth-
ers, those he believed were trying to kill him. Once he was hospitalized,
his medications were changed, usually increased in dose, and he essentially
slept out the crisis. These cycles occurred about every 4 to 6 months and
had done so for the previous 8 years. Peter’s treatment brought with it
tardive dyskinesia and about a hundred pounds of extra weight.
Peter hated the state hospital, and I could truly commiserate, after
my own less-than-inspiring experience there. I felt profoundly sad for this
young man, who was about my age. I also felt completely helpless. Nothing
in my training provided any guidance. I had no clue about what to do to
be helpful to him. I was trying to apply strategies I had learned from my
supervisor about addressing the voices, which were helpful to others but
not with Peter. I knew he was ramping up for another admission—he told

32       on becoming a better therapist

me that he had already emptied his refrigerator and left the contents on
the kitchen floor. It seemed that nothing I said could convince Peter to get
off the merry-go-round to the state hospital. The anguish in his eyes about
his impending hospitalization haunted me.
Only because I had no clue about what to do, I asked Peter what he
thought it would take to get a little relief from his situation—what might
give him just a glimpse of a break from the torment of the voices and the
revolving-door hospitalizations. After a long pause, Peter said something
very curious: He said that it would help if he would start riding his bike
again. This led to my inquiry about the word “again.” Peter told me about
what his life was like before the bottom fell out. Peter had been a competi-
tive cyclist in college and was physically fit as only world class cyclists can
be. I heard the story of a young man away from home for the first time,
overwhelmed by life, training day and night to keep his spot on the rac-
ing team, and topped off by falling in love for the first time. When the
relationship ended, it was too much for Peter, and he was hospitalized,
and then hospitalized again, then hospitalized again, and so on until there
was no more money or insurance—then the state hospitalization cycles
ensued.
On a roll now and enjoying a level of conversation not achieved
before, I asked Peter what it would take to get him going again on his bike.
He said that his bike was in need of parts and what he needed was for me to
accompany him to the bike shop. Peter was afraid to go out in public alone
for fear of threatening someone and ending up in the hospital. I immedi-
ately consulted with my supervisor, who gave me an enthusiastic green
light. The next day, I went with Peter to the bike shop, where I bought a
bike as well. Peter and I started having our sessions biking together. Peter
still struggled with the voices at times, but he stayed out of the hospital
and they never kept him from biking. He eventually joined a bike club and
moved into an unsupervised living arrangement.
You can read a lot of books about “schizophrenia” and its treatment,
but you’ll never find one that recommends biking as a cure. And you can
read a lot of books about treatments in general, and you’ll never read a
better idea about a client dilemma than will emerge from a client in con-
versation with you—a person who cares and wants to be helpful.

so you want to be a better therapist      33

 2
BECOMING A BETTER THERAPIST
WITH PCOMS

The only man I know who behaves sensibly is my tailor; he takes my

measurements anew each time he sees me. The rest go on with their old
measurements and expect me to fit them.
—George Bernard Shaw

First, let’s put all the cards on the table about why you might be reluc-
tant to systematically collect outcome feedback. Finding out how effective
you really are can be risky business. What if you find out that you are not so
good? What if you discover that you are—the kiss of death—just average?
What if the data reveal that you are in the wrong profession? What if . . . ?
You get the picture; you might learn something that you might not want to
know. Measuring outcomes puts you in a vulnerable spot. But, still, you want
to be a better therapist. The only way to get better is to know where you are
now versus where you would like to be—to aspire for the best results, and take
deliberate actions to get them. It does take courage. But so did walking into
therapy, for the first time, with someone in distress, and so does doing it day
in and day out. You have some guts, let’s face it. And we know it works. Recall
that in our large feedback study with couples, nine of 10 therapists improved
their outcomes with feedback (Anker, Duncan, & Sparks, 2009).

http://dx.doi.org/10.1037/14392-002
On Becoming a Better Therapist, Second Edition: Evidence-Based Practice One Client at a Time, by B. L. Duncan
Copyright © 2014 by the American Psychological Association. All rights reserved.

35
 Another thing that may be preventing you from betting on the Partners
for Change Outcome Management System (PCOMS; Duncan, 2012) hand
is the whole idea of “assessment” and the evil D word, “data.” The thought of
using standardized measures to monitor outcome may make your skin crawl
and seem like just more of the same funder mandates. Moreover, the thought
of numbers and—heaven forbid—“collecting data” may be almost enough
to make you run out of the room screaming. But this is different—really
different—because the measures are not used to unravel the mysteries of the
human psyche, nor are they just another rendition of a “biopsychosocial”
assessment. Rather, these measures invite clients into the inner circle of
mental health and substance abuse services; they collaboratively involve
clients in monitoring progress toward their goals, amplifying their voices
in any decisions about their care. PCOMS does involve numbers, but they
are simple and straightforward, and it doesn’t take a stat consultant to inter­
pret them.
Unlike other systems of feedback, all scoring and interpretation in
PCOMS are done together with clients. This represents a radical departure
from traditional assessment and also gives clients a new way to look at and
comment on their experience of therapy. Assessment, rather than being an
expert-driven evaluation of the client or an imposed requirement to fulfill
funder mandates, becomes a pivotal part of the relationship and of change
itself. PCOMS, then, provides the tools to level the therapeutic process, fos-
ter a true partnership with clients, and enable a kind of transparency about
what we do that is rare.
Another reason that you might not embrace PCOMS is that you may
think you already know the information it is designed to reveal. Many of us
believe that we are attuned to the client’s experience and that using the forms
would be superfluous. In fact, in the Norway study (Anker et al., 2009), all
10 of the therapists indicated that they had already informally acquired out-
come and alliance information and, moreover, that formal feedback would
not improve their effectiveness. Nine of 10 did improve their outcomes, so
only one of them was correct. And, a friendly reminder: It is the client’s view
of the alliance that predicts outcomes, not the therapist’s.
There may also be the fear of what others might do with the data, that
your supervisor, agency, or third-party payer may be like the card shark with
aces up his or her sleeve, dealing from the bottom of the deck, and just wait-
ing to use your “tell,” your data, against you. PCOMS is not intended to be
used in any punitive way whatsoever (see Chapter 8). It is not a way to rep-
rimand or give performance bonuses. Such practices undermine the spirit of
outcome management and ultimately damage therapist morale. Collecting
real-time data to inform practice has only one purpose: improving the ben-
efits that clients receive while increasing the effectiveness of therapists.

36       on becoming a better therapist

 And perhaps the trump card of your reticence is the paperwork. You
need more paperwork like you need a hole in the head—it is the bane of the
frontline therapist’s existence. We can get really worked up over anything
that adds paperwork, especially when we don’t see any clinical relevance. For
example, in reaction to a managed care company’s introduction of a 30-item
version of the Outcome Questionnaire (OQ), the New England Psychologist
(Hanlon, 2005) reported that providers complained about its length and fre-
quent administration, that it cut into sessions and increased workload, and
that some items were intrusive. The response by clinicians was so severe that
the State Psychological Association president said, “I have never seen such
negative reaction from providers” (p. 11). This is not an infrequent reaction
in my experience (see below).
But attaining client feedback about progress and the alliance need not
be cumbersome or intrusive. The measures take clients only a minute or less
to complete, so it is not a tedious task or asking too much. In fact, the entire
process of PCOMS only takes a few minutes, generally about 5 but never
more than 10 for administering, scoring, discussing, and integrating into the
work. It is a light-touch, checking-in process indistinguishable from the work
itself. PCOMS works best as a way to gently guide whatever models and
techniques you use toward the client’s perspective and a focus on outcome.
And it is all done within the therapeutic hour because it is part of the work,
not outside of it.
Keep your concerns in the back of your mind as you read this chapter. It
starts with a discussion about the most robust predictors of outcome available—
namely, early change and the alliance—that make PCOMS possible. It also
presents the history and development of PCOMS as well as the psychometrics
of its measures. More important, this chapter provides the pragmatics of getting
started: all you need to begin with your next client. It aims to address all your
concerns or reluctance about giving client feedback a go.

EARLY CHANGE AND THE ALLIANCE

If a man (sic) will kick a fact out of the window, when he comes back he
finds it again in the chimney corner.
—Ralph Waldo Emerson

To retain clients at risk for slipping through the proverbial crack, we

need to embrace what we know about change in therapy: that both early
client change and the therapeutic alliance are robust predictors of ultimate
treatment outcome. The Emerson quote is apropos of the early change phe-
nomenon. Time and again, from the pioneering work of the late Ken Howard

becoming a better therapist with pcoms      37

(Howard, Kopta, Krause, & Orlinsky, 1986) to current sophisticated inves-
tigations using the latest statistical methods (Baldwin, Berkeljon, Atkins,
Olsen, & Nielsen, 2009), studies reveal that the majority of clients experi-
ence the majority of change in the first eight visits. This is a surprisingly
consistent finding. For example, an inspection of the trajectories in the
Treatment of Depression Collaborative Research Program (Lutz, Stulz, &
Köck, 2009), Project Match (Project MATCH Research Group, 1997), and
the Cannabis Youth Treatment Project (Dennis et al., 2004) indicate the
same pattern. Moreover, an examination of these trajectories across studies
demonstrates that early change is an important predictor of short- and long-
term outcome in psychotherapy. In other words, clients who report little or
no progress early on will likely show no improvement over the entire course
of therapy, or will end up on the dropout list. Early change predicts engage-
ment in therapy and a good outcome at termination (Brown, Dreis, & Nace,
1999). The research about early change is quite a gift; monitoring change
provides a tangible way for us to identify folks who are not responding so that
we can chart a new course.
But this fact, seemingly regardless of how often it reappears in the “chim-
ney corner,” rubs some the wrong way. Sometimes therapists think that the
research demonstrating that most change happens early and that early change
predicts outcome is somehow an indictment against long-term work with cli-
ents. This is simply not true. Long-term work is perfectly fine as long as clients
are benefiting. Although as time moves on it may take more time for less gain,
a longer course of sessions can sometimes make great clinical sense.
Similarly, some say that the early-change phenomenon does not apply
to longer term clients—that some clients who do change take longer than
others to do so, and their trajectory is different. It is true that some clients
take longer than others to show a change. However, it is a myth that clients
will show no change for long periods of time and then suddenly have an
epiphany. Clients typically don’t flatline and then spike. I am not saying it
has never happened in the history of psychotherapy, just that it is not very
common. The Baldwin study confirmed that change tends to start right away,
even with clients who spend a long time in therapy and whose changes come
very slowly (more flat if you are looking at a graph).
So the question still remains: When should you start getting worried
if clients are not responding to your therapy? I vote for sooner rather than
later. This of course doesn’t mean that if a client reports early change, the
problem is “cured” or completely resolved. Rather, it suggests that the client
has a subjective sense that therapy has gotten under way and that she’s on the
right path. Early change, then, is a reflection of heightened client hope and
engagement, both powerful common factors stacking the deck for a positive
outcome.

38       on becoming a better therapist

 Finally, when some therapists see the trajectories depicting that the
majority of change happens in the first eight sessions, it just does not feel
intuitively right to them. There is good reason for this reaction. Consider two
data sets, one from a university counseling center (UCC; the Baldwin et al.,
2009, study) and one from a public behavioral health (PBH) agency (Reese,
Duncan, Bohanske, Owen, & Minami, 2014; see Chapter 8 for more about
this study). Both data sets are big, with 4,676 clients at the UCC and 5,168 at
the PBH agency. Seventy-seven percent of clients at the UCC attended eight
sessions or fewer, and 62% attended eight or fewer at the PBH agency; it took
12 sessions to reach 77%. So, at both sites, the majority of clients attended
eight sessions or fewer, and fewer than one client in four went longer than
eight sessions at the UCC and 12 sessions at the PBH center. This just means
that data suggesting that most clients attend eight or fewer sessions, that most
change occurs in that time frame, and that change, if it happens, begins early,
have a pretty good track record of fitting most clients.
However, if one client in four goes longer than eight sessions, this means
that, over time, a therapist will likely develop a caseload dominated by the
longer term clients, given that the shorter term clients cycle through much
more quickly. So, intuitively, it seems as though most clients take longer.
Consequently, when some therapists see the expected treatment response
graphs depicting trajectories through eight sessions, they easily dismiss them
as “not fitting my clients.” Unfortunately, this also dismisses the importance
of early change and how the lack of change can help to reliably identify cli-
ents at risk regardless of the length of therapy.
After much deliberation on this issue, a practical solution came to me:
We could develop expected treatment responses or trajectories for those
clients who attend more than eight sessions. I enlisted statistical whiz and
University of Kentucky professor Michael Toland, and software magician and
webmaster Bill Wiggin, to look at a massive data set with me. We looked at
a total of 427,000 sessions (95,000 clients) and divided them into those who
attended eight sessions or fewer and those who attended nine to 18 sessions
(18 because that represented 97% of the data set and, as in the Baldwin et al.,
2009, sample, 77% of the clients attended eight sessions or fewer). Toland
worked his statistical magic, and Wiggin programmed the magic so we could
see the algorithms in action.
We (Wiggin mainly) also compared the algorithm-based trajectories with
the means of each intake score across sessions, to see if the trajectories made
sense—the “smell” test—and they passed. We also compared the predictions
with the data sets from the randomized controlled trials of PCOMS as well
as the data from the PBH agency discussed above, and the amount of change
predicted by the algorithms was confirmed. And voilà, the new algorithms were
born and incorporated in the web-based systems to be discussed in Chapter 5.

becoming a better therapist with pcoms      39

They predict therapy outcomes based on length of stay (short-term vs. longer
term therapy encounters), thereby addressing the needs of both clients who
attend more sessions and clinicians leaning toward a longer term perspective.
Of course, these trajectories also demonstrate that change happens early even
for those clients who attend therapy longer.
A second robust predictor of positive change described in Chapter 1,
solidly demonstrated by a large body of studies (Horvath, Del Re, Flückiger,
& Symonds, 2011), is our old friend the therapeutic alliance. Clients who
highly rate their partnership with their therapists are more apt to remain
in therapy and benefit from it. Enlisting these robust predictors of outcome,
PCOMS provides invaluable information about the prospects for treatment
success or failure. Specifically, it tells us about the match among ourselves,
our approach, and the client, providing an outcome management system that
partners with clients while honoring the daily pressures of frontline clinicians.

Bottom Line: We know the usual trajectory of change—early change predicts

continued change, and good alliances predict ultimate treatment outcome. You
can therefore predispose therapy to success by implementing an early warning
system—tools that measure change and the alliance, the Outcome Rating Scale
and Session Rating Scale.

PCOMS: MEASURE DEVELOPMENT AND VALIDATION

Although it took me a while to embrace the idea of starting off a session

with an outcome measure, I started using the OQ (Lambert et al., 1996) in
the late 1990s in my private practice as well as in consultations with mental
health agencies (see Duncan & Miller, 2000). I liked the OQ and particu-
larly resonated with the idea that the client’s perspective of benefit could
“direct” the therapeutic process. It seemed a way to systematically privilege
the client’s voice, a radical innovation that could finally give the client his
or her due. During this time, I also supervised graduate students in a com-
munity clinic and attempted to use the OQ there as well. Despite its obvious
strengths, many clinicians complained about the length of time needed to
complete the measure. They also said that it did not seem to fit, because of its
symptom focus, many of the concerns that clients brought to therapy.
It became apparent that, in spite of the quality of the measure, the
benefits of outcome monitoring would not occur if clients saw it as a burden
and therapists didn’t use it. This sobering realization not only came from
my attempts at implementation at the clinic which resulted in an abysmal
1-year compliance rate of 25%, but also thanks to a study I conducted (mainly
with my student at the time, Jacqueline Sparks) that compared a feedback

40       on becoming a better therapist

condition using the OQ and the Working Alliance Inventory (WAI; Tracey
& Kokotovic, 1989) with a condition in which therapists were taught
“checking-in” questions about outcome and the alliance. The checking-in
questions were an attempt to see if a more client/clinician friendly process
would achieve similar results as formal outcome management.
We learned that therapists, despite repeated encouragement, would not
consistently use the OQ and, to our surprise, would also not reliably ask the
checking-in questions. The study was abandoned because of both missing
OQ data points and therapist nonadherence to the checking-in questions
(16% adherence). This failed investigation confirmed that longer measures of
outcome were not feasible for everyday practice and that teaching therapists
checking-in questions did not result in the hoped-for routine discussions of
outcome and the alliance. This study led to the development of the ORS/
SRS (Outcome Rating Scale/Session Rating Scale), a structured yet feasible
way to systematically “check in” with clients about progress and the alliance.

Monitoring Benefit: The Outcome Rating Scale

The ORS emerged from a combination of the OQ and two ideas. The
first idea was scaling questions (Berg & de Shazer, 1993) commonly used in
solution-focused therapy to assess client perceptions of problems and goal
attainment (“On a scale of 0 to 10, with 0 being the worst it’s been with
this concern and 10 being where you want it to be, where are things right
now?”). Client-based scaling provides instant feedback and privileges the cli-
ent’s voice when assessing the effectiveness of therapy (Franklin, Corcoran,
Nowicki, & Streeter, 1997). After the failed investigation, I suggested to my
then colleague Scott Miller that we simply ask scaling questions based on the
major domains from the OQ to enable a total outcome score.
Later, Miller suggested the use of a visual analog scale because of its
demonstrated face validity instead of scaling questions, and the ORS (Miller
& Duncan, 2000) was born. Thereafter, based in 2 years of private practice
experience and that of the multiple teams that I supervised in the commu-
nity clinic, the clinical process of using the ORS was developed and first
detailed in Duncan and Sparks (2002). It became evident that families would
be unable to participate in feedback protocols without a valid measure for
children. With this as an impetus, the Child Outcome Rating Scale (CORS;
Duncan, Miller, & Sparks, 2003) was developed, and the clinical process with
children and families first presented in Murphy and Duncan (2007; all the
measures discussed here are available for free download for individual use at
https://heartandsoulofchange.com).
Figure 2.1 reveals that the ORS assesses four dimensions, expressed
as: (1) Individually—personal or symptomatic distress or well-being,

becoming a better therapist with pcoms      41

 Outcome Rating Scale (ORS)

Name ________________________Age (Yrs):____ Sex: M / F

Session # ____ Date: ________________________
Who is filling out this form? Please check one: Self_______ Other_______
If other, what is your relationship to this person? ____________________________

Looking back over the last week, including today, help us understand how you have been feeling by rating how
well you have been doing in the following areas of your life, where marks to the left represent low levels and
marks to the right indicate high levels. If you are filling out this form for another person, please fill out
according to how you think he or she is doing.

Individually
(Personal well-being)

I----------------------------------------------------------------------I

Interpersonally
(Family, close relationships)

I----------------------------------------------------------------------I

Socially
(Work, school, friendships)

I----------------------------------------------------------------------I

Overall
(General sense of well-being)

I----------------------------------------------------------------------I

Figure 2.1.  The Outcome Rating Scale. Copyright 2000 by S. D. Miller and
B. L. Duncan. Reprinted with permission. For examination only. Download a free
working copy at https://heartandsoulofchange.com.

(2) Interpersonally—relational distress or how well the client is getting along

in intimate relationships, (3) Socially—the client’s view of work/school and
relationships outside of the home, and (4) Overall—a big-picture view or
general sense of well-being. The ORS translates these four dimensions into a
visual analog format of four 10 cm lines, with instructions to place a mark on
each line with low estimates to the left and high to the right. The four 10-cm
lines add to a total score of 40. The score is the summation of the marks made
by the client to the nearest millimeter on each of the four lines, measured by
a centimeter ruler or template (or web-based system). Because of its simplic-
ity, ORS feedback is immediately available for use at the time the service is
delivered. Rated at a seventh-grade reading level and translated into multiple
languages, the ORS is easily understood by adults and adolescents and enjoys
rapid connection to clients’ day-to-day lived experience. The CORS, vali-
dated for children ages 6 to 12 and their caregivers, translates the ORS into
child-friendly language, rated at a third-grade reading level (see Chapter 4
for a figure of the CORS).

42       on becoming a better therapist

 There are no numbers on the ORS, and you may wonder why. We
designed it that way because research with visual analog scales suggested that
numbers influence how many will mark the scale. Numbers tend to influence
people to score more on the average side of things and to round off to whole
numbers as well. It sounds funny, but without numbers, you get more of an
accurate representation of the client’s subjective experience.
On par with its clinical usefulness and feasibility, the utility of the ORS
as an outcome-management tool depends on its reliability and validity. In
addition to the ORS/SRS manual (Duncan, 2011a), four validation studies of
the ORS have been published (Bringhurst, Watson, Miller, & Duncan, 2006;
Campbell & Hemsley, 2009; Duncan, Sparks, Miller, Bohanske, & Claud,
2006; Miller, Duncan, Brown, Sparks, & Claud, 2003). Across studies, average
Cronbach’s alpha coefficients (i.e., internal consistency or reliability) for the
ORS were .85 (clinical samples) and .95 (nonclinical samples; Gillaspy &
Murphy, 2011). Duncan et al. (2006) reported that internal consistency for
the ORS/CORS was .93 for adolescents and .84 for children. As an indica-
tor of treatment progress, the ORS/CORS have been found to be sensitive
to change for clinical samples yet stable over time for nonclinical samples
(Bringhurst et al., 2006; Duncan et al., 2006; Miller et al., 2003).
The concurrent validity of the ORS has primarily been examined
through correlations with established outcome measures. The average corre-
lation between the ORS and OQ across three studies (Bringhurst et al., 2006;
Campbell & Hemsley, 2009; Miller et al., 2003) was .62 (range: .53–.74),
indicating moderately strong concurrent validity (Gillaspy & Murphy, 2011).
Campbell and Hemsley (2009) reported moderately strong relationships
(.53–.74) between the ORS and the Depression Anxiety Stress Scale
(Lovibond & Lovibond, 1995), Quality of Life Scale (Burckhardt &
Anderson, 2003), and Rosenberg Self-Esteem Scale (Rosenberg, 1989).
Duncan et al. (2006) found that the CORS also demonstrated moderate con-
current validity with the Youth Outcome Questionnaire (YOQ; Burlingame
et al., 2001) for adolescents (r = .53) and children (r = .43). In addition,
Miller et al. (2003) reported that pretreatment ORS scores distinguished
clinical and nonclinical samples, providing further support for the construct
validity of the ORS.
Like most outcome instruments, the ORS appears to measure global
distress, which explains how such a brief instrument can measure up to much
longer ones. You can use longer measures, then, but you don’t have to. The
brevity of the ORS really makes a difference because, as is news to no clini-
cian on the front lines and especially in the public sector, the number of
forms and other oversight procedures has exploded. Few have the time or
inclination, as demonstrated above, to devote to the repeated administration,
scoring, and interpretation of lengthy measures, and so feasibility is critical.

becoming a better therapist with pcoms      43

Clients quickly tire of measures that lack obvious face validity, require more
than a few minutes to complete, or appear to take away from time spent with
the counselor.
Intimately related to feasibility is the issue of the immediacy and utility
of the feedback: whether the measure has an intended clinical use to improve
effectiveness. Most outcome measures were developed primarily as pre–post
and/or periodic assessments, or they become that way because they are too
cumbersome to administer in each session. Such instruments provide an
excellent way to measure program effectiveness but do not provide real-time
feedback for immediate treatment modification before clients drop out or suffer
a negative outcome. The ORS was designed first as a clinical tool to provide
real-time feedback to both clients and providers to improve effectiveness—to
get therapists to talk to clients about outcome—and evolved, via psychometric
validation and empirical investigation, to a way to measure and improve out-
comes at individual, program, and agency levels.
To be sure, because of its brevity, the ORS is weaker psychometrically
and does not have the same breadth and depth of assessment as the longer
scales. At the same time, a measure that goes unused is useless regardless of
its strengths. In the real world of delivering services, finding the right out-
come measure means striking a balance between the competing demands of
validity, reliability, and feasibility. The development of the ORS and CORS
reflects our attempt to find such a balance.
Jeff Reese and I (Duncan & Reese, 2013) recently exchanged views
with Halstead, Youn, and Armijo (2013) about this balance, debating when
a measure is too brief and when it is too long. First, regarding when a mea-
sure is too brief: There is no doubt that having 45 items, 30 items, or even
19 items is psychometrically better than four items and that the increased
reliability and validity likely result in better detection, prediction, and ulti-
mate measurement of outcome. But how much better is really the question.
Are these differences clinically meaningful, and do they offset the low com-
pliance rates and resulting data integrity issues from missing data? These are
the questions that require empirical investigation to determine how brief is
too brief, although from my experience, the verdict has already been ren-
dered. But when is a measure too long? The answer is simple: When clini-
cians won’t use it.

Monitoring the Alliance: The Session Rating Scale

Routine assessment of the alliance enables therapists to identify and

correct potential problems before they exert a negative effect on outcome or
result in dropout (Sharf, Primavera, & Diener, 2010). The development of

44       on becoming a better therapist

the SRS followed a similar story line as the ORS. We were experimenting
with using the 12-item WAI (Tracey & Kokotovic, 1989) and the 10-item
SRS. And similarly, even though these instruments were pretty brief,
they apparently were not brief enough; it was tough to get therapists to
do either of them, and implementation rates were terrible. For example,
the 1-year compliance rate was just 29% for the 12-item WAI (Duncan
et al., 2003). Ultimately, the SRS (V.3) was developed (Miller, Duncan,
& Johnson, 2002), pressed by a need for a brief alliance measure at the tel-
ephonic employee assistance program mentioned in Chapter 1, and guided
by Bordin’s (1979) classic definition of the alliance as well as research about
alliance measures.
Recognizing the much-replicated findings regarding the alliance across
modalities and client populations, we also developed the Child Session
Rating Scale (CSRS; Duncan, Miller, & Sparks, 2003b), the Relationship
Rating Scale (RRS) for peer services and self-help (Duncan & Miller, 2004),
the Group Session Rating Scale (GSRS; Duncan & Miller, 2007), and the
Group Child Session Rating Sale (GCSRS; Duncan, Miller, Sparks, &
Murphy, 2011) as brief alternatives to longer research-based measures.
Figure 2.2 reveals that the SRS simply translates what is known about
the alliance into four visual analog dimensions, based in Bordin’s (1979)
classic delineation of the components of the alliance: the relational bond
and the degree of agreement between the client and therapist about the goals
and tasks of therapy. First, the relationship dimension rates the meeting on a
continuum from “I did not feel heard, understood, and respected” to “I felt
heard, understood, and respected.” Second is a goals and topics scale that rates
the conversation on a continuum from “We did not work on or talk about
what I wanted to work on or talk about” to “We worked on or talked about what
I wanted to work on or talk about.” Third is an approach or method dimension,
requiring the client to rate the meeting on a continuum from “The approach
is not a good fit for me” to “The approach is a good fit for me.” Finally, the
fourth scale looks at how the client perceives the encounter in total along the
continuum: “There was something missing in the session today” to “Overall,
today’s session was right for me.” Like the ORS, the instrument takes only a
couple of minutes to administer, score, and discuss. The SRS is scored simi-
larly to the ORS, by adding the total of the client’s marks on the four 10-cm
lines. Rated at a seventh-grade reading level and translated into multiple lan-
guages, the SRS is also easily understood. The CSRS translates the SRS into
child-friendly language, rated at a third-grade reading level (see Chapter 4
for a figure of the CSRS). The GSRS adds a coherence dimension, a factor
more predictive of outcome in group work than the alliance with the leader
or facilitator (see Figure 2.3).

becoming a better therapist with pcoms      45

 Session Rating Scale (SRS V.3.0)

Name ________________________Age (Yrs):____

ID# _________________________ Sex: M / F
Session # ____ Date: ________________________

Please rate today’s session by placing a mark on the line nearest to the description that best
fits your experience.

Relationship

I did not feel I-------------------------------------------------------------------------I

I felt heard,
heard, understood, understood, and
and respected. respected.

Goals and Topics

We did not work I------------------------------------------------------------------------I We worked on and
on or talk about talked about what I
what I wanted to wanted to work on
work on and talk and talk about.
about. Approach or Method
The therapist’s I-------------------------------------------------------------------------I The therapist’s
approach is not a approach is a good
good fit for me. fit for me.
Overall
There was Overall, today’s
I------------------------------------------------------------------------I
something missing session was right
in the session for me.
today.

Figure 2.2.  The Session Rating Scale. Copyright 2002 by S. D. Miller, B. L. Duncan,
and L. Johnson. Reprinted with permission. For examination only. Download a free
working copy at https://heartandsoulofchange.com.

A factor analysis by Hatcher and Barends (1996) revealed that, in addi-

tion to the general factor measured by all alliance scales (i.e., strength of the
alliance), two other factors were predictive: confident collaboration and expression
of negative feelings. Confident collaboration speaks to the level of confidence
that the client has that therapy and the therapist will be helpful. Although
overlapping with the third scale on the SRS, the fourth dimension of the SRS
directly addresses this factor. The other factor predictive beyond the general
strength of the alliance is the client’s freedom to voice negative reactions to
the therapist. Clients who express even low levels of disagreement with their
therapists report better progress (Hatcher & Barends, 1996). The entire SRS
is based on encouraging clients to identify alliance problems, to elicit client
disagreements so that the clinician may change to better fit client expectations.
Regarding psychometrics of the SRS, internal consistency estimates
were reported in four studies with an average alpha of .92, range .88 (Anker,

46       on becoming a better therapist

 Group Session Rating Scale (GSRS)

Name ________________________Age (Yrs):____

ID# _________________________ Sex: M / F
Session # ____ Date: ________________________

Please rate today’s group by placing a mark on the line nearest to the description that best
fits your experience.

I did not feel Relationship

understood, I felt understood,
respected, and/or I----------------------------------------------------------------------I respected, and
accepted by the accepted by the
leader and/or the leader and the
group. group.
Goals and Topics
We did not work We worked on and
on or talk about I----------------------------------------------------------------------I talked about what I
what I wanted to wanted to work on
work on and talk and talk about.
about.
Approach or Method
The leader and/or
I----------------------------------------------------------------------I The leader and the
the group’s
group’s approach
approach are/is not
are a good fit for
a good fit for me.
Overall me.
There was
something missing I----------------------------------------------------------------------I Overall, today’s
in group today—I group was right for
did not feel like a me—I felt like a
part of the group. part of the group.

Figure 2.3.  The Group Session Rating Scale. Copyright 2007 by B. L. Duncan
and S. D. Miller. Reprinted with permission. Download a free working copy at
https://heartandsoulofchange.com.

Owen, Duncan, & Sparks, 2010; Duncan et al., 2003; Reese, Toland, Slone,
& Norsworthy, 2010) to .96 (Duncan, 2011a; Gillaspy & Murphy, 2011).
These alpha coefficients suggest that the SRS assesses a single, global alliance
construct. This is consistent with research on other alliance measures such as
the WAI (Horvath & Greenberg, 1989). The alpha coefficients for the GSRS
ranged from .86 to .90, similarly suggesting a single alliance factor (Quirk,
Miller, Duncan, & Owen, 2013). Three studies (Duncan, 2011a; Duncan
et al., 2003; Reese et al., 2010) reported test–retest reliability of SRS scores
from the first to second session. The average reliability coefficient was .59
(range: .54–.64), indicating adequate stability (Gillaspy & Murphy, 2011).
The test–retest reliability coefficient for the GSRS ranged from .42 to .62
(Quirk et al., 2013).
Three studies have investigated the concurrent validity of the SRS.
Duncan et al. (2003) reported a correlation of .48 between the SRS and the

becoming a better therapist with pcoms      47

revised Helping Alliance Questionnaire (HAQ–II; Luborsky et al., 1996).
Campbell and Hemsley (2009) found that SRS scores correlated .58 with the
WAI (Tracey & Kokotovic, 1989). Reese et al. (2013) reported correlations
with the WAI ranging from .57 to .65. These findings indicate moderate con-
current validity with longer alliance measures. In addition, Reese et al. (2013)
also found evidence for discriminant validity of the SRS. A low correlation
was found between the SRS and the Social Desirability Scale (Ballard, 1992;
r = .05). Regarding the GSRS, correlation coefficients between the GSRS
and the WAI ranged from .41 to .61; coefficients between the GSRS and the
Group Climate Questionnaire (MacKenzie, 1983) and the Therapist Factor
Inventory, Cohesiveness Scale (Lese & MacNair-Semands, 2000) ranged
from .31 to .60 (Quirk et al., 2013). These data indicate that the GSRS
adequately assesses similar constructs.
Finally, the predictive validity of the SRS was supported by Duncan
et al. (2003). Early SRS scores (second or third session) were predictive of
posttreatment ORS scores (r = .29), consistent with previous research linking
early client perceptions of alliance with outcome (Horvath & Bedi, 2002).
Similarly, Quirk et al. (2013) found that GSRS scores were predictive of
change in the fourth session (r = .23).

Bottom Line: The ORS and SRS are the instruments used in PCOMS. Both
have just four items, making them feasible for everyday, every-session use with
clients. Both reliable and valid, these brief measures tell you the most important
things you need to know about your therapy: whether the client and the therapy
are on the right track.

NUTS AND BOLTS OF PCOMS

Frothy eloquence neither convinces nor satisfies me. . . . You’ve got to

show me.
—Willard Duncan Vandiver,
Speech at a Naval Banquet in Philadelphia

Given that, at its heart, PCOMS is a collaborative intervention, every-

thing about the use of the measures and the results attained is shared with
clients. Consequently, the client needs to understand what it’s all about, and
especially these two points: that the ORS will be used to collaboratively track
outcome in every session to ensure the client benefits and that it is a way to
make sure that the client’s voice is not only heard but also remains central to
therapy as it unfolds.
The ORS is given at the beginning of each session. In the first meet-
ing, the ORS pinpoints where the client sees him- or herself, allowing for an

48       on becoming a better therapist

ongoing comparison in later sessions. As noted, the ORS is not an assess-
ment tool in the traditional sense. Rather, it is a clinical tool intimately inte-
grated into the work itself. It requires that the therapist ensure that the ORS
represents both the client’s experience of his or her life and the reasons for
service—that the general framework of client distress evolves into a specific
account of the work done in therapy.
The SRS opens space for the client’s voice about the alliance. It is
given at the end of the meeting, but with enough time left for discussing
the client’s responses. The SRS is not a measure of a therapist’s compe-
tence or ultimate ability to form good alliances, or anything else negative
about therapists or clients. It is designed to facilitate a discussion about
the partnership between the therapist and the client; any lower rating is
an indication that the client feels comfortable to report that something
is wrong. Appreciation of any negative feedback is a powerful alliance
builder, as is the ongoing attention of the therapist to the client’s experi-
ence of it.
There is a factor in PCOMS that is absolutely essential—you. If you
don’t authentically value clients’ perspectives and believe that they should
be active participants in therapy, PCOMS will fall flat. In addition, without
your investment of yourself into the spirit of partnership of the feedback
process, little gain is likely to happen. It’s not enough to flick a form in a
client’s face—you have to use it clinically and allow yourself and the work
to be influenced by it. Obviously, if you don’t look at the feedback, use it, or
expect it to add anything you don’t already know, client feedback will not
improve your outcomes (de Jong et al., 2012). Your task is to make PCOMS
your own.
There are four steps to using the measures in the first session.

Step One: Introducing and Scoring the ORS

Clients need to be on board, and that is up to you. This means inform-

ing them about the nature of the partnership and starting to build a culture
of feedback in which their voice is essential. In the first contact by you or an
intake person, it is important to convey a commitment to improving the cli-
ent’s situation as well as to the highest quality of collaborative care:
I am committed to your reaching your goals here, so I like to monitor
whether my clients are benefiting through the use of two brief forms.
These take only a couple minutes to fill out, but yield a great deal
of information about how things are going and whether or not we
should set a different course. I will give you one in the beginning of
the session and one toward the end. This will allow us to keep an eye
on whether you are getting what you came here to get and how well

becoming a better therapist with pcoms      49

 we are working together. It’s good to know these things sooner rather
than later so we can do something about it—it also lets us know if you
would be better served by someone else. I will explain this in greater
detail when you arrive for your first session. Is this something you can
help me out with?

I have never had anyone tell me that keeping track of progress is a bad idea.
The above script is just a suggestion. Feel free to be creative in your explana-
tion. Put it in your own words and natural way of communicating.
Continue building a culture of feedback in the first session and adminis-
ter the ORS as an invitation into a collaborative partnership. Avoid techni-
cal jargon and instead explain the purpose of the measures and their rationale
in a natural, commonsense way. Make the administration, scoring, and dis-
cussion part of a relaxed and ordinary way of having conver­sations and work-
ing. The specific words are not important. Your interest in the client’s desired
outcome speaks volumes about your commitment to the individual. Convey
that there is no such thing as “bad news” on these forms because feedback
improves the chance for success. Ensure that clients know that the measures
are specifically designed to empower their voice in all aspects of therapy and
include them in all decisions that affect their care, and the ORS will be used
to monitor their progress to make sure that they are reaching their desired
goals. Here are two examples from actual clients:
When I work with people I like to start off with this very brief form, it’s
called the Outcome Rating Scale, and it is a way for me to get a snapshot
of how you are viewing how things are going for you right now, and a
way that you and I can check in each time to make sure that our work
together is beneficial for you. So it’s a way to track progress and it’s also
a way to make sure that how you are viewing things stays central to the
way we are working together.

When I work with folks, what I like to do to start things off is give this
very brief form to fill out called the Outcome Rating Scale and this gives
me a snapshot of how you are doing right now with things. It serves as an
anchor point so we can track your progress so we both know how things
are going so we can talk about that. It’s also a way to make sure that your
voice stays central to this process because sometimes client voice has a
way of falling through the cracks. This is a way to make sure that your
perspective of how you are doing stays central to all the works that’s
done. Would you mind doing that for me?

These excerpts are just examples, not mandates or research protocols. So

put the introduction in your own words, the way that you talk and inter-
act with clients. Remember, in most respects, you are the therapy—you

50       on becoming a better therapist

account for most of the variance in any delivered treatment. Similarly,
you are PCOMS!
Here are the provided instructions on the ORS:
Looking back over the last week, including today, help us understand
how you have been feeling by rating how well you have been doing in the
following areas of your life, where marks to the left represent low levels
and marks to the right indicate high levels. If you are filling out this form
for another person, please fill out according to how you think he or she is doing.

Use your judgment about how much to explain the instructions. Most
people understand the measures with minimal explanation, but you can’t
overexplain the measures, so do whatever it takes to ensure that the client
understands what it is about. Given that the forms are intended to make sure
the client’s perspective is not lost in the shuffle (recall Dan Ariely, the burn
patient, in Chapter 1), the whole point is missed if the client doesn’t get what
the measures and PCOMS are about.
The ORS has very good face validity—the domains make common
sense, so clients very quickly apply their lived experience to the different
areas of functioning and make their marks. Whatever explanation the client
gives in his or her own words is okay. Some clients will say, “You mean like
poor to well?” or “Like 1 on the left and 10 on the right?” Keep in mind it’s
their subjective experience we are interested in, so their understanding of the
measure in the context of their lives is paramount. Your efforts to understand
the meaning of the client’s ratings also contribute to the client’s ultimately
“getting” what the ORS is all about.
Sometimes clients ask for clarification between scales or how they
should rate two aspects of the same dimension. For example, regarding the
Interpersonally line, which looks at close relationships such as partners and
immediate family, clients may say something like, “I am doing great with my
kids, but my relationship with my spouse stinks;” or on the Socially dimen-
sion, “My work is the only thing going right, but I have no friends—should
I average this?”
Here you simply ask the client to rate the dimension relevant to his or
her decision to seek therapy, because you want the measure to reflect prog-
ress in that area. So you say something like, “Are either of the topics related
to why you are here?” (The client responds that he is here because of his
relationship with his partner or she is here because of her troubles making
friends.) “Okay, please rate the line to reflect your concerns there because we
want to see when progress is made.”
It’s also okay to orient clients to how you would like them to rate the
ORS. For example, at the couple clinic where the PCOMS feedback study
was done, clients are asked to rate the Interpersonally dimension according

becoming a better therapist with pcoms      51

to how things are going with their partners, given that is what the service is
about. Similarly if you work in a substance abuse program, you might ask the
client to score the ORS relative to their substance use. Think about what
makes clinical sense to your practice. Some therapists like to orient clients
in the first session to fill out the ORS relative to their reasons for therapy.
That’s okay too. My preference is for clients to complete the ORS without
additional instructions and allow their reasons to emerge from how they filled
it out. But that’s just my preference. It’s okay to provide more context if you
find that more helpful.
Clients rarely say no to PCOMS when a sincere, authentic therapist
conveys that the purpose of the ORS and the SRS is to ensure that the cli-
ent’s voice stays central and that the client will benefit. But the therapist
has to believe that this is true and use the measures in a way that makes
them meaningful to the work. If the ORS is treated as a perfunctory piece
of paper that is not related to the therapeutic process, then clients will see
it similarly.
Next, you have to score the client’s marks. This is easy and only requires
a centimeter ruler or template. But by all means practice it a few times. Many
therapists will not try this because they are afraid they will look inept. They
mostly worry about measuring the marks and adding up the scores. Keep
in mind there are only four marks and four scores, so measuring the marks
and adding the numbers is not quite like calculating regression equations
(although using a calculator is fine). Just practice it a few times until you feel
that you can do it without fumbling around too much.
And, however you do it, won’t be as bad as I’ve done it—no kidding.
When I am doing training, to ease the anxiety around using the measures
for the first time, I show a video of me administering the measures in any-
thing but a cool, expert, and professionally adept way. The agency where
I was consulting used PCOMS and had the ORS on one side of a page
and the SRS on the other. I didn’t notice. So I explained the ORS to the
mother and adolescent daughter who were very tense because of a very trou-
bling, violent daughter-on-mother episode, while giving them the SRS to
fill out. Imagine what they thought, reading “I felt heard, understood, and
respected” (“Sure Barry, in the first minute this is going fine even though
I haven’t said anything yet!”). The clients dutifully filled out the SRS and
gave it back to me, and I went on, totally unaware, with measuring the
marks and adding the scores—and I still didn’t notice that it was the SRS
while I was giving them feedback about their ORS scores. What they must
have thought! Finally I saw it and, laughing, I confessed what I had done
and said I wouldn’t blame them if they didn’t want to talk with such a klutzy
therapist. Then they started laughing too. My bumbling killed the tension,
and it was a great session.

52       on becoming a better therapist

 Bottom Line: Fold the administration and scoring of the measures into your
natural way of talking and being with clients. Make sure clients get what the
ORS is about: privileging their perspective and ensuring that they benefit.
Don’t stress so much about doing it right. Perhaps it is best to practice it a few
times, but just do it.

Step Two: Discussing the Client’s Score and the Clinical Cutoff:
Contextualizing and Making Sense of the Client’s Score

By now, we have given the client the ORS, measured the marks, and
tallied up a total score. Given that everything about PCOMS is 100% trans-
parent, the task now is to discuss the number and make sense of it with the
final authority—the client. The clinical cutoff provides a way to do this.
Clinical cutoff is a statistical term that represents nothing ominous, nor does
it say anything negative about the client. It is only the dividing line between
people who typically do not find themselves in therapy and those who do,
differentiating between a so-called clinical population from a nonclinical
one. The clinical cutoff for the adult ORS is 25 (for adolescents, 28, and for
children, 32). Recall that the ORS is really a measure of distress, so the num-
ber 25 out of 40 generally means that those under 25 are reporting the level of
distress typically associated with being a client, and those over 25 are report-
ing a level of distress generally associated with not being a client. It’s not
magic. It is just the number that reliably distinguishes the two populations.
The average intake score of an outpatient psychotherapy setting is from
18 to 20, but anywhere between one fourth and one third of your clients will
come in over the clinical cutoff. People who score under the cutoff are typi-
cally looking for change, something different in their lives, while those who
score higher or over the cutoff tend to be folks who are more satisfied with the
status quo and therefore may require a bit more context to understand what
they are looking for from therapy.
So, once we have the score, it’s time to say what the number means: to
contextualize client scores using the cutoff as a jumping off point to promote
understanding and best use. Discussing the cutoff allows you to check out
whether the score makes sense to the client and fits what they were trying
to convey in their marks; it is a way to make sure you have a good (i.e., true)
rating. And, finally, addressing the cutoff allows you to validate the client and
convey that he or she is in the right place.
There are only two choices here: The client’s initial score on the ORS
is either above or below the clinical cutoff. Scores that are under the cutoff
may seem a bit more straightforward. The client is reporting distress at a level
similar to those of other persons seeking mental health or substance abuse
services—the lower the score, the higher the distress. These folks are looking

becoming a better therapist with pcoms      53

for a change on the horizon, and a very low score is definitely saying that the
sooner the change happens, the better. Here are two examples, to illustrate
introductions to talking about the cutoff.
First is Connie, a bright, resourceful 31-year-old professional woman
with a strong social network, who sought therapy because of difficulties in
shaking a very painful divorce and a strong desire to make sense of what has
happened to her, especially why her marriage failed. She scored a 19.8 on
the ORS:
Barry: (Client gives her ORS to Barry.) What I do is I just measure this
up. It’s four 10-cm lines and it gives a score from 0 to 40, and
I just pull out this ruler and add up the scores, and then I will
tell you about what this says and you can tell me whether it
is accurate or not, and then we will have an anchor point to
measure each time and see if you are getting what you came
here to get. . . . Okay, you scored a 19.8. And what that means
is that this scale, the Outcome Rating Scale, has a cutoff of
25 and people who score under 25 tend to be those who wind
up talking to people like me; they’re looking for something
different in their lives, there’s something in their lives that’s
not going so well. You scored about the average intake score of
persons who enter therapy, so you’re in the right place. And it’s
not hard to look at this and see pretty quickly that the family/
close relationship area is what you are struggling with the most
right now. Does that make sense?
Connie: Yes, definitely.
Barry: So what do you think would be the most useful thing for us to
talk about today?
Connie: Well, I am in the middle of divorce and struggling with figuring
this out . . . 
Then there was Harold, whom we’ll follow into Chapter 3.
Harold was an incredibly energetic and community-involved 71-year-
old retired engineer whose life had taken a downturn in the past year, when
he started battling “chronic depression and panic attacks.” Harold was com-
ing off his third hospitalization in the past year and was feeling increasingly
frail and hopeless. He especially was distressed about his propensity to rumi-
nate about simple decisions, some of which evolved into panic attacks or
bouts of isolating himself in bed or what the referral source called “debilitat-
ing depression.” Harold scored a 14.2 on the ORS.
Barry: (Client gives his completed ORS to Barry.) What I do is I just mea-
sure your marks on these four 10-cm lines with this ruler, which
will give a score somewhere between 0 and 40. Then I’ll tell you

54       on becoming a better therapist

 what the number may mean and you can tell me whether it is
accurate or not and then we will have a starting point to mea-
sure each time to if you are benefiting from our work together.
Wow, your ORS score is 14.2 and that says things are really
tough for you now. You are in the right place. Generally, a score
under 25 indicates people who are in enough distress to seek
help. Your total score of 14.2 is pretty low. The average intake
score is usually about 18 to 20, so it says you are in quite a bit of
distress. Does that fit your experience?
Harold: Yeah, it sure does. Nothing is the same anymore. Where do
I start?
Barry: You might want to start with what led to you make the mark on
the Individually Scale (picking up the ORS), the one you marked
the lowest or you can start anywhere you’d like. What’s going on?
Harold: I’ve been a personal wreck for the last year—I can’t make a
decision and can hardly get out of bed. . . .
That is all there is to it. Give the score, say what it might mean, and look
for feedback to see if it fits. Keep in mind that it is the client who made the
marks, so you are not going out on a limb when you discuss the score. If it
doesn’t fit for the client, then it’s good that you found out so you take another
pass and ensure a good rating, one that represents the client’s experience of
distress.
There are a couple of noteworthy things about these excerpts. First, the
ORS is not burdensome for the client. Connie and Harold completed the
ORS in 36 and 44 seconds, respectively. And, second, what you will find in
99 out of 100 administrations in the first meeting is that the scale clients mark
the lowest is the one they are there to talk to you about. Connie and Harold
both did just that. The initial ORS score is an instant snapshot of how the
client views him- or herself. It brings an understanding of the client’s experi-
ence to the opening minutes of a session that didn’t previously exist, at least
for me. With Harold, within 2 minutes, I knew that here was an individual
in significant distress, well under the average intake cutoff, and I knew that
of the domains of his life, he felt more impacted in his personal well-being.
So I honed in on that right away.
What about folks over the clinical cutoff? Scores are usually above the
cutoff for one or both of two reasons: (a) although most things are going well,
there is a specific concern or issue for which the person desires help and/or
(b) someone else has either suggested or required this person’s participation
in therapy.
Clients who are mandated (or coerced) to therapy from the courts, their
employers, partners, or child protective services, etc. (and nearly all kids are

becoming a better therapist with pcoms      55

mandated—they typically don’t announce at the breakfast table over a
bowl of Cheerios that they want to talk to a therapist) represent the lion’s
share of clients scoring over the cutoff. In these instances, it is very helpful
to have clients complete the ORS twice, once as themselves, and once as
if he or she were the referral person. If possible, it is preferable to get the
referral person’s actual rating. Although it is easy to obtain these two views
with children and parents, it can be challenging with other mandated refer-
rals, but not impo­ssible. If you have a working relationship with the referral
source, you can fax or e-mail the form so you have it as a point of compari-
son for discussion with the client. You can also call and administer the ORS
over the phone (oral scripts are available at https://heartandsoulofchange.
com) and ask referral sources if you can periodically check in to get their
impressions of how the client is doing. This not only helps you track prog-
ress from the set of eyes that can make a difference for your client but also
helps you identify what specifically the referral source is looking for as sign
of improvement.
Consider Larry: He was referred by the courts because of his second DUI
and was not very happy about that, nor was he happy to be sitting face-to-face
with me in my office. Larry scored a 28.9 on the ORS.
Barry: Thanks for doing that for me. It helps me make sure that I pay
attention to how you think about things. Okay, you scored a
28.9. The way this works is that the four lines there are 10 cm
each and total up to 40. Twenty-five is considered the cutoff,
which means that, generally, when people score above 25, things
are going pretty well for them—not perfect, but pretty much
okay. The score is more indicative of people who don’t usually
find themselves sitting in my office. Does that make sense in
terms of how you marked it?
Larry: Yeah, it does, because I am doing fine and I don’t really want to
be here. The courts are making me.
Barry: Okay, good. I’m always glad when the ORS accurately reflects
the client’s experience.
Larry: You know, things are not perfect, but they are okay. I only had a
few beers at a company picnic. It was the same cop that got me
before—I think he was just waiting in my neighborhood to nail
me. For Christ’s sake, he must have been gunning for me. How
could it be the same cop?
Barry: Does sound fishy, doesn’t it? So things are okay except for this
DUI business and that’s why you are here to see me, because
the courts have that hanging over your head, and that is what
accounts for your lower rating on this first scale (Barry points to
the Individually Scale on the ORS).

56       on becoming a better therapist

 Larry: Yep, that’s it. The PO thinks I have a drinking problem and that
I need treatment.
Barry: You are on probation and your PO believes you to have a drink-
ing problem. And you disagree with that.
Larry: You bet!
Barry: So it sounds like, and let me know if I’m getting this, that one
thing we may need to do is convince your PO that you don’t
have a drinking problem and that you don’t need to come here.
Larry: Yeah, that’s it. That and let her know I can have my license
back.
Barry: Okay, would you be willing to take another pass at that ORS
for me? But this time fill it out like you were the PO rating you?
Given she is the one we have to please, it might help us figure
out a few things.
Larry: Sure. Okay. (Barry gives Larry back his ORS and Larry completes
it from the perspective of the PO.)
Barry: Wow, this is really different. She would rate you a 16.8. Quite a
difference between that and 28.9.
Larry: Yeah, she thinks I’m an alcoholic and that I need to go to AA.
Barry: I see. So what do you think you and I need to do to convince
her that isn’t true? Or (picking up the ORS), what needs to
happen to bring her view of you more in line with your view
of yourself?
The ORS, once again, sets the stage and focuses the work at hand. You
may notice that I didn’t enter into unnecessary clashes over the client’s
view of being set up by the police or how much he had to drink. Mandated
clients are no different from voluntary clients with regard to the alliance.
Attaining the client’s rating as if he or she were the referral source is a great
way to bring in the other view without challenging the client’s perspec-
tive. Confirming my experience with every mandated client I have ever
seen, the referral source rated Larry much lower than he did. I explored
that with Larry to understand the difference. In a sense, the ORS allows
the referral source’s view to be externalized, represented by the form itself,
making it easier to talk about, and not risking the alliance (few things are
worth that risk).
One last thing of note about clients who enter therapy scoring over the
cutoff: Even though the client may be reporting that things are going well,
there will still be one scale that is lower than the rest, and that is often your
invitation to collaborate.

becoming a better therapist with pcoms      57

 Bottom Line: The client’s score in relation to the clinical cutoff provides a
real-time picture of the client’s experience and the first opportunity for feed-
back. Use the cutoff to set the stage for the work, validate the client, and focus
your efforts.

Step Three: Connecting the Marks to the Client’s Described

Experience and Reasons for Service

This is the most important clinical nuance of PCOMS. The ORS and
SRS are not like bread to a sandwich, separate from the real meat of the ses-
sion. Rather, they are clinical tools intimately integrated into the work itself.
Moreover, the ORS is not an emotional thermometer that rates how the cli-
ent is feeling at the particular moment it is given, nor is it intended to be an
ongoing account of how the client’s life is going week to week. Rather, the
ORS is designed to measure how things are going in the client’s life relative
to the reasons for therapy.
Because the ORS has face validity, as noted, clients usually mark the
scale the lowest that represents the reason they are seeking therapy, and often
connect that reason to the mark they’ve made. For example, Harold marked
the Individually scale the lowest, with the Socially scale coming in a close
second. As he was describing how he ruminates about minor decisions, often
working himself into a real frenzy, he pointed to the ORS and explained that
this problem accounted for his mark. With other clients, you may need to
clarify the connection between the client’s descriptions of the reasons for
service and the client’s marks on the ORS. This entails eliciting the client’s
perspective on what the marks mean, so that you are on the “same page”
regarding what the marks say about the therapeutic work and whether the
client is making any gains. This way, both you and the client know what the
mark on the line represents to the client and what will need to happen so that
the client will both realize a change and indicate that change on the ORS. At
some point in the meeting, the therapist needs only to pick up on the client’s
comments and connect them to the ORS:
Okay, it sounds like dealing with the loss of your job [or relationship with
partner, sister’s drinking, or anxiety attacks, etc.] is an important part of
what we are doing here. Does the distress from that situation account for
your mark here on the [_____] scale on the ORS? Okay, so what do you
think will need to happen for that mark to move just one centimeter to
the right?
More specifically, using the example of Connie:
Barry: If I am getting this right, you said that you are struggling with
the divorce, specifically about why it happened and your part

58       on becoming a better therapist

 in it, so you are looking to explore this and gain some insight
into what perhaps was your contribution. You marked the Inter-
personally Scale the lowest (Barry picks up the ORS). Does that
mark represent this struggle and your longing for some clarity?
Connie: Yes.
Barry: So, if we are able to explore this situation and reach some
insights that resonate with you, do you think that it would
move that mark to the right?
Connie: Yes, that is what I am hoping for and that’s what I think will
help me. I know I wasn’t perfect in the relationship and I want
to understand my part. I already know his part!
The ORS, by design, is a general outcome instrument and provides no specific
content other than the broad domains. It offers a bare skeleton to which clients
must add the flesh and blood of their experiences, into which they breathe life
with their perceptions. At the moment in which clients connect the marks on
the ORS with the situations that are distressing, and to what they would like
to accomplish, the ORS becomes a meaningful measure of their progress and
a potent clinical tool.
With Larry, although he scored over the cutoff with a score of 28.9,
his Individually and Interpersonally scales were lower than others—6.1 and
6.8, respectively. Larry’s problems with the courts and his PO were con-
nected to the Individually scale. Larry and I discussed how we might move
this mark over a bit and address the PO’s concerns about his drinking.
After a lively conversation, we concluded that looking at his drinking in
detail might be a good start, given that the PO would be pleased that we
were addressing it.
There is nothing heavy-handed or cast in stone about this. Client goals
can change, and sometimes rapidly. The space between the client’s marks and
the far right represents the zone of potential treatment gains and topics of
discussion—what they want to work on that may move their mark up, even
a little. So if the client’s desires change, don’t worry but continue to connect
the work to that space on the ORS open for improvement. For example, with
Larry, his mark on the Individually scale first represented his distress about the
DUI and the courts, with improvement coming from getting the PO off his
back and securing driving-to-work privileges. In Session 4, the open space on
the Individually scale evolved to represent the benefits accrued from a reduc-
tion in his drinking.
Finally, connecting the client’s experience to the ORS has other benefits.
It can help you and the client stay on track by providing a way to focus the ses-
sion back on the lowest rated scale when the conversation goes astray. The

becoming a better therapist with pcoms      59

ORS helps prioritize topics as well as thematically tie different elements of the
discussion together. Simply pick up the ORS and redirect to the issue at hand as
well as what can be done in session and beyond, to move the mark to the right.

Bottom Line: It is important that the client understand that the marks on the
scales should be connected to and reflect those issues that are the grist for the
therapeutic mill. From the get-go, ensure that the measure is relevant to both
the client’s experience and the work that will ensue in therapy. If that connec-
tion isn’t made, then the ORS becomes an emotional thermometer reading of
weekly moods in response to the inevitable ups and downs of life. And then it
is worthless.

Given that the first ORS provides the comparison point for all future
work with the client, it is essential to get a good rating. This means striving
to get the most accurate rating of the client’s experience possible, a sincere
appraisal of his or her life. Encourage a frank discussion of the issues involved,
express your desire to be helpful, and get the idea across that therapy works
best when the ORS is an accurate reflection. In general, any score 35 or above
is not a good rating, certainly one that should alert you to question whether
it matches the client’s description of his or her life. Even people who consider
themselves doing very well in life do not tend to rate this high.
People score above 35 on a first session ORS for two main reasons: Either
they don’t understand the ORS, or they are disgruntled and are blowing it
off. Neither is difficult to overcome. For example, I was doing a consult for an
agency that was already using PCOMS, so I incorrectly assumed that the cli-
ent understood the ORS. I administered the measure and the client scored a
38.1. I was surprised, given that I was purportedly doing a consult because the
therapist and client felt stuck. But I said that things must be going really well,
and the client just looked at me in a confused way and launched into a horror
story of what she had to go through to get to the appointment. She had to get
up 4 hours earlier than usual and had experienced two panic attacks. In fact,
she said her life was riddled with panic, making every day an ongoing battle.
I simply picked up the ORS and asked, “Where do I see the rather extreme
struggles that you are describing on the ORS?” To which she answered, “Is
that what that’s for?” She redid the ORS and scored a 12.9. Clients have to
understand the ORS, and it has to have meaning arising from their specific life
circumstances. Clients who rate the ORS over 35 and then after a few minutes
start telling you how badly their lives are going do not understand the measure.
All you have to do is ask about it; perhaps the easiest way is to simply inquire
where the distress that the client is describing can be found on the ORS.
How about folks who just blow off the ORS because they are angry
about being in your office or who are disgruntled for some other reason? For
example, I saw Darrell, a referral from the DUI court, who jerked the ORS

60       on becoming a better therapist

from my hand and completed it in about a nanosecond. He just took the pen-
cil and drew a line down the right side of the page. I dutifully measured the
marks and totaled them to a score of 38.8. I commented on how well he was
doing, especially considering his recent arrest. (He had opened the conversa-
tion by angrily telling me that he was forced to be there by the courts because
of a DUI.) When I asked him how the referring PO would rate him, he told
me he did not give a flying f--k about what his PO thought.
Even with this inauspicious start, after a while of talking about things,
Darrell lightened up with me when he figured out that I wasn’t there to nail
him about his drinking. He told me through tears that his girlfriend had
kicked him out and he was really sad about that—she meant a lot to him.
Darrell also told me that he had been sleeping in his truck and was also con-
cerned about losing his job. After commiserating, I asked him to help me
understand how his life could be so hard while his ORS looked like he just
won the lotto and spent a week in Hawaii with Angelina Jolie. He laughed
and told me that he was pissed off in the beginning and rated the ORS with-
out thinking much about it—that he had just blown it off. I asked Darrell if
he would do it again because it would help us keep track of our work together
and make sure he was getting where he wanted to go. And he did. His score
was 18.3 with a 3.4 on the Interpersonally scale. The impact of Darrell’s drink-
ing on his relationship with his partner became the focus of our work. And
when he was sober for 3 months, he invited his ex-partner to join him in
therapy. Sometimes you have to work at that first ORS—to secure a good
rating that reflects what is going on in the client’s life. It is worth the effort.
But please take clients at face value unless you have evidence from
them—not referral sources or family members—to the contrary. Err on the
side of believing that there is a good reason for the client to rate it as he or
she did.

Bottom Line: Getting a good rating on the ORS that reflects the client’s
described experience and reasons for service is critical to PCOMS. It’s up to
you to make that happen. Transparency is the rule. Just ask clients for help if
their scores don’t make sense to you. It usually makes sense to them. If not,
ask the client to redo the ORS. And if it makes sense to the client but doesn’t
to you, take it at face value.

Step Four: Introducing and Discussing the SRS

The best thing about the SRS is that it helps you build a strong alliance.
It encourages you to not leave the alliance to chance and ignore the innumer-
able studies demonstrating the relationship between a strong alliance and
positive outcome. Chapter 1 established that therapists who are better at
forming strong alliances with more clients are the ones who are the most

becoming a better therapist with pcoms      61

effective. The SRS is the only psychometrically reliable and valid instrument
on the planet designed to be a session-by-session real-time alliance measure.
This is important because clients drop out of therapy for two primary reasons:
One is that therapy is not helping (hence the importance of monitoring out-
come), and the other is alliance problems—they are not engaged or turned on
by the process. The most direct way to improve your effectiveness is simply to
keep people engaged in therapy. Traditionally, clients give their evaluation of
the alliance with their feet—they walk out and don’t come back.
The SRS, like the ORS, is best presented in a relaxed way that is seam-
lessly integrated into your typical way of working. And like the ORS, it
designed to be a light-touch, checking-in process that exemplifies the cul-
ture of client privilege and feedback, opening space for the client’s voice
about the alliance. It is given at the end of the meeting but with enough
time left to discuss the client’s responses. Here are some example introductions
to the SRS:
This form, the Session Rating Scale, looks at how it went for you today,
with the idea being that I really want to know whether you think we are
on the right track, that we are talking about the right stuff, and whether
my style and approach are a good fit for you—so I could do something
about it if it wasn’t working out for you. When clients and therapists talk
about these things, it tends to make the outcome come out better.
Let’s take a minute and have you fill out the other form that asks your
opinion about our work together, the Session Rating Scale. It’s kind of
like taking the temperature of our session today. Was it too hot or too
cold? Do I need to adjust the thermostat to make you feel more comfort-
able? The ultimate purpose of using these forms is to make every possible
effort to make our work together beneficial for you and go the way you
want it to go. If something is amiss, you would be doing me the best favor
if you let me know, because then I can do something about it. Would you
mind doing this for me?

Those are just examples, and you have to translate the introduction into
your natural way of communicating with clients. One thing that I learned
over the years is that I have gotten a lot more response from clients when I
have deemphasized that the SRS is about their “feelings” about the “relation-
ship,” because it is hard for folks, in general, to talk about these things. So if
you want people to run out of your office shrieking, say something like, “The
SRS enables you to share your innermost feelings about our relationship.”
Instead I have found that introductions that use a metaphor like temperature
and don’t mention relationship at all, or call the SRS a rating of the session
itself instead of me or the relationship, yield better discussions. The SRS
itself is a bit of an externalization of the alliance. It is a lot easier to mark the

62       on becoming a better therapist

scales lower than to talk about it. That’s the whole idea. People will indicate
a concern on the SRS when they never would have brought it up otherwise.
But you have you use your clinical skills here. Getting feedback on the SRS
is a nuanced interpersonal process that requires you to finesse a response from
clients by making them feel comfortable about offering you feedback.
A valid concern often arises regarding the high scores clients typically
report on the SRS. Therapists worry that clients do not rate the SRS hon-
estly because they don’t want to hurt the therapist’s feelings or because they
are filling it out in the presence of the therapist. Or, in other words, clients
will inflate their scores because of social desirability and/or demand charac-
teristics. It makes sense that some would have this concern, given that the
suggested cutoff is 36 out of 40 and most clients do tend to score the SRS
very high.
So although these concerns are reasonable, they come from mis­
understandings of both the SRS and alliance measurement in general. First,
and to reiterate, there is no bad news on the SRS. It is not a measure of com-
petence or ultimate ability to form good alliances. It is a gift from the client,
actually, that allows therapists the opportunity to both alter the service and be
a better therapist with that client. And, of course, unless the therapist really
wants negative feedback, he or she is very unlikely to get it. So if you are striv-
ing for feedback and not putting any value on positive scores—in fact quite
the opposite—then social desirability and demand characteristics don’t make
much logical sense. In that case, the desire to please, to be socially appropriate,
would lead to a demand for lower scores, not inflated ones.
Second, all alliance measures tend to be scored high by clients. This is
not just a phenomenon of the SRS but runs across alliance scales in general.
So what does that mean? It could say that clients score alliance measures
so high because of social desirability or demand characteristics. But clients
score alliance measures high regardless of whether the therapist is present or
not (Pesale & Hilsenroth, 2009). Project leader and University of Kentucky
professor Jeff Reese and colleagues just confirmed this with the SRS as well
(Reese et al., 2013). Clients were randomly assigned to one of three alliance
feedback conditions: SRS completed in the presence of the therapist and
the results discussed immediately; SRS completed alone and results discussed
next session; or SRS completed alone and results not available to the thera-
pist. No significant differences in SRS scores across the feedback conditions
were found. Additionally, the analysis showed that SRS scores were not cor-
related with a measure of social desirability. These results indicate that alli-
ance scores were not inflated by the presence of a therapist or by knowing that
the SRS scores would be observed by the therapist.
So what do the high scores mean? My preferred interpretation is that
it is just plain hard for human beings to give critical interpersonal feedback.

becoming a better therapist with pcoms      63

It’s hard enough in our closest relationships! But perhaps even harder to give
negative feedback to someone trying to help us, especially given the disparity
in power between therapist and client, combined with any socioeconomic,
ethnic, or racial differences. When was the last time you told your physician,
“Listen, you’re making a big mistake with me”? So we should recognize the
difficulty of the task and give clients a break. It’s all good. High scores are
good, low scores are even better.
And it means this whole process of securing feedback comes back to—us!
This includes being comfortable in our own skin when we ask for feedback, to
really want it, to respond gracefully and do our best to accommodate our work
to the feedback, and, finally, having an authentic desire to coax the client
into a frank discussion about their preferences regarding our work with them.
The cutoff of 36 may be a bit of overkill, given that more recent data
indicate that the average first-session SRS scores range from 33.5 to 33.9
and increase from there. But the importance of the alliance warrants erring
on the side of caution. Moreover, exploration of the alliance in and of itself
helps build the alliance. So if a client scores less than a total of 36, or less than
9 cm on any dimension on the SRS, there is a potential problem that should
be discussed, as well as an opportunity to enhance your relationship. Given
these parameters, you can do a very quick visual check and then integrate the
results into the conversation.
This is not complicated or heavy-handed. There are only two choices.
Either the SRS is 36 or above or not. And your actions are equally simple:
Either you thank the client for the feedback and invite him or her to share any
future concerns—letting him or her know it’s the best favor he or she could do
for you; or you thank the client for the feedback and explore why the ratings
are somewhat lower, so that you can try to fit what he or she is asking for. A
high rating is a good thing, but it can be difficult to interpret unless you unfold
it a bit more. A lower rating is cause for celebration and can yield information
that makes the difference between success and failure.
But don’t stress about it. Remain open and keep encouraging the cli-
ent to let you know if there’s anything else you can do. But don’t think for a
minute that you will get critical feedback from everyone. Some clients will
never do it.
Keep in mind that this is not like having work done at your car dealer
and being told about the forthcoming customer survey: “Make sure you mark
all the questions ‘excellent’ or ‘extremely satisfied’ or they will take it as a bad
rating.” Just remember that you want a “negative” rating, you want the client
to be comfortable enough to tell you if something is wrong. So don’t be the
therapist depicted in Figure 2.4!
Good initial alliances that stay good portend a positive outcome, but
those that start off lower and improve over time are an even more robust

64       on becoming a better therapist

Figure 2.4.  How not to administer the Session Rating Scale. From “When I’m Good,
I’m Very Good, But When I’m Bad I’m Better: A New Mantra for Psychotherapists,”
by B. Duncan and S. D. Miller, 2008, Psychotherapy in Australia, Nov., p. 65. Cartoon
by John Wright. Copyright by John Wright. Reprinted with permission of John Wright.

predictor (Anker et al., 2010). The SRS provides a structure to system-

atically address the alliance, gives you a chance to fix any problems, and
demonstrates that you do more than give lip service to forming good rela-
tionships. Your appreciation of any negative feedback is a powerful alliance
builder.
Thanking and inviting: 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,
because letting me know would be the biggest favor you could do
for me.
Here is how it went with Connie:
Looks like we were on the right track.
Barry:
Connie: This helped me a lot today. This is just what I needed.

becoming a better therapist with pcoms      65

 Was there anything in particular that I should make sure I do
Barry:
next time that you liked about today.
Connie: I liked your guiding questions and the way you led the session.
Barry: Thanks, that’s very helpful.
So the idea here is simply to say thanks and continue to invite any feed-
back to improve the service. Getting at what the client liked about the session
can also be useful. Anything that helps a conversation about the alliance is
good. For example, Connie said that she liked my guiding questions. She was
very anxious at the beginning of the session and was having trouble getting
started. When silence is not helping the client reflect but instead creating more
tension, I tend to structure things more until things relax a bit. And that’s what
I did with Connie, and she liked it. As you gain experience with using the SRS,
you will figure out more ways to make conversations about the alliance in a way
that increases client engagement and partnership in the process.
How about when it falls below 36 or any individual scale is below 9? The
only difference in your response is that you thank and explore, instead of thank
and invite. Don’t be expecting specific feedback or grand revelations, although
they do happen from time to time. Usually the feedback is vague and general.
Remember, it is hard, for nearly all of us, to give interpersonal feedback, espe-
cially critical feedback; any feedback, though, is communicating something.
Just try to get at what it is. “Is there anything else I could have done differently,
something I should have done more of or less of, some question or topic I should
have asked but didn’t?” Another useful question is, “Do you have any advice for
me for next time, anything that would make it a little better?”
Thanking and exploring: 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 honesty 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?
Sometimes clients say that not enough time has passed for them to
know or that the score is the best they can give, and offer no explanation.
Consider Harold. I thought the session went pretty well, and after administer-
ing the SRS I saw that two of the scales were below 9 cm and that the total
score was 33.6.
Barry: Thanks for doing that, Harold. Looks like it could have gone
better for you today. That’s why this thing is great. It allows us
to talk about stuff that sometimes is hard to talk about. I really
appreciate you letting me know things could be better, because
that allows me the chance to do better. What could I have
done differently?

66       on becoming a better therapist

 Harold: Well, it wasn’t really bad or anything. Might just take some time.
Barry: Okay, great. Was there something else I should have asked or
another topic I missed?
Harold: No, it’s just that I think it will take a while for me to trust that
this is going to do any good. I don’t know much about this
therapy stuff. I pretty much have just been seeing the psychia-
trist and taking the medications.
Barry: Okay, that makes sense. So the marks on the “approach” and
“something missing” aspects were a bit lower than the others.
So, part of this is a time thing—so, if we are on the right track,
your scores will likely go up?
Harold: Yes, I think so. After we talk a bit more about what I can do
about my damn ruminations.
Barry: Gotcha. That makes perfect sense. When we get rolling more
on some specific strategies, like you said you were looking for,
that should increase your trust in this process?
Harold: Yes, I think so.
Barry: So we’ll get on that next time for sure and we’ll keep an eye on
things to make sure your trust is building.
Harold: Sounds good.
When time seems to be an issue, set the expectation that the SRS score
will increase as time goes on, as you are able to address anything specific the
client has noted. It doesn’t go this way all the time. Sometimes you just get
a shrug or “I don’t know.” No worries. If you have a hunch about what may
have led to the lower rating, now is the time to mention it and check it out
with the client. Just keep the lines of communication open and continue to
invite. I have had clients who say that nobody’s perfect and that’s the best
I can do. Or they will rate me low but never let me know why, or rate me
high all the way through. It’s all okay. Continue to leave space for feedback,
continue to want it, and many clients will take advantage of it. Even if they
don’t, your attention to the alliance will help secure a strong one. Clients
appreciate our efforts here, especially when we do our best to accommodate
their feedback. This is one of the rare areas in life where we even get points
for trying.

Bottom Line: Talking about the relationship is hard; building a culture of

feedback takes a concerted effort. Don’t expect too much, but recognize that
your authentic attention to the alliance via the SRS builds a strong partnership
that will keep the client engaged through therapy’s ups and downs.

becoming a better therapist with pcoms      67

 CONCLUSION

Improving personal and organizational performance without constant

feedback is like trying to pin the tail on the donkey when we’re blind-
folded. Only through knowing where we are, can we change where we
are going.
—Jim Clemmer, Don’t Wait to See the Blood

This chapter detailed what it takes to start becoming a better therapist,

the practice of PCOMS. First, there is the simple process of introducing,
administering, and scoring the ORS and SRS, which involves (a) building
a culture of feedback, (b) understanding that there is no bad news on the
measures and viewing feedback as a gift that can only improve outcomes,
(c) fitting the introduction into your own language and style, ensuring that
clients understand that the ORS is designed to keep their perspective front
and center and will be collaboratively used to monitor their benefit, and
(d) scoring the measures. Second, there is the more clinically nuanced aspect
of integrating the ORS and SRS into practice: (a) discussing the client’s score
in relation to the clinical cutoff and allowing the client to make sense of it,
(b) connecting the client’s described experience of the reason for service to
his or her marks on the different scales, (c) ensuring that the client’s rating
represents his or her described experience (i.e., that you have a good rating
on the ORS), and (d) discussing the client’s score on the SRS, thanking him
or her for the feedback and either inviting the sharing of any future concerns
or exploring any concerns that were noted.
With the feedback culture established and the first session under your belt,
the business of evidence-based practice, one client at a time begins, with the cli-
ent’s view of progress and the alliance really influencing what happens and mak-
ing you a better therapist in the process. This is our topic for the next chapter.

CLIENTS ARE THE BEST TEACHERS: THEIR STORIES

DOCUMENT OUR DEVELOPMENT

A good action is never lost; it is a treasure laid up and guarded for the
doer’s need.
—Edwin Markham

A gas furnace explosion when Maria was 6 years old killed both her
father and sister. Her mother collapsed emotionally after the accident and
spent most of her days in bed. Maria had essentially grown up without a
parent and, partly as a result of that, had been repeatedly sexually abused
by an uncle.

68       on becoming a better therapist

 By the time I saw her, Maria was 35 and had been in therapy for most
of her adult life. She held a highly responsible but unsatisfying job in a
biotechnology company. Maria had tried to kill herself five times, leading
to five psychiatric stays. She called her latest therapist eight or nine times
a day, leaving agonized messages with the answering service, demanding
to be called back. The literature on “borderlines” frequently admonishes
therapists not to respond to their “manipulative” attempts to extort atten-
tion, and not to reward their “infantile neediness.” So Maria’s demands
were rarely, if ever, met by her therapists, whose failure to respond pro-
voked her into escalating levels of distress and self-harming. She was diag-
nosed borderline and was on Prozac when her discouraged, resentful, and
burned-out therapist referred her, with a sense of relief, to me and an inves-
tigation I was involved in called the “impossible case project” (Duncan,
Hubble, & Miller, 1997).
After consultation with my colleagues, I decided to encourage Maria’s
calls and nurture rather than limit our relationship. I worked hard to court
Maria’s favor during our first three sessions, and it wasn’t easy. She sat in
my office tight-lipped, twisting a handkerchief in her hands. She told me
from the first session that she wanted her phone calls returned, because she
only called when she was in really bad shape.
I returned her calls when I had spare time during the workday and again
in the evenings after my last client, talking each time for about 15 minutes.
Perhaps because I reliably called her back, she rarely called more than once
or twice a day. Once, when in distress, she left a message for me after hours
without leaving her number. When the service called me, I went back to my
office to get her number and called her. In our sessions, she seemed to get
softer and softer.
Then, after our sixth session, I went on a backpacking trip with my
son, Jesse, entrusting my colleagues to cover for me. After setting up camp
the first night, I felt inexplicably worried about Maria. This was before cell
phones. So I hiked 4 miles back to my truck in the darkness and drove to
a pay phone in a nearby town to see how she was getting along. She was
okay.
That call proved to be a turning point. Afterward, Maria became pro­
active in therapy and outside it. She started going to church, got involved
in a singles group, and signed up for additional technical training that
would allow her to change jobs. Her thoughts of suicide stopped and she
discontinued the antidepressant. In sessions, we talked less about how
lousy she felt and more about how she could change her life. Over the
next 6 months, she left her unrewarding job, where everyone knew her
as a psychiatric casualty, and joined a medical missionary project in Asia.

becoming a better therapist with pcoms      69

 Six months later, she wrote to let me know that things were going pretty
well for her in northern Thailand.
I picture myself in your office, just telling you stuff and you listening.
Every time I called you, you called me back. It didn’t always help, but
you were there. And I realized that is just what a little girl would want
from her daddy, what I had been missing all my life and wanting so
badly. Finally, when I was 35 years old, someone gave it to me. I sure
am glad I got to know what it feels like to have someone care about
me in that way. It was a beautiful gift you gave me. You also made me
realize how much God loves me. When you called me that weekend
you went backpacking, I thought to myself, ‘If a human can do that
for me, then I believe what the Bible says about us all the time.’ So
thanks for loving me—because that’s what you did.
Maria taught me to honor the client’s view of the alliance—she knew
that she needed a certain sort of contact to heal, and I gave it to her. That
was not all I did, but it was the affectionate container for our conversations
that included discussions of what she wanted to change and how she could
make it happen. Maria also taught me the power to be found in simple acts
of human caring. Of course, I had no idea of the connection of my actions
to her desires for a loving father in her life. Within the limits of what I can
ethically and personally manage, I have learned to provide as much human
caring as possible.

70       on becoming a better therapist

 3
HOW BEING BAD CAN
MAKE YOU BETTER

However beautiful the strategy, you should occasionally look at the

results.
—Sir Winston Churchill

Don’t tell anyone, but therapists are not successful with all their clients.
You say this isn’t front-page news. Then why don’t we say out loud that, for
most of us, about 50% of our clients don’t benefit? Why isn’t there a more
systematic recognition of this fact? Clients don’t get better, so the story goes,
because they are resistant, too sick, traumatized, or whatever else the latest
explanations are for a lack of change. Or (another perennial excuse), the
therapist is not masterful enough, lacks experience, or hasn’t learned the
latest and greatest. Shoot the client, or shoot the therapist. Take your pick. I
pick neither. Instead, I choose to follow the wisdom of that sage psychothera-
pist, Mae West, who said, “When I’m good, I’m very good; but when I’m bad,
I’m better.” Didn’t you know that Mae West was a psychotherapist?
Mae West’s famous quip, at first pass, hardly seems like words for thera-
pists to live by but, as it turns out, they are. By identifying clients who are not
responding to your usual fare, when, in other words, outcome is bad, you have
the chance to make it better in two ways: First, by changing something about

http://dx.doi.org/10.1037/14392-003
On Becoming a Better Therapist, Second Edition: Evidence-Based Practice One Client at a Time, by B. L. Duncan
Copyright © 2014 by the American Psychological Association. All rights reserved.

71
the therapy that turns things around and, second, if things don’t turn around,
by moving clients to different providers or venues of service that better suit
the possibility for change. Being bad, or when clients are not progressing,
offers you the opportunity to do your very best work, to be even better with
both that client and with everyone who follows.
This chapter details the use of the Partners for Change Outcome
Management System (PCOMS) in the second session and beyond, both when
there is change and when there isn’t. Becoming a better therapist requires you
to identify clients who are not benefiting, keeping them engaged while you
collaboratively brainstorm what can be done differently, and then, if the lack
of change persists despite your best efforts, releasing them to other options.

TRACKING OUTCOMES WITH PCOMS

Advice is judged by results, not by intentions.

—Marcus Tullius Cicero

At the second and subsequent sessions, PCOMS provides the evidence

upon which you base your practice. You and the client monitor the amount
and rate of change on the Outcome Rating Scale (ORS) that has occurred
since the prior visit as well as since intake. The longer therapy continues
without measurable change, the greater the likelihood of dropout and/or
poor outcome. In short, the scores are used to engage the client in a discus-
sion about progress, and more importantly, what should be done differently
if there isn’t any.
There are only two possibilities: Either the client is improving or not;
the ORS score is increasing or it’s not. A way to understand the amount of
change that are you are hoping for is via a statistical metric known as the
reliable change index (RCI). The RCI indicates change that is greater than
chance, error, or maturation of the client. The RCI on the ORS is 6. The
RCI is just a benchmark that provides an easy way to know if you are on
the right track. Change that both exceeds the RCI and crosses the clinical
cutoff (25 on the ORS) is considered clinically significant (Jacobson & Truax,
1991). Reliable change is sometimes called improved, and clinically signifi-
cant change is at times referred to as recovered.
There are a few options available to track outcome with your clients.
You can note the client’s intake score in your progress note and compare the
current session ORS with the previous one you have in the client file, or you
can plot the scores on paper-and-pencil graphs or with Excel so you can see
change or lack thereof over time. Another option is the web-based PCOMS
systems, which graph and compare the client’s progress with the expected

72       on becoming a better therapist

Figure 3.1. The ORS/SRS Graph. ORS = Outcome Rating Scale; SRS = Session
Rating Scale. Note: Download a free working copy at https://heartandsoulof
change.com

treatment response (ETR) of clients with the same intake score (the mean
trajectory based on over 400,000 administrations of the ORS). The first two
options are free (Figure 3.1 depicts the graph that is part of the free download
at https://heartandsoulofchange.com); the web-based options are not. They
are described in Chapter 5.
There is definitely a value added to plotting the scores or displaying
the computer-generated graphs. Graphs provide a visual component to the
feedback process that many clients find helpful. In one glance, just as the
client’s initial ORS score tells you how the client is viewing his or her life, a
graph tells the story of the client’s progress in therapy. It offers an additional
way to focus on the client’s benefit and what may need to happen if there
isn’t any. Graphing, as will be discussed in Chapter 4, seems indispensable
when working with a couple or family, helping to manage multiple view-
points about change while offering a method to discuss what the similarities
and differences mean.
Many clients will complete the ORS in the waiting room, and some
will even plot their scores on the graphs and greet you discussing the implica-
tions. Using a scale that is simple to score and interpret invites clients into
the process of monitoring.
Recall the quote from Orlinsky, Rønnestad, and Willutzki (2004) in
Chapter 1 that boils down more than 1,000 studies about the process of

how being bad can make you better      73

psychotherapy into one word: participation. Anything that increases client par-
ticipation is likely to have a beneficial impact on outcome.

When Things Are Changing: When You’re Good, You’re Very Good

When ORS scores increase—in Ms. West’s words, when you’re good—a
crucial step to being very good is to empower the change by helping clients
see any gains as a consequence of their own efforts, perhaps even as a part of
a newly emerging identity. This requires an exploration of clients’ perception
of the relationship between their own efforts and the occurrence of change
(Duncan, Solovey, & Rusk, 1992); it is also helpful to encourage clients to
reflect about the meaning of the change in the context their unfolding life
story. At the least, it is important that clients come to view the change as
resulting from something they did and can repeat in the future.
Even if clients resolutely attribute change to luck, fate, your expertise, or
a medication, they can still be asked to consider in detail: (a) how they took
advantage of what was offered by others, (b) what they did to use the changes
to their benefit, (c) what they will do in the future to ensure their gains remain
in place, and (d) how the changes reflect new chapters in their lives. The
point here is that it is helpful for clients to see that, although other factors
were involved, the change was a result of some inner or outer action that they
precipitated.
Helping clients take credit for steps in the right direction casts them
in their rightful roles as the main characters in their stories of change, the
heroes or heroines of their own life journeys. You shine a spotlight on any
accomplishments and request that the client take a bow for his or her cre-
ativity, courage, and good ideas. Basking in the limelight of success keeps
the positive performances coming. Recall the retiree, Harold,1 from the last
chapter: Harold made rapid improvements and by the fifth session had made
significant gains, scoring a 23.4.
Barry: (holding the graph) Harold, looks like things are definitely look-
ing up. Your score is up 9 points over when you came in—a
reliable change, which simply means that it is greater than
chance and a change that is likely to stand the test of time.
Harold: Things are definitely better.

1The client vignettes illustrating the use of PCOMS are accurate depictions of what is possible with adding

systematic client feedback to clinical practice. All clients, however, will not respond similarly, nor will all
psychotherapies end so cleanly. In addition, some clients will not be interested in the measures or in dis-
cussing them. Moreover, PCOMS is not a panacea for all the complexity inherent to working with people
in distress but rather simply identifies who is and who is not benefiting. The rest is up to you. That said, the
examples are representative of most clients’ responses to PCOMS when it is delivered in a collaborative
way by an authentic therapist trying to be helpful.

74       on becoming a better therapist

 Barry: Why do you think that is?
Harold: Well, a lot of reasons really. For one, I have really cut my load—
I gave up my role as president of the homeowners’ association
and we are looking to sell our house and get into a condo. The
house is a big pain—always something to do or going wrong.
Barry: Sounds like you are making some decisions to really make your
life more manageable.
Harold: Definitely. And I am working hard not to make a mountain out
of a molehill! I’m using the cognitive strategies we discussed
and I really like the “task focusing” when I start to feel panicky
about anything.
Barry: Okay, you have taken action to lighten your load, and you
have developed coping skills that enable you to show the anxi-
ety who’s boss!
Another way to focus on the client’s efforts is to make “before-and-
after” distinctions. The idea is to encourage client reflection and to distin-
guish between the way things were before the change and how things are
now, after the change. This invites clients to explore the significance of their
actions and tell a different story about their lives—one of triumph, enlight-
enment, and tenacity. The change itself is a landmark on the landscape of
the client’s life—something that he or she can always point to as the place in
the journey where a different path was taken. At its best, fleshing out all the
nuances of success creates a newfound identity of wisdom and competence
gained from the school of hard knocks.
Here is how it went with Harold.
Harold: Yeah, I guess I did finally step up here and do something about
the stuff that was getting me down. I didn’t think that ever
in a million years I would have even considered leaving the
homeowners’ association or selling the house.
Barry: You did really step up—that’s a good way to say it. You weren’t
going to take this thing lying down anymore. Sounds like a bit
of a new you has emerged.
Harold: I think so. After all, I am retired and I need to start acting
like it. I worked hard as an engineer for many years, always
a stickler for details, making sure that every i was dotted and
every t crossed—and driving myself nuts when they weren’t.
But I guess that isn’t necessarily the best way to approach
everyday life.
Barry: Okay, I think I am getting this, but can you say a little more
about what is different about you?

how being bad can make you better      75

 Harold: Sure. I was so organized and so concerned about how every-
thing was going to play out that I didn’t spend much time actu-
ally living my life. Now I am doing that. I find myself really
liking a slower pace and being more in the present, like we
talked about.
Barry: Any example come to mind that illustrates the new you?
Harold: I built my daughter a birdhouse over the weekend and what
I would have done is obsessed about doing it so much that I
wouldn’t have noticed myself even doing the work of it. I’d
be so into thinking how the next step should be done that I
wouldn’t have appreciated the fun in doing the current step I
was working on. It sounds kind of clichéd, but I like being in
the moment and the joy that exists there. Not like I am going
all Zen or anything!
This is an exciting and gratifying process to behold—a new client iden-
tity constructed or a new chapter added. When it happens, you can stick a
fork in them—because they’re done. Harold and I continued to empower
the changes and discuss possible setbacks until Harold reached a plateau,
or where his ORS scores stayed at the same level for a couple of sessions.
We discussed spacing out the sessions or ending therapy, and which option
Harold felt more comfortable with. Benefit represented on the ORS never
means that it is time to throw the client out but rather is a catalyst to discuss
stepping down services, spacing them out, or terminating them altogether.
Everything is transparent and negotiable. Harold wanted to space out his
sessions but continue to come to therapy. He said he didn’t feel confident
enough yet to stop. I asked him how long he would need to maintain his
gains before he would feel confident to stop seeing me. Harold thought that
3 months would do it. He was right. We scheduled the next session in
2 weeks, then 3 weeks the next two times, and then scheduled the next ses-
sion 1 month out. Harold terminated at that session, feeling ready to go at it
alone and comfortable to call me if he wanted.
When clients reach a plateau or what may be the maximum benefit they
will derive from therapy, it is time to start planning for continued recovery
outside of therapy. As illustrated with Harold, this could mean just reducing
the frequency of meetings and continuing to monitor the client’s goals. For
others, it could mean referral to self-help groups, peer supports, or other com-
munity resources. Although the overwhelming majority of clients are ready
to move on once their distress has been reduced enough for them to see a
clearing, a few will want to stay on. Consequently, it is also useful to include
a culture of recovery in your work. This simply means conveying the attitude
that there is a beginning and an end to therapy and that recovery is a lifelong
journey that continues outside of therapy.

76       on becoming a better therapist

 If clients are not stepped down after they have reached maximum benefit,
the graph can start to look like a saw with ORS scores rising and falling with
the everyday vicissitudes of life—the ORS becomes an emotional thermometer
and therapy becomes an ongoing commentary on life events. When the ORS
represents life in general instead of connecting the client’s perception of his
or her life to the purpose of the service, problems can ensue. Clients can walk
away feeling less empowered to handle life’s ups and downs, believing them-
selves to be reliant on the therapy. Ongoing service in the absence of continued
benefit can have other negative effects as well—more on that later.
On the flip side, the client may stop therapy before he or she reaches
maximum benefit. In this scenario, the client’s change is steep (according to
the graph) and he or she discontinues before the plateau occurs. Although this
scenario or what is called underutilization is not as big a problem as overutilization
(continuing without benefit or after maximum benefit has been achieved), it is
cause for conversation with the client. Many clients are ready to bolt once they
experience some relief from the problem. This is fine and perfectly understand-
able. However, they can experience more change if they hang out for a little
while longer, for one or two more sessions. In our Norway Feedback Trial, we
found that the most effective therapists had a few more sessions, about one to
two more than less effective therapists on average. Other research also supports
that clients tend to benefit by additional sessions (e.g., Howard, Kopta, Krause,
& Orlinsky, 1986). So it makes sense to say something like this after you have
empowered the change and attributed it to the client’s efforts:
Great. So glad things are moving in the right direction. A lot of people
are ready to pull up stakes and move on once they have made some gains,
and that is perfectly okay. But it also may make some sense to come back
a time or two just to further consolidate the gains and form a plan for the
future. Your call, totally. What do you think?

Bottom Line: The ORS is at its best when the client sees it as a reflection of his or
her life viewed through the lens of what psychotherapy can offer. When things are
better, you can capitalize on the noted change by empowering the client to take
ownership of the change and his or her contribution to it, sometimes culminating
in a newfound identity of mastery over the presenting concerns. When scores
plateau, it doesn’t mean catapulting the client out of therapy; rather, it’s time to
discuss stepping down services or termination.

When Things Are Not Changing—Checkpoint Conversations

(When You’re Bad, You’re Better)

A more important discussion occurs when ORS scores are not increas-
ing. The ORS gives clients a voice in all decisions that affect their care,
including whether continuing in therapy with the current provider is in their

how being bad can make you better      77

best interest. ORS scores are never an indication of therapist ineffectiveness,
absolute or otherwise, but rather an expression of the benefit the client is
reporting from the services provided—for this pairing of client and therapist.
When the ORS is not demonstrating change, it allows both interested parties
to reflect about the implications of continuing a process that is yielding little
or no benefit. The intent is to support practices that are working and chal-
lenge those that don’t appear to be helpful. The conversation with clients
who are not benefiting begins with talking about whether something differ-
ent should be done to identifying what can be done differently, and progresses
to doing something different, and ultimately to referral if change does not
happen.
Okay, so things haven’t changed since the last time we talked. How do
you make sense of that? Should we be doing something different here, or
should we continue on course steady as we go? If we are going to stay on
the same course, how long should we go before getting worried? When
will we know when to say “when”?
Later sessions gain increasing significance and warrant additional
action—what we have called checkpoint conversations and last-chance discus-
sions (Duncan & Sparks, 2002). In a typical outpatient setting, checkpoint
conversations are usually conducted between the third and sixth meetings,
and last-chance discussions are initiated between the sixth and ninth ses-
sions. This simply means that by the third to sixth encounter most clients
who benefit from services usually show it on the ORS, and if change is not
noted by then, the client is at a risk for a negative outcome. Ditto for the
sixth to ninth session, except that, then, everything just mentioned has an
exclamation mark. Different settings—such as inpatient or residential, case
management, and other services that tend to be longer-term—will have dif-
ferent checkpoint and last-chance numbers.
Determining these highlighted points of conversation requires only
that you collect data. The calculations are simple, and directions follow later
in the chapter. Establishing these two points helps evaluate whether a client
needs a referral or other changes based on a typical successful client in your
specific setting. The same thing can be accomplished much more precisely
by the web-based systems that calculate the expected treatment response or
trajectory of change based on the database of ORS administrations. It is safe
to say, however, that the three-to-six- and six-to-nine-session benchmarks
are pretty accurate for most outpatient psychotherapy settings because, even
if clients are in therapy for longer periods of time, they have likely begun to
change by these benchmarks (e.g., see Baldwin, Berkeljon, Atkins, Olsen,
and Nielsen, 2009). Keep in mind that the two identified points of action are
a call for conversation and not for rote referral, termination, or anything else.

78       on becoming a better therapist

 If change has not occurred by the checkpoint conversation or, in other
words, “when you’re bad,” this is your opportunity to be even better. The
first-line approach is to focus on the alliance. Simply go through the Session
Rating Scale (SRS) item by item. Alliance problems are a significant con-
tributor to a lack of progress. Sometimes it is useful to say something like,
“It doesn’t seem like we are getting anywhere. Let me go over the items
on this SRS to make sure you are getting exactly what you are looking
for from me and our time together.” Going through the SRS and eliciting
client responses in detail can help you and the client get a better sense of
what may not be working.
A common alliance problem emerges when the clients’ goals don’t fit
with our sense of what they need. This may be especially true if clients come
to us with certain emotionally charged diagnoses or presenting problems.
Consider 23-year-old Carly, who was about to be evicted from her apartment
and hospitalized—her landlord was threatening to call the police because of
health violations that would likely result in a hospital admission.
Carly was referred to me at this time of crisis, and I was in full-press
hospitalization-prevention mode. Her mom, Angie, a nurse, called me and
gave me the rundown of her diagnosis (schizophrenia) and all the gory details
about her last hospitalization being precipitated by a refusal to take medica-
tion and an emergency admission after drinking bleach. Angie was clear in
her perspective that my job was to convince Carly to take her medication.
With that hanging over my head, and with my own missionary zeal to keep
Carly out of the hospital, we met for the first session.
Carly conceded that her apartment was a health hazard and her land-
lord could call the police at any moment and that her mom was freaked out
about her medication, but she didn’t much want to talk about any of that.
Nor did she want to talk about the voices she heard. Instead, she expressed
a desire to go to school. I admit, as much as I know about the importance
of the alliance and working on client goals, I was quietly dismissive of this
desire. After all, it seemed that the pending eviction and hospitalization were
far more pressing. So therapy with Carly floundered. After starting out quite
engaged, she settled into a more passive stance and answered questions as
briefly as possible. Carly was at risk for dropout or a negative outcome—
perhaps the hospitalization that I was desperate to prevent.
Although she usually reported that everything was going swimmingly, at
the third session, a discrepancy began to emerge on the goals scale of the SRS.
Although she gave a 9 or above on the rest of the scales, she only gave a 7.6 to
the goals scale. During the checkpoint conversation, at the end of the fourth
session, I reviewed her responses on the SRS in hopes of addressing problems
that have been missed or gone unacknowledged. When I queried about her
rating of the goals, Carly repeated her desire to go to school in nearly a whisper.

how being bad can make you better      79

 I looked at the SRS and off came the blinders! When I finally asked
Carly about her goal, she related a story about always wanting to be a chem-
ist. She sparkled when she spoke of her first chemistry set she received for
Christmas when she was 10 years old. Carly excelled in school in the sciences
and often won the yearly science fair awards. Noticing that it was the most
I’d ever heard her talk, I began asking Carly more about her love of chemis-
try and what she wanted to do with it. I also put the brakes on efforts to get
her to clean her apartment. I did ask the landlord for some more time after I
obtained Carly’s permission to do so.
I turned my attention to what I should have done from the get-go—what
it would take to get Carly in school. We explored several local options, as well
as online possibilities. In the context of these discussions, Carly brought up
her meds, which led to an exploration of her propensity to cut them off cold
turkey and how counterproductive that was. I offered to work with her and
the prescribing doctor to wean her off one medication at a time, which she
accepted. Carly started an online course.
Carly’s SRS score improved on the goal scale and her ORS score increased
dramatically. After a while, she started attending a community college and,
ultimately, after I stopped seeing her, she finished her degree at a nearby uni-
versity. She cleaned her apartment as well, in anticipation of a classmate’s
visit for work on a class project. It wasn’t all smooth sailing; there were a few
storms to weather, and I saw her periodically over a long period of time. But
her involvement with school successfully resolved many of the concerns her
landlord and mom had. And addressing her desire to reduce her medications
increased her adherence to the one she continued to take. Walking the path
cut by client goals often reveals alternative routes to improvement that would
have never been discovered otherwise. And your appreciation for and flexible
accommodation of any negative feedback are powerful alliance builders—
they really made the difference for Carly and me.
Back to the ORS: A lack of progress at this stage may simply indicate
that you need to try something different2—nothing specific may come of your
conversation with the client about the alliance. Don’t worry about that. Just
making the effort to discuss the alliance can yield dividends. Doing some-
thing different can take as many forms as there are clients: inviting others
from the client’s support system, using a team or another professional, a dif-
ferent conceptualization of the problem or another psychotherapy approach,

2Doing something different when current solutions are not working is a very simple but elegant idea
from the interactional approach of the Mental Research Institute (MRI; Watzlawick, Weakland, &
Fisch, 1974). The MRI posited that problems arise from the continual application of ineffective solu-
tions. A client who is not responding to a clinician’s usual solutions identified by PCOMS allows the
application of this simple idea to therapy. Identifying clients at risk and then doing something different,
exemplifying the notion of “if at first you don’t succeed, try something else.”

80       on becoming a better therapist

or referring to another therapist, religious advisor, peer services, or self-help
group—whatever seems to be of value to the client. Here the main goal is
to identify and discuss what the options may be. Of course, if any option in
particular really resonates with the client, that strategy or idea is then imple-
mented, and progress is monitored via the ORS.
Consider Matt, a 20-something software wizard, who because of a recent
promotion was frequently on the road troubleshooting customer problems.
He loved his job. Even so, traveling had become an ordeal. Matt had a per-
sonal problem that made flying unpleasant—an inability to urinate in public
restrooms, especially on planes. At the outset, it caused only mild discom-
fort and was solved by monitoring his fluid intake and repeated visits to his
bathroom before leaving home. In time, though, the problem began to cause
intense apprehension before each trip, excruciating feelings of pressure in his
bladder while on the plane, and sometimes hair-raising panic attacks. One
time his inability to “go” on a long trip to the West Coast resulted in a reten-
tion episode and a trip to the ER for a catheter—a demeaning and demoral-
izing experience that only increased the episodes of panic in anticipation of
travel. Hopeless and demoralized, the young man considered changing jobs.
As a last resort, he decided to seek psychotherapy.
Matt and I seemed to hit it off, and the SRS confirmed that we had a
good start. He was particularly glad that he could finally talk about his diffi-
culty, an embarrassing problem that often has other connotations about one’s
masculinity. Matt didn’t have any particular ideas, definitely communicated
some urgency for resolution, and looked to me for guidance, so I suggested
some possibilities. In short order, he was helped to implement relaxation and
“self-talk” cognitive–behavioral strategies, which he diligently practiced in
session. As agreed, he employed them preceding his next trip and while on
board the plane. The results were far from encouraging. The problem intensi-
fied and his sense of shame along with it. More alarming, his mood became
decidedly hopeless.
Matt was at significant risk for a negative outcome: either dropping
out or persisting in therapy without benefit. At the third session, when the
ORS reflected no change, I went over the SRS and we settled on the item
“The therapist’s approach is a good fit for me.” Matt hesitated, so I asked him,
“Matt, in your heart of hearts, do you think the strategies we are using to
address this situation are going to make a difference for you?” He quietly said
no. It motivated us to brainstorm a range of possibilities for the remainder of
the session. During this exchange, Matt expressed in no uncertain terms how
much his problem was interfering with his work. The possibility that he’d
have to endure any extended separation from his own bathroom had become
almost unthinkable. He became quite animated, even angry, in conspicuous
contrast to the passive resignation that had characterized previous sessions.

how being bad can make you better      81

When one of us said the words “pissed off,” we both broke into raucous laugh-
ter. A possibility was discovered.
Later in the visit, I suggested that there were a lot of ways to tackle
this problem, that changing how one thinks during the problem is a way,
but another is changing what one feels. I wondered aloud whether instead of
responding with hopelessness when the predicament occurred, Matt could
work himself up into righteous anger about how the problem was sabotag-
ing his life. Matt liked that idea and added, since he was a retro rock-and-
roll buff, that he could also sing Tom Petty’s “Won’t Back Down” during his
tirades at the toilet. From then on, he permitted himself, when standing
before the urinal, to become thoroughly incensed, “pissed off,” and somewhat
amused. His problem soon resolved.
Of course, this kind of collaborative, creative process could have hap-
pened with any therapist working with Matt. The difference is that the use
of the ORS spotlighted the lack of early change. Impossible to dismiss, it
brought the risk of a negative outcome front and center. Without the findings
from the ORS, I would likely have continued with the same strategies for sev-
eral more sessions, hoping that these reasonable methods would eventually
take hold. As it was, the evidence obtained through the measure pushed me,
and Matt, to explore different options.
Finally (and this is especially helpful when things seem to be mired
down at the checkpoint session and your usual approach is not getting results),
it is worth exploring the client’s sensibilities about what needs to happen—
or what I have called the “client’s theory of change” (Duncan et al., 1992;
Duncan & Miller, 2000), an idea that has served me well. Chapter 1 empha-
sized, in the section on model/technique factors, the importance of both the
client’s and therapist’s belief in whatever approach is chosen. An approach
that rings true with the client will likely increase the expectation for change
as well as participation. The client’s theory of change unfolds from a con-
versation structured by your curiosity about the client’s ideas, attitudes, and
speculations about change, starting somewhat like this:
Many times people have a pretty good hunch about not only what is
causing a problem but also what will resolve it. Do you have a theory
of how change is going to happen here? Or perhaps something that has
worked for you in the past? Or even something that you think might be
helpful that you heard about from family, friends, or the media?
Consider Ken, a 35-year-old construction supervisor who was convinced
that he was going crazy because panic attacks were becoming ever more intru-
sive. I thought we connected well, and Ken indicated so on the SRS. Ken
told me that he didn’t have a clue what the panic episodes were about or
what to do about them. The only thing that he was doing that was working

82       on becoming a better therapist

was drinking, and he didn’t see that as a good way to cope. Ken looked to me
for some suggestions, something he could do to manage the anxiety. Trying
to address his request as well as his perspective about my role, I called up my
training in cognitive–behavioral therapy and strategic therapy. We tried a
combination of relaxation training, challenging the beliefs that led to the
panic, and some strategic monitoring (symptom prescription). But nothing
happened, and none of these approaches seemed to resonate with Ken.
So, in the fourth meeting, I went over the SRS but lingered on the
“approach” scale and asked Ken about his ideas about how he could tackle
the panic attacks. Ken said that maybe he could try and understand what
they were about, an idea his wife believed to be important. Ken shared that
in tough times he always talked to his dad, but his dad had passed away some
6 months before. He noted that he felt alone in his struggles, although
he knew that really wasn’t true because his wife was supportive and he had
some good friends. As I’m sure you would have done, I asked him if he believed
there to be a connection between his father’s death, his feeling of aloneness,
and the panic. Ken replied with tears, and a quiet yes.
A different kind of discussion ensued, drawing on my existential
training, of not only Ken’s confrontation of his own mortality but also the
incredible dread that accompanies the realization of our essential aloneness
in the world. A new theory of change evolved, one that seemed to make a
lot of sense within the four big existential givens: death, freedom, isolation,
and meaninglessness. I bounced these ideas off Ken, and it made a differ-
ence. Ken found these conversations useful, his ORS scores increased, and
his panic attacks subsided. This story, of course, says nothing about the
absolute value of cognitive–behavioral therapy, strategic, or existentially
informed therapy—all therapy approaches provide useful ideas to pursue.
Rather, Ken’s therapy illustrates that exploring the client’s ideas about
change, perspectives that resonate with the client, and you, can enable
different, more fruitful directions to emerge. This is an important issue to
your development as a therapist, and I’ll pick it up again in Chapter 5. And,
again, the conversation was stimulated by the open recognition of a lack of
benefit identified by the ORS.

Potholes

Sometimes a client’s scores will drop precipitously. In this case, the first
order of business is getting the client’s explanation of what has happened.
Is the drop related to the reason for therapy—a deterioration in an ongo-
ing issue—or is it the pothole phenomenon, where some recent event is hold-
ing sway over the client’s rating? If it’s a deterioration, then this signals the
necessity to have a heart-to-heart about what needs to happen differently to

how being bad can make you better      83

quickly turn things around. Refer to the prior discussion about the lack of
change, although a drop in the ORS does increase the urgency.
But a pothole effect warrants different action. The pothole metaphor
goes like this: The client hit a pothole on the way to the session and got a flat
tire. It was raining cats and dogs, and the client’s nice clothes were soaked
and soiled. Then the client was in such a hurry that police radar caught him
or her, and so on. You get the idea. The pothole effect is where the events of
the day, rather than how the week has gone related to the reasons for service,
overly influence the client’s response on the ORS. If the client reports it is a
pothole, then ask him or her to redo the ORS looking at the week in general
and related to the reasons for therapy. If the event or events seem to trump
the original reasons for therapy, then, of course, go with it. Just reconnect the
issues at hand to the open spaces on the ORS, as discussed in the previous
chapter. Be cautious about turning everyday life events, the ups and downs of
being a human being, into therapy issues.
For example, I was seeing Keesha, a strong-willed 15-year-old, about
academic problems as well as her rather enthusiastic shouting matches with
her stepmother. Things were going well, and we had already discussed spac-
ing things out. So I was surprised one day to see a very upset Keesha, and
even more so when I totaled her ORS score to a 12.2. When I asked her
what was up, Keesha told a very troubling story of double betrayal. She had
walked out of fifth-period class for a restroom break and discovered her best
friend and boyfriend kissing. After commiserating with Keesha and discuss-
ing what she intended to do, I asked her if that “double whammy” was what
accounted for her low score on the ORS. When she said yes, I asked her to
redo the ORS relative to how it has gone since I saw her last regarding the
two reasons she entered therapy: her grades and her relationship with her
stepmom. So I dealt with the situation but refocused the therapy, and the
ORS, to the task at hand.

When Things Are Not Changing—Last-Chance Discussion

(When You’re Bad, You’re Better)

If you and the client have implemented different possibilities and the
client is still without benefit, it is time for the last-chance discussion. As the
name implies, there is some urgency for something different because most
clients who benefit have already achieved change by this point, and there
is significant risk for a negative conclusion. A metaphor I like is that of the
therapist and client driving into a desert and running on empty, when a sign
appears that says “last chance for gas.” The metaphor depicts the necessity
of stopping and discussing the implications of continuing without the client
achieving the desired change. At the very least, supervision or a cotherapist

84       on becoming a better therapist

should be considered. And that, too, can turn things around. There is no last
chance for the client, just for this particular therapist–client pairing.
Again, this is not a subtle dig at long-term work with clients. A lon-
ger course of sessions spaced out over longer periods of time can make great
clinical sense at times (as it did with Carly). Some clients do take longer, no
doubt. However, continuing to see clients in the absence of benefit is another
story altogether, a matter discussed below.
Here are several questions to reflect about in last-chance circumstances.
The longer the therapy goes without change, the quicker the last option—
failing successfully—should be exercised.
77 What does the client say about the lack of change? Remember
that you are in this thing together.
77 Is the client engaged in purposive work to address the problems
at hand? In other words, what about the alliance and the SRS?
In both the client’s and your heart of hearts, do you think this
therapy with you is going to make a difference?
77 What have you done differently so far? What of the identified
options have you already employed?
77 What can be done differently now? We all have limits. Have
you exhausted your repertoire?
77 What other resources can be rallied, both from your support
system and the client’s? How can you bring in fresh blood—new
ideas and directions?
77 Is it time to fail successfully?
Sherry had pretty much been through the mill when I saw her, in ther-
apy for much of her 31 years. She had been diagnosed borderline and had a
history of trauma and abuse. Sherry thought she had pretty much dealt with
all that and was moving her life forward—she now lived independently and
had started school. Her initial ORS was 22.4, and Sherry was looking to
address her self-described binge eating and obesity. Given that she reported
some success with Overeaters Anonymous (OA) and journaling, drawing
upon solution-focused ideas, I worked with her to expand what was working
while hoping to diminish what wasn’t. Things were worse for her at night,
and that was when the cravings came to call.
Sherry’s initial SRS was only a 31.2. When I explored further, she
explained that I didn’t really know her and it would take time. True to
form, I suggested that the SRS could track that for us, and the score should
go up as I got to know her better. Sherry agreed. But it didn’t go up much.
At the checkpoint conversation, there was no change on the ORS, so I
went over the SRS. But no new information was gleaned. Sherry thought
we should continue with the strategies we were doing—taking what worked

how being bad can make you better      85

for her during the day and employing those methods at night in conjunction
with her OA group. Over the next three sessions, we worked to fine-tune her
strategies. Since being around people and relational support were critical, we
discussed more concrete ways to involve people at night, such as online chats
and e-mail, phone calls and texts, and evening OA meetings.
At the sixth session, however, there was still no change, and the SRS
had improved only to 32.8. It was definitely time for something different. We
discussed the questions listed above and frankly addressed the possibility of a
referral, but Sherry said she wanted to try a consult first. So we did. I arranged
for a consult with one of my colleagues while I watched via a camera feed to
a monitor. Having someone else interview your clients is a wonderful eye-
opening experience, revealing how easy it is to get into conversational ruts
with clients. That’s why “new blood” can be so helpful. It wasn’t 10 minutes
into the session with my colleague that Sherry reported that her eating prob-
lems were likely related to her protecting herself from getting into a relation-
ship, adding parenthetically that she was a lesbian.
I asked Sherry if she wanted me to refer her to my colleague or perhaps a
therapist who specialized in working with gay/lesbian issues. But she declined.
Sherry added that she knew I was gay-friendly from the referral source, but
she hadn’t thought her sexuality was relevant to what we were working on.
The new focus made a difference. We discussed Sherry’s loneliness and its
relationship to her eating problems, and we mapped out a plan to involve
her in situations more apt to yield potential romantic partners. Having these
potential encounters gave her more to look forward to and increased her
involvement in OA and exercise activities. The ORS scores increased over
the cutoff, as did the SRS scores.
As noted with Sherry, the last-chance discussion is the time when a
referral and other available resources should be discussed. If you have cre-
ated a feedback culture from the beginning, then this conversation will not
be a surprise. Rarely is there justification for continuing to work with clients
who have not achieved change in a period typical for the majority of clients
seen by a particular practitioner or setting. But rarely is not never. These
situations are highly idiosyncratic and should be negotiated on an individual
basis. The ORS helps keep us honest and addresses the lack of change trans-
parently. These are conversations that I never had before I started using the
ORS and SRS.
Why should we seriously consider moving the client on at this point?
Recall how much of the variability of outcomes is attributed to the therapist
and the nature and quality of the alliance between the client and the thera-
pist. If we hold people in therapy with us, we could actually be the problem,
because they might be better served with someone else. Although talking
about a lack of progress often allows you to snatch victory from the jaws of

86       on becoming a better therapist

defeat, it is still impossible for all of your clients to benefit. There is, however,
a way that you can be useful even with clients who are not responding at this
point. Where in the past I might have felt like a failure when I wasn’t effec-
tive with a client, I now view such times as opportunities to stop being an
impediment to the client’s change process. When I’m bad, I’m better. Now
the work is successful both when the client achieves change and when, in the
absence of change, I get out of the way.

Failing Successfully: When I’m Bad, I’m Better

As illustrated with Carly, Matt, Ken, and Sherry, it’s often possible to
change course and make the therapy experience far more productive for cli-
ents. But what happens when you have implemented new or different strat-
egies and the therapy is still failing to produce benefit? What if you have
exhausted all you know to do? This can be singularly confusing if the thera-
peutic alliance is strong—after all, referring someone whom you don’t like
or doesn’t like you is likely a relief, but when you genuinely connect with
the person, letting go can be more difficult. It may be hard to believe that
stopping a great relationship is the right thing to do, and I have had my
own doubts about it. In my career, there have been many memorable clients
who taught me invaluable lessons about the work that I love. One of the
greatest lessons I learned, though, did not occur until I had over 24 years of
experience—and it made me a fan of Mae West.
Eighteen-year-old Alina sought help because she felt completely devas-
tated. In her estimation, she’d lost everything she’d worked her whole life to
achieve. After captaining her high school volleyball team, commanding the
first position on the debating team, and being named valedictorian, she’d won
a full scholarship to Yale. She was the pride of her Guatemalan community—
proof of the many benefits that her parents had envisioned would come with
living in the United States.
Her unqualified success unraveled during her first semester away from
home and the insulated environment in which she’d excelled. She began
hearing voices. After a visit to the university counseling center, Alina was
admitted to a psychiatric unit and dosed with antipsychotics. Despondent,
she threw herself down a stairwell, prompting her parents to bring her home.
Alina returned home in utter confusion, still hearing voices, and with her
self-image badly eroded. Besides seeing herself as a failure and major dis-
appointment to her family, she believed she’d let down everyone else in her
tight-knit community.
I was the 20th therapist that the family had called, and the first who
agreed to see Alina without medication, a precondition she imposed. From
the start, it looked as though we hit it off famously. Her investigation on

how being bad can make you better      87

the Internet had revealed my consumer-driven philosophy and my leanings
away from pharmaceutical solutions as first-line interventions, both of which
scored high marks with Alina. For my part, I admired her humility and intel-
ligence. I was especially taken by her spunk in standing up to psychiatric
discourse and asserting her preferences about treatment. I couldn’t wait to
be useful to Alina and get her back on track. When I administered the ORS,
Alina scored a 4, the lowest score I had ever seen.
We discussed at length her experience of demoralization—how the epi-
sodes of hearing voices and confusion robbed her of her dreams, and how her
years of hard work had yielded nothing. I did what I usually found to be help-
ful: I listened, commiserated, validated, and worked hard to mobilize Alina’s
resilience to begin anew.
But nothing happened. By the third session, she remained unchanged
despite my best efforts. The therapy was going nowhere fast—a score of 4 was
a rude reminder of just how badly therapy was progressing. At this checkpoint
session, I went over the SRS with her and, unlike many, Alina was specific
about what was missing and revealed that she wanted me to be more active;
so I was. She wanted ideas about what to do about the voices, so I provided
them—thought stopping, guided imagery, content analysis. But no change
ensued, and she was increasingly at risk for a negative outcome. Alina told
me she had read about hypnosis on the Internet and thought that might
help. I was around in the 1980s, when you couldn’t escape hypnosis training,
so I approached Alina from a couple of different hypnotic angles—offering
both embedded suggestions and stories intended to build her immunity to the
voices. She responded with deep trances and gave high ratings on the SRS.
But—and this is a very big but—the ORS remained a paltry 4.
At the last-chance discussion, we discussed what we had done and what
was left to do. One thing we hadn’t done was to involve her family, which
Alina always had put the kibosh on. I brought it up again because it was all
that seemed left to do; I had definitely exhausted my repertoire. I knew we
needed fresh blood. After Alina again refused family involvement, we dis-
cussed the possibility of a referral but settled instead on a consultation with
a team of therapists (led by Jacqueline Sparks). Generally, I observe consults
with another therapist conducting the session via the monitor, but Alina
wanted me to be in the room. As is often the case when you bring new people
in the mix, the conversation with Jacqueline introduced considerations that
I hadn’t thought of and one seemed especially important because it really
brought Alina to life.
Our sessions had been characterized by long silences and rather cryp-
tic conversations, but when Alina started talking about the sequence of
events after she arrived at Yale, that all changed. Alina told the story of
her first semester and how she realized that she was “a 10-year-old trapped

88       on becoming a better therapist

in an 18-year-old body,” that all the other women were going out with men
and she was this frightened child. She called herself “socially retarded” and
surprisingly expressed anger and frustration with her parents and community
for sheltering her so much. Her reluctance to involve her family finally made
sense. Jacqueline and the team commented on the “family differentiation”
issue, and an agreement was reached that it seemed important to pursue.
After Alina rated the encounter very high on the SRS and the session
ended, I commented on how well the session went and how much more
animated Alina seemed. I asked if it made more sense for her to pick up
on the ideas with Jacqueline. Alina responded, “No way. You and I can go
from here.” Since we had some fresh ideas to pursue, I agreed. And we did
for a couple sessions. No progress, though—her ORS score remained firmly
fixed at a 4.
Now what? We were at the ninth session, well beyond the number of
visits clients typically require for the start of change in my practice. After col-
lecting data for several years (more about that later), I knew that 75% of the
clients who benefited from their work with me would show it by the third ses-
sion. Ninety-eight percent who profited would do so by the sixth. Considering
these results, was it right to continue seeing Alina? Was it ethical?
Despite our mutual admiration society, it wasn’t right to continue. A
good relationship in the absence of benefit is a good definition of depen-
dence. I shared my concern that her dream would be in jeopardy if she con-
tinued seeing me. This session was videorecorded, and if you were to watch
the video, you would be likely struck, as many are, by the decided lack of fun
that both Alina and I had during this discussion. We look like two depressed
peas in a pod—so much so that people sometimes ask if I am intention-
ally mirroring Alina for joining purposes. Not even close: In the video I am
simply bummed out, like Alina, about her lack of change and the ending of
our relationship—breaking up is hard to do. And, frankly, I was nervous. In
fact, watching this video is embarrassing. I said “you know” 17 times in the
snippets that follow (edited out, thank goodness). But I knew I needed to do
it nevertheless. We look like two folks who have just lost their best friend—
there are long silences punctuated by deep sighs.
Barry: Wow, still no real change.
Alina: (shakes head)
(long pause)
Barry: Okay, all right (looking at the graph). Well, now, let’s see, we
need to talk about this because this really concerns me, when
I’m seeing people as long as we’ve been seeing each other and
nothing is really happening as a result of it. So, we need to
discuss what maybe some options are about that. We’ve tried a

how being bad can make you better      89

 lot of different kinds of things and we’ve talked about a lot of
things, and it doesn’t have to say anything bad about either one
of us, either you or me, either one, just that, somehow, it’s not
quite the right fit (sigh).
Alina: (head down, very quiet) Mm hmm.
Barry: Frankly, Alina, I don’t know what to do. You have any thoughts
about that?
Alina: (not looking up) I don’t know if it’s not the right fit, I think it’s
maybe me.
Barry: Well, generally speaking, that’s not the way it goes; it’s more that
either my particular approach or style, although you may like me
and all that and I appreciate that, but that somehow it’s not the
right mix for something good to happen for you.
Alina: (still head hung) Mm hmm.
(long pause)
Barry: One thing that we could do is, you could see someone else, you
could see Jackie or someone else here or outside of here if you’d
like. Or, I’m just throwing this out for us to talk about. You
know, I really like you and I like talking to you, but I also want
to see things improve in your life and I kind of want to be a part
of getting you to where you can have some improvement in your
life, not being an obstacle to that. So that’s one thing, that’s one
reason why I do these things with people; so we’re not getting
anywhere and we need to kind of problem solve that and figure
out what we need to do next about that. Because, and again I
don’t look at it as anything that I’m doing bad or wrong or you’re
doing bad or wrong, I mean that doesn’t even really come into
it. It’s really that, you know, we are forming this partnership to
try to make a difference in your life, right?
Alina: Yeah.
Barry: And although we definitely like each other, we’re not making
much of a difference in your life. So, sometimes, new blood can
help that. So, what do you think of that?
Alina: I don’t know, I guess you’re right.
(long pause)
Barry: (picking up the graph) One of the reasons we do these measures is
that they’re predictive of eventual outcome; so if clients don’t
have some experience of some change fairly early on in the pro-
cess, it’s predictive of no change in the long-term process.

90       on becoming a better therapist

 Alina: Mm hmm.
Barry: So that’s why it concerns me for there not to be any movement.
If you change to someone else, it opens up the whole new win-
dow again. Does that make sense?
Alina: (head still hung) Yeah.
Barry: That’s kind of the idea behind this whole process. Do you think
you want to give it a shot with Jackie? Does that seem a reason-
able thing for you to try?
Alina: Yeah, I could. (looking up) I still don’t mind working with you.
Barry: Well, I like working with you, but we’re just not getting
anywhere.
Alina: Mm hmm. (long pause)
Barry: So would you be willing to give it a shot, to talking to Jackie a
couple of times and see if that can get anything positive going?
Alina: Yeah, okay.
You’re right. I was relentless. But I needed to step aside and allow another
opportunity for Alina with another therapist. By the fourth session with the
new therapist, Alina had an ORS score of 19.3 and enrolled to take a class at
a local university. Moreover, she continued those changes and reenrolled at
Yale the following year with her scholarship intact! When I wrote a required
recommendation letter for the reinstatement of her scholarship, I adminis-
tered the ORS to Alina and she scored a 28.9. By getting out of her way and
allowing her and me to “fail successfully,” Alina was given another oppor-
tunity to get her life back on track—and she did. Alina and Jacqueline, for
unknown reasons, just had the right chemistry for change. Alina ultimately
graduated from Yale.
This client turned out to be a watershed for me. I believed in heed-
ing the results of the measures, especially how it placed clients at center
stage and pushed me to do something different when clients didn’t benefit.
Nevertheless, I struggled with letting go of those clients who didn’t ben-
efit, in whose lives I had become personally invested. Alina awakened me
to the perils of such situations and showed a true value-added dimension to
PCOMS—namely, the ability to fail successfully. As many therapists encoun-
ter over their careers, for me this young woman represented a client whom
I was tempted to see for as long as she wanted. I cared deeply about her and
believed that, in time, I’d surely find a way to help her.
But such is the thinking that leads to “chronic clients.” Therapists—
no matter how competent, trained, or experienced—can’t be effective with
everyone they meet. PCOMS makes it easier to determine when clients aren’t

how being bad can make you better      91

improving and arrive at more objective decisions about what to do about it.
Although some clients want to continue in the absence of change, far more
do not, when offered a graceful way to exit.
When I have reached this point with clients, I reiterate my commitment
to help them achieve the outcome they desire, whether with me or someone
else, or on their own. I stress that this encounter says nothing about them per-
sonally or their potential for change. If the client chooses, I continue to meet
with her or him in a supportive fashion until other arrangements are made,
or even remain involved as a consultant. But rarely do I continue to work
with clients whose scores on the ORS show little or no improvement by the
sixth or seventh visit, unless we have charted a definitively different course.
Sometimes the folklore of clinical practice, just as the idea that ripping
off bandages rapidly is the best approach, includes the notion that clients
need only maintenance or sustenance work, or that a positive relationship is
enough to provide for a client in tough circumstances. I probably could have
justified this stance with Alina. While these ideas may make sense at times,
we are not, generally speaking, doing clients any favors by thinking that our
services are what is holding them together—what I call “finger in the dike”
services. Instead of holding them together, we could very well be holding
them up, perhaps keeping them from recovery by miring them in services that
are not promoting growth. The idea that the client is damaged goods and will
not follow a recovery path—that they need us to survive—is surely implicit
in the concept of maintenance work.
Therapy, then, can become a place for clients to hang out and talk,
receive support, and combat loneliness. Therapy can do these things at times,
but it should also create the possibility for clients to attain these benefits
in the community—not from a professional. Without an aspiration toward
helping clients achieve more independence in the community, therapy can
be a disservice to clients—creating dependency and fostering a client identity
of helplessness and pathology. Of course, I don’t mean that keeping clients
who are not benefiting is always harmful but, rather, that each situation needs
to be transparently negotiated. And we must at least challenge ourselves to
consider the implications.
The thing to guard against here is the tendency to explain client non-
response to services through theoretical filters and clinical folklore. Doing
that puts us right back where we started, where the field has traditionally
been: attributing the lack of change to the client. On the contrary, client
nonresponse simply means something else should be done.
The client is final arbiter of what the ORS scores mean, but we must at
least ask the hard question: Are we helping or hindering? The scores are cata-
lysts for conversations with clients of a kind that had rarely happened before,
at least for me. PCOMS is a way to support what is working and challenge

92       on becoming a better therapist

what is not, providing more than just another theory to guide practice, as well
as the antidote to the often poisonous pontifications about why clients are
not responding to therapy, at which many members of our profession have
become so adept.

CALCULATING YOUR CHECKPOINT

AND LAST-CHANCE SESSIONS

Realists do not fear the results of their study.

—Fyodor Dostoyevsky

Not all settings or therapists are alike. Your checkpoint and last-chance
sessions may be different, so it makes sense to gather your own data. A rela-
tively simple method for tracking change based on the work of Ken Howard
(Howard, Moras, Brill, Martinovich, & Lutz, 1996) enables you to determine
the probability of success for a specific client by a given session at a particular
time. The steps are:
1. Collect ORS data on all clients for at least 6 months.
2. Separate the successful from the unsuccessful outcomes, not-
ing the session at which each met or exceeded 6 points. An
alternative that also incorporates clients who take longer to
achieve reliable change is to note the session at which clients
who achieve reliable change begin the change.
3. Chart the results on a graph with the number of sessions
increasing along the bottom (x-axis) and the percent of suc-
cessful clients along the side (y-axis).
An inspection of my practice depicted in Figure 3.2 shows that the major-
ity of successful clients changed by the third session, and the overwhelming
majority achieved a reliable change by the sixth meeting. So for clients in
my practice, the checkpoint conversation should likely occur in the third
session and the last-chance discussion by the sixth meeting. All of the cli-
ents who achieved a reliable change had done so by the seventh session. The
advantage to this calculation method is it allows you to quickly determine
if progress is happening in a manner typical for successful outcomes without
having to make any statistical calculations.
Those calculations are more than sufficient for generating a dialogue
with clients about the value of therapy. However, if you are looking for some-
thing a bit more precise, or you want to calculate the expected treatment
response by intake score, the method described doesn’t cut it. A significant
limitation is the reliance on the RCI to separate successful and unsuccessful

how being bad can make you better      93

 100
90
80
70
60

Clients
50
40
30
20
10
0
1 2 3 4 5 6 7
Session

Figure 3.2.  Change curve of successful clients in my practice.

cases. The problem is that the RCI is an average, arrived at by aggregating

clients of varying levels of severity. As a result, it is likely to underestimate the
amount of change necessary to be considered reliable for some (those in the
severe range), while overestimating the amount for others (those in the mild
range or over the cutoff). A more precise method, discussed in Chapter 2,
is to predict the score over the course of services (the expected treatment
response) based on the score at intake.

CONCLUSION

There is peace in the garden. Peace and results.

—Ruth Stout, The Ruth Stout No-Work Garden Book

This chapter charted the ins and outs of tailoring psychotherapy based
on PCOMS: (a) plotting the ORS scores on a graph, (b) comparing the cur-
rent ORS score with the last and since intake, and (c) looking at the progres-
sion of change or lack thereof. In this case, there are only two options: Either
there is change, or there isn’t. If there is change, work with clients to take
responsibility for the change and empower their ability to continue prog-
ress. Facilitate discussions to tease out before-and-after distinctions. Begin
to space out sessions and discuss termination when the client reaches a pla-
teau. If there is no change, discuss what needs to happen next. If no change
persists, the discussions increase in urgency, represented by the checkpoint
conversation and the last-chance discussion, both intended to brainstorm
options and entertain the possibility of referring the client elsewhere. If no
change still persists, it is time to fail successfully, or gracefully move the client
on to another provider or venue of service and exercise your ability to help
clients in a different but equally important way.

94       on becoming a better therapist

 The basic principle is straightforward: Our daily clinical actions can be
informed by reliable, valid feedback about the factors that drive change in
therapy. These factors include our clients’ engagement, their view of the ther-
apeutic alliance, and—the gold standard—the client’s report of real progress.
Truly, monitoring the outcome and the fit of our services helps us know that
when we’re good, we’re very good, but when we’re bad, we can be even better.

CLIENTS ARE THE BEST TEACHERS: THEIR STORIES

DOCUMENT OUR DEVELOPMENT

It is easier to discover a deficiency in individuals, in states, and in

Providence, than to see their real import and value.
—G. W. F. Hegel

Molly was part of a project that I mentioned in the last chapter, in

which my colleagues and I studied clients who were “multiple treatment
failures” and which resulted in the book Psychotherapy With “Impossible”
Cases (Duncan, Hubble, & Miller, 1997). We learned that success could
occur in the most difficult circumstances when the person’s own ideas were
recruited and implemented. We also discovered, predictably, that alliance
problems accounted for most of the treatment “failures” that found their
way to our investigation. Molly is my favorite story from that project. I
was so impressed with her that ever since I have used her to teach thou-
sands of therapists, via video in my trainings, the value of recruiting client
strengths and ideas, and especially the central importance of the alliance.
Molly’s parents were divorced after a contentious separation.
Nine-year-old Molly was sleeping in her mom’s (Kim’s) bed and having
trouble adjusting to a new apartment, school, and friends. At a mental
health clinic, Molly was identified as coming from a “dysfunctional fam-
ily.” Diagnosed as having separation anxiety disorder, she was referred for
weekly social skills group therapy. After a few weeks, Kim reported that
Molly was also experiencing nightmares. The group therapist responded by
also seeing Molly individually. The therapist encouraged Molly to remove
herself from her parent’s problems. He invited Molly’s dad into therapy,
but he never showed. After 6 months of concurrent group and individual
treatment, things were worse: Molly was having more frequent nightmares
and was beginning to struggle at school. Kim requested a different thera-
pist, a female this time.
The new therapist suspected sexual abuse and played games with
Molly looking for sexual themes, to no avail. Three more months passed
and things continued to get worse—Molly’s grades took a nosedive. Kim

how being bad can make you better      95

 next requested a therapist outside the clinic. Instead, a psychiatric evalu-
ation ensued that reconfirmed the diagnosis of separation anxiety disorder
(and added that Kim had borderline tendencies, a diagnosis often reserved
for those who complain about services). An antidepressant was prescribed
to relieve Molly’s separation anxiety. More time passed and no change
occurred. Molly, in twice-weekly treatment for nearly a year and now on
medication, had become, at the age of 10, an “impossible” case.
The main goal of the “Impossible Case” project was to investigate
how impossibility developed—how clients came to suffer the so-called
bloated file syndrome (staying in therapy for extended periods of time
without benefit). The project deconstructed all the ways that impossibil-
ity had run its course with Molly: First, what I call the Killer Ds (dys-
functional family and separation anxiety disorder) were in full force—her
therapists understood her behavior through those perceptual filters and
ultimately discounted Molly and her strengths. Second, the therapists fol-
lowed their own ideas about change, rather than asking for Molly’s, despite
the lack of positive treatment response. Molly’s first therapist, following
a family therapy tradition, believed that Molly had been “triangulated,”
and the second, without any evidence to suggest that Molly was a victim
of sexual abuse, set a course to explore for it. Finally, the crucial container
for any change process, the alliance, was given short shrift. Molly was not
an active participant; she was not a partner in her own change endeavor.
Kim, dedicated to her daughter’s welfare, discontinued the medication
and demanded an outside referral. That brought Molly to our project. In my
first meeting with Molly, I asked her what she believed would be helpful for
resolving the “nightmares and sleeping in her own room” problem. To this,
Molly expressed astonishment that someone finally wanted her opinion. She
then suggested she could barricade herself in her bed with pillows and stuffed
animals. The barricade would “ward off” the nightmares and her fears. In
the second session, she reported that her plan was working. The excerpts
below reflect Molly’s observations about what was not helpful in her treat-
ment experiences.
Molly: So what I’m saying to all therapists is we have the answers, we
just need someone to help us bring them to the front of our
head. . . . It’s like they’re locked in an attic or something, like
somebody locked them in a closet and nailed them down . . . 
Barry: So the things the therapists told you to do didn’t help?
Molly: It didn’t help. I didn’t want to do them. They weren’t my
ideas, and they didn’t seem right.
***

96       on becoming a better therapist

 Molly: I feel a lot better now that I came up with the solution to
sleep in my own room, and I did it and I’m proud of myself.
And I couldn’t be proud of myself if you told me, “How about
if you barricade yourself in with pillows, maybe that’ll work?”
I wouldn’t feel like I’ve done it. So basically, what I’m saying
is, you don’t get as much joy out of doing something when
somebody told you to do it.
Molly was obviously wise beyond her years—when provided the opportu-
nity, Molly revealed her inventiveness, derived her own solution, and in
that process, enhanced her self-esteem.
But the real lessons of Molly’s course on how to do therapy are about
the therapeutic alliance:
Molly: All my other therapists haven’t asked me what I wanted to
work on. They asked me questions and I didn’t really want
to answer these questions because, shouldn’t I be telling
you what I think about this? (Barry laughs.) I mean you
are not here to tell me my life or anything. (Both Molly
and Barry laugh.) You’re a therapist—you’re supposed to sit
there and listen to me talk! But if they are saying, well,
your mom tells me that your dad is doing such and such a
thing or more stuff. It’s like, since when did I start having
problems with that?
Molly made it clear she felt discounted and ignored. What she perceived
as important was not solicited. Her goals were not given priority, and her
collaboration not encouraged. The alliance literature would accurately
predict her negative outcome.
Recall that this is the same child who was placed in a social skills
group, diagnosed with separation anxiety disorder, treated with medica-
tion, and seen for a year! If a gem like Molly can be missed working with
therapists with all good intentions, we must take special caution to ensure
that we build strong alliances and are mindful of clients’ existing abilities.
Returning to Molly one final time, note how she nails the pitfalls of not
including the client as a valued partner:
Molly: And therapists are basically telling you what they want you to
do. . . . And it is like that they think they are some almighty
power or something. (Both laugh.)
Barry: That drives me nuts when they think they are the almighty
Word.
Molly: Like they are God. (Looks up, extends arms, and sings as though
in a choir.)

how being bad can make you better      97

 Barry: (Both laugh.) Oh, that is music to my ears, Molly. You know,
we think a lot alike.
Molly: It’s like, hang on, I am also somebody. And you laugh at what
I mean to be funny; and back at my old therapy, whenever
I said something, she just busted up. It’s like, hey, I have an
opinion, too!
Barry: She did not take you seriously . . . 
Molly: No! And she even said, ‘I love working with kids and I work
really well with kids.’ (Leans forward and looks very serious.)
Every kid that she sees, goes for, like, years . . . 
Molly is a caution, no doubt, and has been a powerful teaching tool to
illustrate alliance pitfalls to avoid.
When I first submitted Psychotherapy With “Impossible” Cases to a pub-
lisher, an initial reviewer of the book called my alliance-focused approach
“naïve” and “overly simplistic.” He panned it so hard that the original pub-
lisher turned it down and I had to go to another. He was “embarrassed” by
my “complete induction into my clients’ views,” offended by my “joining
with clients as if they were unquestionably telling the absolute truth,” and
critical because I “fell in love with my clients.” I plead guilty as charged on
all three counts. I see these “criticisms” as the real crux of the work.

98       on becoming a better therapist

 4
GETTING BETTER WITH COUPLES,
FAMILIES, AND YOUTH

We are continually faced by great opportunities brilliantly disguised as

insoluble problems.
—Mark Twain

Using the Partners for Change Outcome Management System (PCOMS;

Duncan, 2012) with just two in the room—you and the client—seems emi-
nently doable. Your attention is on one person, the conversation is between
the two of you, you have only one measure to start the session and one to
close, and there is generally little distraction. But surely the system breaks
down when you are talking about two or more clients? Especially if that
“or more” happens to be a family of five with a toddler, an extremely active
5-year-old, and a sullen teen? And what about the couple who leave you
feeling like a referee at a wrestling match? In short, it might seem that
PCOMS with couples and families just has to be unworkable: too much
time, too much orchestration, too much paper, and, plain and simple, too
much effort.
Not so fast. The Child Outcome Rating Scale (CORS; Duncan, Miller,
& Sparks, 2003a) and Child Session Rating Scale (CSRS; Duncan, Miller, &

Jacqueline Sparks contributed substantially to this chapter.

http://dx.doi.org/10.1037/14392-004
On Becoming a Better Therapist, Second Edition: Evidence-Based Practice One Client at a Time, by B. L. Duncan
Copyright © 2014 by the American Psychological Association. All rights reserved.

99
Sparks, 2003b) were, in fact, designed specifically to allow the use of PCOMS
with families. It seemed unfair that youth and their caregivers could not
take advantage of the known benefits of a feedback system, especially given
that therapeutic services to families are offered in such a broad spectrum
of settings. And couple therapy, of course, is widely practiced with a well-
researched array of approaches. Clients in these modalities, not just those in
the tidier individual client–therapist dyads, need to have a voice in their ser-
vices and their benefit monitored. So how can even brief instruments be used
where the number of persons and the complexity of interactions significantly
multiply the demands on the therapist from the outset?
Fortunately, evidence, both empirical and experiential, is accumulat-
ing to the effect that PCOMS is not only doable with couples and families
but is also effective. After a brief look at the lessons taught by the research
evidence of PCOMS with couples and youth, as well as other invaluable tips
gleaned from the studies of couples arising from the Norway Feedback Trial,
this chapter covers the how-to with youth, couples, and families. It addresses
frequently voiced questions to allay any logistical and feasibility concerns
you may have regarding the use of PCOMS with more than two in the room
and to let you see that a seemingly insoluble problem is merely a disguise for
a great opportunity to do better work.

NORWAY FEEDBACK TRIAL AND ITS OFFSPRING

Nothing you do for children is ever wasted.

—Garrison Keillor, Leaving Home

In 2009, “Using Client Feedback to Improve Couples Therapy Outcomes:

A Randomized Clinical Trial in a Naturalistic Setting” was published in the
Journal of Consulting and Clinical Psychology (Anker, Duncan, & Sparks,
2009). It is worthwhile to focus on what this study was about because it is
the prototype for future couple and family feedback trials and is, so to speak,
the mother of four offspring studies. The largest trial to date, the Norway
Feedback Trial enrolled 205 heterosexual Euro-Scandinavian couples seeking
relationship counseling. The couples were randomly assigned to one of two
groups: feedback (PCOMS) or treatment as usual (TAU). Therapists served
as their own controls, working equally with both groups. And the therapists
in the study were not “true believers” and had never used client feedback in
their work. So we tried our best to make the study a true and fair test of the
effects of feedback.
Recall from Chapter 1 that PCOMS couples had nearly 4 times the rate
of clinically significant change and over twice the percentage of couples in

100       on becoming a better therapist

which both individuals achieved reliable and/or clinically significant change.
Moreover, when data were collected from the couples 6 months later, those in
the feedback group were still doing much better, with nearly 3 times the per-
centage of couples in which both partners attained reliable and/or clinically
significant change. In terms of “real-world” differences, feedback couples
were 46% less likely to be separated or divorced at 6 months posttreatment.
In short, this was news to write home about. If someone told you that by
having your couples answer four brief questions at the beginning and end
of each session, you would quadruple their chances of having a successful
outcome short-term and double them long-term, would you say, “Nah, too
much trouble”?
The mass of data collected from the Norway Feedback Trial (thanks to
the meticulous work of Project colleague Morten Anker) became a gold mine
for other analyses that have added to our understanding of what makes couple
therapy tick. We (Anker, Owen, Duncan, & Sparks, 2010) started with the
alliance, examining data from 250 couples because I was burning to answer
the question I asked in Chapter 1: whether the alliance is predictive of out-
come in and of itself, or whether the strong link found between the alliance
and outcome is simply a by-product of the therapy’s effectiveness. In other
words, do strong alliances really produce better outcomes, or do improving
clients produce stronger alliances? It is a classic chicken/egg question. And it
is often used to dismiss the importance of the alliance, in that some say that
the alliance literature is only correlational. As it turns out, this is like saying
the data about cigarette smoking and lung cancer are also only correlational.
When we examined alliance scores, we found that, in fact, the alli-
ance predicted outcome over and above early change. And we looked at a
far more stringent criterion than simple early change because we considered
change that exceeded the reliable change index. So these were individuals
who changed a lot, and the alliance still predicted outcomes over and above
even that. This means that a good alliance is not simply something that hap-
pens because people improve in therapy but rather is something that actually
helps people change. We also found that first-session alliance scores were
not significant predictors of outcome and that alliances that started over the
mean and increased (called the high linear cluster) were associated with signifi-
cantly more couples achieving reliable or clinically significant change: 77.1%
of couples in the high linear cluster both changed, as compared with 45.5%
of couples who started below the mean and whose scores didn’t increase over
the course of therapy. These results suggest, first, the need for ongoing alli-
ance monitoring and, second, that the relative starting place of the alliance
may not be as important as whether it improves over the course of treatment.
Consistent with our wanting to learn directly from clients, in the 6-month
follow-up portion of our investigation we included a short questionnaire

getting better with couples, families, and youth      101

(Anker, Sparks, Duncan, Owen, & Stapnes, 2011) about what couples liked
and didn’t like about their therapy. The responses fell along two dimensions
that will be familiar if you know about Bordin’s (1979) classic definition of
the alliance, namely, relationship and tasks. Favorable comments fell more
along the relationship side of the equation. Interestingly, couples also valued
therapists who could remain neutral. But when it came to tasks, there were
more negative comments. Respondents complained that they wished the ther-
apist had given more advice and had structured things more to provide a safe
place for highly charged discussions. Negotiating tasks and matching client
expectations is an important alliance endeavor, one that requires “stepping
up” when clients are asking for more guidance and structure.
An additional, and somewhat surprising, finding was that many clients
wished that their therapist had been more proactive in arranging appoint-
ments, checking in between sessions, and being flexible in scheduling. Who
thought this had anything to do with the price of tea in China? Apparently,
according to these clients, it does. Looking back at Bordin (1979), there it is:
“Collaboration between patient and therapist involves an agreed-upon con-
tract, which takes into account some very concrete exchanges” (p. 254)—
something to keep in mind when you think therapy only includes the space
between “how has the week gone” and “we have to end now.” Clients in the
feedback group had significantly fewer negative comments in this area than
those in the nonfeedback group.
That clients come into couple therapy for different reasons and want-
ing different outcomes was empirically reinforced by the third Norway
Feedback Trial offspring (Owen, Duncan, Anker, & Sparks, 2012). It might
not be a big surprise that this study found that when both members of the
couple wanted to improve the relationship, the majority of them did, and
only about 8% were separated or divorced 6 months posttherapy. When
one member of a couple wanted to improve the relationship and his or her
partner wanted clarification about continuing the relationship, 45% sepa-
rated at 6 months posttherapy. Finally, when both in the couple were seek-
ing clarification, 56% had separated at follow-up. These results suggest that
initial feedback about the goals for couple therapy is critical to ensure that
the therapist is on target with strategies that are a good fit for their reasons
for seeking counseling.
Couples clinicians play multiple roles in both strengthening and help-
ing dissolve partnerships in constructive ways. This study supports this asser-
tion. Regardless of whether one or both individuals desired an outcome of
clarification about continuing the relationship, higher distress during this
tumultuous time was apparent and reflected by Outcome Rating Scale (ORS)
scores. Couples in all three categories of goals realized significant reductions in
distress pre-to-post, surpassing the reliable change index on the ORS. Therapy

102       on becoming a better therapist

appeared to be helpful regardless of goal, although those with the goal of
improving the relationship fared better. In other words, therapy was shown
to be helpful even with couples on the verge of divorce. Couple work is
tricky, and PCOMS can diminish the guesswork and help the therapist devise
approaches that are in sync with client goals.
One other study spawned by the Norway Feedback Trial, mentioned in
Chapter 1, just entered the published domain. Owen, Duncan, Reese, Anker,
and Sparks (in press) asked the million-dollar question: What makes some
therapists more effective than others (in this case, more effective in couple
therapy)? Therapist effects accounted for 8% of the variance. Recall that
what didn’t make a difference was the therapist’s gender or specific profes-
sional discipline. However, those who had more experience working with
couples did significantly better, accounting for 25% of the variance attribut-
able to therapists. Even more important was the therapist average alliance
score, accounting for 50% of that variance. So if you are a couple therapist,
there are two clear pathways to become better: alliance building and time in
the trenches with couples. Chapter 5 will show you how you can be sure that
you are learning from your experience.

PCOMS WITH YOUTH AND FAMILIES

The Norway Feedback Trial revealed that PCOMS is not just for indi-
viduals; it also shows real promise for expanded treatment systems. Studies
that test feedback with children and families have lagged behind, perhaps
because collecting and analyzing data from multiple clients is more compli-
cated. Nevertheless, one published cohort investigation is charting the course.
As reviewed in Chapter 1, Cooper, Stewart, Sparks, and Bunting (2013) eval-
uated outcomes for 288 youth ages 7 to 11 receiving counseling informed
by PCOMS in their schools in Northern Ireland. The youth were referred
by teachers or parents/caregivers because of social, emotional, or behavioral
difficulties. At the completion of treatment, 88.7% (child’s rating) showed
improvement and 77.6% of caregivers reported reliable change. In addition,
the authors compared their effect sizes (ES) for the Strengths and Difficulties
Questionnaire (SDQ) scores against those from primary school–based coun-
seling in the U.K. in which PCOMS was not used. They found an approxi-
mate twofold advantage in effect on the caretaker-completed SDQ when
PCOMS was used (.99 vs. .47 and .58), and a small advantage in effect on the
teacher-completed SDQ (.55 vs. .39 and .44). Although this was not a family
feedback trial and was focused on children in the schools, it regularly included
caretakers in the therapeutic process and demonstrated a feedback effect for
both youth on the CORS and caretakers (and teachers) on the SDQ.

getting better with couples, families, and youth      103

 Bottom Line: The findings on PCOMS with couples and youth demonstrate
its potential to improve overall effectiveness across age ranges and modalities.
Below are some take-home lessons from PCOMS couple and youth studies:

77 Use PCOMS with couples, families, and youth. You signifi-

cantly enhance your chance of a positive outcome by doing so.
77 When looking at your data and outcomes, consider whether
both members of a couple or a parent–child dyad have ben-
efited. Morten Anker also suggests that it is informative in con-
sidering couple outcomes to separate couples into the three goal
categories discussed above (see Figure 4.1).
77 Monitor the alliance throughout therapy. Ascending scores are
a good sign; don’t be discouraged if the first session is a bit low,
but rejoice when it improves.
77 Use the Session Rating Scale (SRS) to determine if your
approach is matching the goals for each member of a couple

THE COUPLE FIRST SESSION RELATIONAL GOAL SCALE

Name:………………………………………. Date:………….

Please indicate your own personal goal for couple therapy. Please do this independently of

your partner.

1. My goal is: (check only one)

Improve the relationship

Clarify whether the relationship should continue

End the relationship in the best possible way

Other

2. Do you think your partner is in agreement with your goal?

Yes

No

Figure 4.1.  The Couple First Session Relational Goal Scale (available for use).
Copyright 2007 by Psychologist Morten Anker, PhD. Reprinted with permission.

104       on becoming a better therapist

 or family. If members of the couple or family have different
goals, negotiate a goal and an approach all can agree on. Even
if goals are different for a couple and one wants out or clarifi-
cation while the other doesn’t, couple therapy can be helpful
(recall that all three groups achieved significant reductions
of distress).
77 Use the SRS to determine if your approach is a good fit for the
couple or family at hand. Expand your repertoire to provide more
structured and directive approaches to those who want that.
77 Use the SRS to expand your relational repertoire and work on
your alliance skills in complex interpersonal situations. Remem-
ber that your alliance abilities count for half (at least) of any
differences between you and your colleagues.
77 Increase your couple caseload hours over time to enhance your
effectiveness with this modality, but in such a way that you are
learning the lessons that couples teach (see Chapter 5).
77 Attend to clients’ needs both during the session and between
sessions, keeping in touch and being flexible about meeting
times and scheduling.

NUTS AND BOLTS OF PCOMS WITH COUPLES AND FAMILIES

The value of an idea lies in the using of it.

—Thomas Edison

In truth, couples and family work is not for the faint of heart—not for
those with little tolerance for noise, commotion, complexity, and the need to
think on your feet. Think of it as sometimes like a three-ring circus—there is
so much going on, you don’t know what to attend to first: the high-wire act,
the trained lions, or the clowns. Take this, and add on even a brief, feasible
system like PCOMS, and it seems a formidable task. Fortunately, however,
rather than adding complexity, PCOMS is an anchor, providing an orienting
point to begin a session and a ready-made means for summarizing at the end.
When using PCOMS with couples and families it is good to adopt the
Girl/Boy Scout motto: Be Prepared! The last thing you want is to escort fam-
ily members into the office or meet them in their home and not have all the
tools of the trade ready to go. Make sure you know how many people you will
be seeing, their ages, and their likely developmental/intellectual level. This
way you can collect the appropriate measures to be used, the correct number
of clipboards (if there are not enough writing surfaces), and enough writing
implements. Here’s a refresher: Teenagers (ages 13–17) will use the ORS and

getting better with couples, families, and youth      105

children (ages 6–12), the CORS (see Figure 4.2). Have available the Young
Child Outcome Rating Scale (YCORS; see Figure 4.3) for those under age 6
and provide crayons. The point is, don’t leave anyone capable of writing or
scribbling out of the process. This communicates that everyone matters and
you are interested in everyone’s views, however they express it. To reduce the
amount of paper, it is helpful to have the ORS/CORS on one side and the
SRS/CSRS on the other.
Here is an example of not being prepared, and yet another illustration of
the fact that you can’t do it as badly as I have. In my defense, it was after my
last client on a Friday afternoon and I was already in that space in my head
that had me home, sitting on my patio, watching the birds, and enjoying my
favorite beverage. You know the feeling. My notes were done, my stuff put
away, and my laptop packed, and I was headed out the door when my cell
phone rang. It was a school counselor, who said, “Barry, you gotta see this
kid. She cut her arms and is going to wind up in the hospital!” I thought,
“Nooooooo! Anything but that—don’t you understand I am already at home
on my patio sipping a cold, malted, brown-colored soft drink?”
But the school counselor was a friend and a referral source—and I am a
sucker for a prevention-of-hospitalization story—so I said I would see the kid
and the mom. The video shows me talking to a very disgruntled Erica about
the ORS while looking for one to give her. I look in one folder, then another,
hemming and hawing along the way, looking at many forms (“I know it’s
in here somewhere”) while trying to maintain some professional decorum.
Finally, in the third folder, I find the ORS and administer it, and then I can’t
find my centimeter ruler. Finally, I give up and just estimate the numbers.
Audiences think it is quite a hoot. But, you know what, Erica didn’t mind
and the session went terrifically, and this delightful, precocious kid didn’t go
to the hospital. But better to be prepared!
Although there are validated guidelines, clinical judgment comes into
play regarding the appropriate instrument for any given child or adolescent.
For example, some 12-year-olds may find the CORS “babyish,” insulting their
real (or presumed) level of maturity. This was the case for Erica. When I met
her in the waiting room, she seemed to be 12 going on 27 when her mom,
Nancy, asked me to see her daughter first. But use whatever they think works
best for them; it doesn’t hurt to just ask and let them choose if you’re not sure.
On the other hand, a teen may have some developmental challenges and
more readily take to the CORS.
In the case of a family entering services because of a problem related
to a child or adolescent, the parent or caregiver scores only the CORS (for a
child) or ORS (for an adolescent), based on his or her perception of how the
child or adolescent is doing. Asking the parent or caregiver to score his or
her own ORS sends the message that we are interested in their functioning,

106       on becoming a better therapist

 Figure 4.2.  The Child Outcome Rating Scale and Child Session Rating Scale. Copyright 2003 by B. L. Duncan, S. D. Miller, and

getting better with couples, families, and youth     

J. A. Sparks. Reprinted with permission. For examination only. Download free working copies at https://heartandsoulofchange.com.

107
108       on becoming a better therapist
Figure 4.3.  The Young Child Outcome Rating Scale and Young Child Session Rating Scale. Copyright 2003 by B. L. Duncan,
S. D. Miller, A. Huggins, and J. Sparks. Reprinted with permission. For examination only. Download free working copies at
https://heartandsoulofchange.com.
even though that is not the reason for service. That message could risk the
alliance because parents or caregivers may believe that the therapist, rather
than being aligned with their view of the problem, instead has a covert belief
that they themselves are the problem. The primary point is to ensure that
the therapist accepts the reason for seeking help and communicates that as
clearly as possible through both verbal and nonverbal means to clients.
Parental and caregiver scores of a child who is presented as the reason
for service provide crucial perspectives of how therapy is going. From the
CORS validation study, we know that parent/caregiver scores are correlated
with children’s and adolescents’ scores. In other words, when youth record a
change, caregivers typically report similar amounts and directions of change,
and vice versa. In some circumstances, it is also useful to get others who are
significantly involved with a child, or so-called collateral raters, to score their
views using the CORS/ORS. For example, a teacher instrumental in referring
a child for counseling or a probation officer assigned by a court to monitor a
youth charged with a delinquency offense is a good candidate to bring into
the process. People who play pivotal roles in the child’s life can become wit-
nesses to and advocates for positive change. Periodic meetings with these
individuals, the youth, and family can facilitate support for the efforts of a
child or adolescent and collaboratively contribute to goal setting and strate-
gies for problem resolution.
Once the initial how-to is mastered, the instruments provide a welcome
port in a storm. The same may be true for the children and families who come
to expect the familiar ritual of starting and ending with the measures. The trick
is to get practiced and comfortable enough so that PCOMS is not an awkward,
half-done activity that detracts from the flow of conversation, but one that
facilitates a meaningful discussion.

Introducing and Scoring the ORS/CORS With Couples and Families

You have selected the instruments, everything is ready, and you are face-
to-face with either a reasonably focused, calm couple or family, or one that is
filling up the space with energy and noise. You simply need to go through the
steps of the introduction as you would with any individual client, ensuring
that everyone in the room knows the major points that the ORS brings to the
show (i.e., it is a way to ensure they get what they are looking for and that their
voice stays central) and understands how to complete it.
Introducing the ORS to families requires tailoring your talk to the age,
understanding capability, and level of attention of multiple family or couple
members. Even with just two clients, one may be more attentive and one
more disengaged or skeptical. The key is to size up as quickly as possible
whether a blanket explanation will suffice or more individualized descriptions

getting better with couples, families, and youth      109

are required. For example, in the case of a 7-year-old who immediately goes
for the matchbox cars in the corner of the room, you will need to go to him,
get down to his level, shake his hand, introduce yourself, and show him what
you want him to do, letting him know that you really want to get a sense of
how he thinks things are going for him. From then on, it will be important to
include him in this manner, no matter what part of the room he migrates to.
In the best of all scenarios, a parent or caregiver will assume the role of thera-
pist helper—asking the child to join him or her, explaining what is needed
with the instrument, and helping him to fill it out, while still respecting his
unique voice and point of view.
Okay, you are primed to use the measures with a family you are seeing
for the first time. You are visiting them in their home and, when you are
invited into the small living room, you are surrounded by cacophony—the
TV at least 5 decibels higher than your comfort zone, a 4-year-old chasing
a very large and friendly dog who greeted you with exuberance and a thor-
ough (and uncomfortable) sniffing, two older siblings, ages 6 and 8, arguing
(screaming might be a better descriptor) about who gets to sit in the arm-
chair, and a harried mother trying to finish her phone conversation as she
nonverbally directs traffic to get everyone clustered around the coffee table
for the meeting. Panicked, you can’t possibly see how pulling out x number of
sheets of paper, explaining the measures, and providing the rationale can fly
under the circumstances. So, you abandon your best intentions.
In so doing, you have squandered an opportunity. Here’s a secret. Families
that some would pejoratively label “chaotic” appreciate your help with focus
and structure. Children and teens, being naturally curious, want to see what
this activity is all about and generally will jump right in. Lo and behold, to
your wonderment, the room quiets, if only briefly, as all are immersed in their
first counseling task. Future meetings get started almost automatically, with
even very active children coming to expect the structure provided by the
opening assessment of how they are doing.
And that’s exactly what happened with the above-mentioned family
when I did an in-home consult. The family quickly gathered around the cof-
fee table, curiosity piqued by my explanation of the forms, and joined in
the family activity—even the 4-year-old (the Young Child measures are not
scored). As is often the case, I was able to solicit help from one of the children
to graph the scores with me. Essentially, PCOMS, from the very beginning,
provides a critical demarcation of the therapy process. It communicates to
the family, “This is a special time,” and helped carve out a focused space in
the midst of the family’s everyday life in which important matters related to
everyone’s well-being could be discussed. Rather than escalating chaos, it
brings order, giving a consistent, predictable structure when most needed.
Most of all, it engages everyone early on and helps maintain that engagement

110       on becoming a better therapist

over time. At the same time, you are giving hope that you are not intimidated
by who they are and, therefore, just might be someone who will be helpful
to them.
Sometimes children or their parents are confused about how to use the
School line on the CORS if it is summertime and the child is not in school.
The School scale parallels the corresponding Socially item on the ORS. It is
the child’s or caregiver’s perceptions of the child’s peer friendships and social-
based activities or responsibilities, his or her social world. So during the sum-
mer it might be, for example, summer camp, music lessons, sports, scouts,
spiritual groups, summer job—all of which pertain to social functioning and
maintain the parallel “item integrity” between the ORS and CORS.
If school academic or behavioral concerns are the purpose of service
but you are working with the child during the summer, the child can look
back and rate the last week of school as a starting point. Then the scale can
be used to represent the work done to address those concerns over the sum-
mer. If school is not the reason for service, the scale can reflect current social
relationships in general, during or outside of the school year. If any social
domain is the impetus for service, the child rates the scale accordingly. The
important point is that the child’s/caregiver’s concerns need to be represented
in a way that therapy can address, so that progress is reflected on the CORS.
The instruments are filled out, and now you have all these forms to score.
It seems daunting, but fitting it into your natural rhythm of beginning a session
will put everyone at ease. Let everyone know that you will take a few moments
and then you will check out the results with them. By simply letting people
know this, you can relax, and the time does not seem as awkward. As you gain
experience, you can multitask while you add the scores. You can enlist a graph-
ing helper and give the family the task of assigning colors to each member. You
can explain how the measures work (e.g., four 10-cm lines totaling 40 cm) and
make brief comments about each, the lowest and highest score or where you
see agreement or disagreement among the clients.

Discussing Clients’ Scores, the Clinical Cutoff, and Connecting the

Marks to the Reasons for Service

Now that you have completed the scoring, the clients need to under-
stand what their scores mean and have a shared understanding of how the
scores reflect their reasons for seeking therapy. It helps to lay all the forms out
on an open surface (e.g., coffee table, kitchen table, or floor) where everyone
can take a look. This is a powerful gesture communicating that the work is
collaborative, the therapist will not be the private keeper of special informa-
tion, and everyone’s point of view will be known and valued. It is not unusual
for children to flock around a set of scores with a natural curiosity for who

getting better with couples, families, and youth      111

scored what. Partners are often similarly curious about their partner’s scores
and will readily make comments about similarities or differences with their
own. The ORS allows everything to be literally on the table right from
the beginning—the agreements and disagreements that everyone except the
therapist, until now, knows about.
The clinical cutoff facilitates a shared understanding of the measures
and is often a step toward connecting the scores to the reason for seeking or
receiving services. Keep in mind that the cutoff is different depending on age.
Twenty-five is the cutoff for adults, meaning that, on average, persons seeking
clinical services will fall below that and those not typically seeking counseling
will score above. Although adolescents use the ORS, their cutoff is slightly
higher, 28. Children’s cutoff on the CORS is higher still, 32. The cutoff for
parents’/caregivers’ scoring the CORS and the ORS for an adolescent is 28.
Briefly let each person know, in everyday language that is understandable to
them, whether they are above or below the cutoff. As with individuals, for
those showing below-cutoff scores, you can assure them that they made a
good decision to come in. For those scoring above the cutoff, you can simply
validate their score by saying that it looks like things are going pretty well,
which often leads to the next logical question: What are the reasons for meet-
ing at this time?
Erica scored a 35 (I didn’t have a ruler, but later, when I scored it, the
actual total was 34.3) on the ORS. This may surprise you; she had cut her
arms in response to a romantic breakup, yet she saw herself as doing very well.
You might think that she is hiding or misrepresenting her distress. I would
dissuade you from either interpretation and take the score at face value. Erica
did see herself as doing well in all areas of her life—she was popular, inde-
pendent, and a good student—and viewed the cutting as an isolated incident
requiring only some convincing of her mother that she was okay so that her
boy privileges could be reinstated. In other words, her description of her life
matched her ORS score. Erica’s mom, Nancy, confirmed that Erica was doing
well and also considered the cutting incident, although troublesome, as part
of an overall picture of a well-adjusted teenager. Nancy scored Erica on the
ORS as a 32 (actually a 31.6). Here is how the clinical cutoff conversation
went with 12-year-old Erica:
Barry: Okay. Great. Things look like they are going very well for
you. The way this works is that each of the lines is 10-cm long
and they total to 40 points. You scored 35 out of 40. People usu-
ally think their lives are going really, really well when they score
that. Is that true for you?
Erica: Well, yes, things are very good, but I did cut my arm because of
this one boy.

112       on becoming a better therapist

 Barry: Okay, so things are going well for you overall, but this cutting
thing happened recently and that’s why you find yourself here.
Do you want to tell me about it?
Erica: I like this boy named Jake and I can tell him anything. I can tell
him more than my friends who are girls. And he understands
it. But I found out he liked me and when I was falling for him I
didn’t really show it, but now that I am falling for him, like now,
he doesn’t like me that much. So, that’s why I cut my arm.
The ORS gave me a rapid understanding of how Erica saw this situation
and her therapy. She wasn’t looking for any psychological exploration of her
reasons for the cutting (she in fact learned of cutting as a coping mechanism
from Teen People Magazine). When clients score over the cutoff, as Erica’s
example illustrates, it doesn’t mean they are lying (even if they are man-
dated); it just means that they are not experiencing much distress in their
lives (and if they are mandated, they are certainly experiencing less distress
than the person who wants them in therapy). The only distress that Erica was
experiencing resulted from the fact that her mother had grounded her, and it
was reflected in her slightly lower score on the Interpersonally scale.
With any client, and perhaps especially with kids who score over the cut-
off, caution is warranted about any approach that focuses on matters other than
the issues at hand. Why? Think about it. What do we therapists often do with
folks who think they are doing well? We put on our Wicked Witch costume,
suddenly turning green, growing warts and a humongous nose, and we stir the
cauldron. Laughing devilishly as we mix the steaming brew with large strokes,
we shriek, “Oh, you think things are going okay, do you? We’ll see about that,
my pretty!” That is what the school counselor was worried about with Erica,
but it was not what I did. Dealing with the cutting, putting it into perspective,
and moving this family on with their lives were central to the work.
The next vehicle for connecting the ORS and CORS to the reasons
for service relates to the specific domains. Simply seeing which domain
or domains are scored lower allows you to hone in on the most distressed
dimension. You can comment on this area and ask if the score on that domain
represents the reason for seeking or being referred for counseling. Or you
can allow the conversation to reveal the reason for service and then make
the connection to the lowest domain. Once that is established, there is a
shared understanding regarding which domain is the focal point for tracking
change. For example, typically couples will come in with the interpersonal
domain scoring lower than others. It is not hard to confirm that this is what
they want to address through counseling. It also lets you know in a heart-
beat who is more distressed about the relationship and who likely set up the
appointment—and perhaps who was dragged in by the partner.

getting better with couples, families, and youth      113

 Of note, children or adolescents who score above the cutoff will often
still provide a clue to what is troubling them by placing one mark slightly
lower than others, as Erica did. Don’t be deterred by the high score, but men-
tion that he or she might want to talk about school, or family, or whichever
scale is lowest. Finally, the domain scores offer a glimpse of what is going well
in a person’s life. It is worthwhile to briefly mention this when reviewing the
ORS/CORS scores, or, at least, make a mental note to inquire more about these
areas at some point later in the interview.
As the session unfolded with Erica, it became clear that the removal
of her privileges, especially her phone privileges with boys, was her primary
concern. Her rating of how she was doing Interpersonally was slightly lower
than the rest of her ratings. So I simply asked if her grounding and subsequent
conflict with her mother accounted for the lower mark. Erica responded affir-
matively, and I asked her what we needed to do to move it up a centimeter.
She replied that we needed to convince her mom that she was okay.

Bottom Line: Allow the ORS to put the dynamics of the situation, family, and
therapy on the table and ready for action.

When People Agree on the ORS

Couples and families either agree about their views of the level and areas
of distress or they don’t. The key when folks agree is to comment on it as a
strength, highlight the commonality, and use it as a stepping stone to establish
mutual goals. The following is an excerpt from a consult I did with a foster
parent, Sophie, and an adolescent, Lisbeth, who were referred because Lisbeth
had not attended school for nearly a year and a half.
Barry: (talking to Sophie because Lisbeth has her hood up and is looking
away) When I work with people I like to use this very brief
form about how you all see things going in your lives and how
you see Lisbeth doing. This is also a way for adolescents to
have a voice about how things are going in therapy.
Sophie: She does take advantage of that.
Barry: That’s good! That’s a good way of making sure things go well.
So that’s what this form is for. It’s also so we can track whether
or not you are getting anywhere with the services, whether this
therapy is helping. That’s the whole idea.
Sophie: It took her a year to get used to her therapist . . . she didn’t say
anything . . . isn’t that right, Lisbeth? (Lisbeth says nothing.)
Barry: I am sorry, I didn’t even ask you if I could call you Sophie. Is it
okay if I call you that?

114       on becoming a better therapist

 Sophie: Sure.
Barry: And please call me Barry. (still talking to Sophie) Would you be
willing to do this brief form for me?
Sophie: Yes
Barry: This is you looking at her seeing how she is doing (Sophie
reads instructions.). Lisbeth, would you do this for me? It gives
a snapshot of how you think things are going in your life.
(Lisbeth, hood still down, dramatically grabs the clipboard out of
Barry’s hand.) Thanks a lot!
(Both fill out the forms, and hand Barry the ORS.)
Barry: Thanks! (as Barry scores the measures) So the way this works
is, it is four 10-cm lines for a total score of 40, and what I do
then is take this centimeter ruler and measure your marks.
Lisbeth: We don’t need an explanation. We can read it!
Barry: Okay. You already know about this?
Lisbeth: I don’t care for it, buddy.
Barry: (still adding the numbers) I appreciate that you did it given
that you don’t care for it. I hope that you will find it helpful.
(Lisbeth slumps in chair with hood over her face; Sophie intently
watches everything Barry does with the measures.) You scored a
12.6, Lisbeth, which is very low and indicative of someone
who is having a real hard time and is maybe kinda hurting. Is
that right?
Lisbeth: Maybe, but I don’t care about a social life or school and I don’t
care about family.
Barry: Okay, so it fits but you don’t much care about it. (Lisbeth doesn’t
respond.) The cutoff is 28 on the this ORS form so people who
score under that tend to be people looking for something
different in their life.
Lisbeth: I am just fine where I am.
Barry: Okay, you know, Sophie, you scored a 12.7 looking at Lisbeth,
which is almost exactly what she scored. So you guys are on
the same page about how things are going.
Lisbeth: I make it very clear!
Barry: That’s great! I think when teens and caregivers are on the same
page about how things are going, it helps a heck of a lot. You
are starting with a shared understanding of things. And you are
both identifying the areas of most distress on the Socially scale.

getting better with couples, families, and youth      115

 And is that reflecting the whole not-attending-school issue?
That’s what they told me was the reason for this consult.
Sophie: Yes.
Barry: Great. Because, you know, a lot of times, adolescents and care-
givers see things quite differently . . . and you two are defi-
nitely on the same frequency here.
Lisbeth: Oh, piss off!
This rather feisty beginning took a little over 3 minutes, but that was
enough time to comment on what each person’s score meant, their similarity
to one another and how that was a great place to start, and posit the connec-
tion of the lowest score to the reason for service. We will pick up with this
family in Chapter 6, as part of a discussion of the alliance.

When People Don’t Agree on the ORS

Erica and Nancy agreed about Erica doing well, and Sophie and Lisbeth
agreed about Lisbeth not doing well, but what about everyone else? Repeat (or
sing) after me: “Don’t worry, be happy.” Couples and families seek counseling
because . . . they can’t agree! It is true that, in the midst of disagreeing about
everything from who takes out the garbage to who’s responsible for the last
argument, there can be a collective agreement about the degree of distress and
the general domain of that distress. However, it is also true that disagreements
often include how clients see the problem that led to counseling. Why is this
not a cause for despair but a reason to be happy? For starters, different scores
are concrete and visible, allowing therapists to inquire early on about every-
one’s unique perceptions and beliefs. The sooner this is done, the quicker goals
for each person can be identified and efforts made to link these into a common
strategy and mutually desired endpoint. Alternatively, discrepant scores may
persist, and therapists can successfully validate those differences and still work
toward a positive outcome (recall the couple study in which even couples with
discrepant goals benefited from therapy). Different scores are to be expected
and simply represent the reality and complexity of working therapeutically
with more than two in the room.
Disagreements between clients in their scores on the ORS really speak
to the dynamics present anyway. It just puts those differences front and center
in the first minutes of the session. Consider Nathan, a 15-year-old recently
suspended from school for “violent outbursts” against teachers, and his grand-
mother, Margaret. Nathan had recently come to live with Margaret after being
removed from his mother’s home because of her active addiction and viola-
tions of probation. Nathan went from inner city Detroit to rural Montana,
quite a culture shock for everyone involved.

116       on becoming a better therapist

 Barry: (Margaret and Nathan complete the ORS and hand
it to Barry.) Thanks. Okay, I’m going to add this
up and tell you what it means and you can let
me know if it makes sense and fits how you see
things. This is four 10-cm lines and I just total it
up after I measure your marks with this centime-
ter ruler . . . Nathan, you scored a 33.2, and that
basically says that life is going pretty well for you.
The cutoff on this ORS for adolescents is 28, and
when people score over that it generally says that
things are going well, that they are scoring more
like folks who are not talking to people like me.
Does that fit?
Yes. (Margaret looks at Nathan with an exaggerated
Nathan:
smirk.)
But it looks like the Socially or school area (Barry
Barry:
had explained that this scale captured Nathan’s life at
school) is the one that you marked the lowest.
Right, I get in trouble at school.
Nathan:
Okay, we’ll get to that in a minute. And Margaret,
Barry:
your look at Nathan says that things are pretty
rough right now, you scored a 9.9 in looking at
how Nathan is doing . . . that there are significant
problems.
Yes, I definitely think that there are, especially at
Margaret:
school. He is suspended now. And he is not too
easy to live with at home either.
Looks like you made a good decision to be in
Barry:
counseling. Okay, oh, and you also have rated the
Socially scale the lowest, so you two are on the
same page about that, although your total scores
are different. Margaret, is that what you are
referring to, the school suspension and problems
there in your mark here? (Barry lifts up her ORS
and Margaret nods.) So you have different views
about what is going on here, on the one hand, but
both of you see the biggest concern in the same
place. But that’s good that we know that from the
beginning. Let’s see if we can make sense of that
and move things forward. I think, Nathan, in one
way, our job is to bring your grandma’s view of
you more in line with your view of yourself, and
bring both of your marks to the right a bit more

getting better with couples, families, and youth      117

 on that Socially scale. That might be one way of
thinking of what we are up to here. Does that
make sense?
Nathan and Margaret: Yes.
So you both marked the Socially scale the lowest.
Barry:
Who wants to start with that? Or feel free to start
wherever you want.
Different scores, then, are not a big deal and only serve to bring every-
thing out in the open. This can be very helpful with couples as well as kids
and caretakers. Couples often come in for different reasons and have very
different motivations for therapy. The ORS gives you an instant read on
things like who is in the most distress about the relationship and who per-
haps was coerced into therapy. Not surprisingly, the one wanting to work on
or save the relationship is often the one demonstrating more distress on the
ORS. Also not surprising is that the one who is dragged to therapy or the
one who is there to clarify whether the relationship will continue are often
over the cutoff. The discussion of distress via ORS scores shines a light on
these important issues, allowing their open discussion and subsequent plan-
ning for how therapy can meet both individuals’ needs. And, as illustrated in
our study about couple goals for therapy, such information allows therapy to
help couples who are separating as well as those who stay together. Using the
measures helps to identify a host of dynamics very early in the process as well
as where therapy progress will be registered on the ORS.

Getting a Good Rating: One That Accurately Reflects the

Client’s Experience

It is important to remember that the younger the child, the higher the
scores are likely to be; the cutoff for ages 6 to 12 on the CORS is 32. High
scores, therefore, are to be expected on the CORS, and a score of 31 is com-
municating that the child is in some distress. Children can even score higher
and may be expressing discomfort by a 9 on any given scale. It is important,
therefore, to look for variation in domain scores with high youth scores; any
deviation between one domain and others is a flag. For example, an 8-year-old
has a total score of 35, but the Family scale accounts for the entire 5-point dif-
ferential. Clearly this child is conveying information. It would be wise to ask
about why the Family scale is down a bit and not the same as the others, recog-
nizing, however, that it could simply reflect a recent tiff with a parent or sibling.
Children who score this way may, however, want you to pay attention but not
know how to say it outright. The forms give them a voice that is quieter, and
perhaps safer, than to say “Something’s wrong,” or “I need some help.”

118       on becoming a better therapist

 But what about the child who flatlines the form from the beginning
at 10’s and continues that at each session? A few things are helpful to keep
in mind for this scenario. Children are likely receiving services not because
they asked for them but because someone else, generally a parent or teacher,
thought it was a good idea. They are, in essence, mandated clients, so at
the start keep in mind that it is entirely possible that they are simply not
distressed about the situation that led them to services—someone else is. So,
don’t assume that their high scores are not accurate.
However, you should also make sure that children understand the mea-
sure and how it will be used. But know right from the beginning that not all
kids are going to get it. The measure was validated on 6-to-12-year-olds but
that doesn’t mean that all 6-, 7-, and 8-year-olds are going to understand the
CORS. Some never get it no matter what you do. Children of this age can
be very here-and-now oriented. In this case, carrying topics and themes from
session to session just doesn’t work, and the measure winds up describing
how the child is feeling at the moment or how the car ride to the office was
experienced. But many do get it, and the older the child, the more likely it
is that he or she will understand the connections that are made between the
discussions in session, the reasons for service, and what happens between
sessions. Of course, this is your role: to make all those connections manifest
at multiple levels of understanding. But if they don’t, it’s all good. Keep
using the CORS with your young clients so that they have a voice in the
process, but don’t use their scores in your database. You will almost always
have another rater with a child, so it’s not a problem when children don’t
understand it.
When a child you believe understands it still scores very high (above
36), acknowledge the marks as true: “It looks like things are going pretty
good,” followed by, “Will you let me know if anything changes?” Later, the
child might mention some areas of her life that are far from a 10, or a parent/
caregiver might describe events that seem at odds with her scores. At this
juncture, you can take out the form and, in a sincere and curious way, say,
“Mara, help me out here. Your mom seems worried that you are not making
new friends since you moved and you told me that you hate school. How
does that fit with this line here [pointing to the “10” on the School scale]
that says everything is okay with school and your friends?” Give her some
time and ask, “Do you want to do a different mark [offering her the pencil
and the form]?” If she says no, so be it—it is absolutely ill-advised to debate a
client, ever. By trusting her voice, you make it more likely that, if she is not
completely letting you in, she will at some point in the future. If you know
the child’s score to be invalid, that it is not matching the client’s description
of his or her life, then don’t record it in your database and use the parent’s or
caregiver’s ratings.

getting better with couples, families, and youth      119

Introducing and Discussing the SRS

You have spent the allotted time delving into your clients’ dilemmas,
struggles, hopes, and dreams, the kind of special connection unmatched in any
other professional sphere and the privilege enjoyed by all of us doing this work.
It is now time for some very important feedback: How did your clients experi-
ence the session, your attention to them, your ability to grasp their situation,
your helpfulness in offering insight, suggestions, or new perspectives? Without
a read on the alliance, therapy can easily derail. Moreover, simply request-
ing this type of feedback is likely to strengthen the alliance, especially if the
feedback is negative and the therapist responds to and addresses the concerns.
However, in couple or family work, the alliance is a multi-voiced variable and
alliance formation is consequently more complicated. For example, scores on
the SRS will indicate if both members of a couple like how the therapy is
going, or if you have become another bone of contention in their relation-
ship. SRS ratings will also let you know if you have pulled off one of the more
remarkable feats for anyone working with families—being liked by parents/
caregivers and an identified child or adolescent. If the answer is “not so much,”
no need to despair; this is good to know and helps you recalibrate, preferably
before they leave the office or you leave their home or other place of service.
Again, make sure you are prepared and have the forms readily available
for the appropriate ages. As with the ORS, the adult SRS is used for adoles-
cents. The CSRS (see Figure 4.2) is suitable for ages 6 to 12. There is even a
YCSRS (Figure 4.3) with four large faces that children under age 6 can color,
to feel included with the rest of the family. Then be sure to leave enough time
to explain the instrument and respond briefly to the feedback.
The explanation for couples and families is the same as for an individual
client, with the caveat that you attend to the age and developmental level of
youth in a family—literally get down to his or her level if necessary to make
sure he or she understands. Beyond that, the key points to communicate are
the same: You want to know how they think things went, and their feedback
can help you make sure they are getting what they want from counseling and
adjust things if they are not.
Finally, offer any assistance needed for clients to fill out the measure.
Sometimes children, or even members of a couple, mistake the first line “I
felt heard, understood, and respected” (“_____ listened to me” on the CSRS)
to mean their sense of being heard, understood, and respected (listened to)
by a parent, sibling, or partner during the meeting. This needs to be clarified;
the item refers to the therapist’s hearing, understanding, and respecting
the client.
Sometimes, even with further explanation, the tension between mem-
bers may carry over to ratings on the SRS. Your tone at this juncture is critical.

120       on becoming a better therapist

Clients can easily pick up on nervousness or hesitancy. Most clients are polite,
and if they feel a certain comment might offend the therapist, may decide to
keep it to themselves. However, when the therapist is genuinely relaxed and
communicates—both verbally and nonverbally—a true desire for feedback,
clients are more likely to provide it. For some clients, there may be fam-
ily or cultural influences that create more hesitancy. For example, younger
clients may feel it is not okay to tell an adult they didn’t like something he
or she did. Or, in some cultures, it may be considered disrespectful to speak
negatively to a woman or someone considered an elder. If this is the case,
the therapist can explain that providing feedback will not be perceived as
negative but as positive, strange as that may seem. You can then reiterate
your desire to hear what they think so that the best outcome can be secured.
When responding to SRS feedback, let’s go back to what we learned
before we could tie our shoes. When someone does you a favor, what do you
say? That’s right: Thank you. Any and all feedback ought to be accepted with
gratitude—gratitude for their time, honesty, and helpful information. The
therapist’s demeanor during this process ought to be genuine, open, and non-
defensive. Remember, a few “dings” on the scale is a bonus, given low to high
is golden. Beyond saying “thank you,” the therapist inquires about what was
missing or how to move up any mark that even slightly dips below a nine, or
what went well that the clients want you to continue. That is all there is to
it—a light-touch, checking-in process of genuine curiosity about how to make
things go as well as possible.

Second Session and Beyond

If all goes well, your clients will return, or invite you back to their home,
for another meeting. For this session and all subsequent ones, the task is the
same as with an individual: Are things better or not? At the risk of sound-
ing repetitive, things are not quite so clear-cut when you are working with
more than one client. While it may be that you get fairly consistent agree-
ment among members of a couple or family regarding the two possible change
scenarios, it may be more likely that you will encounter different views. For
example, a spouse may be seeing things improve because his wife has returned
to live in the home, but her view of the situation indicates deterioration. Or a
mother may report improvement because the agreed-upon strategies reduced
the conflict with her adolescent, but the daughter rates things lower because
she feels controlled. Welcome to couple/family work. This is of course the
crux of it, the challenge: to create a therapeutic context where everyone, dif-
ferent views and all, benefits from the experience of counseling. Perhaps the
best way to judge success is when both persons in a couple benefit and when
caregivers and kids benefit. Recall from the Norway trial that the percentage

getting better with couples, families, and youth      121

of couples both of whom achieved change was over twice as high with feed-
back as it was with TAU.
Regardless of the congruence or discrepancy between client scores, the
task of the therapist from session to session is the same as for an individual:
Identify client perceptions of progress and the alliance and respond appro-
priately. To keep track of several individuals, it is helpful or even essential to
graph scores from week to week on a single sheet of paper. Different members
of a family or couple can be represented by different-colored lines. Taken as a
whole, the graph captures a picture of the change process. A picture is worth
a thousand words, and clients are intrigued with seeing their progress super-
imposed graphically with other family members or their partner. The graph
often has particular appeal for youth, who can readily interpret what the lines
mean and how they reflect their own and their caregivers’ views.
ORS/CORS scores serve as megaphones for client change. This is espe-
cially true when the quick and rich exchanges between multiple clients and a
counselor make conversations in therapy even more difficult to follow. When
change shows up as higher scores on the ORS or CORS, and improvement
over several weeks is clearly delineated by a graph, it begs to be explored. It
is interesting to see how a simple jump of even a few points on the ORS can
spur conversation about how small changes can be carried forward to address
the problems at hand. For those readers who are versed in solution-focused
therapy (e.g., Berg, 1994), these ideas will not be new. However, the system-
atic collection of progress data via the ORS/CORS energizes and concretizes
the concepts, making them even more accessible as powerful tools for change.
As with individuals, when change is not forthcoming, or things are
worsening, it is time to have a conversation about doing something different
and follow the guidelines set forth in Chapter 3. The presence of more than
one client in the room offers the unique advantage of having just that many
more opinions to draw on to figure out what is preventing progress and how to
get things moving forward. Instead of bemoaning the complexity of working
with many clients at a time, celebrate that you now have a chance to harness
the collective energy and wisdom of an entire couple or family.

CONCLUSION

Chaos is a friend of mine.

—Bob Dylan

In couple work, PCOMS has a growing track record for improving out-
comes, as evidenced by the Norway study and its later replication (see Reese,
Toland, Slone, & Norsworthy, 2010). In addition, a large cohort study found

122       on becoming a better therapist

robust efficacy for use of client feedback with troubled youth (Cooper et al.,
2013) as well as caretakers. Family trials are the next step, but clearly the
adaptability of PCOMS across ages and modalities appears promising.
Incorporating PCOMS to guide the work with more than two in the
room, while admittedly presenting some extra challenges, ultimately facili-
tates engagement and lessens rather than increases the complexity of the
work. For all our angst about what do you do when . . . (fill in the horror story
du jour for couple/family work here), PCOMS offers an elegant and practical
way to harness the innate energy of multiple clients. Rather than just creating
more paper, the measures help organize meetings, give focus to therapeutic
conversations, and provide guideposts as therapy proceeds.

CLIENTS ARE THE BEST TEACHERS: THEIR STORIES

DOCUMENT OUR DEVELOPMENT

I always tell the truth. Even when I lie.

—Tony Montana (Scarface)

Nora was a delightful 7-year-old who suddenly started soiling herself

when she was at school. The problem had persisted through pediatrician
visits and an EAP counseling service that ultimately made the referral to
me. In the first session, I saw Nora and her mom, Kathleen, together for a
while, but Nora didn’t say much and Kathleen indicated that she wanted
to talk to me privately. So I escorted Nora to the waiting room and showed
her the toys, books, and TV. Then Kathleen expressed her concerns as well
as her belief that the encopresis was related to the death of Nora’s biologi-
cal father, who was recently killed in a car accident. Although Nora never
knew her father, Kathleen believed the death was largely responsible for
Nora’s soiling problem. As I tried to wrap my head around that, Kathleen
spent most of the session talking about how Nora had been abandoned by
her father as well as all the things that had been tried to help Nora with
the problem.
I learned a lot, but unfortunately it didn’t leave much time for Nora.
After commiserating with Nora about the toughness of her problem and
how embarrassing it was, I asked her what she thought it was about and
what she should do about it. Nora couldn’t wait to tell me about this very
mean third-period math teacher she had, Mr. Miller, who wouldn’t let
her go to bathroom. Nora said that she repeatedly raised her hand to be
excused but that he ignored her and that was why she soiled her pants.
I was appropriately indignant and told Nora that this just wasn’t right.

getting better with couples, families, and youth      123

 Unfortunately, it was time to end the session, and other clients had already
arrived. So I told Nora that we would get into this more in the next session
and figure out what to do about it.
The next week I asked Kathleen’s permission to start out with Nora
to both explore Kathleen’s hypothesis regarding the biological father but
also to hear the full story about mean Mr. Miller. We played a couple of
games together while we talked, but not much came out of the discus-
sion about her biological father. But Nora came to life when I mentioned
Mr. Miller. Nora hated this guy. With unbridled energy, she described situ-
ation after situation in which he always gave her a hard time and not
others. Mr. Miller particularly favored boys, and it was Nora who got in trou-
ble whenever boys would pick on her. She described one incident in detail
in which a boy next to her pulled her hair three times before she punched
him, whereupon Mr. Miller stood her in a corner and wrote her name on
the board. Regarding the soiling problem, Nora explained, she just couldn’t
get to the restroom in time. Mr. Miller, Nora said, allowed the kids to go to
the restroom by rows, and that was the way it was done, regardless of Nora’s
need to go quicker. Nora asked and was ignored; she waved her arms and was
overlooked; and she stood up to no avail. As Nora told me about this heart-
less teacher, she became more animated, demonstrating each of her failed
attempts to get his attention, with all the attending frustration.
I couldn’t believe what a jerk this Mr. Miller was. I asked Nora what
she thought could be done to set this guy straight, and I offered to call him
(after I talked with Kathleen) to see if I could get to the bottom of this.
But Nora had a different idea. She thought it better to have her mother
write Mr. Miller a note. She even knew what she wanted the note to say.
It was important that it properly put him in his place, essentially scolding
him and telling him that he had better let Nora go to the bathroom. This
sounded like a good plan, especially given that this solution was Nora’s and
she was participating in a meaningful way in our work together. I invited
Kathleen to join our discussion, and Nora and I presented the note idea to
her mom. Although Kathleen looked confused and a bit out of sorts, we
composed the note right there. I continually checked out what we were
writing with Nora to ensure that the note captured her sentiments. Nora
was very happy with the note and put it in her purse to take to school to
give to Mr. Miller. She skipped happily to the waiting room. The note
must have really put that guy on notice because Nora never soiled her
pants again.
But that’s not the whole story. After Nora and I shared her plan with
her mother, Kathleen asked once again to speak to me alone. She told me
that Nora’s math class was actually her fifth period and that her teacher

124       on becoming a better therapist

was a woman—in fact, Nora had no male teachers, and, finally, there
was no Mr. Miller at all in the school! Kathleen was at a loss about what to
do about this and was worried that Nora’s lie reflected deeper psychological
issues. I reassured her that children have rich fantasy lives and that I won-
dered if this was a way that Nora has devised to solve her soiling problem.
I suggested that we implement the plan anyway to see what would
happen and that we could immediately regroup if there was no move-
ment, so to speak. So this impassioned, compelling story of the malicious
Mr. Miller, with all its attending nuance and detail, was a lie, a big fat fab-
rication. But it worked. Nora defeated the poop problem. Perhaps it was
Nora’s way of “externalizing the problem” or saving face with an embar-
rassing situation, or maybe Kathleen was right and it was Nora’s way of
working through issues about her biological father and his death. Who
knows? Follow-up revealed that the problem had vanished and that Nora
had stopped talking about mean Mr. Miller.
Although one can speculate many reasons why Nora suddenly took
control of her soiling problem, the fact remains that the lie served a pur-
pose and was somehow therapeutic. Nora helped me to continue my reflec-
tion about lies and the truth in psychotherapy. Most lies are decidedly not
malicious in nature, and it may be that clients have very good reasons for
lying, and maybe, sometimes, the client is telling the truth, even when it
is a lie.

getting better with couples, families, and youth      125

 5
USING PCOMS TO ACCELERATE
YOUR DEVELOPMENT

Taking charge of your own learning is a part of taking charge of your life,
which is the sine qua non in becoming an integrated person.
—Warren G. Bennis, On Becoming a Leader

Becoming a better therapist requires you to be proactive about two

things: getting feedback from your clients and attending to your growth as a
therapist. The previous four chapters detailed how to do the former. Now it
is time to turn to your development, a critical factor that affects your ability
to do good work, as well as your staying power as a viable force for change in
clients’ lives. As the Venn diagram in Chapter 1 (Figure 1.2) illustrates, you
definitely matter in the therapy effectiveness equation.
As noted in Chapter 1, the field has not provided much help with regard
to our professional growth. Sure, we are often exhorted to take care of our-
selves and our relationships, as well as to continue our professional develop-
ment, but not much guidance is offered about how to be proactive about
becoming a better therapist. We are left to join the field’s obsession with
model and technique as the primary method of development and to hope that
the platitudes about experience making us better will hold true.

http://dx.doi.org/10.1037/14392-005
On Becoming a Better Therapist, Second Edition: Evidence-Based Practice One Client at a Time, by B. L. Duncan
Copyright © 2014 by the American Psychological Association. All rights reserved.

127
 But now there is a better way. A massive, 20-year, multinational study of
11,000 therapists conducted by researchers David Orlinsky of the University of
Chicago and Michael Helge Rønnestad of the University of Oslo not only pro-
vides a clear path to understanding therapist development but also captures the
heart of our aspirations and perhaps the soul of our professional identity. For their
book, How Psychotherapists Develop: A Study of Therapeutic Work and Professional
Growth (2005), they collected and analyzed detailed reports from nearly 5,000
psychotherapists about the way they experienced their work and professional
development. Since then, 6,000 more therapists have participated in the study as
a collaborative project with members of the Society for Psychotherapy Research.
In combination with the Partners for Change Outcome Management System
(PCOMS), their study provides a framework for accelerating your growth. This
chapter explores the implications of that massive study, integrates the findings
with PCOMS, and details how you can take charge of your development and
increase the percentage of your clients who achieve meaningful change.

TAKING YOUR DEVELOPMENT SERIOUSLY

When a man [sic] does not know what harbor he is making for, no wind
is the right wind.
—Lucius Annaeus Seneca

One of the many fascinating aspects of the Orlinsky and Rønnestad

(2005) investigation of therapist development is the consistency of response
across therapist training, nationality, gender, and theoretical orientation.
The study portrays psychotherapy as a unified field, despite what our warring
professional organizations and theories often tell us. The specific findings
reaffirm some characteristics that therapists already know about themselves
and includes new, illuminating details.
As noted in Chapter 1, therapists stay in the profession not because
of material rewards but because—above all—they value connecting deeply
with clients and helping them to improve. Orlinsky and Rønnestad (2005)
termed both what therapists seek in their professional careers and the sat-
isfaction they receive from the work they do healing involvement. This con-
cept describes therapists’ reported experiences of being personally engaged,
communicating a high level of empathy, feeling effective, and being able to
deal constructively with difficulties. PCOMS provides a means to increase
healing involvement and is a perfect fit with its definition: PCOMS ensures
that justice is done to the relationship, effectiveness is a known commodity,
and problems with either the alliance or outcome are handled in a way that
enhances client experiences.

128       on becoming a better therapist

 Healing involvement is the pinnacle of therapist development and rep-
resents us at our best—those times when we’re attuned to our clients and the
path required for positive change becomes clearly visible; those times when
we can almost feel the “texture” of our therapeutic connection and know that
something powerful is happening. But what causes this, and more important,
how can we make it happen more often?
According to Orlinsky and Rønnestad (2005), healing involvement
emerges from therapists’ sense of cumulative career development (hereafter
career development), as they improve their clinical skills, increase mastery,
gradually surpass limitations, and gain a positive sense of their clinical growth
over the course of their careers. As therapists accrue the hard-earned lessons
offered by different settings, modalities, orientations, and populations, they
want to come out on the positive end of any reappraisal of their experience.
We apparently need to feel that we are improving with experience, that we
are better than we were before.
But an even more powerful factor promoting healing involvement is
what the authors called therapists’ sense of currently experienced growth (here-
after current growth)—the feeling that we’re learning from our day-to-day
clinical work, deepening and enhancing our understanding and abilities.
Orlinsky and Rønnestad (2005) suggested that this enlivening experience
of current growth is fundamental to maintaining our positive work morale
and clinical passion, central to our very survival as therapists. According to
their study, the path to current growth is clear. It’s intimately connected to
therapists’ experiences with clients and what they learn from them, and not
to workshops and books trumpeting the latest and greatest advances in our
field. Almost 97% of the therapists studied reported that learning from clients
was a significant influence on their sense of development, with 84% rating
the influence as “high.” Apparently, therapists genuinely believe that clients
are the best teachers.
But the finding that most impressed Orlinsky and Rønnestad (2005)
was therapists’ inextinguishable passion to get better at what they do. Some
86% of the therapists in the study reported they were “highly motivated” to
pursue professional development. It appears that no matter how long they’ve
been in the business, therapists still want to learn more and get better. To the
question “Why is our growth so important to us?” Orlinsky and Rønnestad
posited a close link between healing involvement and current growth. The
ongoing sense that we’re learning and developing in our day-to-day work gives
a sense of engagement, optimism, and openness to the daily grind of seeing
clients. It fosters continual professional reflection, which, in turn, motivates
us to seek out training, supervision, personal therapy, or whatever it takes
to be able to feel that the developmental process is continuing. Borrowing a
term from Jerome Frank, having a sense of current growth “remoralizes” us,

using pcoms to accelerate your development      129

repairing the abrasions and stressors of the work and minimizing the danger
of falling into a routine and becoming disillusioned. Orlinsky said:
[It] is the balm that keeps our psychological skin permeable. Many
believe that constantly hearing problems makes one emotionally cal-
lused and causes one to develop a “thick skin.” But not therapists. We
need “thin skin”—open, sensitive, and responsive—to connect with cli-
ents. (Duncan, 2011b, p. 41)
Current growth, then, is our greatest ally for sending the grim reaper of burn-
out packing: We need to feel we’re growing, to fend off disenchantment.
Achieving a sense of healing involvement, the Mecca of therapist
development, then, requires a continual evaluation of where we are com-
pared with where we’ve been (career development), looking for evidence of
our mastery. And we must keep examining our clinical experiences, mining
our sessions for the golden moments that replenish us (current growth). The
Orlinsky and Rønnestad (2005) study contains important information about
who we are and what we have to do to remain a vital force in our clients’ lives.
It shows that our professional growth is a necessary part of our identity, as is
our need to harvest the experiences that restore and enlighten us.
But let’s do a reality check here: What is the evidence of our mastery or
our professional growth? How do we know that we are learning from experi-
ence? Consider psychologist Paul Clement, who collected outcome data over
his 26-year private practice (Clement, 1994). Impressively, he reported that
75% of his clients were rated as improved at the end of treatment. Keep in
mind, however, that this effectiveness rate did not take into account a 19%
dropout rate, and it was Clement, not the clients, who rated improvement.
More relevant to our discussion is the fact that Clement assumed that he had
improved over time—but the cold, hard reality was that, after he looked at
his effectiveness over time, he discovered that he was no more effective after
26 years of practice than he’d been as a new graduate. The belief that experi-
ence alone will ultimately lead to better outcomes or professional growth is
just as deceiving as the belief in the Holy Grail. There is only one way to know
if we are learning from experience, and that is to track outcome.
Routine collection of client feedback allows you to monitor your out-
comes and plot your career development, so you know about your effective-
ness and, especially, so you can implement and evaluate strategies designed
to improve your outcomes.

Career Development and Tracking Outcomes

Given the spreading institutional and funder pressures for accountabil-

ity (see Chapter 8), combined with the call for outcome management by
professional organizations, the collection of client-based outcome data to

130       on becoming a better therapist

guide practice will likely become routine in the near future. For example, the
American Psychological Association (APA) Commission on Accreditation
(2011) suggested that students and interns “be provided with supervised
experience in collecting quantitative outcome data on the psychological ser-
vices they provide” (C-24). APA also created a new outcome measurement
database to encourage practitioners to select outcome measures for practice
(see http://practiceoutcomes.apa.org).
For outcome management to continue to grow, its inclusion in training
programs is important. Ionita (2013), in a survey of Canadian psychologists,
identified a lack of training as the biggest barrier that prevented clinicians
from implementing outcome measures. Hatfield and Ogles (2004) found that
those clinicians who assessed outcome had received substantial training; early
training has a significant effect on practitioners’ attitudes and behavior. Many
programs across the country have implemented PCOMS and more are doing
so every day. Two members of the Heart and Soul of Change Project (my orga-
nization; see https://heartandsoulofchange.com) have published articles about
the benefits of implementing PCOMS in graduate training: Jacqueline Sparks
(Sparks, Kisler, Adams, & Blumen, 2010) at the Family Therapy Program at
the University of Rhode Island, and Jeff Reese (Reese, Usher, et al., 2009)
in the Department of Educational, School, and Counseling Psychology at
the University of Kentucky. Students are taught to use PCOMS to enhance
therapist flexibility, evaluate outcome, and improve overall effectiveness.
Additionally, many programs are using web-based software (see below) that
allows automated data entry and real-time warnings to therapists when client
ratings of either the alliance or outcome fall outside of established norms. It
also permits data to be stored and analyzed, providing a base for supervision as
well as faculty and student research. Most important, student therapists
and clients receive immediate feedback about therapy progress, enhancing
student learning, client engagement, and ultimate outcomes. Some of the other
programs (including contact person), exemplifying the major disciplines,
are the Graduate Psychology Programs at Our Lady of the Lake University
(Joan Biever); the School of Social Work, University of New England
(Danielle Wozniak); and the School of Humanities and Communication,
College of Counseling, Columbia International University (Harvey Payne).
Consider the benefits for these budding clinicians and for you when
you decide to monitor your outcomes over the course of your career. You will
actually know how you are doing, without conjecture, in direct contrast to
the way things have been to this point. You will not be in the dark about your
effectiveness and suffer the same fate as Clement above or the clinicians in
the Dew and Riemer (2003) and Walfish, McAlister, O’Donnell, and Lambert
(2012) studies, reported in Chapter 1, who only had their fantasies to under-
stand their effectiveness. Take the guesswork out of the equation. Becoming a

using pcoms to accelerate your development      131

better therapist is a proactive process. When you know how effective you are,
you can plan, implement, and evaluate strategies to improve your outcomes.
In short, tracking your career development permits you to learn from your
experience, not repeat it.
And there is good reason to believe that it will help you get better.
Another finding in the Norway Feedback Trial is germane to the purpose of
this chapter. First, recall that nine of 10 therapists benefited from PCOMS.
The effect of feedback, however, varied significantly among therapists. The
less effective therapists (those with the worst outcomes without PCOMS)
benefited more from feedback than the most effective therapists. Feedback,
therefore, seems to act as a leveler among therapists, raising the effectiveness
of lower or average therapists to that of their more successful colleagues. In
fact, one therapist in the low-effectiveness group without PCOMS became
the therapist with the best results with feedback. We return to the lessons
learned by this Norwegian therapist later in the chapter. For now, this finding
provides a hopeful implication: Regardless of where you start in terms of your
effectiveness, you, too, can be among the most successful therapists.

Charting Your Career Development

Getting an accurate look at your development isn’t complicated or

expensive. You can start by simply entering your Outcome Rating Scale
(ORS) data into an Excel file and tracking outcomes over time with calcu-
lations available in Excel: average intake and final session scores, number
of sessions, dropout rates (more on this later), average change score (the
difference between average intake and final session scores), and, ultimately,
the percentage of your clients who reach reliable and/or clinically significant
change (RCSC; see Chapter 3), and your effect size (ES). These easy-to-
calculate performance indicators provide a detailed look at your develop-
ment over time. You may also include client demographic information if you
are interested in finding out which clients benefit the most and least from
your services.
Average change provides a ready snapshot of how things are going. If
your average change is 6 points or thereabouts, that’s great. It means that on
average your clients achieve reliable change from their encounters with you.
The percentage of your clients that achieve RCSC provides a quick and eas-
ily understood metric of your effectiveness. This is a good way to track your
development over time. ES is another way to understand change that sounds
a lot more technical and complicated than it really is. A simple pre–post ES
is just the average difference between the first and last session ORS scores
divided by the first session standard deviation (SD) of the ORS (Excel will
calculate the SD of your clients at session 1 and the ES, or you can use 8 as

132       on becoming a better therapist

the SD). The usual reported ES of psychotherapy is 0.8 and the usual reported
control group ES is 0.2 (accounting for the often heard comment that the
therapy is four times more effective than no therapy). If you are anywhere in
the neighborhood of .8, then you are in the all good range. Excel is a great
way to start and will even plot ORS scores on a graph so that you can discuss
progress in therapy with your clients. I tracked my outcomes with clients for
many years with Excel before a software program was available.
There are easier ways to track your outcomes and career development,
but they do involve some cost. First, if you work in an agency, you likely use
some variety of electronic health record (EHR). These programs often have
open data fields as well as graphing and data analysis functions. You could
consult with your IT department or the EHR company to see if you can
enter ORS scores, graph them, and aggregate the data to give you your aver-
age change, percentage reaching reliable change, and effect sizes. This could
involve programming costs. Of course, such a system would not administer
the measures or include the algorithms discussed in Chapter 2.
Then there are the web-based systems of tracking outcomes. But first
let me say that there is a conflict of interest here. I have a financial relation-
ship with the products I am about to discuss. Please keep this in mind as you
evaluate whether either of the two systems is for you. Also know that there
are other electronic outcome-tracking systems available using other measures
(see Castonguay, Barkham, Lutz, and McAleavey, 2013, or Lambert, 2010,
for a review). The first system is BetterOutcomesNow.com. I am a partner in
this business that provides a web-based application of PCOMS. And I also
license another company, MyOutcomes.com, which translates PCOMS to a
web-based application. Here I receive a royalty based on sales. Both systems
use the recently developed algorithms, administer the measures, compare the
­client’s progress to the expected treatment response (ETR) based on the intake
score, graph the scores, and aggregate the data at individual and agency levels.
MyOutcomes.com also provides feedback messages and suggestions, written
specifically to clients, geared toward informing clients of their progress.
More relevant to tracking outcomes and your career development, both
systems enable a wide range of data collection and statistical reporting pos-
sibilities for individual practitioners and organizations. Both offer the ability
to mine your data according to many parameters of time and performance.
The single bit of information that is likely to be the easiest to understand and
use is the percentage of your clients who reach the target. That is simply the
percentage of clients who reached or exceeded the average change trajectory,
or ETR, for clients entering services with the same intake score. The target
score is the maximum score on the ETR line.
BetterOutcomesNow.com also calculates the percentage of your clients
who attain reliable or clinically significant change. Tracking percentage of

using pcoms to accelerate your development      133

target and RCSC (either or both) provides an ongoing commentary about
how effective you are. I encourage you to evaluate both systems as well as
other options to find the best match for your particular needs and budget.
A brief word about dropouts: Dropout is a rather pejorative description. It
places the onus on the client and essentially blames him or her for not attend-
ing some unspecified number of sessions. Client benefit seems a far better way
to look at clients who have not returned for service. What we are trying to
avoid is the client who discontinues service in an unplanned way, without
experiencing reliable change or the ETR target. If it’s planned, then we have
referred the client on to greener pastures; or, in terms of healing involvement,
we have dealt constructively with an encountered difficulty. If it is unplanned
but the client reached target benefit or reliable change, then that is okay, too.
Of course, this doesn’t include those clients who attend only one ses-
sion. Some of these clients may have gotten what they were looking for, but
some did not. The intake ORS score is telling. If the client was above the
cutoff and didn’t return, it is likely that he or she received all the services
required; however, if the client scored under the cutoff, it may be that he or
she didn’t receive services that were satisfactory. A phone call or e-mail to
these clients may prove helpful in understanding why they did not return, as
well as obtaining information about how to categorize it for your records. It
also offers an opportunity, if the client didn’t get what he or she wanted, to
invite the client in for another try with you or someone else.
Now you are ready to take charge of your career development. Simply
track your effectiveness over time in any way that makes sense to you, either
time increments (e.g., by quarter or annually) or by number of closed cases
(e.g., 30 most recent closed cases vs. previous 30 closed cases). For confidence
in the results, 30 is probably the minimum number. Also plot your unplanned
terminations that did not reach reliable change or ETR targets. Tracking your
outcomes in this manner allows you to consider your development and to
strategically implement ideas, practices, and models, as well as to build skills
to improve your effectiveness. You will readily see whether your efforts are pay-
ing off, and if your chosen methods need to be tweaked or changed outright.
Consider one example that illustrates what can happen when you mon-
itor outcomes and take a proactive stance about your career development.
Certified Trainer Morten Anker has been collecting outcome data since
2005. In 2006, 50% of his couple clients reached ETR and in 2013, 62.3%
attained the ETR target. When asked how the improvement occurred, he sug-
gested a combination of factors, some general and some specific. Generally,
he thought that being more focused on his development and reflecting more
about what could done differently with at-risk clients was a major contribu-
tor, as well as simply knowing that he was monitoring outcomes, pushed him
to stretch himself. Specifically, and largely based on the recognition of clients

134       on becoming a better therapist

who were not benefiting, he sought out training in two areas: a more proac-
tive search for and application of couple strengths to address their relational
concerns and the ability to intervene and provide empathy with couple affec-
tive experiences with those clients who were more emotionally oriented.
And the result: Not only measureable improvements in effectiveness but
also a new take on his work. Anker has reported that he feels more confident
in bringing different ideas and working styles into action, thereby accom-
modating more couples. He concluded by saying, “It’s a strange mixture of
being confident, uncertain, and humble. . . . Believing in my own skills and
that somehow, in this foggy, uncertain ground something useful and good for
clients will come of it” (M. G. Anker, 2013, personal communication).
At some point in time, your growth in effectiveness will slow down and
eventually you will plateau. That is perfectly okay. And don’t get freaked out
if you are not as effective as you thought or think you should be. Be realistic.
For example, Okiishi et al. (2006) looked at the effectiveness of 71 therapists
who saw at least 30 clients for a total of 6,499 clients. Using the Outcome
Questionnaire 45.2 (OQ) system as the outcome measure, the authors con-
trasted the top and bottom 10%, the most and least effective therapists. The
clients of the top 10% changed nearly 3 times more than the bottom 10%.
More germane to what you should expect, the top 10% most effective thera-
pists achieved a reliable and clinically significant change rate of 43.9%, while
the bottom 10% attained a 28.0% rate. So don’t beat yourself up if you are less
than 50% reaching target or RCSC. Most of us are. Keep in mind that you
are including all your clients (except one-session clients) and not just com-
pleters, as most studies do. Also recall that you are now dealing constructively
(failing successfully) with those clients who are not reaching target.

Bottom Line: Charting your career development and implementing strategies

to improve your effectiveness puts you in charge of your growth as a therapist.
Making your career development a central consideration will likely increase
your sense of healing involvement, accelerate your growth, and benefit your
clients. Whatever your effectiveness is, don’t stress.

CURRENT GROWTH

It’s not what you look at that matters; it’s what you see.
—Henry David Thoreau

According to the Orlinsky and Rønnestad study (2005), the most p­ owerful
influence on your development is your perception of your current growth, your
here-and-now sense of ongoing improvement in your understanding and ability

using pcoms to accelerate your development      135

to do this work. Recall that therapist experiences of current growth are mainly
influenced by the quality of their clinical work with clients. Learning from cli-
ents was consistently endorsed as the most influential factor impacting current
growth, with the exception that supervision won by a nose for novices. But your
involvement is required; you have to keep your head and heart in the game
despite all the reasons—like unrealistic productivity requirements; mountain-
ous, meaningless paperwork; and gut-wrenching client circumstances—that
conspire to have us give up on ourselves and accept monotony and negative
outcomes. This is where client feedback can really help us.
Tracking your outcomes gives you a big-picture view of your career devel-
opment and a microscopic view of your current growth. Looking at who is and
isn’t benefiting offers opportunities for learning what is working and what is
not; you also can glean much from how you turn things around for the clients
who are not benefiting, and how you manage “failing successfully.” Your reflec-
tions and discussions with colleagues and supervisors, as well as with clients,
will permit you to squeeze all the learning out of each situation. There is much
there to be had, and attending to feedback can help you make the most of it.
Clients provide the opportunity for constant learning about the human
condition, different cultures and worldviews, and the myriad ways in which
people transcend adversity and cope with the unthinkable. But, although we
learn a great deal almost by osmosis from our clients, tracking outcomes takes
the notion that “the client is the best teacher” to a different, higher, and more
immediately practical level. Tracking outcomes with clients not only focuses
us more precisely on the here-and-now of sessions, it takes us beyond mere
intuition and subjective impressions to quantifiable feedback about how the
client is doing. We get unambiguous data about whether clients are benefit-
ing and whether our services are a good fit for them. From their reactions
and reflections, we receive information that we can use in figuring out the
next step to take in therapy. This in vivo training promotes the expansion of
our theoretical and technical repertoire. In short, tracking outcomes enables
your clients—especially those who aren’t responding well to your therapeutic
business-as-usual—to teach you how to work better. In fact, clients who aren’t
benefiting offer us the most opportunity for learning by helping us, actually
demanding, that we step outside of our comfort zones.
Start by collecting the graphs of all of your current clients. Separate
the graphs into two piles: clients who are benefiting and clients who are not.
Consider the following, with regard to the clients who are benefiting:
77 What is working with these clients?
77 What is client feedback telling you about progress and the
alliance?
77 How are you interacting with these clients in ways that are
stimulating, catalyzing, or crystallizing change?

136       on becoming a better therapist

 77 What are these benefiting clients telling you that they like
about your work with them?
77 What are they telling you about what works?
Also consider the clients who are not benefiting:
77 What is working in the conversations about the lack of progress?
77 What is client feedback telling you about progress and the
alliance?
77 How are you interacting with these clients in ways that open
discussion of other options, including referral?
77 What are these not-benefiting clients telling you that they like
about how you are handling these tough talks?
77 What are they telling you about what works in these discussions?
77 What have you done differently with these not-benefiting cli-
ents? How have you stepped out of your comfort zone and done
something you have never done?
The idea here is to consider the lessons that clients are teaching us
in their feedback via the ORS and the Session Rating Scale (SRS) and to
more proactively reflect about these lessons and their importance to our
development. Recall the anonymous Norwegian therapist who became the
best therapist in the group after using feedback. Here are her reflections
about her current growth after adding PCOMS to her work:
Feedback helped me be more straightforward, more courageous. I
inquired more directly about what we could do together. I conveyed more
of a sense of security, knowing that clients would set me straight. Clients
taught me how to handle it when I was not useful. I never had this infor-
mation before, so I didn’t have this opportunity.

***
Clients and I reflected more on their changes and on the sessions. We got
more concrete regarding change, how it started, and what else would be
helpful. PCOMS helped me to be more to the point and focused.

***
ORS feedback pinpointed that we have a common responsibility. I
seemed to carry too much of the load before. Shared responsibility
engages clients more.

***
PCOMS helped me take risks and invite negative feedback. So, I asked
for it, showed I could handle it, validated it, and then incorporated it in
the work. That is what it’s all about, real collaboration.

using pcoms to accelerate your development      137

 ***
It made things visible, more tangible. I used the graphs. Clients had to
reflect more, and it even challenged them. The graphs brought more
clarity—I could refer to the graph and say, “What did you do here at this
point where things were better?”

***
All in all, PCOMS made me feel more secure and I was more in tune with
what was happening. I am now more collaborative and allow things to
emerge rather than following a set way to work. I definitely dared more,
and did new things. Clients were always there to bring me back in. I
would say, “If you hadn’t told me that, this therapy wouldn’t work.” It
always seemed vague before, without the feedback.
The therapist noted several things that feedback brought to her work
and what she had learned from her experiences with clients: the value of clar-
ity and focus, of shared responsibility, purpose, and true collaboration—and,
important, a sense of security and the courage to take risks, allowing uncer-
tainty to be part of the work (more on that in Chapter 7). Her development
seemed to be accelerated by her attention to how feedback enhanced her
work—her sense of current growth.
Learning from your experiences applies not only to PCOMS but also
to your work in general; any differences can be important markers that can
accelerate your development. Just as Chapter 3 detailed the process with
clients, you can empower yourself by noting your changes, putting a magni-
fying glass on them, and understanding how you were able to pull them off.
Recognize that these improvements depict a new chapter in your develop-
ment as a therapist. Perhaps you did something for the first time with a client,
or a light went off and you now understand something in a different way.
Maybe, because of a client presentation or request, you applied an explana-
tion and solution that you previously had only denigrated. Or perhaps you
noticed that you were bit more keen, engaged, and interactive when the
conversation moved in unplanned ways. When you articulate what is differ-
ent about your work, you make it more real and are more likely to continue it
in the future, so it is important to clearly detail what you are learning as you
go along. Take the time to tease out your new insights and methods as you
examine your current clients. Ask yourself these questions or any others that
help you make sense of your current growth:
How is it different from what I would have done before?
What are the before-and-after distinctions?
How am I going to continue with the strides I have taken?
How was I able to be different this time?

138       on becoming a better therapist

 Was it planned or just emerged? Is this a new pattern for me?
What does this change say about my development as a therapist?
What does it say about my identity as a therapist?
Routine collection of client feedback provides similar benefits for both
therapists and clients. Using the measures helps you and the client clarify
goals, close out distractions, and find out for sure how things are going.
PCOMS sets apart a period of time in each session and allows you to test your
assumptions and adjust to client preference, allowing you to master new tools
and learn new ideas. Perhaps, also, acquiring client feedback and experienc-
ing your current growth may encourage you to enjoy your craftsmanship for
its own sake. When you are enjoying the work of psychotherapy for its own
sake, I believe it is likely that your clients are benefiting. This may be what
the art of therapy is about. And, as the Norwegian therapist who went from
nearly worst to first aptly illustrates, securing PCOMS places you in an accel-
erated course of development, bringing your current growth to light in ways
that can help you write new chapters in your story about being a counselor.

Bottom Line: Orlinsky and Rønnestad (2005) asserted:

We strongly recommend that practitioners of all professions, career levels,
and theoretical orientations give careful and serious attention to their current
work morale as reflected in their ongoing sense of development as psychothera-
pists. (p. 196)

THEORETICAL BREADTH

Believe those who are seeking the truth; doubt those who find it.
—André Gide

Orlinsky and Rønnestad (2005) also identified theoretical breadth as an

important influence on healing involvement, although less so than career
development or current growth. They suggested that understanding cli-
ents from a variety of conceptual contexts enhances therapist flexibility in
responding to the challenges of clinical work. Indeed, therapists at every
career level who combined several theoretical orientations tended to have
greater amounts of career development. Integrative–eclectic practitioners
were the “most growing” therapists—a good reason to take the plunge in
many conceptual pools.
This makes sense. Possessing a range of understandings of client prob-
lems as well as possible methods to address them allows therapists to expe-
rience healing involvement more often with more clients—a suggestion in
line with what the eclecticism/integration movement has been telling us all

using pcoms to accelerate your development      139

along (e.g., Norcross & Goldfried, 2005; Stricker & Gold, 2006). PCOMS can
help here. Tailoring your approach based on client feedback will lead you to
more theoretical breadth as you expand your repertoire to serve more clients.
PCOMS enhances your ability to be tuned to client preferences and encourages
your flexibility to try out new ideas in search of what resonates with clients—
opening you to a range of theoretical explanations and attending methods.
Therapist allegiance to any particular theoretical content involves a
trade-off that enables and restricts options. Theoretical loyalty provides a
clear direction but is inherently limiting; cookie-cutter therapy is much easier
and safer to do, but will be useful for only a portion of the people you see.
This realization is the raison d’être of psychotherapy integration/eclecticism,
which continues to dominate how therapists understand and conduct clinical
work (Lambert, 2013). Stricker and Gold (2006) suggested that, counter to
manualized therapy, which might perhaps be described as “theoretical loyalty
on steroids,” integration/eclecticism is synonymous with psychotherapeutic
creativity and originality. In short, therapists’ preference for more eclectic
integrative practices speaks to their desire to foster what works with the cli-
ent in the office now.
Allegiance to any theoretical dogma can also be unwittingly oppressive.
Theories are not neutral; they were created by someone, and that someone
(or some persons) did not channel truth but operated within his or her own
social location—meaning gender, race, ethnicity, social class, sexuality, and
historical time—with all the biases that go with it. By valuing theoretical
flexibility, we are less likely to try to force a model on someone whose life
experiences and view of reality may be quite different from our own.
One by-product of this increased theoretical breadth is in helping us
let go of the idea of Truth with a capital T, so that we respect and utilize the
unique worldview, culture, and preferences of each client. This means that
you have to grapple with the “truth” value that you may have ascribed to your
favored theories. You may have to challenge yourself when you think theories
represent how people really are and what people have to do to realize benefit
or make changes.
We probably can hold, at most, only two or three systems of therapy in
our heads at one time. However, we can access far more frames or explana-
tions of the difficulties that clients bring to therapy. But to do that, we have
to open ourselves to Jerome Frank’s observation that the important stuff that
models offer is not their inherent truth across clients but, rather, a rationale
for the client’s problem and a ritual to solve it (Frank, 1973). Knowing that
all models can be boiled down to an explanation and remedy makes them
far easier to get a handle on and try out—not the arduous 2 years of inten-
sive supervision to understand or implement that is often portrayed. But you
might want to keep that to yourself.

140       on becoming a better therapist

 In their provocative chapter about model and technique in The Heart
and Soul of Change, Anderson, Lunnen, and Ogles (2010) concluded:
Clearly, the “truth” of any model and associated strategies is not critical
to success. Rather, each merely offers an opportunity for engagement of
the client and therapist in a process that promises to be helpful. . . . The
implications for treatment are clear. Clinicians not only need to be aware
of the many meaningful cultural myths available, but [also to be] open to
altering techniques, style, and approach in order to achieve a better fit
with the client. (pp. 146, 148)
So how does one broaden theoretical horizons or remain open to “the
many meaningful cultural myths available?” First, pay attention to those
theories that just plain make sense to you: the ones that fit your own views of
human nature, problems, and solutions. Expand what you already know. For
example, the interactional approach particularly rang true for me (thanks to
an early mentor, Scott Fraser). That affinity led me to embrace the myths and
rituals of other similar approaches over the years—like Eriksonian, solution
focused, language-based, and narrative therapies—which, although different
from one another, generally come out of the same camp. Another early men-
tor, Steve McConnell, an existential psychotherapist, introduced me to the
humanistic perspectives that opened me up to the likes of Rogers, Bugental,
and Yalom. Finally, my stress management experience during my internship
under the supervision of Fred Ernst and Joe Rock allowed me to see the ben-
efits of behavioral and cognitive–behavioral ways of working. With each new
understanding, I became more flexible in my approach, could consider more
options, and had more things to bring to the table for discussion with cli-
ents. It also allowed what Rønnestad and Skovholt (2013) called continual
professional reflection, a more seasoned way to embrace the lessons of clinical
experience. Perhaps most important, I, like many modern eclectic therapists,
became aware that all approaches have validity—they are but metaphorical
accounts of how people can change in therapy—and became open to the
advantages of many theoretical perspectives.
PCOMS can assist us to broaden our theoretical horizons. Lack of
change on the ORS sounds the alarm and stimulates a reconsideration of any
approach we are using and stretches us to add new ideas to our repertoire.
The Approach scale on the SRS encourages a frank discussion with the cli-
ent about the fit of our methods and the impetus to find ways that resonate
more with the client and encourage his or her participation. Navigating the
waters outside our safe therapy harbors allows new discoveries for us and our
clients.
Another way to expand your theoretical repertoire is to listen to your
client’s ideas and throw your self-consciousness to the side—let the cli-
ent’s theory be your theory with that client. Tailoring your approach to

using pcoms to accelerate your development      141

your client’s ideas provides opportunities for expanding your theoretical
breadth. This may not be so easy to do if a client’s ideas rub you the wrong
way. For example, at one time I was biased against any historical expedition
into clients’ lives. I didn’t like the archeological focus of that approach and
strongly believed that it promoted the view that clients were victims of their
past. I was rigid in my thinking here, and while I didn’t know it, I’m sure
I lost plenty of ­clients because of it. I likely didn’t “hear” what these folks
were asking for, so I didn’t secure an agreement about the tasks of therapy.
Then one day, a young woman, Claire, told me that she had been sexually
abused as a child and that she wanted to pursue therapy based on a “Courage
to Heal” ­framework, a very popular approach back in the 1980s. I immedi-
ately b­ ristled and offered to refer her to therapists who I knew did “that kind
of work.”
But, to the benefit of my development as a therapist (not to mention
Claire’s progress in therapy), she didn’t accept my refusal. She told me that
a close friend of hers (who also had been sexually abused) had seen me,
and Claire was convinced that I was the person for the job. Claire asked,
“Couldn’t you at least look at the book and give it a try?” Essentially, she
shamed me into stepping outside of my comfort zone, and it was incredibly
rewarding. We followed the workbook, I shared my concerns along the way,
and Claire greatly benefited from the work—which was her own idea of how
she could be helped. Her toughest task was to get me on board. The Courage
to Heal approach provided a rationale for Claire’s experience of problems
and a remedy to address them. I learned that if the approach resonates with
the client, it is the least I can do to believe that it can help. Claire helped
me learn that theory has value only in the particular assumptive world of the
participants—the client and therapist—and that theory need not be “true”
across clients; rather, any theory needs only to be valid with this client in my
office now. This realization led me to pursue and incorporate any understand-
ing that made sense to the client.
Client problems also offer a rich area to explore for explanations and
solutions. For example, if a client presents with symptoms of trauma, or if you
tend to see a lot of clients with that presentation, it makes sense to explore
the many approaches that have been successful and offer the one that better
fits the client’s sensibilities about change, preferences, and culture. You can
boil down all of these approaches to their essence, a rationale and remedy,
and attempt to apply the ideas. And if it is your first time applying a particular
myth and ritual, just tell the client and ask for his or her help. Clients tend to
enjoy the collaborative adventure of the endeavor; if they don’t, offer to refer
them on. Put yourself out there a bit more.
Finally, be proactive in adding theoretical dimensions to your work.
Become familiar with many ways of understanding problems and solutions.

142       on becoming a better therapist

Play “on the other hand” games with your colleagues. When someone presents
an explanation about a client difficulty, first ensure that the client’s perspec-
tive is thoroughly represented, and then encourage everyone to present alter-
native myths and rituals. Then turn the discussion toward which description
may represent the better fit with the client. Talking with your colleagues about
varied rationales and remedies will benefit everyone’s work. It is also fun.

Bottom Line: Proactively seek an understanding of many different rationales

and remedies, in addition to learning some systems in detail. Take theoretical
risks. Your theoretical plurality will serve you and your clients well.

CONCLUSION

It is not the strongest of the species that survive, nor the most intelligent,
but the one most responsive to change.
—Charles Darwin

This chapter presented the three pathways to Orlinsky and Rønnestad’s

(2005) empirically derived concept of healing involvement, the therapist’s
pinnacle of development. Tracking your career development via PCOMS
data was presented as taking the guesswork out of your growth and ensuring
that you do, indeed, benefit from your experience over time and not merely
repeat it. Using your outcomes as the ultimate arbiter of your growth also
provides a way to evaluate the different skills and methods you implement
to improve your effectiveness. Different methods of calculating your effec-
tiveness were discussed as well as available systems of data collection and
analyses. The primary pathway to accelerate your development, your current
growth, was also presented. Keeping your finger on the pulse of your day-to-
day encounters with clients has a big payoff, influencing not only healing
involvement but also your morale and ability to stay vital in the face of the
everyday demands of the work. Detailing once again a proactive process in
which you need to take charge, I suggested that you systematically examine
your work with your current clients and apply a strategy of empowerment and
reflection to harvest the lessons of clinical experience. Finally, it was recom-
mended that you drop the belief in the “truth” value of any given approach
in favor of adding many valid myths and rituals to your repertoire. When your
therapeutic business as usual isn’t working for the client, you’ve been offered
a great opportunity to become a better therapist. I encouraged you to pay
attention to your client’s theories, lose your self-consciousness, and try out
differing perspectives and techniques to both find the best fit for the client
and expand your theoretical horizons.

using pcoms to accelerate your development      143

 CLIENTS ARE THE BEST TEACHERS: THEIR STORIES
DOCUMENT OUR DEVELOPMENT

Forget about style; worry about results.

—Bobby Orr

A self-described agoraphobic, Fred left the house only for our ses-
sions, and then only when accompanied by his wife, who stayed in the
waiting room. When he was a long-haired, 19-year-old college student,
Fred had been arrested in an auto-wrecking yard in rural Texas, trying to
steal parts for his broken-down Toyota. In the local county jail, he suffered
multiple rapes and beatings, setting in motion a chain of events that led to
a term in state prison and a stay in a state psychiatric hospital. He’d been
deeply agoraphobic ever since and was the veteran of numerous unsuccess-
ful psychiatric treatments and years of psychotherapy.
In our first session, Fred made only a few brief references to this
history. In fact, most of our conversation was devoted to shooting the
breeze about basketball—the NCAA finals were in full swing and we were
both fans. Fred became very animated as we discussed the various teams,
coaches, and players, and I enjoyed his perceptions and his company. In
each session, we spent more and more time talking about basketball and
less and less about agoraphobia. By the end of the fourth session, though,
I was wondering whether we were ever going to talk about anything else.
So, primarily because I thought we ought to be doing something, I asked
Fred to construct a list (a desensitization hierarchy) of the things he would
like to be able to do, ranking them from the most difficult to the least dif-
ficult. I was happy now because I thought we had a focus and direction,
and I could introduce relaxation, imagery, and covert rehearsal over the
next couple of sessions.
Fred returned for the fifth session. The NCAA final game was over
and we both played Monday-morning quarterback for about 30 minutes
before I asked Fred for the list. He handed it to me, not missing a beat in
discussing the game. Out of 20 items, his three most difficult contemplated
actions were: going to the bank, going to the dentist, and going to the
mall. Although I didn’t comment, I noticed that there was a checkmark by
each of those items. Finally, in a break in the action, I asked Fred what the
checkmarks meant. He casually replied that he’d accomplished all three. I
almost jumped out of my chair, but Fred wanted to return to talking about
the game. So, in the interstices of our basketball conversation, I asked
him what the achievement of these goals meant to him, where he thought
these changes might lead, and what might keep them going.

144       on becoming a better therapist

 In the following weeks, we kept talking mainly about things we both
enjoyed—sports, antiques, camping, and the wilderness. On the margins of
these talks, Fred told me he wanted to exercise and started thinking aloud
about sports he might take up. He also wanted to contribute financially
to his family, which depended on his wife’s modest income as a software
analyst while he took care of their young daughter. Such discussions took
no more than 10 minutes of every session. By the eighth session, Fred had
begun a jewelry business in his garage, regularly ran errands in town, and
had taken up mountain biking.
In Fred’s last session, his 10th, he looked back and talked to me about
all the times we’d shot the breeze. He didn’t even mention the desensitiza-
tion hierarchy, which never became part of the work (given Fred’s audacity
to change before the intervention was implemented). He told me that I
was the therapist who had really understood him. The others, he said, had
cut off his attempts at conversation to focus on his problems—they were
too “clinical.” Fred also said that he valued talking to me man to man, and,
though he realized that I was not his friend, it felt good to connect in that
way nevertheless.
Fred taught me that it was the relationship that counted, and our
potential influence on the client’s evaluation of the alliance was the magic
technique I’d always dreamed of finding. This doesn’t mean I’m suggesting
enshrining “shooting the breeze” as the newest Holy Grail—not all clients
want to spend their sessions talking about basketball. It does mean that it is
important to listen to what clients want and to engage them in the process
of making a difference in their lives. Previously, I’d thought of this sort of
wooing as a precursor to the real business of therapy—much as “foreplay”
was once defined as something separate from the real stuff of sex. Now, I
realized that the alliance was, in fact, the therapy.

using pcoms to accelerate your development      145

 6
tHE HEART AND SOUL OF CHANGE

From the moment I picked up your book until I laid it down, I was
convulsed with laughter. Someday I intend reading it.
—Groucho Marx

I admit it. I am a snob. Not about money, possessions, wine, food, coffee,
social status, or anything like that. I am a snob about psychotherapy, the work
I love, and about who teaches me about it. And I always have been. When I was
graduate student, a professor proclaimed, “Ninety percent of the patients you
see in CMHCs [community mental health centers] are borderlines.” I worked
at a CMHC at the time and thought his comment reflected a jaundiced view
of clients, so I asked him how many clients he had seen in CMHCs. The
answer—zero, nada, zilch, none. I wasn’t impressed and didn’t do much to
hide it (which I wouldn’t recommend to you graduate students out there).
I became very aware of the clinical experience of those teaching me.
I continued my psychotherapy elitism when I was at the Dayton Institute
for Family Therapy, a training center where I was privileged to work side by
side with some very talented folks, one of whom was my friend and colleague,
Greg Rusk. We were both in-the-trenches guys who liked to consider ourselves
“thinking therapists,” and we often went to workshops together, read the

http://dx.doi.org/10.1037/14392-006
On Becoming a Better Therapist, Second Edition: Evidence-Based Practice One Client at a Time, by B. L. Duncan
Copyright © 2014 by the American Psychological Association. All rights reserved.

147
same books about therapy, and spent many late evenings after our one-way
mirror trainings in vigorous conversation. What emerged from these lively
exchanges was the recognition that we were kindred-spirit snobs. We grew
weary of folks telling us how to do therapy who really didn’t do much of it
themselves.
Some of the biggest workshop stars, in fact, have minimal therapy
experience, and some have not held one full-time therapy gig—they pretty
much went from graduate school to doing workshops based on the luck of
associations with celebrities in the therapy field and/or their ability to put on
a good show. Entertainment is huge in the workshop business; some presenters
play instruments, do magic tricks, and incorporate physical comedy into their
schtick. I don’t mean there isn’t any substance to any of them. In fact, many
useful frames for practice have come from these spinmasters. But that’s what it
tends to look like over time: not evolutions of the work but new performances
and frames to sell.
On the other side are the researchers. I have an abiding respect for
research and for the folks who do it. I know firsthand that it is indeed a
herculean task to conduct research and publish it, especially in top-tier journals.
Research should inform practice and be consumed by clinicians—and trans-
lated by clinicians. This has been a core goal of mine since I attempted the
translation of common-factors research in my first book, Changing the Rules
(Duncan, Solovey, & Rusk, 1992). So, I’m not saying that there isn’t much to
learn from researchers. But research needs to pass the through a final clinical
filter. When you get two or more people in the room in an endeavor to make
a meaningful difference in someone’s life, the research needs to resonate with
the work itself and the people doing it.
This chapter brings my voice as a therapist to join in hopeful harmony
with the best of what research has to offer. This chapter picks up on the
discussion of career development and offers empirically based suggestions
that have passed through a clinical filter for improving your work. Although
traditionally the field has urged us to search for the Holy Grail to enhance our
effectiveness, there has not been much return for our efforts here. Psychotherapy
is no more effective now, with all our treatment technologies (400 of them)
and evidence-based treatments (almost 200 of them), than it was 40 years ago.
Nevertheless, although adding models and techniques to your repertoire may
show minimal gains on career development in the short run, your accumulation
of theoretical breadth will ultimately serve you well.
So it is perfectly fine to put time into learning models and techniques,
but it may make more sense to also focus your efforts on the areas that will
bring you the biggest return on your investment: on the factors of change
commensurate with the amount of variance they account for. Here is where
the research about the common factors pays dividends. Recall from Chapter 1

148       on becoming a better therapist

that the client accounts for the overwhelming majority of the variance of
outcome, and that the Gassmann and Grawe (2006) study suggested that
those therapists who spend more time in resource activation as opposed to
problem activation attain better outcomes. Securing clients’ participation and
rallying their resources are good places to start, and this chapter demonstrates
some ways you can harvest client strengths in the service of client goals. This
chapter also embraces the enormous body of evidence supporting the power of
the alliance, translating that research to deepen your appreciation of its potent
impact on outcomes.
In short, Chapter 6 brings you the heart and soul of change. The strength
of what the client brings to therapy and the impact of the alliance on outcome
inspired the title of both this chapter and the book I coedited about the
common factors (Duncan, Miller, Wampold, & Hubble, 2010), as well
as the organization of therapists, professors, and researchers that I direct.
The client’s resources and resiliencies and the therapeutic alliance together
represent the heart and soul of therapy. Your focus on these primary sources,
in conjunction with the Partners in Change Outcome Management System
(PCOMS), I believe, is the best way to accelerate your development.

RALLYING CLIENTS TO THE CAUSE: THE HEROIC CLIENT

Until lions have their historians, tales of hunting will always glorify the
hunter.
—African Proverb

I hate to tell you, but we have been the hunters in the above proverb.
After all, how many books have you read about great clients? As I mentioned
in the preface, I chose the word heroic for a previous book to highlight the
client’s contribution to outcome as well as the field’s propensity to see the more
“unheroic” sides of those we serve (see Duncan, Miller, & Sparks, 2004). I also,
via a literary device, wanted to expose psychotherapy’s hidden assumptions:
the heroic psychotherapist, a knight in shining armor riding high on the
white stallion of theory, brandishing a sword of evidence-based treatments,
ready to rescue the helplessly disordered patient terrorized by the psychic
dragon of mental illness. Hyperbole aside, the client’s role in change has been
significantly dismissed, whereas the therapist’s part in change as the expert
steeped in theory and technique has been greatly exaggerated. We do play
a significant role in change, but we are not knights in shining armor. Using
PCOMS allows clients to be the historians of their own change, central players
in the psychotherapeutic process, and it permits you to be the historian of your
career development.

the heart and soul of change      149

 You can cast clients as the primary agents of change in two ways. The first
way is by believing in your clients and expecting that your outcomes will be
enhanced when clients take the leading role. The second way is by listening
for and being curious about clients’ strengths and competencies: hearing
the heroic stories that reflect their part in bouncing back from adversity,
surmounting obstacles, and initiating action. Although there are many ques-
tions you can ask to catalyze such conversations regarding client abilities, as
well as several “strength-based” approaches to draw on, there is no formula here;
the key is your attitude regarding the client’s inherent abilities and resiliencies.
Attending to heroic stories requires a balance between listening empathically
to difficulties and being alert to evidence of strengths that you know are there—
to resonate with despair but refuse to succumb to it (Duncan et al., 2004).
This does not mean ignoring pain, being a cheerleader, or glossing
over tough issues. Rather, it requires that you listen to the whole story: the
suffering and the endurance, the pain and the coping, the desperation and
the desire for something different. Listening for heroic stories only suggests that
you open yourself to the existence of several competing descriptions about
the client’s experience. Diagnosis tells but one story; a problem description
tells another. Many other tales of survival and courage simultaneously exist.
Human beings are complex and have multiple sides, depending on who is
recounting them and what sides are emphasized. The folklore of our field has
drawn us toward the more pathological account as the only or best version.
It is neither.
Consider Sam, a very distressed young man who scored a 7.4 on the
Outcome Rating Scale (ORS; Miller & Duncan, 2000).
Sam: I’ve been in a lot more physical pain lately. . . . No one wants
to be around me because of my mental illness. . . . My desire to
self-injure has been higher. . . . My financial situation is out of
control. . . . My dreams have been increasingly violent toward
my stepfather; his mental torture is constant, telling me that I am
never going to amount to anything . . . and that I am worthless
and do everything wrong. It’s hard to argue with him because here
I am, I amounted to nothing, he’s right. . . . And I fantasize about
it every day, different ways of just crushing him. . . . And I feel
just hopeless . . . and half the time I am fighting to survive and
half the time I am wondering if I should just stop fighting. . . . 
Part of me hopes that just the whole system will collapse, that
society itself will just fold. I am depressed now and the rest of
the world is normal. Take an event that would depress anyone.
And then being depressed would be normal, so in a way the
whole world would come to my level of depression so I wouldn’t
be abnormal.

150       on becoming a better therapist

 What was running through your mind as you read these excerpts from
the first 20 minutes of the session? Call 911? Here are stories of self-harm,
suicidal ideation, homicidal ideation, and apocalyptic fantasies. While empathic
to such dire issues, I refused to cave in to those accounts as the only or truest
ones of Sam’s identity as a human being. As you read the following excerpts,
consider these questions:
77 What are the obvious and hidden strengths, resources, and
resiliencies?
77 What are the competing stories of Sam’s identity?
77 What is already present that can be recruited to solve the
problems?

Barry: Makes a lot of sense. Another way of saying that would be that
anyone experiencing what you are—if they were in pain, just
came out of surgery, were in a financial hole they couldn’t get
out of, and didn’t have anything going socially—anybody on the
planet would be depressed, anybody walking in your shoes would
be depressed, and anybody would be struggling with whether or
not they wanted to live. That’s a long way to say that no wonder
you are depressed.

***
Sam: I am one of those leeches on society. I am a negative person.
I take away. I think that is one of the reasons why I want to see
it all come apart.
Barry: Well, no wonder. It would be like a new beginning if everything
came apart—you would have a fighting chance to have a different
kind of life. Right now you don’t see any hope for there being a
different kind of life possible.
Sam: Right, I feel like I could contribute to a society that had decayed
to the point where it would need my contribution. I just feel like
I would be really good in a situation like that. I could lead a small
ragtag band of warriors to lead attacks on the machines or bad guys.
Barry: So it’s like there is this inner warrior that wants to come out,
you’d be able to take charge of that situation, to contribute in
that situation.
Sam: I feel like I would be a good leader.

***
Barry: What keeps you from killing your stepfather?
Sam: The only two things that’s keeping him alive is my fear of get-
ting caught and my own personal realization that killing him

the heart and soul of change      151

 would not make me feel any better. . . . I am so full of rage when
it comes to him. He screwed up all of our lives. Everything he
touches is destroyed. I almost feel like it’s my responsibility to
take him out of the world so he can’t do any more harm. But
then I would have to do harm to do that, but I can’t do that
because it’s against my religion.

***

Barry: A couple of things occur to me. One is that it’s really not surpris-
ing that you are struggling now, there are a lot of low spots in
your life, a lot of shit has happened in the past, a lot of animosity
directed at your stepfather, a lot of bad things have happened
to you, to wake up every day and feel like you are a leech on
society, your identity, this inner warrior never being able to be
expressed, all this stigma that goes along with the mental dis-
ability, the physical pain, being in a financial hole—there is just
a lot of stuff conspiring to make you feel very bad about yourself.
On the other hand, not only do you have this inner warrior
aspect of you, that leadership, knowing that there is a lot more
to you than this society at this time allows you to express, there
are also all these other things about you that are very impressive.
You are really a savvy guy, you’re smart, you have a dry sense of
humor; we didn’t laugh much, but you said a lot of things that
were funny. And you have a little bit of a twisted way of looking
at things, and that’s very funny and I think that’s a real strength
you have. You know a lot of stuff about a lot of things—you’re
bringing a lot to the table, not the least of which is your insight
about your stepfather and your ability to control yourself.
Many stories have emerged: The story of Sam’s problems—suicidal/
homicidal ideation, depression, and self-loathing—was real. But it was not
the only one and not the most representative of his identity. There was
another tale of a remarkably insightful and reflective man who wants to con-
tribute to society, a leader, an inner warrior who controls his impulses. Sam’s
realization that killing his stepfather wouldn’t make him feel any better was
more than impressive. Clients’ heroic stories pave the way for change by
showcasing abilities and making them available for use. You might have been
thinking that wishing for the end of the world would provide few resources to
harness for change. Consider Sam’s concluding statements:
Sam: Somehow, in some way, I’ll find a way to give back to society.
And it may not be today or tomorrow, but someday, because I am
pretty young and I have a lot of time to figure out how I can make
society better, and it doesn’t have to be the end of the world.

152       on becoming a better therapist

 A focus on Sam’s more heroic aspects shifted the conversation and
seemed to catalyze his enthusiasm for doing something different. And in no
way did I gloss over the very serious problems that were on the table. I emphasize
this because sometimes people think that when you recruit strengths, it means
that you ignore the real problems. Not so: You rally resources so that you can
address the real problems.
You can also inquire more directly about strengths and resilience. Recall
the discussion in Chapter 1 about problem versus resource activation: The more
effective therapists spend more time on the latter. The ORS fits nicely with
a strength-based focus. Any mark to the right of the far left can be cause for
discussion about why the mark isn’t lower. How is the client managing to
keep the mark where it is? What resources are being drawn upon? Differences
between the domains can spark conversations about what it is about one life
area that makes it better than another. Low scores identify areas in which the
client is looking for change, but high marks on the different scales also pinpoint
client competencies, resources, and social supports. Can strengths in one area
that is going well be harvested and used in the arena of the client’s troubles?
Several systems of therapy are “strength based” and offer a plethora of
ways to inquire about client competencies (de Jong & Berg, 2008; Duncan
& Sparks, 2010; Saleeby, 2006; Thomas & Cockburn, 1998; or visit https://
heartandsoulofchange.com). I encourage you to check out these approaches
and select questions that are a good fit for you. Finding ones that resonate
with you and that you can authentically incorporate is key. Remember that you
are the therapy you deliver, so every part of it has to be genuinely you.
One question coming from a narrative tradition that is a good fit for me is,
“Who in your life wouldn’t be surprised to see you overcome the problem before
you now?” Consider Yolanda, a young woman I saw the day after child protec-
tive services (CPS) removed her children because she had started using crack
again. CPS was not the bad guy here—there was a contract and Yolanda
violated it when she started using again. So one story you could tell about
Yolanda was that she was the crack-addicted mom who had her kids removed
by CPS. But what I am talking about here is believing—no, not believing, but
actually knowing—that this story is not the only one that can be told, and it
is not the one that best reflects who Yolanda really is.
Yolanda was devastated—teary and lethargic—and she had an under-
standable edge. But far worse was that she barely said anything and didn’t
even look at me. Though I started “knowing” that there was more to the story,
as the old saying goes, that and $3 will get me a cup of coffee. I wasn’t getting
anywhere with Yolanda, and I was worried. Here were two people who couldn’t
have been more different from one another—Yolanda was an impoverished
21-year-old African American woman whose world had just split wide open,
and I, an old middle-class white guy without a care in the world, relatively

the heart and soul of change      153

speaking. Silence is indeed golden, but it was not leading to any further reflection
and comment, so I asked a question to see if I could get Yolanda engaged.
Barry: Yolanda, who in your life wouldn’t be surprised to see you
stand up to this situation, stop using crack, and do what CPS
wants so you can get visitation of your kids back?
Yolanda: 
(long pause in which Yolanda looks up at me as if I had suddenly
sprouted a new head out of my neck) Well, my Uncle Charlie
wouldn’t be surprised.
Barry: If Uncle Charlie was here, what story would he tell me about
you that would inspire in me the same confidence he has in
you?
Yolanda: 
(starting very slowly but picking up steam as she talks) Uncle Charlie
was my favorite uncle and he liked to tell the story of when I
used to visit him over the summer with all my other cousins.
We would get away from the city and get a taste of country life.
I really liked it. One summer when I was 6 or 7, my cousins
and I ran deeper into the forest further than we had ever gone
before. We were running full blast over a ravine and I was out
in front, and then I stepped in quicksand and got stuck and
pretty quickly sank to my waist and was slowly sinking. We
were way out in the woods and my cousins ran all the way
back to get my uncle, who rushed to get me, which seemed to
me to be about forever later. Thinking that I would already be
dead, Uncle Charlie was so relieved to see me that he cried
for joy—by that time I had sunk up to my neck. He never
stopped talking about when he found me. I was calm and
collected and just as still as I could be—somehow I instinctively
knew not to struggle or make a move. He always told me and
everybody else what a trooper I was and how I had the heart
of a lion. Uncle Charlie would not be surprised by my ability
to deal with this stuff. He always told me if I could deal with
that situation as a kid, I would be able to deal with anything
in my life. He didn’t live to see me in the mess I’m in now, but
he would still believe in me.
And you know what? Uncle Charlie was right. In fact, there were many
other stories about Yolanda that better captured her humanity: Like when she
stood up, under great peril, to her crack-dealing, abusive partner and left him
and the crack house behind. Despite his continued stalking and the threat
of violence, Yolanda acted to protect her children. In addition, under all this
duress, she chose to quit crack—and did so for 17 months until a combination of
events persuaded her to relapse. So there was a crack-addicted mom who lost
her kids, and there was the heroic mother who stood up to abuse to protect

154       on becoming a better therapist

her children and who also had made good choices for 17 months regarding her
crack use. With these resources and resiliencies to work with, and Yolanda now
engaged in the beautiful thing we call therapy, my job was easy. Yolanda started
going to NA again, worked with CPS and me to complete their requirements,
and started supervised visitation, which ultimately led to regained custody of
her children. I am not questioning the validity of the problem stories. Certainly
Yolanda was a crack-addicted mom who lost her kids. But that wasn’t the whole
story, not the one that engaged her in therapy, and not the one that captured
her identity as a human being. The stories that allow me to see client resources
and resiliencies, those that represent who people are or aspire to be, are the
ones that I work to bring to light.
Finally, as Harold (the meticulous engineer who wrote a more satisfying
story of his retirement) demonstrated in Chapter 3, change or any difference
itself can be a powerful way to encourage further empowerment and client
ownership of positive steps. Noting differences, as solution-focused therapy has
taught us, can also be a way to harvest and recruit client resources, capabilities,
and ideas to overcome the adversity they face—to write a heroic tale of a new
start or embarking on a different path in life.
A recent consult client, Bob, was a man who had been struggling with
alcohol for most of his life. Looking years older than he should, he was a
poster child for all that goes wrong in a life characterized by the long-term
abuse of alcohol: periodic homelessness and the loss of family, employment,
and self-respect. Bob was a man suffering perhaps the worst effect of all: little
hope and destroyed self-esteem, readily revealed by his ORS score of 3.2.
Barry: What do you think would be the most useful thing for us to talk
about today?
Bob: I’m not sure, right now I am struggling with staying sober.
Barry: So are you sober today?
Bob: Yes, I am. It’s been, uh, what’s today, it’s been 11 days.
Barry: Wow, that’s pretty darn good. Congratulations. How have you
been able to do that?
Bob: I have been going to some meetings but maybe I should go to more.
Barry: Okay, so going to meetings is helping. Do you think if you stayed
sober, your marks on the ORS would move to the right, that if
your mark on the Individually scale represented your recovery or
your sobriety or the drinking, however you want to look at it,
if you continued your sobriety, do you think that mark would
move over to the right?
Bob: Definitely.

the heart and soul of change      155

 Barry: It seems like, and correct me if I’m wrong here, your sobriety
is central to the way you are experiencing all these domains of
your life.
Bob: Yes, it is.
***
Barry: I am always curious about when people make a change, and you
are now 11 days sober, and I don’t know how you have done in
the past, but regardless you have 11 days now. Which means
that you got up that first day and you said to yourself in some
way, shape, or form, “I am not going to drink today.” And I am
wondering how you reached that conclusion.
Bob: Like many other times, I wound up in the ER and I just remember
how I felt when I woke up. . . . I was feeling pretty low and I think
I came to the conclusion that as long as I drink like this that I was
going to feel like this. I know it’s not going to get any better if
I continue to drink. Like over the weekend, I had some alcohol
in my apartment, and when I woke up the next day after getting
home from the hospital, there was enough alcohol to get drunk—
I had spent my whole SS check on alcohol and drank most of it
the couple of days before the hospital but there was plenty left
to blow myself away. And I was thinking that I could drink this
and nobody would know about it. Then I remembered how I felt
at the ER . . . (in a very low voice) and I poured it out.
Barry: (smiling) Wow! (Bob smiles slightly.) That was pretty amazing
that you did that. No one would have known. . . . Something
about this memory in the ER was kind of a wake-up call.
Bob: Yes, it was.
Barry: In a little bit different way than before?
Bob: Yeah, a lot different.
Barry: What was different about it?
Bob: The shame, the guilt, I couldn’t shake it. I couldn’t look in the
mirror, and that’s why (pointing at the ORS), on the scale there, on
the Individually part and that’s also why that one is rated so low.
I have a lot of shame . . . 
Barry: Okay. So you think as you get more sobriety under your belt,
you’ll feel better about yourself?
Bob: I hope so.
Barry: So that experience was kind of a turning point in some ways.
Bob: I hope so.

156       on becoming a better therapist

 Barry: This is pretty amazing when you think about it, you’ve been
struggling with this for a long time, and this time you noticed
something different, and it sounds like somehow this has reached
the point for you that you did some additional self-search, and you
somehow decided that this isn’t what you wanted to continue
doing.
Bob: (nodding throughout) Yes.
***
Barry: But you came home from the hospital and you had alcohol in
your apartment. . . . You could have said, “I’ll start tomorrow, let
me get rid of this first.” I am amazed by that and it tells that this
time is different. So are your strategies for sobriety like they were
before in your times of not drinking? Have you tweaked that or
are you doing anything different?
Bob: All the other times I did it on my own. I didn’t really do any
recovery work.
Barry: So you were able to do it, even for as long as 6 months on your
own, but you are thinking now if you do more recovery work
you’ll make it stick better. And you didn’t do that before?
Bob: No, not at all. I didn’t go to any meetings.
Barry: Oh, none at all.
***
Barry: Really sounds like you know what the recipe for success is.
Bob: (smiles big) I hope so.
Barry: It’s not like you have ever given up on this.
Bob: (strongly) No, I haven’t! I keep trying.
Barry: You do. That’s great. You have a real fighter spirit. It’s knocked
you down a few times but you are not down for the count. You
are not ready to call it over.
Bob: (smiling) Not yet.
Barry: That’s great. It makes sense to me and I think it’s a great thing that
you notice how this time is different for you. There are similarities
to the past, but there are some real differences (Bob nods enthusi-
astically). You noticed something very different in your response
to the ER and that led you to a different place. And there’s proof
that it did because you had alcohol in the house when you came
home from the ER. You had to be in a real different place to
decide not to start the next day. You sure could have gotten

the heart and soul of change      157

 away with starting the next day and drinking everything in your
house.
Bob: (sitting up more) I could have.
Barry: That would have been easy, and even understandable! But you
didn’t do that. So this time is different. You have recognized the
difference and enacted the difference at the first opportunity
you had when you dumped the booze. Then you continued by
changing your strategies to include recovery and going to meet-
ings. I think that all this is meaningful.
Bob: I do too.
Barry: Seems like you have some confidence about this time.
Bob: I do.
Bob had had periods of sobriety before, but this time was different: different
insights, resolves, and plans to guide him down a path of redemption and recov-
ery. As I verbalized the differences in this occurrence of sobriety and his plan
of recovery, including the amazing event of pouring out the booze, Bob became
more engaged and ultimately confident. The most striking thing for me was
Bob’s movement in session from passive and defeated, a man of little hope, to
engaged and confident that he was up and still fighting, not down for the count.

Bottom Line: The quickest way to improve your effectiveness is to engage

clients and their resources in service of change. Discovering the client’s heroic sto-
ries and noting change are but two ways that encourage clients to collaborate
from a position of competence and wisdom, as they join you in the purposeful
work of change.

RELIANCE ON THE ALLIANCE

Listening creates a holy silence. When you listen generously to people,

they can hear the truth in themselves, often for the first time. And when
you listen deeply, you can know yourself in everyone.
—Rachel Remen, Kitchen Table Wisdom

The fact of the matter is that the alliance is our most powerful ally
and represents the most influence that we can have over outcome. But it’s
hard not to take it for granted when it gets so little press compared with
models and techniques. How often, for example, is the alliance discussed in
client conferences? Improving your alliance skills is another way to focus your
efforts that will likely lead to progress as you track your career development.

158       on becoming a better therapist

 Recall that the best therapists tend to form strong alliances with more
people; average alliance scores have accounted for 50% (Owen, Duncan,
Reese, Anker, & Sparks, in press) to 97% (Baldwin, Wampold, & Imel, 2007)
of therapist differences. Of course, this is what the Session Rating System
(SRS) is all about, to help you build better alliances; however, you can also
expand and fine-tune your repertoire of relational skills and monitor your
career development to see if it matters. I think it will. The alliance is your
craft. Practice well the skills of your craft. At some point, your craftsmanship
elevates to art.
Bordin (1979) classically defined the alliance with three interacting
elements: (a) a relational bond between 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 thera-
pist behavior and is a property of all aspects of providing services (Hatcher &
Barends, 2006). The alliance is evident in anything and everything you do,
from offering an explanation or technique to scheduling the next appoint-
ment, to engage the client in purposive work. In short, it calls for your utmost
attention and best clinical skills in each and every client encounter—your
conscious, proactive efforts to make it happen. It deserves far more RESPECT
(hear Aretha in the background).
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.
There are many ways to understand alliance skills (for an excellent review,
see Ackerman & Hilsenroth, 2003), as well as many systems to improve your
relational abilities—from classic Rogerian (Truax & Carkhuff, 1967) to ways
of therapeutically addressing alliance ruptures (Safran, Muran, & Eubanks-
Carter, 2011) to specific models that are attentive to relational aspects, such
as motivational interviewing (Miller & Rollnick, 2012), to name just a few.
And the good news is that there is evidence suggesting that you can improve
your ability to form alliances (Crits-Christoph et al., 2006). I encourage you
to investigate multiple ways to practice your alliance skills and consider your
growth as a therapist to be parallel to the development of your relational
repertoire. What follows are a few of my thoughts for your consideration.

the heart and soul of change      159

The Relational Bond

It is helpful to think of each meeting with a client as a first date (without

the romantic overtones, unless you want a very short career-development
trajectory), in which you make a conscious effort to put your best foot forward,
actively woo the client’s favor, and entice his or her participation. This requires
listening intently, staying close to the client’s experience, not steering the
conversation elsewhere unless invited, and just plain being likable, friendly, and
accommodating. Because clients vary widely in their experience of what consti-
tutes a good relationship, your flexibility is important. Pay particular attention to
what excites clients: When do they lean forward, raise their voices, sparkle their
eyes, talk more? What topics and ways of relating raise their activity and engage-
ment? Hold on to the quote from Orlinsky, Rønnestad, and Willutzki (2004;
see Chapter 1, this volume) regarding the centrality of client participation.
A useful way to think of your relational responses, as an overall backdrop
for your comments, is the concept of validation. Validation reflects a genuine
acceptance of the client at face value and includes an empathic search for
justification of the client’s experience in the context of trying circumstances—
that they have good reason to feel, think, and behave the way they do (Duncan
et al., 1992). Clients are often wary about our judgments. Validation helps
them breathe a sigh of relief and know that blame is not a part of our game—
we are on their team.
Validation combines three robust empirically demonstrated aspects of
the relationship: empathy, unconditional positive regard, and authenticity.
Carl Rogers, in his groundbreaking article (1957) that is still well worth the
read, defined empathy as the therapist’s sensitive ability and willingness to
understand clients’ thoughts, feelings, and struggles from their point of view.
It is important to remember that perceived empathy is quite idiosyncratic; there
is no single, invariably facilitative empathic response. Empathy, therefore, is
work. You can’t take it for granted; instead, you have to sort out what the client
finds empathic, what engages the client in the work. But it is really worth the
effort. A recent meta-analysis of 57 studies looking at empathy and outcome
(Elliott, Bohart, Watson, & Greenberg, 2011) found a significant relationship,
an r of 31 (r is a statistic different from the d; an r of .31 is a medium effect).
Another idea championed by Rogers, unconditional positive regard, char-
acterized as warm acceptance of the client’s experience without conditions, a
prizing, an affirmation, and a deep nonpossessive caring or love (Rogers, 1957),
also exerts a robust impact on outcome. A recent meta-analysis of 18 studies
examining positive regard and outcome found a significant relationship,
an r of .27 (Farber & Doolin, 2011). Given its importance to outcome, it is
surprising how often unconditional positive regard is trivialized and taken
for granted.

160       on becoming a better therapist

 And, finally, there’s congruence/genuineness, “that the therapist is
mindfully genuine in the therapy relationship, underscoring present personal
awareness, as well as genuineness or authenticity” (Kolden, Klein, Wang, &
Austin, 2011, p. 65). Kolden et al. (2011) did a meta-analysis of 16 studies
and found a significant relationship between congruence/genuineness and
outcome, an r of .24. Lambert (2013) rightly noted that these relationship
variable correlations are much higher than those of specific treatments and
outcome. Recall that the effect size (ES) of model differences is just a d of .20.
So your client’s perception of any of the big three relational variables is more
powerful than any technique you can ever wield.
Things to consider when validating:
77 What are the invalidations contained in the client’s story?
How is the client blamed for his or her difficulties by him or
herself or others?
77 What other circumstances have contributed to this situation?
How can I place the client’s situation in a context that explains
and justifies his or her behavior or feelings? How can I give the
client credit for trying to do the right thing?
Put the client’s experience in the following format:
No wonder you feel or behave this way [fill in with client circumstance]
given that [fill in the ways you have discovered to justify his or her responses].
Consider again my comments to Sam, after hearing all the things troubling
him and his desire to see the end of world:
Barry: Makes a lot of sense. Another way of saying that would be that
anyone experiencing what you are—if they were in pain, just
came out of surgery, were in a financial hole they couldn’t get
out of, and didn’t have anything going socially, anybody on the
planet would be depressed, anybody walking in your shoes would
be depressed, and anybody would be struggling with whether or
not they wanted to live. That’s a long way to say that no wonder
you are depressed.
These comments replaced the self-invalidations (“I’m a leech, a negative per-
son, etc.”), and the invalidations of others (bizarre thinking, etc.). When cli-
ents feel validation, different conclusions can be reached and alternative
actions can emerge. Sam sighed and relaxed, knowing that I was in his corner,
and the next exchange further clarified why he wanted an apocalypse, as well
as his recognition of his leadership ability.
Sam: I am one of those leeches on society. I am a drag on society. I am
negative, I am a negative person. I take away. I think that is one
of the reasons why I want to see it all come apart.

the heart and soul of change      161

 Barry: Well, no wonder. It would be like a new beginning if everything
came apart—you would have a fighting chance to have a different
kind of life. Right now you don’t see any hope for there being a
different kind of life possible.
Sam: Right, I feel like I could contribute to a society that had decayed
to the point where it would need my contribution. I just feel like
I would be really good in a situation like that. I could lead a small
ragtag band of warriors to lead attacks on the machines or bad guys.
Barry: So it’s like there is this inner warrior that wants to come out,
you’d be able to take charge of that situation, to contribute in
that situation.
Sam: I feel like I would be a good leader.
Validation (authentic empathy and positive regard) paves the way for client
strengths to appear and helps coax the client’s participation. Of course, it has
to be real, straight from your heart.
In summary, to enhance the relational bond:
77 Listen, listen, listen—stay close to the client’s experience.
77 Be likable, friendly, and responsive (like on a first date).
77 Carefully monitor the client’s reaction to comments, explanations,
interpretations, questions, and suggestions; use your alliance filter
and the SRS to keep you on track.
77 Be flexible: Do whatever it takes to engage the client and ensure
his or her experience of empathy, positive regard, and congruence.
Use your complexity to fit clients.
77 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.
The SRS (or any alliance tool) is the only way to know for sure whether you
are accomplishing your relational efforts.
Bottom Line: There are a lot of ways of understanding and applying rela-
tionship skills, and research offers key guidelines regarding what is important to
outcome from the client’s point of view. Take on your relational skills as a project
and as perhaps the central symbol of your development as a therapist. Try the
different systems of skills on for size and watch your outcomes improve as you
refine ways to purposefully involve your clients in the work.

Accepting the Client’s Goals

The second aspect of the alliance is the agreement on the goals of

therapy. Chapter 3 covered this ground in the discussion about the SRS, so

162       on becoming a better therapist

here I will just make a few quick points. When we ask clients what they want
to be different, we give credibility to their beliefs and values regarding the
problem and its solution. Regardless of how unreasonable they may sound, as
illustrated by Carly and her desire to go to school in the midst of a hospital-
ization crisis, you should accept client goals at face value, because those are
the desires that will excite and motivate—that will engage him or her in pur-
posive work. If we are straining our actions through the alliance filter, goals
other than those of the client will likely not fit through. Collaborative goal
formation begins the process of change, wherever the client may ultimately
travel. Both the ORS and the SRS keep us on the same page with clients
regarding their goals. As Carly aptly illustrated, clients are not likely to show
benefit on the ORS if they are not working on their goals, and to ensure our
attention, the SRS directly solicits the goal issue.
It is sometimes helpful to encourage clients to think small (Fisch,
Weakland, & Segal, 1982). A change in one aspect of a problem often leads to
changes in other areas as well. The wonderful thing about thinking small is
that the most easily attainable sign of change becomes symbolic of resolving
the entire problem; it creates a momentum and energy like the first domino
falling in the seemingly never-ending line of the problem. This is why it is
useful to ask clients what it will take for the mark on a given scale to move just
one centimeter to the right. The client’s subjective experience of early change,
as noted earlier, is predictive of continued change and sets an expectation for
progress and smooth sailing. Do not underestimate the power of thinking small.
The first glimmer of light can turn into a neon sign shining the way to the
ultimate destination.
But, once again: Don’t stress. Some clients just don’t think of what they
want from therapy in concrete behavioral terms and perhaps don’t slice up
the world in tangible observables. That’s okay. But you can always connect
whatever experience clients are describing, no matter how vaguely, to the
marks on the ORS. The ORS will measure their benefit in the major domains
of life, regardless of the client’s propensity to set clearly defined goals.
Bottom Line: Work on client goals. Period.

Agreement About the Tasks of Therapy

The final aspect of the alliance is the agreement on the tasks of ther-
apy. Tasks include specific techniques or points of view, topics of con-
versation, interview procedures, frequency of meeting, and all the nuts
and bolts of doing the work. Don’t underestimate the importance of the
seemingly mundane issues of scheduling, cancellation, payment, and
between-sessions contacts. These are all aspects of the task dimension and

the heart and soul of change      163

can count for or against you in the alliance. All of your behaviors need
to go through the alliance filter; each of your actions is a manifestation of
the alliance. As noted in Chapter 4, in our follow-up study of the Norway
Feedback Trial, we found that the category with the most complaints was
just this aspect of the alliance—the everyday aspects of providing the ser-
vice (Anker, Sparks, Duncan, Owen, & Stapnes, 2011).
Asking for help to set the tasks of therapy further demonstrates respect for
client capabilities, as well as our efforts to enlist participation in a collaborative
endeavor. This is probably our biggest alliance blind spot. After all, we’re
supposed to be the experts, right? (Recall Dan Ariely and the nurses ripping
off his bandages.) The beauty of collaboratively setting the tasks of therapy is
that we ensure not only that the alliance is on track with an approach that
resonates with everyone involved, but also that this process provides a continual
impetus to broaden our theoretical horizons. Negotiating the tasks of therapy
sets the stage for expanding your conceptual repertoire, your theoretical breadth,
as discussed in the previous chapter.
So you can’t have a good alliance without some agreement about the goals
and how therapy is going to address the issues at hand. Tryon and Winograd
(2011) conducted two meta-analyses related to the agreement on tasks—goal
consensus (which included agreement on tasks) and collaboration—and their
relationship to outcome. Looking at 15 studies, they found a goal consensus–
outcome d of .34, indicating that better outcomes can be expected when
client and therapist agree on goals and the processes to achieve them. Based on
19 studies, the collaboration-outcome meta-analysis found a d of .33, suggesting
that outcome is likely enhanced when client and therapist are in a cooperative
relationship. Once again, these alliance variables are more powerful than the
impact of model and technique.
In an important way, the alliance depends on the delivery of some
particular technique or treatment—a framework for understanding and
solving the problem. If technique fails to engage the client in purposive
work, it is not working properly and a change is needed. In essence, tech-
nique is the alliance in action, carrying an explanation for the client’s dif-
ficulties and a remedy for them; it’s an expression of the therapist’s belief
that it could be helpful, in hopes of engendering the same response in the
client. Indeed, you cannot have an alliance without a treatment, an agree-
ment between the client and therapist about how therapy will address the
client’s goals. Similarly, you cannot have a positive expectation for change
without a credible way for both the client and therapist to understand how
change can happen.
Here is where the variety of models and techniques pays off. The ques-
tion is: Does the model or technique resonate? Does it fit client preferences?
Does its application help or hinder the alliance? Is it something that both

164       on becoming a better therapist

you and the client can get behind? You matter here, too. If you don’t believe
in the restorative power of any selected approach—if you don’t have alle-
giance to it—then not much good will come of it. Can you get on board
with the client’s notions about how he or she can be helped? Or perhaps
some idiosyncratic blend of client ideas, yours, and theoretical/technical
ones might ultimately be just the ticket. Your alliance skills are truly at play
here: your interpersonal ability to explore the client’s ideas, discuss options,
collaboratively form a plan, and negotiate any changes when benefit to the
client is not forthcoming.
The issue of resonance and the agreement about tasks—finding a frame-
work for therapy that both you and the client can believe in—is why it makes
a lot of sense to ask clients about their ideas on how to proceed, or at the very
least get client approval of any intervention plan. Such a process has not been
highly regarded in traditional psychotherapy; the search has been instead
for interventions that promote change by validating the therapist’s favored
theory. Serving the alliance requires taking a different angle: searching for
ideas that promote change by validating the client’s view of what is helpful,
the client’s theory of change (Duncan et al., 1992; Duncan & Miller, 2000b;
Duncan & Moynihan, 1994). Frank and Frank (1991) said it best: “Ideally,
therapists should select for each patient the therapy that accords, or can be
brought to accord, with the patient’s personal characteristics and view of the
problem” (p. xv).
Perhaps the most important aspect of this collaboration is whether the
favored explanation and ritual of the therapist fit client preferences. Swift,
Callahan, and Vollmer (2011) conducted a meta-analysis of 35 studies of client
preference, breaking client preferences into three areas: role, therapist, and
treatment preferences. They found that clients who received their preferred
conditions were less likely to drop out and that the overall ES for client
preference was d = .31 (once again, more potent than model and technique).
So it makes sense to ensure that whatever explanation and ritual are chosen
are ones that the client can get behind.
Asking about the client’s theories or preferences does not preclude
your ideas, suggestions, models, methods, or in any way mean that you do not
contribute. Instead, it speaks to the more collaborative aspects of formulating
a plan, with the degree and intensity of your input determined by the client’s
expectations of your role. Securing an agreement about the tasks is all but
guaranteed when a given therapy framework—explanation or solution—
implements, fits, or complements the client’s ideas and beliefs. Examples are
found throughout this book (see also Duncan, Hubble, & Miller, 1997; Duncan
et al., 2004). Once again, the SRS can help us not only to focus on this issue
but also to catch ourselves when we are missing the mark, as it did with Ken,
the construction supervisor having panic attacks, in Chapter 3.

the heart and soul of change      165

 Bottom Line: Agreement about the tasks of therapy is a critical component of
the alliance. The application of any agreed-upon explanation or technique rep-
resents the alliance in action. The litmus test of any chosen rationale or ritual is
whether or not it engages the client in purposive work and makes a meaningful
difference determined by the client.

The Alliance: Why Do You Think They Call It Work?

My dad had a stalwart response to any complaint I ever made about

doing any job. Whether it was painting or roofing a house, working in a tire
factory, studying for a test, or working in my private practice, his response was
consistent: “Why do you think they call it work?”
We all have clients who rapidly respond to us, with whom we connect
quickly. But what about the folks who are mandated by the courts or protec-
tive services or who just plain don’t want to be there (like almost all kids)?
What about people who have never been in a good relationship or have
been abused or traumatized? What about folks to whom life just never seems
to give a break, or who have lost hope? Well, the therapist’s job, our job,
is exactly the same regardless. If we want anything good to happen, it all
rests on a strong alliance—we have to engage the client in purposeful work.
The research about what differentiates one therapist from another, as well as
my personal experience, suggest that the ability to form alliances with people
who are not easy to form alliances with—to engage people who don’t want to
be engaged—separates the best from the rest.
It’s hard work. We often think that “therapeutic work” only applies to cli-
ents; it actually applies to us too. We have to earn this thing called the alliance.
We have to put ourselves out there with each and every person, each and every
interaction, and each and every session. It is a daunting task, to be sure, but one
that is perpetually minimized in its importance and difficulty. It gets such little
press compared with models and techniques and is often relegated to statements
like “first gain rapport and then . . . ” or “form a relationship and then . . . ” as if
it were something we effortlessly do before the real intervention starts. The alli-
ance is not the anesthesia to surgery. We don’t offer Rogerian reflections to lull
clients into complacency so we can stick the real intervention to them!
When Lisbeth was introduced to me in the waiting room, she told me to
go f––k myself. I was doing a consult because this 16-year-old was refusing to
go to school and had assaulted four foster parents, with resulting psychiatric
hospitalizations. Lisbeth was one angry adolescent, and my initial thought
was, “Wouldn’t it be sweet if she told me what she was angry about?” because
I knew there had to be a good reason.
In the opening moments, I asked Lisbeth what she thought would be
most useful for us to talk about and she said, “What I think of you is that you

166       on becoming a better therapist

are a condescending bastard with no understanding of your clients whatso-
ever!” Whew, she knew how to hit where it hurt! But I admired her chutzpah.
In essence, if you take out the anger, she was telling me to not condescend
to her because she was a kid, and that I’d better take the time to understand
her. This helped me maintain my conviction that if I understood her story,
everything, especially her anger, would make complete sense.
Lisbeth: I’m just angry all the time, you stupid!
Barry: I’m getting that you are pretty angry.
[After all, I am a trained observer of human behavior!]
Lisbeth: All because of that psychiatrist or should I say mind-f––ker . . .
Just because I threatened to break her knees because she tried
to give me medication. Break her knees, mind you, not break
her neck (raising her finger).
Barry: Right, it’s not like you wanted to kill her or anything, you just
wanted to permanently impair her. There’s a big difference.
Lisbeth: (smiles) Right.
She told me how she refused medication in one of her many hospital-
izations and had threatened to break the kneecaps of the psychiatrist who
attempted to force her to take meds. This likely stimulated replies ad nauseam
about the inappropriateness of her violent tendencies. I responded differently,
got a smile and more conversation.
Lisbeth told me that she had been removed from her home at age 13
because of multiple sexual abuses by her mother’s boyfriends and that, since
then, she had been in four foster-care homes, including that of the fourth
foster parent, Sophie, who sat before me now. She also told me that the previous
18 months of therapy had not addressed her goal of telling her mother off, once
and for all. In fact, no attempt had been made to allow any approximation
of this to happen.
Lisbeth: All I want to do is see my mom once. And then I’m going to
wring her neck verbally and never see her again after that.
Barry: What’s preventing that from happening?
Lisbeth: They think I’m going to get all stressed out and weird. Of course,
I’ve been on edge ever since I left her.
Barry: So you want to tell her off once and for all, you think that will
help you let it go?
Lisbeth: I ain’t letting it go. You stupid?
Barry: (laughs) Most of the time.
***

the heart and soul of change      167

 Sophie: Lisbeth was in several foster homes before she lived with us and
she’s been with us the longest.
Barry: So, Lisbeth, how has it lasted with Sophie?
Lisbeth: I stick to her like a barnacle. (Everyone laughs.)
Barry: You’ve had quite the storied life. You’re like this crusty old
sailor—you curse like a sailor, and you’ve had many harrow-
ing adventures with all these different experiences, so you’re
salty.
Lisbeth: (big smile) Salty?

Given that Lisbeth’s goal had been ignored, her lack of engagement in
therapy seemed a reasonable response. After a while of allowing her story to
wash over me, I ventured a comment that Lisbeth was like a salty old sailor,
crusty at the ripe old age of 16. She smiled in a way that acknowledged that
I both understood and appreciated her. Lisbeth rewarded me with an explana-
tion of her anger—what I was really hoping to accomplish. She told me how she
was relieved to be removed from her home and that her first foster-care parent
had expressed intentions to adopt both Lisbeth and her 5-year-old brother.
But instead, her brother was adopted and Lisbeth was dumped. That’s when the
assaults started and when she began to completely dismiss school. So the first
adult that she trusted, after having none in her life worthy of her trust, betrayed
her totally and completely.
Lisbeth: I just got out of my f––kin’ mom’s house and I went to live with
Tara Traitor.
Barry: I like your names for folks.
Lisbeth: She took me into her home. We lasted about 2 months . . . she
used me, I don’t know, as a get-my-brother-and-toss-me-away
ploy.
Barry: You were going to school at the time?
Lisbeth: Yes. I was going to school full-time.
Barry: You were doing the regular kid thing.
Lisbeth: Yeah. Then she kicked me out and adopted the little abomi-
nation . . . 
Barry: That really changed things. And you became really pissed off.
Lisbeth: Yeah, and then I stopped going to school, and attacking people,
going to the hospital.

168       on becoming a better therapist

 Barry: It’s too bad that you took the fall for her being a traitor. That
really cranked you up to a real righteous anger.
Lisbeth: Righteous anger?
Barry: Yes. Your anger is certainly righteous, given how much you
have been screwed around.

There is no more righteous anger than this kid felt. I said that, we connected,
and the work of therapy could proceed—Lisbeth was purposefully involved.
Our interaction took on a more bantering quality, more as peers, and one in
which I could playfully challenge her a bit.
Barry: Sophie, you’ve made it through the trials and tribulations here
and, you know, she is a tough row to hoe. . . . How have you
done it?
Sophie: Well, I love her . . . and she keeps me on my toes. She keeps
me going. I like that.
Barry: So you two have been able to connect and have a relationship . . . 
Lisbeth: (interrupts) No, I am just stickin’ to her.
Barry: That’s a connection I’d say.
Lisbeth: That’s not a connection, buddy! That’s just me being a leech,
a parasite.
Barry: Isn’t that a connection?
Lisbeth: No, it’s just a feeding thing. . . . I am a parasitic being by strategic
means.
Barry: Okay, strategic parasite, you’re still connected to Sophie, and
you’re suckin’ it for everything you can get, the life blood out
of her. But she’s holding up pretty well (Sophie and Lisbeth look
at each other), because she is holding on to this thing that she
loves you.
Lisbeth: No, no, motherf––king no!
Barry: (smiles) Love, the dreaded four-letter word! I think there is
really something there, that connection, and I am not going
to say the other word . . . 
Lisbeth: (interrupting) I gonna f––kin’ rip your ass off, and feed it to you!
Barry: Wouldn’t taste very good.
Lisbeth: I know, because you are a crusty old man.

the heart and soul of change      169

Now don’t get me wrong, this wouldn’t be my preferred way to interact with
a teenager. But I hope the printed word conveys the difference of our interac-
tion. What started out as anger and somewhat mean-spirited attacks evolved
into a more playful banter. This interchange ended with Lisbeth calling me
crusty, the same adjective I had used to describe her. So now we were crusty
together—a crusty old sailor and a crusty old therapist.
I couldn’t have written a better script for the ending because the session
closed with Lisbeth going one up on me, getting in a final zinger.
Barry: If you want, you can get feedback from the team in the other
room about what they observed here today.
Lisbeth: Shakes her head and gives the camera the finger.
Barry: (to Sophie) I really respect that you have been able to hang in
here with Lisbeth. You are the best thing that ever happened
to her. Her previous experiences were either just plain awful or
people didn’t stay with her through the bad stuff. And you’ve
done that and I think in the long run it will pay off.
Sophie: I do too. I know we are close despite what she says. I don’t pay
any attention to her language.
Barry: (to Lisbeth) You know, I like you, Lisbeth, and I know you have
been through a lot of shit, way too much, actually, and I do
think of you as a crusty old, salty sailor . . . and I think you are
going to figure this out.
Lisbeth: Figure this out?! Now you’re just being like Dr. Phil, and I don’t
particularly like Dr. Phil!
Barry: (grabbing his heart and smiling) I don’t either! You just cut me
to the quick with that one. (Lisbeth beams throughout the entire
interchange.) You got me with that one—I hate that guy!
(Everyone gets up to leave.)
Lisbeth: Pointing to the camera. Be sure to tell them that I hate them!
Barry: You want to give them the finger one last time? (Lisbeth does so
with enthusiasm and playfulness.)

Perhaps it seems over the top to encourage an adolescent to give the finger
to a group of therapists watching in another room. And maybe it is. But
it demonstrated quite a shift from the beginning of the session, a shift that
occurred via the power of the relationship and a deliberate, conscious effort
to forge an alliance to engage a troubled teenager in a process that just might
be helpful via the magic of this thing we call psychotherapy.

170       on becoming a better therapist

 Bottom Line: The alliance is not always easy, and it demands a lot of us, but
it is almost always not only worth the effort but also why we became therapists,
at least why I became a therapist.

CONCLUSION

What is important . . . is not the right doctrine but the attainment of

true experience. It is giving up believing in belief.
—Alan Keightley, Into Every Life a Little Zen Must Fall

Harvesting client resources and securing strong alliances, in all of the

varied ways available, is a great place to start (and continue) to grow as a
therapist. This chapter offered suggestions about how to get started, and it
boils down to two attitudes. First is a dependence on clients and what they
bring as the most potent aspect of change—to rally, recruit, or harvest client’s
existing resources in the service of client goals. The second attitude is the
understanding that the alliance is the therapy and that everything you do
must be strained through the alliance filter. Does your behavior build or risk
the alliance? Do your model and technique engage or not engage the client
in purposeful work? And, of course, the proof of the pudding is in the eating.
The answer can only be derived from the client’s response to any treatment
delivered: the client’s feedback regarding progress in therapy and the quality
of the alliance.

CLIENTS ARE THE BEST TEACHERS: THEIR STORIES

DOCUMENT OUR DEVELOPMENT

Facts don’t cease to exist because they are ignored.

—Robert Louis Stevenson

This is a bit of a tawdry tale, but nevertheless it is an invaluable

marker in my development as a therapist. Richard, a 29-year-old systems
analyst, was referred by his company doctor because of his increasing dis-
tress and frequent absences. When I greeted Richard in the waiting room,
he jumped out of his chair, got right in my face—not 3 inches away—and
demanded, “What are you going to do for me?”
Richard didn’t look too good. The 60-cent therapy words would be
agitated and disheveled. Tension and distress characterized his every move,
and he looked as if he hadn’t slept in days—if he had slept, it was surely in the
clothes he was wearing. I tried to stay calm and just invited him to accompany

the heart and soul of change      171

 me to my office, whereupon Richard raised his voice another notch and
repeated his question, and he was once again too close for comfort. I was
definitely freaked at this point, but I believed that if I could just get Richard
to tell me what was up, all this agitation and hostility would make sense.
I simply replied that I didn’t know if I could do anything for him but
that I would try my very best, and would he please have a seat and tell me
what was going on. After staring intently at me for what seemed like days,
Richard finally sat down on my couch and told his story, and the floodgates
opened. Richard began suspecting his wife, Justine, of having an affair
after he discovered footprints in the snow in his backyard. Other bits of
evidence (telephone hang-ups, Justine staying out later than expected)
resulted in Richard’s becoming increasingly convinced of her infidelity.
He followed her, meticulously searched her belongings, and kept track of
her whereabouts. But he could not find the incontrovertible evidence that
he was sure existed.
Throughout Richard’s growing mistrust, Justine emphatically denied
the affair and told him he needed help. Perhaps in desperation, Richard
began to secretly check Justine’s underwear for signs of semen, which would
provide ironclad evidence of her unfaithfulness (given that there was no sex
with him). Finally, Richard found stains on her underwear and took it to
a laboratory, which confirmed the presence of semen. Justine still denied
his accusations and insisted the semen was his. She stepped up her efforts
to involve others, telling friends, family, his employer, and their own chil-
dren, that Richard was sick and in need of hospitalization. Justine rallied
many to her cause and filed for divorce. The company doctor concurred
with her assessment, as did the first provider that Richard saw, a psychiatrist
who offered an antipsychotic to ease Richard’s pain. Richard didn’t do much
to disconfirm everyone’s assessment of his sanity. He was doing some pretty
wacky things and looked more distressed and haggard with each passing day.
Richard told me that he was obtaining a DNA analysis of the semen
to see if it was a match with his. While scrutinizing my every reaction,
not in a threatening way but rather like a condemned man waiting for a
sentence, he nervously asked me if I believed him.
So was Richard psychotic or was Justine a liar? Subsequently, I talked
with Justine and invited her to therapy, but she declined. She was very per-
suasive and pulled out all the stops to describe Richard as hopelessly psy-
chotic and in need of medical help, noting that Richard’s sister was also
schizophrenic and lived in a group home. What would you say to Richard?
I told Richard that I did believe him. Richard allowed himself a
moment of relief but pressed on and told me that the DNA test was going
to cost a lot of money, money that he had to borrow. He then leaned

172       on becoming a better therapist

forward, stared uncomfortably, and asked me the big question: Did I think
he was crazy for spending all that money?
I responded that peace of mind is cheap at any price. Richard broke down
and cried long and hard. He had been through a lot, and he was starting to
believe what many had told him: that he was paranoid and needed medication.
After a while, we started talking about what he needed to do to stop looking
crazy while he waited on the DNA results. If we took the affair as a given
and also a given that Justine’s intent was to make him look crazy as a loon,
then everything he was doing was playing right into her hands. Richard and I
worked out a plan to get normalcy back in his life: return to work, start spending
time with his kids, and take better care of himself. He did all of those things
and continued to bide his time as best he could.
Finally, the results came in. Although Richard was greatly saddened
when the DNA results confirmed that the semen was not his, he was not
surprised. Ultimately, the whole seamy business came to light, and Richard
went about rebuilding his life. I was both relieved and heartened by the
results. I had taken a bit of a risk to believe Richard. Justine had threatened
legal action against me for not insisting on medication, and the company
doctor had suggested that I was acting unethically. In a sense, I was vindi-
cated along with Richard, but, more to the point, I was heartened that my
belief in him seemed to make a difference regarding getting Richard back on
track in his life—regardless of the ultimate truth of his story.
In retrospect, by encouraging Richard to tell his story and not getting
sidetracked by his initial presentation or by attributions of pathology, I had
the opportunity to make sense of Richard’s hostility and agitation. No won-
der he was hostile, given that others had essentially told him he was crazy and
was wasting his family’s money. In the context of our relationship, Richard
found validation of his concerns to replace the invalidation of others.
I was so moved by the depth of Richard’s suffering, and by his
response to my simple act of believing him and understanding his desire to
know what was going on, that I have never forgotten it. Honestly, while
Richard told me his story, I struggled with believing him, which I knew
was risky to our alliance. But I ultimately made a conscious choice, during
that session, to believe Richard—it didn’t matter how bizarre he seemed
or how classically paranoid he looked. I decided, at the very least, that my
clients deserve to be believed. That was a significant event in my devel-
opment as a therapist. From that day on, I no longer struggled with being
a reality police officer. Such an attitude does not fit through the alliance
filter. And while it’s true that sometimes people do lie, even maliciously,
like Justine, I am willing to suspend disbelief until the “facts” appear, or
maybe even into perpetuity.

the heart and soul of change      173

 7
wIZARDS, HUMBUGS, OR WITCHES

What we do is a measure of who we are. If we imagine our work as labor,

we become laborers. If we imagine our work as art, we become artists.
—Jeffrey Patnaude

Although there were many positives about my graduate school train-

ing for which I am grateful, I was never encouraged much to reflect about
my identity as a therapist. The emphasis, instead, and surely well-meant,
was on my professional role as a psychologist—expert, empirical, objective,
and better than anyone else—like a medical doctor but more scientific and
without the white coat. In fact, “professional” was stuffed down our throats
so much that some of us mirthfully called our program “The School of Real
Professional Psychology.” Perhaps you had to be there, but the point is that
reflection about my identity as a helper didn’t happen much in school.
So confused was I that I avoided the question of what I did for a living
like the plague. I didn’t really like saying I was a psychologist or a therapist
and hearing remarks like, “Are you going to psychoanalyze me?” or other
harmless looks or comments that people give or say off-the-cuff. The reason
I didn’t like it was that I didn’t have an authentic way to describe what I

http://dx.doi.org/10.1037/14392-007
On Becoming a Better Therapist, Second Edition: Evidence-Based Practice One Client at a Time, by B. L. Duncan
Copyright © 2014 by the American Psychological Association. All rights reserved.

175
did that captured what being a therapist meant to me. Instead, I really just
wanted to tell people I was a machinist in a tool-and-die shop and be done
with it.
With other mental health professionals, I would mostly just call myself a
therapist, with no particular description of what that meant. Often, encoun-
ters with other therapists included a mutual and obligatory identification by
discipline or orientation. Sometimes I might say that I was “a psychologist,
but please don’t hold that against me”—it’s funny how many have smiled in
response. There is definitely bad blood among the disciplines. You know the
old joke: Psychiatrists don’t like psychologists, who don’t like social workers,
who don’t like counselors, who don’t like marriage and family therapists,
who don’t like addiction specialists, who don’t like their clients. But it is sad,
really, that we start off with an “us versus them” mentality, holding steadfastly
to what distinguishes us from one another until we figure out that we are
all joined by this common thing called psychotherapy. We all bring a little
something different to the table, but our identity as therapists and desire to
help, as demonstrated in the Orlinsky and Rønnestad (2005) study, transcend
disciplinary wars and theoretical fractionation.
What is your identity as a therapist? How do you describe what you do?
At your very best, what role do you play with your clients? What recent work
with a client represents the essence of your identity, illustrating what you
embrace most about what you do?
In our book, Heroic Clients, Heroic Agencies: Partners for Change, now in
its third rendition (Duncan & Sparks, 2010), Jacqueline Sparks and I assem-
bled an eclectic collection of essays from counselors and therapists of all flavors
and seasonings concerning their identity. We hoped to encourage therapist
introspection about this important topic. Figure 7.1 is Douglas McFadzean’s
(2010) contribution, a clever drawing of the range of possible metaphors
for our identity as therapists. One of the essays was “Wizards, Humbugs, or
Witches,” by Greg Rusk (2010). I still enjoy using this well-worn but compel-
ling tale to stimulate therapist reflection, hence the title of this chapter.
This chapter keeps the focus on you, encouraging you to envision your
identity as a helper and to further contemplate this complexly human enter-
prise called therapy. It takes a whimsical look at therapist identity, using
the classic fable The Wizard of Oz to illustrate three different therapist per-
sonas. While each of the proposed identities—wizard, humbug, or witch—
has advantages, the therapist identity akin to Glinda, the Good Witch of
the North, is recommended for consideration. Closely related to reflection
about your identity is your personal description of what therapy means to
you. This chapter encourages you to define and continually revise your
personal account of what you do as a therapist. I offer my description and
suggest that embracing the inherent uncertainty of therapy is an important

176       on becoming a better therapist

wizards, humbugs, or witches     
Figure 7.1.  Metaphors of therapist identity. From Heroic Clients, Heroic Agencies: Partners for Change (2nd ed.,

177
p. 199), by B. Duncan and J. Sparks (Eds.), 2010, Jensen Beach, FL: Author. Copyright 2010 by Douglas McFadzean.
Reprinted with permission.
developmental milestone. Psychotherapy is presented as a discovery-oriented
process, a non-cookie-cutter search for what works for each unique client.
The Partners for Change Outcome Management System (PCOMS) provides
a comforting compass, a way to manage the uncertainty that is just as char-
acteristic of therapy as it is of life.

THERAPIST IDENTITY AND THE WIZARD OF OZ

The value of identity of course is that so often with it comes purpose.

—Richard R. Grant

L. Frank Baum’s (1900) wonderful story, The Wizard of Oz, brought to

the screen in 1939 (Metro-Goldwyn-Mayer; directed by Victor Fleming), is
a charming metaphor for the journeys people take to resolve problems and,
believe it or not, the identity of psychotherapists.1 The familiar tale involves
four characters who perceive something missing in their lives. Each believes
that a wizard is necessary to help them find completeness. The Scarecrow
sorrowfully exclaims, “Oh, I’m a failure, because I haven’t got a brain.” The
Tin Man laments “that I could be kinda human, if I only had a heart.” The
Cowardly Lion whines, “My life has been simply unbearable . . . if I only had
the nerve.” Finally, there is Dorothy, who simply wants to return home to
Uncle Henry and Auntie Em. As the unusual quartet, plus Toto the dog, skip
down the Yellow Brick Road in search of the Wizard of Oz, they sing:
Dorothy: If the Wizard is a wizard who will serve.
Scarecrow: Then I’m sure to get a brain . . . 
Tin Man:  . . . a heart
 . . . a home
Dorothy:
 . . . the nerve!
Lion:
In time, despite calamity and distance, they arrive at the Emerald City
and are finally granted an audience with the Great Oz. Impressively framed
by fire and smoke, he proclaims in a thunderous voice:
The Great and Powerful Oz knows why you have come! . . . The benefi-
cent Oz has every intention of granting your requests! But, you must
prove yourselves worthy by performing a small task. Bring me the broom-

1This section has been adapted from “Wizard, Humbug, or Witch,” by G. Rusk, 2010, in B. Duncan

and J. Sparks (Eds.), Heroic Clients, Heroic Agencies: Partners for Change, (2nd ed., pp. 211–212). Jensen
Beach, FL: Author. Adapted with permission.

178       on becoming a better therapist

 stick of the Wicked Witch of the West . . . and I’ll grant your requests.
Now go!
Disappointed, the four friends depart on the journey prescribed by
the Great and Powerful Oz. Overcoming insurmountable odds, the four
heroically prevail over the Wicked Witch and return with the broomstick.
Despite their accomplishment, the mighty Oz is reluctant to grant their
wishes. While the Wizard stalls, Toto pulls aside a curtain and exposes him as
a Humbug. The humbled Humbug quickly recovers and grants boons to the
Scarecrow, Lion, and Tin Man. He gives the Scarecrow a diploma—a doctor-
ate in thinkology—to substitute for a brain. The Cowardly Lion is awarded
a “Triple Cross” for valor, signifying his courage. And, finally, the Tin Man
receives a testimonial and a watch that looks and sounds like a human heart.
The Humbug also agrees to fly Dorothy back to Kansas by way of a
hot-air balloon. Yet, when Dorothy jumps out of the basket to retrieve Toto,
the balloon unexpectedly takes off, apparently stranding Dorothy in Oz. Just
when all seems lost, Glinda, the beautiful Good Witch of the North, suddenly
appears and says, “You don’t need to be helped any longer. You’ve always had
the power to go back to Kansas.” Dorothy wonders aloud, “I have?”
The Scarecrow and Tin Man ask Dorothy what she has discovered on her
journey. Dorothy thoughtfully responds, “Well, I . . . I think that it . . . wasn’t
just enough to want to see Uncle Henry and Auntie Em . . . and it’s that if I
ever go looking for my heart’s desire again, I won’t look any further than my
own backyard; because if it isn’t there, I never really lost it to begin with!”
Glinda, nodding and smiling, “That’s all it is . . . she had to find out for
herself. Now those magic slippers will take you home in two seconds!”
Are you a Wizard, Humbug, or Witch? I have been all three. The
Great and Powerful Oz, the expert faced with overwhelming problems (e.g.,
a Scarecrow wanting a brain or Dorothy trying to return to an unknown
place), did what I was trained to do. He prescribed a protracted journey for
them to acquire something he thought they needed—just as I have assessed
clients’ problems (“The Great and Powerful Oz knows why you have come!”),
framed them in my favorite theoretical terms, and constructed therapeutic
tasks and interventions, without collaboration, to provide clients with things
I thought they needed to improve their mental health or address their prob-
lems. Clients proved themselves worthy, not resistant, by complying with my
interventions.
For their part, Dorothy and her companions were so focused on seizing the
Wicked Witch’s broomstick that they did not see how wise and heroically they
had acted in accomplishing the task. When we send clients on trips through
our own theory-land to find our model’s broomstick, their contributions tend
to fall through the cracks and clients often attribute their successes to us—our
guru or wizard status. Sending Dorothy off on the quest for the broomstick

wizards, humbugs, or witches      179

represents the kind of therapy that is theory-directed; the therapist persona is
one of expert.
After his embarrassing exposure, the Humbug cleverly addresses the
requests of the Scarecrow, Tin Man, and Lion, granting each something
tangible. Although not quite what they expected, our heroes are pleased to
receive validation of their experiences and desires for completeness. Literally,
the Humbug pulls the solutions from his black bag—just as I have listened to
clients’ problems, without much collaboration, and dutifully delivered inter-
ventions from my black bag of reframes, techniques, and evidence-based treat-
ments. Sometimes it helped, just as the Humbug’s efforts did. But as the rock
band America’s old song goes, “Oz never did give nothing to the Tin Man/
That he didn’t, didn’t already have.” The Humbug and black bag embody the
kind of therapy that is technique driven—therapist identity is that of a skilled
technician delivering the latest evidence-based treatment and of a salesman
of sorts, enthusiastically convincing the client that the intervention is just
what he or she needs.
Should the therapist identities of Wizard or Humbug be condemned
for the presumption that a journey was required or a solution needed to
be pulled from a black bag? Hardly. We have all been there and done that,
mainly fueled by our desires to be helpful and by the hangovers from our
training. In truth, we have all felt the burden of clients’ expectations that we
fix their problems. And, of course, these identities, not in their caricatures
depicted here but in terms of our theoretical expertise and technical savvy,
are useful at times. But we don’t have to function as “false wizards,” who
send clients with difficult problems on protracted theory driven pilgrimages.
Neither do we have to reach in a “humbug’s bag of tricks” to face clients in
dire circumstances. Understandably, though, we adopt these therapeutic roles
because that is how we’ve been trained, or we just don’t know what else to
do. Our limited tolerance for uncertainty, together with clients’ expectations
of us, also restricts our sense of adventure and co-discovery, influencing us
toward cookie-cutter practices and away from the great, beautiful, and largely
unknown territory of a client’s path to change.
Dorothy’s experience was not like the experiences of her friends.
Neither Wizard nor Humbug was of any service. Glinda offered something
decidedly different. She helped Dorothy to discover her own meaning about
her perilous quest to Oz and her own resources to return home. Glinda
was always there throughout Dorothy’s trek through the magical land, in
the background, offering help when needed and playing an important role.
Although I’m not as pretty as Glinda, and regrettably possess neither a magic
wand nor bubble transportation, I do strive to adopt Glinda’s persona in my
work with clients, helping them to harvest resources and find solutions and
to discover what works.

180       on becoming a better therapist

 How do you see your identity? The Wizard of Oz is a fun way to start or
continue your introspection. Consider all the metaphors presented in Fig­
ure 7.1 and think of your own as well. Do it any way you like, but do it. Your
reflections about being a therapist are important.
Although designed to stimulate your thoughts, the different caricatures
of therapist identity are not without merit and are not mutually exclusive.
The role you assume can be quite different with different clients, depend-
ing on what you and the client negotiate as being most useful. Finding out
explicitly what clients expect from you is important to nail down as quickly
as possible. It gives you a heads-up about what you can do to be most helpful.
Some clients want a sounding board, some want a confidant, some want to
brainstorm and problem solve, many want a collaborator, and some want an
expert to tell them what to do, or at least take charge and chart a therapeutic
course. Explore the client’s preferences about your role by asking:
77 How do you see me fitting into what you would like to see
happen?
77 How can I be of most help to you now?
77 What role do you see me playing in your endeavor to change
this situation?
77 In what ways do you see me and this process as helpful to attain-
ing your goals?
77 Let me make sure I am getting this right. Are you looking for
suggestions from me about that situation?
Flexibility is not without pitfalls. It means that we don’t know what
role, a priori, will be most helpful. We have to discover it with each individual
client. This doesn’t mean you have to be something that you are not, or be
inauthentic in any way. What it does mean is that, just as you know that
there is no single facilitative therapist response for empathy, you know that
you must accommodate the role that the client believes will be most helpful.
When clients want a more expert stance from me—Dr. Duncan instead of
Barry—I can do that. Although I can never genuinely know the definitive
way to solve or “cure” any problem, I can stretch myself, within the limits of
authenticity, to fit what the client is looking for. At the very least, I can be
more expert-like. I can authoritatively suggest that there are many ways of
addressing the client’s circumstance and rely on him or her to let me know
which one resonates the most after I have presented viable explanations.
I can cite research and assume a more expert role but without the fire and
smoke. Similarly, if a client cuts to the chase, asking for suggestions, I can
offer remedies or rituals, pull them out of my black bag, and perform a more
technical role but ultimately implement the one that the client gets on board
most with. Then the client’s response or benefit will show the way.

wizards, humbugs, or witches      181

 Keep in mind that this wide range of different roles is nothing com-
pared with the diversity of parts you already adeptly and genuinely play
in your life: adult, child, parent, friend, sibling, peer, partner, student,
supervisor, mentor, etc. You are multidimensional and can utilize your own
complexity for your clients by fitting their perceptions of what they want
from you.

Bottom Line: Take the time to reflect about your identity and the roles you
play with clients. Evolve a description of your identity that captures the essence
of what it means to be a helper and that you can feel good about sharing.

A WORK IN PROGRESS

Identity is such a crucial affair that one shouldn’t rush into it.
—David Quammen

In their compelling book based on their extensive empirical investiga-

tions, Rønnestad and Skovholt (2013) described a six-phase model of thera-
pist development, from lay helper to senior professional, and spoke of the
importance of continuous reflection. They asserted that continuous reflec-
tion and an attitude of openness to new learning is a prerequisite for profes-
sional development at all levels of experience. As we develop as therapists,
then, it is also useful to contemplate how we describe what we do—to define,
edit, refine, expand, or outright change it altogether. Recall the discussion
about allegiance and the importance of the therapist believing in whatever
explanations and solutions are employed; or, in Frank’s paraphrased words
(Frank & Frank, 1991), our belief in the restorative power of our methods.
Given the impact of our expectations—our allegiance to what we do with
clients—it makes sense to describe our work in ways that we can believe in
and that also do not restrict our flexibility.
Although we originally described our work as “strategic eclecticism”
(Duncan, Parks & Rusk, 1990), my colleagues (mainly Greg Rusk and Andy
Solovey) and I later started calling what we did client directed (Duncan et al.,
1992) to focus attention on the common factors, especially clients’ contribu-
tion to outcome: their resources, ideas, and views of the alliance. In 2000,
because of the influence of Lambert’s work on client-based assessment, the
term client-directed, outcome-informed (CDOI) emerged:
Our vision . . . embraces change that is client-directed, not theory-driven,
subscribes to a relational rather than a medical model, and is committed
to successful outcome instead of competent service delivery. (Duncan &
Miller, 2000, pp. 217–218)

182       on becoming a better therapist

Expanding and refining the description, and making it more value based,
Duncan and Sparks (2007) defined the work:
CDOI contains no fixed techniques or causal theories regarding the
concerns that bring people to treatment. Any interaction can be client-
directed and outcome-informed when the consumer’s voice is privileged,
recovery is expected, and helpers purposefully form partnerships to:
(1) enhance the factors across theories that account for success; (2) use
client’s ideas and preferences (theories) to guide choice of technique and
model; and (3) inform the work with reliable and valid measures of the
consumer’s experience of the alliance and outcome. (p. 14)
Although the CDOI description is one to which I can truly pledge my alle-
giance, in reflecting about the work over the past few years, I now add three
additional descriptors or values: alliance focused, discovery oriented and socially
just. This continues to be a work in progress that I hope never stops. Although
addressed above (i.e., “partnership” and “enhancing the factors across theo-
ries”), I now include alliance focused to ensure it is not given short shrift. As
articulated in the last chapter, the importance of the relationship/alliance
is immense and its empirical support overwhelming, especially as compared
with the more revered aspects of psychotherapy—model and technique. I
emphasize this as a reminder to myself that the alliance is job one in each
and every encounter and requires my continued effort and focus. It is super-
ordinate to everything else. The Session Rating Scale (SRS) is central to this
endeavor. It just doesn’t happen on its own, and it can be damn hard work.
It can be fun, too. I saw a young woman, Miriam, whose description of
herself as extremely depressed was verified by a score of 10.3 on the Outcome
Rating Scale (ORS). I was unable to engage her much, and she spent most
of the time looking down and giving very sparse answers to questions. I was
not at all happy with the session and was concerned that Miriam would not
return for another try. I gave her the Session Rating Scale, and she gave me
high marks. I was hoping for at least one low mark that could potentially spark
a helpful conversation about what was missing. As I perused her marks on the
SRS, I noticed that her name was Marion, not Miriam, the name I had called
her at least six times in the session. I apologized profusely, and said, “Marion,
if you decide to forgive me for my blunder and come back and see me, would
you be willing to please call me Larry throughout the session so we can try and
even out my stupid mistake?” Marion started chuckling, and then I joined her,
and we enjoyed a healthy laugh together. Marion started the next session call-
ing me Larry, participated in therapy, and ultimately benefited.
The term discovery oriented isn’t mentioned in the above quote, although
it is implied in the statements referring to the client’s ideas, preferences, and
theories. I have thought about the discovery aspects of psychotherapy, as

wizards, humbugs, or witches      183

have others, for some time (see Duncan, Hubble, & Miller, 1997). But the
notion of discovery has taken on a different meaning for me. In addition to
unfolding clients’ ideas and theories to secure resonance with any rationale
and remedy or, said another way, their agreement about the tasks of therapy,
the discovery process now has a definitive purpose, a measurable end. It isn’t
vague or theory driven; there is a tangible treasure to be found. It is the
hunt for what works, for what results in an increased ORS score culminat-
ing in the client’s reaching the expected treatment response. Psychotherapy
is an expedition into what will ultimately prove to be beneficial to clients,
an exploration of client beliefs, values, and theories, as well as cultural and
therapy myths and rituals, using client feedback about progress and the alli-
ance as the ultimate arbiter.
And the term social justice isn’t mentioned in the CDOI definition,
although it is implied in the statement about privileging client voice. Providing
socially just services has always been a part of my work, especially since
Jacqueline Sparks became a colleague, but it is now included more explicitly.
Basically, social justice involves working with clients in ways that privilege
their social and cultural locations and ensuring their self-determination in the
process, and it also requires therapists to play an advocacy role in changing
conditions of oppression in the broader society that are seen as sources of the
many clients’ difficulties (Crethar & Winterowd, 2012; Vasquez, 2012). The
broader implications of how PCOMS relates to social justice are discussed in
Chapter 8.
My description of what I do reflects my value system as a therapist. I
encourage you to come up with your own, while keeping client benefit as the
overseer. But, first, a brief foray into the scary land of uncertainty, a terrain
more frightening than the likes of lions and tigers and bears (Oh, my!).

UNCERTAINTY AND DISCOVERY

Certainty? In this world nothing is certain but death and taxes.

—Benjamin Franklin

Franklin’s comment applies equally to psychotherapy, in which noth-

ing is certain but termination and the fee for service. But this can raise our
anxiety levels about the work, especially, perhaps, among students and newer
therapists, although many of the more experienced are none too comfortable
with it. We long for the structured, the scripted, the predictable, the manu-
alized, the surefire way to conduct a session—maybe not even to sequester
success but at times just to get through it, staring eye-to-eye with a person
experiencing significant distress. Who can blame us? But uncertainty and

184       on becoming a better therapist

complexity are endemic to the work, as they are to life, and therefore are
important to embrace for therapist development.
Of course, there’s nothing wrong with wanting a little certainty or
routine. In fact, I like the routine of doing the ORS and SRS and discussing
progress and the alliance with clients. All routine or structure is not bad.
If you are like many people, you appreciate having something you can hold
on to when you are on unfamiliar ground—like when you meet clients for
the first time or feel cast adrift in the sea of information that clients give.
But you want to leave space for the inexplicable. You want uncertainty to
always be lingering.
Why? As frightening as it feels, uncertainty is the place of unlimited
possibilities for change. It is this indeterminacy that gives therapy its texture
and infuses it with the excitement of discovery. This allows for the “hereto-
fore unsaid,” the “aha moments,” and all the spontaneous ideas, connections,
conclusions, plans, insights, resolves, and new identities that emerge when
you put two people together in a room and call it psychotherapy. This doesn’t
mean, of course, that it’s all fireworks (just watch an entire session, rather
than edited video clips, to see what I mean); it just means that your tolerance
for uncertainty creates the space for new directions and insights to occur to
both the client and you.
Uncertainty stokes the flames of such occurrences. Good therapy capi-
talizes on these opportunities. Perhaps, helping at its very best sets the context
for these unique discoveries. The tolerance for uncertainty, however, requires
faith—faith in the client, in yourself, and in psychotherapy. It also requires
patience. I am certain of one thing: Uncertainty is the key that unlocks the
potential for discovery. It is hard to discover something if you already know
what it is that you are looking for and where it is.

DISCOVERING WHAT WORKS

I offer an account of what I do to encourage you to articulate what

it is that you do—to continue your ongoing professional reflections. If you
find it compelling, I invite you to sample discussions elsewhere (especially
Duncan et al., 1997; and Duncan, Miller, & Sparks, 2004), where you will
find detailed client examples and transcripts.
Milton Erickson (Erickson & Rossi, 1979) addressed the process of dis-
covery in what he called utilization:
Exploring a patient’s individuality to ascertain what life learnings, expe-
riences, and mental skills are available to deal with the problem . . . [and]
then utilizing these uniquely personal internal responses to achieve thera-
peutic goals. (p. 1)

wizards, humbugs, or witches      185

 Discovering what works entails embracing the strong probability, as
the Erickson quote suggests, that clients not only have all that is necessary
to resolve problems but also may have already solved them, started to solve
them, have a very good idea about how to do it, or are just about ready to
figure out something important. And you are in the mix as well—it requires
your reactions, ideas, musings, favorite myths and rituals, and consideration
of the rationales and remedies you’ve never tried. Every conversation sets the
occasion for unearthing new avenues out of the client’s dilemma. Because
this work is unencumbered by rote application of any particular theoretical
or explanatory concepts, there is freedom to speculate. Some ideas grow into
relevant discussion, while others fade away as it becomes apparent that they
are not helpful to pursue. Conversing with clients unfolds and expands expe-
riences and can result in new meanings and plans for action. This process
seeks to chart a different course (connections, conclusions, solutions, etc.)
in any form that permits a way to address the client’s goals, to encourage
an increase on the ORS and the client’s benefit from therapy—to discover
what works.
From a discovery-oriented perspective, the word intervention does not
adequately describe the collaborative process that emerges (Duncan et al.,
1997). To intervene is “to come into or between by way of hindrance or modi-
fication” (Merriam-Webster’s OnLine; http://www.merriam-webster.com). It
implies something done to clients rather than with them, and it consequently
overemphasizes the technical expertise of the therapist, inaccurately portray-
ing what makes therapy successful. The word intervention does not capture
the interdependence of technique on the client’s resources and ideas or how
technique is successful to the extent that it emerges from the client’s positive
evaluation of the alliance. The words invent and invention seem more apropos.
To invent is to “find or discover, to produce for the first time through imagi-
nation or ingenious thinking and experiment” (Merriam-Webster’s OnLine;
http://www.merriam-webster.com). Every technique is used for the first time,
invented by clients and therapists to fit the client’s unique attributes and
circumstance.
My description of psychotherapy casts the client and therapist as co-
explorers, searching the client’s world for the map that provides a route of res-
toration. As coadventurers, we encounter multiple opportunities for sharing
our respective vantage points while crossing the terrain of the client’s world,
periodically stopping to consult our ORS/SRS compass to ensure we are
headed in the right direction. When lost along the way, we regroup to look
for alternate routes on our maps, as well as the maps of others we encounter
on the journey. Such expeditions often uncover trails that we never dreamed
existed. The clients whom you met in this book exemplify the proposed
discovery-oriented perspective of psychotherapy.

186       on becoming a better therapist

 CONCLUSION

“Who are you?” said the Caterpillar. Alice replied rather shyly, “I—I
hardly know, Sir, just at present—at least I know who I was when I got up
this morning, but I must have changed several times since then.”
—Lewis Carroll, Alice’s Adventures in Wonderland

This chapter kept the spotlight on you—your identity as a helper and

how you describe what you do. I offered the enchanting tale of The Wizard of
Oz to stimulate your introspection and encouraged you to think of your own
metaphors. Your continued reflection about your identity fits hand-in-glove
with your description of what it is that you do as a therapist. Your ongoing
reflections about your identity and what you do fuel the developmental pro-
cess. Articulating a description that you can authentically believe in brings
your allegiance to the therapeutic table; it reinforces your expectation that
what you are doing with clients will be helpful. You were encouraged to have
your cake and eat it too, to be flexible in your description of your work to
enable a broad range of possibilities for you and your clients to sample. A
good place to start may be to grapple with and embrace uncertainty as a
prerequisite for your continued development. I presented my description of
what I do as a springboard for your consideration of what you do. A discovery-
oriented description was offered that has been illustrated by the clients pre-
sented in this book.

CLIENTS ARE THE BEST TEACHERS: THEIR STORIES

DOCUMENT OUR DEVELOPMENT

When one admits that nothing is certain, one must, I think, also
admit that some things are much more nearly certain than others.
—Bertrand Russell

Natalie told me she’d been a multiple personality since childhood,

when her different alters provided protection from a brutally abusive envi-
ronment. She felt she had already dealt with the abuse and didn’t want to
become integrated into a single self but, rather, wanted “co-consciousness,”
a state in which the alters would be aware of each other’s experience with-
out losing their separate identities. Natalie entered therapy because she
had lost access to some of her most intuitive sub-selves.
Talk about uncertainty. I didn’t have any idea of how to help Natalie
recontact her missing alters or promote co-consciousness. I shared my lack
of experience in these matters, and Natalie responded that her doctor had

wizards, humbugs, or witches      187

 referred her and had said good things about me and that she trusted her
completely. Besides, she added, the previous therapist, a dissociative iden-
tity expert, had all but demanded that Natalie give up her alters in ser-
vice of an integrated personality. Natalie wanted nothing to do with that.
Natalie told me that she didn’t fit the mold of that therapist’s thinking
about multiples, and added, “I can’t help that!”
But I was willing to not know—to explore her world, to find out how
her system worked, to validate it, and try to discover a way to help her
reaccess her alters. Natalie was quite remarkable: witty, obviously bright,
and very artistic. She worked as a copy editor for a magazine by day and by
night was an accomplished oil painter. Over the next few sessions, Natalie
and others in her system explained to me that her alters lived in various
rooms in a visualized house. Some were practical, others intuitive, and
others tough as nails. She would visualize the pathway to the different
alters’ rooms to access them; whoever had the best skills then emerged to
deal with whatever life dished out—except for now, when some of them
had mysteriously gone missing. I sincerely told Natalie—an extremely
intuitive woman, or collection of women—that I thought she had a “won-
derful system” and suggested she think of all the ways she had gained access
to her alters before.
A possible source to the problem was finally discovered. Natalie said
she thought that the alters were hiding because her boyfriend, Joe, was
embroiled in extreme, ongoing arguments with a brother and sister over
the impending sale of their grandparents’ farm. Natalie believed that the
alters were frightened and hiding, much as they did when she was a child.
Once Joe became less unpredictably volatile, Natalie thought, access to
her missing alters would return. With this discovery made, we focused on
ways to address Joe’s anger and otherwise, in Natalie’s words, “deflect it”
and diminish its impact on her alters. Natalie implemented our inven-
tions and Joe responded by calming down and becoming more attentive
to Natalie’s needs. Subsequently, over the next days, several alters “came
home.”
But my confusion and the uncertainty didn’t stop there. With the
crisis with Joe averted, Natalie identified a new goal of addressing her
Epstein-Barr virus. In the next session, a wise, spiritually centered martial
artist alter named Nora showed up. Since Natalie was already adept at
visualization, I had planned to suggest that we fine-tune her skills to rally
her resources against the virus. I suggested this to Nora instead, and we
worked on various martial arts images to combat the virus. I wondered
aloud if it were possible to teach the others the same skills, and Nora said
she would try.

188       on becoming a better therapist

 Perhaps in my most speechless encounter with a client since Tina
(my first-ever client who dispassionately disrobed despite my dismay),
Natalie appeared in the next session and with great enthusiasm exclaimed,
“I’m a me!” My experienced and tempered empathic therapeutic response:
“Say what?” I was so dumbfounded, so confused—I clearly didn’t know
what the hell was going on. Hemming and hawing and undeniably lost,
my clueless response to Natalie’s revelation often brings down the house
when I show the video in my trainings. But as I always say, at least I was
authentically stupid!
Then Natalie explained: Nora had called a meeting in a visual-
ized library to communicate to the alters what she had learned about
Epstein-Barr. It was the first time they had all been in the same room
together. Natalie reported that each alter had come forward, naming her
special gifts to the overall system. After praying together, each alter had
said, “I belong.”
Natalie told me, “Now I’m a ‘me,’ and I’m different. I am the collage
of their gifts. Everybody’s there. And if they want, they could still come
out, but I’m a me. This me is finding out a lot of things. It’s like I’m look-
ing through a pair of new eyes that have never been touched or scarred.”
Again, I was dumbstruck! She had gone beyond co-consciousness to a
form of integration that she welcomed. I sat stunned for some time before
Natalie asked me if she could give me a hug. I am not sure, in retrospect,
whether it was a celebratory hug or one designed to comfort me and reel
in my confusion.
Natalie stands out to me because I never have felt more cast adrift. I
didn’t have a clue about what to do—no theoretical or technical training
prepared me for this client and how therapy progressed over time. But I
was there hunting for what could work, adding something when I could—
the anger suggestions and the imagery to help combat the virus—until the
unexpected occurred. Natalie also illustrates how difficult it can be to write
about psychotherapy. At one extreme, it can sound like I’m hawking a new
improved cookie cutter while condemning cookie-cutter solutions. At the
other extreme, I probably risk offering vague camp counselor platitudes
about the importance of a good alliance. I believe it is best described, for me,
as a collaborative expedition for the magic of the moment: not the magic of
the sweeping, dramatic gesture or an isolated technique or any other novelty
but, rather, the magic that grows out of exploring the client’s world, validat-
ing their experiences, and discovering what works.

wizards, humbugs, or witches      189

 8
bECOMING A BETTER AGENCY

America’s mental health service delivery system is in shambles . . . [and is]

incapable of efficiently delivering . . . effective treatments.
—President’s New Freedom Commission
on Mental Health, Interim Report

Although the efficacy of psychotherapy has been unequivocally demon-

strated in randomized clinical trials (RCTs; Lambert, 2013), the jury is still
out regarding its effectiveness in everyday clinical settings, especially in the
public domain. This is noteworthy because 61% of mental health and sub-
stance abuse care in the United States is publicly funded (Kaiser Commission
on Medicaid and the Uninsured, 2011).
Great strides, however, in determining the effectiveness of services in nat-
ural settings have recently been made through the methodology of benchmark-
ing, which permits comparison with a reliably determined effect size (ES) from
clinical trials. For example, using benchmarks from RCTs of psychotherapy for
depression, Minami et al. (2008) found that clients who received psychotherapy
in a managed care setting received treatment as effective as those clients receiv-
ing evidence-based treatments (EBTs) in clinical trials. Similarly, Minami et al.
(2009) evaluated services provided at a university counseling center (UCC) and
found treatment effects equivalent to those observed in RCTs.

http://dx.doi.org/10.1037/14392-008
On Becoming a Better Therapist, Second Edition: Evidence-Based Practice One Client at a Time, by B. L. Duncan
Copyright © 2014 by the American Psychological Association. All rights reserved.

191
 For those receiving, providing, or funding public behavioral health
(PBH), however, the question is not whether psychotherapy works in RCTs,
private insurance settings, or UCCs but, rather, whether the benefits of psy-
chotherapy routinely provided by therapists on the front lines extend to
the impoverished, disempowered, and disenfranchised. Studies designed to
answer this question have, so far, painted an ugly picture. For example, look-
ing at childhood depression, Weersing and Weisz (2002) compared outcomes
in six community mental health centers (CMHCs) in the Los Angeles area
with a clinical trial benchmark. They found the outcomes of depressed youth
treated in CMHCs approximated those of control groups in RCTs.
Another way of evaluating effectiveness, as discussed in Chapter 5, is
by examining the rates of reliable and/or clinically significant change (CSC;
Jacobson & Truax, 1991). Perhaps the most damning data regarding PBH effec-
tiveness was presented by Hansen, Lambert, and Forman (2002), who reported
a paltry 20.5% reliable change rate and 8.6% CSC rate, a combined reliable
and clinically significant change (RCSC) rate of just 29.1% at a CMHC. This
study seemed to only confirm the conclusion, noted in the epigram above,
reached by the President’s New Freedom Commission on Mental Health,
Interim Report (2002). Hansen et al. (2002) also reported an unimpressive
35% RCSC rate across six different types of outpatient settings. In other words,
almost two thirds of the 6,072 clients did not benefit from psychotherapy.
Can PBH redeem itself? Can outcomes be improved in any organization for
that matter? This chapter addresses these questions and demonstrates that the
Partners for Change Outcome Management System (PCOMS) can raise the bar
of PBH performance as well as any setting willing to take the plunge of systemat-
ically identifying clients at risk for a negative outcome. First, the chapter reports
the results of our recent study (Reese, Duncan, Bohanske, Owen, & Minami,
2014) that evaluated the effectiveness of a large, multicultural PBH agency that
had implemented PCOMS against clinical benchmarks from RCTs—a story of
redemption and success. But there is no free lunch. Implementation of PCOMS
so that gains in effectiveness are realized at the individual therapist and agency
levels takes a concerted long-term commitment that integrates PCOMS in all
aspects of service delivery. The chapter also details the four secrets of imple-
menting PCOMS and the supervisory process that sustains its impact.

ONE AGENCY’S STORY OF REDEMPTION AND SUCCESS

Those who wish to sing always find a song.

—Swedish Proverb

Just as now is not an easy time to be a therapist, as noted in Chapter 1,

it is not a stroll in the park to be a public agency either. Paperwork and

192       on becoming a better therapist

continual oversight is a way of life. In addition to state requirements, man-
aged care companies are frequently retained to handle the distribution of
public funds and ensure accountability. Add more forms. Then, each agency
has its own policies and procedures necessitated by national regulatory and
accrediting bodies. Add still more paperwork. If that were not enough, the
rush to limit service provision to EBTs has added new layers of management,
policies, and procedures. It is easy to see why outcomes and the quality of
service delivery can get shuffled to bottom of the paperwork pile.
But this is not the case at Southwest Behavioral Health Services (SBHS),
a large ($70 million annual budget) nonprofit, comprehensive community
behavioral health organization providing services to people living in Maricopa
(Phoenix), Mohave, Yavapa, Coconino, and Gila counties in Arizona. SBHS
provides clinical services to a diverse group of Medicaid-insured clients at
or below 100% of the federal poverty level through a wide variety of pro-
grams, including mental health and substance abuse treatments for youth and
adults. SBHS is also the professional home of the Heart and Soul of Change
Project (hereafter the Project) leader, Bob Bohanske. Because of Bob’s efforts,
SBHS embarked on a journey of transformation and implemented PCOMS
beginning in 2007, eventually rolling it out across all clinical services (see
Bohanske & Franczak, 2010, for a full description).
The data for the Reese et al. (2014) benchmarking study were collected
from adult clients attending at least two sessions who were discharged between
January 2007 and December 2011. Given that clients completed the measure
at each session, a larger inclusion rate was enabled because the data from last
session were always collected. Although some data sets include only those
functioning in the clinical range at intake (e.g., Minami et al., 2009), we also
included clients who scored over the clinical cutoff at intake (27% of final
data set) to be more representative of typical PBH data. Using these criteria,
we identified 5,168 clients seen by 86 therapists. This total data set was used
to compare with the benchmarks derived from RCTs of client feedback (both
the Outcome Questionnaire [OQ] and the Outcome Rating Scale [ORS]).
The clients were predominantly female (60.7%) and Caucasian (67.8%),
with their ages ranging from 18 to 87 (M = 36.7) and mostly between the
ages of 18 and 40 (61.8%) or 41 and 64 (37.3%). Hispanics were the largest
minority (17.7%), followed by African Americans (9.3%), Native Americans
(2.8%), and other ethnic groups (2.4%). Clients attended a mean of 8.9 ses-
sions. Regarding the primary diagnosis, depression, mood, and anxiety disor-
ders (excluding bipolar disorder) were the most common (46.0%), followed
by substance abuse disorders (18.8%), bipolar disorder and schizophrenia
(14.4%), and adjustment disorder (10.0%). A mix of other diagnostic catego-
ries accounted for the remainder. Exploratory analyses were conducted on cli-
ent demographic variables such as race/ethnicity, gender, and diagnoses. As

becoming a better agency      193

many other studies have found, the demographic variables had little impact
on effectiveness. An interesting “nonfinding” was that diagnosis also had
little impact on outcome, yet another confirmation that it should be given
little importance in the clinical process.
Although the total sample was representative of typical agency prac-
tice, the data were trimmed by eliminating those clients who scored over the
clinical cutoff and who had a diagnosis of any disorder other than a depressive
disorder, to approximate the methodology used in the benchmarking studies
of managed care and university counseling settings. This reduced the sample
to 1,589 clients for the second benchmark comparison.
And our results: The total sample ES estimates of SBHS were compa-
rable with those of RCTs evaluating systematic client feedback (OQ system
and PCOMS combined). In addition, a comparison of ES estimates revealed
that psychotherapy for adult depression provided at SBHS generated ES esti-
mates that were similar to those observed in clinical trials of major depression
treated by EBTs. Therefore, despite differences in clinical and demographic
characteristics between this agency and clinical trials included in the bench-
mark, it is reasonable to conclude that psychotherapy services provided at
SBHS by the rank and file are effective. This is noteworthy because the con-
ditions of RCTs are quite different, often far more posh compared to those in
the trenches. Clinicians in PBH settings must take all comers, many of whose
complicated lives and histories would be an immediate cause for exclusion in
most research settings.
Comparisons to the two noted benchmarking studies (Minami et al.,
2008, 2009) also revealed similar ES estimates. This too is noteworthy, given
the representative nature of the SBHS sample. Both of the other bench­
marking studies lost considerable portions of data. For example, Minami
et al. (2008), the study conducted in a managed care setting in which the
OQ was administered by only 65% of therapists and was required only at
the first, third, fifth, and every fifth session thereafter, lost over 55% of the
data for lack of two data points. The current sample lost only those who
didn’t return for a second visit, again raising the issue of feasibility discussed
in Chapter 2.
So why are services at SBHS superior to previous dismal reports of out-
comes at CMHCs (Hansen et al., 2002; Weersing & Weisz, 2002)? Perhaps
the most obvious answer is the dose of treatment, the issue highlighted by
Hansen et al. (2002), who argued that the dose of treatment (4.3 sessions)
was inadequate exposure to psychotherapy for improvement to occur. Our
study provided some support for their argument, given that the average was
8.9 sessions. Not supportive of the dose explanation, however, and revealed
in Table 8.1, in as few as three sessions, over 50% of clients achieved either
reliable (21.7%) or clinically significant (32.8%) change. The addition of

194       on becoming a better therapist

 TABLE 8.1
Clinically Significant Change by Session of SBHS and UCC
N in clinical
Total N range % CSC (n) of eligible
No. of
SBHSa UCCb SBHSa UCCb SBHSa UCCb sessions
550 NA 420 NA 26.2 (110) NA 2
702 1195 527 706 32.8 (173) 35.8 (253) 3
549 843 401 520 38.2 (153) 40.4 (210) 4
467 597 370 381 47.3 (175) 40.4 (154) 5
360 418 251 270 43.8 (110) 42.2 (114) 6
317 311 226 208 46.9 (106) 43.3 (90) 7
280 257 186 182 51.6 (96) 46.5 (80) 8
260 229 181 153 49.7 (90) 47.7 (73) 9
213 152 155 100 51.6 (80) 50.0 (50) 10
160 128 111 92 41.4 (46) 46.7 (43) 11
144 110 101 76 54.5 (55) 47.4 (36) 12
114 93 81 60 58.0 (47) 41.7 (25) 13
107 82 68 63 45.6 (31) 49.2 (31) 14
87 43 63 32 54.0 (34) 53.1 (17) 15
91 41 63 34 50.8 (32) 47.1 (16) 16
77 32 56 23 48.2 (27) 31.1 (9) 17
586 145 435 95 49.7 (216) 43.2 (41) 18–40
104 NA 79 NA 46.8 (37) NA 41+
5168 4676 3774 2985 42.9 (1618) 41.6 (1242) TOTAL
Note. SBHS = Southwest Behavioral Health Services; UCC = university counseling center; NA = not
available.
aData from Reese, Duncan, Bohanske, Owen, and Minami, 2014.
bData from Baldwin, Berkeljon, Atkins, Olsen, and Nielsen, 2009.

systematic client feedback provides a better explanation. Considering both

the OQ system and PCOMS, identifying clients at risk via the routine use
of outcome measures has now been shown in 11 RCTs to improve outcomes.
SBHS started implementation of systematic client feedback in 2007 and
now integrates routine consumer feedback in all services. In other words,
PCOMS is the reason.
Very few studies have systematically looked at large naturalistic data
sets. We were able to find only one other U.S. study in addition to the bench-
marking studies discussed above, the study by Baldwin, Berkeljon, Atkins,
Olsen, and Nielsen (2009) of a UCC, discussed in Chapter 2. Comparisons
with the current PBH sample (see Table 8.1) revealed a surprising similarity
of the two data sets, measured by different outcome instruments (the ORS
and OQ), in the rates of CSC by session as well as the overall CSC rate
(42.9 in the PBH sample vs. 41.6 in the UCC sample). There were perhaps
some expected differences as well. Regarding clients entering therapy in the
clinical range, 63.8% of the clients in the UCC study entered in the clinical

becoming a better agency      195

range compared with 72.9% in the SBHS sample. The prevailing assumptions
regarding the two sites may be that university counseling clients are likely to
be more functional than PBH clients (e.g., more available resources, educa-
tion) and therefore more likely to achieve better outcomes. While there is
some support for the first assumption, given the percentage of clients entering
in the clinical range, the difference (9.1%) may be less than expected. The
second assumption (better outcomes) was not borne out by our study.
Finally, in addition to the improvements in outcomes resulting in the
noted similarities to RCTs, a UCC, and a managed care setting, SBHS also
realized significant gains in efficiency. After PCOMS implementation, there
was a significant reduction in length of stay across programs, a decrease in
cancellations and no-shows, and an increase in overall therapist and agency
productivity—serving more clients with the same number of staff. The story
of redemption and success was complete. SBHS improved both the effective-
ness and efficiency of services, leaving the dismal report of President’s New
Freedom Commission far behind.

FOUR SECRETS OF SUCCESSFUL PCOMS IMPLEMENTATION

I haven’t failed. I’ve found 10,000 ways that won’t work.

—Benjamin Franklin

The Heart and Soul of Change Project (https://heartandsoulofchange.

com) is a practice-driven training and research initiative that focuses on improv-
ing outcomes via client-based outcome feedback, or PCOMS. The website is a
major dissemination vehicle for PCOMS with over 250 free downloads (articles,
handouts, slides, videos, and webinars) as well as a “member” site with addi-
tional training resources, including client videos. While PCOMS is not tied to
any model-based assumptions and can be incorporated in any treatment, it does
promote a set of service delivery values: client privilege in determining the ben-
efit of services as well as in all decisions that affect care, including intervention
preferences; an expectation of recovery; attention to those common factors that
cut across all models that account for therapeutic change; and an appreciation
of social justice in the provision of care—or client-directed, outcome-informed
clinical work (Duncan, 2010a; Duncan, Miller, & Sparks, 2004; Duncan,
Solovey, & Rusk, 1992; Duncan & Sparks, 2002, 2007, 2010).
PCOMS offers a way to operationalize interrelated ideas that often sound
like platitudes: individually tailored services, consumer involvement, recov-
ery, and social justice. Despite well-intentioned efforts, the infrastructure of
therapy (paperwork, policies, procedures, and professional language) can reify
descriptions of client problems and silence client views, goals, and preferences.

196       on becoming a better therapist

Routinely requesting, documenting, and responding to client feedback trans-
forms power relations in the immediate therapy encounter by privileging cli-
ent beliefs and goals over potential culturally biased and insensitive practices.
Outside the therapy dyad, client-generated data via PCOMS help over-
come inequities built into everyday mental health service delivery by rede-
fining whose voice counts. Use of client feedback applies the principles of
social justice that, until now, have largely existed only in the pages of training
manuals, textbooks, and academic journals (Sparks, 2013). PCOMS seeks to
level the psychotherapy process by inviting collaborative decision making,
honoring client diversity with multiple language availability, and valuing
local cultural knowledge; PCOMS provides a mechanism for routine atten-
tion to multiculturalism and consumer involvement.1 Finally, PCOMS helps
to enable recovery-oriented services (Bohanske & Franczak, 2010; Sparks &
Muro, 2009) via attention to facilitating individually defined change rather
than the treatment of “mental illness.”
Transporting PCOMS to everyday organizational practice by the Project
emphasizes these values in addition to the mechanics and clinical nuances
of using the ORS and the Session Rating Scale (SRS). Over the course of
the past decade, four secrets to successful implementation of PCOMS have
emerged: In it for the long haul; Love your data; Inspire the frontline clini-
cian; and Supervision for a change.

In It for the Long Haul

Organizational change is hard, and many things can sabotage well-

intentioned efforts. People at all levels from the CEO to support staff tire of
hearing about the next great thing (the next paradigm shift is always just around

1Sometimes the question arises regarding whether PCOMS imposes Western thought on nondominant
cultures. Jacqueline Sparks, Project Partner and social justice advocate, believes that the measures
are designed specifically not to impose Western ideology on those who come from non-Western cul-
tures. On a recent post to the Project listserv (https://groups.google.com/forum/?fromgroups#!forum/
heroicagencies), she wrote:
Our mental health system is Western-based, particularly its emphasis on the objective expert apart from
the client who can determine the process and procedures that will “cure” the client, based on Western
norms of [fill in the blank—what is a healthy man, woman, couple, family, etc.]. There are many tragic
histories of how this model has produced oppressive practices. PCOMS, instead, fundamentally alters
this dynamic, inviting a collaboration where the distinction between us and them is broken down and
where client views, including cultural and spiritual preferences, are honored first and foremost. PCOMS
is an antidote to Western oppression of indigenous and non-European cultures. Granted, the forms,
despite being translated into 22 languages, come from systems of measurement that are rooted in West-
ern thought. However, the visual analog continua and lack of specific content questions allow a broad
range of flexibility for the client to communicate his or her unique experience. They, not a diagnosis or
theoretical lens, provide the starting point for the conversation that unfolds the client’s unique story,
views, and preferences. I make the assumption that the desire to not be “done to” but to do (for self/
family however conceived), to have a voice that is heard, is valued cross-culturally.

becoming a better agency      197

the corner), and, as discussed in Chapter 2, measuring outcomes has its own set
of obstacles and fears. Over time, many learn to cope by battening down the
hatches and waiting out the storm, the latest edict dictated by management.
Consequently, it is often best to think small and go slow, garnering support over
time and winning people over. For example, conducting a pilot project in one site
or program can offer a way to get things started in a manageable way, especially if
the pilot is with the easiest implementations first, like outpatient psychotherapy
services. This is how Bob Bohanske at SBHS went about it. Another approach is
to start with so-called early responders or volunteers who embrace the ideas from
the beginning. Then, the findings and enthusiasm from the pilot can be used to
secure ongoing commitment from others. This is how Dave Hanna at Bluegrass
Community Mental Health in Kentucky got things rolling.
Successful transportation of PCOMS requires commitment at all levels
(Exhibit 8.1 is a readiness checklist). Implementation is not a sprint, it’s a
marathon. I learned this the hard way. Some trainings that I had hoped would
inspire implementation were doomed from the beginning. For example,
sometimes an enthusiastic person who had read about PCOMS or attended
a workshop attempted to champion its implementation by bringing me in to

EXHIBIT 8.1
Partners for Change Outcome Management System (PCOMS)
­Organizational Readiness Checklist
1. The Agency/Organization/Behavioral Health Care System has secured Board of
Director approval and support for PCOMS.
2. Has consensus among the agency director and senior managers that consumer
partnership, accountability, and PCOMS are central features of service delivery.
3. Has a business/financial plan that incorporates PCOMS, training, and data
collection.
4. Promotes regular communication with funders about PCOMS data as they apply
to agency effectiveness and efficiency.
5. Has a human resource training and development plan that supports ongoing
PCOMS education at all levels, including a core group of internal trainers, and
that integrates PCOMS into individual development plans, performance apprais-
als, and hiring practices.
6. Has the infrastructure (e.g., support staff, IT, computer hardware, software) to
support the collection and analysis of PCOMS data at the individual consumer,
therapist, program, and agency levels.
7. Has a supervisory infrastructure that allows PCOMS data to be used to individu-
alize treatment planning, identify at-risk clients and proactively address treat-
ment needs, and improve therapist performance.
8. Has a structure to support and a policy for addressing clients who are not pro-
gressing that ensures rapid transfer and continuity of care.
9. Has a Mission Statement that incorporates consumer partnership and account-
ability as central features of service delivery.
10. Has a Client Rights and Responsibilities Statement that emphasizes consumer
feedback and partnership to guide all treatment services.

198       on becoming a better therapist

do training, but without agency support and the infrastructure to maintain
it, implementation quickly fell flat. More often, an agency director would
arrange a training because he or she wanted to steer the organization toward
measuring outcomes because of state requirements but would not have any-
one else on board or any plan of implementation beyond my 1-day overview.
Sometimes these trainings were mandated without any groundwork, resulting
in my surprise to find a somewhat hostile audience in fear of management “big
brother” and the “real” purpose of measuring outcomes. Fueling these fears,
sometimes managed care entities employed my training services with the
intention of using PCOMS to do provider profiling. Of course, once I figured
that out, it didn’t go any further.
Implementing PCOMS requires much more than attendance at a work-
shop because it involves all aspects of service delivery. I finally learned that
certain things have to be in place for any chance of success. No doubt, orga-
nizing services around client preferences and progress challenges conven-
tional wisdom about how to provide treatment—new staff orientation, intake
process, documentation, treatment plans, case staffing, and supervision all
need revision. Without the infrastructure to support such changes, they are
unlikely to happen. Although all of the items on the checklist are important,
I focus here on a few key items.
77 Consensus among the agency director and senior managers that con-
sumer partnership, accountability, and PCOMS are central features
of service delivery. Unless everyone is on board, implementa-
tion is likely to fail because those who are under the skeptical/
indifferent manager in the organizational tree will not follow
through with what is required. This is the first legwork that
needs to occur to ensure success. Having the management team
on board who can speak the language allows the conversation
to start with frontline clinicians and assuage their concerns
about what management is up to.
77 A business/financial plan that incorporates PCOMS. While imple-
menting PCOMS is very low cost compared with EBTs because
it applies to all clients and not just to one specific diagnosis,
it’s not free. The plan must include the initial and follow-up
training and consultation expenses as well as ongoing data col-
lection and dissemination costs. I also recommend that the
plan include the training of a core group of internal champions
who can replace the need for outside consultation. Organiza-
tions that commit to these internal folks have a much greater
chance for success, not only because of their increased expertise
with PCOMS but also because of their ability to use available
resources on the website to train others.

becoming a better agency      199

 77 A supervisory infrastructure that allows PCOMS data to be used to
individualize treatment planning, identify at-risk clients and proac-
tively address treatment needs, and improve therapist performance.
Early on, I encountered many agencies that did not include clin-
ical supervision as part of their routine functioning. Reasons for
this included: no available time because of therapist productiv-
ity requirements, administrative supervision regarding funding
and reporting issues took priority, or only unlicensed therapists
required supervision. The latter is ironic, given that it implies
that licensed therapists are successful with all their clients.
77 Successful implementation is not possible without ongoing
supervision to ensure data integrity, allowing clients at risk to be
identified and addressed proactively. Over time, and faced with
relentless competing demands, staff enthusiasm for any new
approach naturally wanes. The vigilance required to sustain any-
thing new dwindles without ongoing attention. Supervision can
come in many forms, including group and peer supervision, but
there has to be ongoing follow-up and follow-through. Supervi-
sion offers the most direct method of ensuring PCOMS reaches
the front lines and stays there. (More on supervision below.)
77 The infrastructure (e.g., support staff, IT, computer hardware, soft-
ware) to support the collection, analysis, and dissemination of PCOMS
data at the individual consumer, therapist, program, and agency levels.
Everything is based on the data. The use of the ORS and SRS as
clinical tools to facilitate conversations with clients about prog-
ress and the alliance undoubtedly enhances outcomes. But unless
there is a way to collect the data in a reliable way that ensures data
integrity and dissemination, PCOMS will not serve its primary
function. Unless the data are used to identify clients who are not
benefiting, then PCOMS is not going to enhance outcomes at an
organizational level. This leads us to the second secret to success-
ful implementation.

Love Your Data

For a long time, I implemented PCOMS with the belief that data col-
lection would happen organically, that using the ORS would lead folks to see
the value of the numbers and ultimately to systematically enter scores into
some kind of aggregate database. What was I thinking?! While some people
intuitively see the benefits of data collection, the overwhelming majority of
folks don’t. It fact, many people hate numbers and cannot see the relationship
between what they do and numbers on a spreadsheet or scores on a graph.

200       on becoming a better therapist

 The fact of the matter is that you don’t know how implementation is
progressing unless you have data. The data tell all, conveying rapid informa-
tion not only about who is using the measures but also about whether the
measures are being used properly, thus allowing data integrity. Data indicators
of correct and incorrect use are easily taught and integrated into the supervi-
sory process (see below) allowing supervisors to monitor and build therapist
skill level. Until there is data integrity, PCOMS will not do its job of identi-
fying nonresponding clients to enable new directions and better outcomes.
An important part of successful implementation, therefore, involves
building a culture around numbers and data that help people get rid of their
reluctance to embrace them. In fact, the goal has to be not only for people
to see data as their friend, but for them to actually love their data. Keep in
mind, when I say numbers, I am not reducing clients to statistics. Far from it.
The numbers represent clients’ own assessments of progress and their alliance
with a helper. The measures, in short, amplify client voice. Without them,
clients’ views do not stand a chance to be part of the real record—that is,
critical information that guides moment-by-moment, week-by-week treat-
ment decisions or evaluates eventual outcomes. Numbers on the measures, as
concrete representations of client perspectives, offer a direct way to describe
client benefit at individual therapist and agency levels.
The data, of course, offer an organization the ability to demonstrate its
effectiveness to funders, a major motivation for many agencies to consider
PCOMS in addition to the benefits of improved effectiveness and efficiency.
For example, Barbara L. Hernandez, chief operating officer of the Center
for Family Services (CFS) in West Palm Beach, Florida, negotiated with a
funder, Palm Beach County Children Services, to use PCOMS as the primary
outcome data in a program for expectant mothers. Similarly, Dave Hanna,
certified trainer and CEO of Bluegrass CMHC in Kentucky, is using PCOMS
data to negotiate the waiving of initial authorization of services with one of
the center’s managed care entities.

Inspire the Frontline Clinician

The benefits are clear when considering organizational goals, but what
about the benefits of data collection for the frontline therapist? Implementation
also requires an attention to the in-the-trenches practitioner and a more
“inspire” versus “mandate” organizational mentality. Although some may
ultimately need to be mandated, and everyone must know that the organi­
zation is totally committed to this direction, most can be inspired to give it
a shot. A recent study by Ionita (2013) of Canadian psychologists provides
some insight into some of the barriers that prevent therapists from embrac-
ing outcome management. For some who have been in the field for a while,

becoming a better agency      201

outcome management might be a totally foreign concept. Ionita reported that
the longer a person was out of graduate school, the less likely it was that he
or she had heard of measuring outcomes. Among those who had heard of it,
the top three barriers to the task were limited knowledge of measures, lack of
training, and limited accessibility to training on outcome management.
So, to state the obvious, initial and ongoing training is essential to
implementation. Therapists need to feel comfortable and supported with
something that may initially seem quite alien. As anyone who has attended
a workshop knows, enthusiasm quickly dissipates and readily lapses into frus-
tration if continued support is unavailable.
Still others have been turned off by cumbersome measures that seem
far removed from their day-to-day work with clients. Ionita (2013) reported
that the reasons people stopped using outcome measures were worries that
the measures were burdening clients, they added too much work, and clini-
cians were not convinced of the benefits. All of the barriers exemplified in
Ionita’s study can be easily addressed with PCOMS. If you are with me to this
point, you know that the burden on clients is minimal to none, that the work
of doing the measures is folded into the clinical process itself, and that using
PCOMS results in better outcomes at both the individual and organizational
levels. But clinicians are more likely to be convinced of the benefits by their
own clinical experience than by cited studies. That is where the inspira-
tion really comes in. When clinicians experience the conversation they have
never had before, or recapture a client who was headed nowhere, then the
benefits of PCOMS provide motivation to continue. Getting therapists to
that point is the challenge. Don Rogers, clinical director of Bluegrass and a
Certified Trainer says that you have to drag some folks to this point, but once
they get there, the feedback process provides its own motivation. Converts
are good for implementation.
Still others are fearful that P4P or “pay for performance,” or what I call
“punish for performance” (more on this next chapter), or similarly moti-
vated strategies will be used to malign those who do not measure up to some
arbitrary standard. This is essentially an issue of trust and requires that the
management mantra be that the measures will never be used in punitive
ways against therapists. The sole purpose of PCOMS is to improve client
outcomes. I recommend that organizations put this in writing to convince the
skeptical. I also inform folks in my implementation trainings that if PCOMS
is used punitively toward therapists I will remove the agency’s license to use
it. The point is that everyone must know that PCOMS isn’t about nailing
therapists or no one will do it—management needs to be adamant that the
only purpose is to use data to improve the quality of care that clients receive.
Given that most therapists improve their outcomes with feedback, a positive,
noncompetitive approach goes a long way to assuage therapists’ fears.

202       on becoming a better therapist

 Even with these concerns that measuring outcomes tend to stir in
clinicians, the large-scale study of therapist development described in
Chapter 5 suggested three things practitioners bring to the table that help
implementation: therapists want to make a meaningful difference in the
lives of those they serve; therapists want to improve over the course of
their careers; and therapists need to grow to avoid burnout. So implemen-
tation is enhanced when PCOMS is connected to the work that the over-
whelming majority of therapists deeply value and when it appeals to their
best side—their nearly universal desire to do good work and get better. In
an attempt to motivate practitioners to consider the benefits of feedback,
the implementation ­process of the Project also includes an attention to
(a) the common factors, (b) a nuanced clinical process, and (c) therapist
development. Of course, these are the issues that have been emphasized
throughout this book.
The common factors, those elements of psychotherapy running across
all models that account for change (see Chapter 1), provide an overarching
framework for PCOMS. Integrating the use of PCOMS within the larger lit-
erature about what works in therapy promotes therapist understanding of the
feedback process and adherence to the feedback protocol. As detailed in this
book, PCOMS is presented as the tie that binds these healing components
together, allowing the factors to be expressed one client at a time.
Although the more than 400,000 administrations of the ORS/SRS have
yielded invaluable information regarding the psychometrics of the measures,
trajectories, algorithms, etc., PCOMS remains a clinical intervention embed-
ded in the complex interpersonal process called psychotherapy. For successful
implementation and ongoing adherence, PCOMS must appeal to therapists
at a clinical level. Consequently, PCOMS is described as the clinical process
that it is—one that requires skill and nuance to achieve the maximum feed-
back effect. PCOMS speaks to therapists “where they live” by providing a
methodology to address those clients who do not benefit from their services.
Implementation in many ways rests on getting therapists to make it their own
so they will realize the benefits.
Similarly, a focus on therapist development provides a positive motiva-
tion for therapists to invest time and energy in PCOMS. There will always
be organizational motivations for PCOMS in terms of improved outcomes
and reduced costs—the language of “return on investment” and “proof of
value.” But there is also the personal motivation of the therapist, the very
reason most got into this business in the first place: to make a difference in
the lives of those served. PCOMS appeals to the best of therapist intentions
and encourages therapists to collect ORS data so that they can track their
development and implement strategies to improve their effectiveness, as
discussed in Chapter 5.

becoming a better agency      203

 Including these additional aspects allows therapists to see that the
intentions of PCOMS go well beyond management or funder objectives.
Client-based outcome feedback is about consumer privilege and benefit and
about helping therapists get better at what they do.

Supervision for a Change (in Both Clients and Therapists)

If there is any one thing that must be in place for the successful imple-
mentation of PCOMS, it is supervision. Client feedback increases in value
exponentially, and consumer involvement becomes a reality when ORS
scores extend past the clinical session to supervision and are used to iden-
tify those who are not responding. In the Orlinsky and Rønnestad (2005)
study of therapist development, supervision was also rated highly as a posi-
tive influence on current growth. Recall that 97% of therapists in that study
ranked learning from clients to be the most beneficial, with 84% rating it as
highly beneficial. Supervision was rated as beneficial by 95% of therapists and
as highly beneficial by 79%. So supervision is not a hard sell to therapists.
Ongoing supervision is integral to positive work morale. It is often what holds
agencies together in the face of pressures for production and the stress of
hearing the heartaches of people struggling at the worst times of their lives.
Supervision provides a context for camaraderie and support—it fosters an
esprit de corps that both buffers burnout and stimulates rapid learning. And
it is about change for both clients and therapists.
A four-step supervisory process (Duncan & Sparks, 2010) that focuses
first on ORS-identified clients at risk and then on individual clinician effec-
tiveness and how improvement can occur strengthens the possibility of suc-
cessful implementation. This supervisory process is a bit different—it is based
on outcome data instead of theoretical explanations or pontifications about
why clients are not changing. It is aimed at identifying clients who are not
benefiting so that services can be modified in the next session. This type of
supervision is a big departure from business as usual because, rather than the
therapist choosing who is discussed, the clients are choosing themselves by
virtue of their ORS scores and lack of change. So the ORS allows clients to
have a voice in supervision as well.
There is no inherently correct way to conduct supervision, and it can be
accomplished in individual, group, or peer formats. Many agencies combine
group and individual supervision, doing three 2-hour groups per month that
cover clients at risk and one 1-hour individual session to address the develop-
ment of the therapist.
1. Supervisees bring graphs of all clients who are not benefiting; and until data
integrity is ensured, graphs of all clients or a spreadsheet of all client scores. The

204       on becoming a better therapist

first order of business is to ensure data integrity. If this is not done, then
PCOMS will not do its job of identifying clients at risk and will not result
in improved outcomes. A big red flag occurs when therapists say their clients
refuse to do the measures. Given the infrequent nature of client refusal, this is
almost always more about the therapist than the client. This can be solved by
demonstrating the use of the measures with these very clients or simply asking
the therapist to role-play his or her introduction with the supervisor playing
the client.
There are three things to look for in the data to ensure integrity. There
is a learning curve here, so don’t freak out if you have to dump some of your
data. For example, in the SBHS implementation led by Bob Bohanske, 31%
of the data had to be dumped the first year, dropping to 5% in the last (a span
of 5 years). The first data indicator is the percentage of intake scores that are
over the clinical cutoff. If more than 30% of intakes are over the cutoff, it is
likely that the therapist is not introducing the ORS so that the client under-
stands it and/or is not connecting it to the work of therapy. Of course, if the
therapist works primarily with mandated clients or kids, then the percentage
over the cutoff will be higher.
Second, scores 35 and higher are rarely valid. Even those not receiv-
ing services rarely score this high. People tend to see that their lives are not
perfect and generally leave some room for improvement on the ORS. Recall
from Chapter 2 that there are generally two reasons that clients score so high:
They either don’t understand the measure or they are blowing it off. Both
are training issues. Again, the supervisor has to make sure that the therapist
knows how to introduce the ORS and integrate it into the work. And the
therapist needs to know how to follow up on a high score to make sure that it
matches the client’s descriptions of his or her experience of life. Connecting
clients’ marks to their reasons for service provides assurance that the scores
will be a valid representation of client distress.
Finally, the third scenario that quickly reflects improper use of PCOMS
is the seesaw pattern, where client scores go up and down. This typically
means that the client doesn’t understand that the measure is designed to
monitor progress about the reasons for service and not how his or her life is
going; in other words, the ORS has become an emotional thermo­meter. This,
of course, requires that the therapist integrate the ORS into the work, and
that the client view the measure as a reflection of how therapy is addressing,
for better or worse, the reasons for service. Emotional thermometer graphs
are easily spotted and handled.
The data quickly highlight these training needs so that the supervisor
can focus on the skills necessary for data integrity. Exhibit 8.2 lists the com-
petencies required of therapists and a measure of fidelity or adherence that

becoming a better agency      205

 EXHIBIT 8.2
Partners for Change Outcome Management System (PCOMS)
Therapist Competency Checklist and Adherence Scale
1. Administer and score the Outcome Rating Scale (ORS) each session or unit of
service.
2. Ensure that the client understands that the ORS is intended to bring his or her
voice into the decision-making process and will be collaboratively used to
monitor progress.
3. Ensure that the client gives a good rating, i.e., a rating that matches the client’s
description of his or her life circumstance.
4. Ensure that the client’s marks on the ORS are connected to the described
reasons for service.
5. Use ORS data to develop and graph individualized trajectories of change.
6. Plot ORS on individualized trajectories from session to session to determine
which clients are making progress and which are at risk for a negative or null
outcome.
7. Use ORS scores to engage clients in a discussion in every session about how
to continue to empower change if it is happening and change, augment, or end
treatment if it is not.
8. Administer and score the Session Rating Scale (SRS) each session or unit of
service.
9. Ensure that the client understands that the SRS is intended to create a dialogue
between therapist and client that more tailors the service to the client—and that
there is no bad news on the measure.
10. Use the SRS to discuss whether: the client feels heard, understood, and
respected, the service is addressing the client’s goals for treatment, and whether
the service approach matches the client’s culture, preferences worldview, or
theory of change.
PCOMS Therapist Adherence Scale
The PCOMS Therapist Adherence Scale uses the above PCOMS Checklist and
scores it with the following scale:

Never Sometimes Often Regularly Always

1 2 3 4 5

Out of a total possible 50 points, adherence is considered acceptable at 40 or above

at the 6-month mark and 45 or above at 1 year after implementation. High adherence
is ensured by the PCOMS supervisory process and attention to data integrity.

some find helpful. Supervision that holds therapists accountable on these

data validity parameters allows PCOMS to do what it was designed to do.
2. Supervisor reviews graphs, spends most time on at-risk clients, shapes discus-
sion, and brainstorms options. Once data integrity is consistent, the focus in
supervision turns to those clients who are not benefiting from services. To use
the data to full advantage, supervisors will need to get over any squeamish-
ness about trajectories, expected treatment response (ETR) curves, or read-
ing graphs in general. It is not really that complicated, and after you do it a

206       on becoming a better therapist

few times, it will be old hat. If you are using an electronic system, the ETR or
mean trajectory of a given intake score is what you aiming for. It tells you at
a quick glance if the client is progressing according to expectation and your
hopes for them in treatment. If you are not using an electronic system, you
are aiming for reliable change or 6 points on the ORS.
Start with the clients who have been in the system the longest with-
out benefit. As supervision progresses over time, such clients will decrease,
allowing at-risk clients to be identified and dealt with earlier. Each at-risk
client is discussed and options are developed to present to clients, includ-
ing the possibility of consultation with or referral to another counselor or
service. This is perhaps the most traditional role of supervision, but here
you have objective criteria to identify at-risk clients, as well as subsequent
ORS scores to see if the changes recommended in the supervisory process
have been helpful to the client.
To maximize efficiency and enable multiple consumers to be addressed,
it is helpful for the supervisor to shape the way that therapists present non-
responding clients. The goal is for therapists to leave supervision with a
plan to do something different with the clients in question. Steering the
conversation away from why clients aren’t changing to what can be done
differently instead is harder than it sounds. We have made a profession
of explaining why clients don’t change (usually related to client psycho­
pathology), and we are very good at it. The supervisory process, when based
on outcome data, eschews such explanations in favor of the questions dis-
cussed in Chapter 3:
77 What does the client say about the lack of change?
77 Is the client engaged in purposive work to address the problems
at hand in ways that resonate? In other words, what does the
SRS say about the alliance?
77 What have you done differently so far?
77 What can be done differently now? Have you exhausted your
repertoire?
77 What other resources can be rallied now, both from your sup-
port system and the client’s?
77 Is it time to fail successfully?
When therapists come prepared to answer these questions, many cli-
ents can be discussed. It takes only encouragement and follow-through to
implement—and, of course, holding therapists accountable for knowing
the above information.
This process is intended to be the antidote for blaming clients or thera-
pists for negative outcomes. It strives for an end to explaining why clients

becoming a better agency      207

are not changing while simultaneously continuing them with the same clini-
cian or program despite a lack of progress. At the same time, it helps us stop
ascribing any lack of benefit to therapist inadequacies while allowing the
same unhelpful services to persist. Not all clients benefit from services. No
therapist serves all clients. Lack of client response to a given clinician is the
reality of providing services. If we accept that without blame to the client or
therapist, we can move on to the more productive conversation of what needs
to happen next to enable the client to benefit.
This acceptance includes the ability to transfer clients from one thera-
pist to another without shame or blame. Once such transfers, those due to
client lack of benefit, are a part of agency culture, another milestone of
implementation has been reached. Certified Trainer Barbara L. Hernandez,
in her experience at the Center for Family Services, reports that therapists
welcome this process after initial concerns of vulnerability are assuaged.
In addition, she noted that recognizing that clients will ultimately ben-
efit from the transfer appeals to therapists’ best intentions. Once they see
that these transfers most often conclude with client benefit, both those
they transfer and those they receive, the benefits of “failing successfully”
become manifest and therapists can settle in to helping clients in a different
way—by firing themselves. Finally, Hernandez added that, given that these
failing-successfully and transfer situations are often breaking new ground
for therapists, they provide many opportunities for therapist growth via the
supervisory process.
While reviewing graphs, supervisors can also discuss overutilization,
building a culture of recovery, and the iatrogenic effects of keeping people in
therapy when they are not benefiting or have reached maximum benefit, as
discussed in Chapter 3.
3. Supervisor reviews therapist stats, discusses ways to improve, and encourages
action. Although most of the individual supervision hour applies to our primary
directive, improving services to clients, the final two steps shift attention
from the client to the therapist, drawing upon Orlinsky and Rønnestad’s
(2005) sources of development. Attending to counselor growth helps pre-
vent burnout and encourages continued vital engagement in the work in
spite of all the pressures that lead us toward mediocrity. The focus here is
on the therapist’s sense of career development—improvement in clinical
skills, increasing mastery, and gradual surpassing of past limitations. ORS
data provide an objective way to know whether career development is
actually happening as well as the impetus for the therapist to take charge
of it. Supervision provides the structure and encouragement to incorporate
the Chapter 5 suggestions regarding monitoring and accelerating therapist
development via PCOMS.

208       on becoming a better therapist

 Supervision then, promotes the open discussion of stats with the
intent of codeveloping a plan for improvement. It starts with helping the
supervisee to understand the stats, the key performance indicators, and
how they will be used to monitor effectiveness and the therapist’s devel-
opment over time. Recall that perhaps the easiest stat to consider is the
percentage of clients who attain reliable or clinically significant change,
or who achieve ETR, if you are using an electronic system. Using this stat
to compare with a previous period of time or closed cases, as discussed in
Chapter 5, gives a quick look at how things are going. It is important to
remind supervisees of the realities of practice and that, first, the very best
clinicians in some studies achieve about 46% reliable and clinically signifi-
cant change rates, and, second, that wherever he or she starts, it is just that,
a beginning point. By discussing the stats transparently, supervisors encour-
age therapists to use the data for their specific benefit. In so doing, thera-
pists will get over their fear of numbers and looking at their performance.
Over time, therapists will monitor their own stats and use the information
to the greatest advantage.
From the frank discussion of therapist stats and his or her ideas about
improvement, a plan is formed for the counselor to be proactive about his
or her development. The plan is then implemented, monitored in super­
vision, and modified if outcomes are not improving. As discussed in Chap­
ter 6, encouraging therapists to learn models and techniques is fine, but
a focus on the heart and soul of change also makes good clinical sense.
Encourage supervisees to enlist what clients bring and to practice well the
skills of our craft, the alliance.
4. Supervisor mentors via skill building, harvests client teachings, and encour-
ages ongoing reflection about the work and therapist identity. This final com-
ponent brings the supervisor more actively into the process of accelerating
therapist development. Supervision can provide the context for skill building
in a variety of areas that are identified in the therapist’s improvement plan,
from specific models to alliance skills to understanding clients from a variety
of conceptual vantage points (the concept of theoretical breadth). Here, any
number of ways to build skills can be used, from focused video reviews to role-
playing to article discussions.
Perhaps more important, this aspect of supervision sets the stage for
harvesting client teachings and enhancing the most powerful influence on
development identified by Orlinsky and Rønnestad (2005): the therapist’s
sense of current growth. Again, Step 4 of the supervisory process provides the
structure and encouragement for the suggestions made in Chapters 5 and
7 regarding learning from clients and reflecting about one’s identity. Here
the supervisor inquires about what has been learned from successful and

becoming a better agency      209

unsuccessful clients, about anything that happened that was new or differ-
ent, and about the therapist’s thoughts about his or her identity—helping the
therapist experience current growth, value the daily work with clients and
the opportunities for development and replenishment they offer, and stay
invested in the work he or she loves.
As noted, it is important to incorporate discussion/reinforcement of
what the supervisee is doing right with clients who are progressing. Such an
inclusion promotes development by encouraging supervisees to understand
what their role is in the client’s improvement. This can stimulate confidence
and can help supervisees discover their approach/style in therapy. As dis-
cussed in Chapter 5, the process begins with these questions about clients
who are progressing:
77 What is working with these clients?
77 What is client feedback telling you about progress and the
alliance?
77 How are you interacting with these clients in ways that are
stimulating, catalyzing, or crystallizing change?
77 What are these benefiting clients telling you that they like
about your work with them?
77 What are they telling you about what works?
And questions about the clients who are not benefiting:
77 What is working in the conversations about the lack of progress?
77 What is client feedback telling you about progress and the
alliance?
77 How are you interacting with these clients in ways that open
discussion of other options, including referral?
77 What are these not-benefiting clients telling you that they like
about how you are handling these tough talks?
77 What are they telling you about what works in these discussions?
77 What have you done differently with these not-benefiting cli-
ents? How have you stepped out of your comfort zone and done
something you have never done?
The idea here, of course, is not punitive in any way but rather to pro-
mote professional reflection and encourage therapists’ continued growth.
The concept of parallel process (Searles, 1955) or isomorphism (Liddle
& Saba, 1983) in supervision weighs heavily on all the steps of supervision
as well as on the three sources of development identified by Orlinsky and
Rønnestad (2005). First, having supervisees track their career development
is akin to therapists engaging clients to monitor benefit. Both are about

210       on becoming a better therapist

tracking one’s progress and involving oneself in a real way. Second, collabo-
rating with therapists about potential plans to enhance their development
is parallel to the egalitarian conversation that is hoped for with clients
regarding the tasks of therapy. Helping supervisees expand their theoretical
breadth, in turn, helps them to be more responsive to clients’ idiosyncratic
theories and cultural preferences. Finally, supervisor curiosity about the
lessons that clients teach, the therapist’s sense of current growth, helps
therapists make the best of their continued reflections and further enhances
curiosity for and appreciation of what can be learned from day-to-day work
with clients.

CONCLUSION

The person who says it cannot be done should not interrupt the person
who is doing it.
—Chinese proverb

This chapter presented the results of our study (Reese et al., 2014)
of effectiveness in a large PBH setting. Our investigation came on the heels
of the 50th anniversary of the Community Mental Health Act of 1963,
signed into law on October 31, 1963, by President John F. Kennedy. It was
the last piece of legislation JFK signed before his assassination. For millions
of Americans, this legislation opened the door to a new era of hope and
recovery—to a life in the community. As we remember the landmark legis-
lation, our study presents a more hopeful picture of outcomes in PBH. Our
results are reassuring to those who receive, provide, or pay for services in
the public sector, suggesting that therapists in a PBH setting are effectively
treating not only depression but also a range of other psychological problems.
And we believe it is because of PCOMS. Routine collection of outcome data
and consistent involvement of consumers in decisions about their care hold
promise to not only inform us about the effectiveness of PBH care and the
classic question of what works for whom, but also to improve those services
and ensure quality to those who are often not considered in discussions of
psychotherapy.
This chapter also presented the four secrets of successful PCOMS
implementation: In it for the long haul (it’s a marathon, not a 100-yard dash);
Love your data (more than a friend, your data are the core of what improves
outcomes at all levels and demonstrates your effectiveness to funders); Inspire
the frontline clinician (implementation fundamentally happens at the thera-
pist level, and consequently clinicians need reassurance about management

becoming a better agency      211

intentions, must understand PCOMS in a clinical context, and need to expe-
rience its benefits to clients and their own development); and Supervision for
a change (in both clients and therapists).

CLIENTS ARE THE BEST TEACHERS: THEIR STORIES

DOCUMENT OUR DEVELOPMENT

Of all tyrannies, a tyranny sincerely exercised for the good of its victims
may be the most oppressive.
—C. S. Lewis

Shortly after my stint in the state hospital, in addition to my next

practicum I began working in a residential treatment center for trou-
bled adolescents to help ends meet. So “disturbed” were these kids that
everyone “required” at least two diagnoses and two psychotropic medi-
cations. One time, when the psychiatrist was on vacation and the center
director was unable to cover him, a 16-year-old, Dawn, was admitted to
the center.
Dawn was like many of the kids, abused in all ways imaginable,
drop-kicked from one foster home to another, with periodic suicide
attempts and trips to hospitals and runaway shelters. I was assigned
her case and saw her frequently in individual therapy as well as nearly
every day in the groups I conducted. She was very angry at times and
un­cooperative with staff, but I figured she had good reason, a perspec-
tive that has served me well. In spite of all that, Dawn was a pure
delight—creative, funny, and hopeful for a future far different from her
childhood. She told me she just wanted to do her time there and get out
on her own as soon as she was 18. So we talked about what would need
to happen for her to gain emancipation. I liked her a lot, and I admired
the spunk of this worldly street kid. The therapy went great: We hit it
off famously, and Dawn settled in and started attending high school for
the first time in several months. Our shared love of heavy metal seemed
to seal the bond.
As time went on, I felt increasingly protective toward her. Her whole
life she had been betrayed if not abused by so many adults, and I didn’t want
to join their ranks in any way, shape, or form. Three weeks later, the psychi-
atrist returned and conducted a diagnostic interview (with me present) in
which he, unbelievably, started massaging her neck. Didn’t he have a clue

212       on becoming a better therapist

what these kids had experienced in their lives? Dawn told him to get his
f––king hands off her. He responded with a lecture about adhering to treat-
ment and prescribed an antidepressant and lithium for Dawn.
She angrily and adamantly opposed taking the medications—she
said she had been down that path already. Dawn told him that she would
run away if they made her take meds. But her voice went unheard. More
accurately, she had no voice at all in her own treatment. After Dawn left
the room, I protested to the psychiatrist, citing evidence of how well she
was doing, but to no avail. I was only a mental health grunt and a stu-
dent to boot. I argued that forcing meds on Dawn could be harmful, but
he did not listen. Instead, he lectured me about countertransference and
how I was being manipulated into splitting—a sure sign of her psycho­
pathology and my naïveté. He asked me if I thought patients should decide
what treatment they get and told me that it was clear that I was way too
involved. I responded that we were talking about Dawn, not me. You can
imagine how that went over.
Dawn became a different person—sullen, hostile, and combative.
Soon thereafter, she went to school and, true to her word, bolted. Days
went by, and I grew very worried and increasingly angry at what I was
coming to learn: “Treatment” consisted primarily of overmedication
and control. I later found out that Dawn went on a 3-day binge of alco-
hol and drugs. A carload of men picked her up while she was hitch-
hiking and ended the ride with a gang rape. Adding insult to injury,
Dawn was forcefully injected with an antipsychotic when the police
brought her back to the center. When Dawn described this experience,
she saw the horror on my face and reassured me that she had suffered far
worse indignities than being forcefully tranquilized. It was little solace
for either of us. I just held back tears of frustration and anger. Here was
this kid just raped, and then suffering the indignity of a forced injection,
trying to console me!
Dawn persisted in her ardent protests against the medication and did
everything she could to sabotage taking meds. She had an undefeatable
spirit. I felt weak in comparison. I encouraged her to talk to the center
director. Rather than listening, however, the director admonished me
for putting ideas into Dawn’s head and told me to drop it. But I couldn’t.
Instead, fueled by Dawn’s spirit and my frustration, I spent days researching
the literature. What I found surprised me. In contrast to what most clients
were told, little was known about how psychotropic drugs actually worked.
Moreover, there was no empirical support for prescribing these drugs to
children—let alone multiple drugs. I couldn’t find one study. Figuring this

becoming a better agency      213

 wasn’t possible, given the way they were given to kids on the unit, I asked
for library assistance and—guess what?—not one study addressed the use
of tricyclics, lithium, or antipsychotics with adolescents. Finally, I was
shocked to find that the very helpfulness of medication with adults was
suspect. It seemed that everything I had been told about the rationale for
using these medications for youth “mental illness” was simply not true and
not based on any evidence.
I organized my findings into a brief report and made an appointment
to see the psychiatrist, who was less than happy to see me. I presented the
information respectfully and included my astonishment over not being
able to find one study demonstrating the effectiveness of the medications
with kids.
How did he respond?
He fired me on the spot, yelling that I had 5 minutes to clear out.
I managed to see Dawn before I left, and she said with a smile that
at least one of us was getting out. She told me not to worry about her, and
I did know that she was indeed a survivor. Dawn also thanked me for sup-
porting her about the whole med thing and added that no one had ever
done anything like that before for her.
I left demoralized and confused, but this was the defining moment
of my career. Nothing was the same for me after this. I lost my job and my
innocence. I no longer believed the things I had been told just because
they came from authority. This experience taught me never to be com-
placent or complicit again as a function of ignorance—that I had to look
at things myself and draw my own conclusions. From that point on, I
questioned things, much to the chagrin of some teachers and supervisors.
Until this point I had believed that being a therapist, and therapy in
general, were based in only helpful assumptions. I now understood that
“helping” with good intentions can also hurt quite substantially and be
downright oppressive. This was the precursor to my passion for privileging
client perspectives about their own care.
And Dawn was inspirational. Here was this 16-year-old kid able
to stand up to this arrogant doctor and an entire system that completely
ignored her perspective in the name of “helping.” She had been horribly
abused, and yet she found a way to fight back without losing hope or her
dignity. Dawn really believed that she could transcend all the unpleasant-
ness and prevail, and she did. She taught me that if someone like her, who
had been through so much, could overcome this level of adversity, then
anyone could. This led me down the path of being aware of and trusting in
client resources and resiliencies to lead the way in therapy.

214       on becoming a better therapist

 I eventually heard from Dawn years later when she saw my private
practice announcement in the newspaper. She sent me a postcard of a
picture of the Eiffel Tower, and opened her note in true Dawn form: “No,
dumbshit, I am not really in Paris.” She wrote that she was taking classes
at the community college and had a new baby. Life was challenging, but
she was doing well. In the brief note she sent, on that postcard, without
a return address, she said that she wanted me to know that she was still
grateful for all I had done for her. I wish I could have told her all that she
had done for me.

becoming a better agency      215

 9
fOR THE LOVE OF THE WORK

You need to claim the events of your life to make yourself yours.
—Anne Wilson-Schaef

I am not doing direct client work nowadays, beyond consultation and

demonstration sessions, which I enjoy immensely. But I miss the ongoing cli-
ent contact. At some point, I will return to my first passion, psychotherapy,
but in the meantime I am on a mission to help therapists be better at what
they do: to spread the word about what works and how to deliver it, to get
clinicians to incorporate the Partners for Change Outcome Management
System (PCOMS) in their everyday practice, and to encourage counselors to
give significant attention to their development. My motivation comes from
the love of the work because I believe, like you, that despite the bureaucratic
downsides to our job, there is nothing that quite matches the feelings that
come from client change. I am also trying to influence third-party payers
that it is in their best interest to help therapists to become more efficient and
effective—to do good work. I’ll talk about one of those efforts below.
In this book, I have suggested that you step up to the plate with two things:
attaining systematic client feedback via PCOMS and taking your development

http://dx.doi.org/10.1037/14392-009
On Becoming a Better Therapist, Second Edition: Evidence-Based Practice One Client at a Time, by B. L. Duncan
Copyright © 2014 by the American Psychological Association. All rights reserved.

217
as a therapist to heart. Integrating these two critical aspects can open new vistas
for therapists wishing to rapidly impact the quality of their work with clients.
PCOMS was presented as a simple but clinically nuanced process of collaborat-
ing with clients, forming true partnerships, and enhancing the factors known to
affect outcomes. It helps us know we are on track, enables us to empower change,
and provides an early warning system for clients at risk for dropout or other nega-
tive outcomes. PCOMS also paves the way for your development as a therapist.
Accelerating your development is a five-step process, but the prerequisite
is your understanding that you are a primary figure in each client’s ultimate out-
come. The client is certainly central, but, as the old saying goes, it takes two to
tango. Your view of your growth influences your ability to be vitally involved in
the therapeutic process. The first step is to track your career development and
take it on as a project. Proactively monitor your effectiveness in implementing
strategies to improve your outcomes. Practice the skills of your craft and moni-
tor your results. Second, pay close attention to your current growth. Take a step
back, review your current clients, and consider the lessons you are learning.
Empower yourself, as you would your clients, to enable the lessons to take hold
and add meaning to your development as a therapist. Articulate how client
lessons have changed you and your work and what it means to your identity as
a helper and how you describe what it is that you do. Next, deliberately expand
your theoretical breadth—loosen your grip on the inherent truth value of any
given approach. Take multiple vantage points on your journeys with clients
while you search different understandings of client dilemmas. Fourth, reflect
about your identity and construct a story of your work that captures what you
do as a helper. Continue to edit and refine your identity and your accounts of
what constitutes the essence of your work: Evolve a description that you can
have allegiance to but that doesn’t lead to dead ends.
This closing chapter discusses the fifth and final step to keep your devel-
opment in the viewfinder: collecting client notes, cards, and letters about
your work with them, as well as client stories that mark significant events in
your growth as a psychotherapist—what I call the “Treasure Chest.” Then,
this chapter presents my parting thoughts about the major controversies of
the day as they pertain to your identity as a helper. Finally, I discuss what I
think it takes to become a “master” therapist.

TREASURE CHEST

A box without hinges, key, or lid, yet golden treasure inside is hid.
—J. R. R. Tolkien

The Treasure Chest is a way to buffer burnout, a momentary sanctuary

from the downsides of the work when the requirements of the system bring

218       on becoming a better therapist

you down, or when you see several clients in a row who aren’t benefiting
much, or when a client story hits home in a painful way. The Treasure Chest
is the place to go to escape tough times and reconnect to the work, to why
you became a therapist in the first place. It is also where you can add your
own narrative accounts of the clients who influenced your development as
a therapist.
It started simply as a file labeled “Treasure Chest” into which I put cli-
ents’ unsolicited communications about the work I did with them—their feed-
back, usually well after therapy had ended. The letter from Maria in Chapter 2
is an example of the kind of communication that I held on to over the years.
Sometimes it was a long letter or sometimes it is was a brief postcard like the
one that Dawn, in Chapter 8, sent. Sometimes clients talked about something
specific that happened in the therapy—something I said or did—and some-
times they gave a general overview of the time we spent together. Sometimes
the letter described the changes they had made, and sometimes it was about
their belief that God was working through me. Sometimes it was about their
further reflections on their journey in life, and sometimes it was just telling me
how things were going well. Sometimes the letters were deep and evocative,
and sometimes they were light and breezy. Invariably, though, as the research
indicates, client comments addressed relational factors. They were not about
what I knew, but about our relational connection and who I am. Here are just
two examples; although they are different in about all ways you can think of,
they both convey why reading such things recharges our batteries.
Sixteen-year-old Carrie attended therapy with her mom, Janice. Carrie
was distressed about her father’s rapid remarriage and decision to move far
away. Carrie was very close with her dad and understandably felt betrayed.
This was a one-session encounter (Carrie was leaving the next day for a
summer-abroad study experience), and I did what you likely would have
done: I listened and I validated. I didn’t think much else about it until I
received a thank-you note from Janice:
Dear Dr. Duncan:
Just wanted to thank you for the hour you spent with us on January 23.
Carrie’s father has apparently decided to continue his current course of action,
and Carrie has decided to simply avoid him as much as possible for the time
being. Very sad, but the assurance and acceptance you gave to Carrie and me
left us with a wonderful sense of relief and security that no money can buy. I
see many changes in her—happiness and self-confidence—that I credit to you.
I cannot thank you enough.
And then there was Adam, a young man who spent his 18th birthday
in prison for gang violence. Released soon afterward as part of an early parole
program, he was mandated to therapy, and I saw him as a favor to his proba-
tion officer, who had been a student of mine. Adam was a long-time member

for the love of the work      219

of the skinheads as well as a local gang. I wasn’t sure I could work with Adam,
not because of his record or gang status or because he was a scary-looking
dude, but rather because he was openly racist and regularly spewed hate-filled
comments. In amazing ways I had never heard before, Adam strung together
obscenities and slurs with an alarming passion—about me (I was a lackey for
the other side), the PO (an African American woman), and about everyone
else who wasn’t dedicated to white supremacy. But, somehow, therapy worked
its magic with Adam and me. Over time, Adam’s intellect and compassion
pulled him out of the indoctrination of hate that had dominated his life.
He became curious about my attitudes about African Americans, Jews, and
Hispanics when he learned that I grew up not far from where he did—a
serendipitous shot in the arm for our work. Our conversations deepened and
ultimately challenged the lies embedded in hate and prejudice. Adam, an
introspective man, took these discussions to heart and began to let go of his
racist background and understand how poverty and despair set the context
for his beliefs. He moved out of the neighborhood where the specter of gang
life was inescapable and moved on in other ways as well.
About 6 months after I had written a letter in support of Adam’s enlist-
ment in the army, I received this:
Hi Barry,
I wanted to write you and let you know what was happening and to say
thanks. As you know I fulfilled the obligations of my parole and joined the
army (Thanks for the letter!). I just made corporal and things are going well for
me. I am told that I am sergeant material, and I intend to take college courses
when I get stationed after infantry training. But what I really wanted to tell
you about was my barracks. The army has lots of different kinds of people. In
fact, I am the minority here. Most of the guys in my unit are black or Hispanic.
And that’s the thing I wanted to tell you. I see their uniform first before I notice
whether they are white or not. I see them as my team, and I will watch their
backs like I know they will watch mine. My best friend in my unit is a Mexican-
American guy from Texas. We have had some great discussions about racism
and he came from a real poor background, probably even worse than me. He
has gone through some real hard times with white people.
So, thanks, Barry. Thanks for not giving up on me, for putting up with my
bullshit, and for seeing that I was capable of something different. I see now
that you didn’t (pre) judge me just the way that I now don’t prejudge others.
These unsolicited notes, letters, and cards have sustained me in tough
moments as a therapist. Over the years, I added another dimension to my
Treasure Chest file—my reflections about the clients who taught me the most
about being a psychotherapist, a narrative account of my development told
through my experiences with clients. Many of those stories are included in
this book.

220       on becoming a better therapist

 PARTING THOUGHTS

I long to accomplish great and noble tasks, but it is my chief duty to

accomplish humble tasks as though they were great and noble. The world
is moved along, not only by the mighty shoves of its heroes, but also by
the aggregate of the tiny pushes of each honest worker.
—Helen Keller

There is a dark side of the force, things about our field that do not repre-
sent why we became therapists in the first place, things far afield of our desire
to help. Dawn, from Chapter 8, for example, showed me how “helping” could
be abusive and oppressive. I bring up these thorny issues here because they are
potential threats to the work that we love, to our identities as therapists—each
creates a particular story about our identity. It is my hope to stimulate your
reflection, and I also hope that my propensity, at times, to strongly state my
deeply held beliefs doesn’t diminish my main message: Be informed, dig a little
deeper, and rely on your own analysis of the issues—not those of professors,
supervisors, professional organizations, policy wonks, or this book—to create
your identity as a therapist.

Third-Party Payers and P4P

For just about forever, therapists have complained about managed care
and third-party payers, and our professional organizations have heartily joined
the whiner chorus. It’s funny how things are always relative. I remember when
CHAMPUS (the Civilian Health and Medical Program of the Uniformed
Services, today known as TRICARE) first attempted to monitor what hap-
pened behind the closed doors of psychotherapy. There was such outrage.
They paid less than other payers at the time and had the audacity to require a
review and treatment plan at the 24th session! As a new private practitioner
I often received referrals from others who would not work for such measly
pay or acquiesce to such unreasonable demands. To any therapist today,
what CHAMPUS paid then, combined with such limited oversight, would
be to die for.
Unfortunately, we didn’t work with third-party payers to address costs,
but instead we and our professional organizations demonized them. Don’t get
me wrong, some payers definitely deserve their Darth Vader status, and as a
private practitioner, I have bemoaned their existence on many occasions. But
we haven’t offered many alternatives and, as a profession, haven’t addressed
their legitimate concerns regarding the efficiency of services. But managed
care, accountability, and measurable outcomes are not going away and will
only increase in scope with the Affordable Care Act and the movement to

for the love of the work      221

integrated care systems. Instead of fighting third-party payers, we need to join
them at the table and have influence.
Collecting data and managing outcomes can allow therapists, agen-
cies, and professional organizations to become players at the reimbursement
table. But we have to be conversant in the language (e.g., proof of value,
return on investment) and take responsibility for the cost and effectiveness
of the services we provide. It’s high time. As the last chapter demonstrated,
PCOMS, in addition to improving outcomes, can document improvements
in efficiency in terms of cancellations, no-shows, length of stay, etc. These
advantages, in turn, can be bargaining chips when negotiating with third-
party payers. Increased effectiveness and efficiency should increase the value
of our services.
But there could be dangers as well. Some managed care organizations,
both public and private, have implemented outcome management systems.
How will they use the data? Will outcome data be folded into so-called pay
for performance (P4P) initiatives? P4P started in medical care and describes
payment models that offer financial rewards to providers who achieve speci-
fied quality benchmarks using performance measures related to the structure,
process, and outcome of providing services. The intentions are good here—
P4P programs are designed to improve access, quality of care, consumer expe-
rience, and provider participation and to decrease health care costs. The
incentives include higher capitation rates, increased reimbursement rates,
and bonuses to provider networks that meet or exceed performance standards.
P4P makes some sense. For example, it is understandable that payers
would like clinicians who average fewer sessions per client when data reveal
that most clients attend fewer than eight sessions, or who get clients in service
within 3 days of the initial call given the increases in follow-through when
there is a rapid response. But when it comes to performance measures related
to outcome, things get a bit dicey. One way that P4P has been implemented is
by using outcome data to steer referrals to providers who get better results (see
Brown & Minami, 2010) or to pay those providers higher rates. The darker
side here is that the data are used to profile clinicians, resulting in removing
therapists from provider panels or limiting referrals based on their reported
outcomes. No wonder therapists are afraid of measuring outcomes! Using out-
come data in this way could lead to a focus on looking good rather than pro-
viding good care. For example, therapists or agencies may select clients who
are likely to do well in treatment, may avoid taking more challenging referrals,
and may be tempted to leave out the data reflecting poor outcomes—or even
fudge their data. When one’s livelihood is involved, who knows?
Client welfare is invoked as the justification for steering clients toward
the most effective therapists, thereby giving them the best chance for success.
Yes, it makes some sense, but it is not that simple. Recall that even the best

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therapists don’t benefit a substantial portion of their clients. P4P only moni-
tors performance (on those data that are submitted) and does not address
those significant numbers of clients who are not benefiting. So, regardless of
a clinician’s or agency’s success rates, many clients go without benefit, and
there is no infrastructure, support, or incentive to do anything about them.
All you have to do is send your accurate (?) outcome data to meet some
arbitrary performance standard. If this strategy were designed to improve
outcomes, it would provide immediate feedback identifying clients who
were not responding so that something different could be done for them.
Monitoring without feedback has little worth for consumers receiving the
service now—and seems far more about profiling than raising the quality of
everyone’s performance.
A far better idea is another kind of P4P, “pay for participation.” This
initiative rewards providers who use their data to identify nonresponding cli-
ents and participate in a proactive process to recapture those consumers and
improve outcome. This P4P incentivizes a commitment to nonresponding
clients early in therapy so that they do not languish in treatment or drop out.
It encourages clinicians to acknowledge and be comfortable with what we
all know (i.e., that not everyone benefits)—and to open the discussion to
any alternative that would better serve the client, including consultation and
referral. The purpose here is not to profile clinicians according to their out-
comes but rather to assist them in providing better care via outcome feedback
and support. Serving clients and therapists in this way will ultimately improve
outcomes, increase efficiency, and decrease costs.
New Directions (great name) Behavioral Health, a managed care com-
pany serving over 8 million members, is piloting such a program now with
clients who have not been successful in previous attempts at therapy. They
provided PCOMS training to a group of therapists as well as a web-based data
system to track outcomes so that therapists and consumers could keep their
fingers on the pulse of progress and the alliance. An incentive of a value-based
bonus (beyond the incentives of training, the data system, and ongoing sup-
port to improve outcomes) is awarded to those practitioners who demonstrate
data integrity and actively participate in a system of care that openly acknowl-
edges the realities of practice—that not all clients benefit and that therapists
cannot benefit all clients—and proactively does something about it to better
serve consumers. The goal is to build a sustainable value-based collaborative
with providers to improve outcomes for members.
In short, provider profiling and incentive practices based on outcome,
without feedback and the opportunity to improve, pit us against each other.
Such policies risk turning therapists against measuring outcomes and could
perhaps encourage us to “cheat the system” to ensure referrals and a competi-
tive edge. The therapist identity created by a pay-for-performance mentality

for the love of the work      223

is a competitive one that measures success by the defeat of fellow therapists.
Pay for participation, on the other hand, proactively addresses outcome and
cost via the identification of clients at risk; it incentivizes a more realistic
view of clinical practice and also creates an infrastructure to truly improve
the quality of care.
Bottom Line: Become a player at the reimbursement table. Collect data, take
responsibility for costs, learn the language of business, and negotiate for higher
rates of reimbursement. Oppose the collection of data without feedback and
join the conversation about P4P to ensure that it is aligned with sound clinical
practice. Voice your concerns that referral steerage or other incentives will kill
the spirit of outcome management. Insist on safeguards about the misuse of
outcome data.

Diagnosis and the Medical Model

The medical model of psychotherapy remains the dominant paradigm.

The late George Albee (2000) suggested that psychology made a Faustian
deal with the medical model at the famed Boulder conference in 1949, where
psychology’s bible of training was developed with a fatal flaw, namely: “the
uncritical acceptance of the medical model, the organic explanation of men-
tal disorders, with psychiatric hegemony, medical concepts, and language”
(p. 247). Later, in the 1970s, with the passing of freedom-of-choice legisla-
tion guaranteeing parity with psychiatrists, psychologists (and later others)
learned to collect from third-party payers solely on the basis of a psychiatric
diagnosis. Thereafter, drowning any possibilities for other psychosocial sys-
tems of understanding human challenges, the National Institute of Mental
Health (NIMH), the leading source of research funding for psychotherapy,
decided to apply the same methodology used in drug research to evaluate
psychotherapy (Goldfried & Wolfe, 1996)—the randomized clinical trial
requiring both diagnosis and manualized treatments. Diagnosis reached its
pinnacle. Now, both reimbursement and research funding depended on it.
Since then, it has remained a fixed part of graduate training programs, a
prominent feature of evidence-based treatments (EBTs), and a prerequisite
for funding in most mental health and substance abuse delivery systems—all
of which engenders an illusion of scientific aura and clinical utility that far
overreaches the deeply flawed infrastructure of the Diagnostic and Statistical
Manual of Mental Disorders (DSM; Sparks, Duncan, & Miller, 2007).
Diagnosis in mental health is not correlated with outcome or length of
stay, and given the dodo verdict, cannot provide reliable guidance to clini-
cians or clients regarding the best approach to resolving a problem. Recall
that our benchmark study reported in Chapter 8, like other research, found no
relationship between diagnosis and outcome. And of course, it has long been

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known that diagnosis is neither reliable nor valid (Carson, 1997; Duncan,
Miller, & Sparks, 2004; Kirk & Kutchins, 1992); the very authors of the DSM
acknowledge this. Regarding reliability, Robert Spitzer, the architect of the
DSM-III, admitted:
To say that we’ve solved the reliability problem is just not true . . . if
you’re in a situation with a general clinician it’s certainly not very good.
There’s still a real problem, and it’s not clear how to solve the problem.
(Spiegel, 2005, p. 63)
Regarding validity, Allen Frances, lead editor of the fourth edition of the DSM,
confessed that “there is no definition of a mental disorder. It’s bullshit. I mean,
you just can’t define it” (Greenberg, 2010, p. 1). This candid admission merely
confirms what has been known for many years, in fact, since its inception. In
the first edition of his classic 1961 book, Jerome Frank wrote, “Psychotherapy
is the only form of treatment which, at least to some extent, appears to create
the illness it treats” (p. 7), a statement that still rings true today. Finally, in an
amazing turn of irony, NIMH, the organization that almost single-handedly
catapulted its use, recently withdrew support from the DSM, just before the
release of the new fifth edition. Thomas Insel, MD, the director of NIMH,
said, “The weakness of the manual is its lack of validity” (http://www.nimh.
nih.gov/about/director/2013/transforming-diagnosis.shtml).
Diagnosis as a starting point for treatment or reimbursement is empiri-
cally and clinically bankrupt. Collection of outcome data on a large scale
could help usher it out once and for all. It could supply the impetus for reeval-
uating funding parameters and the medical-model assumptions that support
them. As more and more evidence is collected that shows the lack of rela-
tionship between diagnoses, EBTs, length of stay, and improvement, the real
predictors of progress may come to light (like the alliance and early change)
and a different set of assumptions, like those of recovery, individually tailored
treatment, and so on can be implemented.
Moreover, we could escape the medicalization of our identity. Psycho­
therapy is not a medical endeavor; it is a relational one. You have probably
noticed that I haven’t described clients as patients with illnesses who require
treatment from an expert administering powerful interventions. Instead, I
have hopefully demonstrated an empirically based account of psychotherapy
in proportion to the amount of variance attributed to the different common
factors, and I have characterized clients in ways other than the Killer Ds—
their diseases, disorders, deficits, disabilities, or dysfunctions. My identity as
a psychotherapist lies outside of the language of diagnosis, prescriptive treat-
ment, and cure and seeks to reflect the interpersonal nature of the work, as
well as the consumer’s perspective of therapeutic process, the benefit and fit
of the services.

for the love of the work      225

 These are thorny topics to be sure, and in the current zeitgeist of inte-
grated care, they will increasingly come to light. The issues are complex, and
I encourage you to investigate and draw your own conclusions about them
and the other identity-threatening topics discussed. Collaboration with and
respect for medical professionals are essential, as is retention of our own sepa-
rate identity as behavioral health practitioners. Integrated primary care offers
a unique opportunity to provide quality behavioral health services to people
who do not seek mental health services for any number of reasons. Given that
up to 70% of primary care visits have mental health/behavioral components
(Hunter, Goodie, Oordt, & Dobmeyer, 2009), there is a huge potential for
positive impact. Our objective is to be a valued member of a collaborative
team that respects the medical model without being assimilated, while keep-
ing our relational model and the factors that account for behavioral change
central to our work.
Brian DeSantis, director of Behavioral Health at Peak Vista Community
Health Centers, project leader, and veteran of integrated care, suggests that
a successful “marriage” of medical and behavioral health is challenging but
certainly attainable. He currently applies PCOMS in his integrated setting
and believes that it not only brings evidence-based accountability to the part-
nership but also aligns well with medicine’s movement toward collaborative
patient-centered care and an emphasis on both medical and patient-rated
outcomes.
Bottom Line: Diagnosis and the medical model are valid ways to approach
physical problems, but their assumptions do not hold up well in application
to behavioral health. With the rise of integrated care, increased opportunities
for providing quality behavioral services and pressures to assimilate into the
medical model will happen together. Respectfully educate medical profession-
als about the shortcomings of diagnosis, help them understand the factors that
account for change in behavioral health, and demonstrate your accountability
with PCOMS.

Psychotropic Medication

Medication treatment, like all others, offers a myth and ritual for the
client’s consideration, and it occurs in the context of a client, helper, their
alliance, and both of their beliefs in the restorative capabilities of the selected
rationale and remedy. The common factors loom large here, as they do in
psychotherapy (recall from Chapter 1 the psychiatrists in the Treatment of
Depression Collaborative Research Program [Elkin et al., 1989] demonstrating
therapist effects, as well as how the alliance predicted outcome across condi-
tions, including medication). Perhaps because of the widespread cultural accep-
tance of medical myths and rituals or the continual barrage of pharmaceutical

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marketing, to many this is a bitter pill to swallow. Everyone knows someone
who has benefited from drug treatments or even someone whose life has been
“saved” by medication. Clients do benefit from medication, as they do from
almost anything they believe in, but as Saul Rosenzweig (1936) wrote over
75 years ago, that says nothing about the truth value or broad applicability of
the method at hand. That leaves us with the data, and an obligation to discern
science from science fiction. This requires some effort.
Given the infiltration of industry influence, discerning good science
from good marketing requires a willingness to engage primary source material
(see Sparks, Duncan, Cohen, & Antonuccio, 2010, for tips about what to look
for), as I did after my experience with Dawn (Chapter 8). Despite its vaunted
status as a favored treatment, a critical examination of the evidence regarding
the safety and efficacy of psychotropic medication leads to the conclusion that
psychosocial options should be considered a first-line intervention, especially
with children. The very studies purporting to support the use of the major
classes of drugs reveal the limited efficacy of antidepressants over placebo as
well as a high side effect and relapse profile (Kirsch, 2011; Sparks & Duncan,
2013), the underwhelming results of antipsychotics, their pervasive intoler-
ability, and better recovery rates without them (Sparks & Duncan, 2012;
Wunderink, Nieboer, Wiersma, Sytema, & Nienhuis, 2013), and a lack of
meaningful benefit of combining psychotherapy and medication (Forand,
DeRubeis, & Amsterdam, 2013), with psychotherapy alone making the most
sense most of the time, especially considering long-term results.
Sparks et al. (2010) concluded:
Knowing that there is no irresistible scientific justification to medicate,
therapists are free to put other options on the table and draw in the
voices of their clients—to engage in an informed risk/benefit analysis to
help clients choose treatments in concert with their values, preferences,
and cultural contexts. (p. 224)
All this, of course, doesn’t mean that clients are not helped by psycho-
tropics or that those who prescribe them are evil but, rather, that medication
treatment should not be privileged, nor should psychotherapy considered
a secondhand service. Nevertheless, the use of psychotherapy alone and in
combination with medication has decreased while the use of medications
alone has increased (Olfson & Marcus, 2010). Psychotherapy, despite robust
evidence of effectiveness and the unfavorable risk/benefit profile of psycho-
tropics, appears to have been demoted to a lower-tier way to help clients in
distress. Good marketing trumps bad data every time—but not my identity as
a psychotherapist, and I hope not yours. My identity is embedded in the fact
that psychotherapy is an evidence-based, stand-alone, effective treatment for
the wide variety of concerns, problems, and issues—both catastrophic and
everyday—that human beings encounter in life.

for the love of the work      227

 Bottom Line: There is nothing wrong with FDA-approved medication treat-
ment (not polypharmacy or off-label concoctions) when prescribed in line with
consumer preferences and with full informed consent of the risks and ben-
efits, and when patient-rated measures of outcome are used (see Duncan &
Antonuccio, 2011, for a list of patient rights for psychotropic prescription).
But know and be proud that the data say psychotherapy is a better choice most
of the time in the long run. Challenge assumptions and practices that privilege
medication over psychotherapy as a first-line intervention.

BECOMING A MASTER THERAPIST

Nobody can go back and start a new beginning, but anyone can start
today and make a new ending.
—Maria Robinson

I was recently asked four questions (Kottler & Carlson, in press) about
what made my work effective (assuming that it is). Here I use those questions
to summarize the major points of this book.
1. What is it that you do (or who you are) that you believe is most
important in contributing to your effectiveness as a master therapist, meaning
a professional who produces consistently good outcomes and feels reasonably
confident in his or her work?
First I must say something about the term master therapist. The notion
itself is troublesome because it seems to connote that an elite group of “masters”
possesses something special that others do not have. I don’t possess anything
that others don’t have or can’t develop. There are two parts to this question:
What I do and who I am. What I do that is the most important in contribut-
ing to my effectiveness is that I routinely measure outcome and the alliance
(via PCOMS) with every client to ensure that I don’t leave either issue
to chance. This allows me to deal directly and transparently with clients,
involving them in all decisions that affect their care and keeping their per-
spectives the centerpiece of everything I do. In addition, it serves as an early
warning device that identifies clients who are not benefiting so that the cli-
ent and I can chart a different course, which, in turn encourages me to step
outside my therapeutic business-as-usual (see Question 4), do things I’ve
never done before, and therefore continue to grow as a therapist. Finally,
PCOMS improves my focus (see Question 4) on what matters most to the
client, in terms of what needs to change outside of therapy as well as during
the hour. It allows me to focus every session with every client on the alliance
so that I tailor what I do to the client’s expectations. Although it sounds
like hyperbole, identifying clients who are not benefiting is the single most

228       on becoming a better therapist

important thing a therapist can do to improve outcomes—11 randomized
clinical trials now support this assertion.
As for who I am as a therapist, let me first remind the reader that the
client is the engine of change. I believe that, as therapists develop, they learn
that their best ally for successful psychotherapy is not the books on their
shelves touting the latest miracle cure but rather the person in the room
with them right now. After what the client brings to the table of change,
the therapist is the most potent influence on outcome—not what model or
technique he or she is wielding but who the therapist is. Therapists account
for most of the variance of change of any treatment delivered. What I bring
to the therapeutic endeavor is that I am a true believer. I believe in the client,
in the power of relationship and psychotherapy as a vehicle for healing and
change, and I believe in myself, my ability to be present, fully immersed in
the client, and dedicated to making a difference.
There is an old story about two apprentice Zen monks who are discuss-
ing their respective masters while cleaning their temple. The first novice
proudly tells his companion about the many miracles that he has seen his
famous master perform. “I have watched,” the young novice says, “as my
master has turned an entire village to the Buddha, has made rain fall from the
sky, and has moved a mountain so that he could pass.”
The other novice listens attentively and then demonstrates his deeper
understanding by responding, “My master also does many miraculous things.
When he is hungry, he eats. When he is thirsty, he drinks. When he is tired,
he sleeps.”
Like the first monk, many have become too enamored of “miracles”
touted by the masters. My experience with thousands of clients, and the
research about change, however, have taught me to discard the claims of the
gurus and snake-oil salesmen, and instead honor more simple but enduring
acts: believing in clients, the power of partnership, and my ability to show up
in full. These simple but magical acts are the eating, drinking, and sleeping
of effective therapy.
2. What do you think is most important in identifying or defining an
extraordinary therapist, one who stands out from her or his peers?
I mentioned above that the therapist accounts for most of the variance
of any treatment offered. Therapists vary significantly in their ability to bring
about positive outcomes. The big question, of course, is what makes one
therapist better than another. No need to hire a detective here. The answer
is the therapeutic alliance. Therapists who form strong alliances across more
clients get better results, period. The alliance engages the person in purpose-
ful work and is the fuel of all change.
In the 1980s and 1990s, I used to direct a training institute that also
housed a big group practice. I was very fortunate to witness the work of several

for the love of the work      229

very talented therapists. We regularly consulted with therapists and agen-
cies having trouble with a client. We took turns being the therapist in the
room with the client while the team and the primary therapist watched
behind a one-way mirror. It was the most enriching learning experience
of my career and one that I will always look back on with great fondness.
Although all the therapists on the team were very good, Greg Rusk stood
out. He stood out because of his remarkable ability to engage clients from
all walks of life, facing all kinds of despair and destitution, in this thing we
call psychotherapy.
Peg was a particularly memorable client of his. She was referred to us by
her psychiatrist/therapist and was taking max doses of two antidepressants
as well as pain medication. Peg suffered severe pain as a result of a fall in an
elevator shaft 2 years prior, and she had not been able to return to her job
as a night cleaning person in a large office building. She was “profoundly
depressed” and “perpetually suicidal,” and the referring therapist wanted an
opinion about electroconvulsive therapy and involuntary hospitalization
because many changes in medications had been tried and she refused hos-
pitalization. In addition, the psychiatrist reported that Peg didn’t make eye
contact, gave barely audible one sentence replies to questions, and seemed to
punctuate every utterance with “I have no reason to live.”
Greg greeted both Peg and her husband, Wayne, in the waiting room,
and asked Peg if it was okay if Wayne joined them. True to form, Peg never
looked up and responded in a low voice that it was okay. On the way back to
the consultation room, Greg started chatting with Wayne about his “Hooked
on Fishing” hat, and Wayne shared that actually Peg was the true fisherman
of the family. They arrived in the therapy room, and Greg, while ushering
Peg and Wayne to the couch, asked Peg if she remembered the first fish she
ever caught. And Peg looked Greg right in the eye, and told him the story of
her first fish, a sun granny, and moreover, about her very special relationship
with her father who taught her not only about fishing but also about life. She
spoke of her father’s death as a blessing after his horrible bout with cancer,
which happened right after her accident, and Wayne added that many in
Peg’s family compared Peg’s gentle parenting style and overall compassion
with her father’s. Wayne proudly said that Peg was the rock of the family, and
he told about how she stood by him when he was struggling with alcohol and
ongoing unemployment (Wayne said that he was now sober and, on an ironic
note, that he was employed as truck driver of a beer distributor).
It was a very touching conversation, and Greg, visibly moved, com-
mented on his heartfelt admiration for this couple, as well as the difficulty of
the situation. From there, it emerged that Peg felt useless to the family, that
she was unable to contribute financially or, more important, to parenting
their two daughters. Wayne chimed in to say that both their daughters were

230       on becoming a better therapist

honor roll students because of Peg. In essence, Greg said, it was no wonder
that Peg believed she had no reason to live, given that her identity had
been stolen by the accident. From there, a lively discussion ensued about
how Peg could recapture her usefulness and identity. The couple outlined
ways that Peg could start to contribute more to the family, which included
a frank discussion about the merits of the medications and their effects on
her ability to function. The beginnings of a plan surfaced and, even better, so
did hope. This was Greg Rusk. He engaged people, even those who seemed
impossible to engage, in meaningful conversations about how their lives
could be better.
The research about what differentiates one therapist from another, as
well as my personal experience, suggests that the ability to form alliances with
people who are not easy to form alliances with—to engage people who don’t
want to be engaged—is what separates the best from the rest.
3. What do most people, and even most professionals, not really under-
stand about what it takes to be really accomplished in our field?
There are two things (in addition to the alliance). First, although pro-
ponents of different models and EBTs would like you to think otherwise, the
truth of the matter is that we don’t know ahead of time what model or tech-
nique will be helpful with the client who is in our office now. In other words,
there is a lot of uncertainty that accompanies the work of psychotherapy. To be
accomplished, I believe, is to embrace uncertainty. It is the place of unlimited
possibilities for change, the space for new directions and insights to occur to
both the client and the therapist.
A recent consult I did illustrates the possibilities in not knowing what
to do next, when things don’t go as planned. Rosa, who was 7, had gone to
live with her foster parents—her aunt and uncle, Margarita and Enrique—
because the parental rights of her birth parents had been terminated. Both
her father and mother were addicts with long criminal records; the father was
in jail, and the mother was still using. Rosa clearly had been born with two
strikes against her: parents missing in action and her development impaired
by drugs.
Although much psychopathological gobbledygook accompanied her,
it was safe to say that Rosa was a “difficult” child, to say the least—prone
to tantrums that included kicking, biting, and throwing anything she could
find. I began the session by asking Rosa if she was going to help me today,
and she immediately yelled, “NO!” and leaned back, with her arms folded
across her chest. As I turned to speak with Enrique and Margarita, Rosa
began having a tantrum in earnest—screaming at the top of her lungs and
flailing around, kicking me in the process.
With Rosa’s tantrum escalating, Margarita, who’d first tried to soothe
her, dropped a bombshell. In a disarmingly quiet voice, she announced that

for the love of the work      231

she didn’t think she could continue foster-parenting Rosa. The tension in
the room immediately escalated; the only sound was Rosa’s yelling, which
had become more or less rote at that point. I felt as if I’d been kicked in the
gut. I’d expected to be helping foster parents contain and nurture a tough
child. Now it felt like participating in a tragedy. Here was a couple, after try-
ing their best to do the right thing by taking in a troubled kid with nowhere
else to go, who now seemed ready to give up. The situation was obviously
wrenching for Margarita and Enrique, but it was potentially catastrophic
for Rosa. In this rural setting, they were her last hope, not only of living
with family but of living nearby at all, because the next closest foster-care
placement was at least 100 miles away. I contemplated Rosa’s life unfold-
ing in foster care with strangers who’d encounter the same difficulties and
likely come to the same impasse—resulting in a nightmare of ongoing home
placements.
What’s the correct diagnosis for Margarita? Is there an EBT for feeling
overwhelmed, hopeless, and not knowing whether you can go on parenting
a tough kid? Enter uncertainty, and not knowing what the hell will happen
next, let alone what to do next.
Margarita continued explaining why she couldn’t go on, speaking softly
while tears rolled down her cheeks. Not only did she feel she couldn’t
handle Rosa, she also worried about the child’s attachment to her. As
Margarita expressed her doubts in a near whisper, Enrique’s eyes began to
tear up and a feeling of despair permeated the room. At that moment, I
felt helpless to prevent a terrible ending to an already bad story and didn’t
have a clue about what to do. Meanwhile, Margarita began gently caress-
ing Rosa’s head and speaking softly to her—the Spanish equivalent of
“there, there, little one”—until the little girl started to calm down. With
her tantrum at an end, Rosa turned to face Margarita, and then reached
up and wiped the tears from her aunt’s face. “Don’t cry, Auntie,” she said
warmly, “don’t cry.”
Witnessing these actions was yet another reminder to me of how new
possibilities can emerge at any moment in a seemingly hopeless session and
the uncertainty of what will happen next. “It’s tough to parent a child who’s
been through as much as Rosa has,” I said. “I respect your need to really think
through the long-term consequences here. But I’m also impressed with how
gently you handled Rosa when she was so upset, and with how, you, Rosa,
comforted your Auntie, when you saw her crying. Clearly there’s something
special about the connection between you two.”
Margarita replied that Rosa definitely had a “sweet side.” When she
saw that she’d upset either Margarita or Enrique, she quickly became soft,
responsive, and tender. I began to talk with Margarita and Enrique about
what seemed to work with Rosa and what didn’t. While Rosa snuggled with

232       on becoming a better therapist

Margarita, we talked about how to bring out Rosa’s sweet side more often.
As ideas emerged, I was in awe, as I often am, of the fortitude clients show
when facing formidable challenges. Here was a couple in their late 40s, who’d
already raised their own two children, considering taking on the responsibil-
ity of raising another one who had such a difficult history.
By now, the tension and despair present a few moments before had
evaporated. The decision to discontinue foster parenting, born of hopeless-
ness, had lost its stranglehold, though nothing had been said explicitly about
that. Now all smiles and bubbly, Rosa was bouncing up and down in her
chair. She scored all 10s on the Child Session Rating Scale and wrote “very
good” across all the scales. Somewhat out of the blue, Margarita announced
that she was going to stick with Rosa. “Great,” I said quietly. Then, as the full
meaning of what she’d said washed over me, I repeated it a bit louder, and
then a third time with enthusiasm—“Great!” I asked Margarita if anything in
particular had helped her come to this decision. She answered that although
she’d always known it, she’d realized in our session, even more than before,
that there was a wonderful, loving child inside Rosa, and that she, Margarita,
just had to be patient and take things one day at a time. The session had
helped her really see the attachment that was already there. I felt the joy of
that moment then, and I still do.
In my view, the session included that intimate space in which we con-
nect with people and their pain in a way that somehow opens the path from
what is to what can be. My heartfelt appreciation of both the despair of the
circumstance and their sincere desire to help this child, combined with the
fortuitous “attachment” experience, generated new resolve for Margarita and
Enrique. This session taught me, once again, that anything is possible—that
even the bleakest sessions can have a positive outcome if you stay with the
process. Just when things seemed the most hopeless, when both the family
and I were surely down for the count and needed only to accept the inevita-
ble, something meaningful and positive emerged that changed everything—
including me.
Uncertainty is at the core of these occurrences, and staying in those
moments requires both a comfort level with the unknown and the confidence
that it might lead to something good. Embracing uncertainty requires faith—
faith in the client, yourself, and psychotherapy (see Question 1).
The second thing that I think is very understated regarding doing good
work is perhaps the most difficult skill for therapists to master, namely, the
ability to keep sessions focused and not get lost in the sometimes confus-
ing and nearly always complex ways that clients unfold their stories. When
the conversation jumps from important topic to important topic without
thematic connection or relevance to the way the client is experiencing life
between sessions, it is almost a guaranteed recipe for failure. But it is not easy

for the love of the work      233

to change this dynamic. It can require therapists to step up their involvement
and steer the conversation toward ensuring that some meaningful difference
is accomplished in the client’s day-to-day life.
It doesn’t have to be heavy-handed and it can, of course, be collabora-
tive. For example, I ask clients whether they think it is better for us to con-
tinue talking about the topic at hand or whether we should return to what
they are most concerned about. I also ask if it is okay with them if I return
us to task from time to time. But it can be tricky to follow the client’s lead
while simultaneously never losing sight of where the client wants to go—to
balance being empathic with the sometimes overwhelming presentation of
topics and concerns with ensuring that these topics and concerns are tied to
making a meaningful difference in the client’s experience of life. It is much
easier to meander across a myriad of worthwhile topics and legitimate con-
cerns and not connect the conversation to what the client will actually do
in between sessions. The unfortunate result is a therapy that represents an
ongoing commentary of the client’s life and never leads to any real change.
I have been there and done that. Often I used to write in my progress notes,
“Get some focus!”
But PCOMS really helps here. Monitoring benefit on the Outcome
Rating Scale, after ensuring that the client’s reasons for service are repre-
sented, enables the focus to start and remain on what the client would like
to see happen. It helps the therapist stay on task and take charge of chan-
neling the conversation and complexities of clients’ lives toward something
tangible that will make a difference.
4. What advice would you give someone who aspires to be a master
therapist?
First, of course, measure your outcomes to improve your effectiveness
and track your development. The research literature offers strong evidence
that therapists aren’t good judges of their own performance. It’s not that
we’re naïve or stupid; it’s simply impossible to assess our effectiveness with-
out a quantitative standard as a reference point. PCOMS offers a feasible
way to cut through the ambiguity of therapy and discern your clinical devel-
opment without falling prey to wishful thinking. The systematic collec-
tion of outcome feedback will improve your outcomes by identifying that
pool of clients (that we all have) who are not responding, so that you can
collaboratively forge new directions. It also allows you to track your effec-
tiveness over time (your career development) and proactively implement
strategies to improve your outcomes (like your alliance skills—have I said
this before?).
Second, treasure the clients who do not respond to your therapeutic
business as usual. Clients provide the opportunity for constant learning, but

234       on becoming a better therapist

tracking outcomes takes the notion that “the client is the best teacher” to a
more immediately practical level. Tracking outcomes with clients focuses us
more precisely on the here-and-now of sessions, and it provides an in vivo
training ground to expand our theoretical and technical repertoires. From our
openness to client reactions and reflections and our authentic search for new
possibilities, we step out of our comfort zone and do things we have never done
before. Tracking outcomes enables your clients—especially those who aren’t
responding well to your usual fare—to teach you how to work better.
And when the chips are down, remember what I learned from Tina, my
very first client: Authenticity matters, and when in doubt or in need of help,
ask the client, because you are in this thing together.

CONCLUSION

Between stimulus and response there is a space. In that space is our power
to choose our response. In our response lies our growth and our freedom.
—Viktor E. Frankl

This final chapter addressed what I called the “Treasure Chest,” a col-
lection of client comments about your work with them and your own articu-
lations of the experiences that meant the most to your development. Helping
you re-remember why you became a therapist, opening this file enables an
escape from the pressures and disappointments of the daily grind of being a
therapist. This chapter also presented my parting thoughts and, hopefully,
in the process encouraged you to investigate the controversial issues of the
day and take a stand to protect the aspects of your identity as a therapist that
you hold dear. Finally, I shared my thoughts about what it takes to become a
master therapist.
I hope that this book has encouraged you to continue your commitment
to this work that we love. I also hope that it reaffirmed why you became a
therapist to begin with and your belief in psychotherapy as a healing endeavor.
On becoming a better therapist: If you got into this business, like me and the
majority of therapists I meet, because you wanted to help people, you already
have what it takes to become a better therapist. It boils down to two things:
One is your commitment to forming partnerships with clients to monitor
the alliance you have with them and the outcome of the services you are
providing. The second is your investment in yourself, your own growth and
development. PCOMS provides the method for both.
Recall Yolanda from Chapter 6, the courageous young woman who
overcame crack addiction and a violent partner to protect her children and

for the love of the work      235

make a better life. Here is what she said to me after I administered the final
Session Rating Scale (SRS), which was a 38.7:
I didn’t think much of you or coming to therapy when we started. And I
had been to a few others like you about my addiction and the kids during
the whole violence thing and I didn’t think much of them either. They
were okay mostly, but this was different. I like this SRS and the other
form you do. It made me feel a part of this—that this was about me. You
were always so interested in whether I was on the right track and that we
were doing what I thought we needed to be doing. So thanks for that and
thanks for helping me get my kids.
That’s what I am talking about. And that’s why I am a therapist. And
that’s why I am a therapist who collaboratively monitors the alliance and
outcome. And that’s why I’ll always have my compass close at hand.

236       on becoming a better therapist

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references      251
 Index

Abilities, recognizing clients’, 95–98 SRS for monitoring, 44–48

Acceptance, of client’s goals, 162–163 task and relationship dimensions
Accuracy of, 102
of ORS scores, 60–61, 205, 206 therapy as building of, 144–146
of scores from youth, 118–119 Alliance-focused approach, 98, 183
of SRS scores, 120–121 Alliance measures
Active duty soldiers, 15 confident collaboration and
Adolescents expression of negative feelings
appropriate PCOMS scales for, on, 46–47
106, 120 scores on, 63–64
clinical cutoff for, 53, 112 American Psychiatric Association, 27
reasons for service given by, 114 American Psychological Association
scores from parents/caregivers on (APA), 28–29, 131
behalf of, 106, 109 Anderson, T., 141
Affordable Care Act, xiv, 221 Angry clients
Agency directors, 199 building alliances with, 166–170
Agency support, for PCOMS, 198–199 ORS with, 61
Agreement Anker, M. G., 14, 24, 100–104,
on goals of therapy, 162–163 134–135
on PCOMS scores in couples/ Antidepressants, 21
families, 114–116 Antipsychotics, 227
on tasks of therapy, 163–166 APA (American Psychological
“Aha moments,” 185 Association), 28–29, 131
Albee, George, 224 Approach or method dimension (SRS),
Alice in Wonderland (Carroll), 9 45, 141
Allegiance, 25, 140, 182 Ariely, Dan, 12
Alliance, 158–171 Armijo, I., 44
agreement on goals of therapy in, Arthus, Nicholas Maurice, 27
162–163 Atkins, D., 195
agreement on tasks of therapy in, Austin, S., 161
163–166 Authenticity, 4–5
and believing clients, 171–173 Average change score, 132
and collaboration, 102
as common factor, 23–24 Baldwin, S. A., 23, 38, 39, 195
in couple therapy, 101, 103 Barends, A. W., 46
and effectiveness of therapists, 103, Baum, L. Frank, 178–181
230–231 “Before-and-after” distinctions, 75–76
as hard work for therapists, 166–171 Believing clients, 171–173
honoring client’s view of, 68–70 Benchmarking, 191, 193–195
importance of, 158–159 Benefit monitoring, 41–44, 134,
with nonresponding clients, 79–81 136–137
as predictor of outcome, 37, 40 Bennis, Warren G., 127
and referring clients, 87–93 Berkeljon, A., 195
relational bond in, 160–162 BetterOutcomesNow.com, 133–134
skill building for, 159 Blame, for negative outcomes, 208

253
Blanchard, Ken, 30 and ORS/CORS scores, 122
Bluegrass Community Mental Health, reliable and/or clinically significant,
198, 201 132–134, 192
Bohanske, Bob, 193, 198, 205 reliable change index, 72, 93–94
Bordin, E., 45, 102, 159 and uncertainty, 185
Boswell, J., 22 in youth and parents/caregivers, 109
Breadth, theoretical, 139–143 Changing the Rules (Duncan, Solovey, &
Brill, P. L., 13 Rusk), 148
Brown, J., 14 Chaotic families, 110–111
Bunting, L., 15, 103 Checking-in questions, 41
Business plans, incorporating PCOMS Checkpoint conversations, 77–83
in, 199 calculating timing of, 93–94
client’s goals in, 79–81
Callahan, J., 165 client’s theory of change in, 82–83
Calling, psychotherapy as, 6 and doing something different,
Campbell, A., 43, 48 81–82
Cannabis Youth Treatment Project, 38 Child Outcome Rating Scale
Care, privileging perspectives of clients (CORS), 107
about, 212–215 age range for use, 43, 106
Career development, 129, 130. See also brevity of, 44
Professional development and client change, 122
Caregivers clinical cutoff on, 112, 118
change for youth and, 109 development of, 41
clinical cutoff for scores from, 112 getting accurate scores on, 118–119
scores for children/adolescents given introducing, 109–111
by, 106, 109 and PCOMS with families, 99–100
as therapist helpers, 110 and reasons for service, 113–114
Carroll, Lewis, 9, 187 in school–based counseling study,
Castonguay, L., 22 103
CBT. See Cognitive behavioral therapy School scale on, 111
CDOI (client-directed, outcome- scoring, 111
informed) approach, 182–184 validation of, 43
Center for Family Services (West Palm Child Outcome Rating Scale (CORS)
Beach, Florida), 201 scores
CEs (community experts), 11 accuracy of, 118–119
Chalk, B., 14 and change, 122
CHAMPUS (Civilian Health and for children from parents/caregivers,
Medical Program of the 106, 109
Uniformed Services), 221 Children. See also Youth; specific scales
Change appropriate scales for, 106, 120
average change score, 132 clinical cutoff for, 53, 112
client as engine/primary agent of, lies in psychotherapy of, 123–125
150, 229 PCOMS in school-based counseling
client’s theory of, 82–83, 165 with, 15
early, 37–40, 80–82, 101 reasons for service from, 114
empowering, with clients, 74–77, scales for young children, 106, 120
155–158 scores from parents/caregivers on
in Norway Feedback Trial, 100–101, behalf of, 106, 109
120–121 Child Session Rating Scale (CSRS), 107

254       index

 age range for use, 120 tailoring approach to ideas of,
assisting clients with, 120 141–142
development of, 45 as teachers, 136–137, 236
and PCOMS with families, 99–100 view of therapeutic alliance by, 68–70
Chronic clients, 91–92 Client benefit, monitoring, 41–44, 134,
Churchill, Winston, 71 136–137
Cicero, Marcus Tullius, 72 Client deterioration, 9, 13
Civilian Health and Medical Program Client-directed, outcome-informed
of the Uniformed Services (CDOI) approach, 182–184
(CHAMPUS), 221 Client-directed approach to therapy,
Clarification, about ORS ratings, 51–52 xi, 182
Clement, Paul, 130, 131 Client-directed perspective on common
Clemmer, Jim, 68 factors, 19–20
Client(s). See also Nonresponding clients Client expectancy, 25–26
abilities of, 95–98 Client/life factors, 19–21
angry, 61, 166–170 Client’s theory of change, 82–83, 165
asking for help from, 3–5, 61 Clinical cutoff
believing, 171–173 for adults, 53–58, 112
benefits of tracking treatment for children, 112–113, 118
response for, ix and data integrity, 205
chronic, 91–92 Clinical management, 21
collaboration with, 164, 186–189 Clinical trials, vii–viii
communications from, 218–220 Clinicians, frontline, 201–204
doing something different with, CMHCs (community mental health
80–82 centers), 192, 194
as element in psychotherapy, vii–viii Cognitive behavioral therapy (CBT), 8,
empowering change with, 74–77, 10, 21, 25
155–158 Cognitive therapy without exposure, 10
as engine of change, 229 Coherence dimension (CSRS), 45
experience of, 36, 58–61 Collaboration
goals of, 58–59, 79–80 and alliance, 102
heroic stories of, 150–155 with clients in psychotherapy, 164,
insight from conversations with, 186–189
31–33 confident, 46
long-term work with, 38, 39, 85 with families, 111–112
mandated, 56–57, 119, 166–169 with medical professionals, 226
model/technique preferences in PCOMS, 49
of, 165 on tasks of therapy, 164
as primary agents of change, 150 Collaborative goal formation, 163
privileging perspectives about care Collateral raters, 109
from, 212–215 Commission on Accreditation
probability of success by a given (APA), 131
session for, 93–94 Commitment, to PCOMS, 197–200
reasons therapists are unsuccessful Common factors, 8, 18–27
with, 71–72 alliance, 23–24
refusal to use PCOMS by, 205 client expectancy, 25–26
resources of, 149–158 client/life factors, 19–21
as “rites of passage,” 4 feedback effects, 26–27
strengths of, 150–155 as framework for PCOMS, 203

index       255

Common factors, continued Cumulative career development,
history of, 18–20 129, 130
and medication treatment, 226 Currently experienced growth (current
model/technique factors, 24–25 growth), 129, 135–139, 209
therapist allegiance, 25
therapist effects, 21–23 Darwin, Charles, 143
Communications from clients, Data collection, 36, 200–201
218–220 Data integrity, 204–205
Community experts (CEs), 11 Dayton Institute for Family Therapy, 147
Community Mental Health Act, Dayton Mental Health and
211 Development Center, 3
Community mental health centers DBT (dialectical behavior therapy),
(CMHCs), 192, 194 11, 28
Concurrent validity, 43, 47 Del Re, A. C., 23–24
Confident collaboration, 46 Demand characteristics, 63
Confusion, about therapist’s identity, Depression, 21, 191–192
175–176 Depression Anxiety Stress Scale, 43
Congruence, 161 DeSantis, Brian, 226
Consistency, of SRS, 46–48 Deterioration, client, 9, 13
Consultations, 86, 88–93 Dew, S., 17, 131
Contextualization of PCOMS scores, Diagnosis
53–58, 111–112 in outcome research, 194
Continual professional reflection, 141 in psychotherapy, 11, 224–226
Cooper, M., 15, 103 Diagnostic and Statistical Manual of
CORS. See Child Outcome Mental Disorders (DSM), 224, 225
Rating Scale Diagnostic and Statistical Manual of
CORS scores. See Child Outcome Mental Disorders, fourth edition
Rating Scale scores (DSM–IV), 225
Couple First Relational Goal Diagnostic and Statistical Manual of
Scale, 104 Mental Disorders, third edition
Couples, PCOMS with, 100–105 (DSM–III), 225
agreement on ORS scores, 114 Dialectical behavior therapy (DBT),
Couple First Relational Goal 11, 28
Scale, 104 Differences, noting, 155–158
disagreement on ORS scores, Different, doing something, 80–82
116, 118 Disagreement, in scores of couples/
discussing scores and reasons for families, 116–118
service, 113 Discovery
introducing and discussing SRS, and identity of therapist, 179, 180
120–121 purpose of, 183–184
introducing and scoring ORS, 109 and uncertainty, 185, 187–189
and Norway Feedback Trial, 14, Discovery-oriented psychotherapy,
100–103 183–186
preparing for, 105–106 Disorders, treatment based on, 11
tips for, 104, 105 Distress, ORS as measure of,
tracking outcomes, 121–122 43–44, 113
Courage to Heal approach, 142 Dodo bird verdict, 9–10
CSRS. See Child Session Rating Scale Dostoyevsky, Fyodor, 93
Culture of feedback, 49–50 Dropouts, 8–9, 134

256       index

DSM (Diagnostic and Statistical Manual Erickson, Milton, 185
of Mental Disorders), 224, 225 ES (effect size), 8n1, 132–133
DSM–III (Diagnostic and Statistical ETR. See Expected treatment response
Manual of Mental Disorders, Evidence-based practice (EBP), 180
third edition), 225 client feedback in, 13–14
DSM–IV (Diagnostic and Statistical defined, 28–29
Manual of Mental Disorders, evidence-based treatments vs., 29
fourth edition), 225 PCOMS as, xv, 16
Duncan, B. L., 14, 15, 19, 24, 40–41, 43, Evidence-based treatments (EBTs),
44, 48, 98, 101–103, 130, 148, 27–29
176, 182, 183 Excel, 72, 132–133
Dylan, Bob, 122 Expectancy, client, 25–26
Expectations of therapists, 182
Early change Expected treatment response (ETR),
lack of, 80–82 72–73, 133, 207, 209
as predictor of outcome, 37–40 Experience
and therapeutic alliance for and effectiveness of therapists, 130
couples, 101 learning from, 138–139
EBP. See Evidence-based practice and positive outcomes, 7
EBTs (evidence-based treatments), and therapist effects, 22–23
27–29 of therapists providing training,
Eclecticism/integration movement, 147–148
139–140 Experience of therapy, client’s, 36, 58–61
Edison, Thomas, 105 Experts
Effectiveness community, 11
and alliance, 103, 230–231 therapists as, 178–179, 181
of couples therapists, 103 Explanations of SRS, 120–121
plateaus in, 135 Expression of negative feelings, 46
of public behavioral health services, Eye-movement desensitization and
191–192 reprocessing, 10
therapists’ self-assessments of, 16–17,
130, 131, 234–235 Face validity (ORS), 41, 51
tracking outcomes to improve, “Failing successfully,” 87–93, 208
130–132 Families, PCOMS with, 103–105
using PCOMS to track, 134 agreement on scores, 114–116
Effect size (ES), 8n1, 132–133 CORS and CSRS in, 99–100
Efficacy disagreement on scores, 116–118
and evidence-based treatments, 28 discussing scores, clinical cutoff
of psychotherapy, 8–12 and reasons for service,
Efficiency, of public behavioral health 111–114
treatments, 196 introducing and discussing SRS,
Electronic health records (EHRs), 133 120–121
Eliot, George, 3 introducing and scoring CORS/
Emerson, Ralph Waldo, 37 ORS, 109–111
Emotional thermometer, ORS as, and Norway Feedback Trial, 103
205, 206 parent/caregiver scores, 106, 109
Empathy, 160 preparing for, 105–106
Empowering change with clients, tips on, 104, 105
74–77, 155–158 tracking outcomes, 121–122

index       257

Fear(s) Geller, J., 7
about outcome feedback, 36, General effects of treatment, 24–26
202–203 Genuineness, 161
of using “wrong” treatment, 11 Gide, André, 139
Feasibility of ORS, 43, 44 Global distress, 43–44
Feedback, 44 Goals
benefits for therapists, 132, 137–139 of clients, 58–59, 79–81
building culture of, 49–50 identifying, with ORS scores, 118
in evidence-based practice, 28–29 matching approach to couple’s/
improving outcomes with, 12–17 family’s, 104, 105
negative, 64–65 and outcomes of couple therapy,
in public behavioral health settings, 102–103
194, 195 of professional development,
thanking clients for, 65–67, 121 128–130
therapists’ concerns about, 35–37, of therapists, 5–7
202–203 of therapy, 162–163
Feedback effects, 26–27 Goals and topics dimension
Financial plans, incorporating PCOMS (SRS), 45
in, 199 Gold, J., 140
“Finger in the dike” services, 92 Graduate school training, 131, 175
First session with PCOMS Grant, Richard R., 178
agreement on ORS in, 114–116 Graphing ORS scores, 72–73, 122
connecting scores to client’s Grawe, K., 22, 149
experience and reasons for Group Child Session Rating Scale
service, 58–61 (GCSRS), 45
contextualizing and making sense of Group Climate Questionnaire, 48
client’s score, 53–58, 111–112 Group psychotherapy, 15
with couples and families, 105–121 Group Session Rating Scale (GSRS),
disagreement on ORS in, 116–118 45, 47–48
getting accurate scores in, 118–119 Growth, currently experienced
with individuals, 48–67 (current), 129, 135–139, 209
introducing and discussing SRS,
61–67, 120–121 Halstead, J., 44
introducing and scoring ORS, Handbook of Psychotherapy and Behavior
49–53, 109–111 Change (Orlinsky, Rønnestad,
Flexibility, of therapist’s identity, 181–182 and Willutzki), 21
Flückiger, C., 23–24 Hanna, Dave, 198, 201
Focus, maintaining, 234–235 Hannan, C., 9
Forman, E., 9, 192, 194 Hansen, N., 9, 192, 194
Frances, Allen, 225 HAQ–II (Helping Alliance
Frank, J. D., 18, 129, 140, 165, 182, 225 Questionnaire), 48
Frankl, Viktor E., 235 Hatcher, R. L., 46
Franklin, Benjamin, 184, 196 Hatfield, D., 131
Fraser, Scott, 141 Hayes, J., 22
Frontline clinicians, 201–204 Healing involvement
and current growth, 135–139
Gassmann, D., 22, 149 as goal of professional development,
GCSRS (Group Child Session Rating 128–130
Scale), 45 and theoretical breadth, 139–143

258       index

The Heart and Soul of Change Individuals, PCOMS with
(Anderson, Lunnen, & checkpoint conversations, 77–83
Ogles), 141 connecting scores to client’s
Heart and Soul of Change Project, xiv, experience and reasons for
14, 196, 197 service, 58–61
Hegel, G. W. F., 95 contextualizing and making sense of
Help client’s score, 53–58
asking clients for, 3–5, 61 determining probability of success
therapist’s desire to, 5–6 for client by a given session,
Helpers, therapist, 110 93–94
Helping Alliance Questionnaire empowering change with clients,
(HAQ–II), 48 74–77
Hemsley, S., 43, 48 failing successfully, 87–93
Hernandez, Barbara L., 201, 208 first session, 48–67
Heroic Clients, Heroic Agencies (Duncan introducing and discussing SRS,
and Sparks), 176 61–67
Heroic stories of clients, 150–154 introducing and scoring ORS, 49–53
High linear cluster, 101 last-chance discussions, 84–87
“Holy Grail” of psychotherapy, 9–12 methods for tracking outcomes,
Horvath, A. O., 23–24 72–74
Howard, Ken, 13, 37–38 pothole phenomenon, 83–84
How Psychotherapists Develop (Orlinsky recognizing clients’ abilities, 95–98
and Rønnestad), 128 Inflated scores, 63–64
Hypnotherapy, 10 Infrastructure, for PCOMS
implementation, 199, 200
Identity of therapists, 175–189, 227 Insel, Thomas, 225
and collaboration with clients, Insight, 31–33
187–189 Instructions for ORS, 51
confusion about, 175–176 Intake scores, 53–55, 134
and discovery in psychotherapy, Integrity, data, 204–205
185–186 Internal consistency, SRS, 46–48
flexibility of, 181–182 Interpersonal dimension (ORS), 42, 113
graduate school training about, 175 Interpersonal therapy (IPT), 21
and medical model of Interventions, 186
psychotherapy, 225 Inventions, discovery-oriented, 186
reflection on, 182–184 Ionita, G., 131, 201–202
and uncertainty in psychotherapy, IPT (interpersonal therapy), 21
184–185 Isomorphism, 210
The Wizard of Oz as metaphor for,
178–181 Johnson, Spencer, 30
Imel, Z. E., 23 Justice, social, 184, 197
Immediacy, of ORS feedback, 44
“Implicit Common Factors in Diverse Keightley, Alan, 171
Forms of Psychotherapy” Keillor, Garrison, 100
(Rosenzweig), 18 Keller, Helen, 221
Improved (term), 72 Kennedy, John F., 210
Improvements, discussing, 74–75 Klein, M., 161
Incentives for therapists, 223–224 Kodet, J., 15
Individual dimension (ORS), 41 Kolden, G. G., 161

index       259

Kraus, D. R., 22 Microsoft Excel, 72, 132–133
Krupnick, J. L., 24 Miller, S. D., 14, 41, 43, 182
Minami, T., 191, 194
Lambert, M. J., xiv, 9, 13–14, 17, 18–20, Models and techniques
131, 161, 192, 194 and alliance, 164–165
Last-chance discussions, 78 client preferences about, 165
calculating timing of, 93–94 as Holy Grail of psychotherapy, 9–12
with nonresponding clients, 84–87 truth of, 140, 141
Learning, 138–139, 210 Model/technique factors, 24–25
Length of stay, predicting outcomes Morale, current growth and, 129
based on, 39–40 Moras, K., 13
Letters from clients, 218–220 Motivations, therapists’, 129–130,
Levant, Ronald, 28 201–204
Lewis, C. S., 212 Moynihan, D., 19
Lies, 123–125 MRI (Mental Research Institute), 80n2
Life events, scores influenced by, 77, 84 Murphy, J., 41
Life factors, 19–21 MyOutcomes.com, 133
Linehan, Marsha, 11
Listening for client strengths, 150–155 Nafziger, M. A., 7
Long-term work with clients, 38, 39, 85 National Institute of Mental Health
Low scores, on SRS, 64–65 (NIMH), 224, 225
Lunnen, K., 141 National Registry of Evidence-Based
Lutz, W., 13 Programs and Practices, xiv, 16
Negative feedback, from SRS, 64–65
Managed care, 191, 194, 221, 222 Negative feelings, expression of, 46
Mandated clients New Directions Behavioral Health, 223
building alliances with, 166–169 Nielsen, S., 195
children as, 119 Nietzsche, Friedrich, 31
clinical cutoff for, 56–57 NIMH (National Institute of Mental
Manualized therapy, 140 Health), 224, 225
Marcus, D., 23 Nonresponding clients, 77–83
Markham, Edwin, 68 checkpoint conversations with,
Martinovich, Z., 13 77–83
Marx, Groucho, 147 client’s theory of change for, 82–83
“Master therapists,” 228–235 doing something different with,
Mathews-Duvall, S., 15 81–82
Maximum benefit, termination and, “failing successfully” with, 87–93
76–77 goals of, 79–81
McAlister, B., 17, 131 last-chance discussions with, 84–87
McConnell, Steve, 141 pothole phenomenon for, 83–84
McFadzean, Douglas, 176, 177 supervisory process focusing on,
Medical model of psychotherapy, 206–211
224–226 Norcross, J., 7
Medical professionals, collaboration Nordberg, S., 22
with, 226 Norsworthy, L. A., 14–15
Medication, psychotropic, 226–228 Norway Feedback Trial
Mental Research Institute (MRI), 80n2 beliefs about effectiveness in, 36
Method. See Approach or method benefits of feedback in, 14, 132
dimension (SRS) change in, 121–122

260       index

 and PCOMS with couples, 100–103 monitoring client benefits with, 134,
and PCOMS with youth/families, 136–137
103 reliability and validity of, 41, 43–44
termination in, 77 scoring, 52, 111
Nyman, S. J., 7 for teenagers, 105
tracking outcomes with, 72–74
O’Donnell, P., 17, 131 tracking professional development
Ogles, B., 131, 141 with, 132–135
Okiishi, J. C., 135 Outcome Rating Scale (ORS) scores
Olsen, J., 195 accuracy of, 60–61, 205, 206
“On the other hand” game, 143 agreement on, 114–116
OQ. See Outcome Questionnaire 45.2 calculating probability of success
Orientation, for ORS ratings, 52 with, 93–94
Orlinsky, D. E., xv, 7, 21, 73–74, and change, 122
128–130, 135–136, 139, 176, for children from parents/caregivers,
204, 208–211 106, 109
Orr, Bobby, 144 and client’s experience/reasons for
ORS. See Outcome Rating Scale service, 58–61
ORS scores. See Outcome Rating clinical cutoff for, 53–58, 111–112
Scale scores contextualizing, 53–58, 111–112
Orwell, George, 8 disagreement on, 116–118
Outcome(s). See also Tracking outcomes graphing, 72–73, 122
and diagnosis, 224–225 increases in, 74–77
and early change/therapeutic life events as reasons for, 77, 84
alliance, 37–40 non-increasing, 77–87
and length of stay, 39–40 plateaus in, 76–77
positive, 7, 9–10, 65–66 precipitous drops in, 83–84
as proof of effectiveness, 130 reconsidering approach due to, 141
therapists’ measurements of, 16–17 supervisory process based on,
Outcome management systems, 130, 204–211
131, 201–202, 222–223 tracking outcomes with, 72–74
Outcome Questionnaire 45.2 (OQ), 37 Outcome research, clinical trials in,
in CMHC study, 194, 195 vii–viii
and development of ORS, 40–41 Outpatients, intake scores of, 53–55, 134
and development of PCOMS, xiv Overall dimension (ORS), 42
as measure of effectiveness, 135 Overall dimension (SRS), 45
in ORS validity studies, 43 Overutilization, 77, 208
randomized clinical trials of, 13–14 Owen, J., 24, 101–103
Outcome Rating Scale (ORS), 13, 14
development of, 41 P4P (pay for performance) initiatives,
dimensions on, 41–43 202, 221–224
as emotional thermometer, 205, 206 Palm Beach County Children
function of, 49 Services, 201
and goals of couples in therapy, Paperwork, 37, 192–193
102–103 Parallel process, 211
indications of reason for service Parents
on, 114 change for youth and, 109
introducing, 49–52, 109–111 clinical cutoff for child’s scores
maintaining focus with, 234 from, 112

index       261

Parents, continued PCOMS. See Partners for Change
scores for children/adolescents given Outcome Management System
by, 106, 109 PCOMS Therapist Adherence Scale,
as therapist helpers, 110 206
Participation, client, 21, 73–74 PCOMS Therapist Competency
Partners for Change Outcome Checklist, 206
Management System (PCOMS), PDT (psychodynamic therapy), 8, 10
35–70. See also specific topics, e.g.: Person-centered therapy (PCT), 8
Families, PCOMS with Pilot projects, 198
about, xii, xiv Placebo factors, 24–25
assessing effectiveness with, 234–235 Popular culture, therapists in, 5
and current growth, 136–139 Positive alliance, 23
development of, 40–43, 45–48 Positive outcomes
and early change/therapeutic dodo bird verdict on, 9–10
alliance as predictors of and experience, 7
outcome, 37–40 and SRS scores, 65–66
first session with. See First session and training, 7
with PCOMS variability in, 9
in graduate training, 131 Posttraumatic stress disorder (PTSD),
in group psychotherapy, 15 10, 25
and honoring client’s view of Pothole phenomenon, 83–84
therapeutic alliance, 68–70 Predictive validity, SRS, 48
implementation of, 196–211 Present-centered therapy (PRCT),
increasing healing involvement 10, 25
with, 128 Presidential Task Force on Evidence-
in integrated care setting, 226 Based Practice (APA), 28–29
maintaining focus with, 234 President’s New Freedom Commission
organization readiness for, 198–199 on Mental Health, Interim
randomized clinical trials of, xiv–xv, Report, 191, 192
13–16 Probation officers, ratings from, 109
service delivery values of, 196 Problem activation, 22
and theoretical breadth, 140–143 Problems, basing approach on
and therapists’ concerns about client’s, 142
outcome feedback, 35–37 Professional development, 7–8, 127–145
tracking professional development and alliance-building as therapy,
with, 132–135 144–146
validation of, 43–44, 48 becoming a “master therapist,”
with veterans and active duty 228–235
soldiers, 15 and current growth, 135–139
web-based system, 72–73, 133–134 healing involvement as goal of,
Western ideology in, 197n1 128–130
Patient-focused research, 13 as motivator for therapists, 203
Patnaude, Jeffrey, 175 in psychotherapy, 127–128
Pay for participation initiatives, 223–224 and quality of therapist’s work,
Pay for performance (P4P) initiatives, 217–218
202, 221–224 reflection on identity in, 182–184
PayScale, 5 six-phase model of, 182
PBH settings. See Public behavioral steps in, 218
health settings and supervision, 204, 208–210

262       index

 and theoretical breadth, 139–143 privileging client perspectives about
and thorny issues for therapists, care in, 212–215
221–228 Southwest Behavioral Health
tracking of, with PCOMS, 132–135 Services case study, 192–196
and tracking outcomes to improve supervision in, 204–211
effectiveness, 130–132
Treasure Chest for, 218–220 Quality of Life Scale, 43
Professional reflection, continual, 141 Quammen, David, 182
Professional role of psychologists, 175 Questions, checking-in, 41
Psychodynamic therapy (PDT), 8, 10 Quirk, K., 48
Psychologists, professional role of, 175
Psychotherapy With “Impossible” Cases Randomized clinical trials (RCTs)
(Duncan), 98 of Outcome Questionnaire 45.2, 13
The Psychotherapist’s Own Psychotherapy of PCOMS, xiv–xv, 13–16
(Geller, Norcross, & of psychotherapy in public
Orlinsky), 7 behavioral health, 191–192
Psychotherapy RCI (reliable change index), 72, 93–94
alliance as framework for, 159 RCSC (reliable and/or clinically
as calling, 6 significant change), 132–134, 192
client and therapist as elements in, RCTs. See Randomized clinical trials
vii–viii Reasons for service, 58–61, 113–114
collaboration with clients in, Recovered (term), 72
186–189 Recovery, planning for continued, 76
diagnosis and medical model in, Recovery-oriented services, 197
224–226 Reese, R. J., 14–15, 44, 48, 63, 103, 131,
discovery in, 185–186 193–195
efficacy of, 8–12 Referral
lies in, 123–125 in last-chance discussion, 86–87
and medication, 227 of nonresponding clients, 78
models and techniques as “Holy and “successful failures” with clients,
Grail” of, 9–12 87–93
professional development in, 6–7, Referral sources, ORS for mandated
127–128 clients’, 56, 57
uncertainty in, 184–185 Reflection
Psychotropic medication, 226–228 continual professional, 141
PTSD (posttraumatic stress disorder), on identity by therapists, 182–184
10, 25 Refusal, client, 205
Public behavioral health (PBH) Reimbursement, 221–224
settings, 191–215 Reinforcement, 210
commitment to PCOMS in, Relational bond, 160–162
197–200 Relationship dimension (SRS), 45
data collection for PCOMS in, Relationship dimension of alliance, 102
200–201 Relationship Rating Scale (RRS), 45
early change in, 39 Reliability
effectiveness of services in, 191–192 of Outcome Rating Scale, 43–44
inspiring frontline clinicians in, of Session Rating Scale, 46–47
201–204 Reliable and/or clinically significant
PCOMS implementation in, change (RCSC), 132–134, 192
196–211 Reliable change index (RCI), 72, 93–94

index       263

Remen, Rachel, 158 and agreement on tasks of
Research therapy, 165
creating a clinical filter for, 148 in alliance-focused approach, 183
outcome, vii–viii building alliances with, 159, 162
practitioner’s feelings about, 17–18 and confident collaboration/
therapist guidelines from, 17–27 expression of negative
Resilience, 153–155 feelings, 46
Resource activation, 22, 153 development of, 44–45
Resources of clients, 149–158 dimensions of, 45–46
Riemer, M., 17, 131 discussing, 65–68, 121
Robinson, Maria, 228 function of, 49
Rogers, Carl, 160 inflated scores on, 63–64
Rogers, Don, 202 introducing, 61–63, 120–121
Rønnestad, M. H., xv, 21, 73–74, learning from clients’, 137
128–130, 135–136, 139, 141, low scores on, 64–65
176, 182, 204, 208–211 matching goals to approach with,
Rosenberg Self-Esteem Scale, 43 104, 105
Rosenzweig, Saul, 9, 18, 227 and reconsidering approach, 141
Rossi, E., 185 reliability and validity of, 47–48
Rowlands, S. R., 14–15 time as issue on, 66–67
RRS (Relationship Rating Scale), 45 Session Rating Scale (SRS) scores
Rusk, Greg, 19, 147–148, 176, 182, accuracy of, 120–121
230–231 for couples/families, 120
Russell, Bertrand, 187 cutoff for, 63, 64
inflated scores, 63–64
Sa’di, 17 low scores, 64–65
Salaries, of therapists, 5 non-increasing, 79–80, 82–83
SAS (Specialized Adult Services), 31 Shaw, George Bernard, 35
SBHS. See Southwest Behavioral Shimokawa, K., 13
Health Services Skill building, 159, 209–210
School-based counseling, 15, 103 Skovholt, T., 141, 182
School scale (CORS), 111 Slone, N. C., 15
Schuman, D., 15 Smart, D. W., 13
Schweitzer, Albert, xiii Smith, T. B., 7
Scoring Social desirability, 63–64
CORS, 111 Social Desirability Scale, 48
ORS, 52, 111 Social dimension (ORS), 42, 111
PCOMS, 36 Social justice, 184, 197
SRS, 45 Society for Psychotherapy Research, 128
SD (standard deviation), 132–133 Software, outcome management, 131
SDQ (Strength and Difficulties Solovey, A., 19, 148, 182
Questionnaire), 15, 103 Solution-focused therapy, 155
Seesaw patterns, in ORS scores, 205, 206 Solution provider, therapist as, 179–181
Seneca, Lucius Annaeus, 128 Sorrell, R., 14
Senior managers, 199 Southwest Behavioral Health Services
Service, reasons for, 58–61, 113–114 (SBHS), 192–196, 198, 205
Service delivery values, 196 Sparks, J. A., 14, 15, 24, 40–41, 88, 89,
Session Rating Scale (SRS), 13 100–103, 131, 176, 183,
for adolescents, 120 197n1, 227

264       index

Specialized Adult Services (SAS), 31 Thanking and inviting response, 65–66
Specific effects of treatment, 25–26 Thanking clients, for SRS feedback, 121
Spitzer, Robert, 225 Thank-you notes from clients, 219–220
SRS. See Session Rating Scale Theoretical breadth, 139–143
SRS scores. See Session Rating Theory-directed therapy, 180
Scale scores Therapeutic alliance. See Alliance
Standard deviation (SD), 132–133 “Therapeutic work,” alliance in, 166
Stapnes, A. K., 102 Therapist(s), 3–29
Statistically significant (term), 72 alliance as hard work for, 166–171
Stevenson, Robert Louis, 171 asking for help by, 3–5, 61
Stewart, D., 15, 103 authenticity of, 4–5
Stout, Ruth, 94 benefits of PCOMS for, 201–204
Strategic eclecticism, 182 client feedback for, 12–17
Strength and Difficulties Questionnaire clients as teachers of, 31–33
(SDQ), 15, 103 concerns about outcome feedback
Strengths, listening for clients’, 150–155 of, 35–37
Strengths-based therapy, 153 desire to “help people,” 5–6
Stricker, G., 140 effectiveness of. See Effectiveness
Substance Abuse and Mental Health and efficacy of psychotherapy, 8–12
Services Administration, xiv, 16 as element in psychotherapy, vii–viii
Success evidence-based models for, 27–29
“failing successfully,” 87–93, 208 as factor in PCOMS, 49
probability of success for client by a goals of, 5–7
given session, 93–94 guidelines for, 17–27
reasons therapists are unsuccessful identity of, 175–189
with clients, 71–72 incentives for, 223–224
Suicidal behaviors, 11 “master,” 228–235
Summer, use of School scale in, 111 motivations of, 129–130, 201–204
Supervision, 200, 204–211 outcome measurement by, 16–17
Support for PCOMS, 198–199 personal therapy for, 7
Swift, J., 165 in popular culture, 5
Symonds, D., 23–24 professional development by, 7–8
quality of work by, 217–218
Task dimension of alliance, 102 reasons therapists are unsuccessful
Task Force on Promotion and with clients, 71–72
Dissemination of Psychological thorny issues for, 221–228
Procedures, 27–28 tone of, 120–121
Tasks of therapy, agreement on, 163–166 variability in efficacy of, 9
TDCRP. See Treatment of Depression working conditions for, 5
Collaborative Research Program Therapist allegiance, 25
Teachers Therapist effects, ix, 21–23, 103, 229
clients as, 136–137, 236 Therapist Factor Inventory,
ratings of change from, 109 Cohesiveness Scale, 48
Techniques. See Models and techniques Therapist helpers, 110
Teenagers, scales for, 105, 106. See also Therapy. See also specific types
Adolescents alliance-building as, 144–146
Termination of therapy, 76–77, 134 for therapists, 7
Thanking and exploring response, Thinking small, 163
66–67 Third-party payers, 221–224

index       265

Thoreau, Henry David, 135 UCCs. See University counseling
Time, as issue on SRS, 66–67 centers
Time requirement for PCOMS, 37 Uncertainty
Timing of checkpoint/last-chance and discovery, 187–189
discussions, 93–94 embracing, 232–233
Toland, Michael, 39 in psychotherapy, 184–185
Tolkien, J. R. R., 218 Unconditional positive regard, 160
Tone, of therapist, 120–121 Understanding of scales, accuracy of
Tony Montana, 123 scores and, 60, 119
Tracking outcomes Underutilization, 77
checkpoint conversations, 77–83 University counseling centers (UCCs),
determining probability of success 39, 191, 195–196
for client by a given session, University of Kentucky, 131
93–94 University of Rhode Island, 131
empowering change with clients, Unplanned terminations, tracking, 134
74–77 “Using Client Feedback to Improve
and failing successfully, 87–93 Couple Therapy Outcomes”
for families/couples, 121–122 (Anker, Duncan, & Sparks), 100.
to improve therapist effectiveness, See also Norway Feedback Trial
130–132 Utility, of ORS feedback, 44
last-chance discussions, 84–87 Utilization, 185
methods for, 72–74
with PCOMS, 71–98 Validation
and pothole phenomenon, 83–84 of diagnosis, 225
and reasons therapists are unsuccessful of Outcome Rating Scale, 41,
with clients, 71–72 43–44, 51
and recognizing clients’ abilities, and relational bond with clients,
95–98 160–162
Tracking professional development, of Session Rating Scale, 48
132–135 by therapists, 180
Training Vandiver, Willard Duncan, 48
about identity of therapist, 175 Veterans, 15
experience of therapists providing, Visual analog scales, 43
147–148 Vollmer, B., 165
in outcome management, 131
for PCOMS implementation, 198, WAI. See Working Alliance Inventory
199, 202 Walfish, S., 17, 131
for therapists, 7, 10 Wampold, B. E., 23
Transferring clients, 208 Wang, C., 161
Treasure Chest, 218–220 Web-based PCOMS system, 72–73,
Treatment of Depression Collaborative 133–134
Research Program (TDCRP), 21, Weersing, V. R., 192
22, 24–26, 38 Weisz, J. R., 192
Treatment response, benefits of tracking, Wechsler Adult Intelligence Scale—
ix Revised, 3, 4
TRICARE, 221 West, Mae, 71
“Truth,” of models/techniques, 140, 141 Western ideology, in PCOMS, 197n1
Twain, Mark, 99 Wiggin, Bill, 39
Tyron, G. S., 164 Willutzki, U., 21, 73–74

266       index

Wilson-Schaef, Anne, 217 Young children, scales for, 106, 120
Winograd, G., 164 Young Child Session Rating Scale
The Wizard of Oz (Baum), 178–181 (YCSRS), 108, 110, 120
“Wizards, Humbugs, or Witches” Youth, PCOMS for. See also
(Rusk), 176 Adolescents; Children; Families,
Working Alliance Inventory (WAI), 41, PCOMS with
45, 48 getting accurate ratings from clients,
Workshops, 148 118–119
and lies in psychotherapy, 123–125
YCORS. See Young Child Outcome and Norway Feedback Trial, 103
Rating Scale and parent/caregiver scores,
YCSRS. See Young Child Session 106, 109
Rating Scale preparing for, 105–106
YOQ (Youth Outcome selecting appropriate instrument,
Questionnaire), 43 105–108
Youn, S. J., 44 tips on, 104, 105
Young Child Outcome Rating Scale Youth Outcome Questionnaire
(YCORS), 106, 108, 110 (YOQ), 43

index       267

 ABOUT THE AUTHOR

Barry L. Duncan, PsyD, a therapist, trainer, and researcher with 17,000

hours of clinical experience, is director of the Heart and Soul of Change
Project (https://heartandsoulofchange.com). Dr. Duncan has published, as
author or coauthor, more than 100 articles in various publications, as well as
16 books, addressing client feedback, consumer rights and involvement, the
power of relationship, and a risk/benefit analysis of psychotropic medications.
Because of his self-help books (the latest is What’s Right With You), he has
appeared on Oprah and several other national TV programs.
His work regarding consumer rights and client feedback, the Partners for
Change Outcome Management System (PCOMS), is included in the Substance
Abuse and Mental Health Services Administration’s National Registry of
Evidence-Based Programs and Practices and has been implemented across the
United States and in 20 other countries. He codeveloped PCOMS to give
clients the voice they deserve as well as to provide clients, clinicians, admin-
istrators, and payers with feedback about the client’s response to services, thus
enabling more effective care tailored to client preferences. He is the developer
of the clinical process of PCOMS.

269
 Dr. Duncan implements PCOMS in small and large systems of care and
conducts agency trainings, workshops, and keynote presentations on all of
the topics listed above. Drawing upon his extensive clinical experience and
passion for the work, his trainings speak directly to the frontline clinician
about what it means to be a therapist and how each of us can re-remember
and achieve our original aspirations to make a difference in the lives of those
we serve.
Barry L. Duncan may be reached at [email protected].

270       about the author