On Becoming a Better Therapist Evidence Based Practice

One Client at a Time - 2nd Edition

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 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

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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