Transcript Innovations, Best Practices & Policy Change

Strengths-Based Therapy
Bob Bertolino, Ph.D.
Associate Professor, Maryville University
Sr. Clinical Advisor, Youth In Need, Inc.
Sr. Associate, International Center for Clinical Excellence
Tidbits
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A few PowerPoint slides are absent from
your handouts. For any missing slides,
please go to: www.bobbertolino.com
Contact: [email protected]; 314.852.7274
For more information please visit: The
International Center for Clinical Excellence
(ICCE) @
www.centerforclinicalexcellence.com
You may reproduce the handouts, I only ask
that you maintain their integrity
Where is Your Head?
Recalibrating Our Compasses
Recalibrating Our Compasses
1.
2.
3.
4.
5.
6.
What are the core beliefs or ideas you have about the
clients with whom you work (or will work)?
How have you come to believe what you believe and
know what you know? What have been the most
significant influences on your beliefs?
How have your beliefs and assumptions affected your
work with clients? With colleagues? With the
community?
Do you believe that change is possible even with the
most “difficult” and “challenging” clients?
How do you believe that change occurs? What does
change involve? What do you do to promote change?
Would you be in this field if you didn’t believe that the
clients with whom you work could change?
H
Humanism
O
Optimism
P
Possibilities
E
Expectancy
“Optimism is the faith that leads to achievement.
Nothing can be done without hope or confidence.”
- Helen Keller
The Evidence:
40 Years of Data
What is Evidence-Based Practice?
APA (2006)
“The integration of the best available
research with clinical expertise in the
context of patient characteristics, culture,
and preferences.” (p. 273)
APA Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in
psychology. American Psychologist, 61(4), 271–285.
Research Resources
Key Questions
1. Whose data is
it?
2. What kind of
data is it?
3. Compared to
what?
Three Important Questions
1. Does psychotherapy work?
2. How much have our outcomes
improved over the past 30 years?
3. Which models work the best?
The Evidence:
Does Psychotherapy Work?
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The average treated client is better off than
80% of the untreated sample (NNT)
NNT
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NNT = number of patients needed to be treated
to attain one additional success versus the
alternative
Area
Cardiology
Cardiology
Post Menopausal Osteoporosis
Influenza
Hematology Thromboembolism
Smoking Cessation
Acute Asthma
Sickle Cell Anemia
Acute Myeloid Leukemia
Mental Health
Tx
Aspirin Prophylaxis
Beta Blockers
Risendronate
Vaccine
Warfarin
Nicotine Inhaler
Budesonide
Transfusion
Bone Marrow Transplant
Psychotherapy
NNT
176
40
20
12
10
10
9
7
5
NNT
•
NNT = number of patients needed to be treated
to attain one additional success versus the
alternative
Area
Cardiology
Cardiology
Post Menopausal Osteoporosis
Influenza
Hematology Thromboembolism
Smoking Cessation
Acute Asthma
Sickle Cell Anemia
Acute Myeloid Leukemia
Mental Health
Tx
Aspirin Prophylaxis
Beta Blockers
Risendronate
Vaccine
Warfarin
Nicotine Inhaler
Budesonide
Transfusion
Bone Marrow Transplant
Psychotherapy
NNT
176
40
20
12
10
10
9
7
5
3
The Evidence:
Does Psychotherapy Work?
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The average treated client is better off than
80% of the untreated sample (NNT)
Therapy is cost-effective and reduces medical
expenditures
The average clinician achieves outcomes on
par with success rates obtained in randomized
clinical trials (RCTs) (with or without comorbidity)(Minami, et al., 2008)
Minami, T., Wampold, B., Serlin, R., Hamilton, E., Brown, G., & Kircher, J. (2008). Benchmarking for
psychotherapy efficacy. Journal of Consulting and Clinical Psychology, 75, 232-243.
The Evidence:
How Much Have We Improved?
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Nearly 10,000 “how to” books have been published
on psychotherapy
The number of treatment models has grown to over
400
Currently there are 145 manualized treatments for
51 of the 397 possible DSM diagnostic grouping
Every approach claims superiority in
conceptualization, technique, and outcome
The results?
How Much Have We Improved?
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No improvement in outcomes in 30+ years
Dropout rates of 47-50%
Lack of consumer confidence in therapy
outcome
Continued emphasis on the medical model,
prescriptive treatments, and claims of
superiority (relative efficacy) amongst
models
The Search for the Best:
Claims of Superiority & Relative Efficacy
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No differences among treatments intended to
be therapeutic (bona fide approaches)
including CBT, DBT, IPT, MI, BT, etc., etc….
Any differences in single studies do not exceed
what would be expected by chance and have at
most an ES d = .20; NNT = 9 (100%
researcher allegiance effects)
What about specific disorders?
Meta- Analyses of Bona Fide
Treatments for Specific Disorders
• PTSD: All studies published between 1989-2009
• Benish, S., Imel, Z. E., & Wampold, B. E. (2008). The relative efficacy of
bona fide psychotherapies of post-traumatic stress disorder: A metaanalysis of direct comparisons. Clinical Psychology Review, 28, 746758.
• ALCOHOL ABUSE AND DEPENDENCE: All studies between 19602007
• Imel, Z. E., Wampold, B. E., Miller, S. D., & Fleming, R. R. (2008).
Distinctions without a difference: Direct comparisons of psychotherapies
for alcohol use disorders. Journal of Addictive Behaviors, 22, 533-543.
• YOUTH DISORDERS-DEPRESSION, ANXIETY, CD, ADHD: All
studies between 1980-2006
• Miller, S. D., Wampold, B., & Varhely, K. (2008). Direct comparisons of
treatment modalities for youth disorders: A meta-analysis.
Psychotherapy Research, 18, 5-14.
The Search for the Best:
Dismantling Studies
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Specific ingredients are not needed to achieve
a good outcome:
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Wampold (2001): “Research designs that are able to
isolate and establish the relationship between
specific ingredients and outcomes…have failed to
find a scintilla of evidence that any specific ingredient
is necessary for therapeutic change.” (p. 204)
Not convinced? Listen for yourself:
http://www.newsavoypartnership.org/2008conference.htm
Wampold, B. E. (2001). The great psychotherapy debate: Models, methods,
and findings. Hillsdale, NJ: Lawrence Erlbaum.
Why Haven’t We Improved
in Psychotherapy?
Why Haven’t We Improved?
Two further questions:
1. What factors have we held historically as
most influential to therapy outcomes?
2. What accounts for the largest portion of
variance between outcomes?
Factors that Contribute Little to
Therapy Outcomes
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Client factors: diagnosis, gender, and age
(<1%)
Therapist factors: age, gender,
experience level, professional degree,
certification (combined = 0%)
Treatment models (≤1%)
What Accounts for the
Largest Portion of Variance
Between Outcomes?
A Hint….
A Hint: The TDCRP
Treatment of depression – 250; 4 tx cond. – CBT, IPT, IMI, Placebo
CBT vs. IPT
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Variance due to tx = 0%
Variance due to therapist = 8%
Actual practice
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Type of tx = 0%
Dx, degree, experience = 0%
Medication = 1%
Therapist = 5%
Top ¾ vs. entire population – d = .75
Antidepressants vs. Placebo
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Variance due to tx = 3%
Variance due to prescribing psychiatrist = 9%
Better psychiatrists had better outcomes with placebo than poorer psychiatrists
who administered antidepressants
Therapist Effects: The Upside
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6-9% of the variance in outcome
Second most potent contributor to
outcome
9x > tx effects
Wampold, B. E., & Brown, J. (2006). Estimating variability in outcomes attributable to
therapists: A naturalistic study of outcomes in managed care. Journal of Consulting
and Clinical Psychology, 73(5), 914-923.
How Do You Rate Yourself?
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Compared to other mental health professionals within
your field (with similar credentials), how would you rate
your overall clinical skills and effectiveness in terms of a
percentile?
Please estimate from 0-100%. For example, 25% = below
average; 50% = average; 75% = above average
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What percentage (0-100%) of your clients get better
(i.e., experience significant symptom reduction/relief)
during treatment? What percentage stay the same?
What percentage get worse?
How Do We Rate Ourselves?
Researchers surveyed a representative sample of
psychologists, psychiatrists, counselors, social workers, and
marriage and family therapists from all 50 states:
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No differences in how clinicians rated their overall skill level and
effectiveness levels between disciplines
On average, clinicians rates themselves at the 80th
percentile:
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None rated themselves below average
Less than 4% considered themselves average
Only 8% rated themselves lower than the 75th percentile
25% rated their performance at the 90th percentile or higher compared
to their peers
Walfish, S., McAllister, B., & Lambert, M. J. (in press). Are all therapists from Lake
Wobegon? An investigation of self-assessment bias in health providers.
How Do We Rate Ourselves? (cont.)
With regard to success rates:
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The average clinician believed that 80% of their clients improved as a
result of being in therapy with them (17% stayed the same; 3%
deteriorated)
Nearly a quarter sampled believed that 90% or more improved!
Half reported that none (0%) of their clients deteriorated
The facts?
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Effectiveness rates vary tremendously (RCT average RCI = 50%; best
therapists = 70%)
Therapists consistently fail to identify deterioration and people at risk
for dropping out of services (10 & 47%, respectively)
Walfish, S., McAllister, B., & Lambert, M. J. (in press). Are all therapists from Lake Wobegon? An
investigation of self-assessment bias in health providers.
How Do We Rate Ourselves? (cont.)
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In a study Hannan et al. (2005):
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Therapists knew the purpose of the study, were
familiar with the outcome measure used, and were
informed that the base rate was likely to be 8%;
Therapists accurately predicted deterioration in only
1 out of 550 cases;
In other words, therapists did not identify 39 of the 40
clients who deteriorated
In contrast, the actuarial method correctly identified
36 of the 40
Hannan, C., Lambert, M. J.,Harmon, C., Nielsen, S. L., Smart, D. W., Shimokawa, K., et al.
(2005). A lab test and algorithms for identifying clients at risk for treatment failure. Journal
of Clinical Psychology: In Session, 61, 155-163.
Therapist Effects:
The Downside
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Therapists routinely overestimate their
effectiveness
Only about 3% of therapists routinely track their
outcomes
The effectiveness of the “average” therapist
plateaus very early as automaticity sets in
Atkins, D. C., & Christensen, A. (2001). Is professional training worth the bother? A
review of the impact of psychotherapy training on client outcome. Australian
Psychologist, 36, 122-130.
Five Studies Large-Scale RCTs on
Outcome Feedback
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Harmon, S. C., Lambert, M. J., Smart. D. W., Hawkins, E. J., Nielsen, S. L., Slade,
K., et al. (2007). Enhancing outcome for potential treatment failures: Therapist/client
feedback and clinical support tools. Psychotherapy Research, 17, 379-392.
Hawkins, E. J., Lambert, M. J., Vermeersch, D. A., Slade, K., & Tuttle, K. (2004). The
effects of providing patient progress information to therapists and patients.
Psychotherapy Research, 14, 308-327.
Lambert, M. J., Whipple, J. L., Smart, D. W., Vermeersch, D. A., Nielsen, S. L., &
Hawkins, E. J. (2001). The effects of providing therapists with feedback on patient
progress during psychotherapy: Are outcomes enhanced? Psychotherapy Research,
11(1), 49–68.
Lambert, M. J., Whipple, J. L., Vermeersch, D. A., Smart, D. W., Hawkins, E. J.,
Nielsen, S. L., & Goates, M. (2002). Enhancing psychotherapy outcomes via
providing feedback on client progress: A replication. Clinical Psychology and
Psychotherapy, 9, 91–103.
Whipple, J. L., Lambert, M. J., Vermeersch, D. A., Smart, D. W., Nielsen, S. L., &
Hawkins, E. J. (2003). Improving the effects of psychotherapy: The use of early
identification of treatment and problem-solving strategies in routine practice. Journal
of Counseling Psychology, 50(1), 59–68.
Five Studies Large-Scale RCTs on
Outcome Feedback: Findings
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All five studies demonstrated significant gains for the
feedback groups:
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33% of clients deemed at-risk of negative outcome and in the
therapist feedback condition reached reliable improvement
versus 22% for TAU
39% reliable improvement for therapist and client feedback
system
45% reliable improvement: feedback + clinical support tools
Random assignment, no new methods or techniques
taught , high % of licensed clinicians who were free to
practice as they saw fit
Lambert, M. J. (2010). “Yes, it is time for clinicians to routinely monitor treatment outcome. In B. L. Duncan, S. D.
Miller., B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd
ed.) (pp. 239-266). Washington, DC: American Psychological Association.
Before You Do
Anything Else
4 Steps for Improving Clinical
Effectiveness
4 Steps for Improving Clinical
Effectiveness
1. Determine your baseline
2. Engage in formal, routine, and
ongoing feedback
3. Employ strategies and processes
demonstrated to strengthen alliances
and improve outcomes
4. Engage in “deliberate practice”
Step #1
Determine Your Baseline
Step #1: Determine Your Baseline
1. Select an outcome measure that is valid,
reliable, and feasible
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Examples: OQ-45/LSQ; OQ/Y-OQ 30.2; ORS;
SCL-90; Basis 32 (session 1-3 then minimally
every third subsequent session)
Can use pencil/paper and or electronic versions
2. The measure should at minimal elicit the
client’s rating of the subject impact of
services on majors areas of life (individual,
interpersonal, and social role functioning)
3. Have client complete measure at the
beginning of session/meeting
The Outcome Rating Scale (ORS)
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A 40 point measure with 4 subscales
Two versions that can be scored: ORS & CORS
Higher score indicate lower levels of distress; lower
scores indicate higher levels of distress
Clinical Cutoffs: 25 (> Age 19); 28 (Ages 13-19);
32 (≤ Age 12)
Reliable Change Index (RCI): 5
Complete at the beginning of session
Takes less than 1 minute to administer
Paper/pencil and electronic scoring systems are
available (MyOutcomes; ASIST)
Can plot personal data on Excel spreadsheet
Is free to individual users and available for
download at: www.scottdmiller.com
Sample Excel Spreadsheet
Calculating Your Effect Size
Calculating Your Effect Size
Step #2
Engage in Formal, Routine, and
Ongoing Feedback
Engaging in Feedback
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Dose-Response Effect
All major meta-analytic studies indicate the
most significant portion of change occurs
earlier in treatment (within the first 5
sessions)
The client’s rating of the therapeutic
relationship is the most consistent
predictor of outcome
APA Task Force:
The Importance of Feedback
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“The application of research evidence to a given patient always
involves probabilistic inferences. Therefore, ongoing monitoring of
patient progress and adjustment to treatment as needed are
essential” (p. 280).
“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 treatment (Lambert,
Bergin, & 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.” (p.
276-277)
APA Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in
psychology. American Psychologist, 61(4), 271–285.
Lambert, M. J., Bergin, A. E., & Garfield, S. L. (2004). Introduction and overview. In M. J. Lambert (Ed.),
Bergin & Garfield’s handbook of psychotherapy & behavior change (5th ed.)(pp. 3-15). New York: Wiley.
What Are We Seeing?
“Therapists typically are not cognizant of the trajectory
of change of patients seen by therapists in
general…that is to say, they have no way of
comparing their treatment outcomes with those
obtained by other therapists.” (p. 922)
Wampold, B. E., & Brown, J. (2006). Estimating variability in outcomes attributable to therapists: A
naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology,
73(5), 914-923.
Improving on Your Performance
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Excellent performers
judge their
performance
differently
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Compare to their
personal best
Compare to the
performance of others
Compare to known
national standard or
baseline
Ericsson, K. A., Charness, N., Feltovich, P., & Hoffman, R. R. (Eds.) (2006). The Cambridge handbook
of expertise and expert performance. New York: Cambridge University Press.
Further Studies on
Outcome Feedback
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Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client
feedback to improve couple therapy outcomes: A randomized
clinical trial in a naturalistic setting. Journal of Consulting and
Clinical Psychology, 77, 693-704.
Miller, S. D., Duncan, B. L., Sorrell, R., Brown, G. S., & Clark, M. B.
(2006). Using formal client feedback to improve retention and
outcome: Making ongoing, real-time assessment feasible. Journal of
Brief Therapy, 5, 5-22.
Reese, R. J., Norsworthy, L. A., Rowlands, S. J. (2009). Does a
continuous feedback model improve therapy outcomes?
Psychotherapy, 46(4), 418-431.
Wampold, B., & Brown, J. (2006). Estimating variability in outcomes
attributable to therapists: A naturalistic study of outcomes in
managed care. Journal of Consulting and Clinical Psychology, 73,
914-923.
Recent Studies on Outcome
Feedback: Key Findings
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Miller et al. (2006):
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6400+ clients, 75 clinicians
Clients in feedback condition (therapist and client) improved by
65%
Anker, Duncan, & Sparks (2009):
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461 Norwegian couples in marital therapy
Two treatment conditions: (1) routine marital therapy without
feedback; (2) routine marital therapy with feedback
Percentage of couples in which both met or exceeded the target
or better:
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TAU: 17%
Tx with feedback : 51%
Tx with feedback: 50% less separation/divorce at 1-year follow-up
Step #3
Employ Strategies and Processes
Demonstrated to Strengthen and
Alliances and Improve Outcomes
Psychotherapy Common Factors
(Meta-Analysis)
Effects on Outcomes
Hubble, M. A., Duncan, B. L., & Miller, S. D. (Eds.) (1999). The heart
and soul of change: What works in therapy. Washington, D.C.:
American Psychological Association.
Lambert, M. J. (1992). Psychotherapy outcome research:
Implications for integrative and eclectic therapists. In J. C.
Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy
integration (pp. 94-129). New York: Basic Books.
Wampold, B. E. (2001). The great psychotherapy debate:
Models, methods, and findings. New Jersey: Lawrence
Erlbaum.
Variance in Psychotherapy
Outcomes
Client/Extratherapeutic Factors – 87%
Treatment Effects – 13%
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Therapist Effects – 6-9%
The Alliance – 5-7%
Model/Technique – 1%
Factors that account for variance and
influence change are not independent entities
They are interdependent, fluid, and dynamic
Alliance Effects
38-54%
Client/
Extratherapeutic
Factors
87%
Model/Technique
Delivered:
Expectancy/
Allegiance
Rationale/Ritual
30-?%
Treatment
Effects
13%
Model/Technique
8%
Therapist Effects
46-69%
Feedback
Effects
15-31%
Principles of Change
• Castonguay and Beutler (2006), “We think that
psychotherapy research has produced enough
knowledge to begin to define the basic principles
that govern therapeutic change in a way that is
not tied to any specific theory, treatment model,
or narrowly defined set of concepts” (p. 5).
Castonguay, L. G., & Beutler, L. E. (2006). Common and unique principles of therapeutic change:
What do we know and what do we need to know? In L. G. Castonguay & L. E. Beutler (Eds.),
Principles of therapeutic change that work (pp. 353–369). New York: Oxford University Press.
Strengths-Based Therapy
Principles of Clinical Effectiveness
A Strengths-Focus
• Recall: Client/extratherapeutic factors account
for approximately 87% of the variance in
outcome
• Successful providers focus on strengths before
moving to problems
• Unsuccessful focus on problems and neglect
strengths
Gassman, D., & Grawe, K. (2006). General change mechanisms: The relationship between problem
activation and resource activation in successful and unsuccessful therapeutic interactions. Clinical
Psychology and Psychotherapy, 13, 1-11.
Strengths-Based Principles
Client Contributions
The Relationship and Alliance
Cultural Competence
Focus on Change
Expectancy and Hope
Factor of Fit
Strengths-Based Principles
Client Contributions
The Relationship & Alliance
• Clients are the most significant
contributors to outcome
• Recognize clients as
competent and capable of
change
• Identify and employ internal
strengths
• Identify and assist with
developing supportive social
systems, resources, and
networks
• Offer service options that are
respectful of clients and their
cultures and incorporate their
perceptions and preferences
• Incorporate processes for
learning clients’ views of
service-oriented relationships
and integrate feedback into all
aspects of services
• Collaborate with clients on
determining goals and tasks to
accomplish goals (service
planning)
Strengths-Based Principles (cont.)
Cultural Competence
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Maintain self-awareness of one’s
own heritage, background, and
experiences and their influence on
attitudes, values, and biases
Emphasize a multi-level
understanding, encompassing the
client, family, community, helping
systems, culture, etc
Recognize limits of multicultural
competency and expertise;
consult others who share cultural
similarities and expertise with
clients being served
Acknowledge clients as teachers
and experts on their own lives
Change as a Process
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View change as constant and
scan for spontaneous change
View change as attainable and
problems as challenges to
progress, not fixed pathology
Focus on maximizing the impact
of each interaction and/or meeting
Monitor change from the outset
Maintain a future focus
Explore exceptions to problems;
how change is already happening
Focus on creating small changes
Allow reentry or easy access to
future services as needed
Strengths-Based Principles (cont.)
Expectancy and Hope
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Demonstrate faith in clients and in
the restorative effects of services
Build on preservices expectancy
Believe and demonstrate faith in
the procedures/practices utilized
Show interest in the results of the
procedure or orientation
Ensure that the procedure or
orientation is credible from the
client’s frame of reference and is
connected with or elicits
previously successful experiences
View clients as people, not as
their problems or difficulties or in
ways that depersonalize them
Factor of Fit
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Assess the client’s readiness for
change
Use methods as a vehicle for
activating and enhancing the other
core principles of change
Use methods that fit with, support,
or complement the client’s
worldview and expectations
Use methods that capitalize on
client strengths and resources
Use methods that increase the
client’s sense of sense of hope,
expectancy, or personal control,
and contribute to increased selfesteem, self-efficacy, and selfmastery
Strengths-Based Principles
in Motion
Active Client Engagement
5-Point Process
1.
2.
3.
4.
5.
Create a Context of Collaboration
Strengthen Through Presence
Collaborate on Goals and Outcomes
Focus on Change
Evaluate and Monitor Progress, and
Respond
1. Create a Context of
Collaboration
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Keys to Collaboration
Explore client expectations and preferences
Introduce “real-time” feedback processes
[process (alliance) and outcome]
Have client(s) complete outcome measure at
the beginning of sessions
Have client complete alliance measure at the
end of sessions, leaving time to discuss
feedback
Stress importance of honest, genuine
feedback
2. Strengthen Through Presence
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Listen and acknowledge
Convey empathy and positive regard
Be congruent in relationship
Summarize, validate, and soften
Use possibility-laced language
Listen for what clients attribute their problems
and potential solutions to
Begin to gain sense of direction
Check in with clients
The Therapeutic Relationship in
Context…
“Even for those who are convinced that the therapeutic
relationship is healing by and of itself, there are
strategies that can foster its impact. In other words,
since not all kinds of relationships are likely to bring
about change, one needs to be aware of
interventions (including modes of relating) that
should be encouraged or avoided for the
relationship to become a corrective experience.” (p.
353)
Castonguay, L. G., & Beutler, L. E. (2006). Common and unique principles of therapeutic change:
What do we know and what do we need to know? In L. G. Castonguay & L. E. Beutler (Eds.),
Principles of therapeutic change that work (pp. 353-369). New York: Oxford University Press.
Session Rating Scale (SRS)
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A 40 point measure with 4 subscales
Two versions that can be scored: SRS & CSRS
Complete near the end of session (last 5-10 minutes)
Overall scores below 36 or any subscale below 8 should be
discussed with clients
Lower scores at the beginning of services can mean very
different things
Lower scores as services progress are 4x likely to
contribute to dropout
Takes less than 1 minute to administer
Paper/pencil and electronic scoring systems are available
(MyOutcomes; ASIST)
Can plot personal data on Excel spreadsheet
Is free to individual users and available for download at:
www.scottdmiller.com
Strategies for Alliance Ruptures
and Impasses
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Discuss the here-and-now relationship with the client
Ask for feedback about the therapeutic relationship
Create space and allow the client to assert any negative
feelings about the therapeutic relationship
Engage in conversations about the client’s expectations and
preferences.
Discuss the match between the therapist’s style and client’s
preferred ways to relate
Spend more time learning about the client’s experience in
services
Readdress the agreement established about goals and tasks
to accomplish those goals
Strategies for Alliance Ruptures
and Impasses (cont.)
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Accept responsibility for part in alliance ruptures
Normalize the client’s responses by letting him or her know that
talking about concerns, facing challenges, taking action, and/or
therapy in general can be difficult
Provide rationale for techniques and methods
Attend closely to subtle clues (e.g., nonverbal behaviors, patterns
such as one-word answers) that may indicate a problem with the
alliance
Offer more positive feedback and encouragement (except when the
client communicates either verbally or nonverbally that this is not a
good match)
Engage in further supervision and/or training
3. Information-Gathering
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Use information-gathering processes that
identify concerns, risks, and threats to safety
and well-being, and client strengths, abilities,
resources, and exceptions
Enhance hope and expectancy
Establish Goals = observable, measurable,
descriptive behaviors and actions
Focus on Outcomes = the client’s subjective
interpretation of the impact services on major
areas of life functioning (individual,
interpersonal, and social role)
4. Focus on Change
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Assess client readiness for change
Discuss with clients possible benefits and side effects
of services
Enhance placebo effects by building on the client’s
belief in therapeutic processes
Work to increase the “factor of fit” between methods
and client(s) expectations and perspectives
Consider client(s)’ method of coping, previous
attempts and problem solving, and frameworks such
as the “stages of change”
Collaborate on tasks and offer options to increase
client engagement, creativity, and independence
Ensure that the procedure or orientation is credible
from the client’s frame of reference and is connected
with or elicits previously successful experiences
5. Evaluate and Monitor Progress,
and Respond
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Identify, amplify, and extend change
Even when external influences factor into
change (e.g., psychotherapy, medication) or
clients assign change to other variables (e.g.,
luck, chance) attribute the majority of change
to their qualities and actions
Explore ways that clients can extend change
into other areas of life in the future
Continue to incorporate outcome and alliance
feedback
5. Evaluate and Monitor Progress,
and Respond (cont.)
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Respond to alliance ruptures
Modify intensity of services based on feedback
of client and experience as clinician
Step #4
Engage in “Deliberate Practice”
“Deliberate Practice”
“Successful people spontaneously do things differently
from those individuals who stagnate… Elite
performers engage in…effortful activity designed to
improve individual target performance.”
Brown, J., Lambert, M. J., Jones, E., & Minami, T. (2005). Identifying highly effective psychotherapists
in a managed care setting. The American Journal of Managed Care, 11, 513-520.
Deliberate Practice Includes
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Working hard to overcome “automaticity”
Planning, strategizing, tracking, reviewing, and
adjusting plan and steps
Consistently measuring and then comparing
performance to a known baseline or national
standard or norm
Practicing everyday, including weekends, for up
to 45 minutes at a time, with periods of rest in
between, for up to 4 hours per day
Deliberate Practice of HighlyEffective Clinicians
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Maintain a posture of awareness, remain alert, observant, and
attentive in each encounter
Compare new information and what is learned with what is
already known
Remain acutely attuned to the vicissitudes of client
engagement—actively employ processes of gaining and
incorporating ongoing formal feedback
May achieve lower scores on standardized alliance measures
at the outset of services because they are more persistent
and perhaps, more believable, when assuring clients that they
seek honest feedback, enabling them to address potential
problems in the alliance (workers with lower rates of success,
by contrast, tend to receive negative feedback later in
services, at which point clients have already disengaged)
Deliberate Practices of HighlyEffective Clinicians (cont.)
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Spend more time on strategies that might be more effective
and improve outcomes as opposed to hypothesizing about
failed strategies and why methods did not work
Expand awareness when events are stressful and remaining
open to options
Evaluate and refine strategies and seek outside consultation,
supervision, coaching, and training specific to particular skill
sets