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Barry Duncan's book "On becoming a better therapist"

Last month I wrote the post "What shall we do about the fact that there are supershrinks and pseudoshrinks?" on Michael Lambert's very challenging plenary presentation at the British Association for Behavioural & Cognitive Psychotherapies' annual conference.  Then in the final post that I wrote about the meeting - "The four main areas I want to use clinically after this conference" - I said: Supershrinks & pseudoshrinks: OK, I'm quite fast out of the blocks on this one. After the conference I got myself copies of the key papers "Using formal client feedback to improve retention and outcomes", "Using client feedback to improve couple therapy outcomes: a randomized clinical trial in a naturalistic setting", "Does a continuous feedback system improve psychotherapy outcome?" & "Effect of client feedback on couple psychotherapy outcomes".  I've joined the Center for Clinical Excellence and I've booked myself into a two day workshop in Copenhagen in mid-September to hear Scott Miller present on "The heart and soul of change" - a workshop on how to implement simple session-by-session client feedback on therapeutic progress and the therapeutic alliance.  Meanwhile I've downloaded and begun to experiment with the two quick four item questionnaires - "Outcome Rating Scale (ORS) & Session Rating Scale (SRS)".

I also spent some time looking at the websites of Scott Miller and Barry Duncan, the originators of the useable, validated, pretty straightforward ORS/SRS patient feedback system.  I ordered myself copies of a couple of books - Duncan, Miller, Wampold & Hubble's somewhat academic "The heart and soul of change: delivering what works in therapy" and the more how-to-do-it book by Barry Duncan "On becoming a better therapist".  This last weekend I went down to the South Coast for my uncle's 90th birthday party celebrations, and I read most of "On becoming a better therapist" while travelling.  How is this book?

Well, it's fairly slim ... a little over 200 pages.  There's an introduction by Michael Lambert of "Supershrinks & pseudoshrinks" fame (see above).  Michael writes "'On becoming a better therapist' provides new goals for our therapeutic efforts.  These goals shift our attention away from becoming experts in techniques to becoming knowledgeable about our effects on patients and our effectiveness.  Rather than settling for certification in techniques based on participation in workshops, the emphasis is on systematically measuring patient treatment response ... Duncan is confident that practising with progress and alliance feedback will accelerate movement toward becoming a more effective therapist, and he provides evidence that this can be the case ... 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."

In his preface, Barry Duncan comments on three major influences that have shaped this book.  One is his involvement as an editor in the recently published, multi-authored "The heart and soul of change: delivering what works in therapy".  This latter book, Barry writes "gathered the field's most prominent thinkers to address what works in therapy, and more important, how to deliver it to our clients.  As the first editor, I was privileged to be intimately involved in every chapter and was therefore privy to the thinking of these noted psychotherapy research scholars' latest reviews of and reflections about the data ... (On becoming a better therapist), in essence, is the clinical companion of 'The heart and soul of change'; it not only implements its findings regarding the common factors that fuel therapeutic transformation but also details the pragmatics of that volume's primary recommendations: Clinicians should routinely collect client-based feedback and tailor services accordingly."  For further details about this more academic publication, see my blog post on "The heart and soul of change." 

The second major influence, Duncan says, that shapes "On becoming a better therapist" have been findings from the fascinating Norway Feedback Project.  The main paper is  "Using client feedback to improve couple therapy outcomes: a randomized clinical trial in a naturalistic setting".  Also interesting are the follow-up papers "The alliance in couple therapy: Partner influence, early change, and alliance patterns in a naturalistic sample" and "Footprints of couple therapy: Client reflections at follow up using a mixed method design in routine care."  Free full text copies of all three of these articles are available from Duncan's website.  I think this is really important and exciting work.  The main paper's abstract reads "Despite the overall efficacy of psychotherapy, dropouts are substantial, many clients do not benefit, therapists vary in effectiveness, and there may be a crisis of confidence among consumers.  A research paradigm called patient-focused research - a method of enhancing outcome via continuous progress feedback - holds promise to address these problems. Although feedback has been demonstrated to improve individual psychotherapy outcomes, no studies have examined couple therapy.  The current study investigated the effects of providing treatment progress and alliance information to both clients and therapists during couple therapy.  Outpatients (N = 410) at a community family counseling clinic were randomly assigned to 1 of 2 groups: treatment as usual (TAU) or feedback.  Couples in the feedback condition demonstrated significantly greater improvement than those in the TAU condition at posttreatment, achieved nearly 4 times the rate of clinically significant change, and maintained a significant advantage on the primary measure at 6-month follow-up while attaining a significantly lower rate of separation or divorce. Mounting evidence of feedback effects with different measures and populations suggests that the time for routine tracking of client progress has arrived."  Yup, I've read this paper and a cluster of others on this session-by-session method of tracking therapeutic progress and the therapeutic alliance.  I think any psychotherapist who isn't prepared to seriously consider implementing these ideas seems uninformed, uncommitted or disempowered.  For more on this see the posting "The Norway feedback project: a clear and sensible way to make psychotherapy more helpful." 

The third influence Duncan cites is Orlinsky & Ronnestad's "How psychotherapists develop: a study of therapeutic work and professional growth".  Now this seems a jump sideways.  As the book's dust jacket states " ... based on a 15-year study of psychotherapists' experiences and careers ... the authors and their collaborators collected richly detailed reports from nearly 5,000 psychotherapists of all career levels, professions, and theoretical orientations in more than a dozen countries worldwide ... this landmark work emphasizes to researchers the importance of the psychotherapist's contribution to effective treatment, offers guidance to teachers and supervisors of psychotherapists, and - not least - promises to satisfy the curiosity of therapists at all career levels about how their own experiences ... compare with those of their peers and colleagues."  Mm ... I'll write more on this later ... see "Orlinsky & Ronnestad's 'How therapists develop ... ".

So what's my take-home message about Barry Duncan's "On becoming a better therapist"?  The message is simple - if you want to get more helpful background on implementing a progress & alliance tracking system, this book is well worth taking a look at.      

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