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Client-directed, outcome-informed therapy: a workshop with Scott Miller

"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 

Wednesday morning - half way through this two day workshop with Scott Miller on client-directed, outcome-informed (CDOI) therapy.  I flew into Copenhagen on Monday evening, the plane blown fast from Edinburgh on the last gasps of Hurricane Katia as she slowly expired in her long journey across the Atlantic.  I like Copenhagen.  Bizarrely, having never been here before, I have now visited three times in the last 18 months - the European Positive Psychology Conference in June last year, a long weekend with my wife in December, and now this two day workshop.

The workshop is taking place at the somewhat alternative Islands Brygge Kulturhuset.  This suits me fine.  There are maybe 60 to 70 participants - almost entirely Danish.  There seem to be a few therapists who have come over from Sweden and then there's me, apparently the sole non-Scandinavian participant.  As a native English-speaker I'm so lucky.  Scott is from the States and is giving the workshop in English - well actually in American, but I can mostly understand that!  After the lightbulb moment of Michael Lambert's talk on "Supershrinks & pseudoshrinks" at the BABCP conference in July, I was desperate to learn more about CDOI.  Scanning the internet, I came up with this two day workshop just a short flight from Edinburgh.  The fact that I'd already set these two days aside for paperwork meant that I didn't have to cancel any client appointments.  Perfect.  And here I am and the workshop is pretty much what I've been hoping for.  It's all very well reading the research papers and textbooks, but learning from the "horse's mouth" typically provides more nuanced, personal teaching. 

Scott is a very informative, very knowledgeable, engaging and experienced presenter.  Maybe I could do with a little less persistent humour, but hey I'm a Brit and a 61 year old Brit at that!  So why am I here?  Well it's pretty straightforward.  I believe that learning to use better systems for monitoring how my clients are doing could improve how helpful I am for them more than anything else I've learned in the last several years.  Big hope, and it's realistic.  As I wrote last month in my post on "The Norway feedback project" - At follow-up "The ES (Effect Size) for individuals from couples who received feedback versus those who did not was d=0.44.  More specifically, at 6-month follow-up, the proportion of clients responding to treatment as measured by the ORS (Outcome Rating Scale) in the TAU (Treatment As Usual) group was 39.1% (both in couple, 18.8%) and in the feedback group was 66.7% (both in couple, 47.6%) ... the effects of feedback at follow-up were also assessed by examining the marital status of couples ... a significantly greater proportion of couples were intact (i.e., not divorced or separated) in the feedback condition (81.59%) than in the TAU condition (65.75%)".  These are startling differences.  If one was assessing whether one form of psychotherapy was more effective than another, then a 0.44 effect size would be a pretty impressive difference.  Remember too that these results have now been replicated for couple therapy with Reese et al's "Effect of client feedback on couple psychotherapy outcomes" also showing very encouraging benefits - "couples in a client feedback condition demonstrated statistically significantly more improvement compared with couples receiving treatment as usual and that improvement occurred more rapidly.  Also, 4 times as many couples in the feedback condition reported clinically significant change by the end of treatment."  And, as I've noted before, similar gains from instituting a simple, quick feedback system have been noted for individual psychotherapy - see "Using formal client feedback to improve retention and outcomes" and "Does a continuous feedback system improve psychotherapy outcome?" (all articles are freely viewable in full text on Duncan's website). 

In fact, Barry Duncan - in his book "On becoming a better therapist" - writes (p.25): "Practice-based evidence will likely become the rage of the next decade - and for good reason: monitoring client-based outcome, when combined with feedback to the clinician, significantly increases the effectiveness of services.  Lambert (2010) reports that effect sizes for the difference between feedback and TAU ranges from .34 to .92, unusually large considering that the estimates of the ES of the difference between empirically supported and comparison treatments are about .20.  Putting this in perspective, feedback has two to four times the impact of model difference."  And as I said last month - in my post on "The heart & soul of change" - "And central to this "doing more" is the practice of session-by-session monitoring and feedback. As the editors propose in their introduction "In the end, monitoring outcomes may provide a common ground for those who advocate empirically supported treatments and those who espouse the importance of common factors." I heartily agree. They point out that "The combination of measuring progress (i.e. monitoring) and providing feedback consistently yields clinically significant change ... Rates of deterioration are cut in half, as is dropout. Include feedback about the client's formal assessment of the relationship, and the client is less likely to deteriorate, more likely to stay longer, and twice as likely to achieve a clinically significant change." Sounds like territory of interest to any thoughtful psychotherapist. Bring it on!" 

Potentially this is a big therapeutic prize - hence the plane flight, winging along in the last breaths of hurricane Katia, to welcoming Copenhagen.  The two day workshop is entitled "What works in therapy".  We're given a 20 page handout of (most of) the slides we'll be shown - this is freely downloadable, see further down the "Scholarly publications, handouts, vitae" page of Scott's website.  Scott began by talking about the classic "common factors" findings that are explored so fully in the recent multi-authored, second edition of  "The heart & soul of change".  I challenged some of his comments.  I think it's all too easy and understandable for the my-type-of-therapy-is-best advocates to considerably overstate any specific benefits that accrue from their particular form of treatment.  However there also seems to be a tendency for a mirror process in the therapy-is-primarily-about-common-factors devotees.  Even accepting Scott's division of therapy benefit into about 60% from "alliance/common-factors" and about 40% from "allegiance/model/technique", it would be quite a loss not to honour the 40% and only go for the 60%.  We need both common factors and specific methods to be as helpful as possible for our clients.  As Scott stated, but then seemed in danger of ignoring - "You must have a model and you must believe in it."  And as the famous social psychologist, Kurt Lewin, stated "There's nothing as practical as a good theory".  As a doctor & psychotherapist, I would extend this comment and say "It's really important to have a series of models, or theories, or lenses through which one can view a client's situation."  We're like tailors.  After carefully assessing what our client wants, what their hopes are, what their measurements are even, we can begin to explore together what "lenses", what ways of understanding their situation & the potential ways forward, are likely to both genuinely fit them and also meet their tastes & preferences.  We can have a choice of materials and ways of cutting our cloth, and in the end every client will measure somewhat or very differently, and will have somewhat or very different tastes & preferences.

The joy of this way of working is that it is likely to be both more effective and more satisfying.  More effective in that research study after research study has demonstrated the importance of the client feeling well listened to, well understood, and also genuinely  hopeful about how they now understand their situation and the potential way forward.  Meanwhile Orlinksy & Ronnestad, in their book "How psychotherapists develop", have shown a strong correlation between theoretical breadth and therapist healing involvement and job satisfaction. 

Scott contrasted what he called the widely accepted "Medical Model" of psychotherapy (with its emphasis on evidence-based practice) with his preferred "Contextual Model" (with an emphasis on practice-based evidence).  He suggested that the  Medical Model is characterised by a diagnosis-driven   

More to follow ...

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