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Barry Duncan on The Heart and Soul of Change
Filed Under: Advanced Clinical Skills, Clinical Efficacy
In This Interview…
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Lawrence Rubin: You’ve dedicated your professional career to improving clinical outcomes and effectiveness at the individual and organization level with the Partners for Change Outcome Management System (PCOMS). Can you tell us what this is and why you think it’s so important for optimizing clinical outcome?
Barry Duncan: It’s really a very simple idea that fortunately has had a great return on investment. The idea is simply that you monitor outcome with clients and you identify those consumers who are benefiting from whatever treatment or service that you’re providing to them. You then put your heads together with those clients that aren’t benefiting, collaboratively deciding what to do next and based on the information of their lack of benefit, create a new treatment plan. Try a different venue of service.
Try everything at your disposal that meets the client’s resources and needs and your own areas of expertise and limitations
Try everything at your disposal that meets the client’s resources and needs and your own areas of expertise and limitations. And ultimately, maybe give them to a different provider if you’re not able to get things back on track. So, it is a process of monitoring clients’ response to treatment, and then using that feedback to determine the way the treatment is delivered. So, if it’s working, you rock and roll, keep doing what you’re doing. If it’s not, then you figure out what else to do. That prevents dropouts, and by recapturing those clients who would otherwise not have benefited, you can improve your outcomes quite substantially.LR: In the truest sense of the word, and perhaps invoking Carl Rogers, it is truly client centered, for together with them we become partners for change.
BD: That’s exactly it. And that’s the part that the field is a little slower to come around on. The idea of routine outcome monitoring is generally thought of as a therapist-driven process. You know, we monitor outcome and then we get our expert information, we figure out what else to do with people. PCOMS is client directed. We get the information collaboratively from clients and then together, we figure out what to do next based on their reaction to the treatment being administered, their reaction to the services, their experience of the alliance. From there, we can formulate a better path for them if they’re not benefiting from our therapeutic business as usual.
LR: So, your approach to working with clients is really trans-theoretical and trans-methodological. A clinician can bring in their own pet therapy as long as they listen to the client as to how that therapy is working.
BD: That’s exactly it. So, do what you do that works best for you and your clients until you have direct evidence from the client that they’re not responding to that, your business as usual, and then, with that, you can move on and try other things. This also happens to be a great way to grow as a therapist in that you don’t always do what you’ve always done, you step outside your comfort zone and do things you’ve never done with people before, and therefore grow and expand your own repertoire of interpersonal relationship and technical therapy skills.
LR: Didn’t Einstein have something to say about doing the same thing over and over again and expecting different results?
BD: It doesn’t make sense to continue doing the same thing in the absence of response from the client. And we only know if our treatment is working if the client says so, if they are monitoring their benefit and reporting that on outcome measures. We haven’t been very good in our field at changing tracks. When treatment fails, therapists are quick to attribute it to client pathology or resistance. Only later do they consider perhaps that “I’m not competent enough to deal with this person.” So, first, we shoot the client, and then the therapist, right? But we don’t want to shoot anybody actually; we just want to alter the treatment to better fit what the client will respond to.
LR: Why are therapists so entrenched or in love with their models and techniques? What makes it so difficult for them to say, “This isn’t working. I need to change?”
BD: Our field has had a long love affair with models and techniques. I mean, we’re really enamored of them.
That makes it very difficult to say that it’s not the client, it’s actually the method that I’m using, and can we find another thing that’s a better fit? It is very hard to let that sense of certainty go, leaving us with the existential angst. It’s like, “Well, if I don’t have these certainties to hold onto, I’m in the abyss of uncertainty when I’m with clients and I won’t know what to do next.” So, the models give structure and focus to the work, and help us manage our own anxiety when we’re in the room with somebody in a lot of distress.
We also have to acknowledge that there’s no conceivable way that every client will respond to a model and technique that we’re using. If that were the case, we’d all use the same one with everybody that walked in the door. In reality, it’s a far more interactive and changing process that we engage in with clients as we try to figure out what will work best with them.
We begin to believe that our models represent truths about human beings, rather than being metaphorical representations of how people can change
We begin to believe that our models represent truths about human beings, rather than being metaphorical representations of how people can change. We just over-attributed the truth value to all these different ways of thinking about things, and some fit our own view of how people really are, our own view of ourselves, and we hold those close and dear.That makes it very difficult to say that it’s not the client, it’s actually the method that I’m using, and can we find another thing that’s a better fit? It is very hard to let that sense of certainty go, leaving us with the existential angst. It’s like, “Well, if I don’t have these certainties to hold onto, I’m in the abyss of uncertainty when I’m with clients and I won’t know what to do next.” So, the models give structure and focus to the work, and help us manage our own anxiety when we’re in the room with somebody in a lot of distress.
We also have to acknowledge that there’s no conceivable way that every client will respond to a model and technique that we’re using. If that were the case, we’d all use the same one with everybody that walked in the door. In reality, it’s a far more interactive and changing process that we engage in with clients as we try to figure out what will work best with them.
LR: Ironic isn’t it, that on top of this inflexibility, your research strongly suggests that therapeutic technique accounts for only a very minor portion of treatment outcome. Yet still we cleave! May we shift here to a discussion of your remedy for this dilemma which is routine outcome monitoring and use of rating scales like the ORS and SRS?
BD: I’ll start with the Outcome Rating Scale (ORS). It is a four-item analog scale that asks the client how they’re doing in the major areas or domains of their life: individually, their personal wellbeing; interpersonally, how things are going in their close family relationships; socially, how things are going with them outside of the family in the social world at work, school and with friendships; and finally how they are doing overall in their life. The client puts a mark on each of the four 10-centimeter scales. This results in four individual scores and a total score between zero and 40. It takes about 20 seconds to do.
The Session Rating Scale (SRS) is a classic alliance scale built on the major ways of looking at the therapeutic alliance. In fact, it’s built on Borden’s classic view of the alliance, which is the relational bond, the Rogerian triad variables, the degree of agreement with the client about the goals of therapy and then how you’re going to accomplish the goals of therapy. So, it’s a quick check with that. We do the ORS at the beginning of the session. We do the SRS with about five minutes to go in the session to check with them. In essence, we are asking the client, “how is this for you here today?” This way, we can alter our approach if it didn’t go well or there’s something else they want to make sure that we do.
My own style is to do a wrap-up of the session and a take-home message. I ask the client if they have a take home message from the session, and then I give the SRS to check in with them about their experience of the session, with the idea being that
What clients do, amazingly, is that they imbue their life and their life experience on those four little lines of the scale
What clients do, amazingly, is that they imbue their life and their life experience on those four little lines of the scale, and whatever presenting concern they have, they represent that by the scale they mark the lowest. So, if they’re struggling with anxiety or depression, they’ll usually reflect that on the individual scale. If they’re having a relational problem with a kid or a partner, they’ll reflect that, and so on. And so, it goes from this general view of how life is going to a specific representation of what they’re doing in therapy. And at that point, then, it becomes a valid measure of therapy’s progress.The Session Rating Scale (SRS) is a classic alliance scale built on the major ways of looking at the therapeutic alliance. In fact, it’s built on Borden’s classic view of the alliance, which is the relational bond, the Rogerian triad variables, the degree of agreement with the client about the goals of therapy and then how you’re going to accomplish the goals of therapy. So, it’s a quick check with that. We do the ORS at the beginning of the session. We do the SRS with about five minutes to go in the session to check with them. In essence, we are asking the client, “how is this for you here today?” This way, we can alter our approach if it didn’t go well or there’s something else they want to make sure that we do.
My own style is to do a wrap-up of the session and a take-home message. I ask the client if they have a take home message from the session, and then I give the SRS to check in with them about their experience of the session, with the idea being that
I’m building the alliance, not just giving lip service to it. I am very interested in their experience
I’m building the alliance, not just giving lip service to it. I am very interested in their experience. LR: Are these measures a hard sell to clients?
BD: It is not a hard sell at all. First of all, they only take about 20 seconds to fill out, and so it’s not a big investment of time or energy. And it’s all in how you present it to clients. If you’re flicking forms and not using the information, clients are going to get tired of it in a hurry, but if it’s integrated into the therapy that you’re doing, and it makes some sense and they see the benefit of it, then it’s not a hard sell at all. I simply say, “Look, I like to work and use these two very brief forms. The first one is the ORS, and this is a way to ensure that your voice remains central to everything that we do here, that your view of whether your benefiting is going to actually direct what we do in our sessions. And second, it’s going to be the way that you and I can collaboratively look at whether you’re benefiting, and if you’re not, you and I will put our heads together and figure out what else to do.”
LR: I would imagine most good therapists implicitly incorporate some sort of client feedback into therapy. Is there a real difference between those who implicitly check in with their client and those who use standardized measures such as these?
BD: The other advantage is that you have this incredible data that lets you know your effectiveness, so you can then strive to get better and do things to improve yourself over time. You can actually monitor your career development as a therapist and know whether the strategies that you are implementing, the new things you’re learning, are actually improving outcomes. Also, when you have data, then you have your client list, you can look at your client list, and of course, that’s what software does for you. You know, you have a client list and you can look at a glance and see who the clients are who aren’t benefiting so that you can reflect more about them, talk to a colleague, talk to a supervisor before you see them again. And we found just that process alone, to be more reflective about what you’re doing, improves outcomes, improves effectiveness.
LR: And that’s really where psychology is attempting to go; in the direction of a science-based and empirical-based foundation for what some have otherwise called soft science or an art. I’d be remiss if I didn’t ask you to tell us what PCOMS is. We’ve been talking around it?
BD: PCOMS is the Partners for Change Outcome Management System, the title for which came from the book, Heroic Clients, Heroic Agencies: Partners for Change that Jacqueline Sparks and I wrote. We conceptualized the whole therapy process as working together with clients as partners for change. PCOMS brings this partnership process to routine outcome monitoring using the SRS and ORS to solicit the client’s response to therapy and their experience of therapy through the alliance measure. I co-developed the measures with Scott Miller and then developed the process of using them clinically in what would become the EBP of PCOMS. Jackie and I wrote the first PCOMS manual.
I thought it was a great idea to check in with clients more formally, and I wanted to get therapists to talk to clients about outcome and the alliance. Then, we started doing the research to validate the measures and not only were these short, feasible and easy to do, but they were also reliable and valid when compared against much longer measures like the OQ45, Michael Lambert’s gold standard outcome questionnaire. And then, finally, I was able to say, “Well, gosh, I think this really works. Let’s do the language of science. Let’s do a randomized clinical trial.” And
We next expanded our research populations and implemented the PCOMS in many large organizations. My own main work has been in public behavioral health, so I really wanted to apply it to clients who are often get the short end of the stick. We’ve shown that use of the system improves outcomes in real-world settings where we can achieve outcomes comparable to those achieved in randomized clinical trials. The final step in the evolution of these ideas is performing RCT’s in integrative care, and then making it even easier through technology. We launched a web version of PCOMS called Better Outcomes Now, which allows the whole process to be automated, easy and very visually appealing to clients.
I thought it was a great idea to check in with clients more formally, and I wanted to get therapists to talk to clients about outcome and the alliance. Then, we started doing the research to validate the measures and not only were these short, feasible and easy to do, but they were also reliable and valid when compared against much longer measures like the OQ45, Michael Lambert’s gold standard outcome questionnaire. And then, finally, I was able to say, “Well, gosh, I think this really works. Let’s do the language of science. Let’s do a randomized clinical trial.” And
with my colleagues, Morten Anker and Jacqueline Sparks, we did the first RCT of PCOMS. And since then, we’ve done seven more that have shown the increase in benefit
with my colleagues, Morten Anker and Jacqueline Sparks, we did the first RCT of PCOMS. And since then, we’ve done seven more that have shown the increase in benefit.We next expanded our research populations and implemented the PCOMS in many large organizations. My own main work has been in public behavioral health, so I really wanted to apply it to clients who are often get the short end of the stick. We’ve shown that use of the system improves outcomes in real-world settings where we can achieve outcomes comparable to those achieved in randomized clinical trials. The final step in the evolution of these ideas is performing RCT’s in integrative care, and then making it even easier through technology. We launched a web version of PCOMS called Better Outcomes Now, which allows the whole process to be automated, easy and very visually appealing to clients.
LR: Because I’m a child clinician, I wonder what challenges you’ve had using your system with kids, considering their developmental differences.
BD: Great question. There are, obviously, developmental differences, and we have implemented with kids since the very beginning. You know, I did family therapy and seeing children has been a part of my own development as a clinician, and so I wanted to develop measures right away that would apply to kids. Soon after the ORS and SRS were developed, Jacqueline Sparks and I applied these measures to children ages six to twelve. In fact,
By the time a child is nine, they pretty much can make that connection, so you have to use your own judgment. That’s why we always also want to have the parents’ view of how the child is doing. On the research side, we just published an RCT that we did in the UK with Mick Cooper with children under 11 years of age, which demonstrated a very similar feedback effect using the Strength and Difficulties Questionnaire, which is a mandatory measure in the UK.
the child outcome rating scale is the first self-rated outcome measure for children six to twelve in the world
the child outcome rating scale is the first self-rated outcome measure for children six to twelve in the world, because previously, only parents were rating children that young. When you have a child in therapy, it’s always a good idea to get a parent view or an adult view of how the child is doing, as well, just for the reasons that you speak to. While we validated the measure for six-year-olds, that doesn’t necessarily mean they all get it. They have difficulty connecting the dots between what is talked about and what happens in therapy, and what’s going on in their life from session to session.By the time a child is nine, they pretty much can make that connection, so you have to use your own judgment. That’s why we always also want to have the parents’ view of how the child is doing. On the research side, we just published an RCT that we did in the UK with Mick Cooper with children under 11 years of age, which demonstrated a very similar feedback effect using the Strength and Difficulties Questionnaire, which is a mandatory measure in the UK.
LR: Am I correct in assuming that with kids, you would use pictures on the SRS rather than words, per se?
BD: First of all, the child versions of these measures are in eight-year-old language, and there are faces. There are happy faces and frowns that give an orientation to the child. It’s basically, “How did it go for you today? Did you like what we did? How are things in your family? How are things at school?” So, it really puts it in a way that children can understand. I think it’s been very nice to do with kids, because kids can be very lost in the shuffle and not have a voice.
I think a good therapist will make sure that children have a voice in therapy, but this systematizes the process
I think a good therapist will make sure that children have a voice in therapy, but this systematizes the process. And whether the measures are valid, I’m still going to use it to check in with the kid.LR: For the connection.
BD: Yes.
LR: I’m wondering if the PCOMS has been effectively used with families? Are you actually going to give out the SRS and the ORS to six family members in the room, or is that sort of an insurmountable challenge?
BD: It’s not an insurmountable challenge. Actually, it works quite well with families. The more people you get in the room, the greater the logistical challenge, so you’ve got to use it wisely. For example, if I have five people in the room, and the kid is presented as a problem, I’m going to do only the key people. I’ll have everybody do it, but the only data I’ll record will probably be the kid or the main parent that’s there, or both parents, if they’re there. If I also have grandma and a pastor, I’m certainly going to include them in the conversation and get their viewpoints, but the data points will be the parent(s) and the kid.
And you know, in this day and age you can have two iPads in the room for filling out the scales. Twenty seconds each and I’m rocking and rolling. I can put all their scores on the same graph and talk about it in that way. It quickly cuts to the chase with families. I really like that about it, so I’ve used it with families since the very beginning. I know who is seeing the problem the most, who is seeing it the least, what the differences are, and I have them explain those differences to me right at the top of the hour.
And you know, in this day and age you can have two iPads in the room for filling out the scales. Twenty seconds each and I’m rocking and rolling. I can put all their scores on the same graph and talk about it in that way. It quickly cuts to the chase with families. I really like that about it, so I’ve used it with families since the very beginning. I know who is seeing the problem the most, who is seeing it the least, what the differences are, and I have them explain those differences to me right at the top of the hour.
LR: I can see therapists believing that they can easily use the PCOMS measures without training. What do you say to them?
BD: I would encourage them by saying, “I’m glad you’re really interested in this and you’re seeing the benefit this could bring to your practice. So, I would just ask you to invest a very small amount of time. For example, you know, on our website, betteroutcomesnow.com, there are 250 free resources. There are 20-minute webinars about every aspect of doing PCOM, so with very little time investment you can access a whole curriculum of reading and watching free videos about how you might do this.” So, I think it’s quite possible for a thoughtful therapist to implement this just with the available resources.
LR: You’ve mentioned, and I’ve read in your work, that you’ve applied the PCOMS at the institutional level in community mental health centers and hospital settings. And I know documentation is critically important on that end of it. What challenges and benefits have you seen in this facet of your work?
BD: There’s almost always, at the very least, institutional apathy, if not resistance. Because the way therapists are in institutions tends to be “Oh, now, gosh, here’s the new paradigm shift. The next one will be five days from now. Let me just hunker down, the storm will pass, and we’ll go back to business as usual here.” One thing that’s helped is that the three main accrediting bodies now require client generated outcome data.
LR: Yours or just in general?
BD: In general. We’re one of the approved ones, but nevertheless, it’s required now, and people are coming to grips. If they’re going to be re-accredited or accredited by COA (Council on Accreditation) or JCAHO (Joint Commission on Accreditation of Healthcare Organizations), they’re going to have to face this. So, that’s the wakeup call to a lot of places which is making them move. However,
Let’s say you implemented another evidence-based practice like functional family therapy for your kids who have been adjudicated. So, you spend the money, you get the training, you implement it. You’ll know whether that was or wasn’t money well spent because you’re collecting data on every client that comes in the system. So, besides the benefit of looking at your supervisory practice, identifying at-risk clients and looking at programs to address the needs of people who aren’t benefiting, you can track each program to see which ones are really doing the job for you and which ones are not. And again, not to be punitive about that, but to learn from that data what else you can do to improve your outcomes. The largest public behavioral health venue in Arizona, Southwest Behavioral Health, was an early adapter of PCOMS. By collecting and analyzing data, they have been able to raise the bar of their performance in all their programs, including their inpatient units. So, there are institutional benefits, but it’s not for the faint of heart to implement this. You’ve got to be in it for the long haul. You’ve got to think this whole process through.
if an organization’s mission is to put consumers first, outcome monitoring allows for an operationalization of that mission in a very real way
if an organization’s mission is to put consumers first, outcome monitoring allows for an operationalization of that mission in a very real way. That’s an institutional benefit. As a quality improvement or quality assurance initiative, this allows the organization to know whether any of their initiatives are actually working—the beauty of data. You can know at the individual provider level, you can know at the program level, you can know at the location level.Let’s say you implemented another evidence-based practice like functional family therapy for your kids who have been adjudicated. So, you spend the money, you get the training, you implement it. You’ll know whether that was or wasn’t money well spent because you’re collecting data on every client that comes in the system. So, besides the benefit of looking at your supervisory practice, identifying at-risk clients and looking at programs to address the needs of people who aren’t benefiting, you can track each program to see which ones are really doing the job for you and which ones are not. And again, not to be punitive about that, but to learn from that data what else you can do to improve your outcomes. The largest public behavioral health venue in Arizona, Southwest Behavioral Health, was an early adapter of PCOMS. By collecting and analyzing data, they have been able to raise the bar of their performance in all their programs, including their inpatient units. So, there are institutional benefits, but it’s not for the faint of heart to implement this. You’ve got to be in it for the long haul. You’ve got to think this whole process through.
LR: We began by discussing the PCOMS, its use in the individual consulting room and then its use at the institutional level. I’d like to drop back to the level of the client/therapist relationship and ask about the so-called “heroic client” you discussed in your book of the same title.
BD: I coined the name of that book, like I did The Heart and Soul of Change. Titles are important and in guiding readers. For too long, we’ve thought of the client as this helpless victim of their own psychopathology. But what if we think about clients in terms of what they’ve endured, what they’ve accomplished, what they’ve overcome.
We’re a useful component of change in that story, but it’s not us making those changes, so I just wanted to shift that. The notion of the heroic client is really borne out by the literature which says that the client and their life factors account for the majority of the variance of change in psychotherapy. If look at how change happens—at meta-analytic views of psychotherapy change, about 86% of it is due to the client. If we discard them in the process, or only see the more negative sides of who they are, we are really starting out with two strikes against us in terms of how change happens. In fact, we are embarking on a new, edited book process about the common factors, and one of the themes of the book is that you should spend your time in therapy commensurate to the amount of variance that the different factors account for.
Since client variables account for 86% of outcome, you probably ought to be spending most of your time harvesting, recruiting, activating clients’ resources, strengths and resiliencies. You’ve got to spend a fair amount of time doing that because clients walk in with a lot already to contribute to the process of change.
The metaphor of the heroic client was a way of shifting our thinking about therapists riding in on this white horse of theoretical purity and brandishing the sword of evidence-based treatment to slay those psychic dragons that terrorize them
The metaphor of the heroic client was a way of shifting our thinking about therapists riding in on this white horse of theoretical purity and brandishing the sword of evidence-based treatment to slay those psychic dragons that terrorize them. It’s their story of transformation, not ours.We’re a useful component of change in that story, but it’s not us making those changes, so I just wanted to shift that. The notion of the heroic client is really borne out by the literature which says that the client and their life factors account for the majority of the variance of change in psychotherapy. If look at how change happens—at meta-analytic views of psychotherapy change, about 86% of it is due to the client. If we discard them in the process, or only see the more negative sides of who they are, we are really starting out with two strikes against us in terms of how change happens. In fact, we are embarking on a new, edited book process about the common factors, and one of the themes of the book is that you should spend your time in therapy commensurate to the amount of variance that the different factors account for.
Since client variables account for 86% of outcome, you probably ought to be spending most of your time harvesting, recruiting, activating clients’ resources, strengths and resiliencies. You’ve got to spend a fair amount of time doing that because clients walk in with a lot already to contribute to the process of change.
I call it soliciting these heroic stories, because where there’s pain, there’s endurance; where there’s suffering, there’s coping and where there’s destitution, there’s desire for something different
I call it soliciting these heroic stories, because where there’s pain, there’s endurance; where there’s suffering, there’s coping and where there’s destitution, there’s desire for something different. Those are the sides of the story I want to come out in my interview with a client, these more heroic aspects of who they are. Doing this doesn’t invalidate the struggles that they’re having, but it also puts it next to the other things about them that could be utilized to deal with the struggles they’re having, if that makes sense.LR: It reminds me very much of some of the basic tenets of narrative therapy and solution focused brief therapy in that it’s really the therapist’s obligation to dig into the life of their clients to find evidence of strength and resilience. You know, it’s interesting. Patch Adams said that if you treat a disease, you win or you lose, but if you treat a patient, you win, regardless of outcome.
BD: It is a real shift, and as you mentioned, there are approaches that line themselves up with that shift, like narrative and solution focused views, and positive psychology as well. The Heart and Soul of Change books have been best sellers because people like the idea. I wrote an article in 1994, published in Psychotherapy and with Dorothy Monaghan, who was a student of mine at the time, about the clients’ frame of reference guiding psychotherapy.
I had been publishing for almost 10 years at that time, but I got more requests for reprints from that article than all the other articles I’d written. I got almost 1,400 of them for that article. So, the idea of the common factors and actually operationalizing them, what that actually means in therapy, really resonated with a lot of people. So, of course, then that led into “The Heart and Soul” and all that business, so I think there are a lot of people out there that these ideas resonate with, and that speaks to this shift and the way that psychotherapy is thought of as a far more collaborative, client-directed process.
I had been publishing for almost 10 years at that time, but I got more requests for reprints from that article than all the other articles I’d written. I got almost 1,400 of them for that article. So, the idea of the common factors and actually operationalizing them, what that actually means in therapy, really resonated with a lot of people. So, of course, then that led into “The Heart and Soul” and all that business, so I think there are a lot of people out there that these ideas resonate with, and that speaks to this shift and the way that psychotherapy is thought of as a far more collaborative, client-directed process.
LR: In therapy, we try to teach clients, if i may evoke John Bradshaw, how to move from the perspective of human doings to human beings. In your model, we’re asking therapists to do the same, “Don’t be a therapist, don’t be someone doing therapy. Be someone in a caring, monitored relationship with a client, with whom you’re not central, but influential.” It’s almost liberating for the therapist.
BD: I think that is liberating, for sure, and I think that in the course of training, younger clinicians really get that. They like the liberation that flows from the idea that “we’re in this thing together. It’s not solely my responsibility. I don’t want to have to figure everything out, we can come to some terms about what change means.” The measure then provides some structure to that process about how you know whether the client is benefiting and how is the client experiencing their time with me so that I can alter that. So, in that way it does free you from having to know the right way to be a therapist, as if there is some golden right way to be or right method to use. We’ve been in search of that holy grail throughout our history as a field, but it’s not been very fruitful considering all the different models and techniques.
At last “count”, I think it was up around 400 different models and techniques, and still no holy grail yet
At last “count”, I think it was up around 400 different models and techniques, and still no holy grail yet.LR: Why do you think the field is so hell-bent on finding the holy grail? Is that taking us away from the true holy grail, which is the relationship with the client?
BD: People are so dismissive of the relationship, it drives me crazy. It’s my biggest irk with the field, that people think that, “Oh, you form a relationship and then you do the real treatment.” It’s like it’s anesthesia before surgery, right? We dumb the client down with our Rogerian reflections until they’re asleep, and then we kind of on the sly stick it to them, right? It’s crazy, because you could make a much stronger empirical case that the relationship alliance is the therapy, right? That’s the continuum for everything to happen, all the exploration, and it’s not easy to experience with everybody that you see. You have to work at it. I used to love it when someone would come in and we’d hit it off great, we got down to what we needed to be doing really quickly, but then there’s everybody else. It’s the same with those people who are not so sure about therapy or they don’t want to invest, or they’re mandated, or they haven’t ever been in a good relationship, or they’ve been screwed over so many times. My job is still the same. I’ve got to form a relationship with that person, and it’s not easy. It’s a daunting task. It’s not something I do just because I’m a nice guy. So, it’s those things that are real misconceptions about the change process and the skill it takes to form strong alliances with the varied amount of people that we see.
LR: I can’t tell you how many times I hear from interns, “Okay, I built rapport. Now what do I do?” It’s just amazing.
BD: It’s such a simple idea of just asking the client, what do you think, do you have any ideas? A lot of people have ideas about how things started with their struggles, and perhaps even ideas about what would make it any better? You know, I call it the client’s theory of change, and it’s a great alliance building tool, and a way to dig into their own viewpoint. And you know, what I find is clients have very good ideas. Not all the time, but most of the time. These are worthwhile questions to ask. And you know, what do I do next? Well, what does the client think about that? That’s my broken record in the situation. What does the client say? Then you talk to them about them not benefiting. What are their ideas about that? That’s what you’ve got to do, have a dialogue about this.
LR: What would you offer to the readers who are not really tuned into this whole evidence-based relationship gig yet, or who are not even aware of the value of client-driven informed therapy. What would you offer as closing words?
BD: My closing words to them would be, take a step back and think about the way that they are a therapist, and what their identity is as a therapist, and who they aspire to be as a therapist. And that it is a relational process more so than any other way that you can describe it.
That would be the way they can improve. In fact, my recipe for improvement is to focus on harvesting client resources, abilities, and the therapist’s alliance and relational abilities. And the way that you can get at both of those things is to monitor outcomes in the alliance with clients. It’s long-winded advice, but nevertheless, that’s how people can get going. And there’s lots of free stuff to help them do that. Very brief videos to help getting their thinking process going about all those things on the website I mentioned.
Therapy is not a biomedical process, it’s not diagnosis plus prescription equals cure
Therapy is not a biomedical process, it’s not diagnosis plus prescription equals cure. That’s not what we do. It’s a relational process. The main things that account for outcome in psychotherapy are the people involved, the client, the therapist and their relationship. These account for the overwhelming majority of outcome variance, so they should focus on those aspects, harvesting the client, you know, monitoring their own outcomes and improving themselves in that way, and then putting their efforts into getting better at their relational repertoire.That would be the way they can improve. In fact, my recipe for improvement is to focus on harvesting client resources, abilities, and the therapist’s alliance and relational abilities. And the way that you can get at both of those things is to monitor outcomes in the alliance with clients. It’s long-winded advice, but nevertheless, that’s how people can get going. And there’s lots of free stuff to help them do that. Very brief videos to help getting their thinking process going about all those things on the website I mentioned.
LR: As you make these concluding comments, I think of medical practice, and it seems that doctors have this built in magic by virtue of their tools, medicines, techniques and machines. I wonder if medicine could be better oriented if it moved in the direction of outcome monitoring, patient collaboration and relationship building.
BD: I think this would be a very nice fit into the primary care world, and in fact, a colleague and I, Bob Bohanske, developed and validated primary care measures analogous to the PCOMS. The next step will be an RCT, and so they’re patient-guided quality of life measures. We believe that if patients improve the quality of their life with treatment, then that will translate to biomedical markers. The physician checking in to ensure that their intervention is what the patient is looking for—the part of their life they’re most distressed about, and then checking in with them that it was indeed a collaborative process, we think will have an impact on chronic illness outcomes.
LR: This seems to be a necessary next step; taking all that you’ve learned from psychotherapeutic relationships to medical relationships and treatment.
BD: Absolutely.
LR: I want to thank you Barry, for the voluminous amount of time and research you put into developing PCOMS, the contributions you have made to the field and for sharing your time today.
BD: Great, great. No, Larry, thanks very much. I enjoyed it. My pleasure, totally.
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*Not approved for CE by Association of Social Work Boards (ASWB)
- Explain the value of routine outcome monitoring in psychotherapy
- Describe the use of the outcome and session rating scales in treatment
- Discuss the use of outcome monitoring at the institutional level
Barry Duncan, PsyD is a psychologist, trainer and researcher with over 17,000 hours of clinical experience. He is the developer of the clinical process of the evidence-based practice, the Partners for Change Outcome Management System (PCOMS), and leader of the team responsible for PCOMS scientific credibility and evidence based status. Because of the research conducted by Duncan and colleagues, PCOMS is included in the Substance Abuse and Mental Health Services Administration's National Registry of Evidence-based Programs and Practices (NREPP). Better Outcomes Now, the web application of PCOMS, brings his clinical experience and investigative spirit to life. Barry has over one hundred publications, including 17 books addressing client feedback, consumer rights, and the power of relationship in any change endeavor. Because of his self-help books (the latest is What’s Right with You), he has appeared on Oprah, The View, and several other national TV programs. Barry travels nationally and internationally lecturing and implementing PCOMS in small and large systems of behavioral health care. PCOMS is used in all fifty states and in at least 20 countries. The largest public behavioral health agencies in 6 states have implemented or are implementing PCOMS, as well as hundreds of other public and private mental health and substance abuse organizations. Separate from the agencies, there are over 30,000 individually registered users of PCOMS. Internationally, the Norway Health Directorate has implemented PCOMS across its couple and family centers and PCOMS is an integral component of Nasjonal Competansetjeneste TSB (National Competence Center for Substance Abuse Treatment). In Canada, among many implementations, the largest is provincial implementation by the Saskatchewan Health Authority. Finally, New Zealand has incorporated PCOMS into its national policy on outcome management, a consequence of his consultations there. Drawing upon his extensive clinical experience and passion for the work as well as his now 16 years of PCOMS implementations, Barry's trainings speak directly to both front line clinicians and administrators. He talks about what it means to do this work 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 Duncan was compensated for his/her/their contribution. None of his/her/their books or additional offerings are required for any of the Psychotherapy.net content. Should such materials be references, it is as an additional resource.
Psychotherapy.net defines ineligible companies as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. There is no minimum financial threshold; individuals must disclose all financial relationships, regardless of the amount, with ineligible companies. We ask that all contributors disclose any and all financial relationships they have with any ineligible companies whether the individual views them as relevant to the education or not.
Additionally, there is no commercial support for this activity. None of the planners or any employee at Psychotherapy.net who has worked on this educational activity has relevant financial relationship(s) to disclose with ineligible companies.
Lawrence ‘Larry’ Rubin, PhD, ABPP, is a Florida licensed psychologist, and registered play therapist. He currently teaches in the doctoral program in Psychology at Nova Southeastern University and retired Professor of Counselor Education at St. Thomas University. A board-certified diplomate in clinical child and adolescent psychology, he has published numerous book chapters and edited volumes in psychotherapy and popular culture including the Handbook of Medical Play Therapy and Child Life: Interventions in Clinical and Medical Settings and Diagnosis and Treatment Planning Skills: A Popular Culture Casebook Approach. Larry is the editor at Psychotherapy.net.
Lawrence Rubin was compensated for his/her/their contribution. None of his/her/their books or additional offerings are required for any of the Psychotherapy.net content. Should such materials be references, it is as an additional resource.
Psychotherapy.net defines ineligible companies as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. There is no minimum financial threshold; individuals must disclose all financial relationships, regardless of the amount, with ineligible companies. We ask that all contributors disclose any and all financial relationships they have with any ineligible companies whether the individual views them as relevant to the education or not.
Additionally, there is no commercial support for this activity. None of the planners or any employee at Psychotherapy.net who has worked on this educational activity has relevant financial relationship(s) to disclose with ineligible companies.
CE credits: 1
Learning Objectives:
- Explain the value of routine outcome monitoring in psychotherapy
- Describe the use of the outcome and session rating scales in treatment
- Discuss the use of outcome monitoring at the institutional level
Articles are not approved by Association of Social Work Boards (ASWB) for CE. See complete list of CE approvals here
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Psychotherapy.net offers trainings for cost but has no financial or other relationships to disclose.