Strengths-Based Therapy
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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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Strengths based therapy bob bertolino ph d associate professor maryville university sr clinical advisor youth in

Strengths-Based TherapyBob Bertolino, Ph.D.Associate Professor, Maryville University Sr. Clinical Advisor, Youth In Need, Inc. Sr. Associate, International Center for Clinical Excellence


Tidbits

Tidbits

  • 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

Where is Your Head?Recalibrating Our Compasses


Recalibrating our compasses

Recalibrating Our Compasses

  • 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

HHumanismOOptimismPPossibilitiesEExpectancy

“Optimism is the faith that leads to achievement.

Nothing can be done without hope or confidence.”

- Helen Keller


The evidence 40 years of data

The Evidence:40 Years of Data


What is evidence based practice

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

Research Resources

Key Questions

  • Whose data is it?

  • What kind of data is it?

  • Compared to what?


Three important questions

Three Important Questions

  • Does psychotherapy work?

  • How much have our outcomes improved over the past 30 years?

  • Which models work the best?


The evidence does psychotherapy work

The Evidence:Does Psychotherapy Work?

  • The average treated client is better off than 80% of the untreated sample (NNT)


Strengths based therapy bob bertolino ph d associate professor maryville university sr clinical advisor youth in

NNT

  • NNT = number of patients needed to be treated to attain one additional success versus the alternative


Strengths based therapy bob bertolino ph d associate professor maryville university sr clinical advisor youth in

NNT

  • NNT = number of patients needed to be treated to attain one additional success versus the alternative


The evidence does psychotherapy work1

The Evidence:Does Psychotherapy Work?

  • 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 co-morbidity)(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

The Evidence:How Much Have We Improved?

  • 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

How Much Have We Improved?

  • 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

The Search for the Best: Claims of Superiority & Relative Efficacy

  • 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

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 meta-analysis of direct comparisons. Clinical Psychology Review, 28, 746-758.

  • ALCOHOL ABUSE AND DEPENDENCE: All studies between 1960-2007

    • 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

The Search for the Best: Dismantling Studies

  • Specific ingredients are not needed to achieve a good outcome:

    • 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 in Psychotherapy?


Why haven t we improved

Why Haven’t We Improved?

Two further questions:

  • What factors have we held historically as most influential to therapy outcomes?

  • What accounts for the largest portion of variance between outcomes?


Factors that contribute little to therapy outcomes

Factors that Contribute Little to Therapy Outcomes

  • 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

What Accounts for the Largest Portion of Variance Between Outcomes? A Hint….


A hint the tdcrp

A Hint: The TDCRP

  • Treatment of depression – 250; 4 tx cond. – CBT, IPT, IMI, Placebo

  • CBT vs. IPT

    • Variance due to tx = 0%

    • Variance due to therapist = 8%

  • Actual practice

    • Type of tx = 0%

    • Dx, degree, experience = 0%

    • Medication = 1%

    • Therapist = 5%

    • Top ¾ vs. entire population – d = .75

  • Antidepressants vs. Placebo

    • Variance due to tx = 3%

    • Variance due to prescribing psychiatrist = 9%

    • Better psychiatrists had better outcomes with placebo than poorer psychiatrists who administered antidepressants


Strengths based therapy bob bertolino ph d associate professor maryville university sr clinical advisor youth in

YOU


Therapist effects the upside

Therapist Effects: The Upside

  • 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

How Do You Rate Yourself?

  • 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

  • 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

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:

    • No differences in how clinicians rated their overall skill level and effectiveness levels between disciplines

  • On average, clinicians rates themselves at the 80th percentile:

    • 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

How Do We Rate Ourselves? (cont.)

  • With regard to success rates:

    • 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?

    • 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 cont1

How Do We Rate Ourselves? (cont.)

  • In a study Hannan et al. (2005):

    • 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

Therapist Effects:The Downside

  • 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

Five Studies Large-Scale RCTs on Outcome Feedback

  • 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

Five Studies Large-Scale RCTs on Outcome Feedback: Findings

  • All five studies demonstrated significant gains for the feedback groups:

    • 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

Before You DoAnything Else4 Steps for Improving Clinical Effectiveness


4 steps for improving clinical effectiveness

4 Steps for Improving Clinical Effectiveness

  • Determine your baseline

  • Engage in formal, routine, and ongoing feedback

  • Employ strategies and processes demonstrated to strengthen alliances and improve outcomes

  • Engage in “deliberate practice”


Step 1 determine your baseline

Step #1Determine Your Baseline


Step 1 determine your baseline1

Step #1: Determine Your Baseline

  • Select an outcome measure that is valid, reliable, and feasible

    • 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

  • 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)

  • Have client complete measure at the beginning of session/meeting


The outcome rating scale ors

The Outcome Rating Scale (ORS)

  • 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

Sample Excel Spreadsheet


Calculating your effect size

Calculating Your Effect Size


Calculating your effect size1

Calculating Your Effect Size


Step 2 engage in formal routine and ongoing feedback

Step #2Engage in Formal, Routine, and Ongoing Feedback


Engaging in feedback

Engaging in Feedback

  • 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

APA Task Force:The Importance of Feedback

  • “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

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

Improving on Your Performance

  • Excellent performers judge their performance differently

    • 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

Further Studies onOutcome Feedback

  • 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

Recent Studies on Outcome Feedback: Key Findings

  • Miller et al. (2006):

    • 6400+ clients, 75 clinicians

    • Clients in feedback condition (therapist and client) improved by 65%

  • Anker, Duncan, & Sparks (2009):

    • 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:

      • TAU: 17%

      • Tx with feedback : 51%

      • Tx with feedback: 50% less separation/divorce at 1-year follow-up


Strengths based therapy bob bertolino ph d associate professor maryville university sr clinical advisor youth in

Step #3Employ Strategies and Processes Demonstrated to Strengthen and Alliances and Improve Outcomes


Psychotherapy common factors meta analysis

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

Variance in Psychotherapy Outcomes

Client/Extratherapeutic Factors – 87%

Treatment Effects – 13%

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


Strengths based therapy bob bertolino ph d associate professor maryville university sr clinical advisor youth in

Client/

Extratherapeutic

Factors

87%


Principles of change

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

Strengths-Based TherapyPrinciples of Clinical Effectiveness


A strengths focus

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

Strengths-Based Principles

Client Contributions

The Relationship and Alliance

Cultural Competence

Focus on Change

Expectancy and Hope

Factor of Fit


Strengths based principles1

Strengths-Based Principles

Client Contributions

  • 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

The Relationship & Alliance

  • 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

Strengths-Based Principles (cont.)

Cultural Competence

  • 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

  • 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 cont1

Strengths-Based Principles (cont.)

Expectancy and Hope

  • 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

  • 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 self-esteem, self-efficacy, and self-mastery


Strengths based principles in motion active client engagement

Strengths-Based Principles in MotionActive Client Engagement


5 point process

5-Point Process

  • 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

1. Create a Context of Collaboration

  • 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

2. Strengthen Through Presence

  • 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

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

Session Rating Scale (SRS)

  • 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

Strategies for Alliance Ruptures and Impasses

  • 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

Strategies for Alliance Ruptures and Impasses (cont.)

  • 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

3. Information-Gathering

  • 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

4. Focus on Change

  • 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

5. Evaluate and Monitor Progress, and Respond

  • 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

5. Evaluate and Monitor Progress, and Respond (cont.)

  • Respond to alliance ruptures

  • Modify intensity of services based on feedback of client and experience as clinician


Step 4 engage in deliberate practice

Step #4Engage in “Deliberate Practice”


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

Deliberate Practice Includes

  • 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 highly effective clinicians

Deliberate Practice of Highly-Effective Clinicians

  • 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 highly effective clinicians cont

Deliberate Practices of Highly-Effective Clinicians (cont.)

  • 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


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