Professional Documents
Culture Documents
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1
What Doesn’t Work:
The Medical Model Equation
Diagnosis
+
Prescriptive
Treatment
=
Cure or Symptom
Amelioration
© ©
2
Educate the People: You Are Sick
Mental Health Screening Test
3
Diagnostic Dys- Order Diagnoses Portray Clients
9Poor Reliability
9Unknown Validity
As Dim
9Does not predict LOS or outcome Witted
9Little help in treatment selection Plodders…
9Surveys consistently find that
therapists do not like it or find it
Or
useful…
useful…and attribution creep
Kirk, S.A., & Kutchins, H. (1992). The selling of DSM: The rhetoric of science in psychiatry. New York: Aldine
Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass.
4
•Since the 60’
60’s, the # of models The “Battle” of the Brands
has grown from 60 to over 400,
multiplying like…
like…
5
The Treatment of Depression Collaborative
Research Project (TDCRP) Project MATCH
The Results
The Design
•No difference in outcome between approaches:
•The client’
client’s rating of the alliance at the second •The largest study ever conducted on the treatment of
session the best predictor of outcome across problem drinking:
conditions. •Three different treatment approaches studied (CBT,
12-
12-step, and Motivational Interviewing).
•The psychotherapies (CBT, IPT) outperformed the drug
conditions on every single outcome measure: •Treatment administered at multiple sites to over
•Those in the drug condition sought more treatment, had 1700 participants.
higher probability of relapse, and had fewer weeks of •Used treatment manuals and adherence tests.
minimal or no symptoms.
Shea, M. et al. (1992). Course of depressive symptoms over follow up: The NIMH TDCRP. Archives © © Project MATCH Group (1997). Matching alcoholism treatment to client
of General Psychiatry, 49(10), 782-87. heterogeneity. Journal of Studies on Alcohol, 58, 7-29.
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The Wheel of Change:
Factors Accounting for Successful Outcome
If the engine works but has little to do
with its “bells and whistles,”
whistles,” what’
what’s
providing the power? 40.0%
Client/Extratherapeutic
Client/Extratherapeutic
Models/Techniques
Relationship
30.0%
15.0%
Placebo/Hope/Expectancy
© 15.0%
Hubble, M., Duncan, B., & Miller, S. (1999). The Heart and Soul of Change. Washington, D.C.:
APA Press
Meta-Analytic Research
Translating Research into Practice
Treatment:
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The Killer D’s of
Client Diminishment
• No formula here, more of an attitude What kind of person do these aspects describe? Or,
requiring a balance between listening What kind of person do these aspects show an
empathically with mindfulness toward aspiration toward?
resources that you know are there.
What are the qualities that others would describe in
you when you are at your very best? What were you
• Identify not what clients need, but what doing when they noticed these aspects?
they already have in their world that can
be put to use in reaching their goals What kind of person do these aspects describe? Or,
what kind of person do these aspects show an
aspiration toward?
8
Finding the Heroic Client (cont) Telling Heroic Stories
• Who was the first person to tell you that they • What are the obvious and hidden
noticed the best of you in action? What were you strengths, resources, resiliencies, and
doing when they noticed these aspects? competences contained in the client’s
story?
• Who was the last person to tell you that they
noticed the best of you in action? What were you
doing when they noticed these aspects? • What are the competing stories—the
stories of clarity, coping, endurance, and
• Who in your life wouldn’t be surprised to see you desire that exist simultaneously with the
stand up to these situations and prevail? What confusion, pain, suffering, and
experiences would they draw upon to make these desperation?
conclusions about you? What “quintessentially
you” stories would they tell?...Kim
• What is already there to be recruited for The Heroic Client
• When I am at my very best, I am _____________. change?
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Change in Treatment
The Unsung Heroes of Therapy
• The Client:
• Strengths, resources, culture,
world view, existing support
network.
• Chance events:
• Things that simply happen while
the person happens to be in
therapy…
therapy…
Source: Miller, S., Duncan, B., & Hubble, M (1997). Escape from Babel.
© © Source: Howard, et al (1986). The dose effect response in psychotherapy. American Psychologist,
New York: Norton. 41(2), 159-164.
•Those who attribute changes to their own efforts rather than •How can research showing
chance more likely to maintain gains regardless of the cause. the impact of chance events
Frank, J.D. (1976). Psychotherapy and the sense of mastery. In R.L. Spitzer et al. (eds). Evaluation of on the change process be
Psychotherapies. Baltimore, MD: Johns Hopkins.
Liberman, B. (1978). The maintenance and persistence of change. In J.D. Frank et al. (eds). Effective ingredients of
©
utilized?
effective psychotherapy. New York: Brunner Mazel.
©
10
Becoming Change Focused
11
Relationship Factors
The Therapeutic Alliance
The Therapeutic
Alliance:
•Relational Goals,
Bond Meaning
54% Means or
•Agreement on or Methods
goals Purpose
•Agreement on
tasks Client’
Client’s View of the
Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass
Therapeutic Relationship
12
Translating Research into Practice Translating Research into Practice
•Increasingly, the therapeutic
•How have traditional theories relationship is viewed as merely
and models minimized the role “setting the stage”
stage” for the “real”
real” or
of the alliance and client “active”
active” ingredients in treatment:
•Confronting distorted thoughts;
engagement? •Recovering forgotten memories;
•Asking special questions;
•How can research showing the •Tapping on or waving fingers in front of the
face.
importance of the therapeutic
•Research on the power of the
alliance and client engagement
alliance now reflected in over 1000
be utilized?
findings.
© Bachelor, A., & Horvath, A. (1999). The Therapeutic Relationship. In M. Hubble, B. Duncan, & S.
© Miller (eds.). The Heart and Soul of Change. Washington, D.C.: APA Press.
13
The Rubber Hose of Doubt and the Validation: Nuts and Bolts
Bright Light of Blame
• What are the invalidations contained in the
You are the problem! client’s story? How is he or she or others,
You are to blame! discounting or contradicting his or her
experiences? How are he or she or others blaming
him or her?
• What other factors have contributed to this
• Validation does not mean you should agree with
everything the client has done; simply means that situation or are extenuating variables? How can I
you acknowledge the rest of the story! place this situation in a context that justifies the
client’s behavior or feelings? How can I give the
client credit for trying to do the right thing?
• Puts the client’s actions in a context that legitimizes
him or her as a human being—explaining the • Format: No wonder you feel or behave this way
situation in a “big picture” way in which actions are (fill in with circumstance) given that (fill in the
part of a larger scenario involving many aspects. ways to justify client responses).
• Now what different conclusions are reached and
courses of action emerge?
• Clears a path for change because it diffuses self
doubt and dissipates self loathing…John
14
The Client’s Theory of Change:
The Therapeutic Alliance Empirical Findings
Client’
Client’s Theory of
Change In the TDCRP, congruence between
Goals,
the clients TOC and tx resulted in:
Meaning Means or 9Stronger therapeutic alliances;
or Methods 9Longer duration in treatment; and
Purpose
9Improved treatment outcomes.
Client’
Client’s View of the Elkin, I. (1999). “Patient-treatment fit" and early engagement in therapy. Psychotherapy Research. 9(4) 437-451.
Therapeutic Relationship
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A New Equation: A Relational One
Learning the Client’s Theory
•Explore the ways the client has attempted Client Resources and Resilience
Source: Duncan, B.L. & Miller, S.D. (2000). The Heroic Client. San Francisco:
Jossey-Bass.
• The Heroic
Ones
• The Lions of
Change
• The Superstars
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