NP007 The Road to Clinical Excellence

This blog focuses on discussion regarding the course NP007 The Road to Clinical Excellence.

NP007, Excellence, Session 3, Barry Duncan


What is the most important key to improving as a therapist? How can we radically and consistently improve our effectiveness as clinicians? Get the answers to these questions and more in session 3 of The Road to Clinical Excellence with Barry Duncan.

He’ll go over ways in which we can improve as therapists, including what more than 1,000 studies have taught us about the science of the therapeutic alliance. You’ll learn what “healing involvement” is and how to achieve it with any client and how you’ll come away with a much better understanding of why outcome measurement is essential to improvement.

As always, we encourage you to take a few minutes after the session to comment—what was new, or most interesting to you about this session? What questions do you have or relevant experiences to share? And as always, if you ever have any technical questions, just email support@psychnetworker.org!

07.18.2011   Posted In: NP007 The Road to Clinical Excellence   By Psychotherapy Networker
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  • Not available avatar M 07.26.2011 13:32
    Thanks Barry - I don't have anything clever to say, simply how much I enjoyed the session. Just beginning as a therapist, and wishful to start as I mean to go on, so really value wisdom of experience when I find it to be meaningful. Now zooming off to explore the Heart & Soul of Change Project site. Thanks again and take care, Magda.
    • Not available avatar Barry Duncan 07.30.2011 14:27
      Hi Magda,
      Thanks for the feedback. Glad you enjoyed the session. Hope you find the site useful.
  • 0 avatar Valerie Feeley 07.26.2011 16:10
    I had downloaded the SRS and ORS but didn't get how to use it until today - I'm excited to get started using these tools to help me improve.
    • Not available avatar Barry Duncan 07.30.2011 14:28
      Hi Valerie,
      Yes, there is much more to it than meets the eye, some real nuance to getting the max out of them. Glad today helped. Check out the resource page for more info about how to use the measures.
  • 0 avatar Ronald Warner 07.28.2011 13:15

    An excellent session -very insightfull and provacative. I would like my students to view this session (and I am very pleased that these sessions will be available for 6 months). Would I be able to show this session to grad students at the University of Toronto? I can be reached at ronald.warner@utoronto.ca. I would appreciate someone getting back to my on this.
    • Not available avatar Barry Duncan 07.30.2011 14:30
      Hi Ron,
      Thanks for the feedback. I am gratified that you want your students to watch it. You'll have to check with the Networker about your question. If you don't hear anything, let me know and I'll try to help.
    • 0 avatar Psychotherapy Networker 08.08.2011 14:43
      Hi Ronald,

      Thanks for your comment - someone from the Networker team will e-mail you soon with a response to your question!
  • Not available avatar Julie 07.29.2011 14:12
    I got a jolt at the reminder that the alliance must be "earned each and every time". I think, much like in our relationships, it is easy to get lax and forget that we have to nurture even a very strong alliance continuously!
    • Not available avatar Barry Duncan 07.30.2011 14:32
      Hi Julie,
      Thanks, that was the message I most wanted to get across! There ain't no free lunch and earning a good alliance can be tough indeed, and not to be taken for granted. I like the analogy to our other relationships.
  • Not available avatar John 07.29.2011 16:37
    It was great to hear that someone else is a fan of Carl Rogers. Thanks for sharing the forms for free. Albeit, I am not well versed in the process of coaching, I disagree with Rich's statement that this more closely resembles coaching than therapy. If that is the case, then many, many counseling approaches would need to be so labeled because they focus on goals, outcomes, and the empowerment of clients. As a fellow red head, it is nice seeing a "brother" being successful.
    • Not available avatar Barry Duncan 07.30.2011 14:34
      Hi John,
      Glad you appreciated the reference to Rogers. We all stand on his shoulders. Yeah, I agree with you re the coaching and I wouldn't describe what I do that way. But as I said, I wouldn't mind if a client saw me that way.
  • Not available avatar Jacqueline Sitte, LADC I 07.29.2011 18:35
    I am very grateful for Barry's sharing. I am not aware of some of the testing papers which would be helpful to see. I appreciate he various reminders about enhancing my alliance w/ some of my clients. I love it when I hear a webinar and I feel stretched in my work. Change is embracable. Jacqueline Sitte,LADC I
    • Not available avatar Barry Duncan 07.30.2011 14:36
      Hi Jacqueline,
      Thanks for the feedback and thanks for checking out the webinar. I hope you visit www.heartandsoulofchange.com and download the measures. I truly believe that they will help your work.
  • Not available avatar Marion Sharp 07.30.2011 12:14
    Have you used this with groups? both treatment groups as well as project groups? I see enormous potential for using this at those levels as well

    thanks for some wonderful food for thought!!
    • Not available avatar Barry Duncan 07.30.2011 14:38
      Hi Marion,
      Glad you got something you could chew on! Yes, the measures have used with groups in many, many places. There is even a Group Session Rating Scale that is part of the ORS/SRS download. We just finished a randomized clinical trial in a group setting and found a significant effect for feedback. Give it a try and see what you think.
  • Not available avatar eticia 07.31.2011 21:02
    V ery provocative, I had never imagined this could be done in a almost quantitative scale, thanks as always to you and to the dear Psychotherapy Networker¨s Editor Rich Simon
    • Not available avatar Barry Duncan 08.01.2011 14:11
      Hi Eticia,
      Frankly, I didn't imagine it either when we started out! Give it a try and let me know what you think. Rich has an incredible ability to interview and capture things at its essence.
  • Not available avatar Bill Frederick 08.01.2011 09:15
    Barry you always help me with nuances of understanding. I like your dad's question..."why do you think they call it work" Your latest book is excellent.
    Rich once again as I watch a webinar when you interview, I appreciate your involvemnt. Your summarizations and questions consistently add value to the presentations.
    • Not available avatar Barry Duncan 08.01.2011 14:13
      Hi Bill,
      Glad you found it useful. It is the nuances that make the work, I think. My dad was chocked full of little wisdoms that will always travel with me. Yes, Rich definitely takes a conversation to a different and better level.
  • 0 avatar Merrilee Gibson 08.01.2011 12:01
    Thank you for another valuable session with important information. I am a Rogerian from way back, so I feel that much of this has been said by Rogers, and it is interesting to see how much discussion there is about the importance of the therapeutic alliance in current practice. I think Carl Rogers would be very pleased.
    I do very much appreciate the presentation, and to plan to avail myself of the impressive offerings of the website, and thank you so much, Barry Duncan, for your generosity in sharing knowledge and resources with us.
    • Not available avatar Barry Duncan 08.01.2011 14:24
      Hi Merrilee,
      Thanks for feedback and kind comments. It is my pleasure to offer the stuff on the website. This is my passion and I want to do my best to help therapists get better at what they do.
  • 0 avatar James Venneear 08.01.2011 20:58
    Hi Barry,
    Good to " see" you again.
    The article "A lab test and algorithms for identifying clients at risk for treatment failure" noted that the 48 therapists who were treating 551 clients, that when the therapists stopped receiving outcome feedback and were asked to assess for deterioration and client outcomes only one of the therapists was able to assess deterioration correctly. Have I got that right? Would you comment?
    James Venneear
    • Not available avatar Barry Duncan 08.02.2011 16:56
      Hi James,
      Good to hear from you. Here is how that study went: Hannan et al. (2005) compared therapist predictions of client deterioration to actuarial methods. Though therapists were aware of the study's purpose, familiar with the outcome measure used, and informed that the base rate was likely to be 8%, they accurately predicted deterioration in only one out of 550 cases; psychotherapists did not identify 39 out of the 40 clients who deteriorated. In contrast, the actuarial method correctly predicted 36 of the 40. Hope that clarifies it for you.
  • Not available avatar Mia Mantello 08.02.2011 06:55
    Thank you. I so appreciate this material......Last year I created a feedback form covering all aspects of the therapy setting and relationship and even that, my non-researched based self-created questionaire---was positively received.However I had made it anonymous with the ability for people to add names and comments if they so chose. This gave me feedback from 20 clients on their perceptions of our therapy relationship, frame, setting, but did not allow for the direct discussion of each item. Though I ask my clients regularly how they fell about our relationship and work, this is all quite elegant and sophisticated. I appreciate your tone and style of explanation as well, Barry. Hope to see you next Symposium in DC. Many thanks. Mia
    • Not available avatar Barry Duncan 08.02.2011 16:58
      Hi Mia, Thanks for the feedback and kind words. That's great that you did this independently in your practice and found that clients liked it. I hope you give the ORS/SRS a shot and see what they think. Please say hi to me next year at the Symposium.
  • Not available avatar Carol McDermott 08.02.2011 09:44
    Barry, wonderful to hear effective therapy from a Rogerian view.
    My stuckness about questionaires is that they might be a distraction from really listening to what the client brings as important to each session, that as they attend to the "test", the material of the moment is lost. I like the idea of the framework re goals of therapy and the measure of each session at the end of session. I want to have a better idea of my relationship and response to each client and discovering anything I have missed from their experience would be most helpful. Really appreciate your work in this direction.
    • Not available avatar Barry Duncan 08.02.2011 17:03
      Hi Carol,
      Thanks. Glad you found it useful. I had your same concerns and really didn't like the idea of starting a session by shoving a piece of paper in front of someone. But I am glad I did because I think it helps get down to the business of listening all the more quickly, and more quickly to the important stuff. It is really not a distraction--it takes so little time and actually seems to engage the client right off the bat. But don't take my word for it, try it and see.
  • Not available avatar Shabad Kaur Khalsa 08.02.2011 11:32
    Barry, Excellent presentation, I've considered doing this for some time in my practice, but have yet to implement it. How do you ask the client to fill it out? Do you ask them to take a few minutes after the session in the waiting area or right there with you? Do you ever have any hesitation or exaggerated measures on their part that there is no anonymity in their feedback? Just curious.
    • Not available avatar Barry Duncan 08.02.2011 18:01
      Hi Shabad,
      Thanks, glad you liked it. Good questions. It is really is easy to introduce the measures. Regarding the ORS, you just want to get across two things: one is that the measures are a way to ensure the client's voice remains central to the process; and two, that the ORS is a way to monitor whether the client is benefiting from the service you are providing. Scripts for introducing the measures are available to get you started at http://heartandsoulofchange.com/resources/handouts/. Just click on Barry's Handouts. Regarding hesitation or exaggerations, it is a lot less that you would think. People don't, according to research, misrpresent their distress level. And we have found that ratings of the ORS don't vary at follow up when the therapist is not around. The alliance measure, the SRS, is a bit more tricky because clients tend to score all alliance measures high. Some people have suggested that social desirability and demand characteristics are at play even though clients tend to score high whether they are with therapists or not. My friend and colleague Jeff Reese at UK (and a student who I don't know) examined this question directly and found no difference between the therapist in the room or not. Hope this makes sense.
  • Not available avatar Julie Sullivan-Redmond 08.02.2011 12:36
    What stood out for me is that you have offered a simple way to identify how the client sees him or herself progessing in the therapy process and a clear way to identify and focus on what aspect of the therapy session could be improved. Most importantly, you have created a conversation starter about very relevant issues. Rich, I truly appreciate the service you are providing through these webinars. Thanks
    • Not available avatar Barry 08.14.2011 13:18
      Hi Julie,
      Thanks for the feedback. I think you hit the nail on the head by calling it a "conversation starter." I believe the ORS/SRS makes the discussion of progress and relationship a routine part of the process, directing the therapist to what the client considers important.
  • 0 avatar Jack Stoltzfus 08.02.2011 13:33
    Are there some personality variables that interfere with alliance building and such people ought not to be therapists. Without using psychological labels, there are clearly peeople who go into this field because of a need for control, power, attention. On the Big Five Personality Scale I would think those who are open to and like change may fit better than those who rely on precedent and following a strict protocol. Any work you and Scott are doing around such factors. Thanks for your answer.
    • Not available avatar Barry 08.14.2011 13:23
      Hi Jack,
      There is great variability in therapist ability to form alliances with clients and it makes since that those who are flexible to a broad range of client styles would be beter at it. The good news is that most therapist do get better with feedback and feedback tends to level out therapist perfomance. Nine of ten therapists in our big Norway study improved their performance with feedback. But still, as you say, some folks may not listen to the feedback or change to fit clients. I have not done any research about the personality factors involved or this issue in general but it would be very interesting.
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