OnBecomingABetterTherapistCh1

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SO YOU WANT TO BE A

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BETTER THERAPIST

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The only man I know who behaves sensibly is my tailor; he takes my
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measurements anew each time he sees me. The rest go on with their old
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measurements and expect me to fit them.
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—George Bernard Shaw
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While I often don’t remember where I leave my glasses, I still vividly
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recall my first client, including her full name, but I’ll call her Tina. A long
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time ago in a galaxy far way, I was in my initial clinical placement in gradu-
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ate school at the Dayton Mental Health and Developmental Center, the
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state hospital in Ohio. This practicum was largely, if not totally, intended to
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be an assessment experience. After all, you don’t really do therapy with those
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folks, do you? Tina was like a lot of the clients: young, poor, disenfranchised,
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heavily medicated, and on the merry-go-round of hospitalizations—oh, and
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similar to her fellow patients, at the ripe old age of 22, she was called a
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“chronic schizophrenic.”
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I gathered up my Wechsler Adult Intelligence Scale-Revised (WAIS),
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the first of the battery of tests I was attempting to gain competence with, and
was on my merry but nervous way to the assessment office, a stark, run-down
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room in a long-past-its-prime, barrack-style building that reeked of cleaning
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fluids overused to cover up some other worse smell, the institutional stench. But
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on the way I couldn’t help but notice all the looks I was getting—a smirk from
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an orderly, a wink from a nurse, and funny-looking smiles from nearly everyone

3

On Becoming a Better Therapist, by B. L. Duncan
Copyright 2011 by the American Psychological Association. All Rights Reserved.
Learn more about On Becoming a Better Therapist at http://www.apa.org/pubs/books/4317217.aspx

else. My curiosity piqued, I was just about to ask what was going on when the
chief psychologist, a kindly old guy (he was probably younger than I am now)
who likely stayed in the state system long after he knew he should leave, put his
hand on my shoulder and said, “Barry, you might want to leave the door open.”
And I did.
I greeted Tina, a young, extremely pale woman with short, brown,

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cropped hair (who might have looked a bit like Mia Farrow in the Rosemary’s

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Baby era had Tina lived in friendlier circumstances), and introduced myself

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in my most professional voice. Before I could sit down and open my test kit,

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Tina started to take off her clothes, mumbling something indiscernible. I just

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stared in disbelief, in total shock really. Tina was undaunted by my dismay

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and quickly was down to her bra and underwear when I finally broke my

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silence, hearing laughter in the distance, and said, “Tina, what are you

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doing?” Tina responded not with words but with actions, removing her bra

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like it had suddenly become very uncomfortable. So, there we were, a gradu-

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ate student, speechless, in his first professional encounter, and a client sitting

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nearly naked, mumbling now quite loudly but still nothing I could under-

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stand, and contemplating whether to stand up to take her underwear off or
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simply continue her mission while sitting.
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Finally, in desperation, I pleaded, “Tina, would you please do me a big
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favor? I mean, I would really appreciate it.” She looked at me for the first time,
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looked me right in the eye, and said, “What?” I replied, “I would really be grate-
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ful if you could put your clothes back on and help me get through this assess-
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ment. I’ve done them before, but never with a client, and I am kinda freaked
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out about it.” Tina whispered, “Sure,” and put her clothes back on. And
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although Tina struggled with the testing and clearly was not enjoying herself,
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she completed it. I was so genuinely appreciative of Tina’s help that I told her
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she really pulled me through my first real assessment. She smiled proudly, and
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ultimately smiled at me every time she saw me from then on. I wound up get-
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ting to know Tina pretty well and often reminded her how she helped me,
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and I even told her that I thought she looked like Mia Farrow, which she
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immensely enjoyed. Every time she left the hospital, I hoped that I would
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never see her again—but I did.
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Later that day, the chief psychologist caught up with me and asked me
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how I got Tina to put her clothes back on and complete the WAIS. He added
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that others had either just walked out of the room or simply commanded Tina
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to put on her clothes. One time, he said, Tina responded aggressively to the
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commands and was put in restraints. The psychologist smiled a patronizing
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smile that said “someday you’ll understand” and reported that Tina was a sort
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of rite of passage for the psychology trainees. In truth, I was angry but I didn’t
say anything about that to him. I replied that all I did was to ask her to do me

4 ON BECOMING A BETTER THERAPIST


a favor and help me out. The chief psychologist said, “Good approach,” and
walked off.1
So Tina started my psychotherapy journey and offered up my first les-
sons for consideration: authenticity matters and when in doubt or in need of
help, ask the client. Wherever you are, Tina, thanks for the great start. This
book reflects these lessons and highlights the value of transparency and true

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partnerships with clients.

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I am a true believer in psychotherapy and in therapists of all stripes

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and flavors. In my 30 years and 17,000 hours of experience with clients, I

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have been privileged to witness the irrepressible ability of human beings to

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transcend adversity—clients troubled by self-loathing and depression, bat-

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tling alcohol or drugs, struggling with intolerable marriages, terrorized by

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inexplicable voices, oppressed by their children’s problems, traumatized by

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past or current life circumstances, and tormented with unwanted thoughts

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and anxieties—with amazing regularity. As a trainer and consultant, I have

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rubbed elbows with thousands of psychotherapists across the globe, and the

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thing that strikes me most is their authentic desire to be helpful. Regardless

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of discipline, theoretical persuasion, or career level, they really care about
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people and strive to do good work. The odds for change when you combine
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a resourceful client and caring therapist are worth betting on, certainly
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cause for hope, and responsible for my unswerving faith in psychotherapy
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as a healing endeavor.
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The overwhelming majority of psychotherapists, as corny as it sounds,
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want to be helpful. Many of us, including me, even answered in graduate
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school applications “I want to help people” as the reason we chose to be thera-
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pists (see Figure 1.1). Often, some well-meaning person dissuaded us from that
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answer because it didn’t sound sophisticated or appeared too “codependent.”
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Such aspirations, however, are not only noble but also can provide just what
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is needed to improve your effectiveness. After all, there is not much finan-
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cial incentive for doing better therapy—we don’t do this work because we
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thought we would acquire the lifestyles of the rich and famous. It is amazing
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to think, in these hard economic times, that smart, creative individuals
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make the necessary sacrifices to attain advanced degrees only to earn far less
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money than those with comparable degrees in other fields. It says something
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1Although I didn’t consider it while it was happening, the gender politics of this situation are noteworthy.
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Later, and over time, I talked with Tina about what taking off her clothes meant. Two ways of under-
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standing her behavior emerged from our discussions. First, disrobing in the face of male authority and
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pressure to perform usually ended the encounter—it allowed her to exert some control over a continual
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demand for compliance. Second, it was a way that Tina learned to prevent brutal physical abuse by her
father. In effect, Tina learned to trade sexual abuse for beatings. When I conveyed the meanings of Tina’s
behavior as well as my palpable annoyance, it ended the staff’s use of Tina as “a rite of passage.”

SO YOU WANT TO BE A BETTER THERAPIST 5


I just want to
help people!

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Figure 1.1. Barry just wanted to help people.
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quite good about us and our career choice, although less kind interpretations
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are readily available.
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Doing the required servitude without the promise of a rags-to-riches
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future only makes sense because being a psychotherapist is more of a calling
than a job—a quest for meaningful activity and personal fulﬁllment (Orlinsky
et al., 2005). Parks (1996, p. 12) summarizes:



Accounts by psychotherapists of their professional [work] suggest that the
feelings they experience while practicing therapy are very important in
motivating their therapeutic work and that, generally, therapists enjoy
working with patients and derive a deep sense of personal satisfaction from
doing therapy (Dryden & Spurling, 1989; Guy, 1987). That these feelings
are intrinsically satisfying, and not a reward on a par with money or profes-

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sional prestige, is evident from the terms that therapists use. Working with

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patients is described as “interesting” and “fascinating” (Bloomfield, 1989),

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“nourishing” (Thorne, 1989), “meaningful” and “stimulating” (Heppner,

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1989), “exciting” (Fransella, 1989), and “sustaining” (Street, 1989). Some

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consider it a “privilege” (Mahoney, 1989; Chaplin, 1989). It clearly repre-

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sents a part of life which has serious personal meaning and value and which

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therapists would be most reluctant to give up (Fransella, 1989).

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Despite good intentions and commitment to your work, making sense of

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the cacophony of “latest” developments, let alone applying them in your prac-

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tice, may feel overwhelming. Every day, it seems, there are new fully manual-

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ized treatments hot off the press, promising evidence-based change and

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increased effectiveness with this or that disorder. In your day-to-day work with
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clients, however, it is never so black-and-white. It is often difficult to even
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know if you’re achieving the desired results—or worse, you might realize that
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you’re not reaching a particular client but have no idea why and no clue what
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to do about it. Even if your overall success rates are good, the accumulation of
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unfruitful encounters over time can weigh on you and erode the aspirations
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that led you to become a therapist. You read as much as you can, you try new
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approaches, but despite all the hard work you feel as though you’re missing
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something—some, if not many, clients still do not respond to your best efforts.
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How can you achieve better results? In short: how can you become a better
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therapist?
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This book intends to help you answer your calling and remember why
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you became a therapist in the first place. It is not about learning the latest and
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greatest miracle method, or a never-before-available way to unravel the mys-
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teries of the human psyche, or the most recent breakthrough in brain neuro-
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chemistry. No husky voiceover will declare a winner of the battle of the
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psychotherapy brands or add yet another fashion to the therapy boutique of
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techniques. You have already been there and done that. It is also not about
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becoming “accountable” for the sake of funding sources or to justify your exis-
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tence via showing “proof of value” or “return on investment.” Rather, this
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book is about you—this time it’s personal, from one therapist to another. It’s
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about becoming a better therapist because you got into this business to help
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people—you want to make a meaningful difference in as many lives as possi-
ble. Being a therapist is more than a way to make a living to you. Becoming a
better one is what you are about.



THE GOOD, THE BAD, AND THE UGLY

To exchange one orthodoxy for another is not necessarily an advance.
The enemy is the gramophone mind, whether or not one agrees with the
record that is being played at the moment.
—George Orwell

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The good news is that the efficacy of psychotherapy is very good—the

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average treated person is better off than about 80% of the untreated sample

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(Duncan, Miller, Wampold, & Hubble, 2010), translating to an effect size (ES)

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of about 0.8.2 Moreover, these substantial benefits apparently extend from

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the laboratory to everyday practice. For example, a real-world study in the

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UK (Stiles, Barkham, Twigg, Mellor-Clark, & Cooper, 2006) comparing

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cognitive–behavioral therapy (CBT), psychodynamic therapy (PDT), and

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person-centered therapy (PCT) as routinely practiced reported a pre–post

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ES of around 1.30. In short, there is a lot to feel proud about our profession:

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psychotherapy works.

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But there’s more to the story. The bad news is twofold: First, dropouts are

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a significant problem in the delivery of mental health and substance abuse ser-
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vices, averaging at least 47% (Wierzbicki & Pekarik, 1993). When dropouts are
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considered, a hard rain falls on psychotherapy’s efficacy parade, both in random-
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ized clinical trials (RCT) and in clinical settings. Second, despite the fact that
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the general efficacy is consistently good, not everyone benefits. Hansen,
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Lambert, and Foreman (2002), using a national database of over 6000 clients,
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reported a sobering picture of routine clinical care in which only 20% of clients
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improved as compared to the 57–67% rates typical of RCTs. Whichever rate is
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accepted as more representative of actual practice, the fact remains that a sub-
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stantial portion of clients go home without help.
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And the ugly: Explaining part of the volatile results, variability among
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therapists is the rule rather than the exception. Not surprisingly, although rarely
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discussed, some therapists are much better at securing positive results than
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others. In fact, therapist effectiveness ranges from 20–70%! Moreover, even
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very effective clinicians seem to be poor at identifying deteriorating clients.
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Hannan et al. (2005) compared therapist predictions of client deterioration to
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actuarial methods. Though therapists were aware of the study’s purpose, famil-
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iar with the outcome measure used, and informed that the base rate was likely
to be 8%, they accurately predicted deterioration in only 1 out of 550 cases;
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2Effect size (ES) refers to the magnitude of change attributable to treatment, compared to an untreated
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group. The ES most associated with psychotherapy is 0.8 standard deviations above the mean of the
untreated group. An ES of 1.0 indicates that the mean of the treated group falls at approximately the
84th percentile of the untreated one. Consequently, the average treated person is better off than
approximately 80% of those without the benefit of treatment.



psychotherapists did not identify 39 out of the 40 clients who deteriorated. In
contrast, the actuarial method correctly predicted 36 of the 40.
So, despite the overall efficacy and effectiveness of psychotherapy, drop-
outs are a substantial problem, many clients do not benefit, and therapists vary
significantly in effectiveness and are poor judges of client deterioration. Most
of us provide an invaluable service to our clients, but sadly most of us don’t

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know how effective we really are—we don’t know who will drop out or who will

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ultimately not benefit or even deteriorate. Do you know how effective you are?

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With dropouts considered, how many of your clients leave your office absent of

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benefit? Which clients in your practice now are at risk for dropout or negative

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outcome?

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What is the solution to these problems? Sometimes our altruistic desire

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to be helpful hoodwinks us into believing that if we were just smart enough or

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trained correctly, clients would not remain inured to our best efforts—if we

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found the Holy Grail, that special model or technique, we could once and for

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all defeat the psychic dragons that terrorize clients. We come by this belief

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honestly—we hear it all the time, constantly reinforced on nearly all fronts.

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The warring factions carry on the struggle for alpha dogma status in the psy-
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chotherapy pack and claims of “miracle cures better than the rest” continue
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unabated. In a recent article in the Psychotherapy Networker, the most read
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publication by mental health professionals, several approaches were identified
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as significant advancements (Lebow, 2007, p. 46). The article swooned with
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praise (e.g., “impressive outcomes, outcomes light–years ahead”)—the subtext
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is that if we don’t avail ourselves of these approaches we are doing our clients
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a reprehensible disservice—but left out a vital fact: None of the heralded mod-
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els have reliably demonstrated superiority to any other systematically applied
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psychotherapy.
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This, of course, is the famous dodo bird verdict (“All have won and all must
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have prizes”), taken from the classic Lewis Carroll (1865/1962) tale, Alice in
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Wonderland, first invoked by Saul Rosenzweig way back in 1936 to illustrate
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the equivalence of outcome among approaches (see Duncan, 2010). The
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dodo verdict is the most replicated finding in the psychological literature—
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encompassing a broad array of research designs, problems, populations, and
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clinical settings. For example, the study mentioned previously (Stiles et al.,
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2006) comparing CBT, PDT, and PCT as routinely practiced, once again
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found no differences among the approaches.
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Perhaps a more controversial illustration is provided by the treatments
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for the diagnosis du jour, posttraumatic stress disorder (PTSD). CBT has been
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demonstrated to be effective and is widely believed to be the treatment of
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choice, but several approaches with diverse rationales and methods have also
been shown to be effective: eye-movement desensitization and reprocessing,
cognitive therapy without exposure, hypnotherapy, psychodynamic therapy,



and present-centered therapy. A recent meta-analysis comparing these treat-
ments found all of them about equally effective (Benish, Imel, & Wampold,
2007). What is remarkable here is the diversity of methods that achieve about
the same results. Two of the treatments, cognitive therapy without expo-
sure and present-centered therapy, were designed to exclude any therapeutic
actions that might involve exposure (clients were not allowed to discuss their

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traumas because that invoked imaginal exposure). Despite the presumed

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extraordinary benefits of exposure for PTSD, the two treatments without it, or

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in which it was incidental (psychodynamic), were just as effective (Benish

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et al., 2007). This study only confirms that the competition among the more

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than 250 therapeutic schools remains little more than the competition among

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aspirin, Advil, and Tylenol. All of them relieve pain and work better than no

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treatment at all. As the dodo wisely judged, all deserve prizes because none

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stands above the rest. When it is all said and done, model differences only

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amount to an ES of about 0.2, an underwhelming 1% of the overall variance

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of outcome (Wampold, 2001).

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Unfortunately, the mountain of evidence researchers have amassed has

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had little impact on the graduate or postgraduate training of mental health
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professionals, or sadly, on professional attitudes. We spend thousands of dol-
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lars on workshops, conferences, and books to learn highly publicized methods
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of treatment. Unfortunately, instead of feeling hopeful or validated and expe-
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riencing the promised “outcomes light–years ahead,” we often wind up feeling
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demoralized. Why didn’t the powerful sword slay the dragon of misery of the
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client in my office now? The answer all too often is to blame ourselves—we
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are just not measuring up. The Holy Grail seems just out of reach.
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Don’t get me wrong. There is nothing wrong with learning about mod-
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els and techniques—in fact, it is a good thing as I’ll discuss below and through-
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out the book—but becoming beholden to one isn’t, nor is believing that
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salvation will come from them. They are indeed false gods. First, given the
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robust findings supporting the dodo verdict, it is important to keep in mind
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that the much ballyhooed models have only shown themselves to be better
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than sham treatments or no treatment at all, which is not exactly news to write
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home to mom about. Think about it. What if one of your friends went out on
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a date with a new person, and when you asked about the guy, your friend
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replied, “He was better than nothing—he was unequivocally better than
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watching TV or washing my hair.” (Or, if your friend was a researcher: “. . . he
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was significantly better, at a 95% confidence level, than watching TV or wash-
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ing my hair.”) How impressed would you be?
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And second, the idea that change primarily emanates from the model or
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techniques you wield is a siren call destined to smash you against the jagged
rocks of ineffective therapy. That therapists might possess the psychological
equivalent of a “pill” for emotional distress resonates strongly with many, and



is nothing if not seductive as it teases our desires to be helpful. A treatment for
a specific “disorder,” from this perspective, is like a silver bullet, potent and
transferable from research setting to clinical practice. Any therapist need only
to load the silver bullet into any psychotherapy revolver and shoot the psychic
werewolf stalking the client. In its most unfortunate interpretation, clients are
reduced to a diagnosis and therapists are defined by a treatment technology—

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both interchangeable and insignificant to the procedure at hand. This prod-

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uct view of psychotherapy is most empirically vacuous because the treatment

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itself accounts for so little of outcome variance, while the client and the

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therapist—and their relationship—account for so much more.

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Fear is also a potent motivator for the ongoing search for the Holy Grail.

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Going well beyond subtext, we are told that not administering the “right”

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treatment is unethical (Chambless & Crits-Christoph, 2006) and even “pros-

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ecutable”! A New York Times article reported:

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Using vague, unstandardized methods to assist troubled clients ‘should

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be prosecutable’ in some cases, said Dr. Marsha Linehan . . . (Carey,

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2005, p. 2)

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Given the relative contribution of model and technique to change and
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the lack of demonstrated superiority of dialectical behavior therapy or any other
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approach, perhaps it should be “prosecutable” to make such bold statements.
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In truth, we are easily smitten by the lure of flashy techniques and “out-
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comes light-years ahead.” Amid explanations and remedies aplenty, therapists
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courageously continue the search for designer explanations and brand name
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miracles—disconnected from the power for change that resides in the pairing
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of two unique persons, the application of strategies that resonate with both, and
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the impact of a quality partnership. Despite our generally good results and her-
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culean efforts to master the right approach, we continue to observe that clients
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drop out or, even worse, continue without benefit.
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To the Rescue: Practice-Based Evidence
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There is a practical clinical solution to these everyday pitfalls called
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“practice-based evidence” (Barkham et al., 2001; Duncan, Miller, & Sparks,
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2004). Howard, Moras, Brill, Matinovich, and Lutz (1996) were the first to
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advocate for the systematic evaluation of client response to treatment dur-
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ing the course of therapy, and to recommend that such information be used
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to “determine the appropriateness of the current treatment . . . the need for
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further treatment . . . [and] prompt a clinical consultation for patients who
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[were] not progressing at expected rates” (p. 1063). When this occurs—when
client feedback is systematically collected and used to tailor treatment—good
things happen. For example, using the Outcome Questionnaire 45.2, feedback



pioneer Michael Lambert has conducted five RCTs and all five demonstrated
significant gains for feedback groups over treatment as usual (TAU) for clients
at risk for a negative outcome. Twenty-two percent of TAU at-risk cases
reached reliable improvement and clinically significant change, compared
with 33% for feedback to therapist groups, 39% for feedback to therapists and
clients, and 45% when feedback was supplemented with support tools such

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as measures of the alliance (Lambert, 2010). The addition of client feedback

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alone, without new techniques or models of treatment and leaving therapists

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to practice as they saw fit, enabled over two times the amount of at-risk clients

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to benefit from psychotherapy. Think of that advantage in your practice.

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Consider the pool of clients in your practice right now who are not benefiting.

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Systematic feedback could allow you to recapture good outcomes with many

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of those clients who would otherwise not benefit.

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Continuous client feedback individualizes psychotherapy based on treat-

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ment response, provides an early warning system that identifies at-risk clients

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thereby preventing dropouts and negative outcomes, and suggests a tried and

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true solution to the problem of therapist variability, namely, that feedback

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necessarily improves performance and quickens the pace of your development.
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In truth, practice-based evidence can make you a better therapist—it helps you
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get in the zone of effective psychotherapy.3
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GETTING IN THE ZONE
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To follow knowledge like a sinking star,
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Beyond the upmost bound of human thought . . .
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To strive, to seek, to find, and not to yield.
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—Tennyson
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In a remarkable study, veteran researchers David Orlinsky and Helge
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Rønnestad (2005) took an in-depth look at therapists’ experience of their
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work and professional growth. Over a 15-year period, they collected richly
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detailed reports from nearly 5,000 psychotherapists of all career levels, pro-
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fessions, and theoretical orientations from over a dozen countries. From their
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analyses of many specific aspects of therapeutic work, two independent modes
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of therapist participation were identified:
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Healing Involvement reflects a mode of participation in which therapists
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experience themselves as personally committed and affirming to patients,
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3The rationale is compelling for securing client feedback. But before this understanding of how feedback
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could address psychotherapy’s pitfalls, before the randomized clinical trials demonstrating the power of
feedback, and before the validation studies verified the psychometrics of the measures and that the
process might be viable, there was a desire to give clients a voice in their own care, to bring them into
the inner circle of decision making.



engaging at a high level of basic empathic and communication skills, con-
scious of Flow-type feelings during sessions, having a sense of efficacy in
general, and dealing constructively with difficulties if problems in treat-
ment arose. By contrast, Stressful Involvement is a pattern of therapist expe-
rience characterized by frequent difficulties in practice, unconstructive
efforts to deal with those difficulties by avoiding therapeutic engagement,

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and feelings of boredom and anxiety during sessions. (p. 162)

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An Effective Practice, according to the researchers, is characterized by much

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Healing Involvement and little Stressful Involvement. Healing Involvement

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represents us at our best—the way we want to be with our clients. Think of it

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as being “in the zone,” akin to how athletes describe their experience when

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their performance is optimal.

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Elite athletes talk a lot about being in the zone, that magical place where

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mind and body work in perfect synch, flowing without conscious effort to

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athletic nirvana. Perhaps the best theoretical explanation of the zone comes

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from Mihaly Csikszentmihalyi in his book Flow: The Psychology of Optimal

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Experience. Flow is a state of deep focus that occurs when people engage in

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challenging tasks that demand intense concentration and commitment—
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when skill level is perfectly balanced to the challenge level of a task that has
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clear goals and provides immediate feedback (Csikszentmihalyi, 1990).
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All kinds of activity can trigger flow. People talk of “losing track of time”
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when they are gardening, playing softball, cooking an elaborate meal, or con-
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ducting psychotherapy. We’ve all had the experience where we’ve become so
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completely absorbed in our work that time flies by, the outside world is a mil-
oc

lion miles away, and our talents flow freely—those times when our immersion
ss

into our client’s story is so complete, our attunement so sharp, and the path
lA

required for change eminently accessible. These episodes can be deeply grat-
ca

ifying, and some of our best work comes out of them. Sometimes you feel the
gi

texture of your connection with clients, an intimate space where you both
lo
ho

know that there is something very good about this conversation, something
yc

that inspires hope. This is healing involvement. So, what causes this and, more
Ps

important, how can we make it happen more often?
an

Here is where the research of Orlinsky and Rønnestad is priceless. Their
ic

extensive investigation identified three sources of healing involvement, a ther-
er

apist’s experience of being in the zone: First is the therapist’s sense of cumula-
Am

tive career development—improvement in clinical skills, increasing mastery, and
ht

gradual surpassing of past limitations. Therapists like to think of themselves as
rig

getting better, over time, at what they do. Eighty-six percent of the therapists,
y
op

regardless of career level, reported that they were “highly motivated” to pur-
C

sue professional development. This is truly remarkable. There is no other pro-
fession, as a group, more committed to getting better at what they do. Most
professions, it appears, believe that one arrives at some degree of competency



at some point. Not therapists. They want to continue to get better throughout
their careers.
Second, as implied, another important influence on healing involvement
is the therapist’s sense of theoretical breadth. Orlinsky and Rønnestad suggest
that understanding clients from a variety of conceptual contexts enhances the
therapist’s adaptive flexibility in responding to the challenges of clinical work.

n.
Indeed, broad-spectrum integrative-eclectic practitioners were more likely to

tio
experience healing involvement. This suggests that therapists who are in the

bu
zone more do not marry any model, but rather remain theoretically promiscu-

tri
is
ous. Again this makes sense. Possessing a range of understandings of client

rD
problems as well as possible methods to address them allows therapists to expe-

fo
rience healing involvement more often with more clients—a suggestion in

ot
line with what the psychotherapy integration movement has been telling us

N
all along (e.g., Norcross & Goldfried, 2005; Stricker & Gold, 2006).

d.
ve
The third and by far the most powerful influence on being in the zone is

er
the therapist’s sense of currently experienced growth. Therapists like to think of

es
themselves as developing now. Your ongoing experience of professional devel-

R
opment is therefore critical to becoming a better therapist. In a sense we con-
s
ht
tinually ask ourselves, “What have you done for me lately?” Therapists with
ig
the highest levels of current growth showed the highest levels of healing
R

involvement. Orlinsky and Rønnestad suggest that the experience of current
ll
.A

growth translates to positive work morale and energizes therapists to apply
n

their skills on behalf of clients. In addition, currently experienced growth fos-
tio
ia

ters a process of continual professional reflection (Rønnestad & Skovholt,
oc

1991), a bonus that keeps therapists motivated to seek out specialty training,
ss

supervision, personal therapy, or what-have-you to keep the pedal down on
lA

the developmental process. It makes sense, when you think about it, that if we
ca

see our work as a calling and a means to personal meaning and satisfaction,
gi

then our view of our own growth as a therapist would be quite important to
lo
ho

us—so much so that we might do well to keep a finger on the pulse of our
yc

development at all times.
Ps

How do therapists attain a sense of currently experienced growth?
an

According to Orlinsky and Rønnestad (2005), the most widely endorsed
ic

positive influence was practical–experiential learning through direct clini-
er

cal work—by the quality of therapists’ experiences in working with clients.
Am

Not workshops and books trumpeting the latest and greatest. Rather, almost
ht

97% of therapists reported that learning from their experiences with
rig

clients was a significant influence on their development. A full 84% rated
y
op

this influence as high. In truth, beyond cliché, therapists do believe that
C

clients are the best teachers. Our sense of currently experienced growth
depends on these frontline lessons, which in turn, is a primary source of
healing involvement.



How does all this relate to client feedback? Tracking client responses to
therapy provides an accessible route to being in the zone, addressing all three
sources identified by Orlinsky and Rønnestad. First, collection of client feed-
back allows you to monitor your outcomes and plot your career development, so
you will know about your effectiveness and whether you are improving.
Moreover, charting your outcomes not only permits a more systematic process

n.
of planning and implementing strategies to improve your effectiveness, but it

tio
also permits your evaluation of the strategies and whether or not your time

bu
tri
might be better spent elsewhere. Second, tailoring your approach based on

is
client feedback about benefit and the fit of the services will lead you to theo-

rD
retical breadth as you expand your repertoire to serve more clients. Soliciting

fo
client feedback enhances your ability to be tuned to client preferences and

ot
encourages your flexibility to try out new ideas in search of what resonates with

N
d.
clients—opening you to a range of theoretical explanations and attending

ve
methods. Finally, securing client feedback seats you in the front of the class so

er
you can readily see and hear the lessons of the day—to experience your cur-

es
rently experienced growth. Later, I’ll show how client feedback or practice-based

R
evidence encourages your continual professional reflection with each client,
s
ht
thereby increasing your learning potential exponentially. Client feedback is
ig
R

the compass that provides direction out of the wilderness of negative out-
ll

comes and average therapy—taking the notion of clients as the best teachers
.A

of psychotherapy well beyond cliché, significantly accelerating your develop-
n
io

ment as a therapist, and helping you become a better one.
t
ia
oc
ss
lA

CLIENTS ARE THE BEST TEACHERS
ca
gi

Of all tyrannies, a tyranny sincerely exercised for the good of its victims
lo

may be the most oppressive.
ho

—C. S. Lewis
yc
Ps

Dan Ariely, in his book Predictably Irrational (2008; see also http://www.
an

youtube.com/watch?v=8I6wa3eK6zQ), tells a horrendous story of an explo-
ic

sion that left him with 70% of his body covered with third-degree burns.
er

His treatment included a much-dreaded daily removal of his bandages. In
Am

the absence of skin, the bandages were attached to raw bleeding flesh and
ht

their removal was both harrowing and excruciatingly painful. The nurses
rig

removed the bandages as fast as possible, quickly ripping them off one by
y
op

one. Believing that a slower pace would be less painful, Ariely repeatedly
C

asked the nurses to slow down the removal process. The nurses, however,
asserted that finishing as fast as possible was the best approach, and contin-
ued to do so.



This ordeal miraculously inspired Ariely to research the experience of
pain as well as other phenomena. His investigation of pain demonstrated that
a slow and less intense experience of pain over longer periods was far easier to
tolerate than more intense pain over shorter time frames. Consider this story
and its relevance to psychotherapy. It is noteworthy that the nurses dis-
regarded Ariely’s response to their removal methods—his experience of his

n.
own pain did not hold much weight! Ignoring his response as well as his plead-

tio
ings to slow down was not because the nurses were evil or had any malevolent

bu
intentions—in fact, Ariely reports that he grew to love the nurses and believed

tri
is
that they loved him as well. Rather, the nurses assumed they knew more about

rD
his pain than he did and went full steam ahead for his own good! He also later

fo
learned that the nurses considered it easier for them to remove the dressings

ot
quickly. Clinical lore about the rapid removal of bandages, as well as what was

N
convenient for the nurses, prevailed over Ariely’s experience of his own pain.

d.
ve
When services are provided without intimate connection to those

er
receiving them and to their responses and preferences, clients become card-

es
board cutouts, the object of our professional deliberations and subject to our

R
whims. Valuing clients as credible sources of their own experiences allows us
s
ht
to critically examine our assumptions and practices—to support what is work-
ig
ing and challenge what is not—and allows clients to teach us how we can be
R

the most effective with them.
ll
.A

The idea that clients are the best teachers has a long and rich history in
n

psychotherapy. Indeed, it is difficult if not impossible to routinely sit with
tio
ia

people in the throes of emotional or situational disaster, then witness their
oc

journey to a better place, and not be changed by that experience. Some have
ss

written about the reversal of roles that can happen between therapists and
lA

clients, where therapists emerge as the main beneficiary of the therapeutic
ca

process; others have written about the profound lessons that clients teach us
gi

about life; still others have pointed to even a higher learning, an experience
lo
ho

that was personally and professionally transformational. There are also
yc

compendiums of such lessons. Veteran psychotherapy researcher Marvin
Ps

Goldfried (2001), for example, compiled a series of clinical events that
an

resulted in conceptual revisions among well-known theorists. In a book about
ic

the changes incurred in experienced therapists lives (Kahn & Fromm, 2001),
er

Spiegel (2001) notes the personal changes he has made because of his work
Am

with cancer patients—their struggles regarding impending death inspired him
ht

to live his own life more intensely. In their compelling book, The Client Who
rig

Changed Me, prolific authors Jeffrey Kottler and Jon Carlson (2005) focused
y
op

their efforts on the really big changes that therapists experience as a direct
C

result of their work with clients.
Clients provide the opportunity for constant learning about the nature
of the human condition and about different cultures and worldviews, as well



as the myriad ways by which people transcend adversity and cope with the
unthinkable. With each session under our belt, we become more knowledge-
able about people and worldly in our views. While these types of hard-learned
lessons—the everyday and the transformational—are noteworthy (and this
book contains client stories influential in my development as a therapist), the
notion that “the client is the best teacher” is invoked here in a different way.

n.
It carries a far more literal meaning. Continuous client feedback permits a

tio
practical process in which clients proactively shape our behavior until we get

bu
it right with them or we move them on to someone else.

tri
is
Acquiring formal feedback enables a transparent conversation unlike

rD
what most of us have ever experienced. With a collaborative focus on the ben-

fo
efit and fit of psychotherapy, clients can teach us how to do more effective work,

ot
specifically, on a session-by-session, and even within-session, basis. Beyond les-

N
sons about life or about the work of psychotherapy in general, a culture of con-

d.
ve
tinuous client feedback keeps our utmost attention on the here and now with

er
this client in this session. Clients teach us with their responses—whether or not

es
they are benefiting and whether or not our service is a good fit for them—as well

R
as with their reactions and reflections about the next step. In short, practice-
s
ht
based evidence enables your clients to teach you how to do better work, espe-
ig
cially those who are not responding to your therapeutic business as usual.
R
ll
n .A
io

WHAT WORKS IN THERAPY: GUIDELINES FROM RESEARCH
t
ia
oc

Whoever acquires knowledge and does not practice it resembles him [sic]
ss

who ploughs his land and leaves it unsown.
lA

—Sa’di, Gulistan
ca
gi

A story illustrates the sentiments that many practitioners feel about
lo
ho

research. Two researchers were attending their annual conference. Although
yc

enjoying the proceedings, they decided to find some diversion to combat the
Ps

tedium of sitting all day and absorbing vast amounts of information. They set-
an

tled on a hot-air balloon ride and were quite enjoying themselves until a mys-
ic

terious fog rolled in. Hopelessly lost, they drifted for hours until, finally, a
er

clearing in the fog appeared and they saw a man standing in an open field.
Am

Joyfully, they yelled down at the man, “Where are we?” The man looked at
ht

them, and then down at the ground, before turning a full 360 degrees to sur-
rig

vey his surroundings. Finally, after scratching his beard and what seemed to
y
op

be several moments of facial contortions reflecting deep concentration, the
C

man looked up and said, “You are above my farm.”
The first researcher looked at the second researcher and said, “That man
is a researcher—he is a scientist!” To which the second researcher replied,



“Are you crazy, man? He is a simple farmer!” “No,” answered the first
researcher emphatically, “that man is a researcher and there are three facts that
support my assertion: First what he said was absolutely 100% accurate; second,
he systematically addressed our question through an examination of all of the
empirical evidence at his disposal, and then carefully deliberated before deliv-
ering his conclusion; and finally, the third reason I know he is a researcher is

n.
that what he told us is absolutely useless to our predicament.” In this book, I

tio
only present research that directly informs my psychotherapy practice and that

bu
will be useful to your predicament. If it doesn’t pass that test, you will not read

tri
is
it here.

rD
The common factors—what works in therapy—have a storied history

fo
that started with Rosenzweig’s (1936) classic article “Implicit Common

ot
Factors in Diverse Forms of Psychotherapy.” In addition to the original invo-

N
cation of the dodo bird and seminal explication of the common factors of

d.
ve
change, Rosenzweig also provided the best explanation for the common fac-

er
tors, still used today, namely, that given that all approaches achieve roughly

es
similar results, there must be pantheoretical factors accounting for the

R
observed changes beyond the presumed differences among schools (Duncan,
s
2010).
ht
ig
Jerome Frank (Frank, 1961, 1973; Frank & Frank, 1991) advanced the
R

idea that psychotherapy orientations (and other forms of healing) are equiva-
ll
.A

lent in their effectiveness because of factors shared by all: (a) a healing setting;
n

(b) a rationale, myth, or conceptual framework that provides an explanation
tio
ia

for the client’s complaint and a method for resolving it; (c) an emotionally
oc

charged, confiding relationship with a helping person; and (d) a ritual or pro-
ss

cedure that requires involvement of both the healer and client to bring about
lA

“cure” or resolution. Frank’s work is particularly helpful, as noted below, in
ca

understanding the role of model and technique as the vehicle for delivering
gi

the other factors.
lo
ho

Several others have identified these elements found in all therapies, but
yc

Brigham Young University’s Michael Lambert deserves special mention. After
Ps

an extensive analysis of decades of outcome research, Lambert (1986) identi-
an

fied four factors—and their estimated percentages of outcome variance—as
ic

the principal elements accounting for improvement: extratherapeutic (client)
er

variables (40%); relationship factors (30%); hope, expectancy, and placebo
Am

(15%); and model/technique (15%) (see Figure 1.2). Although these factors
ht

are not derived from a statistical analysis, he suggested that they embody what
rig

studies indicated about treatment outcome. Lambert’s portrayal of the com-
y
op

mon factors bravely differentiated factors according to their relative contribu-
C

tion to outcome, opening a new vista of understanding models and their
proportional importance to success—a bold challenge to the typical reverence
many researchers and therapists feel toward their preferred models.



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