GettingBetterAtWhatWeDo

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Editor's note: Dr. Duncan, the Director of the Heart and Soul of
Change Project, was the featured speaker at the spring IPA conference in
Des Moines.
There seems to be a prevailing view that to be an
accomplished psychotherapist one must be well versed in
evidence based treatments (EBT), or in those models that have
been shown in randomized clinical trials (RCT) to be
efficacious for different “disorders.” The idea here is to make
psychological interventions dummy-proof, where the people—
the client and the therapist—are basically irrelevant (Duncan,
2010). Just plug in the diagnosis, do the prescribed treatment,
and voila, cure or symptom amelioration occurs! This medical
view of therapy is perhaps the most empirically vacuous aspect
of EBTs because the treatment itself accounts for so little of
outcome variance, while the client and the therapist—and
their relationship—account for so much more. In fact, it is the
factors common to all psychotherapies that matter the most.
The Common Factors
To understand the common factors, it is first necessary to
separate the variance due to psychotherapy (see Figure 1)
from that attributed to client/life factors, those variables
incidental to the treatment model, idiosyncratic to the specific
client, and part of the client’s life circumstances that aid in
recovery despite participation in therapy (Lambert, 2013)—
everything about the client that has nothing to do with us.
Calculated from the oft reported 0.80 effect size (ES) of
therapy, the proportion of outcome attributable to treatment
(14%) is depicted by the small circle nested within the larger
circle at the lower right side of the left circle. The variance
accounted for by client factors (86%), including unexplained
and error variance, is represented by the large circle on the
left. Even a casual inspection reveals the disproportionate
influence of what the client brings to therapy—the client is
the engine of change (Bohart & Tallman, 2010).
Figure 1 also illustrates the second step in understanding
the common factors. The second, larger circle in the center
depicts the overlapping elements that form the 14% of
variance attributable to therapy. Visually, the relationship
among the common factors is more accurately represented
with a Venn diagram, using overlapping circles and shading
to demonstrate mutual and interdependent action.
Therapist Effects
Therapist effects represent the amount of variance
attributable not to the model wielded, but rather to whom the
therapist is—it’s no surprise that the participants in the therapeutic
endeavor account for the lion share of how change occurs.
Recent studies suggest that 5-8% of the overall variance is
accounted for by therapist effects (Baldwin & Imel, 2013), or
36-57% of the variance accounted for by treatment. The amount
of variance, therefore, accounted for by therapist factors is about
five to eight times more than that of model differences.
Although we know that some therapists are better than
others, there is not a lot of research about what specifically
distinguishes the best from the rest. Demographics (gender,
ethnicity, discipline, and experience) don’t seem to matter much,
and although a variety of therapist interpersonal variables seem
intuitively important, there is not much empirical support for
any particular quality or attribute (Baldwin & Imel, 2013). So
what does matter? There are a couple of possibilities and one
absolute certainty. First, highlighting the importance of
recruiting client strengths and resiliencies suggested by the
variance attributed to client/life factors, Gassman and Grawe
(2006) found that therapists who spend more time in what they
called “resource activation” than “problem activation” got
better outcomes. The next possibility is experience, but not the
generic kind that we were often told that would make us better.
Recent studies suggest that specific experience with particular
populations or “conditions” may yield better outcomes (Crits-
Cristoph, Connally Gibbons, & Mukherjee, 2013). And the
absolute certainty: The client’s view of the alliance—not only a
robust predictor of therapy outcomes, but also is perhaps the
best avenue to understand therapist differences. Research
strongly suggests that clients seen by therapists with higher
average alliance ratings have better outcomes (Crits-Cristoph et
al., 2013). So the answer to the oft heard question about why
some therapists are better than others is that tried and true but
taken for granted old friend, the therapeutic alliance.
The Alliance
Researchers repeatedly find that a positive alliance—an
interpersonal partnership between the client and therapist to
The Heart and Soul of Change: Getting Better
at What We Do Barry Duncan
THEIOWAPSYCHOLOGISTSummer2013
Duncan: To Next Page
Feedback
Effects
21-42%
Model/Technique: General Effects
(Rational & Ritual), Client
Expectancy (Hope, Placebo)
& Therapist Allegiance 28-?%
Model/Technique:
Specific Effects (Model
Differences) 7%
Alliance Effects
36-50%
Treatment
Effects
14% Therapist
Effects
36-57%FIGURE 1: Client/Life Factors (86%)
(includes unexplained and error variance)
THE COMMON
FACTORS

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achieve the client’s goals (Bordin, 1979)—is one of the best
predictors of outcome. Horvath, Del Re, Fluckinger, and
Symonds (2011) examined 201 studies and found the
correlation between the alliance and outcome to be r = .28,
accounting for 7.5% of the overall variance and 36-50% of
treatment. The amount of change attributable to the alliance,
therefore, is about five (counting other studies) to seven times
that of specific model or technique.
We all have clients who rapidly respond to us. But what
about the folks who are mandated by the courts or protective
services or who just plain don’t want to be there (like almost
all kids)? What about people who have never been in a good
relationship or have been abused or traumatized? What about
folks that life just never seems to give a break? Well, the
therapist’s job, our job, is exactly the same regardless. If we
want anything good to happen, it all rests on a strong alliance
—we have to engage the client in purposeful work. The
research about what differentiates one therapist from another
as well as my personal experience suggest that the ability to
form alliances with people who are not easy to form alliances
with—to engage people who don’t want to be engaged—
separates the best from the rest.
Model/Technique: General Effects (Explanation
and Ritual), Client Expectancy (Hope, Placebo),
and Therapist Allegiance
Model/technique factors are the beliefs and procedures
unique to any given treatment. But these specific effects, the
impact of the differences among treatments, are very small, only
about 1% of the overall variance or 7% of that attributable to
treatment. But the general effects of providing a treatment are
far more potent. Models achieve their effects, in large part, if
not completely through the activation of placebo, hope, and
expectancy, combined with the therapist’s belief in (allegiance
to) the treatment administered. As long as a treatment makes
sense to, is accepted by, and fosters the active engagement of the
client, the particular approach used is unimportant.
Feedback Effects
Common factors research provides general guidance for
enhancing those elements shown to be most influential to
positive outcomes. The specifics, however, can only be derived
from the client’s response to what we deliver—the client’s
feedback regarding progress in therapy and the quality of the
alliance. Although it sounds like hyperbole, identifying clients
who are not benefiting is the single most important thing a
therapist can do to improve outcomes. Combining Lambert’s
Outcome Questionnaire System (Lambert & Shimokawa,
2011) and our Partners for Change Outcome Management
System (PCOMS; Duncan, 2012), nine RCTs now support
this assertion. A recent meta-analysis of PCOMS studies
(Lambert & Shimokawa, 2011) found that those in feedback
group had 3.5 higher odds of experiencing reliable change and
less than half the chance of experiencing deterioration. In
addition, collecting outcome and alliance feedback from
clients allows the systematic tracking of therapist development
so that neither client benefit nor your growth over time is left
to wishful thinking. Visit heartandsoulofchange.com for more
information (The measures are free for individual use and
available in 23 languages.). PCOMS is listed by the Substance
Abuse and Mental Health Administration as an evidence
based practice. It is different than what is usually considered
evidence-based because feedback is a-theoretical and therefore
additive to any therapeutic orientation and applies to clients of
all diagnostic categories (Duncan, 2012).
An inspection of Figure 1 shows that feedback overlaps and
affects all the factors—it is the tie that binds them together—
allowing the other common factors to be delivered one client at
a time. Soliciting systematic feedback is a living, ongoing process
that engages clients in the collaborative monitoring of outcome,
heightens hope for improvement, fits client preferences,
maximizes therapist-client alliance potential and client
participation, and is itself a core feature of therapeutic change.
I was recently asked (Kottler & Carlson, 2014) what is it
that I do, and who I am that most made my work effective
(assuming that it is). What I do that is the most important in
contributing to my effectiveness is that I routinely measure
outcome and the alliance via PCOMS—it boils down to
identifying clients who aren't responding to my therapeutic
business as usual and addressing the lack of progress in a
positive, proactive way that keeps clients engaged while we
collaboratively seek new directions.
That’s what I do. But what I bring to the therapeutic
endeavor is that I am a true believer. I believe in the client
and his or her irrepressible ability to overcome adversity, I
believe in the power of relationship and psychotherapy as a
vehicle for change, and I believe in myself, my ability to be
present, fully immersed in the client, and dedicated to making
a difference. The odds for change when you combine a
resourceful client, a strong alliance, and an authentic
therapist who brings him/herself to the show, are worth
betting on, certainly cause for hope, and responsible for my
unswerving faith in psychotherapy as a healing endeavor.
References
Baldwin, S. A., & Imel. Z. (2013). Therapist effects. In M. J. Lambert (Ed).
Bergin and Garfield’s Handbook of Psychotherapy and Behavioral Change (6th ed., pp.
258–297). New York, NY: Wiley.
Bohart, A., & Tallman, K. (2010). Clients: The neglected common factor. In B.
Duncan, S. Miller, B.Wampold, & M. Hubble (Eds.), The heart and soul of change:
Delivering what works (2nd ed., pp. 83-12). Washington DC: American Psychological
Association Press.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working
alliance. Psychotherapy: Theory, Research and Practice, 16, 252-260.
Crits-Christoph, P., Connolly Gibbons, M., & Mukherjee, D. (2013). Process-
outcome research. In M. J. Lambert (Ed.). Bergin and Garfield’s Handbook of
Psychotherapy and Behavioral Change (6th ed., pp. 298–340). New York, NY: Wiley.
Duncan, B. (2010). On becoming a better therapist. Washington, DC: American
Psychological Association.
Duncan, B. (2012). The partners for change outcome management system (PCOMS): The
heart and soul of change project. Canadian Psychology, 53, 93-104.
Gassman, D., & Grawe, K. (2006). General change mechanisms: The relation between
problem activation and resource activation in successful and unsuccessful therapeutic interactions.
Clinical Psychology and Psychotherapy, 13, 1–11.
Horvath, A., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in
individual psychotherapy. Psychotherapy, 48, 9-16.
Kottler, J., & Carlson, J. (2014) Becoming a master therapist. New York: Wiley.
Lambert, M. J. (2013). The efficacy and effectiveness of psychotherapy. In M. J.
Lambert (Ed.), Bergin and Garfield's handbook of psychotherapy and behavior change (6th
ed., pp. 169–218). Hoboken, NJ: Wiley.
Lambert, M.J., & Shimokawa, K. (2011). Collecting client feedback.
Psychotherapy, 48, 72-79.
The Heart and Soul of Change ... Barry DuncanTHEIOWAPSYCHOLOGISTSummer2013
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