Let’s talk about psychotherapy. Why hasn’t it changed much in the last century? And if a patient isn’t getting well, is it the fault of the patient, the therapist or the therapy itself? In today’s podcast, Gabe and psychologist Barry L. Duncan discuss the idea of holding therapists more accountable when the patient isn’t getting better.
Join us for a great discussion that sheds new light on how we should be treating mental health issues.
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Guest information for ‘Barry L. Duncan- Therapist or Patient’ Podcast Episode
Barry L. Duncan, Psy.D. . is CEO of Better Outcomes Now and a psychologist, trainer, and researcher with over 17,000 hours of face-to-face experience with clients. Dr. Duncan is the developer of the clinical process of the evidence based practice, the Partners for Change Outcome Management System (PCOMS), a process that ensures that clients are privileged and therapy is accountable. Barry has over one hundred publications, including 18 books addressing client feedback, consumer rights, and the power of relationship in any change endeavor. Because of his self-help books (the latest is What’s Right With You), he has appeared on Oprah, The View, and several other national TV programs.
About The Psych Central Podcast Host
Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, Mental Illness is an Asshole and other Observations, available from Amazon; signed copies are also available directly from the author. To learn more about Gabe, please visit his website, gabehoward.com.
Editor’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.
Announcer: You’re listening to the Psych Central Podcast, where guest experts in the field of psychology and mental health share thought-provoking information using plain, everyday language. Here’s your host, Gabe Howard.
Gabe Howard: Hello, everyone, and welcome to this week’s episode of The Psych Central Podcast, I’m your host Gabe Howard and calling into the show today, we have Dr. Barry L. Duncan. Dr. Duncan is the CEO of Better Outcomes Now and a psychologist, trainer and researcher. His self-help books, the latest is What’s Right With You, have led to appearances on Oprah, The View and several other national TV programs. Dr. Duncan. Welcome to the show.
Barry L. Duncan, Psy.D.: It’s great to be here again. Thanks for having me.
Gabe Howard: Today we’re going to discuss holding therapists accountable and their need to evolve. Now, as a person living with bipolar disorder, I can tell you that patients are always encouraged to change our way of thinking and to evolve. But in some ways, therapy hasn’t really changed all that much in the 20 years that I’ve been involved. Now, I’ve been involved as a patient. But Dr. Duncan, what are your overall thoughts on that?
Barry L. Duncan, Psy.D.: Well, I think you’re right on the money with that, I mean, as a profession, we really haven’t changed a heck of a lot in the last hundred years in a lot of ways. I mean, there’s a lot of these models and techniques. In fact, there’s over four hundred models and techniques now. But a lot of things about psychotherapy have not changed, like, for example, who’s in charge and how the hierarchy works and who calls the shots and how collaborative it is. And all of those things are pretty much the same as it’s always been. And that’s why we do need for therapists and the field itself to evolve to be a bit more accountable than it’s been in its last hundred years.
Gabe Howard: It’s interesting to me that you say it really hasn’t evolved in the last hundred years because everything’s evolved in 100 years. I can’t hang on to a cell phone for more than six months before it’s considered outdated old technology. So for something to last a hundred years, was it just perfect or are we really using this antiquated method that isn’t giving us our best results?
Barry L. Duncan, Psy.D.: There had been an evolution of different models and techniques and ways of understanding people’s problems and way of treating people’s problems. The only problem with that is that no one approach now developed is any more effective than the approaches developed 50 years ago.
Gabe Howard: Gotcha.
Barry L. Duncan, Psy.D.: All approaches work about equally well. That means, then, that psychotherapy as a treatment endeavor has not improved. It was as effective 50 years ago as it is right now. That’s the disconcerting part, and that is because we have not been results oriented. We haven’t been accountable to the client, the consumer or the patient, whatever you want to call that person sitting in the room with you, we haven’t been accountable to what they think would be a successful conclusion to the therapy.
Gabe Howard: And is that who you think that therapist should be accountable to?
Barry L. Duncan, Psy.D.: Yes, it would be totally accountable to their perception of their own benefit, their perception of their experience of the therapy itself, rather than feeding the therapist, the provider, the psychiatrist, a psychologist, whoever they’re seeing, instead of fitting their viewpoint of how the therapy should go, how the patients should wind up, it should be taken from the construction, the perception of the person receiving the treatment.
Gabe Howard: Do you get a lot of pushback when you say that, because I know people living with mental illness or even people with mental health concerns, we often feel like whenever things go well, it’s because we have a great therapist. And whenever things go poorly, it’s because we’re not listening to our great therapist. That’s our world. But you’re over on the other side. Do your colleagues like you saying this publicly?
Barry L. Duncan, Psy.D.: Actually, a lot of them do, but there’s a portion that don’t like that arrangement where they blame the client when there’s no change and take credit when there is, I would like for that to be spun around completely, 180 there. And when there is change that the client take credit for making the changes because they’re the ones doing it. And when there’s no change, it’s about the treatment model and how the treatment model interacted. Is the right fit for the person receiving it rather than putting the blame on the client’s shoulders, which is what psychotherapy has done since the beginning. Right. When there’s no change, it’s because of the client’s psychopathology. Think about how we organize our profession. If you change, it’s because I’m so super brilliant and I’m a great practitioner, if you don’t change well, you are quite sick. This is going to take more time, more effort, more drugs, more therapy. That’s been the kind of mentality. I think that kind of story is reaching its end at this point. And people are starting to realize that they’re far more fruitful ways of going about this.
Gabe Howard: A lot of my listeners don’t know this, but whenever we set up a guest on the show, we always ask the guests to submit some questions because they know the questions that they get asked most of all. And I can’t know everything as much as I tell my wife that I do. And one of the questions that you submitted, I think it might be my favorite question ever. The question is, what does the death of George Washington have to do with our topic today, Dr. Duncan?
Barry L. Duncan, Psy.D.: Actually, it is the perfect story for our situation today, because here’s what happened to little George after he retired from the presidency, right? Right. His Mount Vernon estate every morning. And on a cold, blustery December day in 1799, he got back from his ride and he got a sore throat and a cough. And so, they put him to bed and they summoned the area physicians. The first physician got there and administered the standard of care of the day, and Washington’s condition grew worse. The second physician got there, re-administered the standard of care of the day and Washington lost consciousness. And then finally, the third physician arrived later that night, re-administered the standard of care to an unconscious George Washington, and by the next morning, George was dead. Now, what was that standard of care? It was bloodletting. And while medical historians quibble over whether or not the bloodletting hastened his demise or outright killed him, the fact of the matter is that they continue to apply the same treatment despite direct evidence from the patient that it clearly was not working and making it worse. And that’s exactly what people do today. They will continue to administer the same treatment to a client despite direct evidence that the treatment isn’t working. That code creates chronicity in clients. It causes them to get worse over time. We used to call that bloated files syndrome. It was more about the person who’d been in so many unsuccessful treatments, more so about that than about the person themselves. The people began to have a mentality about themselves, that they’re untreatable, they’re too sick, they’ll never get better rather than having it look to the outside and saying, gosh, maybe the treatments I’ve been getting or not what I am needing and let me try different people, different treatments to see if I can get to a better place.
Gabe Howard: I think that this leads to patients just giving up. I hear the word quackery a lot. I hear that they the therapist just wanted to talk to me and it didn’t do any good. And you hear a lot of terms to describe therapists from the disgruntled. Do you think that part of that disgruntled-ness comes from what you’ve just described?
Barry L. Duncan, Psy.D.: Absolutely. People become disgruntled when there’s no change and when they see no possibility for change or no hope for change, one of the factors that makes treatment beneficial for people is that it inspires hope. A very famous psychiatrist, Jerome Frank, had a very nice perspective on this. And he thought that when people come to treatment, they are demoralized by their lives and they believe that every day is going to be just as miserable as today. But what therapy does is, in his words, re-moralizes or gives them the possibility that’s not true. And then that inspires people to catalyze them into action. And then they do things to make meaningful changes in their lives when it’s not helping. Therapy can make you quite disgruntled and start to believe that you’re unchangeable, which is the worst conceivable outcome.
Gabe Howard: So this begs the question, Dr. Duncan, how do we get therapy, which, as you stated, hasn’t really changed all that much in the last hundred years? How do we get them all to change?
Barry L. Duncan, Psy.D.: There has been a movement within psychotherapy, this called systematic client feedback, and Michael Lampert is the pioneer of this. And he had this idea that why not measure in each encounter with a client’s believe they’re benefiting from their therapy and then those clients who aren’t benefiting will be identified so that the therapist can then do something different with them? That’s a great idea. But there’s a more radical side that really appealed to me. And that was that don’t make it an expert kind of a process. Don’t make it to where it just gives information to the therapist. Why not let it be a collaborative process that’s done together with the client and the provider and have that process of monitoring outcome to see whether or not the person is benefiting and then collaboratively figuring out what else can be done and or to move them on to greener pastures with somebody else, if indeed they can’t collaboratively come up with different ideas to be beneficial to the client. The relationship is called the Therapeutic Alliance, which if the alliance isn’t good, it’s very unlikely for anything good to happen in the therapy. We also check in with people in each and every encounter about how was this experience for you today? Are we talking about the right stuff, the approach that we’ve taken to address your goals? Do you really think that’s going to be helpful to you? So we check that out with these two four item scales.
Barry L. Duncan, Psy.D.: It takes less than five minutes. And when you do that, you identify the consumers who aren’t benefiting. Because an important thing we know, Gabe, is that who is providing the service accounts for most of the change of any treatment being administered. Now, what that means is that it doesn’t matter whether your psychodynamic or your cognitive behavioral, who you are as a person accounts for much more how change happens with clients than the models and techniques that you use. If that isn’t in line with the clients, the best thing you could do is to fire yourself and let the person see someone else.
Gabe Howard: Let’s step away from therapy for a moment and even step away from mental health treatment and into physical health treatment or just patients versus doctors. There’s a huge movement in America right now for patients voices to be heard. And again, I want to be very clear. This isn’t a therapy relationship or even a mental health relationship. This is all of patients feel that they are not being partnered with. And when I say all of patients, they don’t have the downside of having the discrimination or the stigma of being out of their mind or crazy or not thinking straight or we need to do this for their own good, because after all, they can’t advocate for themselves because they’re sick. And I point that out because if it’s happening over on the quote unquote, physical health side, meaning for somebody with cancer, for example, what hope does the mental health side have? Because we’re much easier to ignore? Can you talk on that for a moment? Because I know that many patients are like, look, even in the best of circumstances, we’re not believed.
Barry L. Duncan, Psy.D.: From a medical point of view, it’s really the same dynamic that exists, you have an expert and the patient who needs the help of the expert. What you find is that relationship and medical treatment is also predictive of eventual outcomes, even with biological markers has been a recent research in the last five years that when patients believe they have a good relationship and good communication with their medical provider, they get better outcomes and even biological marker better outcomes. So the same processes could be helpful in medical care. In fact, my colleagues and I have developed measures for primary care docs, so the same dynamics exists there. So we validated our measures in primary care science and our next step is to actually try and see if it improves outcomes. Once we started measuring outcomes and doing this collaborative process with clients and psychotherapy to solicit their views and whether they’re benefiting and solicit their views of how the experience of therapy was going. We then started doing randomized clinical trials, which is the language of science, where you compare clients who didn’t have the support of their treatment and clients who did. And we’ve done eight randomized clinical trials now and it doubles overall treatment outcomes for those clients who have systematic client feedback as part of their therapy.
Gabe Howard: I don’t know why we separate mental health and physical health out, but for the purposes of this conversation, moving it out of the physical health realm and into the mental health realm, patients know that we have to be involved. We see a therapist one hour a week and then all the other hours or hours. Essentially, if we don’t participate in therapy, it does not work. We know that hard stop. You cannot send an unwilling person to therapy and expect it to do any good. They’ll just sit there and ignore you for an hour and then go off and do whatever they want. So knowing that is an absolute fact, why do you think you’re getting any pushback whatsoever? Is there I’m going to use a mean word. Is there just an arrogance among therapists that they can convince people who don’t want to listen, to listen, or is it just deeper than that?
Barry L. Duncan, Psy.D.: I think there’s certainly an arrogance there, but I think that there’s I call organizational apathy toward doing anything, that it’s a change. We like to work the way we’ve always worked. That’s always worked for us before. They see it as adding to what they’re already doing. A lot of therapists believe that they are overworked and underpaid. The master’s in social work and master’s in counseling are the two lowest paid master’s degrees in the United States. It’s different in Europe, but here in the US, it’s a very low paid master’s degree. People feel up against it a lot of times. And so when they’re asked to do more, know someone comes in from the outside and said, this is the greatest thing since sliced bread and it improves outcomes and decreases dropouts. It’s a way to be collaborate with people like. Oh yeah, I heard that was the last paradigm shift. So people tend to hunker down. Implementation is a long term process for people and it takes training and use and supervision. And I basically tell people when I’m implementing an agency that about twenty five to thirty three percent of therapists will say, I really like this, I’m going to do it. I see the benefit from it right away. But then everybody else has to be brought along. And most people learn from their own experience. So they need to have the experience of it being useful to them before they’ll completely buy in.
Barry L. Duncan, Psy.D.: Arrogance is certainly part of it. And there’s that, that this is an old old idea, back and from the beginning, the sanctity of the closed room, nobody else in there except me and the client, no outside influences. And this is this private time. And I don’t want to let anybody else or anything else in and doing any measurement process or formally soliciting the client’s voice. It’s not what I’m about. The really sad part is that a lot of therapists and this is the arrogance or believe that they know what the client needs and wants without ever asking them. That’s the part that drives me crazy. They think they already know the answer. You did an RCT in Norway, and the person I was working with, Morten Anker, he is a good friend of mine. He did a survey of the therapists before we did the trial and there were ten therapists. And he asked them, do you think that getting systematic client feedback about the client’s view of benefit and their view of the alliance? Do you think that will improve your effectiveness? All ten said no. We already know whether people are benefiting. We already know whether we have a good alliance with people. And guess what happened? Only one of the ten was correct because nine out of ten improved their effectiveness with this systematic feedback from the client.
Gabe Howard: Stay tuned and we’ll be right back after these messages.
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Gabe Howard: Welcome back, everyone. We’re here with Dr. Barry L. Duncan, discussing how to hold therapists accountable and their need to evolve. Dr. Duncan, is that you’re met with this resistance and you are able to overcome it, but what do you say? There’s this knee jerk reaction in me to say, hey, I told you that this would be better for your patients. Why are you arguing with me? But I know as an advocate, yelling at people doesn’t ever work. So I’m curious as to your method, because, as you said, you’re overcoming years of thinking and people’s ways of doing things.
Barry L. Duncan, Psy.D.: Yes, we’ve implemented many places. In fact, we have one point five million administrations of our measures in our database, so there are many people doing it there. Thirty thousand registered users on our website. But there is this kind of initial response. And I first started training people. I was shocked that they didn’t say, wow, this is such a great idea. We’re going to do this right away because it identifies our people who are benefiting in mixed therapy, more collaborative and honoring the client’s voice and all of these values that people are always reporting that they have, that when push came to shove, they wouldn’t actually do it. And I was shocked by that. I had to develop ways of inspiring people rather than mandating people do this. And what really got me into it was it’s about social justice and client privilege and making sure that we level the playing field with clients and we got them engaged and involved. But other people get on board for other reasons. It identifies the people who are likely to drop out before they drop out. It improves effectiveness. It’s been proven in real world settings to raise the bar of everybody’s performance. It involves the known predictors of how people change. My kind of go-to in helping win people over is to show them the work. Therapists really like to see the work itself, because then I go from being a talker about it to showing them.
Barry L. Duncan, Psy.D.: And I, of course, releases from my clients and anonymize the videos. But I show them the actually doing this with people and people’s comments about liking being involved in the process, liking being involved in all of the decisions, liking how transparent the process is and getting better, recapturing some people that would have otherwise not benefited. I have a video that’s very popular with therapists where it’s a client who I was not successful with. I really wanted to be successful with her. I really liked her. She was a great young person, couldn’t have wanted her to work through her struggles more, but I was not the right fit for whatever reason. And then I do a consult with one of my colleagues who took over therapy, and then she changed quite rapidly. So the message is that we all have clients who don’t benefit and there’s nobody that’s one hundred percent effective, the very best therapist on the planet, or about two thirds effective, which means that one third of their clients do not benefit, that if we identify who those third are, we can either change up what we’re doing or we can get them in front of somebody else. That is a better fit. In the old days before I started doing this, I think I would eventually figure out that I wasn’t being helpful to people, but they may have dropped out by the time I figured it out.
Gabe Howard: Right, and then you can’t refer them.
Barry L. Duncan, Psy.D.: They can’t be referred, and it means they walk away saying therapy wasn’t helpful rather than saying therapy with Barry wasn’t helpful and it could be helpful with somebody else, with different ideas, different trainings, different kind of personality, whatever. It got me to the end of right away with people from the second or third encounter saying, does it look like things happened? What do you think we should do about that? And that conversation is really cool because it does comment on the partnership. And we can get to maybe if there is something that’s holding us back, have a frank conversation about it and move on, or we need to change approaches altogether or think about it in a different way.
Gabe Howard: Dr. Duncan, is there any downside to holding therapists accountable and to your method? We’ve talked a lot about the positives, but let’s be fair. Does the pendulum swing back the other way?
Barry L. Duncan, Psy.D.: There could be potential downsides, for example, if the payers, managed care companies, insurance companies use this as the sole decision to throw people out of their you reach maximum gain, no more sessions for you rather than that being. This is information, the decisions made between the client, the therapist, about when therapy should end or when it should be cut back or what have you. It also could be a downside if management decided to use it in a punitive way. For example, to say you’re your therapist, Gabe, and I say to you, well, we measure outcomes here with this system. And if you don’t attain 60 percent effectiveness with your clients, you’ll be reprimanded. Or if you get 60 percent, I’ll give you a raise. That would be a really horrible consequence. So in all of my contracts and all of my agreements, I spell those things out that it can’t be used that way. It can’t be used to reward or punish therapists. It can’t be used as the sole determinant, whether a person continues in therapy or not, because, again, those decisions are far more collaborative than that, than a number from a scale. But the number from the scale, it’s our insurance policy in that it keeps us honest so that we have those conversations with. And one thing that I really is troubling to me as I look at therapy across many organizations and many therapists, is that therapy can devolve into a place where there’s only a processing of the client’s life.
Barry L. Duncan, Psy.D.: It’s just an ongoing commentary on what’s happened that week with no thematic connection to a change that is being tried for. That winds up happening because it’s a much easier thing for people to do rather than being accountable for making a meaningful difference in people’s lives. And that’s why measuring outcomes is very important. You can prevent that. I do implementation a lot of agencies that wind up doing supervision and I’ll say, what are you working on? And I’ll say he’s been through a lot. And this is a place where you can come and get support and say, so what’s the end game to providing support? This is the only place that he can get that. I said, wouldn’t it make sense to have a discussion about a goal that he could get support in his real world because you’re not going to invite him home for Thanksgiving dinner? Right.
Gabe Howard: All right.
Barry L. Duncan, Psy.D.: We’re not really a support system. Not really. We’re temporary support system for people. We hope that they can get support systems in their natural world and that we are not a replacement for those things. And that’s what happens. A lot of time therapy can become replacement. And we’re not that kind of relationship. And those lines can get really blurred when those circumstances when you’re not accountable to person, to clients and first to there being some results that come from it, we can have these endless process oriented, support oriented therapies now in saying that there’s nothing wrong with process or support, but there shouldn’t be that change component. That’s a part of it.
Gabe Howard: Dr. Duncan, as both a patient and a mental health advocate, I like anything that improves outcomes for patients because that’s me. I want outcomes to improve. I do believe that therapists want outcomes to improve as well. It’s just we’ve always done it this way. Why do we need to change? Change is scary. It’s the kind of thing that you often go to therapy for.
Barry L. Duncan, Psy.D.: Absolutely. You know, one of my favorite agencies of working with, they’re called Wesley Community Action, and they have a big poster in their waiting room and it says, We pledge to have as much courage as the people that we serve. We have to be courageous ourselves as therapists to make changes that we know are for the better, rather than saying the way we’ve always done them, because that’s where our comfort zone is. And we ask clients to make changes all the time. We ourselves aren’t willing to do it. Sad commentary on us, basically, but it takes courage to do things that are different. It’s hard for some therapists to get feedback that therapy is not helping. OK? Wouldn’t you rather know? It’s not helping them believing that it does and then the client drops out. You don’t know why some therapists are squeamish about getting direct feedback about the relationship. Those are incredible things for people to say to you because they’re trusting you enough that there won’t be some negative consequence by their being candid with you. And that’s exactly what we want clients to be with us is as candid as possible. It’s a gift when clients say things negative to you, because if you can work through that with them, it will build the alliance even stronger and the client will be more likely to benefit from the service.
Gabe Howard: I like that, I like that a lot, Dr. Duncan, do you have any last words or comments on the topic? And also where can people find you online?
Barry L. Duncan, Psy.D.: BetterOutcomesNow.com is the Web site, BetterOutcomesNow.com and there’s a section called Resources and there’s all kinds of free resources there, articles, videos about a lot of the stuff we talk about there, brief videos about. Lots of free stuff, in fact, 253 downloads are on the website.
Gabe Howard: Wow, lots of cool stuff.
Barry L. Duncan, Psy.D.: And something I’d like to leave you with is if you were a client in therapy, if you would like for that therapy to be accountable, it would be a nice thing to bring up to your therapist. And you could tell your therapist that he or she can download the measures for free from the website. BetterOutcomesNow.com and watch a video and could learn how to use them quite readily. They want to go so far as to read a book. They can do that too. In my book, What’s Right With You, which is written for a general audience, I recommend that you monitor the progress of your own therapy. Even if your therapist says that you do it, you monitor your own progress so that you have a sense from session to session whether or not you are gaining. And of course, that book tells you how to do that. There’s also stuff online that would help you how to do that. That’s a free download.
Gabe Howard: And advocating for yourself as a patient is something that, well, Gabe Howard, Psych Central and pretty much every organization that I’m involved with highly recommend. Steer your own bat. I think that’s really the bottom line. When we wait for stuff to happen to us, we’re not really in control. And when we advocate for ourselves with our doctors, our medical teams and even in our own families, workplaces and general society, I think it really does impact our outcomes, our mental health and, of course, our overall lives.
Barry L. Duncan, Psy.D.: Absolutely.
Gabe Howard: Thank you, Dr. Duncan, and thank you to all of our listeners for listening. My name is Gabe Howard and I am the author of Mental Illness Is an Asshole, which is available on Amazon. Or you can get a signed copy for less money over a gabehoward.com and I’ll even throw in stickers from the show. Remember, we have a super secret Facebook page over at PsychCentral.com/FBShow. I recommend that you sign up for that. If you have any topic ideas, please, please, please send them to me at [email protected] Wherever you downloaded this podcast, please, please subscribe. Use your words and tell other people why they should subscribe. Ratings are powerful and remember, you can get one week of free, convenient, affordable, private online counseling any time anywhere simply by visiting BetterHelp.com/PsychCentral. We’ll see everyone next week.
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