Podcast: Therapist or Patient: Who’s in Charge?

Take part in a great discussion that will shed new light on how we should treat mental health problems.

Guest information for the podcast episode "Barry L. Duncan – Therapist or Patient"

Barry L. Duncan, Psy.D. . is the CEO of Better Outcomes Now and a psychologist, trainer and researcher with over 17,000 hours of personal experience with clients. Dr. Duncan is the developer of the evidence-based practice clinical process, Partners for Change Outcome Management Systems (PCOMS), a process that ensures clients are privileged and therapy is accountable. Barry has over a hundred publications, including 18 books on customer feedback, consumer rights and the power of relationship in any change venture. Because of his self-help books (the latest is What's wrong with you) he has appeared on Oprah, The View, and several other national television programs.

Via the Psych Central Podcast Host

Gabe Howard is an award-winning writer and public speaker living with bipolar disorder. He is the author of the popular book, Insanity 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.

Computer generated transcript for "Barry L. Duncan – Therapist or Patient" episode

Editor's note: Please note that this transcript was computer generated and therefore may contain inaccuracies and grammatical errors. Thank you very much.

Announcer: they listen The Psych Central Podcast, where visiting experts in the fields of psychology and mental health share thought-provoking information in simple everyday language. Here is 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 I'm calling 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 most recent of which is What's Right With You, have featured on Oprah, The View, and several other national television programs. Dr. Duncan. Welcome to the show.

Barry L. Duncan, Psy.D .: It's great to be back here. Thanks for the invitation.

Gabe Howard: Today we're going to discuss holding therapists accountable and moving forward. Now, as a person with bipolar disorder, I can tell you that patients are always encouraged to change the way we think and move forward. But in some ways therapy hasn't really changed in the 20 years I've been in it. Now I was involved as a patient. But Dr. Overall, Duncan, what do you think of that?

Barry L. Duncan, Psy.D .: Well, I think you are right about that. I mean, as a profession, we haven't changed much in many ways over the past hundred years. I mean, there are a lot of these models and techniques. In fact, there are currently over four hundred models and techniques. But a lot of things about psychotherapy have not changed, such as who is responsible and how the hierarchy works and who is in charge and how cooperative it is. And all of these things are pretty much the same as always. And that's why the therapists and the field itself need to evolve to be a bit more responsible than they have been for the past hundred years.

Gabe Howard: It's interesting to me that you say that it hasn't really evolved in the last hundred years because everything evolved in 100 years. I can't hold onto a cell phone for more than six months before it's considered obsolete old technology. Was it just perfect for something that was supposed to take a hundred years, or are we really using that outdated method that isn't getting us the best results?

Barry L. Duncan, Psy.D .: There has been an evolution of various models and techniques and methods for understanding people's problems and treating people's problems. The only problem with this is that no approach being developed now is more effective than the approaches developed 50 years ago.

Gabe Howard: Caught.

Barry L. Duncan, Psy.D .: All approaches work roughly equally well. So this means that psychotherapy as a treatment measure has not improved. It was just as effective 50 years ago as it is today. That's the worrying part, and that's because we weren't results-oriented. We have not been accountable to the customer, consumer or patient. Whatever you choose to call this person sitting in the room with you, we have not been accountable to what they consider to be a successful completion of therapy.

Gabe Howard: And do you think that is the one the therapist should answer to?

Barry L. Duncan, Psy.D .: Yes, it would be entirely responsible for their perception of their own benefit, their perception of their experience with the therapy themselves, rather than feeding the therapist, the provider, the psychiatrist, a psychologist, whoever they see, rather than adapting them to point of view like The course of therapy, how the patient should end, should be inferred from the construction, the perception of the person receiving the treatment.

Gabe Howard: You get a lot of setbacks when you say that because I know people with mental illness, or even people with mental health problems, we often feel that things are going well because we have a great therapist. And when things go bad, we don't listen to our great therapist. This is our world. But you're over on the other side. Do your colleagues like to say that in public?

Barry L. Duncan, Psy.D .: In fact, a lot of them do, but there is a part that doesn't like this arrangement where they blame the customer if nothing changes and if there is a credit I want that to be turned all over, 180 there. And when something changes, the customer is credited with the change for doing it. And if nothing changes, it's about the treatment model and the interaction of the treatment model. Is right for the person receiving it rather than putting the blame on the client's shoulders for what psychotherapy did from the start. Law. If nothing changes, it is due to the client's psychopathology. Think about how we organize our profession. If you change, it's because I'm so super brilliant and a great practitioner. If you don't change well, you are pretty sick. This will require more time, more effort, more medication, and more therapy. That was the kind of mentality. I think that kind of story has come to an end at that point. And people are starting to realize that they are far more fruitful ways of doing this.

Gabe Howard: A lot of my listeners don't know this, but when we set up a guest on the show we always ask guests to submit some questions because they know the questions they are asked the most. And I can't know as much as I tell my wife. And one of the questions you submitted might be my favorite one. The question is, what does George Washington's death today have to do with our subject, Dr. Duncan?

Barry L. Duncan, Psy.D .: Actually, it's the perfect story for our situation today because here's what happened to little George after he retired from the presidency, right? Law. His estate in Mount Vernon every morning. And on a cold, stormy December day in 1799, he came back from his drive with a sore throat and a cough. So they put him to bed and called the local doctors. The first doctor got there and administered the standard of day care, and Washington's condition worsened. The second doctor got there, re-administered the standard of day care, and Washington passed out. And finally the third doctor came later that night, re-administered the standard of care to an unconscious George Washington, and the next morning George was dead. Now what was that standard of care? It was bloodshed. And while medical historians argue about whether the bloodshed hastened his death or killed him permanently, the fact is that despite the patient's direct evidence that it clearly did not work and made it worse, they continue to use the same treatment. And that's exactly what people are doing today. You will continue to give the same treatment to a client despite direct evidence that the treatment is not working. This code creates chronicity for customers. It causes them to deteriorate over time. We used to call it the file bloated syndrome. It was more about the person who had received so many unsuccessful treatments, more than the person themselves. People started to have a mentality about themselves that they are untreatable, they are too sick, they will never get better, instead of letting it look outside and say my gosh, maybe the treatments I got or not what I need and let me try different people, different treatments to see if I can get to a better place .

Gabe Howard: I think this leads to patients just giving up. I hear the word quack a lot. I heard that the therapist just wanted to talk to me and it didn't work. And you hear many terms to describe therapists from the angry. Do you think some of that anger stems from what you just described?

Barry L. Duncan, Psy.D .: Absolutely. People get upset when there is no change and when they see no possibility for change or no hope for change. One of the factors that make treatment beneficial for people is that it inspires hope. A very famous psychiatrist, Jerome Frank, had a very nice perspective. And he thought that when people come for treatment, their life will demoralize them and they believe that every day will be just as miserable as it is today. But what the therapy does, in his words, is to re-moralize them or give them the chance that this is not true. And that inspires people to get them to act. And then they do things to make meaningful changes in their lives when it doesn't help. Therapy can make you quite upset and start to believe that you are immutable, which is the worst possible outcome.

Gabe Howard: So that begs the question, Dr. Duncan, how we get therapy that, as you said, hasn't really changed 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 called systematic customer feedback and Michael Lampert is the pioneer of it. And he had the idea, why not measure at every encounter with a client that he is benefiting from his therapy, and then identify those clients who do not benefit from it so that the therapist can then do something different with them? That's a great idea. But there is a more radical side that really appealed to me. And that wasn't what made it an expert process. Don't make it where there is only information for the therapist. Why shouldn't it be a collaborative process that is done together with the customer and the vendor, and that process is done to monitor the outcome to see if the person is benefiting and then work together to see what else can be done? and / or to develop them greener pastures with someone else, when he can actually not develop different ideas together that are beneficial for the customer. The relationship is known as the therapeutic alliance. If the alliance is not good, it is very unlikely that anything good will happen in therapy. Every time we meet people, we talk about how that experience was for you today. Are we talking about the right thing, the approach we took to achieve your goals? Do you really think this will help you? So let's check that 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 are not benefiting. Because one important thing we know about Gabe is that whoever is providing the service will make up most of the change in a treatment that is being administered. Now that means that it doesn't matter whether your psychodynamic or your cognitive behavior, who you are as a person, is much more responsible for how changes take place in customers than the models and techniques you use. If this doesn't align with the clients, the best way to do it is to fire yourself and let the person see someone else.

Gabe Howard: Let's move away from therapy for a moment and even from mental health treatment to physical health treatment or just from patients versus doctors. There is a large movement in America right now where patient voices are heard. And again I want to be very clear. This is not a therapy relationship, let alone a psychological relationship. This is the feeling of all the patients they do not work with. And if I tell all patients, they don't have the disadvantage of having the discrimination or the stigma of being insane or insane or not thinking clearly, or we have to do it for their own good because after all, they can't do it for themselves kick themselves in because they are sick. And I point this out, because if it happens on the physical health side, which means for someone with cancer, what hope does the mental health side have? Because we're so much easier to ignore? Can you talk about it for a moment? Because I know that many patients look like this even in the best of circumstances, we are not believed.

Barry L. Duncan, Psy.D .: From a medical standpoint, it's really the same dynamic that is out there. You have an expert and the patient who needs the expert's help. What you find is that the relationship and medical treatment also predict possible outcomes, even if biological markers have been studied for the past five years that patients get better when they believe they have a good relationship and communication with their doctor to have results and even biological markers better results. So the same processes could be helpful in medical care. In fact, my colleagues and I have developed actions on primary care documents so that the same dynamic exists there. That is why we have validated our measures in primary care. Our next step is to actually try to see if the results improve. Once we have started measuring the results and doing this joint process with clients and psychotherapists to get their views and if they benefit from it and get their views on how the therapy experience went. We then started running randomized clinical trials, which is the language of science, in which you compare clients who didn't have the support of their treatment and clients who did. We have now conducted eight randomized clinical trials that double treatment outcomes for clients who receive systematic client feedback as part of their therapy.

Gabe Howard: I don't know why we are separating mental and physical health, but for the purposes of this conversation, moving it from physical health to mental health, patients know we need to be included. We see a therapist one hour a week and then every other hour or hour. If we do not participate in therapy, it will essentially not work. We know this tough stop. You cannot send an unwilling person to therapy and expect them to do something good. They just sit there and ignore you for an hour and then do what they want. If you know this is an absolute fact, then why do you think you are getting pushback at all? Is there a mean word? Is there just an arrogance among therapists that they can convince people who don't want to listen in order to listen, or is it just deeper than that?

Barry L. Duncan, Psy.D .: I think there is certainly an arrogance there, but I think what I call organizational apathy towards anything, that it is a change. We like to work the way we have always worked. That has always worked for us. They see it as an addition to what they are already doing. Many therapists believe they are overworked and underpaid. The Masters in Social Work and Masters in Counseling are the two lowest paying Masters degrees in the United States. It's different in Europe, but here in the US it's a very poorly paid Masters degree. People often feel against it. So when asked to do more, they know someone from the outside comes in and says this is the best thing since sliced ​​bread. It improves results and reduces dropouts. It's a way to work with people like. Oh yes, I heard that this was the final paradigm shift. So people tend to crouch. Implementation is a long-term process for people and requires training, use and monitoring. And I basically tell people when I implement an agency that about 25 to 33 percent of the therapists are going to say, I really like this, I will. I see the benefit immediately. But then everyone else must be brought along. And most people learn from personal experience. So, you need to have the experience that it will be useful to them before fully shopping in.

Barry L. Duncan, Psy.D .: Arrogance is certainly part of it. And there is this, that this is an old old idea, back and from the beginning the sanctity of the closed space, no one else there but me and the client, no outside influences. And this is that private time. And I don't want to let anyone or anything else in and do a measurement process or formally solicit the customer's voice. It's not what I'm about The really sad part is that there are a lot of therapists and this is the arrogance or belief that they know what the client needs and wants without ever asking them. That's the part that drives me crazy. You think you already know the answer. You did an RCT in Norway and the person I worked with, Morten Anker, is a good friend of mine. He conducted a survey of therapists prior to the study, and there were ten therapists. And he asked them: Do you think that you will get systematic customer feedback about the customer's view of the benefit and his view of Allianz? Do you think this will improve your effectiveness? All ten said no. We already know if people benefit from it. We already know if we have good alliances with people. And guess what happened? Only one of the ten was correct, as nine out of ten improved their effectiveness through this systematic feedback from the customer.

Gabe Howard: Stay tuned and we'll be right back after this news.

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Gabe Howard: Welcome back everyone. We are here with Dr. Barry L. Duncan and discuss how therapists can be held accountable and how they must move forward. Dr. Duncan, have you encountered and overcome this resistance, but what do you say? I have this knee jerk reaction to saying, hey, I told you this would be better for your patients. Why are you arguing with me? But I know yelling at people never works as a lawyer. So I'm curious about your method because as you said, you overcome years of thinking and the way people do things.

Barry L. Duncan, Psy.D .: Yes, we have implemented a lot of posts. In fact, we have a point five million administrations of our actions in our database, so there are many people out there who do this. Thirty thousand registered users on our website. But there is this kind of first reaction. And I started training people first. I was shocked that they didn't say, wow, that's a great idea. We will do this right away because it identifies our staff who benefit from mixed therapy, are more cooperative and honor the client's voice, and all of these values ​​that people always report they have, that they when it is what mattered was pushing it wouldn't actually do it. And that shocked me. I had to develop ways to inspire people instead of forcing them to. And what really got me into it was social justice and customer privileges and making sure we level the playing field with customers and get them involved and involved. But other people get on for different reasons. It identifies the people who are likely to get off before they get off. It improves the effectiveness. In practice, it has been shown to raise the bar for everyone's performance. It includes the well-known predictors of how people change. My way of winning people over is to show them the work. Therapists like to see the work for themselves, because then I no longer just talk about it, but show them to them.

Barry L. Duncan, Psy.D .: And of course I publish from my customers and anonymize the videos. But I show them how to actually do this with people and the comments of people who like being involved in the process, being involved in all the decisions, how transparent the process is and getting better, and some people back to capture that would not otherwise have benefited. I have a video that is very popular with therapists who are a client I have had no success 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 any more, but I wasn't really fit for some reason. And then I consult with one of my colleagues who took over the therapy, and then it changed pretty quickly. So the message is that we all have clients who are not benefiting, and there is no one who is one hundred percent effective, the best therapist on the planet, or about two thirds effective, which means a third of their clients are not benefiting if we to find out who these third parties are, we can either change what we do or we can put them in front of someone else. That fits better. In the old days before I started doing this, I would probably find out at some point that I was not helpful to people, but they may have dropped out when I found out.

Gabe Howard: Right, and then you can't forward them.

Barry L. Duncan, Psy.D .: They can't be referred, and it means they go away and say the therapy wasn't helpful, instead of saying that therapy with Barry wasn't helpful and that she might be helpful with someone else, with different ideas, different ones Trainings, different personalities, whatever. It immediately brought me to an end when people from the second or third encounter said, do it look like things happened? What do you think we should do about it? And this conversation is really cool because it comments on the partnership. And we may be able to determine if there is something holding us back, have an open conversation about it and move on, or if we need to change approaches altogether or think differently about it.

Gabe Howard: Dr. Duncan, is there a disadvantage in holding therapists accountable and using your method? We've talked a lot about the positive, but let's be fair. Does the pendulum swing back in the other direction?

Barry L. Duncan, Psy.D .: There could be potential downsides, for example, if payers, managed care companies and insurance companies use this as their sole decision to get people out of their community. You get the maximum benefit, no more sessions for you than this. This is information, the decisions made between the client, the therapist, about when therapy should end or when it should be shortened, or what you have. It could also be a disadvantage if management decides to use it punitive. For example, to say that you are your therapist, Gabe, and I tell you, well, we are measuring the results here with this system. And if you do not achieve 60 percent effectiveness with your customers, you will be reprimanded. Or if you get 60 percent I'll give you a raise. That would be a really terrible consequence. In all of my contracts and agreements, I have phrased things in such a way that they cannot be used that way. It cannot be used to reward or punish therapists. It cannot be used as the sole determinant of whether or not a person continues therapy, as those decisions are, again, far more collaborative than a number on a scale. But the number on the scale is our insurance policy keeping us honest so we can have these conversations. And one thing that really worries me when I look at therapy in many organizations and therapists is that therapy can develop in a place where only the client's life is processed.

Barry L. Duncan, Psy.D .: It is just an on-going commentary on what happened this week, with no thematic connection to any change that is being attempted. This happens because it is much easier for people to do than it is to be responsible for making a meaningful difference in people's lives. That is why it is very important to measure the results. You can prevent that. I implement a lot of agencies that end up overseeing and I say what are you working on? And I will say that he has been through a lot. And this is a place where you can get support and say. What's the end game for providing assistance? This is the only place he can get that. I said, wouldn't it make sense to have a discussion about a goal he could support in his real world because you're not going to invite him home for Thanksgiving dinner? Law.

Gabe Howard: Well.

Barry L. Duncan, Psy.D .: We're not really a support system. Not really. We are a temporary support system for people. We hope that they can get support systems in their natural world and that we are no substitute for these things. And that's exactly what happens. Much time therapy can be used as a substitute. And we are not such a relationship. And those lines can really get blurred when those circumstances where you are not responsible to the person, the client and, firstly, the outcomes that result from them, we can have these endless process-oriented, support-oriented therapies now, when we say there is nothing wrong with it with process or support, but that change component shouldn't exist. That's part of it.

Gabe Howard: Dr. Duncan, as both a patient and a mental health advocate, I like anything that improves patient outcomes because I am. I want the results to improve. I believe therapists want outcomes to improve too. It's just that we've always done it this way. Why do we have to change? Change is scary. It's the kind of thing you go to therapy for a lot.

Barry L. Duncan, Psy.D .: Absolutely. You know, one of my favorite agencies that I work with is called Wesley Community Action and they have a big poster in their waiting room and it says, We are committed to having as much courage as the people we serve. We need to be courageous ourselves as therapists to make changes that we know are for the better rather than saying how we have always made them because this is where our comfort zone is. And we ask our customers to keep making changes. We are not ready for it ourselves. Basically a sad comment to us, but it takes courage to do things that are different. Some therapists find it difficult to get feedback that therapy is not helping. OK? Wouldn't you rather know? It doesn't help them to believe that they are, and then the customer falls out. They don't know why some therapists are squeamish when it comes to getting direct feedback on the relationship. These are amazing things people can tell you because they trust you enough that there will be no negative consequences if they are open with you. And that's exactly what we want customers to be with us, as openly as possible. It is a gift when customers say negative things to you because if you can work through this with them the alliance will become even stronger and the customer will be more likely to benefit from the service.

Gabe Howard: I like this, I like this a lot, Dr. Duncan, do you have any final words or comments on this matter? And where can people find you online?

Barry L. Duncan, Psy.D .: BetterOutcomesNow.com is the website BetterOutcomesNow.com and there is a section called "Resources" and there are all kinds of free resources, articles, videos on a lot of things that we are talking about there, short videos. Lots of free content, in fact 253 downloads are on the site.

Gabe Howard: Wow, lots of cool things.

Barry L. Duncan, Psy.D .: And something I would like to leave you with is if you were a client in therapy and if you want that therapy to be held accountable, it would be a nice thing to let your therapist know. And you can let your therapist know that they can download the measures from the website for free. BetterOutcomesNow.com and watch a video and learn how to use them easily. You want to go so far as to read a book. They can do that too. In my book What's wrong with youI recommend that you monitor the progress of your own therapy. Even if your therapist says you do, monitor your own progress so that you can get a sense of whether or not you are winning from session to session. And of course, this book will tell you how. There are also things online that would help you with this. It's a free download.

Gabe Howard: And standing up for yourself as a patient is something that Gabe Howard, Psych Central, and pretty much every organization I am involved with highly recommend. Control your own bat. I think that's really the bottom line. When we wait for something to happen to us, we are not really in control. And when we stand up for ourselves with our doctors, our medical teams, and even in our own families, in the workplace, and in society at large, I think it really has an impact on our results, our mental health, and of course our entire 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 Insanity is an assholewhich is available on Amazon. Or, you can get a signed copy through one for less money gabehoward.com and I'll even throw in stickers from the show. Remember we have a super secret Facebook page over there PsychCentral.com/FBShow. I recommend you sign up for it. If you have any topic ideas, please send them to show@PsychCentral.com. Wherever you have downloaded this podcast, please subscribe to it. Use your words and tell other people why they should sign up. The reviews are powerful and remember that you can get free, convenient, affordable and private advice online anytime, anywhere for a week BetterHelp.com/PsychCentral. We meet next week.

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