September 2004 – Tips & Topics

Vol 2, No.5
September 2004

In this issue
– Until next time


I have just returned from a national conference on behavioral health care, sponsored by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The focus was on outcomes research and the use of data. If you are a clinician, just wait! Before you turn off, and write this edition off to statistics and dry research information, let me assure you that I am interested in bridging the gap between research and clinical practice. Give this edition a chance!

Here are a few pearls which struck me.


Whether you are on the frontlines of clinical care, or an administrator of a program, county or state, there are increasing demands on you to implement Evidence- based Practices (EBP). Whole states have declared they will respond to Federal leadership to move the behavioral healthcare field into Best Practices and EBPs. As we do that, keep in mind some of the other research data as well.


  • Evidence-based Practices (EBPs) must be implemented in collaboration with the client and family.

This may seem obvious.

I will elaborate. Just because you may be trained in Motivational Interviewing for example, and may even be certified and proficient in that, does not mean you will automatically achieve good outcomes with clients in engaging them in treatment and moving through stages of change. Or just because your program has embraced Assertive Community Treatment (ACT) or Multi-systemic therapy (MST), doesn’t guarantee effective care.

The President’s New Freedom Commission on Mental Health established on April 29, 2002, adopted the definition of EBPs developed by the Institute of Medicine in their 2001 report, “Crossing the Quality Chasm”.
Definition of EBPs: “The integration of best research evidence with clinical expertise and patient values.”

Note that EBPs involve:
>> ” Best research evidence “
>> ” Clinical expertise “
>> ” Patient values.”

It is the third component I am addressing in the first tip. You may have the latest scientific model and technique, and be the best practitioner of that model. However, if the client is not engaged and actively collaborating in the care, your effectiveness is likely to be minimal. Research on psychotherapy and what really helps people change emphasizes this point even more.

  • Most of what contibutes to positive treatment outcomes comes from client and extratherapeutic factors, not your program, not your treatment model, not your techniques.

This is a bitter pill to swallow.

Over forty years of outcomes research on psychotherapy keeps finding the same thing:
1. Treatment is better than no treatment;
2. No treatment model is superior to any other;
3. The specific treatment model used contributes very little to the final successful outcome anyway.

And the outcome research in addiction treatment seems to be heading the same direction.
I am processing these research findings through my brain also. I can’t fully get my head around this yet.
But here are some numbers you should become aware of:

>> Overall picture
Only 13% of the outcome is due to psychotherapy; 87% is due to client and extratherapeutic factors. These factors are part of the client’s strengths, personality etc. Others have to do with the client’s environment such as social support, fortuitous events which occur between sessions at your program.
(Bruce E. Wampold: “The Great Psychotherapy Debate – Models, Methods, and Findings” Lawrence Erlbaum Associates, Publishers, Mahwah, NJ 2001, pp 207-208)

>> The treatment effects picture
Of the 13% treatment effects (what clinicians do with the client in treatment) the vast majority of the outcome- 70%- involves common factor effects such as empathy, warmth, acceptance, encouragement etc. These are common to a variety of therapies regardless of theoretical orientation.

Specific effects of your program or theoretical model accounts for (at most) 8% of the outcome due to therapy. That is not much of the total contribution to the client’s outcome.

The bottom line is this:
Instead of getting people to passively comply with your program, model or techniques, we must set up services in such a way as to harness clients’ energies, abilities, strengths and collaboration. The focus is on the alliance, engagement, retention and specific feedback on whether they are getting help. Is there a good fit between what we are doing, and what is working for them?

  • Focus on the quality of your alliance with the client. Find the best fit between the client’s views and the treatment approach.

Jerome Frank, M.D. first published “Persuasion and Healing” in 1961. He studied the unifying principles on which all techniques were based. In the introduction to the latest edition published in 1991 (Frank and Frank), this is what he said:

My position is not that technique is irrelevant to outcome. Rather, I maintain that, as developed in the text, the success of all techniques depends on the patient’s sense of alliance with an actual or symbolic healer. This position implies that ideally therapists should select for each patient the therapy that accords, or can be brought to accord, with the patient’s personal characteristics and view of the problem. Also implied is that therapists should seek to learn as many approaches as they find congenial and convincing. Creating a good therapeutic match may involve both educating the patient about the therapist’s conceptual scheme and, if necessary, modifying the scheme to take into account the concepts the patient brings to therapy.
(p. xv).(Quoted in Wampold’s book, page 217)

Clinicians and programs can adopt EBPs. But if these are not used in the context of the alliance and the “fit” with the client, the outcomes research alerts us that it is just one more model and technique – the latest flavor of the month.


Here are a couple of clinical skills tips to start actualizing these research findings. See whether these work for you.


  • When you ask a client “How are things going? or “How are you?”, listen carefully, explore and discuss their answer.

Often we view these questions as a fleeting greeting, and from there quickly move onto the real ‘meat’ of the session. But the therapeutic alliance is critical. Knowing that the vast majority of change happens outside of the therapy relationship, and is influenced by the client and environmental factors, then this is no idle greeting.

If a person says: “Fine” or “I’m doing OK“, there is a wealth of information to explore.
You could respond something like: “Really? That’s great. What has been “fine” or “doing OK” since I last saw you? And how did you do that?” Even if they say “It was a bad week“, you can say: “I’m glad you came then. Now we can explore how you coped with everything, or where you struggled.

You are actually interested in what has been working (or not) for the client in their world of family, work, school, the street, friends etc. And if they really are fine and doing well, identify and reinforce what has been working well. We want to assist them in doing more of what is working. On the other hand, if things have not gone well, strategize about what could work better today or in the coming week. There is power in the question: “How did you do that?” It reminds the client there probably was something they did differently this week which worked. How did they react to their environment? How did they cope with unexpected events or challenges?

  • Deliberately check with the client and/or family whether the treatment we are doing together “fits”, whether it is working for them.

As yet, you may not use a specific rating scale like the Session Rating Scale (SRS) or Outcome Rating Scale (ORS), developed by Scott Miller, Ph.D. and colleagues at the Institute for the Study of Therapeutic Change ( Nevertheless, you can still be sure to leave time in every session to review whether the client felt they were working on goals important to them. Or whether they felt you were listening to them, whether they felt connected and engaged; or whether they felt they were making progress.

You might say something like:
I’m in charge of the treatment plan, but you’re in charge of me. So if there is anything that doesn’t make sense to you, please say “That doesn’t make sense to me.” I will explain how I think it can help achieve what we’ve agreed to work on. But if it still doesn’t make sense and you don’t want to do it, please say so, and we won’t put it in the treatment plan. Whatever we decide to do together has to be working for you and if it is, then we’ll keep doing it. If it isn’t going well, then we can change what we are doing.”


A summer vacation in Australia- especially snorkeling off a pristine island in the Great Barrier Reef, sounds like a wonderful opportunity. And it certainly is! But August being winter in the Southern Hemisphere, it’s easy to catch colds from the cool winter waters and from coughing, feverish relatives. That’s what happened.

But this time the cold didn’t go away quickly. Sitting in a plane for 13 hours from Sydney to San Francisco didn’t help. And it didn’t just stay a cough; it became laryngitis – not a good thing to develop when you train for a living with a 2-day workshop coming up. The point is for the first time in my speaking career, I feared I might not be able to speak. This had never happened before.

I had no idea how having no voice was so difficult. Answering the phone was hopeless. I’m sure people on the receiving end were baffled by a croaky, inaudible, unintelligible squeak of sounds. Calling out to my wife in the other room was out of the question – she didn’t even know I was trying to summon her. Undertaking 2 full days of training was a daunting prospect.

I’m sure my plight is not as alarming as the image of John Kerry’s losing his voice, consequently valuable campaigning time so close to the election. But it was actually quite alarming to me, another reminder of how easy it is to take for granted what we have – physically, mentally, socially and spiritually. You’ve probably had your version of this. Perhaps it was back pain that left you flat on your back, or depression immobilizing your mind and body, or a death or loss making your heart ache. Laryngitis is trivial next to some of what you may have endured and survived.

It sure did remind me however, to guard my health and well-being carefully, not to take anything or anyone for granted. I am better than last week, and hope you are too.



Recently, I had conducted a workshop on engaging clients. We talked about starting where clients are at, and using Motivational Interviewing principles. One such principle is that of developing discrepancy between what the client wants, and what they actually do (or have done.)

Soon after, a director and supervisor sent me her brief success story. She illustrated how she had avoided a struggle with her client, how she had engaged him around a focus for treatment that made sense to him.

Thought of you yesterday when before me was a 21 year old male with NO PROBLEMS WHATSOEVER, except for his mother (totally). Our discrepancy discussion uncovered a Driving Under the Influence arrest and no high school diploma due to an overabundance of partying and a probation violation due to alcohol. It was all a big misunderstanding, he said. So, I trotted out the treatment plan idea that we could work on a goal of proving us all wrong about him and his alcohol use and his eyes just lit up and said that I understood perfectly. I know that it may not flow that way again but it felt like a good moment. Thanks again.

Joan Bilinkoff, LICSW,
MPH Program Director,
People Incorporated,
St. Paul, Minnesota

So the goal was to work together to gather the “so-called”, “no-problem”, “squeaky-clean” data that would prove everyone wrong about his alcohol use. Undoubtedly there would be some interesting discussion when hitting up against the discrepant data of past arrests, partying, and failure to complete high school.


This is sort of a success story.
It was a nice follow up to the Soul section of the last edition of TIPS and TOPICS. (If you missed it, follow the link on the homepage for previous editions. Go to

“I loved your “5 s” advice. In my son’s first year of college he also fell asleep at the wheel while driving home to Connecticut following an anti-war rally in NYC. Fortunately, he too had at least made use of one’s seatbelt an introject. Too bad we can’t add a sixth “S”: Skin, yours will be with you for life, as will any tattoos you embellish it with.”

Sam Segal

Actually, adding “Skin” would not only be good to alert our kids to consider the permanence of tattoos, but also to remember the power of the sun. Before lying out for hours acquiring a tan, “S” for Skin or “S” for Sun would remind them of the hazards of skin cancer.


A year ago, I excitedly received my allotment of a new book “Maintain Balance in an Unsteady World.” My chapter is called “What Do You Want? – The Not-So-Simple-Question”. With nearly all sold, we checked with our editor and he is shipping another smaller supply of books. So on the anniversary of this book, we are having a sale! You might get some early holiday shopping done in one swift click of your mouse.

Have you ever contemplated changing your job, where you live, or who you live with? How do you decide if you’re making the right decision? If you’d like guidance with these tough, life-changing questions, read the “What Do You Want?” chapter. It is not such a simple question- nor answer!

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Until next time

Well that’s it for now. I hope you found something in this edition to get you thinking about how we can serve people better.

Talk to you next month.