The Heroic Client: A Revolutionary Way to Improve Effectiveness Through Client-Directed, Outcome-Informed Therapy

In the thorougly revised edition of the "Heroic Client", Duncan, Miller, and Sparks now advocate "A Revolutionary Way to Improve Effectivness." They invite mental health professionals, of any discipline, to partner with clients in all aspects of their care and abandon the search for the best therapeutic process or evidence-based therapy, and instead, focus on client-based outcome feedback to improve effectivness by an incredible 65 percent! As in the previous edition, the strength of the authors' arguments for practicing "Client-Directed, Outcome-Informed Therapy" lies in their comprehensive and enlightening review of the science behind "what works" in psychotherapy. The revised edition updates the reader on the latest empirical findings targeting the limitations of applying the medical model toward resolving human problems-namely the myth of psychiatric diagnosis, the myth of evidence-based practice, and the myth of the magic pill. The sections examining the science of evidence-based practice and the ethics and science of using medications (especially for children) are significantly expanded, thought provoking, and timely. Also of significance, in the revised edition is the authors' unvailing of their own empirically tested process (Session Rating Scale-SRS) and outcome (Outcome Rating Scale-ORS) measures which have adequate psychometric properties, and of equal importance, are designed to be feasible for clinical settings. Using the SRS and ORS together, the authors report that their outcome management system offers the only system currently available which tracts both outcome and the alliance in a practical manner. Finally, as in the original text, Duncan, Miller, and Sparks intersperse case examples throughout their book to demonstrate the application of their approach to helping people change. The revised edition could stand alone, without the reader needing to read it's predesesor. The only dissappointment to this reviewer was the mention in the first edition of The Nova Southeastern University (NSU) Pilot Project- Duncan and Miller's proposed solution to address some of the problems associated with conducting outcome research in the clinical setting. In the original "Heroic Client", they stated that results were preliminary because the study was still underway at press time and that two replications were planned. Unfortunately, the revised edition does not revisit this promising study. Nonetheless, Duncan, Miller, and Sparks offer a simple, yet compelling message which has tremendous ramifications for the training, practice, and the delivery of mental health services. They are not just whinning about "business as usual" nor do they advocate another theory or therapy method which falls short of empirical support. Instead, the authors remind therapists that we are in the business of change, and out of respect for our clients who seek our sevices and the third party payors who help reimburse it, we must translate empirical research

Barry Duncan and Scott Miller are with Marc Hubble directors of The Institute for the Study of Therapeutic Change (...). These people play an important role in improving and renewing therapy. In this book, the authors explain how therapy has for too long been been neglecting, ignoring, and depersonalizing clients, by its over-emphasis on methods and techniques, by following the medical model, by its emphasis on pathology, by hegemony of biological approaches, and so on. The authors first debunk the myths of: 1) PSYCHIATRIC DIAGNOSIS: a) it lacks reliability, b) it lacks validity, c) it puts the blame on the client, and d) it is often motivated by self-interest, fueled by greed, and blows with the winds of fashion, 2)DRUG TREATMENT OF MENTAL PROBLEMS: a) they work no better than therapy in the short term b) changes brought about by medication are less likely to persist over time c) there often are severe adverse effects, d) drug studies often look better than they are because they rate improvement by looking to clinicians' perceptions, not clients' e) the relationship between drug companies and psychiatry is an unholy alliance, making most of the drug-effectiveness research very suspect 3) THE MAGIC APPROACH: a) there is no special magic silver bullet approach which is much better than another approach b) the role of the competence and experience of the therapist is rather unimportant According to the authors, four decades of outcome research have shown that there are four main factors of change, being: 1. Client factors (percentage contribution to positive outcome: 40%). 2. Relationship factors (percentage contribution: 30%). 3. Hope and expectancy (percentage contribution: 15%). 4. Model and technique (percentage contribution: 15%). Some conclusions: 1. Thoughts, ideas, actions, initiatives, traits of clients are the most important predictor of therapy success! 2. Next to what the client brings to therapy, the client's perception of the therapeutic relationship is responsible for most of the gains resulting from the therapy. 3. Models and techniques are much less important than generally thought. The authors advocate a new and refreshing approach characterised by: 1) Client-directedness. Clients' beliefs, values, theories and goals are repected, close attention is being paid to clients' initiatives, interventions and perceptions. Much attention is given to establishing the quality of the relationship, and to monitoring the clients' perception of the quality of the relationship. 2) Outcome informedness. Progress is measured from session to session using paper and pencil questionnaires. By the way: the client's experience of meaningful change in the first few visits is emerging as one of the best predictors of eventual treatment outcome. Two thoughts come up after having read this book. First, this book is refreshing indeed and a shock to the therapy system. Second, the ideas ventilated in this book might be relevant

In The Heroic Client, Barry Duncan and Scott Miller consider the whole field of "mental health," the roles of client and therapist, and the central question of what helps in therapy. They address mental health mythologies that affect the practice of therapy, including a pervasive reliance on medication, diagnosis, the medical model and priveleging the therapist's expertise. The book asks us to reflect on why we have lost confidence in the person-to-person collaboration of talk therapy, curious in light of the fact that research continues to show that talk therapy is more effective and enduring than medication for most of the problems people bring to therapy.Duncan and Miller present an exciting, well-researched and thought-provoking argument for client-directed, outcome-informed therapy, which they call "co-therapy." Based on the research on what makes for success in therapy, Duncan and Miller propose we place greater reliance on the theories of change, experiences and strengths clients bring and less on our preferred causal theories and techniques. This is a courageous and challenging book. Every mental health professional and consumer should read it. It can make a difference. Tobey Hiller MFT and Phillip Ziegler, MFT, co-authors of Recreating Partnership: A Solution-Oriented, Collaborative Approach to Couples Therapy (W.W. Norton, 2001)

For many years,both clients and therapists alike have been encouraged, rewarded,and more recently pressured into trying to squeaze themselves into what all too often becomes an ill-fitting medical model box.This box sometimes fits the needs of particular client and therapist,but most of the time one or both of the participants in this drama become disenchanted/disheartened and they remove themself from the interaction either physically ( drop out of therapy - leave the profession ) or emotionally ( burn-out/become bad therapists ).The work of Scott Miller,Barry Duncan,and others have, over the past few years, served to help breath some much needed life into the helping professions...particularly that of psychotherapy.Their most recent book,The Heroic Client, is, with the benifit of hindsight, a logical extension of their previous works/philosophy.This is a book for therapists who work in the proverbial trenches on a day to day basis.It speaks to the everyday concerns of therapists...how to be of help to others, and still like yourself in the morning...and actually want to get up in the morning to do it all over again.This book encourages therapists to surrender their hardwon professional ego/identity in the higher service of helping others discover who they are and what they want versus us trying to " encourage " our clients to learn to want what we think they should want( to be ).I for one though compassionate/sensitive etc. have done more than my fair share of theraputic manipulation over the past 23 years as a social worker.This book nurtures an impulse I've had growing inside of me for years to leave behind the illusion of security of the medical model of mental health ( does that not qualify as an oxymoron?)for the more exciting and potentially liberating process of working in a more colaborating fashion with my clients.This books medium ( no distancing professional jargon;an abundance of enlighting humor; easy to read; it's brevity;and willingness to tackle the difficult and politically incorrent issues like the limits of psychopharmacology )is very much in concert with it's message.I highly recommend The Heroic Client for both therapists and those who are considering going into therapy as a client.

Shakespeare said,"all the world's a stage..." This is very apt for the world of therapy. Indeed, imagine,if you will, that our clients and patients are in a play called Therapy. Imagine, further, that they are not villains,but heroes and villains. Still with me? If you are, then you are in for a rare treat and therapeutic feast of intervention possibilities. "The Heroic Client" is a step forward in collaborative therapeutic thinking and alliance building. If we see ourselves as therapeutic coaches as opposed to cops in the therapeutic alliance, we can empower our clients to be the heroes and heroines they are meant to be.To achieve this worthy goal, we may need to do some introspection and revision of our current approaches to the play of psychotherapy.We need to ask our selves some really pointed and even painful questions. What scripts are in our heads and in session? Are we getting in the way of the empowerment of our clients? Are we focusing on building heroes and heroines? If we are not, why not? If not, what do we plan to do about it? If we are, what can we learn from these most practical authors and exponents of one of the most potent interventions ever developed in the consulting room or lab; the client her/him self. If we are comfortable with the pyschotheatrical postion that every client has the potential to be a heroine and/or hero then we are on the right path. Our approach then must focus on becoming far more collaborative, intuitive,empowering, and inspirational than ever before. What you have in your hand in this new book are the tools to make that happen. "Heroic Client" offers up practical solutions to unleash the client's power of regeneration. By awakening the often dying seed of creativity and growth, the therapist is able to give new life to her/his cleint and in the process be part of the heroine/hero making process. Few would deny the desire to feel like a hero or heroine in the larger play out there- the play of life. As therapists we are honored and privileged to encounter and hopefully treat a variety of clients and patients. If we are doing our job right we should be empowering them to empower themselves. As we journey with them on this most collaborative learning journey we should be providing them with the power of regeneration, hope, freedom, and inevitably a fresh new set of psychological eyes, ears, heart and soul that was in them all along. Shakespeare was right, "all the world IS a play." And we are all in some ways actors and actresses on it. The authors have provided us an inspirational playbill and script that is truly transformational and liberating to both the client and therapist. If you believe in empowering your clients and patients to being more heroic, you will not find a better book to help you get there in this play called Therapy. Ira S.Katz, PhD-Soledad,California