In this controversial book, psychologists Barry Duncan and Scott Miller, cofounders of the Institute for the Study of Therapeutic Change, challenge the traditional focus on diagnosis, "silver bullet" techniques, and magic pills, exposing them as empirically bankrupt practices that only diminish the role of clients and hasten therapy's extinction. Instead, they advocate for the long-ignored but most crucial factor in therapeutic success-the innate resources of the client. Based on extensive clinical research and case studies, The Heroic Client not only shows how to harness the client's powers of regeneration to make therapy effective, but also how to enlist the client as a partner to make therapy accountable. The Heroic Client inspires therapists to boldly rewrite the drama of therapy, recast clients in their rightful role as heroes and heroines of the therapeutic stage, and legitimize their services to third-party payers without the compromises of the medical model.
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About the Author
BARRY L. DUNCAN is associate professor, School of Social and Systemic Studies, Nova Southeastern University, and the cofounder and codirector of the Institute for the Study of Therapeutic Change. SCOTT D. MILLER is cofounder and codirector of the Institute for the Study of Therapeutic Change, in Chicago, Illinois. Duncan and Miller, with Mark Hubble, are the coauthors of the bestselling Handbook of Solution-Focused Brief Therapy.
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Therapy at the Crossroads
The Challenges of Clinical Practice in the Twenty-First Century . . . every man his greatest, and, as it were, his own executioner.
--Sir Thomas Browne, Relgio Medici (1643)
One day, as the ancient fable by Aesop goes, the mighty oaks were complaining to the god Jupiter. "What good is it," they asked him bitterly, "to have come to this Earth, struggled to survive through harsh winters and strong fall winds, only to end up under the woodcutter's axe?" Jupiter would hear nothing of their complaints, however, and scolded them sternly. "Are you not responsible for your own misfortunes, as you yourselves provide the handles for those axes?" The sixth-century b.c. storyteller ends the tale with a moral: "It is the same for men: They absurdly reproach the gods for the misfortunes that they owe to no one but themselves" (Duriez, 1998).
Why the Field Is on the Verge of Extinction
The greatest enemy of the truth is not the lie--deliberate, contrived, and dishonest--but the myth--persistent, pervasive, and unrealistic.
--John F. Kennedy (1917-1963)
A recent flyer from the Behavioral Science Book Service offered to send three books deemed "The Essential Clinician's Reference Set" to any therapist who joined the club. What were these three books the ad claimed every mental health professional would "refer to over and over" throughout his or her career? In the order they appeared on the brochure: Essential Psychopathology and Its Treatment (Maxmen and Ward, 1995a) revised to reflect new and changing diagnostic classifications contained in the Diagnostic and Statistical Manual (DSM)-IV (American Psychiatric Association, 1994); the second edition of Psychotropic Drugs: Fast Facts (Maxmen and Ward, 1995b); and The Clinicians Thesaurus (Zuckerman, 1995), updated to include the ever-increasing special language of mental health. Inside the envelope, a personalized letter urged the recipient to take advantage of a superb offer. All three books could be had for just under six dollars--more than a bargain for clinicians in these lean times. The only requirement was filling out the membership application and agreeing to purchase at least one additional book over the next twelve months. Then, the ad promised, the "'must read' references you'll use every day" would arrive in just a few weeks!
The State of the Field
A cursory review of professional publications and training offerings strongly suggests that those plying their trade in the advertising business are not far off the mark. For example, of all the continuing education workshops to appear in a recent advertisement for the American Healthcare Institute (AHI, 1999)--one of the nation's largest sponsors of training for therapists--nearly 90 percent were organized around a psychiatric diagnosis. Of these, 70 percent taught specific treatments for specific disorders as defined in the DSM-IV. As another example, consider that nearly two-thirds of the articles appearing in the prestigious Journal of Consulting and Clinical Psychology during 1997 were organized around a psychiatric diagnosis and more than a quarter reported on specific treatments for specific DSM disorders. In fact, funding for studies not related to a specific DSM-IV diagnosis dropped nearly 200 percent from the late 1980s to 1990 (Wolfe, 1993). The bottom line: The field is interested in psychopathology and treatment methods.
The Problem with the State of Affairs
Now, at this point, one might reasonably wonder what could possibly be wrong with these three aspects of current mental health practice? What is so bad, for example, about a day of psycho-education aimed at informing people about the nature of mental illness and helping them overcome the stigma and natural resistance to treatment? For that matter, what is wrong with diagnosis and an emphasis on pathology? After all, people do not go to therapy when they are doing well! Doesn't it just make sense that to help a person, the therapist must first figure out what is wrong with them? And finally, isn't interest and growth in medication treatment and the number of available therapy approaches a useful development in the field? For far too long, the mental health professions were dominated by the "one size fits all" approach to treatment based on the thinking and techniques of Sigmund Freud. Does not the increase in the number of techniques, models, and medications reflect a growing sophistication and effectiveness?
HOW THERAPY CAN GET ITS GROOVE BACK
Becoming Client Directed The dogmas of the quiet past are inadequate to the stormy present.
--Abraham Lincoln (1809-1865)
During the 1980s, the attention of the field was riveted on psychiatrist Milton H. Erickson. Clinicians could not seem to get enough information about the hypnosis pioneer whose intriguing therapeutic methods defied conventional practice and seemed to work with the most intractable cases. Learning to do what Erickson did was not an easy task, however, because he steadfastly resisted the temptation to develop a general, organizing theory for his work. He summed up his reason for this by saying, "I think any theoretically-based psychotherapy is mistaken because each person is different" (Zeig, 1980, p. 131). Curiously, this did stop Erickson's students from attempting to understand the magical mysteries underlying his work. Indeed, in the years immediately following his death, a plethora of books and articles were published. Each purported to uncover the rules governing what was fast becoming known as "Ericksonian Therapy" (Bandler and Grinder, 1975; Erickson and Rossi, 1979; Gilligan, 1987; Gordon and Myers-Anderson, 1981; Lankton and Lankton, 1983; O'Hanlon, 1987; Rosen, 1982; Zeig, 1980, 1982).
BECOMING OUTCOME-INFORMED IN CLINICAL PRACTICE
Direct experience is inherently too limited to form an adequate foundation either for theory or for application. At the best it produces an atmosphere that is of value in drying and hardening the structure of thought.
--B. H. Liddel Hart (1967, p. 3)
On a cold, wintery December day in 1799, the sixty-seven-year-old former president of the United States, George Washington, returned to his mansion from his usual morning ride on the grounds of his Mount Vernon estate. The day continued in normal fashion. The former president and first lady read newspapers together in the parlor, while the household staff busied themselves with duties around the estate. As the day wore on, however, a minor sore throat the president had been experiencing since his morning ride worsened. By early the next morning, his condition was so grave that a doctor was summoned.
The doctor--along with two other physicians who eventually made it through the snowy weather to Mount Vernon--skillfully and competently administered the accepted therapy of the day. When no results were observed, the three agreed that more of the same treatment was indicated. Several hours and two additional treatments later, the president was dead. The cause of death? Whatever course the disease might have taken, historians agree that the treatment he received while in an already weakened state likely hastened his demise. This intervention, of course, was the accepted "standard of care" for late eighteenth-century medicine--blood letting (Flexner, 1974).
THE TERRITORY AHEAD
To follow knowledge like a sinking star, Beyond the upmost bound of human thought . . . To strive, to seek, and not to yield.
--Lord Alfred Tennyson, Ulysses (1842)
Let's confront the unpleasant reality and say it out loud: "The field of therapy is in trouble." More distressing but less obvious, popular clinical beliefs and practices are in large part responsible for the mess in which therapists presently find themselves. In Chapter Two, we challenge these standard mental health practices that cast clients as extras and exclude them from their own change efforts. We explode mental health mythology to make room for recasting the client in the leading role.
Table of Contents
Foreward by Larry E. Beutler, Ph.D.
Therapy at the Crossroads.
Mental Health Mythology.
The Shift to Client-Directed Change.
Becoming Outcome-Informed in Clinical Practice.
Client-Directed, Outcome-Informed Therapy in Action.
The Clien'ts Theory of Change.
The Client as Researcher and Supervisor.
Client-Directed, Outcome-Informed Therapy on Planet Mental Health.
Epilogue - Last Call for the Heroic Client.
Appendix I. A First-Person Account of Mental Health Services (by Ronald Bassman).
Appendix II. Consumer/Survivor/Ex-Patient Resource Information (by Ronald Bassman).
Appendix III. Consumer Tips for Therapy.
Appendix IV. Resistance, Subversion, and Insurrection: A Quick Guide.
Appendix V. Process and Outcome Measures.
Appendix VI. Loony Bird Awards.
What People are Saying About This
Praise for this Book:
'The Heroic Client calls forth a therapeutic union between therapist compassion and accountability with client wisdom. This book inspires us to re-remember why we became therapists in the first place.'
----Stephen Madigan, director of training, Toronto Narrative Therapy Project, and managing editor, www.planet-therapy.com
'Warning: If you're addicted to long letters of appreciation touting your clinical prowess, this book will be hazardous to your mental health. Duncan and Miller will show you how to harness your clients' expertise and make therapy a more collaborative, outcome-oriented experience. But fasten your seatbelts, you're in for a humbling ride!'
------Michele Weiner-Davis, author, Divorce Busting
'Few authors have captured and articulated the challenges facing practicing clinicians as well as Duncan and Miller. This is must reading for graduate students and novice therapists who are entering the field, thought provoking and stimulating reading for seasoned professionals.'
----Michael J. Lambert, Brigham Young University