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The Heroic ClientReview - The Heroic Client
by Barry Duncan and Scott Miller
Jossey-Bass, 2000
Review by Daniel L. Buccino, L.C.S.W.-C., B.C.D.
Mar 31st 2001 (Volume 5, Issue 13)

Since it was published last year, The Heroic Client has already established itself as part of the psychotherapy canon. Barry Duncan and Scott Miller's book is, quite simply, one of the most important books about psychotherapy of the last decade.

In many ways The Heroic Client is the companion volume to their earlier, edited collection of state­of­the­art psychotherapy and outcome research, The Heart and Soul of Change: What Works in Therapy. Where The Heart and Soul of Change marshaled an impressive amount of science to make the case that psychotherapy works very well, but not for the reasons we usually think it does, The Heroic Client is a more user-friendly condensation of the literature. Above all else, it champions the cause of effective psychotherapy. Rather than remaining captured in the schoolist fray about what theories and techniques comprise competent psychotherapy, The Heroic Client will allow patients and therapists to focus on issues of outcome and effectiveness to evaluate the utility of their clinical work.

The Heroic Client will appeal to therapists desperate to find not only empowering survival strategies in today's managed mental health care environment, but it also offers simple yet rigorous outcome tracking systems to better make a data­driven case for the effectiveness of one's practice should that be necessary as well. The Heroic Client should also be of interest to current and potential consumers of psychotherapy services in its consideration of the common-sense factors of successful psychotherapy and its taking a somewhat jaundiced eye toward the often inflated claims of a strictly medical model view of treatment.

The Heroic Client not only demonstrates the application of common-factors in psychotherapy process and outcome, but it demonstrates how to utilize scientifically reliable and valid outcome instruments in an ongoing clinical process. The OQ45 is emerging as the gold-standard in patient-anchored outcome measurement and The Heroic Client reveals strategies for incorporating ongoing outcome assessment into the treatment process. Such "research methods" should no longer scare off the clinician; rather simple yet rigorous research methods will provide a key to success for therapist in the future. The Heroic Client helps to demystify the science behind our work while also encouraging us to attend to it.

Though there are times when the tone and arguments of Heroic Client read like the anti-psychiatry polemics of Thomas Szasz or Peter Breggin, the authors seem more interested in helping non-medical therapists and their patients reclaim their power and voice in providing effective psychotherapy than in simply toppling the scientific advances of mainstream psychiatry. In their application of science to "Mental Health Mythology," Duncan and Miller also expose the "Myth of the Magic Pill." Their withering examination of the potential financial conflicts of interest and overstated conclusions within the antidepressant medication outcome literature in particular will, if nothing else, enable patients to have a fuller conversation about the risks and benefits of the medical treatments their physicians may offer. The Heroic Client does not advocate the simple rejection of medication in the treatment of suffering patients; the authors offer a way to evaluate whether the physician's or therapist's theory of change matches with his patient's theory of change.

Additionally, what will strike many therapists and their patients as powerful about The Heroic Client is its exposure of the enormous financial stakes in perpetuating the medical model's dominance of all mental health care practice. The Heroic Client seeks to advance the science behind psychotherapy's similarly compelling effectiveness. Although much less well-funded and well-marketed than the interests of the pharmaceutical industry, psychotherapy has every reason to be proud of its comparable efficacy in many instances. With its companion, The Heart and Soul of Change, The Heroic Client reclaims a scientific legitimacy for psychotherapy and does not merely advocate a new theoretical mythology in contrast to the medical model.

Through the use of many illuminating case histories and a generally breezy tone, the authors provide a roadmap for patients and therapists about how truly collaborative, outcome-informed therapy is co-created. In attending to patients' motivation for change, goals for treatment, view of the treatment relationship, preferred views of themselves, and theory of change, therapists can reduce the chance for treatment failure and enhance cooperation better than in rigidly applying the same model or the same theory to every patient. Therapy becomes something that is truly patient-centered rather than centered on the therapist's theories about what must be wrong with his patient. Not that therapists don't need theories; they just are often not consistent with patient's theories, and sometimes an authoritative imposition of the therapist's position only alienates patients.

Finally, although The Heroic Client is an essential psychotherapy text, what is most intriguing about it are its political implications. The Heroic Client does not just advance anti-psychiatry and post-NAMI consumer/survivor positions by rote, but points to a way to integrate and amplify psychotherapists' voices in the midst of the din from the medical model and managed care.

Psychotherapy has been on the ropes because therapists have not been able to articulate the science behind the effectiveness of our work. We have been too busy squabbling amongst ourselves about how long therapy should take, how many sessions patients should be allowed, and which theory is the best for which diagnosis. Miller and Duncan's work points to a synthesis of therapy interests around issues of effectiveness rather than ongoing debates about competence. If we can collect and pay attention to the data about our work, instead of just relying on myth and tradition to guide us, we will see that therapy works quite well, often as well as medications. We should share this information and sing it from the rooftops.

But in so doing we will also see that some therapists are, quite simply, better than others. Even if we "risk-adjust," for diagnosis, demographics, severity, comorbidity, and the like, we will find that some therapists do a better, more efficient job. And success will not be due to age, gender, professional degree, years of experience, institutional affiliation, or theoretical orientation. Effectiveness will increasingly become a function of how well people have understood the lessons of The Heroic Client.

This is a finding around which patients, providers, and payers must unite if psychotherapy is not to become some elite, expensive, boutique treatment option, threatened perpetually with extinction. Big Brother will continue to watch us unless we can better watch ourselves. The Heroic Client leads us to consider how, ironically, Big Brother must become You, Watching.

Copyright © 2001 DLBuccino

Dan Buccino is Co-Director of The Baltimore-Washington Brief Therapy Institute and is on the faculties of the Johns Hopkins University School of Medicine and the Smith College and University of Maryland Schools for Social Work.


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