Beyond Evidence-Based Psychotherapy

Fostering the Eight Sources of Change in Child and Adolescent Treatment

George W. Rosenfeld

• Publisher: Routledge
• Year: 2008
• eBook ISBN: 9781135850029
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Beyond Evidence-Based Psychotherapy teaches students through a common factors point-of-view, combining research, case studies, multiple treatment orientations, and a perspective that describes the personal growth of a clinician's career. It differs from previous texts in that it presents the recent research on psychotherapy in a format that is understandable, memorable, and relevant to student concerns, while integrating research and clinical experience to pragmatically guide clinical decisions. This book provides students of child and adolescent psychotherapy that are pursuing degrees in psychiatry, clinical psychology, social work, and marriage and family counseling with an insight into the practice of a child psychologist with 40,000 hours of experience working with thousands of clients and families.

In the first part of the book, Rosenfeld presents 8 common factors of change in working with children and adolescents. The second part brings the reader through a "day in the life" of the author as he visits with a series of clients in various stages of treatment, bringing the material discussed in part one to life.

PART 1
Research and Theory

CHAPTER 1
What Are Reasonable Expectations for Psychotherapy?

What I Wish I Knew When I Started Being a Therapist 35 Years Ago

As a clinical psychologist I have completed almost 40,000 hours of psychotherapy in the past 35 years. These sessions have been in relative isolation, with input from a few colleagues and mentors and sporadic explorations of the treatment literature. My excellent graduate education at the University of Minnesota helped me start but became outdated as knowledge expanded and trends changed. I was educated before the field was aware of the pervasive impact of sexual abuse, domestic violence, fatherless households, and the methamphetamine epidemic that has swept the western United States. Cultural diversity was not addressed. This was in a time before brain imaging, managed care, the deinstitutionalization of the mentally ill, and the domination of evidence-based and cognitive-behavioral approaches. The feminization, desecularization, manualization, medicalization, and deprofessionalization of psychotherapy were still yet to come. It seems probable that these trends will continue to mold the development of psychotherapy, leading a panel of experts to forecast the “expansion of evidence-based therapy, practice guidelines, behavioral medicine, and pharmacotherapy” (Norcross, Hedges, & Prochaska, 2002, p. 316). No matter what direction the field takes, 35 years from now, new perspectives and discoveries will make today’s education and practice standards seem as antiquated as my training now seems to me, and the thoughts about treatment presented here will seem just as primitive as the treatment methods to which I was exposed. Being a psychotherapist clearly requires adapting to constant change and constantly changing.

When I began as a therapist, my focus was on quieting my anxieties. I worried about being competent and accepted by colleagues and clients. I greeted clients with the hope of curing them or making them “normal.” Now I am not even sure what normal is. As the saying goes, “Normal is what you think people are until you get to know them.” I tried to take away their problems, but being problem free is not a realistic goal. Life can involve moving from one damn thing to another. Clients are going to have more problems and continue to struggle with many of their same issues.

Clients were not born yesterday with a blank slate and infinite capacities to change. This is not a depressing or hopeless view. It describes the realistic boundaries in which we operate and makes improvement in clients’ lives so much more significant. A great deal is accomplished when therapy helps clients to reduce their symptoms, become more realistic, advance to the next developmental stage, become less trapped in repetitive patterns, tolerate more affect so they do not subsequently resort to as many destructive behaviors and defenses, carry fewer unexamined secrets (often forged under stress in childhood), feel less worried, and be more able to participate and find pleasure in work, play, and relationships.

My interventions were initially aimed at making the most useful interpretations and understanding connections to the past. With experience I found that interpretations were rarely necessary or sufficient to create change, that often what I had to say was not as powerful as what the client had to say, and that dealing with the past was not always appreciated, possible, or helpful. As I developed as a therapist, I focused on acquiring a wide range of other techniques. Now I value many approaches but see their usefulness as depending on the client’s situation and the therapeutic relationship. I focus less on pathology and resistances and more on the therapeutic relationship and getting to know the client’s background, hopes, strengths, feelings, relationships, present struggles, and achievements. Because the influence of family members is so powerful, I rely more on family and conjoint (parent with youth) treatment than individual therapy for treating youths, especially when the client is young, unmotivated, or difficult to engage or believe. I now look for skills to build, and I focus more on the present and future than on the past.

Now I observe not only the client and I but our interaction and progress along a more mapped-out path. I watch us struggle with engaging in the therapeutic relationship, developing a treatment plan that meets our expectations, trying to accomplish our goals without being thrown off course by our personal needs and biases, and finally ending when the clients and I are enjoying each other the most. I find myself trying to understand, attend to, and respond to so many aspects of the treatment process, the client, myself, and our interaction that being a therapist seems an unmasterable task. It is similar to the tension-reduction exercise I try to teach to some clients. I ask them to place their hands almost together with the goal of making all five opposing fingertips almost, but not quite, touch each other. As they focus on one or two pairs of opposing fingers, others stray apart and need to be attended to and brought closer. It is an absorbing, mentally and emotionally taxing task that cannot be fully mastered.

If Change Were So Easy to Accomplish, the Client Would Have Done It Already

Change Is Not as Easy to Accomplish as We Have Been Led to Expect

Our interventions are not as powerful as outcome studies would lead us to believe. Often the data supporting our techniques are derived from research on populations that are different from our typical clients because these studies usually exclude people who have more severe or multiple psychological problems, comorbid physical problems, suicidal ideation or intention, or a personality disorder; abuse substances; or are an ethnic minority (March et al., 2004; Westen & Morrison, 2001).¹ Therefore the research may not be relevant to the typical outpatient who would fail to be included in most outcome studies. Because outcome studies carefully preselect subjects that are most likely to benefit from treatment and exclude the most treatment-resistant subjects, the efficacy of a treatment technique or manual in the laboratory does not ensure that the findings are transferable to the more complex clinical environment. Also, many outcome studies give an exaggerated view of the effectiveness of treatment because they do not count dropouts as treatment failures, and the more subjects who drop out of studies, the more effective the treatment is reported to be (Bradley, Greene, Russ, Dutra, & Westen, 2005). Furthermore, they typically measure only short-term change, so we do not know the shelf life of the changes created by these techniques.

In the child and adolescent psychotherapy research, many of the studies on the efficacy of treatment are completed on nonreferred school populations rather than on groups seeking treatment. Many studies compare treatment with a specific technique to a no-treatment (waiting list) control group (Weisz, Doss, & Hawley, 2005),² so that the technique being evaluated is confounded with the therapeutic relationship, which is a significant contributor to the effectiveness of the technique. Therefore, outcome studies on specific techniques seem unrealistically optimistic.

It is naive to feel we should be able to fix (or even understand) all the people who walk into our office, irrespective of their age, intelligence, sexuality, and gender; their cultural, medical, neurological, genetic, ethnic, spiritual, and educational backgrounds; their social class; the intensity and duration of their problems; and their resources to overcome the obstacles to regularly participate in therapy. Generally, we might anticipate that the longer the client has had the problem, the more severe the problem is the more complicated it is by comorbid conditions; likewise, the less support for change there is outside of the therapy session, the more complex and difficult treatment will be.

For years I told clients not to expect magic, and it took me years to understand what I was really saying. I know how difficult it is for me to change myself and my habits, fears, and expectations, even when I have the resources and social support and am highly motivated to change. Imagine how difficult it is to help others change who may lack motivation, knowledge, and emotional resources and may be embedded in an environment that does not support or even frustrates change. We can make some progress in 1 hour a week, but we may be working with people who fear the unknown and cling to their problems, which have become part of their identity and their familiar friend. Many clients are actually ambivalent about change. They may believe that the devil they know is preferable to the devil they do not know. For many clients change can take time and cause discomfort. Some clients will need to expose themselves repeatedly to their fears. They may have to experience uncomfortable feelings involved in risking intimacy, correcting well-ingrained misconceptions and thought patterns, exposing felt deficits, learning new skills, revisiting painful experiences, or accepting responsibility for poor choices they made. Changing a behavior could require eliminating exposure to many triggers, a task akin to discarding an identity and forging another.

Some clients build their world around their problems and do not want to abandon them, despite the pain they cause. They may take pride in behaving the way their parents acted and get special treatment for their fears and threatening behaviors. They may have learned to adapt to their pain, as many depressed clients do, because they do not recognize how depressed they are since the depression has increased so gradually over time. Clients may not be motivated to change because they do not believe they have a problem, even though everyone else in the universe knows they do. They may believe their problems and defenses allow them to avoid or escape from greater pain, as an overeater may be escaping from boredom, an isolate may be avoiding anticipated rejection, or a thief may be stealing to compensate for loneliness. Just because clients seek therapy and attend sessions does not mean they are ready to change. Clients can be reluctant to abandon their present patterns of behaviors and beliefs without some hope that new patterns will be better. I do not pressure clients to give up their defenses and coping mechanisms until they have alternatives on which they can rely. It is dangerous to leave a sinking lifeboat until another comes along.

We cannot expect clients to easily abandon the behaviors and defenses that repeatedly have been useful solutions to their previous problems, even though these solutions have now become problems themselves. For instance, an abused child might have successfully survived her chaotic environment by being self-reliant and controlling in relationships. Later this pattern could be detrimental by interfering with being intimate or vulnerable in her present relationships. Furthermore, clients cannot erase the genetic and biological contributions to their problems, and they cannot eliminate the effects of the repeated failure, abuse, rejection, chaos, deprivation of nurturance, missed opportunities for training, and dysfunctional models and values to which they have been exposed. Some problems are chronic. For example, depression is often a recurrent disorder (Consensus Development Panel, 1985; Keller, Lavori, Lewis, & Klerman, 1983).³

At times therapists have to handle their feelings about helping someone accept and manage a worsening condition. Physicians are trained to do this. They can even say to a patient, “I think that is all I can do for you.” Therapists are not trained to give up. However, we have to monitor our hope and persistence with a rational evaluation of our progress. I try to recognize when treatment is not working and adjust the goals and treatment plan as I gain a more realistic understanding of the client and his or her situation. Similarly, I may raise the bar when additional strengths and potentials surface. Therapy is the art of the possible; we have to figure out what is doable. When I cannot generate an achievable goal, I consider seeking consultation or adding additional resources, such as medication, including significant others in the treatment plan, adding another treatment modality, or referring to a higher level of care or a different therapist. Sometimes I might orient the client toward acceptance rather than toward change.

The good news is that the same interconnectedness that makes progress difficult can allow a small change to ripple through many domains and multiply. Often I feel as if I am planting and nurturing seeds when I facilitate small changes in cognitive, emotional, and behavioral patterns. Sometimes therapists have a great deal of influence against powerful forces. Sometimes we do have some magic. Some problems respond well to hope generated by treatment, reassurance, psychoeducation, behavior management, environmental changes, cognitive-behavioral techniques, and/or a corrective emotional relationship. Sometimes explaining the nature of a disorder, reframing the client’s problem, or correcting cognitive distortions can generate a cascade of changes. Sometimes irreversible changes flow from teaching parents to use time-out instead of threats, to use “I messages” instead of passivity or aggression, or to emotionally connect to their child. Similarly changes can multiply by helping a depressed person be a little more angry and assertive or an angry person be a little more depressed, mindful, or aware of others’ feelings.

For most clients their problems manifest in an inability to form and maintain relationships, including the therapeutic relationship. So relationship difficulties often connect problems, goals, and treatment. Developing and maintaining the therapeutic relationship is a major part of treatment, because what the client learns from this relationship can affect all other relationships, and often the potency of interventions depends on the therapeutic relationship.

Rapid Change Is Not a Goal—Make Haste Slowly

Clients live in a world of fast food, microwave ovens, and instant text messaging and World Wide Web searches. Some expect quick solutions and immediate gratification. The glimpses of therapy they have been exposed to may have come from the popular media gurus who greet and treat before the next commercial. Therefore clients may not appreciate that the therapist wants to begin with an assessment and ask so many questions. Part of slowing clients down involves helping them postpone their desire to obtain advice, reassurance, and rapid relief. Some clients may need to accept more realistic expectations about change. Change can occur rapidly or require preparation, progress in bursts, and have setbacks. Identifying and removing the patterns that have gotten in the way of the clients’ past attempts to change can be required.

Of course we want to remediate symptoms as soon as possible. There are costs to attending therapy sessions. The following are just a few: missing school and extracurricular activities, having problems with the caretaker’s employer due to taking time off for meetings, becoming overdependent on the therapist to the exclusion of developing other relationships, dealing with the financial expense, experiencing sibling jealousy, having to cope with stigmatization and embarrassment, being the identified patient, feeling at fault for the family’s problems, and feeling stress created by trying new things and dealing with previously avoided patterns of thoughts, feelings, and behaviors.

But some clients need to be slowed down, especially at the start of treatment. Perhaps believing that therapy involves telling painful secrets and facing the uncomfortable past, they, in their zeal to be good clients and get well, can open up too early and expose too much. Then they may become overwhelmed with anxiety and might not return. This can be a surprise to the therapist, who may have felt the session was quite successful, because the client appeared to trust, disclose, and express intense feelings. Actually, the client was allowed to move too quickly without the therapist’s assessing the client’s capacity to handle the impact of his or her disclosures.

Before exposing clients to these stresses, I try to make sure they have established the skills and resources necessary to handle these uncomfortable feelings, so they do not go home and dissociate or act out and then avoid therapy. Clients who are not able or ready to contribute to regulating the speed and intensity of therapy, do not have the skills to self-soothe and modulate their affect, do not have emotional support outside of the therapeutic relationship, or do not have the ability to use relationships to regulate their affect need to first focus on acquiring these and other ways of coping with stress before adding more stress to their lives. If we succumb to the temptation to try to be the client’s only support for handling stress, we could be committing ourselves to always being available, possibly with no limits on time, cost, expectations, and liability. Such ventures can lead to client disappointment and therapist burnout.

As We Slow the Client, We Slow Ourselves

There are benefits to slowing down treatment, but progressing slowly can be uncomfortable for both the therapist and the client. The client expects the therapist to offer something, and the therapist wants to give something. There are many pressures on the therapist to rush to closure, provide solutions, and offer suggestions as soon as possible. Therapists are exposed to a treatment literature that extols brief, even one-session, treatments (Bloom, 2001; Hoyt & Talmon, 1990) in which the clinician teaches a technique (perhaps having the client constantly ask himself or herself, “How does this make me feel?”), prescribes the symptom (worry before you go to bed instead of while you are in bed trying to get to sleep), reframes the narrative, and provides a paradoxical suggestion or a behavioral prescription; then the client is almost cured. We are pressured to intervene rapidly before the client’s money, insurance, or patience run out or the client becomes even worse. We might feel anxious and incompetent when we do not give them something.

Early comments and interpretations by the therapist can be destabilizing and disrupt the initial goal of engaging the client. Some clients are not ready to be seen or be seen as the therapist sees them. Comments that we think are obvious may be earth shattering, even such comments as, “You’re being abused,” “He may be retarded,” “You may need medication,” or “Do you have a drug problem?” Sometimes therapists mistakenly believe that the sooner they offer interpretations or suggestions, the more helpful and competent they are.

Moving too rapidly can be ineffective. Premature suggestions can be perverted by the client’s established belief system. For instance, I once educated an authoritarian, punitive father about natural consequences in an attempt to help him develop priorities about the behaviors he would try to control in his son. I wanted him to understand that natural consequences would teach the lesson if he did not intervene. He returned the next session to proudly tell me how he allowed his son to decide for himself what time he would be home and how the son got the natural consequence—a good spanking.

Often changes create countervailing forces. For instance, helping someone become more assertive without the proper preparation can lead to painful consequences because the person to whom the client expresses his or her assertiveness might be threatened and respond with hostility. Different systems tolerate different amounts of change. If the family is not prepared to appreciate the new behavior, it can be squashed like a bug. Especially at the start of treatment, therapist-generated solutions can be uninformed, create dependency, and prevent the client from developing the skills to solve problems independently. Advice can cut off communication and exploration.

However, with experience, patterns emerge and become familiar. Because I have traveled the same roads with other clients, I may well have useful suggestions, insights, and warnings to offer. When I do offer suggestions, I try to be constantly vigilant that they fit the client’s situation and are not the recycled solutions I relied on with other clients or in my life. When the client seems familiar, I proceed with caution, because I do not want to treat the wrong client. The best treatment happens when I ask clients the right questions that lead them to discover the solutions themselves. Then they are more motivated to implement these changes, but I may not be in total agreement with the cour...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Dedication
• Contents
• Series Editor’s Foreword
• PART 1. Research and Theory
• PART 2. Case Studies
• Notes
• References
• Index