Core Competencies in Brief Dynamic Psychotherapy

Becoming a Highly Effective and Competent Brief Dynamic Psychotherapist

Jeffrey L. Binder, Ephi J. Betan

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780415637763
• eBook ISBN: 9781136870385
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This book addresses the essential clinical competencies required to conduct brief dynamic therapy. Authors Jeffrey L. Binder and Ephi J. Betan discuss the conceptual foundation of their treatment model, and the application of this framework in forming and maintaining a therapeutic alliance, assessment, case formulation, implementing a treatment plan, termination, and treatment evaluation. All topics include a multicultural perspective and sensitivity to ethical issues. Binder and Betan attempt to bridge practice and research by consistently incorporating relevant research findings.  Graduate students in the mental health fields and beginning therapists will find in this text the basic concepts and principles of brief dynamic psychotherapy presented in a clear and straightforward style, with many clinical examples drawn from detailed patient and therapist interchanges. Seasoned psychotherapists will find in Binder and Betan's discussions of case formulation and therapeutic discourse a fresh treatment of classic ideas about the therapeutic value of constructing personal narratives.  At all times, the authors explicitly tie the components of their approach to the competencies required of the brief dynamic therapist. In the current environment of accountability for results, attention is given to the ongoing assessment of therapeutic progress and ultimate outcomes. This text is a scholarly yet practical guide to the evidence-based practice of brief dynamic psychotherapy.

1

Introducing the Clinical Competencies of Brief Dynamic Psychotherapy

Brief dynamic psychotherapy (BDP) is a time sensitive version of the psychodynamic approach to individual psychotherapy with adults. It is one of the products of a diverse and evolving theory of personality, psychopathology, and psychotherapy, which originated with the works of Sigmund Freud (Breuer & Freud, 1893–1895/1955). Freud always focused on modifying and elaborating his theories of personality and psychopathology, derived from systematic and keen observations made during the course of his clinical work. Given the paucity of his writings on the topic, Freud seemed to have given short shrift to the topic of therapy technique. Most of his thoughts on technique appeared in papers written between 1912 and 1915. In his autobiography, he states that the essence of psycho analysis is “the art of interpretation” and that this skill is “not hard to acquire” (cited in Ehrenwald, 1991, p. 285).

During most of the 20th century, the literature on psychoanalysis and psychodynamic theory reflected Freud’s focus on theories of personality and psychopathology to the relative neglect of studies of therapeutic technique and its development. The conduct of psychodynamic therapy continued to be viewed as an “art,” and the therapist’s “artistic” talent was acquired through supervisory relationships not unlike a master– apprentice relationship. The pedagogy of psychodynamic psychotherapy training rested on the successful resolution through personal therapy of the therapist’s neurotic impediments to empathy and objectivity. The implication was that good therapy technique would develop relatively easily once the novice therapist had the requisite mind-set. One of the most influential 20th century books on psychodynamic therapy supervision was based on the idea that the primary task of the therapy supervisor was to identify the way in which the novice therapist’s neurotic entanglements with his patient was impacting the supervisory relationship and interfering with the supervisee’s receptivity to learning (Eckstein & Wallerstein, 1972). In the same vein, a common assumption among teachers of short-term psychodynamic therapies has been that if the novice therapist does not have a bias against time-limited approaches, acquiring the skill to conduct them is relatively straightforward.

Beginning in the latter part of the 20th century, the confluence of a variety of forces has led ultimately to a focus on therapist competency in the mental health disciplines. From the perspective of the delivery of mental health services, increasing concerns with the escalating cost of health care has led to a focus on provider accountability. The pressure to demonstrate effective practices, in turn, has made clinical training programs in the mental health disciplines more sensitive to the quality of their training. In order to evaluate training outcomes, it is necessary to have a clear understanding of the nature of the skills that trainees are expected to acquire. Indeed, for clinical training programs to receive government and professional association accreditations, program learning outcomes must be spelled out and empirically assessed. There also is societal pressure for professionals to explain exactly what is it that they do for the consumers of their services (Borden & McIlvried, 2010). In order to obtain funding from the National Institute of Mental Health (NIMH) for their projects, psychotherapy researchers also have to articulate what is distinctive about therapist performance in the treatments to be studied and evaluated. The methods prescribed for a particular model of therapy have to be spelled out in a “treatment manual.” The original manuals focused on therapist technical adherence, but the need to also articulate what characterized the competent use of techniques became evident. Several of the early treatment manuals provided detailed guidance for the conduct of different forms of short-term psychodynamic therapies (Horowitz, 1986; Luborsky, 1984; Strupp & Binder, 1984; Weiss, Sampson, & Mt. Zion Psychotherapy Research Group, 1986). In recent years additional manuals on brief dynamic therapy have appeared (e.g., Binder, 2004; H. Levenson, 2010).

For the mental health disciplines, we are in an epoch in which professional survival requires that the nature of the competencies associated with being an effective psychotherapist must be articulated and methods for evaluating these competencies must be developed. These realities have led to a major shift in clinical training programs from content-based curricula (in which certain content areas must be covered to satisfy graduation requirements) to competence-based curricula (in which specific competencies must be acquired and their acquisition must be empirically demonstrated; Kenkel & Peterson, 2010). Of course, the foundation of the competency movement in the mental health disciplines is a clear definition of “competency.”

DEFINITION OF COMPETENCIES AND THEIR COMPONENTS

In the broadest sense, a “competency” has been defined as the demonstrated achievement of a sufficient level of quality of performance in a given domain relative to some external standard or training requirements (Sperry, 2010a). As applied to clinical competencies, Sperry (2010b) has provided the following definition:

Competency is the capacity to integrate knowledge, skills, and attitudes reflected in the quality of clinical practice that benefits others, which can be evaluated by professional standards and be developed and enhanced through professional training and reflection. (p. 5)

It should be noted that in this context “competency” refers to a cluster of capacities comprising a complex performance in a specific domain of professional activity. This definition should not be confused with the more common definition of “competence” as a level of performance sufficient for a situation or that meets minimal level of standards as determined by an external agency, such as a licensing board. In fact, the two definitions have some overlap.

A “competency” is composed of three components: (a) knowledge, (b) skills, and (c) attitudes. In the broadest sense, knowledge refers to comprehension of a domain topic, including both an understanding of content and an understanding of when and how to apply this content. For our purposes the term clinical knowledge usually refers to the conceptual foundation for the conduct of psychotherapy. Cognitive scientists call this type of understanding, declarative knowledge, which includes facts, general propositional concepts, principles, and rules. It makes up the content of the “cognitive map” which a therapist uses to identify and focus on those aspects of an immediate therapeutic environment that are relevant to the pursuit of his or her selected goals (Binder, 1999). Declarative knowledge is acquired through reading, course work, and study. It provides the conceptual foundation for clinical practice. Skills, or therapeutic procedures, involve the application of declarative knowledge in real practice situations. Skillful behavior reflects a complementary form of knowledge, which cognitive scientists call procedural knowledge (Binder, 1999). This term refers to largely tacit understanding (Polanyi, 1967) that automatically guides the clinician in applying his or her declarative knowledge in the appropriate contexts and in the most effective ways. Schön (1983) described procedural knowledge as “knowing-in-action.” Skills are acquired through watching the work of more experienced therapists, ideally “master therapists,” and practice with feedback from a teacher or supervisor. The attitudes associated with a clinical competency are those beliefs, dispositions, motivations, and values that support the acquisition and progressive enhancement of the knowledge and skills associated with a competency, as well as its use to improve the well-being of one’s patients. One chooses to become a psychotherapist because of certain long-held attitudes, such as a belief in the importance of psychological health for the overall well-being of the individual. During the course of training, attitudes are acquired that are associated with the development of a professional identity, such as the importance of self-reflection and self-monitoring as part of the conduct of psychotherapy.

The conduct of psychotherapy comprises a set of integrated complex performances and, therefore, the progressive development from novice to expert therapist involves a variety of knowledge organizations and levels of skill complexity. The most basic facet of therapist performance development, however, may be the transformation of therapeutically relevant declarative knowledge into usable procedural knowledge. Without this basic developmental step, the therapist may be a fund of knowledge—a superb “locker room” player—but this declarative knowledge does not provide guidance about when and how to implement theories, concepts, principles, and rules. In the words of the British mathematician and philosopher, Alfred North Whitehead (1929) the knowledge remains “inert.” Any doubts about this observation are easily dispelled when observing a novice therapist fumbling around in an attempt to develop an understanding of a new patient and to do something therapeutically helpful with this person. All of the therapist’s book knowledge appears to have departed his or her head.

Procedural knowledge represents the integration of declarative knowledge, ideally organized in a coherent conceptual framework, with skills associated with the timely and appropriate application of this knowledge in real-world situations.

Procedural knowledge is the gradually accumulated product of experiences with applying theoretical concepts, principles, and technical prescriptions in real practice contexts. It consists of the pairing of propositions and concrete experiences with action strategies and rules, as well as appraisals of the consequences. It is in the form of condition–action sequences. (Binder, 1999, p. 711)

In other words, a therapist’s competencies progressively develop when he or she learns from clinical experiences. Early in a therapist’s development, supervised learning experiences are crucial. Learners need usable feedback on the quality of their performance, in order to make error-correcting changes. Memorizing a golf instructional book by a renowned golf professional will not prepare the novice golfer to play a solid round of golf. On the other hand, the cumulative experiences of repeatedly playing rounds of golf without ever reading about swing technique or getting lessons is unlikely to produce a skilled golfer.

ESSENTIAL CLINICAL COMPETENCIES

The pictures of clinical training and practice are rapidly being redone in the language of competencies. The various mental health disciplines have begun the task of compiling and organizing descriptive lists of knowledge, skills, and attitudes, including such lists for characterizing the practice of psychotherapy. Within disciplines, various workgroups have been formed with the task of articulating the competencies associated with the various types of clinical work, as well as their respective components (Kenkel & Peterson, 2010). In his ongoing review of the clinical competency literature, Sperry (2010b) has enumerated six core competencies and 20 essential clinical competencies required for therapy to be effective. The six core competencies are: (a) conceptual foundation, (b) relationship building and maintenance, (c) intervention planning, (d) intervention implementation, (e) intervention evaluation and termination, and (f) culturally and ethically sensitive practice.

There are several major schools of psychotherapy practiced today, including: psychodynamic; cognitive-behavioral; systemic; person-centered, and emotional-focused. This book elaborates on these core competencies characterize highly effective work in brief psychodynamic therapies.

DEVELOPMENTAL STAGES OF COMPETENCY

As we mentioned above, competency refers both to a cluster of capacities composed of knowledge, skills, and attitudes and to a level of performance. A competent therapist represents a midlevel point in professional development. The seminal work on the progressive development of generic complex performances was written by two brothers, one of whom was a computer scientist and the other a philosopher (Dreyfus & Dreyfus, 1986). Their “stage model” is a conceptual framework widely used in various forms by cognitive scientists who study the nature and development of expertise. This developmental model has five stages, with those beyond the first or novice stage achieved through practice and experience.

Novice therapists operate entirely on the basis of declarative knowledge acquired through coursework and reading. They have been taught to recognize certain situational elements and rules for determining how to manage these elements, but they have not learned how to comprehend what they see within the immediate context nor have they integrated current actions with longer term goals. For example, novice psychodynamic therapists will know the concept of “transference” and can appreciate idiosyncratic behavior, but lacking experience with patients, they will not usually be able to identify transference patterns within the interpersonal context of which they are a part. They also will tend to confuse the idea that “transference” refers to context-relevant explanations of behavior rather than descriptions of specific types of behavior. Consequently, it is not uncommon to hear novice therapists talk about the “amount” of transference in a therapy session. Through practical experiences coping with real situations, advanced beginners are more skillful at recognizing relevant aspects of a situation as well as beginning to develop a meaningful conception of the situation itself. At this stage of development novice therapists are becoming more skillful at recognizing patient attitudes and behavior that can meaningfully be viewed as expressions of transference. They are also beginning to see how they may be playing a role in evoking and influencing the form of the transference behavior; that is, they are becoming aware of their “countertransference.”

With more experience—especially with good mentoring, in order to make these experiences productive learning episodes—declarative knowledge is transformed into procedural knowledge. Consequently, the person engaged in a complex performance is able to independently comprehend a problem situation in terms of selecting what factors are relevant in working toward a specific goal. A given competency is associated with a specific domain of performance. Within a domain, certain kinds of situations tend to recur and become more or less routine. Competent performers automatically recognize in routine situations similarities from one time to the next. This is the stage of competence in which performers begin to see meaningful patterns rather than discrete situational elements, and their goal-directed actions are dictated by the patterns they see. They have accumulated sufficient practical experience so that their reasoning processes are shifting from rule-based to case-based or “analogical reasoning” (Buchanan, Davis, & Feigenbaum, 2006). In this type of reasoning, new problem situations are automatically compared with similar, previously managed past situations that have been stored in memory. This reasoning process facilitates pattern recognition and evokes previously successful action-consequence sequences of behavior. Furthermore, these cognitive and behavioral processes are increasingly tacit and automatic (Sternberg & Horvath, 1999). Thus, the competent performer’s behavior tends to appear smooth and purposeful.

Within a session, competent therapists can construe a patient’s problematic behavior toward them as a manifestation of transference. They compare the patient’s behavior with memories of similar interactions with the same or other patients, in order to help them attach narrative meaning to the behavior. In addition, they automatically embed the immediate interpersonal experience in a conceptual framework of psychoanalytic principles. These principles might include the superimposition on current interpersonal situations of scenarios from the patient’s childhood, the defensive function of action substituted for remembering, and the interpretive linking of transference to other similarly enacted transactions in other relationships. Therapists with an interpersonal orientation may also reflect on their countertransference contribution based on the interpersonal principle that transference and countertransference enactments are ineluctably intertwined.

In the fourth stage of the development of a competency, proficient performers will have continued to expand their memory store of relevant problem situations and the behavior strategies that successfully managed them. Consequently, their capacity to utilize analogical reasoning to comprehend and successfully deal with immediate situations has become more extensive and automatic. Their grasp of situations appears intuitive, especially those problem situations that have come to be experienced as more or less routine. Their management of these situations is increasingly smooth and appears effortless. Proficient psychodynamic therapists’ ability to automatically manage many routine therapeutic situations allows them to remain alert to even very subtle interactions between themselves and their patients that have transference implications. The tacit nature of the therapists routine actions also allow them to be more alert to how their personal reactions to the patient influence their behavior, and how their actions contribute to the specifics of the patient’s transference enactments.

Within their performance domains, experts operate in routine situations with a speed, fluidity, and efficiency that is unparalleled in any earlier stage of competency development. The expert comprehends and acts in one seamless motion. For example, the chess master is not able to plan moves significantly further along than a less accomplished player; rather, he or she “knows” the right move. It is estimated that a chess master has a memory store of at least 50,000 board positions, and the one that best fits the current situation influences his or her perception of the current configuration of pieces and what would be the most advantageous move (Dreyfus & Dreyfus, 1986). But, it is not the routine situation that distinguishes experts from those in earlier stages of competency development. Within his or her domain, the expert sees elements and patterns within the immediate situation with a precision, clarity, and depth of understanding that is unique. World class athletes describe being “in the groove,” when their perceptions of the ball field slow down, allowing them to refine their actions and to anticipate and make adjustments to changing contextual circumstances (Binder, 2004; Ericsson & Charness, 1999). Experts have an enhanced pattern recognition capacity and extensive store of procedural knowledge that makes it possible for them to rapidly respond in ambiguous and unique situations. The psychotherapy relationship is often an ambiguous even unique setting. It is what Schön (1983) has called an “indeterminate zone.”

Researchers who have studied master therapists have observed that one characteristic of these therapists is that they did not “go by the book” as much as nonexpert therapists do, even if the former wrote the books (Goldfried, Raue, & Castonguay, 1996). In relatively routine circumstances, expert therapists’ characteristic mode of engaging a patient and their accompanying technical actions are so seamless a part of who they are that they are largely unaware of their actions and interpersonal style (Dreyfus & Dreyfus, 1986). The base of automatic interpersonal actions allows expert therapists to remain keenly attuned to changing interpersonal circumstances. Expert therapists are continuously able to “reflect-inaction” (Schön, 1983); that is, while they are interacting with the patient, they are simultaneously able to monitor what is happening and modify their understanding and actions accordingly—they are able to “improvise.” It is this capacity to improvise when called for that distinguishes experts (Binder, 2004; Ericsson, 1996; Sternberg & Horvath, 1999). For example, expert therapists always monitor the affective nuances of the patient–therapist interchange, detect their own personal reactions and responses that appear to be part of an unfolding interpersonal scenario having the characteristics of the patien...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• Contents
• Foreword
• About the Authors
• 1 Introducing the Clinical Competencies of Brief Dynamic Psychotherapy
• 2 Understanding the Conceptual Basis of Brief Dynamic Psychotherapy
• 3 Forming an Effective Therapeutic Alliance
• 4 Maintaining an Effective Therapeutic Alliance
• 5 Performing an Integrative BDP Assessment
• 6 Developing a BDP Case Conceptualization and Intervention Plan
• 7 Interventions: Inquiry and Dialogue
• 8 Monitoring and Evaluating Clinical Outcomes
• 9 Planning for Termination and Maintaining Treatment Gains
• 10 Practicing BDP with Cultural and Ethical Sensitivity
• 11 Becoming a Highly Competent and Effective BDP Therapist
• Bibliography
• Index