Highly Effective Therapy

Effecting Deep Change in Counseling and Psychotherapy

Len Sperry

• Publisher: Routledge
• Year: 2022
• Print ISBN: 9780367631468
• eBook ISBN: 9781000538342
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Trainees and practitioners need a trusted resource for mastering the essential skills and competencies necessary for effecting deep, lasting change in their clients. This second edition of Highly Effective Therapy: Effecting Deep Change in Counseling and Psychotherapy is that resource.

It updates the 20 essential skill sets and clinical competencies needed for a highly effective and successful clinical practice. It illustrates them in action with evidence-based treatment protocols and clinical simulations to foster learning and competency. Sperry emphasizes the process of easily learning these research-based clinical competencies with added case examples and session transcriptions. New to this edition is trauma assessment, protective factors, and ultra-brief cognitive behavioral interventions.

This second edition is written in an accessible format and is essential for practitioners, trainees, and instructors working in this field.

1Making and Implementing Effective Clinical Decisions

DOI: 10.4324/​9781003112334-2

In the first edition of Highly Effective Therapy, Chapter 1 was entitled: “Apply a Conceptual Map to Understand and Direct the Therapeutic Process.” It provided a map framework to guide making clinical decisions based on five common therapeutic orientations: cognitive behavioral, dynamic, experiential, relational-systemic, and integrative therapies. Because of the rapidly changing landscape of psychotherapy practice since the first edition was published, which was more than a decade ago, clinical decision making has become increasingly complex, and basing clinical decisions primarily on one’s theoretical orientation is no longer sufficient. For this reason, this chapter has been completely revised.

In contrast, this second edition, and this chapter in particular, offers a broader framework for effective clinical decision making. This framework provides an overview of subsequent chapters in the book structured around the four core dimensions of the therapeutic process and the competencies that support each dimension. A basic premise of this book is that therapists who are able to make effective clinical decisions and implement them sufficiently with the necessary clinical competencies described in this book are likely to be practicing highly effective therapy. As such, the primary and most important of the core clinical competencies is to “make and implement effective clinical decisions.” The four other core clinical competencies are: relationship building and maintenance, intervention planning, intervention implementation, and intervention evaluation, and the 19 clinical competencies that support them are listed in Table 1.1.

Table 1.1 The Core Clinical Competencies and Supporting Clinical Competencies

Primary Clinical Competency Make and implement effective clinical decisions Relationship Building and Maintenance Develop an effective therapeutic alliance Assess readiness and foster treatment-promoting factors Recognize and resolve resistance and ambivalence Resolve transference-countertransference enactments Resolve therapeutic alliance strains and ruptures Assessment and Case Conceptualization Perform an integrative diagnostic assessment Specify an accurate DSM diagnosis Develop an integrative case conceptualization: clinical formulation Develop an integrative case conceptualization: cultural formulation Develop an integrative case conceptualization: treatment formulation Draft an integrative clinical case report Intervention Implementation Establish a treatment focus Maintain the treatment focus Effect therapeutic change Plan and implement culturally sensitive interventions Intervention Evaluation Recognize and resolve treatment-interfering factors Monitor progress and revise treatment accordingly Evaluate progress and prepare clients for termination Utilize supervision effectively to add, enhance, and evaluate competencies

The first part of this chapter introduces three criteria: evidence, circumstances, and ethics, for making and implementing effective clinical decisions. The second part sketches three common psychotherapy practice patterns that therapists employ today. Each of these practice patterns “reflect” and “require” specific supporting clinical competencies. The final section of this chapter discusses the value of the third pattern and the limitations of the first two patterns.

EFFECTIVE CLINICAL DECISION MAKING: THREE CRITERIA

Another basic premise of this book is that highly effective therapy is a result of effective clinical decision making throughout the course of treatment. Such decision making is a foundation for and informs the use of the other strategies and competencies described in this book.

So, what does it mean to “make and implement effective clinical decisions”? In the past, as noted earlier, it was common for therapists to base clinical decisions on their theoretical orientation. Or, they might have based such decisions on their professional experience or preference, or even on clinical lore, e.g., “never give advice,” “always follow the client’s lead,” “don’t ask questions, just respond.” This began to change in the 1990s with the advent of best practices, empirically supported treatments, and evidence-based practice. Along with evidence, at least two other criteria beyond evidence emerged as essential for making effective clinical decisions. Each will be briefly described.

Evidence. Originally, evidence-based practice was considered a process of assisting therapists in making important treatment decisions. In this process, a therapist would decide on interventions after considering research evidence, their experience, expertise, circumstances, available resources, and client values and preferences (Gambrill, 2011). Unfortunately, many have assumed that “evidence” means published empirical research, particularly the list of “empirically supported treatments” promoted by Division 12 of the American Psychological Association promoting. Rather, the originators of evidence-based practice (Sackett et al., 1996) described two kinds of evidence. External evidence refers to quality empirical research, while internal evidence or clinical expertise refers applying external evidence in a way specifically that matches client needs and wants. Unfortunately, there are many practicing therapists who reject evidence-based practice, despite increasing expectation for its use among third-party payers (Lilienfeld et al., 2013). Fortunately, a new generation of emerging therapists is receptive to empirically based treatment interventions (Williams et al., 2014).

Circumstances. I have observed that the therapy process tends to follow three different trajectories. Sometimes, therapy gets stuck and requires refocusing. Occasionally, therapy derails and can result in premature termination unless the therapist intervenes to prevent it. Fortunately, much of the time follows a third trajectory: it goes smoothly and results in effected change (Sperry, 2021). There are a unique set of clinical decisions and actions requiring specific competencies associated with each trajectory. Obviously, there are considerably more decisions and clinical competencies involved when therapists endeavor to refocus treatment that is stuck, or to prevent and deal with derailment and premature termination than when treatment is going smoothly.

Ethics. Usually, when thinking about ethical professional practice, four ethical standards come to mind: confidentiality, informed consent, therapist competence, and conflict of interests. In addition to these, there are three others that are specifically germane to therapeutic decision making.

1. Is it effective?
2. Is it safe?
3. Is it appropriate for this client? (Sperry, 2018)

Take the example of the empirically supported treatment of loving kindness, an increasingly utilized mindfulness intervention. Although researchers have demonstrated that this intervention is effective with a wide range of clients, including those with clinical depression, they have also reported significant concerns about its safety and appropriateness in individuals suffering with the form of clinical depression known as recurrent depression (Segal et al., 2013). In short, while this mindfulness intervention is effective and safe with many individuals, it is neither safe nor appropriate for some. Making the decision to utilize this intervention when it is inappropriate for a given client is not only ineffective and unethical, but it may also have serious medical and psychiatric consequences.

In short, these three ethical criteria are superior to decision making based on one’s professional experience or preference, clinical lore, and, particularly, theoretical orientation. It is noteworthy that justification for basing treatment decisions and recommendations primarily on theoretical orientation has been increasingly discounted. For instance, Sookman (2015) contends that “it is the ethical responsibility of all clinicians regardless of orientation to be guided by current empirical research as well as their own specific areas of competence, experience, and limitations when making treatment recommendation” (emphasis added, p. 1295).

For these reasons, “making and implementing effective clinical decisions” is designated as the primary clinical competency among the 20 clinical competencies described in this book. It is meant to serve as starting point and end point of all planning, implementing, and evaluating psychotherapeutic treatment. In the remainder of this chapter, we refer to these three criteria as “decisional criteria” and the decisional criteria dimension.

PSYCHOTHERAPY PRACTICE PATTERNS

This section describes three common practice patterns that counselors and therapists employ today. Each pattern is described in terms of six dimensions of the treatment process: (1) decisional criteria; (2) therapeutic relationship; (3) assessment and diagnosis; (4) case conceptualization and intervention planning; (5) goals, intervention focus, and implementation; and (6) intervention evaluation and termination. Each begins with a clinical situation that reflects that practice pattern.

Practice Pattern 1

You are supervising a relatively new trainee who presents a case that appears to be progressing nicely. The client reports lessened social anxiety symptoms and is pleased with her progress as is the trainee. You know that higher functioning clients usually respond favorably to most therapeutic interventions, but such therapeutic progress may be short-lived in those with an underlying maladaptive personality pattern unless it is treated. Unfortunately, the trainee had not yet developed a case conceptualization that would suggest such a pattern and treatment focus. From the perspective of Practice Pattern 1, how might you advise the trainee?

This practice pattern reflects the overall manner in which therapists engage in the six basic treatment dimensions. It is a pattern that reflects the formal training of many graduates over the past few decades.

Decisional criteria. Therapists who embody this practice pattern tend to utilize one of the decisional criteria: evidence, circumstances, or ethics, in making and implementing clinical decisions. It is usually circumstance or ethics. Others may base decisions on their theoretical orientation.

Therapeutic relationship. Efforts are made to develop a working therapeutic alliance. This usually includes a focus on attending skills: maintaining an open posture, maintaining eye contact, and being relaxed; as well as responding skills:...

Table of contents

• Cover Page
• Endorsements Page
• Half-Title Page
• Title Page
• Copyright Page
• Introduction: Clinical Competencies and Deep Therapeutic Change
• 1 Making and Implementing Effective Clinical Decisions
• 2 Establishing an Effective Therapeutic Alliance
• 3 Assessing Readiness and Fostering Treatment Promoting Factors
• 4 Recognizing and Resolving Resistance and Ambivalence
• 5 Recognizing and Resolving Transferences and Countertransferences
• 6 Recognizing and Repairing Alliance Ruptures
• 7 Performing an Integrative Diagnostic Assessment
• 8 Developing an Accurate DSM Diagnosis
• 9 Developing a Highly Effective Case Conceptualization: Clinical Formulation
• 10 Developing an Integrative Case Conceptualization: Cultural Formulation
• 11 Developing an Integrative Case Conceptualization: Treatment Formulation
• 12 Drafting an Integrative Clinical Case Report
• 13 Establishing a Treatment Focus
• 14 Maintaining the Treatment Focus
• 15 Effecting Therapeutic Change
• 16 Planning and Implementing Culturally Sensitive Treatment
• 17 Recognizing and Resolving Therapy-Interfering Factors
• 18 Monitoring Progress and Modifying Treatment Accordingly
• 19 Evaluating Progress and Preparing Clients for Termination
• 20 Utilizing Supervision Effectively and Evaluating Competencies
• Index