COURSE OF NEW CLINICAL INTERVENTIONS:IMPLEMENTING TREATMENT

<< IMPORTANCE OF PSYCHOTHERAPY:ETHICAL CONSIDERATIONS

NATURE OF SPECIFIC THERAPEUTIC VARIABLES:CLIENT’S MOTIVATION >>

Clinical Psychology (PSY401)

LESSON 27

COURSE OF NEW CLINICAL INTERVENTIONS

There are so many forms of intervention, along with so many different kinds of problems, that it is

impossible to describe with precision a sequence of procedures that will apply equally well to

every case. Nevertheless, it may be useful to examine the overall sequence of therapeutic

progress as described by Hokanson (1983).

INITIAL CONTACT

When clients first contact the clinic or enter the clinician's office, they often do not know exactly what to

expect. Some will be anxious; others, perhaps, suspicious. Some do not clearly understand the differences

between medical treatment and psychotherapy. Others may be embarrassed or feel inadequate because they

are seeking help. The first order of business, then, is for someone to explain generally what the clinic is

all about and the kind of help that can be given. This is an important step that can have a significant

bearing on the client's attitude and willingness to cooperate. Whether this initial contact is made by a

therapist, a social worker, a psychological technician, or someone else, it is important that the contact be

handled with skill and sensitivity.

Once the client's reasons for coming have been discussed, the next step in the general sequence can

be explained. It may be useful at this point to discuss several specific issues. Who are the professional

staff, and what are their qualifications? What about the matter of fees? Are the contacts

confidential, and if not, exactly who will have access to information? If there are medical

complications, how will these problems be integrated with therapy contacts? Does it seem

reasonable to proceed with the client, or does a referral to another agency or professional seem

more appropriate? These and other questions must be dealt with up front.

ASSESSMENT

Once it has been mutually agreed that the client can likely profit from continued contact with the clinic,

one or more appointments can be arranged for an assessment of the client's problems.

As we know that variety of assessment procedures may be followed, depending on the exact nature of

the client's problem, the orientation of the professional staff, and other factors. Often there is an intake

interview, which may consist largely on compiling a case history. Other information may be gathered by

administering various psychological tests. Sometimes arrangements are made to interview a spouse,

family members, or friend in some instances, too, it may be considered desirable to have the client

systematically record self-observations of behavior, thoughts, or feelings in different situations.

For some clients, consultations with other professionals may be desirable. A neurological workup may

be necessary, or a medical examination may be scheduled to rule out non psychological factors. For

some clients whose problems are related to economic problems or unemployment, additional consultation

with social workers or job counselors may be appropriate.

After all the information has been compiled and analyzed, a preliminary integration is a tempted. What

is desirable here is not a simple diagnostic label but a comp rehensive co nstruction of the client's

problems in light of all the psychological, environmental, and medical data available. This initial

conceptualization of the client will provide guidelines for the specific therapeutic interventions to be

undertaken. A therapy proceeds, changes in the conceptual zation of the client will likely occur, and then

peutic goals and techniques may well change somewhat as a result. Assessment is an ongoing process

that does not cease with the second or third interview.

204

Clinical Psychology (PSY401)

THE GOALS OF TREATMENT

As soon as the assessment data are integrated (the therapist and client can begin to discuss mo re

sy st emat i cal ly t h e n atu re o f t h e p rob l em and what can be done about them. Some therapists

describe this phase as a period of negotiation over the goals of treatment. Others suggests that client and

therapist enter into a `contract' in which the therapist agrees to alleviate a specified set of the client's

problems and to do it in the most effective way possible. Naturally, no one can absolutely promise a

perfect cure or resolution of all problems. Clients, in turn, will state their desires and intentions. In

effect, their contract usually covers such matters as the goals of therapy, length of therapy, frequency of

meetings, cost, general format of therapy, and the client's responsibilities.

Again, it is important to understand that various features of the contract may be modified as time goes on.

One must deal with clients in terms of what they are prepared to accept now. An especially anxious or

defensive client may be willing to accept only a limited set of goals or procedures. As therapy

proceeds, that client may become more open and comfortable and thus better able to accept an expanded

set of goals. Then, too, additional information about the client may surface during therapy, with the

result that some modifications may be necessary. Some clients will want to expand their goals for

treatment as they gain more confidence and trust in the therapist. Discussion of goals and methods

must be handled with discretion, sensitivity, and skill. Therapists must try to take clients only where

they are psychologically prepared to go. Moving too fast or setting up grandiose treatment objectives can

frighten or alienate certain clients. It is usually desirable to proceed with enough subtlety and skill so that

clients feel they are the ones who are establishing or modifying the goals.

Hokanson (1983) uses a classification of therapy goals in terms of crisis management, behavior change,

corrective emotional experience, and insight and change. Given below are the goals. In the most general

sense, the goal of psychotherapy is to improve the patient's level of psychosocial adjustment and to

increase the patient's capacity for achieving satisfactions from life.

1. Therapeutic Goal is Crisis management

Examples of problems are Incipient psychotic episode; poorly planned, impulsive actions; explosive acting-out

behavior.

Treatment Procedures are Supportive therapy; emergency consultation in psychiatric hospital, crisis work in

community.

2. Therapeutic goal is Behavior change.

Examples of problems are Habits and behaviors of long standing that create problems for patient.

Treatment procedures are Behavior therapy, self-regulation techniques.

3. Therapeutic goal is Corrective emotional experience.

Examples of problems are Broadly based maladaptive' way of life' stemming from persistent negative

interpersonal experience.

A treatment procedure is Relationship therapy.

5. Therapeutic goal is Insight and change

Examples of Problems are: Symptoms of distress for which client can find no suitable explanation.

205

Clinical Psychology (PSY401)

Treatment procedures are Psychoanalytic therapy; client centered therapy; existential analysis; gestatlt

therapies; other therapies.

IMPLEMENTING TREATMENT

After the initial goals are established, the therapist decides on the specific form of treatment. It may

be client-centered, cognitive, behavioral, or psychoanalytic. The treatment may be very circumscribed

and deal only with a specific phobia, or it may involve a broader approach to the client's personality style.

All of this must be carefully described to the client in terms of how it relates to the client's problems, the

length of time involved, and perhaps even the difficulties and trying times that may lie ahead. Exactly

what is expected of the client will be detailed as well free association, "homework" assignments, self

monitoring, or whatever. Inherent in all of this is the issue of informed consent. Just as participants in

research have a right to know what will happen, so do therapy patients have the right to know what will

happen in therapy.

TERMINATION, EVALUATION AND FOLLOW-UP

It is certainly to be hoped that a client will not be in psychotherapy her or his entire life. As the therapist

begins to believe the client is able to handle his or her problems independently, discussions of

termination are initiated. Sometimes termination is a gradual process in which meetings are reduced, for

example, from once a week to once a month. As termination approaches, it is important that it be

discussed in detail and the client's feelings and attitudes thoroughly aired and-dealt with. Clients do

sometimes terminate suddenly, in some cases before the therapist feels it is appropriate. Whenever

possible, however, it is important to find the time to discuss at least briefly the client's feelings about

leaving the support of therapy and the possibility of returning later for additional sessions if necessary.

In other instances, the termination is forced because the therapist must leave the clinic, which can pre-

cipitate numerous client reactions. Many therapists find that "booster sessions" scheduled months

after termination-perhaps 6 months and then one year later-can be quite helpful. These booster

sessions are used to review the client's progress, to address new problems or issues that have arisen in

the interim, and to solidify the gains that have been made.

It is important to evaluate with clients the progress they have made. Therapists should also compile

data and make notes on progress in order to evaluate the quality of their own efforts or the agency's

services and continue to improve services to clients. The most reliable data, of course, will come

from formally designed research projects .However, clinicians and individual agencies owe it to

themselves and their clients to evaluate the success of their own efforts.

COMMON ELEMENTS OF PSYCHOTHERAPY

1. Realistic relationship between patient and therapist

2. Restoration of morale

3. Release of emotion

4. Rationale

5. A combination of active listening and talking

6. Suggestion

206

Clinical Psychology (PSY401)

TYPES OF PSYCHOTHERAPY

Psychotherapy encompasses a large number of treatment methods, each developed from different

theories about the causes of psychological problems and mental illnesses. There are more than 250

kinds of psychotherapy, but only a fraction of these have found mainstream acceptance.

Many kinds of psychotherapy are offshoots of well-known approaches or build upon the work of

earlier theorists. We will not go into the details of the popular therapies here as they will be discussed

thoroughly in the coming lectures.

POPULAR THERAPIES

The methods of therapists vary depending on their theory of personality, or way of understanding

another individual.

Most therapies can be classified as:

(1) psychodynamic,

(2) humanistic,

(3) behavioral,

(4) cognitive,

or (5) eclectic.

In the United States, about 40 percent of therapists consider their approach eclectic, which means they

combine techniques from a number of theoretical approaches and often tailor their treatment to the

particular psychological problem of a client.

ANOTHER CLASS OF THERAPIES

Therapies can also be classified in regard to the number of persons that can be helped at a time. Forms

of therapy that treat more than one person at a time include:

Group therapy,

Family therapy,

and Couples therapy.

These therapies may use techniques from any theoretical approach. Other forms of therapy specialize

in treating children or adolescents with psychological problems.

SOME GENERAL CONCLUSIONS

A generalization about the effectiveness of psychotherapy seems to be emerging. However, there is

little evidence to suggest that one form o f t h erapy i s i n any sen se u n i qu ely effect iv e fo r all

207

Clinical Psychology (PSY401)

problems. J. D. Frank's (1979) conclusions about psychotherapy several decades ago also seen to

characterize current thinking:

1. Nearly all forms of psychotherapy are somewhat more effective than unplanned or informal help.

2. One form of therapy has typically not been shown to be more effective than another for all-

conditions.

3. Clients who show initial improvement tend to maintain it.

4. Characteristics of the client, the therapist, and their interaction may be more important than

therapeutic technique.

This last point is important because it suggests that, given the equal effectiveness of various

forms of therapy, the field should turn its attention to those elements that are common to all

forms of therapy. Not all agree with this conclusion, however. Telch (1981), for one, argues that the

more potent the therapeutic technique being used, the less important are therapist or client

characteristics. As an example, Telch notes that evidence strongly suggests that systematic desen-

sitization is highly effective with patients with phobias. Yet for those who have trouble using

mental imagery, desensitization may prove ineffective, and modeling may be the technique of

choice. Lazarus (1980) also argues that specific therapies are indicated for specific problems. At the

same time, however, he seems to suggest that various nonspecific factors play an important role

in improvement. For example, regardless of whether the therapist is using desensitization,

modeling, or the quest for insight, the result may be an increased sense of self-efficacy on the part

of the patient that, in turn, facilitates change.

Perhaps the safest course is to pursue a two front assault. Careful research should be designed

to help us predict which therapy will best work for a given problem. Lists of empirically supported

treatments for common psychological problems should continue to be updated and expanded. At the same

time, effort should also be devoted to investigating the factors common to all therapies and the manner

in which they operate. Research might also focus on the effects of matching patients and therapists in terms

of relevant characteristics. However, in the final analysis, therapist competence may be more

critical than the simple matching of patients and therapists along lines of race, class, or sex.

Therapy is an intermittent process that occurs, for example, once a week. Thus, it is only a small part of

a client's ongoing life. Other, concurrent experiences may be as important or even more important in

determining whether or not improvement occurs. Also, what happens in therapy may interact with

other experiences in complex ways. Others may begin to react differently to the client, and these

changed reactions may reinforce or counteract changes induced by therapy. Changes in the client may

threaten family members, who then quietly conspire to sabotage treatment. The whole process is

so complex and interactive that it is difficult for research to show what factors in therapy are re- lated

to client change or lack of it U. D. Frank, 1982).

Perhaps the greatest reality limitation of all is suggested by Barlow's (1981) charge that many clinical

psychologists simply do not pay attention to outcome research. They continue doing what they have

always done without full realization of the difficulties in making valid inferences from their experiences

with single cases (Kazdin, 1981). Persons (1995) discuss how deficits in training and the perceived

inaccessibility of resources have caused clinicians to delay adopting empirically supported treatment

techniques. However, Chambless et al. (1996) has said it best:

Psychology is a science. Seeking to help those in need, clinical psychology draws

its strength and uniqueness from the ethic of scientific validation. Whatever

interventions that mysticism, authority, commercialism, politics, custom,

convenience, or carelessness might dictate, clinical psychologists focus on what

works. They bear a fundamental ethical responsibility to use where possible

interventions that work and to subject any intervention they use to scientific

208

Clinical Psychology (PSY401)

scrutiny.

Clinical psychologists must learn more about the specifics of the effectiveness of various forms of therapy

and routinely implement this knowledge. They are under both ethical and scientific imperatives to

do so.

209

Table of Contents: