There is an increasing emphasis in psychology, psychiatry, clinical social work, and counseling about the need for the development of “standards of care” in the provision of psychological treatment services. Insurers, other professionals, and legislators ask us to describe what we actually do in psychotherapy. This becomes a particularly important question in an insurance and political era of providers having to be more accountable and focused in the provision of treatment services. There is a concern from insurers, employers, and public policy makers that psychotherapy can keep patients dependent and is of no real benefit, even though research strongly supports the cost-savings and effectiveness of mental health services in relation to health care.
Providers often have a hard time articulating the complexity of the knowledge base required for effective therapy, maybe because we have been trained for so long to utilize our knowledge and skills in a natural way. As a result, we come to see much of what we do as common sense, forgetting the struggles and length of time it took us to acquire these knowledge, skills, and values. The general public many times sees counseling and therapy as a simple process of “just listening to another person”. All of this raises important questions about what a psychotherapist needs to know in order to provide adequate care for patients before specific standards can be established for individual problem and diagnostic areas. This understanding can help providers focus their efforts as they provide treatment services. These “standards” help to assure a common base of understanding against which treatment services can be evaluated by both providers and utilization review committees. They also help to assure quality services provided by providers.
Psychologists, interns, residents, and other mental health professionals are frequently questioned about what theoretical framework guides their practice. Many propose one or two ideas that guide them. The “good enough” therapist may well have to possess a broader-based theoretical understanding for effective interventions with most patients. This article expresses the opinion that an effective therapist must be knowledgeable about a variety of theoretical approaches to treatment if they are to adapt their treatment efforts to various patients during the ever changing process of treatment. Treatment is conceptualized as a much more complex process than has been expressed by many professionals. Defining this complexity can lead to a further refinement of specific standards of care for various problem and diagnostic categories. Providers need to be able to articulate the therapy process to others while at the same time being aware of what it is that they are trying to accomplish in treatment. Our inability to articulate what happens in therapy, and what we know and do in treatment, leads others to lose faith in psychological services as a valuable product.
The Eclectic/Non-Focused Approach to Treatment
Most therapists are trained in developing a relationship and creating a therapeutic environment in which the patient can “grow” and change over time. The patient is seen as growing because the therapist creates a non-threatening therapeutic experience and environment where insight and interpretations are provided. Given such a therapeutic experience, the patient is expected to naturally grow and change, giving up their previous pathology and seeking out new ways of functioning. The idea is to provide for a “corrective emotional experience” where the therapist is seen as the “new introject parent” that allows the “damaged inner child” to grow into a mature “grateful” patient.
When therapists are faced with the realities of the practice world, with “real patients,” new realities are confronted that influence the change process. Therapists comes to realize that the change process involves an understanding of the patient from a variety of perspectives, particularly when services are offered within the context of a short-term focus. Patients evoke behaviors and feelings through “projective identification” in the therapist with counter-transference responses becoming central in understanding and directing treatment. Therapeutic interventions are therefore quite complicated and require that the therapist possess an in-depth understanding of a broad base of theoretical issues and flexible treatment techniques. All of this requires a therapist who appreciates the great therapeutic complexities of offering psychotherapy services. It requires a broad psychological education and experience which can make for an effective therapist.
Providing psychotherapy “is no easy task” unless it is perceived, implemented, and operationalized from a broad perspective. It is also important to understand that the patient may “act out” a variety of feelings “on” the psychotherapist much different than how they would relate to others. New practice requirements require standards of care that help the professional provide directed, focused and active treatment services to patients in order to resolve problems in the shortest possible time. The emphasis is on developing defined outcomes that return the patient to functioning as soon as possible.
Psychological Knowledge and Skill Base
The following outline is designed to assist the psychotherapist in broadening their appreciation of the standards of care. It is designed to assist the therapist in coming to grips with the complexity of knowledge, skills, and awareness that one must possess in order to direct, and conduct, effective therapeutic interventions. The models presented are not meant to be fully comprehensive. While many of these models are historical, they serve as a foundational basis for a strong skillset with any modern therapist in providing treatment services to patients.
I. The Winnicott “Good-Enough” Model
A “good-enough” therapist is much like what Winnicott defines for a good-enough mother. The good-enough mother seeks to provide for the child’s needs. She works hard initially to gratify needs that the child cannot meet for themselves. As the child slowly becomes able to do more on their own, the mother does less and less for the child. The mother slowly frustrates the need for full gratification, allowing the child to learn from their own experiences through logical and natural consequences.
The parent/therapist is still good-enough as she does less and less for the child (patient), though she stays in close supportive proximity to the child. The parent/therapist constantly is aware of what will help the child (patient) grow, and promotes more independent functioning. The parent/therapist sees the importance of the child (patient) needing to be an active doer rather than solely a passive receiver.
The therapist’s job is to promote growth, independence and action, avoiding any promotion of dependence after the initial brief beginning of the first few sessions. The promotion of independence by parents, and therapists, requires an active approach where the therapist works, and comments, on tasks that encourage growth and change designed to fit specific psychological developmental levels.
II. The “Scanning” Model
As humans mature and develop, the initial tendency is to focus on small details. As one grows, gains experiences, knowledge, and meets more people, the individual slowly becomes aware of a greater horizon to be seen. With maturity and experience the effective therapist learns how to “scan” the patient’s environment to understand the total bio, psycho, social, cultural, and vocational inclinations that relate to the patient’s current life and reality. The experienced therapist “scans” the larger picture asking questions upon questions about the vocational, social, family, marital, motivational, along with the practical “here and now” issues of what will help to return this patient to total functioning as soon as possible. The experienced therapist is aware of the tendency in therapy for one to focus on small details of the patient’s psychological reality while ignoring the larger picture of reality in which the patient resides. “Scanning the larger patient reality” helps to keep the therapy, therapist, and patient, aware of the need to see all aspects of the patient’s functioning and life. Such scanning allows the therapist to comment, push, and point out areas of problems, or avoidance, presented by the patient. The “scanning model” also requires that the therapist always has an understanding the “beginning, middle, and ending points” of therapy so that they are constantly aware of where they are “going” in the treatment process.
III. The Ego Psychology Model
This model of therapy admits that the patient does have pathology. However, this model looks to the “Ego Strengths” possessed by the patient. The focus is on how to build on these strengths. It avoids focusing on the pathology and the many problems that “would be nice to solve.” The focuses is on how to help in the “here and now.”
It is a psychodynamic model of treatment that encourages, supports, directs and reinforces strength development. It focuses on “behavioral shaping” of even minor approximations of positive behaviors in order to increase their occurrence and frequency.
IV. The Separation-Individuation Model
This model understands that the organism is always growing, dividing and changing into a distinct human being. The model suggests that the therapist searches for experiences that will help the individual move from a dependent to an independent person. It sees the person’s need to separates and “be his/her own person.” It sees the need to be a separate individual. It creates experiences that “force” and “focus” the individual on being, growing, and having experiences that allow the patient to cope and feel confident in their own abilities. It looks to “push” the individual into taking risks. It blocks the individual from avoiding problems or issues. The focus is instead on avoiding anything that will keep the patient in a dependent relationship. This model allows the therapist to be aware that the patient needs to struggle between the normal issues of dependence versus independence. At times the patient will need to find fault with the “parent/therapist” in order to fully separate and find their own “independent” identity. This struggle can be minimized if the therapist works to establish experiences that allows the patient to “move out on their own.” Additionally, the struggle is minimized if the therapist, and others, do not react to the normal developmental struggles, “adolescent fault finding,” and “normal psychological splitting” between “good and bad” parents/therapists. It acknowledges the fact that as the patient matures they will find therapy to be less and less helpful, or necessary, in their lives for a particular developmental phase. They may even tend to minimize the helpfulness of the process of therapy to their development. It acknowledges that as the patient nears termination there is a tendency for symptoms to worsen, for the patient to become more dependent, and for parents, and therapists, to question whether the patient is really ready to “leave home.” It accepts the “termination regression period” as not being a sign of a lack of being ready to leave “home.” It understands that separation brings out our fears of surviving on our own.
V. The Reframe Model
This model does not rely on insight. It is a model that helps the person see the world somewhat differently. It is based on understanding things in the “here and now.” It is just a different way of looking at things. It’s use is a “surprise” to the patient, giving them something to think over. It does not look for the individual to acknowledge or admit to the reframe. The reframe is promoted to fit with the patient’s experience and functioning. The reframe is not meant to change the patient, but only to help the patient see the world differently. The reframe model accepts the patient as they are in the present time, not as they “could be.” It accepts that patients will get what they want to get from therapy in the end, not what the therapist wants them to get.
This model is designed to assist the patient in seeing things in “psychological terms” in order to assist them in continuing to find psychological explanations in their daily experiences. The “psychological reframe” is seen as an early part of the therapeutic process which needs to start in the first session with the patient. If done in the first session it can help the patient to “bond” to, and be more productive in, therapy.
Reframing is used less and less as therapy continues, with a focus being an encouragement of the patient finding their own “psychological reframe” of problems they encounter. This helps to empower the patient in dealing with problems in their lives, as long as the therapist is subtle in the encouragement of the patient being able to reframe, and find solutions, to their own problems. The therapist avoids any hint of criticism, or a “well you should know by now” response to patients who ask for help in the middle of therapy. The focus is to help the patient feel good about learning to explore solutions. It encourages the “excitement of exploration.”
VI. The Task-Centered, Focused, Outcome Model
This model is active, focused and directed. It is concerned with the task at hand. It keeps a focus on the “bottom line.” It keeps the patient responsible for their own life and their own natural and logical consequence of their actions. It is time-limited, problem-limited, task-centered, and is limited to a specific outcome. It keeps the focus of treatment related to the outcome(s) desired and needed. It requires an active, verbal, directing therapist. It keeps a focus on the beginning, middle, and ending phases of therapy within a time-limited framework. It sees the initial Phase of therapy as developing a relationship, defining goals and directions for therapy and establishing an agreement, or contract, for how therapy will proceed within a time-limited period. This helps to focus therapy in a quick active manner. The second phase of therapy is seen as assisting the patient in self-exploration until an understanding of psychological realities is established. Once this is accomplished the therapy quickly shifts to assisting the patient in finding alternative coping strategies rather than becoming “stuck” in resolving all problems through “in-depth” therapy. The third phase of therapy is designed to assist the patient in disengaging from therapy. There is a realization that symptoms may worsen as the patient moves towards termination. The therapist focuses on the patient taking risks, becoming more assertive, dealing, and managing, the realities of their world. The goal of therapy is to assist the patient in learning how to “manage” their world, and others, rather than having the patient wish that “the others” will change on their own. This step “empowers” the patient in dealing with their “fears of the world.” In all of this the therapist is very active, directive, and focused on moving the treatment process forward.
VII. The “Managed Care” Model
The idea of a managed care provider focuses on the need to direct and focus the type of care provided. It includes the idea that only the most appropriate care is provided. It is concerned with cost-efficient, cost- effective, limited services. It has as its center a knowledgeable provider who “manages” and “guides” the patient in obtaining the desired goals. The provider is suppose to be aware of what may be the most effective way of finding a solution to the patient’s problem without over-utilizing other unnecessary services. The provider’s job is to educate the patient aboutX their condition, (2) the realistic alternatives, (3) what they should expect from treatment, (4) how to realistically obtain their goal, and (5) help the patient make realistic choices about alternatives for treatment and obtaining the desired outcome(s).
The provider is suppose to have developed a relationship of trust with the patient whom he/she has come to know. This knowledge about the patient is suppose to guide the provider in the provision of services. The focus is to develop treatment alternatives and choices which can benefit the patient over the long term to obtain bio-psycho-social goals. The provider’s goal is to “manage services” in a positive growth producing manner. There are many similarities to the time-limited, task-centered model of care. However, the managed care focus is even more specific and directed.
VIII. The Object-Relation Model
The Object-Relations model suggests that the pattern of early parent-child interactions dramatically influences the individual’s capacity for intimacy. Adult relating patterns are established in early childhood. Distortions in relating to other “objects” (people) early in life results in dysfunctional relating later in life. Understanding early life relating patterns can help the professional understand, and predict, how the patient will relate in the present and future.
The model suggests that the therapist must be aware of the patient’s tendency towards the pathological use of “psychological splitting.” The tendency is to “split good and bad parents” in a negative dysfunctional manner. It is understood that this is an expected part of all interactions with the patient. The patient will tend to “split” one staff member, or therapist, against another, therefore recreating similar dysfunctional childhood relating patterns in the present. Such “splitting” can result in one therapist being seen as the “good parent” and the other as the “bad parent.” Such “splitting” can happen in the relationship with just one therapist. It is important for the therapist, or staff members, to be alert to such splitting in order to “stay united” in their approach to the patient. The model suggests that there are specific states to therapy which can be seen in the context of short-term or long-term therapy:
- The Engagement Stage: This first stage is vital to the establishment of an effective relationship. If the patient is not engaged early and quickly in a relationship of trust, it is doubtful that therapy will continue for long.
- The Projective Identification Stage: This stage suggests that not only are certain feelings “projected onto” the person of the therapist, but that the patient induces the professional to react behaviorally in specific ways. Therapist have to be aware of vague feelings that something is not right. They may find themselves becoming irritated, angry, rejecting, aroused, overly-caring, or doubt their abilities as therapists. One must use their own countertransference in a positive diagnostic manner to understand the meta-communication presented in the projective identification. There are four types of projective identifications which induce a behavioral response on the part of the therapist: (a) Projective Identification of Dependency; (b) Projective Identification of Power; (c) Projective Identification of Sexuality; (d) Projective Identification of Ingratiating/encouraging others to care for them.
- The Confrontation Stage: This is an important stage that can take place within a short period of time. It is important to remember that the goal of therapy is to help the patient to admit to the specific goal of their relational pattern. Though the patient may not readily admit to their use of projective identification, they need help in understanding how they are impacting others. The therapist also needs to understand, and respond appropriately, to the projective identifications utilized by the patient. It is a time to utilize “gentle confrontation” techniques whereby the therapist can help the patient realize that there may be better ways of handling the situation in order for them to accomplish their goal. The therapist refuses to respond to the meta-communication demands. It is hard to not rush in to “save” a needy and dependent patient. The confrontation takes place as part of the interactional process. The therapist must only refuse to give into the patient’s demands, while all the time reaffirming the relationship with the patient. The patient needs to confront what they fear most, i.e., the loss of human contact with others.
- The Separation Stage: The therapist must realize that an important part of the therapeutic process, from the beginning, is to assist the patient in separating and becoming independent. It is a stage where the therapist recognizes that they must be constantly aware of the mixed feelings about separation experienced by the patient. Many times the patient’s angry responses, or relapses, are related to their fears of leaving the therapist and being on their own. The patient needs help in attaching to social supports and experiences which can allow them to separate and be able to handle their problems in a more competent manner. The therapist must be aware that they need to guide and direct the patient towards this stage of therapy rather than focus on keeping them dependent in treatment too long. It may help to start, toward the end of treatment, to start to stretch out the time intervals between treatment sessions in order to facilitate the patient relying more on themselves before all supports are removed. It is important to know that in order for the patient to receive the maximum benefit from therapy the therapist must continue the focus on the therapy relationship. Patients are rarely aware of the kind of messages they have conveyed in their projective identifications. The vital goal of this last stage of therapy is for the patient to be provided information about the way they are perceived by others. It is important to remember that the significant issues for the patient revolve around fears of abandonment, rejection, and splits between “good and bad” people and feelings.
IX. The Psycho-Educational Model
This model understands that all change and growth requires information and education. The therapist, or parent, is first of all an educator. Patients many times have not had explicit information which can help them in making choices. The choices made by patients are frequently made by “bluffing it” to look as though they are confident. All the time the patient is fearful that they are not really sure that this is the right choice for them. They “fake it” but are never sure that the choices they make are correct, even if it turns out fine. Therapists provides for a “feedback- educational -loop” of information which can reassure the patient about choices and directions that others make. This process helps patients to gain information, to obtain feedback, and to feel that they have the knowledge now to make informed choices. It assumes that with time, information, and repetition, the patient will gain confidence in their ability to grow and make independent choices.
X. The “Quick-Responding/Early Identification” Model
This model suggests that the therapist must be able to identify early on the patient’s concerns. These concerns are not only obvious one, but the underlying feelings, emotions, and fears. The patient must see the therapist as being able to understand them quickly. The therapist must demonstrate an ability to identify by quickly responding to the needs and problems presented by the patient. Patients tend to stay in therapy if they feel that the therapist is capable of meeting their needs. Patients need to see this happen within the first contact with the therapist. However, therapists will need to be aware that though there is a need to identify and discuss problems early, moving too fast can also “scare the patient away.” It requires that the therapist constantly assess, adjust, change, and focus their responding as part of a broader change process that takes time. At the same time, it is important to remember that there is also comfort and security for the patient if they feel that they are understood by the helping professional. Patients are many times “stronger” than we give them credit for. As such therapists delay discussing important issues out of their own fears. Providing for a trusting, safe, therapeutic environment allows the patient to feel comfortable and safe even when disturbing information is presented by the therapist. Though the patient may be upset and anxious following such discussions, they frequently feel that they have gained much through this intense experience. Providing for only “warm fuzzy” reassuring treatment has been found to help in the short term, but not help in the long run. Dealing with difficult problem areas as part of the therapy process provides for later growth, even though parts of the process may be difficult and uncomfortable.
XI. The Empathic/Carina Model
The empathic/caring model requires that the therapist be able to intimately understand the patient. The therapist is able to actively communicate to the patient that they are understood and cared about. It is a model that is NOT just one of praise and cheering the patient on. It is based on a true understanding of the patient’s problems, their needs, and their feelings. It is one that requires the therapist to not be just a listener, but also an active, verbal participant who responds to the patient’s verbalizations in a caring, warm and concerned manner. It is the basis of developing a positive therapeutic relationship with the patient.
XII. The “Mechanics/Presenting Problem” Model
Patients present to providers with a need that they hope will be solved. They expect that the provider will have “magical pills” and solutions that can quickly resolve the problem. They hope to be passive-recipients of care from the Shaman, or the one with the magical powers and superior knowledge. They expect that the provider will “look like the mechanic (healer).” The provider must meet these expectations initially in order for the patient to feel that they have come to “the right place.”
This model requires that the provider ask questions, give specific suggestions, and be more active initially in establishing the relationship and directions for treatment. Patients’ do not perceive that they will need to be active participants in much of their treatment. The provider must, over time, direct the patient at how they are to become active self- participants in the change process.
The provider must initially focus on the presenting problem(s) as perceived by the patient. Though the provider may be aware of many underlying problems that are in need of assistance, the patient may not be ready initially to deal with these problems. The provider must initially be perceived by the patient as an effective, helpful, and competent “mechanic” for the presenting problem. However, within this context the therapist is aware of the need to provide for an early reframing of the patient’s problem in order for the patient to be engaged in the full therapeutic encounter. At the same time the initial presenting problem must not be forgotten since it is the one thing that is of a major concern to the patient and others. This model is particularly important for patients presenting with psychophysiologic and behavioral medicine problems. The focus at these times is on the physical complaints and problems that are being presented to a behavioral medicine specialist.
XIII. The Relationship Model
This model, which had its origins in psychodynamic theory, assumes that change is only possible within the context of a relationship. The therapeutic relationship is seen as having a central importance to therapeutic effectiveness. It is felt that for the therapist to have any impact on the patient, an early therapeutic alliance must be formed with the patient. It assumes that the patient will then bring into that relationship various distortions in relating patterns. The therapist is to provide for a “corrective emotional experience” for the patient. This assumes that the therapist will NOT respond in the manner in which the patient expects. In fact, the therapist must “do the opposite of what is expected” for the patient to “experience the necessary correction” in relating patterns. This model further assumes that no growth can take place outside of a caring and helpful relationship.
The therapist utilizes the relationship context to make statements about patterns noted in the relationship. It is assumed that the therapeutic relationship is a dynamic, changing, explosive, dramatic, exciting, and at times threatening environment, and process, for all concerned. The relationship, especially in the context of the psychotherapeutic arena, is constantly changing. Patients tend to constantly make “approach/avoidance” moves in response to being in an intense, intimate, interaction with a therapist who is seen as more powerful.
It is expected that both the therapist and patient will experience many transference, and countertransference, reactions to these important interactions. It is also expected that the therapist must keep a watchful “eye,” or “Third Ear,” on the constantly changing therapeutic relationship environment in order to manage the many feelings, and the overall directions for treatment. The therapist is seen as being the master of managing relationships towards therapeutic ends.
The therapist is seen as one who constantly tries to maintain an objective view of the interactions. There is a realization that the patient is less objective, more subjective, having more needs, and therefore not as able to provide for an “observing ego.” The goal of therapy is to help the patient develop an ability to observe their interactional patterns both in the therapy situations, and within the wider world. The therapist is aware that their reactions, both positive and negative, relate directly to the intensity of the interactional relationship. These reactions are utilized by the therapist to gain an understanding of various patterns in the relationship, and the manner in which the patient interacts in the wider world.
XIV. The Needs/Fear Model
The patient has both a desire and need to reach for growth and change. Change is seen as something that is a constant in the human experience. There is a need to be independent and dependent. The human organism will resist any attempt to keep them dependent and from growing. At the same time the patient’s fears will cause them to resist and fear change unless they feel safe and secure in meeting the challenge. Though they can feel the need, they can fear the unknown. Parents know that they need to encourage, guide, push, educate, and direct their child towards taking risks if the child is to become a healthy adult. The job of the parent, and therapist, is to assist the individual in developing a variety of experiences, over time, that will give them the confidence to try. This allows the individual to know that if they have problems there are alternatives for them to turn to. Patients’ who present for therapy do not have much confidence, have come from families where they have been frequently criticized, and have had many experiences of failure. Patients in therapy want to “play it safe” but are also frustrated by the need to grow and adapt. This establishes a “neurotic paralytic trap” which tends to immobilize the patient, creating much anxiety and confusion. Such patients have become demoralized and have developed a depression resulting from a feeling of “learned helplessness.” Such patients need to have many repeated successful experiences in order to develop new confidence in themselves. This model assumes that change is a process, over time, of many accumulated positive and successful experiences. It is a model that suggests that people move towards pleasure and avoid pain. It assumes that “for the Ego to integrate, it must also regress” where progress going up and down throughout the therapeutic encounter. It allows the therapist to not react to the regressions, relapses, and flare-ups in pain and problems experienced by patients.
XV. The Cognitive-Behavioral Model
This model suggests that behavioral variables are specifically influenced by the type of cognitions, or thinking styles, that are utilized by the patient. Dysfunctional cognitions, distorted cognitions, including negative and positive automatic thoughts and attributional styles (attributing negatives events to themselves and their actions), are seen as having a major impact on the ways in which the patient functions and responds. Negative cognitions, and cognitive distortions, are seen as directly related to depressed functioning. The cognitive-behavioral therapist is more active in assisting, and challenging, the patient to examine the various negative cognitive distortions which impact functioning. The patient is challenged to check out issues in their environment, such as asking others not involved in the problem about how they perceive the situation. The goal is not only to change cognitions, but to make the patient an active participant in their own healing. It is understood that examining negative cognitions may by itself not be enough to bring about a change. The lack of positive cognitions, and experiences, is seen as influencing maladaptive emotions. The cognitive-behavioral approach also involves issues of Rational Emotive Therapy (R.E.T.), relaxation, biofeedback. Eye Movement Desensitization and Reprocessing (EMDR), and similar techniques, all directed at specific active things that the patient can involved in doing and receiving various forms of feedback, or reinforcement, from accomplishing. Non-depressed patients are seen as having more positive cognitions and autonomic thoughts. Research into the use of cognitive behavioral therapy supports its significant value in treating depression. The results of Cognitive-Behavioral Therapy initially equal to the results of utilizing anti-depressant medications. However, the long-term results provide for superior sustainable outcomes for the cognitive behavioral approach to therapy.
XVI. The Crisis Intervention Model
The definition of a crisis is one of risk and opportunity. The very nature of a crisis is that it is short-term in nature. The model suggests that in a crisis, people tend to look sicker than they actually are. The goal is to re-establish the former level of functioning and equilibrium. The job of the therapist is to focus on the “here and now” problem focus. The focus is only on the presenting problem. Other problems are not necessarily dealt with. The goal is to get the patient to be active in solving and resolving their own problems. The therapist lets the patient vent feelings, rather than to cover and block feelings that can cause later more involved problems. The therapist then slowly assists the patient in making decisions and moving forward with their life again. The focus is on the issues and the desired outcome.
XVII. The Salesmanship Model
Most salespersons know that they must survey the situation quickly. They know that they must “tap into” the desires and needs of the client quickly. The ideal salesman knows that they must get to know something about the other person without exploiting and being “pushy” and as a result encountering resistance. They know that they need to “give room” and as such they look for ways to “withdraw” at the right moment, but only to return in a very short time (“Planned Detachment”) . They know that what makes for the most successful ethical salesperson, as compared to the “average salesperson,” is an intense focus on “follow-through and a disciplined focus on the task at hand.” If the client “gets away” they reach out, show personal interest, and try to re-engage indirectly. They do everything to maintain a positive relationship and focus to the interactions. They work to “create a need” without pushing or forcing. They think and plan actions “ahead” of the present situation. They think of alternatives and are constantly scanning for solutions.
XVIII: The Counter-Transference Model
Psychotherapists are particularly vulnerable to problem reactions which can interfere with the treatment focus. Patients use “Projective Identification Defenses” to evoke behaviors and feelings in the therapist. This allows them to “blame the therapist” for their “unconscious” projections of feelings. Therapists may respond with anger, helplessness, or a desire to withdraw, punish, or attack. Therapists need to know that the presence of such feelings are “clues” of what the patient is feeling. Though patients try hard to “tape into” the therapists own unresolved issues, “unconsciously,” therapists need to be aware, and take responsibility for, these important counter-transference “diagnostic” and “treatment-directing” feelings. Within this context, counter- transference feelings can be helpful in guiding the therapist in understanding and handling the various therapeutic issues with the patient. It requires that the therapist use their “third ear” to understand the various levels of messages, and feelings, evoked within the person of the therapist. These “messages” and “feelings” are diagnostic clues that guide if responded to appropriately.
XIX: The Therapeutic Compliments/Joining Model
Patients enter therapy with fear and anxiety. They come from life experiences that may well have not supported the development of self-esteem. Compliments have been shown to be highly effective in motivating patients, along with engaging them to pay attention to, and accept, interpretations and statements. Compliments “do the opposite of what is expected” allowing the patient to move towards a “yes set” responding style. It also helps the patient “bond” to the therapist and therapeutic process.
XX: The Chemical Dependency/Abuse Model
It is vital that therapists become aware of any chemical dependency patterns presented by patients. Dependency on any chemicals inhibits the potential for change. Before any real therapeutic change can happen the approach to treatment must include withdrawing the patient from the chemicals. The therapist must ask questions about drug and alcohol use along with being aware that the extent of chemical use/abuse might not become obvious until later in therapy. One sign of chemical abuse is noted when a lack of progress in therapy is seen. Panic attacks are frequently associated with individuals who are, or have, abused alcohol.
It is also important to note the extent of use of chemicals other than alcohol and drugs. Caffeine use in coffee, teas, cola drinks above 240 mg per day (usually 150 mg in a cup of coffee) can suggest reasons for tensions, anxiety, panic attacks, pain and muscular/pain problems, withdrawal headaches, and many other symptoms.
Pain medications are CNS depressants that can also make patients depressed and dependent. Many alcoholic patients stop drinking when injured only because they have started on pain medications. Such pain medications substitute for the previous dependence on alcohol or drugs. Again a withdrawal from the involved chemicals is important.
Use of tranquilizers, and other psychiatric medications, can be helpful to many patients while causing problems for others. It is vital that psychotherapists be aware of the impact of any type of medications on patient’s functioning and mental status. This requires questions about medications with patients as part of the history taking process.
XXI: The Motivational Interviewing Model
Motivational interviewing techniques focuses on how the therapist should respond to particular problematic situations encountered in the therapeutic situation. It asks why certain statements were made at specific times. It has a practical focus that engages the patient in a different way of thinking and responding to difficult problems situations. Its focus involves five general principles:
- The Expression of Empathy: As indicated previously, this is the acceptance of the patient’s feelings and experiences without judgement, blaming, or criticizing. Such acceptance does not imply approval or prohibit the therapist from disagreeing with the patient’s view. It does though involve a respectful listening where the client is not seen as being “bad” but as being “stuck.”
- The Discrepancy Development Stage: The goal is to create, and amplify, a discrepancy between the patient’s present behavior and their desired goal or outcome. This can help the patient understand the costs of their present course of action. The goal of motivational interviewing is to develop, amplify, and increase the discrepancy between behaviors until the patient gives up their present behavior. The goal is to do this with the patient rather than having to rely on external motivators. Patients can be more influence by their own actions and what they hear themselves saying as they respond to the various differences noted by the therapist.
- The Avoidance of Argumentation Stage: Arguments and head-to-head confrontations are avoided since they lead to resistance and strongly defending “positions.” Arguments elicit opposition and defensiveness from patients. Accusing others of denial, or being resistant, only undermines motivation for change.
- The Roll with Resistance Stage: It is vital to note that therapists are not to see patients as opponents to overcome and defeat. Therapy is not a competition of wills. Ambivalent feelings are not confronted but acknowledged as natural and expected. Reframing what is said though can create new movement towards change. Rolling with resistance involves engaging the patient in the “process of problem solving.”
- The Support of Self-Efficacy Stage: It is important to instill hope and faith that change is possible. Positive expectations on the part of therapists can be powerful tools to impact and encourage change on the part of patients. The goal is to help the patient see that they have the ability to cope and overcome obstacles. Self-efficiency relates to the ability to cope and handle challenges, problems and tasks. The individual must be in charge understanding that no one else can do this for them. Even a series of failures is not seen as hopeless but only that the individual has not yet found the right approach. Change takes time and experience. The therapist is there to encourage, challenge, reframe, focus, and push the patient forward to being an active participant in their own life.
XXII. The Containment/Holding Environment Model
Some patients present with quite primitive defenses, emotional instability, suicidal ideation, or go through periods when they are not able to contain their emotions very well. Part of the goal of therapy is to help patients organize their feelings and emotions in new ways. At times this can be upsetting and threatening to an individual’s sense of well being. Therapists need to know how to provide for a “psychological holding environment” where there are varying levels of ego supports provided depending on the patient’s level of development and emotional functioning. Progress requires an understanding of the concept “for the Ego to integrate changes, it has to regress.” This is also known as “regression in the service of the Ego.” When problems are faced fear and anxiety are present. As patients grow emotionally in therapy there will be natural periods of regression and problems when nothing seems to be working, the patient feels vulnerable, or they start to act out in some manner. At these times it is important that the therapist “put the lid on the Id” allowing for some containment, or holding, of primitive impulses or destructive tendencies. At these times it is important to be aware that growth will continue to occur if the patient is given a “good-enough holding environment” that at the same time allows for growth. The therapist has to be continually aware of when to provide for more structure while watching for opportunities to encourage independence and growth.
With some patients, who have poor impulse control, direct and open discussions about the need for such structure is vital so that they come to understand the need to incorporate structure into their lives. Other patients are more labile and require the “holding” to be an actual hospital setting for a period of re-stabilization. The therapist must always be alert to issues of suicidal ideation and balance between the need for “less or more” structure depending on the patient. At times it is better to take risks with unstable patients in order to encourage growth and health while the therapist is constructing “psychological containments” which allow the patient to grow and become independent.
XXIII. The Developmental Life-Cycle Model
Working with patients requires that the therapist have a historical perspective on the developmental issues that the individual has experienced as they have progressed through their life. It is particularly important that the therapist be alert to “traumatic events” or issues that might have caused conflicts (even minor events or changes), or a developmental “arrest” at specific points in the early childhood life of the individual. Knowing when a the individual’s parents divorced, when one or both parents started drinking or started to have an affair, when the child felt alone or abandoned emotionally, or when a traumatic event occurred, can help in understanding how certain psychological issues were never resolved. To assist in this the therapist must not only ask about early family history and relationships and interactions, they must also understand these events in terms of Erikson’s “Eight Ages of Man” which proposes the tasks each individual must resolve as they move through life. The first stage is one of “Basic Trust vs. Basic Mistrust” with the hope that the infant comes to find that their relationship with others is one that engenders a sense of comfort, trust, and positive expectations. If the crisis occurs at age 8, the individual might be still struggling with issues of “Industry vs. Inferiority” feeling always overwhelmed and fearful that if they are not always a workaholic and pushing themselves that they will feel overwhelmed with feelings of inferiority. Being able to integrate this type of understanding into the therapeutic process can help the individual, and therapist, understand some of the difficulties faced by the patient.
A developmental understanding provides for a process where the therapist can create a therapeutic environment that allows for the proper situation that encourages growth and resolution of a “early arrested stage of development.” Without this understanding it is difficult to appreciate the individual’s conflict many times in the present situation. Such a perspective allows for an appreciation of normal ego development of the individual.
XXIV: The Solution-Focused Therapy Model
The Solution-Focused Interview Brief Therapy model was recently developed by Steve de Shazer, MSW, and is best described in terms of the questions asked that focus on solutions. It also focuses on what therapists do to get clients to talk and think about change through a sequential series of questions. The questions focus on what the client is doing that is working. It also asks clients to focus on imaging solutions and ideas about how to make things happen. It helps the client regain a perspective that there are times and things they are doing that are helpful. Though clients tend to focus on what is not working (problems), the therapist helps them look for “exceptions.” The therapist must look to anything the client says that can be seen as a positive, or times when the problem is not occurring.
The therapist is especially sensitive to noting any exceptions to problems, no matter how small. Once this is noted, a series of questions are asked that help the client note that they do not always have the problem and already practice some of the solutions. These questions include:
- “What is different about those times?”
- “What do you think you do differently?”
- “What do you think they see you doing differently?”
- “What has to happen for more of that to happen?”
- “What will you have to do?”
- “How will you know the problem is solved?”
- “How do you think others will know?”
- The Miracle Question: “If a miracle happened and you woke up tomorrow and your problem was solved, what will be different?” (helps with goal setting).
This is a task-centered model that uses homework assignments for clients to do between therapy sessions. It is unique in that there is a lack of a focus on problems, complaints, or patterns of these complaints. Questions are used as sequential building blocks towards finding solutions in terms of what the client is already doing. It builds on the client’s strengths as an active participant in the treatment process.
XXV: The Systems Theory Model
It is vital that the psychotherapist understand each patient in terms of a systems theory of interactions. Individuals are not isolated islands but are part of larger systems which are in constant interaction. Any change in one part of a system impacts the entire system in some manner. Changes made by the individual do influence others. Others work hard to maintain the system’s functioning in its usual manner. “Once a system is set in motion it works to continue in motion the same way.” This is a basic physics, and psychological, principle about systems. Roles, expectations, needs, desires, definitions of identity, and so on are always in interaction with the entire system. Asking a patient about what they thought their role in the family was as a child growing up will always shed light on their present interactions. Change is resisted by systems, so as the individual works in therapy to make changes the system works equally hard to maintain the status quo. It is not that the system is necessarily “bad,” it is just that the system is used to a certain way of operating and interacting. For this reason it is important that the therapist always be aware of the larger system when working with parts of the system. It is also helpful to involve other system members, spouses and family members, if possible in the change process in order to help develop the support systems that can allow for, and facilitate, changes. This is particularly important in working with children and adolescents. Involving the family system in some manner in the treatment process becomes essential to developing long-term changes.
Anticipating system responses to the individual, and discussing them openly, allows the patient to understand the various issues involved. It allows each “part” to understand the “whole” with greater depth and appreciation. It is also more realistic in terms of the environment in which the individual lives and interacts on a daily basis. Appreciation for, and involvement of other system members, becomes an essential component in developing realistic change.
XXVI: The Sustaining. Maintaining, Relapse Prevention Model
We have all come to understand that change is a difficult process that is both resisted and desired. When change is achieved, we no longer expect that the individual will never have a problem again. We expect that “for the Ego to Integrate it has to regress.” This is known as, “regression in the service of the Ego.” No change can be sustained change without periods of ups and down. The best way to prevent a relapse is to expect that it is going to happen. Problems are, therefore, no longer defined as “failures” but are “opportunities for learning.” Even young children go through ups and downs in their ability to grasp a new subject area.
It is the job of the therapist to understand this concept, to educate the patient about the naturalness of this process, to anticipate when it might occur (most occur at times of strong emotions and interpersonal conflict), and to establish a manner in which such regressions can be used therapeutically for further growth and stability.
In this process it is important for the therapist to be an effective manager of the mental health dollars left available to the patient in their insurance plan, to plan for periods of stretching out times between sessions, to offer periods of time where the patient can “practice” their new skills, and to think of ways of helping the patient sustain and maintain their gains over time. This may require that after the initial intensive stabilization period of therapy has been completed, the therapist may need to think about how to stretch out time between sessions to help the patient sustain and maintain their gains over time. Some patients do best if they are seen monthly over a lengthy period of time. Such an approach to treatment could be seen as “psychologically/medically necessary” in order to prevent the patient from relapsing, to keep them out of the hospital, and/or to keep them focused on being functional again, to keep them employed, and to be emotionally stable over time. Such an approach could be seen as highly cost-effective, therapeutic, and important to the community of providers, and employer, who interact with this patient in different settings.
Sometimes it might be helpful to arrange for a referral of the patient to a support group, group psychotherapy, or other community resource as part of helping to insure that the patient maintains their gains.
It is also important to be aware of the concept of “sequential short- term/long-term therapy.” Patients can be seen for short-term interventions at different developmental, and crisis, points in their lives. It is important that the therapist be seen as a “general practitioner” who can be available to help the patient for short-term periods at different times in their life spans. Coming back for therapy should not be seen as “a failure” but more that the individual is working through different developmental issues that impact with the other aspects of their lives in dynamic and moving ways.
Much of this relates to the research literature on the importance of continuing to work with depressed patients. Many depressed patients have recurrences of problems over time. The most effective manner of helping them is to provide the support to help them deal with problems that come up over time. However, the goal is to not make the patient dependent, but to help them once stabilized to maintain and sustain their gains as they are learning to deal with life in a more productive manner. Anticipating this with patients, making arrangements to provide the supportive psychotherapeutic assistance over time, working to provide the most cost- effective and cost-savings approach for the patient, employer, and insurer, can make a major difference in helping those who make it. The first year following therapy can be a difficult one for the patient and no one should expect that they will not have set-backs. Anticipating this and planning for ways to sustain and maintain gains, as part of the early treatment thinking and planning, is vital to long-term success.
This article is not meant to be a comprehensive discussion of the various models, techniques, or issues, that need to be considered in interacting with patients. Additionally, it is obvious that these models do overlap and interact in a variety of ways, without any specific order, throughout the therapeutic process. However, the above discussion points to the numerous factors that the professional must always be aware of in working with patients, particularly within a brief therapy context. The therapist must constantly shift the focus, direction, and emphasis, while utilizing a broad context in which to relate to patients. At the same time the therapist must ask, “what is necessary to help the patient achieve the stated goals.”
The models for standards of care presented above point to how complicated the therapeutic process is for the professional. People present with multiple issues well beyond the presenting and underlying problems, or diagnostic, issues. Each crisis activates multiple issues from anxiety to family and marital problems. Problems previously not dealt with come to the front when crises arise. Therapist must scan, manage, and direct clients towards resolving both the crises, problems, and multiple related issues. The goal is not just stabilizing the diagnosed problems but to help insure resolution of all problems so the patient leaves therapy stronger in a broad-based manner. This does not mean that each and every problem must be solved. However, it must be considered, focused, and managed so that the patient has tools to deal with them after treatment. This does not mean that the patient should never be seen again. It is normal to see people at different times in their lives. Developmental crises, and changes, provide new opportunities to continue to change and grow in new and more adaptive ways.
It is critical that the professional utilize this knowledge base as part of developing an effective individualized treatment plan. As the professional psychotherapist evaluates the situation, fits them into the various theoretical models for intervention, considers the problems presented, along with evaluating resources available to support treatment directions, goals and treatment directions can be established. Having this broad-based knowledge base requires that the professional develop a differential diagnostic and treatment assessment that can determine whether the patient can benefit from short-term, or longer-term, treatment approaches. Even for long-term treatment patients these standards point to the importance of the therapist staying active in directing treatment, keeping things moving forward, all with a focus on the goals and directions for treatment. Psychotherapy is more than being “a pal” and hoping that patient’s will gain insight as they “talk.” It is an active dynamic interactive process between therapist, patient, family, and others involved. It is a process that should have a focused outcome which is kept in mind from the point of the initial evaluation through the various phases of treatment. If the therapist is to be effective in providing treatment, they must be aware of the stages of treatment. This helps to insure that proper personal change can happen happen in therapy.
Psychology must also be considered in the broader context of “a health profession” rather than in the narrow “mental health” label. The latter label overlooks the professions role in treating wide ranging disabilities, health compliance issues, over-use of the medical system, improving health and functioning, issues in rehabilitation, adjustment, coping, neuropsychological and cognitive interventions, family/domestic violence, chemical abuse, and a large range of human problems. Diagnostic labels confine and limit roles, definitions, and scope and training of the profession.
This article further emphasizes how complex the standards of care for psychotherapy is for the professional. It is a “standard” that requires much effort, energy, and determination to keep the proper focus and direction for therapy. These standard of care highlights the “helping process” as one requiring more than just being a “good friend,” or providing for an “in-depth experience.” It is process that requires a great deal of knowledge, skills, values, experience and determination, along with personal psychological understanding, to deal with the varied aspects of therapy.
It further requires that the therapist personally “manage” their own needs and feelings within the therapeutic process if quality services are to be provided. It suggests that no treatment encounter, or interpretation, statement, or “piece of advice” will provide for “the” solution. This type of approach to treatment suggests that psychotherapy is a complicated, moving, changing, organized, confusing, enjoyable, exhausting and difficult “process” that evolves over a period of time, much like the manner in which humans evolve in life. For this reason it is important that the professional realize that “change is a process” rather than a defined event, or interpretation, in time. This process though can be structured and directed so as to accomplish specific goals within a time-limited framework if the therapist is alert to the need to be an ACTIVE PARTICIPANT in the psychotherapeutic process. With these factors in mind more specific standards of care can be defined for the various problem and diagnostic groups.
These standards of care though do require that the therapist be aware of the importance of managing the treatment case, goals, and plans from the first contact with the patient. It requires a therapist who is active, focused, specific and clear about the directions and goals of treatment for different diagnostic categories, along with understanding the need to bring to bear a number of therapeutic techniques and theories on the treatment process. To allow a treatment case to “just evolve” does not take into consideration the complex, and powerful, nature of the treatment process.
Ron Lechnyr, Ph.D., D.S.W., holds two doctorates, one in clinical social work, and the second in psychology along with being licensed by both professions. He is Past President, and the former Professional Affairs Chair, of the Lane County Psychologists’ Association. He is also former Chair, Carrier Relations Committee, Lane Mental Health Provider Group, Inc., an Independent Practice Association (IPA) of psychologists, clinical social workers, and psychiatric nurse practitioners which is working to contract with various managed care organizations, insurers, and employers. In his professional practice he has been Clinical Director of Oregon Health & Rehabilitation and worked in private practice. He is currently retired.
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