Conjointly Defining a Therapeutic Direction. Joshua M. Gold. University of South Carolina

Transcription

1 Running head: CONJOINTLY DEFINING A THERAPEUTIC DIRECTION 1 Conjointly Defining a Therapeutic Direction Joshua M. Gold University of South Carolina Author Contact Information: 253 Wardlaw College University of South Carolina Columbia, SC Telephone: Fax: josgold@mailbox.sc.ed The author holds the rank of professor in the Counselor Education Program at the University of South Carolina.

2 CONJOINTLY DEFINING A THERAPEUTIC DIRECTION 2 Abstract The rationale for the use of therapeutic conversations to generate collaborative intentionality in clinical service are presented. This treatise is exemplified by a sample case study. In addition, implications for graduate education, clinical supervision, and future research are provided. Keywords: Common factors, intentionality, therapeutic direction

3 CONJOINTLY DEFINING A THERAPEUTIC DIRECTION 3 Conjointly Defining a Therapeutic Direction The efficacy of counseling is well-confirmed; however questions as to which specific therapeutic dynamics promote successful therapy remain under debate (Laska & Wampold, 2014; Shadish & Baldwin, 2009; Tschacher, Junghan & Pfammatter, 2014). Such uncertainty does not seem to hamper the impetus to provide clinical services. One basic premise of counseling is that doing anything is better than doing nothing, so therapist activity, as compared to passivity, seems a cornerstone of efficacious clinical service. However, clinicians still contemplate exactly what will work with which clients and which conditions for which presenting issues (Leibert & Dunne-Bryant, 2015). Graduate students, beginning counselors, and perhaps even those with extensive experience, ruminate about the process of creating a clinical directionality for, or with, their clients (McAleavey & Castonguay, 2014). The professional literature provides a diversity of answers, offering scholarly discussions about the strengths and limitations of common factors approaches, theoretical purity, eclecticism and theoretical integration. The practice of counseling seems to oscillate between the orthodoxy of theoretical implementation, without divergence, and the spontaneous enactment of a counselor s unique expression of eclecticism (Laska, Gurman & Wampold, 2014). The first practice seems based on the principle that divergence from theory leads to clinical confusion; while the second practice reflects the principle that adherence to theory leads to clinical stagnation. In the mid-range of this dilemma seem to lay those scholars advocating eclecticism or integrationist approaches, with little guidance about which aspects of which theory complement each other than perhaps other combinations toward more efficacious clinical service for which clients. However, perhaps, there is an approach that alleviates the responsibility for these decisions solely from the counselor and provides a framework to share

4 CONJOINTLY DEFINING A THERAPEUTIC DIRECTION 4 that accountability with all those individuals invested in the success of the therapeutic relationship (Harris, Kelley, Campbell & Hammond, 2014; Weinberger, 2014). However, before this approach can be presented, much akin to a common factors recommendation (Lambert & Ogles, 2014), the question must be addressed: given the multiplicity and diversity of client presenting issues, on what aspects of client s case perceptions can such an intervention be founded? Rationale It is the thesis of this proposed approach that the term common factors can be applied to epistemological patterns across clients presenting issues. This notion implies that the meaning-making focus expressed by each client seems to represent client perceptions that transcend each problem but also which are characteristic of that individual. For example, a client who believes in a medical model searches for a biological roots of all personal suffering, with the attendant belief that an appropriate pharmacological intervention will alleviate one s pain. As a second example, an individual presenting with issues of continual blame believes that other persons are responsible for the client s pain and ought to change their actions accordingly. In each case the counselor s focus of insight development, goal setting, and appropriate interventions would be distinctly different. However it can also be thought that clients are unaware of their problem orientations and that the orientation itself serves to render the problem unsolvable. In addition, it could be held that the client and counselor begin counseling with divergent views on what exactly is the problem. It can be extrapolated that, perhaps, the common elements within a client s perspective provide a starting point for counseling. Relationship variables (Lambert & Ogles, 2014, p. 501) repair alliance ruptures and increase motivation by reengaging clients through renegotiation of

5 CONJOINTLY DEFINING A THERAPEUTIC DIRECTION 5 the therapeutic contract to increase patient participation and collaboration (p. 502). This discussion is less about client change than an overt, counselor-led exploration of providing information to patients themselves that appears to improve the quality of service ((Laska & Wampold, 2014, p. 522). This investigation addresses those same questions of which the counselor has already made professional sense and the answers to which direct one s clinical approach. However, rather than impose those answers on clients or assume that clients share or are willing to accept the counselor s decisions, these matters are integrated into the first three sessions (Leibert & Dunne-Bryant, 2015) to foster rapport; to create a template for therapeutic conversations; and to co-author an initial direction for counseling (Brooks-Harris, 2008; Harris, Kelley, Campbell & Hammond, 2014). There seem to be four commonalities in a client s issues: a) the client feeling defeated or hopeless, while client actions to solve the problem are congruent with the conceptualization of the problem and somehow are repeatedly unsuccessful; b) that clients have learned, through selfstudy, previous counseling, psycho-diagnosis and/or personal meaning-making, the stories to explain and or justify their circumstance in life; c) that those stories are repeated usually to those who support its content and become anchored into the client s life perception; and d) clients come for therapy as they feel frustrated at not being able to effect meaningful change in their lives around the presenting issue, usually seeking behavioral direction as to how to quickly improve their lot. Across these four domains of commonality, it seems as though the client story echoes repeatedly and permeates all client perceptions. In addition to recognized patterns of client expression, attention has been directed as well to those relational and therapeutic techniques proven efficacious regardless of the clinician s theoretical orientation (Davis, Lebow & Sprenkle, 2012; McAleavey & Castonguay, 2014). As

6 CONJOINTLY DEFINING A THERAPEUTIC DIRECTION 6 Laska and Wampold (2014) asserted [these practices]...are based on the science of how people heal in social contexts and describe specific factors that yield conjectures about what should be observed under various conditions (p. 519). There are multiple listings of such factors, stemming from the work of Rosenzweig (1936); examples of which include Frank (1961), Garfield (1980), and Norcross and Lambert (2011). The thrust of these writings seems to emphasize the equivalence of differing therapeutic approaches, differing change factors and perhaps the most salient beneficial factors. It is in the identification of similarity, as compared to difference based on theoretical preference, client diagnosis, and/or presenting issue; and/or cultural factors etc., that the current proposed notion is hypothesized. As Lambert and Ogles (2014) offered, the identification of potentially common elements across theoretical orientations offers a foundational approach. While such a trans-theoretical approach would allow counselors to work across a spectrum of clients, it can be wondered whether a modification of these common factors could serve to direct counselor attention with each client. However the counselor approaches the intake session with a decidedly-distinct agenda. The clinician s case analysis usually attends to the following issues: Specific aspects of the client history, in what areas and how much emphasis versus a focus solely on the present; The balance of psycho-diagnostics and developmental theory in understanding the client s issues and symptoms; The relevance of cultural factors to each client which influence how the issue is perceived, the range of acceptable solutions and one s referent group(s) of social support;

7 CONJOINTLY DEFINING A THERAPEUTIC DIRECTION 7 The client prioritizing of affect, behavior, and cognition relative to the presenting issue; and The client s adherence to a bio-psycho-social hierarchy of problem understanding and amelioration. The conceivable answers to these controversies are ones to which counselors were introduced in their graduate training programs; enacted through their post-degree licensure supervision; and honed through their professional clinical practice. These solutions direct which questions, insights and interventions the counselor deems as viable and comprise their therapeutic toolbox. While the clinician is versed in the discussion of each issue, the client may be wholly unaware of the process impact of the resolution of each question. Yet the answers to each of these questions would seem germane to how clients are making sense of the presenting issue (McAleavey & Castonguay, 2014). Therefore, client and counselor may be at an impasse of intention, as the counselor is well aware of the services provided as perspectivespecific expressions of the professional resolution of these concerns, while the client probably is not even aware of their existence (Harris, Kelley, Campbell & Hammond, 2014). If permitted an analogy, it is as though client and counselor wish to arrive at the same destination; however only the counselor has a map of which the client may be totally unaware but which the client is expected to simply to follow, regardless of whether or not the client may know a short-cut, is fearful of the terrain, or sees little point in such a lengthy journey. The rationale for the inclusion of this proposed orientation toward beginning clinical service can be theoretically and empirically supported. Conceptually, it was suggested that a restriction of the lens through which a phenomenon is observed restricts what can be observed (Laska, Gurman & Wampold, 2014, p.469). This assertion implies that clients perceptions of

8 CONJOINTLY DEFINING A THERAPEUTIC DIRECTION 8 their presenting problems limit their available options to understand and resolve those challenges and that their perceptions tend to lack the comprehensiveness of that of a clinician whose professional knowledge offers a broader scope and understanding of individual functioning and growth than the client may possess (Weinberger, 2014). So the initiation of counseling entails both honoring the client s views and inviting the client to ascertain which views provided by the counselor seem to resound with the client s orientation and perhaps expand that orientation to increase potential insights and ways of coping (Fife, Whiting, Bradford & Davis, 2012). By doing so, the counselor fosters client optimism, consensus and commitment; all key predictive variables in the therapeutic work yet to come (Blow, Davis & Sprenkle, 2012). Therefore, it must be borne in mind that the counselor s clinical view is at best a tentative plan until accepted by the client and the counselor must be willing to modify or abandon that therapeutic schema based on client input. The recent empirical support for this idea is also strong. Fife, Whiting, Bradford, and Davis (2012) cited previous analyses by Wampold (2001), Safran and Muran (2000), and McHugh, Murray and Barlow (2009) in confirming the quality of the therapeutic relationship as contributing to 30% of the variance in clinical outcomes. Tschacher, Junghan and Pfammatter s (2014) analysis identified client engagement (active participation in the therapeutic process), provision of an explanatory scheme (a plausible explanation for client problems and which prescribes procedure for their resolution) and the therapeutic alliance (consensus about goals and tasks) as the most relevant clinical interventions; findings echoed by Fife, Whiting Bradford and Davis (2012), Weinberger (2014), and Leibert and Dunne-Bryan (2015). Therefore, conceptual and empirical substantiation can be found to support the proposed approach to clinical direction.

9 CONJOINTLY DEFINING A THERAPEUTIC DIRECTION 9 Case Example David presents in counseling concerned about resolving a recent divorce. He is in the legal stage of separation with a pending court date for final dissolution. All the financial issues are resolved, more or less amicably, and he has had no contact with his ex-spouse even though he invited her to join him in counseling for some attempt at closure. When he first began the divorce proceedings, his moodiness, anxiety and obsessions prompted a visit to his primary physician who referred him to an in-practice psychiatrist for assessment, resulting in a diagnosis of depression, with a prescription for medication. Now, almost a year later, David is worried that his depression has not abated and perhaps requires a new prescription. Jefferson, his counselor at a community mental health agency, holds an LPC credential and bases his clinical work in intergenerational therapy. After meeting with David for an intake session, he begins the next session explaining the purpose of a genogram assignment to trace depression in David s family-of-origin, assuring his client that this insight is necessary for understanding his condition. However, after two sessions, David openly challenges the course of this exercise, claiming to get nothing out of it and stating his intent to terminate immediately. He storms out of the office, and refuses to return or accept any communication from Jefferson. In frustration and disappointment, Jefferson wonders what might have improved this situation. From the orientation of this article, it seems obvious of the misunderstanding between the counselor and client as to the intent of counseling and the interventions that would follow. The lack of negotiated connection between what the client saw as a biological concern and the counselor perceived through a social lens foretold confusion on the client s part as to the purpose and direction of counseling. While the client did obediently comply with the counselor s imposed direction, the client s barometer of success (i.e.: depression symptom reduction) and the

10 CONJOINTLY DEFINING A THERAPEUTIC DIRECTION 10 counselor s intended impact (client cognitive insight) reflected the gulf in the intent of counseling. While it is to be expected that no client s entering epistemology of the presenting concern will align perfectly with that of the clinician, it can be expected that it is the counselor s responsibility to recognize this incongruence and work immediately to overtly discuss the creation of a mutually-agreeable working model to begin counseling. Implications for Graduate Education For the student, it could be imagined that graduate education is a confusion of theory that seems to discriminate between salient client factors and yet common techniques that seem to apply to all situations. A significant commonality to all theories and techniques is the relationship-building or rapport establishing phase. Results showed that the therapeutic alliance had robust alliance-outcome links across therapeutic contexts, substantiating the need for counselors to establish a strong alliance with clients (Leibert & Dunne-Bryant, 2015, p. 232). Therefore graduate education may attend to two related agenda relative to this suggested approach: stressing the value of a strong yet flexible therapeutic alliance, and learning and practicing the necessary skills to generate such a collaboration. The initial task lies in teaching students the importance of client involvement in creating a therapeutic directionality; evidencing a belief in the client s capacity to do so and supporting its necessity in building client optimism and perseverance. This view is predicated on the assertion that the effectiveness of clinical techniques rests on the strength of the therapeutic alliance which in turn rests on the quality of the therapist s way of being (Fife, Whiting, Bradford, Davis, 2012, p. 30). Therefore, therapy becomes an invitation for client participation rather than an imposition of theory and intervention. The more fully clients participate, the more clearly

11 CONJOINTLY DEFINING A THERAPEUTIC DIRECTION 11 they understand the direction and purpose of counseling technique and, hopefully, are more invested in its unfolding. To establish this common foundation, the questions in this document may be asked without a discernible preference for client response by the counselor (McAleavey & Castonguay, 2014). The act of the asking creates a collaborative foundation; the answers a conjoint direction. In essence, this approaches continues the balance between common factors and evidence-based practices (Lambert & Ogles, 2014) and supports the suggestion by Laska, Gurman and Wampold (2014): to focus on the forming and repairing of working alliances, regardless of training programs and treatment approaches. Implications for Clinical Supervision Laska, Gurman and Wampold (2014) advised that clinical supervision needs to firstly cocreate a cogent and deliverable treatment modality with each client regardless of diagnosis and counselor preference. The next step would be to broaden the counselor s capacity to integrate the differing client responses and negotiated focus into coherent treatment plans. These plans might identify topics for client insight and evaluation and methods of value clarification to develop meaningful client goals. The third step may be to identify, practice, implement, and evaluate differing therapeutic techniques. While the supervisory relationship may attend to the choice and practice of interventions, the determination of their efficacy remains with the client and counselor in reviewing the relative movement that was generated along the pre-determined directions. While this approach offers direction for therapeutic success, there is also the potential for reasonable grounds for client referral. Should the client and counselor not be able to co-create a meaningful therapeutic direction, as the counselor cannot combine the client s perspectives with

12 CONJOINTLY DEFINING A THERAPEUTIC DIRECTION 12 his/her own, perhaps another counselor would better serve the clients. In addition, should the counselor prove unable to implement the chosen techniques then perhaps referral is required. In both cases and relevant to clinical supervision, the obstacle to clinical success seems to reside with the counselor s capacity to professionally expand the therapeutic approach to adequate engage and maintain client interest and involvement. Implications for Future Research As with any new prosed process of case conceptualization or clinical intervention, the current question revolves around ascertaining its impact. Impact can be viewed from two related perspectives; that of the client and of the clinician, with hopes that the two views will prove similar as to what was, and was not, effective. Other possible measures of the efficacy of the proposed approach might focus on client retention, hypothesizing that its implementation would reduce client attrition. A third focus may revolve around the duration of counseling with the researcher hypothesizing that its usage will significantly shorten the length of treatment. Conclusion Perhaps the middle ground between theoretical orthodoxy and spontaneous eclecticism lies in the development of multi-theoretical practice or common factors approaches (Harris, Kelley, Campbell & Hammond, 2014). However, as the thesis of this paper suggests, common factors transcends a skill set but may be perceived as an approach to clinical service that is rooted in collaboration and conversation. If this approach represents a conceptually valid treatise, then the next evolution revolves around its purposive implementation and assessment, for, as Laska and Wampold (2014, p. 522) asserted, we know that these things matter and it is time to truly expand the lens of evidence-based practice in psychotherapy.

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