What Are Reasonable Expectations For

Beyond
Evidence-Based
Psychotherapy

COUNSELING AND PSYCHOTHERAPY:
INVESTIGATING PRACTICE FROM SCIENTIFIC, HISTORICAL,
AND CULTURAL PERSPECTIVES

A Routledge book series
Editor, Bruce E. Wampold, University of Wisconsin

is innovative new series is devoted to grasping the vast complexities of the practice of counseling and psychotherapy. As a set of healing practices delivered in a context shaped by health delivery systems and the attitudes and values of consumers, practitioners, and researchers, counseling and psychotherapy must be examined critically. By understanding the historical and cultural context of counseling and psychotherapy and by examining the extant research, these critical inquiries seek a deeper, richer understanding of what is a remarkably eﬀective endeavor.

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Uwe P. Gielen, Juris G. Draguns, Jeﬀerson M. Fish

Cognitive-Behavioral erapy for Deaf and Hearing Persons With Language and Learning Challenges

Neil Glickman

Forthcoming

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Lee Cohen, Frank Collins, Alice Young, Dennis McChargue

Making Treatment Count: Using Outcomes to Inform and Manage erapy

Michael Lambert, Jeb Brown, Scott Miller, Bruce Wampold

e Handbook of erapeutic Assessment

Stephen E. Finn

IDM Supervision: An Integrated Developmental Model for Supervising Counselors and erapists, ird Edition

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e Great Psychotherapy Debate, Revised Edition

Bruce Wampold

Casebook for Multicultural Counseling

Miguel E. Gallardo and Brian W. McNeill

Culture and the erapeutic Process: A Guide for Mental Health Professionals

Mark M. Leach and Jamie Aten

Beyond
Evidence-Based
Psychotherapy

Fostering the Eight Sources of Change in Child and Adolescent Treatment

George W. Rosenfeld

New York London

Routledge

Taylor & Francis Group 270 Madison Avenue New York, NY 10016
Taylor & Francis Group 2 Park Square Milton Park, Abingdon Oxon OX14 4RN

Printed in the United States of America on acid-free paper 10 9 8 7 6 5 4 3 2 1

International Standard Book Number-13: 978-0-415-99336-4 (Softcover) 978-0-415-99335-7 (Hardcover) Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers.

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Library of Congress Cataloging-in-Publication Data

Rosenfeld, George W., 1945- Beyond evidence-based psychotherapy : fostering the eight sources of change in child and adolescent treatment / George W. Rosenfeld. p. ; cm.
Includes bibliographical references and index. ISBN 978-0-415-99335-7 (hardbound : alk. paper) -- ISBN 978-0-415-99336-4 (pbk. : alk. paper) 1. Child psychotherapy. 2. Adolescent psychotherapy. 3. Evidence-based psychiatry. I. Title.
[DNLM: 1. Psychotherapy--methods. 2. Adolescent. 3. Child. 4. Evidence-Based Medicine. 5. Mental Disorders--therapy. WS 350.2 R813b 2008]

RJ504.R67 2008

618.92’8914--dc22

2008015242

Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com

and the Routledge Web site at http://www.routledge.com

is book is dedicated to Jean Rosenfeld, LCSW, BCD, whose thinking has blended so much with mine over the years that I am not sure which ideas are hers and which are mine. Her contributions of content and editing are on every page. ank you for your support and patience.

v

Contents

Series Editor’s Foreword Introduction ix xi

Part 1 Research and eory

Chapter 1 What Are Reasonable Expectations

for Psychotherapy?

3

Chapter 2 e Eight Sources of Change in Psychotherapy Chapter 3 e erapist’s Contribution to Treatment
13 47
Chapter 4 Using the erapeutic Relationship as a

Treatment Tool

109

Chapter 5 How Can I Keep Clients in Treatment

so ey Can Beneﬁt?

121

135

Chapter 6 Managing Treatment

Chapter 7 Engage Clients by Helping em Seek

Greater Happiness

163

173
Chapter 8 Has Being a erapist Been a
Good Career Choice?

vii viii • Contents

Part 2 Case Studies

Chapter 9 A Typical Day Chapter 10 ree Month Follow-Up Chapter 11 Conclusion Notes
179 207 227 239 245 267
References Index

Series Editor’s Foreword

is innovative new series is devoted to grasping the vast complexities of the practice of counseling and psychotherapy. As a set of healing practices delivered in a context shaped by health delivery systems and the attitudes and values of consumers, practitioners, and researchers, counseling and psychotherapy must be examined critically. By understanding the historical and cultural context of counseling and psychotherapy, and by examining the extant research, these critical inquiries seek a deeper, richer understanding of what is a remarkably eﬀective endeavor.
Delivering psychotherapy to children and adolescents is a complex undertaking because of the institutional, political, and social context in which these services are provided. One of the pervasive inﬂuences in the current context is the notion of evidence-based practice in mental health services. Narrowly interpreted, evidence-based practice has become a rationale for mandating particular treatments for youth. George

Rosenfeld, in Beyond Evidence-Based Psychotherapy: Fostering the Eight Sources of Change in Child and Adolescent Treatment, cogently proposes

principles for conducting psychotherapy for children and adolescents that value evidence but recognize the broad context in which services are delivered. His years of experience as a therapist bring to this volume the clinical wisdom that supplements the research evidence; this synthesis yields a remarkably important contribution that should interest clinicians and scientists alike.

Bruce E. Wampold, PhD, ABPP, Series Editor

University of Wisconsin–Madison

ix

Introduction

Psychotherapy is an art influenced by science. e art involves developing and maintaining rapport with clients; using clinical judgment in applying therapeutic approaches supported by research, while incorporating the therapist’s clinical knowledge and experience into treatment; respecting and using clients’ beliefs and intentions; and deciding how to proceed when the research literature provides no, ambiguous, or conflicting guidelines. is text will review the psychotherapy research and fill in the gaps with personal experience to identify the factors that contribute to change in psychotherapy and build on these factors to identify an evidence-supported, theoretically eclectic approach to psychotherapy.
Political and economic forces are defining psychotherapy in our society. Psychotherapy is expected to follow the medical model that dictates that the therapist is responsible for diagnosing the patient and then selecting and implementing “the treatment of choice” for the diagnosis. e patient’s primary role is to comply with the therapist’s directions. e treatment is expected to be evidence based, which means that several studies using the highest standard of research (randomly assigned, double-blind, controlled clinical trials) have proved the intervention to be effective for the client with that particular diagnosis. “ere are presently 145 officially approved, manualized, evidence-based treatments for 51 of the 397 possible DSM diagnostic groups” (Miller, Hubble, & Duncan, 2007, p. 31). Because almost all the present evidence-based treatments are cognitive-behavioral and behavioral, these are seen as the most

xi xii • Introduction

effective treatments. When clients do not benefit, their dropping out and lack of progress are viewed as resistance, lack of motivation, or entrenched psychopathology. is model has led textbooks and continuing education classes to be obsessed with teaching diagnostically related treatment techniques.
Traditionally, textbooks in child and adolescent psychotherapy have been organized in two main ways. ey have been based on the medical model and have presented the evidence-based “treatments of choice” for youths according to their diagnosis. ey have claimed that the power of therapy lies in the treatment offered by the therapist, whose job it is to direct the course of treatment by identifying the problems and selecting the proper, oﬅen manualized, treatment. Other textbooks have presented a particular theoretical orientation that is then applied to youths with particular diagnoses. ese approaches assume that the best preparation for seeing clients involves being armed with proven techniques and/or the best theoretical orientation. However, they misinterpret and ignore the research, so the complexity of psychotherapy, if not the practice itself, is being threatened.
is book focuses on the other 85% to 90% of psychotherapy that is marginalized by textbooks and the medical model. It reviews the therapy research and offers an evidence-based alternative to the medical model. It identifies a variety of factors that have an even more powerful effect on treatment outcome than the presently favored theoretical orientations and techniques and describes techniques and strategies therapists can use to allow these factors to improve outcome. is book is intended to be a companion and complement to the typical text that emphasizes cognitivebehavioral and evidence-based treatments.
e research supports an alternative approach to psychotherapy that is more client driven and collaborative and focuses on the factors that most affect outcome. is leads to a different formulation of the therapy process and the roles of the therapist and client. e research indicates that (a) many theoretical approaches are equally effective, not just cognitive-behavioral and behavioral; (b) the treatment techniques supplied by the therapist contribute a small part to the change generated by psychotherapy; and (c) other factors are a greater contributor to change than therapist-selected treatment techniques. e research on psychotherapy supplies answers to the therapist’s questions that are very different from those suggested by the medical model: What causes change? What is the therapist’s role in helping the client? What should the therapist do and say during therapy?
e number of effective therapies has led to eclecticism and integrationism (Downing, 2004). Eclecticism has challenged therapists to seek

Introduction • xiii

strategies to inform choosing the most appropriate treatment. is text will describe a strategy for selecting the treatments based on particular client characteristics and desires, the problems being remediated, the abilities of the particular therapist, the strengths and resources in the client’s environment and the state of the client–therapist relationship, and adjusting their treatment to the client’s progress.
Integration has spawned an exciting exploration to identify the elements that are common in effective treatments. Many of the common factors that account for change in effective treatments have been identified. is text will present a treatment approach that evolves from these sources of change. In comparison to the medical model, it is a more client-driven approach in which the client’s view of the problem and goals and the client’s and therapist’s resources and characteristics contribute to the choice of intervention. It is an approach that attends to the relationship between the client and therapist and de-emphasizes treatment techniques as change agents.
Despite the research that indicates that no particular theory or orientation is more effective than others, graduate training has traditionally fostered a commitment to a particular theoretical orientation, under the assumption that beginning therapists could not handle the overwhelming tension of treating clients without being grounded in a predominant theoretical orientation. e lack of a widely accepted unifying theory of psychotherapies and the lack of a theory for determining which treatment to select from the smorgasbord of possible approaches have been seen as two problems that have to be resolved before beginning therapists can abandon being guided by a predominant theoretical orientation. In this vein, Stricker and Gold suggested that student therapists should begin by learning “one approach thoroughly rather than many approaches simultaneously” (Norcross & Goldfried, 2005, p. 453). en, aﬅer beginning therapists become more experienced, they can, as more seasoned therapists tend to do, incorporate different approaches into their repertories and eventually create their own integrated, eclectic style.
Only recently have some graduate programs come to believe that beginning therapists need not adopt premature identities to cope with uncertainty; that they can benefit from knowing early in their careers that no single approach fits all clients, problems, and situations; that students should have respect for a wide variety of orientations because there are multiple approaches that could benefit a client; and that tolerating uncertainty is an unavoidable part of being a therapist (Lampropoulos & Dixon, 2007). Given these guidelines, this book will help therapists navigate through a complex, exciting, and meaningful career. Without a single theory to cling to, therapists are not adriﬅ. e research does offer guidance

xiv • Introduction

to inform the choice of technique and the therapist’s contribution to treatment. is book presents guidelines for selecting treatment strategies from a wide variety of orientations and directing the therapist’s input based on maximizing the factors that promote client change. is text will present a theoretical frame that will allow therapists to incorporate into their work techniques from a variety of orientations.
Now, particularly in the public sector and with managed-care clientele, goal-driven, client-directed, and rapid treatment is expected. In this confusing environment child and adolescent therapists are expected to diagnose, identify factors that will help the client change, develop realistic goals and expectations, formulate treatment plans that incorporate evidence-based techniques, appropriately select and time interventions, adjust treatment to client feedback, manage the therapy hour, and then be evaluated by their clients. erapists are expected to help clients tolerate the frustrations of treatment, manage their ambivalence to change, feel motivated to change, help direct treatment by contributing to the choice of goals and identifying how they will support accomplishing them, ameliorate problems, and successfully terminate. Without clear guidelines from the research, our daily practice requires us to develop our unique balance between self-disclosing and being neutral; between allowing sessions to be client driven and therapist directed; between supporting and confronting the client; between focusing on problems or strengths; between choosing to focus on the client’s past, present, or future; and between dealing with behavior, cognitions, or affect. erapists are expected to cope with the emotional effects of dealing with traumatized clients; balance personal, organizational, legal, and ethical demands; and use transference and countertransference reactions to improve outcome. We struggle with a stressful occupation characterized by conflicting theories and demands. No wonder beginning therapists, armed with only a favored theoretical orientation, meet clients with trepidation.
Part 1 of this book offers practical advice to guide therapists through these common struggles by identifying the factors that cause change in psychotherapy, presenting treatment techniques supported by the literature and clinical experience, and describing an evidence-based rationale for selecting and timing therapist interventions. Part 2 presents a typical day of treatment cases and describes their progress over a 3-month period in which many of the treatment approaches are demonstrated. e reader can get a realistic sense of a therapist’s day and the pace of change in a typical session and over a 3-month period.
e youths’ problems are interwoven with the parents’ problems, so in most treatments the caretakers need to actively participate and therapists

Introduction • xv

need the skills to keep them productively involved. Child and adolescent therapists need to form relationships with family members of all ages, and, therefore, they need the skills of an adult therapist as well as the ability to treat youths. Although this is a book about treating children and adolescents, much of the research that is reviewed and the suggestions provided also apply to the treatment of adults.

George Rosenfeld, PhD

PART

1

Research and Theory

1
CHAPTER

1

What Are Reasonable Expectations for Psychotherapy?

What I Wish I Knew When I Started Being a erapist 35 Years Ago

As a clinical psychologist I have completed almost 40,000 hours of psychotherapy in the past 35 years. ese sessions have been in relative isolation, with input from a few colleagues and mentors and sporadic explorations of the treatment literature. My excellent graduate education at the University of Minnesota helped me start but became outdated as knowledge expanded and trends changed. I was educated before the ﬁeld was aware of the pervasive impact of sexual abuse, domestic violence, fatherless households, and the methamphetamine epidemic that has swept the western United States. Cultural diversity was not addressed. is was in a time before brain imaging, managed care, the deinstitutionalization of the mentally ill, and the domination of evidence-based and cognitive-behavioral approaches. e feminization, desecularization, manualization, medicalization, and deprofessionalization of psychotherapy were still yet to come. It seems probable that these trends will continue to mold the development of psychotherapy, leading a panel of experts to forecast the “expansion of evidence-based therapy, practice guidelines, behavioral medicine, and pharmacotherapy” (Norcross, Hedges, & Prochaska, 2002, p. 316). No matter what direction the ﬁeld takes, 35 years from now, new perspectives and discoveries will make today’s education and practice standards seem as antiquated as my training now seems to me, and the thoughts about treatment presented here will seem just as primitive as the treatment methods to which I was

3

4 • Beyond Evidence-Based Psychotherapy

exposed. Being a psychotherapist clearly requires adapting to constant change and constantly changing.
When I began as a therapist, my focus was on quieting my anxieties.
I worried about being competent and accepted by colleagues and clients. I greeted clients with the hope of curing them or making them “normal.” Now I am not even sure what normal is. As the saying goes, “Normal is what you think people are until you get to know them.” I tried to take away their problems, but being problem free is not a realistic goal. Life can involve moving from one damn thing to another. Clients are going to have more problems and continue to struggle with many of their same issues.
Clients were not born yesterday with a blank slate and infinite capacities to change. is is not a depressing or hopeless view. It describes the realistic boundaries in which we operate and makes improvement in clients’ lives so much more significant. A great deal is accomplished when therapy helps clients to reduce their symptoms, become more realistic, advance to the next developmental stage, become less trapped in repetitive patterns, tolerate more affect so they do not subsequently resort to as many destructive behaviors and defenses, carry fewer unexamined secrets (oﬅen forged under stress in childhood), feel less worried, and be more able to participate and find pleasure in work, play, and relationships.
My interventions were initially aimed at making the most useful interpretations and understanding connections to the past. With experience I found that interpretations were rarely necessary or sufficient to create change, that oﬅen what I had to say was not as powerful as what the client had to say, and that dealing with the past was not always appreciated, possible, or helpful. As I developed as a therapist, I focused on acquiring a wide range of other techniques. Now I value many approaches but see their usefulness as depending on the client’s situation and the therapeutic relationship. I focus less on pathology and resistances and more on the therapeuticrelationshipandgettingtoknowtheclient’sbackground,hopes, strengths, feelings, relationships, present struggles, and achievements. Because the influence of family members is so powerful, I rely more on family and conjoint (parent with youth) treatment than individual therapy for treating youths, especially when the client is young, unmotivated, or difficult to engage or believe. I now look for skills to build, and I focus more on the present and future than on the past.
Now I observe not only the client and I but our interaction and progress along a more mapped-out path. I watch us struggle with engaging in the therapeutic relationship, developing a treatment plan that meets our expectations, trying to accomplish our goals without being thrown off course by our personal needs and biases, and finally ending when the