Beyond Evidence-Based Psychotherapy RT21601_C000.indd i 9/5/08 7:29:11 AM COUNSELING AND PSYCHOTHERAPY: INVESTIGATING PRACTICE FROM SCIENTIFIC, HISTORICAL, AND CULTURAL PERSPECTIVES A Routledge book series Editor, Bruce E. Wampold, University of Wisconsin Th is innovative new series is devoted to grasping the vast complexities of the practice of coun- seling 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 eff ective endeavor. Published Counseling and Th erapy With Clients Who Abuse Alcohol or Other Drugs Cynthia E. Glidden-Tracy Th e Great Psychotherapy Debate Bruce Wampold Th e Psychology of Working: Implications for Career Development, Counseling, and Public Policy David Blustein Neuropsychotherapy: How the Neurosciences Inform Eff ective Psychotherapy Klaus Grawe Principles of Multicultural Counseling Uwe P. Gielen, Juris G. Draguns, Jeff erson M. Fish Cognitive-Behavioral Th erapy for Deaf and Hearing Persons With Language and Learning Challenges Neil Glickman Forthcoming Th e Pharmacology and Treatment of Substance Abuse: Evidence and Outcomes Based Perspective Lee Cohen, Frank Collins, Alice Young, Dennis McChargue Making Treatment Count: Using Outcomes to Inform and Manage Th erapy Michael Lambert, Jeb Brown, Scott Miller, Bruce Wampold Th e Handbook of Th erapeutic Assessment Stephen E. Finn IDM Supervision: An Integrated Developmental Model for Supervising Counselors and Th era- pists, Th ird Edition Cal Stoltenberg and Brian McNeill Th e Great Psychotherapy Debate, Revised Edition Bruce Wampold Casebook for Multicultural Counseling Miguel E. Gallardo and Brian W. McNeill Culture and the Th erapeutic Process: A Guide for Mental Health Professionals Mark M. Leach and Jamie Aten RT21601_C000.indd ii 9/5/08 7:29:13 AM Beyond Evidence-Based Psychotherapy Fostering the Eight Sources of Change in Child and Adolescent Treatment George W. Rosenfeld New York London RT21601_C000.indd iii 9/5/08 7:29:14 AM Routledge Routledge Taylor & Francis Group Taylor & Francis Group 270 Madison Avenue 2 Park Square New York, NY 10016 Milton Park, Abingdon Oxon OX14 4RN © 2009 by Taylor & Francis Group, LLC Routledge is an imprint of Taylor & Francis Group, an Informa business 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, trans- mitted, 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. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. 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 RT21601_C000.indd iv 9/5/08 7:29:14 AM Th 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. Th ank you for your support and patience. v RT21601_C000e.indd v 6/23/08 3:00:28 PM RT21601_C000e.indd vi 6/23/08 3:00:29 PM Contents Series Editor’s Foreword ix Introduction xi Part 1 Research and Th eory Chapter 1 What Are Reasonable Expectations for Psychotherapy? 3 Chapter 2 Th e Eight Sources of Change in Psychotherapy 13 Chapter 3 Th e Th erapist’s Contribution to Treatment 47 Chapter 4 Using the Th erapeutic Relationship as a Treatment Tool 109 Chapter 5 How Can I Keep Clients in Treatment so Th ey Can Benefi t? 121 Chapter 6 Managing Treatment 135 Chapter 7 Engage Clients by Helping Th em Seek Greater Happiness 163 Chapter 8 Has Being a Th erapist Been a Good Career Choice? 173 vii RT21601_C000toc.indd vii 7/18/08 9:09:51 AM viii • Contents Part 2 Case Studies Chapter 9 A Typical Day 179 Chapter 10 Th ree Month Follow-Up 207 Chapter 11 Conclusion 227 Notes 239 References 245 Index 267 RT21601_C000toc.indd viii 7/18/08 9:09:52 AM Series Editor’s Foreword Th 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 eff ective 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 infl uences in the current context is the notion of evidence-based practice in men- tal 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 RT21601_C000g.indd ix 6/20/08 7:08:59 AM RT21601_C000g.indd x 6/20/08 7:09:01 AM Introduction Psychotherapy is an art infl uenced by science. Th e art involves develop- ing and maintaining rapport with clients; using clinical judgment in applying therapeutic approaches supported by research, while incor- porating the therapist’s clinical knowledge and experience into treat- ment; respecting and using clients’ beliefs and intentions; and deciding how to proceed when the research literature provides no, ambiguous, or confl icting guidelines. This text will review the psychotherapy research and fi ll in the gaps with personal experience to identify the factors that contribute to change in psychotherapy and build on these fac- tors to identify an evidence-supported, theoretically eclectic approach to psychotherapy. Political and economic forces are defi ning psychotherapy in our soci- ety. 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. Th e patient’s primary role is to comply with the therapist’s directions. Th e treatment is expected to be evidence based, which means that several studies using the highest standard of research (randomly assigned, dou- ble-blind, controlled clinical trials) have proved the intervention to be eff ective for the client with that particular diagnosis. “Th ere are presently 145 offi cially 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 RT21601_C000h.indd xi 6/20/08 7:11:37 AM xii • Introduction eff ective treatments. When clients do not benefi t, their dropping out and lack of progress are viewed as resistance, lack of motivation, or entrenched psychopathology. Th is model has led textbooks and continu- ing 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. Th ey have been based on the medical model and have presented the evidence-based “treatments of choice” for youths according to their diagnosis. Th ey have claimed that the power of therapy lies in the treatment off ered by the therapist, whose job it is to direct the course of treatment by identifying the problems and selecting the proper, oft en manualized, treatment. Other textbooks have presented a particular theoretical orientation that is then applied to youths with particular diagnoses. Th 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. Th 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 off ers an evidence-based alternative to the medical model.