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Key Competencies in Brief Dynamic Psychotherapy

The Guilford Press

Chapter One

There always has been a large gap between the way competent psychodynamic therapists conduct therapy in their real world practices and the way their conduct is formally depicted in the professional literature and at professional meetings. This gap was empirically demonstrated in the two-decade-long Menninger Foundation Psychotherapy Research Project (Wallerstein, 1989) and across theoretical models (Goldfried et al., 1998). What is most neglected in the formal conceptualizations of therapists' activities is their crucial reliance on common sense about living a satisfying and meaningful life, particularly in terms of interpersonal relationships. For competent and expert therapists, this common sense is refined over the years, through a multitude of personal and professional experiences. Another neglected characteristic of the conduct of good therapists is their technical flexibility-that is, their ability to respond constructively to the circumstances they face at the moment. A final essential characteristic of the competent therapist, often neglected in formal discussions, is good interpersonal skills; fortunately, this characteristic isreceiving more appropriate acknowledged, at least by some (Norcross, 2002). The most promising students in graduate therapy training programs arrive with a foundation comprised of these characteristics. All too often, however, our training methods then bury this foundation under a pile of knowledge about personality, psychopathology, and rules about how to conduct therapy that are either too vague to provide useful guidance or too rigid. For extended periods of time students are completely preoccupied by the theories and facts they are expected to learn.

Therapists who turn out to be competent or expert manage to develop a way of doing therapy, to some extent, in spite of their training. They recover their buried common sense and flexibility, which allows them to use their inherent interpersonal skills. At that point these characteristics have been refined by the acquisition of extensive clinical knowledge and accumulating clinical experience. Unfortunately, not all therapists move in this direction. They either lacked the characteristics or, for whatever reasons, have been unable to recover them, at least in the practice of psychotherapy.

The purpose of this book is to reduce the extent to which these essential characteristics get buried during training and to accelerate their recovery, when needed. It aims to accomplish these goals by reducing the gap between the way competent therapists actually think and act while they are conducting psychotherapy and the way their thoughts and actions are formally depicted. For students who already have learned basic psychodynamic therapy concepts and principles, this book is meant to serve as a guide on how to apply these concepts and principles practically and in a time-limited format. Practicing therapists may find this book to be a useful aid in fully recovering and using their common sense, technical flexibility, and interpersonal skills in their practice of therapy.

This depiction of how to conduct psychotherapy is based on over 30 years of psychotherapy practice and training and over 20 years of involvement in treatment and training research. The clinical theory used as a conceptual framework for discussing treatment is an integration of psychodynamic-interpersonal and cognitive aspects (discussed in Chapter 2). The treatment model also represents what has been called "assimilative integration" (Lazarus & Messer, 1991; Messer, 1992), which refers to reliance on a predominant theoretical framework, within which principles and techniques from other treatment models are incorporated.

My strategy for minimizing the gap between how good therapists actually think and act and how I depict their performances is to avoid, or at least minimize, the use of clinical language to describe therapist performances. Although useful for dealing with clinical issues, the languages of clinical theories are ill suited for the job of adequately depicting the mental processes and actions associated with a complex skillful performance, such as that of conducting psychotherapy (Binder, 1993, 1999). As a more effective alternative, I rely on a theoretical framework and language from the cognitive sciences, as noted in the Preface. I employ a conceptual framework for understanding the generic skills that appear to underlie all domain-specific performances (Chi, Glaser, & Farr, 1988; Feltovich, Ford, & Hoffman, 1997; Schon, 1983). My approach is to focus on generic skills that appear to underlie and support the effective implementation of techniques associated with clinical theories and theory-guided models of treatment, particularly those of a dynamic-interpersonal model. Most people have acquired these generic skills, to some degree, because they are required for successfully managing the challenges of living, including managing interpersonal relations. These skills include recognizing recurrent interpersonal patterns, the disciplined use of curiosity, common sense, and selfreflection. The process of learning theory-guided therapy principles and techniques should allow trainees to preserve their relevant generic skills and facilitate the use of these skills to guide the implementation of techniques.

With sufficient practice, the novice therapist can develop into a practitioner who can implement treatment models in a competent manner. Master therapists, in contrast, are capable of transcending the technical parameters dictated by treatment models. They are able to improvise, which means they are able to further therapeutic progress by whatever creative means necessary, given the circumstances-which are often unforeseen. The ability to improvise is one of the essential features that characterizes experts, be they psychotherapists, physicians, professional actors, musicians, professional athletes, or representatives of any other performance domain. Throughout this book, I maintain a focus on what I consider to be therapeutically relevant generic skills as well as the general clinical skills derived from them. Mastery of these generic and general clinical skills is required to become a competent, and eventually an expert, therapist.

ASSUMPTIONS ABOUT EMPIRICALLY SUPPORTED TREATMENTS AND TREATMENT MANUALS

The idea that the foundation of competent and expert psychotherapy practice consists of the flexible deployment of various skills, culminating in technical improvisation, diverges from the view prevalent among health care policymakers. The pressure to reduce health care costs has motivated the various stakeholders in the health care system to develop strategies for delivering care more efficiently and, hopefully, effectively. The prevalent view is that efficiency can be maximized, as well as effectiveness, by precisely determining the disorder or problem and addressing it with a treatment or technical protocol that has been empirically found to resolve the disorder or problem with maximum efficiency and effectiveness. This view is most vigorously promoted by managed care organizations, which can increase their profits by reducing the expenditure of health care funds. Consequently, these organizations are constantly seeking practice guidelines that will increase at least the efficiency of health care treatments. The medical field has responded with various sorts of "evidenced-based" practice guidelines. In the mental health field, the American Psychiatric Association responded with treatment guidelines for several disorders and mental illnesses (e.g., unipolar depression, bipolar disorder, eating disorders, substance abuse (American Psychiatric Association, 1994). Organized psychology, through the American Psychological Association, responded to the psychiatrists' actions with its own Division 12 Task Force on the Promotion and Dissemination of Psychological Procedures, which published-and continues to publish-a growing list of approved psychotherapeutic treatments for specifically designated categories of "disorders" (Chambless & Ollendick, 2001). These "empirically supported" treatments have produced positive outcomes under controlled research conditions across several studies and therefore are considered superior to treatments that have not been put to this kind of test.

Those who put their faith in the effectiveness of empirically supported therapies also tend to put their faith in the use of treatment manuals as the foundation for training therapists in the use of effective treatment methods. Treatment manuals were originally developed by psychotherapy research teams for the purpose of improving the internal validity of research studies by precisely explicating the technical principles, strategies, and tactics of a therapy model (e.g., Barlow & Cerny, 1988; Beck, Rush, Shaw, & Emery, 1979; Klerman, Weissman, Rounsaville, & Chevron, 1984; Luborsky, 1984; Strupp & Binder, 1984). Although these manuals usually originate as part of research protocols, increasingly they are being used as all-purpose texts for students and more experienced practitioners. In fact, their use is being promoted as a requirement for accreditation of clinical psychology training programs (Crits-Christoph, Frank, Chambless, Brody, & Karp, 1995). Treatment manuals have contributed to the formulation of a more precise language for describing and explaining technical strategies and interventions, and they are associated with increased therapist adherence to the techniques prescribed in the models being taught (Binder, 1993).

The use of treatment manuals as an innovative method for enhancing psychotherapy training was greeted with tremendous optimism (Luborsky & De Rubeis, 1984; Strupp, Butler, & Rosser, 1988). Evidence does indicate that manuals are useful training tools for decreasing variance attributed to therapists in controlled studies-which was, after all, their original intent (Crits-Christoph & Mintz, 1991). After two decades of experience in using manuals in controlled studies of therapy process and outcome, however, this training innovation has not resulted in the large increment in therapist competence or effectiveness that was anticipated (Addis, 1997; Henry, Schacht, Strupp, Butler, & Binder, 1993; Lambert & Bergin, 1994; Miller & Binder, 2002). Treatment manuals usually are designed to guide the therapy of specific, circumscribed problems by applying specific techniques. A controlled research context oversimplifies the complexity and ambiguity of clinical problems encountered in actual practice. Therefore, if manuals have not made a significant impact on therapists' performances in controlled research settings, it is highly unlikely they will have a noticeable impact on real-world practitioners. Indeed, a decade after publishing his optimistic view of the potential of treatment manuals to enhance therapy research and training, Strupp (Strupp & Anderson, 1997) expressed concern about the "blind acceptance" of manuals as an effective means of improving therapist performance.

The fundamental presumption in the promotion of empirically supported treatments is that correctly chosen technical interventions are the primary determinant of therapeutic change and positive treatment outcome. Furthermore, treatment manuals are the best method of disseminating information about these correct techniques. Nevertheless, over two decades of manual-guided psychotherapy process and outcome research "have not produced support for more superior treatments or sets of techniques for specific disorders" (Lambert & Ogles, 2004, p. 167). Furthermore, "little evidence exists that efficacious treatments are readily transportable [from controlled research conditions to real-world practice]. Similarly, little evidence supports the notion that specific techniques make a substantial contribution to treatment effects" (Lambert & Ogles, 2004, p. 176).

Although there may be a host of reasons for these findings, I want to focus on two. First, practitioners working in real-world contexts are unlikely to limit themselves to specific treatment protocols designed for isolated disorders, because most patients desire help for a mix of symptomatic, interpersonal, and environmental difficulties that defies the circumscribed diagnoses used to generate outcome criteria in controlled studies. Second, even in controlled treatment trials, where there is an attempt to standardize therapists' performances, there remains significant variability in competence and effectiveness across therapists and across patients for any given therapist (Beutler, 1997; Blatt, Sanislow, Zuroff, & Pilkonis, 1996; Garfield, 1997; Lambert & Okiishi, 1997, 1986). Luborsky and his colleagues (Luborsky, McClellan, Diguer, Woody, & Seligman, 1997) used an innovative research strategy that involved compiling data from sufficient numbers of therapists who have treated sufficient numbers of patients in research studies in order to use each therapist's caseload as the unit of measure. Accordingly, therapists' caseloads could be compared for relative treatment effectiveness. Significant differences in therapeutic effectiveness across therapists again were demonstrated, with some therapists identified as generally ineffective and others as generally effective. Even the most effective therapists, however, demonstrate noteworthy variability in effectiveness across patients, although they tended to be relatively more effective with difficult patients than were the less effective therapists (Najavits & Strupp, 1994). In sum, the argument can be made that what needs to be identified are not empirically supported treatments but empirically supported psychotherapists (Lambert & Ogles, 2004).

Regardless of the evidence, those who have advocated for the use of treatment manuals and empirically supported treatments have achieved a hegemony in public policy. How has this development come to pass? The turmoil around health care financing is one exacerbating factor. A more fundamental and enduring reason, however, is that the advocates embody a positivistic epistemology of clinical practice (both in the mental health and general medical fields) that has attained supreme influence with health care administrators-with the support of many researchers, educators, and practitioners. This philosophy of practice posits that "standards of care" associated with specific technical strategies and interventions should be developed for each disorder. These standards of care should be derived from the findings of treatment outcome research. It is presumed that deviations from these standards would produce inefficient and ineffective treatment (Elstein, 1997).

Continues...

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Excerpted from Key Competencies in Brief Dynamic Psychotherapy by Jeffrey L. Binder Copyright © 2004 by The Guilford Press. Excerpted by permission.
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