Discussion

Chapter 23

Revisiting the Generalist-Eclectic Approach

Kristin W. Bolton and Kim Stansbury

LEARNING OBJECTIVES

By the end of this chapter, you should be able to:

•understand the conceptualizations of levels of theory,

•understand the relationship between the direct practice theories and the generalist-eclectic approach, and

•understand the application of the problem-solving model and the generalist-eclectic approach.

INTRODUCTION

The first two chapters (Part I) of this book dealt with the major elements and basic principles of the generalist-eclectic approach to direct social work practice. Given that the last chapters have focused on various theoretical perspectives for direct practice, for purposes of review and integration it is important to revisit the generalist-eclectic approach in this final chapter.

In the first part of this chapter, we review conceptualizations of levels of theory and broad classes of mid-level practice theory (psychodynamic, cognitive behavioral, humanistic, critical, and postmodern) that were discussed in Chapter 1 and revisit how these conceptualizations can facilitate an eclectic use of theory in practice. Second, the compatibility between the various mid-level practice theories reviewed in Part III (Chapters 7–22) of the book and the generalist-eclectic approach are considered. The third part of the chapter revisits how the problem-solving model is a useful framework for integrating the eclectic use of theory with the artistic, reflective, and intuitive-inductive elements of practice. Finally, some of the challenges to generalist-eclectic practice are identified and strategies for dealing with these challenges are suggested.

THE USEFULNESS OF CONCEPTUALIZING LEVELS AND CLASSES OF THEORY TO FACILITATE ECLECTICISM

Reflecting on the variety of theoretical perspectives that are represented by chapters in this book raises the potential for feeling confused and overwhelmed by the wide variety of views about the causes of human problems and ways of helping. This potential for theoretical overload becomes heightened when one considers that in the 1980s, estimates of the overall number of theories for direct practice ranged from 200 (Henrick cited in Lambert, 2013a) to 400 (Kazdin cited in Lambert, 2013a) and that this number is likely much higher presently.

Given this confusing and overwhelming array of theories, many of which feature rather esoteric and mystifying language, one can understand why some practitioners eschew eclecticism because they prefer the simplicity, structure, and certainty that can be provided by a narrow allegiance to a single theoretical framework. As understandable as this may be, we are convinced of the arguments for eclecticism that were reviewed in the first chapter. In order to make eclecticism feasible, however, strategies for simplifying and demystifying the vast array of theoretical perspectives are necessary. It is our hope that the organization of this book reflects two helpful strategies in this regard: (a) differentiating among high-, mid-, and low-level theoretical perspectives, and (b) classifying the vast array of mid-level practice theories into like categories and providing general descriptions of the commonalities within each broad category.

Differentiating Among the Levels of Theory

A consideration of the differential function and usefulness of the various levels of theory can be a helpful first step in dealing with theoretical overload. Most theories for direct practice exist at or are linked closely to the mid-level of abstraction denoted in Figure 2.1, and most of this book is devoted to reviewing mid-level theories. Although there has been a recent trend toward the development of many low-level models and therapies for specific problems and populations, many of these have a primary allegiance to one of the mid-level practice theories (e.g., cognitive-behavioral therapy for anorexia nervosa).

In the 1980s, estimates of the overall number of theories for direct practice ranged from 200 (Henrick cited in Lambert, 2013a) to 400 (Kazdin cited in Lambert, 2013a). It is likely that this number is now higher. Because of the overwhelming and confusing array of direct practice theories from which to choose, another useful strategy for conceptualizing and understanding these theories is to organize the mid-level practice theories in like groupings. We believe that mid-level direct practice theories can be divided into five major classifications: (a) psychodynamic theories, (b) cognitive-behavioral theories, (c) humanistic theories, (d) critical theories, and (e) postmodern theories. Table 23.1 provides a broad characterization of these five major classifications of direct practice theories. After a brief discussion of the usefulness of this broad characterization of the major classifications of theory, each of the five classifications will be discussed in more detail.

The broad characterization of the major classifications of direct practice theory found in Table 23.1 allows for identifying the commonalities among theories in each of the five groups, as well as for pointing out differences across groups. This description helps to bring order and clarity to the overwhelming number of theories within the field and allows for the identification of the strengths and weaknesses of the various classes of theory, both of which facilitate the eclectic use of theory.

The concepts in the left-hand column of the table represent some of the important dimensions by which theoretical perspectives can be compared. It should be emphasized that the characterizations of the classes of theory with regard to these dimensions are very general and should be construed as descriptions of central tendencies. For example, although the primary focus in most cognitive-behavioral and humanistic therapies is on the present, this is not to say that such therapies do not focus on the past at all. The same caution applies to the characterization of the classes of theory with regard to focus on affect, cognition, and behavior; focus on symptoms or general growth/development; and degree of structure and directiveness. The dangers of such broad characterizations include the potential to minimize differences within groups of theory and to overlook similarities across groups.

An example of the danger of minimizing differences within groups of theory is found in some of the major differences between solution-focused therapy and the other types of postmodern theory. As pointed out in the discussion of postmodern theories (see later in this chapter), solution-focused therapy concentrates more on specific symptoms and behaviors and is more directive compared with narrative and collaborative therapies. With regard to the danger of exaggerating differences across groups of theory, integrative theorists have demonstrated how seemingly antithetical theories are not as different and incompatible as one might suppose (e.g., see discussion in Wachtel et al. (2005) for integrative relational therapy that combines psychodynamic and behavioral theories).

With these limitations in mind, a general consideration of how the concepts in the left-hand column of Table 23.1 are construed by or manifested in each class of theory can help the practitioner to consider which class of theory might best suit particular clients at particular points in the counseling process, as well as to consider which classes of theory might be used simultaneously to address clients’ concerns more holistically. For instance, a client who wants to focus on specific symptoms in current day-to-day functioning, to avoid exploration of painful feelings, and to have a high degree of structure and direction in counseling, may be best served, at least initially, by a cognitive-behavioral approach. Once this client learns to cope more effectively with presenting symptoms, however, they and the worker may decide that a focus on feelings (i.e., affect) may be helpful to consolidate and further gains. If client issues seem to be connected to early problematic relationships with caregivers, a psychodynamic approach might then be used to explore the link between affective difficulties in the present and the past and to work through such feelings. If a connection to earlier intimate relationships is not apparent or if the client is averse to exploring such connections, a humanistic approach may be more appropriate for dealing with affective issues. If the client’s presenting issues seem to be connected to oppression and marginalization, it would be important to integrate a critical approach (e.g., empowerment and/or feminist) with any of these other approaches. Also, a postmodern approach could be integrated with any of the other theoretical approaches or used as a follow-up to other approaches in order to integrate changes into more empowering views of one’s self and one’s life story.

These theories represent foundational knowledge for generalist-eclectic practice, and their main value is in providing broad, normative lenses for data collection and assessment. Although these high-level theories can also provide general ideas for intervention, they do not provide the guidelines or prescriptions for interventions that lower level theories do.

The conceptualization of levels of theory is one way of bringing order to the overwhelming number of theoretical perspectives for practice. The three levels of theory can be viewed as complementing rather than competing with each other. High- and low-level theories can be construed as providing support to the use of mid-level theories. High-level theories provide a broad lens for viewing human behavior and ensure that a broad range of factors (e.g., biological, personal, interpersonal, environmental, and sociocultural factors) are considered in the effort to understand clients’ problem situations. These theories ensure that the big, person-in-environment picture is considered in data collection and assessment, and they guard against the danger of tunnel vision or myopia that exists with mid- and low-level theories. On the other end of the spectrum, the type of in-depth knowledge that low-level theories provide about specific client problems can be seen as a valuable resource to support the use of more general, mid-level theory. For example, even if one is drawing eclectically from a range of mid-level theories in working with a client, if a specific clinical issue (e.g., grief) surfaces, it would be helpful to refer to low-level models (e.g., interactive trauma/grief-focused therapy) for more specific ideas for understanding and treating such issues.

THE COMPATIBILITY OF THE DIRECT PRACTICE THEORIES WITH THE GENERALIST-ECLECTIC APPROACH

Compatibility With Elements of the Generalist Perspective for Social Work

All of the chapters in Part III of this book included a brief discussion of the compatibility between the particular practice theory under consideration and at least some of the five elements of the generalist social work perspective that are central to our generalist-eclectic approach (as outlined in Table 1.1 in Chapter 1). Although there were differences in emphasis noted by some authors, overall there was a strong endorsement of the importance of (a) a person-in-environment perspective that is informed by ecological systems theory, (b) the development of a good helping relationship that fosters empowerment, (c) the flexible use of a problem-solving process to provide structure and guidelines for practice, (d) a holistic assessment that includes a focus on issues of diversity and oppression and on strengths, and (e) an eclectic use of other theories and techniques.

A cynic might wonder if authors felt compelled to endorse such principles, either to conform to the wishes of the editors or to the social work profession’s commitment to the generalist perspective; however, we do not think that this was the case. Instead, it seems to us that this convergence in thinking reflects the relatively recent trend in the clinical field toward valuing these elements of the generalist social work perspective. We think that this is a major and healthy shift in thinking because the historical legacy of the clinical field has been marked, to a large extent, by rigid adherence to single models of therapy that tended to have narrow, mostly psychological, views of human problems and noncollaborative, expert orientations.

It is particularly noteworthy that the older, more traditional theoretical perspectives (i.e., psychodynamic and cognitive-behavioral theories) have undergone significant changes in emphasis over the years. In general, psychodynamic theories have broadened their intrapsychic focus to include much greater consideration of environmental factors; have moved away from a rather distant, expert-oriented therapeutic stance toward a much more collaborative and empathic approach; and have become more open to the value and usefulness of other theories and their techniques. It should be noted, however, that we chose to include in this book the psychodynamic theories that had moved furthest in these directions. There are still psychodynamic theories that do not embrace these trends.

Similarly, cognitive-behavioral theories, particularly the more behaviorally oriented ones, have not always embraced generalist principles. Over time, these theories have broadened their focus of assessment beyond stimulus–response patterns to include cognitive and social factors; have embraced the importance of a good therapeutic relationship, at least as a facilitating factor for change; and have become more open to eclecticism. Again, for the cognitive-behavioral section of the book, we selected theories that were most compatible with the generalist approach. In particular, readers should be reminded that the task-centered and crisis intervention models have a strong connection to social work and are perhaps better conceptualized as theoretical and eclectic models, respectively. There are still traditional behavioral theories that are not consistent with generalist principles.

Despite the overall compatibility between the variety of practice theories presented in this book and the elements of the generalist social work perspective that are central to our generalist-eclectic approach, it would be remiss to not make a closer examination of differences. The strongest contrast that we noted between an element of the generalist social work perspective and a theoretical perspective is solution-focused therapy’s dismissal of the value of holistic assessment. In Chapter 20, Corcoran states that “solution-focused therapy departs from a generalist-eclectic framework in eschewing a holistic assessment of the various system levels, along with information gathering about the problem and history taking” (p. 286). This and other conflicts between solution-focused therapy and mainstream social work principles have been noted by others (Stalker et al., 1999). This suggests that social workers should be particularly mindful of following generalist social work principles when using solution-focused therapy as part of their eclectic approach.

Another difference that emerged between some theoretical perspectives and an element of the generalist perspective related to the use of a problem-solving process. Again, the strongest difference was with solution-focused therapy. Corcoran challenged any focus on problems or problem-solving as antithetical to a focus on strengths. We expressed our disagreement with this view in Chapter 2 when we cited the argument by McMillen et al. (2004) that those who advocate for a strength versus a problem focus set up a false dichotomy. We agree with McMillen et al.’s contention that “the best social work practice has always maintained a dual focus on both problems and capacity building” (p. 317). Similarly, Walsh (2009) has stated that “problem-focused and strengths-oriented social work are not dichotomous, but complementary” (p. 32).

There were more moderate challenges to the use of a problem-solving process expressed by other authors. Authors of the chapters on existential, narrative, and collaborative theories noted that the open, process-oriented nature of their approaches did not fit well with a structured, pragmatic, problem-solving focus. We understand this concern, but we think it is based on a misconception of our use of a problem-solving process. We believe that problems can be defined in many different ways. Although identification of a specific, tangible problem may be the preferred approach of a cognitive behaviorist or a task-centered practitioner, our generalist-eclectic approach allows for a much broader conception of problems, including problem conceptions of an existential or postmodern nature. Also, we believe that the problem-solving process needs to be used flexibly and that, while it can offer guidelines for practice, these should not be construed as prescriptions or followed rigidly. Our valuing of artistic, reflective, intuitive-inductive practice processes attests to this and reflects openness to the less structured, more process-oriented theories. As Perlman (1957) argued many years ago about the problem-solving model: “In no sense is such a structure a stamped out routine. It is rather an underlying guide, a pattern for action which gives general form to the caseworker’s inventiveness or creativity” (p. vi).

We agree that a good helping relationship is often not sufficient to cause change, but we maintain that it can contribute directly to change and that it is sometimes sufficient. A good helping relationship contributes directly to change by combating demoralization, instilling hope, and bolstering self-esteem. For some clients, particularly for those who have not been subjected to severe, longstanding stressors and who have supportive networks, this may be sufficient. We would also contend that our understanding of the impact of relationship factors is consistent with the research. As a recent review of research concluded, “research supports the potential causal role that a positive therapeutic alliance plays in leading to relatively better treatment outcomes” (Crits-Christoph et al., 2013, p. 308; see Chapter 1 for a brief review of research on the importance of relationship and other common factors).

More generally, we should also note that, despite endorsement of the elements of the generalist perspective that are central to our generalist-eclectic approach, there are certainly differences in the degree to which various theories emphasize these elements. First, despite a commitment to a person-in-environment perspective and holistic assessment by all but one practice theory represented in the book (i.e., solution-focused therapy), specific practice theories, by definition, have more preconceptions and are less comprehensive than a generalist perspective. Every practice theory has preconceived ideas about the cause of human problems. For example, psychodynamic theories may give consideration to environmental and sociocultural factors in assessment, but focus is directed primarily to intrapsychic and interpersonal issues. Thus, despite a commitment to broad-based assessment, the preconceptions that exist for all practice theories can function as blinders.

Second, most practice theories pay much less attention to issues of diversity and oppression than a generalist social work perspective. Of the practice theories reviewed in this book, only task-centered, feminist, and empowerment theories devote considerable attention to broad social issues (e.g., poverty). These same three theories, along with narrative therapy, are the only theories that focus considerably on issues of diversity and oppression.

Finally, despite an openness to eclecticism, by virtue of their primary theoretical orientation, all practice theories are less theoretically and technically “open” than the generalist-eclectic approach. Thus, despite the general compatibility between many theoretical perspectives and the generalist-eclectic approach, we believe that, when drawing on theories, clinical social workers need to consciously integrate the central principles and values of the generalist perspective of social work into their practice.

REVISITING THE IMPORTANCE OF THE PROBLEM-SOLVING MODEL AS A FRAMEWORK FOR INTEGRATING THE ARTISTIC AND SCIENTIFIC APPROACHES TO PRACTICE

As discussed in Chapter 2, the downside to both the reflective, intuitive-inductive approach to practice and the deductive, eclectic use of theory in practice is a lack of structure and guidelines for practice. Without some dependable structure and guidelines, both the artistic and the theoretically eclectic approaches to practice can lack focus and direction and become haphazard—which is the common criticism from those who advocate following a single model of therapy. We have argued that the problem-solving model provides such structure and guidelines for practice and thus facilitates the integration of the artistic and scientific approaches to practice.

The broad guidelines that are contained in the problem-solving model for each phase of practice provide sufficient structure for the eclectic use of various theories, but because they are not rigidly prescriptive they also afford enough flexibility to allow for reflection, intuition, and inductive reasoning. For instance, with regard to data collection and assessment, the general structure and guidelines of the problem-solving model remind practitioners to use a person-in-environment perspective and direct them to give consideration to a broad range of factors (micro and macro, stressors and strengths) in order to understand clients’ life situations. The problem-solving guidelines in this phase of practice also direct practitioners to consider a broad range of theoretical perspectives to help make sense of clients’ situations, including mid- and low-level practice theories, as well as high-level or metatheories. Furthermore, the general nature and the flexibility of these problem-solving guidelines allow for practitioners to use reflection, intuition, and inductive reasoning to develop together with their clients an in-depth understanding of unique problem situations. Thus, as with other phases of the problem-solving process, the general guidelines of the data collection and assessment phase allow for a synthesis of an eclectic use of theory and intuitive-inductive processes.

CHALLENGES FOR GENERALIST-ECLECTIC DIRECT SOCIAL WORK PRACTICE

Given the fact that we have tried to extol the virtues of, and argue persuasively for, a generalist-eclectic approach to direct social work practice, we would be remiss if we did not consider some of the challenges that exist for this approach. In the following, we discuss important challenges for research and for practice, as well as strategies for dealing with these challenges.

Challenges for Research

Although cumulative research on psychotherapy has found no significant differences in the effectiveness of the various theoretical approaches (the “equal outcomes” phenomenon), the research indicates clearly that psychotherapy is effective compared with nonintervention (Lambert, 2013b). Because single-theory approaches have predominated historically in the helping professions, the cumulative research that has established the effectiveness of psychotherapy has been based primarily on single-theory approaches. Due to the newness of the movement toward eclecticism in psychotherapy and to the preoccupation with theory development in this movement, until recently, research on eclectic models has been neglected. In 1997, Norcross noted, “the commitment to psychotherapy integration is largely philosophical rather than empirical in nature. The adequacy of various integrative and eclectic approaches remains to be proven” (p. 87).

Even before much research on eclectic therapies had been conducted, however, proponents of eclecticism argued for the probable effectiveness of such approaches. In 1992, Lambert argued:

To the extent that eclectic therapies provide treatment that includes substantial overlap with traditional methods that have been developed and tested, they rest on a firm empirical base, and they should prove to be at least as effective as traditional school-based therapies. (p. 71)

In recent years, research on eclectic/integrative therapies has increased significantly. As reported in Chapter 1, a recent review of such research (Schottenbauer et al., 2005) found empirical support from randomized controlled studies for 20 such therapies. This accumulating body of research on eclectic/integrative therapies provides support for Lambert’s (1992) prediction that eclectic therapies will prove to be at least as effective as single-theory approaches. Still, research on eclectic approaches is in its early stages. Prochaska and Norcross (2014) have noted that “perhaps the only conclusions that can be reliably drawn are that coherent ‘eclectic’ and ‘mixed’ psychotherapies outperform no treatment and that these treatments are insufficiently compared to other systems of psychotherapy” (p. 446).

In Chapter 1, we considered how the cumulative research findings of the equal outcomes of various types of therapy and the importance of factors that are common across therapies (particularly the therapeutic relationship) provide indirect empirical support for the movement toward eclecticism. We also reviewed how, despite these research findings and the emerging direct empirical support for eclectic therapies, the empirically supported treatment (EST) movement in psychology has continued to push a research focus of establishing the effectiveness of single-theory approaches with specific disorders. Furthermore, because EST research protocols that require the use of treatment manuals (in order to standardize treatment) and a focus on specific disorders with outcome measurements related to the disorder are best suited to cognitive behavioral treatments, the vast majority of treatments that have achieved “empirically supported” status are cognitive-behavioral therapies (Messer, 2001; Wachtel, 2010; Wampold & Imel, 2015).

Although some eclectic approaches have been supported by EST research, most eclectic approaches are ill-suited to the protocol requirements of this research. In particular, the EST requirement for the development of standardized, manualized treatments for specific disorders does not fit well with the flexible, creative nature of most eclectic therapies. Because most eclectic therapies cannot and would not want to specify what therapists should do during therapy sessions, treatment manuals are not used, results of studies on eclectic therapy cannot be replicated (i.e., because what therapists do during treatment is not clearly defined or standardized), and eclectic therapies cannot achieve the status of an empirically supported therapy. For similar reasons, the same is true for most psychodynamic, humanistic, critical, and postmodern therapies. This becomes especially problematic because ESTs have been made mandatory by some managed care and insurance companies and thus practitioners feel pressured to use ESTs (Wampold, 2001).

We will not repeat here our critique of the EST movement in Chapter 1; however, among many other authors, we believe that the focus of EST research is misplaced and the interpretations of the results are misleading. As Lambert (2013a) has concluded from reviewing the research:

Although many practitioners and the public may be comforted by the notion that they are offering or receiving an empirically supported psychotherapy that works best, the fact is that success of treatment appears to be largely dependent on the client and the therapist, not on the use of “proven” empirically based treatments. (p. 8)

Nevertheless, the EST movement presents a serious challenge to establishing the credibility of eclectic therapies. The solution is not, however, to make eclectic therapies more standardized in order to fit EST research protocol requirements. This could compromise the effectiveness of eclectic therapy, which we think depends in large part on the artistry of relationship development and reflection and on the flexible, creative use of theory.

On an individual level, one response to counter the negative effects of the EST movement is to become familiar with the conceptual and empirical arguments against ESTs and to enter into the debate on the issues (e.g., in classroom, agency, or professional training settings). We refer readers to Chapter 1 for a summary discussion of the issues and for references to more detailed arguments provided by authors such as Henry (1998), Lambert (2013a, 2013b), Messer (2001), Norcross (2001), Wachtel (2010), and Wampold and Imel (2015).

On the level of a program of research, Wampold and Imel (2015) have called for a move away from the current dominant paradigm of clinical trials that compare the effectiveness of different treatments for specific disorders. They cite a review of eight such studies conducted between 1992 and 2009 (Laska et al. cited in Wampold & Imel, 2015) that had cumulative funding in excess of $11 million from the National Institute of Mental Health. The review of the results of these eight studies determined that little useful knowledge was generated from them, other than to further reinforce the equal outcomes conclusion. Wampold and Imel (2015) have argued that such research money could be used more productively:

Money should be spent investigating what makes various treatments work. Consider what we might learn if we had a well-funded research agenda to investigate the characteristics and actions of effective therapists. Such an agenda would lead to results that would likely improve the quality of care and focus training efforts. (p. 268)

Challenges in Practice

A generalist-eclectic approach to practice does not provide the comfort and certainty for practitioners that following a single model of therapy can provide. Practitioners who adhere to one theoretical approach, particularly if it has a narrow focus and prescriptive guidelines, can gain comfort in “knowing” at the outset of counseling what the problem is and/or what they need to do to help ameliorate it. In generalist-eclectic practice, the emphasis on theoretical openness and broad-based assessment precludes this type of certainty. Furthermore, the emphasis on the artistic, reflective, intuitive-inductive elements of practice, as well as on collaboration and partnership with the client, involves giving up control and certainty in the helping process.

Although the guidelines of the problem-solving model and understanding and/or techniques gleaned from a variety of theories provide helpful guidance for practice, a generalist-eclectic approach requires the practitioner to be creative and to find courage “in the face of the uncertain” (Papell & Skolnik, 1992, p. 22). This can be difficult, particularly for beginning practitioners who frequently yearn for “a ‘secret handbook’ of practical ‘how-to-do-it’ knowledge” (Mahoney, 1986, p. 169); however, it is our contention that clients respond better to this humble, open, and humane approach to practice than to theoretical certainty and prescriptive formulas. As Cameron (2014) has argued in promoting a common factors approach to social work practice: “We are at our best when we are being who we really are … (helpers) empowered by the sharing of their imperfect and compassionate humanity, not their ‘expertise’” (p. 155). Wampold and Imel (2015) have noted empirical support for this argument: “Interestingly, therapists who report having professional self-doubt have better outcomes, which suggests that a reflective attitude toward one’s practice is helpful” (p. 275).

Another obvious challenge in this approach to practice is that of becoming familiar with the wide variety of theories for direct practice. Although we have offered strategies for simplifying and demystifying the confusing array of clinical theories (i.e., conceptualizing levels and broad classes of theory, and identifying the general characteristics of classes of theory), there is no denying that developing in-depth knowledge and skill in a variety of theoretical approaches is a formidable task. This is particularly difficult given the unfortunate but continuing use of “idiosyncratic jargon” by many theoretical orientations (Goldfried & Castonguay, 1992). This not only makes learning different theories more difficult and intimidating but also hinders the development of understanding about similarities across theories.

With regard to the latter issue, we support the long-range goal of translating theories into ordinary English in order to further demystify and facilitate cross-theory dialog (Goldfried & Castonguay, 1992). With regard to the more general difficulty of becoming a “master of all trades” (i.e., of all theories and techniques), we think that practitioners should construe this as a career-long goal, in the context of understanding that theoretical knowledge and technical expertise can never be complete and that artistic elements of practice such as interpersonal sensitivity and relationship skills are of prime importance to counseling effectiveness.

A third general challenge to practicing from a generalist-eclectic orientation concerns the necessity of integrating a consideration of broader social issues, particularly issues of diversity and oppression, into both assessment and intervention. As noted earlier in this chapter, very few counseling theories pay much attention to these issues. Thus, from a generalist social work perspective, there is a need to utilize other sources of knowledge about working with issues of diversity and oppression. In addition to the generalist social work literature, practitioners can draw from critical theories, such as feminist theory (Chapter 14) and empowerment theory (Chapter 15), as well as the strengths perspective (Chapter 6), all of which pay special attention to these issues.

Managed Care

The major transformation in counseling services that has been brought about over the past 20-plus years by the managed care industry deserves special attention as a potential challenge to a generalist-eclectic approach to practice. We surmise that the managed care industry, which frequently limits the number of counseling sessions they will reimburse to about eight sessions (Lambert, 2013a), might be skeptical of an approach to practice that values holistic assessment, the development of in-depth understanding within the context of a good therapeutic relationship, and the intervention that draws on a range of theories and techniques. In fact, in advising practitioners how to present themselves to case managers within the managed care industry, Nichols and Schwartz (2004) suggest that “calling yourself ‘eclectic’ is more likely to sound fuzzy than flexible” (p. 87). We do not doubt that this type of pejorative thinking about eclecticism continues to exist, particularly with regard to brief treatment, and we see this as a challenge that needs to be addressed.

Although we do have concerns about the rigid enforcement of short-term counseling limits, particularly for clients who have multiple, severe, and/or longstanding stressors, we believe that a generalist-eclectic approach to practice can be used effectively in the context of brief treatment and managed care. Holistic assessment does not usually involve a long, drawn-out process of data collection. Practitioners can learn to focus a broad lens rather quickly and some holistic assessments (which are always tentative and subject to change) can be completed in single sessions. Similarly, the development of a strong therapeutic relationship does not usually require long periods of time; research has shown that alliances predictive of outcome are usually formed within the first few sessions (Horvath & Greenberg, 1994).

With regard to intervention, a generalist-eclectic approach to practice can be as focused and brief as necessary. Within a managed care context, practitioners and clients should plan and contract to focus on the most pressing problem that can be dealt with within the allotted time frame. From a generalist-eclectic perspective, however, practitioners working within the managed care industry would be obligated to attempt to secure longer term help for those clients who want and require it. This could involve lobbying a case manager for extending the counseling limits, contracting with the client to continue work together after the managed care session limits have been reached (and working out payment issues), or referring the client to other services.

There are two myths that can limit the managed care industry’s openness to eclectic and other process-oriented therapeutic approaches and that therefore need to be challenged. First, as previously discussed, is the myth that designated ESTs are, by virtue of the designation, more effective than other therapeutic approaches. Psychotherapy researchers who challenge the empirical basis of this contention need to continue to debate proponents of ESTs in professional arenas (e.g., in refereed publications and in professional associations) and to educate the managed care industry about this issue.

The second myth is that only therapeutic approaches that are self-labeled as “brief” are suitable for the parameters set by the managed care industry for treatment duration. In particular, brief solution-focused therapy’s “promise of quick solutions has endeared it to the managed care industry. Indeed … many applicants for provider status call themselves ‘solution-focused’ regardless of whether or not they have any training in this approach” (Nichols & Schwartz, 2004, p. 312). There are, however, good reasons to believe that most models of therapy (whether single theory or eclectic) are adaptable to the treatment duration parameters of managed care. Reviews of studies that have examined length of treatment across settings and theoretical orientations have established that the median or mean number of sessions was between five and eight (Garfield, 1994; Hansen et al. cited in Lambert, 2013a). Thus, traditional counseling approaches are often as brief as the so-called brief therapies. Even the psychodynamic school, which is traditionally the longest term approach to counseling, has developed brief treatment models that can fit the constraints of managed care (Barber et al., 2013; Koss & Shiang, 1994; Messer, 2001). Thus, the managed care industry needs to be educated to the fact that all theoretical orientations, including an eclectic orientation to the use of theory, are adaptable for brief treatment.

SUMMARY

In addition to providing a survey of contemporary theories for direct social work practice, this book represents an attempt to integrate a number of important and compatible ideas in the field of counseling into a broad framework for practice. To summarize, there are three important aspects to what we have called the generalist-eclectic approach to direct practice.

The first aspect is commitment to social work principles and values reflected by elements of the generalist perspective of social work practice. These elements include a person-in-environment perspective informed by ecological systems theory, an emphasis on a good helping relationship that fosters empowerment, the flexible use of a problem-solving process to guide practice, holistic assessment that includes a focus on issues of diversity and oppression and on strengths, and the flexible and eclectic use of a wide range of theories. The latter element is informed by theory and research in the broader movement toward eclecticism in the fields of counseling and psychotherapy. A second important aspect of our approach to practice is the valuing of the artistic elements of practice, or what we have called reflective, intuitive-inductive practice. This includes the recognition that much of the time practice does not involve the conscious application of theory and technique and that reflection, intuition, inductive reasoning, and creativity play important roles in practice. The third key aspect of our approach is the use of the problem-solving model of generalist practice to provide a flexible structure and general guidelines for practice in order to support the integration of the eclectic use of theory with the artistic elements of practice.

In conclusion, we wish to stress that the generalist-eclectic approach is not meant to represent yet another competing approach to or framework for direct social work practice. It is a way of conceptualizing practice that encourages flexibility in the use of multiple theories, perspectives, and ideas, while placing the principles and values central to the profession of social work at the forefront.