Module 7
Theory and Practice
a. Introduction
Ethical practice in counseling indeed rests on a foundation of sound theoretical
frameworks, as therapists' theoretical positions and conceptual views play a
significant role in shaping their approach to therapy and their interactions with clients.
A solid theoretical framework provides counselors with a guiding philosophy, a set of
principles, and a roadmap for understanding human behavior, addressing clients'
concerns, and facilitating meaningful change.
One key aspect of ethical practice is the recognition that therapists' theoretical
orientations and conceptual frameworks influence every aspect of the therapeutic
process, from assessment and diagnosis to intervention and termination. For example,
a therapist who adheres to a psychodynamic perspective may focus on exploring
unconscious conflicts and childhood experiences as drivers of present-day difficulties,
while a cognitive-behavioral therapist may emphasize the role of maladaptive thought
patterns and behaviors in maintaining psychological distress.
Moreover, therapists' theoretical orientations can also shape their beliefs about
the nature of the therapeutic relationship and their role as counselors. For instance,
therapists who ascribe to a person-centered approach may prioritize empathy,
unconditional positive regard, and genuineness in their interactions with clients,
viewing the therapeutic relationship as a collaborative partnership in which clients are
empowered to explore their own experiences and insights. In contrast, therapists who
adopt a more directive or structured approach may view themselves as experts who
guide and instruct clients in implementing specific strategies or techniques to achieve
therapeutic goals.
Additionally, therapists' theoretical frameworks influence their ethical
decision-making processes, particularly when faced with complex or ambiguous
situations. For example, a therapist's theoretical orientation may shape their approach
to issues such as confidentiality, boundary setting, and dual relationships. A therapist
who values autonomy and self-determination may prioritize respecting clients'
confidentiality and privacy rights, while a therapist who emphasizes relational ethics
may prioritize the maintenance of strong therapeutic boundaries to ensure the integrity
of the therapeutic relationship.
Furthermore, ethical practice requires therapists to engage in ongoing self-
reflection and critical examination of their theoretical assumptions and biases.
Counselors must be willing to challenge their own beliefs and be open to integrating
new perspectives and evidence-based practices into their work. This process of self-
examination and growth is essential for ensuring that therapists' theoretical
frameworks remain flexible, adaptive, and responsive to the diverse needs and
experiences of clients.
In summary, ethical practice in counseling requires therapists to operate within
a solid theoretical framework that guides their approach to therapy, informs their
ethical decision-making processes, and shapes their interactions with clients. By
recognizing the influence of theoretical orientations on practice and engaging in
ongoing self-reflection and growth, therapists can uphold the highest standards of
ethical conduct and provide effective, culturally sensitive, and client-centered care.
Ideally, theory helps practitioners make sense of what they hear in counseling
sessions. In this we address a variety of interrelated ethical issues, such as why a
theory has both practical and ethical implications, the goals and techniques that are
based on a theoretical orientation, the role of assessment and diagnosis in the
therapeutic process, issues in psychological testing, and issues surrounding evidence-
based practices (EBPs).
Clinicians must be able to conceptualize what they are doing in their
counseling sessions and why they are doing it. Sometimes practitioners have difficulty
explaining why they use certain counseling interventions. When you first meet a new
client, for example, what guidelines would you use in putting into a theoretical
perspective what clients tell you? What do you want to accomplish in this initial
session?
It's important to note that change is not always linear, and individuals may
cycle through the stages multiple times before achieving lasting change. Additionally,
the model recognizes that change is influenced by a variety of factors, including
individual characteristics, social support, environmental influences, and the specific
nature of the behavior being targeted.
Overall, the Stages of Change model provides a useful framework for
understanding the process of behavior change and can inform interventions and
strategies to support individuals in making positive changes in their lives. By
recognizing where individuals are in the change process and tailoring interventions to
their specific stage of readiness, counselors can effectively support clients in
achieving their goals and improving their well-being.
b. Developing a Counseling Style
Theories of counseling are based on worldviews, each with its own values,
biases, and assumptions of how best to bring about change in the therapeutic process.
Contemporary theories tend to be oriented toward individual change and are grounded
in values that emphasize choice, the uniqueness of the individual, self-assertion, and
ego strength. Many of these assumptions are inappropriate for evaluating clients from
cultures that focus on interdependence, de-emphasize individuality, and emphasize
being in harmony with the universe. In some cultures, basic life values tend to be
associated with a focus on inner experience and an acceptance of one’s environment.
Within cultures that focus more on the social framework than on development of the
individual, a traditional therapeutic model has limitations. In addition, it is not
customary for many client populations to seek professional help, and they will
typically turn first to informal systems such as family, friends, and the community.
Developing a counseling approach is more complicated than merely accepting
the tenets of a given theory. Ideally, the theoretical approach you use to guide your
practice is the result of intensive study, reflection, and clinical experience.
Furthermore, because a theory of counseling is often an expression of the personality
of the theorist and of the therapist, it is worthwhile to take a critical look at the
theorist who developed it and try to understand why it appeals to you. Uncritically
following any single theory can lead you to ignore some of the insights that your life
and your work open up to you. This is our bias, of course, and many would contend
that providing effective therapy depends on following a given theory. Ultimately, your
counseling orientation and style must be appropriate for the unique needs of your
clients and for the type of counseling you do. Developing an approach to counseling
is an ongoing and fluid process. It is common for counselors in training to be drawn to
a particular theory initially but to modify it as they gain more experience and evaluate
what seems to be working or not working with their clients.
When developing or evaluating a theory, a major consideration is the degree to
which that perspective helps you understand and organize what you are doing with
clients. Does your framework provide a broad base for working with diverse clients in
different ways, or does it restrict your vision and cause you to ignore variables that do
not fit the theory? Does your theory address all types of problems? Does your theory
take into consideration how cultural differences operate? It is important to evaluate
what you emphasize in your counseling work.
Your assumptions about the nature of counseling and the nature of people have
a direct impact on the way you practice. The goals you think are important in therapy,
the techniques and methods you employ to reach these goals, the way in which you
see the division of responsibility in the client–therapist relationship, your view of your
role and functions as a counselor, and your view of the place of assessment and
diagnosis in the therapeutic process are all largely determined by your theoretical
orientation—and all of these factors have implications for ethical practice. Practicing
counseling without an explicit theoretical rationale is somewhat like trying to sail a
boat without a rudder.
Just as a good sailor can adjust to the movement of the wind, a good therapist
goes along with the movement of the client. A theoretical orientation is not a rigid
structure that prescribes specific steps of what to do in a counseling situation; rather, it
is a set of general guidelines that counselors can use to make sense of what they are
hearing and what needs to change. Some practitioners favor an integrative approach
rather than relying on a single theoretical model (Corey, 2013a, 2017).
Indeed, an integrative approach in therapy is not merely a "catch-all" style
where therapists indiscriminately blend different theoretical models without purpose
or intention. Instead, it represents a thoughtful and deliberate integration of theoretical
perspectives and techniques that align with the therapist's values, beliefs, and clinical
expertise. This intentional blending allows therapists to create a customized and
flexible approach to therapy that best meets the unique needs and preferences of each
client.
One of the key benefits of an integrative approach is its ability to draw upon
the strengths of multiple theoretical models to address the complex and multifaceted
nature of human experience. Rather than adhering rigidly to a single theoretical
orientation, integrative therapists have the flexibility to incorporate elements from
various schools of thought, such as psychodynamic, cognitive-behavioral, humanistic,
and systemic approaches, as well as newer modalities like mindfulness-based
interventions or narrative therapy.
By integrating multiple theoretical perspectives, therapists can offer a more
comprehensive and holistic understanding of clients' concerns and experiences. For
example, an integrative therapist may draw on psychodynamic concepts to explore
unconscious motivations and early childhood experiences, cognitive-behavioral
techniques to identify and challenge maladaptive thought patterns, and humanistic
principles to foster self-awareness, self-acceptance, and personal growth.
Moreover, an integrative approach allows therapists to tailor their
interventions to the specific needs, preferences, and cultural backgrounds of
individual clients. Rather than adhering rigidly to a one-size-fits-all approach,
integrative therapists can adapt their therapeutic strategies to match the unique goals
and circumstances of each client. This personalized approach increases the likelihood
of a successful therapeutic outcome and enhances the client's sense of engagement,
empowerment, and ownership in the therapeutic process.
Furthermore, an integrative approach encourages therapists to engage in
ongoing self-reflection, professional development, and collaboration with colleagues.
Integrative therapists continually evaluate and refine their theoretical framework,
drawing upon research findings, clinical experience, and feedback from clients and
peers to inform their practice. This commitment to lifelong learning and growth
ensures that therapists remain current, competent, and effective in their work with
clients.
In summary, an integrative approach in therapy is characterized by purposeful
and intentional integration of theoretical models that resonate with the therapist's
values, beliefs, and clinical expertise. By drawing upon the strengths of multiple
theoretical perspectives, tailoring interventions to the individual needs of clients, and
engaging in ongoing self-reflection and professional development, integrative
therapists can provide effective, client-centered care that promotes healing, growth,
and positive change.
c. The Division of Responsibility in Therapy
Beginning mental health practitioners often burden themselves with too much
responsibility for client outcomes. They may be critical of themselves for not
knowing enough, not having the necessary skill and experience, or not being sensitive
enough. Overly anxious counselors frequently fail to include clients in the therapeutic
work, focusing too much on the interventions, treatment plans, and goals rather than
being present with their clients during sessions (Kristin Vincenzes, personal
communication, October 14, 2016).
The question of responsibility is an integral part of the initial sessions and
includes involving clients in thinking about their part in their own therapy. One way
to clarify the shared responsibility in a therapeutic relationship is by a contract, which
is based on a negotiation between the client and the therapist to define the therapeutic
relationship. A contract encourages both client and therapist to specify the goals of the
therapy and the methods likely to be employed in obtaining these goals. For clients
who have little or no knowledge of what the counseling process involves, this
discussion may be limited. Legal and ethical considerations need to be taken into
account in designing the contract and the treatment plan, and this is especially true
when dealing with vulnerable populations such as children, the elderly, and clients
with disabilities. A contract can be written, or it may be part of an ongoing discussion
between therapist and client regarding treatment goals, progress, and outcomes.
Therapists who work within a managed care context need to discuss with clients how
managed care will influence the division of responsibility between the health
management organization (HMO), the client, and the therapist.
Providers working within managed care systems often face a structured and
somewhat rigid framework that dictates various aspects of the therapeutic process.
These providers may determine what kinds of problems are deemed acceptable for
treatment based on the guidelines and criteria set forth by the managed care company.
This determination can significantly influence which clients are eligible for treatment
and which types of psychological issues are prioritized. For example, conditions that
are more easily quantifiable or have shorter treatment durations might be favored over
those that require long-term care.
The duration of treatment is another area where managed care exerts
considerable control. Providers may find themselves constrained by predefined
treatment timelines that dictate how long therapy can last for a given issue. This can
be challenging, as the pace of therapeutic progress varies widely among individuals,
and some clients may need more time to work through their issues than others.
Nevertheless, the managed care model often imposes strict limits on the number of
sessions allowed, which can create pressure for both the therapist and the client to
achieve significant progress within a limited timeframe.
Moreover, the focus of the therapeutic work is often directed by the managed
care company's objectives. Practitioners might have to tailor their therapeutic
approaches to align with the specific goals and measurable outcomes valued by the
company. This can sometimes conflict with the therapist’s clinical judgment or the
client’s unique needs and preferences. For instance, a managed care plan might
emphasize short-term symptom reduction and measurable improvements, while the
client may benefit more from a holistic, long-term approach that addresses underlying
issues and promotes overall well-being.
These providers often play a significant role in shaping the therapeutic process
by determining what kinds of problems are deemed acceptable for treatment. This
means that not all issues a client may want to address will be covered. For instance,
managed care companies might prioritize more acute mental health issues such as
major depressive disorder or severe anxiety, while potentially downplaying or
excluding concerns that are considered less urgent or more chronic in nature, such as
long-term stress management or self-esteem issues.
Additionally, these providers set limitations on the duration of treatment. This
often involves prescribing a specific time frame within which the therapy must be
completed. Such constraints can be based on standardized treatment protocols or
financial considerations. For example, a managed care plan might approve a certain
number of sessions, typically ranging from six to twelve, depending on the diagnosed
condition. These predetermined time limits can place pressure on both the therapist
and the client to make rapid progress, which may not always align with the client's
unique needs or pace of healing.
The number of sessions allowed is another critical factor controlled by these
providers. This number is usually fixed at the outset based on the initial assessment
and diagnosis. However, it may not account for the individual variability in clients'
responses to therapy. Some clients might require fewer sessions to achieve their
therapeutic goals, while others might need significantly more time. The rigidity of
these session limits can be a source of frustration for therapists who feel that their
professional judgment and understanding of the client's needs are being overridden by
external, often bureaucratic, guidelines.
Furthermore, the focus of the therapeutic work is also often dictated by these
managed care providers. They may require that therapy be goal-oriented with specific,
measurable objectives that must be achieved within the approved sessions. This can
sometimes lead to a more symptom-focused approach, emphasizing quick fixes rather
than addressing underlying issues. While this method can be effective for certain
acute problems, it may not be conducive to dealing with deeper, more complex
psychological issues that require a more nuanced and long-term approach.
Under this system, practitioners are required to be accountable to the managed
care company by demonstrating that specific objectives have been met. This
accountability typically involves regular reporting and documentation, where
therapists must provide detailed progress notes and evidence that the therapy is
working as intended. These reports often need to show measurable improvements in
the client's condition, such as reduced symptom severity or enhanced functioning in
daily life. Failure to meet these objectives can result in denial of continued coverage,
putting additional pressure on the therapist to produce tangible results within a limited
timeframe.
The necessity for such accountability can also lead to a significant
administrative burden for therapists. They must allocate time and resources to fulfill
documentation requirements, which can detract from the actual therapeutic work and
the quality of care provided. Moreover, the focus on meeting specific objectives can
sometimes lead therapists to prioritize short-term symptom relief over the client's
long-term well-being and personal growth.
In conclusion, while managed care providers play a crucial role in making
mental health services accessible and affordable, their influence on the therapy
process can sometimes create challenges. The predetermined parameters regarding the
types of problems treated, the duration and number of sessions, and the focus of
therapy can limit the flexibility and effectiveness of treatment. Therapists are required
to navigate these constraints while striving to provide the best possible care, balancing
the demands of accountability with the needs of their clients. This dynamic
underscores the complex interplay between healthcare systems, professional practice,
and the ethical imperative to support clients' well-being.
From our own perspective, therapy is a collaborative venture of the client and
the therapist. Both have serious responsibilities for the direction of therapy, and this
needs to be clarified from the very beginning of counseling. Lambert (2013) notes that
“learning how to engage the client in a collaborative process is more central to
positive outcomes than which process (theory of change) is provided” (p. 202). Most
probably the therapist has the greater responsibility in the initial phase of therapy,
especially in exploring the presenting problem and designing the treatment plan. In
essence, the therapist has the responsibility to create the environment that allows
change to take place.
However, as therapy progresses, the responsibility generally shifts more to the
client. Clinicians who typically decide what to discuss and are overdirective run the
risk of imposing their own views and perpetuating their clients’ dependence. Clients
should be encouraged to assume responsibility from the beginning of the relationship.
This is especially true of the cognitive-behavioral approaches, which emphasize
client-initiated contracts and homework assignments as ways in which clients can
fulfill their commitment to change. These devices help to keep the focus of
responsibility on clients by challenging them to decide what they want from therapy
and what they are willing to do to get what they want. It also keeps the therapist more
active in the process.
My perspective on the division of responsibility in therapy has evolved over
time, much like any evolving understanding. Initially, I approached this issue from a
more traditional standpoint, where the therapist held a significant portion of the
responsibility for guiding the therapy process. However, as I delved deeper into the
complexities of therapeutic relationships and the diverse needs of clients, my
perspective began to shift.
I began to recognize the importance of collaboration and shared responsibility
between the therapist and the client. Therapy is not a one-sided process where the
therapist dictates the direction and the client merely follows along. Instead, it's a
collaborative journey where both parties contribute to the therapeutic process. This
collaborative approach fosters empowerment and autonomy in the client, allowing
them to take an active role in their own healing journey.
Moreover, I've come to appreciate the ethical implications of taking
responsibility for the direction of the therapy process. While it may seem noble for the
therapist to assume full responsibility, it can potentially disempower the client and
perpetuate a dynamic where the client becomes overly reliant on the therapist. This
imbalance of power can hinder the client's growth and inhibit their ability to develop
the skills necessary for self-reflection and problem-solving.
On the other hand, allowing the client to take an active role in the therapy
process empowers them to become agents of change in their own lives. It fosters a
sense of ownership and accountability, which can lead to more meaningful and
sustainable outcomes.
However, it's essential to acknowledge that the division of responsibility in
therapy is not always clear-cut. There may be situations where the client is unable or
unwilling to take an active role, and in such cases, the therapist may need to provide
more guidance and direction. Additionally, cultural and contextual factors can also
influence the dynamics of the therapeutic relationship and the division of
responsibility.
Overall, my evolving perspective on the division of responsibility in therapy
emphasizes the importance of collaboration, empowerment, and ethical
considerations. By fostering a collaborative partnership between therapist and client,
we can create a more equitable and effective therapeutic process that honors the
autonomy and agency of the individual.
d. Deciding on the Goals of Counseling
Therapy without a goal is unlikely to be effective, yet practitioners may fail to
devote enough time to thinking about the goals they have for their clients and the
goals clients have for themselves. The initial task of therapy is to identify a client’s
problems and concerns, which leads directly to establishing goals with the client. The
therapist’s theory will greatly influence the types of goals established as well as the
methods used to reach those goals. Both the therapist and the client should clearly
understand the goals of their work together and the desired outcomes of their
relationship.
When considering therapeutic goals, it is important to keep in mind the
cultural determinants of therapy. The aims of therapy may be specific to a particular
culture’s definition of psychological health. An effective theory considers the person-
in-relation and the cultural context as essential aspects in developing appropriate
goals for the helping process.
Clinicians should not impose goals, but some practitioners may persuade their
clients to accept certain goals. Others are convinced that the specific aims of
counseling ought to be determined entirely by their clients. Who sets the goals of
counseling is best understood in light of the theory you operate from, the type of
counseling you offer, the setting in which you work, the problems of the client, and
the characteristics of your clients. Your theoretical orientation influences general
goals, such as insight versus behavior change. If you are not clear about your general
goals, your techniques and approach may be random and arbitrary.
Other factors can also affect the determination of goals. For example, if you
work with clients in a managed care system, the goals will need to be highly specific,
limited to reduction of problematic symptoms, and often aimed at teaching coping
skills. When you work in crisis intervention, goals are likely to be short term and
functional, and you may be much more directive. Working with children in a school,
you may combine educational and therapeutic goals. As a counselor to the elderly in
an assisted living facility, you may stress coping skills and ways of relating to others
in this environment. Working with veterans, you may intertwine career counseling,
psychoeducation, and therapeutic goals.
The goals you set in therapy, as well as the extent to which you actively
involve your client in determining these goals, are highly influenced by several key
factors, including the type of counseling you provide and the specific characteristics
of the client you are working with. Understanding these factors is essential for
tailoring the therapeutic approach to best meet the needs of each individual client.
First, consider the type of counseling you provide. Different counseling
modalities have distinct philosophies and methodologies that shape goal-setting
processes. For example, in cognitive-behavioral therapy (CBT), the goals are often
very specific, measurable, and focused on changing particular patterns of thinking and
behavior. CBT typically involves a collaborative approach where both the therapist
and the client work together to identify these goals and develop a plan to achieve
them. This approach is grounded in the idea that the client should be actively involved
in their treatment, contributing to a sense of ownership and motivation to make
changes.
In contrast, psychodynamic therapy might focus on exploring deeper, often
unconscious processes and unresolved past conflicts. The goals in this type of therapy
can be more abstract and long-term, such as gaining deeper self-awareness or
understanding the root causes of emotional difficulties. While the client’s involvement
in goal-setting is still important, the therapist might take a more guiding role, helping
the client uncover insights over time rather than setting concrete objectives from the
outset.
Humanistic and person-centered therapies, on the other hand, emphasize the
client’s autonomy and self-directed growth. In these approaches, the therapist’s role is
to facilitate an environment where the client feels safe and supported to explore their
own goals. The client is encouraged to take the lead in determining what they want to
achieve from therapy, reflecting the belief in the client’s inherent capacity for self-
healing and personal growth.
The specific characteristics of the client also play a crucial role in how goals
are set and pursued in therapy. Factors such as the client’s age, cultural background,
level of insight, and readiness for change can significantly influence this process. For
instance, a client who is highly motivated and has a clear understanding of their issues
may be more proactive in setting and working towards their goals. They might come
to therapy with specific objectives in mind, and the therapist’s role would be to
support and refine these goals collaboratively.
On the other hand, clients who are new to therapy or are dealing with complex
and multifaceted issues may need more guidance from the therapist in identifying and
articulating their goals. These clients might benefit from a more structured approach
where the therapist helps them break down their concerns into manageable parts and
set achievable milestones. This step-by-step process can help clients build confidence
and momentum as they work towards their larger, overarching goals.
Cultural factors also influence the goal-setting process. Clients from different
cultural backgrounds may have varying expectations and comfort levels with the
therapeutic process. Some cultures might place a strong emphasis on collective well-
being and relational harmony, leading clients to focus on goals related to improving
family dynamics or community relationships. Others might prioritize individual
achievement and personal development. Being culturally sensitive and aware allows
the therapist to align the therapeutic goals with the client’s values and cultural context,
fostering a more effective and respectful therapeutic alliance.
Furthermore, the client’s stage of change, as conceptualized in the
Transtheoretical Model of Behavior Change, can affect how actively they participate
in goal-setting. Clients in the precontemplation stage may not yet recognize the need
for change and may require the therapist’s assistance in exploring and understanding
their situation before setting goals. Conversely, clients in the preparation or action
stages are typically more ready to define and pursue specific therapeutic objectives,
and the therapist’s role may shift to supporting and facilitating their efforts.
In conclusion, the process of setting goals in therapy and the degree to which
clients are involved in this process is multifaceted and depends significantly on the
type of counseling provided and the unique attributes of each client. By considering
these factors, therapists can tailor their approach to create a collaborative and effective
therapeutic experience that respects and empowers the client, ultimately enhancing
the likelihood of achieving meaningful and lasting change.
e. The Use of Techniques in Counseling
Your use of techniques in counseling is closely related to your theoretical
model. What techniques, procedures, or intervention methods would you use, and
when and why would you use them? Out of anxiety, counselors may feel pressured to
try technique after technique in an indiscriminate fashion. Practitioners must have a
clear understanding of the techniques they use and why they are using them. From an
ethical perspective, practitioners should have a rationale for using a particular
technique and have training in the interventions they use. In a legal proceeding, a
counselor may be required to provide an explicit rationale and evidence-based
documentation to substantiate the interventions used with a particular client.
Empirical research consistently supports the centrality of the therapeutic
relationship as a primary factor contributing to the psychotherapy outcome. Over the
decades, numerous studies have delved into various aspects of the therapeutic
relationship, examining its nuanced impact on the effectiveness of different
therapeutic modalities. This body of research highlights several key elements that
contribute to the strength and quality of the therapeutic relationship, including trust,
empathy, and the perceived competence of the therapist.
Trust forms the foundational bedrock of any therapeutic relationship. Without
a solid base of trust, clients are unlikely to open up about their innermost thoughts and
feelings, which can severely limit the effectiveness of therapy. Empirical studies have
shown that when clients feel that their therapists are trustworthy, they are more likely
to engage fully in the therapeutic process, leading to better outcomes. Trust is
cultivated through consistent, reliable interactions and a demonstrated commitment to
the client's well-being.
Empathy is another critical component that empirical research has repeatedly
identified as essential to a successful therapeutic relationship. When therapists are
able to demonstrate genuine empathy, clients feel understood and validated. This
sense of being heard and accepted can significantly reduce feelings of isolation and
distress, paving the way for deeper therapeutic work. Studies have shown that
empathy is not just a nice-to-have trait but a crucial factor that can predict the success
of therapy across various treatment approaches, whether cognitive-behavioral,
psychodynamic, or humanistic.
The perceived competence of the therapist also plays a significant role in the
therapeutic relationship. Clients are more likely to engage in therapy and trust the
process when they believe their therapist is knowledgeable and skilled. This
perception of competence is not solely based on the therapist’s qualifications and
experience but also on their ability to apply their skills effectively in the therapeutic
setting. Research indicates that therapists who can adapt their techniques to the
individual needs of their clients tend to foster stronger therapeutic relationships and
achieve better outcomes.
Furthermore, the therapeutic alliance, which encompasses the collaborative
and affective bond between therapist and client, has been extensively studied. The
alliance involves agreement on the goals of therapy, consensus on the tasks to be
performed, and the development of a personal bond characterized by mutual trust,
respect, and liking. Empirical evidence suggests that a strong therapeutic alliance is
one of the most consistent predictors of positive therapy outcomes, regardless of the
therapeutic approach used. This highlights the importance of therapists being able to
build and maintain strong alliances with their clients.
In addition to these core elements, other factors such as cultural competence,
therapist self-awareness, and the ability to provide a safe and nonjudgmental space
also contribute to the strength of the therapeutic relationship. Cultural competence
involves the therapist's awareness and respect for the client's cultural background and
identity, which can significantly enhance the therapeutic relationship.
In addition to these core elements, other factors such as cultural competence,
therapist self-awareness, and the ability to provide a safe and nonjudgmental space
also contribute to the strength of the therapeutic relationship. Cultural competence
involves the therapist's awareness and respect for the client's cultural background and
identity, which can significantly enhance the therapeutic relationship. Therapist self-
awareness, including an understanding of their own biases and limitations, allows for
more authentic and effective interactions. Providing a safe and nonjudgmental space
is crucial for clients to feel free to explore their thoughts and feelings without fear of
judgment or retribution.
The therapeutic alliance enhances the quality of the working relationship, and
this alliance is the product of the collaborative efforts of both client and therapist.
Researchers have repeatedly confirmed that a positive alliance and a collaborative
therapeutic relationship are the best predictors of a positive therapy outcome.
Practitioners would do well to pay attention to the way they interact with clients and
the manner in which they participate in the therapy, providing high levels of empathy,
respect, and collaboration. Lambert (2013) believes too much attention is sometimes
devoted to studying techniques rather than focusing on therapists as people and their
interactions with clients. The techniques counselors employ, although important, are
less crucial to therapy outcomes than are the interpersonal factors operating in the
client–counselor relationship.
Your techniques cannot be separated from your personality and your
relationship with your client. When practitioners fall into a pattern of mechanically
employing techniques, they are not responding to the particular individuals they are
counseling. To avoid this pitfall, you must pay attention to the ways you use
techniques. The purpose in using a technique is to facilitate movement. You may try a
technique you have observed someone else using very skillfully only to find that it
does not work well for you. In essence, your techniques need to fit your therapeutic
style, your level of training, and the specific needs of your client. When working with
culturally diverse client populations, it is clinically and ethically imperative that you
use interventions that are consistent with the values of your client.
With all clients, it is best to adapt your techniques to the needs of your clients
rather than expecting your clients to fit your techniques. This client-centered approach
recognizes the unique individuality of each client, acknowledging that each person
comes with their own specific background, personality, and set of circumstances that
shape their experiences and responses. The adaptability of therapeutic techniques is
essential in creating a personalized and effective treatment plan that respects and
addresses these differences.
By tailoring therapeutic methods to align with the individual needs of each
client, therapists can foster a more supportive and effective therapeutic environment.
This involves being attuned to the client's preferences, cultural background, and
personal history, and adjusting strategies to meet their specific requirements. For
instance, some clients might respond better to cognitive-behavioral techniques that
focus on changing thought patterns and behaviors, while others might benefit more
from psychodynamic approaches that explore underlying unconscious processes and
past experiences.
In practice, adapting techniques might mean varying the pace and structure of
sessions, incorporating different therapeutic modalities, or even modifying the
language used during therapy to better resonate with the client. This flexibility allows
therapists to be more responsive to the client's immediate needs and to address any
emerging issues more effectively. For example, a client experiencing high levels of
anxiety might initially benefit from mindfulness and relaxation techniques, while later
sessions could focus on cognitive restructuring once their anxiety levels have
decreased.
Moreover, this client-centered approach enhances the therapeutic alliance,
which is the collaborative and trusting relationship between therapist and client. When
clients feel that their therapist is genuinely attuned to their needs and willing to adapt
their approach, they are more likely to feel understood and valued. This can lead to
increased engagement in the therapeutic process, greater openness in sharing thoughts
and feelings, and a stronger commitment to the goals of therapy. Research
consistently shows that a strong therapeutic alliance is one of the most significant
predictors of positive therapy outcomes.
Another important aspect of adapting techniques to client needs is the
acknowledgment of cultural diversity. Clients come from varied cultural backgrounds,
and their cultural context can significantly influence their worldview, coping
mechanisms, and the way they interact with therapy. Therapists who are culturally
competent and sensitive to these differences can better understand their clients'
perspectives and avoid misunderstandings that might arise from cultural disconnects.
This involves not only an awareness of cultural factors but also an openness to
learning from the client and an ability to incorporate culturally relevant practices into
therapy.
Additionally, adapting therapeutic techniques to client needs involves ongoing
assessment and flexibility. Therapy is not a static process, and what works for a client
at one stage might not be as effective at another. Continuous assessment allows
therapists to gauge the effectiveness of the current approach and make necessary
adjustments. This might involve switching techniques, introducing new interventions,
or revisiting and revising therapeutic goals. Such an approach ensures that therapy
remains relevant and responsive to the client's evolving needs and circumstances.
In conclusion, the principle of adapting therapeutic techniques to meet the
individual needs of clients is fundamental to effective psychotherapy. This approach
acknowledges the uniqueness of each client and fosters a more empathetic, flexible,
and responsive therapeutic process. By prioritizing the client's needs and being
willing to adapt techniques accordingly, therapists can build stronger therapeutic
alliances, provide more effective interventions, and ultimately facilitate better
therapeutic outcomes. The adaptability of the therapist, combined with a deep
understanding and respect for the client's individuality, forms the cornerstone of
successful therapeutic practice.
f. Assessment and Diagnosis as Professional Issues
Assessment and diagnosis are an integral part of the practice of mental health
counseling and psychotherapy. No matter what their theoretical orientation, all
competent mental health practitioners use some type of assessment to arrive at a
client’s diagnosis. This assessment is subject to revision as the clinician gathers
further data during the therapy sessions; assessment is an ongoing part of the
therapeutic process. Assessment consists of evaluating the relevant factors in a client’s
life to identify themes for further exploration.
Diagnosis, which is sometimes part of the assessment process, consists of
possibly identifying a specific mental disorder based on a pattern of symptoms that
leads to a specific diagnosis described in the Diagnostic and Statistical Manual of
Mental Disorders, fifth edition (American Psychiatric Association, 2013a), the official
guide to a system of classifying psychological disorders and generally referred to as
the DSM-5. Both assessment and diagnosis are intended to provide direction for the
treatment process.
Psychodiagnosis (or psychological diagnosis) is a general term covering the
process of identifying an emotional or behavioral problem and making a statement
about the current status of a client. Psychodiagnosis might also include identifying a
syndrome that conforms to a diagnostic system such as the DSM-5. This process
involves identifying possible causes of the person’s emotional, cognitive,
physiological, and behavioral difficulties, leading to some kind of treatment plan
designed to ameliorate the identified problem. The clinician must carefully assess the
client’s presenting symptoms and think critically about how this particular
conglomeration of symptoms impairs the client’s ability to function in his or her daily
life. Practitioners often use multiple tools to assist them in this process, including
clinical interviewing, observation, psychometric tests, and rating scales.
They also may make a referral for a medical evaluation. Differential diagnosis
is the process of distinguishing one form of mental disorder from another by
determining which of two (or more) disorders with similar symptoms the person is
suffering from. The DSM-5 is the standard reference for distinguishing one form of
mental disorder from another; it provides specific criteria for classifying emotional
and behavioral disturbances and shows the differences among the various disorders.
The DSM-5 deals with a variety of disorders pertaining to developmental stages,
learning and cognition, trauma, personality, substance abuse, moods, anxiety, sex and
gender identity, eating, sleep, impulse control, and adjustment.
Some dispute that diagnosis should be part of the psychotherapeutic process;
others see diagnosis as an essential step leading to a treatment plan. Some approaches
stress the importance of conducting a comprehensive assessment of the client and see
it as the initial step in the therapeutic process. The rationale is that specific counseling
goals cannot be formulated and appropriate treatment strategies cannot be designed
until a thorough picture of the client’s past and present functioning is formed.
Furthermore, evaluation of progress, change, improvement, or success may be
difficult without an initial assessment. Those who oppose a diagnostic model claim
that the DSM labels and stigmatizes people.
In performing psychodiagnosis of any type, it is crucial that clinicians consider
cultural factors and how these may influence the client’s current behaviors, feelings,
thoughts, and symptom presentation. Dadlani, Overtree, and Perry-Jenkins (2012)
emphasize the importance of addressing clinicians’ and clients’ experiences with
privilege and oppression as a basic aspect of diagnostic assessment. They call for a
reformulation of diagnostic assessment that puts culture at the center of the
assessment process. The multicultural and social justice perspective on assessment
and treatment focuses on client strengths within a cultural and historical framework.
Later in this we address more fully the cultural dimensions of diagnosis.
Nystul (2016) believes the clinical interview is a useful tool in the assessment
and diagnostic process because it provides a structure for organizing information. The
clinical interview serves many purposes, some of which are providing information on
a client’s presenting problems, giving glimpses of historical factors that may be
contributing to the client’s condition, and providing a framework for making a
differential diagnosis to determine whether an individual suffers from a particular
mental disorder. Because most therapy settings require a clinical interview, familiarity
with this form of assessment is essential. Nystul claims that the clinical interview can
be structured to suit both the counselor’s theoretical orientation and the unique needs
of the client.
Depending on the theory from which you operate, a diagnostic framework
may occupy a key role or a minimal role in your therapeutic practice. Practitioners
using a cognitive-behavioral approach and the medical model may place heavy
emphasis on the role of assessment as a prelude to the treatment process. Many
practitioners using relationship-oriented approaches view the process of assessment
and diagnosis as external to the immediacy of the client–counselor relationship. They
feel that it distracts the therapist from concentrated attention on the subjective world
of the client. The developmental, multicultural, and social justice theoretical model
emphasizes client strengths. The individual develops within a family in a community
and cultural context, and this model places greater attention on environmental and
contextual issues. By establishing an egalitarian therapeutic relationship, clients can
be actively involved in diagnosis and case formulation, with the goal of fostering their
psychological liberation.
Understanding differences among theoretical models has relevance for ethical
practice because the way in which diagnosis is practiced rests on theoretical
foundations. Regardless of the particular theory espoused by a therapist, both clinical
and ethical issues are associated with the use of assessment procedures and diagnosis
as part of a treatment plan. Practitioners within the same theoretical model often differ
with respect to the degree to which they employ a diagnostic framework in their
clinical practice. The box titled “Assessment and Diagnosis and Contemporary
Theories of Counseling” provides a summary of the way each model addresses
assessment and diagnosis.
Although you may not yet have had to face the practical task of diagnosing a
client, you will need to come to terms with this reality at some point in your work.
Many state licensing boards require applicants to demonstrate competence in the use
of diagnostic tools including the DSM-5. Regardless of your theoretical orientation,
you will most likely be expected to work within the DSM framework if you are
practicing in a community mental health agency or in any other agency in which
insurance companies pay for client services. Because you will need to think within the
framework of assessing and diagnosing clients, it is important that you become
familiar with the diagnostic categories and the structure of the DSM-5. The Council
for Accreditation of Counseling and Related Educational Programs (CACREP, 2016)
emphasizes the need for counseling students to acquire the competencies that will
enable them to effectively use DSM-5 assessment in their practices.
Important advances in neurology, genetics, and the behavioral sciences over
the past two decades have increased our understanding of mental illness. In the DSM-
5, considerable attention has been given to developmental issues, gaps in the current
system, disability and impairment, neuroscience, and cross-cultural issues (American
Psychiatric Association, 2012a, 2013a). Cultural factors are included in assessment by
using the Cultural Formulation Interview, a semistructured interview with 16
questions. Comas-Diaz and Brown (2016) contend that this cultural formulation is
limited because “the American Psychiatric Association’s cultural formulation is
medically oriented and is, consequently, based on clients’ deficits and
psychopathology instead of focusing on clients’ strength and resilience” (p. 250).
The DSM-5, like its predecessors, has attracted broad criticism and debate
(Pickersgill, 2014). Vanheule and Devisch (2014) point out that the DSM-5 lacks an
operational framework for assessing distress when diagnosing a mental disorder.
Other scholars have also been critical of the contents of the DSM-5, but Cosgrove and
Wheeler (2013) focus on the firestorm of controversy surrounding DSM-5 panel
members’ ties to the pharmaceutical industry. It was reported that 69% of task force
members who oversaw development of the revised manual had ties to the
pharmaceutical industry, an increase of 21% over previous edition task force members
who had such relationships (Cosgrove & Krimsky, 2012). Blumenthal-Barby (2014)
believes this emphasis will have consequences: an increasing number of phenomena
that were previously considered “clinically unremarkable” (p. 531) are now labeled as
mental disorders and are likely to be treated pharmacologically.
“The authors of the DSM-IV have critiqued the authors of the DSM-5 for
expansions that they believe will cause harm from over-diagnosis and falsepositives in
practice”. Reflecting on lessons they learned from working on the previous edition of
the manual, the authors of that edition cited examples of diagnoses such as Asperger’s
and bipolar II, which were added to the DSM-IV, that ultimately were “wildly
overused in ways that were never intended” (p. 532). They expressed their concerns
that the DSM-5 could potentially provoke several more epidemics. Another
controversy emerged prior to publication of the DSM-5 when the National Institute of
Mental Health (NIMH) announced plans to develop its own psychiatric nosology, the
Research Domain Criteria (RDoC), which would classify mental disorders based on
specific functional analysis of certain cells, genes, neural circuits, and behaviors. With
the aim of informing future editions of the DSM and the International Classification
of Diseases (ICD), another widely used classification system, the RDoC rests on the
premise that the only objective way to classify disorders is to start with biology and
work back to symptoms. The NIMH hopes to create biosignatures for mental
conditions and, through the creation of the RDoC, suggests that mental disorders can
be explained through a value-neutral combination of genetics, imaging, and
neuroscience.
Some mental health professionals believe DSM diagnosis has many
limitations and that it can harm clients. Some voices in the field have been critical of
the broader philosophy behind this diagnostic and medical model, and we include
their concerns here. Carl Rogers (1961) consistently maintained that diagnosis was
detrimental to counseling because it tended to pull clients away from an internal and
subjective way of experiencing themselves and to foster an objective and external
conception of themselves. The result was an increased tendency toward dependence,
with clients acting as if the responsibility for changing their behavior rested with the
expert and not with themselves.
Carlos Zalaquett, a counselor educator, contends that some professionals
assume they understand a particular person by knowing his or her diagnosis. In
reality, DSM diagnoses do not capture the uniqueness of the individual. A diagnosis is
a label with no capacity to describe the totality of a human being. Therefore, it is
always important to learn how the specific diagnosis is expressed in a particular
client. Zalaquett adds that, once formulated, a diagnosis can follow an individual even
if the assigned diagnosis no longer fits the person. For example, a college student
diagnosed with a major depressive disorder associated with difficulties in college may
not be accepted in a work-related position at some later time. Even though the person
is no longer depressed, he or she may still carry the stigma of being labeled as
depressed, which could have long-term implications.
From our perspective, assessment and diagnosis (either formal or informal)
help the practitioner conceptualize a case, implement treatment, and evaluate
outcomes. The clinician and the client can discuss key questions as part of the
therapeutic process. Clinicians will develop hypotheses about their clients, and they
can talk about these conjectures with them. Diagnosis does not have to be a matter of
categorizing clients; rather, practitioners can think more broadly, describe behavior,
and think about its meaning. In this way, diagnosis becomes a process of thinking
about the client with the client. Diagnosis can be viewed as a general descriptive
statement identifying a client’s style of functioning. The therapist can develop
hunches about a client’s behavioral style and perhaps even share these observations
with the client as a part of the therapeutic process. Comas-Diaz and Brown (2016)
suggest that a process-oriented clinical assessment can be appropriate for culturally
diverse clients. The first task in this assessment is to engage clients in treatment by
inviting them to tell their story. Comas-Diaz and Brown recommend “that cultural
similarities and differences be explored during the initial stages of assessment and
then continuously throughout treatment”
As we emphasized earlier, we favor a collaborative approach to assessment
that includes the client as a therapeutic partner. After the initial assessment of the
client is completed, a decision can be made whether to refer the individual for
alternative or additional treatment. The assessment information can be used in
exploring the client’s difficulties in thinking, feeling, and behaving and in establishing
treatment goals. Assessment and diagnosis can be linked directly to the therapeutic
process, forming a basis for developing methods of evaluating how well the
therapist’s procedures are working to achieve the client’s goals. Using diagnostic
nomenclature is a reality that most practitioners must accept, especially if they work
within a managed care system or with a third-party reimbursement system. For
therapists who are required to work within a diagnostic framework, the challenge is to
use diagnosis as a means to the end of providing quality service to clients rather than
as an end in itself that leads to a justification for treatment. We concur with Herlihy,
Watson, and Patureau-Hatchett (2008) that it is possible to work within a diagnostic
framework in an ethical and diversitysensitive manner. They offer the following
suggestions for diversity-sensitive diagnosis. Reflecting on their recommendations
can be a useful route to avoiding bias in one’s diagnostic practices.
Ethical dilemmas are often created when diagnosis is done strictly for
insurance purposes, which often entails arbitrarily assigning a client to a diagnostic
classification, sometimes merely to qualify for third-party payment. Some
practitioners who are opposed to a diagnostic framework take the path of least
resistance and give every client the same diagnosis. Clients who consult therapists
regarding problems that do not fit a standard “illness” category may not be
reimbursed for their psychotherapy. Some therapists may agree to see a couple or a
family but submit a claim for an individual as the “identified patient,” using an
acceptable DSM diagnosis. Although it may be tempting for a clinician to present an
“acceptable” but inaccurate diagnosis, this is both unethical and fraudulent. Braun and
Cox (2005) note that the intentional misdiagnosis of mental disorders for the purpose
of seeking insurance reimbursement constitutes health care fraud, which can lead to
legal censure and court action at the local, state, and federal level.
Under no circumstances should clinicians compromise themselves regarding
the accuracy of a diagnosis to make it “fit” criteria accepted by an insurance company.
If therapists do not understand how to work within some kind of diagnostic and
assessment framework, and if they do not have a clear picture of the client’s problem,
it is possible that they will not help the client. We also think it is an ethical (and
sometimes legal) obligation of therapists to be mindful that a medical evaluation is
many times indicated. This is especially true in dealing with problems such as
dementia, schizophrenia, bipolar disorder, and depression with suicidal ideation.
Students need to learn the clinical skills necessary to do this type of screening and
referral, which is a form of diagnostic thinking. Practitioners may cause harm to
clients if they treat them in restrictive ways because they have diagnosed them on the
basis of a pattern of symptoms. Therapists may then behave toward clients in ways
that make it very difficult for clients to change. If practitioners do not possess the
competence to use DSM diagnosis appropriately, this raises an ethical issue.
Practitioners who use the DSM-5 must be trained in its use. This training requires
learning more than diagnostic categories; it involves knowing personality theory,
psychopathology, and seeing how they relate to therapeutic practice. Zalaquett and
colleagues (2008) recommend reframing the way counselors are trained to use the
DSM model. They write about the benefits that can be derived from building a
collaborative relationship with clients in ways that result in meaningful case
formulations, diagnoses, and treatment planning.
The DSM system tends to pathologize clients, perpetuating the oppression of
clients from diverse groups (Remley & Herlihy, 2016). Durodoye (2013) notes that
“because of biases in mental health treatment, diverse populations have been
psychiatrically mislabeled and treated on the basis of mainstream definitions of what
is normal” (pp. 299–300). La Roche, Fuentes, and Hinton (2015) argue that the DSM
is based on Western American assumptions (such as individualism and universalism),
which limits its usefulness among different cultural groups. They also contend that the
cultural contexts of clients must be included in the assessment process to prevent
misconstruing the meaning of symptoms. For example, it is a mistake to assume that a
Mexican American woman who resides at home with her parents until she marries is
enmeshed. Instead, her living situation may be a result of gender-role expectations in
her family. Zalaquett and colleagues (2008) acknowledge that cultural biases exist in
both traditional helping models and the DSM model, yet they do not suggest that
either should be discarded from a counselor’s practice. Instead they emphasize the
responsibility of counselors to use these models in more culturally competent ways.
Cultural sensitivity is essential in making a proper diagnosis, and a range of factors
need to be considered in interpreting the assessment process. See the Ethics Codes
box titled “Cultural Sensitivity in Assessment” for some professional guidelines
regarding culturally sensitive diagnosis.
g. Using Tests in Counseling
Testing is different from assessment, although tests may be used in the process
of assessment. A test generates a score that represents a sample of behavior on a
particular day. An assessment is an integrated process that yields a comprehensive
picture of the client’s functioning using multiple measures in multiple settings.
Clinicians do not interpret test scores; rather, they interpret assessment batteries to
produce a comprehensive, holistic picture of the client’s psychological functioning as
it applies to the referral question. It is important to understand the common
assessment tools used in your profession, even if you choose not to use these tools in
your practice. As is true of diagnosis and assessment, the proper use of psychological
testing in counseling and therapy is the subject of some debate. Generally, those who
use therapeutic approaches that emphasize an objective view of counseling are
inclined to use testing procedures as tools to acquire information about clients or as
resources that clients themselves can use to help them in their decision making.
Therapists who employ person-centered and existential approaches tend to view
testing in much the same way that they view diagnosis—as an external frame of
reference that is of little use to them in counseling situations.
We think the core issue is not whether you will use tests but rather under what
circumstances and for what purposes. Tests are available that measure aptitude,
ability, achievement, intelligence, values and attitudes, vocational interests, or
personality characteristics. Unfortunately, these tests are often misused, and when this
occurs, ethical concerns are raised. Tests may be given routinely, given without
providing feedback to clients, used for the wrong purposes, interpreted without
consideration for cultural factors, or given by unqualified testers. Clinicians may
choose measures based on what is available or easy to give rather than on which
measure will best provide information to address the referral question or the reason
for the testing in the first place. Here are some guidelines that will help you think
about the circumstances under which you might want to use tests for counseling
purposes and how to use them in an ethical manner.
Paying attention to the above points when considering administrating or
interpreting testing is one way to increase the likelihood that you are practicing in a
culturally sensitive manner. From a social justice perspective, clinicians can use their
power to bring to light the misuses and inaccurate applications of assessment,
especially with those from underserved and oppressed communities. Clients being
tested should know what the test is intended to discover, how it relates to their
situation, and how the results will be used. Perhaps the most basic ethical guideline
for using tests is to keep in mind the primary purpose for which they were designed:
to provide objective and descriptive measures that can be used by clients in making
better decisions. It is wise to remember that tests are tools that should be used in the
service of clients.
h. Evidence-Based Therapy Practice
Mental health practitioners are frequently expected to make decisions about
what they believe to be the best therapeutic approaches or interventions with a
particular client. Clinical practice should be based on the best available research
integrated with a practitioner’s expertise within the context of a particular client
(Norcross, Hogan, & Koocher, 2008). For many therapists the choice of interventions
they make in their practice is based on their theoretical orientation. Over the past
couple of decades, however, a shift has occurred toward promoting the use of specific
interventions for specific problems or diagnoses based on empirically supported
treatments. Treatment manuals were developed for a wide range of psychological
disorders, and they yielded impressive research results. Lazarus and Rego (2013) state
that this success ushered in the movement toward empirically supported treatments
and evidence-based practice.
Increasingly, clinicians who practice in a behavioral health care system are
encountering the concept of evidence-based practice (Bride, Kintzle, Abraham, &
Roman, 2012; Norcross et al., 2008). Evidence-based practice (EBP) is “the
integration of the best available research with clinical expertise in the context of
patient characteristics, culture, and preferences” (APA Presidential Task Force, 2006,
p. 273). This idea encompasses more than simply basing interventions on research.
Norcross and colleagues (2008) advocate for inclusive evidence-based practices that
incorporate each of the three pillars of EBP: best available evidence, clinician
expertise, and client characteristics. Evidence-based practice is often associated with
cognitive-behavioral approaches.
These approaches are the most extensively researched psychotherapies, with
hundreds of studies supporting their effectiveness for a wide range of emotional and
behavioral problems (Antony, 2014). Hollon and Beck (2013) report that cognitive-
behavioral interventions have generated powerful evidence of success in treating
depression, anxiety disorders, panic disorders, social phobia, posttraumatic stress
disorders, eating disorders, substance abuse, personality disorders, and childhood
depression and anxiety disorders. Although abundant research has been conducted on
cognitive-behavior therapies, it is a mistake to conclude that these approaches have a
monopoly on evidence-based therapy practice.
In their extensive review of research on humanistic psychotherapy from 1990
to 2015, Angus and colleagues (2015) concluded that “humanistic psychotherapy
researchers have made significant contributions to innovative advancements in the
field of psychotherapy methods and research findings over the past 25 years” (p. 338).
Angus and colleagues also contend that humanistic psychotherapies “ are supported
by multiple lines of scientific evidence and should therefore be included in clinical
guidelines and lists of evidence-based psychotherapy” (p. 339). Elliott, Greenberg,
Watson, Timulak, and Freire (2013) compiled a comprehensive review of the
humanistic-experiential psychotherapies and report that a substantial and rapidly
growing body of data supports these approaches with a wide range of client problems
including depression, relationship problems, anxiety disorders, eating disorders,
coping with chronic medical conditions, psychotic disorders, and substance abuse.
The movement toward grounding psychotherapy practice on a scientific
foundation led to the concept of empirically supported treatments (EST). “Proponents
of ESTs believe that each form of therapy needs to be tested in carefully controlled
experimental research. The results would show which therapies actually worked and
which, though well intended, did nothing to help the patient or, worse, were harmful”
Managed care companies and other third-party insurance companies embrace
the concept of ESTs and tend to restrict payments to therapies that demonstrate
evidence of being effective and efficient (Pope & Wedding, 2014). Increasing the
availability and use of ESTs has become a focus of public policy, and some
individuals have concentrated their efforts on discovering the best ways to train
practitioners in the use of these treatments and to disseminate this information.
However, there is another side to the EST issue. In his extensive review of the
efficacy and effectiveness of psychotherapy, Lambert (2013) states that identifying
lists of empirically supported treatments for specific disorders is controversial and
puts too much emphasis on small differences in outcomes associated with certain
treatments. Lambert concludes, “to advocate empirically supported therapies as
preferable or superior to other treatments is probably premature”
