Healing the Incest Wound, originally published in 1988, was a landmark achievement in the modern era of trauma psychiatry and psychology. Christine Courtois, PhD is one of the pioneers who helped rediscover the long-neglected effects of pandemic childhood sexual abuse and to introduce treatment models that could help incest victims reclaim their lives. The original book became a classic, providing guidance and support to countless clinicians during a time when there was a profound dearth of information on the subject of incest. Now, more than 20 years later, Courtois has succeeding in integrating the explosion of knowledge and expertise developed over the intervening years into a comprehensive and authoritative second edition. In the original edition, she relied largely on her own experience and expertise along with the relatively few published papers concerning sexual abuse and posttraumatic responses. In this current edition, she has supported her observations with the empirical evidence and clinical wisdom of hundreds of publications. Courtois has heightened the complexity of her thinking with the expertise of other professionals in the trauma field – many of whom based their efforts on her earlier work.
As in the original edition, Healing the Incest Wound is divided into three sections. Section I provides a meticulous review of the characteristics, categories, epidemiology and dynamics of incest. Section II describes the many and varied aftereffects of incest. Perhaps most helpful to practitioners is Section III that comprehensively details the treatment process: the philosophy, goals, sequencing, diagnostic considerations and psychotherapeutic processes, as well as specifics concerning treatment modalities and special populations. This second edition is nearly twice length of the original. Quality should not be judged by quantity, but the additions and elaborations in this edition provide information that is timely, relevant and useful.
It is testament to the quality of the original edition of Healing the Incest Wound that Courtois’ observations and understanding of the nature, effects and treatment of sexual abuse have held up extremely well. For example, in the 1988 original edition, based on nascent research and anecdotal experiences in the trauma field, Courtois speculated about the association of sexual abuse with deficits in physiologic, developmental and psychological functioning. In this new edition, there is a wealth of data and findings that support these negative effects of sexual about in virtually all domains of human functioning. The new edition also helps to integrate many diverse approaches to treatment that have been developed in the past decades including feminist, traumatic stress, developmental/attachment, relational, and loss/bereavement perspectives, which can be of enormous assistance to clinicians in using effective and eclectic approaches in their treatment of sexual abuse survivors.
In the current edition of Healing the Incest Wound, Courtois describes the stage-oriented treatment model for complex PTSD. Developed in the 1990s, this model of treatment proposed that effective treatment for severely and chronically abused individuals requites an early stage of safety and stabilization along with building functional and relational skills prior to active work on the traumatic events themselves. Courtois offers a clear and concise description for stage-oriented treatment for complex PTSD, a model which has become the standard of care for severely traumatized patients. Throughout the remainder of the book, she further elaborates on the issues that will allow clinicians to learn about how to provide skillful, effective and helpful care to some of their most challenging patients. Consistent with developments in the trauma field, the current edition offers a new focus on both the intricacies of working with patients who have sustained immense relational damage and the effects on the clinicians who treat them. Courtois pays particular attention to how the dynamics of the original abuse become reenacted in the transference-countertransference relationships in the therapy.
Although this book is a truly academic work and a source book for both historical and current information in the trauma field, its primary value is for practicing clinicians. For example, there are nuanced discussions of the assessment process concerning how to interview and how to detect hidden presentations of sexual abuse. There are also detailed discussions of new newer treatment modalities including various cognitive-behavioral techniques, EMDR, expressive therapies, and more recent proposed treatments such as sensorimotor, somatosensory and energy techniques. As an added benefit, Treating the Incest Wound concludes with comprehensive appendices that provide a rich resource for both professionals and survivors of sexual abuse.
I have been an unapologetic admirer of Courtois over many years as a colleague, a collaborator in teaching workshops, and a reader of her published works. She is one of those gifted professionals who can combine the kind of meticulous academicity, clinical wisdom, warmth and compassion that is so evident in Healing the Incest Wound.

Race and Culture in Teaching, Training, and Supervision
October 15-16, 2010 in Boston , Massachusetts

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Two days of presentations and workshops for teacher educators, researchers,
mental health professionals, community members, and students interested in
community activities and activism, developments in research, professional practice,
education, and/or social initiatives as they pertain to teaching, training, and supervision.

Sponsored by the Institute for the Study and Promotion of Race and Culture
Dr. Janet E. Helms, Director
Featured Presenters Include:
Nancy Boyd-Franklin, Ph.D., Rutgers University
Barry Chung, Ph.D., Northeastern University
Anderson Franklin, Ph.D., Boston College
Paula Martin, Ph.D., Needham Public Schools
Kevin Nadal, Ph.D., John Jay College
Lisa Patel Stevens, Ph.D., Boston College
Usha Tummala-Narra, Ph.D., Boston College
LaQueta Wright, Ph.D., Richland Community College
Jean Wu, Ph.D., Tufts University

Reduced registration fee before September 15, 2010
Special Student Rate
PDP’s available; CE’s for psychologists and other mental health professionals pending

Please complete the attached registration form and return it with payment to:
Institute for the Study and Promotion of Race and Culture
The Peter S. and Carolyn A. Lynch School of Education
Campion Hall 318,140 Commonwealth Avenue
Chestnut Hill, MA 02467

For more information and to register online please visit: http://www.bc.edu/isprc

I am curious about ethical considerations when treating individuals who are HIV positive. What are my responsibilities as a clinician if I know that my client (HIV positive) is engaging in risky/unsafe sexual practices with someone? In this case, the other person’s life is endangered.

This issue always stumps me, thank you for your thoughts!

Jeff Barnett Responds:

Hi Stephanie. Great question. This is one that often is very confusing and challenging for psychotherapists. One of the major concerns involves the different but related roles of ethics, law, and clinical practice. I believe some of what is behind your question concerns the issue of “duty to warn and protect” that comes from the landmark Tarasoff decisions in 1974 and 1976 (Tarasoff v. Regents of the University of California.

In 1974 in the initial ruling the court opined that “where a psychotherapist had reason, arising out of a professional relationship with a patient, to believe, or reasonably should have believed, that the patient was intending to harm a specific victim, that a duty existed to warn that victim” (Mills, 1984).

In 1976 the court revised and updated its opinion, adding to the obligation to warn the intended victim with the need to take actions to protect the intended victim such as by contacting the police, and possibly by even using treatment to prevent the harm from occurring.

The Tarasoff rulings set legal precedent. But, over the years as states have passed laws to address these issues, the precedent has been codified into law. Yet, various states’ laws are different in their requirements. Some states have duty to warn statutes, some have duty to protect statutes, some have duty to warn and protect statutes, and some include treatment in their statutes. For example, in Maryland , the law is the duty to warn, protect, or treat. That is, if treatment can prevent harm to another person from occurring , it should be used first. Confidentiality should only be breached in these situations when treatment is ineffective or is not possible.

But, it is important to note that the Tarasoff rulings and these various state laws are speaking of a specific threat made in treatment to do harm (typically interpreted as lethal harm) to an identifiable victim or group of victims. This brings up several important points. First, it must be a threat to do harm. This implies that the harm did not already occur. The goal of these laws is to prevent future harm. Second, it must be an identified victim, otherwise who would we warn and who would the police potentially take action against? Third, the harm that is threatened should be lethal. If a client said in session that later that day they are going to punch their spouse, this would not meet the standards needed for breaching confidentiality.

But, if one’s state law allows for this the psychotherapist should always consider treatment as the first option. These laws do not require that the psychotherapist make a call to the intended victim and to the police the moment a client discloses such a threat. We are to conduct a thorough risk assessment, address these issues in the treatment plan, and work to address underlying issues, in an effort to prevent the harm from occurring, and thus, to prevent the need to breech confidentiality.

With regard to the issue of a client with HIV or AIDS disclosing engaging in unprotected sex with other individuals this is of course a very serious concern that will hopefully be addressed in treatment. With regard to breaching confidentiality there are several issues of relevance and great importance. First, it is essential that we always include potential limits to confidentiality in our informed consent agreements with our clients.  Then, the following factors are relevant: intent to do harm, likelihood of actual harm occurring, the inability to know the identity of future sexual partners, and the likely presence of consent to engage in these behaviors (Chenneville, 2000). When it comes to unprotected sexual behavior one might reasonably argue that your client’s partners are engaging in this behavior consensually. To date there has been so much education about sexually transmitted diseases, practicing safe sex, and the like, that this situation can be seen as substantively different than the typical Tarasoff-like situation. Of course, if your client stated in session that he was going to rape a specific individual in the future and to do so without a condom, that might more closely approximate the need for the Tarasoff-like actions described above. But, when considering lethal actions, unprotected sex by an HIV-Positive or AIDS-infected individual is does not possess the lethality of shooting, stabbing, etc. another person. The rate of transmission of HIV from unprotected sex is not even close to 100% and for those who are infected there now exist effective treatments.

Thus, it is important to keep in mind the requirements of your state’s laws. This includes duty to warn, protect, and treat laws as well as those relevant to reporting HIV. Some states do not all the reporting of HIV or AIDS status by licensed psychotherapists (e.g. Wisconsin) while other states require the reporting of it (e.g. Washington). So, knowledge of the relevant laws in one’s jurisdiction is essential. It is also important to keep in mind that breaching confidentiality due to harm to others has strict limitations. The harm must be threats of harm in the future, not in the past or ongoing. Additionally, the harm typically must have potentially imminent lethality (again, check your state laws for their specific wording). Finally, if these issues can effectively be addressed in treatment, that is preventing the risk of future harm through treatment, that should carefully be considered unless your state’s law contraindicates this. When addressing these issues are addressed in treatment it is important to thoroughly document all discussions, recommendations, interventions and actions taken, your client’s responses, and all consultations. Further, it’s not just important to document what you did, but also all that you considered and the rationale behind your decisions.

I hope this is helpful to you. I do not represent myself as an attorney or an expert on every jurisdiction’s laws, and I do not know all the details of your case. But, I do hope this provides some issues for consideration and discussion. Please feel free to share your comments and any additional thoughts. I also welcome other members sharing their thoughts and perspectives on this important and challenging issue.

References

Chenneville, T. (2000). HIV, confidentiality, and duty to protect: A decision-making model. Professional Psychology: Research and Practice, 31(6), 661-670.

Mills, M. (1984). The so-called duty to warn: The psychotherapeutic duty to protect third parties from patients’ violent acts. Behavioral Sciences & The Law, 2(3), 237-257.

Stephanie is currently a doctoral candidate at the University of Wisconsin-Madison in the Department of Counseling Psychology. At present, she is a pre-doctoral intern at the University of Minnesota-Twin Cities counseling center (UCCS). In April, she successfully defended her dissertation regarding mental health outcomes for transsexual individuals throughout their transitioning process. As the recipient of the Charles Gelso Psychotherapy Research Grant, she will be conducing three separate meta-analyses regarding the efficacy of research trials for personality disorders. The first meta-analysis will be conducted regarding trials that compared evidence-based treatments to treatment-as-usual for personality disorders. The second meta-analysis will determine differences in efficacy for bona-fide treatments for personality disorders. Last, a cost-effectiveness analysis will be conducted on those trials that have compared treatments for personality disorders.

Please see the awards section of the Division 29 website for more information on the grant program and watch for upcoming details of the call for applications for the coming year’s grant awards. Eligibility for the Charles J. Gelso Psychotherapy Research Grant rotates biannually between graduate students/predoctoral interns and doctoral level psychologists/postdoctoral fellows. In 2011, doctoral level psychologists and postdoctoral fellows will be eligible.

President-Elect: Marvin R. Goldfried, Ph.D.

Diversity Domain Representative: Caryn Rodgers, Ph.D.

Early Career Domain Representative: Susan S. Woodhouse, Ph.D.

Science and Scholarship Domain Representative: Norman Abeles, Ph.D.

Council Representatives: Linda F. Campbell, Ph.D., and John C. Norcross, Ph.D.

Congratulations and thank you for your service to the Division of Psychotherapy.

Libby

As graduate students we receive training not only in academia but in a myriad of different clinical settings, which often lead to a wide range of experiences in terms of supervision. Because of the emphasis that is placed on clinical/practical training for clinical psychology programs in particular a graduate student’s competencies are strongly related to the quality and type of supervision that he or she receives during practica experiences.  Given this, how important do you think it is for supervisors of graduate students to receive training in the area of supervision?  Should there be specific competency requirements for psychologists or other mental health clinicians who plan to train graduate students?

Jeff Barnett Responds:

This is a really important question. Clinical supervision is an essential aspect of every psychologist’s professional training. We each participate in supervision during different stages or phases of our professional growth and development. Without it, we couldn’t develop the competence needed as professionals. Yet, the quality of the supervision we receive is of great importance. Inadequate, unethical, or insufficient supervision has serious ramifications for our developing competence as well as for the clients to whom we provide professional services.

Competence is generally thought of as being comprised of knowledge, skills, attitudes and values, and the ability to implement them effectively. In general, we obtain much of the knowledge we need from academic course work, reading, attending seminars, and the like. We also should be able to obtain additional knowledge from our clinical supervisors. Our skills are developed primarily in clinical supervision. Our supervisors also serve as professional role models; we learn and develop many of our professional attitudes and values from the examples set by our supervisors.

It is essential that supervisors possess two major types of competence; competence in the clinical areas they are supervising and competence in being a supervisor. It is definitely important that supervisors have training in being a supervisor. Like any other clinical role, it has it’s own literature, research, and requisite skills. Merely having been supervised in the past is not a sufficient credential for being a supervisor. Also, just because a job may require a psychologist to supervise a certain number of trainees, that doesn’t mean one is competent to provide the supervision. One must first obtain the necessary training to develop needed competence so that one may provide supervision skillfully and ethically. There are different models of supervision, various methods of supervision, and a number of clinical and ethical issues supervisors should be aware of.

Some jurisdictions require clinical supervisors to have  a certain number of hours of continuing education in clinical supervision for their license to be renewed every two years if they are to provide clinical supervision. That’s a good start, but a minimal requirement. Training programs should require that potential supervisors submit documentation of their training, experience, and competence in providing supervision before being allowed to supervise students. This may involve submitting continuing education certificates, transcripts, a statement of professional experience, and/or letters of recommendation. But, often training programs have a difficult time getting supervisors for their students since the supervisors are often volunteers. As a result, programs may just be glad to get supervisors for students and may not be as careful or thorough in screening potential supervisors. Just as supervisees receive written and verbal feedback throughout the course of supervision, perhaps supervisors should receive written feedback and evaluations from supervisees that are shared with training programs.

There are also many ethics issues that supervisors and supervisees should be aware of. Additionally, there’s a body of research that highlights the qualities of effective and ineffective supervisors (and supervisees!) that both supervisors and supervisees should be aware of. I also believe that there should be an informed consent agreement or supervision contract completed at the outset of the supervision relationship that clarifies all roles, responsibilities, obligations, and the like. These issues and other relevant ones are addressed in the PowerPoint slides below that are from a presentation on the topic I gave recently.

I hope this is helpful. If you have any comments in response to what I have written here or if you have other questions please don’t hesitate to ask. I also welcome others’ comments and questions as well. I wish you much success in your training. A final thought is to keep in mind that as a supervisee, you are an active consumer of a service. You must be provided with the needed oversight, training, supervision, mentoring, and role modeling that are needed for you to flourish and develop as a professional psychologist.

Best wishes – Jeff

Ethical and Legal Issues in Supervision

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By Staci Weiner, Psy.D.

Apple Psychological, LLP.
www.applepsychological.com.

Choose to be Happily Married, How Everyday Decisions Can Lead to Lasting Love by Bonnie Jacobson, Ph.D., Publisher Adams Media, May 2010.

This is a relationship road map; a manual for relationships that leads to successful communication, listening skills, and ultimate connection between two people. Illustrating twenty-five crucial turning points, the author raises the reader’s consciousness about critical individual and relationship decisions.  Readers learn how to translate the abstract emotions of everyday life into concrete expressions, making them more manageable in the process.

Dr. Jacobson empowers readers to make conscious choices in moments of empathic disconnect between themselves and significant others as well as encouraging readers to explore inventive ways of working with conflict and constructive forms of aggressive expression. The approaches discussed are derived from attachment theory, neurobiology, and theories of healthy aggression and conflict resolution to help people manage their daily life without being a victim of their own history.

This work helps readers gain insight into some of the choices that can lead to lasting love including:

• Learning different ways to respond or react to conflict in the moment
• Learning  to pick and choose your battles and decide when and how to establish boundaries
• Developing new ways to be tolerant of your partner’s need for personal space, change, and his/her own family values
• Developing self-awareness and control with regard to your role in the relationship and your own style of interacting
• Establishing effective communication
• Sharing your thoughts and yourself
• Using intimate listening skills
• Supporting and empowering your partner
• Understanding the difference between joy and happiness and embracing what lasts

This book is a modern dissection of relationships that acknowledges how roles shift over time.  It can be immensely helpful to couples who struggle with communication and listening skills as well as those who have difficulty establishing and maintaining personal relationships. Enjoyable and easy to read, the author uses everyday examples to illustrate her points.  The Emotional Turning Point Test at the end of the book allows readers to gain insight into themselves.

There are several online Self-Help Book Clubs in which participants read selected chapters and discuss them with other readers and mental health professionals.  More information on the Self-Help book clubs can be obtained by going to www.applepsychological.com and www.drbonniejacobson.com.

I have a client (18yr female) who I have seen twice a week for 8 months who is currently in a relationship plagued with intimate partner violence. This has been dubbed “mutual combat” by several of my co-workers, but in exploration with her, it appears as though the severity of his violence, his physical strength, and his emotional control create a dynamic where she sometimes reacts with violence (i.e., pushing him so she can escape, scratching his arms when they are around her neck). She has asked to begin couples therapy with her partner, and he has agreed. I am familiar with some of the literature on couples therapy and intimate partner violence and have had some training in this area, but no one else at my location (a community mental health center) is trained in couples therapy and/or intimate partner violence. My agency is now discussing the possibility of me seeing them as a couple while continuing to see her. Are there guidelines or best practice recommendations about
whether it would be appropriate for me to see them as a couple?

Response by Jeffrey Barnett

Thanks for this great question. I’m really glad you are asking it. Clearly you are sensitive to the issue of competence with regard to the knowledge and skills needed to provide couples therapy. As your question implies, being competent in individual psychotherapy doesn’t necessarily translate over to clinical work with couples. Once must have the necessary education and training from course work, readings, CE activities, and supervised clinical experience before expanding our practice into a new area. I agree with you that you need to be aware of relevant practice standards and guidelines as well.

The situation you describe is also challenging because of the highly volatile nature of the relationship and the risks present for all involved (including yourself!). It will be important to be sure you have in place safeguards to protect yourself should anyone become aggressive or violent during a session. Having a colleague present or nearby during sessions, having a ‘panic button’ at your desk to quickly summon security if needed, positioning yourself near the door and not having clients seated between you and the door each may be important. Additionally, having a treatment contract/informed consent agreement that clearly specifies rules of conduct for the psychotherapy relationship is important as well. It should specify acceptable and unacceptable behaviors, appropriate alternatives to use if one is angry, and responses or consequences that will occur should certain specified behaviors happen.
With regard to the competence issue and relevant standards I suggest you consult with colleagues who are experts in couples therapy and in clinical work with intimate/partner violence. APA’s Division of Family Psychology and the Family Psychology section of the American Board of Professional Psychology may be good resources. While you may not have a competent supervisor on site, consultation and supervision may be done across distances by use of televideo communications such as Skype or by telephone and by sending the supervisor tapes of sessions with appropriate consent of the clients.

You are wise to be concerned about practicing in a new area without first knowing relevant practice standards, obtaining needed education and training, and receiving ongoing consultation or supervision. Then, should you proceed with this case, be sure your expert colleagues provide suggestions on how to structure the treatment sessions and relationships to ensure the safety of all involved. I hope this is of help. Should you have additional questions or comments please let me know. I also hope others will share their thoughts on this important area of practice as well. Perhaps some colleagues who work with these types of couples can share their perspectives.

Thanks and best wishes – Jeff

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{from: Psychotherapy Bulletin 45(2): Online Version}

Kenneth L. Critchfield (University of Utah) & Sarah Knox (Marquette University)

“Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” APA Presidential Task Force on Evidence-Based Practice (2006, p. 273)

An advanced graduate student therapy trainee recently expressed concern about treatment of a difficult case seen in one of her placements. She was frustrated with a supervisor and torn between utilizing knowledge of the patient’s treatment history and family patterns versus following a different path suggested by a particular treatment manual. The frustration had been stirred up in context of a group discussion about tailoring treatments to fit individual patients, and using the empirical literature to do so. She asked: “But doesn’t the research literature say that fidelity to treatment will bring the best effects? A patient I’m seeing now doesn’t like the approach for specific reasons, and it also hasn’t worked for her in the past. But, how can I respond to my patient’s needs and still be evidence-based? Isn’t it unethical to deviate from the manual if it is empirically supported?” Her plan before this discussion was simply to comply with supervisory input to follow the manual, but without much hope for its success with this patient.
The questions asked by this psychotherapist-in-training points to several challenges we face as educators and supervisors in the age of evidence-based practice. On the one hand, we need to provide specific training for empirically supported interventions. On the other hand, we need to help therapists develop the conceptual tools necessary to continue integrating research findings into their clinical work, and apply all these skills in a manner that takes into account individual client needs, preferences, and unique context (APA, 2006).

Reflecting our field’s current emphasis, the trainee mentioned above has been taught that empirically supported treatment packages (ESTs) represent the most ethical approach to treatment because of their proven track record in research (cf. Chambless & Crits-Christoph, 2006). She has even been told to steer clear of “non-EST” approaches by some faculty advisors. Given these directives, plus the constraints of time around provision of therapy in graduate training, she has focused almost exclusively on learning ESTs. As a result, she has considerable skill implementing a number of treatment packages for specific disorders, and can cite their empirical basis in randomized control trials (RCTs) with accuracy.

Her skill set as a psychotherapist is still quite limited, however. While she is gaining skill with a few interventions developed for discrete diagnoses, she has received little encouragement to be aware of (much less think integratively about) the broader empirical literature or identify principles that could help her more flexibly generalize and tailor her interventions (e.g., Castonguay & Beutler, 2006). When faced with clients whose needs do not easily fit the molds the models she knows, she is at a loss.

As educators, we should not be pleased with this result. Without additional input, this young psychotherapist will go out into practice with a relatively rigid skill set of limited applicability. The frustration she already feels suggests she is at risk for eventual “burn out” as a practitioner.

Old and new views of evidence based practice

Our trainee’s problems reflect tensions in our field over how best to weigh and apply research evidence. The primary view that has guided this young therapist’s education has held sway for roughly a decade and places emphasis on developing, testing, and disseminating treatment packages for discrete disorders (e.g., Gotham, 2006; McHugh & Barlow, 2010; Kazak et al, 2010). A treatment qualifies as an EST based on successfully replicated, randomized control trial (RCT) studies (multiple single-case studies with strong research controls may also qualify for EST status; Chambless & Hollon, 1998). Lists of ESTs were initially compiled in an attempt to demonstrate that psychosocial treatments produced effects comparable to pharmacological interventions and should therefore receive research funding, training, and reimbursement in the era of managed care (APA Division of Clinical Psychology, 1995). An RCT study answers a single question about psychotherapy very well: “Does therapy X have an effect on disorder Y, if all other factors are controlled?” The information provided by an RCT directly addresses the needs of an administrator overseeing a large system of care who wishes to ensure that “on average” there will be a positive effect if a particular approach is implemented. In an RCT, treatments are usually applied to a single category of disorder by clinicians trained to a high level of adherence. Randomization is used to distribute pre-treatment characteristics such as personality type, age, gender, motivation, and prior treatment experience evenly across groups so that they are unlikely to be responsible for any group differences in outcome. Dissemination of an EST tends to flow logically from the same research design: psychotherapists are trained to adhere to the EST manual and apply it with patients having a particular disorder (McHugh & Barlow, 2010; Kazak et al, 2010), just as in the case of our frustrated trainee.

By contrast, “evidence-based practice of psychology” (EBPP) has been defined by an APA Presidential Task Force (2006) as invoking all available research methodologies and focusing treatment on individual clients:

“It is important to clarify the relation between EBPP and empirically supported treatments (ESTs). EBPP is the more comprehensive concept. ESTs start with a treatment and ask whether it works for a certain disorder or problem under specified circumstances. EBPP starts with the patient and asks what research evidence (including relevant results from RCTs) will assist the psychologist in achieving the best outcome. In addition, ESTs are specific psychological treatments that have been shown to be efficacious in controlled clinical trials, whereas EBPP encompasses a broader range of clinical activities (e.g., psychological assessment, case formulation, therapy relationships). As such, EBPP articulates a decision-making process for integrating multiple streams of research evidence—including but not limited to RCTs—into the intervention process.” (p. 273)

Ultimately, the APA application of EBPP requires a higher standard from therapists and educators, and is likely to be worth the effort if it allows therapists like our trainee to effectively answer the questions she poses and meet the needs of her client. In addition to training with discrete treatment packages and intervention “tool kits,” the most successful therapists will also be prepared with sufficient background and conceptual skills to integrate what is known from across the research literature, combine it with clinical expertise, and apply it in ways that are flexible and responsive to client characteristics.

Skills needed for successful EBPP

The “competencies movement” in psychology seeks to identify the skills and attitudes that need to be acquired for professional development (Fouad et al, 2009; Kaslow et al, 2009). Its focus is comprehensive and sees psychotherapy skill acquisition as unfolding across levels of graduate training and professional practice. Competencies are divided into two broad classes, those that are “functional,” reflecting discrete domains of professional activity (assessment, intervention, consultation, supervision, research/evaluation, supervision, teaching, administration, and advocacy), and those that are “foundational,” cutting across functional domains (professionalism, reflective practice, knowledge of scientific methods and findings, relationship skills, sensitivity to individual differences and cultural diversity, attention to ethical and legal standards and policies, and ability to interface with interdisciplinary systems). We wish to draw particular attention to foundational competencies that involve scientific method and recommend a particular kind of scientifically-minded thinking style vital for evidence based practice.

Scientific-mindedness

By scientific-mindedness, we refer to a clinician’s willingness to engage in a process of inquiry that should involve not just consideration of the empirical literature, but also evidence available directly from clients. Ideally, the process begins with careful assessment that results in an individual case formulation, that is, a set of hypotheses about the sources and maintaining factors associated with an individual’s problems. Interventions are then selected in light of the relevant literature, and in consultation with the patient about his or her needs and preferences. Ongoing evaluation of therapeutic impact then provides data about the effects of the intervention and can lead to flexible modification or a change in course as needed, and in collaboration with the client. Lambert and colleagues (e.g., Slade, Lambert, Harmon, Smart, & Bailey, 2008) provide evidence that feedback from formal, ongoing monitoring of symptom states can improve outcome. To extend this logic, depending on the individual formulation of a client, relevant outcome data may also involve clients’ patterns of thinking, feeling, or relating with others, motivation for change, quality of the in-session relationship, and more. To summarize, the proposition here is that psychotherapists be trained in a manner that leads to primary identity as a clinical scientist whose work places emphasis on generating and testing individual-level hypotheses about change, in a context of collaboration with clients and consultation with the empirical literature.

Critical thinking and integration

Critical thinking involves evaluating logic and weighing evidence. As applied to psychotherapy, it involves the ability to understand and evaluate published research results as well as to accurately assess the circumstances and experiences of individual clients. The complement to critical thinking is integrative ability, which involves being able to pull together different studies, different strands of data, and synthesize them into a specific hypothesis with associated plans of action. Examples of integrative thinking would include pulling assessment data together into a case formulation with clear implications for treatment, detecting areas of overlap and convergence between multiple treatment methods, and using clinical experience to inform treatment decisions. With critical thinking, clinicians learn how to break problems into separate parts, evaluate and analyze underlying logic. Then, using integrative abilities they shuttle in the opposite direction, synthesizing information, generating new hypotheses and possible solutions that respond to unique circumstances. Both skills are needed.

Supervisors and educators can model these thinking skills and invite the same from trainees in concrete ways. For example, problems presented by an individual client could be used to demonstrate and directly apply principles of evidence-based practice. Students could be assigned to scour the empirical database about some aspect of the client’s presentation. The contents of EST manuals and other relevant material would be reviewed with an eye toward finding specific interventions of relevance. Once this review has occurred, the underlying logic and evidentiary base for treatment would be taken into consideration, as would areas of potential convergence across multiple studies or schools of thought. A mindful, collaborative, application of what has been learned would then be applied with the specific case. Optimally, supervisor and trainee would become engaged in an active, collaborative, evidence-based endeavor involving careful assessment, consultation with the empirical literature, hypothesis formation about useful interventions, and systematic evaluation of their impact for an individual case. Three key elements of EBPP are present in the foregoing suggestion: primary focus on the individual through use of case conceptualization methods, active use of the existing evidence-base, and exercise of EBPP as a process of decision-making and empirical inquiry. At first, the training model would be slow and resource intensive, with a great deal of time spent focused on individual cases. With time and practice, the process can be abbreviated and tailored to training needs as clinical skills are effectively practiced and internalized.

Relationship skills and EBPP

One of the more consistent findings in psychotherapy research studies with many different treatments and disorders is that a positive therapeutic relationship correlates with improved outcome (Horvath & Bedi, 2001; Wampold, 2001). Resources are increasingly available to summarize empirical work on the alliance and provide specific training recommendations (e.g., Muran & Barber, 2010; Norcross, 2002). The most studied aspect of the therapeutic relationship is the alliance, which consists of the affective bond between a patient and therapist, as well as their agreement about goals and therapeutic tasks for reaching them. Evidence-based practice may be particularly well-suited to enhance collaboration to the degree that it begins with focus on the individual client, thereby planting the seeds for a strong alliance.

Final comments

The approach outlined here suggests that the curriculum for psychology training needs to include greater emphasis on “foundational” competencies so that skilled intervention is learned and applied in broader context of EBPP. Scientific-mindedness, critical thinking, integrative capacity and relational skills all must be modeled and practiced across the curriculum so that they become part of the language and culture of evidence-based professional practice. We believe that a basic introduction to evidence-based practice should occur from the earliest phases of psychotherapy training, rather than being treated as an ‘advanced topic’ to be learned only after diagnosis-specific interventions and ESTs have been mastered. Perhaps the easiest place to start implementing EBPP in training settings is simply to introduce the APAs definition of evidence-based practice and encourage critical thought and discussion about its elements and implications, as recommended by Levant and Hasan (2008). An edited volume by Norcross, Beutler, and Levant (2006) also provides a related, excellent overview of the issues and challenges our field faces integrating science and practice as the empirical database continues to grow.

Ultimately, our hope for future trainees is that they will continue to push and expand boundaries of our current knowledge, improving client outcomes through a process of active engagement with the evidence-base. 

References

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