Ha! BSWDavid is not going to answer that. He doesn't give a flying crap about the field nor the patients. He is solely interested in justifying his own inability to cut the mustard for a doctoral psychology program by throwing around a concept that he has not even bothered to learn about: empirical data and outcomes assessment. He is content to use the "prove to me that X really matters" argument to make the case that it is not him or any other failed applicant that is the problem, it is the selection criteria that is to blame.
Independent practice for LPAs?
- Thread starter O Gurl
- Start date
Ha! BSWDavid is not going to answer that. He doesn't give a flying crap about the field nor the patients. He is solely interested in justifying his own inability to cut the mustard for a doctoral psychology program by throwing around a concept that he has not even bothered to learn about: empirical data and outcomes assessment. He is content to use the "prove to me that X really matters" argument to make the case that it is not him or any other failed applicant that is the problem, it is the selection criteria that is to blame.
In the end, you have your opinions and that's all that matters to you. Nothing I say or anyone else says will make a difference. If I find evidence to support my claim or refute yours, I am cherry picking. It is clear that most of you have a fear of anything that's different and assume that different = inferior. You have become so wrapped up in your own methods and standards that anything different is threatening.
I have spoken with numerous professors, admissions committee members, etc. who have clearly stated that the GRE is pointless. So an independent program that doesn't have to require the test, doesn't requite it; that doesn't mean they are shooting for the bottom of the barrel. It could very well mean they don't give a crap about the GRE and don't buy into the notion that one standardized test is predictive of graduate success. I think it is quite telling on your part that you believe high GRE scores and conformity to academic tradition equates intellectual and clinical superiority (the top of the barrel), and those of us who select a non-traditional route are at the bottom. I suppose you have to believe this as it appears your self-worth is tied up in the idea that somehow you are special, because you made it into an "elite and selective" group. Please, get over yourselves!! The arrogance is overwhelming...😱
I have spoken with numerous professors, admissions committee members, etc. who have clearly stated that the GRE is pointless. So an independent program that doesn't have to require the test, doesn't requite it; that doesn't mean they are shooting for the bottom of the barrel. It could very well mean they don't give a crap about the GRE and don't buy into the notion that one standardized test is predictive of graduate success. I think it is quite telling on your part that you believe high GRE scores and conformity to academic tradition equates intellectual and clinical superiority (the top of the barrel), and those of us who select a non-traditional route are at the bottom. I suppose you have to believe this as it appears your self-worth is tied up in the idea that somehow you are special, because you made it into an "elite and selective" group. Please, get over yourselves!! The arrogance is overwhelming...😱
You know KayJay, you don't know me, nor do you have any idea what I think. I am not a failed applicant, as I have both the grades and the GRE scores to enter a psych program; the difference is that I chose not to because individuals like you give the profession a bad name. Please, take a hard look in the mirror and ask yourself why you are so driven to discount every statement I make. Clearly, even with the high standards of the psychology program, open mindedness and tact are unimportant. 😎
- Joined
- Jan 30, 2009
- Messages
- 4,218
- Reaction score
- 14
Several unnecessary comments.
Anyway, amount of training in anything corresponding to ability in that thing, regardless of lack of empircal evidence, has very high face validity. Nothing requires a specific curriculum or specific degree to learn and be proficient in. There are multiple routes for anything. Psychologists, however, are currently the "gold standard" for psychotherapy. Why one with a primary desire to become proficient in a psychotherapy would pursue a doctorate in anything other than psychology is confusing to me, particularly when it won't allow the same scope of practice.
- Joined
- Apr 2, 2005
- Messages
- 11,357
- Reaction score
- 21
How about refraining from personal attacks on all sides? Speaking for myself, and probably some others who have been lurking on this thread, seeing the same old arguments rehashed again and again is kind of getting boring. To all those who feel like they're 
, I suggest you stop before you give yourself a virtual concussion.
, I suggest you stop before you give yourself a virtual concussion.
- Joined
- Jan 7, 2010
- Messages
- 9,868
- Reaction score
- 6,983
To bring up a point you mentioned earlier, then, do you happen to have evidence (either for or against) the notion that the program doesn't require the GRE because they don't buy into it, or that it isn't causing them to recruit less-qualified students? That's not meant to be facetious, it's an earnest question.
erg does make a good point that any school which goes against an established trend such as standardized assessment MAY very well be shooting for the "bottom of the barrel." We don't know if that's the case, but it would seem to be the knee-jerk reaction in many people's minds.
Another point erg mentioned is that the GRE is not used in isolation; it is a single data point used to help an admissions committee determine the qualifications of an applicant as a whole. Other information obviously includes GPAs, statements of purpose, letters of recommendation, etc. However, the GRE provides a standardized approach to comparing students in ONE area of potential graduate school performance. To use anecdotal experiences, I personally would say that if a student makes it past their first year or two in graduate school, their chances of finishing the degree program significantly increase (the majority of people I've seen who've left my program have done so in their first three semesters). Thus, to me, a prediction of first-year graduate school GPA could be a very useful piece of information.
There are just as many DCTs and department heads who approve of the GRE as there are those who deride it (actually, given the preponderance of schools that still require it, I would imagine there are likely more who approve than deride). It's not perfect, but it's one useful piece of information.
Additionally, no one has as of yet related the GRE to any measure of clinical success of competence. Neither has anyone specifically derided a "non-traditional route." However, if there is an established path/method of training, then the onus of proving its equivalence or improvement usually falls on the new method. If a GRE-less admissions process, or some non-traditional training route, were shown to be consistently superior to (or at least equivalent with) established methods, I don't know that anyone here would argue against its utility.
How about refraining from personal attacks on all sides? Speaking for myself, and probably some others who have been lurking on this thread, seeing the same old arguments rehashed again and again is kind of getting boring. To all those who feel like they're
I agree. This has gotten too personal therefore I'm done!
- Joined
- Jan 7, 2010
- Messages
- 9,868
- Reaction score
- 6,983
How about refraining from personal attacks on all sides? Speaking for myself, and probably some others who have been lurking on this thread, seeing the same old arguments rehashed again and again is kind of getting boring. To all those who feel like they're
One of the biggest problems in online communication is the complete lack of body language and intonation. What one person might mean as a light-hearted jest or a perfectly neutral statement can be significantly mis-construed, leading to a fairly severe snowballing of negative emotions.
That being said, I agree. We don't all have to be cuddly, get along, or even like each other. However, it's definitely quite possible to make a point while still maintaining some semblance of professional courtesy.
I've said it before, I'll say it again. Why does everyone love Sternberg's work on the GRE so much? I've had several statistics classes actually use it as an example of a poorly done study and/or to illustrate the potential effects of range restriction on correlations.
I posted a meta awhile back that showed it was linked to a number of positive outcomes. That study is not without flaw either, but its a significant improvement over Sternberg. Yes, we can argue about the relative effect size...however pointing out the amount of variance it predicts isn't useful without telling us how much variance other factors predict, unless the argument is for open admissions (which I'm not convinced is far away from what some people here seem to expect/want....though not necessarily within this thread).
Frankly, I think its telling about why its important to look at prediction of more than just clinical outcomes. I'm clearly heavy on the research side, but I think its a great illustration of why extensive research training is important even for the clinically-inclined...because the problems with the Sternberg study should be immediately obvious to anyone who has taken stats. Without research training...people might mistakenly read more into the Sternberg paper than what it really says. Which is "Among students who did very well on the GRE, and/or had otherwise exceptional credentials allowing them entrance into one of the top universities in the world, portions of the GRE were still able to predict outcome in some circumstances".
I posted a meta awhile back that showed it was linked to a number of positive outcomes. That study is not without flaw either, but its a significant improvement over Sternberg. Yes, we can argue about the relative effect size...however pointing out the amount of variance it predicts isn't useful without telling us how much variance other factors predict, unless the argument is for open admissions (which I'm not convinced is far away from what some people here seem to expect/want....though not necessarily within this thread).
Frankly, I think its telling about why its important to look at prediction of more than just clinical outcomes. I'm clearly heavy on the research side, but I think its a great illustration of why extensive research training is important even for the clinically-inclined...because the problems with the Sternberg study should be immediately obvious to anyone who has taken stats. Without research training...people might mistakenly read more into the Sternberg paper than what it really says. Which is "Among students who did very well on the GRE, and/or had otherwise exceptional credentials allowing them entrance into one of the top universities in the world, portions of the GRE were still able to predict outcome in some circumstances".
I will admit, I am not well versed in stats, which is one of the downsides of social work. Another reason why I am attending a PhD program.
- Joined
- Feb 10, 2008
- Messages
- 8,316
- Reaction score
- 8,870
That's kind of one of our points: how can you really know what treatments to implement if you can't critically analyze research?
And the desire to do so is admirable, but its important to acknowledge that a little knowledge can be a dangerous thing. Interpretation of a research article by someone well-versed in stats/methodology often leads to vastly different conclusions than interpretations by someone without that background...just look to the news outlets to see things getting botched left and right. There's a reason researchers often feel torn about the popular press picking up their findings🙂
I hate to call you out on this since frankly, that has already derailed this thread a bit too much, but I feel the same way about many of the articles you have posted regarding the evidence base for psychodynamic practice. My read of many of those articles is likely very different from yours...and clinical outcome research isn't even my focus so I'm not as capable of picking apart the methodology as many others would be. Many of the articles that frequently get tossed around on this board (and you are FAR from the only one guilty of this) to support those views have some pretty serious flaws. One of the favorites here (can't remember if you or someone else posted it) actually calculated their effect sizes wrong, resulting in an effect size that was nearly double what it should have been. I think seeing that thread along with this one, may be contributing to what has a lot of people up in arms about your posting. Many of us have pretty extensive research training, and these are the things that drive us crazy about the scientific literature...seeing people argue vehemently while using research to back up their claim can be extremely frustrating when the person using the research, at least from our perspective, appears to not either not have actually read the articles, or not have enough of a background to truly understand them.
No doubt this is a problem, in general, with MSW programs. I do hope to rectify that with a PhD.
- Joined
- Apr 6, 2007
- Messages
- 10,827
- Reaction score
- 5,612
Ok, so its just a great coincidence that these program just so happen to all be independent/professional (often profit driven) schools such as Alliant, Argosy, etc. who also have many other well-known indicators of low admissions standards? You really think its because they think the GRE is worthless? Really? Come on, dude. Wake up! Let me know when Yale, or even the the University of Anystate drops the GRE... and then I might buy into your argument. 🙄
Again, please please understand what we are saying with regards to preponderance of studies/evidence supporting the GRE for its predictive ability. Its there. Its real. There are outliers such as the studies you pulled from your Google search today. But the Line of best fit hasnt moved much because of them. Do you get what we are saying? You can think the GRE is bunk all you want, but it is what it is. Let it be, let it be...
Last edited:
- Joined
- Jan 30, 2009
- Messages
- 4,218
- Reaction score
- 14
Just as a point if interest, wake forest school of medicine doesn't require an mcat score for application through it's early assurance (apply early jr yr) program. It's reputed to be incredibly competitive however.
- Joined
- Jan 30, 2009
- Messages
- 4,218
- Reaction score
- 14
that's interesting - I take it it would be a bit optimistic to assume mechanism has been researched?
- Joined
- Oct 16, 2001
- Messages
- 2,871
- Reaction score
- 1,009
I agree it's essential. I disagree that everyone does it. Professionals trust their mentors, and if your mentor tells you something is evidence based, you're less likely to pore through the literature in every step of your education. Did all the psychology students here read ALL of the original foundation articles before they started learning any CBT? Be honest.
The truth is that we're busy professionals, and critically ripping apart articles (which I love to do) takes time. So it's not done much with established treatments, unless you get curious about something or are writing a review article.
I personally apply it for new literature. Have to be able to tease out the hype from the science.
Sorry, guys, but I am reserving my empathy and concern for those who are getting the raw end of the deal from people who are hell bent on bucking the system in lieu of their own self-focused needs.
Did BSWDavid answer Erg923's question? Did he answer how more stringent licensing standards for all therapists could in any way hurt patients? Has he made any comment on the potential effect of more rigorous standards on the field or the patients at all? Nearly every response has been in defense of the non-traditional psychology route and the people who choose it. Of course this is purely circumstantial but it is not far-fetched for me to imagine someone getting the master's level degree and then pursuing the least painful doctorate degree possible (no GRE, no dissertation, etc.) and henceforth never, ever, ever neglecting to advertise as Dr. Thus-and-So in private practice. True, they have a doctorate, so it is not illegal at all and in the eyes of the public, a Dr. of Psychoanalytic Therapy is no different than a clinical or counseling or school psychologist. But when you all come across things like this:
http://forums.studentdoctor.net/showthread.php?t=778835
Where a concerned provider outs someone who is misrepresenting their credentials or find yourselves having to work tirelessly to validate that you actually did take the time after undergrad to study for the GRE and gain research experience and in many cases applied several times to gain admission to a doctoral program, complete an established and accredited grad program, complete a thesis/dissertation, compete nationally for an accredited internship, secure a postdoc, and jumped through the hurdles for licensure (EPPP/orals) and credentialing, I sure hope you remember to "not get too personal".
Did BSWDavid answer Erg923's question? Did he answer how more stringent licensing standards for all therapists could in any way hurt patients? Has he made any comment on the potential effect of more rigorous standards on the field or the patients at all? Nearly every response has been in defense of the non-traditional psychology route and the people who choose it. Of course this is purely circumstantial but it is not far-fetched for me to imagine someone getting the master's level degree and then pursuing the least painful doctorate degree possible (no GRE, no dissertation, etc.) and henceforth never, ever, ever neglecting to advertise as Dr. Thus-and-So in private practice. True, they have a doctorate, so it is not illegal at all and in the eyes of the public, a Dr. of Psychoanalytic Therapy is no different than a clinical or counseling or school psychologist. But when you all come across things like this:
http://forums.studentdoctor.net/showthread.php?t=778835
Where a concerned provider outs someone who is misrepresenting their credentials or find yourselves having to work tirelessly to validate that you actually did take the time after undergrad to study for the GRE and gain research experience and in many cases applied several times to gain admission to a doctoral program, complete an established and accredited grad program, complete a thesis/dissertation, compete nationally for an accredited internship, secure a postdoc, and jumped through the hurdles for licensure (EPPP/orals) and credentialing, I sure hope you remember to "not get too personal".
Last edited:
Actually, my program does require a dissertation.
- Joined
- Jan 30, 2009
- Messages
- 4,218
- Reaction score
- 14
Whether or not my perspective is (un)colored by my lack of going through the rigors isn't really relevant. Character demeaning isn't going to accomplish anything you have in mind, unless character demeaning was your sole goal. Based on what David has posted, it would take a larger leap to assume he doesn't care about patients than it would to assume other things.
Character demeaning? I will own that and apologize for it. I have no way of knowing his or anyone's intent. That said, piece mealing a path to practice therapy with the ever-amorphous title of "Dr" raises concerns in my mind. I do wonder, why not a certification from a psychoanalytic institute if that is an area of particular interest? A novel/little known PhD? Ignoring concerns raised about the content, quality, or actual benefit of the pursuit? I just don't know.
- Joined
- Oct 16, 2001
- Messages
- 2,871
- Reaction score
- 1,009
That's...just...mean.
I'm with Love of Organic on this one. BSWDavid obviously cares or he wouldn't be here debating about the evidence in patient outcome.
While the internet is a nice bastion of anonymity, crushing your opponents to death in the process never helps your cause.
To paraphrase Jon Stewart -- Americans have trouble recognizing the difference between opponents and enemies. Those on the other side of politics are opponents. Terrorists are enemies. You shouldn't cultivate a drive to destroy both. Some say cultivating the drive to destroy any at all is unhelpful.
KayJay hasn't actually revealed his/her training status, and I'd be curious.
I must confess that part of what originally bothered me was the suggestion that masters level clinicians are putting their clients at harm. I do care for my patients/clients a great deal, which is why I have chosen this field. I agree that it would be nice if we could refrain from assuming the values/ethics of individuals we don't really know (me included). In the end, we each have different opinions, values, and interests that send us in different directions. My hope is that we can learn to learn from one another, and leave the insults on the playground where they belong. On a positive note, I have learned a lot from this rather heated discussion, and I thank each of you for helping me to understand the bigger picture. In the end, whether I agree with your positions or not, I respect the amount of passion, integrity, and intellect that has been exemplified throughout this thread, and wish you all the best of luck in your future endeavors.
3rd year clinical psych trainee with clinical interests in eating disorders, trauma, and substance dependence and research interest in pharmacotherapies for opiate dependence.
I am not exactly sure what you mean about "piece mealing". Certification is an option, which I have considered, however, the cost is quite high without the ability to utilize student loans. Additionally, I felt it necessary to get the extra research training which will be undoubtedly useful in practice. I also would like to teach in clinical MSW programs, or even become a professor in the future, which a PhD will allow. If I can utilize my psychoanalytic training and add a research component in order to obtain a PhD, why not? It may open up a lot of doors that an MSW cannot.
Last edited:
I am referring to the path less traveled. I cannot say out right that ICSW is trouble, but there are huge red flags. We've already talked bout the admissions standards, cost, and emphasis in a modality that is traditionally not considered evidenced-based or easy to get reimbursed for in many settings. Beyond that, my very surface understanding of DSW and PhDs in social work is that the goal is to increase training in research and policy and prepare graduates for academic endeavors. There can be huge limitations to training outside of a university setting and then transitioning to work in academia. Perhaps that is why so many of the ICSW faculty are teaching there as opposed to other settings. Also, from a review of their materials, it is not quite clear how research practicum and dissertations are supported. Are they affiliated with a nearby university that has active research? Where do the samples come from? How do the distance learning students meet this requirement? Not to oversimplify, why not follow the established path? Your investment in time and money will be virtually the same. I do not know how funding works at traditional DSW/PhD social work programs or the exact cost of psychoanalytic training, but $16,500/year minus funding for 4 years certainly is not cheap.
I think one of the reasons so many of ICSW's graduates teach there is because there aren't too many psychodynamically oriented swk PhD programs. I would imagine they have a difficult time recruiting faculty given the limited number of social work psychoanalysts available. I also know that the institute is affiliated with Robert Morris University in Chicago (they are actually located in their building), and ICSW students have access to Robert Morris research and technology facilities. I honestly don't know the answers to the rest of your questions, but for my own sake, I will find out.
One extra point regarding ICSW, I have taken a look at their alumni biographies and of those who are teaching or involved in academia, most are doing so at ICSW (already discussed) and among those not involved in teaching, most appear to be in private practice. So I just started Google searching some of them and low and behold, I am now up to 6 alumni who are advertised as PhD therapists. Again, I don't think this is illegal as they are graduates of a PhD program. However, their PhD is non-license eligible and does not in any practical way elevate their license beyond the LCSW level. Still, the "Dr" aspect is in full play in their advertisements. Seriously, how does a patient in the greater Chicago area read:
"John Doe, PhD, psychotherapist at [insert practice]"
and know the difference between Dr. Doe and the licensed psychologist at the practice across the street? How do they know that Dr. Doe and Ms. Jones, LCSW (who is accurately presenting her credentials in her ads) are actually at the same level of clinical training?
In my brief search I have found at least one ICSW alumnus listed this way on LinkedIn, Healthgrades, and TherapistLocator. I will not provide their names out of respect for their privacy, but if anyone wants to take the time, you can search for a few from http://www.icsw.edu/alumni/biographies.php
"John Doe, PhD, psychotherapist at [insert practice]"
and know the difference between Dr. Doe and the licensed psychologist at the practice across the street? How do they know that Dr. Doe and Ms. Jones, LCSW (who is accurately presenting her credentials in her ads) are actually at the same level of clinical training?
In my brief search I have found at least one ICSW alumnus listed this way on LinkedIn, Healthgrades, and TherapistLocator. I will not provide their names out of respect for their privacy, but if anyone wants to take the time, you can search for a few from http://www.icsw.edu/alumni/biographies.php
Last edited:
So your argument is that because someone isn't a psychologist, they shouldn't advertise as a "doctor"? They have a doctorate degree, they can use it. If a psychologist walks into a hospital and introduces himself as doctor how does the patient know the psychologist isn't in fact a medical doctor and assume they are at the same level of practice? When did doctor become synonymous with psychologist? As long as a practitioner clearly states his or her licensure credentials after their name, I see no problem.
Do you honestly think that most individuals are going to see doctor and assume the individual is a psychologist? Most don't even understand the practical difference between psychologist, psychiatrist, or social worker.
Last edited:
Whether the doctorate degree elevates the individual's license or not doesn't mean it doesn't signify that the practitioner has an advanced level of training beyond the MSW. What about a psychologist or medical doctor that hasn't become licensed yet? Does that mean they shouldn't use the term doctor until they are licensed ( as you are saying that the term doctor is only appropriate if the individual is licensed at the doctoral level). In fact, in most states, the requirement to apply for an LCSW is that an individual holds a doctorate or an MSW from a CSWE approved program.
Last edited:
- Joined
- Jan 7, 2010
- Messages
- 9,868
- Reaction score
- 6,983
I don't think KayJay takes issue with the person's use of the term "doctor," and I believe as much is said in an earlier post. I think the issue is that it might mislead patients into believing that the individual is trained or licensed in a way that they are not. Now, in this case, the ICSW graduates are not doing that--they are doctorally-trained in psychodynamic therapy, and advertise themselves as doctoral psychotherapists. I would prefer to see that they also mention that they are licensed as clinical social workers for full disclosure, but I don't believe that is required by law.
I believe KayJay's example could be further exemplified if a master's-level obtained, for whatever reason, a Ph.D. in something like graph theory or English literature, and then advertised themselves as "John Doe, Ph.D., psychotherapist." It's still not false, but it could definitely be misleading, as his/her Ph.D. has nothing to do with the treatment of patients. At least in the case of the ICSW graduates, their degrees are related to therapy.
As for the psychologist-in-a-hospital example, it happens to my colleagues and I all the time. My supervisor's coat has "Dr. XXXXX, Ph.D." embroidered on it for that reason. I've, on numerous occasions and in the interests of full disclosure, informed patients who referred to me as "Dr. XXXX" that 1) I am graduate student and not yet a doctor, and 2) I am training in psychology and not medicine.
Well, at least these PhDs actually earned a doctorate arguably relevant to their clinical scope of practice. On the other hand, not directly advertising that their PhD is in Social Work is a little misleading - but it's much harder, probably, to make the argument that sort of thing is unethical.
- Joined
- Oct 7, 2006
- Messages
- 22,770
- Reaction score
- 5,198
It is a slippery slope though....what about a degree in some fringe area of loosely related practice are with no license eligibility?
I don't think stating you are Dr. is misleading. Of course, if you don't explain "doctor of" then certainly it could be misleading, but that is the case with any doctorate, including psychology. All the PhD social workers I know state John Doe, PhD, LCSW. I don't think there is anything misleading about that. However, I would be less inclined if, for example, I had a PhD in American History - then I don't think it makes a lot of practical sense - I guess it is all about context. We certainly have to be careful as the average Joe equates doctor with physician, but as long as you are clear about your role, I see no harm. After all, a Phd, by definition, is an academic degree, regardless of profession. But using it appropriately is key. Hence, why one should always include their licensure initials. Personally, I think using Phd out of context is tacky, but I feel the same way about MD or DO as well. I think part of being a good therapist is explaining to new clients who you are, what your credentials are, what your scope of practice is, etc. Too often we assume clients/patients understand the distinctions between degrees, titles, licenses, etc., but more times that not, they really have no clue. In the end, I don't think clients care a lot about titles; they care about your ability to listen, show empathy, and understand their problems.
If I refer to myself as Dr. John Doe, PhD, Licensed Clinical Social Worker, what is misleading? I'm not stating or implying that I am a medical doctor, and I have clearly identified my title - so where is the confusion? Regardless of whether or not the PhD lead to a license doesn't matter. I would argue that a PhD in clinical social work is relevant to the individual's practice. It clearly signifies an advanced level of knowledge that the individual has indeed achieved.
However, I have read that proper etiquette dictates that using both Dr. and PhD together is incorrect. In other words, the "doctor" part is implied in the PhD, therefore, placing Dr. before your name is redundant. So you would instead state John Doe, PhD, LCSW, or HSPP, or whatever...
- Joined
- Jul 29, 2010
- Messages
- 671
- Reaction score
- 21
And getting better. I'm not trying to be facetious. A therapist that is skilled at assessment is able to identify the most likely areas of intervention and is able to actually keep tabs on whether therapy is producing objective change. A therapist that is well-versed in more than one approach is able to tailor the therapy to the individual. A therapist who understands broader principles of mental health is able to attack a problem from more angles (developmental, cognitive, physiological, family systems). Depending on what the presenting problem is, a therapist that stays abreast of and contributes to the literature is aware of newer alternatives. Even if these variables are not a major factor in selecting a provider, I imagine they are the underlying reasons for staying with one.
Yes getting better is important; I wasn't referring to goals per say, but more to the therapeutic alliance.
Wow, I wasn't trying to argue. I thought we were having a civilized conversation and I was giving my perspective. If anything, I think the "jumping on every comment" as come from the other side (i.e. every comment or point I have made has been devalued or challenged in some form).
- Joined
- Jul 29, 2010
- Messages
- 671
- Reaction score
- 21
I would say that being an empathetic, good listener is not even important in some cases. Does a borderline patient need that? Is that the ideal rapport/alliance to approach DBT? I'd say no. Really, the goal is to get better/improve functioning. But that is my hard-edged, non-fuzzy, outcomes-focused opinion.
- Joined
- Oct 16, 2001
- Messages
- 2,871
- Reaction score
- 1,009
Ah but how many patients will follow your instructions if you don't have a treatment alliance with them, regardless of how well versed in DBT you are. And showing some level of empathy (at appropriate times) can be part of achieving that.
I can't help but notice the ongoing position of opposition rather than discussion going on here.
- Joined
- Apr 6, 2007
- Messages
- 10,827
- Reaction score
- 5,612
Huh? I cant tell you how many times patients have told me that they didn't go back to a therapist, despite still being depressed (or symptomatic or whatever), simply because this person was not very good with them interpersonally (not friendly, not warm, "too clinical", too structured, too dogmatic, etc). Relationship is VERY, VERY important. Even the most disturbed of folks will not cooperate optimally, and possibly not even come back if they dont "like" being around you for an hour.
I dont if there's any research to support your statement and I know there is a plethora of research supporting how powerful the relationship is (ie., how much variance it accounts for) in the context of the therapeutic relationship. You might wanna reread Rogers 1957 classic "The Necessary and Sufficient Conditions for Therapeutic Personality Change" as well.
Last edited:
- Joined
- Feb 10, 2008
- Messages
- 8,316
- Reaction score
- 8,870
There's actually a study that showed people who found their therapists to be warm and empathetic had greater improvement on the BDI after cognitive therapy for depression.
- Joined
- Apr 6, 2007
- Messages
- 10,827
- Reaction score
- 5,612
That kinda makes me cringe and I think thats a great example of diagnosis getting in the way of the human...as well as the clinical work that might need to be done. I really cant advocate not listening to your patient and/or blindly plowing through DBT modules because that what their diganosis says they need. In some cases, you might be the only one who really listens to them. They might really need that, despite the interpersonal turmoil/splitting they often turn that into outside the therapy room. Dont lose the person in quest for "outcome."
Last edited:
- Joined
- Apr 6, 2007
- Messages
- 10,827
- Reaction score
- 5,612
Yea, well "ineffective treatment" can be different for different people. Some people like highly structured CBT. And with a good relationship, the literature tells us it has a good chance of working. However, some patients may hate that kind of thing. Thus, an effective treatment in the literature become an ineffective treatment with that particular client. The more you do therapy, I think the more one realizes that the patient's "theoretical orientation" and expectations often guide what is actually effective for them, not yours.
- Joined
- Jan 7, 2010
- Messages
- 9,868
- Reaction score
- 6,983
I think a key point to make is that treatments can be ineffective for various reasons. Perhaps the therapist is unskilled, the client doesn't "buy into it," or the original conceptualization was incorrect or incomplete. I would definitely agree, though, that a solid therapeutic relationship with the client can both increase his/her likelihood of earnestly adhering to the treatment, while also increasing the chance that he/she will stick around after an initial failure or stall for a reconceptualized and redirected treatment.
This is what I had in mind as well. Certainly, what constitutes a therapeutic alliance is different with each client, and it is important to meet individuals where they are and to provide the structure that's best for their personality; however, if a client doesn't come back or drops out prematurely due to the lack of alliance with the therapist, treatment has failed, regardless of all other variables. I need to recheck the literature, but I believe around 3 sessions is the average span of treatment for most clients. To me, this suggests we have some work to do!
From my initial scan of the literature, here is one meta-analysis suggesting a moderate correlation between therapeutic alliance and dropout rate.
This meta-analytic review of 11 studies examined the relationship between psy- chotherapy dropout and therapeutic alliance in adult individual psychother- apy. Results of the meta-analysis dem- onstrate a moderately strong relation- ship between psychotherapy dropout and therapeutic alliance (d 􏰀 .55). Findings indicate that clients with weaker therapeutic alliance are more likely to drop out of psychotherapy. The meta-analysis included a total of 1,301 participants, with an average of 118 participants per study, a standard devi- ation of 115 participants, and a range from 20 to 451 participants per study.
Sharf, J., Primavera, L. H., & Diener, M. J. (2010). Dropout and therapeutic alliance: A meta-analysis of adult individual psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 47(4), 637-645. doi:10.1037/a0021175
This meta-analytic review of 11 studies examined the relationship between psy- chotherapy dropout and therapeutic alliance in adult individual psychother- apy. Results of the meta-analysis dem- onstrate a moderately strong relation- ship between psychotherapy dropout and therapeutic alliance (d 􏰀 .55). Findings indicate that clients with weaker therapeutic alliance are more likely to drop out of psychotherapy. The meta-analysis included a total of 1,301 participants, with an average of 118 participants per study, a standard devi- ation of 115 participants, and a range from 20 to 451 participants per study.
Sharf, J., Primavera, L. H., & Diener, M. J. (2010). Dropout and therapeutic alliance: A meta-analysis of adult individual psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 47(4), 637-645. doi:10.1037/a0021175
Evidence suggests that 60-75% of patients drop out before the eighth session (Rau, 1989).
Rau, F. (1989). Length and stay in therapy: Myths and reality. Paper presented at the annual convention of he California State Psychological Association, San Francisco.
Rau, F. (1989). Length and stay in therapy: Myths and reality. Paper presented at the annual convention of he California State Psychological Association, San Francisco.
- Joined
- Jan 7, 2010
- Messages
- 9,868
- Reaction score
- 6,983
This was before many of the shorter and more manualized treatments had really started to gain widespread and secure footing in the majority of practitioners' offices, but I wouldn't be surprised if those numbers were at least somewhat similar to today's.
However, I think it's also important to remember that this can vary HIGHLY by setting, and even more so if you erroneously include individuals whose therapy course was originally proposed to be finished in fewer than eight sessions (e.g., those in one-session phobia treatment) in that data. For example, I'd imagine that attrition rates are MUCH higher at the indigent care hospital where I work vs. the campus psych clinic or a private practice office. I would also imagine that attrition rates could be affected by the type of therapy employed.
But yes, I would make the argument that your ability to establish and build rapport with clients can significantly affect various components of assessment and therapy (such as their willingness to sit around and attempt to give you their best effort for 6-8 hours of neuropsych/psychoed testing).
Last edited:
- Joined
- Jul 29, 2010
- Messages
- 671
- Reaction score
- 21
Yes. Reading that comment on its own would make anyone cringe. Much like walking through the door in the middle of a conversation and simply hearing: "I could have strangled him." That is the beauty of a context.
I was responding to the idea that
My general stance toward therapy is that my job is to help the person produce the changes in their life and functioning that he/she wants to make. I never want to find myself in a situation where a patient is coming back primarily because I am nice and I listen to them (read: billing for friendship). If that is the critical issue for them (lack of a support system) then my job is to help them address the interpersonal problems that are preventing them from having close relationships—not to substitute for them.
So, I used the case of a BPD patient, who 9 times out of 10 is in your office because they are unintentionally wreaking havoc on everything around them. In those cases, my approach to building alliance is wildly different than say, a person with PTSD. I have one guy right now who has been in therapy for the better part of the last 10-15 years of his life with various providers and is still a mess. My strong belief is that he is still in therapy because no therapist has kicked his ass yet. If given an inch, he takes not a yard, but a mile. I squeezed him in for a full session when he came 30-40 minutes late, he then came late the next 3 sessions with a different tale of woe as to what went wrong in his schedule. I stayed on the phone with him for his first crisis call for 10-15 minutes, and he started trying to get his therapy over the phone. The treatment goals now are establishing boundaries, teaching him to assert control over his own life, and teaching effective communication. He comes 40 minutes late for a 60 minute session, he gets 20. All phone calls are limited to 3 minutes and then I have a patient/meeting to get to. Sessions are now not driven by his crisis of the week. Quite frankly, I am humming show tunes in my head when he launches into stories about what the new chick has done and how women can't be trusted and blah, blah, blah. Once he has gotten enough out of his system, we redirect back to his response to the problem—never losing the fact that he can have some control over the chaos. Now we are engaging in therapy.
I am not an advocate for being mean and cold. My point is that there are times where taking the empathetic listener approach is simply not going to do much for therapy.
