Theoretical Orientation crisis on internship

[FreudianSlippers]

I have no idea the responses i'll get to this, but it is something I have wanted to post here for a while. Long story short, I was trained heavily in the evidence-based CBT-behavioral traditions during graduate school. Currently I am on my internship at a counseling center, and I have been doing more research into common factors (e.g. Bruce Wampold's work)...and it has kind of been blowing my mind.

For the longest time I considered therapists who don't use Evidenced Based Treatments like CBT, exposure, behavioral activation to be not practicing to the best "gold standard." However, I'm not quite sure what to think of now. I'm really curious of thoughts about the more common factors approach and whether or not CBT is all that it says it is.

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[traumamama]

Look at interpersonal integrative theory

 

[calimich]

IMO, you're in a good spot and exhibiting intellectual maturity. Maintain an open mind, question what you've been taught, search for your own answers.

Having our mind blown from time to time can be wonderful!

also, I really like Teyber "Interpersonal process in therapy: An integrative model"

 

[erg923]

I have no idea the responses i'll get to this, but it is something I have wanted to post here for a while. Long story short, I was trained heavily in the evidence-based CBT-behavioral traditions during graduate school. Currently I am on my internship at a counseling center, and I have been doing more research into common factors (e.g. Bruce Wampold's work)...and it has kind of been blowing my mind.

For the longest time I considered therapists who don't use Evidenced Based Treatments like CBT, exposure, behavioral activation to be not practicing to the best "gold standard." However, I'm not quite sure what to think of now. I'm really curious of thoughts about the more common factors approach and whether or not CBT is all that it says it is.

It is, and its not. Mainly because it may or not be for the patient in front of you (their beliefs, commitment to tx, cognitive resources, degree of psychological insight, etc). Common factors are included within any CBT protocol.

Making someone feel validated and/or feel heard helps and feels good in the moment, but is unlikely to reduce most any symptoms of combat PTSD, for example.

 

[FreudianSlippers]

Look at interpersonal integrative theory

Thanks for the recommendation, I will check it out

 

[FreudianSlippers]

IMO, you're in a good spot and exhibiting intellectual maturity. Maintain an open mind, question what you've been taught, search for your own answers.

Having our mind blown from time to time can be wonderful!

also, I really like Teyber "Interpersonal process in therapy: An integrative model"

Thanks for the encouraging words I will definitely check it out...might be an early holiday present to myself

 

[Groupthink]

My guiding principle is: what will be the most cost- and time-effective method of achieving your goals?

If a client meets the criteria for Specific Phobia, and their goal is to reduce their symptoms, I would be remiss to rely only on "common factors" and hope that reflective listening is going to magically treat a lifelong fear.

However, there are hundreds of clients you will treat across your lifespan who will not fit into a diagnostic category. Take the student who is overachieving in her classes yet has this vague sense of being "unwell", high motivation but cries at random, seemingly has a healthy lifestyle yet has nightmares, and maintains a history of poor relationships.

No thought record or mastery-pleasure worksheet is going to challenge that existential feeling, that drive to seek more satisfaction out of life, to pair bond, to find meaning in a realm of infinite possibility.

The process of being heard, building insight into how one functions within family/academic/workplace systems, and reflecting on how one participates in the here-and-now working alliance: that is what empowers clients to make decisions in their life, and can serve as preventative factors for future mental health diagnoses.

CBT is a wonderful, effective, and often brief approach for mental disorders. And then there is the rest of life, where not all of us have a healthy parent or a guiding mentor to teach us how to simply live.

 

[deleted343839]

Put some time and effort into your case formulations up front and monitor your treatment outcomes accordingly, whether or not you use EBTs. Every patient is a single case study, regardless of your orientation.

 

[PsyDr]

@FreudianSlippers You might find it interesting to reread Dollard and Miller, and read Functional Analytic Psychotherapy books. In practice, the latter looks like psychoanalytic psychotherapy but is based upon behavioralism.

 

[foreverbull]

Interesting when that happens!

All theoretical approaches lead to positive outcomes (Wampold's Great Psychotherapy Debate if you want to read it), and common factors are part of that success.

I think where it gets nuanced is treatments for specific disorders.

But for sure, I echo reading Teyber's book if you're interested in how to develop competence in using the relationship directly to support healing and growth for clients. It really can be mind-blowing!

 

[erg923]

"My views (like the world) are complex and cannot be neatly subsumed under some simple-minded undergraduate rubric (e.g., behavioristic, Freudian, actuarial, positivist, hereditarian)."

-Paul E. Mehl, 1973

 

[Fan_of_Meehl]

I have no idea the responses i'll get to this, but it is something I have wanted to post here for a while. Long story short, I was trained heavily in the evidence-based CBT-behavioral traditions during graduate school. Currently I am on my internship at a counseling center, and I have been doing more research into common factors (e.g. Bruce Wampold's work)...and it has kind of been blowing my mind.

For the longest time I considered therapists who don't use Evidenced Based Treatments like CBT, exposure, behavioral activation to be not practicing to the best "gold standard." However, I'm not quite sure what to think of now. I'm really curious of thoughts about the more common factors approach and whether or not CBT is all that it says it is.

Absolutely keep an open mind as you progress through your career. I would recommend getting all of the structured (up to protocol) therapy training you can, it's good stuff. However, if you look at the history of the field (including the development, rise, and fall of various 'schools' of psychotherapy), you'll realize that we haven't discovered any sort of realized perfection that won't evolve into something else entirely as the decades pass. I was well-trained in behavioral theories/methods/protocols (including exposure-based paradigms for anxiety disorders) as well as general (Beckian) cognitive therapy and, of course, the cognitive-behavioral approach to case formulation and treatment planning (which is highly flexible and applicable to a wide range of diagnoses and clinical problems). However, I've also found a lot of value in learning from other therapeutic traditions including motivational interviewing, mindfulness/acceptance, interpersonal, and--heck--even some Jungian stuff, recently (original writings, not the paragraph or two that is covered in general course textbooks). I have found the alternative (especially Jungian) material helpful in trying to join with veterans to make sense of some of the destructive, dark, irrational, and chaotic elements of their lives (as they deal with PTSD, substance abuse, depression/suicidality, relationship problems, existential crises and what, to me, seems like an 'adult developmental disorder'-type presentation that is common in post-deployment and return stateside). I have found that it's best to be flexible with them and provide the degree of therapeutic structure that they are willing to tolerate at that point (some can be plugged straight into a cognitive processing therapy protocol starting second session and do great, others tolerate lower levels of structure/assignments). Although I consider myself primarily mainline cognitive-behavioral in my orientation, I have found that training/reading from various other sources has been helpful in not feeling compelled to pull away from the largely irrational elements of my client's presentations or to respond negatively (inwardly) when they passively resist therapeutic structure, goal-setting, or assignments (motivational interviewing training has been extremely helpful in this regard, also). There are few things more intellectually or emotionally demanding than trying to utilize evidence-based principles in a flexible and customized manner to help an individual client with a complex history and who is struggling with many separate (sometimes arbitrary and conflicting) emotional impulses from moment-to-moment. And, I'm sorry, but what we do is a heck of a lot more complicated than simply following a session-by-session recipe in 100% of our therapy cases. You don't do therapy 'to' a client. If it isn't collaborative, authentic, and flexible...then it ain't really therapy (I don't believe). Again, though, some people do wonderfully when plugged into a protocol, it's just not the only approach you can or have to take.

 

[calimich]

woah, are we all agreeing?

 

[psych1420]

I have no idea the responses i'll get to this, but it is something I have wanted to post here for a while. Long story short, I was trained heavily in the evidence-based CBT-behavioral traditions during graduate school. Currently I am on my internship at a counseling center, and I have been doing more research into common factors (e.g. Bruce Wampold's work)...and it has kind of been blowing my mind.

For the longest time I considered therapists who don't use Evidenced Based Treatments like CBT, exposure, behavioral activation to be not practicing to the best "gold standard." However, I'm not quite sure what to think of now. I'm really curious of thoughts about the more common factors approach and whether or not CBT is all that it says it is.

Really nice to hear someone else also thinking about this. I'm also on internship and have been having similar concerns....I ordered this book through my school interlibrary loan and it was very helpful. Published in 2017 by APA: How and Why Are Some Therapists Better Than Others?: Understanding Therapist Effects

 

[Sanman]

Rethink your question, CBT and the like is the gold standard for what? Skills in these modalities are like tools, you will vary in your level of expertise using them and master of the craft knows when to pull each tool out of the bag and use it appropriately. A hammer works better than a screwdriver for driving in a nail, but any tool is better than using your hands. That is what all tools have in common.

Now, insurance or whatever form of payment is utilized dictates the tool used and the quality of the work. Is your goal to treat a specific issue, generalized concens, parental wounds, or existential crisis?

 

[Fan_of_Meehl]

Rethink your question, CBT and the like is the gold standard for what? Skills in these modalities are like tools, you will vary in your level of expertise using them and master of the craft knows when to pull each tool out of the bag and use it appropriately. A hammer works better than a screwdriver for driving in a nail, but any tool is better than using your hands. That is what all tools have in common.

Now, insurance or whatever form of payment is utilized dictates the tool used and the quality of the work. Is your goal to treat a specific issue, generalized concens, parental wounds, or existential crisis?

I would also recommend that today's interns supplement their CBT readings (of the more modern material/authors) with some of the older books and articles from the 1960s - 1990s such as books by Aaron Beck, Michael Mahoney, Donald Meichenbaum and the like. I find that these earlier writings are a bit more theoretically rich, complex, integrative, and nuanced than most of the modern stuff, which can be a bit technique/worksheet-heavy and theory-light.

 

[cara susanna]

I love EBPs but I think there is a limitation to them. Sometimes patients won't adhere to them or, like others were saying, they don't fit into a neat box. I think that PE is a great example. PE works really well--if you can get a patient to do it. Many refuse or drop out. So what are we supposed to do, not offer them anything?

 

[Fan_of_Meehl]

Sadly, very few VA administrative-types (even those who supposedly know what they're doing in 'mental health') will acknowledge that it's possible to do 'evidence-based' psychotherapy outside of a session-by-session (every agenda scripted out) protocol. It's how the vast majority of international experts on cognitive and behavioral therapy (you know, the likes of Judith Beck, David Barlow, Jesse Wright, Jackie Persons, etc.) actually conduct professional psychotherapy. They do an intake, basic solid differential diagnosis, maybe some motivational interviewing as needed to establish goals, then create a collaborative cognitive-behavioral case formulation, then flexibly address goals utilizing empirically-supported principles of behavior change, set agendas, work through agenda items, ask for feedback and collaboratively decide on between-session assignments. They have an overarching structure and 'plan' to what they do and it is all guided by theory and evidence...it's just not a scripted session-by-session recipe.

 

[G Costanza]

I think people tend to forget that a mandatory component of every EBT is that it accounts for the clients worldview, life experiences, and preferences. So while I often use CBT in my work, some clients are never going to complete a thought log on their own or practice challenging automatic thoughts. For these clients, CBT ceases to be an EBT.

 

[Sanman]

Part of this boils down to one's view of what psychotherapy is as well as economic and life issues. EBTs fit well into the medical model of addressing specific sx in a time limited manner. Is that where we draw the line? Some do and some don't. Judith Beck has the luxury of turning down unmotivated patients that this rural VA psychologist does not. Then again, those that seek her out likely are very motivated. I often wonder what some of the "experts" would do if stuck seeing patients in the very non-private home-based and nursing home settings that I worked in. I feel many would refuse to do such work.

 

[DynamicDidactic]

I'll add something a little different but in the same sphere as what has been said up till now. I think the key that separates well-trained doctoral psychologists is the science component. Having camps and theoretical orientation is only a barrier to providing the best care. Use the skills you learn as a scientist in your treatment (e.g., hypothesis testing, data collection, rational understanding of mechanisms) and you will likely be providing good care.

EBTs are a limited term indicating something has evidence but often evidence can be biased or misinterpreted. The key is to separate science from pseudoscience in your treatment and apply scientific principles in helping others. This is why I wont be using EMDR or Energy Therapies anytime in my life but I am open to any type of treatment model/orientation/procedure/camp that is scientifically derived and has evidence.

While I think Wampold's work has much merit and highlights the importance of the a "good" therapist in treating many common problems, I think it is limited when we get to more specific and severe problems (e.g., eating disorders, suicidality, phobias, trauma-related disorders). I don't care how much reflective listening and warmth you provide it wont be enough to help the typical person that is experiencing some of the problems I listed (or , at least, the evidence does not indicate that it will compared to more efficacious CBTs).

 

[DynamicDidactic]

In response to examining treatments from a scientific point of view, I think one needs to carefully assess the types of writing that come from people like Shedler.

Some links:

Selling Bad Therapy to Trauma Victims

Please see the response to Shedler's blog post here
Clinical Practice Guidelines

https://www.apa.org/pubs/journals/releases/amp-65-2-98.pdf

Shedler makes some good points but there are many limitations to his arguments. I can provide a litany of citations but folks should definitely look over the comments to this article:
The efficacy of psychodynamic psychotherapy. - PubMed - NCBI

Here are some other important citations
https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2010.08060843
https://cdn-61ba.kxcdn.com/wp-conte...iveness-de-Scott-O.-Lilienfeld-et.al-2014.pdf
https://www3.nd.edu/~ghaeffel/Resistance.pdf

 

[cara susanna]

In response to examining treatments from a scientific point of view, I think one needs to carefully assess the types of writing that come from people like Shedler.


Please see the response to Shedler's blog post here
Clinical Practice Guidelines


Shedler makes some good points but there are many limitations to his arguments. I can provide a litany of citations but folks should definitely look over the comments to this article:
The efficacy of psychodynamic psychotherapy. - PubMed - NCBI

Here are some other important citations
https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2010.08060843
https://cdn-61ba.kxcdn.com/wp-conte...iveness-de-Scott-O.-Lilienfeld-et.al-2014.pdf
https://www3.nd.edu/~ghaeffel/Resistance.pdf

Thanks for sharing. As a trauma therapist, I greatly disliked Shedler's article and that rebuttal captured all of my objections.

 

[FreudianSlippers]

In response to examining treatments from a scientific point of view, I think one needs to carefully assess the types of writing that come from people like Shedler.


Please see the response to Shedler's blog post here
Clinical Practice Guidelines


Shedler makes some good points but there are many limitations to his arguments. I can provide a litany of citations but folks should definitely look over the comments to this article:
The efficacy of psychodynamic psychotherapy. - PubMed - NCBI

Here are some other important citations
https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2010.08060843
https://cdn-61ba.kxcdn.com/wp-conte...iveness-de-Scott-O.-Lilienfeld-et.al-2014.pdf
https://www3.nd.edu/~ghaeffel/Resistance.pdf

This is great, excited to read through the articles. Thank you!

 

[FreudianSlippers]

All of your responses are great...so much food for thought! One point I wanted to make, it seems like in this thread the term "common factors" has been equated with reflective listening, validation, and warmth. That is in part true, but at least in Wampold's model it goes beyond that. For common factors to work well, the therapist and client must be actively working on congruent goals, where the client is engaged in some sort of healthy behavior which she/he expects will be helpful. For example, instead of exposure (i.e. for anxiety) working via the mechanism of habitation, Wampold would probably say exposure works through the common factors, whereas just listening and offering empathy to a client with social phobia would be missing important components. Anyways, it is much more complex than my example, but I just wanted to point out that Wampold would say CBT works...but not for the reasons people often think. And other things would work just as effectively if they met the specific common factors criteria.

 

[DynamicDidactic]

All of your responses are great...so much food for thought! One point I wanted to make, it seems like in this thread the term "common factors" has been equated with reflective listening, validation, and warmth. That is in part true, but at least in Wampold's model it goes beyond that. For common factors to work well, the therapist and client must be actively working on congruent goals, where the client is engaged in some sort of healthy behavior which she/he expects will be helpful. For example, instead of exposure (i.e. for anxiety) working via the mechanism of habitation, Wampold would probably say exposure works through the common factors, whereas just listening and offering empathy to a client with social phobia would be missing important components. Anyways, it is much more complex than my example, but I just wanted to point out that Wampold would say CBT works...but not for the reasons people often think. And other things would work just as effectively if they met the specific common factors criteria.

Truthfully, I only had to read Wampold while on internship and it was being used by old school psychodynamic folks to push an anti-science agenda. Though, if you what you say is accurate (and I have no reason to doubt it) he is talking about mechanisms of change. People are actively doing research on mechanisms of change for different problems. I know Craske is a big one for exposure treatments while the area I know best is suicide treatment. The research in those two disparate areas indicate very different mechanisms of action. I think this type of research is the most important work psychologists can do now that the era of RCTs is passing. My only concern is when common factors are used to support pseudo-therapy and an anti-science agenda.

 

[foreverbull]

Truthfully, I only had to read Wampold while on internship and it was being used by old school psychodynamic folks to push an anti-science agenda. Though, if you what you say is accurate (and I have no reason to doubt it) he is talking about mechanisms of change. People are actively doing research on mechanisms of change for different problems. I know Craske is a big one for exposure treatments while the area I know best is suicide treatment. The research in those two disparate areas indicate very different mechanisms of action. I think this type of research is the most important work psychologists can do now that the era of RCTs is passing. My only concern is when common factors are used to support pseudo-therapy and an anti-science agenda.

Interesting that it was used for anti-science agenda on internship because I see it as more of a validation of the common threads within all approaches and a reminder that absence of research for a particular approach or treatment doesn't automatically imply lack of efficacy/effectiveness, just lack of interest in researching that approach (our field is susceptible to fads in research and treatment just as in any other field). Wampold does a good job of delineating some of the research issues but certainly doesn't seem to advocate for less research or less scrutiny, in my opinion, just more critical thinking. I would hope it would stimulate more research on all types of approaches and treatments, not less!

 

[WisNeuro]

While I think Wampold's work has much merit and highlights the importance of the a "good" therapist in treating many common problems, I think it is limited when we get to more specific and severe problems (e.g., eating disorders, suicidality, phobias, trauma-related disorders). I don't care how much reflective listening and warmth you provide it wont be enough to help the typical person that is experiencing some of the problems I listed (or , at least, the evidence does not indicate that it will compared to more efficacious CBTs).

This. Wampold does great work and it does indeed look like common factors soaks up a good deal of variance in general. What some of, at least his early work that I am more familiar with, lacks is nuance between conditions as DD alludes to. When you collapse a bunch of disorders into one misshapen clump, you tend to wash out a lot of variance. It's a good starting point, but we need to look at things a little more in depth. It'd be like in medicine if you collapsed every infection into one or several groups and looked at antibiotic efficacy and concluded that all antibiotics work the same.