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| Buzz Words in Practice (And those that should be) |
| Written by David J. Powell, PhD | ||||||||||||||||||||||||||||||||
| Friday, 04 January 2008 | ||||||||||||||||||||||||||||||||
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In today’s parlance, there are certain key buzzwords one must learn to practice, and to receive funding for one’s organization. For example, if you asked the average counselor what is their model of therapy, almost everyone will say they use cognitive-behavior therapy (CBT) techniques. CBT is the current poster child in counseling, regardless of whether a clinician truly understands or practices CBT, in much the same way as decades ago the “Minnesota Model” (or the Hazelden Model) of counseling was the gold standard for addiction counseling. Humans are mimetic, we’re hero worshippers, which means we need to find models to follow, which is probably a good thing. Remember a decade ago, we all “wanted to be like Mike.” This article looks at some of the current buzz words and proposes some others that should be on the Top Ten list of most-oft used words in addiction counseling. Today’s top buzz words 1. Arguably, topping the list of buzzwords today is Evidence-Based Practice (EBP), or Science-Based Practices. EBPs are interventions for which there is consistent scientific evidence showing that they improve client outcomes (according to the Northeast Addiction Technology Transfer Center’s latest document on EBPs for clinical supervision). EBPs are derived from multiple randomized trials, consensus reviews of available science, and expert opinion based on clinical observation. There are a number of evidence-based practices which researchers have highlighted as having positive outcomes: CBT, Solution-Focused Counseling, Brief Interventions, Motivational Interviewing, Relapse Prevention, 12-Step Interventions, the Matrix Model, Community Reinforcement Approaches, Supportive-Expressive Therapy, Brief Family Therapy Interventions, Contingency Management, and pharmacotherapy. In the 1990s, EBPs were important and studied. In the 21st century their importance has been elevated from “good things to practice” to “must haves if you wish to receive federal and state funds.” This upping the ante has resulted in a mild backlash from the field. Counselors traditionally do not like to be told what they must do, but understand, if they are to be funded, they must “play the game by the funders’ rules.” So now, everyone uses EBPs, or so they say. When all is said and done, and our research is complete on what brings about improved client outcomes (if it ever is completed), I believe we will find that instead of speaking about evidence-based therapies, we need to speak about evidence-based therapists. We can have two therapists with the same training, practicing the same approaches, and one will have more positive outcomes than the other. This is due to the one counselor’s ability to establish a more positive therapeutic alliance with the client. 2. Related to the buzzwords connected to EBPs is the word “fidelity,” which is “the degree of fit between the developer-defined components of a program, and its actual implementation in a given organizational or community setting.” EBPs speak also of program adaptation, which is a deliberate or accidental modification of the EBP, emphasizing that adaptation may diminish the effectiveness of a specific intervention whereas “rigid fidelity may produce an adverse effect.” An indicator of technology transfer (learning, understanding, and putting into practice a specific EBP) is the degree of fidelity a counselor (or agency) has with a particular EBP. The stepchild, then, of this process is implementation of manualized treatment, what I affectionately (and somewhat irreverently call “cookbook counseling”). 3. On the other side of the coin are other key buzz words, based mostly on the work of Hubble, Duncan and Miller, in The Heart and Soul of Change, such as “allegiance,” which is the degree to which a counselor believes his therapy approach is effective; and “adherence,” the extent to which a counselor uses prescribed approaches. Allegiance to a therapeutic model is important. A counselor needs to believe that her approach works; after all, why use it if one does not believe in it’s effectiveness. But, as in EBP parlance, rigid adherence to a model (a “one size fits all” approach) can have a negative impact on client outcome. A third “A” word they speak of, and perhaps the most important, is therapeutic “alliance,” which is the counselor’s affective relationship with a client; the client’s motivation and ability to work with a particular counselor; the therapist’s empathic responding to and involvement with the client; and the client’s and counselor’s agreement about the goals of therapy. Alliance is based on therapeutic empathy, which consists of emotional empathy; personal emotional responses; concern and compassion; and cognitive empathy, the ability to identify with and understand another’s experiences and feelings. Hubble's, Duncan’s and Miller’s research demonstrates that the curative factors in therapy have more to do with the extent of the therapeutic alliance and less on actual techniques used. As I speak to audiences worldwide, this resonates with most counselors, who, although they might desperately cling to a therapeutic model (“My goodness, this is what I learned in grad school, and whether the client needs it or not, he’s getting this model”), in her heart of hearts, she knows that what brings about change in counseling is the nature of the therapeutic alliance. Proposed other key buzz words Topping David Powell’s (not Letterman’s) top list of key buzzwords is the word “acceptance.” Marcia Linehan in the Dialectical Behavior Therapy model speaks of “radical acceptance.” A dialectical worldview emphasizes wholeness, interrelatedness, and process as fundamental characteristics of reality. Change happens, according to Linehan, when the patient is able to radically accept her present situation in the moment, and willing to change it to a better life (begins to sound like a prayer said at 12-Step meetings, doesn’t it). The therapist articulates the wisdom, correctness or values in the patients’ emotions, cognitions and behaviors, and conveys a sense of radical acceptance of the clients, as they are, balancing the need for them to change certain behaviors. An earlier generation of therapists, who were espousing client-centered approaches, might have spoken of “unconditional positive regard” in the same way Linehan speaks of radical acceptance. I believe what we need do as therapists is to accept the client, as he or she is. Carl Rogers said that the curious paradox is when I accept myself as I am, I change. Paul Tillich, the Christian theologian said that change strikes us when we are in great pain. In that moment a wave of light breaks into our darkness and it is as if a voice were saying, “you are accepted, just as you are.” Therapists need to practice a radical acceptance towards clients. This does not mean we condone all they do. It means that through our acceptance of them, they begin to change. In fact, until there is a sense of understanding and acceptance by the client, change is far more difficult. Second on my list, is the word “accountability.” I don’t know if you’re like me but I don’t like to be held accountable for too much. Ask my wife if you doubt that. But, in the substance abuse field, and especially in the area of clinical supervision, we desperately need to be held accountable for what we do. An important positive outcome of the managed care systems put in place in the 1990s is that counselors and organizations were held accountable for what they did. Although the pendulum might have swung too far in the other direction, to disallowing patients admission for treatment, no longer could counselors say “trust me.” We had to demonstrate client outcomes if we wished reimbursement for our care. In the area of clinical supervision, accountability is critically needed. In most organizations there remains little oversight or observation for what goes on behind the closed doors of a counselor’s office. Clinical supervisors rarely observe staff in action, and even worse, rarely confront inappropriate clinical behaviors. I have the benefit of watching many counselors in action, either on DVDs or in role-plays at training sessions, and I often am amazed at what goes on and is called “counseling” or clinical supervision. Supervisors need to hold counselors accountable for what they do. The only way to truly know what is happening in therapy is through direct observation. How often do you watch your counselors work? How comfortable is the clinical supervisor in addressing clinical “no-nos?” We now have an external system of managed care because in the 1980s and 1990s we failed as a field to develop our own internal systems of care management. It is time that counselors and supervisors add another “A” word to their vocabulary, accountability. The reader could likely add many more key buzzwords to this list. To continue the discussion, please write to me at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it I’d love to hear your top ten favorite buzzwords.
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