Clinical Psychology

for Trainees

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Clinical Psychology
for Trainees
Foundations of Science-Informed Practice
Andrew C. Page
University of Western Australia, Perth

Werner G. K. Stritzke
University of Western Australia, Perth

Peter M. McEvoy
Curtin University, Perth

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© Andrew C. Page, Werner G. K. Stritzke and Peter M. McEvoy 2022

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First published 2006

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Library of Congress Cataloging-in-Publication Data

Names: Page, Andrew C. (Andrew Charles), 1964– author. |
Stritzke, Werner G. K., 1956– author. | McEvoy, Peter M., author.
Title: Clinical psychology for trainees : foundations of science-informed practice /
Andrew C. Page, University of Western Australia, Perth, Werner G. K. Stritzke,
University of Western Australia, Perth,
Peter M. McEvoy, Curtin University, Perth.
Description: Third edition. | Cambridge, United Kingdom ; New York, NY:
Cambridge University Press, 2022. | Includes bibliographical
references and index.
Identifiers: LCCN 2021054775 (print) | LCCN 2021054776 (ebook) |
ISBN 9781108457101 (paperback) | ISBN 9781108611350 (epub)
Subjects: LCSH: Clinical psychology. | Clinical psychologists–Training of. |
BISAC: PSYCHOLOGY / Mental Health
Classification: LCC RC467.2 .P34 2022 (print) | LCC RC467.2 (ebook) |
DDC 616.89–dc23/eng/20211227
LC record available at https://lccn.loc.gov/2021054775
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ISBN 978-1-108-45710-1 Paperback

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or appropriate.

...............................................................
Every effort has been made in preparing this book to provide accurate and up-to-date
information that is in accord with accepted standards and practice at the time of
publication. Although case histories are drawn from actual cases, every effort has
been made to disguise the identities of the individuals involved. Nevertheless, the
authors, editors, and publishers can make no warranties that the information con-
tained herein is totally free from error, not least because clinical standards are
constantly changing through research and regulation. The authors, editors, and
publishers therefore disclaim all liability for direct or consequential damages resulting
from the use of material contained in this book. Readers are strongly advised to pay
careful attention to information provided by the manufacturer of any drugs or
equipment that they plan to use.
Contents

1 A Science-Informed Model of Clinical 13 Managing Ruptures in

Psychology Practice 1 Therapeutic Alliance 217
2 Relating with Clients 12 14 Respecting the Humanity of
Clients: Cross-Cultural and Ethical
3 Assessing Clients 26
Aspects of Practice 245
4 Matching Treatments and
15 Providing Therapy at a Distance
Monitoring Client Progress 49
and Working in Rural and
5 Linking Assessment to Treatment: Remote Settings 260
Case Formulation 63
16 Psychologists as
6 Treating Clients 96 Health Care Providers 271
7 Brief Interventions 128 17 Working in Private Practice -
Dr Clair Lawson; Clinical
8 Low Intensity Psychologist and Director;
Psychological Interventions 149 Lawson Clinical Psychology 286
9 Group Treatment 157
10 Programme Evaluation 168
11 Case Management 178 References 299
12 Supervision 200 Index 343

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 Chapter
A Science-Informed Model

1 of Clinical Psychology Practice

There has never been a better time to train as a clinical psychologist for three reasons.
First, there is an increasing response to the recognition of the unmet need in mental
health which is resulting in an increase in the number of clinical psychology jobs.
Second, clinical psychology is enjoying a privileged position in mental health care
because of its ability to provide an evidence-base for the services it offers (Newnham &
Page, 2010). Thus, despite the expense incurred by the provision of psychological
services, we can show that their effectiveness assures savings that offset those costs.
Third, the pandemic associated with COVID-19 has put the spotlight on evidence-
based decision-making in health-care. It has been possible to model the impact of
various public health interventions and some nations and states have used this to
guide decision-making to good effect. Some areas have made decisions based on
criteria other than the health evidence and the impact on health at the state and
national level has been evident. In addition to the impacts of the disease itself, the
pandemic has drawn attention to many existing unmet needs in the area of mental
health (Marques et al., 2020) and ongoing, technology-driven changes have been
accelerated in therapy delivery modalities and legal and reimbursement codes for
therapy at a distance. The pandemic has also pointed to the need for a flexible and
responsive attitude to the data. For example, some of the early dire predictions of the
impact of COVID-19 on suicide have not been supported (Pirkis et al., 2021), and
reminded many that we neglected older data showing that national crises can be
protective against suicide, arguably due to improved social cohesion (Botchway & Fazel,
2021) ). This is the exciting challenge facing the graduates of today’s programmes: how will
you shape clinical psychology?
Considering the first of these points, governments across the world are acknowledg-
ing the need to deal effectively with mental health. Within the United Kingdom, the
response has been the development of an Improving Access to the Psychological
Therapies (IAPT) (NHS, 2021) programme. This initiative aims to deliver interventions
for people with depression and anxiety disorders that have been approved by the
National Institute of Health and Clinical Excellence (NICE). In the United States, the
Affordable Care Act (ACA) aims to improve equitable access to an improved quality of
mental health care. In Australia, the Better Outcomes in Mental Health Care
(Department of Health, 2021) programme improves community access to quality pri-
mary mental health care by providing access to allied psychological services which
enables general medical practitioners to refer consumers to allied health professionals
who deliver focused psychological strategies. Thus, the desire being expressed inter-
nationally (and tailored to thehttps://avxhm.se/blogs/hill0
specific contexts of each nation) is to increase access to
1
2 Chapter 1: A Science-Informed Model of Clinical Psychology Practice

mental health services. This desire is leading to an increasing demand for mental health
professionals who are able to provide the treatments required.
Second, there is a common theme across the international initiatives to increase the
quantity of mental health care; namely a focus on quality. Funding agencies want to
ensure that they receive value for money. Consequently, funding is often limited to
treatments that have a strong evidence base. Private and public funders are looking to
allocate scarce health care resources to areas where there is an assurance that treatment is
effective and efficient (McHugh & Barlow, 2010). The profession of clinical psychology
has enjoyed a privileged position as a result of these pressures because it has a long
history of accountability (Lilienfeld, Ammirati & David, 2012). Its professionals are
trained in the critical skills required to evaluate evidence and research methods to
generate data on both existing and new treatments (Pachana et al., 2011). The status
afforded to clinical psychologists, by virtue of their long history in demonstrating the
accountability of their treatments, has meant that the profession as a whole benefits from
the research base documenting the efficacy, effectiveness and efficiency of psychological
treatments (Barlow, 2010; McHugh & Barlow, 2010).
We are at a juncture when clinical psychology will carve out a path that will affect the
profession as it goes forward (Barkham, Hardy & Mellor-Clark, 2010; Castelnuovo et al.,
2020; Gruber et al., 2020). The decision facing the profession is: will science-informed
practice inform the future practice of clinical psychology? The perception that psych-
ology is scientific is not universal (Lilienfeld, 2012). Thus, will science continue to inform
the future practice of clinical psychology (see Lilienfeld & Basterfield, 2020; Safran et al.,
2011; Stewart, Chambless & Baron, 2012)? To contextualize this decision, we will now
discuss a revision of the psychiatric classification system.
Allen Frances chaired the committee responsible for the fourth revision of the
American Psychiatric Association’s diagnostic system; the Diagnostic and Statistical
Manual of the Mental Disorders (DSM-IV). After the publication of the fifth revision
(i.e., the DSM-5) he wrote a book, Saving Normal (2014), in which he cogently critiqued
the new taxonomy and the malign forces which he believed to be responsible for the
errors. As a psychiatrist writing from retirement, he was excluded from any decision-
making, but there is another level on which the book can be read. Much of his invective
is directed at the multinational pharmaceutical companies who, in his opinion, control
the agenda and directly and indirectly influence the formation of diagnostic categories
and the uses to which they are put. However, what is clear is that Frances has seen
(perhaps too late) the predicament that psychiatry has found itself in. In recent years, the
number of prescriptions for medications used to treat mental health conditions has
increased to meet the rising demand. Since the number of psychiatrists has remained
relatively static, general practitioners have taken over the role of key provider of
psychopharmacology. Psychiatrists have been relegated to the position of small players
in a big market and their voice, once pre-eminent, has become one among many. For
example, the head of the Royal Australian and New Zealand College of Psychiatrists
echoed the same sentiment in an interview (ABC, 2014) where he noted that some
groups in the community were increasingly more likely to seek advice from their GP
rather than a psychiatrist. Thus, psychiatry is realizing that its pre-eminent position in
mental health care has been eroded. As society has realized that the burden of mental
health care is far larger than psychiatry can ever manage, it has sat by while other
professions have stepped up to the task.
 Chapter 1: A Science-Informed Model of Clinical Psychology Practice 3

This cautionary tale provides clinical psychology with a window of opportunity. In

the coming years the profession of clinical psychology will be settling itself down into the
new mental health care environment. Clearly there are not enough clinical psychologists
to meet the mental health care needs of the twenty-first century; clearly, there will never
be enough (Kazdin, 2011). The appropriately stringent and lengthy training of the
profession will always be a limiting factor. Therefore, the exciting challenge for clinical
psychologists is how to adapt themselves to this new environment. If the profession
continues in the way it has been operating, it risks losing its pre-eminent role, just as
psychiatry has. The remainder of the book will outline one possible future, where we will
argue that clinical psychology must be a science-informed practice. By continuing to
develop, evaluate and offer evidence-based treatments; by delivering treatments in a
monitored error-correcting clinical practice (Lillienfeld & Basterfield, 2020; Scott &
Lewis, 2015); by training other mental health professionals in evidence-based treatments;
and by fostering skills that complement (rather than duplicate) those of our colleagues in
other professions, clinical psychologists will bring to the mental health team an expertise
that will ensure them a continuing strong future (Barlow, 2010; Ward et al., 2018;
Youngstrom et al., 2017).
These are both exciting and challenging times and the profession of clinical psych-
ology has a bright future ahead. We are confident because psychologists know that the
best predictor of future behavior is past behavior. If we consider the history of clinical
psychology, we can see that a science-informed approach to practice has served the
profession well. Last century, Hans Eysenck (1952) threw down the gauntlet to clinical
psychologists when he reviewed the 24 available studies and concluded provocatively that
individuals in psychotherapy were no more likely to improve than those who did not
receive treatment. Although the conclusion itself was questionable given the extant data
(Lambert, 1976), the field responded assertively and effectively to these criticisms (e.g.,
Meltzoff & Kornreich, 1970). Perhaps the most effective response came from Smith,
Glass, and Miller (1980). Using meta-analytic statistical techniques to review 475 studies,
they provided quantitative support for the conclusion that psychotherapy was superior
to both no-treatment and placebo control conditions (see also Andrews & Harvey, 1981;
Prioleau, Murdock & Brody, 1983). More recently, reviewers in the USA, the UK and
Australia have sought to take the next step and identify criteria for empirically supported
treatments, thereby providing listings of treatments that are “effective” for particular
disorders (e.g., Andrews et al., 1999; Chambless & Hollon, 1998; Nathan & Gorman,
2015; Roth & Fonagy, 2004; Task Force on Promotion and Dissemination of
Psychological Procedures, 1995). In parallel, other reviewers have collated evidence
regarding the effective components of psychotherapy relationships (e.g., Norcross &
Lambert, 2019; Norcross & Wampold, 2019; Orlinsky, Grawe & Parks, 1994; Orlinsky,
Rønnestad & Willutzki, 2004). Together, these two lines of research provide a strong
response to Eysenck’s criticism. While people continue to debate the relative merits and
contributions of the psychotherapy relationship and the specifics of particular therapies
(e.g., Asnaani & Foa, 2014; Laska, Gurman & Wampold, 2014; Norcross & Lambert,
2019; Norcross & Wampold, 2011; Wampold, 2001), the conclusion that psychotherapy
is better than no treatment, and better than a supportive caring relationship alone, is
strongly supported.
Thus, Eysenck’s provocative comments spurred a spirited and methodical response
that allowed clinical psychology to clearly defend itself against general criticisms of
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4 Chapter 1: A Science-Informed Model of Clinical Psychology Practice

ineffectiveness. In addition, the profession is able to identify, with increasing precision,

the relational and specific therapeutic factors that mediate clinically meaningful change.
Why was clinical psychology able to respond so effectively?

The Scientist-Practitioner Model

Arguably, the manner and effectiveness of the response owes a debt to the origins of
clinical psychology within the scientific discipline of psychology and to an early and
sustained commitment to a scientist-practitioner model (Eysenck, 1949, 1950; Raimy,
1950; Shakow et al., 1947; Stewart, Stirman & Chambless, 2012; Thorne, 1947; see Hayes
et al., 1999; Pilgrim & Treacher, 1992 for historical reviews). From the establishment of
the first clinical psychology clinic by Lightner Witmer, it was clear that science and
practice were strategically interwoven (Norcross & Karpiak, 2012). For instance Witmer
(1907, p. 9) wrote,
The purpose of the clinical psychologist, as a contributor to science, is to discover the relation
between cause and effect in applying the various pedagogical remedies to a child who is suffering
from general or special retardation . . . For the methods of clinical psychology are necessarily
invoked wherever the status of an individual mind is determined by observation and experiment,
and pedagogical treatment applied to effect a change.
Although there has been much written about the scientist-practitioner model, the broad
principles are that clinical psychologists, as scientist-practitioners, should be consumers
of research findings, evaluators of their own interventions and programmes, and produ-
cers of new research who report these findings to the professional and scientific commu-
nities (Hayes et al., 1999). The commitment to an ideal of combining research and
practice has infused the profession of clinical psychology to such a degree (e.g.,
Borkovec, 2004; Martin, 1989; McFall, 1991) that the response to Eysenck’s scepticism
(see also Peterson, 1968, 1976a, 1976b, 2004) was not an appeal to the authority of a
psychotherapeutic guru, nor a rejection of its legitimacy followed by attempts to ignore
it; rather, the profession produced and collated empirical data to refute the claim (Butler
et al., 2006).
Despite the success of the scientist-practitioner model in shaping clinical psychology
as a discipline committed to empiricism and accountability, advocates of the model have
not been blind to its failure to achieve the ideal (Hayes et al., 1999; Nathan, 2000).
Shakow et al. (1947) of training individuals who could not only be scientists and
practitioners, but could blend both roles in a seamless persona. They sought to achieve
this goal by giving an equal weighting to research and practice in training programmes.
However, ensuring the mere presence of these two equally weighted components did not
by default produce an integrated scientific practice and did not win the hearts and minds
of many graduates. In the words of Garfield, “unfortunately, (psychologists in training)
are not given an integrated model with which to identify, but are confronted instead by
two apparently conflicting models – the scientific research model and the clinical
practitioner model” (Garfield, 1966, p. 357; Peterson, 1991). More recently, there have
been renewed efforts to provide a concrete instantiation of scientific practice (Borkovec,
2004; Borkovec et al., 2001; Scott & Lewis, 2015). Hayes and colleagues (1999) attributed
the apparent lack of better science-practice integration to two factors: First, the “almost
universally acknowledged inadequacies of traditional research methodology to address
issues important to practice”, and second, the “lack of a clear link between empiricism
 Chapter 1: A Science-Informed Model of Clinical Psychology Practice 5

and professional success in the practice context” (p. 15). Our goal in the remainder of the
book is not to address the first of these concerns (see Hayes et al., 1999; Neufeldt &
Nelson, 1998; Seligman, 1996a), but to speak to the second. Our goal is to articulate ways
that a scientific clinical psychology can be practiced.

The Aim of This Book

Our aim is to assist the student of clinical psychology to contemplate a scientific practice
and to develop a mental model of what a scientist-practitioner actually does to blend
state-of-the-science expertise with quality patient care. Our goal is not to describe a
model of clinical practice (e.g., Asay et al., 2002; Borkovec, 2004; Edwards, 1987), nor to
outline a broad conceptual framework for a scientist-practitioner (see Beutler & Clarkin,
1990; Beutler & Harwood, 2000; Beutler, Moliero & Talebi, 2002; Fishman, 1999;
Hershenberg, Drabick & Vivian, 2012; Hoshmand & Polkinghorne, 1992; McHugh &
Barlow, 2010; Nezu & Nezu, 1989; Schön, 1983; Spencer, Detrich & Slocum, 2012;
Stricker, 2002; Stricker & Trierweiler, 1995; Trierweiler & Stricker, 1998; Yates, 1995),
or even to portray a scientifically grounded professional psychology (Peterson, 1968,
1997), since each of these has been effectively presented elsewhere. Our aim is to consider
each of the core competencies that a trainee clinical psychologist will acquire with the
following question in mind: “how would a scientist-practitioner think and act?” The
value of the scientist-practitioner model as a sound basis for the professional identity and
training of clinical psychologists lies in its emphasis on generalizable core competencies,
rather than specific applications of these core competencies to each and every client
problem or service setting (Shapiro, 2002). Accordingly, we will first describe our
conceptual model of the core elements of science-informed practice. Then, in the
remainder of the book, we will illustrate how this model allows individual practitioners
to provide value for money in a competitive health care market indelibly shaped by the
forces of accountability and cost-containment (see also Detweiler-Bedell et al., 2003;
Fishman, 2000; Kraus et al., 2011).

A Science-Informed Model of Clinical Psychology Practice

The starting place for any action in clinical psychology practice is the client and his or
her problems. Therefore, the discussion of a science-informed model needs to begin with
the client. In addition, the meeting of client and therapist involves a relationship, so that
at its heart the interaction is relational. The beginning of the relationship involves the
presentation of the client’s problems to the clinical psychologist. As shown in Figure 1.1,
this information is conveyed to the clinician (depicted by the thin downward arrows)
and some of it passes through the “lens” of the clinical psychologist. This lens comprises
the theoretical and empirical literature as well as clinical (and non-clinical) experience
and training. It serves to focus on the information about the client. Continuing with the
lens metaphor, not all the information passes through the lens (indicating by some
arrows missing the lens) because clinicians will be limited by the level of current
psychological knowledge, their theoretical orientation and the extent of their experience.
The client might also not disclose important information that would otherwise influence
clinical decision-making. For example, the client might not initially see the relevance of
particular information or may not be aware of it in the initial phases of treatment.
Information may also be intentionally withheld because of shame, at least until trust has
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6 Chapter 1: A Science-Informed Model of Clinical Psychology Practice

Client data (problem, context, history, etc.)

Theoretical and Clinical training &

empirical literature experience

Assessment &
case formulation
Process dimension

Treatment planning
& measurement

Treatment implementation
& monitoring

Evaluation &
accountability

Figure 1.1 Linking client data to treatment decisions using case formulation.

been developed in the psychologist. The clinician needs to be alert to relevant new
information that emerges during therapy so that it can be integrated into the
treatment plan.
As with all metaphors, the notion of a lens filtering client data is limited in that it
does not capture the dynamic nature of the interaction between client and clinician. The
client is not analogous to a light source passively emitting illumination, but a client
actively engages in an interactive dialog with the clinician so that the information elicited
is influenced by the clinician’s responses, and the material the client proffers in turn
influences how the clinician chooses to proceed. Thus, the interaction between client and
clinician is a rich and dynamic dialogue, but while it has the potential to be a free-
ranging and unconstrained discussion, the process has an “error correcting” mechanism,
whereby the clinician focuses on the information and channels it into diagnosis and a
case formulation. The case formulation, described later, provides direction to the deci-
sions that a clinical psychologist, together with the client, makes about treatment
(indicated by the dotted arrows), which are then implemented and their outcomes
measured, monitored and evaluated. These processes involve feedback loops, so that
information garnered at each stage feeds back to support or reject earlier hypotheses and
decisions in a cycle of error correction.
Finally, there are processes associated with the public accountability of clinical
practice. The results of treatment are fed forward by the clinical psychologist to modify
the theoretical and empirical bases of practice. In addition, the results will be fed back to
inform the person’s clinical experience that will guide future clinical practice.
Dissemination of evaluations of clinical practice outcomes serves not only to demonstrate
that the practice is accountable, but also ensures the sustainability of clinical psychology.
In the same way that logging forests without replanting new trees is unsustainable because
 Chapter 1: A Science-Informed Model of Clinical Psychology Practice 7

it starves the timber industry of its raw material, if clinical psychology fails to replenish its
resources (effective assessment and treatment), then it will be unsustainable. Other
professions will step forward with potentially more efficient and effective alternatives to
those that are presently available. To stretch the logging metaphor further, trees will grow
stronger over time if weaker branches are removed so that finite resources and energy can
be redirected towards strengthening the trunk. Likewise, psychologists’ iterative use of
evidence-based practice and practice-based evidence provides new knowledge about less
effective or efficient approaches that need to be cleaved off so that therapeutic time and
effort can be redirected into approaches that have demonstrated the strongest and most
rapid effects. Thus, we would agree with Miller (1969) that, “the secrets of our trade need
not be reserved for highly trained specialists. Psychological facts should be passed out freely
to all who need and can use them in a practical and usable form so that what we know can be
applied by ordinary people” (pp. 1070–1071). We can “give psychology away” in the sure
knowledge that we are capable of generating new knowledge at least as fast as we can
disseminate existing knowledge.
Operating alongside the skills associated with each of the elements of linking client
data to case formulation to inform treatment planning and implementation is the
process dimension, upon which all therapeutic content is superimposed. The “superim-
posed” nature of therapeutic content on therapeutic process is reflected in Figure 1.1,
where process is shaded behind assessment, treatment planning and measurement,
treatment implementation and monitoring, and evaluation and accountability.
Process refers to the interactions between therapists and clients. Clients come to
therapy with a range of experiences, relational patterns and beliefs that will play out
during therapy sessions. For example, clients with a history of maltreatment or abuse
may expect further maltreatment from others, including the therapist. Strategies clients
use in an attempt to prevent these feared outcomes will differ (e.g., overly compliant and
eager to please, defensive, or sarcastic interaction styles), but they aim to serve a common
protective function. Freud (1912, cited in Parth et al., 2017) initially coined the term
transference to capture the idea that clients may transfer or re-enact patterns of relating
to others learned in the context of developmental relationships into the therapeutic
relationship. The term countertransference reflects all of the responses therapists have
to their clients. For example, a client who is meek and overly apologetic (“client stuff”)
may initially elicit nurturance and support followed by frustration and rejection from
others, and the therapist may also experience these feelings as therapy progresses. On the
other hand, therapist-induced countertransference occurs when the client triggers the
therapist’s own problematic beliefs or relational patterns (“therapist’s stuff”). For
example, a therapist might feel resentful or dismissive of a client who reminds them of
a parent with whom the therapist has a problematic relationship.
Although the concepts of transference and countertransference initially derived from
psychoanalytic theory, the idea that clients’ (and therapists’) relational styles contribute
to therapeutic outcomes is pan-theoretical and is supported by empirical evidence
(Cartwright, 2011; Gelso, 2014; Parth et al., 2017). Cognitive therapists can easily
accommodate these concepts within cognitive theory by referring to constructs such as
core beliefs and schemas (Cartwright, 2011). Therapists will benefit from an ability to
identify and formulate the process dimension, but in some instances they may choose to
circumvent process issues during therapy. For example, in very brief therapies there may
not be time for significant process issues to emerge between the therapist and client, or
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8 Chapter 1: A Science-Informed Model of Clinical Psychology Practice

the therapy may be focused on teaching specific skills and addressing broader relational
styles may not be a priority or necessary. In these instances, therapists may simply use
their awareness of process issues to formulate their own reactions to the client and to use
this knowledge to guide the way in which they relate to the client to optimize engagement
so that process issues (e.g., ruptures) are less likely to interfere with therapy outcomes
(Cartwright, 2011; Gelso, 2014; Parth et al., 2017) . Therapists who are unable to identify,
formulate and respond effectively to clients’ interpersonal styles are at risk of replicating
and reinforcing these problematic patterns. Effectively responding to unhelpful relational
styles can reduce the risk of ruptures in the therapeutic alliance, non-adherence to
treatment and client dropout. This book will draw readers’ attention to potential process
issues that may emerge at each stage of therapy, and how these can be understood and
managed by trainee clinicians, to optimize effectiveness.

Stakeholders in the Practice of Clinical Psychology

In the previous section we outlined how the foundations of science-informed practice
rest on the clinical psychologist assuming three interrelated roles. Clinical psychologists
are consumers of research, in that they draw on the existing theoretical and empirical
literature, they are evaluators of their own practice, and they are producers of new
practice-based research and knowledge. However, the style of research and type of
research product varies according to the stakeholder. Three classes of stakeholders can
be identified (see Figure 1.2). The first stakeholder is the client (included in this category
are the client’s family, friends and supporters). The second class of stakeholder is the
clinician, including the professional’s immediate employment context (e.g., clinic, hos-
pital, government department). The final class of stakeholder includes the broader society
comprising individual members of society, government agencies, professional groups,
academics and the private sector. The type of research that each group will be interested
in is displayed schematically in Figure 1.2
Clients have a legitimate interest in efficacy studies. Efficacy studies demonstrate in
randomized controlled designs the superiority of a clinical procedure or set of proced-
ures, presented in a replicable manner (e.g., using a treatment manual) over a control
condition. The research has clearly defined inclusion and exclusion criteria, with an
adequate sample size, and participants are evaluated by assessors blind to the experi-
mental condition. Collating information across a group of efficacy studies permits the
identification of evidence-based or “empirically supported treatments” (e.g., Andrews
et al., 1999; Chambless & Hollon, 1998; Nathan & Gorman, 2015; Roth & Fonagy, 2004;

Client Clinician Society Figure 1.2 The relevance of three types of research
activity in clinical psychology for three classes of
stakeholder. The larger the area, the greater the
Monitoring & effectiveness relevance for a particular group.

Efficacy

Mechanism & process

 Chapter 1: A Science-Informed Model of Clinical Psychology Practice 9

Task Force on Promotion and Dissemination of Psychological Procedures, 1995). Clients

may find this information useful in deciding which treatment has a good probability of
success for carefully selected groups of individuals with problems like their own.
Clients will have an even greater interest in the effectiveness of a given treatment and
ongoing monitoring of their own condition. That is, effectiveness research evaluates
treatments as they are usually practiced. In contrast to the treatment described in efficacy
studies, clients who present for treatment may have multiple problems, may not meet all
diagnostic criteria and will choose (rather than being randomly assigned) to receive a
particular treatment whose duration is aimed to match their needs. The clinician may
modify treatment based on a client’s response. Within this class of research one can
include studies that examine the generalizability of efficacious treatments to “real-world”
settings (e.g., Peterson & Halstead, 1998), consumer surveys (e.g., Seligman 1995, 1996a,
1996b), as well as information on the outcomes of a specific clinic or clinician.
Effectiveness can also be used broadly to refer to the measurement of change (e.g.,
pre- and post-treatment) within the client in question, the ongoing and idiographic
monitoring of the client’s problems (see Dyer, Hooke & Page, 2014; Hawkins et al., 2004;
Howard et al., 1996; Lyons et al., 1996; Newnham, Hooke & Page, 2010a; Sperry et al.,
1996 for examples) and issues concerning service delivery. Arguably, as the data become
more personal, they become more relevant to the particular client and those who may be
involved in the client’s care. Thus, in the left-hand box in Figure 1.2, proportionally more
space is allocated to monitoring and effectiveness (light gray), than efficacy research
(gray) to reflect the interests of an individual client.
Moving to the far right-hand side of Figure 1.2, the interests of society are depicted.
In contrast to the individual client, society will have a general interest in knowledge
about the effectiveness of treatments but will have no particular interest in monitoring
the progress in treatment of a particular individual. Thus, the relevance of monitoring
and effectiveness studies (light gray) is less for society in general than the individual,
indicated by the smaller proportion of the right hand rectangle devoted to it. Society will
have a greater interest in knowing the results of efficacy studies, so that governments and
investors can make rational planning and funding decisions and services can be effi-
ciently and effectively managed. Additionally, society takes an interest in a research
agenda that may have little interest to individual clients, namely the research on the
mechanisms and processes of disorders and treatment (dark gray). Included within this
category of research endeavor are investigations of descriptive psychopathology and the
etiological mechanisms that initially cause or maintain a set of client problems as well as
those mechanisms involved in client change (e.g., O’Donohue & Krasner, 1995). The
category also includes research into the process of psychotherapy (e.g., Norcross &
Lambert, 2019; Norcross & Wampold, 2019); that is, research on the relationship
variables critical to client improvement.
Standing between the clients on the one hand and society on the other, is the clinical
psychologist. Clinical psychologists share the interests of both the client (in the moni-
toring and measurement of each client’s particular problems and the delivery of the most
efficacious treatment) and society (in understanding the fundamental mechanisms
involved in each problem a client may present with and knowing which treatments
are efficacious for a particular problem, and the degree to which these treatments
translate into practice). For example, for the present authors, when we manage our
clinic’s smoking cessation (Stritzke, Chong & Ferguson, 2009) and anxiety disorder
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10 Chapter 1: A Science-Informed Model of Clinical Psychology Practice

programmes (Andrews et al., 2003; Page, 2002a) we not only want to know that the
programs are empirically supported, that they are effective outside the centres where they
were tested on carefully selected samples, but we need to be able to demonstrate that the
outcomes of our clinicians running our programs are comparable to those in the
published literature. Studies that compare effects from a psychologist’s clinical practice
to past clinical trials can be used to confirm that outcomes are meeting international
benchmarks (e.g., McEvoy et al., 2012, 2015a) Likewise, while a single case study may not
be publishable unless it reveals particularly important information about a novel case
presentation or application of an intervention, it provides an excellent way for individual
practitioners to demonstrate to themselves and to a client the degree of improvement
(Fishman, 2000).
Drawing together the themes discussed (and portrayed in Figures 1.1 and 1.2), the
scientific practice of clinical psychology exists in a social network that ripples outward
from the individual client, with a research agenda that becomes more generalizable.
Thus, there is probably not one single science-informed model of clinical psychology, but
an array of ways that science informs practice and vice versa. The knowledge generated
by large-scale efficacy studies (e.g., Elkin et al., 1989) exists alongside the knowledge
generated by an individual clinician tracking the Subjective Units of Discomfort (SUD)
of a phobic progressing through an exposure hierarchy. Both can appropriately be
considered the products of a scientific practice of clinical psychology. Acknowledgement
of diversity in the type of research product across different stakeholders is not to imply that
there are no boundaries to a scientific clinical psychology, just that it is broader than is
often characterized.
It is worth noting that specification of the different stakeholders helps to clarify what
information needs to be presented to which groups and by whom. Individual clients will
be interested in feedback about how they have performed on psychological tests relative
to appropriate normative samples and about the rate and extent of progress, both
referenced against their pre-treatment scores and relevant norms (see Crawford et al.,
2011; Woody et al., 2003). Further, the results of therapy may be communicated to other
stakeholders in ward rounds, clinic meetings, training workshops and other clinical
settings (cf. Castonguay, 2011; Haynes, Lemsky & Sexton-Radek, 1987; Mitchell, 2011).
In contrast to the local presentation of individual client data, professional societies and
funding bodies will seek information about the most cost-effective ways to treat specific
disorders of all clients who present for treatment. They will require reliable answers,
based on studies comprising good internal and external validity that point to answers
that can be generalized to particular populations. Thus, an important skill for clinical
psychologists is not only to be able to produce evidence, but to know how to generate
and present research outcomes relevant to the target stakeholder.
One example of the targeted presentation of research evidence is the way that clinical
psychology is responding to the increasing industrialization of health care. Health care
costs began to rise dramatically during the 1980s and it became clear that both the
private and public sectors needed to be more assertive in the management of health
funds. Employee Assistance Programmes (EAPs) were one of the first responses, offering
corporations targeted services of early identification and minimal, time-limited inter-
ventions followed, if necessary, by appropriate referral. In the US, managed (health) care
organizations evolved with the development of Health Maintenance Organizations
(HMOs; where individuals or companies contract an organization to provide all health
 Chapter 1: A Science-Informed Model of Clinical Psychology Practice 11

services), Preferred Provider Organizations (PPOs; who reimburse a panel of providers

on a fee-for-service basis, typically with some form of co-payment), and Individual
Practice Association (IPAs; in which providers organize themselves to contract directly
with companies to provide health services). Although the particular structure of health
care varies markedly across different countries, all Western nations face the same
problems of increasing costs of health care (compounded by a growing aged population)
and share the same need of third-party payers (i.e., insurance companies and govern-
ments who pay the health bills) to rein in health care costs. Increasing costs have focused
attention more than ever upon efficient and effective health care and thus the need for
clinical psychologists to be able to demonstrate that their assessment and treatment
processes are not only effective, but they can be targeted, delivered in a timely manner
and offered in a definable and reproducible manner. Thus, in the past the rationale for a
scientific-informed practice was promoted within the discipline by professional organ-
izations (e.g., the American Psychological Association, the British Psychological Society)
and foresighted individuals (e.g., Thorne, 1947), but in recent times the rationale has
become increasingly externally motivated, in the form of third-party payers who are
demanding cost-effective health care. Whereas in the past the scientist-practitioner
model could be seen as a luxury representing an ideal worthy of pursuit, in the present
era of accountability it is a necessity ideally suited to demonstrate the value that can
be returned for every health care dollar invested in clinical psychology services
(Schoenwald et al., 2010). Stepped-care approaches, where lower-intensity psychological
interventions (e.g., brief focused interventions) are first delivered by generalist psycholo-
gists, with clients only referred to clinical psychologists if they do not recover, aim to
maximize the number of people who can be assisted within finite workforce resources
and without compromising outcomes. Lower-intensity interventions can also be helpful
for reducing the burden on clients (e.g., travel time, time away from work). The aim is to
match the level of care to clients’ needs – no more, no less. As consumers seek to
purchase quality services at cheaper prices, there will be a market edge to those who are
able to demonstrate that their products are both effective and economical.
In sum, science-informed clinical psychology does not have a single product to
market, but it produces many different outputs relevant to diverse audiences
(Castonguay, 2011). Clients will be interested in their personal well-being, whereas
society will be interested in the broader issues of descriptive psychopathology, etiological
models of disorders, treatment processes and outcomes, as well as efficient and effective
health care (Kazdin & Blase, 2011). The individual clinical psychologist requires the skills
to collect and present data relevant to particular stakeholders. Not all clinical psycholo-
gists are employed in the same capacity and the stakeholders each person deals with are
different, and therefore it is better to conceptualize the implementation of a science-
informed model of clinical practice as not being epitomized by a particular instantiation,
but as a strategic commitment to a scientific approach at the core of clinical practice.
Priority of strategy over procedure is essential, because the evidence base will always be
incomplete. The core competencies of a scientist-practitioner are most needed when the
evidence is equivocal or lacking (Newnham & Page, 2010; Shapiro, 2002). In the
remaining chapters we outline ways that a person with a commitment to the application
of science to clinical practice might approach the many tasks clinical psychologists
engage in. The first of these activities will be the difficult task of developing a strong
therapeutic relationship. https://avxhm.se/blogs/hill0
 Chapter
Relating with Clients

2
Imagine sitting face to face with your first client. What is the best thing to do or say?
What if you open your mouth and say the wrong thing?
This is an appropriately daunting image because you want to do the best for your
client and the stakes are high. Minimally, a therapist must aim to do no harm, but how is
one to exert a positive influence? One common response among students is to seek
technical guidance in the form of a treatment manual. There are published lists of
evidence-based treatments (e.g., Nathan & Gorman, 2015; NICE, 2021) that identify
the relevant treatment manuals and it makes sense to find the manual that matches the
client’s problem and to begin therapy. Furthermore, this seems reasonable because the
practice is scientific in that you can base your clinical decisions on the scientific
literature. Other students respond to the challenge of exerting a positive influence upon
clients by seeking to focus on the therapeutic relationship (Norcross & Lambert, 2019;
Norcross & Wampold, 2019). Once again, this is not an unscientific strategy, since there
is a substantial body of literature identifying aspects of the therapeutic process beneficial
to outcomes (e.g., Beutler et al., 2004; Bohart & Wade, 2013; Castonguay & Beutler, 2006;
Norcross, 2010; Orlinsky, Rønnestad & Willutzki, 2004). This approach has a long
history, with Frank (1973) suggesting that psychotherapy is an encounter between a
demoralized client and a therapist aiming to energize the client. Frank placed less
emphasis on what was done in therapy, and more emphasis upon how it was done;
specifically, he emphasized the therapist’s ability to mobilize a client’s motivation
and hope.
Thus, there are sound reasons for identifying an evidence-based treatment best suited
to a client, but there are also good reasons for fostering the therapeutic relationship. The
clinical psychologist will begin therapy by thinking about how best to manage the
relationship with the client to foster change and will be constantly reviewing it, and
responding to it (see Figure 2.1). This still leaves you with an apparent dilemma as a new
therapist: What is the best thing to do or say? However, the dilemma is easily resolved if
one understands that the two approaches are not mutually exclusive, but complement
each other.
Borkovec (2004, p. 212) spoke to this issue as he outlined his vision of an integrated
science and clinical practice. In answer to the question, “What is the empirical evidence
for what you do with a client?”, he commented that,
Certainly research on relevant empirically supported treatments (ESTs) is part of this review
process, but it goes further. The professional commitment of clinical psychologists is to be
knowledgeable about, and guided by, the empirical foundation of everything they do during the
therapy hour, and the psychological literature contains far more information relevant to this
12
 Chapter 2: Relating with Clients 13

Client data (problem, context, history, etc.)

Theoretical and Clinical training &

empirical literature experience

Assessment
The p rocess d imension

and The relationship

case formulation with the client is
a foundation
upon which
treatment is built
and a
Treatment planning & measurement
mechanism of
change
Treatment implementation & monitoring

Evaluation &
accountability

Figure 2.1 The therapeutic relationship is central to change in psychotherapy.

potential foundation than merely (though importantly) therapy outcome studies documenting the
efficacy of specific protocol manuals (italics added).

The empirically-based choice of the best treatment programme is one component of a

scientific practice of clinical psychology, but it is not the whole of it. To use a culinary
metaphor, scientific practice is not a garnish sprinkled onto clinical psychology, but it is
like salt that, once added to food, permeates the whole dish. The scientific practice of
clinical psychology and the use of evidence-based treatments do not abdicate a clinician
from the responsibility of fostering a therapeutic relationship in the best interest of the
client. We will later consider some components of evidence-based treatments, but first
we will review evidence-based components of the therapeutic relationship. The separ-
ation is not intended to imply that these are alternative options of conducting psycho-
therapy. Both aspects are integral parts of a strategic approach to provide an empirical
foundation for everything that happens in a therapy hour.

Empirical Foundations of the Therapeutic Relationship

The promulgation of treatment manuals could give the false impression that a therapist’s
behaviour exerts little influence over and above the specific ingredients of the manua-
lized therapy. A series of studies by Miller and colleagues highlights how this conception
would be false (Miller & Baca, 1983; Miller, Taylor & West, 1980). They found that a
treatment programme for problem drinking was equally effective when delivered by
therapists or in a self-help format. However, when they further explored the data, they
found considerable variability within the therapist-administered treatment programme.
Specifically, two-thirds of the variance in drinking outcomes at six months post-
treatment was predicted by the degree of therapist empathy. Even two years after the
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14 Chapter 2: Relating with Clients

completion of therapy, still one-quarter of the variance in drinking outcomes was

predicted by therapist empathy. Thus, there were some therapists who administered a
standard treatment programme with outcomes that far exceeded those achieved with
self-help, but there were other therapists whose clients would have been better off if they
had read the book by themselves. Therefore, scientist-practitioners will need to identify
and cultivate those therapeutic behaviors that reliably relate to positive client outcomes
(e.g., Miller & Rollnick, 2012).
One way to identify evidence-based therapeutic behaviours is to determine which
behaviours that occur during treatment are positively correlated with therapeutic out-
comes. These were reviewed by a task force of Division 29 of the American Psychological
Association (Ackerman et al., 2001; see also Orlinsky et al., 1994, 2004; Norcross, 2010;
Norcross & Wampold, 2011). They divided the behaviours into those that were demon-
strably effective and those that were promising and probably effective. Of the demon-
strably effective behaviours they identified the therapeutic alliance (or cohesion in the
context of group therapy), empathy, and having goal consensus and a collaborative
relationship. Of promising and probably effective behaviours they identified establishing
a relationship where there is positive regard for the client, the therapist interacts in a
manner where they are genuine (i.e., their manner of presentation is congruent with who
they really are), elicit feedback about the psychologist’s behaviour, repairs ruptures to
alliance (an issue we will return to in subsequent chapters), occasionally and appropri-
ately discloses information about themselves, while managing their own issues so that
they do not adversely impact on therapy (i.e., manages countertransference).
From the review it is clear that process variables can be divided into the three
categories, namely those related to the client, the therapist and the relationship. In
addition, Norcross and Wampold (2011) noted a variety of ways that therapy can be
adapted to individual clients that may enhance outcomes. Their review noted that
outcomes could be improved when therapists adapted therapy in response to factors
such as the resistance expressed by the client, the preferences for therapy, the client’s
cultural background, the client’s religious beliefs and spiritual values, as well as the
client’s typical coping style and the person’s stage of change. We will return to the
methods of adapting therapy in light of the client’s response to therapy and their
particular attributes later in the book, but for now we will focus on the general issues
concerning the client, the therapist and their relationship. Bearing in mind the caveat
that the actions of a client and therapist affect each other reciprocally, it is possible to
draw a number of lessons from these reviews of the literature.
First, the quality of the therapeutic relationship is related to outcome and both client
and therapist behaviours are involved. Thus, it is relevant to consider what activities
enhance the therapeutic bond. Second, clients possess a variety of qualities that are
positively associated with outcome. While there will be individual differences in these
qualities, it behoves the therapist to maximize the extent to which these behaviors are
exhibited during treatment. For instance, client conversational engagement is positively
correlated with outcome and, although clients will vary in terms of their levels of verbal
activity, the therapist should be mindful of strategies to maximize client verbal activity.
Third, a novice therapist may take some comfort from the observation that although
therapist credibility is related to outcome, the size of the effect is weaker than many other
factors. That is, even if you feel unsure when you are seeing a client, remember that this
variable is not among the largest predictors of therapeutic outcome.
 Chapter 2: Relating with Clients 15

Thus, certain client behaviours as well as specific therapist behaviours should be

maximized to enhance outcome. Outcomes will be enhanced when the therapist creates
an environment in which the client is able to discuss their problems collaboratively in an
open and easy manner. The therapist will be working hard to maximize the therapeutic
bond, by showing empathic affirmation (acceptance, warmth, positive regard) of the
client. In a nutshell, the therapist will work hard to develop the therapeutic alliance.

Building a Therapeutic Alliance

Broadly speaking, the therapeutic alliance involves three components (Bordin, 1979).
First, the client and therapist agree on therapeutic goals. Second, the therapeutic alliance
involves the assignment of a task or set of tasks for the client, which can occur within the
therapy session or between sessions. The final component is the development of a
therapeutic bond. As Ackerman and Hillensroth (2003) noted, despite much research
focusing on the relationship between the therapeutic alliance and outcome (e.g., Bohart &
Wade, 2013; Martin, Garske & Davis, 2000; Norcross & Wampold, 2019; Orlinsky et al.,
1994, 2004), much less research has addressed the particular behaviours of the therapist
that foster and strengthen the alliance. Based on a review of the existing literature, they
identified a set of therapist attributes and techniques that are positively related to a strong
therapeutic alliance. Their work suggests that in terms of personal qualities, a good alliance
is associated with therapists who present with warm and friendly manner, and who appear
confident and experienced. Therapists with a good therapeutic alliance will be interested in
and respectful towards their clients, and they will relate with honesty, trustworthiness and
openness. During therapy, they will remain alert and flexible. In terms of providing a safe
environment for clients to discuss their issues, therapists will be supportive and use
reflective listening skills, affirm the clients’ experiences and demonstrate an empathic
understanding of each client’s situation. Therapists will attend to the clients’ experiences
and facilitate the expression of affect, to enable a deep exploration of concerns. In terms of
the practice of therapy, clinicians with a positive alliance provide accurate interpretations of
clienta’ behaviours, are active in treatment and draw attention to past therapeutic successes
(Ackerman & Hillensroth, 2003).
Drawing together the themes evident from the preceding reviews of therapy processes
and the therapeutic alliance, a number of general conclusions can be drawn about the
conduct of a therapy session. First, in terms of the therapist, it is important to be warm,
empathic and genuine. Second, the client needs to be actively engaged in therapy, with a
good understanding of what is occurring. Third, the relationship between the client and
therapist needs to be collaborative, with a good rapport. We will now illustrate the
specific behaviours that can strengthen the alliance by describing how they may be
appropriate at different points in an initial session with a client.

Relating with a Client to Build an Alliance

It is useful to begin a session with a polite introduction, making an effort to be warm and
friendly. Therefore, make sure that you make eye contact as you say the client’s name and
permit time for the small talk that often follows an introduction (e.g., a discussion of
parking difficulties or problems finding the clinic). However, the small talk must not
detract from attention to the problem, so to convey a genuine interest in the client you
need to shift focus swiftly to thehttps://avxhm.se/blogs/hill0
client’s main concerns. Thus, invite the client to sit down
16 Chapter 2: Relating with Clients

with chairs arranged so that you sit side on, but still facing the client, at a comfortable
distance. Before asking the client to describe their concerns, it is important to discuss
issues of confidentiality (see Chapter 11). Briefly, there are two aspects to this. On the
one hand, you want to make it explicit that material raised remains confidential. On the
other hand, confidentiality is not absolute and there will be occasions when you may be
legally or ethically bound to inform a third party. It is prudent to draw the client’s
attention to these circumstances (e.g., when there is an explicit threat to harm the self or
another specified person, when a child is in danger or when subpoenaed by a court of
law) verbally or in written documentation. Although it may seem a little awkward to
raise these issues, it is easier to raise them at this point and it also allows clients a few
moments to settle themselves.
Once the preliminaries are over, it is time to ask the client to introduce the problem.
Since you are trying to be respectful and affirming, it is useful to let the client provide
this introduction. On some occasions you will have referral information or prior case
notes and therefore you may want to begin by indicating to the client that you would
“like to hear it from you first”. In asking about the client’s difficulties, you are aiming to
create a sense of openness. One way to do this is to begin by asking, “What seems to be
the problem?” or “What brought you along today?” In so doing do not impose a
structure, but let the client raise the issues as they would like to (but see Chapters 7,
8 and 16 for circumstances when it is important to impose structure right away; for
example, in many medical settings, time constraints often require rapid assessment skills,
and a purposeful structure is essential for eliciting as much information as possible in the
limited time available). Ask questions, but permit the client to define their problems.
Sometimes you will have prior information and it can be helpful to mention this. For
example, “You mentioned on the phone that you were having difficulty with ‘depressed
mood’, could you tell me about it?”
On occasions clients are reticent at the outset of therapy and it may be useful to
acknowledge some of the discomfort, perhaps by saying, “People are often concerned
about seeking professional help, but I’m glad you came to see me. It is the first step in
doing something about your difficulties.”
In asking a client questions, the form of questions can be closed or open. Closed
questions can be answered in a few words or even with a simple “yes” or “no” (e.g., “Do
you live with your family?”). They are useful for focusing an interview and obtaining
specific information, but used to excess they constrain the client and place the burden of
directing the session upon the therapist. Open questions are those that take many words
to answer and in so doing, encourage the client to provide the maximum amount of
information (e.g., “What is your relationship with your family like?”). Thus, open
questions are preferable as ways to begin an initial interview with a client, but relatively
more closed questions may be used to begin a session later on in therapy (e.g., “Last week
we talked about managing your tension while asserting yourself. How did you go
with that?”).
As the client is talking you need to reflect upon how you are coming across to the
client. First, be aware of your eye contact. Make sure that you look at the client. Although
you will normally look away more often when you are speaking than when you are
listening and eye contact is rarely a continuous stare, you need to be able to watch the
client for behavioural signs relevant to their problems (e.g., breaks in eye contact, shifting
in their seat). In addition, eye gaze is an important implicit cue in communication used
 Chapter 2: Relating with Clients 17

to signal turn taking (i.e., a speaker will restore eye contact to signal that a communi-
cation is complete) or to seek confirmation (e.g., a speaker will look to a listener when
expecting a response to their communication). It is also important to be aware of cultural
differences in eye contact (e.g., Australian Aboriginal people tend to avoid contact when
discussing serious topics). One trap for the novice therapist to avoid is excessive note
taking. The client is not a topic to be studied, but a person with whom you are relating.
Therefore, jot down an occasional aid to memory rather than a transcript of the
conversation. Building a warm and friendly relationship is more important to the
therapeutic alliance than a comprehensive record of the session.
Second, in terms of body language scan both the client and yourself. Ensure that your
proximity is comfortable to the client, so that if they move their chair forward or
backward, do not adjust yours to a distance negating the client’s move. Watch for
changes in body posture that indicate discomfort or greater assurance. Also be alert
for discrepancies between the client’s body language and their verbal tone and content.
For example, the client who folds her arms while saying that she is quite comfortable
with her boss’s decision may prompt further questioning from the therapist. Likewise,
ensure that your body posture does not communicate impatience (e.g., pen tapping),
boredom (e.g., doodling), defensiveness (e.g., arms crossed), discomfort (e.g., breaking
eye contact), or excessive earnestness (e.g., sitting too far forward in your seat). Your aim
is to convey honest acceptance while supportively affirming the client. If you feel unsure
how best to sit, mirroring the client’s behaviour can be a good start or leading the client
by modelling a relaxed and open manner (e.g., feet firmly on the floor, arms on your legs
with palms open).
Third, your voice needs to convey friendly interest. Therefore, watch for signs of
emotional tone in your voice and ensure that it matches any emotional content. Likewise,
pay attention to the client’s emotional tone. In addition to tracking the vocal tone, track
the verbal content. Align your conversation with the client’s interest and signal any
transitions (e.g., “I was wondering if we could switch from the problems you are
presently having with your drinking and go back to when it all began, so that I can get
a clearer idea of where it all came from. Is this OK with you?”). Transitions signal a
change, but it is also useful to include a brief summary of the material covered most
recently in the session to indicate that you have been listening to the client. The way that
you respond to the client will influence the course of the interview, so track the verbal
tone and content of your responses. For instance, consider how the tone of the interview
and the content of the client’s response would vary if you responded to the client saying,
“I’ve just lost my job” with (a) “that was very careless of you”, (b) “how did that happen?”
or (c) “how do you feel about losing your job?” Another way to track the client’s verbal
content is to identify important words. Statements that begin with “I” can often be
relevant because they are important to a client and the use of the personal pronoun
communicates the personal significance. Clients will also emphasize certain words to
highlight key issues. For instance, confusion or ambivalence about impulsive behaviour
may be indicated by emphasis in a sentence such as, “WHY do I keep drinking too much
and getting together with the wrong sort of guys?”
The questions that you ask will help the client to elaborate upon their responses. For
example, in an initial interview you could ask open questions to facilitate greater
discussion of a topic by asking, “Could you tell me more about that?” or “How did
you feel when that happened?” Sometimes you will need to get a client to be more
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18 Chapter 2: Relating with Clients

specific or concrete and at such times you could ask, “Could you give me a specific
example?” or “Tell me about a typical drinking session.”
The form of a question will also influence the type of answer. What questions, often
lead to factual answers, therefore they are the easiest to answer. How questions initiate a
discussion of processes and an account of a sequence of events. Why questions bring
about a discussion of possible reasons. One problem with why questions is that even
though they give you an indication of the client’s perceptions of causation, they can put
individuals on the defensive and may produce discomfort if they imply blame. Further,
Nisbett and Wilson (1977) mount a convincing case that humans do not have introspect-
ive access into the causal cognitive processes despite being happy to elaborate on what
they believe to be the correct answer. This is perhaps also one reason why a frequent
response by clients to a “why” question is “I don’t know.” “Why” questions are difficult
to answer on the spot. Nonetheless, awareness of a client’s perception of the cause of
their problems (independent of its validity) is useful information when presenting to a
client a problem formulation. An alternative to asking direct “why” questions is to
indirectly pave the way toward some causal insight by beginning with a “what” question.
For example, an answer to the question “Why are you upset with your husband’s
decision?” requires considerable cognitive processing entailing deliberation and judge-
ment. In contrast, the question “What is it about your husband’s decision that upsets
you?” prompts the client to simply describe and list all the “things” that come to mind
that are upsetting to her. It is far easier for the client to look at a list of concrete
exemplars, and then arrive at an overall judgement “why” she was upset, than to ponder
that question in the abstract via internal processes. Thus, “what” questions are often
better than “why” questions when it comes to eliciting answers about the reasons for a
client’s behaviours, thoughts or feelings. Finally, could questions (e.g., “Could you tell me
what your husband does that makes you mad?”) tend to be maximally open-ended and
therefore useful for generating many options for the client (including a refusal
to answer).
However, as you ask questions, remember the goal of therapy is not just to elicit
information, but to facilitate a communication. Therefore, track the client’s responses to
your style of interaction. If your client looks confused, check that you have not been
using multiple questions (e.g., “I wonder if you could tell me when the difficulties with
your wife began, first her jealousy and then her drinking, but also tell me how you felt
about each of them and how each of your children reacted to the whole situation?”). If
your client looks uncomfortable, check that you are not asking an excessive number of
overly probing or closed questions. In a therapy context, the clinician exerts a degree of
influence over the interview that is not present in social contexts, such that clients feel
obliged to answer each question. Therefore, reflect on each question and ask yourself if
you need to know the information. Although the material elicited in a session is
confidential, you do not wish to explore a client’s private life any more than you need
to. Also, if the client is reticent about answering your questions, consider if you have
been using statements framed as questions. For instance, you might say, “Don’t you
think it would have been more helpful if you had studied harder?” which is really a
judgement about the client’s effort rather than a helpful therapeutic question. In our
experience, one word to watch out for in this respect is “so”. Often a question or
statement that begins with “so” is one that is about to tell the client what you think.
For instance, you might say, “So you’ve been feeling pretty bad lately.” These comments
 Chapter 2: Relating with Clients 19

are much better re-phrased as genuine questions (e.g., “Could you tell me how you’ve
been feeling lately?”).
Fourth, non-attention and silence are potentially useful therapist responses. If a client
repeatedly brings up the same topic, you may feel the need to shift attention elsewhere.
The danger with this strategy is that clients may keep returning to topics when they do
not believe you have understood what they are saying or how distressed they are. We will
discuss reflective listening in more detail later, but if you are sure that you have heard the
message and it is time for a change in topic it is sometimes useful to say, “I hear how
distressed you are” while maintaining eye contact with the client. Wait until you get a
clear sense that your message has been heard by the client before moving on.
The novice therapist is sometimes worried about silence, believing that the job of the
therapist is to fill the therapy hour with words. Notice in our review of the process
variables that were related to outcome, the verbal output of the client, but not of the
therapist, was consistently related to outcome. Therefore, do not worry about silence.
Sometimes saying nothing is the best support you can give. Sometimes you cannot think
of what to say because there is nothing to say. Sometimes you need time to think about
the best response. Either way, a receptive silence can be a useful therapeutic tool.

Encouraging, Restating and Paraphrasing

So far we have considered the style of questioning and behaving. Although these
techniques are important, the goal of a session is to both give and receive information.
The information the client is providing will be both verbal and non-verbal. Some
information will be explicitly communicated by the client. Other information will be
communicated without the client’s awareness or will need to be inferred by the therapist.
Receiving all the client’s messages, decoding them correctly, and conveying to the client
that you have accurately heard and understood the rich and complex tapestry of words,
emotion and behaviours is at the heart of empathic communication.
Three strategies that assist the therapist to communicate that client messages have been
received are encouraging, restating and paraphrasing. Encouraging typically involves
behaviours such as head nods, open gestures, positive facial expressions, and verbal
utterances (e.g., “U-huh”). Each of these therapist responses seeks to convey an encourage-
ment to continue with a particular line or style of responding. These encouragers need to
be used judiciously, since too few leave the therapist looking wooden and too many can be
annoying. Remember, the responses are intended to encourage elaboration on particular
points, so make sure that you use them when you wish to reinforce a particular utterance.
Thus, one trap to avoid is saying “yes” before a client has finished a sentence or idea.
Therapists can also provide encouragement by repeating key words from a client’s
response. For instance, if a client said, “It happened again. I walked into the office, it
went quiet, and I felt that everyone was looking at me. Suddenly I felt that rush of anxiety
and started to blush” you might respond, “Everyone was looking at you?” or “you
blushed?” Each response encourages the client to elaborate on a particular facet of the
experience and the clinician will opt for a particular line of response depending on the
overall agenda. The preceding responses would lead the session towards a discussion of
the office workers’ perceptions on the one hand or the client’s physiological response on
the other. Later in therapy a clinician might wish to explore recurring patterns and may
wish to draw attention to the repetition by responding, “It happened again?”
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20 Chapter 2: Relating with Clients

Other encouragers may be more focused. For instance, you might ask questions to
establish the generality of a behaviour (e.g., “How often do you drink each day?”),
situational influences (e.g., “Where do you drink?”), onset (e.g., “When did it all
begin?”), or course (e.g., “Has it been the same all the time?”).
Paraphrasing is a deceptively simple skill. The aim is to distill the client’s explicit and
implicit messages into a single utterance. The verbal and non-verbal cues, the key ideas
that have been spoken and inferred concepts, are concisely summarized. Thus, the key
skill in paraphrasing is not speaking, but listening. Begin by paying attention to every-
thing the client is communicating and take time to reflect on the explicit and implicit
messages. Consider any themes or important features, evaluate the discrepancies
between verbal and nonverbal communications, and formulate a response. Although
we will now turn to ways that a summary can be expressed, we cannot emphasize enough
the extent to which the key to a successful summary is the thought that occurs before you
open your mouth. Providing a good summary can also be facilitated by collecting
relevant information. Asking the client how they react to their problems and how others
respond can provide you with key elements to include in a summary.
A summary often begins with a stem, such as “It looks to me . . .” or “What
I’m hearing is . . .” or “Putting these ideas together . . .”. The summary brings together
the main points of the issue from a client perspective. To convey clients’ perspectives,
try to use their language. For instance, if clients have used the terms “sadness” and “grief”
to describe their experiences, use their words rather than another such as “depression.”
Try to clearly express the main elements of the problem. Often clients will be confused
and ambivalent so the therapist can assist by highlighting key themes or drawing
together seemingly unrelated symptoms into a coherent picture. Finally, after presenting
a clear, succinct and meaningful summary, request explicit feedback to check your
understanding. You might ask, “Am I hearing you right?” In addition, check that your
coverage has been sufficient. We prefer questions such as “What have I missed out?”
rather than “Have I missed anything out?” because the former presumes incompleteness
and inaccuracies and therefore implicitly encourages correction.
Putting together these three skills of encouraging, restating and paraphrasing,
imagine how you would respond to a client who said, “I’m really concerned about my
teenage daughter. She used to talk to me and now she has become sullen and withdrawn,
so we don’t talk. I’m so worried that she’s getting into something bad. She’s got all these
new friends and she won’t tell me what they get up to. I don’t know what to say, but if
she’s been using drugs then she can just leave home as far as I’m concerned!”
An encourager might be to respond, “You don’t talk?” A restatement might be,
“You are terribly concerned about your daughter.” Finally, a paraphrase might be, “I’m
hearing a few themes emerge in what you say. One theme is that you seem concerned;
concerned about the loss of communication with your daughter and concerned about the
possibility of harm, so much so that you’d consider asking her to leave. Another theme
seems to be one of loss; you describe a sense of loss of communication, closeness and
influence. Have I heard you right?” In the paraphrase, some elements are reflections back
of what the client said, but others are inferences based on the client’s comments. That is,
the client did not discuss her feelings about a loss of influence and control over her
daughter as she becomes more independent. However, the therapist knows this is a
common issue between parents and teenage children, so speculated that this unspoken
theme was present, and therefore presented it as a hypothesis. It is wise to check that a
 Chapter 2: Relating with Clients 21

paraphrase is correct, but essential to do so when an inference or speculative interpret-

ation is being presented.
These three communication skills are useful steps in developing an empathic under-
standing between you and your client; however, empathy goes deeper than communi-
cation. Empathy is the ability to see the world from the perspective of another person
and communicate this understanding. Behaviourally, it is possible to define verbal and
nonverbal actions and attending skills that are associated with empathy, but at its heart
empathy is a relational construct. It involves putting yourself into another person’s shoes
so that you can share a deeper relationship (Egan, 2019). The deep relationship involves
positive regard. Positive regard involves selectively attending to the positive aspects of a
client’s communication. It stems from a humanistic worldview that people are inherently
moving forwards and growing in positive way (i.e., self-actualizing). Highlighting these
positive aspects identifies positive assets a client can build upon and conveys a sense of
warmth and acceptance. Empathic communication also conveys respect and warmth.
Clients may not have told others about the issues that they raise in therapy, and thus it is
important to convey respect for the client. Show that you know that they are doing their
best to deal with their issues. Transmit appreciation for the person’s worth as a human
being and communicate warmth by smiling or using facial expressions conveying
empathic concern when responding to a client’s emotions. Clues that the therapist
may be failing to empathize and understand the client’s worldview may be feelings of
confusion, frustration, boredom, irritability or anger. The therapist’s job is to notice
these emotional reactions, formulate them and respond to them in therapeutic rather
than counter-therapeutic ways. We will discuss these process issues more in Chapter 13.
The empathic therapist also needs to demonstrate congruence (having a minimal
discrepancy between their perceived and actual self ), genuineness and authenticity.
Possession of these attributes ensures congruence between verbal and nonverbal behav-
iours, which ultimately facilitates communication with clients. Clients are the focus of
any session and therefore the therapist’s issues must not clutter the therapy process.
Therapists who are not fully accepting of their clients may exhibit incongruence between
their verbal and nonverbal behaviours, which clients may pick up on. If a therapist
responds more strongly emotionally to a particular client than others, this might be a
clue that counter-transference is occurring (e.g., therapist beliefs, values or relational
patterns are being challenged by the client) along the process dimension. It is critical that
therapists develop the skills to attend to these reactions, understand and formulate them,
and respond to the client in therapeutic ways. Responding emotionally to clients is not at
all a reflection of therapist incompetence and in fact it is very normal. However, if
countertransference interferes with the therapist’s ability to empathize with the client,
then ruptures in the relationship may occur. Later in this book (Chapter 13) we will
return to how therapists can learn to better understand and formulate their own
reactions to clients to prevent ruptures or repair them when they occur. To reiterate, it
is normal for therapists to react more strongly emotionally to some clients than others
and, rather than being a problem, this can be a very important source of information for
the therapist to use when deciding how to respond most therapeutically for a particular
client. The therapist needs to determine whether their reaction is likely to be client-
induced (i.e., probably typical of how most people respond to the client’s behaviour) or
therapist-induced (i.e., triggering the therapist’s issues). Client-induced reactions provide
important information about the impact the client is likely to have on others in their life,
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22 Chapter 2: Relating with Clients

how others are likely to respond and how the therapist can respond in new, more helpful
ways. Therapist-induced reactions provide clues about issues the therapist needs to
discuss in supervision and/or their own therapy to ensure they do not continue to arise
in unhelpful ways during therapy. The therapist’s ability to formulate their emotional
response to a client will increase the likelihood that they will respond in the session with
“client specificity”, that is, in the most therapeutic way for that particular client.
Like reflecting the verbal content of a communication, reflecting an emotion begins
with a sentence stem followed by a feeling label. The emotional word or phrase aims to
use the minimum number of concepts to reflect the affect in the correct tense. For
example, match your tense to that used by the client, so that if a client says, “I felt down”
it would be better to use the past tense, than to say, “Your mood seems low.” Once again,
conclude with a check to ensure that your reflection of feeling is accurate.
One facet of a session that is easy to omit is an assessment of the client’s skills,
strengths and resources. It is a common trap to fall into because clients want to discuss
their problems. However, clients are first and foremost people, who also happen to have
some problems. Therefore, spend time explicitly considering clients’ coping mechanisms
and supports. You might ask, “With whom do you talk most often?” and then discuss
what they enjoy talking about. Evaluate if they use other people for distraction, depend-
ence, encouragement and motivation, or clarification. You can also ask the client about
interests, social activities and religious/spiritual practices.
When coming to the end of a session, summarize the issues covered and draw the
themes together. Typically clients will have identified a set of concerns, thus you could
say, “Have I got it right, it seems that the main issues for you are . . . let us try to rank
them into a ‘stepladder’ of concerns beginning with the least problematic and stepping
up to the more concerning.” This hierarchy can help set an agenda and identify a
tentative treatment plan. Also check that nothing has been omitted by saying, “You have
talked about your checking and the intrusive thoughts as well as your depressed mood.
Are there any issues we haven’t talked about that you’d like to discuss?” or “Is there
anything else you would like to tell me?” Finally, at the end of a session, conclude with a
clear statement about what is going to happen next. This may involve psychological
testing or scheduling a referral or another appointment. The goal is to leave clients with a
sense of closure and clarity about the next step.

Troubleshooting
One of the attributes of a strong alliance is flexibility. Therefore, as a clinician it is
important to be able to bend with clients. A planned session structure may need to be put
on hold or re-organized depending on what clients raise. The uncertainty created may
instill a degree of discomfort, which the therapist needs to learn to tolerate in order to be
responsive. Having said this, there are common issues clients raise that it is good to have
some considered answers.
First, clients often ask, “Do you think you can help me?” Therapists must avoid being
overly optimistic, especially if clients raise the issue at the outset of an initial session. If
you have not collected sufficient information to answer the question, then indicate that
you would prefer to return to it at the end of the session. If you say this, then make sure
you do return to the issue (perhaps putting a reminder at the end of your notes). On the
other hand, if you have a clear idea about the probable treatment response and a client
 Chapter 2: Relating with Clients 23

asks, “Can you cure me?”, then emphasize that you will be working with the client to help
them to learn strategies to better manage troubling situations, relationships, behaviours,
and emotions. Sometimes describing a stress-diathesis model is helpful in communi-
cating to the client their role in dealing with their problem. For instance, a sunscreen
metaphor can be of assistance, where you explain that a person with fair skin will burn
more easily in the sun. They might not be able to change their tendency to burn, but they
can learn to put sunscreen on to cope better with the potentially damaging rays of
the sun.
Second, some clients (especially those with anxiety) may worry that they are going
crazy. Silence can be damning at this point, as clients will watch you for signs of
hesitation and interpret these as indications of your true beliefs. Therefore, respond
quickly and convincingly. For instance, people (with anxiety) may worry that they have a
disorder like schizophrenia and comparing and contrasting their symptoms with those of
a psychotic disorder can be helpful.
Third, clients will often cry during a session. Ensure that tissues are on hand (and it is
wise to routinely check they are within a client’s easy reach before the session begins). In
addition, use non-verbal cues to convey support and sympathy. Lean forward in your
chair (but do not touch the client) and allow silence. Do not rush in and provide
reassurance, but allow the client’s crying to reach a natural conclusion. Be satisfied with
silence until the client uses verbal or non-verbal cues to signal they are seeking a
response. Clients often end a period of crying by apologizing or saying “that was silly”.
Rather than engaging with these sentiments, it is more useful to redirect attention to the
trigger and its response by saying something like, “It seems this situation upsets you a
great deal.”
Fourth, clients can be agitated in the session. When you notice increasing agitation, it
is most helpful to break off from the current line of inquiry and focus on it directly by
saying, “You seem uncomfortable today, what is going on for you at the moment?”
Fifth, although novice therapists often worry they will not be able to fill the therapy
hour (and hence over-prepare), a more common problem is a talkative client. It is
particularly a problem for novice therapists because if you have worried that you will
not fill the session, or are concerned that you might say the wrong thing, a talkative client
is a seeming godsend since you do not have to say another word. However, silence is not
always the best response. The client may need your guidance, so start to use more specific
closed questions. You also may need to be more intrusive and interrupt the client to
impose some order. For instance, you might say, “You have raised many issues, which
one is the most important?” Trainee therapists often worry that interrupting the client
will upset them and damage the therapeutic alliance, but most clients are quite comfort-
able with therapists providing explicit cues about how much detail is required in their
answers. Clients will usually be responsive and easily shift focus. If a client does react
strongly to gentle redirection, this provides the therapist with useful information about
their cognitive and interpersonal style.
Sixth, clients can ask you for your advice (e.g., “what do you think I should do?”) or
invite you to take sides (e.g., “You agree with me don’t you? No-one should have to put
up with that sort of behaviour.”) In each of these situations, it is helpful to draw attention
to the collaborative nature of the session. As a therapist you are there to work with the
client, but at the end of the day, they are the ones who must live their lives. Therefore,
you might respond, “I don’t want to talk about what I would do, because we are talking
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24 Chapter 2: Relating with Clients

about the problems you are facing. However, I am going to work with you to see if we
can find some solutions to these problems.”
Seventh, clients (and therapists) may wander off topic and it becomes necessary to
refocus the interview. Sometimes is it useful to say, “I’d like to get back to your main
concerns” or “I’m wondering if it might be more productive to focus on your current
situation for the time being.” Clients may also depart from the therapist’s schedule by
wanting to move too rapidly into treatment. This is understandable, since clients seek
resolution of their problems, but it may be necessary to cover other material in the
session first. The clinician might say, “I need to know more about your current problems
before we can work out a plan of action.” The client may also want to focus on a domain
(e.g., childhood relationships) before fully explaining the problem. Thus, the therapist
might say, “I would like to know more about your upbringing, but first I need to
understand more about your current difficulties. Is this OK with you?”
Finally, clients can ask you for information that you deem to be personal and off
limits. The therapeutic relationship is not the same relationship that exists between
friends, acquaintances, or even doctor and patient. Rather, it is friendly, in that it is
truthful, honest, caring and attentive. Thus, there is empathy, but also appropriate
professional separateness and boundaries. Clients come to discuss their problems; you
are not there to discuss yours. Clients are there to discuss their lives; you are not there to
elaborate on yours. That being said, it can be discourteous and unhelpful to refuse to
respond to any requests. Clients may reasonably desire to have some idea of the person
they are sharing intimate details with. Therefore, consider before therapy begins, the
nature and extent of material you are willing to divulge. For instance, clients can ask if
you have had a problem like theirs. Therefore, consider if you have, how you will
respond and equally, if you have not, how you will respond. Additionally, clients may
ask about your personal life (e.g., “do you have children?”) since this may establish your
credibility to them. How will you respond comfortably in a genuine and truthful way and
what will be most beneficial to the client? Refusing to answer questions point blank can
disrupt the relationship, and evasive and disingenuous answers are often annoying to
clients. However, if you decide to divulge personal information, ensure that you have
considered all the potential effects (therapeutic and counter-therapeutic) and that you
are clear about the reasons you are self-disclosing. Some questions you might ask before
self-disclosing are: Am I about to self-disclose because I believe it will strengthen the
therapeutic relationship in an important way (carefully consider any potential down-
sides)? Am I disclosing because I feel anxious about setting or enforcing appropriate
boundaries (consider seeking supervision or therapy to work on your need to please and
under-assertiveness)? Am I disclosing to get my own needs met (seek supervision or your
own therapy)? In Chapter 13 we will discuss the differences between self-disclosing and
self-involving statements. The former runs the risk of refocusing the session on you
rather than the client and may reveal more about yourself that you wish your clients to
know. The latter are statements about the therapeutic relationship (the process dimen-
sion) and can be helpful ways of strengthening the alliance and moving therapy forward.
In some settings (e.g., rural and remote locations) the issue of therapist confidential-
ity is a moot point. Since you live in the community in which you work and socialize
with the people who are potential clients, the boundaries need to be made explicit with
clients (see Chapter 13). Even therapists in urban areas need to reflect on the possibility
of meeting a client in a non-therapy setting. For example, the authors have met their
 Chapter 2: Relating with Clients 25

clients in the changing room of a gym, at parties, at airports and even on a remote
wilderness track! Therefore, consider how you are going to respond when you meet your
clients outside of therapy and if this is likely, then it may be wise to raise it explicitly.
If you have reason to believe it is likely that you will see your client between sessions
(e.g., you share acquaintances, live in the same area, engage in the same activities), you
might pre-empt the discomfort by letting them know that when you see clients outside of
session you do not acknowledge them to protect their confidentiality, so this should not
be interpreted as rudeness. If you are working in a small town and will encounter the
person in social settings, you might discuss the fact that there will be a clear boundary
between what is discussed in therapy and that you will avoid any mention of the client’s
therapy sessions (including that they even attend your clinic) in the social setting.
Although this might seem obvious to the therapist, a frank discussion can be important
for easing clients’ concerns and ensuring they feel safe to disclose in therapy.

Destroying the Therapeutic Alliance

The novice psychologist can often be daunted by the prospect of building a therapeutic
alliance and may worry, “am I doing the right thing?” To this end, it can be helpful to
reflect on the therapeutic behaviours that can undermine a good relationship with your
client. Being cognizant of these factors can provide a sense of the “boundary conditions”
of a good therapeutic alliance.
Norcross and Wampold (2011; Norcross, 2010) in their review identified a series of
factors that damage the alliance. The authors warned psychologists to avoid confron-
tation and criticism of clients. Miller, Wilbourne, and Hettema (2003) demonstrated that
confrontation tended to lead to adverse therapy outcomes, whereas rolling with the
resistance was associated with positive outcomes (Lundahl & Burke, 2009). Therefore,
avoid comments that are pejorative, critical, blaming, invalidating or rejecting. Norcross
and Wampold also cautioned against being therapist-centric and assuming an all-knowing
approach. The client’s perspective predicts outcomes better than the therapist’s perspective
(Orlinsky et al., 2004) and psychologists are not good judges of poor progress (Lambert,
2010). This raises the question, how can a psychologist know the client’s perspective on
therapy and be sure of their progress? Subsequent chapters will consider how best to obtain
the client’s perspective and respond to difficulties that arise in the therapeutic relationship,
but at this stage it is sufficient to say that using the listening skills described can provide a
good foundation. We will then consider how a measurement system that collects data to
supplement clinical impressions can assist this process (see Lambert, 2010; Newnham &
Page, 2007, 2010; Nordberg et al., 2014; Scott & Lewis, 2015).

Summary
In conclusion, a science-informed clinical psychologist needs to be cognizant of the
empirical literature relevant to the therapeutic relationship. Empirically supported treat-
ments may include specific components that bring about change in the client’s behav-
iour, but the therapeutic relationship is a way of bringing the client into contact with the
therapy. Deciding upon a treatment requires careful consideration of many client-related
factors and making this decision requires careful assessment of the client as a person and
their presenting problems. Assessing clients is the topic to which we now turn.
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 Chapter
Assessing Clients

3
Picture yourself conducting a clinical interview. A 32-year-old married woman has
presented to the service where you are working with difficulties getting to sleep and so
you have prepared by reading about insomnia. You open the interview by asking the
client to elaborate on her problem. She describes lying in bed, unable to sleep because
concerns and worries spin around her mind. In addition to the symptoms you expected,
the client tells you that she is overly irritable during the day, has extreme difficulty
concentrating, is chronically indecisive and feels immense fatigue. Suddenly, the seem-
ingly simple problem of insomnia has expanded as the client describes other problems
that could be part of the sleep difficulties, but could represent another problem
altogether. As a clinician you are faced with a number of dilemmas:
 Are the problems related in any way? If so, which problem do you treat first?
 Are the problems manifestations of one underlying cause or multiple causes?
 What treatment is best for which problem or constellation of problems?
Clinical psychologists tackle these dilemmas with every new client. From Figure 3.1 it is
apparent that the assessment process involves an objective psychometric assessment, the
gathering of relevant background information during an intake interview and an examin-
ation of the client’s mental state based on observations made during the interview.
Together, these data permit a description of the particular profile of symptoms, along with
a formulation of the predisposing, precipitating and maintaining factors of symptom
presentation.
Diagnostic manuals represent the distillation of clinical experience and research into
a format that identifies which problems tend to group into meaningful clusters. These
clusters can assist therapists to plan potentially effective treatments because as scientist-
practitioners they are then able to refer to and use the psychological literature that bears
on the relevant diagnoses. In this chapter we will first consider current diagnostic
practices and their limitations, as well as structured ways to conduct diagnostic inter-
views and a mental state examination. However, before considering diagnostic systems, it
is necessary to define “mental disorder”.

What is a Mental Disorder?

In its Eleventh Revision of the International Classification of Diseases and Related Health
Problems (WHO, 2021) the World Health Organization (WHO), defines mental dis-
orders as “clinically significant disturbance in an individual’s cognition, emotional
regulation, or behavior that reflects a dysfunction in the psychological, biological,
or developmental processes that underlie mental and behavioral functioning. These
26
 Chapter 3: Assessing Clients 27

Client data (problem, context, history, etc.)

Theoretical and Clinical training &

empirical literature experience

Psychometric assessment
Interview and mental state examination
Process dimension

Diagnostic impression
Case formulation

Treatment planning & measurement

Treatment implementation & monitoring

Evaluation &
accountability

Figure 3.1 The complementary processes of testing, interviewing and examining mental state as precursors to
diagnosis, case formulation and treatment planning.

disturbances are usually associated with distress or impairment in personal, family,

social, educational, occupational, or other important areas of functioning.” The
American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental
Disorders (American Pschiatric Association, 2013) defines a mental disorder similarly
and adds, “Mental disorders are typically associated with significant distress or disability
in social, occupational, or other important activities. An expectable or culturally
approved response . . . socially deviant behavior and conflicts that are primarily between
the individual and the society are not mental disorders unless the deviance or conflict
results from a dysfunction in the individual” (p. 20). In addition, the authors note that
the definition does not include an expectable and culturally sanctioned response to a
particular event (e.g., bereavement). Further, they note that the “behavioral, psycho-
logical, or biological dysfunction” must lie within the individual, thereby excluding
behaviour that is deviant (e.g., political, religious or sexual) or conflicts with society
(see Blashfield, 1998; Rounsaville et al., 2002).

Current Diagnostic Practices

The many different instances of psychopathology present a complex array of phenomena
to be organized. Clinicians need to organize the various manifestations of psychopath-
ology for a number of reasons. First, it is necessary to have an agreed nomenclature so
that mental health professionals can share a common language. Second, a common
language is needed so that information about particular psychopathologies can be
retrieved. Third, classification is a fundamental human activity that is necessary to
organize the world within which we live. Presently, there are two main diagnostic
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28 Chapter 3: Assessing Clients

systems, the American Psychiatric Association’s DSM-5 (APA, 2013) and the World
Health Organization’s ICD-11 (WHO, 2021). Both of these diagnostic systems classify
disorders (rather than clients; Spitzer & Williams, 1987) and thereby assist clinicians as
they try to plan treatment in a systematic, rational and scientific way.

Diagnostic Systems: The Diagnostic and Statistical Manual

of Mental Disorders (DSM) and the International Classification
of Diseases (ICD)
The DSM
The opening section of the DSM-5 (APA, 2013) provides a comprehensive discussion of
how to use the manual. Importantly, the manual acknowledges that in addition to a
mental disorder diagnosis, it is necessary to construct a clinical case formulation to
identify factors that may have contributed to developing the mental disorder. Case
formulation will be discussed in a later chapter, but for now we will focus on diagnostic
issues and postpone consideration of how to manage the complexity of moving from a
description of the presenting problem to a treatment plan using a conceptual formula-
tion of the causes of the client’s presentation.
The psychological disorders that may be the reason for treatment that the DSM-5 lists
are: (i) Neurodevelopmental Disorders, (ii) Schizophrenia Spectrum and Other
Psychotic Disorders, (iii) Bipolar and Related Disorders, (iv) Depressive Disorders, (v)
Anxiety Disorders, (vi) Obsessive-Compulsive and Related Disorders, (vii) Trauma- and
Stress-Related Disorders, (viii) Dissociative Disorders, (ix) Somatic Symptom and
Related Disorders, (x) Feeding and Eating Disorders, (xi) Elimination Disorders, (xii)
Sleep-Wake Disorders, (xiii) Sexual Dysfunctions, (xiv) Gender Dysphoria, (xv)
Disruptive, Impulse-Control, and Conduct Disorders, (xvi) Substance-Related and
Addictive Disorders, (xvii) Neurocognitive Disorders, (xviii) Personality Disorders,
(xix) Other Mental Disorders, (xx) Medication-Induced Movement Disorders and
Other Adverse Effects of Medication and (xxi) Other Conditions That May Be a Focus
of Clinical Attention.
Each section in the DSM-5 follows a similar format. The title of the disorder
(accompanied by a DSM code and a corresponding ICD code) is followed by the
diagnostic criteria and a verbal description of the diagnostic features. This final section
provides clarification of the diagnostic criteria and includes examples. It complements
the somewhat stark listing of the diagnostic criteria, in that it provides a rich verbal
picture of the disorder, thereby giving the clinical psychologist the context within which
the symptoms occur and the manner in which the disorder may present. It develops a
sense of the “flavour” of each disorder. In addition to the DSM material, case studies are
a useful complementary source of information. Some particularly good examples include
Barnhill (2013), First et al. (2017), Meyer and Weaver (2012), Oltmans and Martin
(2018), Sattler, Shabatay and Kramer (1998) and Ventura (2016).
Following this section, the DSM-5 provides information on the subtypes of the
disorder, associated features, specific cultural, age and gender features, the prevalence,
course, familial patterns and differential diagnosis (i.e., distinguishing features from
similar or related disorders). By way of illustration, a Major Depressive Disorder is
 Chapter 3: Assessing Clients 29

characterized by a period of at least two weeks with depressed mood and/or a loss of
interest in pleasure. To meet diagnostic criteria, a client must also report or exhibit a
total of five symptoms, of which three (in addition to depressed mood and anhedonia) or
four (in addition to depressed mood or anhedonia) may be of the following: significant
weight or appetite change; insomnia/hypersomnia; psychomotor agitation or retard-
ation; fatigue/energy loss; feelings of worthlessness or excessive/inappropriate guilt;
decreased thinking ability or concentration, or indecision; recurrent thoughts of death;
suicidal ideation without plan; or suicide attempt or plan. Subsequent criteria require the
clinician to ensure that the distress or impairment in social, occupational, or other
important areas of functioning is “clinically significant” and to rule out other possible
diagnoses (e.g., a medical condition or the effects of a substance). The decision about
clinical significance relies upon clinical judgement and may use information from
friends, family, and other third parties.
The clinician is then asked to specify the severity and other features of the disorder.
The severity of a disorder is coded as mild if few, or no, symptoms in excess of those
required to make the diagnosis are present (in this case five), and symptoms produce
minor impairment in social or occupational functioning. It is coded as severe if many
symptoms in excess of those needed to make a diagnosis are present, and severity is
moderate if number of symptoms falls between “mild” and “severe” categories. For
instance, a client with severe repeated episodes of depression would receive a diagnosis
of “Major Depressive Disorder, severe, Recurrent Episode.” The DSM diagnostic code
would be 296.33 and the corresponding ICD code would be F33.2. The clinician also
needs to consider a variety of specifiers that describe the course of the disorder (e.g.,
chronic), its recurrence and the features that are present. By way of example, one set of
features is melancholia, in which the depression involves loss of pleasure in activities and
lack of reactivity to usually pleasurable stimuli in the presence of other symptoms such as
“empty mood”, a depression that is worse in the morning, involves early morning
wakening, psychomotor agitation or retardation, significant weight loss and excessive
or inappropriate guilt.
The previous edition of the DSM permitted the clinician to code significant psycho-
social and environmental problems that have occurred in the preceding year, in part
acknowledging that such factors may moderate the treatment and prognosis of mental
disorders. Environmental problems included negative life events, environmental diffi-
culties or deficiencies. Psychosocial problems included relationship difficulties and the
associated interpersonal stress, as well as insufficient social support or personal
resources. Both psychosocial and environmental problems are relevant, as they may be
causally related to the onset of problems but can also be a consequence of mental health
problems. However, the DSM-5 has decided not to develop its own listing of such
problems, and encourages clinicians to use the WHO’s taxonomy and ICD 9’s V codes
(or Z codes in the ICD 11). A listing of the codes can be found in the DSM-5. Consider
the example of a woman who plunged into a deep depression following her forced idle
state due to a medical condition preventing her from lifting heavy objects. The situation
was exacerbated by her also losing her part-time job as a carer working with adults with a
disability, where heavy lifting of patients was part of her daily job routine. Thus, noting
the concomitant job loss as an “Other problem related to employment” provides insight
into the pervasiveness of her recent role transition from active provider for the family to
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30 Chapter 3: Assessing Clients

The previous edition of the DSM provided the clinician’s Global Assessment of the
individual’s Functioning (GAF). Although the measure has been criticized in terms of both
reliability and validity, the information is useful in planning treatment and measuring its
impact, and in predicting outcome. Functional impairment is not the same construct as
subjective distress, even though impairment and distress are frequently confounded in the
concept of “problem severity”. Separating the constructs is important because impairment is
negatively related to improvement during treatment (McClellan et al., 1983), clients with a
high degree of impairment appear to improve to a greater degree with longer and more
intensive treatment (Shapiro et al., 1994), and impairment is a predictor of relapse (e.g.,
Brown & Barlow, 1995). Functioning can be measured with the full 36-item or the 12-item
short version of the World Health Organization Disability Assessment Schedule (Üstün et al.,
2010). The scale measures the extent to which there is disability in six of areas: cognition,
mobility, self-care, interacting with others, life activities and participation in society.
From the perspective of a clinical psychologist, arguably the most progressive step
forward in the DSM system was a tentative move towards dimensional assessments (that
has been followed up with additional progress being made with the ICD-11). While
medical approaches have tended to favour discrete categories, psychologists have typic-
ally viewed many constructs dimensionally. That is, while we are happy to speak casually
about a person being “intelligent”, we understand intelligence to be a construct that is
distributed (approximately) normally across the population. We may identify cut-points
in the distribution for clinical purposes, but we tend to think about the meaning of a
person’s location on a distribution.
Section III of the DSM-5 lists “emerging measures and models” and contains a set of
tools to assist the clinical decision-making process. The crosscutting symptom measures
(APA, 2021) provide dimensional assessments of constructs such as anxiety, depression,
mania, memory, somatic symptoms, suicidal ideation, psychosis, sleep problems, memory,
repetitive thoughts and behaviours, dissociation, personality function and substance use.
These measures can help the clinical psychologist not only in forming a diagnosis, but also
by providing a richer picture of the symptom profile than a diagnostic label can achieve.
A final consideration about the DSM relates to the issue of diagnostic inflation. That
is, when diagnostic criteria are changed, there is always the possibility that the rates of
specific diagnoses are no longer comparable. Even though the same label may be used, if
the criteria shift substantially, then the number of people being identified may be more
or less than previously. As the DSM-5 was being discussed, there was substantial
commentary about potential diagnostic inflation (see Haslam et al., 2020). For instance,
the removal of an exclusion criterion in major depression for a bereaved person was
among many points of contention (Wakefield & First, 2012). Fabiano and Haslam (2020)
systematically reviewed these concerns and concluded that they had been overstated once
the evidence was available. The revisions of the DSM were neither inflationary nor
deflationary (cf. Boysen & Ebersole, 2014). However, they did note some exceptions in
autism, eating disorders and substance dependence, with Attention-Deficit/Hyperactivity
Disorder (ADHD) showing large apparent increases.

ICD-11
Despite the popularity of the DSM in many countries, the official coding system for
international comparisons is the World Health Organizations’ International Classification
 Chapter 3: Assessing Clients 31

of Diseases, Eleventh Revision, (ICD-11). Chapter 6 refers to “Mental, Behavioral or

Neurodevelopmental Disorders” and other chapters contain Sleep-wake disorders, condi-
tions related to sexual health and gender incongruence. Like the DSM-5, the ICD-11
organizes the disorders into various categories, including (i) Neurodevelopmental
Disorders, (ii) Schizophrenia and Other Primary Psychotic Disorders, (iii) Catatonia, (iv)
Mood Disorders, (v) Anxiety and Fear-Related Disorders, (vi) Obsessive-Compulsive and
Related Disorders, (vii) Disorders Specifically Associated with Stress, (viii) Dissociative
Disorders, (ix) Feeding and Eating Disorders, (x) Elimination Disorders, (xi) Disorders of
Bodily Distress and Bodily Experience, (xii) Disorders due to Substance Use and Addictive
Behaviors, (xiii) Impulse Control Disorders, (xiv) Disruptive Behavior and Dissocial
Disorders, (xv) Personality disorders, (xvi) Paraphilic Disorders, (xvii) Factitious
Disorders, (xviii) Neurocognitive Disorders, (xviv) Mental and Behavioral Disorders associ-
ated with Pregnancy, Childbirth and the Puerperium.
We will not discuss the key changes from the previous edition of the ICD, or conduct
a side-by-side comparison with DSM-5, as the reader can find these matters reviewed
elsewhere (Gaebel, Stricker & Kerst, 2020; Stein et al., 2020). Rather, we will focus on a
key change in the ICD that arguably reflects developments in the way that diagnosis is
being approached.
The changes in the Personality Disorders section reflects a shift in thinking from a
categorical approach to taxonomy to a dimensional one (see Bagby & Widiger, 2020).
The diagnostic working group approached the matter of diagnosis without having a pre-
conceived notion about the immutability of personality and the existence of diagnostic
categories, but studied the evidence. They argued that this evidence pointed towards a
more clinically useful system that was based on first acknowledging the severity of the
personality pathology (Tyrer et al., 2019). That is, a single dimension of severity is
postulated that ranges from normal personality at one end to extreme to severe person-
ality disorder at the other. This dimension was selected as there was strong evidence that
the best description of pathology was the degree of severity rather than the patterns
of symptoms (e.g., Tyrer & Johnson, 1996). After considering severity, the second
diagnostic step is to assign up to five prominent domain traits (negative affectivity,
anankastia – what DSM-5 refers to as obsessive compulsiveness, detachment, dissociality
and disinhibition). One specific diagnostic category (Borderline Personality Disorder)
has been retained, but if we focus on the big picture, the main change has been the
replacement of a categorical taxonomy with a dimensional one.
From a clinical perspective, this brings about a shift in thinking. The attention of the
clinical psychologist is less upon targeting a specific treatment to particular symptoms,
but becomes drawn in the first instance to the overall severity of symptoms (regardless of
the make-up of those symptoms). The particular dimensions help direct attention to the
areas where the pathology is manifest. In this way, the ICD-11 categorization of
personality disorders is more akin to a transdiagnostic approach that will be discussed
in Chapters 5 (Case Formulation) and 6 (Treating Clients).
Before moving to consider the conduct of a diagnostic interview, it is worth noting
that both DSM and ICD acknowledge the need for cultural sensitivity when assigning
diagnoses. This will be achieved by explicitly considering the client’s ethnic or cultural
reference groups and possible cultural explanations of a client’s symptoms. For instance,
the mode of expression may vary across cultures (e.g., greater somatic presentations of
mood disorders in some cultures), and so too can the meaning of symptoms and causal
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32 Chapter 3: Assessing Clients

models used by clients to explain their symptoms. Although some disorders appear
culture-specific, the more usual situation facing the clinician requires sensitivity to the
ways in which cultural and other social factors influence the presentation and impact of a
disorder, as well as the way they are communicated to and understood by the clinician.

Conducting a Diagnostic Interview

Independent of the diagnostic system used, one product of an initial interview (when
possible) is a diagnosis. Eliciting symptom information is a necessary, but not sufficient
component of a diagnostic interview. In addition to determining which symptoms a
client possesses and which they do not, the clinician aims to develop a clear picture of the
client, the problem(s), and the personal, social and environmental context within which
these issues occur. The exact nature of the interview will be tailored to the client and to
the problem, but a useful conceptual structure for an interview is outlined below.
The way that you meet the client will frame the dialogue. Since your aim is to assist a
client discuss potentially sensitive issues, a good rapport is required. Therefore, commu-
nicate a sense of goodwill by being courteous. As discussed in Chapter 2, questioning at
the outset of the interview should be open and designed to help the client talk while the
clinician listens. One possible obstacle to an open dialogue is note taking. This occurs if
the clinician focuses excessively on the notes at the expense of the client. Spend time
building rapport with the client and respond to what they say in a way that communi-
cates that you understand not only what the client has said, but how they felt. Therefore,
try to take sufficient but brief notes and in a manner that does not interfere with the flow
of the interview.
Usually, a diagnostic interview will quickly move to the presenting problem(s) and
the aim will be to identify the problem that the client has brought to therapy. While there
may be times when tact and sensitivity dictate a more gradual introduction, clients
typically arrive at a consultation prepared to tell their story. Thus, it may be helpful to
encourage the client to phrase the problem in their own words. For instance, you might
ask, “I wonder if you could tell me what brought you here today?” As the client begins to
respond to this question, ensure that you model good listening behaviour. Respond with
verbal and nonverbal indications that you have heard and understood both the content
of the speech, but also the broader emotional and social context that the person is in.
For example, a clinician might interview a client with Generalized Anxiety Disorder
(GAD) in the following manner.
THERAPIST: Your referral suggests that you are having trouble with sleeping. Could you tell me a bit about
the troubles you’ve been having?
CLIENT: Well, I just can’t get off to sleep at night because these worrying thoughts keep popping into my
head. They just go around and around, so that I can’t fall asleep. I’m now so tired that I feel that if I could
just get a good night’s sleep everything will be OK again.
THERAPIST: These worries seem to be having a huge impact on you.
CLIENT: They are. In fact, they seem to be the main problem.
THERAPIST: What sort of things do you worry about?
CLIENT: About anything and everything. I worry about my children’s health, I worry about not having
enough money, I worry about the house burning down, I worry about work . . . I even worry that I worry
about worrying.
 Chapter 3: Assessing Clients 33

THERAPIST: Can you tell me about this “worry about worrying”?

CLIENT: I feel I need to worry. If I don’t, then I worry that something terrible will happen. Like when my
children go out at night, I’m never sure that they’ll be safe, but if I worry then I feel that things are better
because I’ve done everything I can.
THERAPIST: Do these worries occur at times other than when you are trying to go to sleep?
CLIENT: Yes, they happen all the time. Right now I’m worrying that you might not be able to help me because
I’m not being clear enough. This has been going on for years now and I don’t know if I have a problem or if
it’s just the way I am.
THERAPIST: When people worry a lot for a long time, there can be effects in the rest of their life. Have you
noticed any impact of the worry?
CLIENT: As well as the sleep, I notice that I get really tense. The muscles around my neck tighten up so much
that I’m in pain.
THERAPIST: That must be exhausting as well as painful.
CLIENT: You’re right. I am so tired from all the worry and tension, but I still don’t seem to be able to sleep it
doesn’t make sense.
THERAPIST: We’ll talk about trying to make sense of your experience a little later, but for the time being I’d
like to continue to get a clear idea in my head of the problems you are facing. When other people
experience excessive worry and uncontrollable tension, they sometimes notice that they are more irritable
or feel on edge and tense. Have you felt like this?
CLIENT: Always on edge and . . . erm . . . what was the other thing?
THERAPIST: Irritable?
CLIENT: Yes, often irritable at home, but never at work.
THERAPIST: How about difficulties with concentration?
CLIENT: I don’t seem to have trouble concentrating, just that I concentrate on my worries.
THERAPIST: When you are trying to concentrate on your work, do your worries break into that
concentration?
CLIENT: Yes, but it’s not that I can’t concentrate. I concentrate on the wrong thing.

A number of issues are evident in the preceding conversation. First, if you consult the
DSM-5 criteria for Generalized Anxiety Disorder, you can see that the clinician is asking
the client about symptoms relevant to the disorder. At the beginning, the clinician begins
with open questions, but towards the end of the section the questioning becomes closed
and more focused as the clinician moves to check that material was omitted because the
symptoms are indeed absent, rather than the client just failing to report material even
though the symptoms are present. Second, you will see that the client becomes confused
when multiple symptoms are included in a single question. Try to avoid questions that
contain multiple issues and requests. Third, you will see that the client and clinician do
not have a shared understanding of the word “concentration”. For the client, concen-
tration refers more to the cognitive process, whereas the clinician is referring to the
ability to focus on a particular thought. In the preceding conversation, the client took the
initiative in clarifying the issue, but had the client not done this, the clinician could have
been more explicit in questions. Finally, at the end of this section, the clinician would be
in a position to speculate that the client may be suffering from GAD. Further questioning
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34 Chapter 3: Assessing Clients

would clarify this but it would appear that the client has been experiencing excessive
worry about a number of events more days than not for some years (DSM-5 Criterion A).
There is difficulty controlling the worry (Criterion B), the worry is associated with feeling
keyed up or on edge, easily fatigued, irritability, muscle tension and sleep disturbance
(Criterion C), and there is clinically significant distress and impairment (Criterion D).
Criteria E and F require the clinician to determine that the worries are not better
explained by another disorder. Thus, the clinician will need not only to explore GAD,
but it will be necessary to entertain the possibility that the symptoms are a manifestation of
other disorders (e.g., primary insomnia, major depression and substance abuse) and
hence a differential diagnosis is required to determine the best label to describe the
client’s problems. It is also possible that the client exhibits comorbidity, and hence two
disorders (e.g., GAD and depression) are present simultaneously. Further interviewing
is required and for each disorder, the DSM-5 provides details about how to make a
differential diagnosis.
After the client has begun to describe the problem, the clinician is confronted with a
choice of direction. On the one hand, the clinician could choose to remain with a
discussion of the presenting problem and elicit personal and historical information later.
The advantages of this strategy are that the interview continues to flow naturally and the
client keeps relating the details of the presenting problem. However, the disadvantage is
that the clinician does not have a good picture of the client as a person, the social and
historical background to the problems, a sense of other psychological problems and so
on. Instead, the clinician could signal a change of direction by saying, “Thank you. You
have given me an idea of the difficulties that you are having. I would like to pursue them
in more detail, but before we talk about these difficulties I was wondering if I could get
some idea about you as a person?” The interviewer could then proceed to ask questions
about the client’s social and personal background. The advantages of this strategy are
that the psychological problems are then unveiled in the context of the whole person. The
main disadvantages are that the clinician may not know what aspects of the personal
history are relevant until the problem is explicated and the interview may need to be cut
short because insufficient time remained to discuss the client’s difficulties before the
session ended.
Assuming that the clinician has decided in this instance to remain with a discussion
of the presenting problem, this could be signalled with a comment such as, “I wonder if
we could discuss the difficulty you have been mentioning in some detail. When did you
first notice that something was not right?” This will direct the client to discuss the
evolution of the problem; acknowledging the fact that psychological difficulties exist in a
dynamically evolving system. However, within the complexity, the clinician will be
focused on trying to highlight the key milestones in the development of the problem.
This history will lead the client towards the present, at which time it will be possible to
get a clearer description of the difficulties and any associated behaviours. As a mental
checklist, the clinician will be aiming to identify (i) what the problem is, (ii) when it
occurs, (iii) where it happens, (iv) how frequently the problem takes place, (v) with
whom these difficulties arise, (vi) how distressing and (vii) impairing the problem is. In
collecting this information, the clinician will also identify distal factors associated with
the problem. These will be identifiable from a discussion of the environment, context
and lifestyle present when the problem began, other predisposing and triggering factors,
 Chapter 3: Assessing Clients 35

the consequences of the problem’s onset, the way the problem has changed over time and
factors associated with these changes (both increases and decreases in severity and
frequency). The interview will evolve from a historical discussion to consideration of
the problem in its current form. The clinician might ask, “Could you please tell me about
a typical day or occurrence of the problem?” and then explore some of the maintaining
factors. The clinician will also ask about variability in the problem and factors associated
with any fluctuations (i.e., moderating variables).
As far as the diagnostic aspect of an interview is concerned, the clinician will elicit a
comprehensive description of the problem and its various manifestations. Clients may
often focus on one aspect of the problem because it is salient to them, but remember to
explicitly consider their behaviour and actions, consciously available thoughts and other
cognitive processes, as well as physiological changes. The clinician also needs to ask
about the frequency, intensity, topography (typical and unusual patterns), duration and
temporal sequence of symptoms. In addition, the consequences of any behaviour need to
be thoroughly assessed (see Chapter 5).
After the clinician has a good sense of the presenting problem, its present mani-
festation and its history, the interview can expand to provide a more complete picture
of the person. The clinician might say, “You have given me a good idea of the problems
you are struggling with, but I don’t think I have got a good idea about you as a person.
Could you tell me something about you, apart from these difficulties?” The aim of this
process is to be able to put yourself in the client’s shoes and imagine what it must be
like to experience the life the client has had. Therefore, it may be relevant to ask about
family history (details of parents, other significant figures, brothers and sisters, as well
as the childhood environment of family, school and peers), a personal history (birth
date and any significant issues, general adjustment in childhood, lifelong traits or
behavioural patterns and tendencies, significant life events), schooling (duration and
significant events), work history and present duties, relationships (current status,
history and problems), leisure activities, living arrangements, social relationships, prior
significant accidents, diseases and mental health problems and personality (and par-
ticularly any changes).
An important aspect of a diagnostic interview is to identify the coping resources that
a client can bring to bear in seeking to overcome their problems. Therefore, enquire
about coping resources and other personal strengths the individual possesses. Within
this context, motivation for change is a critical dimension (see Miller & Rollnick, 2012
for an excellent discussion). The clinician will not only attempt to identify the motiv-
ations intrinsic to the person, but identify any extrinsic motivators that are present or
have been successful in the past. The clinician can also try to identify the “stage of
change” that the client is in. That is, Prochaska, Norcross and DiClemente (2007;
Prochaska & Norcross, 2018) have suggested that clients move through a series of stages.
In the first instance, individuals are pre-contemplators – they have their problem, but
have not yet got to the point of desiring to modify their behaviour. As a person begins to
notice the impairment or becomes increasingly concerned about the distress being
triggered, they move into the contemplation phase in which they are considering the
pros and cons of dealing with the problem. From contemplation, a client will move into
preparation and action, after which time they will either relapse into any of the preceding
stages or continue to manage the problem successfully.
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36 Chapter 3: Assessing Clients

Annotated initial interview pro forma

Interview date: ____/____/____

Name: ________________________.
Sex: M / F
Date of birth: ____________
What has brought you here today?
Presenting problem

Relevant background/personal history

Family history:
Personal history:
Birth
Childhood adjustment
Schooling
Work
Relationships
Leisure
Significant illnesses/disorders
Accidents
Physical illnesses
Mental disorders/problems
Personality

Problem history
Evolution
Distal factors
Context of problem
Circumstances of onset
Consequences of onset
Change over time/milestones
Variables assoc. with severity

Figure 3.2 Annotated pro forma of initial interview.

At the end of the interview, summarize and synthesize the material covered. Often it
is useful to present this summary in a provisional manner by saying, “I will try to draw
together some of the themes we have been discussing. If I miss something out or if I get a
point wrong, please let me know.” It is also prudent to ask the client if there are any
problems or issues you have not asked them about or which there has not been time to
discuss. This increases confidence that the main problems have been covered and also
provides an opportunity for clients to raise other significant issues now they feel more
at ease.
A pro forma (Figure 3.2) that may be assist you with note taking and structuring an
interview follows. The text in the right hand column is a series of prompts and can
function as a checklist.
 Chapter 3: Assessing Clients 37

Current problem presentation

Proximal factors
Typical presentation
Variations in presentation
Maintaining factors?
1. Antecedents
2. Behaviour
3. Consequences
Motivation for change
Stages of change
Mental status examination

Summary

Test results

DSM/ICD diagnosis:

Formulation
Presenting problems
Predisposing factors
Precipitating variables
Perpetuating cognitions and consequences
Provisional conceptualization
Prescribed interventions
Potential problems and client strengths

Action plan
1. Treat
2. Refer
3. Other

Figure 3.2 (cont.)

Adapting Diagnostic Interviews for Different Client Groups

(Children and the Elderly)
The diagnostic interview will need to be adapted in a flexible manner to be suitable for
each client. However, some general points can be made about certain client groups. One
important group to consider is children. When interviewing children, the clinician needs
to contextualize the information in the normative developmental process. Deviations
from normal childhood development need to be understood both in terms of the
normative processes, but also in terms of the typical variability (see Sattler, 2008,
2014). Assessments of children may also require the collection of information from
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38 Chapter 3: Assessing Clients

parents, teachers, other family members and professionals. Collection of data from
multiple sources provides a rich picture of the problem as well as insight into the way
the problematic behaviours are observed and interpreted by individuals prominent in the
child’s life (see Sattler, 2014, 2020).
When interviewing the elderly, there are a variety of considerations when arriving at
a diagnosis. Medical conditions, cognitive impairment and pharmacological issues may
all have a bearing on the client’s presentation (Edelstein et al., 2002). The same disorder
does not always present itself in the same way in older adults as it does in younger adults.
For instance, depression is more likely to present with somatic symptoms and with less
dysphoria (Fiske, Kasl-Godley & Gatz, 1998). Further, the clinician will need to entertain
differential diagnostic possibilities among older adults that are less common with
younger clients. For instance, depression and dementia can co-occur at times, and need
to be distinguished (see Brzezińska et al., 2020; Kaszniak & Christenson, 1994).

Screening for Psychological Symptoms

A large amount of information needs to be collected during a diagnostic interview and
there is a risk that key issues will be missed. One way to complement the information
gleaned from a diagnostic interview is to collect information from screening tests.
Screening is the, “presumptive identification of unrecognized disease or defect by the
application of tests, examinations or other procedures which can be applied rapidly to sort
out apparently well persons who probably have a disease from those who probably do not”
(Commission on Chronic Illness, 1957, p. 45). Therefore, when administered before a
diagnostic interview, they provide the clinician with an efficient means of collecting and
collating symptom information, as well as giving an indication of the extent to which a
client’s symptom profile deviates from statistical norms. For example, the United
Kingdom’s National Health Service has introduced a good series of measures as part of
its Improving Access to Psychological Therapies (IAPT) National Health Service, 2021).
The IAPT lists a series of outcome measures and recommends particular measures to be
used for specific problems. Details can be found in the IAPT Data Handbook (National
Health Service, 2021), but for present purposes one example will be highlighted.
All patients seen through the IAPT system are to be assessed in terms of depression
(using the nine-item Patient Health Questionnaire; PHQ-9), general anxiety (using the
seven-item Generalised Anxiety Disorder scale; GAD-7), phobias (using the IAPT
Phobia Scales), functioning (using the Worker and Social Adjustment Scale) and the
IAPT patient choice and experience questionnaire. In addition, specific instruments are
recommended for particular clinical presentations. Each of the scales is provided with
relevant psychometric information and clinical cut-offs. For instance, the PHQ-9 can be
used to monitor change in symptoms of depression over time and the clinical cut-point
of 9 identifies “caseness”, such that any person who scores 10 or higher is judged to be
experiencing clinically significant symptoms of depression. Clinical psychologists can
use these scales not only to be accountable in their own practice, but they can also use
these scores to discuss progress with their clients. In summary, each of the preceding
scales provides a good screening for psychopathology. They can assist the clinician in
recognizing a disorder by making the clinician aware of particular symptoms, as well as
their levels and patterns. However, none of the screening instruments reviewed can
 Chapter 3: Assessing Clients 39

indicate that a client has met diagnostic criteria for a particular disorder. Structured and
semi-structured diagnostic interviews serve this function.

Structured and Semi-Structured Diagnostic Interviews: Adults

Any diagnostic method must be both reliable and valid. However, the validity of a
diagnostic interview and a diagnostic system are not identical. The validity of a diagnos-
tic interview is judged by the extent to which the outcome of the interview matches the
disorder in the diagnostic taxonomy. The validity of a diagnostic system is judged by the
degree to which the disorders describe clinically meaningful clusters of symptoms.
Although reliability does not guarantee validity, validity requires reliability. In the past,
diagnoses were notoriously unreliable, but the decision to introduce specific diagnostic
criteria for each disorder into the DSM-III (APA, 1980) successfully increased the
reliability of diagnoses. Although some have suggested that the validity of the diagnoses
themselves was sacrificed in the pursuit of reliability (see Rounsaville et al., 2002),
another source of unreliability is the diagnostic interview itself. Clinicians may omit
key questions, fail to consider all diagnostic possibilities, or be overly influenced by
dramatic symptoms and hence arrive at a diagnosis that would not be obtained by a
second interviewer, or even by the same clinician on a separate occasion. One way to
increase diagnostic reliability in generating DSM and ICD diagnoses is to use structured
and semi-structured diagnostic interviews (Summerfeldt & Antony, 2002).
Structured diagnostic interviews are particularly helpful in research (where replic-
ability is essential), in training (where the structure can assist a novice clinician), and in
practice (where use of a standardized instrument can increase the confidence in a
diagnosis). A variety of instruments are available and they will be reviewed next. There
are a set of dimensions along which the instruments vary (e.g., diagnostic breadth and
depth, duration of the interview, extent to which clinical skill is required, target popula-
tion) and thus the individual electing to use a structured diagnostic interview will need to
consider the purpose of the interview. Specifically, the clinician will need to evaluate the
instrument in terms of (i) coverage and content, (ii) the target population, (iii) the
psychometric features of the instrument, (iv) practical issues (e.g., duration, training), (v)
administration requirements and support (e.g., scoring algorithms, standardized manual;
see Page, 1991a; Summerfeldt & Antony, 2002). With updates to diagnostic criteria over
time, new versions of structured interviews are developed – therefore caution needs to be
exercised when evaluating the generalizability of the most recent diagnostic system.

A Mental Status Examination (MSE)

A Mental Status Examination (MSE) provides a template that assists a clinical psycholo-
gist in the collation and subsequent conceptual organization of clinical information
about a client’s emotional and cognitive functioning. By systematically basing observa-
tions on verbal and non-verbal behaviour, the aim is to increase the reliability of the data
upon which subsequent diagnoses and case formulations are made. The particular
perspective of the interview and the use to which the data are put will vary depending
upon whether the goal is psychiatric (see Daniel & Crider, 2003; Treatment Protocol
Project, 1997) or neurological (see Strub & Black, 2000), but the domains covered by the
clinician are similar. Reporting an MSE also requires the clinician to be familiar with the
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40 Chapter 3: Assessing Clients

Table 3.1. An outline for a Mental Status Examination

PHYSICAL
Appearance Motor Activity
Behaviour
EMOTIONAL
Attitude Mood and Affect
COGNITIVE
Orientation Attention and Concentration
Memory Speech and Language
Thought (Form and Content) Perception
Insight and Judgement Intelligence and Abstraction

descriptors of various symptoms, such as those found in the glossary of the DSM-5
(APA, 2013; see also Kaplan & Sadock, 2017).
Broadly speaking (and following Daniel & Crider, 2003), a MSE collates information
about the client’s (i) physical, (ii) emotional and (iii) cognitive state. Under each of these
domains fall a number of topic areas which are summarized in Table 3.1.
The summary of an MSE does not note every detail under each heading, but draws
attention to the key features that describe the client and frame the presenting problem
within a context of who the client is. Typically, the description begins with a statement
about their age, gender, relationship status, referrer and presenting problem (i.e., the
reason for presentation at the service on the particular occasion). For instance, the
description may begin by saying, “Gill, a 35-year-old self-referred single woman was
referred by her medical practitioner who had suggested treatment for her obesity that
was contributing to hypertension.”

Physical
The description will draw attention to noteworthy aspects of the client’s physical state.

Appearance
A concise summary of the client’s physical presentation is given to paint a clear mental
portrait. The description may refer to dress, grooming, facial expression, posture, eye
contact, as well as any relevant noteworthy aspects of appearance. For instance, a clinician
might note that the client “wore an expensive, but crumpled suit. He sat slumped in the
chair and was unshaven, with dark circles under his eyes”. Importantly, the aim is to
describe what is observed rather than your interpretation (e.g., “he was exhausted”).

Behaviour
A description of behaviour may make reference to the client’s level of consciousness
extending from alert through drowsy, a clouding of consciousness, stupor (lack of
reaction to environmental stimuli) and delirium (bewildered, confused, restless and
disoriented), to coma (unconsciousness). It may also include reference to the degree of
 Chapter 3: Assessing Clients 41

arousal (e.g., hypervigilance to environmental cues and hyperarousal such as observed in

anxious and manic states), mannerisms (e.g., tics and compulsions).

Motor Activity
An account of the observed motor activity aims to describe both the quality and the types
of actions observed. Reductions in movement can be variously described as a reduction
in the level of movement (psychomotor retardation), slowed movement (bradykinesia),
decreased movement (hypokinesia), or even an absence of movement (akinesia).
Increases in the overall level of movement are referred to as psychomotor agitation,
but it is also important to note minor increases in movement such as a tremor.

Attitude
The clinician will also consider the way in which the client participates in the interview,
as a way of gauging their manner and outlook. These judgements will be based on the
client’s response to the context of the interview, but also to the interviewer. Identifiers
may be open, friendly, cooperative, willing and responsive, or alternatively, they may be
closed, guarded, hostile, suspicious and passive. These terms will be used to describe
complex sets of behaviours including attentiveness, responses to questions, expression,
posture, eye contact, tone of voice and so on.

Emotional
Moving from the physical domain, the clinician will portray the person’s emotional state,
once again drawing upon the verbal and nonverbal behaviour of the client.

Mood and Affect

Although affect (an external expression of an emotional state) is potentially observable,
mood (the internal emotional experience that influences both perception of the world and
the individual’s behavioural responses) is less apparent and will require the clinician to
depend to a greater degree on the client’s introspections. Descriptors of mood include
euphoric, dysphoric (sad and depressed), hostile, apprehensive, fearful, anxious and
suspicious. The stability of mood can also be noted, with the alternation between extreme
emotional states being referred to as emotional lability. The range, intensity and variability
of affect can be variously portrayed, but some important expressions are restricted (i.e., low
intensity or range of emotional expression), blunted (i.e., severe declines in the range and
intensity of emotional range and expression), flat (i.e., a virtual absence of emotional
expression, often with an immobile face and a monotonous voice) and exaggerated (i.e., an
overly strong emotional reaction) affect. The clinician will also consider the appropriate-
ness of the affect (and note if the emotional expression is incongruent with verbal descrip-
tions and behaviour) as well as the client’s general responsiveness.

Cognitive
The cognitive components in an MSE will be familiar to clinical psychologists, since
many components are assessed more comprehensively and within memory tests.
However, during the MSE, the aim is to provide a general screening which requires
interpretation using clinical judgement, with one outcome being to recommend further
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42 Chapter 3: Assessing Clients

Orientation
A person’s orientation refers to their awareness of time, place and person. Orientation
for time refers to a client’s ability to indicate the current day and date (with acceptance of
an error of a couple of days). Orientation for place can be assessed by asking clients
where they have presented. Behaviour should also be consistent with that expected in the
setting in which they have arrived. Orientation for person refers to the ability to know
who you are, which can be assessed by asking the client their name or names of friends
and family which you can verify.

Attention and Concentration

“Working memory” (Baddeley, 1986, 1990) is the term used in psychology to refer to the
constructs called attention and concentration. The aim is to describe the extent to which
a client is able to focus their cognitive processes upon a given target and not be distracted
by non-target stimuli. Digit span (the ability to recall in forward or reverse order
increasingly long series of numbers presented at a rate of one per second) is a common
way to assess these working memory functions, and normal individuals will recall
around 6–8 numbers in a digits forwards and 5–6 numbers in digits backwards.
Another method used is “serial sevens”, in which seven is sequentially subtracted from
100. Typically, people will make only a couple of errors in 14 trials.

Memory
An MSE will typically assess memory using the categories of short- and long-term
memory. Although these categories do not map neatly onto models of memory in
cognitive psychology (Andrade, 2001), the aim of the MSE is to provide a concise
description of a person’s behaviour and screen them in a manner that can guide further
assessment. Therefore, more sophisticated assessments and analyses may follow. To
assess recent or short-term memory, clients can be asked about a recent topical event
or who the president or prime minister is. Clients can also be asked to listen to three
words, repeat them and then recall them some time later in the interview. Most people
will usually report 2–3 words after a 20-minute interval. Visual short-term memory can
also be assessed by asking clients to copy and then reproduce from memory complex
geometrical figures (such as those in the Rey Auditory Verbal Learning Test). Long-term
memory can be assessed by asking about childhood events.

Thought – Form and Content

During an MSE the clinician will address the client’s thought processes, inferred typically
from speech. Disturbances in the form of thought are evident in terms of the (i) quantity
and speed of thought production. The client may jump from idea to idea (flight of ideas)
or show a poverty of ideas. Thought may be disordered in terms of (ii) the continuity of
ideas. The client may leave a topic of conversation and perhaps return to it much later
(circumstantiality), or maybe never return (tangentiality) on the one hand or may
perseverate with the same idea, word or phrase. They may show a loosening of associ-
ations, where the logical connections between thoughts are esoteric or bizarre.
Problems in the content of thought also need to be noted by a clinician. Delusions are
profound disturbances in thought content in which the client continues to hold to a false
belief despite objective contradictory evidence, and despite other members of their
culture not sharing the same belief. Delusions vary on dimensions of plausibility, from
 Chapter 3: Assessing Clients 43

the plausible (e.g., the CIA is spying on me) to the bizarre (e.g., the newspaper contains
coded messages for me), and systematization, from those that are unstable and non-
systematized to stable and systematized. The content of delusions can be persecutory
(others are deliberately trying to wrong, harm or conspire against another), grandiose
(an exaggerated sense of one’s own importance, power or significance), somatic (physical
sensations or medical problems), reference (belief that otherwise innocuous events or
actions refer specifically to the individual), control, influence and passivity (belief that
thoughts, feelings, impulses, and actions are controlled by an external agency or force).
Clients can also have delusions that are nihilistic (belief that self or part of self, others, or
the world does not exist), jealous (unreasonable belief that a partner is unfaithful), or
religious (false belief that the person has a special link with God). The clinician needs to
consider cultural factors as well as other clinical issues in identifying delusions. For
example, belief in the sovereignty of God is not a delusion of control, because this is
shared by others within a culture. In addition, oversensitivity to the opinions of others is
not a delusion of jealousy, since clients will typically not hold the belief in the face of
contradictory evidence (behavioural experiment reference) and can concede that it is
conceivable that the belief is wrong. Although the distinction between strongly held false
beliefs and delusions is sometimes difficult, the clinician will find it easier if the focus
remains on the chain of reasoning whereby a person comes to believe a particular false
belief rather than solely relying upon the content of the belief.
In addition to these extreme forms of thought disturbance, there are more frequent
issues such as phobias (excessive and irrational fears), obsessions (repetitive and intru-
sive thoughts, images or impulses), and preoccupations (e.g., with illness or symptoms).

Perception
Hallucinations are a perceptual disturbance in which people have an internally generated
sensory experience, so that they hear, see (visual), feel (tactile), taste (gustatory) or smell
(olfactory) something that is not present or detectible by others. The most frequent
hallucinations are auditory and typically involve hearing voices, calling, commanding,
commenting, insulting or criticizing. Hallucinations can also occur when falling asleep
(hypnogogic) or when awaking (hypnopompic).
Other perceptual disturbances include a sense that the external world is unreal,
different or unfamiliar (derealization), or an experience that the self is different or unreal
in that the individual may feel unreal, that the body is distorted or being perceived from
a distance (depersonalization). Perceptions can also be dulled, in that perceptions are flat
and uninteresting, or heightened, in that each perception is vivid.

Insight and Judgment

Insight is a dimension that describes the extent to which clients are aware that they have
a problem. A strong lack of insight can be an important indicator of unwillingness to
accept treatment. Insight refers also to an awareness of the nature and extent of the
problem, the effects of the problem on others and how it is a departure from normal. For
instance, clients may deny the presence of a problem altogether, or may recognize the
problem but judge the cause to lie within others.
Judgement is another issue that the clinician will consider during an MSE. The ability
to make sound decisions can be compromised for a number of reasons. The clinician will
try to ascertain if poor decisions are the result of problems in the cognitive processes
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44 Chapter 3: Assessing Clients

involved in the decision-making process, motivational issues or failures to execute a

planned course of action.

Speech and Language

A client’s speech can be described in terms of its rate (e.g., slow, rapid), intonation (e.g.,
monotonous), spontaneity, articulation, volume, as well as the quantity of information
conveyed. At one end of the dimension of information conveyed is mutism (i.e., a total
absence of speech), extending through poverty of speech (i.e., reduced spontaneous
speech) to pressured speech (i.e., extremely rapid speech that is hard to interrupt and
understand).
Speech is a subset within the broader domain of language. Language also includes
reading, writing and comprehension. Cognitive dysfunctions can be indicated by lan-
guage disturbances (see Lezak et al., 2012 for an extended discussion) such as aphasia.
Aphasia can be non-fluent, in which speech is slow, faltering or effortful, or fluent.
Fluent aphasia involves speech that is normal in terms of its form (rhythm, quantity and
intonation), but is meaningless – perhaps including novel words (i.e., neologisms).

Intelligence and Abstraction

A general indication of intelligence can be gained from the amount of schooling a person
has had, with a failure to complete high school indicating below average intelligence,
completion of high school indicating average intelligence and college or university
education indicating high intelligence.
Abstraction is the ability to recognize and comprehend abstract relationships – to
extract common characteristics from a group of objects (e.g., in what way are an apple/
banana or music/sculpture alike?), interpretation (e.g., explaining a proverb such as “a
stitch in time saves nine”). However, care needs to be exercised interpreting responses to
abstract questions, since they may reflect the degree to which the person’s cultural group
has permitted exposure to the content of the sayings.
In summary, an MSE interview provides a useful conceptual organization for the
clinician and a mental checklist to consider a client’s functioning across broad domains.
During a diagnostic interview it would be rare to systemically work through each area,
but relevant questions are included as judged appropriate.

Limitations of Diagnosis and Future Directions

Diagnosis is important because without it, the social processes required for the delivery
of mental health services could not be justified, research would be hampered, and
communication among professionals and information retrieval would be difficult.
However, this is not to say that current diagnostic systems are without fault. Rather,
the clinician needs to be cognizant of these weaknesses and use diagnoses accordingly.
First, following the introduction of specific criteria and a focus on observable (rather
than inferred) symptoms, the reliability of diagnoses has increased. Notwithstanding the
improvements in reliability, the outcomes of the DSM-5 field trials have been questioned
and attention has been drawn to the low reliability of some diagnostic categories
(Greenberg, 2013). Additionally, the validity of some diagnoses has been called into
question. A problem with the diagnostic system is that the confidence in the validity of
 Chapter 3: Assessing Clients 45

each diagnosis in not specified, yet not all diagnostic categories are equally valid. Second,
generally there are no identifiable psychometric assessments that relate to particular
diagnoses. Thus, the clinician will need to evaluate the available psychological tests and
determine which tests, and which normative groups and cut-offs, are relevant for
supplementing a diagnosis. Third, the diagnostic system is focused upon existing dis-
orders and makes no reference to precursors to particular disorders. With the increasing
focus on prevention and early intervention, the clinical psychologist needs to remember
that there may be good reasons for intervening in specific problem behaviours, even
though they may not be listed in DSM-5 or ICD-11. Fourth, it is critical for clinical
psychologists to remember that many problems worthy of intervention and treatment
are not listed as clinical disorders within diagnostic systems. Relational disorders (First
et al., 2002), such as couple distress, are just one example of the disorders that do not fit
within the focus of current diagnostic taxonomies upon the individual, rather than a
dyad, family system or other social groups.
Finally, perhaps the most serious criticism of the diagnoses arrived at using current
diagnostic systems is that they are limited predictors of treatment outcome (Acierno,
Hersen & van Hasselt, 1997). Ultimately, diagnostic systems are valuable if they can
predict treatment response. Symptoms are one factor that determines outcome, but not
the sole predictor; however, the DSM-5, the ICD-11, and the empirical literature tend to
focus almost exclusively upon this dimension. Further, the assignment of a DSM or ICD
diagnosis does not regularly imply that a specific intervention is indicated (see Nathan &
Gorman, 2015). From the perspective of a clinical psychologist, the absence of indices
other than symptoms is disturbing. Most psychological models of psychopathology
acknowledge the important etiological role of stressful life events (Miller, 1996), yet
these factors are absent from diagnoses. Alternative systems have been proposed, includ-
ing suggestions to measure (i) symptoms of behaviour, cognition and physiology
through behavioural observation, self-report and physiological monitoring (Bellack &
Hersen, 1998), (ii) maintaining factors through a functional analysis of contingencies of
reinforcement and other contextual factors and (iii) etiology (see Acierno et al., 1997).
Even though the revision to the DSM-5 represented an attempt to form etiological
diagnostic systems (primarily based on neuroscience; see Charney et al., 2002), the goal
remains largely elusive for two reasons. First, neuroscience presently remains too
imprecise to provide a sufficiently solid foundation to achieve the “goal to translate basic
and clinical neuroscience research relating brain structure, brain function, and behav-
iour into a classification system of psychiatric disorders based on etiology and patho-
physiology” (Charney et al., 2002, p. 70; e.g., there is still no biological marker for any
psychiatric diagnosis), and second, it fails to acknowledge that there are social and
psychological factors that exert important and complicated effects. For instance, Gil,
Wagner and Vega (2000) have shown that higher rates of alcohol use by US-born
Latino adolescents compared with recent immigrants are associated with the reduction
over time in familyism, cohesion and social control. Thus, it seems unlikely that
diagnostic taxonomies in the near future will incorporate factors such as a comprehen-
sive symptom assessment, a systematic examination of maintaining factors, personality
and consideration of various aspects of etiology. Nonetheless, there is room within a
clinical intervention to address these important factors and this will be the focus of the
next chapter.
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46 Chapter 3: Assessing Clients

Additional Assessment and Testing

Reviewing our model (Figure 3.3), it is apparent that assessment may begin concurrently
with diagnosis, but it extends far beyond. The clinical psychologist (i) distils information
into a case formulation, (ii) assists treatment planning in which interventions are
matched to clients and (iii) measures the degree of success. The process of assessment
is indicated by the shaded area and the process is divided into matching, measurement
and monitoring, which are located within an overall management structure.
 Management: of outcomes involves the ongoing assessment and evaluation of clinical
and administrative processes involved in the delivery of care.
 Matching: refers to the process of matching the client to the appropriate treatment
option. This process begins with screening and problem description, which have been
discussed earlier. Problem description is followed by treatment planning or matching
(in which specific information is collected that aids the clinical decision-making
process). Once the problem has been accurately identified, the psychologist can give
thought to the most appropriate treatment (Beutler & Clarkin, 1990; Beutler &
Harwood, 2000; Castonguay & Beutler, 2006). Sometimes the relevant treatment will
be evident by examining a list of empirically-validated treatments (e.g., Nathan &
Gorman, 2015). However, at other times the picture will be more complicated, due to
patterns of comorbidity and involved presentations. At these times, case formulation
can be used to identify potential treatments that are linked to the causal mechanisms
involved.
 Measurement: involves the pre-, post-, and follow-up assessments of a variable(s) to
determine the amount of change that has occurred as a result of an intervention.

Client data (problem, context, history, etc.)

Theoretical and Clinical training &

empirical literature experience

Assessment &
case formulation

Treatment matching
& measurement

Treatment implementation
& monitoring

Evaluation & accountability:

management of assessment

Figure 3.3 The centrality of assessment processes and techniques to the scientific practice of clinical
psychology (shaded area indicates the components involving assessment).
 Chapter 3: Assessing Clients 47

 Monitoring: refers to the periodic assessment of intervention outcomes to permit

inferences about what has produced observed changes. Progress monitoring
determines deviations from the expected course of improvement; whereas outcomes
monitoring focuses upon the aspects of the intervention process that bring about
change.
Thus, these four activities all occur within a context of evidence-based and evidence-
supported assessment. Although the concept of measurement will be familiar to a
psychologist, ongoing monitoring may be less familiar (Newnham & Page, 2010). Lutz,
Martinovich and Howard (1999; see also Asay et al., 2002; Lutz et al., 2002, 2021)
distinguished treatment-focused research from patient-focused research. Patient-focused
research, what we have called monitoring, asks the question, “Is this particular client’s
problem responding to the treatment that is being applied?” (Lutz et al., 1999). Thus, with
the move from treatment- to patient-focused research the spotlight shifts from the average
client to the particular individual currently being treated (Lutz et al., 2020).
Before describing some general principles of monitoring, a scientist-practitioner
needs to consider the empirical evidence regarding monitoring. Monitoring will take
time and effort on the client’s part and the clinician will need to collect, score, store,
collate, interpret and feed back all data to the client. Therefore, the clinician needs to be
able to justify to the client, themselves and their employer the “costs” incurred. To this
end, work by Lambert et al. (2001) is useful. They assigned clients to treatment as usual
condition in which their clinician received weekly feedback on their symptom change
relative to expected progress. The sample was then divided into clients who were
predicted to have good versus poor outcomes, based on initial assessment. For clients
who were predicted to have poor outcomes, treatment duration increased and the
outcomes were improved, such that twice as many clients achieved clinically significant
(Jacobson & Truax, 1991) change. For clients who were expected to have a positive
response to treatment, the outcomes were no better, but the number of sessions was
reduced. Therefore, the provision of monitoring data to the clinicians allowed them to
target therapy time to clients where it was most needed and in so doing, they maximized
the overall benefit.
Monitoring of clients highlights the various phases of treatment. Lutz et al. (1999,
2002) identify three phases of therapy. The client passes through remoralization, as
subjective wellbeing improves, remediation, as symptoms begin to reduce, and rehabili-
tation, as the improvements in wellbeing and symptoms spread to domains of life
functioning. The process of symptom amelioration will follow a log linear curve for
the average client (Howard et al., 1986; Robinson, Delgadillo & Kellet, 2020; Sembill
et al., 2019), such that the greatest change occurs in the initial sessions, with improve-
ment gradually flattening out. If assessments are collected during treatment (e.g.,
Howard et al., 1995; Lutz et al., 2020), it is possible to plot an expected course of recovery
using a variety of predictor variables. For instance, Lutz et al. (1999) used archival data
on subjective wellbeing, current symptoms, current life functioning, global assessment of
functioning, past use of therapy, problem duration and treatment expectations to
generate an expected treatment trajectory. Using a client’s pre-treatment scores it is then
possible to plot an expected course of improvement for each particular client, over which
can be overlaid actual progress. Boundaries can be placed around the expected trajectory
of improvement. The lower range is set by the failure boundary (e.g., scores of clients in
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48 Chapter 3: Assessing Clients

the 25th percentile) and an upper range (e.g., mean scores of non-clinical sample)
indicates good progress. As a result, it is possible to display a graphical depiction of a
client’s progress through therapy relative to their expected course. Further, as the client’s
actual scores approach the normal range, the clinician will receive feedback that treat-
ment is progressing optimally. On the other hand, if a client’s scores approach the failure
boundary, the clinician will be alerted that the treatment outcome is not optimal and an
alternative treatment plan may need to be set (see Lambert et al., 2001; stergård, Randa &
Hougaard, 2020; Tasca et al., 2019, and Chapter 4 for a discussion of individualized outcome
measures in psychotherapy). The same logic can be applied to the prediction of drop-out
from treatment, in addition to optimal treatment strategy selection and personalized adaptive
recommendations during psychotherapy (Lutz et al., 2019).
Thus, repeating testing during an intervention can provide an indication of the extent
to which a person is changing according to expectations. Sometimes this is talked about
as a “glide path”. In the same way that an aircraft approaches a runway along a glide path
and deviations from the expected trajectory signal time for corrective action, the place
where an individual is along a treatment trajectory provides useful information.
Deviations from the expected path of improvements may signal a problem. The expected
changes in symptom severity, alliance social function and occupational performance can
all be monitored against normative references to identify if remedial action is appropri-
ate (Flückiger et al., 2020).
Although these approaches to monitoring are more recent than efficacy and effect-
iveness research, the client-focused research approach typified by monitoring has great
potential to bridge the gap between science and practice. Science, by its nature, is
concerned with generalizable results, whereas clinical practice is concerned with the
instance. By increasing the relevance of data collection to the individual client, monitor-
ing strategies will allow clinical psychologists to collect client-relevant data that can be
integrated with data available from treatment-relevant efficacy and effectiveness
research. Furthermore, monitoring permits a science-informed practitioner to test and
evaluate hypotheses about each client. How to monitor client progress is the topic of the
next chapter.
 Chapter
Matching Treatments and

4 Monitoring Client Progress

Clinical psychologists are referred clients who are in distress; the problems have pro-
found impacts on their lives and the psychologist’s intention is that, after some interven-
tion, the client will leave treatment no longer distressed and with their problems
resolved. One way to guide the selection of treatments to achieve this desired outcome
is by using evidence-based practice. In so doing, it is possible to make inferences about
the progress of the average client. Evidence-based practice draws upon efficacy studies
that contrast active treatments with appropriate comparisons under controlled condi-
tions and permit an estimate of the effect size of treatment to be made. Effectiveness
studies can then examine the degree to which the effect sizes observed under controlled
conditions are reproduced in clinical settings. The reduced control over the types of
clients, the extent of comorbidity and the training of therapists can all affect the extent to
which effect sizes observed in efficacy studies may fail to generalize. Lambert (2013) has
documented that the effect sizes tend to be smaller in clinical practice than in efficacy
studies, but nonetheless, as a scientist-practitioner, it is possible to know that a given
evidence-based treatment will have a particular effect size and to infer that the average
client treated will experience a similar benefit. The present chapter, while not arguing
against the application of evidence-based treatments, will present the case that the blind
application of evidence-based treatments is not optimal clinical practice.

Matching Clients to Therapeutic Interventions

As the field of clinical psychology matures, the complexity of using evidence-based
practice becomes more evident. That is, when there is a set of randomized controlled
trials that provide a strong evidence base for a single treatment, there is little basis for
choice. However, once there are two or more treatments with an evidence base, the
clinical psychologist is faced with the issue of treatment selection. A clinical psychologist
who wishes to be evidence based, then needs to ask, what evidence do I need to select one
treatment over another?
There are two ways this question could be answered. One response might be to
examine the effect size of a treatment and initially select a treatment with the larger
average impact. Oftentimes, the size of the difference between two effective treatments is
not significant (Cuijpers et al., 2020) and larger effect sizes do not necessarily imply
replicability (Frost, Baskin & Wampold, 2020). Another response is to match treatments
to clients. Matching can be achieved by assigning clients to treatments on an a priori
basis using information available at the beginning of treatment. Another form of
matching (discussed later in the chapter) can be performed in real time during treatment,
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based on the progress of a particular client as they progress through therapy.
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50 Chapter 4: Matching Treatments and Monitoring Client Progress

Despite promising much, the benefits derived from matching treatments to clients
based upon individual differences have not been as large as people had hoped. For
instance, project MATCH (Mattson et al., 1993) was a large multisite clinical trial of
treatments for clients with alcohol disorders, who were matched on the basis of client
characteristics to one of three different treatments (Twelve-Step Facilitation – such as
used by Alcoholics Anonymous – Cognitive-Behavioural Coping Skills or Motivational
Enhancement Therapy) and the outcomes were changes in drinking patterns, quality of
life and the use of treatment services. Importantly, interactions with individual charac-
teristics were studied but still the study found that the outcomes for the different
treatments were similar (Cutler & Fishbain, 2005).
Nonetheless, a more recent innovation in a priori treatment matching has been
identified. It promises greater potential for personalized treatment selection in clinical
psychology (Fisher & Bosley, 2015). The Personalized Advantage Index (PAI), developed
by Robert DeRubeis and colleagues (Cohen & DeRubeis, 2018; DeRubeis et al., 2014;
Lopez-Gomez et al., 2019), is a metric that aims to quantify the degree to which a client is
expected to benefit from one treatment as opposed to another (Lorenzo-Lucaces et al.,
2017). Skimming over the computational complexity, in a nutshell, the PAI can be
derived from two groups of clients who receive different treatments. For instance,
imagine depressed clients treated either with a psychological therapy and a pharmaco-
logical therapy. Each client will have a score that reflects the degree to which they
responded to treatment (e.g., the pre-post difference on a Beck Depression Inventory
(BDI)). The PAI then uses a variety of possible methods to generate a predicted score for
each client. Thus, there will be one algorithm that predicts the outcomes for psycho-
logical treatment from pre-treatment information and another that predicts pharmaco-
logical treatment outcomes. The validity of the predictive algorithms can be tested by the
concordance between the actual and predicted scores. However, the ingenious step is to
take the algorithm derived from the psychological therapy and apply it to the clients who
had received the pharmacotherapy (and vice versa). Thus, each client will now have two
predicted scores – a predicted score showing how much they would respond to the
treatment they received and a predicted score showing how much they would respond to
a treatment they did not receive. These two sets of data become the variables of interest.
Clients can be ordered in terms of those who are predicted to benefit more from
psychological than pharmacological therapy. At one end of the list are people who will
respond better to psychological treatment, at the other end are those who will respond
better to pharmacological treatment and in the middle are people who could have been
assigned to either treatment. Furthermore, each client can be categorized based on
whether they received the optimal or non-optimal predicted treatment. Thus, from a
treatment matching perspective, the PAI could provide a clinical psychologist with an
index reflecting the degree to which a client is predicted to benefit from one treatment as
opposed to another. This index could assist with treatment decision-making and make
treatments more efficient (Delgadillo et al., 2021; Hollon et al., 2019; Page, Camacho &
Page, 2019; Page, Cunningham & Hooke, 2016).
To illustrate the potential value in treatment decision-making, we can see from the
work of Huibers and colleagues (2016), who contrasted two different evidence-based
therapies (Cognitive Therapy and Interpersonal Psychotherapy; IPT) and found that
clients who received their predicted optimal treatment completed treatment with a BDI
score of 11.8, compared to 17.8 for those clients who received their predicted non-
 Chapter 4: Matching Treatments and Monitoring Client Progress 51

optimal therapy. Thus, the PAI can be used to quantify the relative benefits for a
particular individual of different treatments, even when these treatments have similar
average levels of treatment outcomes (see also Fisher & Bosley, 2015; Lopez-Gomez et al.,
2019; van Bronswijk et al., 2019). Friedl and colleagues (2020) examined the differential
benefits of Cognitive-Behaviour Therapy (CBT) when compared with CBT that inte-
grated exposure- and emotion-focused elements. The predicted post-treatment depres-
sion scores were 14 per cent lower (i.e., BDI-2 scores of 8.65 versus 10) for those given
the optimal rather than the suboptimal treatment. Thus, the PAI can also be used to
quantify the relative benefits of different versions of the same treatment.
While the PAI seeks to match treatments to clients based on a priori information,
another approach to matching has been outlined by Fisher (2015), which seeks to
identify the optimal sequence of treatment elements based on a mapping of each client’s
unique profile of symptoms over time. Illustrated with clients with diagnosed
Generalized Anxiety Disorder (GAD) who completed symptom surveys over 60 days,
the analyses identified unique latent symptom dimensions by modelling the dynamic
interrelationships within and between symptom domains for each person. These profiles
can then be incorporated into a treatment selection algorithm (Fisher & Boswell, 2016)
that predicts the optimal sequence with which elements in an evidence-based treatment
can be delivered.
Another approach to matching uses the a priori client data to assign clients to
therapists rather than therapies (e.g., Delgadillo, Rubel & Barkham, 2020). These
methods begin from the observation that a similar amount of variance in outcomes is
predicted by therapist effects (i.e., systematic differences in outcomes that are attribut-
able to the individual providing treatment) as therapy effects (Castonguay & Hill, 2017).
Systematic differences among therapists explain around about 5–8 per cent of variance in
outcome (e.g., Baldwin & Imel, 2013) and client drop-out (Zimmerman et al., 2016). The
implication is that for a given client, some therapists will be more effective than other
therapists. Delgadillo and colleagues (2020) demonstrated that it is possible to match
clients to the therapists with whom they are more likely to have better outcomes.
Table 4.1 summarizes the three different ways that matching can be used. Each of
these are an element in the greater personalization of clinical care and, importantly, they
are not mutually exclusive. For example, the Trier Treatment Navigator (TTN; Lutz
et al., 2019) illustrates how a combination of algorithms can be used to enhance clinical
real-time decision-making by giving personalized pre-treatment recommendations, pre-
dicting drop-out risk and predicting the optimal treatment strategy. It potentially allows
the matching of clinical psychology trainees with the optimal supervisors. In addition,
the TTN permits a responsive approach during therapy by personalizing adaptive
recommendations during treatment by using a dynamic risk index to identify clients

Table 4.1. Options for treatment matching and monitoring

Matching Monitoring and Feedback

Programmes Outcomes
Ordering Programme Components Processes
Therapists
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52 Chapter 4: Matching Treatments and Monitoring Client Progress

who are at risk of a non-optimal outcome. These monitoring principles are noted in the
right-hand column of Table 4.1 and are the topic to which we now turn.

Monitoring and Feedback is a Specific Therapeutic Intervention

Evidence-based practice is not incompatible with practice-based evidence (Castonguay
et al., 2013, 2021a, 2021b). In evidence-based practice, we use interventions and
practices that have a reliable and valid foundation in empirical findings. However,
practice-based evidence uses practice-oriented research and allows clinicians to monitor
client progress during treatment and adapt therapy accordingly. Therapists adapt treat-
ment but they do so by allowing their clinical judgements to be guided by evidence and
to be responsive to the data collected. Before describing how this can be done, let us
review the evidence showing that clinical outcomes are improved by using practice-based
evidence.
The pioneering research in patient monitoring of outcomes (Table 4.1) and feedback
was conducted by Mike Lambert and colleagues. They have published many randomized
controlled trials evaluating the effectiveness of providing individualized feedback to
clinicians (Harmon et al., 2005; Hawkins et al., 2004; Lambert et al., 2001, 2002;
Whipple et al., 2003). Conducted in routine clinical settings, each of the studies assigned
clients to “treatment as usual” or to a condition in which therapists were given feedback
about the progress of each client during treatment. Broadly speaking, the client data
collected in each session provided the therapists with feedback that could be distilled into
information as to whether the client was progressing as expected (i.e., was “on track”) or
was not progressing as expected (i.e., was “not on track”). Therapists were not given any
additional treatments, but were free to use their clinical experience to adapt the treat-
ments in light of the feedback. The clear result was that when patients drifted off track,
providing therapists with that information led to improvements in patient outcomes
(Shimokawa, Lambert & Smart, 2010). Specifically, the effect size was moderate (even
though this was over and above the benefits of treatment) and the deterioration rate was
halved.
Expressing this differently; an efficacy study provides information that the average
client will improve by a particular amount. However, some people will improve more
than the mean and others will improve less than the average. Just using evidence-based
practice does not provide information about what to do with clients who improve less
than the average. Practice-based evidence, on the other hand, complements evidence-
based practice and uses data collected during therapy to allow clinicians to target those
who are falling behind and the potentially avert negative outcomes. Not surprisingly, the
outcomes for patients who are “on track” are less affected by feedback. Presumably, when
a clinical psychologist uses an evidence-based treatment and learns that the client is
responding as expected, the therapy will not require a modification to standard practice.
Lambert’s group uses the 45-item Outcomes Questionnaire (Lambert, Gregersen &
Burlingame, 2004) to measure outcomes and to provide feedback to therapists. They
have amassed an impressive evidence-base for their outcomes monitoring system (OQ
Measures, 2021). However, other researchers have replicated the same beneficial effects
using different assessment measures (e.g., Lutz et al., 2002; Miller, Duncan & Hubble,
2005a; Miller et al., 2005b), with different age groups and diagnoses (Kelley & Bickman,
2009; Kelley Bickman, & Norwood, 2010), and across different treatment settings
 Chapter 4: Matching Treatments and Monitoring Client Progress 53

(Byrne et al., 2012; Newnham et al., 2010b). Innovative research from Wolfgang Lutz’s
clinical research group has carefully studied the behaviours of clinicians and one
important finding has relevance for clinical psychology trainees (Castonguay et al.,
2013). They compared experienced psychologists with trainees, and found that when
trainees encountered a client who was not proceeding as expected, they were more likely
to seek supervision. Thus, it is clear that the provision of feedback is a specific treatment
intervention that has beneficial effects on clients who are not progressing well and, as
such, science-informed practice should include such a system (de Jong et al., 2021; Lutz
et al., 2021). Sometimes those benefits appear to be in the form of enhanced outcomes
for clients who are not on track and at other times, it seems that treatments are delivered
more efficiently (e.g., Delgadillo et al., 2018). For clinical psychology trainees, the system
provides a complement to training. It does this by signalling when extra supervision
could be needed and thus, timely and focused help can be sought. While there are many
commercially available patient monitoring systems, the remainder of the chapter will
outline the key principles of a system describing a freely available version (because some
versions are still not available in many clinical settings; Tasca et al., 2019) and then cover
some reasons why feedback and monitoring might be beneficial. Trainees can then
experiment with a system and use it to seek targeted help from supervisors (Peterson &
Fagan, 2017).

An Outcome Monitoring and Feedback System

Think of a monitoring system like a thermometer. In physical medicine, a thermometer
provides a quick measure of temperature and allows staff to compare the reading against
an expected distribution, with a threshold distinguishing normal from abnormal levels.
An elevated temperature does not tell the doctor or nurse what is wrong, but signals that
something is not right. Further investigations then guide clinical decisions about how to
modify treatment. Extending this logic to mental health, it means that we need a quick,
repeatable measure of mental health and a way to identify when scores are “normal”
and “abnormal”.
There are a number of instruments that can serve as “mental health thermometers.”
The 45-item Outcome Questionnaire (OQ-45; Lambert & Finch, 1999; Lambert et al.,
2004) has been the most widely used instrument and it has been shown to be acceptable
in both outpatient and some inpatient settings. The sophisticated software that is
available provides clinicians with a comprehensive suite of tools to monitor outcomes
and to provide feedback to clients. Added benefits are that comparable instruments have
been developed for use among children and adolescents (Cannon et al., 2010;
McClendon et al., 2011; Nelson et al., 2013) and the scale has been translated into many
languages, with the beneficial outcomes being replicated in countries other than the US
(e.g., de Jong et al., 2008, 2012; Wennberg, Philips & de Jong, 2010). The Outcome
Rating Scale (ORS; Miller et al., 2005b) is a popular measure in counselling psychology,
since the system provides indications about the quality of the therapeutic relationship as
well as distress. It also shows similar benefits to the OQ system (Lambert, Whipple &
Kleinstäuber, 2018; although cf. stergård et al., 2020). Another instrument, developed
by Bickman and colleagues (Bickman et al., 2011) permits assessments of youths’
symptoms and functioning. Its strength is that it draws on a theoretical foundation
about feedback developed within industrial and organizational psychology (Sapyta,
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54 Chapter 4: Matching Treatments and Monitoring Client Progress

Riemer & Bickman, 2005) and its use has also been shown in a randomized controlled
trial to improve outcomes (Bickman et al., 2011). Within the United Kingdom, the
Clinical Outcomes in Routine Evaluation 10-item (CORE) (Barkham et al., 2010, 2013;
Connell et al., 2007) has proved to be popular and its strength that it is accompanied by a
whole suite of associated indices (CORE, 2021). There are adaptations of the systems so
that they can also be appropriate for group treatment (Janis, Burlingame & Olsen, 2018)
and couples (Tilden & Wampold, 2017). Yet each of these different outcomes monitor-
ing systems shares a common methodology in which an instrument is used to provide
the practice-based evidence upon which clinical decisions are made (Boswell, 2020;
Delgadillo et al., 2018).
By way of illustration we will describe an outcomes monitoring system that we have
developed. Since the instruments and the tools are in the public domain it means that
you can use them in your clinical training. To capture both mental health as well as
psychological distress, we have developed two companion measures. The first instrument
we use is the World Health Organization’s Well-Being Index (WHO-5; Bech, Gudex &
Johansen, 1996). The WHO-5 has good internal consistency in medical settings
(α = 0.91; Löwe et al., 2004) and psychiatric samples (α = 0.89; Newnham et al.,
2010a). The instrument consists of five items rated on a six-point Likert-type scale
measuring frequency from “All of the time” to “At no time”. Participants endorse the
appropriate option for the previous 24 hours (adaptation by Newnham et al., 2010a),
with high scores indicating increased wellbeing. The items ask patients the amount of the
time that they have felt (i) cheerful and in good spirits, (ii) calm and relaxed, (iii) active
and vigorous, (iv) woken up feeling fresh and rested and (v) that their daily life has been
filled with things that interest them. Similar to other research groups, we demonstrated
in a controlled trial that providing feedback about progress to staff and patients reduced
depressive symptoms in patients at risk of poor outcomes post-treatment (Newnham
et al., 2010b). A companion symptom measure assesses psychological distress is the
5-item Daily Index (DI-5; Dyer, Hooke & Page, 2014). Items assess a variety of symptom
domains, including thoughts about suicide. It has strong reliability α = 0.88) and has
good sensitivity to treatment change. It also shows good validity, with strong correlations
with other longer symptom measures, and in a recent controlled trial it is apparent that
combining symptom and wellbeing feedback leads to even greater benefits for “not on
track” patients (Kyron, Hooke & Page, 2020).
The DI-5 (Dyer et al., 2014) asks patients to rate five items on a 6-point Likert-type
scale (0 = At no time; 1 = Some of the time; 2 = less than half of the time; 3 = more than
half of the time; 4 = most of the time; 5 = all of the time). The items are “Over the last day
I have” (i) felt anxious, (ii) felt depressed, (iii) felt worthless, (iv) had thoughts about
killing myself, (v) felt that I am not coping. Each scale is scored by summing items to
create a score that ranges from 0 to 25. Scores on the DI-5 and WHO-5 scales will be
negatively correlated because high scores on the DI-5 represent elevated symptoms
whereas higher scores on the WHO-5 reflect greater wellbeing. Calculation can be
performed by hand, but spreadsheets were developed by Kale Dyer and are available
for the DI-5 (Dyer, Hooke & Page, 2013a) and the WHO-5 (Dyer, Hooke & Page, 2013b)
that not only add up the relevant scores, but assist with interpretation.
The two spreadsheets are similar, so we will illustrate only the DI-5. The three tabs at
the foot of the page (see Figure 4.1) are labelled (i) INPUT, (ii) Therapist Graph and (iii)
Therapist Graph (B&W). The Input screen is shown below for a patient who has
 Chapter 4: Matching Treatments and Monitoring Client Progress 55

Figure 4.1 Screenshot of input for symptom monitoring using the Daily Index-5 (Dyer et al., 2014).

attended four sessions. The clinical psychologist has entered data into columns E–H and
the programme has provided totals. The first data set is identified as the pre-treatment
session (Column B) and the last and most recent data set as the post-treatment (Column C).
Were data from another session to be added, this would now be identified as post-treatment
column D. The information below the table relates to the calculation of clinical significance.
Before discussing this, the therapist graphs on the two tabs will be reviewed.
The Therapist Graphs have identical content, but one is coloured. They plot the
client’s scores in a graphical manner so that progress can be evaluated. The x-axis is the
number of sessions and the y-axis is the extent of psychological distress (or wellbeing)
rated from 0 to 25. The line depicting the client’s data is overlaid on a series of horizontal
bands. In the colour version of the graph, the top red band (labelled “Deteriorating”)
reflects that relative to the pre-treatment score, the client had significantly worsened. The
green band (titled “Improving”) indicates significant improvement and the blue band
(titled “Healthy Range”) shows that the client has improved significantly and the post-
treatment score is now in the healthy range. The amber (“Potential for Change”) band is
anchored to the client’s pre-treatment score and movement within this area is not yet
statistically significant. Therefore, the client depicted in Figure 4.2 has psychological
distress that improved non-significantly between the first and second sessions, but the
change by session three was significantly different to the pre-treatment score. The client
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56 Chapter 4: Matching Treatments and Monitoring Client Progress

25

Deteriorating

20

Potential for change

15
DI-5 score

10 Improving

5
Healthy range

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Session

Figure 4.2 Screenshot of output for symptom monitoring using the Daily Index-5 (Dyer et al., 2014).

is thus now in the “Improving” range, but has not yet exhibited a reduction in psycho-
logical distress that is in the “Healthy Range”.

Clinical Significance
It is important to understand the logic that underpins the categorization because the
principles are those that tend to be used by the majority of outcome monitoring systems.
“Clinical significance” has been developed as an ecologically valid index (Flood, Page &
Hooke, 2019; Ronk, Hooke & Page, 2016) because statistical significance alone does not
reflect the “meaningfulness” of clinical change (Balkin & Lenz, 2021; Ogles, Lunnen &
Bonesteel, 2001). Even with large effect sizes, it is impossible to conclude that any
participant is asymptomatic. To redress this deficiency, “clinical significance” was
developed (Jacobson & Truax, 1991). While there are a variety of calculation methods
(Ronk, Hooke & Page, 2012; Ronk et al., 2013) and approaches available (Lambert,
Hanse & Bauer, 2008), the most common illustrative approach is the Jacobson and Truax
method. It comprises two components, the first of which is the Reliable Change Index
(RCI). The RCI expresses the pre- to post-difference in standardized units and identifies
if pre-post change is reliable (i.e., exceeds measurement error). The second component
assumes client scores are drawn from an “unhealthy” population and non-client scores
from a “healthy” one. A cut-off is established to estimate if a client’s score moves into the
healthy range. Consequently, a client with a post-treatment score that is not reliably
different from their pre-treatment score will be classified as “unchanged”. Someone who
has reliably improved, but failed to move into the healthy range is “improved” whereas
someone who has reliably improved and moved into the healthy range is “recovered.”
Finally, clients who exhibit a reliable change in the opposite direction will be classified as
“deteriorated.”
The Jacobson and Truax (Jacobson et al., 1984; Jacobson & Truax, 1991) method
identifies a cut-off between “functional” and “dysfunctional” populations. There are
three ways to identify a cut-off, but the optimal method is possible when both normative
 Chapter 4: Matching Treatments and Monitoring Client Progress 57

and clinical data are available. The resulting cut-off (i.e., criterion C) is calculated using
the formula below:
Spop M pre  Spre M pop
C¼
Spop þ Spre
where Spop and Spre are standard deviations of functional and dysfunctional (pre-
treatment) groups respectively, and Mpop and Mpre are the means of functional and
dysfunctional (pre-treatment) groups respectively. For the DI-5, the result of applying
these calculations (to obtain the value of 6.17) can be seen in the Input worksheet
(Figure 4.1) in the row called “non-clinical border” and the values entered into the
equation are listed in the rows above.
The second step calculates the Reliable Change Index (RCI). This expresses each
individual’s pre- to post-treatment change score in standard error units of measurement
and signals that a reliable change has occurred when this value exceeds an increase or
decrease of 1.96. The formula used is:
X post  X pre
RCI ¼ qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
pffiffiffiffiffiffiffiffiffiffiffiffiffiffi
2ðSpre 1  r xx Þ 2

where Xpost and Xpre are the individual’s raw scores post- and pre-treatment respect-
ively and rxx is the reliability of the measure (e.g., test-retest reliability, Cronbach’s
alpha). Thus, the equation expresses the difference between pre- and post-values as a
standard score, and asks the question “is the difference larger than that to obtain a
probability value less that .05?” Since change can be both positive and negative, there are
two values. One is the “deteriorated boundary” (i.e., 20.54) and the other is the
“improved boundary” (i.e., 13.46) which are the pre-treatment score plus or minus the
RCI. The categorization of “Achieved” in Figure 4.1 is included because the change for
this particular individual from the first to fourth sessions has exceeded the value
necessary for reliable change.
By combining the cut-off with the RCI, it is possible to create the four categories
depicted in the spreadsheet. While the calculations are relatively straightforward, the
spreadsheet performs the operations for you. However, understanding the logic is
necessary for the informed use of the categories. The interested reader may also consider
the literature about clinical significance because there are other calculation methods and
approaches (Ronk et al., 2012).
The clinical psychologist can then use a monitoring tool such as the DI-5 and WHO-
5 to provide feedback to clients about their progress. Since we know that the average
client will respond favourably to an evidence-based treatment, the expectation would be
that a client who is responding appropriately to the treatment will move from the pre-
treatment levels into the “Improving” or even the “Healthy” range. Furthermore,
Howard and colleagues demonstrated that the typical trajectory of improvement follows
a negatively accelerating curve. That is, the reduction in symptoms (or growth in well-
being) is maximal in the first few sessions of therapy with the improvement gradually
plateauing, until the amount of improvement after each subsequent session is marginal.
Importantly, the degree of change in the first few sessions is predictive of later improve-
ment. Clients who make rapid gains early in therapy go on to have the best outcomes,
whereas clients who make rapid early losses, will tend to have the worst outcomes
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58 Chapter 4: Matching Treatments and Monitoring Client Progress

(Lambert et al., 2005). This information is clinically useful because the clinical psycholo-
gist does not have to wait until post-treatment to know which clients are going to fare
badly. In fact, the amount of progress (or lack thereof ) by three sessions into therapy is
sufficient to predict end-state. The implication is that monitoring the progress allows the
clinical psychologist to use this practice-based evidence to guide and inform clinical
decisions about treatment progress.
If a client is not progressing as expected, the clinical psychologist can review possible
obstacles. It may be that the treatment is not being appropriately applied or that elements
have been omitted. It is possible that the problem has not been appropriately conceptual-
ized. Alternatively, it may be that the client is not ready for change, social support may be
inadequate, the therapeutic alliance has not been established or it may have been
ruptured, or life stresses or comorbid conditions may be impeding progress. The
clinician can evaluate these options using relevant psychometric assessments and then
implement treatment options that are appropriate (Harmon et al., 2005; Lambert et al.,
2005). There is growing evidence that when such clinical support tools are used in the
context of an outcomes monitoring system, the benefits to clients are even greater still
(Shimokawa et al., 2010).

Monitoring Therapy Processes

Client monitoring has largely focused on Routine Outcomes Monitoring (ROM), but a
possible future adaptation is the monitoring of core therapeutic processes (see the right-
hand column of Table 4.1). For example, two treatments may have similar outcomes on
average for clients, but that does not mean that the therapeutic change is mediated by the
same therapeutic processes. That is, if a clinical psychologist monitors symptoms and
finds that a client is off-track, it is not immediately obvious what needs to be done and
further testing is needed. Typically, this is achieved with a set of structured tests that seek
to identify the cause of the lack of progress. However, another possibility would be to
identify the mediators of therapeutic change (e.g., Seow, Page & Hooke, 2020) and then
to monitor and provide feedback to clients and therapists about a lack of progress in
terms of these mediators. The issue of monitoring the mechanisms responsible for
treatment change will be addressed in later chapters.

The Reasons Why Feedback Works

Before leaving the discussion of outcomes monitoring it is worth considering explan-
ations of why the provision of feedback would be beneficial. After all, do not therapists
already ask clients how they are progressing? Do not clinical psychologists already know
when a client is not on-track and use their clinical judgment accordingly?
Clearly, we must answer in the affirmative to these questions and this probably
explains why the majority of clients do not deteriorate and that even without a formal
monitoring system, therapists are able to turn around the negative progress of many
clients who get worse during treatment (Lambert, 2010, 2013). However, the observation
remains that when monitoring systems are implemented and the results are fed back to
therapists, client outcomes improve. Why is this?
One part of the answer is that statistical prediction of outcome tends to be more
accurate than clinical judgements (Grove et al., 2000). Specifically, when clinical and
statistical methods for prediction of treatment failure were contrasted, clinicians tended
 Chapter 4: Matching Treatments and Monitoring Client Progress 59

to vastly underestimate the probability that a treatment failure would occur (Hannan
et al., 2005). The authors found that even though clinicians could identify which patients
were worse off during a particular session, they did not use that information to modify
their treatment. If a feedback system is in operation, it is much harder to maintain an
overly positive (potentially self-serving) cognitive bias in the face of data that the client’s
actual treatment progress is not proceeding according to plan and it is harder to ignore
the objective evidence of potential treatment failure (Newnham & Page, 2010).
Furthermore, not all patients follow the same trajectory through treatment (Nordberg
et al., 2014) and algorithms can be used to identify which group a client is a member of
and this in turn can guide treatment (Lutz, Stulz & Kock, 2009). The identification of a
particular client’s therapeutic trajectory is hard for a clinician to identify, but computers
can do this more easily and this information can feed into the clinician’s decision-
making process.
Another part of the answer may also be that client recollections of progress may not
always be accurate. Page and Hooke (2009) found that an increase in the amount of
psychological therapy was associated with increased gains in self-reported pre- to post-
treatment outcomes. However, when patients reflected on their treatment gains, those
who had received more therapy and improved to a greater degree recalled less improve-
ment and were less satisfied with treatment. Thus, retrospective self-report is not
completely valid. Therefore, by collecting data in real time and presenting it in an
objective manner to therapists, clinical decisions can be made on a more rational basis
(Schulte & Eifert, 2002).

How to Give Feedback to Clients

Given that client recollections are not perfect, that clinicians tend to underestimate
negative outcomes and that even when clinicians are aware of evidence of poor progress
they do not always use the information to modify practice, it is not surprising that
supplementing clinical judgement with practice-based evidence can improve outcomes.
Having described the evidence base for progress monitoring and illustrated a method for
doing so, the remaining issue is the process of providing feedback to clients. In our
experience, there are a few concerns that we need to address, because while clinicians
have favourable attitudes to monitoring, the majority do not incorporate them into
practice (Jensen-Doss et al., 2018).
The first issue is a concern that clinicians have about the possible risks of sharing the
progress graph and it’s meaning with a client. One worry is that it may be demoralizing
to clients to see a lack of progress. In fact, in a naturalistic study we not only found that
clients benefited from feedback, but that, paradoxically, therapists were less likely to
provide feedback to the clients who needed it most (Hutson, Hooke & Page, 2020; see
also Tasca et al., 2019). In this context, it is important to remember that the graphs are a
depiction of information that the client has provided. Therefore, it is typically more
newsworthy for the clinician than for the client. Concerns about a lack of progress will
already have been in the client’s mind. The graph allows the topic to be put on the
clinician’s agenda and clients find the presentation of their performance relative to
trajectories beneficial (Hooke et al., 2018). It is in the open and available for discussion.
The depiction legitimizes both progress and lack of progress as a topic for collaborative
consideration. The conversation can be guided by the data and therapist and client can
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60 Chapter 4: Matching Treatments and Monitoring Client Progress

consider the best way to progress. However, do not be surprised to find that the graphs
challenge your perception of progress more than they challenge your client’s view.
A second issue relates to the value of the self-report. It is possible that the self-report
fails to capture the nuances of the client’s problems. We do not see this as a fatal flaw, but
it is a reason for the clinical psychologist to interpret the meaning of the score. This
interpretation will be guided by an understanding of both the construct validity of the
scales and the meaning of the clinical significance categories. The two scales are a
“thermometer” and just as a doctor will take patient’s temperature but will also use a
plethora of other tests, the clinical psychologist should be no different. Each test is
interpreted with a view of its strengths and weaknesses.
A third concern raised by clinical psychology trainees is the view that formal feedback
is not needed because routine clinical practice already involves therapists asking clients
about their progress. In response to this concern, it is useful to remember that the
controlled trials involved “treatment as usual” conditions. The therapists who used
feedback had better outcomes than therapists who did not. One important methodo-
logical detail of the studies (see Shimokawa et al., 2010) is that it was often the therapists
who were randomly assigned to conditions. That is, one therapist had feedback graphs
on one client, but not on another. Hence, the benefits were not attributable to the normal
behaviours of particular therapists, but an effect of giving a therapist access to the graphs
and the opportunity to discuss them with a client led to improvements with that person
but not the next client (for whom the graph might not be available). The exact mechan-
isms underpinning the benefits will need to be revealed by future research, but for the
time being it is sufficient to know that progress monitoring and feedback is beneficial.
Finally, while some argue that Routine Outcomes Monitoring has matured to a point
that it is becoming unethical not to use a system (Muir et al., 2019), it is prudent to be
aware of circumstances under which providing feedback may not be optimal. This could
be an issue of timing and so the focus on the feedback may not be the optimal
therapeutic action for some patients, such as those with severe symptoms (Errázuriz &
Zilcha-Mano, 2018). Further, there are indications that some personality disorders
(e.g., Borderline Personality Disorder) may respond to feedback with increased symptoms
(de Jong et al., 2018).
With these concerns addressed, the clinical psychologist who collects data on session-
to-session progress will be in a place to start to provide feedback once three sessions of
data are collected. Take for example the data from a client with agoraphobia that are
depicted in Figure 4.3. The client had been on antidepressant medications before coming
to see the psychologist and there had been no changes in medication. The psychologist
had begun a programme of cognitive-behaviour therapy. The session with the client
might have an interaction such as follows:
THERAPIST: Thank you for completing the questionnaires so reliably. Since the last time we reviewed the
graph at the fifth session you can see that the amount of psychological distress that you reported increased.
I wonder if you could tell me what you think might have been going on then?
CLIENT: I think that was when I had to start confronting the situations that I was afraid of. I found it all too
much and I was about to give up.
THERAPIST: But you didn’t give up and what happened then?
CLIENT: My distress has come right down.
 Chapter 4: Matching Treatments and Monitoring Client Progress 61

25

Deteriorating

20

Potential for change

15
DI-5 score

10 Improving

5
Healthy range

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Session

Figure 4.3 A graph depicting a client’s progress with a lapse around session 6 and 7.

THERAPIST: That’s right. It has come back into the improving range, which is great to see, and the distress
has continued to decline. To what extent does this match with your experience?
CLIENT: When things were deteriorating I was a mess and that fits, but I don’t feel close to the healthy range.
There are still so many normal things that I cannot do.
THERAPIST: You have a sense that the questions that make up the scale aren’t fully capturing the
agoraphobia?
CLIENT: I guess so. They ask me about recent anxiety and stuff, but my anxiety really depends on what I’ve
got to do. How depressed I’m feeling also seems to depend on whether I have panic attacks or not.
THERAPIST: That’s an interesting observation. Throughout this whole time your medication has been stable,
yet your mood has been going up and down in response to events in your life.
CLIENT: I feel the medication takes the edge of my depression.
THERAPIST: So, if the medication is stable and taking the edge off some of the feelings, what might explain
the fluctuations?
CLIENT: When things go badly, then I get depressed.
THERAPIST: When things go badly, what does it mean to you?
CLIENT: Isn’t that obvious? When I get a panic, then I feel like I’m never going to get over this anxiety.
THERAPIST: Can I check I’ve understood what happens. When you have a panic, you think, “Oh no, I’ll never
recover” and then you start to feel more depressed.
CLIENT: That’s right.
https://avxhm.se/blogs/hill0
62 Chapter 4: Matching Treatments and Monitoring Client Progress

In the preceding interaction you can see that the clinical psychologist was able to use
the graph to elicit thoughts from the client that could be used if the therapist was going
to engage in cognitive restructuring. The therapist was also able to challenge the view
that the medication was responsible for all mood improvements, with a view to ultim-
ately helping the client to perceive their role as an active manager of their own mood,
rather than as a passive responder. The client seemed comfortable both with an idio-
graphic interpretation, comparing their own scores with earlier data points, and also
with normative comparisons when the bands were used to interpret. One outstanding
issue the clinical psychologist would need to return to was the point that the scale did not
capture the agoraphobia. The clinician would need to address this point by noting that
the scale is a “mental health thermometer” and is not intended to measure all symptoms,
but to capture psychological distress. Maybe it would be time to suggest some more
pertinent assessments that focus on panic and agoraphobia and the scores on these
instruments could be compared with the pre-treatment levels.
In summary, the monitoring of progress through treatment is possible with the
repeated administration of appropriate scales. Using this practice-based evidence, it is
possible to identify potential treatment failures and other adverse outcomes (Kyron,
Hooke & Page, 2018, 2019, 2020) to more accurately target treatment and reduce
deterioration. Future questions to be addressed by clinical psychology researchers will
be how change can be optimally measured, how often it should be measured during the
therapy process, and how therapists can make the best use of change measures in clinical
practice (Lutz et al., 2021). As Lutz and colleagues note, client monitoring has now
become an integral part of best practice in health care systems. The near future will see
steps taken towards better implementation of outcome navigation systems (e.g., clinical
support tools with enhanced monitoring, feedback and problem-solving tools) into
clinical services and training programmes as the field moves towards greater
personalized client care.
 Chapter
Linking Assessment to Treatment:

5 Case Formulation

Case formulation is a,
. . . hypothesis about the causes, precipitants, and maintaining influences of a person’s psychological,
interpersonal, and behavioural problems. A case formulation helps organize information about a
person, particularly when that information contains contradictions or inconsistencies in behaviour,
emotion, and thought content. Ideally, it contains structures that permit the therapist to understand
these contradictions and to categorize important classes of information with a sufficiently
encompassing view of the patient. A case formulation also serves as a blueprint guiding treatment
and as a marker for change. It should also help the therapist experience greater empathy for the patient
and anticipate possible ruptures in the therapy alliance. (Eells, 2007a, p. 4)

The above quote by Eells highlights that a case formulation links the client and his or her
problems with the treatment. It captures both the strengths and the weaknesses of the
client, thereby placing the problem and the potential resolution in the context of the
whole person. To use a metaphor, if the treatment is the locomotive and the client’s
problems are the carriages, then the case formulation is the coupling that holds the two
together. Without the coupling, a treatment might chug along nicely but it will fail to
bring about any movement in the problems. In addition, case formulation enhances the
therapeutic relationship by fostering a deeper understanding of and responsiveness to
the client.
Clients present to a professional psychologist with a large quantity of information.
There is information specific to the presenting problem, but there is also historical,
familial, demographic, cultural, medical, educational and social information. Some of
this ancillary information will have a direct bearing on the presenting problem, some will
provide a background and context to the problem, and other information will be largely
irrelevant to the problem. In addition to this descriptive information, psychologists will
aim to identify the personal meaning of the information. They will try to understand the
client’s experience of events and the way that they interpret them. The psychologist’s task
is to distill the relevant information quickly and efficiently into a treatment plan. It is the
case formulation that provides the link. As shown in Figure 5.1, information about a
client passes through the “lens” of the theoretical and empirical literature and is
channelled into a case formulation. The case formulation provides the coupling between
diagnostic and assessment information and clinical decisions about treatment planning.
Case formulation itself can be broken down into the eight steps illustrated in the callout
box in the Figure and described later in this chapter. As indicated by the two-way arrows,
case formulation is not a one-off event. The process of assessment, formulation and
treatment planning continues to cycle throughout therapy as a client’s progress is
measured and monitored. https://avxhm.se/blogs/hill0
63
64 Chapter 5: Linking Assessment to Treatment: Case Formulation

Client data (problem, context, history, etc.)

Theoretical and Clinical training &

empirical literature experience

Assessment &
case formulation
(i) Presenting problems
(ii) Predisposing factors
(iii) Precipitating variables Treatment planning
(iv) Perpetuating cognitions & measurement
and consequences
(v) Provisional
conceptualization Treatment implementation
(vi) Prescribed & monitoring
interventions
(vii)Potential problems and
Evaluation &
client strengths
accountability

Figure 5.1 The process of linking client data to treatment decisions using case formulation.

While there are a variety of psychotherapy case formulations, they typically share
much common ground (see Eells, 2007b). We will begin with a behavioural functional
analysis, extend this model to include cognitions, and then consider case formulations
from an interpersonal psychotherapy perspective, as these specifically include interper-
sonal aspects in the formulation.

Behavioural Case Formulation: Functional Analysis

One area where the core elements of a behavioural case formulation have been used with
great success is in the area of developmental disabilities. Behavioural case formulation
uses hypothesis-driven approaches to identify the function of a given behaviour and then
uses this understanding in planning treatment (Repp et al., 1995; Turkat, 1985). This
approach has received empirical support, such as from Carr, Robinson and Palumbo
(1990), who noted that the success with non-aversive treatments was higher when the
treatment was based upon an assessment of the functional relationship between environ-
mental variables and the problem behaviours (see also Schulte, 1997). This analysis of
functional relationships is called a “functional analysis”. A functional analysis involves the
identification of important, controllable, causal functional relationships applicable to a
specified set of target behaviours for an individual client (Haynes & O’Brien, 1990). Let us
examine each component of the definition in turn.
The causal variables must be important and controllable. In other words, they need to
explain a relatively large proportion of the variance and variables that explain larger
portions of the variance are probably going to be more useful in treatment. They must
also be controllable. For instance, a history of child abuse may be an important causal
variable in the psychopathology of an adult client, but because it is no longer controllable
(for this particular individual) it is not going to be an appropriate target for intervention.
 Chapter 5: Linking Assessment to Treatment: Case Formulation 65

Antecedents & setting

* Distal and proximal factors
* Originating and maintaining factors
* Moderators and mediators

Behaviours
* Frequency * Intensity
* Topography * Duration
* Temporal sequence * History
* Relationship to other behaviours

Consequences

Punishment Negative Positive Response cost

(Onset of event reinforcement reinforcement (Offset of event
causes decrease (Offset of event (Onset of event causes decrease
in behaviour) causes increase causes increase in behaviour)
in behaviour) in behaviour)

Figure 5.2 The three main components of a functional analysis.

The aim of a functional analysis is not to “explain” behaviour in terms of identifying all
of the important causal variables, but to identify those that can be manipulated (i.e.,
those under control of the client and/or therapist). The purpose of identifying causal
variables is so that you know which ones to modify.
Thus, the focus is upon the effects treatment has on the target behaviour. This target
behaviour will exist within a broader array of behaviours. Ultimately, these behaviours
exist within social systems and therefore a functional analysis will require a consideration
of the action of any changes on other aspects of the system and the bidirectional effects
that these will have upon the target behaviour.
In practice, the chief elements of a functional analysis involve identifying three sets of
variables; A for Antecedents, B for Behaviours, and C for Consequences (see Figure 5.2).
The first set of variables in the functional analysis comprises the antecedents. The
antecedents are those variables which are both proximal in time and those which are
more distal to the behaviour. Identification of the antecedents also separates the variables
that were important in the origin of the problem as distinct from those which are
involved in the maintenance of the problem. Antecedents can also be divided into those
which are moderators or mediators. Moderators have a direct effect on the behaviour in
question, whereas mediators serve to influence a relationship between two variables. For
example, a stressor such as a threatened assault might have a direct (or moderating)
effect upon anxiety, whereas cognitions about being helpless in the face of possible death
during the threat would have an indirect, or mediating effect on anxiety. The worrying
thoughts would mediate the relationship between the threat and anxiety by amplifying
the influence of the threat upon the anxiety response.
The second set of variables examined in a functional analysis is the behaviour itself.
The behaviour can be described in terms of its frequency, duration, intensity and
topography (such as the typical and more unusual patterns). Behaviours can also be
https://avxhm.se/blogs/hill0
66 Chapter 5: Linking Assessment to Treatment: Case Formulation

Behaviour

Increases Decreases

Onset Positive reinforcement Punishment

Event

Offset Negative reinforcement Response cost

Figure 5.3 Four categories of behavioural consequences.

examined in terms of their temporal sequence, their history, and their relationships with
other behaviours. While the term “behaviour” may conjure up images of actions, the
term is typically used broadly to include physiological responses and cognitions.
The final components of a functional analysis are the consequences of any behaviour.
Traditionally, consequences have been divided into four categories based upon whether
the event is turned on or off, and whether the behaviour increases or decreases (see
Figure 5.3).
When the onset of an event causes an increase in a behaviour, the event is said to be a
positive reinforcer. For instance, if a teacher responds with attention each time an
otherwise disruptive child sits in his seat, the likelihood of “in seat” behaviour will be
increased. Positive reinforcers do not necessarily need to be pleasant, however, many
pleasant events do make effective positive reinforcers.
When the onset of an event causes a decrease in behaviour, the event is called a
punisher. For example, if a parent responds with criticism and ridicule every time a child
plays a wrong note on a musical instrument, the probability of the child continuing to
play the instrument is reduced and the ridicule and criticism would be defined as
“punishment”. Once again, just as positive reinforcers do not necessarily need to be
pleasant, punishers do not need to be aversive, but many aversive events make
effective punishers.
When the offset of an event causes an increase in behaviour, the event is said to be a
negative reinforcer. For example, drinking alcohol in the early morning to alleviate the
“hangover” effects of a previous night’s excessive drinking increases the probability of
future early morning drinking.
Finally, when the offset of an event causes a decrease in some behaviour, this is called
“response cost.” An example of a response cost is when the frequency of a child’s shouting
in class is reduced as a consequence of not permitting her to play during the lunch hour.
The removal of the break was the cost incurred each time the child made the undesirable
response and hence the behaviour would decline.
These four categories of behavioural consequences appear straightforward, but war-
rant careful reflection. Consider your response if you heard on breakfast radio that you
 Chapter 5: Linking Assessment to Treatment: Case Formulation 67

could win £1,000 if you were the first caller to correctly identify the number of
Australian Prime Ministers to date. You might well feel inclined to call up and have a
guess, even if you were not sure; after all you have nothing to lose and £1,000 to gain.
Now compare how you might respond if you opened a letter from a radio station
which contained £1,000 for you to keep and the accompanying letter asked you to call
the station and let them know how many British Prime Ministers or American
Presidents there have been to date. The letter noted that if you were incorrect, then
you would be required to return the money. Presumably, you would put the money
into your wallet and not risk losing the money by calling the radio station and giving
the wrong answer.
The first example was an instance of positive reinforcement and the second was an
instance of response cost. If your reactions were similar to those described you would
agree that in this context, the positive reinforcer encouraged (guessing) behaviour,
whereas response cost inhibited (guessing) behaviour. Therefore, if you were identifying
consequences that might be beneficial for a socially anxious girl and an impulsive boy,
you might well choose to implement positive reinforcement as a way to draw out the girl
and use response cost to curb the impulsiveness of the boy.
These concepts have been applied in the area of developmental disabilities to under-
stand the existence of many problem behavioural excesses, such as self-injurious behav-
iour. In identifying the reasons for a behaviour, three variables have been identified as
important when making case formulations. These three variables are (i) positive
reinforcement, (ii) negative reinforcement and (iii) automatic reinforcement (Iwata,
Vollmer & Zarcone, 1990; also called “stimulation” by Carr, 1977). The third category
of automatic reinforcement refers to the strengthening of behaviour by the consequences
directly produced by a behaviour. Examples of this behaviour include rocking and
rhythmic or repetitive behaviours. Technically, these behaviours could be explained in
terms of the four types of reinforcement outlined in Figure 5.3, but the term is useful for
describing situations where there does not appear to be any reinforcement being derived
from the external environment. In the instances described, the sensory feedback itself
appears to be reinforcing, so that when the sensory feedback is removed, the behaviour is
extinguished (e.g., Rincover, 1978).
To identify the function of behaviour, one can use three methods of assessment. First,
the psychologist can use indirect assessments. Indirect assessments depend on question-
ing an observer about the occurrence and nonoccurrence of the behaviour in question.
These can be done with unstructured interviews or with the use of structured question-
naires (e.g., Durand & Crimmins, 1988; O’Neill et al., 1990). Second, the psychologist
can use analog assessments, in which artificial conditions are constructed to test hypoth-
eses about the hypothesized reinforcers. For instance, a control condition can be
contrasted with situations involving negative reinforcement, positive reinforcement
and automatic reinforcement, and the influence upon the behaviour of the schedules
of reinforcement can be measured. The results of such an assessment might identify the
reinforcer controlling a given behaviour (e.g., Iwata, Dorsey, Slifer, Bauman & Richman,
1982). Third, the psychologist might identify the reinforcement contingencies that are in
operation by conducting naturalistic assessments. That is, the behaviour is observed in its
natural setting, and changes in the frequency and topography are measured as different
contingencies occur (or are established).
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68 Chapter 5: Linking Assessment to Treatment: Case Formulation

A Case Example of a Functional Analysis

This adaptation of functional analysis applied in the context of developmental disabilities
can be illustrated by considering the presence of problem behaviours in a child with self-
injurious behaviour. A 7-year-old boy, Sebastian, with severe mental retardation came to
the attention of the psychologist following referral by the teacher. Sebastian would
engage in tantrums that involved screaming and self-injury. The psychologist began
with an interview with the teacher to obtain a description of the problem behaviour. The
teacher described that he would suddenly start to scratch at his face and forearms,
beginning by pinching and squeezing the skin, which could escalate into banging his
head and face with his hands. Thus, the psychologist had developed a description of the
problem behaviour and, thus, it was necessary to identify the antecedents of the problem
behaviour. To this end, the teacher had reported that these outbursts occurred infre-
quently during classtime, but were most common during breaks and lunchtime.
However, she was unclear what consequences were maintaining the behaviour. The
psychologist then collected baseline data, recording the events that occurred during each
break (since this was the time with the most likelihood of observing the behaviour) and
then calculating the probability of the behaviour’s occurrence and nonoccurrence in a
one-minute interval. These formal assessments revealed that the probability of self-
injurious behaviour was more probable (i.e., 62 per cent) when the supervising teacher
was attending to another child. The self-injurious behaviour was less probable
(i.e., 38 per cent) when the supervising teacher was only observing the other children
or attending to Sebastian. Thus, a working hypothesis was formed that there was a
relationship between the self-injurious behaviour and the perceived withdrawal of
attention. That is, it was one of negative reinforcement, such that the self-injurious
behaviour reduced the unpleasant state experienced by the child by the perceived
withdrawal of attention by the teacher. To test this working hypothesis, an additional
teacher was assigned at one break, who then spent the time ensuring that his attention
was allocated to Sebastian. When this occurred, the probability of self-injurious behav-
iour dropped to 0 per cent, thus giving the psychologist confidence in the working
hypothesis. This last component of the functional analysis, when the psychologist tests
the working hypothesis by manipulating contingencies, is referred to as “clinical experi-
mentation” by Turkat and Maisto (1985). This step can often be overlooked, since it
takes time and effort to test a working hypothesis; however, it represents a sound step for
clinical practice. Without testing in a potentially accountable manner, the risk is that a
treatment strategy will be embarked upon that is misguided and potentially ineffective. If
the psychologist waits for the outcome of treatment to gauge validity of the formulation,
then it may well be too late, as the client has decided that therapy is ineffective and
dropped out or changed psychologists.
In summary, a functional analytic strategy identifies the Antecedents of a Behaviour
and its Consequences. The consequences are divided into four categories, namely pun-
ishment, negative reinforcement, positive reinforcement, and response cost. A working
hypothesis is then developed and tested, which identifies which particular contingency is
related to the problem behaviour. At this point a treatment will be developed which will
aim to modify the contingencies that are controlling the problem behaviour. Functional
analyses have been useful in the domain of developmental disabilities, but their useful-
ness is much broader (e.g., see a discussion by Ward et al., 2000 of formulation-based
 Chapter 5: Linking Assessment to Treatment: Case Formulation 69

treatments for sexual offenders). Although a very powerful clinical tool (Wolpe &
Turkat, 1985), one limitation of a functional analysis is that it does not make reference
to the cognitions that may occur between the antecedent and the consequence.

Cognitive Behavioural Case Formulation

Persons and Tompkins (1989) outline an approach to case formulation that extends
upon the functional analysis described in a number of ways. The most obvious extension
is that it includes an assessment of cognitive beliefs and attitudes (see Beck, J., 2011;
Freeman, 1992, Muran & Segal, 1992, Turkat & Maisto, 1985 for other examples). We
will first review their model and indicate where it overlaps with or complements a
functional analytic strategy. Following identifications of some limitations of their
approach, we will outline ways to address these limitations.

Problem List
Persons and Tompkins (1989) suggest that a cognitive behavioural case formulation
begins with obtaining a comprehensive problem list. This is a comprehensive, descrip-
tive, concrete list of the presenting problem(s) and any other difficulties that the client
may have. The emphasis is upon the comprehensive nature of the list, in order to ensure
that no difficulty is omitted or overlooked. In the language of the functional analysis
introduced earlier, the problem list is analogous to the Behaviour of the ABC.

Assign a DSM/ICD Diagnosis

Psychologists are next invited to consider the diagnoses that may be applicable and
appropriate. In keeping with the functional analytic principles outlined by Haynes
and O’Brien (1990) in which attention is focused on variables that are important,
causal and controllable, they suggest that the principle of parsimony means that the
diagnosis selected is the one that accounts for the largest number of items on the
problem list (i.e., is “important” and “causal”) and is a target for change (i.e.,
controllable). The diagnosis provides a link to the literature on evidence-based
theories and treatments, but on its own a diagnosis is limited. A diagnosis is a
description of a clustering of signs and symptoms and it lacks a theory to explain
their co-occurrence.

Select a Nomothetic Formulation of the Anchoring Diagnosis

The psychologist then investigates the literature surrounding the anchoring diagnosis,
searching for an evidence-based nomothetic formulation. That is, since “nomothetic”
describes the study of groups of individuals, a nomothetic formulation is an explanation
of the type typically found in the literature that serves to provide an account of all people
who have a diagnosis. It complements a diagnostic description, by giving a causal
explanation of why the symptoms occur and how they are related. By extension, the
targets for treatment become evident. An example would be Rapee and Heimberg’s
(1997, see Heimberg et al., 2014) model of social anxiety disorder or Clark’s (1986)
model of panic disorder. Importantly, the nomothetic formulation is not an end point.
Rather, it provides a template for the development of an idiographic, or individualized,
formulation. https://avxhm.se/blogs/hill0
70 Chapter 5: Linking Assessment to Treatment: Case Formulation

Individualize the Template

The psychologist collects additional information concerning cognitive, behavioural,
emotional and somatic aspects of the problem. The relationships between the variables
are examined. The goal is to take the nomothetic explanation and apply it to the
particular client. For example, Rapee and Heimberg’s (1997) model makes no reference
to alcohol problems or depression; both of which are commonly comorbid with social
anxiety disorder. Therefore, to provide a complete account of a client who may also have
depression and alcohol problems that are intimately related to the social anxiety dis-
order, a more complete explanation is needed. By individualizing the nomothetic
template, a comprehensive account is possible.

Propose Hypotheses About the Origins of the Mechanisms

The psychologist then aims to generate hypotheses about (i) how the client has developed
the cognitive schemata that underlie the problems, (ii) how the dysfunctional behaviours
were learned, (iii) how functional behaviours were not acquired, (iv) how emotional
regulation deficits were acquired and (v) the origins of any genetic or biological
vulnerability.

Describe Precipitants of the Current Episode or Symptom Exacerbation

The clinical psychologist will inquire about the activating situations and precipitating
events. The client can be asked, but family members can also provide insights into the
relevant factors. Precipitants are analogous to the antecedents within functional analysis.
That is, precipitants are the events or stimuli that cause the particular problem in a
particular context. Activating situations are also antecedents, but refer to those that
explain the problem more generally and explain the consistency across situations.
The strengths of Persons’ approach are that (i) the process of diagnostic assignment is
assigned a key role and the nomothetic formulations are linked explicitly with idio-
graphic accounts. The chief weaknesses are that (i) it fails to describe how the hypotheses
are linked to particular treatments or treatment plans and (ii) there is no encouragement
to identify potential obstacles to treatment.

A Model of Case Formulation

Thus, our preference is to organize case formulation under a modified set of headings:
(i) Presenting problems, (ii) Predisposing factors, (iii) Precipitating variables,
(iv) Perpetuating cognitions and consequences, (v) Provisional conceptualization,
(vi) Prescribed interventions and (vii) Potential problems and client strengths. In the
course of the initial assessment interview(s), the psychologist will identify the main
problem and any ancillary concerns (i.e., the Presenting problems), identify any experi-
ences, social, familial or cultural issues, and temperamental factors that may set the stage
for the emergence of the problem or that may influence the manifestation of the problem
(i.e., Predisposing factors). The proximal and distal Precipitants of the origin problem will
be identified, as well as the precipitants of the problem behaviours in the current episode.
The next step will be to identify the cognitive and behavioural factors that Perpetuate the
problem and then link the preceding information into a Problem conceptualization that
will look backwards (and explain the origins of the problem), look around (and
 Chapter 5: Linking Assessment to Treatment: Case Formulation 71

Cognitive behavioral case formulation worksheet

Presenting problems
1. 2.
3. 4.
5. 6.

Predisposing factors
1. 2.
3. 4.

Precipitating variables
1. 2.
3. 4.

Perpetuating cognitions and consequences

Cognitions Behavioral consequences

Problem conceptualization

Prescribed interventions
1. 2.
3. 4.

Potential problems and client strengths

1. 2.
3. 4.

Figure 5.4 Cognitive Behavioural Case Formulation Worksheet.

understand the current problem), and look forward (and make a prognosis, Prescribe
treatment options, and identify Potential problems to treatment and client strengths) (see
Figure 5.4).

A Case Example of a Cognitive-Behavioural Formulation

To illustrate these various components of a cognitive behavioural case formulation, an
annotated case illustration will be presented next. An example of how the worksheet
(Figure 5.4) can be completed follows the case example of a client with Panic Disorder
with Agoraphobia. https://avxhm.se/blogs/hill0
72 Chapter 5: Linking Assessment to Treatment: Case Formulation

Presenting Problems
THERAPIST: What’s brought you here today?
CLIENT: I’ve been suffocating, all of a sudden for no reason. My doctor tells me there’s nothing wrong but
she’s never done a test when it’s happening.
THERAPIST: What’s it like when you start suffocating?
CLIENT: Well I can be sort of normal one minute and then, bang, it’s like the panic button gets pushed and
I’ve just got to get out of there to get some air. I start to choke and my throat closes over like I’m going to
suffocate. If I don’t get some air I’m sure I’ll pass out, die or something like that.
THERAPIST: This lack of air is so great it’s as if you are going to die.
CLIENT: That’s right. No one seems to understand and they all say that I’m not going to suffocate, that there is
plenty of air, that my lungs are OK, but it doesn’t help. I know there’s plenty of air, but no one seems to
understand that the air isn’t getting where it should. I don’t need anyone to tell me that these problems are
in my head. I can feel these sensations in my body. My heart pounds, I feel dizzy, my legs go to jelly. I even
get tingling in my hands. Try to tell me that’s not a sign of suffocation!
THERAPIST: It’s a pretty serious problem to have all these signs of suffocation. I’d be quite worried if I started
suffocating out of the blue.
CLIENT: Out of the blue, that’s how it is. I’ll be walking along one minute and then my body just packs up and
there’s no air.

The psychologist is starting to build up a picture of the client’s presenting problem. The
problem for the psychologist is trying to balance the need to collect information on the
symptoms and the need to establish a good rapport that will provide a foundation for the
rest of the assessment and intervention. The client is making it clear that she feels a lack
of understanding about her problems and is trying to convince the psychologist of the
reality of the problems. Therefore, while additional material about the problem would be
gleaned later in the interview, the psychologist has enough information to start building
a profile of it. Specifically, the client is describing an experience that involves the sudden
unexpected distressing bodily sensations (heart pounding, dizziness, choking, shortness
of breath and tingling in the extremities) that the client believes, despite reassurance to
the contrary, are signs of possibly life-threatening suffocation.
At this stage, the clinical psychologist is generating hypotheses about the client’s
presenting problem using their knowledge of theories of mental disorders (e.g., Clark’s,
1986, model of panic disorder), clinical diagnoses (e.g., symptoms of panic disorder), and
clinical experience. The clinician needs to be careful that these hypotheses do not blinker
them so that they focus their questions too narrowly, or important information may be
missed. During the assessment the clinician will use strategic questioning to test prelim-
inary hypotheses about what (a) principal diagnoses might best characterize the client’s
main problems and (b) what theories might help to guide the case formulation and
treatment plan. It is important for the clinical psychologist to explore for comorbid
problems and disorders, because most clients with a clinical disorder will have at least
one comorbid disorder. For example, the client in this example may also meet criteria for
major depressive disorder or generalized anxiety disorder. If the clinician stops assessing
for other problems once an initial diagnosis of panic disorder is made, these additional
problems will be excluded from the case formulation and could lead to suboptimal
treatment. Approaches to transdiagnostic conceptualizations will be described later in
this chapter.
 Chapter 5: Linking Assessment to Treatment: Case Formulation 73

Precipitating Variables
Following a discussion of the problem, the psychologist decided that the interview would
flow best if the precipitating variables were considered next.
THERAPIST: Thanks for telling me about how you feel during one of the suffocating episodes. I’d like to talk
some more about what they are like and the effect they are having on your life a little later, but, if it’s OK
with you, for the time being I’d like to concentrate on what triggers the suffocation. Could you tell me
about the most recent time you felt you might suffocate?
CLIENT: I was out to dinner with some friends; a hen’s night actually. I was a bit worried that I might not feel
well and have to leave. Since it was Claire’s hen’s night I felt that I really couldn’t walk out on her, so I was
extra worried. Before I got to the restaurant, I got hot and flustered because I couldn’t find a parking spot.
I was driving round and around thinking, “If I don’t get a spot quickly, then I’ll be late and all the seats near
the door will be gone.”
THERAPIST: And if they were all gone?
CLIENT: I wouldn’t be able to get out for some air without everyone noticing. And that’s just what happened.
I walk in all hot and bothered only to find that the only seat left is the one at the end of the table, right
down the back of the restaurant.
THERAPIST: So what did you do?
CLIENT: I just felt like leaving right then and there, but I didn’t. I took a couple of deep big breaths and took
my seat. The moment I sat down I knew it was all over. My throat tightened up and my chest started to
hurt. I started to breathe faster to get some air, but the air in the restaurant was too hot. It wouldn’t get into
my lungs no matter how hard I breathed – perhaps it was the spices in the cooking – but whatever it was,
I knew I just had to get out.
THERAPIST: What if you didn’t get out?
CLIENT: I’d probably pass out or die. I don’t know exactly, because I gave some excuse about having forgotten
to put some money in the parking meter and I left. Just like that. I got up, walked out, and never went back.

After discussing these situations the psychologist continues:

THERAPIST: Have you always had these episodes of suffocation?
CLIENT: When I was young I used to have asthma attacks, but they’ve stopped. Anyway, the asthma attacks
were different. I can’t really describe it in words, but I know an asthma attack and these feelings of
suffocation are different. They’re not wheezy, like asthma.
THERAPIST: After the asthma attacks stopped was there a time before these episodes of suffocation began?
CLIENT: Yes, the asthma stopped in my teens and the suffocation didn’t start until my mid 20’s.
THERAPIST: Was there anything going on around the time they started?
CLIENT: It was a pretty horrible time in my life. Things were pretty stressed at work. There were lots of people
being made redundant and there was a new round of redundancies in the wind. I went to a party and
everyone was smoking dope. I hadn’t smoked before because of my asthma, but I figured that since it was
gone I deserved a bit of relaxation. The first few puffs were OK, but then I started to feel short of breath, my
throat started to close up, and I started to think I was having an asthma attack. I stopped smoking and ran
outside to get some fresh air.

From this section of the interview you will notice that the psychologist is asking about
precipitating events, but the client’s answers are blurring into the next section, namely
https://avxhm.se/blogs/hill0
the perpetuating cognitions and consequences. This is not a problem and your job is to
74 Chapter 5: Linking Assessment to Treatment: Case Formulation

use the case formulation as a template to filter and organize information. Even if you are
asking about one domain and the client gives information about another, you can keep
that information in mind for later. Nonetheless, a series of precipitants were evident.
The psychologist covers both the precipitants of the present attacks and those of the
first panic. This is important because the initial precipitants will assist the psychologist in
presenting a formulation that covers both the initial onset as well as the maintenance of the
problem. In terms of the current precipitants, a number of elements can be gleaned from
the interview. First, it is clear that the client is apprehensive about the event even before she
arrives. This anticipatory anxiety is setting the stage for a panic attack. Second, building on
this foundation of anticipatory anxiety is the failure to find a parking spot, which increases
the worry and encourages her to rush, which in turn generates a number of bodily
sensations – becoming hot and breathing rapidly. Third, upon entering the restaurant
she takes a series of big deep breaths, effectively hyperventilating. Hyperventilation pro-
duces a number of bodily sensations which are able to exacerbate the sensations of panic
(Andrews et al., 2003; Hazlett-Stevens & Craske, 2009); these sensations include feelings of
choking and smothering, among others. Finally, the atmosphere of the restaurant appears
to have exacerbated the feelings. It appears to have been hot and this could have increased
feelings of discomfort, given that the client was already reporting feeling hot and bothered
from driving around looking for a parking spot. However, in addition to all these triggers
is it clear that the client is not just a passive recipient of environmental stimuli; she is
actively processing the information. Thus, the clinician can expand upon these cognitions
and identify the consequences (e.g., punishment, negative reinforcement, positive
reinforcement or response cost) of any actions the client takes.

Perpetuating Cognitions and Consequences

THERAPIST: You have told me about a lot of things that seemed to trigger these sensations of suffocation, but
I wonder if you could tell me more about what you were thinking. What is the last thought you remember
before the feelings of suffocation were at their worst?
CLIENT: When they were at their worst I don’t think I was thinking anything. I just go blank.
THERAPIST: What was the last thought you remember before going blank?
CLIENT: I thought, “I’ve just got to get out”
THERAPIST: Why did you need to get out?
CLIENT: I needed fresh air. I’ve found that when I’m suffocating, getting out and into the fresh air
sometimes helps.
THERAPIST: What if you hadn’t been able to get out?
CLIENT: That was what I was worried about. I was sure that I was going to run out of air. The restaurant was
full of people, the door was closed, and there was an open fire in the kitchen out the back.
THERAPIST: An open fire?
CLIENT: You know a BBQ type of thing where they were cooking the steaks. I could see the flames coming up
and I know that flames use oxygen to burn.
THERAPIST: So, the fire was using up the oxygen in the room?
CLIENT: And because the door was closed and the restaurant was full, the oxygen was getting used up. If I had
been able to sit closer to the door I might have been able to get more oxygen, but being close to the kitchen
meant that I had less oxygen.
 Chapter 5: Linking Assessment to Treatment: Case Formulation 75

THERAPIST: Had anyone else noticed the lack of oxygen?

CLIENT: No. I think I’ve got some sort of allergy that makes me sensitive to the absence of air. I’ve read about
this disease called Undine’s Curse where babies die because they aren’t sensitive to oxygen or carbon
dioxide or something so they don’t breathe enough. I’ve worried I might have that, but all the doctors say
my heart and lungs are fine.
THERAPIST: Does their reassurance help?
CLIENT: For a while, but once the suffocation comes back again I think, “What do they know. If they had
done their tests while I was suffocating, the readings would be different.”
THERAPIST: You can’t remember what you were thinking when the feelings of suffocation were at their
worst, but do you remember how you were feeling?
CLIENT: Really panicky, freaked out. My heart was beating so fast and I was really scared I was going to die.
THERAPIST: And then what happened to these feelings when you left?
CLIENT: Once I got out into the cool air, they melted away. I walked away from the restaurant and after a few
minutes of letting myself breathe the rich air I started to feel the oxygen flooding through me. I didn’t have
to breathe so quickly and I knew that I was going to be OK. Well sort of OK.
THERAPIST: Sort of OK?
CLIENT: Well I wasn’t going to suffocate, but then I started to think about my friends. They would all be
sitting there waiting for me to come back, but there was no way I was going back. By the time I got back to
the car I had tears running down my face. They were tears of relief that I had got out alive as well as tears of
shame that I couldn’t even sit in a restaurant without leaving. Why can’t I be normal?

In terms of the cognitions associated with the situation, the client was interpreting the
sensations as consistent with fears that she was going to suffocate. The environment was
scanned to provide information (e.g., the fire was consuming the oxygen) to justify the
belief that the sensations of choking and chest pain were signals of imminent death
through suffocation. However, it is more plausible that the physical sensations were a
normal consequence of worry and anxiety, combined with sensations generated by
exertion, and exacerbated by hyperventilation (Andrews et al., 2003; Page, 2002b;
Taylor, 2000).
It is also apparent that there was a clear contingency between the client’s actions
and the intensity of the panicky feelings. After the client had fled the situation, the
unpleasant experience of anxiety and panic reduced (albeit to be replaced by feelings of
shame, embarrassment and distress), increasing the probability of future avoidance.
Thus, their avoidance would be maintained by negative reinforcement. In addition, it is
clear that the client would not be able to test the validity (or otherwise) of her beliefs
about the lack of oxygen. Had she remained, she would have been able to attest to the
fact that the oxygen would not have run out, and she would not have suffocated and
died. However, the client escaped without ever finding out if the threat would prove
fatal.

Predisposing Factors
So far the sections of the interview that have been reproduced do not reveal the
background to the problem. Thus, to help the psychologist to contextualize the problem,
it is important to consider the variables that may have predisposed the client to the
attacks of panic. https://avxhm.se/blogs/hill0
76 Chapter 5: Linking Assessment to Treatment: Case Formulation

THERAPIST: You have described some pretty terrifying experiences, all of which seem to involve intense
feelings of suffocation. Feeling you are about to suffocate leads you to do the only sensible thing, which is to
get out and get to a place where there is more air. I wonder if you have thought about where this all has
come from?
CLIENT: I don’t really know, but my mother was pretty highly strung and worried about everything. When
I was a child she worried a lot about my asthma. There were certainly lots of kids at school who were worse
than me, but she kept insisting that we went to the doctor or emergency room to get me checked out. It
seemed to make her feel better when they said I was OK.
THERAPIST: How’s your asthma now?
CLIENT: The doctors say they can’t find a trace of it but sometimes I think I’ve taken on the role of my
mother, looking after my health.
THERAPIST: You described your mother as “highly strung.” Are you like your mother in this respect?
CLIENT: I’ve always been a nervous person. I’ve worried about my health for as long as I can remember.

From this interaction, the psychologist was able to establish a couple of hints about
predisposing variables. First, it seems it could be that the mother was high on trait
anxiety or neuroticism and this family trait has passed on to her daughter, perhaps
through inheritance or learning. Second, the health behaviour of her mother regarding
her asthma could well have established a pattern for dealing with these sensations. That
is, there is a similar pattern of concern about symptoms of suffocation, followed by an
escape response that reduces the distressing emotion. Thus, the psychologist is in a
position to start to develop a formulation and present this to the client for feedback.

Provisional Conceptualization
In this instance, the psychologist suggested that the client’s personality was likely to
reveal elevations on neuroticism, which set the stage for the development of an anxiety
disorder. The experience of management of asthma attacks provided a template for
health behaviour that involved worry about symptoms and escape and reassurance-
seeking as ways to reduce the distress associated with possible illnesses. Against this
backdrop, each individual attack began with awareness of a particular bodily sensation or
set of sensations (e.g., shortness of breath). These sensations were misinterpreted as
signals of impending danger, which in turn triggered the anxiety (or fight or flight)
response. Increased respiration, a normal part of the anxiety response, led to hyperventi-
lation in the absence of either flight or fighting, which in turn produced more sensations.
Together, these sensations would be misinterpreted as signals for suffocation, and so on
in a vicious circle of panic (see Figure 5.5). The spiral would be ultimately broken by
flight, which would involve action (thereby reducing the effects of hyperventilation).
It is important to note that the formulation of the panic attack is not original to the
present authors. Rather it draws on the literature about panic attacks and the seminal
work of David Clark (1986) conceptualizing the panic in terms of a cognitive model.
Substantial research laid an empirical foundation for the proposal of the model and
subsequently much research has supported the model (see Pilecki, Arentoft & McKay,
2011; Taylor, 2000). Given this, it is not surprising that the model serves as a useful
clinical heuristic. It allows the clinician to organize the information provided by the
client. It permits the clinician to take short cuts by building upon the theoretical and
empirical work of others. It was Isaac Newton who said, “If I have seen further it is by
 Chapter 5: Linking Assessment to Treatment: Case Formulation 77

Figure 5.5 Clark’s (1986) cognitive model

Triggers
of panic attacks (adapted from Andrews
et al., 2003).

Misinterpretation

Hyper-
ventilation
Fight or
Symptoms flight

Perceived
breathlessness

standing on the shoulders of giants” (in a letter to Robert Hooke, February 5, 1675/1676)
and professional psychologists can likewise “see further” in their clinical practice by
standing on the “shoulders” of those in psychology who have synthesized clinical experi-
ence, as well as the empirical and theoretical literatures, into a clear and useful model of a
clinical condition. Knowledge of evidence-supported psychological models that explain
the etiology and maintenance of clinical problems, and thus guide case conceptualization
and treatment planning, is a core and critical component of a clinical psychologist’s
unique expertise.
Not every client will present in a way that so neatly fits into the “textbook case.” Some
will include elements that are not found in models published in the literature, others will
present with a blending of two or more models and still others will present with
symptoms or patterns of symptoms that appear unique. The strength of a case formula-
tion approach is that it is applicable in every instance. What varies is the degree to which
the psychologist can draw upon existing theoretical and empirical literature and clinical
experiences to conceptualize the case (see Turkat & Maisto, 1985, for examples of
applying case formulations to novel symptom patterns).
When the case formulation is novel, the link to treatment will need to be clearly
articulated and the greater the burden of proof will be upon the psychologist to test and
demonstrate the validity of the model. Even when applying an existing model to a client,
it is important to test the validity of the formulation. This can be done by presenting the
formulation to the client in a formal manner and asking for feedback as to its ability to
consolidate the client’s problems. A further way is to test aspects of the formulation with
psychometric tests (see Turkat & Maisto, 1985, for some examples). With the client in
question, a personality inventory (the NEO-PI-R) (Costa & McCrae, 1992) was adminis-
tered to determine if the trait anxiety was elevated. The SCL-90-R was also administered
to provide a standardized broad pre-treatment assessment that could be used to evaluate
changes during and post-treatment. The results of testing are displayed in Figure 5.6. The
scores for the personality dimension of Neuroticism (N) are very high, consistent with
the expectations; however, interestingly, conscientiousness (C) is very low. The low
conscientiousness was not a theme that had emerged during the interview and suggested
an area that required further investigation, particularly as it might indicate a problem for
compliance with treatment. Extraversion (E), Openness (O) and Agreeableness were
average. The SCL-90-R showed elevations on somatization, anxiety and phobia, which
were all consistent with the reports of panic attacks. In addition, the elevation on the
https://avxhm.se/blogs/hill0
78 Chapter 5: Linking Assessment to Treatment: Case Formulation

NEO-PI-R
SCL-90-R
Very high
Nonpatient adult female
80
High
70
Average 60
50
Low 40
30
Very low
Som

O-C

I-S

Dep

Anx

Hos

Par

Psy

Gsi

i
Pst
Psd
Pho
N E O A C
Figure 5.6 Results on the NEO-PI-R and the SCL-90-R of a female client with Panic Disorder and Agoraphobia.

obsessive-compulsive, interpersonal sensitivity and depression dimensions all suggested

the existence of symptoms that have not been discussed in the sections reproduced. This
highlights one advantage of using broad symptom measures at the outset of treatment, in
that they can identify areas of symptomatology that may have been missed in the initial
assessment interview(s).
A verbal interpretation of these test results was presented to the client along with the
formulation and the client’s response indicated that both seemed to summarize how she
perceived herself. If anything, she expressed impatience and wanted to know what to do
about these sensations.

Prescribed Interventions
The evidence-based interventions for panic disorder and agoraphobia have been clearly
documented in many different sources (Andrews et al., 2003; Barlow, 2002; Craske &
Barlow, 2008; Clark & Salkovskis, 1996; Sánchez-Meca, Rosa-Alcázar, Marín-Martínez &
Gómez-Conesa, 2010; Taylor, 2000). What is involved in these treatments will be
discussed in later chapters, but for present purposes the aim is to demonstrate the link
between the formulation and treatment. This is displayed in Figure 5.7. The fear elicited
by the trigger stimuli will be addressed using “graded exposure”, the misinterpretation of
these triggers as potential threats will be addressed using “cognitive restructuring”,
hyperventilation and its effects will be targeted using “breathing control”, anxiety about
the bodily sensations will be treated with “interoceptive exposure” (Forsyth, Fusé &
Acheson, 2009) and excessive reactivity of the fight or flight response will be dampened
down with “relaxation”. Thus, each important component of the model will be addressed
with a particular treatment, and the rationale for each component can be demonstrated
to the client with reference to the formulation. Importantly, the cognitive-behavioural
package that involves these components has been empirically-validated in a variety of
studies, lending further support to the use of these techniques (see Barlow et al., 2017;
Clum, Clum & Surls, 1993; Cox et al., 1992; Gould et al., 1995; Mattick et al., 1990;
Taylor, 2000). In addition, there are studies demonstrating the individual efficacy
of each component (Ito, de Araujo, Tess, de Barros-Neto, Asbahr & Marks, 2001;
 Chapter 5: Linking Assessment to Treatment: Case Formulation 79

Figure 5.7 Adaptation of cognitive

Graded Trigger Cognitive
formulation to include treatments targeted at
exposure restructuring
each component.
Misinterpretation
Hyper-
ventilation
Fight or
Symptoms flight

Perceived
breathlessness

Interoceptive Relaxation Breathing

exposure control

Meuret et al., 2012; Michelson et al., 1996; Rapee, Mattick & Murrell, 1986; Salkovskis,
Clark & Hackman, 1991; Teachman, Marker & Smith-Janik, 2008; Öst & Westling, 1995;
Williams & Falbo, 1996).

Potential Problems
The final component of a cognitive behavioural formulation involves the identification
of potential problems to treatment. The low conscientiousness identified by the NEO-PI-
R (Costa & McCrae, 1992) represents a possible problem in treatment, suggesting that
the compliance with treatment and homework exercises will need to be monitored
carefully. The second problem, which flows more directly from the formulation, is the
presence of worry and anxiety combined with the need for exposure to bodily sensations
and situations associated with anxiety. It is likely that the client’s motivation and their
impatience to begin treatment will wane as the threat of elevated anxiety and panic
looms, therefore these will need to be monitored and addressed if treatment is going to
be successful.
The completed case formulation worksheet for this particular client is shown in
Figure 5.8.
This particular cognitive behavioural case formulation would represent a component
of the entire clinical process outlined in Figure 5.1. As depicted in Figure 5.9, the case
formulation (in the left-hand callout box) represents the link between the client data and
the treatment (in the right-hand callout box).

Case Formulations in Interpersonal Psychotherapy

Up to this point the discussion of case formulation began by describing behavioural (or
functional) analyses and then developed this foundation into a broader cognitive behav-
ioural formulation. However, it would be misleading to convey the impression that case
formulations are unique to CBT. The diversity of case formulations is evident in Eells
(2007a), however, not all of these therapies have strong empirical validation (Lipsitz &
Markowitz, 2013). Therefore, we will review one more approach to case formulation to
illustrate its application in the evidence-based Interpersonal Psychotherapy (IPT) and in
so doing contrast the approach with a cognitive behavioural formulation for the
same case. https://avxhm.se/blogs/hill0
80 Chapter 5: Linking Assessment to Treatment: Case Formulation

Cognitive behavioral case formulation worksheet

Presenting problems
1. Distressing bodily sensations (heart pounding, dizziness, choking, shortness of breath
and tingling in the extremities)
2. Fear of suffocation 3.
4. 5.
Predisposing factors
1. Parental anxiety 2.
3. 4.
Precipitating variables
1. Anticipatory worry 2. Situations where escape difficult
3. 4.
Perpetuating cognitions and consequences
Cognitions Behavioral consequences
I’ve just got to get out Flee situation and panicky feelings decrease
Sensations of shortness of breath mean I will
suffocate and die
Problem conceptualization

Triggers

Misinterpretation

Hyper-
ventilation
Fight or
Symptoms Flight

Perceived
Breathlessness

Prescribed interventions
1. Graded exposure 2. Cognitive restructuring
3. Interoceptive exposure 4. Breathing control and relaxation
Potential problems
1. Low conscientiousness 2. Worry and anxiety about exposure
3. 4.

Figure 5.8 Example of a completed Cognitive Behavioural Case Formulation Worksheet.

A Case Example of a Case Formulation in Interpersonal Psychotherapy

The transcript is designed to faithfully illustrate IPT as described in the treatment
manual by Klerman et al. (1984; Weissman, 2020; Weissman, Markowitz & Klerman,
2017). To facilitate a synthesis with their work, many of the therapist’s responses draw
heavily from examples provided in their book. The client is an amalgam of individuals
and draws upon a reference by Meighan et al. (1999).
 Chapter 5: Linking Assessment to Treatment: Case Formulation 81

Client with panic disorder

Clark’s cognitive Clinical training &

model & CBT experience

Graded Trigger Cognitive

exposure restructuring

Misinterpretation
Breathe
Assessment & Fight or
faster

Trigger Symptoms
case formulation flight
Perceived
breathlessness
Misinterpretation
Interoceptive Breathing
Breathe exposure
Relaxation
control

Fight or
faster CBT treatment &
Symptoms flight measurement
Perceived
breathlesness

Treatment implementation
& monitoring

Evaluation &
accountability
Figure 5.9 Inclusion of a particular case formulation for a client with panic disorder into a model of clinical
practice.

IPT is structured with three phases in mind. During the early phase an assessment is
conducted to develop an interpersonal case formulation and a therapeutic contract is
negotiated with the patient1. During the middle phase the psychotherapeutic work on one
or two of the nominated problem areas is conducted, before the termination phase
occurs. There are three tasks of the early phase. These are to deal with the depression,
conduct an interpersonal inventory and negotiate the therapeutic contract.

Deal with the Depression

IPT begins with the patient’s problem. Symptoms are systematically reviewed with
reference to diagnostic criteria, such as those outlined in the ICD or DSM systems.
However, the process is not one of simply reading out a checklist and ticking off each
item that is endorsed. It involves asking the person about the symptoms so that you gain
a “feel” for them. Once this is done the diagnosis is confirmed or communicated to the
patient. This communication is an explicit statement that aims to make it clear that the
cluster of symptoms is a whole. After this, is it possible to explain the nature of depression
and identify ways that it can be treated. The patient is then encouraged to adopt a sick
role. The psychologist is asked to legitimize the patient in the sick role without fostering
dependency. Following Parsons (1951), the sick role means that the person is exempt

1
Note that the term “patient” will be used in place of our term “client”. IPT explicitly adopts a
“medical model” in which the therapeutic relationship is conceptualized in terms of a “doctor and
patient”. https://avxhm.se/blogs/hill0
82 Chapter 5: Linking Assessment to Treatment: Case Formulation

from certain normal social obligations, certain types of responsibilities and considered to
be in a state that is socially defined as undesirable, to be gotten out of as quickly as
possible. The person is in “need of help” and should take on the role of patient, which
means affirming that one is ill and cooperating with the doctor. The possible value of
medication should be assessed, which for the psychologist would involve referral; but our
experience is that most people who attend our clinic with depression have already
consulted a General Practitioner and been offered antidepressant medication. They have
consulted a psychologist because they were reluctant to take medication, or stopped
taking it due to side-effects, or the antidepressant has only been partially successful.
These steps are illustrated sequentially in the following excerpts. The interview opens
with an examination of the problem and a systematic review of the symptoms. The client
is a male in his late twenties who has presented with concerns about his mood.
THERAPIST: I was wondering if you could tell me what brought you here today?
CLIENT: Sure. Well, it began about two years ago now, after the birth of our son, Aubrey. Things seemed to be
going very well and then the wheels fell off everything. My wife became really depressed. The depression
was so bad that she had to see a psychiatrist, and then spent a few weeks in hospital. Things have really
gone from bad to worse for me since then and I really don’t know if I can cope any more. I think I’m
catching her depression. That’s why I came to see you, but I really don’t want to be here because I should be
able to cope, I should be able to keep things together. It’s my wife who is sick and if I have a breakdown,
then there will be no one left to look after Aubrey. I’ve got to be the stable one. I’ve got to keep the
family together.
THERAPIST: Life’s been terribly difficult for you lately, with your wife’s depression, your need to cope with
everything that her being depressed entails and starting to feel depressed yourself. We’ll talk about each of
these topics, but first of all, I wonder if we could talk about you and how you are feeling. I wonder if you
could tell me something about these feelings of depression.
CLIENT: Well, I just feel empty all the time. I’m just like a hollow shell just doing the same things each day
that I have to do, but there’s no life left in me. I can’t get out of bed in the morning, not only because I’m so
tired due to not being able to go to sleep, but because I just haven’t got any energy. I try to get myself
motivated, but nothing appeals any more. I used to play golf, but I’ve given that up; and sex, well there’s
nothing in that department. I know they say that having a child is the most effective form of contraception
known to man, but she’s not up for it and quite frankly I could take it or leave it; and this is not like me at
all. Eating too – I’ve lost 7kg in the past month because I can’t seem to bring myself to eat. Food tastes
bland and I just don’t feel hungry.
THERAPIST: These feelings seem to impact everything you do. Has this depression had an impact on your life;
say looking after Aubrey or at work?
CLIENT: I’ve just received my second warning from my boss at work. I’m just not able to concentrate at work,
so I keep making mistakes. Also, every couple of weeks I get a call from Suzanne, that’s my wife, saying that
she can’t cope with Aubrey and I need to come home to rescue her before she does someone an injury. I’m
just in a bind, I can’t afford another mistake at work, but at the same time I worry that something bad will
happen at home.
THERAPIST: Often when people feel as depressed as you have been telling me you feel, they think about
ending it all. Have thought about killing yourself?
CLIENT: Every day. Usually as the day goes on I think about it more often, but I’d never do it. I’m all that there
is holding the family together right now.
 Chapter 5: Linking Assessment to Treatment: Case Formulation 83

The therapist then moves on to confirm the diagnosis to the patient. The name of the
disorder (in this case “depression”) is used. The use of the name is intended to organize
what otherwise might be a group of seemingly unrelated symptoms into a condition that
the psychologist knows about.
THERAPIST: The feelings of depression, the lethargy, the lack of interest in previously pleasurable activities,
the difficulties sleeping are all symptoms of depression. Although they don’t seem to have a physical basis,
this isn’t to say that they aren’t real. What you have told me are pieces to a puzzle, that when put together
suggests to me these are all part of being depressed. Your eating and sleep are changed. You’ve lost interest
in activities that you used to enjoy. Your thoughts about death, your tiredness . . . are all part of the
constellation of depression. Your symptoms are common ones for depressed persons.
CLIENT: So you really think I have depression? What am I going to do? When it was just Suzanne, that was
bad enough, how are we going to manage?

The psychologist can respond to this question by leading into a presentation of details
about depression and its treatment.
THERAPIST: Depression has been called the common cold of mental disorders because it is so common. It
affects about four out of every hundred adults at any one time. Although you may feel a lot of hopelessness
right now, this is part of depression and the good news is that depression can respond to treatment. The
outlook for your recovery is good. We know there are quite a few treatments that can reduce depression, so
many people with depression recover quite quickly with treatment. I expect that you will soon start to feel
better and you will be able to resume your normal life and activities as the symptoms of depression
decrease in response to treatment. One effective treatment for depression is Interpersonal Psychotherapy. It
has been shown to be effective in a number of research trials. IPT helps you to understand the issues and
difficulties that have produced this depression.
CLIENT: Well I’m glad that you’re hopeful, because quite frankly I’ve lost all hope. Life’s just all too much for
me right now. In fact, I can’t even face up to having the parents-in-law over for dinner.

The next task for the therapist in IPT is to outline the “sick role” to the patient.
THERAPIST: It’s fine if you don’t feel like being quite as sociable now. You are feeling depressed and so it’s
quite reasonable that since you are feeling so bad you won’t be able to do many things you might feel you
should. Perhaps you could speak to Suzanne and suggest that for the next month you’d like to keep social
obligations to a minimum. The reason is that during the active phase of treatment for your depression we
are going to be working towards your recovery. I expect you to be able to take up your normal life
gradually. You will be able to become more active again, but for the time being the focus needs to be on
getting you better.
CLIENT: Can I tell Suzanne that you said this? I wouldn’t want her to get the impression that I’m not handling
everything. I’ve got to hold this family together. The way things are right now, I can’t be the weak link.
THERAPIST: Yes you can, it’s important that you talk with her and make sure that she is clear that you are
going to need some time right now to work on yourself so that you are in a stronger position to help her.

For many psychologists, casting the patient in the sick role elicits a negative reaction. As
a profession we are more likely to consider that clients need to take an active role in their
recovery. In particular, psychologists who are expert at CBT will be familiar with the
need to recruit and sustain motivation during treatment (Miller & Rollnick, 2012) and
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84 Chapter 5: Linking Assessment to Treatment: Case Formulation

the importance of a collaborative relationship that includes homework activities. The

notion that the “patient” is “sick” may feel like the psychologist is fostering dependency.
These points are well-taken, but take a moment to reflect on the experience of being
depressed. The sufferer may have been struggling with their daily tasks and to the extent
that they have not completed these, they may have felt a failure to meet the real or
projected expectations of others or themselves and the consequential guilt. Being
instructed that treatment not only permits, but actually requires them and others to take
things a bit easier could well make the person feel some relief from guilt and unattainable
expectations. This is not to say that the psychologist should not consider the risks of
fostering dependency, but that these risks need to be weighed up in light of the potential
benefits.

Assess the Interpersonal Problems

Once the presenting problem has been addressed the interview moves to assess the
interpersonal problems, and this begins with an Interpersonal Inventory. The psycholo-
gist asks questions to elicit information about what has been going on in the patient’s
present (or past) social and interpersonal life that is associated with the onset of the
symptoms. Thus, the interview will focus upon important interactions, expectations of
everyone in these important relationships and the degree to which they are met. The
satisfactory and unsatisfactory aspects of relationships are reviewed and the patient could
be asked to identify ways they would like to change their relationships. The ultimate aim
is to identify the main problem area or areas. Within an IPT framework there are four
problem areas, which we prefer to summarize under the two headings of Loss and
Growth and Interpersonal Communication. Under the heading of Loss and Growth,
IPT identifies grief reactions (associated with the loss of a loved one) and role transitions.
In a role transition the person loses past relationships and must grow into a new role and
new relationships or ways of relating as they move from one stage of life to another (e.g.,
work to retirement, partner to parent, employee to manager). Under the heading of
Interpersonal Communication, IPT identifies interpersonal role disputes (in which
people in a relationship have unshared or unmet expectations) or interpersonal deficits.
THERAPIST: Now, let’s try to review what has been going on in your life. What else has been happening in
your life about the time you started feeling bad?
CLIENT: As I said earlier, it seems that everything has happened since the birth of my son. Before Aubrey was
born Suzanne seemed normal, and we had a great relationship. She seems to think that she was depressed,
but I wasn’t aware of anything.
THERAPIST: Things seem to have changed after the birth.
CLIENT: I was so looking forward to our future together as a family. I had just got the promotion at work I’d
been striving for, we now had the money to have a child and really give him the life that we wanted. But all
that has changed. Before the birth, Suzanne was all clucky and maternal, but now she’s so different. I’ve not
seen that side of her before.

The patient is describing a role transition (from being a partner to being a parent), but
what is also apparent, that the patient is describing a loss. The patient is lamenting the
loss of the previous relationship as well as the loss of the relationship that could have
been. Both of these themes emerge during grief work, and for these reasons we tend to
group the categories of grief and role transition under the same heading.
 Chapter 5: Linking Assessment to Treatment: Case Formulation 85

THERAPIST: What is this side that you haven’t seen before?

CLIENT: I’d get home and there she is holding the screaming baby. She hands me the baby and starts crying
and screaming at me, blaming me for doing this to her. Then she collapses in tears saying she didn’t mean
it and she feels so guilty. All I know is that at one moment there was a crying baby to care for, then there
was a crying wife to care for, and all I felt like doing was crying myself. The problem is there is no one to
pass the baby to – the buck stops with me.
THERAPIST: This seems like an incredible burden for you to carry.
CLIENT: I just wished I knew what to do. If she was a car I would have lifted up the bonnet, found the
problem, fixed it and that would be the end to it, but nothing I did made any difference. This was the
hardest thing to cope with – knowing that I couldn’t fix it.
THERAPIST: You felt hopeless even though you wanted to help your wife.
CLIENT: All I could do was hunker down for the duration. It was up to me to hold things together so I had to
take care of them, no matter what the cost. I hate the way things are at work, but if that’s what I’ve got to
do, then that’s what I’ll do.
THERAPIST: Do you take that “hunker down” attitude home with you too?
CLIENT: I guess I’ll do whatever it takes to get through this. I’ve tried to keep the peace at home. I had to
sacrifice my own feelings. I didn’t want Aubrey to be damaged by all this so I just put my feelings on hold.
THERAPIST: This must have taken its toll on you.
CLIENT: I just feel so exhausted. I would get so tired doing my job at work and then coming home to another
one when I got home. I’m on duty 24-hours a day, 7-days a week and all the time dreading the call from
home when she’d say, “you’ve got to come home, I can’t take it another minute.”
THERAPIST: It sounds like it took a toll on your relationship too.
CLIENT: There’s no relationship between us anymore. We are just living day by day. It’s like I’ve lost her and
she’s not even gone away. I’m learning that things have changed. There’s nothing I can do to make her
happy and I can’t make myself happy now either.
THERAPIST: What sort of things used to make you happy?
CLIENT: Work used to be my best source of happiness, but things have changed there.
THERAPIST: How have they changed?
CLIENT: The promotion has changed everything. I used to just be able to do my job, but now I’m in charge of
the whole purchasing department. I used to have heaps of friends at work, but now I don’t know who my
friends are. Sometimes I need to reprimand people who used to be my mates, and other people who never
used to speak to me, seem to crawl to me all the time. I just hate it and wish I could have my old job back.
The problem is I’m trapped, because we need the extra money now we’ve got the baby.

It appears that the patient is describing some ways of relating that might suggest
interpersonal skill deficits. That is, the person’s way of relating in past relationships
appeared effective, but in the new relationship there could well be behaviours that are not
in the patient’s repertoire (e.g., reprimanding colleagues, assigning tasks, conducting
performance reviews). A more detailed analysis of these situations could reveal the
absence of certain interpersonal deficits that need to be redressed.
THERAPIST: Has work changed anything apart from your friendships?
CLIENT: I used to be really comfortable with my work. I knew my job and I knew that I could do it. Now
https://avxhm.se/blogs/hill0
everything’s changed. I don’t know what my job is anymore and I don’t know if I can do it. My self-esteem
has gone through the floor because I’m no longer confident that I’m succeeding.
86 Chapter 5: Linking Assessment to Treatment: Case Formulation

The psychologist then moves to summarize this part of the interview and starts to draw
out some interpersonal patterns. Although the two role transitions are different, there are
common elements that suggest some recurring patterns that could well benefit from
being addressed within the course of subsequent IPT sessions.
THERAPIST: It seems from what you have been telling me that you have been having trouble in your marriage
since the birth of your son and at work following your promotion. The problems can certainly lead to
depression. I’d like to meet with you over the next few weeks, for about an hour each time, to see if we can
figure out how you can cope better with the situation.

Negotiate a Therapeutic Contract

Finally, the psychologist and patient negotiate a mutually agreeable therapeutic contract.
This involves explaining the role that interpersonal factors may play in depression.
Patients are informed that they will be responsible for deciding on the focus of treatment,
bringing new material and choosing the topics to discuss. Following this, two or three
treatment goals are set. These goals need to be potentially achievable within the time
frame of therapy and may be symptom-related or interpersonal.
CLIENT: But what is causing this depression?
THERAPIST: We live in a social world and we are social beings. People play a significant part in our lives.
When depressed we are inclined to think we are alone, but we remain social beings. It is not surprising then
that relationships play an important role in depression. So far we don’t know all the causes of depression,
but what is clear is that when you are feeling depressed you tend also to be having problems with personal
relationships. These problems in relationships could include issues with your partner, children, family or
work colleagues. Sometimes relationship problems or bereavement may bring on depression. At other
times, or with other people, being depressed may stop them from dealing with other people as well as they
would like (and used to). We will try to find out what you want and need from others and help you learn
how to get it. We will try to understand how your relationships are related to your depression.
CLIENT: How long are we going to do this for?
THERAPIST: My preference would be for us to meet once a week for about 16 more sessions. During this time
we will work to understand how your relationships are related to your depression.
CLIENT: Okay, but what will we do?
THERAPIST: From what you tell me, your depression began with recent transitions. One of the transitions
was the birth of your son and your wife’s depression, the other was your promotion at work. I’d like to
discuss with you the critical areas you seem to describe as related to your depression. One is the kind of
transition you’ve had to make from being a worker to a manager. The second issue centres on how you are
relating to your wife, the impact of her depression on you and how you are acting in this relationship. Do
these sound like the issues we should work on?
CLIENT: Sure.

Summary and Contrast of IPT and CBT

In the preceding discussion and case example, the key aspects of an IPT formulation have
been clarified. In the early phase of IPT the psychologist will deal with the depression,
assess the interpersonal problems and negotiate a therapeutic contract. A case formula-
tion from a CBT perspective will share many similarities with an IPT approach.
 Chapter 5: Linking Assessment to Treatment: Case Formulation 87

However, the emphasis and treatment plan would be different. Therefore, let us consider
how the preceding case might be conceptualized from a CBT perspective.
Under the heading of “Presenting Problems” would come the list of symptoms of
depression that the client described. At this point there would be no difference between
CBT and IPT case formulations. In terms of predisposing factors, little attention was
paid to predisposing factors and therefore minimal information is available in the IPT
formulation. This highlights an important point, which is that the framework within
which the case formulation is conducted has the capacity to influence the information
elicited from the client. Considering the Precipitating variables, there appear to be a
variety of factors. These precipitants include the birth of his son, the promotion at work,
his wife’s onset of depression (and the impact and stress that this is having upon the
relationship, his work and so on). Once again, these are factors that would be drawn out
within an IPT framework. One important difference arises when the Perpetuating
cognitions and consequences are considered. The client describes quite a number of
themes that would be relevant within CBT. For example, he comments, “I should be able
to keep things together. It’s my wife who is sick and if I have a breakdown, then there will
be no one left to look after Aubrey. I’ve got to be the stable one. I’ve got to keep the family
together.” It is evident from these sentences that the client is identifying expectations that
he has about himself that will be counterproductive and likely to enhance feelings of
hopelessness, a lack of coping and stress. In addition to these and other cognitions a CBT
therapist would consider the consequences of his behaviours. Two patterns are evident.
First, it is apparent that positive reinforcement is lacking and punishment occurs
regardless of his responses, both at home and at work. That is, unpleasant consequences
seem to arise whatever he does. The lack of sufficient positive reinforcement has been
identified as an associate of depression (Soucy Chartier & Provencher, 2013) and so too
has the occurrence of aversive stimulation that is not contingent upon any responses a
person might give (Seligman, 1975). Putting this together, a provisional conceptualiza-
tion might be that the client had certain beliefs about his role as a father (e.g., being the
one to hold things together) and his wife’s role as a future mother (e.g., she could be
maternal and clucky), as well as expectations about his promotion. In each of these
scenarios, the expectations he had of himself and others were not met. He did not modify
these expectations and thus became depressed as he felt increasingly unable to control his
negative emotional reactions and his inability to control his home and work life so that it
met his expected ideal. Thus, a prescribed intervention might involve behavioural
activation to reinstate previously pleasurable activities, moving to identify the links
between actions and moods, and cognitions and mood. Cognitive therapy might then
be used to modify the unhelpful cognitive patterns and behaviour management strategies
implemented. Finally, some potential problems in treatment might be his wife’s depres-
sion as well as his “hunker down” attitude, which might lead to a reluctance to become
involved in treatment and wait for it all to “blow over”.

Transdiagnostic Approaches to Assessment and Case Formulation

Commonalities across Theories, Treatments and Symptoms
Clinical psychology students learn numerous psychological theories during their training
that explain the development https://avxhm.se/blogs/hill0
and maintenance of a range of clinical problems, which
88 Chapter 5: Linking Assessment to Treatment: Case Formulation

then guide assessment, case formulation and treatment. Trainees usually start learning
about theories for the most common mental disorders, and then gradually familiarize
themselves with theories of less common disorders. The richness of understanding that
develops from studying a broad range of evidence-supported theories and treatments is
important for therapists, as it prepares them for helping more clients in skilled and
nuanced ways, and for clients, as they receive more specialist interventions. However, at
some point in their training, clinical psychology trainees usually start to discover that the
etiology and maintaining factors described in many disorder-specific theories overlap to
a greater or lesser degree.
Around the same time (it isn’t a coincidence!), trainees start to notice that many
treatment principles and techniques appear to be common across evidence-based treat-
ment manuals, albeit with different emphases, such as with the examples of CBT and IPT
described earlier in this chapter. For example, most evidence-based treatments involve
some form of context engagement (e.g., behavioural activation, exposure), attentional
change (e.g., attentional refocusing, increased flexibility), and cognitive and metacognitive
change (e.g., reappraisal, distancing; see Mennin et al., 2013). Most models will also
describe similar functional relationships between cognition, emotion, physiology and
behaviour (see Figure 5.10). Even if the specific belief differs across individuals and clinical
problems (e.g., belief that I can’t breathe during a panic attack vs. belief that I am being
negatively evaluated in a social situation), there can be a similar impact on affect (e.g., feel
anxious), behaviour (e.g., avoid the trigger), and physiology (e.g., hyperarousal).
As trainees start to appreciate these commonalities, the immense number of treat-
ment manuals, which would take more than one career to develop competency in, starts
to feel less overwhelming. The trainee realizes that the task of learning new theories or
treatments is more one of understanding the unique elements that will complement their
existing understanding of common principles and processes described in other models. In
fact, the substantial overlap in theories and treatments has led some clinical researchers to
conclude that much of the discourse comparing evidence-supported treatments focuses on
the differences between approaches, and that “. . . shining the light here may inordinately
focus the discourse on the fringes, thereby picking apart smaller differences at the
boundaries while ignoring the substantial overlap and synergy of these approaches”
(Mennin et al., 2013, p. 235). Note the emphasis on evidence-supported treatments here,
which is very different to saying all treatments are the same or similarly effective.
Learning to diagnose clinical problems and carefully establish differential diagnoses
are also important competencies for clinical psychologist trainees to develop. However,
trainees will notice that establishing differential diagnoses can at times be challenging,
given that symptoms of different mental disorders overlap. For instance, symptoms such
as sleep problems (e.g., depression, generalized anxiety disorder, post-traumatic stress
disorder), hyperarousal (e.g., post-traumatic stress disorder, generalized anxiety dis-
order, mania), irritability (e.g., depression, mania), and weight change (e.g., depression,
anorexia nervosa) can be features of multiple disorders. In addition, there are functional
relationships between disorders that mean they are more likely to co-occur than would
be expected by chance. For example, people with anxiety disorders may use alcohol to
self-medicate, which can then develop into a dependency. Alternatively, people whose
lives are heavily restricted by their anxiety disorder may develop depression if they
withdraw from activities they have enjoyed in the past, and start to believe their future
is hopeless and bleak. It appears, therefore, that nature has not carved out specific
 Chapter 5: Linking Assessment to Treatment: Case Formulation 89

Figure 5.10 The relationship

between a threatening thought,
Emotion: emotion, behaviour, and physical
symptoms is functionally the same
Apprehension, regardless of whether the perceived
panic, anxiety threat is a panic attack (top) or
negative social evaluation (bottom).
Although unidirectional arrows are
drawn to show that cognitions affect
emotion, behaviour and physiology,
the relationships between each of
these components are reciprocal.
Cognition:
I will have a
panic attack

Behaviour:
Physiology:
Hyperarousal Avoid
triggers

Emotion:
Apprehension,
panic, anxiety

Cognition:
I will be
negatively
evaluated
Behaviour:
Physiology:
Avoid
Hyperarousal
triggers

psychological problems in isolation, such that comorbidity (having more than one
disorder) is the norm for clients (Brown et al., 2001).
In Chapter 3, the move towards dimensional approaches to psychopathology was
introduced, particularly with respect to personality disorders. Several “hierarchical
models” of psychopathology have recently been proposed that attempt to explain the
high rates of comorbidity between all common mental disorders by accounting for
correlations between symptoms and disorders (see Lahey et al., 2021). Hierarchical
models view psychopathology as existing along continuous dimensions (e.g., from low
to high) rather than only as discrete categories, and developers of these models suggest
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90 Chapter 5: Linking Assessment to Treatment: Case Formulation

that they could eventually replace the DSM and ICD. These models argue that there is a
higher-order general factor of psychopathology (the “p factor”) that captures the covar-
iance between symptoms of all disorders, and which is influenced by common genetic
and environmental factors. This general factor is supported by evidence that many genes
and environmental risk factors appear to be common across disorders. Additional
variability in psychopathology is explained by narrower, although still broad, second-
order dimensions including internalizing (reflecting, for example, anxiety disorders and
depression) and externalizing dimensions (reflecting, for example, aggression and con-
duct problems). Third-order dimensions capture correlations between the disorder
symptoms themselves. We won’t go into detail here about the various hierarchical
models and the controversies (interested readers are directed to the special issue in
World Psychiatry, February, 2021), because there remains much work to be done before
these models present a viable alternative to the DSM and ICD for diagnosing clinical
problems. Putting the diagnostic issues aside for the moment, the critical question for
clinical psychology trainees is, how might understanding the common and unique
components of theories and evidence-supported treatment approaches help with formu-
lation and treatment planning in the context of comorbidity and complexity in clients’
presentations?

Linking Commonalities to Case Formulation and Treatment Planning

Understanding the commonalities across different theories of the same disorder and of
different disorders can help trainees to identify the shared maintaining factors that need
to be targeted in treatment, along with each model’s unique contribution. Clinical
psychologists can then be vigilant for both the common and unique factors during their
assessments, and incorporate them into an individual client’s formulation when relevant.
For example, Generalized Anxiety Disorder (GAD) is characterized by excessive anxiety
and worry about a number of events or activities that is difficult to control, and is
associated with physical arousal symptoms such as restlessness, fatigue, difficulty con-
centrating, irritability, muscle tension and sleep disturbance (American Psychiatric
Association, 2013). Behar and colleagues (2009) reviewed different theories of GAD
and identified several commonalities (see Figure 5.11 for examples). The importance of
avoidance of internal experiences in maintaining GAD was common across all models,
which suggests that treatment of GAD is going to require (a) engagement with these
internal experiences and (b) skills training to build the client’s confidence that the
experiences can be tolerated. The specific internal experiences that are avoided differed
somewhat across models. For instance, the Avoidance Model of Worry (Borkovec,
Alcaine & Behar, 2004) emphasizes avoidance of vivid negative images and somatic
symptoms, the Intolerance of Uncertainty Model (Dugas et al., 1995) emphasizes avoid-
ance of uncertainty, and the Meta-Cognitive Model (Wells, 1995) emphasizes dysfunc-
tional attempts to manage “worry about worry”. Understanding these theories informs
the clinical psychology trainee that a client with GAD is likely to be engaging in some
form of unhelpful avoidance (overlapping principle across theories), so the task becomes
understanding how the client might be avoiding negative images, sensations, uncertainty,
worry itself and/or negative emotions (unique contributions of theories).
After identifying the common and unique mechanisms, the trainee would collabora-
tively design a treatment plan with the client to target the relevant maintaining
 Chapter 5: Linking Assessment to Treatment: Case Formulation 91

Avoidance theory Metacognitive model

(Borkovec) (Wells)

Negative
Worry negatively metabeliefs
reinforced by about worry
suppressing mental (worry about worry)
imagery
Avoidance
Perception of threat
Cognitive suppression
Positive metabeliefs

Intolerance of
uncertainty

Intolerance of
uncertainty model
(Dugas/Freeston)
Figure 5.11 Examples of commo and unique factors across three theories of Generalized Anxiety Disorder.

mechanisms based on the individualized case formulation. Assuming there is evidence

supporting each of the theoretical models, the clinician needs to decide whether one or
more of them is helpful in explaining the client’s problems. If one of the models is
supported from the assessment, the clinician would apply the specific evidence-
supported treatment developed from the relevant theoretical framework. If multiple
alternative models are supported, the clinician has at least three options.
The first option is to discuss the alternative treatments with the client so that a
decision to try a particular approach first can be made collaboratively. The clinician and
client would then proceed with treatment based on the preferred model and monitor the
client’s symptoms to ensure the client is responding as expected for a positive outcome.
The second option available to the clinician is to use multiple models to guide the
case formulation. For example, based on the assessment, the therapist may hypothesize
that the client’s positive beliefs about worry (as described in the Avoidance Theory of
Worry, the Metacognitive Model and the Intolerance of Uncertainty Model), negative
beliefs about worry (as described in the Metacognitive Model) and intolerance of
uncertainty (as described in the Intolerance of Uncertainty Model) all need to be
targeted. These models might therefore be blended in the case formulation so that the
client understands how these beliefs all contribute to the maintenance of the problem.
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92 Chapter 5: Linking Assessment to Treatment: Case Formulation

Intolerance of uncertainty
I can’ t stand the “unknown”
I must be certain or something
bad will happen

Triggers
Social situations (social anxiety)
Contamination (OCD)
Daily issues (GAD)

Perception of threat
I might be negatively evaluated
I might be contaminated
Something terrible might’ve
happened

Behavioural avoidance
Avoid uncertainty by avoiding
triggers as much as possible, engage Positive beliefs about worry
in reassurance-seeking, or use Worrying about my fears will
overcontrol so that: help me to be prepared
• I don’t need to worry
• My fears won’t come true

Negative beliefs about worry

My worrying is uncontrollable
and harmful

Figure 5.12 Formulation of a client with social anxiety disorder, Obsessive Compulsive Disorder (OCD), and
Generalized Anxiety Disorder (GAD).

A simple formulation based on a “blended” model for a client with features of social
anxiety disorder, obsessive compulsive disorder and generalized anxiety disorder might
look like Figure 5.12. Unlike the previous example of the client with symptoms of
depression, this client reports a range of symptoms consistent with more than one
diagnostic category. Based on the assessment, the clinician might hypothesize that the
client has a general intolerance of uncertainty, which arises in situations of social
evaluation (e.g., job interviews, presentations, work meetings), contamination (e.g.,
touching door knobs, sharing pens), and in many daily situations where there is any
potential for threat (e.g., partner calls later than usual, child is a few minutes late home
from school). The client notices a range of negative thoughts around themes of being
negatively evaluated (e.g., “they will think I’m an idiot!”), contamination (e.g., “what if
that person who just used this pen had a cold sore?”), and general threat (e.g., “what if
 Chapter 5: Linking Assessment to Treatment: Case Formulation 93

my partner has had a car accident?!?”). Once a negative thought has occurred, the client
might believe that continuing to engage in worrisome thoughts about the possible threat
will help them to be prepared (positive belief about worry), which will escalate the
perception of threat (double-headed arrow) and will lead to behavioural avoidance as
the person attempts to exert control over the situation (e.g., avoid going to a party to
avoid the possibility of negative social evaluation, wash hands excessively to avoid any
possibility of contamination, regularly call partner and children to check on their safety).
Excessive worry to prevent negative outcomes reinforces negative beliefs that worry is
uncontrollable and harmful, and this will also lead to unhelpful avoidance and over-
control strategies, which may lead to short-term relief (i.e., avoidance is negatively
reinforced). However, behavioural avoidance ultimately maintains the perception of
threat because the true probability and cost of the negative events, and the person’s
capacity to cope, are never directly tested by tolerating uncertainty for long enough to
“see what actually happens”. Over time, the avoidance progressively diminishes the
individual’s confidence in their ability to tolerate uncertainty in life, so the
cycle maintains.
As you can see, the clinician has “borrowed” from several different theories to guide a
blended formulation. The clinician and client would then develop a treatment plan
designed to increase the client’s tolerance of uncertainty in a range of life domains by
(a) encouraging them to engage with social-evaluative, “contamination” and uncertainty
situations in general to challenge the threat perceptions, (b) challenge their positive and
negative beliefs about worry and (c) reduce reliance on behavioural avoidance and
instead rely on more adaptive, approach-oriented coping styles. The clinician has the
opportunity to simultaneously treat three mental disorders by following the same broad
principles, rather than attempting to treat each disorder in isolation (which may seem a
bit like “putting out spot fires”) or sequentially (which might take more time and would
not help the client to learn how to apply the principles to new sources of uncertainty and
anxiety).
The third option available to the clinician is to use treatment based on a single theory
with the expectation that processes described in alternative models will be naturally
modified along the way. For example, although the case formulation in Figure 5.12
indicates that positive and negative beliefs about worry, in addition to intolerance of
uncertainty, maintain the client’s worry, the clinician may decide that challenging
negative and positive beliefs about worry will be sufficient to reduce the client’s intoler-
ance of uncertainty. Indeed, there is evidence that metacognitive approaches have a
similar impact on intolerance of uncertainty as on intolerance of uncertainty therapy
(van der Heiden et al., 2015). This finding illustrates that, unlike the precision of a
surgeon cutting out a discrete tumor, psychological interventions are somewhat blunt
instruments that modify multiple processes. For instance, a common strategy for chal-
lenging the belief that worry is uncontrollable (negative metacognitive belief ) is worry
postponement, whereby the client is instructed to postpone worries until a particular
time of day whenever they notice the worry cycle outside of the allocated “worry time”
(Wells, 2008). A common strategy for challenging a belief that worry helps to prevent
bad things from happening (positive metacognitive belief ) is to compare worry up
(engage with worry) and worry down (postpone worry) days with respect to feared
outcomes. The client is asked to monitor negative events each day to investigate whether
worry does in fact prevent bad things from happening. It is clear that both of these
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94 Chapter 5: Linking Assessment to Treatment: Case Formulation

experiments (postponement, worry up/worry down) require clients to sit with and
tolerate uncertainty – they need to “not” use worry or behavioural avoidance as strategies
to protect themselves and instead they need to “wait and see what happens”. Therefore,
implementing metacognitive therapy may be all that is required to increase the client’s
tolerance of uncertainty. If the therapist identifies that after the course of metacognitive
therapy more work is required to target intolerance of uncertainty directly, components
of intolerance of uncertainty therapy may be integrated. As you can see from this
example, a deep understanding of the common and unique elements of theories of a
particular disorder will directly inform case formulation and treatment planning.
A similar approach can be used for theories of different disorders, which is particu-
larly important when clients present with comorbidities. In the case where one disorder
is clearly secondary to (i.e., caused by) another disorder, such as when a moderate
depression is caused by severe social anxiety, the clinician would most likely start by
targeting the primary disorder. However, sometimes it is difficult to nominate a func-
tionally primary versus secondary disorder, and instead they appear to be synergistic
(mutually reinforcing) and linked by common processes. For instance, understanding
theories of OCD and GAD can help a trainee understand common and unique processes
that may be maintaining both disorders in the same individual. Cognitions (worries) in
GAD tend to be more ego-syntonic (i.e., consistent with the client’s values and who they
are as a person), whereas cognitions (obsessions) in OCD can be ego-dystonic (i.e.,
inconsistent with their values and who they are as a person). For instance, a father with
GAD might willingly engage with worry about his child’s safety because it is important to
him that his child is safe and well and he sees it as part of being a caring parent.
Alternatively, a father with OCD might experience ego-dystonic intrusive thoughts that
he is a paedophile, which causes him severe anxiety because he is not sexually interested
in children and it is inconsistent with who he believes himself to be (although he
misinterprets simply having these obsessions as potentially meaningful and therefore
doubts himself ). Despite these differences, theories of GAD (e.g., Borkovec et al., 2004)
and OCD (e.g., Salkovskis, 1985, 1999) suggest that both disorders are maintained by
well-intentioned but maladaptive attempts to avoid the cognitions or the possibility of
them coming true. In the case of the father with GAD, he may overplan and overcontrol
his child as a way to stave off worry that the child will be harmed, which serves to
maintain his focus on the risks and make his worry worse. He never learns that his
worries are “just thoughts”, his child is not more likely to be harmed even if he does not
worry, and that there are other more helpful ways of demonstrating care for his child
(e.g., he could just take “reasonable” precautions and drop his futile worrying entirely).
In the case of the father with OCD, he may try to neutralize his anxiety by rigidly and
excessively avoiding being close to his own and other children for fear that he will act on
his obsessions. He therefore has no opportunity to learn that he will not act on the
obsessions, as they are “just thoughts”. The common process of avoidance serves the
same function – maintaining and exacerbating the perceived importance of these nega-
tive thoughts and the associated distress.
By using knowledge of the commonalities and differences between theories of these
two disorders, the clinical psychology trainee understands (a) what aspects of each
problem need to be assessed for a differential diagnosis, (b) what common processes
may be maintaining the problems, (c) how to integrate both problems into the same case
formulation and (d) how to distil treatment into the simplest and most efficient
 Chapter 5: Linking Assessment to Treatment: Case Formulation 95

principles so that multiple problems can be targeted simultaneously. In this instance, the
therapist might initially provide psychoeducation to normalize the client’s worries and
obsessions as “simply experiences of a creative mind” that need not, in and of themselves,
have any particular significance. The consequences of rigidly responding to these cogni-
tions (worries and obsessions) with avoidance in the short term (i.e., negative reinforce-
ment – temporary reduction of anxiety strengthening further avoidance tendencies), and
longer term (i.e., increases significance of cognitions – leading to more vigilance and
avoidance) might then be described. Once the client understands that his avoidance is
maintaining his negative cognitions and anxiety, the therapist and client would collab-
oratively work towards building his acceptance of these cognitions by exposing him to
his worries and obsessions without the avoidance behaviours (i.e., take a “wait and see”
approach). If the client attempts to gain reassurance from the therapist that his worries
(my child might be harmed) or obsessions (I might harm a child) are unfounded, the
therapist may simply shrug his shoulders and say, “I’m not sure . . . let’s wait and see!” Of
course, this approach requires the therapist to be confident that these beliefs are ego-
dystonic (i.e., inconsistent with the client’s morals and actual impulses) and, if so,
reinforces the fact that thoughts per se are not harmful and do not need to be responded
to with additional attention or behavioural avoidance. In this way, the therapist is
modelling the common approach to responding to worries and obsessions, which
simplifies the principles for the client and distils treatment into the most
critical intervention.
In summary, it is important for clinical psychology trainees to become familiar with
the most common and evidence-supported theories and treatments for a range of mental
disorders. With this familiarity, trainees can begin to notice commonalities across
different theories attempting to explain a particular disorder, but also across different
disorders. Understanding these commonalities and differences will help to guide treat-
ment formulations within the context of comorbidity, because targeting the common
maintaining factors is likely to be effective at modifying multiple disorders, after which
unique components of each model can be targeted if required.
It is important to note that the approach being advocated here is “modular” in the
sense that it involves potentially integrating mechanisms described by different theories,
either of the same disorder or of different disorders, into a case formulation. However, it
is critical that where possible the theories and mechanisms, and the treatments targeting
them, are evidence-supported for the client’s clinical problems. This approach therefore
is not “eclectic” in the sense that the clinician “throws together” a collection of strategies
from different theories and treatment approaches without a clear theoretical and clinical
rationale that is based on evidence-based practice (e.g., clinical trials and strong levels of
evidence) as well as practice-based evidence (e.g., symptom tracking to ensure that
strategies used to modify mechanisms are having the desired impact on the mechanisms
and on symptoms). An alternative to combining different disorder-specific theories to
guide case formulation and treatment planning is to use evidence-supported transdiag-
nostic theories that were developed precisely to account for common dimensions of
psychopathology across disorders. A number of transdiagnostic theories and treatments
have been developed and shown to be effective and we will briefly review some of these
approaches in the next chapter.

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 Chapter
Treating Clients

6
Much effort has been expended trying to partition the variance attributable to the
specifics and non-specifics of therapy; however, for a practitioner the specifics of a
therapy are invariably delivered in the context of a therapeutic relationship. Clinical
psychologists generally consult with clients in person, be this individually or in groups.
In Chapter 2 we considered some of the important aspects of the therapeutic relation-
ship, but in the present chapter we will turn to some of the specific psychotherapeutic
techniques that have empirical support.
As evident from the model in Figure 6.1, treatment planning follows from a careful
assessment and formulation of the client’s problems. The selection of treatment involves a
considered and critical evaluation of the empirical literature. Although this consideration
also draws upon clinical training and experience, published literature has passed through a
peer review process and hence deserves greater weighting in the selection process.
One comprehensive review of the psychotherapy literature is A guide to treatments
that work edited by Nathan and Gorman (2015; see also Roth & Fonagy, 2004). The
process adopted in this review was that criteria for standards of proof were established
and then the available literature was summarized in a way that the quality of the
empirical support for the treatment of each disorder could be coded. The strongest
support came from Type One Studies, which used a randomized prospective clinical
trial. To qualify at this high level, the study needed to involve random assignment to
conditions, blind assessments, clear exclusion and inclusion criteria, sound diagnosis,
adequate sample sizes, and clear and appropriate statistical methods. Type Two Studies
were similar to Type One Studies, except that some aspects were absent (e.g., non-
random assignment). Weaker empirical support again was taken from Type Three
Studies, which were open treatment studies and case-control studies collecting retro-
spective information. Type Four Studies were those that involved secondary data analysis
(e.g., meta-analysis). Type Five Studies were reviews without secondary data analysis and
Type Six Studies included case studies, essays, and opinion papers. This classification
system is similar to levels of evidence used by the National Health and Medical Research
Council (2008–2010), although a systematic review of randomized controlled trials is
classified as Level I (strongest) evidence, followed by Level II (randomized controlled
trials), Level III-1 (pseudo-randomized controlled trial such as alternative allocation),
Level III-2 (comparative study with concurrent controls such as a cohort study), Level
III-3 (comparative study without concurrent controls, such as a historical control study),
and Level IV (case series with either post-test or pre-post outcomes).
Any interpretations based on reviews such as the one reported by Nathan and
Gorman (2015; see also Weisz & Kazdin, 2017 for a review of children and adolescents),
96
 Chapter 6: Treating Clients 97

Client data (problem, context, history, etc.)

Theoretical and Clinical training &

empirical literature experience

Assessment & Choosing an empirically-

case formulation supported treatment or set of
empirically-supported
therapeutic principles
Treatment planning
& measurement

Treatment implementation
& monitoring

Evaluation &
accountability

Figure 6.1 A science-informed model of treatment selection.

and other sources such as the National Institute for Health and Care Excellence (NICE),
Cochrane Reviews) and clinical practice guidelines developed by professional bodies, are
open to allegations of being incomplete and potentially biased. For example, conclusions
can only refer to treatments that have a broad research base and the review will omit
newer treatments or those that may be effective but have not been well-researched to
date. The treatments included may be ones that emphasize efficacy (i.e., prioritizing
internal validity, with tight controls and selection criteria) over effectiveness (i.e., priori-
tizing external validity by using “real-world” settings and patients), focus on ICD and
DSM diagnoses, and some procedures (e.g., in vivo exposure for specific phobias) may
suffer from the bulk of the research being conducted during times when the criteria for
conducting and reporting outcome research were less stringent. However, while a
scientist-practitioner must always recognize the limitations of any data upon which
interpretations are based, critical evaluation must acknowledge that the products of a
systematic review place individual practitioners in a strong position to lay empirical
foundations for the practice of clinical psychology. In comparison to the state of the
empirical foundation of clinical psychology when Hans Eysenck (1952) claimed that
psychotherapy was no more effective than spontaneous remission, it is now possible to
identify some broad areas where psychotherapy is efficacious. This is the nature of
science. Our conclusions will always be tentative, more and better data available tomor-
row will alter the inferences we would draw today, but scientist-practitioners must allow
their treatment decisions to be influenced by a careful appraisal of the best data
currently available.
When examining contemporary reviews (e.g., Nathan & Gorman, 2015) and clinical
practice guidelines (e.g., national guidelines from psychological associations such as the
British Psychological Society, Australian Psychological Society, Canadian Psychological
Association and American Psychological Association), it is clear that psychological and
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98 Chapter 6: Treating Clients

pharmacological treatments can alleviate a wide array of psychological problems.

Focusing on the psychotherapies, Behavioural (including variants such as Dialectical
Behaviour Therapy; DBT) and Cognitive-Behavioural Therapies (CBT) have fair to
strong empirical support in the treatment of Attention Deficit Hyperactivity Disorder,
Alcohol Use Disorders, Avoidant Personality Disorder, Body Dysmorphic Disorder,
Borderline Personality Disorder, Bulimia Nervosa, Conduct Disorder, Conduct
Disorders, Depression, Generalized Anxiety Disorder, Hypochondriasis, Obsessive-
Compulsive Disorder, Paraphilias, Panic Disorder (with and without Agoraphobia),
Post-Traumatic Stress Disorder, Schizophrenia, Sexual dysfunctions (e.g., erectile
dysfunction), Sleep Disorders, Social Phobia, Somatoform Pain Disorder, and
Specific Phobias. Interpersonal Psychotherapy (IPT) has a demonstrated efficacy
only for depression, and Dynamic/Psychoanalytic Psychotherapy has some support
in the treatment of Borderline Personality Disorder and other Personality Disorders.
Thus, when making decisions about the direction of treatment, a clinical psychologist
will need to be cognizant of the relevant empirical literature to best inform these
decisions. One way to keep abreast of current developments is to search the internet
sites that list the evidence for particular treatments. For instance, there is the
Cochrane Collaboration, which publishes systematic reviews of health care (includ-
ing psychological and psychosocial) interventions. Another listing, that focuses on
broader social welfare interventions, is the Campbell Collaboration. Professional
associations will also often publish literature reviews of evidence-based treatments.
The remainder of this chapter will introduce some elementary components of these
evidence-based treatments. Further, since many techniques are modified for applica-
tion in many different clinical problems and psychological disorders, we will concen-
trate on providing a description of particular procedures that are broadly applicable.
The chapter will conclude with a summary of some recent transdiagnostic
interventions.

Behaviour Therapy
In contemporary clinical practice, behaviour therapy is often delivered alongside cogni-
tive interventions, but for didactic purposes it is useful to consider them separately. The
theoretical underpinnings of behaviour therapy have a long tradition (Pavlov 1927;
Watson, 1924). Since then, learning theory has emphasized contingency over contiguity
(De Houwer, 2020; Rapee, 1991; Rescorla, 1988). That is, the important relationships are
those in which there is a contingency between two events, rather than a temporal
contiguity between a stimulus and a response. Thus, in contrast to its early roots,
behaviour therapy is much more “cognitive” and learning theory emphasizes the learn-
ing of relations between events (“if X then Y” learning).
Clinical psychologists can use their understanding of contingencies in one of two
ways. First, an awareness of the way that contingencies control behaviours can help
clients understand why particular behavioural patterns became established and main-
tained. Second, modifying the contingencies may allow clients to establish and maintain
new patterns of behaviour. Consequently, understanding the “if X then Y” rules that
influence behaviours can be applied to case formulation (as you help the client under-
stand the origins of problem behavioural patterns) and treatment (as you help the client
to act in new ways by modifying contingences and learning self-control strategies.)
 Chapter 6: Treating Clients 99

Contingency Management
Contingency management refers to the presentation of reinforcers and punishers in a
contingent manner, where the goal is to help the client to manage or modify behaviour.
Treatment begins, therefore, with a baseline measurement against which changes can be
measured and monitored. Reminiscent of the methods of case formulation, these ratings
will be direct measures of the behaviour in question, its antecedents and its consequences.

Increasing Desired Behaviours

Positive reinforcement (sometimes called reward) increases the likelihood of a desired
response when a reinforcer occurs contingent upon the desired behaviour. For example,
when constructing a case formulation of smoking behaviour it may be relevant to note
that positive reinforcement can be a factor in the acquisition of behaviours, such as drug
taking. The stimuli (e.g., a cup of coffee) associated with the positive reinforcing effects
of nicotine when smoking (Vinci, Sawyer & Yang, 2021) can acquire the capacity to elicit
a craving to smoke (Van Heel et al., 2017). Positive reinforcers can be useful helping
clients to increase the frequency of helpful behaviours. Once you have agreed with a
client on a target behaviour to increase in frequency or intensity, it is important to ensure
that the reinforcement occurs immediately after a target behaviour and that it does so
contingently and consistently. Be mindful of the need to vary reinforcers to avoid loss of
potency, and while reinforcers may be used often to begin with, it is important to fade
out and allow the natural reinforcement to take over. For this reason it is also desirable to
ensure social reinforcements whenever possible – fading out primary reinforcers to
ensure they are replaced with social reinforcement. For example, to increase peer
interaction, a shy or socially anxious client might use a star chart with primary reinfor-
cers to reinforce their social contact with peers, but then check that the inherent
reinforcement from social interactions are brought to bear as the primary reinforcers
are faded out. Another method of fading out is to use a “pyramid chart” in which the
number of behaviours (i.e., stars on a chart) required to obtain a primary reinforcer
increase in a linear manner so that as time goes on, the reinforcers become more sparse.
Negative reinforcement is a factor that is pertinent to the case formulation of many
emotional disorders (Dymond, 2019). Negative reinforcement is not punishment (which
decreases undesirable behaviours), but it involves the removal of a reinforcer contingent
upon some behaviour, which in turn increases the likelihood of that behaviour being
emitted in the future. When considering when a client escapes or avoids threatening or
aversive situations, the reduction in emotions such as fear, anxiety and worry can
reinforce such avoidance in the future (Hofmann & Hay, 2018). Negative reinforcement
is also a useful process when clients wish to strengthen desired behaviours. For instance,
a client with tension headaches who notices that using a newly learned relaxation
technique successfully alleviates the headaches, and this in turn can be helpful in
ensuring that the client will be more likely to use relaxation exercises in the future.
Similar to positive reinforcement, the termination of a reinforcer should follow imme-
diately, contingently and consistently after the target behaviour.

Decreasing Problem Behaviours

Contingent punishment describes any procedure that decreases the future probability of
a response being emitted. Punishment has a long and controversial history and
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100 Chapter 6: Treating Clients

contemporary clinical practice reflects the deliberate move away from aversive interven-
tions and towards reinforcing appropriate behaviour (Trump et al., 2018). Thus, it can be
more relevant when constructing case formulations, where an unhelpful behaviours can
be established and maintained by contingent punishment, such as may occur with
criminal victimization and spousal abuse (Reisig, Holtfreter & Turanovic, 2018).
A conceptually related method of reducing undesired behaviours is time-out from
reinforcement. Time-out from reinforcement describes a period in which previously
available positive reinforcement is unavailable. It is useful to use the full title, rather
than the abbreviated “time-out” because it will help you remember what the necessary
conditions are. Namely, there needs to be an ongoing schedule of positive reinforcement
and the person needs to be removed from the environment where the positive reinforce-
ment is ongoing at least for long enough to have missed out on one reinforcer. Many
discussions arise because people forget that it is time out from reinforcement. For
instance, parents may send children to their rooms but find this is ineffective because
they like being there. Another signal that you have forgotten the nature of the procedure
is if you start to identify the optimal duration of time-out with respect to a clock rather
than with reference to the schedule of reinforcement that the person is being removed
from. It also indicates that if a person is a reinforcer, removal of the person (rather than
the client) for a specified period of time (e.g., a mother ignoring a child and going off to
read a magazine) may also be effective. Time-out from reinforcement needs to be used in
conjunction with reinforcement of desired behaviours (Trump et al., 2018). It is useful to
identify a time-out area that is safe and free of reinforcement. Shorter durations are
preferred because while a person is in time-out from reinforcement, they are often
removed from learning opportunities.
Undesirable behaviours can reduce via response cost and extinction. Response cost
involves a previously acquired reinforcer being forfeited contingent upon the emission of
an undesired response (e.g., a teacher may have a child lose playtime at school by having
them pick up rubbish).
Extinction involves the cessation of reinforcement of a previously reinforced behav-
iour. It is important to note that extinction is not unlearning, but is the learning of a new
contingency. Once extinction has occurred, the person has two “if X then Y” rules, but
one is given more weight. Remembering this aspect of learning theory helps you to
expect four phenomena that regularly occur in clinical practice. First, there is reinstate-
ment of the response. As the Rescorla-Wagner (1972) model predicts, learning can be
reinstated by the presentation of the Conditioned Stimulus (CS) or the Unconditioned
Stimulus (US). Therefore, experience of the US may reinstate old learning. For instance,
once a phobia has been extinguished, the occurrence of fear may be sufficient to reinstate
fears (Jacobs & Nadel, 1985; Menzies & Clarke, 1994, 1995). Second, changing the
context can lead to renewal of responding (Bouton, 1991; Rosas, Todd & Bouton,
2013). For example, Kelley and colleagues (2015) were assisting two children with
developmental disabilities. A behaviour was trained in one context (e.g., the color of
t-shirts worn). Extinction then occurred in the same or a different context. They
demonstrated that despite extinction remaining in effect, the response rates temporarily
increased upon returning to the original training context. A third factor is re-acquisition,
such that previously extinguished behaviours are much more rapidly learned. For
instance, drug tolerance is more rapidly acquired following each period of detoxification.
Finally, there is rebound (extinction burst). That is, when behaviours are extinguished,
 Chapter 6: Treating Clients 101

there is an increase in the behaviour (e.g., a child may tantrum if a parent no longer pays
attention to an undesired behaviour).

Contingency Contracting
Importantly, behaviour therapy is not a modification technology applied to a client, but
involves a collaborative relationship. Contingency contracting is beneficial to achieve this
end. Contingency contracting involves clearly specifying in advance the nature of the
contingencies now in operation if they are going to be controlled by someone other than
the client. Research indicates that the most effective contracts are those that specify the
treatment strategies and the expected outcomes. Further, efficacy is increased if the
contract elicits from the client an agreement to participate fully in the programme.
One form of contract is the deposit contingency, in which a deposit is forfeited if a
behaviour is not emitted (e.g., lose deposit if therapy is prematurely discontinued). For
instance, in smoking cessation groups, clients may be given a discount if all sessions are
paid in advance, but with the understanding that this would be forfeited if clients stop
coming.

Habit Reversal
Behaviour therapy techniques can be combined as required. An example of such a
combination is a procedure called habit reversal. Developed by Azrin and Nunn
(1973) it involves the practice of behaviours that are incompatible with or opposite to
the habit in question. For instance, nail biting, may be treated by practicing hand
clenching. The components of treatment are (i) self-monitoring in which the behaviours
are identified, (ii) habit control motivation in which the clinician reviews the inconveni-
ences of the undesirable behaviour, (iii) awareness training, in which the normally
“automatic” and habitual sequence of behaviour is brought into conscious awareness,
(iv) competing response training, where the client practices a behaviour incompatible
with the habitual behaviour, (v) relaxation training and (vi) generalization training in
which high- risk situations are identified and contingency plans are organized and
practiced (see Heinicke et al., 2020; Stanley & Mouton, 1996).

Maintenance of Behaviours
One main problem with contingency management is that of stopping the contingency
but maintaining the desired behaviour. A way of solving this is to ensure that the
behaviour soon comes under the reinforcement of natural contingencies. For instance,
reinforcing peer play may soon be unnecessary if peer interactions become inherently
rewarding. However, thought needs to be given to fading out the contingency. Generally,
this involves moving from continuous to partial reinforcement, fading from some
situations and not others, and then self-control.
Among the issues involved in behavioural maintenance is generalization; both the
acquisition of new and inhibition of old responding. The general rule is that generaliza-
tion should be programmed rather than assumed to be a natural consequence of therapy.
Thus, work done in the clinic or with the clinician needs to be conducted in or translated
into the natural environment. For example, working with clients who fear internal
sensations of anxiety, the clinician may encourage them to generate such physical
sensations in a therapy session (Page, 1994). A client who fears a pounding heart may
run on the spot to deliberately raise cardiac rate and challenge the associated fearful
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102 Chapter 6: Treating Clients

thoughts (“I might have a heart attack and die”). Generalization might involve the client
repeating these exercises between therapy sessions in everyday settings, such as using the
steps and not avoiding the sensations by taking an escalator or elevator.

Self-Management
Contingency management involves procedures to increase desirable and reduce undesir-
able behaviours. The client can be considered a passive recipient of treatment in that
behaviour is controlled by the environment and modifying the environment will modify
the client’s behaviour. In contrast, self-management therapy is based upon a participa-
tory model of treatment (e.g., Kanfer & Gaelick-Buys, 1991; Page, 1991b). The responsi-
bility for change is viewed as lying within the client and therapy is part of a transition to
self-control. The therapist plays an important part in providing the context for change,
but the burden of engaging the change process is left with the client. The main reasons
for a self-management role are that (i) many behaviours are not easily accessible for
observation by anyone but the client, (ii) change is often difficult, unpleasant, and
conducted with ambivalence, and therefore collaboration and negotiation are needed
and (iii) the aim of psychotherapy is to teach generalizable coping strategies, not only
management of specific problems.
Self-regulation develops out of social learning theory in which behaviour is seen to
arise from learning, and complex chains of behaviours become more automatic through
repetition. The greater the automaticity of a behaviour, the harder it will be to control.
Self-management procedures are then required when new behaviours must be learned,
choices need to be made, goals are to be achieved or blocked or when habitual response
sequences are interrupted or ineffective. Self-management brings into play controlled
cognitive processing.
Finally, self-reinforcement is important. How the person reacts cognitively and
emotionally to the self-evaluation is instrumental to motivating change. Two attribu-
tional processes come into play. The person must correctly attribute both the cause and
the control of a behaviour to something under their influence/control.
Since self-management will require a degree of motivation, the strategies of motiv-
ational interviewing (Miller & Rollnick, 2012) will be useful in recruiting and building
motivation for change. Motivational interviewing will be described later but for now
some of the key interventions and techniques involved are summarized in the following:
Express Empathy: Warm reflective listening during which you work to understand the
clients, accept them as who they are and acknowledge their feelings without judging,
criticizing or blaming. Acceptance is not identical to approval, but will facilitate
change, while confrontation will inhibit change.
Develop Discrepancies: The discrepancy in life goals between where a client is and
where they would like to be can be used to motivate change.
Avoid Argumentation: Arguments encourage resistance and are frequently counter-
productive and for this reason they are best avoided in psychotherapy.
Roll with Resistance: Respond to a force by sidestepping and then using the force for
your own end. For instance, Westra and Norouzian (2018) describe ambivalence in a
clinical context where there is an internal conflict between approach and avoidance
motivations. They identify “I want to, but . . .” thoughts (such as “I want to be happy
but I feel guilty, like I don’t deserve it”), “I know it doesn’t make sense, but I can’t seem
 Chapter 6: Treating Clients 103

to stop” thoughts, and “Logically I know it, but emotionally. . .” thoughts (e.g., “I know
I’m not worthless, but it feels like I am”). Rather than pushing back against a client
who thinks “I know I’m not worthless, but it feels like I am” by challenging and
disagreeing, a therapist might roll with that resistance and ask, “What does that
worthlessness feel like?” and then “What is it that prompts you to know that you are
not worthless despite those feelings?”
Support Self-Efficacy: Although the non-contingent encouragement of self-esteem has
been questioned (Baumeister et al., 2003), self-efficacy is an important predictor of
behaviour and its enhancement (discussed later) increases the probability that a
desired behaviour will be engaged in.

Use Behavioural Contracting

One particular motivational strategy is behavioural contracting. Contracts can help to
assist clients to initiate specific actions, to identify criteria for success and to clarify the
consequences of particular behaviours. When negotiating contracts with clients it is
useful to (i) describe the behaviour in detail, (ii) identify criteria (e.g., duration or
frequency) for completion of a goal, (iii) specify the nature and timing of contingent
positive and negative consequences upon fulfillment and non-fulfillment of the contract
and (iv) clarify how the behaviour will be observed, measured, recorded and conveyed
back to the client (if a third party is involved). If possible, a public commitment to the
contract can be useful as a means to enhance compliance, but caution needs to be
exercised if the consequences of a “public failure” would be detrimental.
For instance, when working with a client trying to overcome agoraphobic avoidance
a contract might be negotiated that describes the behaviour (e.g., travelling unaccompan-
ied by train between two railway stations during peak hour), which will be celebrated by
the person buying themselves a treat at the station’s shop once they have travelled there.
The client might also have agreed to call a partner upon arrival if they felt that this might
help motivate them.
Once a sufficient motivational foundation has been laid, self-regulation begins with
the self-monitoring stage, in which clients monitor and evaluate their behaviour. Self-
evaluation involves a comparison between the person’s actual behaviour and his or her
standards for that behaviour. Even though self-monitoring may lack validity for experi-
mental purposes, many of the reasons that make it problematic for research become
assets for clinical work. In particular, we know that performance is reactive and therefore
monitoring may have a therapeutic effect. Baseline data can be used to provide an
incentive to change and as encouragement when change occurs. You can also select to
measure a response that is incompatible with the problem behaviour. For example,
spouses may be asked to record the interactions that lead up to a fight. This makes them
conscious of those interactions that are leading to a fight and, by inducing the awareness,
increases the chances that alternative responses will be engaged.
Once monitoring has begun it is possible to start modifying the environment and the
contingencies. Stimulus control is a useful self-management procedure, since the client
can construct conditions that reduce the possibility of an undesired behaviour. For
example, a person with a gambling problem may put restrictions on a bank account
and a person with a drinking problem may choose to only drink with people who are
unlikely to encourage excessive consumption. Alternatively, stimulus narrowing may be
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used to decrease the range of stimuli or environments under which the behaviour occurs.
That is, the behaviour is gradually put under the control of certain discriminative
stimuli. For instance, sleep hygiene rules (Van Brunt, Riedel & Lichstein, 1996) encour-
age the use of beds for sleeping, and stipulate that other behaviours (e.g., watching TV,
reading) are to be carried out in other locations. The aim of these procedures is to
narrow the stimuli that are associated with sleep.
When introducing self-management procedures, it is helpful to consider how diffi-
cult they are for the client to execute. Task assignment is managed so that assignments
are graded in difficulty and begin with the easier ones. These “homework” assignments
(sometimes more fruitfully called “active practice”) need to be presented to clients as
essential to the process of therapy. To learn self-management, clients need to practice
self-management. This will involve (i) information, in which the requirements of the task
are made explicit, (ii) anticipatory practice in which the client imagines and practices the
assigned task within the safety of the therapeutic context (e.g., role plays), (iii) active
practice (or response execution) in everyday settings, followed by (iv) a review. The
review aims to translate the episodic memory that the person will have of an event into a
semantic memory so that clients will form general rules and create knowledge about
themselves and appreciate the meaning of events. The data routinely collected as part of
measurement and monitoring activities can be useful in demonstrating the effectiveness
of the behaviours to the client. For instance, in a group treatment context, clients could
review their individual progress and discuss how improvements or setbacks are related to
use (or not) of key therapy skills (Hooke et al., 2018).
In summary, when using self-management models, the client controls the contingen-
cies of reinforcement. Behaviour is then rewarded or punished according to specified
rules, as in contingency management, but their implementation is under the control or
management of the client. However, learning can occur without the use of external
reinforcement and one important method is through procedures associated with social
learning theory.

Modelling
Modelling and its use in behaviour therapy (and CBT) draws on an extensive empirical
literature in psychology more generally (Bandura, 1977, 2017; Frith & Frith, 2012;
Rosenthal & Steffek, 1991). Modelling describes the learning that occurs from the
observation of others and any imitative change in behaviour that may follow.
Therefore, it refers to changes in the behaviour of the individual who observes another
(i.e., the model). Two subsets are observational learning and imitation. Observational
learning is learning that occurs from observing others (e.g., members of a treatment
group observing other members’ progress in implementing change strategies) and
imitation refers to the behaviour of a person who observes and then copies the actions
of others (e.g., a therapist can model assertive ways of how a client can improve
communication with others, and the client can then copy and practise those ways first
in the session and then as a homework assignment).
Modelling has many applications, but we will illustrate one usage in the training of
social skills. In this context a clinical psychologist will begin with an assessment of social
skill deficits, including the expressive features of language, speech content, the paralin-
guistic elements (e.g., volume, pace, pitch, tone), nonverbal behaviours (e.g., proxemics,
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kinesics, eye contact, facial expression), response timing, receptive features of social
interactions (e.g., attention, decoding), contextual and cultural mores, and specific
deficits (e.g., assertiveness). Once the deficits have been specified, appropriate behaviours
are taught using direct behaviour training. Role plays, in which the client makes an
attempt to produce the desired behaviour, are used along with a demonstration by the
therapist of the target behaviour in the form of a modelling display. Thus, there is role-
reversal. This role-reversal will provide extra information about the client’s perceptions
and abilities. The role-reversal also provides an opportunity to allow the client to
experience thoughts and feelings associated with being the other person in the inter-
action. The role play is repeated, but the client now tries to incorporate the new
behaviours into their repertoire. The clinical psychologist will provide response-specific
feedback, giving praise for successive approximations and concrete instructions for
change in future rehearsals. When giving feedback, it is useful to begin with positive
feedback, then negative, and finally some more positive feedback so that the client does
not feel overwhelmed with criticism. The role-reversal continues with repetition of the
cycle that may include response escalation and variation, to enhance the flexibility of the
client’s skills and to overtrain responses, so that they appear more “naturally”. Initially
role plays should be brief, highly structured and deal with relatively benign topics, until
the client becomes comfortable with the procedure and has begun to acquire the
principles. Finally, the client practices outside the therapy sessions to consolidate skills
and generalize the behaviours.

Dialectical Behaviour Therapy (DBT)

Dialectical Behaviour Therapy (DBT; Linehan, 1993a, 1993b) is an adaptation of the
behavioural techniques and is worth considering in some detail for two reasons. First, the
treatment has empirical support for managing symptoms of Borderline Personality
Disorder (e.g., Bedics et al., 2012; Kliem, Kröger & Kosfelder, 2010; Panos et al., 2013).
Second, it is an illustration of how existing therapies can be modified to suit particular
domains, and the techniques of acceptance and validation are being incorporated into
many newer variants of CBT with promising empirical bases (e.g., ACT; Hayes, Strosahl &
Wilson, 2011; Hayes & Strosahl, 2004; Veehof et al., 2011) and developed in team-based
clinical settings (Sayrs & Linehan, 2019). Thus, rather than describing the particular
techniques of DBT (see Linehan, 1993b), we will focus on the ways that Linehan presents
psychotherapy. Linehan suggests that Borderline Personality Disorder evolves within an
emotionally vulnerable individual who develops in an “Invalidating Environment”.
Individuals who are emotionally vulnerable are more sensitive to stress and therefore
stressors elicit excessive responses, and it takes a long time to return to a baseline level of
functioning when the stressor has finished. An invalidating environment occurs when a
child’s experience and behaviours are disqualified or discounted by people who are
important to the child. The child’s utterances are not accepted as valid descriptions of
their feelings or even if they are accepted, the person rejects the feelings as a valid
response to the stress. When a high value is placed upon self-control then any perceived
deficiencies in self-reliance are taken to indicate that the child lacks motivation or is
disturbed.
DBT recognizes the difficulties faced by an emotionally vulnerable person living in an
invalidating environment and identifies three dialectical dilemmas. Individuals may not
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learn to identify and comprehend feelings. When feelings are recognized, they will be
judged to be invalid. Further, growing up in an invalidating environment may inhibit
children from learning appropriate coping strategies to manage intense emotions. The
paradox of the invalidating environment will cause an alternation between excessive
emotional inhibition (to elicit acceptance from significant others) and extreme emotional
expression (to elicit acknowledgment of feelings by others). This seemingly erratic behav-
iour will bring about erratic schedules of reinforcement, which in turn will strengthen the
erratic behavioural patterns. To Linehan (1993a), this situation is the primary dialectical
dilemma: both inhibition and expression of emotions become distressing.
A second dialectical dilemma arises because one emotional trigger is not resolved
before another stressor occurs. This blurring of unresolved stressors and the associated
emotional reactions produces a series of unrelenting crises. A third dialectical dilemma is
the alternation between active passivity and seeming competence. They will convey a
sense of competence in an effort not to be determined by a current mood state, while
simultaneously seeking out people to solve their problems. Thus, Linehan’s (1993a)
therapy is dialectical because it presumes that for any issue (i.e., the thesis), there is an
alternative position (i.e., the antithesis), and that one arrives at a synthesis through the
clash of these two positions. The synthesis is not a compromise, but is a third way that
takes the assets of each position, leaves their deficiencies and resolves any contradictions.
The key dialectic in DBT is the balance between acceptance on the one hand and the
change on the other. Any attempt by the patient at self-invalidation is balanced with
training in adaptive problem-solving techniques. In addition, given the emotional
vulnerability of clients with Borderline Personality Disorder, the therapeutic relationship
is of central importance within DBT. Therapists are responsive to the client, and express
warmth and genuineness. They use appropriate self-disclosure on the one hand and
“irreverent communication” on the other. The irreverence involves confrontational
communications that aim to nudge the client when therapy appears stuck or moving
in an unhelpful direction. Linehan (1993a) encourages therapists to adopt a perspective
that, despite appearances, clients are doing their best. Therapists are reminded of the
therapeutic model within which the behaviour can be understood as a reasonable
reaction of an emotionally vulnerable person to an invalidating environment. This
acceptance is balanced with the dialectic of change. That is, even though the reaction is
understandable, clients need to work to change the situation. The client may not be the
(sole) cause of their current circumstances, but they can choose to be responsible
for change.
One valuable contribution of DBT is that it identifies a therapeutic hierarchy.
Decreasing suicidal behaviours is the first priority in therapy, and therapy interfering
behaviours is the second. Therefore, if either of these behaviours is signalled, these
become the focus of therapy until they are dealt with. Other goals moving down the
hierarchy are to decrease behaviours that interfere with the quality of life, to increase
behavioural skills, to decrease behaviours related to post-traumatic stress, and to
improve self-esteem and specific behavioural targets. However, a drawback of a rigid,
therapist-supplied hierarchy is that it could be at odds with both a science-informed
approach to clinical practice and with a key ingredient in the therapeutic relationship
shown to be related to positive treatment outcome. That is, the order of treatment goals
should be informed by a case formulation incorporating practice-based evidence and
should be negotiated in a collaborative manner with the client.
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In summary, behaviour therapies extend from relatively straightforward contingency

management to more complex treatment regimes found in DBT. In addition, they are
typically delivered alongside cognitive interventions, even though they evolved
separately.

Cognitive Therapy
One of the central techniques in cognitive therapy is Cognitive Restructuring. Cognitive
therapy has a strong evidence base (Beck & Dozois, 2011; Carpenter et al., 2018;
Hofmann et al., 2012; Laws et al., 2018; Linardon, Wade, De la Piedad Garcia &
Brennan, 2017; Tolin, 2010). Within Ellis’s (1962) Rational Emotive Therapy (RET) it
is argued that Activating events (called A’s) do not cause emotional and behavioural
Consequences (called C’s), but that thoughts or Beliefs (called B’s) intervene as mediators
(Beck, 2011). For example, an activating event, such as preparing to consult with one’s
first client, does not cause the emotional consequences of anxiety, but the emotion is
mediated via beliefs such as, “I must be a perfectly competent therapist or I am a
professional failure.” Psychological disorders arise when the beliefs are irrational. By
“irrational”, Ellis means that they are unlikely to find empirical support in the person’s
immediate environment and do not promote survival and enjoyment. Although there are
many irrational beliefs, Ellis argues that they can be distilled into a relatively small set of
basic irrational thoughts (see Ellis & Harper, 1975). Therefore, Ellis would argue that the
preceding example is an illustration of a basic irrational belief such as, “you must prove
thoroughly competent adequate and achieving” (Ellis & Harper, 1975, p. 102).
Treatment adds D and E to the “ABC” model, where D refers to Disputing the
irrational thoughts and replacing them with more rational thoughts. This is achieved
through a Socratic dialogue and a logic-empirical method of scientific questioning,
challenging and debating. The consequence of replacing the old beliefs with the new
more rational ones is more positive Emotions (i.e., E’s). Rational thoughts are based on
objective facts and if acted on will lead to a preservation of life and a more rapid
achievement of one’s goals, and prevent undesirable conflict (Ellis & Harper, 1975).
Thus, the procedural steps of RET are to (i) persuade the client that an RET analysis of
the problem is useful, such that the client is convinced of the mediating role of cogni-
tions, (ii) identify the most important irrational beliefs underlying the present complaint,
which can be achieved using a case formulation approach described in Chapter 5, (iii)
show the client how to dispute the irrational thoughts and (iv) generalize learning so the
client can apply the newly acquired knowledge and skills without the assistance
of therapy.
Once the core irrational beliefs have been identified, the aim is to challenge them.
The clinician achieves this goal by asking questions such as, “What thinking errors are
you making?”, “What is the evidence for what you thought?” and “What is the effect of
thinking the way you do?” In so doing, Ellis would argue that one looks for thinking
errors such as “Awfulizing” (e.g., it’s awful when I’m stood up”), “I can’t” thoughts (e.g.,
“I can’t bear it when you ignore me”) and “Damning” (e.g., “You deserve to burn in hell
for what you did to me”).
Similar to Ellis’, RET is Beck’s cognitive (-behaviour) therapy. Beck’s approach clearly
focuses on cognitions, but there is an added behavioural emphasis, especially with
behavioural experiments (Bennett-Levy et al., 2004) that is less apparent in RET.
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Beck (1967) assumes that emotional difficulties such as depression and anxiety arise
from negative automatic thoughts. They are negative in emotional content and auto-
matic in the sense that they appear to occur involuntarily, and consequently are not
easily dismissed. Depressed thinking is characterized by the cognitive triad: negative
thoughts about the self, the world and the future. Overlaid on this content are cognitive
processes (attention, abstraction and encoding) that transform environmental stimuli.
Beck argues that these cognitive processes are biased (cf. Williams et al., 1997), which has
the consequence that anxious and depressed individuals tend to make judgements in a
systematic and consistent manner. The biases identified are (i) Selective Abstraction,
which describes forming conclusions based on isolated details of a single event (e.g.,
“I had a bad therapy session because I forgot one question.”), (ii) Overgeneralization,
which involves holding extreme views based on particular events and then generalizing
the conclusion (e.g., “I had trouble with my first client, therefore I must be a failure as a
clinical psychologist”), (iii) Dichotomous Thinking, which includes thinking in all-or-
nothing terms (e.g., “My first client was a success, but I just know my second will be a
failure”) and (iv) Personalization, which describes incorrectly making an inference about
one’s self, based on an external event (e.g., “My client has cancelled, therefore I must be a
bad therapist”). These cognitive processes harden into stable characteristic cognitive
beliefs (called schemata) that Beck argues render people vulnerable to anxiety or
depression.
To identify and modify these dysfunctional beliefs, the first step is to identify
automatic thoughts. This is achieved by getting the client to monitor automatic thoughts,
which are verbal thoughts or images that seem to arise without effort and are associated
with negative emotion. Clinicians can elicit these thoughts by asking clients to introspect
(e.g., “What’s going through your mind right now?”). For instance, you might ask a
client to try to identify the automatic thoughts that occur when you notice an abrupt
shift in mood in a session, you could use evocative, personally-relevant role plays or you
might model the process by “thinking aloud” your own automatic thoughts.
Burns (1980, 1999) described a downward arrow technique that can be very helpful.
The clinical psychologist identifies an important automatic thought that could arise from
an underlying dysfunctional belief. By repeatedly asking the client the meaning of the
thought (e.g., “What’s the worst thing that could happen?” or “What would be upsetting
about that?” or “What would that mean?”) the clinician aims to spiral down towards the
dysfunctional belief. Other methods to help clients focus on the content of cognitions are
to help them to attend to global words (e.g., always, never) and imperatives (e.g., must,
should and ought), exploring a client’s explanations of negative or positive moods, and
attending to self-referent thinking. The clinical psychologist might also want to focus on
the form of the cognitions, by drawing the client’s attention to typical cognitive biases
and asking about the degree to which these are used in other areas, especially those where
emotional problems are observed. Therefore, during the session with a client, the
observation of intense emotion may suggest the activations of more central automatic
thoughts.
Outside the cognitive therapy session, clients are encouraged to maintain a record of
the automatic thoughts and their effects. In a series of columns, clients record activating
events, the accompanying emotion (rated from 0 to 100 in terms of intensity), a written
verbatim record of the automatic thought, and finally the degree of belief in the thought
(0–100). Clients are then encouraged, first within the therapy session and then more
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often on their own outside of therapy, to challenge the automatic thoughts. Similar to
RET, clients will assess (i) the evidence for a thought by asking “What is the evidence?”
or “How could it be tested?”, (ii) evaluate alternative ways of thinking, by posing the
questions “Is there another way to look at it?” or “What can I do about it?”, (iii) consider
the implications of a way of thinking by asking “What is the effect of thinking?” or
“What is the worst that could happen?” and finally (iv) identify any thinking errors. The
aim is in each of these activities is to identify a new more helpful and believable thought
that leads to a more positive emotional reaction.
One issue of relevance to cognitive therapy is the role of unconscious thoughts. For
example, it has been long argued that we only have access to cognitive products, not
cognitive processes (Nisbett & Wilson, 1977). We might know that we decided to choose
clinical psychology as a profession, but we do not have direct access to the reasons why
we made this choice (even though we believe we do). That is, much thought is uncon-
scious and inaccessible but we continue to answer “why?” questions, even though we
arguably do not have access to the data. This could be a problem for cognitive therapies if
one believes that clients truly cannot get access to their automatic and irrational
thoughts. However, it is also possible to assume that in therapy we are evaluating the
evidence for and against different thoughts and we decide on which are best accounted
for by the data. This latter position is agnostic as to whether we have direct access to
automatic thoughts, by only assuming that we can evaluate and change our belief
structures.

Presenting a Rationale for Cognitive Therapy

When conducting any psychological treatment, presentation of a rationale is critical.
Giving a rationale is part of the broader goal of orienting a client to treatment, which has
been identified as a clinical activity that is predictive of positive therapeutic outcomes
(Orlinsky et al., 2004). The challenge when giving a rationale for cognitive therapy is no
different to any other therapy, since it is important to present the treatment in a manner
such that the client understands it sufficiently well to be able to apply, and so that
sufficient hope and motivation are recruited to encourage the client to want to fully
engage with the intervention. Therefore, the principles of treatment need to be outlined
and any potential objections must be addressed.
For example, in outlining a rationale for cognitive therapy, in which cognitions are
postulated to mediate the emotional responses to antecedent events, a few points are
worth bearing in mind. First, the language must be clear, simple and appropriate to the
client. If you consider the first sentence in this paragraph, you could well find that
phrases such as “cognitions are postulated to mediate emotional responses to antece-
dents” could be better expressed for clients (e.g., “the way you think about something
greatly influences how you feel about it”).
Within cognitive therapy, a common way of presenting information and challenging
unhelpful thoughts is to use “Socratic dialogue”. Rather than presenting information in a
direct and didactic manner, or correcting unhelpful thinking styles, a clinician will use a
technique of structured questioning. The aim is to elicit from clients what they are
thinking (rather than telling them) and to question assumptions (rather than disputing
them; Beck et al., 1979). Following a method used by the ancient Greek philosopher,
Socrates, the method guides discovery by posing questions ordered so that they help
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clients to define their problems and to identify unhelpful thoughts and beliefs. The
questions address meaning and impact of events that arise from particular thoughts
and beliefs.
By way of illustration, a Socratic dialogue can elicit the treatment principles from the
client, rather than tell them directly. This can be done by eliciting the relationship
between thoughts and emotions as illustrated in the following dialogue.
THERAPIST: You’ve been telling me that your husband makes you angry, and I can see how it might feel as if
he causes you to feel angry, but let’s think this through. For example, I often facilitate groups as a therapist
and at some point in almost every group, I catch someone yawning. Now, it is certainly possible that the
person is finding what I have to say boring, and if I think this is the case I’ll feel pretty disappointed that
I couldn’t keep their attention. I might even think that makes me a pretty bad therapist and I might start to
feel quite anxious as I anticipate the next yawn. But before I jump to that conclusion I’m wondering if there
might be any other way I could interpret the yawn?
CLIENT: Well, I suppose it could be that the person didn’t sleep too well and they are tired?
THERAPIST: Yes, I see that might be a possibility. Are there any other ways I could interpret the yawn?
CLIENT: Um, well, perhaps the room is a bit stuffy and they are gasping for some air?
THERAPIST: Actually, yes, you are right. The rooms in this building do get quite stuffy, particularly when we
run groups. So, now I have three different interpretations of the exact same situation. One will make me
feel bad (I’m a boring therapist), whereas the other two have nothing to do with me. What do you make
of this?
CLIENT: Well, I guess you don’t really know why the person yawned. And if you interpret it as a sign that you
are doing something wrong, you’ll feel pretty bad about it.
THERAPIST: Exactly. And if I think about it in a different way so that the yawn has nothing to do with me?
CLIENT: Well, you’ll feel ok.
THERAPIST: Right. So is it the situation – the yawn – or the way I think about it, that determines how I feel?
CLIENT: The way you think about it seems more important.
THERAPIST: Yes, I agree with you. My feelings are not so much prompted by the person’s yawn in the
group – it is what I am thinking about that yawn that plays a far bigger role in my feelings. So, what does
this mean for when you said, “my husband makes me feel angry”.
CLIENT: Well, it really seems like he does make me feel angry. And I think some of the things he does would
make most people feel angry. But, I guess what you’re saying is that the way I think about his behaviour will
determine how I feel and how angry I get.

Here the clinician has used an emotionally benign example for the client to draw out the
principle that thoughts determine feelings, and then Socratically encouraged the client to
generalize from that example to her own situation.
Whether one uses a simple direct explanation or a Socratic approach, it is important
to avoid jargon. Our rule of thumb is that if any word of phrase needs an explanation,
then you are better to deliver the explanation than to use the word. That is, if you need to
tell the client what “cognitive” means, why use the word in the first place? Sometimes it
will be useful to teach clients names and phrases to facilitate communication, but the
main goal is therapy not education about therapy and so we suggest keeping jargon to a
minimum. A second point is to try to make the rationale memorable. Since the rationale
is a key point in therapy, you want to do everything you can to help the client focus on it
 Chapter 6: Treating Clients 111

and remember it. One way to do this is to Socratically elicit the information above and
“guide the client’s discovery”, so that the client generates the answers themselves.
Another way is to use a memorable metaphor/illustration. Sometimes the client will
have already given you an illustration (e.g., a client with panic disorder and agoraphobia
might have said, “as I stood in the queue at the supermarket I started to worry that
I might not be able to get out in case of a panic and then whoosh, there was the panic”) or
you might choose a metaphor based around a client’s interest. One example might be as
follows:
THERAPIST: Let me try to show you what I mean about thoughts causing feelings. The other day I was driving
along like normal and feeling fine. All of a sudden I caught sight of a police speed camera by the side of the
road and I thought “did I just see it flash?” I quickly braked; I felt panicky; my heart started to beat fast and
my hands got sweaty; I began to worry that I’d have to pay a fine and I didn’t have the money. Then
I realized that the camera hadn’t flashed and so I hadn’t been caught. A wave of relief swept over me and
I drove on comfortably.

You can then discuss with the client what caused your emotional reactions, by asking if
the speed camera had caused your emotional response (e.g., “how did the speed camera
sitting by the side of the road cause my heart rate to increase?”) and what causes the
changes in emotions (e.g., “how did the unchanging speed camera cause both anxiety and
relief”?). Sometimes starting with these illustrations can be difficult, if the client responds
by indicating that their emotional problems are different to the example given. Usually,
however, they can help clients to see clearly relationships that can be obscured when they
try to reflect upon event–emotion sequences that have been occurring for a long time or
when the emotions are very intense. Thus, beginning to develop a suite of rationales is a
good therapeutic skill.
When presenting a cognitive rationale, clients may object to the ideas and it is wise to
tackle these head on. For example, clients may say that it is their distressing feelings that
they want help with and that their thoughts don’t bother them. One way to respond to
this is to ask them to imagine a distressing situation and see if it elicits an emotional
response. If so, then you can respond that it shows how turning one’s thoughts to a
distressing memory can trigger this kind of emotional response. To bring runaway
emotions under control, therapy is therefore trying to tackle those thoughts and replace
them with more helpful thoughts that do not trigger the same distressing feelings.
Another objection clients may raise is that you are asking them to deny reality. One
response is to indicate that, to the contrary, the goal is to ensure that our assumptions are
as accurate and reality-based as possible (e.g., is it the case that the actions of others or
events in the world can cause my feelings?). Sometimes clients will respond that they
must express their feelings and that cognitive therapy is about denying these feelings and
their expression. A possible response to these concerns is to highlight that once you have
a feeling it may be useful to express it, because indeed emotions provide us with
important information (e.g., anxiety helps us to respond to genuine threat, anger helps
us to identify when our boundaries may have been breached). The therapist could then
explain that cognitive therapy involves a process that allows the client to explore if the
feeling followed an accurate interpretation of the situation and therefore whether the
client needed to have the feeling (or one of that intensity) in the first place.
Clients might also claim that thoughts happen too quickly or automatically/uncon-
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has English as their first language and so is aware of the impact of tense on pronunci-
ation). Write on a piece of paper, “a pen without ink is no use” and ask the client to read
the sentence aloud. Then write, “I prefer to use a pen that works” and ask the client to do
the same. When the client has said these two sentences, ask them why they pronounced
the word “use” differently. Some clients will recall enough grammar to explain why, but
most will respond that they “just knew it from the context”, but we have not found a
client who will attest to having consciously articulated the grammatical rules to decide
between possible pronunciations. This allows you to illustrate that there are rules/beliefs
that we have learned and we can infer their current operation from our behaviour, but
they may be so practiced that they no longer need to be articulated. Having made this
point, the client can be asked; just because it has been that way does it always have to be
that way? At this juncture, examples of learning to drive and then travelling to a country
where the practice is to drive on the opposite side of the road may be useful. Although
driving on one side of the road was learned and became automatic, nonetheless it is
reversible with effort and concentration. Finally, clients later on in cognitive therapy may
indicate that they believe the rationale intellectually, but not emotionally. One way to
address these concerns is to reframe “believing intellectually” as an initial sceptical belief.
It reflects an openness to be convinced by the evidence and therefore the client can be
encouraged to take the cognitive rationale and “try it on for size” or “borrow the belief
for a while and see what happens.” Thus, the issue becomes an empirical question that
client and therapist work on together. As the client starts to “act as if” the beliefs are true,
feelings typically become more closely aligned. Behaviour often needs to change before
beliefs and emotions change.
In summary, cognitive therapies focus attention on modifying psychological prob-
lems by identifying and then working with the client to modify thoughts and beliefs that
are postulated to intervene between the activating event and the problem emotion or
behaviour. More recently, cognitive therapies have started to move away from a focus on
the content of cognitions and towards the underlying cognitive processes. For example,
Wells (2009) emphasizes the role that metacognitions play in selecting cognitive pro-
cesses which in turn can influence cognitive content. In a similar vein, Hayes and
colleagues (Hayes, 2019; Hayes, Strosahl & Wilson, 2011; Hayes & Strosahl, 2004;
Zhang et al., 2018) in their Acceptance and Commitment Therapy (ACT) focus on the
cognitive processes clients use when responding to unwanted thoughts and emotions,
and suggest replacing avoidance with an attitude of acceptance.

Interpersonal Psychotherapy (IPT)

In contrast to the focus of behavioural and cognitive therapies, interpersonal psy-
chotherapies emphasize different factors in treatment. Interpersonal psychotherapies
have been found to be efficacious for depression, eating disorders, and some personality
disorders (e.g., Cuijpers et al., 2011; Gunlicks-Stoessel & Weissman, 2011; Rieger et al.,
2010), although it remains unclear for whom IPT is a superior alternative to other
treatments (Bernecker et al., 2017).
An Interpersonal Psychotherapy (IPT; Weissman et al., 2017) approach conceptual-
izes treatment as falling into three phases, with treatment mechanisms specific to each
phase (Lipsitz & Markowitz, 2013). The present discussion will focus on the middle
phase, in which problem areas are selected and treatment is engaged in, and the
termination phase.
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During the middle phase, the clinical psychologist using IPT will (i) facilitate a
discussion of topics that are relevant to the problem area, (ii) maximize self-disclosure
by fostering a strong therapeutic relationship and identifying topics which heighten the
client’s affective state during therapy, (iii) and ensure the smooth passage of the client
through therapy by identifying therapy-interfering behaviours. A session of IPT will
often begin by asking the client, “Where should we focus today?” This contrasts with
CBT, where the direction of treatment is more often managed by the therapist in line
with a chosen course of treatment components that map onto a problem list and
associated treatment plan. In IPT, the client chooses the topic for discussion and can
change focus from a previous session. One particularly good point about this opening is
that it gives a client license to bring up previously unmentioned problems, however, the
novice clinical psychologist needs to be cautious at this point because you run the risk of
having therapy “hijacked” by clients who skip between topics without resolving any issue.
Notwithstanding, once the focus of the session has been decided upon, the therapist
will move through four developmental stages in therapy. First, the clinical psychologist
will explore the problem area. Second, the therapist will focus on the client’s expectations
and perceptions, then analyse alternative ways to handle the problem area. Third, the
therapist work with the client to initiate new behaviours.
For example, one problem area in IPT is an abnormal grief reaction, for which the
first stage of problem exploration could involve an analysis of points at which a client
fails to move through the grieving process or in which the mourning process has become
distorted (e.g., depression in the absence of sadness), delayed (e.g., when grief is experi-
enced long after a loss), or prolonged. The perceptions and expectations could be
explored by a discussion of the client’s life with their loved one and their life in the
present. This discussion will move into treatment, which will aim to facilitate the
mourning process and help the client re-establish interests and develop new relationships
to meet the interpersonal needs that have been unmet since the loved one’s death. The
particular strategies that could be used include a non-judgemental elicitation and explor-
ation of feelings by encouraging the client to consider the loss, to discuss events
surrounding the loss and the consequences of those events, with a view to bringing out
any associated feelings. Often clients need reassurance that grief is not a sign of abnor-
mality and therefore a discussion of both the typical grief process (and the variability
therein) can be beneficial to facilitate the client discussing, experiencing and “owning”
the distressing feelings. During IPT, a clinical psychologist might try to shift a client
from the death per se, because a fixation on the death as such can lead to avoidance of
some of the complexities within the relationships with the deceased. By discussing both
the factual details of the dead person and the client’s affective experiences to the dead
person (both when alive and in the present context), it may be possible to move through
some of the negative feelings feared and avoided by the client. In so doing, the client will
be able to identify a new formulation of the relationship and understand the memories of
the dead person that incorporate both the strengths and the weaknesses of the relation-
ship. As treatment moves into behavioural change, the clinical psychologist will seek to
help the client to become more open to developing new relationships and, in this way,
the therapist can lead the client to consider new and different ways of re-engaging with
people.
A second problem area of focus in IPT is interpersonal role disputes, where the client
and another person significant to them have non-reciprocal expectations about the
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conduct of a relationship or the roles therein. For instance, a married couple may have a
dispute about the work–family balance of each partner. The clinical psychologist begins
by trying to identify the chief issues and clarify the nature of any dispute by highlighting
differences in expectations and values between the client and their significant others.
This will also entail considering both the client’s wishes about the relationship and the
options and resources available to them. In addition, it is worthwhile spending time
searching for patterns in behaviours (e.g., has the same issue appeared in previous
relationships or does the same conflict manifest in a variety of presentations?) and, if
they exist, exploring the possible reasons. Moving to consider new ways to handle the
issues, it can be useful to focus on avoidance of confrontation and an unwillingness to
express negative feelings. If these unassertive behaviours are occurring, then treatment
can involve assisting clients to devise strategies for managing the disputes and resolving
differences.
A third target of IPT is role transitions, in which a person has moved from one social
role to another (e.g., promotion, marriage, childbirth). Since people who do not cope
adequately with transitions are at risk of developing depression, treatment will try to
enable a client to view their new role in a more positive manner. By exploring both the
(usually forgotten) negative as well as the positive aspects of a previous role, it may be
possible to develop a more balanced view of the present circumstances while simultan-
eously working to restore the client’s self-esteem. In terms of new behaviours, IPT will
encourage the client to initiate new relationships in their new role. This will require an
assessment of the client’s social skills to determine the degree to which previously
successful social skills may generalize to the new context and if new skills are required.
Since some of the difficulties with role transitions arise because there is a loss of familiar
social supports and attachments (often accompanied by a reduction in self-esteem to the
extent that it was bound up in the previous role), and because there are demands for new
social skills, the therapist should address these deficits (Webber & Fendt-Newlin, 2017).
Once identified, the clinical psychologist will try to put the lost role in perspective by
evaluating the activities and attachments that were given up, and by using the processes
in IPT, such as encouragement of the expression of affect and training of required social
skills, to help the client establish a new system of social support.
Finally, IPT will focus on interpersonal deficits. These are targeted when it is
apparent that a client lacks the skills for initiating or sustaining relationships. These
deficits may be observable in the therapeutic sessions or from a review of the client’s life.
Since interpersonal skill deficits remove a person from a major source of enjoyment, a
major goal of the treatment is to reduce any social isolation. Maladaptive patterns in
previous relationships will be sought and, if identified, the clinical psychologist will
discuss with the client negative and positive feelings associated with these relationships.
At this point the clinician may explore with the client the feelings about the therapist and
the therapeutic relationship, with the aim of using this relationship as a model for other
relationships. That is, the therapeutic relationship can be used to help clients learn
interpersonal skills which they can then apply outside therapy.
In summary, IPT focuses treatment upon the interpersonal difficulties that may cause
the presenting problem or may arise from it. In so doing, the treatment seeks to reduce
the presenting problem by addressing issues that may cause or exacerbate the client’s
difficulties.
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Delivering Evidence-Based Treatments

Having described some of the basics of Behaviour Therapy, Cognitive Therapy and
Interpersonal Psychotherapy, it is worth bearing in mind that no psychotherapy can be
completely captured in a description of its components. This is not to say that compon-
ents cannot be isolated, manualized and even automated using computerized technolo-
gies (Andrews et al., 2018; Tate & Zabinski, 2003), but the ability to deliver the treatment
in a manner that connects with the client is a critical skill. Therefore, we will provide two
detailed examples of particular treatments, illustrating how they might be presented to a
client. We present these not as scripts to follow, but as illustrations of how a treatment
may be delivered to a particular client. Putting this another way, the manualization of
psychological treatments has facilitated the dissemination and reproduction of treat-
ments in the same way that musical annotation facilitated the dissemination of music.
However, in the same way that a skilled musician interprets the notes or arranges a piece
for different instrumentation, a skilled clinical psychologist will modify and adapt
treatments so that they meet a client’s needs. One example is graded exposure for a
phobic anxiety and the second is relaxation.

Example: Exposure to Feared Stimuli

Exposure to feared stimuli is a broadly applicable treatment (Andrews et al., 2003) that
has a strong empirical foundation. However, while the efficacy of exposure is not in
question, the mechanism whereby the beneficial effects are brought about is not as clear
as once thought. Procedurally, confronting a feared stimulus in the absence of aversive
consequences parallels extinction as it involves the repeated presentation of a
Conditioned Stimulus (CS) in the absence of the Unconditioned Stimulus (US), with
the end result that a new contingency is learned. However, the procedure also parallels
that of habituation and counterconditioning. For example, in systematic desensitization
counterconditioning occurs as a client is first taught relaxation training so that they are
able to elicit the relaxation response rapidly and effectively. Once this skill has been
taught, the client is taught to construct anxiety hierarchies so that feared stimuli are
organized into a “step ladder” of fear. For example, a 100-point “fear thermometer” is
used to help clients rank feared situations and stimuli in terms of the amount of fear
elicited. Exposure (often in imagination) is then conducted, beginning with the least fear-
provoking and during stimulus presentation the client is encouraged to relax, with the
goal being that relaxation functions as a competing response inhibiting anxiety. If
anxiety begins to escalate, exposure is terminated or reduced until relaxation dominates
over anxiety. At this point exposure is recommenced. However, in contrast to counter-
conditioning, exposure is also effective when conducted in vivo without the buffering of
anxiety and when high levels of anxiety are elicited (i.e., flooding). Further, a client needs
to confront a feared stimulus, yet in some circumstances distraction from the stimulus
appears to enhance the anxiety reduction both within (Johnstone & Page, 2004; Penfold &
Page, 1999) and between (Oliver & Page, 2002) sessions. The variety of procedures
(e.g., imagination versus in vivo; distracters present versus absent) and differences in
the intensity of anxiety (e.g., systematic desensitization versus flooding) present difficul-
ties for many different theories of anxiety (see Barlow, 1988; Craske, 1999, 2003).
However, for a scientist-practitioner these differences are non-trivial, because a good
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conceptual understanding of the mechanisms whereby an intervention brings about its

clinical effects is essential to good clinical practice. Without a strong theoretical founda-
tion it is unclear how to apply a treatment under conditions that differ from a “textbook”
situation, what factors to consider when a client does not respond as expected and when
clients present with a complex mix of different problems.
One theory that can accommodate the variety of situations within which exposure is
effective is the more pragmatic approach typified by Barlow’s (1988; Bullis et al., 2014)
essential targets for change. Barlow first suggests that exposure should address action
tendencies. Anxiety primarily involves action tendencies that are typified by vigilance, or
a chronic state of readiness to respond. Consequently, exposure treatment should aim to
modify these action tendencies by encouraging approach rather than avoidance. Second,
Barlow identifies that a key belief structure/meaning proposition in anxiety appears to be
the perception of a lack of control. Exposure exerts its effect in part by enhancing
perceived control. Thus, during successful exposure and in combination with anxiety
management strategies, clients learn that they have increased control over the feared
objects and situations themselves as well as the anxiety response. Finally, Barlow identi-
fies self-focused attention as a critical variable. Anxiety is associated with self-focused
attention in general and a self-evaluation in particular. Barlow cites evidence that clients
fail to exhibit reductions in anxiety when they are in a self-evaluative mode, but that
reduction of anxiety is greatest when attention is focused on the external and non-
emotional aspects of the environment. Thus, exposure should aim to do more than
simply confront a person with the feared stimulus. The treatment should also aim to
change outcome expectancies, which it could do through successful experiences of
confronting feared stimuli and situations.
These principles are consistent with an inhibitory learning approach to exposure,
which suggests that the mechanism of exposure is through the development of new, non-
fear associations rather than the “un-learning” of old fearful associations (Craske et al.,
2014). The idea is that maximizing the “expectancy violation”, that is the difference
between what the client expects to occur and what actually occurs with respect to the
frequency and intensity of aversive outcomes, during an exposure task will lead to more
powerful new learning that will effectively “compete with” the old fearful associations. In
addition to maximizing the expectancy violation, examples of additional approaches to
strengthen new learning include deepened extinction (i.e., testing feared situations
separately and then combining them), occasionally reinforced extinction (e.g., encour-
aging people with social anxiety occasionally to intentionally draw negative attention),
removal of safety signals (i.e., cues or behaviours that signal safety, such as having a
mobile phone and medication handy for someone with panic disorder) and conducting
exposure in a variety of contexts (see Craske et al., 2014 for more examples). From an
inhibitory learning approach, the priority is optimizing the strength of the new learning
rather than habituation or anxiety reduction within a session (see Abramowitz & Arch,
2014; Arch & Abramowitz, 2015 for examples of applying inhibitory learning within the
context of obsessive compulsive disorder).
With these principles in mind, it is possible to examine some questions about the
conduct of exposure to feared stimuli. A first question is, how much anxiety should be
permitted? Although grading exposure does not appear to be essential, graded exposure
is preferable because it tends to have lower dropout rates than flooding. A second
question is, how similar to the feared situation or original trauma does exposure need
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to be? In general the closer the exposure situation resembles the actual situation, the
greater the anxiety-reducing effects will be (Andrews et al., 2003). This is important to
remember when using imaginal exposure, but it also needs to be borne in mind that
although in vivo is generally superior to imaginal exposure, better imaginers improved
more with imaginal exposure (Dyckman & Cowan, 1978; Mertens, Krypotos &
Engelhard, 2020; Saulsman, Ji & McEvoy, 2019). Further, imaginal exposure is excellent
for “filling in steps” that aren’t possible in real life (e.g., having a plane take off for one
metre and land again) or undesirable or impractical to replicate (e.g., a trauma), but
effect size of the transfer from imagination to real life is only around 50 per cent. A third
issue concerns the temporal parameters of exposure. Broadly speaking, the more fre-
quent and the closer the sessions, the stronger the treatment effect, and longer sessions
(i.e., until anxiety reduces to around 10–20 per cent) appear better than shorter ones.
These factors allow anxiety to reduce and the person’s expectations and beliefs to change
as they come to feel in greater control of their anxiety.
We will now illustrate how a therapist may present a rationale for exposure to a client
and then proceed to introduce exposure hierarchies.
THERAPIST: A universal truth about anxiety is that avoidance makes fears worse. This is the case because
first, anxiety is unpleasant, second, avoiding fear-provoking situations or activities stops anxiety, and third,
escaping when anxiety is rising brings enormous relief.
CLIENT: It sure does. Getting away from spiders is the best thing I can do.
THERAPIST: In the short-term avoiding is the most sensible thing to do, but what have been the longer-term
effects?
CLIENT: I’ve just got more fearful and had to avoid not only spiders, but places where they might be.
THERAPIST: And what happens when you escape or avoid these places?
CLIENT: I feel relief.
THERAPIST: That relief is a problem because, in the short-term, avoidance and escape give you a sense of
control over your anxiety but in the long-term you spend more and more time organizing your life to avoid
what you fear. In this way fear spreads throughout your life. Phobic avoidance develops a little like a child’s
tantrum to get something to eat when out shopping. When the candies come into view, the child throws a
tantrum. To a frustrated parent, the candies provide a simple solution to stop the noise and
embarrassment. The problem is that the next time the parent ventures into the supermarket, a tantrum is
even more likely. Avoiding or escaping from what you fear is like giving a kid a candy to stop a tantrum.
Every time that you flee before your anxiety subsides, you make it more likely that you will be anxious the
next time.
CLIENT: But I’ve tried to face my fears, but it hasn’t worked.
THERAPIST: A common mistake made by people trying to manage fears is to progress too quickly. Their
anxiety reaches very high levels and never goes down until the person runs away from the frightening
situation. Is this what happened to you?
CLIENT: It almost sounds like you were there! But I’ve tried so hard and it hasn’t worked.
THERAPIST: Putting in so much effort and not seeing any benefit can be very demoralizing. For that reason
we are going to carefully monitor your anxiety to make sure that we can tell what we are doing is working
and if it isn’t, we can re-think our strategy. What I am going to suggest is that we try a different way and
face your fears gradually. To face your fears step-by-step, you first must clearly identify what you want to
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achieve. Your goal may be to go somewhere or do something that you presently find frightening.
Remember, a goal is something to strive towards; don’t worry if you can’t achieve it yet. Later you’ll be able
to break it down into easier steps. Let’s try to write down a goal.
CLIENT: Well, I’d like to be able to walk into my house like a normal person and not have to check each room
for spiders before I can feel comfortable.
THERAPIST: OK, let’s try to break this goal into smaller, easier steps. Each step must be specific and we’ll try
to build a “step ladder” so that we begin with steps that cause little fear and anxiety and work up to
something that is quite scary.
CLIENT: Well I could begin by standing outside a room, but not going in.
THERAPIST: How much anxiety on our fear thermometer would that cause?
CLIENT: About 10 out of 100.
THERAPIST: OK, that sounds like a good place to be, what might be a little more fear-provoking for the next
step. Say around 20?

The client and therapist then continue to work out the hierarchy.
THERAPIST: Now we’ve got the anxiety stepladder, let’s get some guidelines in place for when we start to face
these fears. First, it is important that you to agree that you are going to do everything you can not to leave
because of fear. Only leave once your anxiety has begun to decline. You will become panicky and fearful,
but you can use the anxiety management techniques we’ve covered to control it.
CLIENT: Is this absolutely necessary?
THERAPIST: Good question. I wouldn’t want to do such a difficult thing without believing that it could be
helpful to me. What do you think?
CLIENT: I guess I need to do it, because otherwise I’ll keep reinforcing the anxiety through relief.
THERAPIST: Yes, that’s right. I know it’s going to be difficult, but this is the most powerful way to break the
cycle. The next guideline will be that you will repeat each step until your predictions have been directly
challenged, and your confidence has increased enough for you to attempt the next step. For example, your
prediction might be that “a spider will chase you and bite you”. The task will be to put yourself in a position
that will allow you to test these fears directly in as many different situations as possible. One possibility is
that your fears will come true, so it will feel risky to test this out. Another possibility is that in fact no matter
how many times you approach spiders they are more afraid of you than you are of them, so they try to
escape and are not at all interested in biting you. I’ll work with you to make sure that you don’t go too
quickly or too slowly, but facing your fears and testing your predictions regularly and systematically can be
very effective for reducing them.
CLIENT: If that’s the only way.
THERAPIST: I know it will be hard, so don’t forget that after each attempt you reward yourself. No one else
understands how frightening your steps are for you, so praise yourself or give yourself a treat whenever you
face your fear and your anxiety decreases. Let’s spend a minute or two reflecting on what your life might be
like if you find out that spiders tend to run away from you and, even if they don’t, they aren’t interested in
biting you. Imagine if you discovered this to the point where you were convinced that this new belief was
true. What would that be like?
CLIENT: It would be a huge relief. My phobia wouldn’t rule my life anymore. I’d feel a sense of freedom and
confidence. OK, I think I’m ready.
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THERAPIST: Before we start, there is one last thing to mention and this is an important point to remember.
When people start to face their fears, they sometimes feel as though they are getting worse before they feel
better. Their anxiety feels stronger and their ability to control it weaker. This experience is not only normal;
it is a signal that you are beating your anxiety. Your anxiety is behaving like the child in the supermarket
who screams to get a candy. The more you say “No”, the louder your anxiety will scream to make you give
in. Expect a tantrum – and we’ll work together to manage it without avoiding or escaping.

Evidence-Supported Transdiagnostic Interventions

Most treatments shown to be effective for a particular clinical problem are then trialled
on additional disorders. In fact, CBT and IPT were both initially developed for depres-
sion before being applied to other clinical problems. DBT skills are also often used for
enhancing emotion regulation skills more broadly than only for people with borderline
personality disorder. Treatment principles across a range of disorder-specific treatments
are “transdiagnostic” in the sense that they are effective for multiple disorders. Hence,
some clinical researchers have developed interventions designed to target broader
dimensions of psychological problems rather than only symptoms linked to specific
disorders. The breadth of disorders targeted by different transdiagnostic interventions
varies, from all emotional disorders to more specific subsets or classes of disorders (e.g.,
anxiety disorders only). We will now review some treatment approaches that were
explicitly designed to be transdiagnostic.

Targeting Negative Affect

One transdiagnostic treatment approach has been to target higher-order dimensions that
are common across anxiety disorders, or across both anxiety and depressive disorders,
such as negative affectivity (Brown, Chorpita & Barlow, 1998; Paulus et al., 2015).
Negative affectivity (NA) is a temperamental predisposition to respond to negative
stimuli with negative emotions (Barlow et al., 2014). Treatments targeting NA aim to
reduce the frequency and intensity of negative emotions in general, and therefore can be
applied to a range of emotional disorders.
Barlow and colleagues’ (2011) unified protocol is one example of a transdiagnostic
treatment that aims to down-regulate negative emotions that reflect underlying NA. This
is done through increasing emotion awareness and acceptance, modifying emotion-
driven actions (e.g., reducing safety behaviours), reducing emotional avoidance, increas-
ing cognitive flexibility and reappraisal skills, enhancing motivation and relapse preven-
tion (Barlow, Allen & Choate, 2004; Sauer-Zavala et al., 2012; Wilamowska et al., 2010).
Treatment strategies cover five core modules, including emotional awareness training,
understanding how thoughts can influence emotional experiences, learning how to
identify behaviours associated with the avoidance of emotional responses, increasing
awareness and tolerance of physical sensations, and confronting strong emotions
through interoceptive and situation-based emotion-focused exposures. The potential
advantage of this approach is that clients with multiple diagnoses may only need to
complete one treatment as they learn to generalize the treatment principles across their
clinical problems. For instance, if they learn the functions of anxiety and depression, how
their responses to these emotional experiences will impact on the trajectory of these
emotions, and that they can manage, tolerate and accept the emotions as they continue to
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approach their valued goals, then the frequency, intensity and duration of negative affect
should reduce and quality of life should improve.
The unified protocol has been shown to be helpful for people with comorbid
principal anxiety disorders (Farchione et al., 2012), depression (Boswell, Anderson &
Barlow, 2014), and bipolar disorder with comorbid anxiety (Ellard et al., 2012). Within
mixed-diagnosis and comorbid samples, the unified protocol has demonstrated positive
effects on the common higher-order constructs of negative and positive affect, symptoms
of primary and comorbid disorders and the symptom clusters of anxiety and depression
(Bullis et al., 2014; Ellard et al., 2012; Farchione et al., 2012).
Norton’s (2012) 12-session transdiagnostic CBT protocol was developed for mixed-
anxiety disorder samples (not depression) and proposes that the functional relationships
between cognitions (e.g., exaggerated threat perceptions), behaviours (e.g., avoidance),
and threat-based emotions (e.g., anxiety and fear) are essentially the same across anxiety
disorders. Techniques are tailored to client’s specific fears, but common components that
everyone receives include psychoeducation, self-monitoring of negative cognitions and
affect, cognitive restructuring of threat-related beliefs, exposure to feared situations and
symptoms, and response prevention (i.e., reducing use of safety and avoidance behav-
iours). Through these methods, clients learn how to manage negative emotional experi-
ences in more flexible and adaptive ways and reduce the temperamental vulnerability to
future negative affect. Trials of this transdiagnostic group protocol using mixed-
diagnosis samples have demonstrated superiority over waitlist controls (Norton, Hayes &
Hope, 2004; Norton & Hope, 2005), large reductions in anxiety symptoms (d = 1.06;
Norton, 2008), and no differences in outcomes from transdiagnostic compared to
diagnosis-specific treatments or relaxation (Norton & Barrera, 2012). Patients with comor-
bidities also improved at a similar rate to those without comorbidities, and two-thirds of
patients who had a comorbid disorder at pre-treatment no longer did post-treatment
(Norton et al., 2013; see Norton & Paulus, 2016, for a detailed review).
Transdiagnostic internet-based CBT (iCBT) has also been increasingly used to teach
skills for managing negative affect. For example, Titov and colleagues (2010) developed
an iCBT protocol with the most recent version comprising five lessons over eight weeks
(e.g., Dear et al., 2016). Core lessons include (1) psychoeducation about anxiety, depres-
sion and the relationships between thoughts, feelings and behaviours; (2) cognitive
restructuring; (3) management of physical symptoms of hyperarousal and pleasant
activity scheduling; (4) avoidance and safety behaviour reduction strategies and (5)
relapse prevention. Additional resources help with commonly co-occurring issues and
complement the core skills, such as sleep management, mental health emergencies,
structured problem-solving, worry time and assertiveness. The transdiagnostic iCBT
protocol provided information and examples applicable to a variety of disorder symp-
toms rather than to any particular primary disorder.
Trials of transdiagnostic iCBT have also been promising, with small to large between-
groups effect sizes compared to waitlist controls on general measures of anxiety, depres-
sion, disability (Johnston et al., 2011; Titov et al., 2010) and comorbid disorders
(Johnston Titov et al., 2013). In a series of four large RCTs, transdiagnostic iCBT for
emotional disorders was directly compared to diagnosis-specific protocols for symptoms
of panic disorder (N = 145), GAD (N = 338), social anxiety disorder (N = 233),
and depression (N = 290; Dear et al., 2015, 2016; Fogliati et al., 2016; Titov et al.,
2015). Transdiagnostic iCBT was consistently found to be as effective as diagnosis-
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specific iCBT up to 24-month follow-ups on the higher-order construct of neuroticism

and also on disorder-specific and comorbid symptom measures.

Intolerance of Uncertainty and Anxiety Sensitivity

NA explains a substantial proportion of common variance across the emotional dis-
orders but it cannot fully explain the differences between disorders, so some researchers
have developed treatments that target second-order factors that are theoretically more
closely related to specific disorders than NA (i.e., NA is assumed to have an indirect
effect on mental disorders via these “second-order” factors; Nolen-Hoeksema & Watkins,
2011; Paulus et al., 2015). Two examples of these second-order constructs are intolerance
of uncertainty (Freeston et al., 1994) and anxiety sensitivity (Reiss & McNally, 1985).
While these factors were initially conceptualized as disorder-specific vulnerability
factors, and evidence suggests they are differentially associated with different anxiety
disorders (Hong & Cheung, 2016; Olatunji & Wolitzky-Taylor, 2009; Paulus et al., 2015),
they nonetheless appear to be associated with multiple anxiety disorders (e.g., McEvoy
et al., 2019). Transdiagnostic treatments have therefore been developed to target these
second-order factors.
Intolerance of uncertainty therapy aims to assist patients “recognise, accept, and deal
with uncertain situations” (Dugas et al., 2003, p. 822). This treatment also involves
challenging positive beliefs about worry (e.g., “my worries help me get things done”)
to illustrate that worry is an unhelpful strategy, while structured problem-solving is
taught as a more helpful strategy even when an outcome is uncertain. Patients are also
repeatedly exposed to threatening and uncertain descriptions of their fears with a
habituation rationale. For example, a client who overplans and overcontrols weekend
activities for her children to ensure that everything “goes to plan” and “nothing bad
happens” might be encouraged to ask her partner to list a range of activities (that are
unknown to the client) numbered from 1 to 6 and then place these in envelopes. The
homework task will be to roll a die just before leaving the house and for her to engage in
the activity in the corresponding envelope. The client needs to then tolerate her uncer-
tainty about being unprepared for the activity and the possibility that something bad will
happen. Through activities such as this, the client is encouraged to pursue the goal of
increasing her tolerance of uncertainty instead of the unattainable goal of certainty.
Most evidence for intolerance of uncertainty treatment derives from studies of GAD
(Dugas et al., 2003; van der Heiden, Muris & van der Molen, 2012), although a limited
number of studies have investigated associations between intolerance of uncertainty
and symptoms in transdiagnostic treatments within mixed-diagnosis samples (e.g.,
Boswell et al., 2013).
Anxiety sensitivity has been defined as fear of physical symptoms due to the belief
that they lead to adverse consequences, and has traditionally been conceptualized as a
risk factor for panic disorder (Reiss & McNally, 1985). Transdiagnostic CBT targeting
anxiety sensitivity has been applied to anxiety disorders more broadly and focuses on
modifying catastrophic misappraisals of bodily sensations through cognitive restructur-
ing and interoceptive exposure, whereby the patient is repeatedly exposed to physical
sensations in the absence of catastrophic outcomes. For example, Olthuis et al. (2014)
evaluated a transdiagnostic CBT protocol targeting anxiety sensitivity in a treatment-
seeking sample. Although participants were selected based on elevated anxiety sensitivity
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(rather than diagnostic profile), 41 per cent of the sample had one disorder, 29 per cent
had two disorders, and 14 per cent had 3 disorders (84 per cent had at least one disorder).
The most common anxiety disorder diagnoses were panic disorder/agoraphobia (40 per
cent), generalized anxiety disorder (35 per cent), and social anxiety disorder (28 per
cent), and the most common mood disorder diagnosis was major depressive disorder
(15 per cent). Compared to waitlist controls, the treatment successfully reduced anxiety
sensitivity and comorbid diagnoses, as well as diagnosis-specific symptoms. Moreover,
changes in anxiety sensitivity mediated changes in the symptom measures. Larger effects
were observed for panic than social phobia and PTSD, and the intervention failed to
improve symptoms of depression or GAD. The authors speculated that interoceptive
exposure may not have influenced the cognitive component of anxiety sensitivity, and
anxiety sensitivity may simply be less relevant to depression and GAD. The transdiag-
nostic anxiety sensitivity intervention had larger effects on anxiety sensitivity than on
neuroticism, the effect on anxiety sensitivity remained after controlling for neuroticism,
and the significant mediation effects remained significant for panic and social phobia
(but not PTSD) after controlling for neuroticism. The authors argued that their findings
support targeting AS in particular, at least for individuals with high anxiety sensitivity,
rather than neuroticism more broadly.

Avoidance and Safety Behaviours

Other transdiagnostic approaches to anxiety disorders emphasise behavioural processes,
such as false safety behaviour elimination therapy (F-SET; Riccardi, Korte & Schmidt,
2017; Schmidt et al., 2012). Safety behaviours can maintain anxiety by (a) preventing
disconfirmation of the perceived threat, (b) promoting preoccupation with the perceived
threat, (c) misattributing threat non-occurrence to the use of the safety behaviour, and
(d) eliciting the feared consequence and thus becoming self-fulfilling prophecies (e.g.,
being quiet in social situations to prevent negative evaluation leading to the appearance
of arrogance (Clark & Wells, 1995; Salkovskis, Clark & Gelder, 1996). Safety behaviours
may differ across diagnoses (e.g., carrying medication in panic disorder vs wearing
makeup to cover blushing for social anxiety disorder), but their function is the
same across the disorders (i.e., threat avoidance). Safety behaviours interfere with the
elicitation of fear and the provision of corrective information (Foa & Kozak, 1986;
Schmidt et al., 2012). F-SET therefore aims to facilitate optimal emotional processing
by reducing safety behaviours, enabling activation of fear networks and disconfirming
perceived threats.
F-SET consists of five, 50-minute individual (Riccardi et al., 2017) or 10, 120 minute
group (Schmidt et al., 2012) weekly sessions. Sessions include introducing clients to the
cognitive-behavioural model of anxiety with a focus on how safety behaviours prevent
corrective information being obtained. Clients are also introduced to the concept of
“antiphobic” activities that encourage the patient to behave in the way opposite to how
anxiety is motivating them. For example, in the case of social anxiety, a client who feels
the urge to isolate themselves in the corner of a pub might be encouraged to engage in
the antiphobic behaviour of walking up to someone and introducing themselves. F-SET
teaches cognitive reappraisal skills and involves repeated exposure to feared stimuli,
which are techniques common to most CBT protocols. Different to diagnosis-specific
CBT protocols, F-SET teaches these skills within the context of the broader principles of
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reducing safety behaviours and engaging in antiphobic activities across principal and
comorbid anxiety disorders. For example, a client with panic disorder and social anxiety
might be encouraged to leave her benzodiazepine medication at home (drop safety
behaviour) while travelling on a train (antiphobic) to address her fear of panic attacks
on public transport, as well as wear some red makeup on her cheeks (drop safety
behaviour of covering up any redness with makeup) while approaching strangers for
directions (antiphobic). The client therefore learns to identify safety behaviours in a
range of situations related to different fears and the common concept of “doing the
opposite” of what the anxiety is encouraging her to do as a way of challenging her fears.
Compared to waitlist controls, F-SET has been associated with significant and large
improvements in avoidance, depression, anxiety sensitivity, disability and clinician-rated
severity (ds = 0.79–1.55), which were maintained at six-month follow-up (ds = 0.88–1.55,
Schmidt et al., 2012). Most patients experienced reliable and clinically significant change,
and patients receiving F-SET reported greater improvements than controls for all three
diagnostic groups. These findings suggest that F-SET is associated with significant
improvements in symptoms regardless of principal diagnoses at least for the three
disorder groups included in the study. Unfortunately, Schmidt et al. (2012) did not
measure avoidance and use of safety behaviours, therefore evidence could not be
provided that the proposed primary mechanism of change was in fact associated with
symptom change.
Riccardi et al. (2017) recently evaluated a briefer version of F-SET delivered indi-
vidually in a mixed-diagnosis sample (panic disorder with or without agoraphobia, social
anxiety disorder, GAD). Compared to a waitlist control condition, F-SET demonstrated
superiority and large effects on anxiety symptoms, avoidance of anxiety-provoking
situations, functional impairment, clinician-rated severity and depression up to one-
month follow-up. In addition, consistent with the hypothesized mechanism, a significant
indirect effect of treatment condition (waitlist vs F-SET) on symptom reduction via
reduced avoidance strategies was found. These findings suggest that reducing avoidance
is important across anxiety disorders, which is a core component in most evidence-
supported treatments.

Emotion Regulation
Emotion regulation models also take a transdiagnostic approach to anxiety and affective
disorders. The process model of emotion regulation (Gross, 1998, 2007) describes four
sequential stages along a temporal dimension (see Figure 6.2, Valuation System 1:
Emotion generation), including the situation stage (what situation is the person in?),
attention stage (where is their attention deployed?), appraisal stage (are the stimuli good
or bad with respect to my goals?). If stimuli are appraised as being meaningful with
respect to the individual’s goals, then a response can be triggered that comprises
experiential, behavioural and physiological components. Gross (1998) argued that emo-
tions can be regulated at each of these stages prior to full emotional activation by using
situation selection (e.g., selecting a kind vs critical friend for emotional support),
situation modification (e.g., selecting a seat next to the most supportive friend), atten-
tional deployment (e.g., focusing on the pleasure derived from spending time with
friends who genuinely care rather than ruminating about a relationship breakdown),
or cognitive change (e.g., reappraising a relationship breakdown as not meaning that “I
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124 Chapter 6: Treating Clients

Valuation system 1: Situation

Emotion generation Attention
Appraisal
Response

Situation
Valuation system 2: “emotion”
Emotion valuation Attention
Appraisal
Response

Figure 6.2 An illustration of Gross’s (2015) extended process model of emotion regulation.

am unlovable” and “I will find someone else I prefer”). Response modulation occurs after
an emotion has been fully activated and may be maladaptive and exacerbate emotional
distress, such as suppression, or more adaptive and reduce emotional distress, such as
observing emotions in a non-judgmental way.
Gross’s (2015) extended process model distinguishes between first-level and second-
level valuation systems, whereby the first-level systems described in the modal model of
emotion generate the emotional response, and the second-level systems evaluate the
emotional response (see Figure 6.2, Valuation System 2: Emotion Valuation). In this
second-level system, the individual’s emotions become the “situation”, which may
become the focus of their attention, lead to appraisals, and then responses to modify
and therefore regulate the trajectory of the emotion. Fernandez, Jazaieri and Gross
(2016) have recently argued that the emotion regulation perspective may provide a
unifying framework for transdiagnostic factors in psychopathology.
Studies have attempted to identify adaptive and maladaptive emotion regulation
strategies using Gross’s (2007) process theory as a framework. Webb, Miles and
Sheeran (2012) conducted a meta-analysis of 306 experimental comparisons (across
190 studies) testing the effectiveness of strategies derived from the process model of
emotion regulation. These researchers reviewed studies using a taxonomy of emotion
regulation strategies divided into attention deployment strategies (distraction, concen-
tration), cognitive change (reappraisal) and response modulation (emotional suppres-
sion, expressive suppression) to control conditions. Within each of these strategies,
several subtypes were further delineated (e.g., reappraising emotional response,
reappraising emotional stimulus, reappraise via perspective taking). Cognitive change
strategies were found to have small-to-medium effect sizes, which were larger than
attentional deployment (distraction or concentration). Response modulation yielded null
or small effects on emotional responses. Gross’s (2007) process model and the taxonomy
developed by Webb et al. (2012) therefore provide a transdiagnostic framework for
understanding and investigating the complex relationships between different emotion
regulation strategies and the processes of emotion generation and modulation.
 Chapter 6: Treating Clients 125

The model provides guidance for clinicians about points of intervention in both the
emotion generation phase (as described above), but also after an emotion has been
generated. The degree to which a client focuses their attention on the emotion, their
appraisal of these emotions with respect to their desired state (e.g., “I can’t cope”, “my
emotions will overwhelm me”), and their responses (i.e., attempts to modify and regulate
their emotion via avoidance or more adaptive strategies) may all serve to up-regulate or
down-regulate the client’s emotions. Clients may benefit from learning to understand
their emotional reactions, how to flexibly increase or decrease their attentional focus on
their emotional state, how to challenge unhelpful appraisals about emotions and how to
learn adaptive ways of regulating emotions that are less likely to escalate them an instead
allow them to be processed in helpful ways.

Metacognitive Therapy
The majority of published work on Metacognitive Therapy is informed by Wells and
Matthews’s (1996) metacognitive model of emotional disorders. In brief, they propose a
Self-Regulatory Executive Functioning (S-REF) model of emotion that is formed of three
levels. Intrusions into awareness are managed by metacognitive procedures, which are in
turn informed by stored metacognitive beliefs. These beliefs specify how intrusions
including thoughts, feelings and impulses enter awareness, and are appraised and
regulated. Within the context of GAD, for example, positive metacognitive beliefs (e.g.,
worry is helpful for preventing negative events) increases engagement in worry, while
negative metacognitive beliefs (e.g., worry is uncontrollable) can result in dysfunctional
attempts at overcontrol, which backfire and increase worry and distress. The model was
originally applied to worry within GAD, but has since been applied to a range of
emotional disorders (Wells, 1997, 2009; Wells et al., 2020). Metacognitive therapy
involves building a shared formulation of metacognitive beliefs that are maintaining
distress, and engaging in a range of techniques to challenge these. For example, for the
belief that “my worry is uncontrollable” (negative metacognitive belief ), the therapist
may Socratically explore the veracity of this belief by enquiring about when and how the
client has attempted to control their worrying in the past. Clients will often explain that
they have either not really tried to disengage from their worry or, when they have, they
tend to try and suppress or “chase” their worry. The therapist might then explain the
difference between suppression and “detached mindfulness”, where the latter is more
about observing worries without engaging with them emotionally. Therapists might then
encouraged clients to set a worry time each day (e.g., 7–7.15 p.m.), during which they can
freely engage with their worries. During the day, they are to postpone their worries until
their worry time. Clients can monitor the degree to which they worry each day and their
emotional state, along with their success at postponing and their need to engage with
worries at the planned worry time. Clients often discover that (a) they are able to
postpone their worries at least to some degree, (b) they therefore do have some control
over the degree to which they engage in their worry and (c) they often no longer need to
worry during their worry time as they are no longer concerned about the issue at hand.
Positive beliefs about worry (e.g., “worry keeps my children safe”) can then be tested by
monitoring outcomes on “worry up” (worry as much as you like) and “worry down”
(postpone worry) days. If the client observes that bad things are not more likely on worry
down days, then this undermines the perceived value of engaging with worry. Exercises
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126 Chapter 6: Treating Clients

in detached mindfulness and attentional training are used to increase cognitive flexibility
and ability to disengage from to intrusions.
Several MCT outcome studies have been published with transdiagnostic samples.
Nordahl (2009) examined the effects of MCT in a small transdiagnostic sample in
primary care. Mental health patients with comorbid diagnoses were randomly allocated
to cognitive behavioural therapy (N = 13) or metacognitive therapy (N = 15). Patients in
the MCT arm showed similar drops in depression and greater drops in anxiety than the
CBT arm, in addition to showing greater reductions in the mediating mechanism of
MCT as assessed by self-reported “meta-worry” (worry about worry). In a recent
uncontrolled study of a modified MCT protocol that targeted metacognitive beliefs in
groups with primary and non-primary GAD, MCT was associated with large effect sizes
on repetitive negative thinking, anxiety and depression, and that changes in negative
metacognitive beliefs were associated with changes in symptoms (McEvoy et al., 2015a,
2015b).

A Note on Integrating Disorder-Specific and Transdiagnostic Approaches

The clinical psychology trainee needs to be familiar with diagnosis-specific and trans-
diagnostic approaches to treating mental disorders. We encourage trainees to pay close
attention to the commonalities in the rationale, principles and treatment strategies across
these interventions. Although they may use slightly different language to describe the
processes and procedures, in practice there are probably more commonalities than
differences. Blending treatment components from different models and approaches
(a modular approach) to target mechanisms in a clinical case formulation is a pragmatic
solution to treating people rather than disorders – the nomothetic information (diagno-
sis, theory) guides the clinician’s assessment, case formulation and treatment planning.
However, where one diagnosis or theory is inadequate to capture the complexity of a
client’s presentation, a clinical psychology trainee needs to have sufficient knowledge of
different models to ensure that the formulation adequately explains the depth and
breadth of an individual’s presenting problems. Once the formulation has been
developed, the clinician needs to decide whether it is likely to be most effective and
efficient to (a) deliver a disorder-specific treatment, (b) a treatment based on more than
one model of the client’s principal disorder, (c) a blended treatment based on models of
the client’s principal and comorbid disorders or (d) a treatment explicitly designed to be
transdiagnostic. The clinical psychology trainee should be guided by the evidence for
these different approaches, as well as client and clinician preference when there are
multiple evidence-supported choices.

Summary
In conclusion, clinical psychologists have an array of psychotherapies that have an
evidence-base for a variety of conditions. However, there are psychological problems
for which empirical support is still lacking and there are no doubt psychotherapies that
do not yet have “empirical support” which will in time be so identified. Thus, as a
scientist-practitioner it is important to be familiar with evidence-based treatments, and
to continually evaluate the psychological literature to identify and become familiar with
new treatments as they become supported. Behaviour Therapy (and variants such as
Dialectical Behaviour Therapy) (Linehan, 1993a and b), Cognitive Therapies,
 Chapter 6: Treating Clients 127

Interpersonal Psychotherapy (IPT) (Klerman et al., 1984), and transdiagnostic

approaches (e.g., Barlow et al., 2011; Norton, 2012) represent some current treatments
it is important to be familiar with; however, it is one thing to use an efficacious
treatment, but another to be an effective clinician. Thus, even when using treatments
with a known efficacy, it is necessary to evaluate the effectiveness in your setting by
measuring and monitoring the progress of clients in therapy. Furthermore, with pres-
sures to make treatment not only effective but also efficient, there has been an increasing
awareness that brief and less intense interventions are valuable treatment options
supported by a growing evidence base. Therefore, we will now turn to consider the
delivery of brief interventions and then low-intensity psychological interventions.

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 Brief Interventions
Chapter

7
It is likely that demand for health care will always outstrip supply. Stepped-care
approaches provide a partial solution by aiming to detect health problems at an early
stage and offering efficient, less costly, low intensity interventions before problems
become more complex and less tractable. Known as the prevention paradox
(Kreitman, 1986; Spurling & Vinson, 2005), more problems can be averted by interven-
ing with a large number of people at low risk than with a small number of people who are
already at high levels of risk. Brief interventions target people with health-compromising
behaviours at the lower end of the risk spectrum who are not formally seeking help, but
are offered the intervention opportunistically whenever they present to health profes-
sionals, including psychologists.

Brief Interventions for Alcohol

Here, as an example with a strong evidence base, we focus on brief interventions for
alcohol use. The aim of these interventions is to raise awareness of alcohol-related risk
and reduce hazardous and harmful drinking behaviour. There are at least two reasons
why clinical psychology trainees need to develop competencies in brief interventions for
alcohol. First, many patients when presenting to the clinician focus on their primary
presenting symptoms (e.g., depression or anxiety) and may not mention alcohol use or
any associated problems. The brief intervention protocol allows the clinician in just a few
minutes to conduct a formal screening for potentially risky alcohol use and – if
indicated – provide personalized advice to motivate the client to do something about
it. Unidentified alcohol use problems can otherwise hinder therapy progress with the
primary presenting problems. Second, the motivational interviewing principles and
strategies that often complement the brief feedback and advice are universally applicable
in all types of interventions (brief or intense) aimed at positive behaviour change.
Brief interventions for alcohol address four levels of alcohol risk as identified by the
Alcohol Use Disorders Identification Test (AUDIT; Babor et al., 2001). Education and
positive reinforcement is provided to individuals at low risk, including abstainers. Simple
advice including personalized feedback and information about strategies to reduce
drinking and avoid hazardous drinking is provided to those identified as risky drinkers.
This is often combined with brief counselling and motivational interviewing especially
for those at higher levels of risk. Finally, those at the highest, possibly dependent, level of
risk are strongly encouraged to seek specialist help.
The effectiveness of brief interventions at reducing alcohol-related problems is well
established especially in primary health care (Kaner et al., 2018; O’Donnell et al., 2014),

128
 Chapter 7: Brief Interventions 129

Client data Brief screening

Theoretical and Clinical training &

empirical literature Experience

Assessment &
Assessment & feedback & advice
Case Formulation
5–10 min
Treatment Planning
Initiation of change/treatment
& Measurement
5–10 min
Treatment Implementation
Motivational interviewing
& Monitoring

Evaluation &
accountability

Figure 7.1 Adapting clinical psychology practice for brief interventions.

but also in university, school and community settings (Bray et al., 2017; Carey et al.,
2012). However, the evidence to date does not support the effectiveness of brief inter-
ventions for drinkers in the dependent range who will require specialist care and more
intense monitoring and support (Saitz, 2010). Nonetheless, as it is inevitable that
excessive drinkers at the dependence end of the spectrum will be identified though
routine screening, the brief intervention contact can be used to encourage the person
to consider and accept a specialist referral.
Figure 7.1 shows that the client data to inform the brief intervention is gathered via a
brief screening instrument. A copy of the AUDIT adapted for Australian standard drinks
is shown in Figure 7.2 (a copy of a version used in the UK can be found in Kaner,
Newbury-Birch & Heather, 2009). In brief interventions, assessment information is
limited and targeted. It is not used to inform a comprehensive case formulation, but
the screening score is used to immediately provide feedback following guidelines for a
given risk category, and offer advice on how to act on that feedback. If a person is willing,
this can flow on into a brief motivational interviewing segment to increase the likelihood
that a person initiates behaviour change by following the strategies listed in a brochure
handed out during the intervention, or if possible dependence is identified by accepting
specialist referral information. These interventions typically last between 5 and 25
minutes (O’Donnell et al., 2014), and the key steps in the intervention are based on
the “5 As” model – Ask, Assess, Advise, Assist, and Arrange.
1. Persons are asked if they would be willing to fill out a short questionnaire and discuss
their drinking.
2. Their drinking (and risk of alcohol-related harm) is assessed using the Alcohol Use
Disorders Identification Test (AUDIT).
3. Persons are advised about the meaning of their AUDIT score, the likely
consequences of their drinking pattern and provided with simple strategies for
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130 Chapter 7: Brief Interventions

Drink check AUDIT

Number of standard drinks in common beverages

1 Average Premix
1 middy of 1 Can or Premix spirit High strength
1 Pint of full restaurant 1 shot of spirits
full strength stubbie of full can (7%) spirits
strength beer serve of wine spirits full strength
beer strength beer full strength bottle or can
(568ml) or champagne (30ml) (5%)
(285ml) (375ml) 375 / 440ml 330 / 660ml
(150ml) 330 / 600ml

1 2 1.4 1.5 1 1.3 / 2.6 1.5 / 1.7 1.8 / 3.6

Please circle the response that best fits your drinking.

Scoring system Your
Questions
0 1 2 3 4 Score

1. How often do you have a drink containing Monthly 2 - 4 times 2 - 3 times 4+ times
Never
alcohol? or less per month per week per week

2. How many standard drinks do you have on a

1 or 2 3 or 4 5 or 6 7–9 10 or more
typical day when you are drinking?

3. How often do you have 6 or more standard Less than Daily or

Never Monthly Weekly
drinks on one occasion? monthly almost daily

4. How often during the last year have you found

Less than Daily or
that you were not able to stop drinking once Never Monthly Weekly
monthly almost daily
you had started?

5. How often during the last year have you failed

Less than Daily or
to do what was normally expected from you Never Monthly Weekly
monthly almost daily
because of your drinking?
6. How often during the last year have you
needed an alcoholic drink in the morning to Less than Daily or
Never Monthly Weekly
get yourself going after a heavy drinking monthly almost daily
session?

7. How often during the last year have you had a Less than Daily or
Never Monthly Weekly
feeling of guilt or remorse after drinking? monthly almost daily

8. How often during the last year have you been

Less than Daily or
unable to remember what happened the night Never Monthly Weekly
monthly almost daily
before because you had been drinking?

Yes, but
9. Have you or somebody else been injured as a Yes, during
No not in the
result of your drinking? the last year
last year

10. Has a relative or friend, doctor or other health Yes, but

Yes, during
worker been concerned about your drinking or No not in the
the last year
suggested that you cut down? last year

Total

Figure 7.2 A Drink check audit.

 Chapter 7: Brief Interventions 131

modifying their drinking (if necessary). A structured information brochure is

typically used to facilitate this feedback (for an example see Kaner et al., 2009).
4. Persons who drink at levels considered to be risky or very risky are encouraged to
discuss their motivation for change. The aim of this motivational interviewing
segment is to assist persons to increase their motivation to change.
5. Persons with AUDIT scores that suggest dependence on alcohol are helped to
arrange a referral or follow-up with a specialist health professional.
The structure of the brief intervention using the “5 As” is shown in the flowchart in
Figure 7.3. We next explain each step of the intervention in detail. This training protocol
was developed in collaboration between our clinical psychology training programme at
the University of Western Australia and our university’s health promotion unit and
medical centre. Volunteer student peer counsellors, clinical psychology trainees and
interested student services staff undergo training in a half-day workshop, followed by
supervised experience in the delivery of brief interventions to the campus community.

Step 1: ASK – Begin the AUDIT

The first step in the intervention is to ASK the student if he/she is interested in
completing an alcohol use questionnaire.
Would you like some feedback about your current drinking levels?

If the student says “yes”:

Great. I’ll get you to fill out this form. I’ll then be able to provide you with some feedback on your
drinking.

Responding to Students Who Say They Do Not Drink

If the student responds that he/she does not drink, then ask question 1 from the AUDIT to
clarify this.
 If the student never drinks, do not complete the full AUDIT (i.e., skip Step 2)
 Then provide the student with some feedback and positive reinforcement about their
decision not to drink, referring to Step 3a (Feedback for low risk drinkers).
 If the student drinks occasionally, then complete the AUDIT as usual.

Step 2: ASSESS – Complete and score the AUDIT

Once the student has agreed to complete the AUDIT, you are ready to assess how risky
the student’s drinking pattern is.
Now I’ll ask you to fill in this questionnaire called the AUDIT, which will only take a minute or two.
It was developed by the World Health Organization and is extensively used worldwide. Some of the
questions ask about standard drinks. There’s some information at the top of the form that will help
you work out how many standard drinks you normally have each time you drink. What do you drink
most often?

As an example, the student may answer that he or she usually drinks beer. Use this to
point out the number of standard drinks in the student’s usual alcoholic drink.
Ok, well you can see here that there’s 1 standard drink in a middy, 1.4 standard drinks in a can, and
2 standard drinks in a pint. https://avxhm.se/blogs/hill0
use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/9781108611350.007
Downloaded from https://www.cambridge.org/core. Southern Cross University, on 27 Apr 2022 at 17:16:50, subject to the Cambridge Core terms

132 Flow Chart for Brief Alcohol Intervenon

A
Would you like to complete a quesonnaire on drinking?
S
K

I don’t drink Yes No thanks

A
S Screening by AUDIT
S
E
S Low risk Risky (score 8-15) OR Possible dependence
S (score 0-7) Very risky (score 16-19) (score 20-40)

Feedback and simple advice Feedback and simple advice (2 min) Brief simple advice
emphasising benefits
(alcohol educaon/posive of referral, with an
reinforcement; 2 min) offer of details for
Do you have a bit more me to talk about whether you’d like to make
any changes to your drinking and how you might go about doing that? specialist assessment
(2 min)
A A
D S Yes No Not accepted Accepted
V & S
I I
Motivational interview focused
S S Could we discuss your concerns
on reducing alcohol use (10 min) about a referral a lile more?
T

Yes No

Motivational interview
focused on referral (10 min)
A Referral
R Referral Provide
not referral
R accepted accepted
A card for
N specialist
G assessment/
Provide individual with self-help booklet and details on further advice and informaon treatment
E

Figure 7.3 Flowchart for brief alcohol intervention.

 Chapter 7: Brief Interventions 133

Once the student has completed the AUDIT, you need to work out his/her total score.
Thanks for filling this in. I’ll add up your score now and give you some feedback about your results.

Troubleshooting
If a student says he or she drinks a beverage that is not featured at the top of the AUDIT,
you can refer to the Standard Drink Chart. This chart contains a wider range of drinks
than listed on the AUDIT – use this to work out how many standard drinks the student
typically consumes.

After calculating the AUDIT score, determine the category into which the student’s score
falls (low risk, risky, very risky or possible dependence).

Scoring Procedure for the AUDIT

 The response to each item is scored from 0 to 4, according to the number at the top of
the response column.
 Write this number into the column titled “Your Score”.
 Sum the scores for each response to give a total score and write this at the bottom of
the page next to “Total”.
 Determine which drinking category the total score falls into.
: Scores of 0–7 are categorized as “low risk”.
: Scores of 8–15 are categorized as “risky”.
: Scores of 16–19 are categorized as “very risky”.
: Scores of 20–40 are categorized as “possible alcohol dependence”.

Step 3: ADVISE and ASSIST – Give feedback about the AUDIT score
After scoring the AUDIT, you need to ADVISE and ASSIST the student by:
 providing feedback about his/her AUDIT score
 where necessary, providing simple advice about how to reduce alcohol consumption.
During this step you should use the Drink Check Brochure to guide the discussion.
This step should take 2 minutes or less to complete.
The intervention will progress differently depending on the student’s AUDIT
score.
(a) If the student scores in the low risk range, provide feedback, simple advice and
positive reinforcement.
b) If the student scores in the risky or very risky range, provide feedback and simple
advice and encourage the student to participate in a brief individualized discussion
about their drinking, using motivational interviewing.
(c) If the student scores in the possible dependence range, provide feedback and simple
advice that focuses on the importance of seeking a referral for further assistance and
advice about drinking. If the student is resistant to this idea, encourage him/her to
participate in a brief discussion about referral using motivational interviewing, with
the intention of encouraging the student to take up the referral.
These steps are now describedhttps://avxhm.se/blogs/hill0
in detail, according to the AUDIT score.
134 Chapter 7: Brief Interventions

STEP 3a: Feedback for Low-Risk Drinkers (score 0–7)

The main goal of feedback with low-risk drinkers is to provide positive reinforcement
and encouragement for them to continue drinking at safe levels. You need to:
 Tell the student that their level of drinking falls in the low-risk range.
 Point out that, like them, most UWA students are low-risk drinkers.
 Reinforce the benefits of low-risk drinking.
 Encourage the student to continue drinking at a low risk level.

Steps in Detail
Write the student’s score on the beer glass on the How Risky is
My Drinking? section of the Drink Check Brochure.
Your AUDIT score is X.

Point to the graph titled What is everyone else like?

Congratulations, this means that you’re drinking at a low- risk level.
About 53 per cent of UWA students are also low-risk drinkers.

Point to the What does your score mean? section

of the brochure.
Compared with students who drink at risky levels,
you’re likely to feel better, study more effectively, and
are unlikely to suffer from health problems. Basically,
drinking is unlikely to have a negative impact on your
life.
Motion to the relevant parts of the brochure as
necessary.
This brochure also provides information for those students who are drinking at more risky levels, with
suggestions on how to cut down and support services available on campus should you or someone you
know ever need them.

Provide encouragement.
I’ll leave the brochure with you. Keep up the low-risk drinking! Enjoy the rest of your day.
 Chapter 7: Brief Interventions 135

STEP 3b: Feedback for Risky (Score 8–15) and Very Risky
(Score 16–19) Drinkers
For students with an AUDIT score in the risky or very risky range:
 Tell the student that his/her score falls in the risky or very risky range.
 Point out that most UWA students are low-risk drinkers.
 Point out the negative consequences of risky/high-risk drinking
 Point out the potential benefits of reduced drinking.
 Show the student the list of drinking targets.
 Advise the student about where he/she can access further information
and support.

Steps in Detail

Important
As you work through the Drink Check Brochure with risky, very risky and dependent
drinkers, it is important to try and engage the student in conversation, rather than talking
at them.

Write the student’s score on the beer glass on the How Risky is
My Drinking? section of the Drink Check Brochure.
Your AUDIT score is X.

Point to the graph titled What is everyone else like?

This is in the risky/very risky category. About 32 per cent/13 per cent of
UWA students fall into this category. Most UWA students are low-risk
drinkers. Does that surprise you?

Point to the What does your score mean? section of the

brochure.
If you continue to drink at your current level,
you may experience some negative effects,
like poor judgement and decision-making,
hangovers, and health problems. Have any of
these things been a problem for you?https://avxhm.se/blogs/hill0
136 Chapter 7: Brief Interventions

Point to the section titled Drinking Targets.

This shows Australian drinking guidelines to help
avoid alcohol related problems. It’s recommended
that people should have no more than 2 standard
drinks a day on average, with no more than
4 drinks at a time, and should have at least
2 alcohol free days each week.

Motion to the section titled Benefits of

Reducing Your Drinking.
If you reduce how much you drink you’ll experience
some of the benefits listed here, like having more
money and energy, and you’ll be less likely to
experience health problems.

Motion to the Ways to Cut Down section.

If you want to reduce your drinking then there are
some strategies listed here that other students have
found helpful, such as drinking more slowly and
having water in between drinks. Are there any
things that you already do to try to slow down
your drinking?
Motion to the Further Information section of
the brochure.
You could visit or telephone these centers if you’d like
more information.
Give the student the brochure to keep, and seek
permission to undertake the Motivational
Interview.
If you have a few more minutes I’d like to talk to you
about whether you’d like to make any changes to your
drinking and how you might do that. Is that ok?

If the student declines, give them the Self-Help

Booklet to take away.
That’s fine. I’ll give you this to take away – you could use it to help you decide whether changing your
drinking pattern is something you’d like to do. Enjoy the rest of your day.
If the student consents, move on to the fourth A – Assist (i.e., conduct a Motivational
Interview). This is discussed below; but first we show how to give feedback to someone in
the possibly dependent range.
 Chapter 7: Brief Interventions 137

STEP 3c: Feedback for Drinkers Who Are Possibly Dependent

(score 20–40)
For students with an AUDIT score in the Dependent range
 Tell the student that his/her score falls in the very risky range, and that a score above
20 usually indicates alcohol dependence.
 Point out that most UWA students are low-risk drinkers.
 Point out the negative consequences of high-risk drinking.
 Point out the potential benefits of reduced drinking.
 Show the student the list of drinking targets.
 Show the student the contact details for further support.
 Encourage the student to make an appointment with a health professional.

Steps in Detail
Write the student’s score on the beer glass on the How Risky is My
Drinking section of the Drink Check Brochure.
Your AUDIT score is X

Point to the graph titled What is everyone else like?

This is in the very risky category. As you can see here, most UWA students
are low-risk drinkers. About 13 per cent of UWA students are like
you, which is a high-risk drinker. However, not many students score over
20 – only around 6 per cent. A score of 20 or more suggests you might be
experiencing alcohol dependence. Do you know what that means?

Encourage the student to talk to you. If necessary, give the

following explanation of dependence:
Dependence means that your alcohol use can cause a lot of problems but you might feel like you can’t,
or don’t know how to, reduce how much you drink.

Point to the What does your score

mean? section of the brochure – dis-
cuss both the “risky” and “very
risky” sections.
If you continue to drink at your current level, you’re likely to experience some negative effects, like
poor judgement and decision-making,https://avxhm.se/blogs/hill0
hangovers, conflicts with friends and family and you’ll be at
risk of serious health problems. Do any of these things concern you?
138 Chapter 7: Brief Interventions

Motion to the section titled Benefits of

Reducing Your Drinking.
If you reduced how much you drink you
might experience some of the benefits listed
here, like having more money and energy,
and you’ll be less likely to experience health
problems.

Point to the section titled Drinking Targets.

This shows Australian drinking guidelines to help
avoid alcohol related problems. It’s recommended
that people should have no more than 2 standard
drinks each day on average, with no more than
4 drinks at a time, and at least 2 alcohol free days
each week.

Motion to Ways to Cut Down

section.
There are some strategies listed here
that other students have found helped
them reduce their drinking. However,
because your AUDIT score was in the dependent range, it might be helpful for you to speak with a
health professional like a GP or alcohol counsellor about your drinking, rather than trying to follow
these strategies on your own. What do you think about that idea?

Motion to the Further Information

section of brochure.
There is more information here about where you
can get help on campus, as well as telephone
lines and internet sites you might find helpful.
 Chapter 7: Brief Interventions 139

Provide students who have expressed an

interest in getting professional help with a
copy of the referral card.
The number on this card is for a person who
regularly talks with students about their drinking.
All you need to do is telephone and make an
appointment. Do you have any other questions? . . .
Ok, well thanks for your time today and I hope
things go well when you speak with (whoever is on
the referral card).
For students who indicate that they are unsure whether they want to make an appoint-
ment, ask if they are willing to discuss this further.
I understand that you’re not sure what you want to do from here – many people feel the same way.
Can we talk a bit more about your concerns?

Next, move onto the Motivational Interview.

Step 4: ASSIST and ARRANGE – Motivational Interviewing

(and Referral if Indicated)
The broad aims of the final step in the intervention are to:
 ASSIST students by increasing their motivation to change their drinking pattern
 ARRANGE for the student to seek professional help (if this appears necessary).
These aims are achieved by conducting a brief Motivational Interview with the student.
Because our protocol was designed for trainee psychologists at the beginning of their
practical training, and for health promotion volunteers to administer peer-delivered brief
interventions, we also designed a flip chart to guide both the interviewer and interviewee
through this more challenging part of the intervention. This step of the intervention is
only conducted with students whose AUDIT scores are in the risky, very risky or
dependent drinking ranges (i.e., scores of 8–40). The focus of the intervention differs
depending on whether the student’s AUDIT score is in the risky/very risky range (8–19),
or in the dependent range (20–40).
Step 4a) For students with AUDIT scores between 8 and 19, the motivational interview
should focus on increasing the student’s motivation to reduce their
alcohol consumption.
Step 4b) For students with AUDIT scores between 20 and 40, the motivational
interview should focus on increasing the student’s motivation to seek help from a
health professional.

The Motivational Interviewing Stance

When you are conducting a motivational interview, you should try to keep the following
things in mind.

Be Empathic
 Try to put yourself in the shoes of the student. Show a respect for and a genuine
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interest in the student’s concerns and views.
140 Chapter 7: Brief Interventions

Be Non-Judgmental
 Don’t fall into the trap of negatively judging students who are drinking at risky levels,
or who are ambivalent about change. Remember that change is difficult. Your job is to
support the student by increasing their motivation to change. Ambivalence can be an
important first step towards change.

Use Summary and Reflective Statements

 Try to summarize and reflect back to the student the things they say to you. For
example, if they tell you a list of negative things about drinking, repeat these back to
them. For example, you might say, “It sounds like some of the things you dislike about
drinking are x, y and z”.

Develop Discrepancy
 Try to point out contradictions in the student’s current behaviour (e.g., drinking
excessively). For example, the student may say they enjoy drinking but it may be
causing them lots of problems. For example, you could say, “So, on the one hand there
are things you like about drinking, but on the other hand there are things about
drinking that you don’t like, such as. . .”

Enhance Self-Efficacy
 Try to build the student’s sense of confidence that they can reduce their drinking. This
is achieved by equipping them with strategies they can use to reduce their drinking, as
well as by providing encouragement.

STEP 4a: Assisting Risky or Very Risky Drinkers (AUDIT scores 8–19)
 The interview should focus on
encouraging the student to
reduce their alcohol
consumption.
 Use the flip chart to guide
the interview.
 The same information covered
in the flip chart and interview is
in the Self-Help Booklet, which
the student will take away after
the interview.

Steps in Detail
Work through each page of the Flip Chart.
Start with the Thinking about Drinking 1 exercise in the flip chart.
The aim of this exercise is for the student to consider and contrast the positive and
negative consequences of their drinking, and to increase their motivation to change.
People often feel unsure whether they want to make changes. This is understandable, since there are
positive and negative aspects to every decision. Thinking about these positive and negative aspects might
help you to clarify how you feel about drinking. First, we’ll focus on your current drinking patterns.
Tell me some of the benefits that drinking has for you.
 Chapter 7: Brief Interventions 141

What are some things that aren’t so good about your drinking at the moment?
Some extra prompting questions about the negative aspects of drinking might be:
What dont you like about xx?
How does xx affect you?

Use a double-sided reflection to summarize what the student has said to you.
So on the one hand you like drinking because . . . On the other hand, there are things about drinking
that you don’t like, such as. . .
Turn to Thinking About Drinking 2 and discuss the positives and negatives of reduced
drinking.
Now, imagine that you decide to reduce your drinking. What do you think would be some of the likely
benefits of reducing your drinking?
OK, what would be some of the negatives of reducing your drinking?
Use the examples in the Drink Check brochure to prompt discussion of the benefits of
reducing drinking if need be.
Again, use a double-sided reflection to summarize what the student has said.
It sounds as though it would be worthwhile for you to reduce your drinking because . . . but some
barriers to you deciding to reduce your drinking would be that. . .
Now move onto the page titled – Are You Ready to Change? 1. Ask the student to rate how
important changing their drinking is, and how confident they are that they can change.
Write their answers on the back of the AUDIT.
Now that we’ve talked about the pros and cons of reducing how much you drink or keeping things as
they are now, how important to you is reducing your drinking, on this scale that goes from 0, for not
at all important, to 10, for very important.

Summarize the student’s response. This may help him/her to elaborate upon it.
Ok, you feel that it’s not at all/somewhat/moderately/highly important to reduce your drinking.

If the student picks a low number on the scale, (e.g., 1 or 2), you could say:
It seems that changing your drinking isn’t something you think is very important at the moment.

If the student picks a moderate number on the scale (e.g., 4, 5, 6), you might say:

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142 Chapter 7: Brief Interventions

Changing your drinking is somewhat important to you, but you’re not fully convinced it’s something
you want to do at the moment.
If the student picks a high number on the scale (e.g., 8 or 9), you could say:
So, reducing your drinking is very important to you.
Then ask the student how confident they are that they can reduce their drinking, using
the scale provided. Don’t forget to write their response on the back of the AUDIT.
How confident are you that you could reduce your drinking, if you decided to?
Summarize the student’s response, for example:
Ok, you feel not at all/somewhat/moderately/very confident that you could reduce your drinking if
you decided to.

Then turn to Are You Ready to Change? 2.

Discuss the similarity or difference between the student’s perceived importance of
change and their confidence in their ability to change.
Example response to a student who feels that change is not important:
So although you’re confident that you could change if you wanted to, you don’t feel that change is
very important at the moment. On the other hand you were telling me before that drinking has . . .
(list negatives of current drinking). Can you tell me a bit more about how important, or unimportant,
you feel it is to change your drinking?
Example response to a student who does not feel confident that they can reduce their drinking:
So although reducing your drinking is very important to you, you don’t feel very confident that you’ll
be able to do it. What makes you feel like that?

Move on to the Plan to Reduce Your Drinking 1 section of the flip chart. The aim of this
exercise is to encourage the student to verbalize the main reason(s) for and benefits of
reducing their drinking.
It sounds as though you’d like to make some changes to your drinking.
OR

It sounds as though you’re not wanting to

make changes to your drinking at the
moment, but perhaps you can just imagine
that you’re wanting to change your drinking.

Talk to the student about why they

might want to reduce their drinking.
What are your top 3 reasons for wanting to reduce your drinking?

Reflect and validate the student’s response.

You’re saying that you want to reduce your drinking because . . . They sound like really important reasons.

Ask the student to imagine what would change with reduce drinking.
Can you tell me a bit about how your life might be different if you do reduce your drinking?
Reflect the response.
 Chapter 7: Brief Interventions 143

So if you reduce your drinking you expect that . . .

Turn the flip chart to Plan to Reduce My Drinking 2. The aim of this exercise is to
clarify the student’s drinking goals and develop strategies for meeting the goals.
A good way to make something happen
is to make a plan. This increases the
chances that you’ll be successful. First,
let’s think about what sort of drinking
pattern you’d like to have.
How many days each week do you want
to drink?
How many drinks would you like to have each day?
What is the highest number of drinks you want to have at any one time?

Summarize and reflect the student’s response, and compare them with the Australian
guidelines for healthy drinking.
So you think it would be realistic for you to have __ drinks on __ days each week.

This matches well with the Australian guidelines for healthy drinking.
OR
This is higher than the Australian guidelines, but seems like it would have a lot of benefits compared
with how you’re drinking at the moment.
Turn to Plan to Reduce my Drinking 3.
Discuss strategies for meeting the student’s
goals, dealing with lapses and rewards.
Do you have any ideas about some strategies you
could use to help you meet your drinking goals?
Those are great suggestions that should help
reduce how much you drink. It is common for
students who are trying to drink less to
sometimes slip up and drink more than they had
planned. If that happens to you, what will you do to make sure
you don’t slip back into old habits?
Some people find giving themselves a reward for sticking to
their goals helps motivate them to keep sticking to their
goals. Would this be helpful for you? What rewards would you
give yourself?
Finally, give the student a copy of the Self-Help
Booklet, thank them for their participation and encour-
age them to reduce their drinking.
Thanks for talking to me today. I’ll give you this handout to
keep, which covers everything we just talked about. It might be
helpful if you filled it in, particularly the plan, and put it in a
place where you’ll see it regularly, like on your fridge or next to
https://avxhm.se/blogs/hill0
your bed. Thanks again for talking to me today, and good luck
in reducing your drinking. Enjoy the rest of your day.
144 Chapter 7: Brief Interventions

STEP 4b: Assisting Possibly Dependent Drinkers (AUDIT scores 20–40)

 The interview should focus on encouraging the student to seek professional help to
reduce their alcohol consumption.
 Use the flip chart to guide the interview.
 The same information covered in the flip chart and interview is in the Self-Help
Booklet, which the student will take away after the interview.

Steps in Detail
You will have just said something along the lines of:
I understand that you’re not sure what you want to do from here – many people feel the same way.
Can we talk a bit more about your concerns about your drinking and about making a more formal
appointment?
If the student consents, work through the flip chart.
Start with the Thinking about Drinking 1 page.
The goal is for the student to think about the negative consequences of their drinking,
in order to increase their motivation to seek professional help.
People often feel unsure whether they want to make changes. This is understandable, since
there are positive and negative aspects to every decision. Thinking about these positive and
negative aspects might help you to clarify how you feel about drinking. What are some things that
you like about drinking? What are some things that you don’t like about your drinking at the
moment?
Use a double-sided reflection to summarize what the student has said to you.
So on the one hand you like drinking because . . . On the other hand, there are things about drinking
that you don’t like, such as . . .”
Now turn to Thinking About Drinking 2 and discuss the pros and cons of reduced
drinking.
Now, imagine that you decide to reduce your drinking. What do you think would be some of the likely
benefits of reducing your drinking?
OK, what would be some of the negatives of reducing your drinking?
Use the examples in the Drink Check Brochure to prompt discussion of the benefits of
reducing drinking if need be.
Again, use a double-sided reflection to summarize what the student has said.
It sounds as though it would be worthwhile for you to reduce your drinking because . . . but some
barriers to you deciding to reduce your drinking would be that . . .
Move onto Are You Ready to Change? 1 and Are You Ready to Change? 2 and have the
student answer the questions about the importance of reduced drinking.
Now that we’ve talked about the pros and cons of reducing how much you drink or keeping things as
they are now, how important to you is reducing your drinking, on this scale that goes from 0, for not
at all important, to 10, for very important.
 Chapter 7: Brief Interventions 145

Write the student’s answers on the back of the AUDIT.

Summarize the student’s response. This may help him/her to elaborate upon it.
Ok, you feel that it’s not at all/somewhat/moderately/highly important to reduce your drinking.
If the student picks a low number on the scale (e.g., 1 or 2), you could say:
It seems that changing your drinking isn’ t something you think is very important at the moment.
If the student picks a moderate number on the scale (e.g., 4, 5, 6), you might say:
Changing your drinking is somewhat important to you, but you’re not fully convinced it’s something
you want to do at the moment.
If the student picks a high number on the scale (e.g., 8 or 9), you could say:
So, reducing your drinking is very important to you.
Then ask the student how confident they are that they can reduce their drinking, using
the scale provided. Don’t forget to write their response on the back of the AUDIT.
How confident are you that you could reduce your drinking, if you decided to?
Summarize the student’s response, for example:
Ok, you feel not at all/somewhat/moderately/very confident that you could reduce your drinking if
you decided to.

Now, discuss the similarity or difference between the student’s perceived importance of
change and their confidence in their ability to change.
Example response to a student who feels that change is not important:
So although you’re confident that you could change if you wanted to, you don’t feel that change is
very important at the moment. On the other hand you were telling me before that drinking has . . .
(list negatives of current drinking). Will you tell me a bit more about how important, or unimportant,
you feel it is to change your drinking?
Example response to a student who does not feel confident that they can reduce their
drinking:
So although reducing your drinking is very important to you, you don’t feel very confident that you’ll
be able to do it. What makes you feel like that?

Turn to Are You Ready to Change? 3 and discuss whether the student will talk to a
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health professional. You might say:
146 Chapter 7: Brief Interventions

Earlier on you were saying you weren’t keen on talking to a health professional about your drinking.
Now that we’ve talked some more about the pros and cons of your current drinking pattern, and the
benefits of reducing how much you drink, has anything changed? How important to you is it that you
speak with a health professional about your drinking?
Ok, so you feel that it’s not at all/somewhat/moderately/highly important that you speak with a
health professional about your drinking.
How ready are you to speak with a health professional about your drinking?
If the student is keen to reduce his/her alcohol consumption but not keen to talk to a
professional, highlight this discrepancy.
It sounds as though on the one hand it’s important to you that you reduce your drinking, but on the
other hand you’re not keen to talk to a health professional about how to do that. Will you tell me
more about that?

Some prompters for this question might be:

What would make you more likely to talk to a health professional?
What would be some of the pros and cons of this?
Then move on to Plan to Reduce My Drinking 1.
What would be your top 3 reasons for wanting to reduce your drinking?
Ok, you’re saying that you want to reduce your drinking because . . .
They sound like really important reasons.
How might your life might
be different if you do reduce
your drinking?
So if you reduce your
drinking you expect
that . . .
Turn to Plan to Reduce
My Drinking 2 and discuss the student’s goals.
 Chapter 7: Brief Interventions 147

A good way to make something

happen is to make a plan. This
increases the chances that you’ll be
successful. First, let’s think about what
sort of a drinking pattern you’d like to
have.
How many days each week do you want to drink?
How many drinks would you like to have each day?
What is the highest number of drinks you want to have at any one time?
So you think it would be realistic for you to have __ drinks on __ days each week.
This matches well with the Australian guidelines for healthy drinking

OR

This is higher than the Australian guidelines, but seems like it would have a lot of benefits compared
with how you’re drinking at the moment.
Turn to Speaking with a Health Professional.
Reinforce the importance and likely benefits of speaking with a health professional.
Point out that talking to a professional is a recommended strategy for reducing very risky
drinking patterns.
Given the things we’ve discussed today, what would you like to do next? Would you like to make an
appointment to speak with someone further?
YES
 Give the student a referral card.
The number on this card is for someone who regularly
talks with students about their drinking. All you need to
do is telephone and make an appointment. I hope things
go well when you speak with. . .
NO, appointment not wanted
There is more information here on the brochure about
where you can get help if you change your mind later.
Remember that if you decide to reduce your drinking it
might be hard, but you can do it, and there is lots of
support on and off campus if you want to access it.

Finish by giving the student a copy of the self-

help booklet, irrespective of whether they’ve
made an appointment to speak with someone
further.
I’ll also give you this handout to keep. It would be a
good idea if you filled it in at home, particularly the
plan, and put it in a place where you will see it
regularly, like on your fridge or next to your bed. Do
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148 Chapter 7: Brief Interventions

you have any other questions? Ok, well thanks for your time today and for talking with me. Enjoy the
rest of your day.
Brief interventions are available for a number of health compromising behaviours other
than alcohol use, such as for smoking cessation (Aveyard et al., 2011) or suicide
attempters (Doupnik et al., 2020; Fleischmann et al., 2008; O’Connor et al., 2015).
Online versions of brief interventions are also becoming increasingly utilized
(McCambridge & Cunningham, 2013). In this chapter we focused on an example of
the briefest type of interventions that typically last between 5 and 25 minutes, although
they may extend up to 60 minutes in some contexts (Bray et al., 2017). For example, in
the United States, the reimbursement code for this briefest of interventions is demar-
cated from other brief treatments that provide a stronger, yet still low-intensity dose of
service by the 30-minute mark (Aldridge, Dowd & Bray 2017). In the next chapter, we
turn to these higher-dose yet still low-intensity psychological interventions that aim
“to increase access to evidence-based psychological therapies in order to enhance
mental health and wellbeing on a community-wide basis, using the minimum level
of intervention necessary to create the maximum gain” (Bennett-Levy, Richards &
Farrand, 2015, p. 6).
 Chapter
Low-Intensity

8 Psychological Interventions

In the previous chapter on “brief” interventions, we focused on one example of this

briefest type of interventions that typically last between 5 and 25 minutes and are offered
opportunistically as a one-off contact to people not formally seeking help. The rationale
is that intervening in such a resource-effective way with many people at lower levels of
risk can reduce the number of people needing more costly intense treatments once
problems have become more complex and entrenched. Because demand for more intense
psychological interventions outstrips available supply of specialist services delivering
such high-intensity treatments, the last decade has seen the growth of access to less
intense, evidence-based psychological interventions to better meet community-wide
mental health needs. The aim of such low-intensity psychological interventions is to
use the minimum level of intervention necessary to create the maximum gain (Bennett-
Levy, Richards & Farrand, 2015).
Low intensity refers to low usage of specialist therapist time, or usage of specialist
time such that it reaches a greater number of people (e.g., group treatments). Low
intensity does not refer to the client’s experience. Even though the contact with the
specialist is less, the client’s involvement in terms of time, effort and emotional invest-
ment can be intense (Bennett-Levy et al., 2015).
In low-intensity psychological interventions, the number of sessions is reduced.
Whereas high-intensity interventions are typically around 16–20 sessions, low-intensity
interventions may provide weekly support contacts for 5–8 sessions (Bennett-Levy et al.,
2015). For example, the average number in low-intensity treatments delivered during
routine practice as part of the Improving Access to Psychological Therapies (IAPT)
programme in the United Kingdom is just under seven sessions, with patients moving to
recovery after attending an average of eight sessions (Wakefield et al., 2020).
The length of sessions is also reduced. As noted by Bennet-Levy and colleagues
(2015), “the sacred cow of 50–60-minute therapy sessions delivered by highly trained
psychotherapists that has persisted for over a century is being overturned” (p. 9). Low-
intensity sessions are limited to 30–40 minutes duration and may be as brief as 10 min-
utes depending on the setting and modality of treatment delivery (e.g., remote online
support contact; McEvoy et al., 2021). A low-intensity intervention may even be limited
to a one-off, 30-minute appointment in the context of an advice clinic (e.g., White, 2015).
Here, the aim is to (1) offer rapid access to mental health advice via self-referral, (2)
direct clients to self-guided solutions that are immediately available, manageable and
problem focused, (3) facilitate access to preventive care at an early stage of experiencing
problems and (4) provide pathways to more intense services if indicated. For example,
White (2015) describes two cases illustrating this approach. The first is a recent retiree
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150 Chapter 8: Low-Intensity Psychological Interventions

who had experienced a loss of confidence and self-esteem following his change in daily
routine. This led to him feeling irritable with his wife and increased retreat into his
bedroom, watching TV alone and drinking more. When previously working as a
bricklayer, he had especially enjoyed training and mentoring apprentices. The advice
session identified that he would benefit from greater structure in his life and a sense that
he was contributing to society. Building on valuable skills gained in his previous
mentoring role, the advisor’s help in accessing an online resource of local volunteering
projects provided the client with a choice of readily available approaches to manage his
mental health while adjusting to his new status as a retiree. In another case, a client
ostensibly seeking help with being unable to relax or switch off revealed toward the end
of the brief session that he was concerned about “Security Agencies” and his daily life was
preoccupied with protecting himself from assassins he believed were searching for him.
Here, the brief, low-threshold session with a mental health advisor helped to identify a
hitherto undiagnosed psychosis. An appropriate follow-up with more intense commu-
nity mental health services could be arranged.

Using a Stepped-Care Approach

The two examples in the previous section illustrate the stepped-care approach central to
low-intensity psychological interventions. That is, the least intrusive intervention should
generally be offered first as in the case of the retiree opting to pursue a volunteering
activity to address his feelings of irritability and recent behavioural withdrawal. Such a
low-intensity intervention can be stepped up to a more intense intervention if subse-
quent assessment or monitoring suggests a higher dose of treatment should be initiated.
However, some people require more intense treatments more promptly, as in the case
where a brief assessment revealed the presence of more complex psychotic symptoms. In
the latter case, there should be no delay in accessing high-intensity interventions because
an insufficient dose of treatment at a low-intensity step of care may lead to prolonged or
increased distress, disability and hopelessness about the benefits of treatment (McEvoy
et al., 2021). Conversely, if symptoms abate or clients report increased efficacy and
confidence in managing their distress after a period of high-intensity treatment, the
intervention can be stepped down to a lower level of intensity. Appropriate stepping to
achieve the right dose of treatment at the right time for the right duration therefore
requires the routine collection of outcome measures at initial assessment and each
treatment contact (see Figure 8.1).

Offering a Choice to Service Users

Low-intensity interventions use manualized and protocol-driven strategies to communi-
cate CBT principles in accessible ways (Bennett-Levy et al., 2015). This allows for content
to be delivered in a variety of flexible forms, including self-help materials, video confer-
encing, and in-person support sessions. This offers opportunity for the service user to
have a choice in treatment planning and implementation (see Figure 8.1). Not all clients
want or need high-intensity interventions. If given a choice between different evidence-
based practices, some may prefer low-intensity options. Especially for highly protocol-
driven interventions such as many CBT strategies, a client may prefer to work with
structured self-help materials and check in with the treatment provider during a few
 Chapter 8: Low-Intensity Psychological Interventions 151

Client data (problem-focused & suitable for protocol driven interventions)

Theoretical and Clinical training &

empirical literature experience

Manualised & Diverse

protocol driven qualifications
Assessment
case formulation

Treatment planning
measurement
Stepped-care Service user choice

Treatment implementation
monitoring

Evaluation
accountability

Shared decision-making

Figure 8.1 Adapting psychological interventions to less intense formats.

online sessions for support. Self-help may be more suitable for a client if time constraints
due to work and childcare commitments, inadequate access to transport or discomfort
with more intense in-person encounters would otherwise hinder access to timely
evidence-based care. The choice for a given client is not just between different steps of
more or less intense treatments, but also within steps, where a client might choose
between different evidence-based formats of delivery such as attending five weekly
sessions via video conferencing rather than at a clinic for in-person appointments.
A client might also prefer a combination of in-person and online visits.
Thus, in determining the appropriate level and format of care, there has been a shift
in focus from service provider to service user. With the proliferation of evidence-based
CBT treatment manuals and associated guided self-help materials, and protocol-driven
intervention strategies, the effective implementation of CBT principles and strategies
now largely resides within the materials rather than within the therapist (Bennett-Levy
et al., 2015). That is, the materials now bring the expertise about CBT, and the practi-
tioner is skilled in providing effective guidance and support. This also means that low-
intensity interventions are not typically delivered solely by specialist mental health
professionals. Instead, they are provided by a variety of practitioners specifically trained
to deliver them (including some without prior qualifications in health such as peer
supporters) (McEvoy et al., 2021). Therefore, clinical training and expertise shaping
decisions about treatment planning and implementation reflect a diverse range of
provider qualifications (see Figure 8.1), and decisions about intensity and format of care
are made collaboratively with a greater role for the service user.
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152 Chapter 8: Low-Intensity Psychological Interventions

Shared Decision-Making: Towards a New Normal

Shared decision-making is considered a disruptive idea because of the shift in the power
and control of interactions between clinicians and patients; the presumption that
“doctors know best” no longer holds (Elwyn et al., 2017). Instead, the health care
professional and patient bring complimentary forms of expertise to the decision-making
process (NICE, 2019). Whereas the health care professional has the expertise in diagno-
sis, the understanding of causal models of the presenting problem(s), the evidence base
supporting different treatment options and how to link a case formulation to treatment
planning, the patient’s expertise is grounded in the experience of their mental health
problems, their social circumstances, their values as to what matters to them and their
personal preferences, which all impact greatly on treatment engagement and hence
outcomes. Thus, shared decision-making is a collaborative process linking evidence-
based options within a stepped-care approach with the personal informed choices, values
and preference of the patient (see Figure 8.1). Shared decision-making is particularly
relevant for “preference-sensitive decisions”, which are decisions for which more than
one evidence-based option exists (NICE, 2019). Most decisions about mental health care
are preference sensitive, because alternative psychological treatments and delivery for-
mats are available that each are supported by their respective evidence base.
Of course, understanding clients’ ideas, concerns and expectations along with associ-
ated building of rapport has always been one of the core competencies to be mastered by
mental health professionals. So, while it appears that “We do it already”, shared decision-
making goes beyond that (Elwyn et al., 2017). It is a truly joint process by which people
are empowered to make decisions about the treatment and care that is right for them at
that time (including doing nothing or opting for a less intense intervention). The task for
the health professional is to actively and deliberately support a person to reach an
informed decision about their care (NICE, 2019). This is not the same as the clinician
suggesting a specific treatment plan flowing from a largely therapist-generated formula-
tion and to which the client then agrees after some opportunity for questions and
clarifications. The typical outcome is that the therapist-preferred suggested course of
action is adopted because the clients are willing to follow the expert’s lead. This outcome
is likely even though clients might have some reservations about their commitment and
level of engagement required if the intensity of the planned intervention does not match
their needs. Such reservations might manifest in a delayed (non-shared!) decision by the
client to not engage in certain assigned activities, miss sessions or drop out of treatment
altogether. Although progress monitoring can prompt the therapist to re-visit and
correct the treatment plan (hopefully before a rupture to the therapeutic alliance),
therapists can be proactive in eliciting patients’ preferences during shared decision-
making at the initial point of implementing a treatment plan. This increases the
likelihood that intensity of the intervention is matched to what the client decides is right
for them.
According to the three-talk model of shared decision-making, shared decision-
making involves a fluid transition between different kinds of collaborative consultation
components or “talks” (Elwyn et al., 2017). During each of these decision-making talks it
is essential that the clinician engages in active listening and responds accurately to the
client’s contributions. Equally important is that the clinician creates the space for
deliberation during these talks, where the client is supported in thinking carefully about
 Chapter 8: Low-Intensity Psychological Interventions 153

available options when facing a decision about their care. The process typically starts
with team talk (“Let’s work as a team to make a decision that suits you best”). This
places emphasis on working together with patients by offering support when they are
made aware of treatment choices and by eliciting their goals as a means of guiding
deliberations about those choices. Then, option talk discusses alternatives, including
consideration of benefits and risks associated with each option (“Let’s compare the
possible options”). Finally, decision talk refers to highlighting the patients’ informed
preferences and arriving at decisions that reflect those informed preferences, guided by
the experience and expertise of health professionals (“Tell me what matters most to you
for this decision”).
The principle that people should have a say in managing their own mental health and
be empowered to make informed choices about the services and care that are right for
them is a key goal of a person-centred mental health system (e.g., Australian
Government Productivity Commission, 2020). Low-intensity psychological interven-
tions are one of those options. They are evidence-based and decisions about their use
must be responsive to patients’ cultural, social and clinical preferences.

Adapting Case Formulation and Treatment Planning

to Low-Intensity Psychological Interventions: A Case Example
Because low-intensity psychological interventions are limited in number and length of
sessions, assessments are less concerned with collecting a detailed history of the present-
ing problems, but focus on what triggers these problems, and how they impact the
person’s life in the here and now. This information can be condensed into a simple case
formulation to work out together with the client how four interconnected factors work
together to maintain the current distress (Padesky & Mooney, 1990). Emotions refer to
the feelings the client experiences in relation to their distress, and the thoughts (including
beliefs, assumptions and mental images) that accompany those experiences are identi-
fied, along with any bodily sensations (e.g., fatigue, shaking or sweating). What the client
does in response to these emotions, thoughts and sensations is noted under the behaviour
component of this simple formulation (e.g., disengaging from social activities or hobbies,
or avoiding issues at work by calling in sick). As noted by McEvoy and colleagues (2021),
these behaviours are a particularly good target for treatment, because these symptom-
maintaining and associated safety behaviours are generally within the direct control of
the client. The following case example is taken from Low Intensity Psychological
Interventions (LIPIs) for Anxiety and Depression: A Clinician Manual (McEvoy et al.,
2021; Figure 8.2) to illustrate a simple case formulation and treatment planning within
the limited scope of a low-intensity intervention. Janet is a 50-year-old schoolteacher
who had noticed that she is more irritable than usual with the children in her class. After
a conversation with her GP she decided to see a mental health professional. Using a
formulation and treatment planning template designed to accommodate low-intensity
psychological interventions (see below), the problem formulation is succinctly organized
around the four components of thoughts, behaviours, body sensations and emotions.
Note that options varying in intensity of treatment modality are explicitly listed in the
template to be completed by the health professional. It is also made explicit that client
preference is to be considered when selecting one or more of these options. The number
of agreed sessions in the case ofhttps://avxhm.se/blogs/hill0
Janet is limited to five, with a brief description of what is
154 Chapter 8: Low-Intensity Psychological Interventions

The clinical problem(s) to be treated

1. Persistent worry (Generalised Anxiety Disorder)

2. Mood disturbance

3. Sleeping difficulties

Problem statement: In Janet’s words

I worry about bad things happening. To prevent bad things from happening, I try to think of all the
possible outcomes that could happen, especially all the negative outcomes. This makes me worry
more about bad things that could happen. As a result, I constantly check up on my family and
avoid situations that could result in something bad. I sleep poorly because I can’t stop the worrying
thoughts. As a result, I feel tired and tense most of the time, and often feel teary or grumpy.

Problem formulation

Use case formulation handout to complete this section.

Thoughts What if I’m a bad teacher, I get sick and I lose my job, interest rate goes up,
we lose the house, something happened to my kids, my husband’s mine
collapses?

Behaviours Checking up on family, avoid anxiety-provoking situations, pre-empt any

negative outcomes

Emotions Anxious, grumpy, snappy, teary

Body sensations Tension, headaches, jaw and toothaches, sleep problems, fatigue, fidgety

Formulation

By trying to manage her worry through pre-empting all possible outcomes to a situation, especially
negative outcomes, Janet’s anxiety is maintained as she feels this prevents bad things from
happening. Janet is negatively reinforcing her worry behaviour by trying to avoid situations that
provoke her worry, such as allowing her daughter to drive without her. Janet tends to worry late
into the evening when she goes to bed, which causes her sleep to be disrupted and for her to feel
fatigued throughout the daytime. This results in her feeling emotionally teary and grumpy, and
physically tense.

Identify specific treatment goals

1. Cognitive restructuring to improve Janet’s ability to identify, dispute, and re-frame

negative thoughts
2. Problem-solving to help Janet develop healthy ways to manage life stressors
3. De-arousal to decrease physical tension and improve sleep quality

Identify the most appropriate LIPI modality

Consider client preference and available resources. Tick all that apply.

Self-help: written

Figure 8.2 A clinical example of a Low Intensity Psychological Interventions (McEvoy et al., 2021).
 Chapter 8: Low-Intensity Psychological Interventions 155

Self-help: online

Guided self-help: telephone

Guided self-help: video conferencing

Face-to -face individual (number of sessions 5)

Face-to -face group (number of sessions _____)

High-intensity treatment is indicated (provide details):

Plan intervention

What resources are available within your service and what additional resources may be needed
(e.g., psychoeducation materials, handouts, online resources).

List helpful resources for intervention (hard copy, online)

• Handouts and psychoeducation from the Centre for Clinical Interventions’ (CCI):
www.cci.health.wa.gov.au/Resources/Overview
• Use materials from CCI’s workbook What? Me Worry!?!
www.cci.health.wa.gov.au/Resources/Looking-After-Yourself/Worry-and-Rumination

Based on case formulation and treatment goals, which strategies are indicated:

• CBT formulation and psychoeducation

• Thought challenging
• Mindfulness and attention training
• Behavioural experiments and postponing worry
• Active coping (structured problem-solving)

Treatment session plan

Provide a brief description of what each treatment session will involve:

Session 1
Explain the CBT formulation, and provide psychoeducation about generalised anxiety and
worry . Introduce the de-arousal technique of progressive muscle relaxation (applied
relaxation). Plan to practise these techniques to improve sleep and reduce body
sensations of tension and aches.

Session 2
Review sleep patterns and use of de-arousal techniques. Introduce challenging beliefs
about worry ( positive , controllability ). Plan to practice postponing the worry , as well as
continuing with progressive muscle relaxation.

Session 3
Review practicing postponing worry and troubleshoot any difficulties with the task.
Introduce and teach mindfulness and attention training. Plan to complete the attention
training diary as homework.

Session 4

Figure 8.2 (cont.) https://avxhm.se/blogs/hill0

156 Chapter 8: Low-Intensity Psychological Interventions

Review completion of the attention training diary. Troubleshoot any difficulties with the
task. Introduce active coping, and teach problem-solving and accepting uncertainty.
Continue to practice the strategies that have been taught.

Session 5
Review progress with strategies and discuss relapse prevention. Encourage ongoing
commitment to the strategies. Consider planning a 1-month follow-up session.

Outcome monitoring

What measures will be used to monitor treatment targets?

GAD-7

How often will the measures be administered? (e.g., baseline and every session)
At the initial assessment and in the waiting room before every session

What would indicate treatment has been successful?

Janet would report that she is worrying less and is able to fall asleep within an appropriate
amount of time at night. She would also report experiencing less bodily tension and aches,
and feeling less irritable. Janet would also report feeling more confident in managing her
own mental health in the future, using the strategies she has learned during treatment.

Referral to other services?

Not currently required

Required (provide details)

May be required (to be determined following the LIPI)

Consider referral to higher intensity services if symptoms persist or worsen after treatment.

Figure 8.2 (cont.)

to be achieved in each. A valid and reliable measure for frequent outcome monitoring
is specified.
Note that one of the options in identifying the most appropriate modality for the low-
intensity intervention includes “Face-to-Face group”. As with individual interventions,
group interventions can be delivered at both lower and higher levels of intensity. The
number and timing of group sessions can vary depending on the presenting problem and
what is recommended, based on the evidence for optimal outcomes. Even though groups
may involve as much as ten sessions (plus an appropriate number of follow-up sessions
depending on the likely recovery/relapse trajectory for a given target problem), they can
still be considered a low-intensity intervention because specialist time is spread across a
larger number of clients. In the next chapter, we turn to the competencies involved in
delivering group-based treatments.
 Chapter
Group Treatment

9
Group-based interventions are available for almost every conceivable problem a person
might experience over the course of a lifetime. A myriad of therapeutic groups facilitated
by trained mental health professionals exist alongside an even greater number of self-
help and mutual support groups (Dies, 1992). Short-term group interventions designed
to achieve relatively rapid relief from specific symptoms are increasingly well-supported
(e.g., McEvoy et al., 2021). The latter are highly goal-oriented and use interpersonal
interaction in small, carefully planned groups to effect change in individuals specifically
selected for the purpose of ameliorating a circumscribed set of problems.
The use of interpersonal interaction as a therapeutic tool in the here-and-now
context of a group is an inherent advantage of group interventions. The presence of
other people provides opportunities for vicarious learning and the experience of
universality, the relief felt from realizing that one’s concerns are not unique and are
shared by others (Dies, 1992; Yalom, 2005). Moreover, by engaging with and helping
others, patients learn to help themselves more effectively (Rose, 1993; Yalom, 2005).
Finally, a group functions as a social microcosm that approximates the individual’s
day-to-day reality more than a therapist-patient dyad does (Dies, 1992). Thus, patients
can rehearse change strategies in the group and, after trying out those strategies in the
real world, the group helps the patients evaluate the outcomes (Rose, 1993). This
iterative rehearsal in the group and community increases the probability that learning
will generalize beyond the immediate context of treatment. Given the unique thera-
peutic advantages and cost-effectiveness of group interventions compared to dyadic
sessions, how does a therapist go about selecting, modifying or developing a group
treatment programme that meets the standards of science-informed practice and
accountability in patient care?

Selecting a Treatment Programme

The first step in selecting a group programme is to determine if there is a treatment
manual based on the evidence base for the problem that is targeted by the intervention
(see Figure 9.1). For example, excellent treatment manuals with step-by-step clinician
guides and ready-to-use patient materials are available for group treatments of social
anxiety disorder (Andrews et al., 2003; McEvoy, Saulsman & Rapee, 2018) and obesity
(Cooper, Fairburn & Hawker 2003). But what if such detailed manuals are not yet
available? Consider the example of smoking cessation. Until the publication of a com-
prehensive Tobacco dependence treatment handbook in 2003 (Abrams et al.), that
included a chapter describing an eight-session behavioural treatment programme for
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157
158 Chapter 9: Group Treatment

Client data (nicotine dependence, health problems, social stigma, etc.)

Theoretical and Clinical training &

empirical literature experience

Treatment manuals?
Clinical practice guidelines? Assessment &
Addiction literature case formulation Group
Group treatment literature
formulation
Treatment planning
& measurement
Pre-group orientation
Group progress
Treatment implementation
& monitoring

Group outcome
Evaluation &
accountability

Figure 9.1 The process of integrating individual case formulation and treatment within science-informed,
group-based interventions for the example of nicotine dependence.

smoking cessation, practitioners had to develop their own programme based on their
knowledge of the literature. In the case of smoking cessation, this process was greatly
facilitated by clinical practice guidelines, which had been derived from systematic reviews
of treatment approaches and were disseminated by the end of the last millennium (Fiori
et al., 2000; Miller & Wood, 2002; Raw, McNeill & West, 1998; West, McNeill & Raw
2000). Practice guidelines identify the treatment strategies, formats and parameters for
which there has been sufficient evidence of their effectiveness. This may include recom-
mendations about what treatment strategies to include or what the optimal number of
sessions is, but the clinician is still left with the nuts and bolts of translating that infor-
mation into a coherent treatment programme. For smoking cessation treatment groups
there is now a programme available that is based on such a translation of clinical practice
recommendations into a step-by-step treatment manual with a detailed session-by-session
guide for therapists and ready-to-use client materials, activity sheets and routine sessional
monitoring tools (Stritzke, Chong & Ferguson, 2009).
In the absence of clinical practice guidelines, the individual clinician has the add-
itional task of critically distilling from the literature what a smoking cessation pro-
gramme should entail and how it should be structured. Alternatively, if an available
treatment manual focuses primarily on behavioural strategies (e.g., Brown, 2003), but the
literature suggests that a combination of behavioural, cognitive, and pharmacological
approaches outperforms either treatment alone, the clinician may want to modify the
existing programme by incorporating a pharmacotherapy component (e.g., Goldstein,
2003) and other relevant principles of treating addictive behaviours (e.g., Miller &
Heather, 1998), as well as cognitive-behavioural strategies relevant to group treatments more
generally (e.g., Rose, 1993). In either case, the onus is on the clinician to evaluate if this newly
 Chapter 9: Group Treatment 159

designed or modified treatment programme produces outcomes that are comparable to

those published in the literature (see “Evaluation & Accountability” box in Figure 9.1).
For example, the literature on smoking cessation treatment recommends the use of
biological markers such as carbon monoxide (CO) to infer strength of habit from
nicotine levels in the patient’s body (Niaura & Shadal, 2003), to provide feedback on
initial CO levels to increase motivation for change and to assess post-cessation CO levels
to demonstrate the positive physical health consequences of quitting (Emmons, 2003).
From these general recommendations, it is not clear how closely changes in CO levels
would correspond to changes in smoking levels. If CO levels are measured weekly, but
are not sensitive enough to reflect small reductions in the average number of cigarettes
smoked per day over the previous week, then lack of change in the “true” biological index
undermines the boost in self-efficacy patients typically experience when realizing that the
effort of executing small, planned, behavioural changes in daily routines has resulted in
immediate, tangible reductions in their cigarette intake. If, on the other hand, changes in
CO levels closely parallel those gradual reductions in daily cigarette intake, they can serve
as a powerful motivator to stay committed to the ultimate goal of becoming smoke-free.
Given that earlier available treatment handbooks did not offer explicit guidance on how
to resolve the above issue, a scientist-practitioner would act as a “local clinical scientist”
(Stricker & Trierweiler, 1995) and evaluate the results of the decision to use weekly CO
monitoring. We will return to this example and show how this can be done quite easily in
our Documenting Progress and Outcomes sections below, but first, we will describe what
factors need to be considered in selecting patients for a group, and how the process of
individual case formulation and treatment is modified and enriched within a group-
based intervention.

Selecting Patients for a Group

In goal-oriented groups where the emphasis is on support and reduction of a specific set
of symptoms over a short period of time, the composition of the group by definition will
be relatively homogenous in terms of symptomatic complaints. One advantage of such
homogeneous groups is that their concerns and goals for treatment are closely aligned,
and therefore they can be quickly moved into a working mode by an active and
facilitative therapist (Klein, 1993). The manageable size of groups ranges from four to
12 members, with eight members usually regarded as the ideal number (Klein, 1993,
Yalom, 2005). In order to approximate this ideal number, it is important to consider
attrition rates. These can range from 17 to 57 per cent (Yalom, 2005). It is therefore
advisable to start with a group that is about 20 per cent larger than the targeted size, so
that the predictable dropouts of two or three members early in treatment do not affect
the critical number needed for interactive group processes to occur.
The principal consideration in selecting individuals for a group is that they are able
and willing to participate in the primary task of the group (Yalom, 2005). That is, they
must be available regularly over a specified period of time, have a desire for change, and
have the capacity to tolerate a group setting. Beyond these basic inclusion and exclusion
criteria, the choice of patients is often determined by expedience, the availability of
suitable candidates and the need to respond flexibly to referral requests, especially when
working in multidisciplinary settings.
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160 Chapter 9: Group Treatment

Assessment and Pre-Group Orientation

In group-based interventions, the process of linking assessment data and case formula-
tion to treatment planning involves two components. One is the individual case formu-
lation that follows from the synthesis and integration of the assessment information
regarding each patient’s history and circumstances with respect to the presenting prob-
lem. The other component is a group formulation (see Figure 9.1). That is, treatment
planning is also informed by the unique constellation of individual group members’
characteristics and circumstances. The aim is to anticipate and plan for likely patterns of
group interactions and processes that can either facilitate or hinder individual patients’
treatment goals. For example, some of the participants in a smoking cessation group may
have been prompted by similar motives to join the group, such as worry about ongoing
medical problems that are caused or exacerbated by smoking, or concern about exposing
their children to the harmful effects of secondary smoke, or embarrassment toward work
colleagues for engaging in a stigmatized behaviour. This information can be used at the
start of the group to build cohesion and mutual support among group members.
Likewise, some group members may report similar barriers to their aspirations of
becoming smoke-free, such as high levels of stress, worry about weight gain following
cessation, or significant others who are smoking in their presence. The group formula-
tion determines which of these potential impediments to treatment success are particu-
larly relevant in a given group, and thus influences the selection and timing of curricular
elements during treatment planning (Rose, 1993).
In addition to adjusting aspects of the treatment delivery based on the group’s pattern
of factors specifically related to symptom presentation (for our example, this would
include a detailed smoking history, level of dependence, craving, previous quit attempts,
readiness to quit, etc.), group formulation and treatment planning are informed also by
more general information about patient characteristics obtained during assessment. For
example, patients may have other medical or psychiatric conditions that they may not
wish to reveal in front of other group members, and that are not critical to address within
the group’s explicit purposes. Equipped with this knowledge, the group facilitators can
plan their sessions accordingly and skillfully manoeuvre around such confidential issues
to protect individual members from unintentional disclosure and embarrassment. Other
general assessment information that is particularly relevant to the planning of groups
includes pre-existing relationships between group members and interpersonal styles. It is
not uncommon that problem-focused groups (e.g., smoking cessation, weight manage-
ment, fear of flying) are attended by individuals jointly with a partner or a friend. The
dynamic between such dyads within the group may require special attention and
management. Similarly, considering which members were particularly talkative or timid
during assessment can be helpful for facilitating group interactions while ensuring that
all members receive equal attention. Finally, assessment yields a wealth of information
on the particular personal meanings, circumstances and events that individual patients
associate with their struggles and tribulations with the presenting problem. The planned
use of these patient-generated examples at the start of the group is an effective way to
personalize explanations of the rationale, principles and strategies underlying the
treatment programme.
Besides the primary assessment function of informing individual case and group
formulations as a basis for treatment planning, it is also essential that the therapist uses
 Chapter 9: Group Treatment 161

the assessment session to prepare the patient for the group and start the process of
building a therapeutic alliance. Recently, this strategy of initiating pre-treatment pro-
cesses has also been recommended for interventions with individuals to enhance
informed patient choice in the treatment planning, especially when implementing new
evidence-based treatments in a setting where patients might be unaccustomed to the new
intervention mode and hence reluctant to engage with it (Karlin & Cross, 2014). Drawing
on Yalom (2005) and others (Klein, 1993; Salvendy, 1993), we recommend the following
preparatory tasks to be covered with a patient prior to entrance into the group.

Enlist Patients as Informed Allies

Explain the rationale underlying the treatment programme. For a smoking cessation
group, this would involve an explanation that nicotine addiction is not only maintained
by the reinforcing pharmacological effects of nicotine on the brain, but is also powerfully
driven by the behavioural aspects of the addiction. Consequently, both the pharmaco-
logical and behavioural components of this addiction need to be addressed in treatment.
This is why patients need to hit the deck running and start from the first session
implementing the behavioural strategies taught in that session, which may then be
complemented by chemical treatments such as nicotine patches.

Offer Guidelines about How to Best Participate in the Group

This will of course vary according to the purpose of the group, although some aspects are
common to most groups. Emphasize that group therapy is hard work and that patients
are expected to take responsibility for their treatment progress. Stress the importance of
punctual and regular attendance. Explain that they will benefit the most by actively
engaging with the programme and the other members. Introduce the mantra of treat-
ment success, that is, change comes from doing things differently, and that they need to be
prepared to apply their new skills every day once treatment has commenced. Encourage
them to provide support to fellow group members.

Clarify Format and Duration of the Programme

Provide information on what to expect in the first session and beyond. Preview the
timeframe of critical treatment components and follow-up sessions. For example, in a
smoking cessation group, patients might be informed about the relative timing of
behavioural strategies, quit day and nicotine replacement therapy. Explain the nature
of between-session work with the help of patient handouts, worksheets and goal-
attainment monitoring materials. Describe the session structure and any key staff (e.g.,
co-therapist, supervisor, nutritionist, social worker) that may be part of the treatment
team. Clarity on organization, structure and procedures of the group helps to alley
anticipatory anxiety that stems from uncertainty and misconceptions about group
therapy.

Set Ground Rules

When it comes to setting rules for groups, less is more! Too many rules constrain the
very processes by which group interactions add value over the narrower bandwidth
inherent in one-on-one communications. Yet, two simple ground rules are essential for
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162 Chapter 9: Group Treatment

groups to fulfill their therapeutic potential. First, what occurs in the group remains
confidential. This is not to say that patients are not permitted to share any of their
experiences and the benefits they derived from them with someone outside the group.
After all, many clients join a group on the recommendation from a family member,
friend or colleague, who was satisfied with attending the same or a similar group in the
past. What must remain strictly confidential is any identifying information that could be
linked to a person, place or event associated with the other members of the group.
Second, time and attention in the group are shared equally. Patients are asked to be active
participants while being mindful of the needs and different views of other members in
the group.

Anticipate Frustrations and Disappointments Along the Way

Patients often develop feelings of frustration or annoyance with the therapist when
realizing early during the group programme that quick fixes are not forthcoming and
that the responsibility for “doing things differently” ultimately rests with each patient.
Similarly, seeing some group members progress at a much faster rate, or another group
member relapse after considerable treatment gain, can be upsetting and undermine
motivation. It is important to communicate to patients from the outset that there are
different paths to achieving the treatment goals and that setbacks are normal. Challenge
the patient’s perception of setbacks as failures and re-frame setbacks as important
opportunities for learning to do better the next time.

Instill Faith in the Programme and Optimism about the Outcome

One of the great benefits of adhering to a science-informed approach to practice is that
even the novice group therapist can, with utmost confidence, assure patients that the
programme works and has helped many patients to get better. Especially if the therapist
can refer to recent outcome data collected from previous groups conducted in the same
clinical setting (see Figure 9.1 for feedback loop from “Evaluation & Accountability” to
“Clinical Training & Experience”), patients will react to this information with hope and
optimism about their own chances of success. This will go a long way in getting patients
“on board” with the rationale for the treatment and the methods to implement it.

Getting the Group under Way

Yalom (1995) observed that the first session is invariably a success, because both patients
and novice therapists tend to “anticipate it with such dread that they are always relieved
by the actual event” (p. 294). Although this should be reassuring to the novice group
therapist, it cannot be overemphasized how important it is to get a group off to a
good start. Given the brevity of many contemporary evidence-based group programmes
(i.e., typically not exceeding 10–12 sessions), the first session constitutes an important
anchoring function, a point of departure where patients are coached to rapidly embrace
the rationale and treatment principles that are at the very heart of what makes the
programme evidence-based and hence successful. A directive and purposive approach
is essential.
A first meeting typically begins with a brief restatement of the ground rules, some
housekeeping issues (e.g., when are breaks, where is the restroom), and an opportunity
 Chapter 9: Group Treatment 163

for group members to introduce themselves and their reasons for joining the group.
Because generally these reasons are already known to the therapist from the assessment
interviews, the therapist can use this knowledge to strategically plan a tentative outline of
whom to draw in to the interaction during this introductory phase on what occasions, so
as to initiate the process of sharing and bonding among members. Thus, while this
interaction may appear quite conversational and free-flowing to the patients, the therap-
ist is hard at work and can guide the process into fairly predictable patterns with the aim
of accelerating the establishment of group behaviour that is instrumental to change and
sets the stage for the “working phase” of the session.
Following the introductions, therapists will review the rationale of the programme,
the strategies that will help patients change and the reasons why these strategies will work
for them! In other words, here is where scientist-practitioners give all the “secrets” of the
profession away. They demystify the process of treatment and make it clear that it is the
patients’ responsibility to engage in the change strategies that they learn and practice in
the group, if they want to experience change. Change does not happen from doing things
the same way, change happens from doing things differently. Therefore, while therapists
need to communicate warm and empathetic understanding of the patients’ concerns and
frustrations stemming from the presenting problem, it is equally important to communi-
cate in a firm and directive manner that patients need to begin acting on what they learn
in group from day one. For example, in the context of a smoking cessation group, this
involves the introduction of a menu of options of change strategies, from which each
patient must select at least one or two strategies to be implemented between the first and
second group sessions. In addition to immediately engaging in active change behaviours,
patients need to be educated about the benefits they can expect from monitoring and
evaluating the outcomes of their efforts.

Monitoring and Evaluating Progress and Outcomes

Just as treatment planning in group-based interventions is informed by an integration of
individual case data within the overall group pattern, so is treatment monitoring and
outcome evaluation (see Figure 9.1). While group programmes allow for flexibility in
how and at what pace individual members progress toward the treatment aims, there are
often phases or milestones that provide a common thread and that serve to gauge
individual members’ progress towards goal attainment relative to the change trajectory
of the group as a whole. For example, in the first phase of a smoking cessation group,
most members will be successful in gradually reducing their daily intake of cigarettes by
increasingly adopting a variety of behavioural change strategies. This is followed by a
preparation phase for planning a “quit day” and the start of nicotine replacement therapy
to ease withdrawal distress after becoming smoke-free. The last phase and follow-up
assist with reducing relapse risk and adjusting to the significant lifestyle changes associ-
ated with becoming a non-smoker. As illustrated in Figure 9.2, two smokers from the
same group can have different trajectories toward becoming smoke-free. Whereas
Patient A showed a gradual progression towards goal attainment and was smoke-free
by Week 9, Patient B experienced some significant health problems during the early
weeks of the group which precluded her from attending for a couple of weeks. With the
help of between-session materials supplied by the therapists, and by redoubling her
motivation and effort upon rejoining the group, this patient was determined to “catch up
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164

0
5
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10
15
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10
20
30
40
50
60
70
Assessment Assessment

Week 2 Week 2

Week 3 Week 3

Week 4 Week 4
Chapter 9: Group Treatment

Week 5 Week 5

Week 6 Week 6
Patient A

Patient B
Week 7 Week 7

Week 8 Week 8

Figure 9.2 Change trajectories of two patients from a smoking cessation group.
Week 9 Week 9

Week 10 Week 10
CO levels

CO levels
Cigarette intake
Cigarette intake

Follow-up Follow-up

0
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45

Weekly CO levels (ppm) Weekly CO levels (ppm)

 Chapter 9: Group Treatment 165

with the group” and hence showed a much steeper trajectory towards successful goal
attainment than Patient A did.
As shown in Figure 9.1, treatment implementation is continually adjusted as a
function of progress achieved by individual members within the parameters of the
group’s progress overall. In the case of Patient B in Figure 9.2, the lack of progress early
on could be attributed to external factors associated with stressful medical procedures
that interfered with her ability to fully adhere to the group’s treatment plan. For other
patients, lack of progress may be indicative of internal factors, such as ambivalent
attitudes towards change or low motivation. In that case, the timing and intensity of
programme components dealing with motivational interviewing techniques can be
adjusted accordingly. At the same time, the group therapist can use the positive example
set by Patient A, who started out with one of the highest levels of nicotine dependence
and daily cigarette intake within the group (i.e., 60 per day), as tangible evidence that
engaging with the treatment process leads to goal attainment. However, for therapists to
fully exploit these opportunities for vicarious learning within groups, they need to wear a
scientist-practitioner’s hat. They need to be committed to regular, systematic evaluation
and documentation of the group’s progress.
Likewise, for patients to fully harness the benefits of making the link between
implementation of the treatment strategies learned in group and the resulting gradual
changes toward goal attainment, they first must be aware of these changes. Often these
changes will be subtle at first and become obvious only when viewed as a trend over
repeated measurements. It is therefore essential to provide group members with regular,
easy-to-follow feedback on critical outcome measures such as those illustrated in
Figure 9.2. Evaluation of individual and group progress with the help of clear graphs
should be a routine component of any group treatment programme (Woody et al., 2003).
The value of systematic documentation of group progress and outcomes is threefold.
First, routine examination of group progress data stimulates vicarious learning and
mutual support among group members. Consider the pattern of treatment progress
for five members of a smoking cessation group in Figure 9.3. Note that all patients show
the predicted gradual decline in daily cigarette intake over the first six weeks, with Patient
C showing the steepest decline (over 50 per cent reduction) after initially starting out
with the highest level of cigarette use. Because of her excellent progress, her determined
and upbeat attitude, and her strong encouragement of others in the group, Patient C had
become somewhat of a role model. After she experienced a severe relapse in Week 7,
three things were particularly instrumental in getting her to re-commit to her treatment
goal. One was a brief, caring phone call by the group therapist following her absence in
Week 7 to encourage her to re-join the group the following week. Another was the
nonjudgemental, warm, supportive reaction by her fellow group members following
Patient C’s return in Week 8. But particularly important to Patient C in overcoming this
setback was the compelling evidence of her successful steady progress prior to her
relapse, which reinforced her belief that she had the capacity to succeed at this difficult
task. Equally important was the evidence following her decision to re-commit to treat-
ment, which confirmed to her that she had overcome the setback and consolidated the
treatment gains achieved prior to the relapse. Although Patient C was not smoke-free by
the end of the last group session, she succeeded in becoming smoke-free prior to the
follow-up session two months later.
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 166 Chapter 9: Group Treatment

35
A
Relapse B
30 C
D
Re-committed E
to treatment
25
Daily cigarette intake

Consolidated
20 treatment gains

15

10

Smoke-free
5

Follow-up
Week 10
Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Week 9
Figure 9.3 Pattern of treatment progress for five patients in a smoking cessation group.

Second, systematically accounting for group progress and outcomes is valuable

because accurate feedback on partial improvements that fall short of the ideal outcome
can still be therapeutically meaningful. For example, smokers who reduce their daily
cigarette intake by at least 50 per cent (see Patients A and B at follow-up in Figure 9.3),
have an increased chance of becoming smoke-free in the future (Hughes, 2000) and have
reduced their exposure to harmful levels of carbon monoxide (CO) in their body (see
Figure 9.2).
Third, accurate documentation of successful group treatment outcomes adds value to
any services offered in a competitive health care market. This is especially critical if the
clinician had to newly design or modify a treatment programme. Recall the earlier
example of incorporating the monitoring of CO readings as an outcome measure into
a smoking cessation programme. If CO readings lacked sensitivity to accurately mirror
small, gradual changes in smoking behaviour, then their addition to the treatment
protocol could undermine motivation to continue with the behavioural strategies. The
scientist-practitioner can use replication of positive outcomes across clients within a
group (e.g., see the close correspondence between self-reported behavioural changes and
CO reading for Patients A and B in Figure 9.2), followed by replication of this pattern
across subsequent groups, to build confidence that the introduction or modification of a
new treatment component was useful in improving treatment outcomes. If these treat-
ment outcomes are comparable or exceed the average success rates of smoking cessation
treatments published in the literature, the clinician can be confident that the newly
refined treatment programme is providing value for money.
Treatment decisions and protocols can also be informed by evaluating these moni-
toring and outcome data over time across several groups. For example, in smoking
 Chapter 9: Group Treatment 167

cessation there is a certain dilemma when considering whether to encourage a “cold

turkey” or “warm turkey” approach to setting a quit date for patients (Miller & Page,
1991). Patients have typically tried abrupt cessation many times before and failed each
time; another failure at the start of treatment may prompt disengagement from treat-
ment and hence should be avoided. In contrast, gradual reduction in cigarette intake
before setting a quit date provides opportunities to become engaged in treatment,
experience some success and build confidence before attempting again to stop altogether.
However, the latter approach can lead to procrastination and stalling of serious treat-
ment engagement. So, the question becomes: when to gently nudge, and when to firmly
push? An evaluation of our own monitoring and outcome data showed that abstinence at
follow-up was associated with: (1) attending more treatment sessions, (2) completing
treatment and, importantly, (3) achieving treatment milestones such as a 50 per cent
reduction in cigarette intake and a 48-hour smoke-free period earlier in treatment. This
suggests that while patients can benefit from a gradual approach to quitting, this does not
mean that effort can be at half throttle; patients must be encouraged to work towards
critical change milestones from the outset and engage in vigorous early
behavioural change.
Thus, using aggregate treatment process and outcome data to refine treatment
protocols is central to the activity of a science-informed practice and this will be the
focus of the following chapter on programme evaluation.

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 Programme Evaluation
Chapter

10
The concept of ongoing quality improvement is inherent in the science-informed
approach to clinical practice. The evaluation skills needed to ensure that treatment
programmes and services are delivered in line with best practice standards, and reliably
achieve clinically meaningful improvements in patient health and satisfaction, are as
important to acquire for clinical psychologists as the therapeutic skills involved in the
actual treatment of individual patients (Health Service Psychology Education
Collaborative, 2013). The role of psychologists as health care providers in a competitive
health care market (see also Chapter 16) makes it imperative that outcome evaluation is
not only conducted at the level of the individual patient but is routinely extended to
outcome evaluation at the aggregate level of the service provider or agency (see
Figure 10.1).
Traditionally, the focus in evaluation of health care programmes and systems has
been the improvement of clinical outcomes and how to achieve delivery of these
outcomes in the most cost-effective ways. More recently, there has been increasing
attention on how interactions with health care services are experienced by both health
care consumers and health care staff. For example, a systematic review found that patient
experience is positively associated with clinical effectiveness and patient safety (Doyle,
Lennox & Bell, 2013). Co-design is a collaborative process that brings together both the
patient experience and staff experience as a critical component of health service evalu-
ation (Dawda & Knight, 2017). The idea is that a mutually beneficial partnership between
consumers (along with their carers and families) and health workers during the planning
and implementation of health care improvement leads to better outcomes for all.
Creating such a person-centred mental health system is a long-term goal and is
expected to require a number of reforms over many years (Australian Government
Productivity Commission, 2020). Implementation of such a system requires that a least
three significant challenges are successfully addressed. First, the evidence base support-
ing the effectiveness of co-design approaches to health care improvements is still
outstanding, although such efforts are currently under way (e.g., Lowe et al., 2019).
Second, because co-design is a participatory methodology involving an equal and
reciprocal relationship between professionals, people using services, their families and
their community, implementation is time and resource intense, often requiring many
years. For example, in experience-based co-design, experiences from patients and staff
are gathered through in-depth interviewing, observations and group discussions (Dawda
& Knight, 2017). A short, edited film is created from the patient interviews and used as a
prompt in a joint session between staff and patients to convey how patients experience
the service. This provides a shared starting point for identifying key emotionally
168
 Chapter 10: Programme Evaluation 169

Figure 10.1 Programme evaluation extends routine evaluation of individual patient outcomes to evaluation of
outcomes, procedures and policies at the level of the service setting.

significant points (“touch points”) impacting on the effectiveness of the service delivery.
Staff and patients then work together to explore ways to improve the service. Reliance on
such a resource-intense video production process at early implementation sites proved
difficult to manage (Dawda & Knight, 2017). Since then, an accelerated experience-
based, co-design approach using an existing archive of filmed patient/carer narratives
has been successfully tested, with co-design improvement activities being achieved more
quickly and at lower cost (Locock et al., 2014).
Third, and perhaps the most challenging in implementing co-design approaches to
programme evaluation, is the principle of equal partnership between service users and
health care staff. The transition to sharing control of decision-making is a disruptive
concept. It goes against the status quo of non-shared control of decision-making that is
often unconscious, ingrained, and reinforced through existing processes and hierarchies
(Dimopoulos-Bick et al., 2018). Nonetheless, those training to become mental health
professionals today will enter their profession at a time when health care systems are
undergoing challenging transformations. At the heart of that transition is a shift from
doctor-centred care which is criticized for being paternalistic, medically dominated and
illness-oriented, towards more person-centred care which empowers people to have a say
in what type of services are the most suitable for them (Australian Government
Productivity Commission, 2020; Lowe et al., 2019).
To promote the adoption of co-design skills in programme evaluation, readily
available toolkits have been widely disseminated (e.g., Dawda & Knight, 2017, in
Australia, which also includes links to similar toolkits in the United Kingdom and
New Zealand). Although these toolkits were developed to aid with evaluation of mental
health services at a macro level, the guiding principles of experienced-based design are
also applicable when applied tohttps://avxhm.se/blogs/hill0
less resource-intense evaluations of specific aspects of a
170 Chapter 10: Programme Evaluation

programme or policy within the local context of a specialist service or clinic. For
example, evaluation data may be used to demonstrate that service provision achieves
stated outcomes and is cost-effective, to account for the resources spent on developing
and implementing a new service, to monitor quality of care and that the consumers’
experience is positive and their needs are being met, to articulate the value of particular
services to management and funding bodies, to determine financial incentives to pro-
viders, or to market services to consumers.
To achieve these goals, the views and values of relevant stakeholders need to be
considered. Good negotiation skills in the planning stage of an evaluation are essential to
clarify and endorse the purpose of the evaluation, and to maximize the quality and utility
of the data to be collected. Good communication skills are needed because evaluation
data need to be translated into effective recommendations. Effective recommendations
are those that are specific, realistic in scope, easily translated into action and mindful of
any constraints within the organizational environment that might hinder their full
implementation (Sonnichsen, 1994). Finally, the gathering of patient data for the pur-
pose of quality improvement programmes must follow clear processes that protect the
rights of patients (e.g., confidentiality, treatment preferences and choices), and respect
the professional responsibilities and clinical judgement of treating staff (APA, 2009).
Although formal ethical approval is often not required for quality assurance and service
improvement activities, ethical guidelines identify triggers when a formal ethics review
may need to be initiated (National Health and Medical Research Council, 2014):
 where the activity potentially infringes the privacy or professional reputation of
participants, providers or organizations
 secondary use of data – using data or analysis from quality assurance or evaluation
activities for another purpose
 gathering information about the participant beyond that which is collected routinely.
Information may include biospecimens or additional investigations
 testing of non-standard (innovative) protocols or equipment
 comparison of cohorts
 randomization or the use of control groups or placebos.
 targeted analysis of data involving minority/vulnerable groups whose data is to be
separated out of that data collected or analysed as part of the main quality assurance/
evaluation activity.
Clinical psychology trainees typically experience two modes of skills training in pro-
gramme evaluation: didactic teaching including practical experience in conducting
small-scale evaluation projects, and modelling via exposure to and participation in
ongoing programme evaluation activities within their training clinic and community
placements. By embracing evaluation as a continuous learning process of asking ques-
tions, reflecting on the answers to these questions, and modifying actions and strategies
in light of those answers, trainees learn to be committed to a process of continual
improvement that forms the basis of accountability and good practice. As shown in
Figure 10.1, members of the agency staff may be the direct beneficiaries of evaluation
findings. To the extent that these findings are incorporated in continuing education and
training of staff, programme evaluation adds to the wealth of clinical experience that
practitioners bring to bear in treatment planning and implementation.
 Chapter 10: Programme Evaluation 171

In this chapter, we introduce trainees to a few basic steps of programme evaluation

that are common to the sort of evaluation projects that practitioners are likely to use in
their respective local clinical setting on a routine basis. We will illustrate these steps with
examples drawn from evaluation projects that clinical psychology trainees may encoun-
ter in their own clinical training setting.

Five Basic Steps of Programme Evaluation

1 Asking the Right Questions
The questions that form the impetus for a programme evaluation can be categorized
according to their primary purpose. Owen and Rogers (1999, 2007) identify five concep-
tual categories. Proactive evaluation is conducted prior to the design and implementation
of a treatment or programme. Questions addressed in proactive evaluation might
include: is there a need for a particular treatment or program? (e.g., should a women’s
health centre offer a smoking cessation programme aimed at pregnant women? Is there a
need for offering clinical psychology trainees practicum experience in rural and remote
settings?). What does the relevant literature or professional experience tell us about the
problems and benefits of introducing a particular service? Have there been previous
attempts to address this need or problem? Are there external sources or agencies that
could contribute expertise and solutions to problems in implementing a programme?
Clarificative evaluation examines the internal structure of a programme or policy. It
clarifies how the programme’s elements and activities link to intended outcomes. Data
will need to be collected that might address questions such as the following: what are the
intended outcomes of the programme? What does the programme do to achieve those
outcomes? Is the rationale for certain aspects of the programme plausible? One example
of clarificative evaluation that clinical psychology students may experience with respect
to their own training programme is accreditation. Accreditation aims to certify that the
structure, components, and procedural guidelines of a programme are of a standard that
instills confidence that the programme can deliver what it intends to deliver.
Unlike clarificative evaluation, which is concerned with design and logic of a pro-
gramme, interactive evaluation is concerned with implementation of a programme or its
components. This form of evaluation is formative in nature and is particularly appropri-
ate for the purpose of ongoing quality improvement. Questions asked in an interactive
evaluation might include: are there ways in which the delivery of services can be changed
to make it more effective? Are therapists implementing agency practice guidelines? Do
programme activities or innovative approaches make a difference? Are there changes in
the type of patients and problems that present at the clinic? Are the skills taught in a
training clinic up to scratch in meeting the demands of current and projected workplace
requirements?
Monitoring evaluation aims to provide quantitative and qualitative information at
regular intervals to gauge if performance indicators are in line with specified programme
targets and implementation is carried out as intended. Questions asked during monitor-
ing evaluation might include: how do patient outcome and satisfaction indices compare
with the previous year? Are the resources available to therapists sufficient to meet
current and projected trends in service delivery and patient needs? What is the average
length of treatment provided by therapists? What is the rate at which clinical psychology
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172 Chapter 10: Programme Evaluation

trainees accumulate supervised client-contact hours? This type of evaluation often uses
outcome monitoring data. Unlike programme evaluation, outcome monitoring itself is
not explanatory, but simply generates routine reports of programme results, which are
then available for periodic evaluation and interpretation. Thus, results-oriented moni-
toring generates the “proof” needed to satisfy the accountability mandate (Affholter,
1994). In addition, routine outcomes monitoring facilitates the early detection and
correction of problems as well as the timely identification of opportunities for innov-
ation and performance improvement (Affholter, 1994).
For example, in a clinical context one of us was involved in the roll out of a routine
outcomes monitoring programme that allowed mental health inpatients to enter their
self-report data daily in an electronic format. The team evaluated the completion rate
and found that after initial enthusiasm, the daily completion rate was around 25 per cent.
We continued to evaluate completion rates as we worked with the individual therapists
to encourage patient completions. The daily completion rate increased temporarily to
around 35 per cent, but then dropped back. So we tried another intervention of having
“roadshows” for all other staff (nurses, administrators and we included the therapists
once more). Evaluating the completions rates each day saw it increase to 60 per cent, but
once more it dropped back but this time to around 40 per cent. We then changed the
electronic feedback to include feedback information to patients (indicating how many
data points were needed before we encouraged them to discuss their progress with their
therapists) and completion rates increased to around 60 per cent and remained there.
Although we have continued to identify system changes to keep the daily completions
rates high, the key point is that the evaluation of the programme delivery allowed us to
determine the immediate and sustained impact of each process as we refined the
mechanism to achieve our goal.
Finally, impact evaluation assesses the attainment of intended outcomes against
specified criteria or outcome indicators. This category of evaluation is often summative
in nature and may assist in decisions to scale back, terminate, continue, or expand
certain services or programmes. Impact evaluation may also include an analysis of
unintended programme outcomes and of the integrity of implementation. Questions
addressed in impact evaluation might include: do patients receiving treatment in a
training clinic achieve reliable and meaningful improvements in psychiatric symptoms
and well-being? Are patients showing improvement in a timely and cost-effective
manner? How long does it take graduates from a training programme in clinical
psychology to find employment in their chosen field?
Once a set of critical evaluation questions has been determined that reflects the
primary purpose and scope of the evaluation, the next step is to develop an evaluation
plan.

2 Developing an Evaluation Plan

The second step of programme evaluation involves planning how to find answers to the
critical questions agreed upon in the first step. Several issues need to be considered when
negotiating an evaluation plan (Owen & Rogers, 1999, 2007). One consideration is who
the recipients and users of the information are going to be. For example, if the question
is how long it takes to find employment after graduation from a clinical psychology
training program, information will be primarily used by (a) current students from the
 Chapter 10: Programme Evaluation 173

programme for career planning, (b) future applicants to the programme for weighing the
pros and cons of entering the programme, (c) potential employers for gauging the
quality of graduates from the programme and (d) programme directors for promoting
the quality of programme graduates to employers and for advertising the strengths of the
programme to prospective quality applicants.
A second consideration is what personnel and material resources are available to
conduct the evaluation project. All evaluations are subject to resource and time con-
straints which determine the extent of information gathering, the complexity and
sophistication of data management, and the range of dissemination strategies. If the
people who deliver a programme are also part of the evaluation team, then time and
resources need to be made available for the evaluation tasks. These tasks should not
present an additional burden on normal workload and should therefore be integrated
within the routine demands of day-to-day programme activities.
A third consideration in developing an evaluation plan is selecting the data collection
and management strategies that are most appropriate for each evaluation question. It is
important to bear in mind that the level of data analytic complexity should not exceed
the sophistication of the intended audience. Clarity and utility are paramount. To answer
the question of how long it takes for graduates to find employment, a brief survey could
be designed that examines not only time taken to secure the first job, but also provides
further informative details such as number of job interviews relative to job offers, success
in obtaining most preferred positions, duration of first contracts, starting income level
and time taken to progress to more senior or permanent positions and/or higher income
levels. If data on prompt employment of graduates are not only of interest as an index of
recent training success, but are also viewed as a performance target to be maintained in
the future, data gathering may also require the simultaneous elicitation of critical
feedback. Thus, the plan for data collection may include some open-ended forms of
information gathering where respondents can identify areas for improvement in
training, so that future graduates are kept abreast of evolving trends in knowledge and
skills expected of their profession. In addition, the evaluation plan would articulate
sampling strategies and may identify potential external resources that could aid in data
collection. For example, a survey of recent psychology graduates could be mailed with
the help of existing mailing lists kept by the university alumni services and could be
included in their regular mailings at no cost to the evaluators. Finally, the data manage-
ment component of the evaluation plan must specify how data will be processed
and analysed.
A fourth aspect in developing an evaluation plan concerns the strategies that will be
used to disseminate the outcomes of the evaluation. This involves determining when and
in what format reporting will take place, and what kind of results, conclusions and
recommendations will be included.
Finally, an evaluation plan must estimate the costs associated with carrying out the
plan. The constraints imposed by the size of the budget and the amount of available
resources have a direct impact on the timeline that can be set for achieving the various
phases of the evaluation project. The timeline may also be constrained by any ethical
issues that need to be addressed before and during the implementation of the evaluation.
How these ethical issues will be handled needs to be made explicit in the evaluation plan.
After completion of the evaluation plan, the data gathering phase commences.
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174 Chapter 10: Programme Evaluation

3 Collecting and Analysing Data to Produce Findings

The third step of programme evaluation produces evaluation findings. These findings
link the evaluation questions to answers that are then disseminated to relevant stake-
holders. The key tasks during the evidence gathering phase involve selecting and gaining
access to the most appropriate sources of data, and then obtaining the data. Sources may
include existing records and documents, as well as individuals who can either provide
relevant information directly or are the gatekeepers of the information required. One of
the most important tasks of data management is the maintenance of a reliable database.
Clinical psychologists trained within a science-informed approach to clinical practice are
usually very experienced in conducting and supervising the tasks involved in data
reduction and analysis. Interpretation of the results of the analyses must, of course, be
grounded in the evidence, but in programme evaluation it is also important to ensure
that the interpretation of evaluation findings reflects the diversity of viewpoints by
different stakeholders. Are the conclusions based on a valid and balanced reflection of
the evidence? Are there any limitations of the evaluation findings? Could these limita-
tions have different implications for different stakeholders? It is essential to remember
that evaluation conclusions must win the support of relevant stakeholder if they are to be
utilized and lead to action.

4 Translating Findings into Recommendations for Action

The fourth step of programme evaluation produces recommendations based on the
judgements and interpretations derived from the evaluation findings. All recommenda-
tions have the purpose of influencing organizational decision-making. They may be used
to justify decisions already made or, more typically, they inform and shape decisions
about courses of action intended to bring about organizational change (Owen & Rogers,
1999, 2007). Whereas the first three steps of evaluation look backward and examine the
status quo, the recommendations developed in the fourth step as part of the written
evaluation report are designed to think forward. They are prescriptive and present
solutions to problems, which in turn provide the impetus for organizational debate
and action (Sonnichsen, 1994). As such, writing good recommendations is the most
pivotal component of the final evaluation report if the evaluation effort is to bring about
desirable change.
Effective recommendations are characterized by several basic qualities (Sonnichsen,
1994). Foremost, recommendations must be delivered in a timely manner. Evaluation
outcomes that are not available when they are needed are of little value to decision-
makers. Recommendations must also be realistic. Unless factors that might constrain the
implementation of a recommendation are carefully considered, the recommendation
may be viewed as impractical and hence is likely to be ignored. For the same reason, it is
wise to avoid recommending changes that are so fundamental that they threaten values
perceived by staff to be core aspects of the programme under evaluation. Such radical
proposals for change are bound to meet with strong resistance and hence have little
chance of being implemented successfully. In addition, care must be taken to direct each
recommendation to the appropriate persons who are in the position to act on and
oversee its implementation. Otherwise, recommendations will collect dust and get
bogged down in organizational inertia. Good recommendations are simple and specific.
Each should focus on only one issue and make explicit what tasks are to be executed by
 Chapter 10: Programme Evaluation 175

whom to ensure its implementation. Finally, the link between each recommendation and
the empirical findings that underlie it must be clear. This will enhance the credibility of
the recommendations and thereby their potential for acceptance and implementation.
The written recommendations can be seen as the ultimate product delivered by the
programme evaluators. Because they are embedded in the final evaluation report, it is
important that evaluators present their final report in a way that makes it easy for readers
to understand the evidence behind a recommendation, the benefits of implementing it,
and how to get there. If recommendations are entombed in a thick, unwieldy report, they
are likely to remain unread, and hence cannot have an impact on ongoing quality
improvement of service delivery. Therefore, they need to be displayed prominently in
the final report. Sometimes adding page references to the relevant sections of the report
can make it easier for readers to find sections of interest. Although the specific content,
structure and format of an evaluation report will depend on the target audiences and the
guidelines imposed by funding bodies, most evaluation reports present upfront a brief
section with an executive summary. This summary provides a brief overview of the
evaluation aims, methods and key findings, and highlights the recommendations that
follow from these findings. The remainder of the report typically contains a more
detailed introduction to the evaluation, a review of the literature, a description of the
methodology, a succinct report of outcomes, and a discussion of the interpretations and
judgements leading to the recommendations. Further details are usually relegated to
appendices in the form of tables or figures.
Even if great care has been invested in writing effective recommendations and
presenting them in a way that is quick to absorb and easy to understand by the
stakeholders, this is not a guarantee that they will be adopted and lead to change. It
may be desirable and possible, especially within local clinical settings where interactive
forms of evaluations are often useful, for evaluators to be also actively involved in
facilitating the transition from recommendations for action to the actual initiation and
follow-up of the recommended changes.

5 Advocating and Promoting Change

Evaluation findings produce recommendations, but recommendations do not always
influence organizational decision-making. As Sonnichsen (1994) noted, “some evalu-
ators labor under the delusion that elegant methodologies, eloquent reports, and scien-
tific neutrality are sufficient qualities to ensure that evaluation results will be used”
(p. 535). Non-use of recommendations may in part be due to the judgemental nature of
evaluation. If recommendations for change are perceived as criticism and elicit defensive
reactions, they are not likely to be universally met with enthusiasm. For recommenda-
tions to lead to change, the evaluation process must include a plan and strategies for
actively promoting that change. The onus is on the evaluators to market the benefits
relative to the perceived risks of changing, while highlighting the risks of not changing.
In clinical settings, failure to act on reliable and valid evaluation outcomes is costly and
harmful, because it leads to overuse of unhelpful care and underuse of effective care
(Berwick, 2003). Thus, the translation of evaluation recommendations into practice must
be actively promoted as a value-adding organizational enterprise.
One important strategy of promoting recommended changes is to not wait for
audiences to request information, but to actively seek opportunities for communicating
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176 Chapter 10: Programme Evaluation

key findings regularly and frequently in a variety of formats (Hendricks, 1994). The
consequences of recommended changes may impact differently on individuals or groups
within the provider organization. Thus, readiness for change can be enhanced if the
recommendations are as compatible as possible with the values, beliefs, past experiences
and current needs of the various stakeholders (Berwick, 2003). When promoting change,
simplify! Audiences tend to be busy and are not so much interested in general infor-
mation as in the bottom line. They want guidance on what they are expected to do
differently, and reassurance on how the benefits of doing things differently outweigh the
costs of doing things the same. This means that delivering recommendations only as part
of a lengthy evaluation report may be insufficient to initiate and sustain change.
Personal, concise briefings tailored to select individuals or small audiences, accompanied
by effective visual aids and handouts, and delivered with ample opportunities for
questions, comments and discussion, provide additional momentum for translating
recommendations into action (Hendricks, 1994).
Another important strategy for promoting recommended changes is to form a team
of individuals and invest them with sufficient power to lead the change effort (Owens &
Rogers, 1999, 2007). These local change coordinators serve as “champions” or internal
field agents to facilitate local implementation of the recommended change agenda (e.g.,
Karlin & Cross, 2014). The primary task of such a team is to mould the various
recommendations into a coherent vision, and to communicate that vision synergistically
to all stakeholders. The efforts of this team must be supported by administrators in the
form of structures that facilitate the changes and remove potential obstacles to
implementing them.
Finally, the adoption of recommended changes can be greatly facilitated if one allows
for, and even encourages, local adaptation of the recommended courses of action.
Recommendations will have their greatest impact if changes are not only adopted locally,
but also adapted locally (Berwick, 2003). That is, programme innovators must guard
against the tendency to be too rigid in their insistence on exact replication of the
recommended courses of action. Innovations and improvements are remarkably robust
to modifications suggested by those who are ultimately responsible for translating them
into the reality of practice. In fact, locally “owned” adaptation is a critical and nearly
universal property of successful dissemination of novel ideas and practices (Berwick,
2003). Such fertile reflection on the process, findings and recommendations of an
evaluation project is the essence of continuing quality improvement. It enhances capacity
building by developing a culture of reflective practice and quality assurance. Moreover,
local adaptation of evaluation outcomes stimulates the generation of new critical ques-
tions within the group of key stakeholders, which in turn set in motion the wheels of
subsequent rounds of programme evaluation. Good practice is reflective practice!
Programme evaluation is the tool to ensure that reflective practice is happening.
A special case of local adaptation of recommended treatment guidelines occurs when
empirically supported, manualized prevention and intervention programmes have to be
adapted for use with different populations or to address the unique aspects and con-
straints of a particular local context. To ensure the validity and fidelity of the newly
adapted manualized intervention, Goldstein, Leff and Lochman (2012) offer guidelines
for a step-wise development and evaluation process. One begins by selecting a base
manual for adaptation and determines its adaptability for the current situation. A very
important principle at this stage is that one remains true to the underlying theory and
 Chapter 10: Programme Evaluation 177

change mechanisms that were empirically supported in the original manual. The essence
of those core mechanisms must remain unaltered. In the next phase, one conducts focus
groups with members of the new target population and makes initial revisions to the
manuals based on the feedback received. This is followed by pilot testing of the initial
revisions, collecting feedback from the facilitators of the new manualized intervention,
and seeking consultation with experts. On the basis of staff, expert and consumer
feedback, further rounds of more formal evaluation trials, or even a randomized control
trial (resources permitting) may be conducted as part of the manual adaptation process.
In sum, empirically-based outcome evaluation is the foundation of accountable
clinical practice, both at the level of the individual patient and at the aggregate level of
the service provider or agency. The mandate of accountability pertains to both the
products of treatment and the procedures used to achieve these products. Regardless
which level of service delivery is targeted for quality improvement, delivering a high-
quality product in patient care requires good case management skills. In the next chapter,
we will describe the key tasks involved in conscientiously managing all aspects of patient
care, from the first contact to termination of the therapeutic relationship.

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 Chapter
Case Management

11
The effective, efficient, and ethical delivery of psychological services requires good case
management skills. Case management involves the integration of three interrelated tasks.
In addition to the fundamental conceptual task of integrating evidence-based practice
with practice-based evidence, which is the essence of the science-informed approach to
clinical practice, treatment involves management tasks and documentation tasks. In this
chapter, we will outline the key management and documentation tasks associated with
specific phases of the treatment process, as well as some tasks that are important at all
stages of treatment. Although many case management tasks have a purpose clearly linked
to a specific treatment phase (e.g., a good intake report needs to be produced at the start
of treatment), two particular tasks with respect to client data are relevant throughout
the entire treatment process: keeping good records and maintaining confidentiality
(see Figure 11.1).

Keeping Good Records

Professional practice guidelines stipulate that treatment providers must maintain
adequate records of all contacts with clients or other persons involved in the treatment
(e.g., family members, physicians), indicating date, time and place of contact, persons
present, and the nature of service provided or action taken. Good clinical records provide
a clear picture of the patient and a clear account of what key actions or decisions the
therapist did – when and why. Documentation of these clinical activities serves several
purposes (Luepker, 2003):
 Records can facilitate communication between therapists and patients. Jointly
reviewing reports, test results, data on goal attainment, attendance patterns, etc. can
help patients to gain insight into and become active partners in their change efforts,
while building trust in the process and the therapeutic relationship.
 Records document that a sound diagnosis, case formulation and treatment plan have
been generated. This forms the basis for a purposive course of action and is essential
for monitoring and detecting change, or modifying diagnostic impression and
treatment strategies.
 Records satisfy the accountability mandate. Science-informed practice brings the
attitude of a scientist into the clinical consulting room. This includes a commitment
to showing “proof” of what was done, when and how, and to whom, resulting in what
outcomes. Contractual obligations with third-party payers often require this
information for reimbursement of services. Inadequate records may be interpreted by
auditors as health care fraud, making practitioners vulnerable to criminal
178
 Chapter 11: Case Management 179

Documentation tasks Conceptual task Management tasks

Keep good records Client data Maintain confidentiality

Theoretical & Clinical training &

empirical literature experience

Integrate evidence-based practice with practice-based evidence

Assessment &
case formulation

Treatment planning
& measurement

Treatment implementation
& monitoring

Evaluation &
accountability

Figure 11.1 Conceptualization, documentation, and management of client data.

prosecution, civil penalties or suspension of third-party payments (Foxhall, 2000).

From an auditor’s point of view, if a service was not documented, it did not happen; if
it was billed, it constitutes fraud.
 Records assist with continuity of care. Good records of previous interventions can help
facilitate treatment planning in the event that a patient seeks help again, or needs to
be transferred to a different therapist.
 Records protect therapists and clinical supervisors against spurious allegations of
harmful practices. As in cases of alleged health care fraud, the lack of
contemporaneous, detailed documentation makes it difficult for practitioners to
prove that they acted in accordance with best-practice standards. Keeping good
records allows a therapist to document that decisions and actions were made in good
faith and conformed to accepted professional practices.
Because of the multiple, simultaneous, challenging tasks that novice therapists must
gain mastery over when learning the “exciting” business of doing therapy, they may be
tempted to view the seemingly mundane tasks associated with documentation as an
additional burden of secondary importance. It should be clear from the above list of
purposes of documentation that conscientious record keeping is an integral part of good
case management, and that patient care will suffer without it. Trainees must be mindful
not to neglect this important task, but they must also guard against the common
tendency among beginning therapists to be overly detailed and comprehensive in
documenting their every impression and each piece of information concerning their
patients. We will review specific documentation tasks in more detail below, but will first
present a few characteristics common to all “good” clinical records that help to keep
records concise, relevant and accurate.
 Good records are relevant. They include only information germane to the presenting
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problem, treatment strategies, and outcomes. We will return to this point later, when
180 Chapter 11: Case Management

describing strategies for keeping records (and presentations of client information)

concise and relevant.
 Good records are accurate. They identify the sources of information. For example, if
the patient says that her father “was an alcoholic”, it would be inaccurate to indicate
in the record that “the patient’s father was an alcoholic”, because the therapist has no
objective information to confirm this as a fact. In this case, the record would be
accurate if the therapist indicated that “the patient stated that her father was an
alcoholic”. Similarly, if the therapist makes an interpretation based on information
provided by the patient, this should be made explicit in the record (e.g., “The patient
clenched her fist and raised her voice, almost shouting; she appeared very angry with
her husband’s decision”). In addition to identifying unambiguously the sources of
information, accuracy in records is achieved by checking and double-checking for
errors. This is particularly important when recording test results and interpretations.
 Good records are contemporaneous. They are generated in a timely fashion, preferably
immediately after a session or any action taken in relation to case management.
 Good records are continuous. They are recorded in a chronological order, each record
is signed and progress notes should be written in a continuous stream. This reduces
the possibility of tampering and instills confidence in others that the records
are complete.
 Good records are consistent. They reflect the course charted in the formulation and
treatment plan. If, for example, the aim is to reduce a patient’s fear of flying, a
progress note stating that “the session focused on an exploration of the patient’s
rivalry with her stepsister” would not be logical in the context of a treatment
programme for reducing phobic anxiety, unless reducing distress associated with
sibling discord was part of the agreed treatment plan.
 Good records are legible. Unless records are legible, they cannot serve the purposes
outlined above. Illegible records have the same liabilities as no records at all.
Typically, entries are written in black ink to ensure that, when copied, any record
continues to remain legible. When using electronic record systems, legibility is not an
issue, but all other aspects of good record keeping apply regardless of format.
 Good records are sensitive. They avoid jargon, use simple language, and respect the
uniqueness and complexity of each patient. A good rule of thumb for the beginning
therapist is: if you would feel uncomfortable if the client were to read your report or
notes in your presence, you should consider alternative ways of expressing the
relevant passages.

Maintaining Confidentiality
The second task that pertains to all aspects of case management (including record
keeping) is the obligation to protect the privacy of the patient. Maintaining confidential-
ity not only requires attention throughout all phases of treatment, but remains a case
management responsibility well after a patient’s active file has been closed. The purpose
of confidentiality between a patient and therapist is to create a safe therapeutic environ-
ment and to safeguard the patient from harm due to the unintentional disclosure of
sensitive patient data. The establishment of trust based on a mutual understanding about
confidentiality and its limitations is the foundation of an effective therapeutic relation-
ship. To achieve the best health outcomes for patients, it is often necessary to share
 Chapter 11: Case Management 181

information between professional staff as part of multidisciplinary case management, as

well as between patients’ families and other carers. Maintaining confidentiality, then,
involves maintaining a balance between the need to respect the patients’ privacy and the
need to consult with nominated people to optimize patient care, within the guiding
parameters set by professional ethics codes and legal obligations. The parameters of
confidentiality and its exceptions should be discussed with patients at the start of the first
session. Likewise, if communication with families and other carers or professionals is
desirable during treatment, an agreement about the purpose, nature and extent of
sharing information with others should be reached with the patient. This may require
ongoing discussion and negotiation, and may entail the setting of very specific con-
straints, defining periods of time during which disclosure is permitted, and delineating
precisely what may or may not be divulged to whom under what circumstances.

Talking about Confidentiality with Patients

Therapists have the responsibility of explaining confidentiality and its exceptions to
patients when commencing a therapeutic relationship. A beginning therapist might
worry that having such “technical” discussions at the outset of the initial interview could
be perceived by patients as uncaring and rigid, and hence interfere with rapport building.
However, trust in the therapist, and the profession as a whole, will be undermined if total
confidentiality is promised or implied without making patients aware of the limitations
of confidentiality. Most patients will welcome the therapist’s concern that they under-
stand what is involved in the treatment process, and they are likely to experience this
open and frank communication as reassuring. The brief focus at the start of the session
on more innocuous procedures can even help to ease trepidations patients may hold
about the treatment process, before they talk about what is troubling them and what they
are seeking help for.
Therapists in training will by definition consult extensively with supervisors and
fellow-trainees about their cases. Because supervision is typically aided by the routine
review of recorded sessions, and because the presence of a camera and microphone in the
consulting room can be initially intimidating to patients, this special arrangement in
training clinics should be explicitly addressed when trainees discuss confidentiality with
their patients. The following example shows how confidentiality information can be
communicated to a patient. This is not intended as a proscription of how it “must” be
said verbatim, but is meant to illustrate the level of detail and clarity needed to convey in
a matter-of-fact, yet warm, manner what the patient needs to know:
I like to take a few minutes to explain some of the clinic procedures to you and give you an
opportunity to ask any questions you have about our services here.
First, you should know that in general everything we talk about in here is confidential. Of course,
creating a safe place for talking about things that are often difficult to talk about and can make one
feel very vulnerable is very important in our work together.
As you know, this is a training clinic, and so, information about a client is regularly discussed
between therapists and supervisors. That is also why many sessions are videotaped. You should
know that these video recordings are not permanently stored. They are only a tool to aid in
ongoing supervision and ensure quality in care, and they are typically erased shortly thereafter or
recorded over with subsequent sessions.
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182 Chapter 11: Case Management

Do you have any questions about the video recording?

[pause for patient to respond]
There are three circumstances that I need you to tell about, where I might be required by
professional standards and the law to disclose information about our sessions to parties outside our
clinic:

1. The first one is that, if you were to tell me that you intend to harm yourself or others,
I would be required to take some appropriate action to prevent you from doing that
and to help and assist you further in that situation.
2. The second circumstance relates to information about abuse or severe neglect of
children or the elderly. In that case, I would have to notify appropriate authorities to
provide assistance with that situation.
3. The third circumstance where I might have to release information is when I or the
clinic gets a subpoena for client records from a judge or court.

Do you have any questions regarding any of these issues relating to confidentiality?
The above discussion would typically take less than five minutes. This can be followed
with a brief transition statement, outlining the goals and structure of this session, before
“turning it over” to the patient with a phrase such as: “Ok then, what brings you here?”

Negotiating Confidentiality when Working with Minors

When working with children and adolescents, therapists need to balance the patient’s
need for confidentiality with the parent’s or guardian’s need for information. Therapists
must be familiar with applicable laws and statutes governing the withholding of infor-
mation from parents. Beyond the need to conform to any legal obligations, therapists
should consider what level of information sharing with parents, guardians and teachers
is most helpful to achieve the best care and outcomes for their child and adolescent
patients. Based in part on recommendations summarized by Luepker (2003), the
following guidelines can help to determine whether or not to disclose information to
parents or guardians:
1. Weigh the pros and cons of telling or not telling other parties. This includes
determining if the recipient of the information would be in a position to protect the
patient’s privacy and to help with the treatment.
2. Discuss with the parents or guardians the importance of respecting the child’s need
for privacy for the success of treatment.
3. Explain to parents or guardians the importance of the therapist being able to make
professional decisions, in accordance with professional ethics and applicable laws,
about what is necessary for others to know.
4. Reassure parents or guardians that they will be informed of any risk which they can
help to manage.
5. Limit discussions with teachers and principals to (a) information necessary for the
child’s safety, (b) general information about prognosis, such as when they might
expect to see change in the child’s behavior, (c) assurances that the school’s concerns
are being addressed in treatment and (d) things school personnel can do to assist the
child’s treatment.
 Chapter 11: Case Management 183

6. Discuss with the child or adolescent the nature and extent of arrangements planned
for the exchange of information with others.
Luepker (2003) further suggests having parents and guardians sign a confidentiality
statement that acknowledges their agreement with the principles listed above in points
two to four.

Controlling the Scope of Disclosure

When it is to the benefit of the patient to share confidential information with third
parties, the type and extent of disclosure should be carefully controlled. The guiding
principle is to restrict the information to be disclosed to the least amount necessary to
serve a narrowly defined purpose, for a specified occasion or time frame, involving a
designated target person or persons. Different consent forms should be used that
correspond to different types and levels of disclosure. For example, one type of form
pertains only to requesting information from others. This deliberately restricts the infor-
mation flow to one direction only (i.e., from others to the therapist), and does not release
any current patient details to the other party (e.g., results from a medication evaluation
by a general practitioner). Alternatively, another version provides consent only for
releasing information to others (e.g., to the patient’s lawyer in a custody case), but does
not permit the other party (e.g., the lawyer) to divulge information to the therapist.
Finally, the least restrictive type of consent form allows for the exchanging of information
with others. That is, information may flow in both directions. Within each of those
general categories of consent forms for disclosure of patient information, each one
should be uniquely tailored to a specific purpose, clearly identify which person(s) are
to provide or receive information, state the date or event when authorization expires and
document the patient’s right to revoke consent at any time (Luepker, 2003).
As a general rule, when disclosing information to third parties, it is best to err on the
side of caution and send too little rather than too much information. Recipients can
always request additional information if necessary. Importantly, unless there are special
circumstances defined by law or professional codes as discussed earlier in the chapter,
therapists must seek the consent of their patients before disclosing any patient infor-
mation. Thus, when receiving phone calls or letters from third parties offering or
requesting information about a patient, beginning therapists must be on guard to not
even acknowledge that they know the patient, or that the patient is receiving services. For
example, the simple confirmation of a patient being seen at a “mental health” clinic could
have harmful consequences for the patient, if the caller had sinister motives (e.g., a nosy
employer or an ex-spouse involved in a custody battle). Therapists can respond to such
requests for information that are not covered by prior signed consent agreements by
saying: “All information held at this clinic is confidential. I cannot tell you whether or
not the person you are referring to is a patient here. If you want information regarding
that person, you need to contact that person directly.”

Securing Patient Information

Therapists must ensure that all their patient records are stored securely and locked.
Nowadays, information storage and transmission often occur in electronic format, which
presents additional security risks that therapists must take care to minimize. Therapists
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184 Chapter 11: Case Management

have the responsibility of ensuring that no such materials are exposed in any way to the
eyes of the innocent or interested. The following guidelines can help trainee therapists
avoid the risks posed by some of the common threats to confidentiality:
 Return records (including USB sticks, portable drives, and video or audio recordings)
to locked filing cabinets immediately after use.
 Cloud storage of medical data is becoming increasingly common. Cloud storage
involves storing data online, rather than storing it locally on a device such as a hard
drive. Risk mitigation procedures are continuously updated, and it is important to
ensure that one’s own practices comply with current workplace security requirements
(for further information and useful resources on the safe cloud storage of medical
data see MDA, 2018).
 Do not leave any materials on which identifying patient information is visible on
counters, desks, floors or in unlocked furniture.
 Do not remove any files or patient records from the clinic or authorized premises
(see also the case example below). This applies to the files themselves, as well as to
electronic copies.
 Ensure that computers or workstations have appropriate security and that the
security is operational (e.g., activate a password protected screensaver when leaving
your desk). If the computer is networked, ensure that your files are not in a
shared directory.
 Patient materials should not be duplicated for therapists’ private records.
 Make it a routine practice to write in bold letters “STRICTLY CONFIDENTIAL” at
the top of all reports, faxes, and electronic or other similar communications.
 When writing or editing drafts of reports electronically, it is good practice to only use
initials of the patient’s name and disguise other identifying information, until you are
ready to print the final version.
 When printing patient reports, test results, etc., collect printed materials immediately
(e.g., do not stop on the way to the printer to chat with a colleague in the hall; an
emergency call or other event can easily divert attention and result in the report being
forgotten and left unattended in the printer tray).
 In the event of printer problems, always first delete your current print job before
attempting to print again (e.g., having pushed the print button repeatedly in the belief
it did not work the first time, can result in additional copies being printed and left
unattended without the therapist being even aware of it).
 If faxing patient records, it is good practice to first call the recipient and ensure that
authorized personnel are on standby to collect the transmitted materials. Conversely,
when expecting a fax, ensure that incoming faxes are monitored and processed by
authorized personnel only.
 Erase audio and video recordings of sessions immediately after their intended
purpose (e.g., use in supervision) or in accordance with established agency policy.
 Do not discuss with others identifying patient information in hallways, reception
areas, elevators, or similar environs that are open to the public or non-authorized
personnel.
The following case example illustrates how the failure to follow these basic guidelines in
securing confidentiality of patient information can lead to serious potential risk for the
 Chapter 11: Case Management 185

clients involved, as well as to serious repercussions for the trainee therapist responsible
for the breach in security.
Case example. A student had taken various confidential case materials out of the
treatment centre with the intention of completing several assessment reports at home.
While the case materials were still in the student’s car, the vehicle was stolen along with
all the confidential case materials and some expensive testing kits. One of the serious
implications for the affected clients was that the breach in security and the resultant
failure to protect the clients’ confidential details made them vulnerable to the risk of
“identity theft”. The repercussions for the student responsible for this security breach
were appropriately severe. The student failed the practicum course, had to repeat an
ethics course, had to purchase two test kits that had been stolen, had to recreate each of
the clients’ files, and had to inform the clients about the theft and the potential threat to
their confidential details. Although most clients took the information well, one client
expressed concern over becoming a victim of identity theft. In response, the training
clinic offered the client a one-year membership to an identity theft company.
As this example illustrates, a breach of confidentiality resulted as a direct conse-
quence of a student failing to adhere to established case management policies and
procedures. It underscores the point made at the beginning of this chapter; there is no
good treatment without good case management.
Protecting clients from unintended disclosure of confidential information has
become more complex, with rapid technological advances changing the ease by which
psychologists create, transmit and share electronic patient records. Trainees must learn
how to understand and use the unique aspects of electronic record keeping in each of the
settings they encounter during their practical training (APA, 2007). Even beyond their
current training environment, graduates must recognize the benefits and dangers inher-
ent in the technological transformation of health care delivery and communication
methods, anticipate how future advances will continue to impact practice, and prepare
to embrace the opportunities it brings for improving patient care (e.g., Druss et al., 2014)
while meeting new challenges to the security of patient information (Maheu et al., 2012).
As the use of mobile smart devices and cloud computing spreads in health care delivery,
it is imperative that psychologists provide protection against unauthorized access of
sensitive patient records via the use of passwords and encryption methods (APA, 2007).
In Australia, the Notifiable Data Breaches scheme was established in 2018 to improve
consumer protection and strengthen security standards for protecting personal infor-
mation (Office of the Australian Information Commissioner, 2020). One key objective of
the scheme is that individuals who are at risk of serious harm due to a data breach are
notified of the breach in a timely manner and can take steps to reduce the risk of harm.
There were over 1,000 data breaches noted under the scheme in the most recent financial
year alone. Although malicious or criminal attacks (including cyber incidents) are the
leading cause of data breaches (just over 60 per cent), human error accounts for about
one-third of all data breaches (e.g., sending personal information to the wrong recipient
via email or post). It is noteworthy that health service providers have consistently
reported the most data breaches compared to other industry sectors since the start of
the Notifiable Data Breaches scheme (Office of the Australian Information
Commissioner, 2020). The high rate of human error as the cause of data breaches
highlights that the case management task of keeping patient information secure requires
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vigilance.
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A particular challenge to privacy and confidentiality arises from the unrelenting

penetration of digital culture and social media for patients and treatment providers
alike. Both psychologists and clients access personal information about each other via
search engines and social networking sites (Kolmes, 2012). Trainees must be mindful of
how they want their private and professional identities in the virtual world to appear to
their clients. When is finding this information beneficial or harmful to the therapeutic
relationship? When does accessing information about a client on the internet blur the
professional boundaries between therapist and client? There are many ethical pitfalls to
be avoided when accessing internet data about clients. As a rule of thumb, Kaslow,
Patterson and Gottlieb (2011) warn that one should never seek internet information
about a client simply out of curiosity. When in doubt, they recommend that the best
course of action is always to consider how one would wish to be treated in a similar
situation, and to keep the interests of the client paramount.

Tasks Associated With the Intake and Treatment Planning Phase

In the following sections, we will review the key case management and documentation
tasks associated with intake and treatment planning (see Figure 11.2).
Good management of the intake and treatment planning phase is essential for getting
the treatment off to a good start. It facilitates early rapport building, generates momen-
tum for change, and sets the tone for a goal-oriented working relationship with
the client.

Getting Treatment Underway

The first case management task is to seek informed consent from the client prior to
carrying out any assessment or intervention. Many clients sign informed consent forms

Documentation tasks Conceptual task Management tasks

Client data

Theoretical & Clinical training &

empirical literature experience

Integrate evidence-based practice with practice-based evidence

Communicate treatment parameters

Assessment & Clarify referral issues
case formulation Consider ethical issues
Produce intake report Open file
Present case information
Treatment planning
[Develop risk management plan]
& measurement
Monitor payment
Enter baseline data in data base

Treatment implementation
& monitoring

Evaluation &
accountability

Figure 11.2 Tasks associated with the intake and treatment planning phase.
 Chapter 11: Case Management 187

as part of their application for services; others may wait until their first appointment to
clarify any questions before signing. In either case, the parameters of the treatment
process should be discussed before commencing therapeutic work. These include the
limits to confidentiality (discussed earlier in this chapter), payment procedures, schedul-
ing of sessions, arrangements for consultation with third parties if applicable (e.g.,
monitoring medication by a psychiatrist, referrals for specialist testing, or periodic joint
sessions with a spouse). When a client is accepted following a referral, the nature of the
involvement (if any) of the referral source needs to be clarified. Regardless of the extent
of their continued involvement, referrers should be advised whether or not a referral has
been accepted.
In addition to obtaining informed consent and clarifying referral issues, it is the
therapist’s responsibility to consider any ethical issues before providing services. For each
client, therapists have a professional duty to make a judgement if their abilities match the
needs of the presenting case, or if other circumstances (e.g., prior acquaintance or
relations with the client outside the therapeutic context) could jeopardize optimal client
care. In those instances, clients should be referred to another professional.
Once a decision is reached to take on a client, a file needs to be opened that contains
the signed consent form and any relevant referral information.

Presenting and Documenting Case Information

An important aspect of good case management is the therapist’s ability to communicate
to others verbally and in writing who the client is, what the presenting problem is, what
the factors are that cause and maintain the presenting problem, and how these factors
can be influenced by the proposed treatment plan. Presentation of summary case infor-
mation during the intake and treatment planning phase occurs in two main formats:
brief verbal presentations at clinical staff meetings or rounds, and succinct written intake
reports. The operative words here are brief and succinct! Unfortunately, the aim of
achieving brevity and succinctness in presenting case information tends to conflict with
the novice’s understandable anxiety over evaluation and their fragile confidence in
knowing what details are germane to the case and should or should not be included
when presenting a case. As a consequence, novices often test the patience of their
colleagues and supervisors by indulging in meandering discourse about their patients’
life journeys, only to end up rushing through what is the most important part of
communicating case information – offering an integrative case formulation along with
specific, measurable treatment goals derived from it. Unduly long presentations and
reports also result from a tendency among novices to use templates of the structure and
content of case reports inappropriately as a mandatory proscription to cover every point
of the template, rather than using the template as a guide to be selective about which
aspects of a case are the most germane for enabling others to understand the basis for the
case formulation and treatment plan. What, then, is the cure for the novice’s affliction of
producing case presentations and reports that typically are too long to be useful in the
fast-paced reality of modern clinical practice?
The first antidote to overly long case presentations and reports is to remember that
clinical psychology services are delivered in a competitive health- care market where time
is a precious commodity. Put simply, there is no time for long presentations. Long
reports do not get read and unread reports are not in the best interest of your client.
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188 Chapter 11: Case Management

Figure 11.3 Schematic illustration of the

Client details & presenting problem Seconds relative importance of case presentation
components.
Relevant background
3 Minutes
Relevant results of tests

CASE FORMULATION

2 Minutes
TREATMENT PLAN
(specific goals & strategies)

Consultation 1–5 Minutes

The second antidote is to approach preparation of case presentations and reports not in
the order in which they are eventually delivered (client details, presenting problem,
background, etc.), but by first writing out the case formulation and treatment plan.
For example, presenting a formulation and treatment plan should take about two
minutes. That means there are about three minutes left out of a finite total presentation
time of circa five minutes. Thus, the number of background details that can be presented
must be restricted to those that are the most relevant and that best illustrate the rationale
for the formulation and treatment plan, while still fitting within the remaining three-
minute time limit (see Figure 11.3).
The primary purpose of a case presentation is quality assurance. That is, an integra-
tive case formulation and the treatment plan that follows from it are presented to
colleagues for the purpose of feedback and consultation. Therefore, precious presenta-
tion time must be used wisely, with the components covering case formulation, treat-
ment plan and consultation with colleagues receiving the greatest weight (see
Figure 11.3). The primary purpose of case reports is accountability. Similarly to case
presentations, the emphasis in case reports should be on the case formulation and
treatment plan, with details from background information, current interpersonal and
social functioning, and scores on objective assessment measures serving as “evidence” to
support and selectively illustrate the rationale behind the case formulation and treatment
plan. Because the complete test results are available in the patient’s file for future reference,
and because background details, if they were relevant enough to be recorded in the
progress notes, can be retrieved at any time if necessary, it is sufficient for summary
reports to only include illustrative key details supporting the formulation and treatment
plan. This will ensure that case reports are succinct, focused on the presenting problem,
and practical in day-to-day case management (see Chapter 3 for a comprehensive list of
intake information from which key client data would be selected for inclusion in a case
report). Notwithstanding the importance of succinctness in presenting and documenting
case information, case reports do require greater detail when the assessment indicates that
the treatment must also be accompanied by a risk management plan.
 Chapter 11: Case Management 189

Assessing and Managing Risk

The burden of determining when clients are at risk of harming themselves or others
weighs heavily on any therapist, especially on the inexperienced trainee. With respect to
self-harming behaviours, the disconcerting fact is that they cannot be reliably predicted
at the level of the individual (Fowler, 2012). Suicidal states are variable and usually time
limited in nature, and they are modifiable in response to treatment. Therefore, the
continual monitoring, assessment and documentation of current risk level is an essential
part of good case management and reasonable and prudent patient care (Bongar &
Sullivan, 2013). Science can serve as an ally in the effective management of risk (Kashyap,
Hooke & Page, 2015; Restifo et al., 2015; Seligman, 1996a), because the burden of
uncertainty can be allayed somewhat with the help of empirically derived practice
guidelines on how to assess and manage suicidal clients.
A reasonable and prudent approach requires a multidimensional assessment incorp-
orating both a thorough clinical interview asking about suicidal thoughts, plans, behav-
iour and intent, supplemented by actuarial data from scales measuring relevant risk and
protective factors. This information is used to benchmark risk, conduct a risk-benefit
analysis of alternative courses of action, and inform an intervention plan to increase
safety and reduce risk (Fowler, 2012). There are over 60 risk factors identified in the
literature (American Psychiatric Association, 2003), with the strongest empirical support
for history of previous suicide attempts, mental disorders, social isolation, physical
illness, unemployment and family conflict (Bongar & Sullivan, 2013). There is emerging
evidence that assessment of proximal risk factors arising from a sense of perceived
disconnectedness from others and the belief that one is a burden on others, combined
with an acquired confidence in being able to overcome one’s innate fear of death and
engage in lethal self-harm, should be part of a prudent risk assessment (Ribeiro et al.,
2013). Particular emphasis is on those risk factors (e.g., social isolation, psychological
distress, hopelessness, etc.) that can be modified as part of the intervention plan.
Protective factors are also important to consider (Page & Stritzke, 2020). The
counterbalancing role of protective factors in strengthening resilience in the face of
elevated risk may prove crucial in determining the outcome of a suicidal crisis (Johnson
et al., 2011). Protective factors can be external, such as responsibility to loved ones or
supportive interpersonal relationships, as well as internal, such as strong reasons for
living and zest for life (George et al., 2020; Malone et al., 2000), a sense of meaning and
purpose in life (Collins et al., 2018; Kleiman & Beaver, 2013), as well as good coping
skills, frustration tolerance and religious affiliations (Fowler, 2012). Scales such as the
Reasons for Living Inventory (Linehan et al., 1983) and the Zest for Life Scale (George
et al., 2020) can enhance the evaluation of suicide risk. One practical risk assessment
framework that explicitly evaluates the counterbalance of protective factors is the Suicide
Assessment Five-step Evaluation and Triage protocol (SAFE-T; Jacobs, 2007;).
Because suicide risk is fluid and can wax and wane rapidly, it is important to make a
distinction between chronic and acute features of a suicidal crisis (Kyron et al., 2019;
Rudd, 2008). Those with a history of multiple suicide attempts should be considered at a
higher baseline and chronic level of risk for suicide. That is, their risk is elevated even in
the absence of acute risk factors, and their vulnerability to exacerbation in response to
acute stress is greater than for those who are not multiple attempters. Taking this critical
distinction as a starting point, an empirically grounded decision framework for
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190 Chapter 11: Case Management

determining the level of risk associated with suicidal symptoms, and what actions to take
depending on the severity of risk, has been described by Joiner and his colleagues (Joiner
et al., 1999). According to this decision framework, the mere presence of some suicidal
ideation is not very useful in determining risk status, because some suicidal thoughts are
encountered routinely among treatment-seeking individuals and are not uncommon
even in the general population. The most crucial variables determining suicide risk are
history of prior attempts combined with the nature of current suicidal symptoms and the
number of other known risk factors. Accordingly, the first step in the assessment of
suicide risk severity is to determine if the client can be categorized as a multiple attempter
or non-multiple attempter, because the baseline risk for multiple attempters is always
elevated compared to single attempters and mere ideators. Therefore, risk is assessed
differently for multiple and non-multiple attempters (see Figure 11.4). The presence of at
least one risk factor translates into at least a moderate risk level for multiple attempters,
but not necessarily for non-multiple attempters, unless it involves resolved plans and
preparation to commit suicide. Thus, the second step in assessing risk severity is to
determine if the client has a plan, how specific that plan is, if the means and opportunity
to execute the plan are available and if the client has made any preparations for the
attempt. One should also consider here the duration and intensity (rather than fre-
quency) of suicidal desire and ideation. The third step in suicide risk assessment is to
identify if there are additional risk factors that can raise the level of risk beyond that
associated with the domains of resolved plans and preparation or suicidal desire and
ideation alone. These risk factors include but are not limited to (a) recent stressful life
events (e.g., divorce, legal troubles), (b) diagnostic comorbidity (especially mood and
anxiety disorders, alcohol use and hopelessness), (c) chaotic or abusive family history, (d)
impulsive behavioural style and (e) limited social connectedness. Others such as hope-
lessness and perceived burdensomeness as mentioned above should be assessed.
Once the level of risk severity has been classified as either low to mild, moderate or
severe to extreme, different risk management strategies are called for depending on the
level of risk. Table 11.1 summarizes the various risk management activities associated
with each level of severity. It also provides example statements of how to discuss with
clients the risk management activities at each level of intervention. It is recommended
that patients at moderate risk be given a crisis response or safety plan. This can be done
on a card that they can carry with them at all times (Joiner et al., 1999; Oordt et al., 2005),
or by using an app such as “Beyond Now” (Melvin et al., 2019). If using a card, it has a
step-by-step list of what to do when thoughts about suicide occur, including phone
numbers of alternative support services (e.g., “If the thoughts continue, and I find myself
preparing to do something, I call the clinic at: _____”; or “If I cannot reach anyone at the
clinic, I call: _____”). If using a smartphone application such as the Beyond Now app,
individuals can use it to create, edit, access and share their personalized safety plan.
Online resources such as those provided by Beyond Blue (2021) show how this app helps
with putting all the person’s coping tools in a series of steps:
 recognising your warning signs
 making your surroundings safe
 reminders of reasons to live
 things that can make you feel strong
 people and places to connect with
 Chapter 11: Case Management 191

Multiple attempters

Resolved plans and

preparation?

Suicidal desire and

Yes No ideation?

Yes No 1 other risk factor?

Extreme

Moderate Yes No

Moderate Mild

2+ other risk factors?

Severe

Non-multiple attempters

Resolved plans and

preparation?

Suicidal desire and

Yes No ideation?

Yes No
Moderate

Mild Low
1 other risk factor?

2+ other risk factors?

Severe

Moderate
2+ other risk factors?

Extreme

Figure 11.4 A decision framework for the assessment of suicide risk severity (based on Joiner et al., 1999).

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192 Chapter 11: Case Management

Table 11.1. Summary of what to do in response to different suicide risk categories

Risk Risk management activities Example statements

Severity
Low to – continued risk assessment “In the event that you start feeling that you
mild – document in progress notes want to harm yourself, here’s what I want
you to do: First, use the skills for self-control
we’ll discuss, such as challenging your
negative thoughts and seeking social
support. If suicidal feelings remain, contact
me or the clinic. If you are unable to reach
anyone, or, if you feel you need assistance
straight away, call or go to the emergency
room – here is the number.”
“Have you had any thoughts of harming
yourself since I last saw you?”
Moderate – increase frequency of sessions “It is important that we put some strategies in
– involve supportive others place that keep you safe and help you gain
– stay in touch via phone contacts control over your suicidal feelings.”
– consider medication “One of the things that will help you is . . .”
– provide detailed emergency plan “Until you feel things are under control again,
– monitor changes in risk level I recommend that for the next [time period]
– reevaluate treatment goals we schedule more frequent visits.”
- seek consultation “I want you to carry this crisis response plan
– document changing risk levels card with you at all times. It lists the steps you
– document clinical decisions need to take when thinking about suicide. Do
– document actions taken you agree to follow those steps when
– document risk resolution thinking about suicide?”
Severe to – accompany and monitor patient “At the moment you are not safe on your
extreme – evaluate for hospitalization own.”
– involve emergency services “Is there someone in your family that we can
– involve family members contact right now?”
– seek consultation “I am calling emergency services so they can
– document risk status assist us getting you to the hospital for
– document clinical decisions evaluation and crisis care.”
– document actions taken “I am going to ask my colleague/supervisor
– document risk resolution [add name] to come and join us while we are
waiting for your family/emergency staff to
get here.”
Note: If highest risk category becomes
apparent during a phone contact, ask the
following questions right away:
“Where are you? [do your best to determine
the exact location]
“What is the phone number there, in case we
get disconnected?”
“Are you alone or is someone with you?”
“Have you eaten or did you drink anything
that is dangerous to your health?”
“Have you harmed or injured yourself?”
 Chapter 11: Case Management 193

 family and friends you can talk or chat with

 contacts for professional support.
One advantage of using a smartphone app for safety planning is that a red emergency
phone button can be included on each scroll down page to provide quick access to
preloaded local emergency service phone numbers (Melvin et al., 2019).
The importance of routinely documenting all decisions and interventions for main-
taining the safety of clients until the suicidal risk has been resolved cannot be overstated
(Rudd et al., 1999). In terms of the characteristics of good records, more detail than usual
is appropriate, because details are highly relevant in the context of risk management. In
this instance, failure to be thorough can compromize patient safety, as well as the
therapist’s ability to prove that the level of care conformed to professional standards of
empirically grounded practice and reasonable and prudent care. Trainees should note
that the traditional widespread practice of using so-called no-suicide contracts is not
recommended (Rudd, Mandrusiak & Joiner, 2006). Documenting in the file that a
patient has “contracted for safety” has no force in law and has little value in protecting
therapists from malpractice liability (Bongar & Sullivan, 2013). Instead of a no-suicide
contract, it is recommended, as mentioned above, to negotiate with the client a crisis
response plan with the focus on an alliance for safety. Here, the client is encouraged to
make a commitment to living by agreeing to actively participate in the intervention and
make use of the crisis response plan and any safety planning strategies agreed upon
(Stanley & Brown, 2012). Finally, it is reasonable and prudent practice that when suicide
risk increases, the level of documentation must increase to reflect this, so should the
amount of peer and expert consultation (Bongar & Sullivan, 2013). It is paramount for
trainees to maintain meticulous, contemporaneous notes of the rationale for all critical
crisis management decisions. That is, what actions were taken and why, as well as what
actions were not taken and why not. This approach clearly demonstrates the clinician’s
decision-making, that less and more restrictive actions were considered and the rationale
for the final plan. If a client completes suicide, the Coroner will not expect the clinician
to be able to predict the future, but will expect to see evidence that the clinician engaged
in a process of sound decision-making based on the information that was available at the
time. When writing those notes it can be helpful for trainees to imagine that a lawyer is
looking over their shoulder.
In addition to assessing and managing any risks to a patient’s own safety, it may also
become necessary to respond to situations where the patient’s behaviour, or expressed
intent to act, constitutes an imminent risk to others, including the therapist. When such
a crisis situation arises, the therapist must initiate emergency procedures. Although it is
likely that a supervisor will be at hand to assist with or handle a crisis situation, every
trainee has the responsibility to not only be aware of the emergency procedures pertain-
ing to their training clinic or clinical placement sites, but to know them by heart. Once a
crisis unfolds, it is too late to consult the procedures manual for guidance. Emergency
procedures are usually tailored to specific demands associated with the locale, type of
client population, availability of onsite staff and proximity of support services such as
police and psychiatric emergency response teams. Because these demands can vary
considerably across sites, the onus is on the trainee to become thoroughly familiar with
the emergency procedures specific to each training site. In general, all emergency
procedures share the following core principles:
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194 Chapter 11: Case Management

 Foremost, be aware of your own safety and that of others in close proximity.
 If necessary, get yourself and others away from the danger.
 Notify everyone in the clinic of the emergency situation (e.g., activate “panic button”
in the consulting room; alert the reception staff ).
 Notify any available supervisors.
 Request intervention by security staff, police or psychiatric emergency response units.
When it becomes necessary to involve especially trained emergency response personnel,
the therapist needs to be prepared to tell them everything they want to know about the
client and to listen to their advice on how the situation is to be handled. They are the
experts, and once they are on the scene, they are in charge and the responsibility for the
patient’s wellbeing rests with them.
Finally, there are situations where the risk is not imminent, but where a client’s
behaviour nonetheless poses a potentially serious risk to others. For example, an HIV-
positive patient might tell the therapist that he or she is engaging in unprotected sex with
their partner(s) who are unaware of the patient’s disease status. In many jurisdictions,
therapists have a legal obligation to report infectious diseases to health authorities. In
some jurisdictions, there are also provisions for health care providers to protect and
notify identifiable others. In these situations it is good practice for therapists to seek legal
advice on reporting infectious and potentially harmful conditions without the patient’s
consent (Luepker, 2003). As always, all activities associated with the risk management of
such cases must be carefully documented in the client’s file.

Tasks Associated With the Treatment Implementation Phase

Once an intake report has been filed, baseline assessment data have been collected for
each treatment goal and treatment has commenced, the focus of case management is to
ensure that the therapeutic process unfolds in a manner consistent with the treatment
plan. Thus, the key management tasks associated with the treatment implementation
phase are (a) the routine review of progress toward goal attainment, which may necessi-
tate adjustments to the treatment plan or diagnostic impression (in response to the
monitoring data being collected) and (b) the initiation of preparatory steps that will
strengthen the client’s capacity for independent coping upon termination of treatment
(see Figure 11.5). If applicable, risk management activities need to be executed as
planned and carefully documented, noting any change in risk status and any modifica-
tions to the risk management plan, and the reasons for those modifications. In the fiscal
domain of case management, therapists must monitor the payment of services and keep
accurate billing records which document the date, length and type of services, the cost of
the services and in what form payment was received (e.g., cash, check or credit card).

Documenting Progress towards Goal Attainment

All events associated with the treatment of a client should be recorded in the progress
notes. These provide records of every contact with the client (in person, by phone, email,
text messaging or post), or concerning the client (e.g., a phone call to arrange aftercare
services), as well as an up-to-date summary of therapy sessions. Table 11.2 provides an
outline and examples of how to write a typical progress note.
 Chapter 11: Case Management 195

Documentation tasks Conceptual task Management tasks

Client data

Theoretical & Clinical training &

empirical literature experience

Integrate evidence-based practice with practice-based evidence

Assessment &
case formulation

Treatment planning
& measurement
[Execute risk management]

Document progress Review goal attainment

Document risk management Treatment implementation Initiate termination planning

Keep billing records & monitoring Monitor payment

Update database

Evaluation &
accountability

Figure 11.5 Tasks associated with the treatment implementation phase.

Initiating Termination Planning

The ultimate goal of treatment is to help clients to regain agency over their lives and
emotional wellbeing in the shortest period possible. Thus, termination of treatment
becomes an automatic goal as soon as the client walks through the door for the first
appointment. In order for the client and therapist to know when treatment can be
brought to a close, it is important for the therapist to consider this question jointly with
the client throughout the treatment process as part of ongoing case management. Of
course, thinking about the time after treatment and being on their own again without the
regular support of the therapist may be furthest on the mind of clients who have just
turned to therapy for help because they felt helpless on their own. Similarly, beginning
therapists understandably get preoccupied with the immediate demands of current
treatment, rather than preparing simultaneously for the more distal time when they
are not needed any more by the client. Thus, the fear of the client to be “abandoned” by
the therapist before the client feels ready, and the inclination of the therapist to aim for
the best possible treatment outcome before “letting go” of the client, can conspire to
overshoot the target and unnecessarily prolong treatment. That is, the failure to initiate
termination planning early in treatment, could lead to a bumpy ending of the therapeutic
relationship, rather than a smooth transition towards closure and a return to life without
therapy. Further, for individuals who require inpatient treatment, it is good practice to
discuss possible discharge dates early in the hospitalization and subsequent plans for
follow-up care so that patients have a clear concept of the treatment plan.
Routine termination planning during the treatment implementation phase helps the
therapist to determine when treatment is “good enough” (see also Chapter 16 on the
concept of “good enough treatment”). It also ensures that any distress associated with
feelings of loss or abandonment that a client may experience as a result of terminating
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196 Chapter 11: Case Management

Table 11.2. How to write progress notes

Order Content Examples From Different Clients

1. A sentence describing the client’s “Came on time, neatly dressed, sat stiff
▪ appearance and tense the whole interview,
▪ moods and feelings occasionally fidgeting with things on
▪ behaviour the table; seemed anxious and angry.”
“Came ten minutes late, un-ironed
clothes, sat motionless staring at the
floor, seemed deeply dejected.”
2. A sentence or two on what the client “He said he was working more, but still
told the therapist about unable to sleep and the quarrels with
▪ changes in symptoms and behaviour his wife were getting worse.”
▪ changes in life situation “She said that the children were getting
▪ new insights along better at daycare and she wasn’t
▪ thoughts on previous session or so irritable at work anymore and that
treatment goals she and her husband seemed to be
talking better. Now that
communication within the family has
improved, she wants to focus more on
her goal to take up again some non-
family-related activities.”
3. A sentence stating what the primary “The primary goal of the session was to
goal(s) was (were) for the session examine X’s catastrophic thinking in
response to her recent worries about
her upcoming promotion to head one
of the regional company offices.”
4. A sentence or two on the overall “He began by complaining about his
content of the session, and a wife, but towards the end of the
statement to what extent the session session was talking more about how
goal(s) was (were) met, or to what he may be contributing to what went
extent overall treatment goals were on. This insight represents significant
successfully addressed progress towards him taking more
responsibility for his part in the
ongoing distress and frustration he
experiences in interpersonal
interactions. The conflict with his wife
served as an example for continuing
with the assertiveness module and
practising alternative approaches to
communicating with his wife.”
5. A sentence indicating goals for the “In the next session, we will again
next session or any changes or emphasize behavioural training in
innovations in the treatment plan social skills via role plays, now that
trying to gain insight into the reasons
for her shyness seems to have led to
little change in the level of social
interactions for the client.”
 Chapter 11: Case Management 197

Table 11.2. (cont.)

Order Content Examples From Different Clients

Throughout If applicable, important statements by “I said that at this point it would be
the therapist or client should be best for her to participate in the group
recorded verbatim program offered at GetWell Hospital.”
“He described his boss as a ‘liar and
womanizer’, and he believed that he
had no chance of promotion despite
his boss promising he ‘was next on the
list’.”

the therapeutic relationship can be dealt with in a gradual and supportive rather than
abrupt fashion. There is a simple way of incorporating termination planning during
treatment that is non-threatening and informative for both client and therapist. Early in
treatment, the therapist can initiate termination planning by telling the client that
“therapy has a beginning, middle, and end”, followed by the question, “where do you
see yourself at this moment in treatment?” The simple opening statement raises the
awareness of the client that treatment is time-limited and progresses toward a logical
endpoint. At the same time, the use of an open-ended follow-up question reassures the
client that the decision about ending treatment is reached collaboratively involving the
joint input of client and therapist. The answers clients give to that question are often eye-
opening for beginning therapists and serve as a reality check. Novice therapists are less
experienced in picking up cues from clients that treatment gains have solidified, or have
already generalized to domains in the client’s life that were not particularly targeted by
the treatment. Consequently, novices tend to underestimate their clients’ readiness for
termination. The use of routine termination planning can help to correct for this bias
and ensure that the focus of valuable session time at the latter stages of treatment
matches the client’s increasing readiness for moving on.

Tasks Associated With the Evaluation and Termination Phase

Ideally, goal attainment signals the end of treatment. Therefore, the key case manage-
ment tasks during the evaluation and termination phase are to collect final outcome data,
examine the change from baseline values and evaluate the clinical significance of the
change in relation to the goals specified in the treatment plan (see Figure 11.6). If there is
only partial change, or no change at all, or a worsening of symptoms in some areas
targeted by the treatment, then the therapist should consider follow-up services. If it is
clear that the client would not benefit from simply extending services, a referral to
alternative treatment providers should be considered. Analogous to brief case presenta-
tions during the intake phase, where therapists share case information with colleagues
for consultation on treatment decisions and planning, therapists often present a brief
update or termination summary to their colleagues, who can provide reflective feedback
on aspects of the treatment or suggestions for follow-up strategies if applicable. In
terminating relationships with clients, therapists must have the best interest of the client
in mind and show regard for the client’s ongoing wellbeing. In the event that therapists
must terminate treatment prematurely due to personal reasons (e.g., illness, change of
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198 Chapter 11: Case Management

Documentation tasks Conceptual task Management tasks

Client data

Theoretical & Clinical training &

empirical literature experience

Integrate evidence-based practice with practice-based evidence

Assessment &
case formulation

Treatment planning
& measurement
[Assess risk status]
Evaluate goal attainment
Treatment implementation
Consider follow-up
& monitoring
Present case information
Monitor payment
Produce termination/transfer report
Evaluation & Enter outcome data in database
Document risk management
accountability Close file

Figure 11.6 Tasks associated with the evaluation and termination phase.

employment, extended leave of absence), they should provide clients with an explanation
of the need for such early termination and take all reasonable steps to arrange for
alternative care.
If a risk management plan was in place during treatment, an important case manage-
ment responsibility is to re-assess risk status immediately prior to termination. Readiness
for termination is contingent upon resolution of the circumstances that had put the
client at a heightened level of risk at the start of treatment. Resolution of risk status needs
to be carefully documented in the termination report. Should the assessment of risk
status indicate any residual level of risk for the client, the therapist must document
carefully what preventative steps have been taken to ensure the client’s safety after the
end of the therapeutic relationship.
A major documentation task at the end of treatment is for the therapist to produce a
succinct termination or transfer report. A termination report should contain the
following information:
 Introductory summary: A brief statement about the presenting problem(s), the
number of sessions, and the time period over which services were provided (e.g., Ms
P. self-referred to the clinic for depression and relationship problems. She was seen
for eight sessions between 15 November 2019 and 27 March 2020).
 Focus of treatment: A brief paragraph on the treatment plan and the strategies used to
address goals of the plan.
 Progress and goal attainment: A paragraph stating what goals have and have not been
achieved, with direct reference to objective outcome measures (including a statement
on risk resolution if applicable).
 Concluding recommendation(s): A brief statement about the reasons for termination
and whether termination was mutually agreed upon, any specific arrangements for
 Chapter 11: Case Management 199

continuing care, and recommendations for relapse prevention and/or follow-ups if

applicable.
The final case management task is to close the client file in a timely manner and ensure
that it is stored securely in accordance with ethical guidelines and applicable
legal obligations.
The processes of case management may appear difficult, and the prospect of juggling
these management responsibilities alongside the many tasks associated with conducting
therapeutic interventions may seem daunting. However, this is where availing yourself of
competent and experienced supervision can be of real benefit. Clinical supervision will
be the topic of the following chapter.

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 Chapter
Supervision

12
Making the Most of Supervised Practice
Supervised practice is paramount to the teaching and learning of psychotherapy
(Watkins, 1997). The novice therapist in a university training programme typically
receives formal supervisory feedback at least once a week, and often benefits from
additional ad hoc and informal guidance by readily available supervisors. After graduat-
ing, therapists move on to positions where their contracts stipulate and guarantee them
the accumulation of a required minimum number of supervised practice hours for
accreditation. Once accredited, however, supervision is often harder to come by.
Reviews of clinical supervision in various mental health professions (Spence et al.,
2001; Strong et al., 2003; Townend, Iannetta & Freeston, 2002) concluded that the
realities of high caseloads, higher priority of crisis management, poor access to super-
visors and lack of clear policy guidelines are cited as reasons for many practitioners
receiving little or infrequent supervision. For example, in a sample of 170 cognitive-
behavioural therapists in the UK, the mean number of supervision hours received was
just over two hours per month for 52 hours of direct face-to-face client contact
(Townend et al., 2002). Thus, the intense level of supervision available during the initial
training of psychotherapists is a time-limited privilege! Moreover, in a survey of over
4,000 psychotherapists with different professional backgrounds, career levels, theoretical
orientations and nationalities, getting formal supervision was rated as the second most
positive influence on their career development, after the experience of working directly
with clients (Orlinsky, Botermans & Rønnestad, 2001). With that in mind, novice
supervisees should be highly motivated to be actively engaged in their supervision, and
to make the most of this important and valuable aspect of their training.

Goals of Supervision for Science-Informed Practice

Supervision is an interpersonal intervention that is both collaborative and evaluative. It
has the simultaneous goals of developing in supervisees the skills for science-informed
practice, monitoring the quality of the treatments delivered, and providing a safeguard that
keeps a supervisee who puts clients at risk from entering the profession (Bernard &
Goodyear, 2004). In addition, by encouraging self-efficacy in supervisees (Falender &
Shafranske, 2004), and by supervisors serving as role models, supervision provides a
supportive learning environment for supervisees to develop their own professional identity.
Figure 12.1 illustrates how these four primary goals of supervision map onto the
processes of the science-informed practice model introduced at the beginning of this
manual. The development of skills and competencies focuses on the specific clinical tasks
200
 Chapter 12: Supervision 201

Client data (problem, context, history, etc.)

Theoretical and Clinical training &

empirical literature experience

Sources of client data:

Assessment & Professional identity
referral information
test results case formulation
supervisee self-report
supervisee non-verbal behaviour Treatment planning
video tape & measurement Skills development
live observation +
Quality assurance
Treatment implementation
& monitoring
Gatekeeper function

Evaluation &
accountability

Figure 12.1 An illustration of how the four primary goals of supervision map onto the treatment process
highlighting the sources of client data available for supervisory input.

involved in linking client data to case formulation, treatment planning, implementation

and outcome evaluation. As such, “supervision provides the structure and framework for
learning how to apply knowledge, theory, and clinical procedures to solve human
problems” (Falender & Shafranske, 2004, p. 6). The aim of enhancing the professional
functioning of the supervisee in these essential clinical tasks goes hand-in-hand with the
supervisor’s primary ethical responsibility of monitoring client care. The supervisor
must assure that the quality of the services delivered by the supervisee meets appropriate
standards and achieves optimal outcomes for the client. In cases where formative
feedback has failed to enhance the supervisee’s competence and readiness to assume
the role of an independent practitioner, the supervisor’s summative assessment serves a
gatekeeper function to protect the welfare of clients, the integrity of the profession and
society at large.
In addition to enhancing professional functioning and monitoring quality of client
care, supervision serves the function of socializing supervisees into their professional
discipline (Bernard & Goodyear, 2004). That is, the personal growth experienced by
supervisees during training, as they gain experiences and mastery in clinical practice,
occurs in close association with the role models provided by senior members of the
supervisee’s own professional discipline. This collaborative process allows supervisees to
develop a professional identity, along with a clear sense of the unique contribution they
can make within the context of health care delivery systems that are multidisciplinary.
Good supervision must achieve a delicate balance in meeting the four goals discussed
above. This poses quite a challenge, because the relative weight assigned to each goal
varies depending on the stakeholder involved. Figure 12.2 shows how the supervisor
needs to consider the welfare of three principal stakeholders: the client, the clinician and
society at large. For example, quality assurance is of utmost importance to the client as
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202 Chapter 12: Supervision

Supervisor

Client Clinician Society

Quality assurance

Skills development

Professional identity

Gatekeeper function

Figure 12.2 The relevance of the four primary goals of supervision for three classes of stakeholders.

well as society and supersedes educative and training goals of the clinician. At the same
time, beginning therapists are expected to make mistakes and will need to hone their
skills. These mistakes may result in some delays and detours before treatment strategies
are successfully implemented. Formative supervisory feedback will help to facilitate this
learning process. The integration of the dual tasks of providing supervisees with practical
experience in learning how to apply their knowledge and skills to the provision of clinical
services, and ensuring that client welfare is not compromised in the name of training,
requires careful consideration of the sources of data available for supervisory input and
oversight (see Figure 12.1). Some client data (e.g., test results, video-recorded verbal and
non-verbal behaviour) are directly available for inspection by the supervisor. Similarly,
direct observation of live interactions between trainees and clients (e.g., via one-way
mirrors, online video access of live therapy sessions, or during jointly delivered client
contact) provide unfiltered data for the supervisor to consider. However, formal min-
imum requirements for supervisors to directly observe trainees can be as low as once per
academic term (Borden & McIlvried, 2020). This means that much of the data forming
the basis for supervisory scrutiny and feedback (e.g., supervisee self-report of session
content or process) will first pass through the selective and interpretative lens of the
supervisee. It is therefore important that supervisees learn to present supervision data in
a way that maximizes their utility for skills enhancement, professional growth and
quality assurance.

Setting an Agenda
As we have highlighted at the start of this chapter, to make the most of the supervision
experience, the supervisee must be an active participant in supervision. There are a
number of simple strategies that assist supervisees in harnessing the anxiety they
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inevitably experience in their initial work with clients, so that they can make the most of
the guidance provided by their supervisors. Evidence suggests that inexperienced super-
visees benefit from directive and structured supervision methods (Spence et al., 2001).
One such method is setting an agenda for the supervisions sessions. Coming to supervi-
sion without a plan of what issues demand the most attention is the least productive way
to use precious supervision time (Bernard & Goodyear, 2004). In contrast, developing a
tentative agenda for their supervision sessions is empowering to supervisees (Pearson,
2004). At the beginning of each supervision session, supervisees should be prepared to do
the following:
1. State what client contact has or has not occurred since last supervision.
2. Identify which issues with what clients need to be attended to.
3. Prioritize the importance of these issues. This includes estimating and requesting
specific periods of time for each issue keeping in mind the total available time.
4. State how this time is best to be used (e.g., I’d like us to review and discuss about six
minutes of videotape with Client A, and for Client B, I’d like to know whether I need
to shift greater focus on the third goal of the treatment plan, and how I should go
about doing that; this probably shouldn’t take more than 10 minutes, since we
already touched upon this last time).
5. Clearly identify your most immediate needs. As you help setting the tentative agenda,
let your supervisor know what you definitely need to take away from this particular
supervision session. One might call this stating your “conditions of satisfaction”.
That is, what is the absolute minimum you need to achieve during this supervision
session, so that you can be satisfied that you have a plan and a reasonable degree of
confidence for going into your next client sessions?
6. If supervision occurs in a group format, agenda setting may involve some negotiation
and “tradeoffs” between supervisees within and across supervision sessions in light of
perceived urgency and complexity of all issues deserving attention.
In sum, agenda setting and good time management enhance the effectiveness of
supervision.

Learning From (Audio) Video Recordings

Video recording is the technology of choice in supervision (Bernard & Goodyear, 2004),
although audio recording may serve as a back-up. The capacity to directly examine what
actually occurred during supervisee–client interactions provides an important tool by
which quality assurance can be achieved. Supervisees can be coached and validated with
respect to specific therapist behaviours in the context of specific situations, rather than
receiving feedback that is only as good as the general “picture” that is generated in the
supervisor’s mind through the lens of the supervisee’s self-report. While the advantages
for all stakeholders are obvious, supervisees tend to feel, at least initially, anxious and
vulnerable when using video recordings, as “there is no hiding from the stark reality of
one’s picture and voice being projected into the supervision room” (Bernard &
Goodyear, 2004, p. 219). However, evidence suggests that after repeated exposure to
being video recorded these initial aversive effects dissipate quickly (Ellis, Krengel & Beck,
2002). There are three simple steps that supervisees can take to get the most out of using
video recordings, while guarding against any inclination to engage in avoidance behav-
iours for the short-term gain of reducing their sense of vulnerability.
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204 Chapter 12: Supervision

Selecting Segments of Tape

The first step involves the pre-selection of segments of tape that would be most
productive to review. Although supervisors may at times review an entire tape prior to
supervision, supervisees are encouraged to become actively involved in this process from
the outset (Bernard & Goodyear, 2004). In deciding which segment to select for supervi-
sion, the supervisee can consider the following questions:
1. What part of the session seemed to be particularly productive?
2. What happened when I attempted to direct the session towards a specific goal as
planned in supervision?
3. What part was I particularly struggling with?
4. Was there a part that I was confused about?
5. Was there a part that raised a particularly important issue or recurrent theme?
6. Was there a part during which I felt a strong emotional reaction?
7. Was there a part during which my client expressed or showed signs of a significant
emotional reaction?
8. Was there a part where something occurred that made me change my plans for the
session?

Setting the Stage

The second step involves succinctly introducing each video segment so that the super-
visor is primed for what to expect and look for. Bernard and Goodyear (2004) recom-
mend the following procedure for supervisees when presenting their pre-selected video
segments:
1. State the reason for why you want to discuss this particular segment
in supervision.
2. State briefly what transpired up to that point.
3. Explain what you were trying to accomplish at that point in the session.
4. Clearly state the specific help desired from your supervisor.

Guarding Against Impression Management

The third step involves making a continuous commitment to contain counter-productive
levels of evaluation anxiety. Consider the following checklist (Table 12.1):

Table 12.1. Impression management checklist

Impression management checklist:

Yes No
1 Did I forget to press “record” on the video equipment? □ □
2 Did I forget to turn on the camera? □ □
3 Did I record over the relevant session by mistake? □ □
4 Was part of the session missing because of a technical glitch? □ □
5 Did I “run out of time” before I got to show the session? □ □
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If you find yourself answering “yes” on any of the above items more than once over
the course of two or more supervision sessions, there is a strong possibility that you are
engaging in counter-productive avoidance behaviours designed to reduce your fear of
being vulnerable. If so, it is important to address this issue with your supervisor.
The benefits of learning from moment-to-moment analysis of video recorded
client–supervisee interactions far outweigh the concerns.

Accounting for Supervisory Activities and Outcomes

Standards of practice in most mental health disciplines stipulate that written records of
supervisory contracts and supervisee evaluations are kept (Falvey & Cohen, 2003). In
addition, there are at least four reasons why it is good practice to document activities and
outcomes of supervision sessions. First, documentation of supervisory decision pro-
cesses, recommendations and outcomes affords some protection for supervisors who
may be held liable for a supervisee’s harmful actions. Second, it is a structural tool that
brings into focus the deliberate nature of science-informed, accountable practice. Third,
it provides the data for a proactive model of monitoring client progress, which can be
used to modify treatment plans that appear to be ineffective (Lambert & Hawkins, 2001).
Finally, the process of systematic and regular documentation reduces the risk that
supervisees feel overwhelmed with the complexities of their cases, fail to implement
key interventions in a timely manner, or overlook critical aspects of case management
(Lambert & Hawkins, 2001).
Various templates have been developed for documenting supervision activities and
outcomes (e.g., Bridge & Bascue, 1990; Falvey & Cohen, 2003). An example of a
Supervision Record Form is presented in Figure 12.3. The form begins with a section
to record the supervisee name, client ID, date of supervision session, and information on
frequency and type of client contact. The next few sections document the activities
central to a goal-directed approach to supervision. First, the supervisee’s specific agenda
items are listed, along with previous session goals and progress on achieving them. The
next item adds context (or the “big picture”) in terms of overall progress on the primary
treatment goals. Then any relevant new issues that have arisen in the work with the client
are recorded. This is followed by an explicit statement of what is planned for the next
session. Finally, a separate section focuses attention on risk management issues and the
steps taken to address them. Of course, risk assessment, crisis management and safety
planning decisions must be documented in greater details than is room for in this form
(e.g., Rudd, Cukrowicz & Bryan, 2008). Likewise, some of the other sections on goals,
progress, and treatment planning would often require more details in the progress notes.
The value of this succinct form is not in providing an exhaustive record, but it serves as a
“shorthand” tool to organise and focus the supervisee’s thinking about the key aspects of
the case at that point in time. This helps the supervisee to make the potentially complex
and overwhelming task of preparing for and benefiting from supervision a more
structured and manageable task.

Group Supervision
The proactive, structured, and goal-oriented activities associated with agenda setting,
purposeful examination of supervision data, and documentation of supervision
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206 Chapter 12: Supervision

SUPERVISION RECORD FORM

Supervisee: ________________________ Client ID: ________________ Date:__________

Client contact: Yes No If YES, indicate:

Face-to-face Phone Correspondence
Other
Date(s):____________Date(s): __________ Date(s): ____________ Date(s): _________
Duration: __________Duration: _________

Agenda/ i ssues/ request(s) for feedback: _______________________________

_____________
________________________________ ________________________________
________________
________________________________ ________________________________
________________
Previous session goal(s): ________________________________
__________________________
________________________________ ________________________________
________________
________________________________ ________________________________
________________
Progress on previous session goal(s): ________________________________
_______________
________________________________ ________________________________
________________
________________________________ ________________________________
________________
Progress on main treatment goal(s):________________________________
_________________
________________________________ ________________________________
________________
________________________________ ________________________________
________________
________________________________ ________________________________
________________
New issues:________________________________
________________________________
_______
________________________________
________________________________
________________
________________________________
________________________________
________________
Plan for next session:________________________________
______________________________
________________________________ ________________________________
________________
________________________________ ________________________________
________________
________________________________ ________________________________
________________
Supervisory activities: ________________________________
_____________________________
________________________________ ________________________________
________________
________________________________ ________________________________
________________
Risk management
(a) Issues:
________________________________
________________________________
___________
________________________________
________________________________
___________
(b) Action(s)
taken:
________________________________
________________________________
___________

Figure 12.3 Supervision Record Form.

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interventions and outcomes are equally applicable whether supervision is delivered in an

individual or group format. One often-cited potential limitation of group supervision
(Bernard & Goodyear, 2004), that individuals may not receive sufficient time to address
all their individual concerns, is a case in point. There is little risk that supervisees who
turn up to group supervision prepared, who have prioritized the issues that must be
attended to before supervision ends, and who routinely document feedback and recom-
mendations for these issues, will get less of what they need during group supervision
than during individual supervision. Likewise, although there may be more opportunities
for confidentiality concerns and unhelpful personal interactions to emerge when several
individuals are involved rather than just two (Bernard & Goodyear, 2004; Lyons, Mason,
Nutt & Keville, 2019), these problems can arise and require resolution in both formats.
Moreover, when a supervisee experiences discomfort in a particular interaction with a
supervisor, the presence of peers in the same room can be comforting and reduce
supervisee dependence on the supervisor, and peers can be helpful in validating the
supervisee’s perspective during or after the event. In addition, there are a number of
other advantages of the group format, including opportunities for vicarious learning,
exposure to a broader range of clients, increased diversity of feedback, and greater
resources to use action techniques. The modelling literature emphasizes that models of
coping are better than models of mastery, and, therefore, watching one’s peers and senior
students can be beneficial. Thus, the assumption that individual supervision is inherently
superior is not only a myth (Bernhard & Goodyear, 2004), but the efficiency and
advantages of group supervision often make it the format of choice, albeit within the
constraints set by accreditation bodies that typically require a certain minimum number
of individual supervision hours.

The Challenge to Advance Beyond the Familiar

The ultimate goal of supervised practice is for the supervisee to achieve competency as a
clinician and readiness to assume the role of a colleague who independently contributes
to the community and the discipline (Falender & Shafranske, 2004). The rate at which
beginning supervisees increase the proficiency with which they apply complex therapy
procedures and facilitate internal therapeutic processes varies considerably across indi-
viduals. The novice typically experiences high anxiety, is self-focused, is preoccupied
with performance of techniques and following guidelines, and worries about evaluation
(Stoltenberg & McNeill, 1997). Supervisory guidance during this period is therefore
highly supportive, structured and prescriptive. It focuses on consolidating basic strat-
egies rather than challenging supervisees to quickly expand their repertoire of techniques
beyond the trusted and familiar. As client contact increases and supervisees experience
some successes in implementing planned interventions, their initial sense of incompe-
tence gives way to a sense of accomplishment and even pride. At that point, supervisees
must guard against getting stuck in this comfort zone, where a set of rudimentary skills
may help a client or two and stave off disaster, but is inadequate for functioning within
the full scope and demands of independent clinical practice. Indeed, early adoption of
only one particular therapeutic approach or a rigid set of skills can lead to frustration
with situations not fitting that narrow range of skills, and ultimately to professional
stagnation or failure (Neufeldt, 2003). The challenge for supervisees is to remain flexible
and open when prompted by their supervisors to use each increase in their competence
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as a platform for pushing off towards the next level of professional development.
Venturing into unfamiliar territory will temporarily revive feelings of insecurity, but
this is a small price to pay for the rewards associated with gaining mastery over an
advanced repertoire of complex skills.

Formative and Summative Evaluation

Bernard and Goodyear (2004) described evaluation as the “nucleus” of clinical supervi-
sion, because it simultaneously supports the learning process, case management and
quality client care. Formative evaluation is ongoing and involves direct feedback on the
supervisee’s professional growth and effectiveness in performing clinical services. This
may take the form of formal reports at certain intervals (e.g., at the end of each rotation
or period of working with a given supervisor), or informal, frequent feedback during
each supervision session. In contrast, summative evaluation refers to “the moment of
truth when the supervisor steps back, takes stock, and decides how the trainee measures
up” (Bernard & Goodyear, 2004, p. 20). Anticipatory anxiety about receiving summative
evaluations can be quite distressing to supervisees. However, supervisees should bear in
mind that the criteria used during summative evaluation are the same that were
introduced at the outset of supervision as learning objectives, and that were used to
provide intermittent formative feedback throughout their supervision. That is, if there
was no clear indication during formative evaluation that a supervisee’s performance was
consistently below standard, then the supervisee should rest assured that summative
evaluation will not be suddenly negative. Supervisors have an ethical obligation to
apply due process procedures before a supervisee is given a negative final evaluation
(Bernard & Goodyear, 2004). This involves providing the supervisee with sufficient prior
warning, specific remedial advice and a reasonable period of time to improve.
The more supervisees get actively involved in the formative evaluation process, the
less daunting summative evaluation becomes. For the supervisee who establishes a habit
of self-scrutiny and responsibly documenting their supervision activities and outcomes,
it is only a small step to also self-evaluate their own work using the same criteria as the
supervisor. This will prepare them for the summative evaluation process. As illustrated
in Figure 12.1., supervisee competencies are evaluated in part against the measurable
outcomes of supervisees’ clinical interventions. That is, a competency-based approach to
clinical training and supervision is goal-directed and accountable to stakeholders
(Falender & Shafranske, 2012). In the following sections we review some of the chal-
lenges the profession has faced in implementing competency-based training and
accreditation models, and we provide some guidance on how to navigate the pitfalls
associated with the controversies plaguing this current “culture of competence” (Rodolfa &
Schaffer, 2019). Forewarned is forearmed!

A Competency-Based Approach to Supervision and Evaluation

The science-informed approach to education and training of psychologists encompasses
learning the basic science of the discipline, conducting research, and developing the
competencies for providing evidence-based psychological services in diverse clinical
settings (American Psychological Association, 2012). There are several indices of com-
petence in current use. Traditionally, these have focused on the number of clinical
contact hours accrued, satisfactory completion of practicum placements or internships
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and a certain period of time of supervised experiences following successful completion of

the degree. While these indices are still widely used, the aspiration of the competency
movement has been to shift the focus to the specific knowledge, skills, attitudes and
values necessary to be a competent practitioner and to the difficult task of assessing these
(Rodolfa & Schaffer, 2019). From a science-informed perspective on clinical training and
practice, it is concerning that current competency frameworks for evaluating trainees
have been derived through expert consensus and largely lack empirical validation
(Gonsalvez et al., 2020). Moreover, consensus views of which competencies are essential
change over time (Borden & McIlvried, 2020), or indeed, “consensus” has not always
been achieved. For example, in the United States, there have been two rival accreditation
systems since 2007, because no consensus could be reached on how essential science-
centred competencies should be in education and training in clinical psychology (Rodolfa &
Schaffer, 2019).
One of the psychology practitioner competencies that has been widely accepted as
“essential” or “foundational” is the concept of reflective practice (American
Psychological Association, 2012; British Psychological Society, 2019; Psychology
Board of Australia, 2017). Despite near universal adoption in training programmes
the world over, reflective practice techniques are still lacking an evidentiary base
(Lilienfeld & Basterfield, 2020).

On Becoming a Reflective Practitioner: Navigating the Science Gap

The conceptual boundaries of reflective practice as a competency are not well defined
(Gonsalvez et al., 2020). One viewpoint is that reflective practice and science-informed
practice are “orthogonal” and “coequal” elements of competent practice and, therefore,
as much time and attention during the supervisory process should be devoted to
reflective practice as to the acquisition of knowledge and skills (Schaffer & Rodolfa,
2020). In the United Kingdom, this presumed equivalence of self-reflection and scientific
evidence is reflected in the fact that clinical psychology training programmes at many
major universities subscribe to a “reflective scientist-practitioner model”. The underlying
belief is that scientific data can only take us so far and hence one also needs to rely on
thoughtful reflection (Lilienfeld & Basterfield, 2020). It can be confusing to trainees
when supervision guidelines emphasize that “the knowledge, skills, attitudes, and values
that serve as the foundation of competent practice must be evidence based (i.e., come
from research that is based on sound scientific methodology)” (Schaffer & Rodolfa,
2020), but competency in reflective practice is conceptually decoupled from the need for
such supportive evidence. A recent critical review urged that the use of reflective practice
methods during clinical training and supervision should come with a disclaimer in that
there is no evidence that these reflective practice training activities yield more reflective
practitioners or that they improve patient outcomes (Lilienfeld & Basterfield, 2020).
Moreover, the implicit assumption of reflective practice that trainees and current
practitioners can improve their performance by retrospectively thinking about any
shortcomings and then take corrective action lacks solid grounding in basic psycho-
logical science (Lilienfeld & Basterfield, 2020). There are several cognitive biases, heuris-
tics and logical fallacies that can adversely affect clinical decision-making (Bowes et al.,
2020). Attempting to acquire insight via introspective self-reflection is subject to the
same cognitive pitfalls.
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210 Chapter 12: Supervision

The introspection illusion refers to the erroneous belief that introspection affords
accurate insight into one’s own biases (Lilienfeld & Basterfield, 2020). That is, we are not
only biased but oblivious to our bias blind spots, because cognitive biases in clinical
practice tend to be inaccessible to conscious awareness (Bowes et al., 2020). Supervisees
who are left to their own self-reflective devices, will be unable to spot their own
shortcomings. For clinical trainees who are still at the early stages of their skills
development, this is further exacerbated by the Dunning-Kruger effect, whereby indi-
viduals who possess low levels of skills and knowledge tend to overestimate their skills
and knowledge. Thus, inexperienced clinicians required to self-reflect are the most likely
to fail to detect knowledge and skills gaps in need of improvement (Lilienfeld &
Basterfield, 2020).
Self-reflective practice is also prone to confirmation bias which refers to the propen-
sity to selectively accept information that aligns with one’s beliefs and disregard infor-
mation that does not (Bowes et al., 2020). This can preclude consideration of legitimate
alternatives, especially when information is ambiguous. Supervisees have an interest in
being judged to be competent. Hence, an uncertain trajectory of patient progress may be
misinterpreted as their intervention being effective and on track, when in fact the
uncertainty in patient progress may signal the need for corrective action. As we will
show later in this chapter, an alternative to such error-prone decision-making based on a
potentially biased, retrospective self-appraisal of clinical situations is a data-driven
process of reflection on clinical effectiveness based on proactive routine outcome
monitoring.
Overly self-focused reflection that is not grounded in routine outcome monitoring
and guided by collaborative patient input can turn into self-rumination (Lengelle, Luken
& Meijers, 2016). If retrospective, self-focused reflections fail to generate solutions, this
can be experienced as mental traps where one is stuck in continued thinking about
questions that cannot be answered without reference to data. This in turn can raise self-
doubt and bear risks for the well-being and adequate functioning of supervisees. One of
the supervisors’ tasks is to help supervisees accept and manage these uncertainties,
question their practice in more helpful ways, and disengage from unhelpful rumination
while considering strategies for drawing boundaries.
Many self-reflection activities that psychology training programmes ask trainees to
engage in (e.g., completing logbooks, personal journals, diaries or creating reflective
portfolios) are repetitive and time-consuming. Given the relentless demands of an
already busy training programme, there is a risk that supervisees will discharge these
prescribed tasks by merely checking the boxes of “good reflection” (de la Croix & Veen,
2018). Likewise, it remains unclear if supervisor evaluations of competency in reflective
practice assess the ability to actually do it, or just knowledge of what should be done and
skill in conveying that knowledge (Borden & McIlvried, 2020). Paradoxically, merely
conveying the perceived right attitude and value towards reflective practice does little to
foster genuine growth in competence but may increase vulnerability to engaging in
impression management. Such practices can feed into the impostor phenomenon where
supervisees experience a sense of professional fraudulence or inauthenticity and fear
being evaluated and found out (Mak et al., 2019). This is not a trivial impediment to
genuine competence building, as nearly nine in ten psychology trainees report at least a
moderate sense of feeling like an impostor (Tigranyan et al., 2020).
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In sum, reflective practice is considered a foundational competency to be achieved

during clinical training. It is lacking in supportive outcome evidence and is disconnected
from basic psychological science. From a science-informed perspective, this is far from
ideal and these pitfalls pose a challenge to trainees as they engage in required reflective
practice activities during their training. Fortunately, the increased use of automated
routine outcome monitoring recorded on a weekly or session-by-session basis together
with electronic patient management systems heralds a new era of data-driven reflective
practice and a patient-oriented model of supervision (Bennett-Levy et al., 2015).

Towards Data-Driven Reflective Practice

Proficiency in measurement-based mental health care and routine outcome monitoring
will become one of the core competencies required of the next generation of clinical
psychology trainees (Peterson & Fagan, 2017). Reflective practice will be increasingly
informed by computer-based feedback, decision-making and clinical problem-solving
systems such as the Trier Treatment Navigator (Lutz et al., 2019). Automated routine
outcome monitoring and patient-focused feedback provide an objective basis for super-
visees to gauge the strength and weaknesses of their work with a given patient. Reflection
on their practice is grounded in observable behaviours and progress indicators. This
transparency can be applied to both supervisory input and shared decision-making in
subsequent sessions with the patient. Unlike the lack of empirical validation of intro-
spective reflective practice activities, evidence shows that data-driven reflective practice,
where therapists, supervisors and patients receive progress monitoring feedback gener-
ated by an automated system, improves patient outcomes (Newnham, Harwood & Page,
2007; Newnham et al., 2010b) and reduces the likelihood of readmission (Byrne et al.,
2012). Patients who actively participate in such patient-focused, collaborative reflective
practice concerning their progress show better improvement across therapy than those
who have never discussed progress monitoring information (Hutson et al., 2020). From a
supervisee perspective, it is reassuring to know that patients who were not on track for a
desirable therapeutic outcome showed a prompt improvement in their recovery trajec-
tories after the therapist discussed with them the feedback from the progress monitoring
system (Hutson et al., 2020). These benefits of data-driven, reflective practice were
achieved as part of routine clinical practice. Once these computer-based routine outcome
monitoring and feedback systems become more prevalent in psychology training clinics,
supervision methods will also adapt and become more patient-oriented. That is, issues
for supervision will be more often flagged by an automated patient management system
rather than by supervisees identifying issues for supervisory input based on introspective
reflection for which there is no evidence that it improves patient outcomes.
As noted earlier, conceptual boundaries of reflective practice as a competency have
been influenced by a prominent viewpoint that reflective practice and science-informed
practice are “orthogonal” and “coequal” elements of competent practice (Schaffer &
Rodolfa, 2020). However, it remains an ethical imperative for competent practice to use
approaches that have scientific support and show respect for the scientific method
(Gonsalvez et al., 2020; Rodolfa & Schaffer, 2019). Thus, reflective practice that relies on
retrospective introspection is not a “coequal” alternative to a science-informed approach to
reflective practice. Instead, reflective practice that is data-driven is superior in that it
provides supervisees with the empirical grounding to benefit from supervisory input.
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Reflection-in-Action
In addition to being guided by routine, patient-centred outcome monitoring and feed-
back data, the supervisee can bring a scientific mindset to the monitoring, evaluation and
adaptation of their session-to-session behaviours and strategies in working with a client.
Access to reflection requires externalization (de la Croix & Veen, 2018) and hence must
be linked to observable actions and their consequences. This is known as reflection-in-
action, where supervisees are encouraged to pay close attention and note the unfolding of
specific client interactions while implementing verbal or non-verbal strategies according
to a plan devised with the help of supervisory input (cf., Schön, 1983). Here, reflectivity is
used as a deliberate process by which practitioners frame problems, modify their
behaviour to test hypothesized solutions, evaluate the outcomes of these tests and then
decide how to proceed in their work with clients in light of these observable outcomes
(Neufeldt, 2007). Reflection-in-action is proactive, and a chosen path is subject to
falsifiability and hence correction. Reflection-in-action is patient-centred, because the
focus is on observing the outcomes of planned therapist actions on observable changes in
client reactions or interpersonal dynamics of the interaction. Reflection-in-action
increases accountability, because supervisees can review their interpretation of and
conclusions from a reflection-in-action moment with reference to observable indicators
from video recordings of their sessions, and so can their supervisors. Importantly,
reflectivity in supervision is only complete if it results in supervisees changing their
behaviour in subsequent sessions.
We will draw on the integrated model of reflectivity described by Neufeldt and her
colleagues (Neufeldt, Karno & Nelson 1996) to illustrate with an example what the
supervisee’s role, tasks, and responsibilities are throughout the sequential and iterative
process of engaging in, and learning from, reflection-in-action.

The Trigger Event

Consider a novice supervisee who is experiencing considerable frustration in her first
couple of sessions with a new client, because the client “does not provide much detailed
information and seems reluctant to respond to follow-up questions when asked to
elaborate on points”.

Following the Trigger Event

A reflective supervisee reacts to the trigger event as follows: She (a) is puzzled or feels
stuck and unsure how to proceed, (b) knows that feelings of uncertainty signal a problem
ripe for reflectivity, (c) takes responsibility for learning and professional growth, (d)
avoids defensive self-protection, tolerates a sense of vulnerability and is prepared to take
a risk and (e) is proactive and presents the trigger event in supervision.

Prior to Supervision
A reflective supervisee understands that most of her learning occurs between supervision
sessions. Therefore, she engages in several preparatory activities: she (a) selects represen-
tative information about the trigger event (e.g., relevant video segment of a typical
incident of the client not responding to her questions), (b) considers her own actions,
emotions, and thoughts during the incident (e.g., How did I feel during the silence?
 Chapter 12: Supervision 213

Am I getting anxious to “do something” during silent moments with the client? What
was I thinking? Was I worried about getting through all the questions I had prepared?
Did I give the client enough time to answer?), (c) considers the interaction between the
client and herself during the event (e.g., What am I doing? What is the client doing? Did
my follow-up questions interrupt the client’s thoughts? Would the client have answered
had I listened for just a little longer? How would I respond myself to rapid-fire questions
from someone?) and (d) formulates a summary statement about the event and any
hypotheses or questions gleaned from the self-assessment to take into the next supervi-
sion session.

During Supervision
The reflective supervisee brings a stance to supervision that is characterized by the intent
to understand what has occurred, and by an openness to accept and try solutions
generated with the guidance of the supervisor. Hence, she (a) is open to new ideas, (b)
critically examines supervision data such as a pre-selected video clip (e.g., the client
appears to be contemplating answer. The client shifts her body and begins to open her
mouth, but then stops and listens to my next question.), (c) entertains alternative
explanations (e.g., the client is not reluctant to answer. Rather, I am impatient, and
client is polite and/or not assertive enough) and (d) formulates alternative explanations
as hypotheses and plans how to test these new ideas with the client in the next session
(e.g., I will sit back after asking a question to rein in my impatience and to signal to the
client it is her turn. I will tell myself that silence is ok. I will wait for the client to
answer. I will attend to and observe outcomes of this deliberate change to my
behaviour).

During the Subsequent Session with Client

The reflective supervisee understands that an event becomes “reflective” only if the
supervisee changes behaviour as a result of the reflective process. Consequently, she (a)
puts into action her plan to “experiment” and test the new ideas developed during
supervision, and (b) uses reflection-in-action; that is, she attends to and evaluates what
is happening while it is happening during therapist–client interactions (e.g., the client
answers after a delay. Silence does not feel so uncomfortable after all. Let me try this
again with the next question. Yes, it works again. Now look what happens, the client
becomes talkative. I relax. I am getting somewhere with this client.)

Following the Subsequent Session with Client

The reflective supervisee contemplates the consequences of her “experiment”. She (a)
evaluates outcomes of having used new behaviours and strategies (e.g. What worked
and what did not work? Does the client provide more detailed information and
respond to follow-up questions when asked to elaborate on points?), (b) selects infor-
mation to document conclusions drawn from the above evaluation (e.g., relevant video
clip(s) of attempts to use the new strategy) and (c) goes through the routine steps of
considering her own actions, internal experiences and the dynamics of the interactions
with the client, and then prepares a summary statement to take to the next
supervision session.
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214 Chapter 12: Supervision

During the Subsequent Supervision Session

The reflective supervisee takes responsibility for following up with her supervisor on any
treatment decisions and plans suggested to her during the previous supervision session.
She (a) updates her supervisor on outcomes of previously recommended changes to her
in-session behaviour, (b) critically examines supervision data (e.g., a pre-selected video
clip of events that were targeted with newly adopted strategies), (c) considers the need for
further refinement or alternative strategies and (d) plans to consolidate new skills,
transfer new skills to other situations or test alternative ideas.

Learning Supervisory Skills

Novice therapists are likely to give little thought to what skills are needed to shift from
the role of direct service provider to the role of supervising someone else to be the best
service provider they can be. Yet, their experiences as “consumers” of supervision,
combined with the modelling by different supervisors, function as tacit training in the
practice of supervision itself (Falender & Shafrankse, 2004). Many training programmes
may also offer some formal training in supervisory skills in the form of workshops or
tiered training where more advanced trainees contribute to the supervision of less
advanced students, typically in a group supervision format. But trainees are not required
to achieve competency in providing supervision by the time they graduate (Schaffer &
Rodolfa, 2020). There are post-graduate pathways towards formal supervisor training
and approval according to guidelines set by relevant national and state psychology
boards (e.g., Association of State and Provincial Psychology Boards, 2020; Psychology
Board of Australia, 2017). Thus, trainee therapists are not expected to already undertake
hands-on supervisor training while their energies are still directed towards making their
own fledgling steps as therapists. However, understanding some basic supervision
principles and strategies can help the novice to be better informed about what to expect
and how to make the most of the supervision experience.
When thinking about what it takes to become a supervisor, it is helpful to start by
clarifying what a supervisor is not. First, the supervisor is not the therapist of the client.
That is, the supervisee is not a surrogate for the supervisor as a clinician. Second, the
supervisor is not the therapist for the supervisee. The supervisee’s personal issues are
only addressed to the extent that they bear directly on client–therapist or therapist–
supervisor interactions. Consider a trainee who is getting very emotional during a
session with a client who relates feelings of guilt and distress regarding her indecision
over whether to abort her unborn child or to keep it. If reflective inquiry reveals that the
supervisee’s strong discomfort was related to her own past experience of an unplanned
pregnancy, then the supervisor would focus on helping the supervisee figure out how she
can be helpful to her client (from her client’s perspective!) without letting her own
emotional reactions get in the way of that task. In contrast, if it becomes apparent that
the supervisee struggles to separate her own distress and needs from that of the client,
and that she might benefit from personal therapy to better cope with the personal issues
raised by this event, then it would be unethical for the supervisor to act as her therapist.
Thus, when making the transition from clinician to supervisor, the focus shifts from
exploring the meaning of an event to the way in which this event might affect the
supervisee’s work with the client (Neufeldt, 2003). In sum, the acquisition of supervisory
skills begins with getting past being a clinician and attending to the supervisee’s learning,
 Chapter 12: Supervision 215

building one’s own managerial competence to facilitate that learning, and fulfilling the
ethical obligations that arise from protecting the safety and welfare of clients while
simultaneously monitoring the progress and wellbeing of trainees.
Supervisees will encounter a variety of strategies that supervisors use to facilitate their
learning, depending on whether supervisees are at an early or more advanced stage of
their training. Some basic strategies that supervisors apply at all levels of training (or that
more advanced trainees might use in assisting junior peers) include supportive, reflective
and prescriptive strategies

Supportive Strategies
 Provide praise and encouragement. Highlight any aspects that the trainee did well.
Acknowledge that doing things for the first time is difficult. Help shift the focus from
what went wrong to how to do better the next time.
 Be respectful and tactful when commenting on things that did not go well.

Reflective Strategies
 Examine the trainee’s behaviour. Ask the trainee to explain how a given behaviour
does or does not serve the intention of the trainee at the time, the goals for this
particular session and the overall treatment goals.
 Ask the trainee to generate hypotheses about the client’s behaviour, thoughts or
feelings. Consider a client who informs the therapist that her 16-year-old son is going
to leave her in the near future to live with his father in another region, and then
remarks quickly that she is “OK with this”. Encourage the trainee to suggest several
examples of what the client might be feeling about the upcoming event (e.g., does “it
is OK” mean “it is not very painful” for the client, or does it mean it is very painful,
but “I will manage”, or does it mean “I am not OK”, “I will be lonely”, “I am afraid,
my son won’t talk to me anymore”?)
 Explore the trainee’s feelings during client and supervision sessions. Ask in what ways
these feelings can hinder or help working with the client.
 Help the trainee to plan ahead. Encourage the trainee to make predictions about
which hypotheses about the client are most likely, given what the trainee already
knows about the client’s circumstances and history. Then suggest testing that
prediction in the next session.

Prescriptive Strategies
 Offer alternative interventions or conceptualizations for the trainee to use.
 Explain and/or demonstrate how to use intervention techniques.
Bernard and Goodyear (2004) noted that one particular benefit of receiving feedback
from fellow advanced trainees is that they are closer to their own recent experiences as
novices than the senior supervisor is. Therefore, their explanations may at times be easier
to follow than those of the expert.
In addition to facilitating novice supervisees’ learning, advanced trainees can increase
their managerial competence by taking an active role in structuring the supervision
session, facilitating good time management and keeping records of their
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216 Chapter 12: Supervision

Finally, advanced trainees must be aware of their ethical obligations when they
participate in the supervision of junior peers. This includes maintaining a professional
distance from the junior colleagues they are supervising, which can pose a challenge
within the small community of a training programme where students interact in classes,
research teams and social activities. However, dual relationship problems can be avoided
by observing a few simple guidelines. Neufeldt (2003) recommends that (a) role obliga-
tions are clarified from the outset, (b) supervisory activities remain confidential and
there should be no “gossip” about supervisors or supervisees and (c) advanced trainees
should not supervise a peer who is a roommate, close friend or romantic partner. In
general, when considering dual relationships between a supervisor and trainee, the
supervisor’s needs are subordinate to the needs of the supervisee and the needs of the
supervisee’s clients (Falender & Shafranske, 2004). Any benefits derived from such
relationships must be weighed against the imperative to minimize the potential for
harm. A useful decision-making model by Burian and Slimp (2000) raises awareness
of the issues and circumstances to be considered when contemplating the merits and
risks of engaging in social dual-role relationships between supervisors and trainees. The
first question to consider is the reason for engaging in the relationship. A dual relation-
ship may have merit if there are professional benefits to the trainee or supervisor. For
example, conducting workshops together may involve planning meetings, lunches or a
social gathering with workshop attendees for a drink at the end of the day. As long as the
purpose of the social activities remains focused on workshop-related activities and
associated professional benefits for both persons involved, the risk of harm is minimized.
In contrast, a social relationship should not proceed if it only has personal benefits to the
supervisor, and should only proceed with caution and after careful consultation if it is
primarily of personal benefit to the trainee. The second question to consider is the degree
of power the supervisor has over the trainee. A possible social relationship is best
postponed until a time when the supervisor has no evaluative role, either directly or
indirectly, with respect to the trainee. The third question to consider is where this social
relationship takes place. If the social contacts are in the context of the work site and are
not exclusive of others who may wish to join the social interaction, the potential for
harm, such as the perception of favouritism, is reduced. In addition to considering these
three basic questions, before deciding to pursue a social dual-role relationship, it needs to
be established that the trainee has the ability to leave the social relationship or activity
without repercussions, and there is no negative impact on uninvolved trainees or staff
members.
However, supervision is not the only context where difficult situations arise. More
often than not, tricky situations arise in the course of consulting with a client.
Supervision is a key component in responding effectively to problems during therapy.
One such common problem is treatment non-compliance or therapeutic resistance, and
it is to this topic that we now turn.
 Chapter
Managing Ruptures

13 in Therapeutic Alliance

Consider a client with depression who has intense fears of abandonment. After a period of
therapy the symptoms of depression have begun to reduce in severity and she comments:
CLIENT: Do you think I am depressed?
THERAPIST: When you began therapy you were very distressed, but my impression is that now you have got
to a point where you have a greater understanding of the issues in your life, you can manage them better
and that your symptoms have improved. Is that right?
CLIENT: Yes, I’m not feeling as depressed and I’m feeling more hopeful. I think I understand my triggers
better, and I have a number of tools I can now use to keep me well. If it hadn’t been for you I don’t know
how I would have coped. You have been a life-saver and I mean that literally. I might have killed myself if it
hadn’t been for our therapy.

One possible explanation for the client’s responses is that they are worrying about the
possible termination of therapy and beginning to test the psychologist. The tests involve
seeking reassurance that the psychologist still sees the client as having a problem that
deserves treatment and highlighting the potential risks of discontinuation. For a client
who fears abandonment, the prospect of the termination of therapy will be scary. How
would you manage the potential rupture to the therapeutic alliance that the symptom
improvement has brought about?
Now consider beginning a treatment session with an anxious client, who you had
given the task of completing a diary with a “fear thermometer” (i.e., rating anxiety on a
0–100 scale) along with a record of any anxiety-provoking situation, any unhelpful
thoughts and subsequent feelings. The session opens like this:
THERAPIST: How have things been going this past week?
CLIENT: Pretty good. I’ve been doing what you asked me and I’ve noticed that the anxiety is a lot less than it was.
THERAPIST: In terms of the “fear thermometer” that you were using each day to rate your anxiety as
homework, what sort of ratings did you get?
CLIENT: Well I didn’t put them in my diary, but I thought about it each day and I’ve remembered my ratings.
THERAPIST: That’s OK. But it would be really good if you did it next week instead because it might show
something useful.
CLIENT: Yeah, no problem at all.

In subsequent sessions, if this pattern continues, it will become entrenched with the
client not ever bringing any homework to the sessions. Ultimately, the client may
terminate therapy, leaving you to lament that if they had been more motivated, treatment
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would have had a more positive outcome. Could anything have been done differently to
increase compliance with treatment?
While it perhaps seems self-evident that repairing alliance ruptures is necessary for
the successful conduct of therapy, it is useful to note that there is an evidence base for the
practice (e.g., Strauss et al., 2006). In a meta-analytic review Eubanks, Muran and Safran
(2018) and Safran, Muran and Eubanks-Carter (2011) reported a moderate (r = 0.29)
correlation between the repair of alliance ruptures and overall outcomes. The earlier
review showed a positive correlation between the provision of training and supervision
in rupture-repair and therapy outcomes, supporting the idea that the ability to repair
ruptures is an important therapy skill, which can be learned and refined (see also Safran
et al., 2014). However, the more recent meta-analysis found no significant impact of
rupture resolution training or supervision on outcomes, but did observe that the
training–outcome relationship was stronger in samples with fewer personality dis-
ordered clients, when training was more closely aligned with CBT and when treatment
was brief (Eubanks et al., 2018). Thus, these caveats suggest that the following recom-
mendations about rupture resolution may have the most relevance to CBT with non-
personality disordered clients. In addition, it is relevant to note that therapist ratings of
alliance and ruptures appear to be less valid than client-rated measures (Humer et al.,
2021; Rubel et al., 2018). It is therefore critical to pay greater attention to the client’s
perspective of the relationship (Penix, Swift & Trusty, 2020).

A Model of Ruptures to Therapeutic Alliance

Reviewing our model of clinical practice (see Figure 13.1), it is apparent that in normal
circumstances there is a flow of information from one element within the model to
others. However, when these links are broken, clinical practice has the potential to break
down. Some of these links can be affected by actions that are more under the control of
the psychologist than the client and many of these have been considered in previous
chapters. For instance, failing to conduct an adequate assessment or case formulation can
undermine effective treatment planning. Poor treatment planning can in turn result in
the implementation of potentially inappropriate, ineffective or inefficient therapies.
Likewise, failing to monitor progress towards treatment goals or to measure outcomes
can lead to unnecessarily long persistence with an ineffective or counter-productive
therapy. However, there are other points at which psychological practice can be dis-
rupted by activities that appear, at first glance, more under the control of the client than
the psychologist. The client may fail to disclose all the relevant information, thereby
hindering case formulation and weakening the value of pre-treatment assessments.
A client may also be non-compliant with therapeutic suggestions and exhibit resistance
within psychotherapy. Such non-compliance with treatment strategies will hinder imple-
mentation and reduce the ultimate success of any intervention. The therapeutic alliance
can be ruptured during treatment and the psychologist will need to work to restore
the relationship.
The focus of the present chapter will be twofold. We will discuss client behaviors that
can have a negative effect of treatment outcomes, and we will review strategies the
psychologist can use to deliberately exert influence over the therapeutic relationship to
minimize the hindering impact of these client behaviors, even though many of the
relevant client behaviours will not be under the clinician’s direct control.
 Chapter 13: Managing Ruptures in Therapeutic Alliance 219

Client’s problems existing within a sociocultural context, history, etc.

Theoretical and Clinical training &

empirical literature experience
Client’s cultural and
Psychologist must subcultural context and
respect the humanity own individuality need
of each client and Assessment & to be considered
grant them the case formulation
dignity this affords
while maintaining Psychologist’s own cultural
Treatment planning
their own humanity context will influence the
& measurement
and socio-legal perception of information
obligations and the treatment chosen
Treatment implementation
& monitoring

Evaluation &
accountability

Figure 13.1 Interference in the clinical process by client resistance and non-compliance.

What is a Rupture to the Therapeutic Alliance?

The therapeutic alliance describes the working relationship between psychologists and
clients (Barber et al., 2013; Flückiger et al., 2018; Horvath & Bedi, 2002; Okamoto &
Kazantzis, 2021). As reviewed earlier, the stronger the therapeutic alliance, the better the
outcomes of therapy. When the quality of the alliance is strong, psychologists foster a
safe, trusting environment in which a shared purpose forms a means to working towards
common goals. Therapist empathy and collaboration, as well as the use of progress
monitoring and feedback, build the alliance (Flückiger et al., 2018; Norcross &
Wampold, 2011; 2019). An alliance rupture occurs when this collaborative relationship
breaks down or becomes strained (Safran & Muran, 2006). The rupture may be indicated
by confrontation (where the client exhibits hostility or criticism of the psychologist) or
by withdrawal (when the client disengages from the therapeutic process or begins to
express negative feelings and attitudes about the therapy or therapist in an indirect
manner).
Broadly speaking, alliance ruptures can be addressed in a sequential process (Safran,
Eubanks-Carter & Muran, 2010). First, the psychologist identifies the marker of the
rupture (e.g., refusal to complete homework). The psychologist then explicitly attends to
this marker. This provides the foundation for the third step, in which the psychologist
explores the experience of the rupture with the client. Finally, the psychologist explores
any avoidant behaviours and any reasons for the behaviours that the psychologist has
observed. As you work through the remainder of the chapter, you will see how these
steps can be addressed for different instances of alliance ruptures.
One instance of an alliance rupture involves therapeutic resistance. Resistance is
defined differently depending on whether the source of the client’s resistance is con-
strued as residing within the client or as being triggered by something the therapist does
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220 Chapter 13: Managing Ruptures in Therapeutic Alliance

or fails to do. Lazarus and Fay (1982) suggested that the notion of client “resistance” is,
“the most elaborate rationalisation that therapists employ to explain their treatment
failures.” These writers place the responsibility for the non-compliance in the lap of the
psychologist. Accordingly, the non-compliance may be illusory and an interpretation by
the psychologist to rationalize therapeutic failures, or it may reflect the fact that client
and psychologist have disagreed about the outcomes. In contrast, other writers place the
responsibility with the client. For instance, Wachtel (1982) defines resistance as occur-
ring when, “the sincere desire to change confronts the fears, misconceptions, and prior
adaptive strategies that make change difficult”. Implicit in this latter definition is the
notion that “ambivalence” towards treatment lies at the heart of client behaviours that
manifest as resistance and non-compliance. Later in this chapter, we will review strat-
egies that help clients shift from being stuck in a state of ambivalence by enhancing the
value of changing relative to the benefits of not changing.
Reflecting upon these different approaches to defining resistance in therapy, it is
evident that they are not mutually exclusive. It is conceivable that a therapist may
rationalize a failure or unintentionally act in ways that impede therapeutic progress. It
is also plausible that a client may fail to engage in the activities designed to bring about
therapeutic change. Indeed, the reasons clients are “non-compliant” may be precisely the
issues for which they are coming to therapy! Thus, it is not very helpful to debate in the
abstract who is to “blame”. It is more fruitful to consider how to manage resistance and
non-compliance when it becomes a hindrance to achieving positive treatment outcomes.
The ruptures experienced in therapy are likely to provide the therapist with clues
about obstacles or relational difficulties contributing to the client’s problems more
broadly, which can then be incorporated into the case formulation. Therapy provides a
unique opportunity to start exploring these issues, and experimenting with new ways of
responding, within the relative safety of the therapeutic relationship. Many trainees fear
ruptures and interpret them as therapist failures, when in fact they are common for new
and experienced therapists alike. Managing ruptures directly and effectively when they
arise can strengthen rather than weaken the therapeutic alliance and ultimately result in
better outcomes.
We suggest that the clinical psychologist should take responsibility for dealing with
resistance (without necessarily taking the blame for poor therapeutic outcomes). That is,
the psychologist is a professional who is providing an expert service and part of that
service is being able to deal with hindrances to a positive outcome. By way of analogy,
consider a schoolteacher trying to teach an uncooperative 14-year-old. Good teachers
will not blame the child, but see the situation as a problem to be solved and they will
accept responsibility for attempting to find a solution. It will not help the student to
blame him for not learning, or just to give up and accuse him of being uncooperative
(even if this is true). Good teachers will look for ways to help the child to learn by
overcoming the resistance rather than using resistance as a reason or an explanation for a
failure to learn. Thus, we view therapeutic resistance as an issue to be addressed in the
overall treatment plan, not as an explanation for therapeutic failure. In taking a problem-
focused approach to resistance, we are also adopting a transtheoretical approach to
resistance and non-compliance. The transtheoretical perspective is important because
psychodynamic and family therapists may view the exploration of resistance as a critical
ingredient for intervention, whereas cognitive and behavioural therapists tend to view
resistance as a problem that must be dealt with so that therapy can return to its primary
 Chapter 13: Managing Ruptures in Therapeutic Alliance 221

objectives. Our approach is a pragmatic one; the goal is the amelioration of the client’s
problems, and the clinician’s job is to help the client achieve this goal. To the extent that
alliance ruptures interfere with this goal, they need to be addressed during treatment.

Managing Alliance Ruptures during Different Phases

of the Therapeutic Process
During the Assessment Phase
During the initial assessment there are a variety of ways that a psychologist can reduce
the probability of therapy-interfering behaviours arising. First, contacting the client
before the initial session will increase the probability that the client will attend for the
first contact. Second, it is important to establish your credibility as a competent profes-
sional who can create the context for change. At first glance this presents a dilemma to
the novice psychologist who will dread the question from their initial clients, “how many
people have you treated with problems just like mine?” How do you establish credibility
in the absence of years of experience? One way to enhance credibility is by preparing
thoroughly and drawing on the collective expertise of the setting within which you are
working (e.g., you might respond, “I have not treated anyone with this problem before,
but we have been using these treatments with success in this clinic for many years.”).
Your credibility will also be conveyed in the professional manner in which you interact
with your client, such as dealing with the referral promptly and efficiently, having
relevant materials to hand and so on. In maintaining a credible demeanor, it is important
to remember that although you may feel inexperienced, you have had many years of
training in psychology and your knowledge base of normal and abnormal behavioural
patterns will be substantial. Therefore, try to focus on what you do know, rather than
worrying about the things that you might not yet know. Finally, credibility is enhanced
most by honesty and integrity in communication. Communicating accurately your
expertise and experience in response to an enquiry will facilitate the therapeutic rela-
tionship more than trying to bluff your way through.
A third way to reduce the probability of therapy-interfering behaviours is to begin
treatment by rapidly establishing good rapport with clients using the techniques outlined
in Chapter 2. Fourth, alliance ruptures can be reduced by modelling good listening
behaviours. Allow your client to finish each statement and reflect back both the infor-
mational and the emotional content. In so doing, ensure that you permit your client to
express emotions fully. Fifth, when you are ready to use assessment procedures, take time
to provide a clear rationale for the tests and give strong encouragement about completing
the procedures. When the assessment process is finished, reward the clients for their
efforts put into completing the assessments by providing them with clear and informa-
tive feedback. Sixth, employ strategies that increase the engagement of the client in
therapy. It is possible to increase the engagement by gaining an explicit commitment to
complete assessment, then treatment and finally follow-up. These commitments or
contracts are obtained in a sequential manner, so that you are just asking the client to
commit to the next phase in the process of therapy. Seventh, if appropriate, engagement
can also be enhanced by maintaining contact with the client between sessions with the
aim of asking how things are going, checking that there have not been any difficulties
with the homework assignments and gaining a commitment to attend the next session.
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Finally, given the important role of homework completion (Kazantzis, Deane & Ronan,
2000; Kazantzis & L’Abate, 2007; Kazantzis et al., 2005), it is necessary to ensure that
homework is consistent with the client “take home” message from each session (Jensen
et al., 2020), and to reinforce the completion of any assignments – a point that will be
discussed in greater detail below.

During the Implementation Phase

Once treatment has begun, the psychologist can continue with many of the strategies
described above and some other strategies can be added. First, articulating a clear, shared
formulation of the problem and an explicit rationale for treatment is likely to increase
the engagement of a client (but cf. Chadwick, Williams & Mackenzie 2003). This
rationale may need to be repeated to repair a rupture so do not think that, just because
it has been articulated once, the client will continue to remember, agree with or continue
to find relevant the initial rationale (Safran, Muran & Eubanks-Carter, 2011).
Sometimes, the issue can be a simple misunderstanding that, once cleared up, allows
therapy to proceed more smoothly. Second, client engagement can be fostered by
conveying optimism about change, which can be achieved by citing data on the prob-
ability of success and by identifying the factors that predict improvement. For instance,
you might comment, “we know that two out of three of clients are improved to the point
that they no longer meet diagnostic criteria for the problem that they sought help for.
However, you might be thinking to yourself, ‘I bet I’m in the one in three of therapy
failures.’ However, we know from research the reasons why people find themselves in the
one in three of people who don’t succeed so well. One of the main factors is not
complying with the treatment. Thus, the good news is, the harder you work in the
programme, the more likely it will be that you will be one of the two out of three who
succeeds.” In addition to citing research evidence, optimism about change can also be
enhanced by establishing a collaborative set. For instance, you might add: “Also, I don’t
see therapy as a process where I sit on the sidelines watching you succeed or fail. I see my
role as working with you all the way, overcoming obstacles, and doing everything I can to
ensure that together, as a team, we can collaborate to help you overcome this problem.”
Third, client engagement can be enhanced by anticipating possible obstacles to treat-
ment. The process of case formulation described in Chapter 5 provides a mechanism for
identifying a client’s weaknesses that may adversely impact on outcomes, as well as the
client’s strengths and resources that may be drawn upon to attenuate any adverse effects.
Fourth, when resistance or non-compliance is blocking the process of treatment you may
decide to raise the issue with the client explicitly (perhaps preferring to use less judge-
mental descriptions, such as “something appears to be blocking our progress” or “we
seem to be encountering some difficulties in taking the steps we agreed would be helpful
at this stage”). Work with the client to identify the meaning and function of the resist-
ance, and then respond accordingly. Some examples of resistance are outlined below:
 The psychologist might describe a therapeutic technique and the client refuses to
comply, claiming that she does not understand what to do. This problem may have
arisen because the therapist has miscommunicated or the client has difficulty
comprehending. The response would be that the psychologist would re-present the
technique, using different words than before, drawing upon examples and metaphors
to assist comprehension.
 Chapter 13: Managing Ruptures in Therapeutic Alliance 223

 The client might appear unmotivated due to a lack of expectation of success. The
psychologist could identify the reasons why the client has formed this view, clarify
any misconceptions or unrealistic expectations, and then identify the probability of
success and demonstrate which of the predictors of a favourable outcome the client
possesses or are present in the environment.
 The client might be making unusually slow or erratic therapeutic progress. This
could arise from any number of causes and so the psychologist should review the case
to ensure that all the problems have been identified, and the treatment is appropriate
for the problem and the particular type of client. If these possible causes are not
reasonable explanations, then the psychologist could consider other explanations,
such as that the client’s problem serves a function or meets a need that would remain
unmet if the problem was ameliorated. For instance, the client’s familiar problem
may maintain an uneasy but reassuring balance within a family structure, whereas
change in the client would disrupt this balance, and the need to adapt to this
unfamiliar situation may be perceived as “too hard” or distressing. Consider a client
who, after making successful progress in overcoming her agoraphobic avoidances,
reported that her partner was complaining that he did not like her newfound
freedom. He was no longer sure that she was at home and hence worried that she
might be forming relationships with other men. He did not like the fact that his
dinner was no longer on the table when he walked through the door because his
partner had been busy with other activities during the day. In this case, these issues
did not necessarily cause the problem in the first instance, but interfered with
progress by weakening the client’s resolve (albeit temporarily) to overcome the
agoraphobic avoidances. It is also possible that a client slows down progress
deliberately to test the psychologist. For example, a client with a fear of abandonment
may observe the psychologist’s reaction to his failure to progress, waiting to see if the
psychologist will, “dump him, just like all the other shrinks”. In these cases, the
reasons for non-compliance need to be explored as possible causes or maintaining
factors in the problem and dealt with accordingly.
 Another scenario is when the client presents with a meaningful behavioural pattern
or sequence that is a manifestation of avoidance behaviour. A client may behave in
their relationship with the psychologist in a manner than “acts out” some aspect of
their presenting problem. For instance, a client who fears negative evaluation in
performance settings could well view therapy as a social performance within which
he is required to behave in a certain way, and if he fails to do so, then the psychologist
will judge him negatively as a “bad patient”. In this case, the psychologist would
address the client’s fear of negative evaluation and could use the manifestation as an
opportunity to bring the problem into the therapy room and deal with it as the
behaviour unfolds.
It is also important to consider that there may be a need to change or to re-negotiate the
clinical tasks or goals (Safran et al., 2011). For instance, Miller and Page (1991) describe what
they call a “warm turkey” approach to abstinence for alcohol dependent clients. A client might
initially insist on aiming for warm turkey, despite the clinician believing a harm-reducing
controlled drinking approach would be less successful than abstinence (“cold turkey”). The
clinician might “roll” with the client’s resistance, only to find that after a number of “slips” the
client is more willing to agree that abstinence is likely to be more successful.
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Finally, confrontational ruptures to the alliance can occur when a client deliberately
challenges the therapist. When this occurs, it is wise not to be defensive, but to make the
concern explicit, and to deal with the challenge by addressing it. Sometimes the situation
can be defused through humour (although, unless the therapeutic relationship is strong
and the humour is preceded or followed by validation, this has the potential to backfire if
the client interprets a humorous retort as belittling them or their concern). At other
times, the concern can be dealt with by matter-of-factly citing appropriate data. If a
client’s challenging style continues to the degree that a cooperative working relationship
cannot be maintained, and working with the process dimension does not address the
issue (to which we turn later in the chapter), it might be appropriate to refer the client to
another therapist.

During the Termination Phase

Considering termination, there are a number of ways to facilitate an end to formal
therapeutic contact. Addressing termination in an explicit manner is important. This
allows the client to plan for termination, to deal with any grief and loss that may be
experienced, and to raise any further matters that should be dealt with before termination
is complete. Phasing the last treatment sessions so that they are spaced at greater intervals
can be beneficial, as can scheduling a formal follow-up session (so that the client does not feel
abandoned at the end of treatment). It is also useful during the latter phases of treatment to
reinforce independence and discuss relapse prevention strategies. This will help to develop
the client’s self-efficacy that they are now able to continue to implement and apply the
lessons and skills learned in therapy even after therapeutic contact has ceased. Clients who
are confident that they will be alright after completion of therapy are not prone to show non-
compliant stalling behaviours as the end of therapy approaches.
Sometimes the client’s confidence can be undermined by unhelpful cognitions they
hold. Jacobson (1984) suggests the psychologist first tries to identify cognitions that may
be impeding termination planning. Once possible cognitions are identified, the clinician
proceeds to construct behavioural experiments to test the validity of these cognitions,
with the ultimate goal of disputing them. For example, one of us saw a client who became
distressed at the prospect of termination, despite having made substantial progress.
Careful interviewing revealed that the client was concerned that if he lapsed back into
problem drinking, there would be no way to access therapeutic assistance. Therapy then
shifted to address these beliefs; examining the nature and consequences of termination,
reviewing the skills attained, practicing relapse prevention strategies and clarifying ways
to access future therapy if required.
For the beginning psychologist it may be a daunting prospect to think about
identifying and managing alliance ruptures. Fortunately, there are some good psycho-
metric instruments that may assist therapists in describing and characterizing problems
with the therapeutic relationship, such as the California Psychotherapy Alliance Scale
(Marmar, Weiss & Gaston, 1989). One such measure is the Working Alliance Inventory
(WAI) (Horvath & Greenberg, 1989); for which a shorter version is now available (i.e.,
the Working Alliance Inventory-Short Revised) (Hatcher, Lindqvist & Falkenström,
2020; Munder et al., 2010). The WAI examines the tripartite components of alliance –
namely bonds, goals and tasks. Since the scale is completed by the client, it provides the
psychologist with a formal way of characterizing the client’s perception of the alliance
 Chapter 13: Managing Ruptures in Therapeutic Alliance 225

and can help guide a consideration of issues in therapy. A methodology, using the WAI,
that looks promising to track deviations in alliance uses control charts (Lipner et al.,
2021). Control charts are a form of time-series line graphs (similar to the monitoring
methodologies in Chapter 4) which can identify probable rupture-repair episodes that
are associated with psychotherapy outcome.

Preventing Therapy Withdrawal by Enhancing Motivation

The therapeutic alliance may be ruptured as the client withdraws or disengages. Often it
is useful to not label the withdrawal as “resistance” and identify it as a problem as such,
but instead to reframe resistance and withdrawal as understandable processes common in
many people seeking treatment. The psychologist could identify benign explanations for
“resistance” and seek to side-step a direct confrontation. For instance, instead of treating
ambivalence about continuing in treatment as an absence of motivation, the psychologist
could discuss how ambivalence is a natural response to the simultaneous presence of
approach and avoidance motivations. When either approach or avoidant motivations
dominate, then the behavioural outcomes will be clear, but when approach and avoidance
motivations are similarly strong, ambivalence will occur (Page & Stritzke, 2020). This can be
reframed as a “good state to be in”, because it is evidence that the client still sees enough
value in treatment to not have simply dropped out. The focus of therapy can then shift
towards an evaluation of the twin motivations and seek to “tip the balance” in favour of
continuing to engage in treatment (cf. Breiner, Stritzke & Lang, 1999).
Arguably the most helpful and readable book on this topic is Miller and Rollnick’s
(2012) Motivational Interviewing (see also Arkowitz, Miller & Rollnick, 2015; Arkowitz
et al., 2007 and Rollnick, 2007). One of the important contributions the original book
makes in the present context, is the acknowledgement that motivation is not an issue that
is constrained to the initial assessment, at which time the psychologist judges to what
degree motivation for change is present or absent. Instead, motivation is to be recruited
at all points throughout therapy to get and to keep the client engaged with treatment. In
particular, motivational interviewing is especially relevant to clients who are ambivalent
about treatment. Clients with substance use problems typically fall into this category, but
many other clients are ambivalent too. For example, clients with anxiety disorders are
often highly motivated at the beginning treatment but once the prospect of confronting
feared situations emerges, the client can become scared and ambivalent. In addition,
clients may have participated in failed treatment attempts and hence are ambivalent
about the value of the present intervention, especially if it is similar to one that has
already been tried. Clients may also be ambivalent about treatment if their relationships
are threatened by the prospect of successful treatment or if undesirable consequences
follow amelioration of the problem. For instance, clients may derive social support and
reassurance as a consequence of having problems and recovery may put an end to such
secondary “benefits” of the status quo.
To counter the negative impact of these hindrances on treatment compliance, the
task of the clinician is to ensure that the person’s motivation for treatment is maximized
and remains sufficient to propel the individual to a successful completion of the
treatment programme. To this end Miller and Rollnick (2012) identified five general
principles of motivational interviewing that can be applied fruitfully to a broad range of
presenting problems, not just addictive behaviours. The five principles are expressing
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empathy, developing discrepancy, avoiding argumentation, rolling with resistance and

supporting self-efficacy (Davis, Hooke & Page, 2006).

Expressing Empathy
People who suffer with psychological problems frequently complain of being misunder-
stood. For instance, a person suffering from Obsessive-Compulsive Disorder may finally
bring themselves to describe their uniquely terrifying experiences to another, only to be
frustrated with their response. Trite advice may be forthcoming (e.g., “You must be
uptight, why don’t you just relax?”), or even worse, sympathy is offered (e.g., “I check
too. When I leave my car I check I haven’t locked my keys in. I really understand how
you must feel”). Therefore, it is imperative that the individual feels that their complaint
has been heard from the psychologist’s first utterance.
An empathic response reflects the meaning and emotion expressed in a communi-
cation, all the time accepting the validity of the person’s experience. For instance, a
person describing the experience of a panic attack is usually trying to communicate an
occurrence of fear that is perceived to be qualitatively different from any anxiety, worry,
tension or fear that they have experienced before. In addition, they often conclude on the
basis of this experience that the event must be unique and an indication of a serious
physical or mental problem. By extension, the person is communicating that, although
they have previously been able to manage anxiety in all its forms using various coping
strategies, this is different; these attacks of panic are uncontrollable. An accurately
empathic response accepts the validity of the person’s experience, leaving them with
the perception that the listener has heard what has been said. These principles that
underlie empathic communication are illustrated by contrasting two client–therapist
interactions, where one does not include an empathic response (Psychologist 1) and the
other does (Psychologist 2).
CLIENT: Panics are the most terrifying experience I have ever had. Have you ever had a panic attack?
THERAPIST 1: Yes, I think I did after having a car accident.
THERAPIST 2: I’ve been anxious before, but it sounds as if you have found panic attacks to be quite different
from the anxiety that you used to feel.

The first response is less helpful because the therapist fails to identify with the client’s
experience. The client is testing to see if the therapist understands the uniqueness of their
experience of panic, but the therapist does not respond to this theme. Instead, the
psychologist moves to relating personal experiences that may or may not be relevant,
but thereby shifting the focus from the client to the therapist. The second psychologist
draws attention to the qualitative difference sufferers perceive between anxiety and panic.
Such a response is preferable because it draws attention to the uniqueness of the
experience and returns the interview to the client’s concerns.
CLIENT: When I’m having a panic attack all my rational thoughts go out the window and I think I AM going
to die of a heart attack.
THERAPIST 1: But you have had many clean ECGs, your cholesterol is low and you are young. Everything
points against you actually dying of a heart attack.
THERAPIST 2: That must be really terrifying. It makes it difficult to stop the panic when the worry about
dying becomes so overpowering.
 Chapter 13: Managing Ruptures in Therapeutic Alliance 227

The first psychologist jumps in to offer premature reassurance. However, the client is not
saying that she really believes that she is dying, only that the panic appears to rob her of
her rational powers. The second psychologist responds to this comment by reflecting the
emotion and meaning conveyed. It is the second response which will lead to the client
continuing the interaction with the accurate perception that the psychologist has heard
the communication.
CLIENT: I’ve had this problem for ten years, I’ve been to so many different psychologists it is not funny, and
I haven’t got better so far.
THERAPIST 1: Well, we use a cognitive-behavioural programme which is very successful and I’m very
experienced in delivering the technique. You should improve quickly.
THERAPIST 2: Having failed before it must have been hard to bring yourself along to the clinic. What made
you decide to try again?

The first psychologist responds to the client’s implied doubt about whether psychological
treatment works for her by presenting therapeutic credentials. In contrast, the second
psychologist perceives the deeper issue and draws the person’s attention to the motiv-
ation that was recruited in order to re-engage in treatment. Having done so, the
psychologist will be in a position to build upon the person’s existing motivation to
engage in treatment. Importantly, the second psychologist implicitly acknowledges that
ambivalence about treatment is normal, and models that building on existing motiv-
ations is a useful therapeutic strategy.
In summary, expressing empathy involves accurately responding to the meaning and
emotion in a communication in such a manner that the other feels understood.

Developing Discrepancies
Accepting the validity of a person’s experiences does not necessarily involve accepting
that clients stay as they are. To the contrary, the purpose of offering empirically validated
treatments is to modify maladaptive cognitions and behaviours. However, encouraging
change should not involve vigorous confrontation, as this can lead to alienation of the
client (Miller & Rollnick, 2012). That is, while the goal may be to produce an awareness
of the need for change, direct verbal challenges may not be the best way to achieve this
goal. A better strategy is to focus on developing a discrepancy between the person’s
current behaviour (and its consequences) and future goals. Every client presents to
treatment with some degree of ambivalence. The task is to ensure that the rewards of
recovery outweigh the benefits associated with maintaining the status quo.
By drawing attention to where one is, in relation to where one wants to be, it is
possible to increase awareness of the costs of a maladaptive behavioural pattern.
Importantly, it is necessary to focus upon costs that are seen as relevant to the client
rather than the psychologist. For instance, one of us mistakenly suggested to a person
with agoraphobia that her child might be pleased and proud when she could be taken on
the train into the city, only to face the response, “I know I should want to get better for
my kids, but I don’t. Everyone says I should, but I can’t seem to care.” Instead, for this
client the most salient motivation was the freedom to be able to go to the local shops
while unaccompanied. Once this goal was identified it was possible to use it as leverage to
further enhance the value of personal freedom. The greater the discrepancy is between
these competing values, the greater the motivation for change.
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One way to develop discrepancies between current behaviour and future goals is to
enquire about what the person would most enjoy doing when unshackled from their
panic disorder or agoraphobic avoidance. When this image has been developed, it can be
contrasted with the person’s present state. The resulting dissatisfaction with the status
quo can then be used to motivate the person to engage in therapeutic activities.
In summary, all clients are ambivalent about treatment to varying degrees. To
enhance motivation it is useful to develop a discrepancy between clients’ current behav-
iour and their desired state. By increasing the perceived value of changing relative to the
perceived benefit of staying the same, the balance can be tipped towards greater treat-
ment compliance.

Avoiding Argumentation
Once a person initiates treatment and begins to comply with the components of the
programme, setbacks invariably occur. An unsatisfactory way for a psychologist to
respond is to harass the person to complete an exercise or berate the person’s non-
compliance (quietly cursing the client’s passive aggressive personality disorder). Miller
and Rollnick (2012) suggest that it is more profitable to avoid argumentation. They
encourage the view that therapeutic resistance is not so much a signal of client failure,
but a signal for the psychologist to shift strategy. Resistance is a problem that the
psychologist must take the responsibility to solve. The shift towards problem-solving
enables the psychologist to avoid argumentation and “roll with resistance”.

Rolling With Resistance

Therapeutic resistance may signal a lack of understanding of the purpose of part of the
programme or it may indicate a lack of success with one of the treatment components.
Resistance may also reveal a weakening of resolve, indicating the need to develop a
discrepancy to once again enhance motivation. Whatever the case, the psychologist must
backtrack and solve the problem. Regardless of the origin of the difficulty, it is necessary
to avoid argumentation and roll with resistance. Rather than pushing against the resist-
ance, the therapist can extract from the complaint or refusal a foundation of motivation
upon which to re-build the treatment. Consider the following examples of therapeutic
interactions.
CLIENT: I’m having a bad day with my agoraphobia. I don’t think that I can do today’s assignment.
THERAPIST 1: You have to face your fears. Remember, avoidance makes fears worse. You will just have to go
out and catch the bus.
THERAPIST 2: When we agreed to the assignment yesterday you felt that it was achievable. What do you
think it would take for you to achieve the task?

Both psychologists have the same goal in mind: they want to motivate the person to
complete the agreed assignment. The first psychologist pursues this goal by reinforcing
good reasons for attempting the assignment. Even though the reasons are valid, they are
suboptimal for two reasons. First, they encourage refusal from the client, leading to a
possible confrontation. Second, the response indirectly encourages dependence upon the
psychologist for the recruitment of motivation necessary for task completion. When
treatment is terminated the client will no longer have the psychologist’s support and
 Chapter 13: Managing Ruptures in Therapeutic Alliance 229

therefore, the aim is to encourage client autonomy. In contrast, the second psychologist
encourages the client’s autonomy by asking the person to find a solution. While the
psychologist would obviously provide assistance, the goal is for the client to identify why
the task is no longer achievable and how these obstacles can be overcome.
As part of rolling with resistance it is useful to implicitly convey the expectation that
the client has the resources necessary to achieve the task. For this reason the second
psychologist did not ask how the task could be made more simple (which may implicitly
convey that the task is too difficult), but shifts attention towards how the task can be
achieved. While the latter approach may involve breaking the step into a series of graded
easier steps, the psychologist conveys an expectation that the task is achievable.
CLIENT: I did everything right, but I still find myself having panic attacks. Your treatment just isn’t working.
THERAPIST L: We know the treatments are effective, what do you think you did wrong?
THERAPIST 2: Even though you battled hard to manage your anxiety, the panic still breaks through. I can see
how that must be frustrating for you. Are there any lessons that you can learn to help you have greater
success next time?

The client is expressing frustration that despite the best effort, the treatment techniques
appear to be ineffective. The first psychologist responds by drawing attention to the
person’s possible poor conduct of the technique. Although clients may have difficulties
because they fail to use the treatment techniques appropriately, it rarely helps to direct
blame towards the client. Instead, the second psychologist empathically acknowledges
the frustration but directs attention to the future. Implicitly the psychologist is commu-
nicating that setbacks are not a reason to throw in the towel, but an opportunity to learn.
The second psychologist also implicitly assumes that the client is going to continue to
work towards managing panics. Probably both psychologists would identify the same
problems in performance. However, the second does not oppose the resistance. Rather,
the psychologist rolls with the resistance, arriving at a position where motivation can be
evaluated and practical strategies to attempt the next assignment can be identified.
In summary, argumentation can be avoided if one rolls with therapeutic resistance.
In doing so it is helpful to respond to resistance with a shift in strategy to problem-
solving. The psychologist always implicitly conveys the knowledge (based on clinical
experience and the empirical literature) that the disorders can be managed more
effectively using the techniques being taught.

Supporting Self-Efficacy
Resistance in therapy can often follow a setback. At such times self-efficacy decreases as
the person feels that successful mastery of the problem is no longer an achievable goal. In
working with a client, it is particularly important to reverse decreases in self-efficacy.
Low self-efficacy appears to be a predictor of the development of fearful avoidance, the
exacerbation of depression and substance use. Therefore, if self-efficacy fails to increase,
or even decreases during therapy, it is highly probable that the problem behaviours will
return and therapeutic progress will be hindered.
Central to supporting self-efficacy is conveying the principle that change is possible.
This has already been alluded to in the context of rolling with resistance but it is
important that the belief that change is possible be conveyed throughout therapy. In
addition, there are three critical times when the likelihood of change needs to be
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explicitly communicated. First, at the start of therapy it is essential to communicate a

positive and realistic expectation of therapeutic change. For example, in our group
programme for agoraphobia, it is common to begin with a comment such as:
We have seen how fearful avoidance is driven by panic attacks and we have discussed how life
would be different if you could be free from panic attacks. We know from past groups that around
nine in ten people, just like you, become free from panic attacks. Free from panics not only in the
short term, but we have followed these people for up to two years after treatment and they remain
panic free. Although you may find this difficult to believe, our results are no different from other
similar centres around the world.
However, I suspect that even though I have told you that people can learn to master panics you are
thinking, “I bet I’m the one in ten who doesn’t get better.” Therefore, the more important question
is not how many people are panic free, but how do you move from being the one in ten, to being
one of the nine in ten? The simple answer is, you will need to work hard.
The techniques that we will teach you are effective and this is demonstrated by the high success
rates. Our experience has shown us that those people who do not improve (i) do not put in the
effort necessary to learn the techniques, (ii) do not practise the techniques or (iii) give up and go
back to using the strategies which they have used before to partially manage anxiety and panics. We
will teach you new techniques which will enable you to control your panics. It is up to you to learn
and practice the techniques, working hard to conquer the panics, because when you do, you can be
free of panic.
The second time when self-efficacy must be supported is during setbacks. At these times,
when the client is demoralized and possibly resistant to therapeutic interventions, it is
necessary to solve any problems while conveying the belief that change is still possible. The
third time when self-efficacy must be particularly supported is at the termination of treatment.
At these times clients are often worried how they will fare without the support of the
psychologist, and if treatment has been in a group context, without the support and encour-
agement of other group members. This difficulty can be tackled by reminding clients that the
gains during treatment were due to their efforts. In addition, it can be helpful to offer follow-
up sessions. Clients are invited to attend follow-ups if they suffer setbacks or need some extra
encouragement. Clients often say that they feel comfortable knowing that there is a “safety
net” should they need one, and they feel that they can use the resource on an irregular basis.
In summary, low self-efficacy is related to failure to progress in many problems.
Therefore, it is helpful to foster and support a belief in the possibility of change. Then the
psychologist can provide the effective treatment techniques which make long-lasting and
self-initiated change possible.

Summary
Ambivalence about treatment is common among clients. There are both gains and losses
associated with recovery and it is the psychologist’s role to ensure that the former always
outweigh the latter. It is possible to achieve this goal by expressing an empathic
understanding for the client’s condition and experience while developing a discrepancy
between current functioning and the desired functioning. Conflict or resistance in
therapy is best handled by avoiding argumentation (and subsequent polarization) as
the psychologist rolls with the resistance, seeking to solve any problems and restore
motivation, rather than “pushing” the client towards recovery. Implicit in all of this is
that the psychologist must keep uppermost in mind the knowledge that the treatment
 Chapter 13: Managing Ruptures in Therapeutic Alliance 231

techniques are effective and that change for the better is within the person’s capability.
Conveying the attitude that change is possible will not in and of itself cure the client’s
problems, but it will bring the person to the point where effective change is possible.

Homework in Therapy
Completion of homework assignments plays an important role in outcome (Burns &
Auerbach, 1992), such that clients who complete more of these exercises demonstrate
better outcomes (Kazantzis et al., 2000). For instance, Kazantzis and colleagues in their
meta-analysis found that setting homework accounted for 13 per cent of the variance in
outcomes (r = 0.36) and homework completion accounted for 5 per cent (r = 0.22) in
therapeutic outcomes. The size of these effect sizes can be used to support a number of
points. First, it is important and worthwhile to collaboratively set homework assign-
ments with clients (Bryant, Simons & Thase, 1999). Second, it is worthwhile reflecting
upon the amount of time that should be allocated to homework, given that these
activities only predict a relatively modest amount of variance in outcomes. If a client is
unwilling to complete homework assignments, even when the rationale for the collabora-
tively designed tasks appears clear to them, there is still a substantial portion of the
variance in therapeutic outcome to be explained by other factors. Therefore, in these
instances it may be better to build upon the client’s strengths and focus more on those
aspects of treatment with which the client does engage. However, most of the time,
homework is an important component of therapy and there are a number of ways to
increase the likelihood that the client will benefit from the completing the tasks.
Birchler (1988) produced a number of recommendations for increasing the likeli-
hood that homework is a helpful component of therapy. First, only set homework
assignments once a satisfactory level of rapport has been established. The rationale
behind this is that the more your client values you and your opinions, the more likely
they are to work with you to develop and complete challenging homework tasks (see also
Linehan, 1993a). Second, any homework that is set should correspond to the therapeutic
goals. Accordingly, the psychologist needs to help the client understand how completing
homework will alleviate presenting problems. Third, the client should be involved in
planning the homework. By maximizing the perception of control and willing participa-
tion, the likelihood of the client completing the homework will increase. Fourth, check
that the assignment does not exceed the client’s present motivational levels. In this
regard, consider factors such as time, energy and cost. Fifth, ensure that the task does
not exceed the client’s level of competence. One way to achieve this is to observe the
client practising within the therapeutic session. Sixth, reduce any threatening or anxiety-
provoking aspects of homework, unless of course the homework is specifically designed
to test negative predictions (in which case there will necessarily be a perception of risk
and some anxiety). In these cases it is particularly important that the client understands
the rationale for the tasks and that they are collaboratively designed with the therapist.
Seventh, make sure that tasks are specific and clear. Asking a client to repeat or to
paraphrase the rationale and homework plan can assist this process. Writing homework
assignments in a therapy notepad or scheduling them into the client’s electronic diary
can also help. Further, Birchler (1988) suggests that the psychologist considers any
possible secondary gain if the client does not complete the homework. Think about
the impact of the assignment on the client’s family system and any supportive or
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sabotaging effects that others may have. The therapist should not interpret non-
compliance as a client failure, but should rather seek to understand the reason(s) why
the client does value the task(s) at this point in therapy. Were the tasks not set collabora-
tively enough? Does the client not understand the rationale (i.e., how the task can be
helpful)? Is the task perceived to be too challenging? Is the task not aligned with the
client’s goals of therapy? The therapist needs to understand, formulate, and work with
the client to pre-empt obstacles to homework completion. If any can be anticipated,
identify the potential problems and setbacks, and normalize these experiences. Finally,
review all homework assignments. During the review the therapist should provide
support for the client, help to shape early behaviour change and acknowledge positive
efforts. It is easy to extinguish homework compliance through non-attention.
Thus, when giving homework it is important to allocate time to the process. Typically
novice therapists will underestimate the time taken and will try to cram it into the last
few minutes of a session. If you consider that planning homework assignments will
involve (i) explaining why you are suggesting that the client complete homework, (ii)
getting the client’s involvement and commitment, (iii) collaboratively planning home-
work in detail and (iv) requesting that the client paraphrase and then practice the
exercise, it is apparent that a reasonable amount of time will need to be allocated to
the exercise (especially initially). Our experience suggests that 10 minutes will not
underestimate the time required to assign homework, although the time reduces as
therapy progresses and the client is more familiar with the process.
In addition, homework must be essential to therapy. If the assessment or the task is
not essential and linked to specific therapeutic goals, then why are you wasting the
client’s time with it? If the homework is essential, then it follows that you must review the
homework exercise at the next session. In addition, if the homework is essential to the
progress of the next session, then it is problematic if the client does not complete it.
Readers are referred to Waller’s (2012) paper on the myths of motivation that, within the
context of eating disorders, makes the point that many clients might say that they wish to
change but this does not always translate into behaviour change. Waller argues that a
client’s stated intentions to change are best considered as a manifesto rather than a sign
of actual motivation for change. If the client does not apply the therapeutic knowledge
and skills learned in therapy in their life outside of treatment sessions, despite the
clinician being confident that the rationale is clear and the alliance strong, then it is
important for the clinician to be clear that the client is not completing therapy.
A decision may be made to suspend therapy or therapy should explicitly change goals
from achieving change to learning to live with the clinical problem. In the case of eating
disorders, this would involve working with the client to develop a plan for them to get
their needs met as much as possible with the eating disorder. For example, if the client
wishes to become a parent but her eating disorder means this is impossible, the therapist
would help the client to satisfy her need to nurture by planning to spend more time with
her nephews and nieces. The main point here is that it is the client’s decision to change or
not change. The therapist’s role is to facilitate change if this is aligned with the client’s
goals, and behaviour change (not verbal declarations of motivation) is evidence that
therapy is effective. If change is the client’s manifesto but behaviour change does not
follow, then one approach to “rolling with the client’s resistance to change” can be to
explicitly alter the treatment goals to help the client cope with an absence of change. This
addresses the issue of clients believing the therapy is ineffective (because they haven’t
 Chapter 13: Managing Ruptures in Therapeutic Alliance 233

actually completed therapy targeting behaviour change) and avoids there being conflict
between the therapist’s belief about the client’s goals and client’s actual goals. Of course,
shifting focus to coping with an absence of change (what Waller calls “disability
training”) can have the paradoxical effect of increasing clients’ motivation for change,
at which point the goals of therapy can change again (if it is clear to the client and
therapist why this motivation is no longer only a “manifesto”).
Engaging the client with therapy so that it stands the best chance of success is an
important clinical activity. During the course of ensuring compliance, it is not unex-
pected that client-related factors may become of importance and these will require
sensitive handling on the part of the therapist. It is to some of these issues that we will
now shift our discussion.

The Process Dimension

You will recall from Chapter 1 that the process dimension was superimposed on the
components of the model from assessment through to evaluation and accountability (see
Figure 13.2). The process dimension refers to relational factors occurring between the
client and therapist, which are often about what is not explicitly discussed or not even
necessarily within the client’s (or therapist’s) awareness. This section will first describe
the process dimension in more detail, before providing a framework for formulating and
responding to process issues during therapy.

What is Process?
Trainees can initially find it difficult to distinguish between content and process. Put
simply, content is what is overtly spoken within the session, whereas process is how the
therapist and client interact (Kiesler, 2000). Content includes identifying diagnoses and

Client data (problem, context, history, etc.)

Theoretical and Clinical training &

empirical literature experience

Assessment &
case formulation
Process dimension

Treatment planning
& measurement

Treatment implementation
& monitoring

Evaluation &
accountability

Figure 13.2 The process dimension operates throughout therapy.

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234 Chapter 13: Managing Ruptures in Therapeutic Alliance

the problem list, selecting evidence-based treatments to address the identified clinical
problem, selecting ongoing assessment measures, and aspects of the agenda, skills and
strategies that are explicitly discussed with the client. Most of the chapters of this book
focus on what to do in therapy, along with some suggestions about how to implement the
strategies. In contrast, process includes all of the “stuff” that the client and therapist
bring to the therapeutic relationship that influences how they interact with each other –
experiences in past relationships, beliefs and expectations about themselves and others,
strategies (e.g., avoidance, confrontation) for managing uncomfortable emotions (e.g.,
anxiety, shame) and so on. Process issues may emerge within the therapeutic relationship
in ways that can facilitate or interfere with outcomes, so it is important for therapists to
learn to formulate using the process dimension, and to consider how they can work
effectively to circumvent or directly address process issues as they arise. Process com-
ments reflect or explore aspects of the interactions that are occurring between the
therapist and client in the here-and-now (Hill et al., 2014).
Beginning therapists are understandably preoccupied with what they need to do within
each session and they dutifully plan agendas based on evidence-based approaches to achieve
particular outcomes. Treatment manuals provide clearly structured sessions with some
degree of predictability for clinicians, and these can be highly effective. For solution-
focused clients who can rapidly form strong alliances with therapists, are highly motivated
and compliant, and are able to easily separate from the therapist after a course of treatment,
an emphasis on content can be highly efficient and effective. Treatments that are short-
term, highly structured, and skills-based (e.g., brief and low-intensity interventions dis-
cussed in Chapters 7 and 8) are also likely to focus on content so that clients can achieve the
agreed outcomes in a timely way. These types of interventions are often completed before
significant process issues arise in therapy and, as described in Chapter 8, shared decision-
making can go a long way to preventing unhelpful process issues in brief interventions.
But what about when therapy is not progressing well and you notice yourself reacting
strongly to the client – you are relieved when they cancel a session, you become more
preoccupied with them than other clients, you start to dread their appointments, or you
feel anxious, ineffective, bored or other negative emotions within session? What if a
client reminds you of past clients who have been non-compliant or for whom treatment
has been unsuccessful, or of someone in your own life with whom you have had a
difficult relationship? And what if you then judge yourself harshly for having these
reactions, because you believe a therapist should not feel this way? These are just some
clues that process dimension might be presenting challenges for the therapist that may
interfere with the client’s progress. Repeatedly encountering process issues without a
framework for formulating and responding to them can also increase therapists’ stress
and presents a risk for burnout.
The process dimension includes both the client and therapist’s relational styles
because, at the risk of stating the obvious, all relationships involve an interaction between
at least two individuals’ relational patterns. Beginning therapists sometimes believe that
they must adopt a professional role and appearance, which to them means neglecting
aspects of themselves that are triggered within the therapeutic relationship and main-
taining a sole focus on the client. In fact, a skillful therapist will pay attention to their
own reaction, recognize it as an important source of information, formulate it and then
consider how to respond to the situation in a therapeutic way for the client. This
response will differ from client to client, and learning how to respond with “client
specificity” (i.e., what is most therapeutic for this client right now) will ensure that the
 Chapter 13: Managing Ruptures in Therapeutic Alliance 235

clinician is not reacting to their “own stuff”, but instead is considering the impact of
alternative responses on the client.
Working with the process dimension using process comments is often very challen-
ging for therapists, particularly new therapists. It can feel precarious to stray from a
structured agenda with a focus on the client, to the process dimension that includes self-
involving statements. Self-involving statements are those that refer to what is occurring
between the therapist and the client, which can be distinguished from self-disclosing
statements. Self-disclosing statements are those that involve the therapist shifting focus
from the client to their own issues or experiences that are unrelated to the client, and are
therefore often unhelpful. Self-involving statements are intentionally made by the clin-
ician to draw attention to a relational issue that is occurring with the client in the here-
and-now. For example, consider a situation where a client reports being frustrated by his
partner refusing to talk and resolve issues between them. Consider the alternative
responses from Psychologist 1 versus 2.
CLIENT: I just find him so frustrating (client’s voice is raised slightly). He refuses to listen to me, and when
I try to talk to him he shuts down and refuses (client starts to shout). HE JUST MAKES ME SO ANGRY
I CAN’T STAND IT! WHY WON’T HE LISTEN TO ME?
THERAPIST 1: I can see how frustrated you feel by your partner not listening to you. I feel the same way when
my partner doesn’t listen to me. Let’s talk about what might help you get your point across.

CLIENT: I’m not sure how to make him listen, but I’m willing to try.
THERAPIST 2: I can see how frustrated your feel by your partner not listening to you, and it sounds like this is
important for us to talk about. I wonder if you mind me being quite frank with you?

CLIENT: Sure. We aren’t going to get anywhere by not being open with each other.
THERAPIST 2: I agree that it is important for us to be open with each other. In fact, I think this is one of the
most helpful things about therapy – we can sort of break social rules a bit and talk about things that would
often be left unsaid, which means we can be more real and honest and hopefully this will lead to more
progress. What I was going to say is that as you were talking then about this frustrating situation, I noticed
that you raised your voice. Initially a little bit, but then quite a lot. Did you notice this?

CLIENT: I guess so. Well, not really at the time, but now that you mention it. Yes.
THERAPIST 2: You may not have been aware that when you were shouting I actually felt quite intimidated –
like I wasn’t sure how you would react to me if I were to say something, particularly if I thought you would
disagree with what I said. I hadn’t felt that with you before. I usually feel like we can speak quite freely with
each other. I wonder what you think might’ve been going on between us there?

CLIENT: Oh no. I had no idea I was having that effect on you. I’m sorry about that. I just get so
frustrated sometimes.
THERAPIST 2: Yes, I could definitely see your frustration. I’m just wondering aloud here, but perhaps your
partner feels the same way I did when you raise your voice? What are your thoughts about that?

CLIENT: Well, if he does feel that way then it would make sense that he wouldn’t want to continue the
conversation. I’d never thought about that before.
THERAPIST 2: That sounds like quite an important insight. Let’s talk about how you think you could
approach these situations so that your partner may be more able to listen and so that you can feel heard.
Perhaps we could starting by youhttps://avxhm.se/blogs/hill0
describing the situation to me again, but in a way that feels more like a
conversation that I can be a part of?
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Psychologist 1 showed reflective listening skills by identifying the client’s emotion

(frustration) and attempted to validate the client’s frustration with a self-disclosing
statement, before moving on to try and solve the problem. Validating the client’s
emotion and trying to solve the problem are not problematic, and it may be that the
client would learn some more helpful ways to express his feelings using this approach.
However, there are risks with the self-disclosing statement used by this psychologist.
First, the client might believe that the psychologist was also validating his behaviour
(speaking in a loud, domineering voice), which may strengthen his unhelpful belief that
he must be listened to regardless of how his partner feels. Second, the therapist’s feelings
and relationships are a distraction from the client’s problem (his unawareness of how his
behaviour might be impacting his partner, resulting in a communication breakdown),
and provides no clear benefit to the client.
Psychologist 2 also validated the client’s feelings, but was careful not to validate his
behaviour. In fact, Psychologist 2 used his own reactions to inform the client in real time
how his behaviour might be impacting on others (the therapist had a hypothesis that this
might be a recurrent interpersonal problem for the client). The therapist sensitively
asked permission to be open and honest with the client, and then provided the direct
feedback as a tentative hypothesis to be explored (rather than as a fact). The client was
invited to consider how his behaviour might be impacting on his partner before
considering alternative ways of behaving to get his own and his partner’s needs met.
You can see with this example that if the psychologist was too anxious about directly
addressing the process issue with a self-involving statement, then an important oppor-
tunity for the client to understand the impact of his relational manner on others would
have passed by. The therapeutic relationship can typically be more open and honest than
other relationships, which provides a unique opportunity to address often unspoken
relational factors. The therapeutic relationship is a microcosm of the client’s life, but is
often a safer space within which to experiment with new relational patterns, which can
then be generalized to other relationships.

Working with Transference

Transference is a concept that has evolved over time, from classical roots in psycho-
dynamic theory to one that is conceptualized from a cognitive perspective as a set of
interpersonal, personal and relational schemas that are reflected in an individual’s
interpersonal strategies (Cartwright, 2011). Transference is essentially an inappropriate
overgeneralization of past patterns of feelings, thoughts and behaviours learned within
the context of an individual’s developmental history into (i.e., transferred to) the
therapeutic relationship (Gelso, 2014). For instance, a client with overly critical parents
with unrelenting standards may present as excessively compliant and self-critical within
the therapeutic relationship. The therapist might observe the client repeatedly pre-
empting expected criticism from the therapist by criticizing herself first (e.g., “I probably
did the homework wrong”, or “sorry my writing is so messy” when in fact it is very neat).
The client may have learned that self-criticism and subjugation protected her from
punishment within the context of her family, and this strategy has been generalized to
all relationships. In this example, the client is behaving as if the therapist will respond in
the same way as other significant people in her life.
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It is important for trainees to “tune in” to the way clients relate to them so they can
start generating hypotheses about whether these patterns may be serving to maintain the
client’s presenting clinical problem(s). In the example of the overly compliant and self-
critical client, the therapist may choose to assess the client’s expectations of the therapist
in the here-and-now with a self-involving (process) comment.
CLIENT: I think I did the homework all wrong, and sorry if you can’t read my writing because it is so messy.
THERAPIST: I’ve noticed a few times in session that you seem to doubt yourself and be quite self-critical. Is
this something you’ve noticed in yourself?
CLIENT: Yeah, I do it all the time. It’s just the way I am. I always think I’m going to stuff things up.
THERAPIST: I’m curious about what sort of reaction you expect from me if, say, you did make a mistake or if
your writing was a bit messy?
CLIENT: I don’t really know.
THERAPIST: If you think about it now, what do you expect me to think about you if you made a mistake?
CLIENT: Um, I guess that I’m not trying hard enough and I’m a bit of a hopeless case.
THERAPIST: Ouch! That sounds like it would be pretty upsetting. And if I did think that about you, what do
you expect me to do?
CLIENT: Probably tell me I’m wasting your time.
THERAPIST: And what if you didn’t “warn” me that you hadn’t done the homework properly, or that your
writing might be messy? What might happen then?
CLIENT: Well, I guess if I get in there first you might be less likely to criticize me. Or at least you know that
I’m aware of my failures and don’t think I’m deluded or something.
THERAPIST: I really appreciate you being open with me about this because it helps me to understand why you
feel so anxious in social situations. It also gives me an opportunity to let you know that I don’t think these
things about you at all. In fact, I’ve been thinking how hard you are working and how courageous it is for
you to come along each week and work on these problems. No part of me thinks you are wasting my time.
Quite the contrary. I’m wondering whether you expect these sorts of reactions from other people in your
life as well?
CLIENT: I guess I expect that everyone thinks these things about me. And to be honest, I think these things
about myself.
THERAPIST: And how do you feel while you’re expecting criticism from others or criticizing yourself?
CLIENT: Really anxious and like I just want to hide on my own.
THERAPIST: It seems important that we understand how these negative expectations and beliefs about
yourself, as well as your self-criticism, might be maintaining your anxiety and making it difficult for you to
develop relationships. What are your thoughts about this?

In this example, the psychologist used a process comment in the here-and-now (also
called an immediacy intervention) as a way to assess the client’s expectations of the
psychologist and of others. This provides an important opportunity for the psychologist
to test an hypothesis in the client’s case formulation, specifically that her expectations of
criticism from others drive her self-critical behaviour and avoidance, which, in turn,
maintains her sense of inadequacy. The psychologist is also able to provide a corrective
emotional experience by violating her expectations of criticism, which can start to
challenge the client’s overgeneralized expectation that everyone has unrelenting
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standards that she needs to meet to avoid criticism. She learns that the psychologist has
more realistic and reasonable expectations, and receives the surprising feedback that the
psychologist has no critical thoughts about her and in fact values her courage. Over time,
the psychologist and client can work together to gather evidence that most people also
have realistic expectations, and therefore she need not pre-emptively assume that she
is inadequate.
The psychologist might recognize links between the client’s earlier significant rela-
tionships and the presenting problems, and occasionally might make some of these
explicit with the client. However, process comments are likely to be most powerful when
they are used to identify beliefs, expectations and patterns of behaviour within the
therapeutic relationship in the here-and-now (e.g., I’m just wondering how you expect
me to respond to you right now? As I hear you talking about all your worries I’m starting
to feel a little lost . . . I wonder what might be going on between us at the moment?),
rather than repeatedly linking them back to past relationships (e.g., So you’re expecting
me to be critical of you at the moment . . . this sounds more like an expectation that you
have of your parents than of me?). The psychologist’s job is to help the client feel safe
enough to explore process issues within the therapeutic relationship, work collabora-
tively to identify any misperceptions and contributions from the client or therapist to
problematic interactions, and then to work together to modify the relational style. The
client and therapist would typically experiment with these changes within the therapeutic
relationship before the client then begins to explore the impact of these changes in other
current and new relationships.
Some useful questions for psychologists to identify and formulate transference are:
 Given what I know about the client’s other relationships, what patterns of thoughts
and behaviour might I need to be alert for?
 What patterns have I noticed in the client’s interpersonal expectations or behaviour?
 How might the client’s responses to me be replicating the client’s developmental
relationships?
 Based on what I know about the client’s past experiences, what sort of reactions
might the client be expecting from me right now?
 Is the client’s response to me similar to other clients and people in my life? If not,
how might the client be interpreting what I said or did differently? How might this
relate to their interpretations of other people’s behaviour in their life?
 How might these interpersonal patterns relate to the client’s presenting problems?
 Might there be something “unsaid” at the moment that is affecting how the client is
relating to me?
 Would it be helpful to offer a process comment about the interpersonal pattern I’ve
noticed? If so, in what ways might this be helpful? In what ways could it be unhelpful?
 How would I need to respond to the client in this moment to provide a corrective
emotional experience that will violate unhelpful interpersonal expectations?
These questions will help the clinician to formulate the process issue and consider
ways of responding to the client in a therapeutic way. The aim is to increase the client’s
awareness of their expectations and behaviour, and their impacts, provide a safe space for
them to explore these patterns, and ultimately to increase their flexibility and exert more
choice over how they wish to respond (Teyber & Teyber, 2014, 2017).
 Chapter 13: Managing Ruptures in Therapeutic Alliance 239

You will notice that the word “pattern” is frequently used in many of these questions.
It is important to emphasize the fact that clients’ behaviours that result in temporary
strains in the therapeutic relationship may not need to be addressed (e.g., the client
flippantly refers to the therapist as appearing young on one occasion in the initial
session), particularly if they do not occur frequently, cause interpersonal problems in
the client’s life or significantly interfere with therapy. The psychologist also needs to
consider the strength of the therapeutic relationship, the stage of therapy and the goals of
therapy before introducing a process comment. Therapists might be well-advised to
circumvent process issues if the therapeutic relationship is not strong, in the early stages
of therapy before patterns have emerged or the therapist has a clear formulation, and if
the process issue is unlikely to present a serious impediment to achieving the
therapeutic goals.
What if the clinician is feeling uncomfortable about what is occurring in the session
and suspects there has been a rupture, but is unsure whether this is the client’s
transference or whether it is a consequences of the therapist’s personal history, beliefs,
expectations, assumptions or values that are being triggered or challenged? We will now
turn to the concept of countertransference to assist trainee clinicians to disentangle their
own issues from those of their clients.

Working with Countertransference

The concept of countertransference has also shifted from a classical conflict-based
reaction from the therapist’s childhood in response to the client’s transference, to a
broader definition encompassing the therapist’s unique emotional, cognitive, behav-
ioural, physiological reactions to clients that stem from the therapists’ previously learned
interpersonal patterns and biases (Gelso & Carter, 1985; Hayes & Hofman, 2018).
Countertransference need not be triggered in response to a client’s dysfunctional rela-
tional style, but could be triggered by any aspect of their presentation. For example,
aspects of the client’s presentation might remind them of a family member or past client,
which may result in positive countertransference (if the therapist feels positively towards
these cues) or negative countertransference (if the psychologist has a negative emotional
reaction). Trainee psychologists need to understand that they will react to their clients in
various ways – this is normal and need not be ignored. It is not a failure or sign of
incompetence, but rather a natural consequence of relating to others as a human being.
The skilled therapist does not have an absence of reactions to clients. The skilled
therapist pays attention to their own reactions, generates hypotheses about the source
of the reaction, and responds accordingly.
If the psychologist’s formulation is that their reaction is client-induced, such that the
client’s behaviour would likely trigger these reactions in most people, a process comment
might be appropriate to increase the client’s awareness of the issue as described in the
section on transference. Alternatively, if the psychologist suspects that their reaction is
therapist-induced, such that it is a consequence of the therapist’s own personal issues or
stressors being triggered, the therapist should carefully consider how to respond to the
client and take great care not to re-enact their own problematic interpersonal styles with
the client (e.g., defensively respond to what the client is saying as the therapist would to
their own critical parent). During the session, the therapist should reorient to what is
pertinent to the client’s progress. After the session, the therapist should spend some time
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formulating their countertransference reaction and consider several options for

moving forward.
One option is to ignore the reaction and hope that it does not occur again. This
option will stymie the therapist’s development as an effective clinician and may continue
to interfere with therapy with current and future clients. Recurrent and problematic
countertransference reactions will also increase the therapist’s stress and potential for
burnout. One option is to write a thought diary, which might be helpful for identifying
precisely the emotional trigger within the session along with any problematic appraisals.
The psychologist can then work through a cognitive restructuring process to help shift
their perspective such that the issue is less likely to trigger strong reactions in the future.
A complementary option is to discuss the issue in supervision, which is highly recom-
mended. A supportive supervisor will help the trainee to “unpack” what might be going
on for the therapist and either (a) help to resolve the issue or (b) suggest that the trainee
seek therapy if the issue goes beyond what is appropriate to discuss within the supervis-
ory relationship. Of course it is possible that ruptures involve both client-induced and
therapist-induced countertransference, and it is important for the therapist to respond to
the client-induced reaction within the session and the therapist-induced reaction outside
the session. It might be important to re-emphasize here that recognizing these reactions
and their potential impacts, and being willing to discuss these in supervision, are trainee
strengths rather than signs of incompetence.
Trainee psychologists invariably experience anxiety when they start seeing their first
clients, as they fear being unprepared, appearing incompetent or being unable to help
their clients. This is normal and most trainees are able to sufficiently contain their
anxiety through preparation, supervision, peer support and their own emotional regula-
tion skills. Nonetheless, most trainees will still find their anxiety interferes with their
ability to be present with the client and will question their readiness and suitability.
Although this is common, a trainee who, for example, holds a particularly strong core
belief of inadequacy and fear of negative evaluation, is likely to experience more severe
anxiety. It is important to consider the types of client behaviours or presentations that
are most likely to trigger strong responses in you. Your formulation skills will be critical
to understanding what is occurring and how to respond.
One author recalls running a therapy group for people with social anxiety disorder.
The psychologist had run many social anxiety groups and, as usual, in one of the sessions
the group conducted a behavioural experiment designed to test the belief that the group
would draw a lot of attention from other people by walking down a busy street in single
file. The group members’ predictions were carefully elicited before the experiment (e.g.,
“people will laugh”, “most people will stare”, “the police will arrest us!”) and they headed
off. When they returned, all but one client was (pleasantly) surprised that in fact none of
the group’s fears had come true. No one really cared about what they were doing and the
only reactions were benign (e.g., fleeting looks). However, one client was clearly dis-
tressed and very angry and with only 10–15 minutes left in the session she expressed her
lack of trust in the group. The interaction played out something like this:
CLIENT: (looking angry and upset) I can’t believe you made us do that!
THERAPIST: As we’ve just heard, others in the group were surprised that none of the group’s fears came true.
This was a relief and they are now questioning some of their social fears. How did you experience it?
 Chapter 13: Managing Ruptures in Therapeutic Alliance 241

CLIENT: We made fools of ourselves. Why would you make a group of people with social anxiety do
something like that? It’s not necessary for us to act like idiots to help us with our anxiety. It makes it worse
not better. (staring angrily right into the psychologist’s eyes)
THERAPIST: (Feeling shocked at the intensity of the client’s anger and response.) Oh, I’m sorry that this was
so challenging for you (silence for a few seconds, thinking about what to say). It sounds like you didn’t
experience what others experienced in the group. It is probably a good point to remind ourselves, (asking
the group) why did we do that task?
CLIENT: I don’t know, but it wasn’t helpful (looking distressed, angry, and on the verge of tears). I can’t believe you
would make us do something like that. I don’t trust this group any more. I don’t think I can trust you!
THERAPIST: (Feeling somewhat defensive.) Well, I didn’t make anyone do the task. Group members always
have the choice to complete the task or not. One of the difficulties with group treatment is that there are
tasks that everyone does and there isn’t as much flexibility to tailor the tasks to each person (making
excuses for the treatment format). I’m really sorry that you don’t feel able to trust the group now. That’s
definitely not what we are hoping to achieve. It appears that the reason we did the task wasn’t entirely clear
to you beforehand. I wonder if others in the group could reflect on why we would take a risk and do
something that was unusual in public?
OTHER GROUP MEMBER: Well, I think it was because we think that all these bad things are happening, but
because we avoid social situations we don’t really know if they will happen. We walked down the street in
single file to test our predictions – that people would think we were idiots by staring, laughing and
criticizing us. But none of that happened. So, I learned that perhaps I don’t have to worry as much about
being the focus of other people’s attention.
THERAPIST: (To the distressed client.) What are your thoughts about that?
CLIENT: (Silent for a while and still looking angry.) I just don’t think it’s necessary to make fools of ourselves
to help our social anxiety and I won’t be doing anything like that again.
THERAPIST: (Feeling somewhat dazed and concerned.) Again, I’m sorry that you found it so distressing and
I hope that we can regain your trust. Perhaps you and I could have a chat after the group. Would that be Ok?

The client in this example was highly anxious and recruited an aggressive strategy to
protect herself against exposure to further perceived social threats within the group. This
client responded very differently to all other members of the group, and to the hundreds of
socially anxious clients the psychologist had worked with before using the same techniques.
In the session, the therapist attempted to draw the group’s attention back to the treatment
principles and rationale for the task, all while feeling very uncomfortable and somewhat
attacked. Within the session, the therapist did not have a clear formulation about what was
occurring with the client and he therefore felt uncertain and anxious.
The psychologist met with the distressed client after the session (during which she
acknowledged her tendency to get angry with people she perceived to be “responsible”
for her anxiety), and then immediately sought supervision. His supervisor helped the
psychologist to process the client’s and therapist’s reactions. The client’s response to the
psychologist was formulated as a transference response, whereby it was hypothesized that
when this client became anxious, she used the strategy of blaming others and attributing
her anxiety to their untrustworthy behaviour, which served the function of protecting
her from exposure to further anxiety-provoking situations (as people in her life then left
her alone) but also reinforced her negative beliefs of others. This formulation was
supported by the client’s admission after the session.
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The psychologist also experienced an intense countertransference reaction. He felt

shocked and somewhat dazed in response to her intense reaction, and he started to doubt
his competence. During the session, the therapist had not yet considered the possibility
that the client was trying to protect herself by blaming him, so he questioned himself and
was at risk of accepting the label of being an “untrustworthy therapist.” The counter-
transference reaction was formulated as client-induced, given that her reaction was
unusually intense based on the therapist’s experience with many other clients.
However, there was also a component of therapist-induced countertransference with
respect to him doubting his ability, which is something that sometimes occurs in other
situations as well. This issue was discussed with the supervisor and the psychologist
decided to work through a thought diary to identify and challenge some of the beliefs
that were triggered in this situation.
This example shows that clients will use strategies designed to protect them. These
behaviours (also known as eliciting manoeuvres) are used to elicit responses from others
that will stave off their anxiety. Different clients will use different eliciting manoeuvres.
Some will adopt an overly agreeable, compliant, and even subjugating manoeuvre to
avoid confrontation and conflict. Others will adopt a more arrogant and controlling
presentation to avoid anxiety about being controlled by others. Others will be highly
avoidant of expressing their opinion or of social contact. The function of these behav-
iours is often the same – to avoid threats or potential conflicts. Understanding the
function of these various eliciting manoeuvres can help trainees to circumvent unhelpful
countertransference and instead formulate the key threat or conflict that is being avoided
and respond with client specificity to help resolve the problem.
If the psychologist had been able to formulate the process issue within the session, he
may have been better equipped to “put aside” the therapist-induced countertransference,
which would have enabled him to focus on the client’s anxiety rather than the interpersonal
strategy of blaming others. The psychologist’s task was made more difficult by the issue
being raised close to the end of the session and within the group context, but the example is
still illustrative. After the session, the client was willing to explore her pattern of externalizing
blame for her anxiety and, instead, refocus on her beliefs and how her behaviour may have
maintained her fears (e.g., blaming others provided a justification for avoiding people,
particularly those who encouraged her out of her “comfort zone”). If the client was in
individual therapy, the psychologist could encourage the client to refocus on what she could
do to better manage her anxiety as she continued to approach social situations. The
psychologist would not abandon efforts to push her out of her comfort zone (as others
did in her life, which reinforced her lack of self-efficacy), but would rather consistently
convey the message that he believed she was capable of moving forward.
If a trainee experiences a strong emotion in session (e.g., anxiety, sadness, anger,
boredom, confusion, guilt, controlled, intimidated), the following questions can be helpful
for identifying and responding to countertransference. They can also help the therapist
determine whether the countertransference is client-induced or therapist-induced.
 Is my reaction being triggered by something the client is doing or saying? If so, what
is going on between us at this moment?
 If other people were experiencing this client’s behaviour right now, might they be
feeling the same way? If so (client-induced), what’s the function of this behaviour? If
not (therapist-induced), do I need to reflect on this after the session in a thought
diary and/or in supervision?
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 If client-induced, is it important for me to sensitively bring this process issue to the

client’s awareness? If so, how can I raise this issue in a way that will not re-create past
unhelpful interpersonal patterns to provide a corrective emotional experience?
Here, we offer a note of caution if the client appears to respond negatively to the
therapist. It is important for therapists to self-reflect and consider whether they did in
fact make a mistake, in which case the client’s response may be understandable, appro-
priate and require validation. For example, if a psychologist made an assumption about
the client that went beyond the evidence, made a statement that did in hindsight sound
judgemental or became overly didactic and somewhat argumentative because the client
had difficulty understanding the rationale for a particular therapeutic task, it is import-
ant that the psychologist does not externalize the blame for this error by attributing it to
transference or client-induced countertransference. Psychologists need to be humble,
self-reflective, and honest enough to acknowledge their mistakes with clients so that they
avoid re-creating the client’s own unhelpful interpersonal patterns and can build trust in
the therapeutic relationship. Here is an illustrative example:
CLIENT: I just don’t really understand why I have to be rude to people to treat my social anxiety.
THERAPIST: (Somewhat exasperated.) As we’ve discussed several times before, the idea is to challenge these
strict rules you have about what is and is not appropriate to do in social situations. If you are able to
challenge these beliefs and find that people are not offended, or even if they are temporarily “put out” they
don’t get very upset and you can cope with this. Wouldn’t these things be helpful to learn? What part of
this is hard for you to understand?
CLIENT: Yes, sorry. I’m really quite stupid sometimes. (sits silently, looking down)
THERAPIST: (Recognizing that he might have come across as judgmental.) It seems like what I said might’ve
been quite unhelpful there. I’m wondering if it came across as though I was judging you for not
understanding why the task might be helpful for your social anxiety.
CLIENT: Yes you did, but I am quite slow to pick things up sometimes (the client is using the eliciting
manoeuvre of self-criticism to avoid more criticism from the therapist).
THERAPIST: Actually, I haven’t found you slow to pick things up at all. You always pay close attention to
what we talk about and you have worked hard to apply the treatment strategies. I can see how what I said
might have sounded like I was criticizing you, and I am sorry it came across that way. In fact, I understand
your perspective. You’ve worked very hard for many years to avoid offending other people, to the point
where you now worry about offending people all the time, which causes you to feel anxious in most social
situations. The idea of asking if you can go ahead in a queue must therefore be really anxiety-provoking for
you, particularly if you expect it to lead to hostility and criticism from other people. It makes sense that you
would really want to understand how this could possibly be helpful for you before you do it. I’m curious
about what it was like for you to express your doubt about that task? Was that difficult for you?
CLIENT: Yeah, I usually find it really difficult to disagree with people. I usually just go along with whatever
I’m told.
THERAPIST: Well I just want to say that I appreciate you being honest with me and telling me that I sounded
judgemental. I will do my best to avoid this in the future, but I would really like it if you continue to speak
openly with me about how we are working together, particularly times when you feel uncomfortable.
Would that be Ok?

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244 Chapter 13: Managing Ruptures in Therapeutic Alliance

CLIENT: Sure. I do understand that I need to push myself out of my comfort zone. I am too concerned about
what other people think about me. Perhaps we could try another way to challenge my fears first while
I think more about pushing in front of a queue?
THERAPIST: That sounds great. What ideas do you have about where to start?

This client tends to subjugate his own needs in relationships and the fact that he was
willing to question the psychologist about a task was actually a testing behaviour designed
to see if the therapist would respond in the same, critical ways in which the client has
experienced in past relationships. On this occasion, the therapist initially failed the test,
re-creating past relationships by expressing some frustration with the client, which just
reinforced his core beliefs that others are judgemental and he is inadequate. Recognizing
that the client’s willingness to question the psychologist was actually a sign of progress
(starting to express his opinion, which he rarely does), rather than a sign of resistance,
the psychologist quickly responded to the process issue by taking responsibility for the
mistake and providing a corrective emotional experience. Rather than move on and leave
the client feeling inadequate, the psychologist took the time to acknowledge the rupture
in the relationship and repair it by gently challenging the client’s negative self-beliefs
(slow to pick things up), validating the client’s response to the therapist, and showing
that sharing a genuine relationship mattered by expressing gratitude about the client’s
willingness to take the risk of expressing his doubt. This led to the client re-stating his
commitment to treatment and being willing to collaborate with other tasks that will help
him to move forward in therapy. The psychologist’s response to his mistake provides an
alternative relational model which the client can generalize to other relationships.

When Might Process Issues Arise in Therapy?

The process dimension can arise at any stage of therapy. Trainees should be formulating
tentative hypotheses from the first time they meet their client based on their observed
relational style. During the initial assessment, trainees might ask questions such as:
 How readily does this client appear to form a therapeutic alliance?
 How open is the client with personal information?
 Is there anything of note about their interpersonal style that could be relevant to their
presenting problems?
 Am I able to form any hypotheses about how these relational aspects may impact on
my capacity to work effectively with the client?
Obviously these will be preliminary hypotheses, many of which may be discounted in
subsequent sessions. As patterns emerge the clinician will need to make some decisions
about how to manage these issues, either directly or indirectly. Interested readers are
directed to Teyber and Teyber (2017) for more details about working with the process
dimension. Our aim here is to alert trainees to the point that the process dimension is
operating throughout therapy and, where indicated, can provide another opportunity for
intervention if indicated by the individualized case formulation. Greater awareness of the
therapist’s own interpersonal patterns, through structured self-reflection, supervision or
therapy, can also lead to further personal and professional development.
 Chapter
Respecting the Humanity

14 of Clients: Cross-Cultural
and Ethical Aspects of Practice

Individuals function within a complex array of familial, social, historical, political,

cultural and economic influences. Consideration of these influences draws attention to
individual-specific matters such as cultural and ethical issues. In addition, we need to be
cognizant of those factors that pertain to the broader social systems and structures within
which both our clients and ourselves are located. Clinical psychologists must deal
sensitively with these issues in a manner that respects each client’s uniqueness and
humanity while being mindful of the socio-cultural context.
From Figure 14.1 it is apparent that there are a variety of ways that social, cultural
and legal issues may influence the relationship between the psychologist and the client.
Running through all these facets is a central theme, in which the psychologist seeks to
afford the client the dignity that is warranted by virtue of being a member of the human
race. This perspective acknowledges both the history of psychology and growth in our
profession’s understanding of its role. For instance, the longevity of the approach is
reflected in the American Association for Applied Psychology’s Committee on
Professional Ethics proposal that psychologists needed to, first, consider the welfare of
human beings as individuals and, second, to advance psychological knowledge (Coxe,
1940). However, as society has grown in its understanding of the complexity of the issues
and the nuance required to implement them (Allan, 2020), the framing of these ambi-
tions tends to be less as obligations or guidelines, but more in aspirational terms
(Sinclair, 2012, 2017).
Recognizing our humanity requires acknowledging our individuality as well as our
social nature. We are individuals who live in social structures and as such we both act
upon and are acted upon by our environments. This means that clients will present for
therapy as unique individuals, who have been shaped by particular social, cultural,
historical and political forces. The clinical psychologist needs to understand and respect
how these forces can both constrain and enrich the therapeutic relationship. Like their
clients, psychologists will be influenced by their own social, cultural, historical and
political experiences, and they must strive to minimize any negative or constraining
impact that may have on the client.
If the broader social context of the practice of clinical psychology is not considered,
then unforeseen problems may arise. For example, MacIntyre (2001; MacIntyre &
Petticrew, 2000) has drawn attention to circumstances where the provision of a well-
meaning health intervention may exacerbate health inequalities because a socio-
economically advantaged person’s greater resources may offer that person greater access
to the health intervention. Some of these resources will be financial, but other less
obvious ones may include education, coping skills, as well as the chance or ability to
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245
246 Chapter 14: Respecting the Humanity of Clients

Client problems existing within a sociocultural context, history, etc.)

Theoretical & Clinical training &

empirical literature experience
Psychologist must
respect the humanity of Client’s cultural and sub-
each client and grant cultural context and
them the dignity this Assessment & individuality needs to be
affords while maintaining case formulation considered
their own humanity and
socio-legal obligations Treatment planning
& measurement
Psychologist’s cultural
context will influence the
Treatment implementation perception of information
& monitoring and treatment chosen

Evaluation &
accountability

Figure 14.1 Influence of social, legal and cultural factors on the practice of clinical psychology.

take up health opportunities. Thus, an intervention can have the greatest effect among
those who need it least. For instance, Schou and Wight (1994) examined the effectiveness
of a dental health campaign in Scotland. They found that mothers of caries-free children
were better educated, had better awareness of the campaign and engaged in better dental
hygiene than mothers of children with caries. This is not to say that the campaign overall
was not a success, but that the intervention was differentially successful depending upon
socio-economic factors. Similarly, in our own work one of us was examining the extent
to which exercise was being taken up by people with intellectual disabilities living in
group homes. In general, the picture was positive, but the degree of activity was strongly
correlated with independent ratings of ability, such that the more active lifestyles were
more common among those with the higher ability levels. Now while it is predictable
that individuals with greater abilities will be more likely to hear and respond to messages
about increasing physical activity, in an ideal world, a health intervention would be
uncorrelated with ability. The practical implication is that clinical psychologists need to
carefully consider each client as an individual and examine all the factors that may
impinge upon a particular intervention. In the remainder of this chapter, we will first
examine some of the challenges and parameters associated with conducting clinical
practice in a culturally sensitive manner. Then we will present a structured problem-
solving approach that can be applied when relating to clients as unique individuals while
bearing in mind cultural as well as ethical issues that may arise within the therapeutic
relationship.

Culture-Sensitive Practice of Clinical Psychology

Acknowledging that each client is a human being entails a recognition that each person
must be treated with the dignity they deserve. This will involve appreciating the unique
 Chapter 14: Respecting the Humanity of Clients 247

qualities of each person and the cultural influences that shape them (Kazarian & Evans,
1998; Ryder, Ban & Chentsova-Dutton, 2011). Before we review some principles of
culture-sensitive practice (Sue Sue, Neville & Smith, 2019), it is necessary to consider
several caveats. First, a focus on culture as a specific topic in clinical psychology could
unintentionally lead to the neglect of other important qualities of an individual when
planning treatment (such as their socio-economic status, social class, gender, sexual
orientation and so forth). These attributes will vary in their perceived importance among
individuals and will vary according to the social context in which they live. For example,
the difficulties a transgender person can have finding a health professional with expertise
in transgender care, or the person’s fears about discrimination when securing care, may
be seen as relatively unimportant to a middle-aged cisgender person, whose gender
identity and expression matched the sex assigned at birth (Puckett et al., 2020).
Second, the focus on apparent cultural differences (e.g., White American versus Black
American versus Hispanic American) may overshadow important but less obvious
differences. For instance, two Christian clients may present for treatment with obses-
sional guilt about their sinful thoughts, but if one is Roman Catholic and the other is
Lutheran, the theological frameworks within which they would conceptualize guilt and
forgiveness are fundamentally different. Third, the literature on cultural psychology itself
suffers from a cultural bias, with the majority of it being based in North America and
Europe. As residents of Australia, we notice this because rarely is there any mention of
the Indigenous peoples of Australia, Torres Strait Islands and New Zealand, and there is
less coverage of people likely to migrate to Australia. Although relevant research is
accessible, the difficulty for the individual clinical psychologist is that there is still an
insufficient empirical base for guidelines that cover each of the myriad cultural groups
and subgroups whose members may present for treatment. Nonetheless, it is pleasing
that clinical psychology students continue to be eager to have training that improves
their cultural competence (Hayward & Treharne, 2021; Tormala et al., 2018). For these
reasons, we suggest a structured problem-solving approach to organize a culturally-
sensitive understanding of each individual client.
The application of culturally relevant knowledge will be so varied that it is more
helpful to focus on broad principles of application rather than the specifics of each
culture. In so doing, it is important to acknowledge that mainstream clinical psychology
tends to reflect Western values, such as individualism. The treatments outlined in
Chapter 6 all emphasize the individual as the central organizing feature. Thus, the
treatments tend to give implicit assent to values such as self-reliance, self-determination,
self-understanding, self-awareness and self-initiated action (Toukmanian & Brouwers,
1998). These attributes contrast with values of family kinship and community member-
ship, and a sense of self embedded within the needs and norms of a particular group, that
are emphasized in many non-Western cultures. For instance, a recent qualitative study of
Chinese migrants’ and clinicians’ attitudes to cognitive-behaviour therapy emphasized
the need to consider the “interdependent self” (Bercean et al., 2020), whereby thoughts,
feelings, actions and autobiographical memories that shape wellbeing and general
function are oriented towards significant others. Some clinicians in this study suggested
that cognitive restructuring should only target negative automatic thoughts and inter-
mediate beliefs (rules, attitudes, assumption) that are not related to an interdependent
self, to avoid conflicts with fundamental family and cultural values. Bercean and col-
leagues suggested that in this population case formulations should include relationships
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to significant others. The need for clinicians to develop cultural humility, rather than (or
at least in addition to) cultural competency, was also emphasized. Whereas cultural
competency refers to acquisition of knowledge and culture-specific expertise (which is
impossible to develop for all cultures), cultural humility involves “self-reflection; learning
from clients about their culture, values, and beliefs; not making assumptions about clients’
cultures; and not assuming expertise” (Bercean, 2020, p. 620). A major advantage of
cultural humility is that it does not assume that every individual within the same culture
holds the same values and beliefs, and rather encourages the clinician to understand each
individual client’s worldview. In developing a problem-focused approach to address
potential biases, it is first necessary to appreciate the ways in which cultures differ.

Parameters of Culture-Sensitive Practice

One context to culture-sensitive practice for a science-informed practice is to examine
the data on outcomes. Ryder and colleagues (2011) conducted a meta-analytic review
and drew three conclusions. First, clients had a moderately strong preference for a
therapist from their own ethnic group and second, they tended to perceive them more
positively than therapists from other ethnic groups. Together, these data suggest that it
is important to be sensitive to clients’ preferences and be aware of the potentially less
favourable impression that you might have when treating a person from a different ethnic
group. However, the authors did not observe evidence of beneficial or harmful effects in
terms of treatment outcomes when there were ethnic differences between client and
therapist. Thus, be aware of the clients’ preferences, but there does not yet seem to be
widespread evidence that outcomes will be adversely affected by any differences (see also
Lambert, 2010).
Given the concerns that clients have, it is important to be as sensitive to differences as
possible. Kluckhohn and Stodtbeck (1961) identify a variety of parameters of relevance
when considering the values implicit and explicit in different cultures. The first param-
eter is the orientation to human nature, which describes the ways that different cultures
may view the nature of human character. People may differ with respect to whether
humans are considered to be basically good, bad, neutral or a mixture of both. They may
vary in terms of what is considered to be innate to the human character, how character is
produced and what makes a human a person.
A second parameter is relational orientation, which can be lineal, collateral or
individualistic. That is, a key issue for any individual is how to relate to others and one’s
culture provides guidelines for doing so. Within a lineal culture a person relates to others
on the basis on their lineage. People may be of a higher or lower social standing
dependent upon the lineage into which they are born and therefore relationships are
“vertical” in that they extend vertically through time.
Another way to address the issue of relationships with others is collateral, where
society is divided into “us”, who may be trusted and collaborated with, and “them”,
who are not to be trusted. In contrast to a lineal and collateral group orientation is an
individualistic approach to others, in which others in society are dealt with in a manner
determined by their perceived individual merit. Relationships are “horizontal” in that
one’s lineage through time or group membership is much less relevant. Society in the
US tends to be individualistic, whereas some Middle Eastern countries are lineal and
collateral.
 Chapter 14: Respecting the Humanity of Clients 249

The third parameter is the relationship between people and the natural world, such
that people are in subjugation to nature, are in harmony with nature or seek to master
nature. Is life determined by external forces beyond personal control? Within this
category we can also include the perceived relations between the person and their
internal (emotional) environment. Thus, cultures may vary in terms of the value placed
on the mastery of emotions.
The fourth orientation refers to preferred mode of activity, and the orientation can be
one of being, being-in-becoming and doing. This orientation will express itself in terms
of the degree to which life is valued in itself, the extent to which development of the inner
self is valued, and the extent to which rewards in life are seen to be self-determined and
obtained through individual effort.
The fifth parameter refers to cultural variations in terms of the relationships between
people. Individuals in different cultures may differ with respect to the extent to which
they believe in individual autonomy, independence, and competition versus leadership,
helping, cooperation and interdependence. These perceptions will also influence the way
that friends and family may be perceived, such that some cultures may view friends and
family as the primary means of problem-solving, whereas other cultures may emphasize
autonomy and independence in problem-solving.
Finally, there is an orientation to time, where the focus can be on the past, the present
or the future. Cultures within which people tend to focus on the past may emphasize
tradition and focus on history, whereas people from present-focused cultures emphasize
living for today and people from cultures with a future focus will be more inclined to live
in a way that sacrifices are made with the aim of creating a better future. For example,
Western culture tends to view human nature in a negative or neutral manner, possesses
an individualistic focus, perceives the need to exercise mastery over nature, evaluates
individual worth in terms of what one can do and emphasizes the future more than the
past or present.
Conducting a self-evaluation will assist a psychologist to be aware of the extent to
which they are able to accept differences and the need to learn about other cultures.
Awareness of the parameters of cultural differences allows clinical psychologists to
articulate their own beliefs, values and attitudes so that they can recognize differences
and respond appropriately. Training in cultural competency is available, but data
showing improved client outcomes is still limited (Benuto et al., 2018; Lie et al., 2011).
Generally, knowledge is increased, but the impact on attitudes, awareness and skills is
mixed (Benuto et al., 2018; Smith et al., 2006; Smith & Trimble, 2016). The literature
about training reveals that although students desire to learn more about other cultures
and find readings useful, the more valued elements are guest speakers, cultural explor-
ation and cross-cultural contact (Díaz-Lázaro & Cohen, 2001; Neville et al., 1996). As
trainees, you do not need to limit your learning to the classroom. Learning about other
cultures can involve deliberately taking opportunities to expose one’s self to other social
groups, cultures and sub-cultures. This may include partaking in cultural events and
activities, as well as seeking insights through media such as books, podcasts, panels and
film to develop multicultural awareness. Keep in mind that, as described earlier, cultural
humility may be more important than cultural competency (Bercean et al., 2020).
With the benefits of a self-evaluation regarding the relevant cultural parameters, the
psychologist will be in a better position to assess if any of these parameters are relevant to
the treatment of a particular client. Most often this assessment will need to be made by
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250 Chapter 14: Respecting the Humanity of Clients

the therapist, because values tend to be implicit and therefore clients may not be able to
articulate key issues. The aim is to evaluate the extent to which the attributes of the
individual affect the therapeutic communication and process of treatment. In so doing,
be aware that as a clinician both your verbal and nonverbal messages are congruent and
culturally appropriate. For instance, some cultures tend to be more reserved than other
cultures and therefore it can be inappropriate to engage with the client in an open and
frank discussion about problems related to themselves and their family if that is not
customary within the client’s cultural background. In terms of the therapeutic process, it
is important to consider that the therapeutic goals are culturally consistent or that the
method of intervention is including the relevant individuals. For example, certain
behavioural changes may meet with the approval and support of key family members
while other changes may bring about cultural disapproval or sanctions. O’Leary et al.
(1986) found that training women in assertiveness was associated with increases in
domestic violence; therefore, a clinician needs to be mindful of the social and cultural
context within which a person resides. When a few possible courses of action or methods
of proceeding are enumerated, the clinician can discuss options with the client. Rather
than providing a list of options, the psychologist can elicit relevant information from the
client and facilitate their decision-making and consideration of the likely consequences
by specifying the possible consequences, both positive and negative, to the different
options. Once articulated, a decision can be made, implemented and evaluated. If the
evaluation indicates a negative outcome, then an alternative action plan is initiated.
Thus, the process once more is akin to structured problem-solving in that the stages are:
define the problem, develop alternative courses of action, evaluate and then choose an
action and evaluate the outcomes. Before articulating the problem-solving technique in
detail, we will review some of the issues that may arise when considering the role of
clinical psychology among older adults.

Clinical Psychology and Older Adults

The number of older adults continues to grow and the population is becoming increas-
ingly diverse. These two demands put pressure on the profession of clinical psychology
to ensure that its practitioners are able to meet the challenge (Karel, Gatz & Smyer, 2012)
and the American Psychological Association has provided helpful guidelines (APA,
2014) which serve to illustrate the application of the general ethical principles to the
particular instance.
For example, one ethical principle is respect for the dignity of persons. That is,
the belief that each person should be treated primarily as a person or an end in him/herself . . . (i)n
so doing, psychologists acknowledge that all persons have a right to have their innate worth as
human beings appreciated and that this worth is not dependent upon their culture, nationality,
ethnicity, colour, race, religion, sex, gender, marital status, sexual orientation, physical or mental
abilities, age, socio-economic status, or any other preference or personal characteristic, condition,
or status
(Canadian Psychological Association, 2000, p. 7; italics added)
In terms of older persons this means that it is necessary to ensure that your practice is
not clouded by stereotypes. Some stereotypes of elderly people are that they are frail,
depressed, in cognitive decline or dementing, socially isolated and stubbornly inflexible.
In addition to the cognitive error of assuming that characteristics of some individuals
 Chapter 14: Respecting the Humanity of Clients 251

must apply to all members of a defined group, Knight and Poon (2008) distinguish
negative and positive maturation. Even though aging is associated with some negative
maturation, such as physical decline and reductions in some facets of cognition (i.e.,
fluid intellectual abilities may decline while crystalized intelligence may remain
intact; Dixon, 2003), the detrimental effects are not universal. In addition, positive
maturation can be observed in areas of cognitive complexity. That is, adults demon-
strate improving performance across the lifespan in tasks that involve information,
vocabulary and mathematical skills. The wisdom that comes from the accumulation
of knowledge, both factual and procedural, means that older adults can exhibit
superior performance in some areas relative to younger adults. Likewise, older age
tends to be characterised by greater emotional complexity than is seen in younger
adults and also better emotional regulation and more positive emotion (Urry &
Gross, 2010). Falling prey to the negative stereotypes may lead to a style of therapy
that is overly paternalistic, which arises from a misperception that the older person is
weak, frail and needs protection. However, paternalistic attitudes in psychotherapy
tend to undermine the therapeutic relationship and foster dependency. Thus, when
working with older clients it is important to be mindful of stereotypes and seek
information to ensure that they do not impede your ability to work effectively
with clients.
Another couple of principles that clinical psychologists abide by are to keep
up to date with a broad range of relevant knowledge, research methods, and techniques . . . in order
that their service . . . will benefit and not harm others (and they need to evaluate) how their own
experiences, attitudes, culture, beliefs, values, social context, individual differences, specific
training, and stresses influence their interactions with others, and integrate this awareness into
all efforts to benefit and not harm others
(Canadian Psychological Association, 2000, p. 16–17)
Keeping up to date demands that clinical psychologists actively engage with other
professionals. It will enrich the typical individual focus of clinical psychologists by
engaging with societal interventions that can promote autonomy and quality of life to
create desirable living situations in older age for those with good health and those with
greater care needs (Tesch-Römer & Wahl, 2017). Therefore, it behoves clinical psych-
ologists to familiarize themselves with the dynamics of aging. Developmental theories
identify social and psychological factors that influence the individual and the life trajec-
tory they are on. Retirement, relationship losses and life changes will affect the social and
occupational environment for an older person (Dawson & Sterns, 2012). Age-related
physical changes, health concerns and disability all have the capacity to impose restric-
tions on a person’s life and functioning (Aldwin, Park & Spiro, 2007). For a trainee
clinical psychologist, these life events may seem distant and may require investigation
and self-reflection (see Craik & Salthouse, 2008; Lichtenberg, 2010; Schaie & Willis, 2011;
Scogin & Shah, 2012). For instance, a process issue that can arise is one of the beliefs
trainees expect older clients to have about them. These examples are potentially ripe for
transference, whereby the older client sees their own children or grandchildren in the
therapist.
However, when faced with an older client it can be challenging to know how to
proceed. One helpful strategy can be derived from reminiscence-based approaches to
therapy (Bornat, 1994; Gibson, 2004). The approach uses music, photographs and
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252 Chapter 14: Respecting the Humanity of Clients

archival recordings to prompt memories and to stimulate a discussion about past events.
The process can be helpful for a junior clinician in getting to know an older client. By
asking about a person’s favourite music it can help you to start a conversation and get to
know a person better. The relatively neutral topic can serve as a way of engaging with the
client and building a rapport. Furthermore, reminiscence is a mechanism used by older
adults to process and integrate experiences in a way that builds wellbeing (O’Rourke,
Cappeliez & Claxton, 2011) and may assist in fostering a positive relationship for
therapy. Reminiscence therapy reduces depressive symptoms and improves life satisfac-
tion, self-esteem, psychological wellbeing and happiness (Bohlmeijer et al., 2007;
Westerhof & Bohlmeijer, 2014; Woods et al., 2018) although the benefits appear stronger
among cognitively intact older adults (Tam et al., 2021). Thus, these interventions could
be an effective community-level solution to improve psychological wellbeing among
older adults.
There are also specific areas that clinical psychologists will need to be mindful of
because they are associated with issues that arise due to the client’s stage of life. These
issues moderate the clinical presentation and can determine the life events that impact
upon a client. Older clients are more likely to experience loss of friends and family
members. The older they become, the more likely it will be that they are the last of their
common-aged peers and this brings with it social ramifications as well as practical issues
of care (Johnson & Bacsu, 2018; Wrzus et al., 2013). Older clients may also require
additional care, for both physical and psychological wellbeing. Managing these multiple
demands needs to be done in a way that does not neglect other needs and intersection-
ality. For example, LGBTQ individuals have articulated the importance of continuing to
accept people’s sexual orientations while in care (Löf & Olaison, 2020). In addition, there
is also the caregiving responsibility that may fall upon friends and family members. For
example, a spouse might become the primary caregiver for an infirmed partner or for
younger family members.
As well as these factors, the clinical presentation may differ among older adults.
A common issue is the differential diagnosis of depression and dementia, since not only
can these conditions be comorbid, they share overlapping symptom profiles.
Awareness of these conditions and the methods of disentangling the separate contri-
butions against a backdrop of normal aging requires additional skills and careful
practice (Fiske, Wetherell & Gatz, 2009). Similarly, anxiety disorders, while less
prevalent, may also have a different profile. Panic disorder, for example, may be
characterized more by intrusive cognitions and memories than physiological arousal
(Lauderdale et al., 2011) and worries may be more health-related. Certain assessment
requests (e.g., competence to manage one’s affairs) may be more common than in
younger clients (Moye & Marson 2007).
By way of summary, while there are many nuances in the delivery of psychological
services to older adults, there is good evidence that both individual (Cuijpers et al., 2020;
Scogin & Shah, 2012) and group (Burlingame, Strauss & Joyce, 2013; Tavares & Barbosa,
2018) psychological treatments are effective and so clinical psychologists can be confi-
dent that the wellbeing of clients can be improved with the provision of appropriate
services. Clinical psychologists need to familiarize themselves with these nuances when
working with this client group, as they will need to do with every client group. We will
now turn to a consideration of structured problem-solving as a clinical technique and its
application to the practice of culture-sensitive clinical psychology.
 Chapter 14: Respecting the Humanity of Clients 253

Table 14.1. Analogies between structured problem solving, the process of research and the conduct
of clinical practice

Problem Solving Research Clinical

Problem definition Research question Presenting problem
Brainstorming Hypothesis generation Preliminary formulations
Choose solution Select hypothesis Choose intervention
Implement solution Conduct study Implement treatment
Evaluation Analysis/interpretation Evaluation

Applying Structured Problem-Solving to Culture-Sensitive Practice

Structured problem-solving was developed by D’Zurilla (1986) and it can assist clients to
identify problems, recognize resources they possess, and teach a systematic method of
overcoming and preventing problems. Structured problem-solving recommends moving
through a sequence of steps (see Hawton & Kirk, 1989).
The first step is to define the current problem. If there are multiple problems, these
can be dealt with sequentially after an order for dealing with them has been chosen. The
second step is to brainstorm all the possible solutions. Once a list of possible solutions is
written down, then the therapist and client can evaluate the pros and cons of each and in
so doing select what they think will be the best solution. This option is then imple-
mented – a step that will involve preparing a plan of action in which the necessary steps
are clearly articulated and then enacting that plan. Sometimes cognitive or behavioural
rehearsal (e.g., role plays) can be useful in preparing the client, for anticipating difficul-
ties and building a sense of self-efficacy. Finally, the implemented solution is evaluated,
by asking if the solution did indeed solve the problem, and by assessing the degree of
success and failure against some pre-agreed criteria. If it failed to redress the difficulty,
the clinical psychologist and client can select the next best solution, brainstorm some
other solutions or even check that the problem has been correctly identified and
fully articulated.
Table 14.1 outlines these five stages of problem-solving, by drawing parallels with two
activities familiar to psychologists. The central column identifies a series of stages in the
process of conducting research. Research begins with the identification and selection of
the research question, which in turn will lead to hypothesis generation. Of the possible
hypotheses, the researcher will select a subset. These steps of research are analogous to
problem definition, brainstorming and selecting a solution. A researcher then conducts a
study to test between hypotheses and analyses the data to determine the fate of the
hypothesis, which is analogous to implementing and evaluating a possible solution to a
problem. Thus, the structured problem-solving approach is one that is familiar to a
psychologist trained in research. Furthermore, the parallels also extend to the model of
clinical practice we have been outlining. The clinician identifies a presenting problem
and generates a formulation, which in turn will guide the choice of intervention. After
implementing the intervention, the clinical psychologist will measure the effectiveness of
the treatment by conducting an evaluation.
This same approach can be extended to situations where cross-cultural matters need
to be considered and responded to. The strength of the approach is that it is possible to
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take into account some general principles or theories about culture, even though each
situation is unique and will require a considered individual solution. For example, López
(1997) describes a couple who migrated to the US from North Mexico. They presented
with marital difficulties that had reached a point at which the couple had settled into a
pattern of silence interspersed with verbal hostility. Initially, the husband only agreed to
attend treatment without his wife. Therapy was soon abandoned when he indicated that
his wife was to blame for their problems. He believed that he fulfilled his role as a
husband (by working hard and providing financially), but that she failed to fulfill her role
as a wife (by failing to cook meals, wash clothes and be available for sexual relations).
Later they attended as a couple, but one problem arose when the therapist offered the
interpretation that perhaps the husband felt hurt that his needs were not being con-
sidered by his wife. He responded that no one could hurt him but that if they did, he
would make sure that they knew it. He indicated that he was a strong man and that the
efforts on behalf of his wife and daughters to make him a wimp would fail. The case
study highlights a number of problems which could be addressed by taking a problem-
solving perspective. In reflecting on the case, López notes that his suggestion was
problematic in that it elicited a vehement response from the client that did not facilitate
change. Thus, the therapist could reconsider the way this suggestion was made by re-
evaluating the impact of the cultural context from which the couple came, issues that
may have arisen concerning acculturation to life in the US, possible discrepancies
between the husband and wife’s views of the problem and the person responsible for
change, and perceptions of the purpose of therapy. In so doing, the problem-solving
provides a framework for addressing potentially difficult cultural issues in therapy. The
same holds true when considering how ethical principles (such as those articulated in the
codes of ethics developed by each country’s psychological society) apply to a particular
situation or therapeutic relationship.

Applying Structured Problem-Solving to Ethical Decision-Making

Consider a client who seeks counselling after receiving a positive HIV test result. He is
unsure how he became infected but thinks that it followed a homosexual encounter while
he was exploring his sexuality. A typical session would involve outlining his prognosis as
well as describing “safe sex” and what he could do to protect sexual partners from
infection. Consider how you would respond if the client informed you that he was soon
to marry his fiancée and settle down. He did not want to inform her that he was HIV
positive in case it affected his marriage plans.
A practical way to handle ethical situations such as the one just described builds upon
a structured problem-solving approach (see Keith-Spiegel & Koocher, 1985; Koocher &
Keith-Spiegel, 1998; 2008 and Eberliein, 1987). It identifies ethical dilemmas as problems
that require solutions and rather than prescribing answers, it provides a problem-solving
framework within which to seek a set of possible solutions. Problem-solving, as an
approach to ethics, also has an advantage in that it does not seek to just comply with
an enforceable standard, but it is consistent with an aspirational ethic of striving for the
best possible outcome in an evidence-based manner (Gawthrop & Uhlemann, 1992)
Keith-Spiegel and Koocher (1985; Koocher & Keith-Spiegel, 1998, 2008) suggest that
the place to begin is by describing the parameters of the situation. In the preceding
example, these would involve his HIV infection and the relationship with his fiancée.
 Chapter 14: Respecting the Humanity of Clients 255

The second step is to expand on the problem by identifying the key ethical issues. Redlich
and Pope (1980) suggested the following principles to guide ethical decision-making.
They noted that psychologists should (i) do no harm, (ii) practice only within compe-
tence, (iii) should not exploit (iv) should treat people with respect for their dignity as
humans, (v) should protect confidentiality, (vi) should act (except in extreme cases) only
after obtaining informed consent and (vii) should practice (as far as possible) within the
framework of social equity and justice. These principles highlight the need to protect the
client’s confidentiality, but also to take into account the need to avoid harm to the client’s
fiancée. However, what is needed is an organizing framework to decide when there are
conflicts among principles.
The Canadian Code of Ethics for Psychologists (Canadian Psychological Association,
2000; see also Truscott & Crook, 2013) is a seminal model for ethical thinking about
psychology and it has isolated a set of principles and organized them into a hierarchy to
assist ethical decision-making. One of the strengths of the principled approach to ethical
practice is that they can be applied to situations that were not in the minds of the people
framing the guidelines (e.g., how the principles can be used to examine online personal
information accessibility, web-based advertising and electronic data storage; Drogin,
2019; Nicholson, 2011). The hierarchical organization implies that the principles are
considered in order and greater weight is given to those higher in the hierarchy. The first
principle is respect for the dignity of persons. Except when a person’s physical safety is
under threat, assuring people’s dignity should be the most important ethical principle.
Responsible caring is the second principle and implies that caring should be carried out
competently while respecting dignity. The third principle is integrity in relationships.
They note that on occasions, the values of openness and straightforwardness might need
to be subordinated in order to maintain respect for human dignity and responsible
caring. Finally, they highlight responsibility to society and suggest that this principle is
given the lowest weight when they are in conflict. They suggest that
When a person’s welfare appears to conflict with benefits to society, it is often possible to find ways
of working for the benefit of society that do not violate respect and responsible caring for the
person. However, if this is not possible, the dignity and well-being of a person should not be
sacrificed to a vision of the greater good of society, and greater weight must be given to respect and
responsible caring for the person.
(Canadian Psychological Association, 2000, p. 4)
As an aside, the reader will notice that this last point makes explicit a cultural position on
the parameter of the relationships between people in which individual autonomy is
valued over interdependence and therefore it will be necessary to be sensitive to the
cultural sensitivities of clients who may not hold this view. However, when considering
the preceding example, it would be clear that the possible specific threat to another
person may take ethical precedence.
The next step is to consult any available professional guidelines to see if these might
assist in the resolution of each issue. Most professional guidelines for psychologists now
share a similar structure. That is, while ethical guidelines used to be prescriptive, modern
versions tend to be principle-based and outline aspirational values, with practice guide-
lines sitting under the code. For example, the British Psychological Society’s (BPS) (2018)
Code of Ethics is based on four ethical principles: respect; competence; responsibility;
and integrity. In terms of respect, psychologists must value the dignity and worth of all
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persons. Competence requires psychologists to value continuing development and

maintenance of high standards of competence in their professional work and the
importance of working within the recognized limits of their knowledge, skill, training,
education and experience. Responsibilities extend to persons and peoples, the general
public and the profession and science of psychology. Finally, integrity means that
psychologists will value honesty, probity, accuracy, clarity and fairness.
There are guidelines relating to professional practice, the conduct of research, issues
that are specific to working with humans or animals, and regulations relating to the
professional society. The ethical guidelines cover matters related to general professional
conduct, maintaining and working with professional competence, obtaining consent and
confidentiality. Considering the preceding example, the Canadian Psychological Society
(2000) recommends psychologists to “Do everything reasonably possible to stop or offset
the consequences of actions by others when these actions are likely to cause serious
physical harm or death. This may include reporting to appropriate authorities (e.g., the
police), an intended victim, or a family member or other support person who can
intervene, and would be done even when a confidential relationship is involved”
(p. 22). Thus, professional guidelines provide some direction about how to proceed.
Another aspect of applying the “do no harm” principle (Dimidjian & Hollon, 2010),
relates to the topic of monitoring discussed previously in this book. The routine
monitoring of client outcomes allows clinical psychologists to acknowledge that despite
psychological therapy being effective for most clients, some may be unchanged or even
deteriorate. Muir and colleagues (2019) note that because psychologists (like all people)
are poor predictors of which clients will improve when they rely solely on clinical
judgement, monitoring “should occupy a central role in discussions of, and guidelines
about, the ethical practice of psychotherapy” (p. 459). Similarly, Pinner and Kivlighan
(2018) argue that routine outcomes monitoring is an ethical obligation as part of
ensuring that psychologists practice within the boundaries of their competence.
Perhaps controversially, they argue that experience and supervision may not be the best
predictors of clinical effectiveness. Instead, they suggest that general and multicultural
competence should be determined by the monitoring of therapist outcomes. Consistent
with a science-informed model of practice, they suggest that monitoring provides
psychologists with an objective and effective method for determining competence (or
the absence of ). For instance, multilevel modelling of outcomes data reliably identified
therapists who return consistently poorer rates of patient dropout and deterioration
compared to their peers (Barkham et al., 2017; Saxon et al., 2017). This technology can be
potentially used to ensure optimal matches between clients and psychologists, and
thereby reduce the impact of potential dropout or deterioration (Delgadillo et al.,
2020). Thus, there appears to be an ethical obligation for regular data collection and
feedback to clients and staff about treatment progress because it can help treatment
selection and adaptation (Page, Camacho & Page, 2019) and thereby ensure that psych-
ologists have an evidence-base for practicing within the ranges of their competence.
When a psychologist is presented with such ethically relevant information, Keith-
Spiegel and Koocher (1985; Page, Camacho & Page, 2019) suggest that the next step is to
evaluate the rights, responsibility and welfare of affected parties. In the present example
of a client seeking counselling after receiving a positive HIV test result, these issues relate
to the client’s right to privacy and the fiancée’s right to safety and protection. After
 Chapter 14: Respecting the Humanity of Clients 257

Table 14.2. Worksheet for assessing ethical dilemmas

Worksheet for Assessing Ethical Dilemmas

Describe the parameters of the situation.
Define the potential issues involved.
Consult guidelines, if any, already available that might apply to the resolution of each issue.
Evaluate the rights, responsibility and welfare of affected parties.
Generate the alternative decisions possible for each issue.
Enumerate the consequences of making each decision.
Present evidence that various consequences or benefits resulting from each decision will occur.
Make your decision and evaluate the outcome.

describing these rights, the next step is to generate the alternative decisions possible for
each issue and enumerate the consequences of making each decision, considering any
evidence that the various consequences or benefits resulting from each decision will
actually occur. When this has been done, it will be possible to make a decision and
evaluate its success, which in the current example would identify the need to inform the
fiancée. After having made a decision, the best way to implement the chosen course of
action will need to be determined. For example, the clinician could boldly inform the
client that regardless of his wishes the therapist was going to contact his fiancée or,
alternatively, could decide to spend time in therapy considering the consequences for the
client and fiancée of his proposed course of action. The aim of the latter would be to
bring the client to a realization of his responsibilities as a fiancée and a fellow human and
the possible outcomes of different actions. The principle of respecting the client’s
confidentiality and individual dignity must be weighed against the risk of delaying
disclosure to the fiancée, who would remain at risk of being seriously harmed if the
therapist chooses to not inform the fiancée immediately.
Thus, ethical decision-making is like structured problem-solving in that the stages
are: define the problem, develop an alternative course of action, analyse options, choose
actions and evaluate. This process is depicted in the following worksheet (see Table 14.2).
You may find it helpful to use this worksheet as you consider how the model would apply
to situations you might encounter in your training. In addition, Benuto and colleagues
(2018, p. 132) offer an invitation to future clinical psychologists that we will reiterate.
They recommend that the
field should reconsider the foundation of cultural competency training using psychological science
as a basis. This may include an examination of the empirical literature regarding what clinician
characteristics and behaviors are linked to poor or positive client outcomes (for diverse clients) and
a review of the strategies that have documented success in changing problematic clinician
characteristics (i.e., attitudes, biases, and stereotypes) and behaviors . . . to devise a training
curriculum that is rooted in science.

Thus, there is ample opportunity for future research to benefit the clinical practice
of psychology.
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Confidentiality
Having described a general problem-solving strategy for addressing ethical issues, it is
relevant to consider some specific ethical issues. Confidentiality is an issue that arose in
the context of discussing case management. To reiterate, the term acknowledges that
when a client enters therapy, they inevitably relinquish a degree of personal privacy by
providing the therapist access to normally private information. However, the client has
the reasonable expectation that any information disclosed to the therapist remains
confidential. Thus, confidentiality refers to legal rules and ethical standards that protect
clients from the unauthorized disclosure of information that has been disclosed in
therapy or has arisen in the course of therapy. Ethical guidelines require clinical
psychologists to maintain client confidentiality and in so doing reflect the principle that
confidentiality is the prerogative of a client not a therapist. That is, a client can choose to
take a therapist into their confidence by providing that information, but the client still
retains control of that information. The client may permit the therapist to communicate
the confidential material to a third party (e.g., give the writer permission to include the
material in a referral letter to another mental health professional), but the decision in
almost all circumstances lies with the client.
One aspect of confidentiality that has arisen with the ubiquity of social media is the
ability of psychologists to obtain information about their clients online, but it is also
possible for clients to access information about you . . . and they do (Lehavot, Barnett &
Powers, 2011; Reamer, 2018). Therefore, it is wise to be prudent about information that
you display in public forums and social media sites. Lehavot (2007; cited in Lehavot et al.,
2011; Reamer, 2020) recommends asking yourself four questions before posting infor-
mation online: first, what costs and benefits accrue? Second, what is the probability that
clients will be negatively affected? Third, how might this disclosure affect my relationship
with my clients? Finally, does the disclosure threaten my credibility or undermine the
public’s trust in clinical psychology? It is also prudent to give careful thought to who you
accept as friends and the degree of privacy you grant to others (Barnett, 2008). Be
mindful that the online information may have an impact not only on you, but also
your employer.
The online environment also requires us to consider the ethical issues associated with
seeking out information about a client from social media sites. Avoid obtaining infor-
mation on your client without their permission, not only because of the ethical issues but
because this has the potential to undermine the relationship of trust that is foundational
to psychotherapy.

Dual Relationships
Having described a general problem-solving strategy for addressing cultural as well as
ethical issues in respecting the humanity and dignity of individual clients, one aspect is
worthy of specific attention. This concerns dual relationships (Reamer, 2020). A dual
relationship exists when a therapist is in another, different relationship with a client.
Usually this second relationship is social, financial or professional. For instance, if a
professor of clinical psychology required students to enter into psychotherapy with him
or herself as part of their training in clinical psychology a dual relationship would exist.
In such an instance, the psychotherapeutic relationship co-exists with an educational
relationship where the professor grades the student’s work. These other relationships
 Chapter 14: Respecting the Humanity of Clients 259

have the potential to erode and distort the professional nature of the therapeutic
relationship, create a conflict of interest, as well as potentially compromise the profes-
sional disinterest and sound judgement required for good practice. On the other hand,
the existence of a therapeutic relationship means that a client or an ex-client cannot enter
into a business or secondary relationship with the therapist on an equal footing because
there is the potential for a therapist to use confidential information maliciously. In
addition, if a therapist is invited or compelled to offer testimony regarding some aspect
of therapy, the existence of a dual relationship will undermine credibility as a witness.
Thus, as a general rule, it is best for psychologists to avoid dual relationships with clients
altogether. Sometimes, though, clinical psychologists work in settings where it is not
possible to entirely avoid dual relationships (see Chapter 15 for strategies on how to deal
with dual relationships in a manner that does not compromise the wellbeing and dignity
of the client)
One particular form of dual relationship that therapists need to be on their guard
about is sexual relationships with their clients. For instance, the Canadian Psychological
Association (2000) warns “Be acutely aware of the power relationship in therapy and,
therefore, not encourage or engage in sexual intimacy with therapy clients, neither
during therapy, nor for that period of time following therapy during which the power
relationship reasonably could be expected to influence the client’s personal decision
making” (p. 21). If trainees find themselves in a situation where sexual tension or
innuendo appears to be present during sessions with a client, the onus is on the trainee
to immediately consult with a supervisor on how to resolve the situation and ensure that
interactions with the client are re-focused on the purposeful application of science-
informed treatment strategies within the bounds of a caring and strictly
professional relationship.
Although dual relationships are to be avoided, there are some situations in which
avoidance becomes increasingly difficult. One such situation is in the context of clinical
practice in rural or remote settings. The luxury of restricting the relationship between the
clinical psychologist and the client to a purely professional one is often not possible in
small rural towns, and therefore this special case will be examined in some depth in the
following chapter.

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 Chapter
Providing Therapy at a Distance

15 and Working in Rural and

Remote Settings

Engaging with psychological services at a distance involves the use of technology that
enables clients to meet with their clinician no matter where they are located. Telemental
health conducted via video-conferencing provides real-time mental health care remotely
(Connolly et al., 2020). Until recently, the uptake of telehealth had been limited primarily
to improving access to psychological services for rural and remote communities. However,
the sudden and profound impact of the COVID 19 global pandemic had a rapid trans-
formative effect on how clinical psychologists interact with their clients. COVID 19 neces-
sitated the use of telehealth applications for providing therapy to any client regardless of
location who otherwise would receive no support due to physical distancing requirements
imposed by government authorities. Therefore, skills to conduct assessments and therapy
remotely via technology are expected to become part of the essential competencies required
of clinical psychology trainees (Borden & McIlvried, 2020).

Is Therapy at a Distance Effective?

The COVID 19 crisis prompted the rapid refinement and dissemination of guidelines to
meet the legal, ethical and practical challenges of conducting therapy at a distance. These
guidelines are continuing to evolve, as some form of reliance on telepsychology is likely
to become the new normal. Indeed, hybrid models of care may prove to be ideal in many
cases where clients receive a combination of in-person and telepsychology sessions
depending on their specific or changing needs over the course of therapy (Connolly
et al., 2020). Of course, adoption of technological enhancements in clinical care – even
when there is little choice in the context of a global pandemic that curtails traditional
face-to-face contact – does not necessarily translate to evidence-based practice (Anton &
Jones, 2017). The science-informed practitioner still needs to ask if newly emerging
modes of conducting therapy with their clients that do not involve in-person contact are
effective. It is reassuring that a 2013 review found that telemental health is as effective as
in-person care across a range of populations, mental health disorders and settings (Hilty
et al., 2013). Importantly, reviews also find that, while providers may be less sanguine
about the use of telemental health, patients tend to report satisfaction with this service
modality (Connolly et al., 2020; Kruse et al., 2017).

Compliance with Relevant Legislation or Regulations Local

to the Client
In this digital age, technology often outpaces policy. Progress on the need for profes-
sional organizations and regulatory bodies to resolve legal and regulatory issues of
260
 Chapter 15: Providing Therapy at a Distance 261

providing care at a distance across regions and different jurisdictions has been accelerat-
ing since first identified as an urgent priority (Comer & Barlow, 2014). COVID 19 has
further increased the pace of regulatory change. It is incumbent upon trainee psycholo-
gists, who are about to enter the profession at a time of profound technological changes
to models of care, to be aware of and comply with evolving standards of practice for the
jurisdiction(s) in which they engage in telepsychology activities (Drude, 2020). Providers
offering services to a client residing in a different state from the provider must comply
with the applicable privacy and health records laws in each region. For example, in
Australia, mandatory reporting requirements currently are not uniform across states
(Australian Psychological Society, 2020). In the United States, interjurisdictional practice
barriers to inter-region service provision are currently being lowered via an inter-region
compact designed to facilitate inter-region licensure reciprocity and the practice of
telepsychology across regional boundaries (Drude, 2020; see also The Psychology
Interjurisdictional Compact – PSYPACT, 2020).

A Practical Guide to Providing Therapy at a Distance

There are detailed guidelines and regularly updated resources for clinicians seeking to
adapt their services to the safe, ethical and effective provision of therapy at a distance
(e.g., in Australia: Seabrook et al., 2020; Australian Psychological Society, 2020; in the
United Kingdom: Royal College of Psychiatrists, 2020; and in the United States: Shore
et al., 2018). These guidelines provide practical tips on navigating ethical challenges,
creating an appropriate work environment, setting up an effective digital space and
adapting therapeutic skills to overcome some of the communication constraints when
interacting via a digital platform rather than the immediacy of an in-person visit to a
consultation room.

Privacy and Security

Privacy laws require that telehealth practitioner take reasonable steps to secure infor-
mation that is in the electronic environment. When selecting a video conferencing
platform, it is important to ensure that platform specifications are suitable for complying
with data protection, privacy and health records legislation for the applicable jurisdiction
(s), and health insurance regulations. For example, security measures to protect elec-
tronically held or transmitted information include end-to-end encryption for data
transmission, up-to-date security software for firewalls, intrusion detection, and protec-
tion of access to personal information via multi-factor authentication. In the same way
that a science-informed practitioner must keep up with the evolving literature on
evidence-based practices to benefit their clients and do no harm, it is an ethical impera-
tive that practitioners keep up to date with ever-changing cyber security threats and the
recommended measures to protect their clients from potential data and privacy breaches
when conducting therapy at a distance. Such information is readily available from
government websites (e.g., Australian Cyber Security Centre, 2021). It is also good
practice to work with clients to help them understand their role in protecting their
own privacy when using telehealth applications. Some clients may benefit from being
directed to consumer-friendly information about how they can protect their privacy
online (e.g., “Do things safely” (Australian Cyber Security Centre, 2021)).
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Risk Management
The use of telepsychology enables the provision of services to clients whose access to in-
person consultations is limited or non-existent. Of course, when the client is not
physically present in the same location, this presents additional challenges for clinical
risk management. Contact may be lost during critical moments of online interactions
and in the event of elevated risk or crisis, the options and pathways for alternative
support services a therapist can draw on routinely in one location may not be readily
available in a client’s distant location. A contingency plan should be in place as part of
any telehealth risk management protocol that typically includes at least the following
elements:
 Establish that an alternative means of contact such as telephone is available.
 Record contact details of the client’s local mental services or general practitioner and
the client’s ability to access them.
 Clarify what (if any) psychiatric triage services local to the client are available.
 Confirm the client’s location at the commencement of each telehealth session and
consider the impact that any location changes have on risk management and access to
local resources.
 Request contact details of at least two people (e.g., next of kin, health practitioner,
support person) who could be contacted in case of elevated risk or an emergency.
 Incorporate the risk management procedures into the informed consent process and
clarify when, how and with whom a crisis plan may be activated.
 Establish a protocol for communications out of session. For example, a client’s
communication attempts during a crisis may not be promptly responded to because
practitioners are otherwise engaged. Clarify the likely speed and frequency of the
provider’s responses to client communications and alternative resources in case of
emergencies or communication problems. Avoid the use of communication
platforms that may also be used socially and hence can weaken professional
boundaries. Errors in judgement in one’s online professionalism can led to serious
disciplinary actions (Greysen et al., 2012).

The Telehealth Work Environment and Digital Space

The workspace where a video consultation takes place must be private for both the
provider and the client. This includes taking steps to ensure that no one can overhear the
session and that it is free from interruptions. Signage on doors and the closing of blinds
or curtains may be considered if others are nearby. The provider’s workspace should be
edited to avoid visible objects or decorations that could be distracting. The setup should
provide optimal lighting conditions to facilitate clear perception of facial expressions and
eye contact. Backlighting from windows or light fixtures positioned behind the provider
(or client) produce shadowing which can obscure eye gaze and facial nuances. Similarly,
the space should be free of background noises so that it is easy to hear one another. If
some noise interference is unavoidable, the use of headphones with an in-built micro-
phone can partially mitigate the problem.
When adapting to the digital workspace, the camera becomes the client’s eyes. That
is, the positioning of the camera should make it easy to look towards the lens. This will
approximate eye contact when the client or clinician is speaking. It is recommended that
 Chapter 15: Providing Therapy at a Distance 263

the camera is sitting slightly above your eye- line (Grondin, Lomanowska & Jackson,
2019). Another aid to naturally draw one’s gaze toward the camera is to minimize and
drag the video conferencing window nearest to the camera.
Some clients will benefit from being sent a written guide sharing these tips prior to
commencing video conferencing sessions. This may also include some guidance and
reassurance in advance on how to anticipate and deal with any technical difficulties that
may arise such as experiencing lagged conversation, typically due to internet connectiv-
ity. Awareness of common problem-solving strategies helps to allay undue distress while
experiencing connectivity issues (e.g., increasing bandwidth by closing any other pro-
grammes using the internet, switching temporarily to audio connection only, re-starting
the connection or switching to the back-up plan). It is also recommended to communi-
cate what the provider’s standard practices are for dealing with interruptions due to
technical difficulties (e.g., under what circumstances length of a session could be
extended) prior to commencing video conferencing sessions.
As with in-person sessions, note-taking can be distracting. Hence, mentioning to
clients the purpose of it and ensuring that eye contact and active listening is promptly
resumed helps clients to experience it as part of active engagement with what the client is
saying rather than a shift in the clinician’s focus. If taking notes electronically, one must
be mindful that vigorous keyboard use and associated noise can impact body posture and
convey unhelpful non-verbal cues incongruent with an active listening stance. On the
other hand, using screen sharing or whiteboard functions for jointly creating notes on
certain topics can provide a shared point of focus and enhance a collaborative use of the
technology. The collaborative stance can also be reinforced by checking with the client
during the session how they are finding interacting in this manner, and whether it is
going well at their end.

Adapting Therapeutic Skills

Telehealth services are an effective means of developing strong therapeutic alliances
between clinicians and clients (Grondin et al., 2019). Although the reduced bandwidth
in the transmission of important verbal and non-verbal signals can influence the quality
and richness of electronic communications, there are adjustments clinicians can make to
nonetheless convey active listening and promote empathic exchanges with their clients.
In addition to setting up the digital space to approximate the experience of eye contact,
active engagement with what the client is saying can be effectively conveyed by sitting far
enough away from the camera so that one can lean forward from time to time to signal
attentive listening. Similarly, expressing empathy for the client will require some delib-
erate adjustments in the video conferencing context. Because the experience and expres-
sion of empathy is an emotional process, its perception by the client as genuine and
alliance building typically rests on a mix of direct verbal statements and more subtle
visual and auditory cues such as facial expressions, eye contact, bodily gesture, and tone
of voice. Although these more subtle communications may be less readily perceived
during teleconferencing, this can be compensated for by relying more heavily on direct
verbal support, explicit clarification of the client’s affective state, intentional statements
of feelings and deliberate exaggeration of non-verbal behaviours (Grondin et al., 2019).
For example, gestures and nodding might be a bit more overt than what occurs during
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typical in-person interactions, and inflections in tone of voice or vocal utterances are
expressed with sufficient clarity to carry across the audio-visual interface.

Mental Health Services in Rural Communities

Psychological practice in rural and remote settings involves several unique personal and
professional challenges. Generally, very few psychology trainees are formally prepared
for those challenges because curriculum components and supervised practice experiences
tend to be focused on urban and metropolitan settings. A common characteristic of rural
and remote communities is that they are descriptive of areas where the population
density is low (U.S. Census Bureau, 2002) and geographic distance imposes restriction
upon accessibility to the widest range of goods and services and opportunities for social
interaction (Australian Bureau of Statistics, 2001). Long distances and harsh environ-
mental conditions constitute significant barriers for rural residents to access mental
health services (DeLeon et al., 2003). Likewise, delivering services to where they are
needed by consumers can be a daunting routine if a home visit by a psychologist means
driving several hundred kilometres (Lichte, 1996). If hospitalization for severely dis-
turbed individuals is required, the logistics of transferring a client to an inpatient
psychiatric unit, usually located in the nearest regional centre or city, creates consider-
able burden for the referring clinician as well as for clients and their families (Lichte,
1996). Economic barriers to health care utilization in rural areas also exist, because rural
economies are fragile. They often depend on a single industry and are at the mercy of the
uncontrollable whims of nature such as floods, draughts, wildfires, frost and hail
(Barbopoulos & Clark, 2003). As a result, financial stresses among rural residents are
common and health insurance coverage may be suboptimal.
In addition to these geographic and economic barriers to mental health service
utilization, help-seeking behaviours are influenced by social context. Rural residents
may be reluctant to seek help for psychological problems because of prevailing attitudes
of self-reliance and the consideration that talking about one’s problems a luxury (Boyd
et al., 2008; Kennedy et al., 2014). The diminished degree of privacy in close-knit small
communities can also heighten self-consciousness about seeking help for problems that
are associated with social stigma such as mental illness, drug abuse, or domestic violence
(Stamm et al., 2003). This high visibility and interconnectedness of individuals living in
small communities is often likened to living in a “fishbowl”, which makes it impossible
for anyone, including the local psychologist, to slip into anonymity (Dunbar, 1982).
Psychology trainees who wish to gain experience in rural settings will need to learn to
cope with specific personal and professional challenges that living and working in the
rural fishbowl present.

Professional Boundaries in the Rural Fishbowl

The activities and associations of a small town psychologist are under regular observa-
tion. Encounters with clients in the street, supermarket, post office, swimming pool,
social clubs, school functions or any local event are inevitable, and those benign
boundary crossings are a normal and healthy part of rural living (Malone, 2012). The
highly visible public image of rural practitioners greatly curtails their personal privacy
and affects the personal and professional lives of their families. Likewise, the opportun-
ities for observing clients or potential clients outside the treatment context are enhanced,
 Chapter 15: Providing Therapy at a Distance 265

Figure 15.1 Applying the scientist-practitioner approach in rural practice.

and the therapist may inadvertently learn more about a client from other clients, since
their social and professional lives are more intertwined in a small community (Hargrove,
1982). Figure 15.1 illustrates how this blurring of professional and personal roles affects
the therapeutic process. The context of the rural fishbowl increases the likelihood that the
client data available for inspection includes information and affective reactions linked to
the clinician’s own personal and private life. This has the potential to both sharpen and
blur the acuity of the expert lens through which the therapist filters client data for the
purpose of case formulation.
Whereas urban-based ethical guidelines hold psychologists responsible for avoiding
interactions with clients outside the therapy sessions, there are at least two reasons why
“rural practitioners must be careful not [italics added] to ignore or avoid their clients
outside of the therapy sessions” (Campbell & Gordon, 2003, p. 432). First, unlike their
urban counterparts, rural psychologists typically do not have other colleagues to whom
they could refer clients they personally know. Thus, avoiding dual relationships could
mean depriving rural clients of the only specialist mental health service available to them.
Second, to be effective, psychologists must first become part of the community (DeLeon
et al., 2003). Their active community involvement is essential for lessening suspicion,
increasing approachability and ultimately gaining acceptance as the “local” mental health
expert (Schank & Skovholt, 1997). This is increasingly true if there are particular sub-
cultures, racial minorities or Indigenous groups living in the area and appropriate
provision of services requires working as an ally with the community (Dudgeon,
Milroy & Walker, 2014; Malone, 2012). Consequently, multiple nonsexual relationships
in rural practice are not only expected, they are encouraged! (Campbell & Gordon,
2003). This blurring of professional and personal roles in rural practice requires that
practitioners are particularly mindful of the ethical obligation to manage multiple
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relationships in a way that does not impair the objectivity and effectiveness of the
therapist or expose the client to exploitation or harm (American Psychological
Association, 2002; Australian Psychological Society, 2003). The extent to which these
ethical ambiguities are handled in a comfortable and competent manner may in large
part determine the success of the rural practitioner (Hargrove, 1982).

Strategies for Managing Multiple Relationships in Rural Practice

Because of the specific ethical demands that arise in rural settings, the standard principle
of strict separation between personal and professional roles expected in urban practice
cannot be applied automatically in rural practice. Several authors (Barbopoulos & Clark,
2003; Campbell & Gordon, 2003; Schank & Skovholt, 1997) sought to address this ethical
dilemma by offering practical guidelines for how rural practitioners can manage multiple
relationships in an ethical manner:
 Compartmentalize roles and relationships. This involves keeping different roles
mentally separated when interacting with clients and adopting a demeanor in line
with the role relevant in a given instance. This allows the practitioner to be a
professional helping expert one day, and a fellow parent at a school meeting the next.
That is, in the latter situation, the practitioner can be warm and friendly while
maintaining confidentiality, but will drop any air of the expert helper and will
deliberately embrace a stance reflecting the situational context and purpose of the
present contact. Relationships can also be separated in terms of degree of
involvement. Shopping at a local grocery store where a client might be working
constitutes less of a softening of boundaries than hiring a client (who may be the only
electrician in town) to do some work in one’s home. In the urban environment,
boundaries usually are protected by the cloak of anonymity; in the rural setting,
compartmentalizing private and professional roles means learning to wear the right
hat for the right occasion.
 Document overlapping relationships in case notes. An important strategy to avoid the
risk of boundary violations or the accidental disclosure of confidential information is
to make explicit in the documentation of case progress the nature and details of
overlapping relationships. This will help clinicians to keep original sources of
information clear in their mind and minimize the risk of unintentional breaches of
confidentiality.
 Discuss out-of-therapy contact with clients upfront. It is good practice to routinely
discuss with clients at the start of treatment the high likelihood of out-of-therapy
contact. Clients can be assured that every effort is made to respect their privacy
during chance encounters and contacts that may even be predictable in a small
community. Clients are given the opportunity to communicate how they feel about
such encounters, how they intend to respond, and how they wish the therapist
to respond.
 Obtain informed consent. As with explicit documentation of overlapping
relationships in case notes, informed consent forms should include explicit mention
of any multiple relationships and state that the client has been made aware of this
issue when consenting to engage in treatment.
 Educate clients about professional boundaries. Clients should not be assumed to know
what therapists mean by professional boundaries. It may be necessary to explain to
 Chapter 15: Providing Therapy at a Distance 267

some clients what a professional boundary is. This may take the following form:
“Because you are my client, you cannot be my friend. I listen to you, I care about
you – but friends care about one another. But you don’t come in so that I can sit
down and tell you about my problems and my life. I don’t call you when I am hurting
or need a friend for support” (adapted from Schank & Skovholt, 1997, p. 47)
 Stick to time limits. Beginning and ending therapeutic contacts strictly within the
designated appointment times helps to highlight the professional nature of the relationship.
 Develop procedures that reduce accidental disclosures. The exchange of information
between professionals in a small community may require additional safeguards to
protect client confidentiality. For example, files or reports sent to a physician in a
hospital might be open to inspection by administrative or other staff who know the
client or members of the client’s family.
 Monitor one’s own comfort level. If therapists experience discomfort with a dual
relationship, that can compromise their objectivity and effectiveness. For example, a
therapist might learn that her daughter is bringing a friend home after school who
also happens to be a client of the therapist. The therapist has to weigh competing
ethical choices: protect the client’s confidentiality and cope with the personal
discomfort, or break confidentiality by restricting the people her daughter can have
as friends. Which choice is in the best interest of the client depends on the therapist’s
ability to compartmentalize the relationships and manage her level of discomfort
while remaining therapeutically effective.
 Put client’s needs first. Therapists need to reflect about their motives for maintaining
dual relationships, so that clients are not used inadvertently for one’s own
gratification or exploitive purposes.
 Imagine the worst-case scenario. In deciding whether or not it is in the client’s best
interest to maintain a dual relationship, it can be very instructive to consider the
possible harm that could stem from the relationship not only in the present but also
in the future.
 Monitor the “slippery slope” phenomenon. Boundary compromises that seem minor in
isolation can have cumulative effects and lead to more substantial
boundary violations.
 Monitor warning signs of role-boundary conflicts. It is essential to be aware of any changes
in the nature of interactions in overlapping relationships. Is there more self-disclosure by
the therapist? Is there greater anticipation of meeting with a client? Does the therapist feel
a desire to prolong a session with a client or increase the frequency of meetings with the
client? Is the therapist reluctant to terminate or refer a client? Does the therapist want to
please or impress a client? Affirmative answers to these questions indicate an increased
potential for role-boundary conflicts in multiple relationships.
 Terminate overlapping relationships as soon as possible. Prompt termination of
multiple relationships following the conclusion of their primary purpose is in the
client’s best interest.
 Seek consultation. Because of the professional isolation of rural psychologists which
limits the opportunities for ad hoc consultation with colleagues regarding ethical
issues, the onus is on the psychologist to make special efforts (e.g., using
telecommunication or internet tools) to maintain links with other professionals who
can provide feedback on ethical decision-making.
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268 Chapter 15: Providing Therapy at a Distance

Coping with Professional Isolation

Ethical decision-making is not the only aspect of rural practice affected by professional
isolation. As shown in Figure 15.1, rural psychologists must deliver the core clinical tasks
of applying science-informed, up-to-date knowledge and skills to case formulation and
treatment planning, often without easy access to consultation from other mental health
experts, state-of-the-art diagnostic and treatment resources or continuing education
(Stamm et al., 2003). It is therefore essential that rural practitioners learn to practice
independently with minimal support from colleagues within their own discipline, and be
comfortable with assuming ultimate responsibility for decisions concerning case man-
agement (Lichte, 1996). On some occasions this might mean working under conditions
well beyond what they were prepared for (Gibb, Livesey & Zyla, 2003). As a back-up,
rural practitioners must become familiar with what clinical services are available in the
nearest metropolitan area and develop procedures for facilitating long-distance referrals
(Keller & Prutsman, 1982). Although working in relative isolation is demanding and can
lead to professional burnout, there are also positive features associated with isolation
including a greater sense of autonomy and opportunities to respond to community
circumstances with a great deal of flexibility and creativity (Wolfenden, 1996). Moreover,
Figure 15.1 indicates how the impact of professional isolation on the ground can be
overcome, at least in part, by seeking professional consultation via the internet and by
accessing informal support networks and multidisciplinary collaboration. For example,
in Australia, the national Suicide Call Back Service uses telephone and online technolo-
gies to provide professional, suicide-specific mental health care services available
24 hours a day all year round.
The relative scarcity of mental health resources in rural regions makes coordination
with medical practitioners, social services, law enforcement agencies, educational insti-
tutions, religious communities and informal support systems imperative (Stamm et al.,
2003). As mentioned earlier, rural residents often feel reluctant to seek help for mental
health problems. In one study, of those who had screened positive for depression, anxiety
and alcohol abuse disorders, and who had received education about the respective
disorders and available treatment services, 81 per cent failed to seek help because they
“felt that there was no need to” (Fox et al., 2001). Of those who had sought help for
mental health problems in the past year, most approached a friend or family member
rather than a psychologist or physician (Fox et al., 2001; see also Judd et al., 2006). By
tapping into such natural support networks during treatment planning, the isolated
professional can extend the reach of continuing care. Of course, before family members
and friends are co-opted in any treatment plan, it is important to determine to what
extent the social group is creating or exacerbating the presenting problems of the patient
(Dunbar, 1982). Similarly, paraprofessionals and volunteers for crisis counselling and
similar adjunct services can be a valuable resource, but care must be taken in selection,
training and supervision of those informal helpers (Heyman & VandenBos, 1989).
Traditionally, most rural psychology is practiced by professionals without expertise
in advanced psychological skills, such as physicians, nurses, welfare workers, teachers or
clergy (Wolfenden, 1996). Developing partnerships with these established mental health
service providers in rural communities is particularly important. By collaborating with
established agencies and community referral systems (see Figure 15.1), the psychological
expert can engage their familiarity and credibility to contribute quality mental health
 Chapter 15: Providing Therapy at a Distance 269

care to the community (Sears, Evans & Kuper, 2003). Depending on available resources
and local circumstances, such multidisciplinary collaboration may involve informal
contacts or coordinated links between referral systems, or even integrated partnerships
with sharing of resources, personnel and responsibilities for the development of service
delivery systems (Lewis, 2001; Sears et al., 2003). Thus, the development of consultancy
skills is an essential prerequisite for psychologists in rural settings. Rural psychologists
need to educate the community about the unique expertise that they bring to patient
care, and they need to be prepared to provide consultancy services for a broad range of
community needs and problems.
Rural psychologists have an important educational role. Community education
involves expanding the appreciation of what psychologists have to offer, reducing the
stigma and misinformation associated with mental disorders, and providing information
on how to achieve and maintain optimal health (Lichte, 1996; Wolfenden, 1996). In
addition, rural psychologists can address the relative lack of professional development
opportunities in rural settings by offering information sessions and workshops for other
mental health workers (Barbopoulos & Clark, 2003). Similarly, rural psychologists can
help inform laypersons and self-help groups by organizing public presentations and
community events related to mental health. They should liaise with community leaders
and elders, including religious institutions, to promote psychological approaches for
bringing relief to people who experience personal crises and suffering. Enlisting the
sponsorship of these influential members of the community helps to gain the trust of
rural residents and establish the psychologist as a valuable participant in addressing local
needs.
Perhaps the best advertising for psychological services is first-hand experience of
what the psychologist does (Wolfenden, 1996). One thing that psychologists are trained
to do particularly well, and that sets them apart from most other mental health profes-
sionals, is applying research skills to applied problems such as the design and implemen-
tation of programme evaluation studies. For example, rural practitioners can play a
critical part in developing prevention and outreach programmes or crisis response teams
(Barbopoulos & Clark, 2003). Many rural mental health services have few, if any, staff
resources in this area. By virtue of their training as scientist-practitioners, psychologists
will be called upon to contribute their expertise in selecting the appropriate techniques
from the programme evaluation literature and measuring the success of target outcomes
(Sears et al., 2003). This important role of the rural psychologist as a programme
evaluator is illustrated in Figure 15.1 by the additional feedback loop linking the
“Evaluation & accountability” component of the model to “Community referral
systems”. Particularly, these evaluations will be useful in supporting efforts of a commu-
nity to lobby for additional resources to support local health care services.
However, the specialist knowledge and skills of the psychologist are not sufficient for
being a successful rural practitioner. In light of the scarcity of mental health professionals
in rural settings, psychologists can achieve maximum utility with practical patient
outcomes only if they are able to respond to a wide range of problems across people of
all ages, types and backgrounds (Sears et al., 2003). In addition to dealing with adult
psychopathology, the clinical activities include relationship and family counselling,
behavioural management programmes for children or individuals with disabilities, care
of rape and domestic violence victims, critical incident management and a host of other
problems. Rural psychologists https://avxhm.se/blogs/hill0
may also find themselves acting as social workers, housing
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advocates or liaison officers between distressed individuals and other community agen-
cies. In other words, the effective rural psychologist above all fulfils a generalist role (see
Figure 15.1). Of course, it is desirable for a generalist to have a wide repertoire of skills,
but more important is that “the generalist has a method of intervention that can provide
a guide and framework into most any situation” (Dunbar, 1982, p. 63). As we have
illustrated throughout this manual, and again in Figure 15.1 in this chapter, a scientist-
practitioner approach serves as a reliable framework for adapting one’s practice to the
particular professional challenges one might encounter in any situation or setting,
including those presented by working in the rural fishbowl. A science-informed practi-
tioner of clinical psychology is also well-placed to extend their professional role beyond
the traditional focus on “mental” health into the broader domain of general health care.
Thus, the next chapter will consider how clinical psychologists can add value within
multidisciplinary systems of health care delivery.
 Chapter
Psychologists as Health Care

16 Providers

Clinical psychologists today increasingly will need to be competent to function in the

broader context of health service psychology (HSPEC, 2013). The core identity of
clinical psychologists has broadened from the traditional focus on “mental health” to
a professional role that brings psychological expertise to the maintenance and
restoration of “health” more generally (APA, 2005). Major health care reform
agendas are being implemented in a number of developed countries such as the No
Health Without Mental Health strategy in the United Kingdom (HM Government,
2011), and the Better Access to mental health initiative in Australia (Australian
Government Department of Health, 2020). These reforms mark a new era in health
care delivery where there is greater recognition that mental health issues substantially
contribute to the burden of disease worldwide (Prince et al., 2007).
Among the ten leading causes of illness in industrialized nations are lifestyle
behaviours such as smoking, poor diet, lack of exercise, alcohol misuse, sexual
behaviour and illicit drug use (Johnson, 2003). Globally, there has been no real
progress over the past three decades in reducing exposure to behavioural risks
(GBD 2019 Risk Factors Collaborators, 2020). In addition to health threats associated
with these behaviours (e.g., cardiovascular diseases, cancer, HIV/AIDS), health and
illness are influenced by psychological factors such as stress, positive and negative
emotional states, beliefs and coping styles, and social relationships (Compare et al.,
2013; Salovy, 2000; Stowell et al., 2003). Psychological interventions targeting these
factors can make a significant contribution to the prevention and treatment of
medical conditions, as well as the promotion of healing (Christensen & Nezu, 2013;
Nicassio, Meyerowitz & Kerns, 2004; Schein, 2003). As noted by Belar (2012),
psychological service provision is relevant to each and every one of the health
conditions listed in the International Classification of Diseases (ICD-10; World
Health Organization, 2010). The essential role of mental health to achieving health
for all people was confirmed in the World Health Organization’s (2013) Mental
Health Action Plan 2013–2020, which articulates a clear vision of “parity of esteem”
(HM Government, 2011, p. 2) between mental and physical health services. These
comprehensive, global reform agendas for mental health care have major implica-
tions for the training of clinical psychologists. A clinical psychologist needs to be
prepared to add value within a health care environment that is increasingly charac-
terized by integrated, patient-centred, accountable, and efficient systems of care, and
economic incentives to keep people healthy (Kelly & Coons, 2012).

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Evolving Parameters of Psychological Service Delivery

Towards Integrated, Patient-Centred Care
Prominent in the redesign of health care systems is the spread of integrated care models,
where health care is comprehensive, continuous, coordinated, culturally competent and
consumer centred (Kelly & Coons, 2012). This includes a greater emphasis on mental
health promotion, early intervention in crises and accessible community-based care. At
the heart of the integrated approach is the notion of “one stop” care in settings such as
Patient Centered Medical Homes in the United States (Department of Health & Human
Services (2021) or Primary Health Networks in Australia (see Department of Health,
2021a), where primary and speciality service providers are collocated in the same
premises providing team-based care. This goes beyond multidisciplinary care where
diverse health professionals add their individual ingredients of expertise to a consultative
meal. Integrated care involves interprofessional teamwork, communication and team-
based decision making in all aspects of patient care (Epperly, 2011; Metusela et al., 2020).
In such a care environment, patients encounter psychologists as a member of the team,
often in the form of a “warm hand off”, where a primary care provider introduces and
transfers patient care to the “behavioural specialist” while the patients present for their
primary care appointment (Cubic et al., 2012).

Evidence-Based Care and Accountability are Here to Stay

Accountable health care is measured in terms of both the effectiveness of interventions to
achieve optimal health outcomes, and the relative economic value of alternative inter-
ventions within the context of competing models of health care delivery, funding
and reimbursement.
Competitive health care is care that reliably improves health outcomes at a cost the
market will bear, and that satisfies the consumer (i.e., the patient). The scientist-
practitioner training, with its emphasis on science-informed practice, outcome evalu-
ation, and ongoing quality improvement in service delivery, provides precisely the skills
needed for clinical psychologists to add value to health care in the context of integrated
care settings. However, for clinical psychologists to become established as health care
providers on a par with medical professionals, they need to make adjustments to their
traditional modes of delivering psychological treatments. This includes an understanding
of the health care marketplace, a focus on good enough treatment, an investment in
consumer education and marketing of services, and a willingness to embrace the culture
and pace of integrated care settings (Kiesler, 2000).
To be competitive in the health care marketplace, providers – including psycholo-
gists – need to offer evidenced-based, cost-effective services with measurable outcomes
(Kelly & Coons, 2012), increasingly in accordance with national guidelines for quality
standards (e.g., NICE, 2021), or innovative reimbursement structures such as
Accountable Care Organizations (ACOs, 2021). In the traditional fee-for-service model,
practitioners tend to treat patients over an extended period of time, without require-
ments to account for outcome or length of treatment (Sanchez & Turner, 2003). In
such a system, there is no incentive for cost-effective treatment, because the more
services are offered, the higher the income for the provider. The resulting escalation of
 Chapter 16: Psychologists as Health Care Providers 273

mental health care costs has led to the emergence of various managed care systems.
Although these systems vary considerably in the type of cost-control strategies used
(e.g., limit number of sessions, reduce fees for services, provide financial rewards for
efficient and effective care), and in the extent to which they have private or public
sector involvement, they all involve some kind of capitation or rationing (Hinton et al.,
2020; Strohsahl & Robinson, 2018). That is, the demand for services by a specific
number of patients (or potential patients) is predicted for a given period of time, and a
fixed amount of money is allocated to meet that demand (Tovian, 2004). In contrast to
a fee-for-service system, a pay for performance model includes financial penalties and
rewards (Kelly & Coons, 2012). That is, the risk is shared between provider and payer,
and simply offering more services does not generate more income for the provider.
Instead, incentives are geared towards care that produces quality outcomes with high
efficiency. Thus, cost containment strategies and capitation together with integrated
care models are designed to rein in uncontrolled escalation of overall health care costs
by improving quality and efficiency of services for a greater number of people. From a
public health perspective, this is desirable, but cost cutting must be balanced with
optimal patient outcomes, because failure to adequately treat mental health conditions
impacts service utilization and costs in every area of primary and speciality health care
(Gray, Brody & Johnson, 2005).
Competition for health care resources is therefore not so much an issue of who costs
the least, but rather who adds value (Kiesler, 2000), where value is a function of optimal
treatment outcomes achieved in a time-limited, resource-efficient manner for the
greatest number of people. By virtue of their scientist-practitioner training, psychologists
are particularly well prepared to function in such an empirically based service system.
The value of psychological services must be communicated via information feedback
loops between the data generated by routine outcome evaluation and both the system
managing Health care costs, and the consumer determining demand (see Figure 16.1).
The main difference to traditional outcome assessment is that psychologists must not
only show that treatment works, but that it is cost-effective. Cost-effectiveness compares
the costs of an intervention with the amount of improvement in health status (Kaplan &
Groessl, 2002). Improvement is evaluated in relation to specified treatment goals and
against standard criteria of normal functioning in a normative comparison group. Cost-
offset compares the costs of an intervention with the costs saved elsewhere in the health
care system as a result of that intervention (Kaplan & Groessl, 2002). For example, a
programme to achieve weight loss may reduce a patient’s number of visits to a hyper-
tension clinic or eliminate the need for hypertension medication. If the reduction in
visits and medication use saves more money than it costs to run the weight loss
programme, a cost-offset has been achieved. There is robust evidence that psychological
interventions can produce medical cost-offset effects (Chiles, Lambert & Hatch, 1999;
Meuldijk et al., 2017). Although the demonstration of cost-offset can enhance the value
of psychological services, the goal of treatment is not to save money, but to improve
health. Indeed, if health status is unaffected by treatment, the cost of that treatment
amounts to waste of limited health care resources. For example, in the US more than
650,000 arthroscopic surgeries for osteoarthritis of the knee are performed at a cost of
over three billion dollars annually, but carefully controlled trials showed that this
intervention did not achieve any better pain relief or improvement in function than a
placebo procedure (Kirkley et al., 2008; Moseley et al., 2002). This creates an opportunity
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274 Chapter 16: Psychologists as Health Care Providers

Client data (multidisciplinary sources)

Theoretical & Clinical training &

empirical literature experience

Assessment Problem-focused
case formulation Managed
capitated
care
Promotion of
consumer demand Treatment planning Solution-focused
& measurement
Good enough treatment

Treatment implementation
Stepped-care
& monitoring

Evaluation & Outcome +

Consumer satisfaction
accountability cost

Figure 16.1 The scientist-practitioner approach to clinical practice is tailor-made for an empirically-based
health care system.

cost problem (Kaplan & Groessl, 2002). The billions of dollars spent on ineffective
surgeries for pain relief are not available to non-surgical interventions that may have a
superior evidence base (e.g., Gatchel, 2005). In the competition for health care resources,
the onus is on psychologists to build on their strengths as scientist-practitioners and
demonstrate that their treatments provide value for money, and that they add unique
value to multidisciplinary health care (Tovian, 2004).

Psychologists Add Value to Integrated Care

About three out of four mental health patients are treated by primary care physicians
(Hickie et al., 2005; Olfson et al., 2002). Patients talk to their general practitioner about
mental health more than any other health issue (Royal Australian College of General
Practitioners, 2019), but only a minority of patients receive adequate treatment at the
primary level of care (Gray et al., 2005). For example, general practitioners fail to
accurately recognize common mental disorders in 30–70 per cent of patients who have
a psychological problem (Coyne et al., 2002; Hickie et al., 2005; Sanchez & Turner, 2003),
and they often fail to follow up or adjust treatment (Gray et al., 2005), or may over-
prescribe psychotropic medications (Coyne et al., 2002; Medco Health Solutions, 2011).
For example, in treating depression, psychological treatments alone or combined treat-
ments achieve superior treatment outcomes than pharmacotherapy alone (Pettit, Voelz &
Joiner, 2001), and prolonged use of antidepressants can worsen depression (Fava, 2003;
Fava & Offidani, 2011). Thus, integrating mental health specialist services in primary care
does not only add value by achieving better health outcomes, but integrated care is
estimated to reduce health care costs by 20–30 per cent (Gray et al., 2005). Importantly,
when primary care physicians and mental health specialists operate as a team within the
 Chapter 16: Psychologists as Health Care Providers 275

same setting, the number of referrals for psychological services that are followed through
by the patient have been found to increase eightfold (Cummings, 1999). However, for
psychologists to become valued players on integrated health care teams, they need to tailor
their interventions and strategies to the needs and circumstances of general practice and
hospital settings.
As indicated in Figure 16.1, it is important in the initial encounters with patients to
be problem-focused, so that assessment information is relevant to the specific referral
question within the context of other assessment data contributed by different members
of the multidisciplinary team (Haley et al., 1998). Likewise, treatment planning and
implementation must be solution-focused, because in medical settings results are
expected far more quickly than in traditional mental health settings. Finally, the need
to balance optimal care with efficient utilization of health care resources means that the
modal form of treatment is guided by the concept of good enough treatment. As Kiesler
(2000) noted, good enough treatment is guided by three principles: (a) no treatment is
perfect, (b) more treatment might achieve better outcomes, but would do so at the
expense of other patients who would miss out on care because the amount of available
resources is finite and (c) treatment to relieve acute distress and avoid relapse is
sufficient under the circumstances. Because a large percentage of patients show
“sudden gains” after three to five therapy sessions, they often no longer meet symptom
criteria for being considered a “case” (Strohsahl & Robinson, 2018). Under these
circumstances, the patient and therapist might routinely agree that the treatment
outcome is good enough at this point and schedule a booster session for a future
date (Strohsahl & Robinson, 2018).
One way to ensure that patients receive all the care they need, but not more, is
through the application of stepped-care models. Davison (2000) described stepped-care
as “the practice of beginning one’s therapeutic efforts with the least expensive and least
intrusive intervention possible and moving on to more expensive and/or more intrusive
interventions only if deemed necessary in order to achieve a desired therapeutic goal”
(p. 580). A stepped-care approach is readily compatible with the purposeful planning,
monitoring and modification of treatment strategies inherent in the scientist-
practitioner approach to clinical practice (see Figure 16.1). It also requires greater
attention to patient preferences and the utilization of flexible delivery formats (c.f.
Bennett-Levy et al., 2015). In the broader context of health services delivery, the question
is not simply “Which treatment(s) are known to work best with which specific mental
health problem”, but the question would be: “Which treatment (s) works best, in the
shortest possible time, with the least resources used, with the lowest refusal and attrition
rates, when delivered by mental health and non–mental-health providers (with different
levels of training) in a variety of different community settings, and with patients
suffering from medical and mental health conditions of varying levels of severity?”
(Strohsahl & Robinson, 2018, p. 8).
One example of how psychologists add value to integrated care by applying a focused
set of treatment strategies within a stepped-care framework is the treatment of hyperten-
sion. The first step in the sequential implementation of graded interventions involves the
initiation of lifestyle modifications such as physical activity, weight loss, smoking
cessation and stress management (Blumenthal et al., 2002). For instance, a weight loss
of as little as five to eight kilograms can produce clinically meaningful reductions in
blood pressure (Blumenthal https://avxhm.se/blogs/hill0
et al., 2002; Smith & Hopkins, 2003). If the lifestyle
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modifications fail to achieve blood pressure values within the desired range, adherence to
the treatment regimen will be assessed, and care may be “stepped-up” by introducing a
low dose of medications such as diuretics or beta-blockers. If response is still inadequate
or side effects are experienced, another drug might be substituted or a second drug from
a different class might be added. Thus, ongoing treatment decisions of stepping-up or
stepping-down care are directly informed by the degree of satisfactory progress a patient
makes. Psychological interventions add value because they can reduce or eliminate the
need for medications in some patients, and they can improve poor rates of treatment
adherence at every level or type of treatment modality (Blumenthal et al., 2002).
Another example of how psychologists can add value to integrated care involves the
stepped-care approach to pain management. We mentioned earlier the poor outcomes of
some very costly surgical procedures to alleviate knee pain (Kirkley et al., 2008; Moseley
et al., 2002). In a stepped-care approach, less costly and intrusive interventions should be
attempted first. With respect to pain management, the first step is a brief, one-off
psychological intervention addressing patients’ fears and beliefs about their pain to help
them adjust to and manage their pain while returning to regular daily activities (Otis,
Reid & Kerns, 2005). For patients who do not improve after a few weeks, care can be
stepped up to include multiple visits to providers from different disciplines (e.g.,
psychologists, physical therapists, physicians) to initiate structured activity programmes,
practise cognitive-behavioural coping strategies, or prescribe pain medication to assist
patients with resuming work and recreational involvement. Only if these less intense
interventions fail to bring about improvement, or if the initial assessment indicates a
high risk of becoming permanently disabled, should Step 3 interventions be considered.
These may include surgical techniques and more intense speciality services, often within
multidisciplinary pain management centres (Gatchel, 2005; Otis et al., 2005).
Value adding to health care delivery based on a stepped-care model is also increas-
ingly achieved by implementing broad health workforce reforms such as the Improving
Access to Psychological Therapies (IAPT) initiative in the UK (NHS Digital, 2020). The
aim is to increase availability of first-tier treatment providers who require less training
(and hence less pay) to deliver low-intensity, evidence-based interventions for the most
common mental health conditions (i.e., anxiety and depression disorders). Only individ-
uals who fail to respond adequately to the low-intensity interventions (e.g., guided self-
help or computerized CBT) will be stepped up to higher-intensity interventions such as
face-to-face therapy sessions delivered by more qualified (and hence more costly) service
providers (Clark, 2011). The rationale is that allocating a larger share of limited health
care resources to the broad dissemination of evidence-based treatments for the most
prevalent mental health problems will improve health outcomes for a majority of
treatment seekers. After the first decade following the implementation of the IAPT
programme, a systematic meta-analysis of the effectiveness of IAPT interventions
delivered during routine practice found large pre- to post treatment effect sizes for
reductions in depression and anxiety, with a medium effect regarding improvements
in work and social adjustment (Wakefield et al., 2020). Of the 6.9 million referrals in the
most recent year, over half of the patients moved to recovery in just under seven sessions
on average (NHS Digital, 2020).
The British example of successfully initiating rapid growth of a large skilled mental
health workforce delivering effective interventions with demonstrable economic benefits
will provide added momentum to similar sweeping reforms to health workforce models
 Chapter 16: Psychologists as Health Care Providers 277

underway in other countries (e.g., Cromarty et al., 2016). A substitute psychology

workforce (Littlefield, 2012), requiring shorter training courses and less qualified to
provide the full range of psychological services, will become preferred providers for less
complex, manualized treatments within a structure of ongoing supervision and session-
by-session outcome monitoring systems (e.g., Clark, 2011). These reforms constitute a
seismic paradigm shift in a new way of thinking about sustainable health care design and
planning to meet current and future health workforce demands, “one that works
backwards from outcomes for communities, consumers and population need, versus
the current thinking that is generally focused on working forward from the base of
existing professions and their interests and skills, demarcations and responsibilities”
(Health Workforce Australia, 2011, p. 5). Clinical psychologists are well positioned to
flourish in this new health care world and can add value to mental health care delivery.
However, their role in reformed health care systems will be alongside a range of
practitioners across and within professions, including an army of mental health workers
less qualified but nonetheless effective within the scope of their targeted training and
low-intensity service provision for certain mild to moderate conditions (Clark, 2011).
This push towards more integrated, generalist models of care means that clinical
psychology training must be adapted to produce more generalists to match workforce
demands. However, at the same time, there remains a vital need for those competencies
that are needed to deliver speciality care for the more complex or less prevalent condi-
tions (Comer & Barlow, 2014). That is, a practitioner workforce strong in generalist
skills, or trained in focused skills targeted for providing front-line care to the less intense,
common conditions, may not be sufficient to address the full spectrum of the burden of
mental illness. Health service psychologists, therefore, encompass competencies as both a
primary care professional and a speciality care professional (Health Service Psychology
Education Collaborative, 2013). Comer and Barlow (2014) envision a range of psycho-
logical stepped-care options which at the initial level include low-intensity, technology-
based options with minimal therapist involvement, followed by direct care from a
generalist provider, then direct care from a generalist provider with consultation from
a specialist and then at the highest step direct care from a specialist. As technological
innovations are beginning to transform health care delivery, behavioural telehealth care
models are likely to have a vital role at each level of stepped care in direct service
provision, consultation and supervision. The core scientist-practitioner training provides
psychologists with a solid base from which to venture into this changing is continuation
of previous sentence health care market. However, there are a number of specific,
practical tips emerging from the evolving field of psychology as a broader health care
profession on how psychologists need to adapt their repertoire of skills to provide quality
services in primary care and other medical settings.

Psychologists Need Specific Skills to Adapt to Integrated

Care Settings
1 Psychologists Need to Provide Effective Interventions Expeditiously
Focus on the Presenting Problem or Referral Question
Clinical psychologists have traditionally been trained to conduct thorough assessments
by obtaining information fromhttps://avxhm.se/blogs/hill0
lengthy interviews and extensive psychometric testing. In
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medical settings, psychologists must be able to assess presenting problems far more
quickly and offer practical recommendations immediately (Gatchel & Oordt, 2003).
There may be no more than two treatment contacts in inpatient settings, and typically
six or less contacts in outpatient settings (Cubic et al., 2012). Across OECD countries, the
average length of inpatient admissions is about seven days, and only five days in
Australia or the United States (OECD Health Data 2013).
Rather than working within a standard 50-minute session schedule, initial appoint-
ments rarely exceed 25–30 minutes, with follow-up visits typically lasting between 15 to
20 minutes (Rowan & Runyan, 2005). Moreover, the initial appointment is not all
reserved for assessment, but swiftly moves towards the initiation of an intervention.
Rowan and Runyan (2005) recommend five phases for conducting a highly structured
initial evaluation appointment:
 Introduction (1–2 minutes). This is a well-rehearsed statement to clarify the psychologist’s
role on the health care team, the purpose of the appointment, and the nature of the
information that will be documented in the patient’s medical record. A brochure with the
same information may be handed to the patient at the same time for future reference.
 Bridge to assessment (10–30 seconds). The bridge usually is a sentence or two that
serves to direct the patient’s attention straight to the referral question or primary
presenting problem (e.g., “Dr. Morgan was concerned about the recent increase in
your blood pressure and was wondering how your everyday behaviours and activities
might contribute to it. What does a typical week look like for you in terms of physical
activity, eating patterns or daily stress?”) A purposely vague bridge (e.g., “What
brings you here today?”) is less useful, because it is likely to invite responses that stray
too much from the referral problem.
 Assessment (10–15 minutes). Assessment of the patient’s symptoms and daily
functioning is focused on the referral question. To identify possible avenues for
appropriate interventions, it is important to also assess strengths and strategies that
have helped the patient in the past to alleviate or manage the impact of the presenting
problem, as well as any barriers that might render particular psychological treatments
less likely to succeed.
 Bridge to intervention (1–2 minutes). This bridge is a brief summary of the most
critical parts of the assessment information, how they link to the presenting problem,
and what interventions have proven successful in treating this type of problem.
Building on any helpful strategies the patient is already doing well can enhance
rapport and readiness to engage in change.
 Intervention (5–10 minutes). Intervention strategies should be concrete, practical and
easy to implement after minimal instruction. They should be aimed at producing
tangible symptom reduction or improvement in functioning soon after treatment
commences. Because opportunities for in-session education and demonstration of
techniques are only brief, therapists have an extensive array of sufficiently detailed,
stand-alone handouts and “self-help” materials ready for patients to take with them.
They may also use “behavioural prescription” pads to outline the treatment plan and
associated patient tasks.
Follow-up appointments are variable in length and serve to help establish momen-
tum for change. They can be as brief as five minutes, if progress and the current
presentation of the patient reveal no need for more intense intervention or consultation.
 Chapter 16: Psychologists as Health Care Providers 279

Be Decisive with Limited Data

Sheridan & Radmacher (2003) noted that the great time pressures, the flood of infor-
mation from multiple sources and people, and the distracting stimuli typical of medical
environments may stretch the health care provider’s capacity to process information
accurately and efficiently. Hence, the ability to arrive at a correct diagnostic impression
and intervention plan under those circumstances requires that psychologists adapt to the
rapid pace of medical settings and learn to make efficient use of the brief time available
with each patient (Gatchel & Oordt, 2003). Just as psychologists need to be comfortable
with the principle of good enough treatment, they need to be tolerant of gaps in the data
guiding their decision-making during case conceptualization and treatment planning.
This process can be greatly facilitated by the judicious use of brief, validated psychomet-
ric instruments relevant to the particular aspects of a presenting problem (Gatchel &
Oordt, 2003).

Fill Your Toolbox with Effective Short-Term Treatments

Considering the practicalities of integrated care settings, the modal form of treatment
will be solution-focused and brief (Kiesler, 2000; Sanchez & Turner, 2003). Hence,
students should strive to develop an extensive repertoire of behavioural and cognitive-
behavioural short-term strategies. These include approaches such as Screening, Brief
Intervention, and Referral to Treatment (SBIRT; SAMHSA, 2014) and the 5 A’s model
(e.g., Kaner, Newbury-Birch & Heather, 2009). The five A’s refer to ask about the
problem, advice to change the problem using clear personalized feedback, assess willing-
ness to change, assist to change, and arrange follow-up and support. Motivational
interviewing skills are core components of these brief intervention approaches.

Become an Expert in Motivational Interviewing Techniques

Medical patients are often reluctant to engage in action-oriented lifestyle changes
(Gatchel & Oordt, 2003). Brief motivational interventions can enhance a patient’s
readiness to make the recommended changes and become an active partner in their
own treatment. As with other interventions in medical settings, the constraints on time
and the limited number of patient contacts requires that motivational interviewing is
adapted to a briefer format, sometimes referred to as “brief negotiation” (Resnicow et al.,
2002). Whether it is the adoption of lifestyle changes or adherence to medication
regimens, treatment compliance is a common problem. Sheridan and Radmacher
(2003) list the following principles for encouraging treatment compliance:
 Interact with patients in a warm, empathic manner.
 View patients as a key partner in the treatment team.
 Be specific with your instructions and make sure they are understood.
 Explain why you are confident that the treatment plan will be effective.
 Provide skills training when appropriate.
 Arrange for social support when appropriate.
 Provide praise for effort and for actual compliance.
 Use at-home reminders.
 Anticipate barriers to compliance and help patients cope with them.
 Monitor compliance in a caring, respectful manner.
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2 Psychologists Need to Be Good Team Players

Accept all referrals. Good integrated care depends on good interprofessional collabor-
ation (Cubic et al., 2012). In a team-based environment everyone needs to pull their
weight. Psychologists in medical settings are expected to attend to all behavioural and
psychosocial aspects of general health care (Gatchel & Oordt, 2003). To the extent that
they are willing and able to meet those expectations, they will be regarded as a valuable
asset to the team. In fact, psychologists should not just wait for patients to come to them,
but they should actively promote their services and enhance the visibility of the broad
range of interventions they offer (Haley et al., 1998).

Communicate Clearly and Frequently

As participants in interprofessional care, psychologists must be mindful of the formal
and informal ways by which information is exchanged and documented (APA, 2013).
Communication occurs during onsite patient encounters, team meetings, phone or email
consultations and via medical record systems. Psychologists must understand and speak
the languages of diverse care providers, and in turn communicate psychological concepts
in a manner useful to other professionals. This also requires familiarity with using
succinct technical terms which are routinely abbreviated for rapid communications
based on Latin phrases such as “PRN” for “as needed” or “PO” for “by mouth” (Kelly
& Coons, 2012). Psychologists must make sure that their interventions are in sync with
the treatment objectives of other members in the team. According to Gatchel and Oordt
(2003), good communication with medical colleagues involves (a) getting to the point
quickly, (b) avoiding psychological lingo and jargon, (c) keeping documentation suc-
cinct, (d) giving feedback promptly and (e) expressing one’s perspective confidently, but
not be offended if one’s advice is not taken on board by other team members. It is also
important to avoid ambiguity when responding to requests for input and always clarify
what the specific referral question is (Haley et al., 1998).

Be Sensitive to and Tolerant of Hierarchical Team Structures

Physicians typically have the final say in treatment matters. Medical appointments often
take precedence over non-medical (even scheduled) activities. For example, patients
participating in a small group session on stress management may be pulled out for
medical tests without prior notice.

Be Flexible and Available

Psychologists need to establish ways of being reachable when not in the office and
should be willing to respond to calls for assistance without delay whenever possible.
This might also mean interrupting the “sanctity” of the treatment session, which
psychologists are accustomed to when working in traditional mental health clinics
(Gatchel & Oordt, 2003).

3 Psychologists Need to Gain Familiarity with “All Things Medical”

Become Knowledgeable about Physical Conditions, Medical Procedures and Medications
When working on psychological components of a patient’s treatment plan, it is essential
that psychologists remain mindful of the patient’s experience with physical disability and
 Chapter 16: Psychologists as Health Care Providers 281

suffering (France et al., 2008; Haley et al., 1998). They should develop a basic under-
standing of the symptoms associated with common health problems and the procedures
and medications to treat them (Gatchel & Oordt, 2003). Because patients presenting with
psychological symptoms in integrated care settings may first be assessed by a psycholo-
gist, it is important that psychologists are able to obtain a brief medical history
(Robinson & James, 2005). This is important because psychological symptoms can mask
the presence of certain medical disorders. A brief set of questions can be incorporated
into the interview asking about recent changes in health status, awareness of any medical
conditions, family history of medical disorders, current medications, results of last
physical examination, history of head trauma and loss of consciousness and changes in
weight, diet, sleep or appetite (Robinson & James, 2005).

Become Familiar with Health Policy and Care Systems and Reimbursement Structures
and Codes
In the last two decades, progress towards establishing reimbursement codes for psychological
services that do not require a mental health diagnosis but target physical health problems has
been made in the US (Smith, 2002). Similarly, in Australia, psychologists became eligible to
receive Medicare rebates for their services (Martin, 2004). These were significant milestones
toward redefining “health as a multidisciplinary enterprise rather than a medical monopoly”
(Martin, 2004, p. 5). During this period of “health-care reform exploration” (Ivey &
Doenges, 2013) and proliferation of integrated health settings with a diversity of reimburse-
ment structures, it is important that psychologists seek clarity on different contractual and
financing arrangements operating in different care organizations (Kelly & Coons, 2012).
Psychologists need to keep abreast of further developments in this arena, as these are likely to
further smooth the path for psychologists practicing in medical settings.

When in the Medical World, Do As the Medicos Do

A core component of interprofessional competence is to recognize and respect the
competencies of other professions (Belar, 2012). Becoming part of the team means that
psychologists, while maintaining their distinctive qualities, must adopt the pace and culture
of their medical colleagues. This includes getting involved in the things that the other
providers do, such as attending presentations by pharmaceutical representatives, staying
informed about current medical issues by reading relevant medical journals, and participat-
ing in professional events and social functions (Gatchel & Oordt, 2003). Psychologists should
also be willing to be trained and educated on issues that initially go beyond their expertise
(Haley et al., 1998). Admitting ignorance is the first step towards acquiring the information
necessary to become familiar with the local culture. Receptiveness to the complimentary
expertise offered by psychologists is highest if it comes packaged in the wrappings and
trimmings familiar to medical professionals. This is not to imply that psychologists should
“disguise” their professional identity or not stand behind their perspective in the face of
opposing opinions (Gatchel & Oordt, 2003). After all, it is their different training and
expertise that adds value to the medical model of health care delivery.

4 Psychologists Need to Articulate Their Distinct Roles and Services

Although when in the medical world psychologists need to adjust to the specific culture,
language and pace of those care settings, it is equally important that they foster reciprocal
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understanding by other professionals of the unique skills and potential contributions

psychologists bring to collaborative care (APA, 2013). This is done in the context of both
routine communication and team meetings, but also by regularly participating as a
presenter at information seminars or lunchtime talks. Likewise, psychologists should
invest in enhancing psychological health literacy directly among patients to provide them
with the knowledge and tools to make informed decisions about the psychologist’s role in
their own care (Karlin & Cross, 2014; Santucci, McHugh & Barlow, 2012). The strong
scientific training and skills in practice-based research essential for programme develop-
ment, evaluation and quality improvement remain distinctive features in the core
competencies brought by clinical psychologists to integrated care (Health Service
Psychology Education Collaborative, 2013).

5 Psychologists Need to Be Accountable for Outcomes

Accountability requires good skills in database management. Kiesler (2000) noted that
“the database needed to track services is about the same as the database needed to do
good research” (p. 486). Thus, psychologists with a scientist-practitioner background are
well equipped to enhance the quality and utility of locally relevant data management
systems. However, research-skilled psychologists must fine-tune their approach to docu-
menting outcomes in line with the principles of time-efficiency, practical utility and good
enough treatment.

6 Psychologists Need to Attend to Ethical Issues

Adapting the delivery of psychological services to the pace and culture of medical settings
raises some important ethical issues for psychologists. Perhaps foremost among those is
the ethical obligation to provide services only within the boundaries of one’s competence
(APA, 2013). In particular, the pressure to conduct consultations more rapidly and for a
larger number of patients than is typical of the specialist mental health setting must be
balanced with a calm and methodical approach to determining if more comprehensive
psychological assessments and/or interventions are indicated (e.g., in cases of high suicide
risk, substance abuse, or complex family problems). If so, psychologists must triage those
patients and refer them to appropriate specialist care (Haley et al., 1998). It is important that
psychologists are skilled in managing these ethical dilemmas unique to interprofessional care
settings and avoid compromising their professional judgement in the face of systemic
constraints or pressures by other team members (APA, 2013). In this context, it is important
that psychologists guard their professional integrity and are upfront with a patient about
their particular role in the patient’s overall care, so that they avoid making unwise commit-
ments or raising false expectations (Gatchel & Oordt, 2003).
Confidentiality is an issue of heightened concern in settings where many staff
members from different disciplines are involved in patient care and have access to
patient records, and where the setting is dominated by the culture and practices of
another profession (Ivey & Doenges, 2013). For example, for physicians it is common
and acceptable to treat multiple members of a family or friends that come to the same
practice, whereas psychologists strive to avoid such dual relationships in their work if
possible. In care settings where many patients can be expected to know each other, it is
important to balance ethical concerns about confidentiality and any potential harm to
patients with the opportunity loss for patients to access vital behavioural health care. Ivey
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and Doenges (2013) recommend considering three dimensions in ethical decision-

making to determine the risk for harm regarding multiple relationships in primary care
settings: (1) what is the duration of treatment contacts? (2) What is the chance of future
contacts? and (3) What is the level of intensity of treatment contacts? If the intervention
is brief (1–3 contacts), with a low chance of future contact, and the care is limited to
consultation with or without the patient present, there is a low risk of harm. If several
contacts are required (4–10), with a medium chance of future contact, and the care
involves brief interventions such as psychoeducation, skill building and motivational
interviewing, there is a medium risk of harm. If longer-term care is required (more than
10 contacts), with a high chance of future contact, and the care involves a therapeutic
relationship with high level of patient disclosure and vulnerability, there is a high risk of
harm. Decision-making can be guided by considering whether answers to the questions
along these three dimensions for each of two patients predominantly fall in the lower- or
higher-risk categories. The ultimate decision must take into account whether the poten-
tial harm from treating multiple patients that know each other outweighs the harm
resulting from the loss of an opportunity to intervene. Sometimes the question might not
just be “Can I see this patient?” but rather, “What services can I ethically provide to this
patient to maximize benefits and avoid harm” (Ivey & Doeges, 2013, p. 222). As with all
ethical decision-making in patient care, if in doubt seek consultation.

Striving for prescriptive authority – a bridge too far?

For the past three decades there has been vigorous debate over whether clinical psych-
ologists should strive to gain the right to prescribe psychoactive medications (Lavoie &
Barone, 2006). Some consider seeking prescription privileges for psychologists (RxP) as
“psychology’s next frontier” (DeLeon, Fox & Graham, 1991), whereas others have
documented the lacklustre success of the campaign to promote RxP and view it as a
misguided agenda (Robiner, Tumlin & Hathaway, 2020). The rationale for seeking RxP
was that the mental health needs of society were not being met, therefore by increasing
psychology’s scope of practice the underserved public would have increased access to
qualified professionals who can prescribe. However, only a minority of psychologists is
interested in pursuing the training and authority to prescribe (Fox et al., 2009). Indeed,
only 0.18 per cent of the estimated workforce of 95,180 Full Time Equivalent active
psychologists in the five states in the US where psychologists have been granted pre-
scriptive authority have obtained RxP (Robiner, Tumlin & Tompkins, 2013). Despite this
general lack of enthusiasm among most practicing psychologists, some national bodies
such as the American Psychological Association view the further spread of RxP as
inevitable (APA, 2011) and, along with other professional bodies such as the
Australian Psychological Society (Stokes, Li & Collins, 2012), continue to lobby for it.
However, others such as the Canadian Psychological Association Task Force on
Prescriptive Authority for Psychologists in Canada (2010) have viewed the push towards
prescriptive authority as premature and recommended against making it a priority goal
or the focus of professional advocacy. Instead, they recommended active collaborative
practice with prescribing professions as the optimal standard for contemporary
psychological practices.
Although some interest groups within psychology continue to hanker for RxP, the
modest progress of the RxP movement appears destined to stall even further as the era of
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integrated care is gaining momentum amidst radical health care reforms aimed at
incentivizing efficient team-based care. Interprofessional collaboration in collocated care
settings is rapidly emerging as a compelling alternative to RxP (Robiner et al., 2013).
Clinical psychology trainees have more to gain from pursuing training opportunities that
enhance readiness for collaborative, team-based practice (HSPEC, 2013) than from
investing additional years of training to achieve the standards necessary for prescriptive
authority and thereby simply duplicating the competencies already represented by the
prescribing members of the team. The future of psychologists as health providers is only
bright if they can make a distinct contribution to collaborative care and are not seen as
doing the same thing as other types of providers working in the team (Belar, 2012).
More so than ever, the public interest is better served by access to mental health
professionals who can offer effective alternatives to medication than by adding psych-
ologists to the number of providers who already can prescribe (DeNelsky, 1991). There is
no consumer demand from the general public for psychologists being granted prescrip-
tion privileges (Lavoie & Barone, 2006), and for the most common mental health
conditions (depressive and anxiety disorders), 3 in 4 patients prefer psychological
treatments to medication (McHugh et al., 2013). When patients do receive medication,
adherence is poor (APA, 2011). Of those initiating antidepressant medications, 4 in 10
discontinued the medication within the first 30 days of treatment, and nearly 3 in 4 had
stopped taking it after 90 days (Olfson et al., 2006). Moreover, while pharmacological
treatments dominate the mental health market, their burgeoning use over the past
decades has proven ineffectual in stemming the worsening chronicity and severity of mental
disorders or reducing stigma associated with mental illness (Deacon, 2013). Why then would
psychologists strive to jump on the medication bandwagon, when most patients do not want
to take medications for the duration prescribed, prefer psychological treatments and, for the
most common conditions, achieve superior long-term outcomes with psychological compared
to pharmacological treatments? The integration of patient values and preferences with the best
research evidence is integral to evidence-based practice in psychology, along with clinical
expertise (APA Presidential Task Force on Evidence-Based Practice, 2006). On both counts,
psychological treatments generally outperform pharmacological treatments. Rather than
joining the pharmaceutical industry in the multibillion effort promoting consumer demand
for pharmacological treatments, psychologists must invest more in “pull” strategies designed
to enhance informed choice and demand by patients and other stakeholders for evidence-
based practices offered by psychologists as a distinct alternative (Karlin & Cross, 2014). The
pursuit of RxP diverts the profession’s resources and presents an opportunity cost associated
with an agenda producing few significant benefits to psychologists or patients (Deacon, 2013).
At this juncture, the predominant challenge of the field is to improve the dissemination and
implementation of evidenced-based psychological interventions, which includes greater adop-
tion of direct-to-consumer marketing strategies for building patients’ health literacy and
demand for evidence-based psychological interventions (Santucci et al., 2012).
In sum, psychologists’ involvement in medication issues can occur at three levels
depending on their qualifications and the jurisdiction they work in (APA, 2011). As
prescribers of pharmacotherapy, they have legal responsibility for decision-making in the
patient’s care; as collaborators in interprofessional practice, they may share involvement
in decision-making but no legal responsibility; as consultants, they may provide
decision-makers (including the patient) with relevant information but are not involved
in decision-making. Thus, clinical psychologists operating in patient-centred,
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interprofessional care settings have ample scope to be involved in any pharmacotherapy

components of their patients’ care, without also needing to be prescribers. In contrast,
pursuing the competencies critical to add distinct value to interprofessional collaboration
in the context of primary, specialist as well as preventative health care, is the defining
challenge of clinical psychology trainees as they venture into this new era of patient-
centred, integrated health care systems. In the final chapter, we turn to the ins and outs of
running a private practice offering specialist psychological services.

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 Chapter
Working in Private

17 Practice – Dr Clair Lawson; Clinical

Psychologist and Director; Lawson
Clinical Psychology
The already increasing demand for mental health services across the Western world
accelerated as a consequence of the COVID-19 pandemic. In Australia, increasing
demand was accompanied by a 1.5 per cent annual increase in mental health expenditure
per capita from 2014–15 to 2018–19, which equated to 7.8 per cent of government health
expenditure in 2018–19 (Australian Institute of Health and Welfare, 2021). In 2016, the
estimated cost of mental ill-health in Australia was around $4,000 per person (Cook,
2019). In addition to meeting the demand for mental health services to improve clients’
functioning, there is great potential for clinical psychologists in private practice to
demonstrate that their services can mitigate a substantial proportion of these economic
costs and can, in fact, provide a net gain to the economy. However, despite the rapid
uptake of private psychological services following the introduction of schemes supported
by public funding, some evaluations have failed to demonstrate a positive impact on
distress and suicide in the community (Jorm, 2018). If clinical psychologists working in
private practice want their clients to have continued access to public money for their
services, it is critical that they demonstrate that their interventions are effective and
efficient. However, private psychology practice requires the development of strategies to
overcome the unique professional and business challenges in demonstrating effectiveness
and efficiency, particularly with respect to activities that do not directly lead to funding
(e.g., research and evaluation). Very few psychology trainees are formally prepared for
these challenges because curricula and supervised practice experiences tend to focus on
hospital and larger non-government settings.
Increasing consumer demand has seen more psychologists moving into private
practice settings. In Australia, the number of psychologists working in private practice
increased by 26 per cent from 2015 to 2019 (Department of Health, 2019), with similar
increases observed in the United States of America. While private practice settings have
traditionally been the domain of more experienced clinical psychologists, increasing
numbers of early career psychologists and new graduates are now venturing into private
practice (APA, 2017). Early career psychologists entering private practice face several
challenges when transitioning from the supportive environment of a university training
programme into the dynamic and busy atmosphere of private practice. During this
transition, new graduates must practice increasing autonomy and responsibility for their
clinical work, while also engaging in a period of intense learning as they become more
comfortable with their new role. Specifically, the role of private practitioner requires
clinicians to deliver efficient and effective psychological services within a profitable
business model.

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Like any business, the provision of services in a private practice has associated costs,
including rental costs, insurance, professional development activities, marketing,
accounting fees and administrative services. The operating costs of a private practice
typically equate to 35 per cent of revenue but can vary to between 25 per cent and 50 per
cent depending on the level of administrative support, office rental costs and the types of
services delivered (Walfish & Barnett, 2009; Yenney, 1994). Clinicians’ salaries, taxes and
superannuation costs account for between 40 per cent and 55 per cent of revenue, leaving
approximately 10–15 per cent as profit. Without profitability, the business will be
unsustainable and will be unable to continue to service the community. Clinicians in
private practice, typically need to spend between 50 and 70 per cent of their working
week in the direct provision of clinical services to cover the operating costs of the
business, which equates to approximately 19–27 clients per week. Therefore, decisions
regarding service delivery in private practice need to balance the provision of high-
quality and effective evidence-based services to clients in a cost-effective manner while
ensuring that the business is financially stable and profitable in the long term.
Clinical psychologists considering solo private practice need to have good clinical
skills and the necessary business knowledge to manage the additional challenges of
working within this environment. Given that the essential business skills are not typically
taught in clinical psychology training programmes, solo private practice is generally not
recommended for new graduates. Larger group private practices are an attractive option
for recent graduates, as the practice owner assumes responsibility for managing the
business activities of the practice. Group private practices therefore provide new gradu-
ates with the support and structure needed to develop their skills in delivering psycho-
logical services without the additional responsibilities of running a business. Readers
interested in learning more about establishing and running a private practice and the
business skills necessary are directed to Walfish, Barnett and Zimmerman (2017), and
Frankcom, Stevens and Watts (2016).
This chapter will show how a scientist-practitioner model can be applied in a private
practice setting. Figure 17.1 illustrates how each component of the model used through-
out this book can facilitate a science-informed approach while balancing the imperatives
of a private practice setting, including attracting new clients (e.g., via promotion and
community education), continuing professional development (e.g., via engagement with
professional bodies and research networks), developing effective yet efficient assessments
and case formulations (e.g., using focused, brief and free measures), selecting and
delivering evidence-based psychological interventions (commitment to effective and
efficient evidence-based treatments), ensuring the practice’s financial viability (monitor-
ing of costs and revenue) and ensuring accountability (quality improvement to demon-
strate quality outcomes and value for money). Importantly, clinical psychologists need to
remember that a commitment to evidence-based clinical practice, adoption of clear
methods of monitoring outcomes, and disseminating results of examining accountability
are all activities that are consistent with a thriving private practice.

Client Data: Promotion and Community Education

Clients seeking solutions to their mental health difficulties find themselves with many
possible treatment options, including psychological treatments, medical treatments,
therapy services offered by other allied health professionals and a range of alternative
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Client data (problem, context, history, etc.) Promotion and

community
education
Theoretical and Clinical training &
empirical literature experience Engagement with
Focused, efficient, professional bodies,
effective, cost- practice research
effective, reliable, networks, &
valid Assessment & universities
case formulation
Plan that effective
service is provided Treatment planning
efficiently & measurement

Monitoring of costs
Treatment implementation and impact on
Quality & monitoring
improvement that revenue of clinical
permits marketing activity
of services to Evaluation &
consumers and accountability
funders
Figure 17.1 Issues for clinical psychologists to consider in private practice.

therapies. While clinical practice guidelines may recommend specific psychological

therapies for many disorders, this does not mean that consumers will necessarily choose
to engage in the psychological treatments appropriate for their concerns. By providing
consumers with evidence-based information about mental health disorders and therap-
ies, clinical psychologists can provide prospective clients with information to make an
informed choice about their mental health care. In addition, clinical psychologists’ well-
developed verbal and written communication skills are well suited to developing and
engaging in marketing and promotional activities that educate prospective clients and
referrers about the services they offer (Wallin, 2017). Engaging in marketing and
promotional activities is essential for attracting prospective clients, ensuring the sustain-
ability of any private practice.
Clinical psychologists are often reluctant to engage in marketing or promotional
activities due to beliefs that marketing is unprofessional, unethical, expensive, time-
consuming or requires specific training in marketing. However, a balance can be struck
between the marketing of clinical services and clinical psychologists’ ethical obligations.
Clinical psychologists must ensure that their marketing activities are implemented in a
manner that is consistent with the relevant code of ethics, such as the protection of client
privacy, an appropriate representation of practitioner qualifications and the expected
outcomes of therapy (Barnett, Zimmerman & Walfish, 2014). Professional ethical guide-
lines also require that clinical psychologists refrain from soliciting reviews or testimo-
nials from clients when promoting their clinical services.
With this in mind, marketing and promotional activities should aim to promote
clinical services to two distinct prospective audiences: clients within the community and
referrers, and third-party funding bodies such as Employee Assistance Programme
(EAP) providers. The specific marketing strategies and information disseminated will
vary depending on the intended audience. For example, promotional activities completed
through online mediums such as a practice websites, social media accounts, blogs and
 Chapter 17: Working in Private Practice 289

practice listings within online directories are effective strategies for increasing awareness
of the clinical services available to prospective clients within the community. Online
marketing mediums present opportunities for clinical psychologists to educate the
community about psychological matters by providing information pertaining to mental
health disorders, the types of psychological treatments available and the effectiveness of
these approaches. Clinical psychologists are able to utilize a range of marketing and
promotional strategies to develop and strengthen relationships with referrers. Providing
high-quality clinical care, providing timely reports to referrers and working collabora-
tively with all members of a client’s treatment team are simple but effective strategies for
building and strengthening relationships with referrers. Furthermore, activities such as
delivering workshops or providing brief educational presentations to medical practition-
ers or EAP providers are an effective strategy for clinical psychologists to demonstrate
clinical expertise and promote their services. Readers interested in learning about
additional marketing or promotional activities are directed to Yenney (1994) and
Wallin (2017).
Marketing activities come with an associated cost, whether that is a time commitment
by the clinician or costs associated with running promotional campaigns on social media
and the like. Therefore, it is crucial to evaluate the effectiveness of marketing strategies to
ensure they are producing the intended results. Clinicians can determine the return on
investment from marketing or promotional activities by measuring the impact of the
activity on the number of new client referrals received from specific marketing or
promotional activities (e.g., website, medical practitioners, social media, print media).
This information allows clinicians to determine the effectiveness of their marketing
efforts, make adjustments to the marketing materials if required or redirect resources
to those marketing strategies that yield more referrals. Effective marketing and promo-
tional strategies will generate a steady flow of new referrals to the practice, while
providing valuable education about issues pertaining to mental health disorders and
their treatment to the community and medical professionals alike.

Ongoing Professional Development: Currency of Knowledge

and Training
Scientist-practitioners are committed to being consumers and producers of scientific
literature. Clinical psychologists need to remain up to date with recent changes and
developments in psychological knowledge about mental health disorders. Without access
to university library systems, engaging in ongoing professional education and learning
can be challenging for new graduates in private practice settings. Barriers to maintaining
professional knowledge include the costs associated with accessing journal articles and
scientific publications, the time commitment required to complete professional develop-
ment activities, and revenue loss related to time away from direct clinical work.
Clinical psychologists should aim to regularly review journal articles relevant to their
areas of clinical practice; however, subscriptions to journals and purchasing individual
peer-reviewed articles may not be financially viable for many private practitioners.
Alternative avenues for accessing scientific literature can be found through databases
provided by professional associations, the Directory of Open Access Journals (2021),
personally contacting the authors (via services such as ResearchGate, 2021), and google
scholar offer workable alternatives. The preprint service, PsyArXiv (2021), provides
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review or in preprint. The Unpaywall (2021) and Open Access Button (2021) browser
extensions can also be added to Chrome or Firefox to identify paywalls and suggest open
access options for accessing articles. Access to university library collections for research
purposes can also be obtained by developing an adjunct relationship with a university or
contacting the university library directly. Professional bodies also often conduct litera-
ture reviews and develop clinical practice guidelines that are available to
their membership.
Establishing a professional development plan with specific learning objectives rele-
vant to clinical practice will assist graduates to make effective use of the time they allocate
to professional development and learning. Recent graduates should also ensure that they
engage a clinical supervisor who demonstrates a commitment to consuming scientific
literature and evidence-based practice to further support their professional development.

Effective Yet Efficient Assessments and Case Formulations

The assessment process forms the foundation for formulating the client’s current diffi-
culties and developing an evidence-based treatment plan to address the client’s needs and
goals. In private practice settings, clinicians must be skilled at obtaining the required
information during the initial assessment to determine if they have the requisite clinical
skills and knowledge to assist the client. In addition, clinical psychologists must be
proficient in the use of evidence-based assessment processes that are cost-effective
and efficient.
The challenge for private practitioners is to conduct an assessment and diagnostic
interview quickly and cost-effectively. Administering and scoring a structured diagnostic
interview takes a considerable amount of time, thus limiting their utility in private
practice settings. Clinicians need to be familiar with the diagnostic criteria for high-
prevalence disorders, or those likely to present to the specific private practice setting, to
ensure they can conduct diagnostic assessments without the use of time-consuming
structured assessments. That said, utilizing a structured diagnostic interview or specific
sections of the structured diagnostic interview may be indicated where a diagnostic
assessment is required for a medicolegal report, where there is diagnostic uncertainty
or where a differential diagnosis is required.
Viable assessment measures for use in private practice need to be targeted to the
client’s presentation such that they effectively guide the case formulation and treatment
evaluation, while also being reliable, valid and available via open access. Online assess-
ment administration programmes and many practice management software packages
now include features that allow clinicians to administer and score a range of assessment
tools that are freely available in the public domain. While these programmes typically
require a small monthly subscription, the time saving nature and convenience of
computerized delivery and scoring of assessment measures typically outweighs the
subscription cost.

Treatment Planning and Measurement

When delivering psychological services in a private practice setting, clinical psychologists
must consider the financial implications of delivering a particular treatment because
factors such as attrition and treatment efficiency will directly impact both client
 Chapter 17: Working in Private Practice 291

outcomes and the financial sustainability of the business. Clinical psychologists can pre-
empt these issues in private practice by establishing realistic expectations with clients
regarding the number and frequency of sessions, and expectations regarding symptom
reduction over time, which will now be discussed in more detail.

Establish Realistic Expectations and Common Goals

Early career psychologists can underestimate the number of sessions required to achieve
symptom relief, which creates a mismatch between clients’ expectations about therapy
and their subsequent therapy experience. This mismatch in expectations and experience
of therapy has been associated with increased rates of clients prematurely terminating
treatment (Swift & Callahan, 2011). In addition, clients who have not achieved any
meaningful improvement in symptoms, or who have experienced a deterioration, are
also more likely to end therapy before it is completed (Roos & Werbart, 2013).
Premature terminations result in poor client outcomes and a financial consequence
for the business through increased administrative and marketing costs (Hatchett &
Coaston, 2018).
Clinicians can reduce the likelihood of premature termination by providing clear
information to clients about the expected outcomes of therapy, such as when symptoms
are likely to begin to improve as well as the number of treatment sessions required to
achieve significant and stable changes in their symptoms (Lindhiem et al., 2014). For
example, clients with mild to moderate levels of depression and anxiety have been found
to require approximately four to six sessions of therapy to achieve clinically significant
change. In contrast, clients presenting with co-morbid disorders may require between
four and 26 therapy sessions to achieve clinically significant change (Robinson,
Delgadillo & Kellett, 2020). Using the research literature, clinical psychologists can
provide clients with science-informed expectations about the likely trajectory of change
over time and reduce the likelihood of dropout.

Determine an Appropriate Session Frequency

Insurers and third-party funding bodies typically cap the number of available session
rebates or the number of sessions available to clients accessing services under their
programmes. Session caps may lead to clients or clinicians spacing out available appoint-
ments to ensure that clients can continue to receive sessions throughout the year. While
this approach may serve to manage the client’s financial concerns in the short term, it
may have the unintended consequence of increasing health care costs in the longer term.
Studies comparing rates of symptom relief for different session frequencies found that
clients improved faster and achieved better outcomes when therapy was delivered weekly
compared to fortnightly (Erekson, Lambert & Eggett, 2015). Furthermore, when clients
attended fortnightly appointments, the rates of improvement were not only slower but
more treatment sessions were required to achieve equivalent outcomes to clients
attending weekly (Tiemens et al., 2019). Studies comparing different session frequencies
in the treatment of depression found biweekly sessions, compared to weekly sessions,
resulted in greater symptom reduction (Cuijpers et al., 2013; Hollon et al., 2020). Clinical
psychologists are well placed to provide information to clients about the research
regarding appointment frequency to facilitate informed decisions about the best ways
to balance their financial constraints and psychological therapy needs.
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Attending to Adherence in Therapy

Missed and cancelled appointments are commonplace in all mental health care settings,
but they do present an immediate concern for the sustainability of private practice
(DeFife, Conklin & Smith, 2010). Reported rates of missed or cancelled appointments
vary at between 13 per cent and 50 per cent of scheduled mental health outpatient
appointments (DeFife et al, 2010; Gandy et al., 2019; Sibiya & Ramlucken, 2018). Missed
appointments are problematic as they slow therapy progress, reduce treatment effective-
ness and negatively impact therapy outcomes (Hwang et al., 2015). The impact of missed
appointments extends beyond the individual client as they reduce a clinician’s through-
put of clients, resulting in increased waiting times for new clients. Furthermore, missed
appointments result in lost revenue and increased administrative costs associated with
following up and rebooking clients.
Reducing missed appointments requires a multipronged approach, including identi-
fying clients at risk of missing appointments and implementing administrative and
therapeutic strategies. Several studies have explored demographic and clinical factors
that contribute to an increased risk of missed appointments (Centorrino et al., 2001;
Fenger et al. (2011). For example, clients are more likely to miss appointments if they
present with either mild symptoms or acute illness, are under 25 years of age, or have
appointments that are scheduled infrequently or more than one week apart (Fenger, et al.
2011). Strategies for improving appointment attendance include scheduling additional
reminder text messages or telephone calls to clients at risk, adjusting appointment
schedules, offering alternative modes of therapy (e.g., telehealth or phone consultations)
to reduce barriers to attending and addressing missed appointments with clients at their
next scheduled session (DeFife, Smith & Conklin, 2013).

Monitor Therapy Outcomes

Establishing an effective treatment plan and attending to factors that may impact
treatment adherence provide important foundations for ensuring the best possible
outcomes for clients. Measuring and monitoring client progress during therapy allows
clinicians to further safeguard and enhance client outcomes by identifying clients at risk
of deterioration so that the therapy approach may be adapted accordingly. As discussed
in Chapter 4, the use of routine outcome measurements (ROM) improves outcomes for
clients, particularly those who are not responding or are at risk of deterioration.
However, despite the benefits, only 30 per cent of clinicians report using ROM in clinical
practice (Hatfield & Ogles, 2004; Ionita, Ciquier & Fitzpatrick, 2020). Obstacles to using
routine outcome measures (ROM) in private practice settings include financial and time
burdens, and a lack of resources and processes to support sustained practice.

Financial and Time Burdens

Unlike medical tests that are reimbursed by insurers or government schemes, such as
blood screening, scans or x-rays, the administration of routine outcome measures is not
considered as a billable activity by insurers and government funding bodies.
Consequently, private practitioners are not reimbursed for the time taken to administer,
score and interpret data collected from routine outcome measures. When private
practitioners’ livelihoods depend on the number of billable hours they complete, the
 Chapter 17: Working in Private Practice 293

time taken to complete non-billable ROM activities may not be prioritized, unless it is
seen as fundamental to informing case formulation, treatment planning, and client and
practice outcomes. Given the growing pressure for accountability and quality improve-
ment in health care settings, private practitioners who develop systems and processes to
measure the effectiveness of the services provided will have an edge in an increasingly
competitive health care market (Clement, 1996).
There are several ways in which private practices can benefit from integrating ROM
within their service while minimizing the burden on clients, clinicians and the practice.
First, measures must be brief and highly relevant to the client’s presenting problems.
Second, it is vitally important that the clinician discusses with the client why the
measures are critical to their care, including helping to understand their problems,
planning their treatment and ensuring that the treatment is helping them. Third,
embedding measures into electronic delivery systems may serve to decrease the burden
on both clients and clinicians, and asking clients to complete measures in the waiting
room before their session ensures that the session can be used to act on the information.
Even if these strategies are implemented, ROM will require a time commitment from the
private practice clinician. Ultimately, the decision to consistently integrate ROM into
clinical practice needs to be values-based. If a clinician values ROM to (a) guide their case
formulations and treatment plans, (b) identify when a client’s symptom trajectory is
indicative of a good or poor outcome, (c) be able to respond immediately when the client
is not progressing well (rather than waiting until the end of a course of therapy) and (d)
ensure a culture of accountability and ongoing quality improvement within their service,
then the additional time commitment will be sustained within the practice.

Treatment Implementation and Monitoring: Profitability

vs Quality
The business of private practice can be approached from two different perspectives.
Focusing on the financial sustainability of the practice will lead to decision-making
driven primarily around the most profitable delivery strategy but may not result in the
best outcomes for clients. Focusing on delivering the highest-quality clinical care for
clients, on the other hand, is likely to improve the business’s financial viability. Focusing
on the most effective service to deliver and how can this be done cost-effectively, rather
than focusing on the cheapest way to deliver the service, will result in a successful private
practice that runs an ethical and client-focused business model. Practices and practition-
ers that prioritize profitability above quality service provision risk jeopardizing the
effectiveness of the services they deliver and their reputation with referrers, ultimately
resulting in poor client retention and negatively impacting the business’s financial
sustainability. Applying the lens of the scientist-practitioner, and thereby high-quality,
evidence-supported care, improves outcomes for clients and assists in ensuring the
business’s financial well-being.

Commitment to Quality Improvement and Business Sustainability

Purchasers of mental health care, such as insurers and governments, increasingly require
providers to demonstrate a commitment to continuous quality improvement. Those
practitioners and practices demonstrating a commitment to continuous quality
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improvement and high-quality care will be more competitive in the health care market
(Friedberg & Thordarson, 2019). Quality improvement involves providers accepting
responsibility for making continuous improvements to service delivery over time
(Yenney, 1994). Continuous quality improvement involves establishing a set of key
performance indicators (KPI’s) related to measurable and actionable behaviours or
activities. These performance measures can be used to identify and remediate gaps or
problems with service delivery, clinical outcomes or the financial sustainability of the
practice. They can be used to benchmark a clinician or group of clinicians against
evidence-based practice and can be used to improve outcomes and processes within a
clinic (Kilbourne, Keyser & Pincus, 2010). When selecting KPIs to measure within a
private practice setting, it is important to consider whether there is an evidence base to
support particular measures and whether existing benchmarks exist. Selected indicators
must have clinical relevance and represent actions or behaviours that clinicians have
control over; measures must be clinically sound, related to improved clinical care and
sensitive to change over time. Finally, the collection of selected key performance indica-
tors must be easy to collect, record and review. Clinical psychologists are well placed to
use their statistical and data management skills to select and track key measures. Example
KPI’s are included in Table 17.1.
A framework for quality improvement should consider three key areas for measuring
performance: client outcomes, process measures and financial health measures
(Lizarondo, Grimmer & Kumar, 2014). KPIs in the area of client outcomes relate to
the effectiveness of the therapy delivered in reducing symptoms and improving func-
tioning. In addition to the collection of routine outcome measures, KPIs in the area of
client outcomes measure factors known to be related to better outcomes in therapy, such
as improved appointment attendance rates. Process measures provide information about
client engagement and the client’s experience of the service they have received. Finally,
financial indicators provide information about the capacity of the practice to deliver
psychological services and the financial sustainability of the service; these include
completed appointment attendance rates, the total revenue generated, business operating
costs and practitioner utilization rates. Changes to these key performance indicators may
lead to increased capacity to provide psychological services and increased financial
sustainability for the business.

Client Outcome Indicators

Key metrics related to client outcomes include the average number of sessions attended
per episode of care, the number of cancelled appointments and the number of missed
appointments. The number of cancellations or missed appointments can be standardized
by reporting them as a percentage of the total number of booked appointments for the
week. A high percentage of cancellations or missed appointments (more than 20 per
cent) may suggest that clinicians are not providing sufficient education to clients about
the importance of regular attendance, have not established agreed goals and expectations
regarding therapy with clients, or have not addressed barriers to attending appointments
with clients. The average number of sessions attended per episode of care provides
valuable information about client retention and is influenced by the development of
shared goals and expectations, as well as client outcomes. The average number of
sessions attended per episode of care can be used along with the average client fee to
 Chapter 17: Working in Private Practice 295

Table. 17.1. Example key performance indicators for measuring performance in private practice

KPI Description Frequency

Cancelled appts Number of cancellations per week as a percentage of Weekly
total number of booked appointments
Did not attend Number of DNA per week as a percentage of total Weekly
number of booked appointments
No future bookings Percentage of clients seen within the week who do not Weekly
have a further appointment booked
New referrals Total number of new referrals received Weekly
New client appts Number of new clients who attended an appointment Weekly
within the specified week
Source of referral Number of referrals per referral source (e.g., website, Weekly
social media, medical practitioner, word of mouth)
Appts attended Total number of sessions attended Weekly
Total revenue Sum of revenue collected Weekly
Cost per service Calculate the average monthly expenditure and divide by Monthly
the number of sessions conducted per month
Practitioner Percentage of working hours engaged in billable hours. Weekly
utilization Calculated by dividing the number of appointments
attended by the number of working hours

determine the average “spend” per new client, which is helpful in determining return on
investment from marketing activities.

Process Indicators
Tracking the number of clients who attended an appointment that week but do not have
a future appointment booking provides a simple measure of client retention. Clients
without a future booking may not attend therapy regularly, be less engaged in treatment
and are at risk of dropout. Tracking the number of clients without future bookings
encourages clinicians to engage in regular follow-ups with clients to ensure they maxi-
mize therapy outcomes.
Client satisfaction ratings are obtained by administering a client satisfaction ques-
tionnaire at specific intervals within the client’s episode of care. Client satisfaction
surveys are typically brief assessments (three to eight items) assessing the quality of the
service received (Pekarik & Guidry, 1999). These surveys ask participants to rate their
experience on a 5-point Likert scale in regard to (a) their overall satisfaction with the
service, (b) whether they would recommend the service to others, (c) how likely they are
to return to the service and (d) how they would rate their therapist (Pekarik & Guidry,
1999). In addition, these surveys provide information regarding the client’s satisfaction
with their therapist, the quality of the therapeutic relationship and the likelihood of
completing treatment (Lindhiem et al., 2014).
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Financial Indicators
Financial performance indicators measure the effectiveness of the service in delivering
psychological care and provide information regarding the financial sustainability of the
business, including the supply of clients (new client referrals), the total revenue gener-
ated, operating costs and practitioner utilization. Key supply metrics include the number
of new clients that attended or the number of new referrals received, and the source of
these new referrals. A growing number of new referrals or new clients attending
appointments indicates that the marketing or promotional activities are delivering a
steady stream of new business to the practice. For practices or practitioners with a
waiting list for appointments, calculating the average number of new clients seen per
week can assist in providing estimates of waiting times for new clients referred to the
practice. Key revenue metrics include the number of completed appointments and the
total revenue generated each week. Understanding these metrics allows the practitioner
or practice owner to determine whether there is sufficient revenue to cover operating
costs and make forecasts about future revenue to assist in planning and budgeting. The
cost of delivering a service can be calculated from the total outgoings for the business,
including salary payments, divided by the total number of sessions completed over the
same period. If the average cost per session is lower than the average fee per client, the
business is operating sustainably. Finally, practitioner utilization provides a measure of
the efficiency of the service. The utilization rate is the number of billable or appointment
hours as a percentage of the practitioner’s available hours within a week. For example, a
practitioner working 40 hours a week with 20 billable hours during the week will have a
utilization rate of 50 per cent. Practitioner utilization rates provide information
regarding a practitioner’s current capacity for client appointments.
Monitoring Key Performance Indicators The effective use of key performance indicators
requires regular data entry, evaluation and interpretation of the data, and the development
of actionable strategies to address areas identified for improvement. KPIs should be carefully
selected to ensure that they are meaningful, and the time taken to enter the required data is
not prohibitive. For example, the KPIs for a new private practice seeking to establish a steady
stream of referrals to increase the number of psychological sessions offered would benefit
from measuring (a) the number of new referrals received and (b) the number of appoint-
ments delivered each week. In contrast, an established practice with a waiting list for services
would be more interested in measuring factors related to the efficiency of the service or
factors that may impact on client throughput, such as (a) missed appointment rates, (b)
practitioner utilization rates and (c) the number of new clients seen.
KPIs can be tracked weekly using a simple spreadsheet. The two tabs at the foot of the
spreadsheet (see Figure 17.2) are labelled (i) “KPI inputs” and (ii) “Practice graphs”. The
KPI Input screen is shown in Figure 17.2; weekly summary data for two practitioners has
been entered into the shaded sections on the KPI input screen. The spreadsheet has
calculated the totals and percentages displayed. The Practice graphs screen summarizes
the information entered on the KPI input screen and plots practitioners KPIs. An
example graph is shown in Figure 17.3. The x-axis represents the weekly summary data
for each practitioner. The y-axis is the number of appointments completed displayed as a
percentage of the practitioner’s working hours within the week. As depicted in
Figure 17.3, while the utilization rate for Practitioner A has remained stable, the utiliza-
tion rate for Practitioner B has decreased over time, indicating they have the capacity to
add an additional client to their caseload.
 Chapter 17: Working in Private Practice 297

Figure 17.2 KPI dashboard template.

75%
Practitioner 1 Practitioner 2

70%
Practitioner utilization

65%

60%

55%

50%
4 Jan 11 Jan 18 Jan 25 Jan 1 Feb 8 Feb 15 Feb 22 Feb 1 Mar 8 Mar
Week beginning
Figure 17.3 Example practitioner utilization KPI.

Research and Evaluation

It has been argued that one attribute of a scientist-practitioner is that not only does the
person consume science, but they also contribute to its production (Hayes et al., 1999).
Thus, private practice provides a solid foundation from which to contribute to our
knowledge of psychological disorders and their more effective treatments. Engaging in
research in private practice requires a commitment from the clinician and private
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298 Chapter 17: Working in Private Practice

practice that is in good financial health. Research activities do not generate revenue and
are unlikely to be prioritized unless the practice is able to support these activities
financially (Corrie & Callahan, 2000). In addition, conducting research in clinical
settings requires a specific skill set and a significant investment in time and money that
are often scarce when working in private practice (Haynes, Lemsky & Sexton-Radek,
1987). That said, there are many ways to engage in meaningful research in clinical
settings. We will outline two models that might be used.
First, a clinical psychologist might engage with a practice research network (PRN). As
Borkovec and colleagues (Borcovec et al., 2001) outlined, a rationale for the formation of
a PRN is to foster collaboration between practicing therapists and clinical scientists to
facilitate the conduct of scientifically valid effectiveness research. Thus, the clinical
scientists, who are often based in universities, can contribute to their institution’s
research resources as well as help to construct research that has strong internal validity.
Additional resources include access to research funds, research students, analytical skills
and engagement with the international research community. However, the practicing
therapists are a key contributing group because they provide access to patients in real-
world clinical settings, thereby ensuring that the research also has external validity. By
pooling resources, groups can identify and agree on research questions that are of mutual
interest and collect appropriate data with consistent, standardized measures. In these
arrangements, each clinician and clinical practice will often be one node in the larger
network. The benefits are that the whole will be greater than the sum of parts, so that the
group can achieve outcomes that would never have been possible by a single clinical
practice (e.g., in terms of sample size, variations in patient samples, etc.). However, PRNs
limit the autonomy of individual clinical practices.
Another approach is for a private practitioner to form a personal research relation-
ship with clinical scientists at a university and develop a similar productive research
engagement. A key advantage of this approach is that there is capacity for each practi-
tioner to have a greater influence over the research direction. A trade-off is that the
economies of scale that come with a PRN will not accrue. Nonetheless, the clinical
psychologist in private practice may consider these two models of practice as being
points on a dimension of collaborative research relationships. The smaller end tends to
be more nimble and focused, whereas larger groups may be slower and more inertia-
laden, but can deliver large-scale outcomes that have an impact on a wide range of
parties. For a scientist-practitioner, either of these models serves an important mechan-
ism for the clinical psychologist not only to be a consumer of evidence-based practice,
but also a producer.

Summary
Clinical psychologists are well-placed to deliver high-quality and cost-effective psycho-
logical services within the context of a thriving private practice. As we have illustrated
throughout this manual, a scientist-practitioner approach serves as a reliable framework
for adapting one’s practice to the professional challenges one might encounter in any
situation or setting, including those presented by working in private practice settings.
A science-informed practitioner of clinical psychology is well-placed to extend their
professional role beyond the traditional focus on direct client care into the realm
of business.
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Index

abnormal grief reaction, 113 ASK element in, 131 glide path in, 48
abstraction, 44 ASSESS element in, indirect, in functional
selective, in Beck’s approach 131–133 analysis, 67
to cognitive therapy, ASSIST element in, 139 matching of, 46
108 discrepancy development measurement of, 46–47
ACA. See Affordable Care Act in, 140 monitoring of, 46–47
Acceptance and Commitment drink check-ins, 130 naturalistic, in functional
Therapy (ACT), 112 empathy in, 139–140 analysis, 67
accountability feedback mechanisms, in private practices, 290
in clinical psychology, 2 133–139 testing and, 46–48
in science-informed for dependent drinkers, theoretical approach to, 26
model, 6–7 137–139, 144–148 transdiagnostic approaches
in psychological service for low-risk drinkers, 134 to, 87–95
delivery, 272–274 for risky drinkers, ASSIST element, in AUDIT,
of psychologists, for patient 135–136, 140–143 139
outcomes, 282 for scoring, 133 attention, 42
for supervised practices, 205 for very risky drinkers, self-focused, 116
supervision record forms, 135–136, 140–143 attentional training, 125–126
206 motivational interviewing audio/video recordings, in
ACT. See Acceptance and in, 139 supervised practices,
Commitment Therapy non-judgmental approach 203–205
action tendencies, 116 in, 139–140 impression management,
adults. See also elderly reflective and summary 204–205
interviews for, 39 statements in, 140 segment of sessions,
affect and mood assessment, scoring procedures, 133 selection of, 204
41 feedback mechanisms for, stage setting with, 204
Affordable Care Act (ACA), 133 AUDIT. See Alcohol Use
U.S., 1 self-efficacy enhancement Disorders
agenda setting, for supervised in, 140 Identification Test
practices, 202–203 American Psychiatric Australia
age-sensitive clinical practices, Association (APA), Better Outcomes in Mental
250–252 26–27 Health Care program,
clinical presentations analog assessments, in 1
among elderly, 252 functional analysis, 67 confidentiality issues, in
cognitive complexity as antecedents, 65, 68–69 case management, 185
element of, 251 anxiety sensitivity therapy, mental health services in,
delivery mechanisms in, 252 121–122 increased demand for,
dignity as element of, ARRANGE element, in 286–287
250–251 AUDIT, 139 Notifiable Data Breaches
dynamics of aging as ASK element, in AUDIT, 131 scheme, 185
element of, 251 ASSESS element, in AUDIT, automatic reinforcement, 67
reminiscence issues and, 131–133 automatic thoughts, 108
252 assessment processes, for avoidance behaviors, 122–123
agoraphobia, 78 clients Avoidance Model of Worry,
Alcohol Use Disorders analog, in functional 90
Identification Test analysis, 67
(AUDIT), 128–131 centrality of, to scientific Beck’s approach to cognitive
ARRANGE element in, practices, 46 therapy, 107–108
139 complementary, 27
https://avxhm.se/blogs/hill0 automatic thoughts in, 108
343
344 Index

Beck’s approach to cognitive brainstorming, 253 prescribed interventions,

therapy (cont.) brief interventions, for alcohol 78–79
dichotomous thinking in, clinical psychology practices in private practice, 290
108 for, 129 problem presentation in, 72,
overgeneralization in, 108 flowcharts for, 132 79
personalization in, 108 prevention paradox, 128 provisional conceptualization
selective abstraction in, 108 purpose of, 128 in, 76–78
behavior therapies, 98–105. Standard Drink Chart, 133 for social anxiety disorder,
See also cognitive business sustainability 92
behavior therapy; strategies, 293–298 theoretical approach to,
contingency financial performance 63–64
management indicators, 296 transdiagnostic approaches
cognitive elements of, 98 to, 87–95
dialectical behavior therapy, Canadian Code of Ethics, 255 modular approaches, 95
105–107 case formulation. See also for symptoms, 87–90
for Borderline Personality cognitive behavioral theoretical commonalities
Disorder, 105 case formulation; in, 87–90
for invalidating functional analysis treatment commonalities
environments, 105–106 for agoraphobia, 78 in, 87–90
therapeutic hierarchy in, behavioral, 69–70 treatment planning,
106 client data linkage with, 64 90–95
with unresolved stressors, with cognitive behavior case management. See also
106 therapy, 86–87 confidentiality
modeling as, 104–105 for Generalized Anxiety conceptual tasks, 178–179
role-play in, 105 Disorder, 90–92, 94 documentation tasks,
self-management, 102–104 Avoidance Model of 178–179
behavioral contracting, Worry, 90 during intake phase,
103–104 Meta-Cognitive Model 187–188
empathy in, 102 for, 90 evaluation phase, 197–199
motivational Uncertainty Model for, 90 goal attainment
interviewing, 102–103 group treatment and, 158 documentation of,
self-efficacy as element of, in interpersonal 194–196
102 psychotherapy, 79–87 termination phase after,
social learning theory assessment of 197–198
and, 102 interpersonal issues, intake phase of, 186–194
behavioral contracting, 84–86 case information
103–104 for depression, 81–84 documentation during,
behaviors, in functional Interpersonal Inventory, 187–188
analysis, 65–66, 68–69 84–86 ethical issues during, 187
consequences of, 66–67 participants in, 81 informed consent in,
Better Outcomes in therapeutic contract 186–187
Mental Health Care negotiations in, 86 quality assurance issues,
program, 1 for low intensity 188
bodily sensations, in low psychological risk assessment and
intensity psychological interventions, 153–156 management during,
interventions, 153 for obsessive compulsive 189–194
body language, in therapeutic disorder, 92, 94 management tasks, 178–179
alliances, 17 for panic attacks, 76–77 record keeping, 178–180
Borderline Personality Disorder, for Panic Disorder, 78, 81 risk assessment and
dialectical behavior perpetuation of cognition, management
therapy for, 105 consequences of, classification of risks,
boundary-setting, in rural and 74–75 190–193
remote settings, precipitating variables, emergency procedures
264–266 73–74 and, 193–194
in management of multiple predisposing factors in, during intake phase,
relationships, 266–267 75–76 189–194
 Index 345

protective factors in, 189 evidence variables in, 14 promotion of, 169–170
of suicidal states, 189–193 outcomes in, 14–15 stakeholders in, 170
termination phase, 197–199 treatment-focused research, cognitive behavior therapy
after goal attainment, 47 (CBT), 50–51
197–198 clinical psychologists case formulation with, 86–87
termination reports, as consumers of research, 4 client matching with, 50–51
198–199 as evaluators of in feedback interventions,
treatment planning phase interventions/ 60–61
of, 186–194 programs, 4 Internet-based, 120–121
documentation of as producers of research, 4 low intensity psychological
progress, for goal purpose of, 4 interventions with,
attainment, 194–196 as stakeholders, 9–10 150–151
implementation of clinical psychology transdiagnostic approaches
treatment in, accountability in, 2 in, 119–123
194–197 in science-informed cognitive behavioral case
initiation of, 195–197 model, 6–7 formulation, 69–70
CBT. See cognitive behavior contemporary theoretical for agoraphobia, 78
therapy approach to, 1–4 assignment of DSM-5/ICD-
children during COVID-19 11 diagnosis, 69
confidentiality for, in case pandemic, 1 individualization of
management, 182–183 funding of programs, 2 nomothetic template, 70
interviews of, 37–39 health care nomothetic formulation
clarificative evaluation, 171 costs of, 10–11 of anchoring
client data linkages, in science- industrialization of, 10–11 diagnosis, 69
informed model, 6 in U.S., 10–11 origin hypotheses for client
client matching, for methodological approach issues, 70
interventions, 49–52 to, 3 for panic attacks, 76–77
with cognitive behavior science-informed model of, for Panic Disorder, 78, 81
therapy, 50–51 5–8 perpetuation of cognition,
with cognitive therapy, accountability in, 6–7 consequences of, 74–75
50–51 client data linkages in, 6 precipitating variables,
with interpersonal countertransference and, 73–74
psychotherapy, 50–51 7–8 predisposing factors in,
Personalized Advantage error correcting 75–76
Index, 50–51 mechanisms in, 6 prescribed interventions,
Project MATCH, 50 transference and, 7–8 78–79
Trier Treatment Navigator, scientist-practitioner model problem lists, 69
51–52 as influence on, 4–5 problem presentation in, 72,
client outcome indicators, stakeholders in, 8–11 79
294–295 clients as, 8–9 provisional conceptualization
clients. See also assessment clinical psychologists as, in, 76–78
processes, for clients; 9–10 symptom descriptions in, 70
therapeutic alliances; society as, 9 worksheet for, 80
specific topics specifications of, 10 cognitive complexity, among
efficacy studies for, 8–9 Subjective Units of elderly, 251
empirically supported Discomfort, 10 cognitive restructuring,
treatments, 12–13 clinical significance, of 247–248
evidence-based treatment monitoring Cognitive Restructuring, 107
for, 12 interventions, 56–58 cognitive theory, 7–8
patient-focused research, Jacobson and Truax cognitive therapy, 7–8,
47 method, 56–57 107–112. See also
stepped-care approaches, 11 Reliable Change Index, 56–57 cognitive behavior
therapeutic relationship for, co-design approaches, to therapy
13 program evaluations, Acceptance and
empirical foundations of, 168–170 Commitment Therapy,
13–15 implementation of, 169
https://avxhm.se/blogs/hill0 112
346 Index

cognitive therapy (cont.) contingency contracting, 101 culture-sensitive practices,

Beck’s approach to, contingency management, in 246–250. See also
107–108 behavior therapies, structured problem-
automatic thoughts in, 108 99–102 solving
dichotomous thinking in, behavior maintenance, cognitive restructuring in,
108 101–102 247–248
overgeneralization in, 108 contingency contracting, parameters of, 248–250
personalization in, 108 101 human character, 248
selective abstraction in, contingent punishment, orientation to time, 249
108 99–100 preferred mode of
client matching with, 50–51 extinction, 100–101 activity, 249
Cognitive Restructuring, habit reversal, 101 relational orientation, 248
107 negative reinforcement, 99 relationship between
downward arrow technique, positive reinforcement, 99 people and natural
108 response costs, 100 world, 249
Rational Emotive Therapy, time-out from relationships between
107 reinforcement, 100 people, 249
rationale for, 109–112 contingent punishment, 99–100 as Western-centered, 247
Socratic dialogue in, coping resources and
109–111 strategies Daily Index-5 (DI-5), 54–58
unconscious thoughts and, interviews for identification data collection
109 of, 35 in case formulation, for
communication skills, for for isolation issues, for client data linkage, 64
psychologists, 280 clinical therapists in in program evaluations, 174
competency-based approach, remote settings, by psychologists,
to supervised practices, 268–270 application of, 279
208–209 evaluation mechanisms data-driven reflective
compliance, with local for, 269 practices, 211
regulations and through multidisciplinary DBT. See dialectical behavior
legislation, 260–261 collaborations, therapy
concentration, 42 268–269 decision talk, 152–153
conceptual tasks, in case social contexts for, 268 decision-making
management, 178–179 cost offsets, in health care, ethical, 254–259
confidentiality 273–274 in Canadian Code of
in case management, cost-effectiveness, in health Ethics, 255
180–186 care, 273 confidentiality in, 258
in Australia, 185 countertransference under “do no harm”
breaches of, 185 process dimension with, principle, 256
control of disclosure and, 239–244 with dual relationships,
183 in science-informed model, 258–259
guidelines for, 184 7–8 worksheets for, 257–258
for minors, 182–183 COVID-19 pandemic shared, in low intensity
negotiation of, 182–183 clinical psychology during, psychological
Notifiable Data Breaches 1 interventions, 152–153
scheme, 185 clinical therapy in rural and decision talk in, 152–153
parameters of, 181 remote settings, 260 option talk in, 152–153
for patient information, cultural issues, ethical three-talk model of,
183–195 practices and, 246 152–153
with patients, 181–182 DSM-5 assessments and, dependent drinkers, in
purpose of, 180–181 cultural considerations AUDIT, 137–139,
in ethical decision-making, in, 31–32 144–148
258 ICD-11 assessments and, depression
for psychologists, 282–283 cultural considerations case formulation and, 81–84
congruence, in therapeutic in, 31–32 interpersonal
alliances, 21–22 practical approach to, psychotherapy and,
consent. See informed consent 245–246 81–84
 Index 347

detached mindfulness, digital space, long-distance empathy

125–126 therapy in, 262–263 in Alcohol Use Disorders
DI-5. See Daily Index-5 dignity, in age-sensitive Identification Test,
Diagnostic and Statistical clinical practices, 139–140
Manual of the Mental 250–251 in self-management, 102
Disorders, Fifth “do no harm” principle, 256 therapeutic alliances and, 21
Revision (DSM-5), 2, documentation congruence and, 21–22
26–30 case management and, 178 as therapy withdrawal
classifications of disorders through record keeping, prevention strategy,
in, 28–29 178–180 226–227
coding in, 29 with group treatment, 165 empirically supported
cognitive behavioral case in management of multiple treatments (ESTs),
formulation, 69 relationships, 266 12–13
cultural considerations in, documentation tasks, in case empirically-based health care
31–32 management, system, 274
diagnostic inflation in, 30 178–179 Employee Assistance Programs
emerging measures and during intake phase, (EAPs), 10–11
models, 30 187–188 ESTs. See empirically
formatting in, 28–29 downward arrow technique, in supported treatments
Global Assessment of the cognitive therapy, 108 ethical decision-making,
Individual’s DSM-5. See Diagnostic and 254–259
Functioning, 30 Statistical Manual of in Canadian Code of Ethics,
previous editions of, 29–30 the Mental Disorders, 255
diagnostic manuals, 26. See Fifth Revision confidentiality in, 258
also Diagnostic and Dunning-Kruger effect, 210 under “do no harm”
Statistical Manual of principle, 256
the Mental Disorders, EAPs. See Employee with dual relationships,
Fifth Revision Assistance Programs 258–259
diagnostic practices and efficacy studies worksheets for, 257–258
systems. See also clients and, 8–9 ethics
Diagnostic and for monitoring during intake phase of case
Statistical Manual of interventions, 52 management, 187
the Mental Disorders, treatment strategies and, 49 for psychologists, 282–283
Fifth Revision; elderly confidentiality as,
interviews; Mental age-sensitive clinical 282–283
Status Examination; practices for, 250–252 evaluation mechanisms.
specific practices clinical presentations See also program
future directions for, among elderly, 252 evaluations
44–45 cognitive complexity as for case management,
ICD-11, 26–27, 30–32 element of, 251 197–199
classification of disorders delivery mechanisms in, in case management,
in, 31 252 197–199
cultural considerations in, dignity as element of, clarificative evaluation, 171
31–32 250–251 clinical psychologists and, 4
limitations of, 44–45 dynamics of aging as for group treatment,
dialectical behavior therapy element of, 251 163–165
(DBT), 105–107 reminiscence issues and, through documentation,
for Borderline Personality 252 165–166
Disorder, 105 interviews of, 37–39 pattern of treatment
for invalidating emotion regulation, 123–125 progress, 166
environments, in low intensity impact evaluation, 171–172
105–106 psychological interactive evaluation, 171
therapeutic hierarchy in, 106 interventions, 153 for isolation issues, in
with unresolved stressors, process theory for, 124 remote settings, 269
106 emotional status, in MSE, 41 monitoring evaluation,
dichotomous thinking, 108 affect and mood, 41
https://avxhm.se/blogs/hill0 171–172
348 Index

evaluation mechanisms. financial performance goal setting

(cont.) indicators, for private through discrepancy
proactive evaluation, 171 practices, 296 acknowledgment,
for structured problem- Frances, Allen, 2 227–228
solving, 253 F-SET. See false safety in private practices, 291
for supervised practices, behavior elimination good enough treatment
208–209 therapy concept, 275
competency-based functional analysis, in grief. See abnormal grief
approach to, 208–209 behavioral case reaction
formative evaluation, 208 formulation, 64–69 group treatment
summative evaluation, 208 adaptation of, 68 assessment of, 160–162
evaluation phase, of case analog assessments, 67 through documentation,
management, antecedents in, 65, 68–69 165–166
197–199 automatic reinforcement in, early meetings in, 162–163
evidence-based practices 67 evaluation of, 163–165
interventions and, 52 behaviors, 65–66, 68–69 through documentation,
in psychological service consequences of, 66–67 165–166
delivery, 272–274 components of, 65–77 pattern of treatment
in treatment strategies, 12, definition of, 64 progress, 166
115–119 indirect assessments, 67 ground rules for, 161–162
action tendencies, 116 naturalistic assessments, 67 implementation of, 165
exposure to stimuli in, negative reinforcement in, 67 individual case formulation
115–119 negative reinforcers, 66 and, integration into,
inhibitory learning positive reinforcement in, 158
approach in, 116 67 monitoring of, 163–165
for lack of control in, positive reinforcers, 66 optimism as foundation for,
perception of, 116 punishers, 66 162
self-focused attention in, response costs, 66–67 outcomes from, 163–165
116 through documentation,
extinction, 100–101 GAD. See Generalized Anxiety 165–166
Disorder patient selection for, 159,
false safety behavior GAF. See Global Assessment 161
elimination therapy of the Individual’s pre-group orientation,
(F-SET), 122–123 Functioning 160–162
feedback generalist models of care, 277 format clarification, 161
in Alcohol Use Disorders Generalized Anxiety Disorder participation guidelines
Identification Test, (GAD) in, 161
133–139 case formulation with, patients as informed
for dependent drinkers, 90–92, 94 allies, 161
137–139, 144–148 Avoidance Model of program duration, 161
for low-risk drinkers, 134 Worry, 90 program selection for,
for risky drinkers, Meta-Cognitive Model 157–159
135–136, 140–143 for, 90 short-term, 157
for scoring, 133 Uncertainty Model for, for smoking cessation, 159,
for very risky drinkers, 90 164
135–136, 140–143 metacognitive therapy for, Tobacco Dependence
as intervention, 52–62 125 Treatment Handbook,
benefits of, 58–59 glide path, 48 157–158
client progress with, Global Assessment of the theoretical approach to, 157
monitoring of, 60–61 Individual’s
with cognitive behavior Functioning (GAF), 30 habit reversal, 101
therapy, 60–61 goal attainment, case health care
processes of, 59–62 management and competition in, 272–274
self-reports in, 60 documentation of, 194–196 fee-for-service systems,
fee-for-service systems, in termination phase after, 273
health care, 273 197–198 cost offsets in, 273–274
 Index 349

cost-effectiveness in, 273 Improving Access to assessment of

costs of, 10–11 Psychological interpersonal issues,
empirically-based system, Therapies (IAPT) 84–86
274 program, 1, 38 for depression, 81–84
industrialization of, 10–11 9-Item Patient Health Interpersonal Inventory,
in industrialized nations, Questionnaire, 38–39 84–86
leading causes of indirect assessments, in participants in, 81
illness, 271 functional analysis, 67 therapeutic contract
Mental Health Plan, WHO, Individual Practice negotiations in, 86
271 Associations (IPAs), interpersonal deficits and,
rationing of, 272–273 10–11 114
tele-health work informed consent for interpersonal role
environment, 262–263 in intake phase of case disputes, 113–114
in U.S. management, 186–187 role transitions in, 114
Affordable Care Act, 1 in rural and remote settings, transdiagnostic approaches
Employee Assistance 266–267 to, 119
Programs, 10–11 inhibitory learning approach, interpersonal role disputes,
Health Maintenance in evidence-based 113–114
Organizations, 10–11 treatments, 116 interventions. See also brief
Individual Practice insight, 43–44 interventions; low
Associations, 10–11 intake phase, of case intensity psychological
Preferred Provider management, 186–194 interventions;
Organizations, case information monitoring
10–11 documentation during, interventions
Health Maintenance 187–188 in case formulation, 78–79
Organizations ethical issues during, 187 client matching for, 49–52
(HMOs), 10–11 informed consent in, with cognitive behavior
health policy systems, medical 186–187 therapy, 50–51
knowledge of, 281 quality assurance issues, 188 with cognitive therapy,
health service psychology, 271 risk assessment and 50–51
HMOs. See Health management during, with interpersonal
Maintenance 189–194 psychotherapy, 50–51
Organizations intelligence, 44 Personalized Advantage
homework assignments, for interactive evaluation, 171 Index, 50–51
ruptures in therapeutic International Classification of Project MATCH, 50
alliances, 231–233 Diseases and Related Trier Treatment
human character, in culture- Health Problems, Navigator, 51–52
sensitive practices, Eleventh Edition evidence-based practices, 52
248 (ICD-11), 26–27, feedback as, 52–62
hypertension, 275–276 30–32 benefits of, 58–59
classification of disorders in, client progress with,
IAPT program. See Improving 31 monitoring of, 60–61
Access to cognitive behavioral case with cognitive behavior
Psychological formulation, 69 therapy, 60–61
Therapies program cultural considerations in, processes of, 59–62
iCBT. See Internet-based 31–32 self-reports in, 60
cognitive behavior Internet-based cognitive practice-based evidence, 52
therapy behavior therapy by psychologists, 277–279
ICD-11. See International (iCBT), 120–121 data collection and,
Classification of interpersonal deficits, 114 application of, 279
Diseases and Related Interpersonal Inventory, 84–86 motivational interviewing
Health Problems, interpersonal psychotherapy as element of, 279
Eleventh Edition (IPT), 50–51, 112–114 presenting problems,
impact evaluation, 171–172 for abnormal grief reaction, 277–278
impression management, 113 short-term treatment
204–205 case formulation in, 79–87
https://avxhm.se/blogs/hill0 strategies, 279
350 Index

interviews, in diagnostic in digital space, 262–263 Mental Health Plan (WHO),

practices, 32–39 privacy issues, 261 271
for adults, 39 risk management issues, 262 mental health services
assessment of presenting security issues, 261 in Australia, 286–287
problem, 34–35 tele-health work person-centered, 168
of children, 37–39 environment, 262–263 in rural and remote settings,
of elderly, 37–39 low intensity psychological 264
goals and purposes of, interventions, 151 economic barriers to, 264
32–34 case formulation for, social contexts for, 264
identification of coping 153–156 Mental Status Examination
resources, 35 clinical examples of, 154 (MSE), 39–44
motivational interviewing, with cognitive behavior cognitive components of,
102–103 therapy, 150–151 41–44
pro forma of, 36 definition of, 149 abstraction, 44
screening for symptoms bodily sensations in, 153 attention, 42
through, 38–39 emotions in, 153 concentration, 42
semi-structured, 39 thoughts in, 153 insight, 43–44
structured, 39 length of sessions in, intelligence, 44
intolerance of uncertainty 149–150 judgment, 43–44
therapy, 121–122 service users in, 150–151 language functions, 44
invalidating environments, shared decision-making in, memory assessments, 42
105–106 152–153 orientation, 42
IPAs. See Individual Practice decision talk in, 152–153 perception, 43
Associations option talk in, 152–153 speech, 44
IPT. See interpersonal three-talk model of, thought processes, form
psychotherapy 152–153 and content of,
isolation issues for clinical stepped-care approach in, 42–43
therapists, in remote 150 for emotional status, 41
settings theoretical approach to, affect and mood, 41
coping strategies for, 149–150 outline of, 40
268–270 treatment planning as result for physical status, 40–41
evaluation mechanisms of, 153–156 appearance, 40–41
for, 269 low-risk drinkers, in AUDIT, attitude, 41
through multidisciplinary 134 behaviors, 40–41
collaborations, 268–269 Lutz, Wolfgang, 53 motor activity, 41
social contexts for, 268 Meta-Cognitive Model, 90
management of multiple metacognitive therapy (MCT),
Jacobson and Truax method, relationships, in rural 125–126
56–57 and remote settings, attentional training and,
judgment, 43–44 266 125–126
boundary setting in, detached mindfulness and,
key performance indicators 266–267 125–126
(KPIs), for quality of through documentation, for Generalized Anxiety
treatment, 294–295, 297 266 Disorder, 125
informed consent in, Self-Regulatory Executive
Lambert, Mike, 52–53 266–267 Functioning model,
language functions, 44 monitoring mechanisms in, 125
legal issues, ethical practices 266–267 mindfulness. See detached
and, 246 management tasks, in case mindfulness
practical approach to, management, 178–179 minors. See children
245–246 MCT. See metacognitive modeling, as behavior therapy,
long-distance therapy, therapy 104–105
practical guidelines memory, in Mental Status role-play in, 105
for, 261–264 Examination, 42 monitoring
adaptation of therapeutic mental disorders, definition of, of assessment processes for
skills, 263–264 26–27 clients, 46–47
 Index 351

of clinical therapy, in rural naturalistic assessments, in of supervised practices, 205

and remote settings in, functional analysis, 67 for therapeutic
266–267 negative affect (NA), 119–121 relationships, with
of group treatment, negative reinforcement, 67 clients, 14–15
163–165 in contingency
in private practice, 293 management, 99 PAI. See Personalized
for clients, 294–295 negative reinforcers, 66 Advantage Index
routine outcome NICE. See National Institute pain management, 276
measurement, 292 of Health and Clinical panic attacks, 76–77
routine outcomes Excellence Panic Disorder, 78, 81
monitoring, 58, 60 9-Item Patient Health paraphrasing, in therapeutic
in private practice, 292 Questionnaire (PHQ- alliances, 19–22
monitoring evaluation, 9), 38–39 patient-centered care, 272–281
171–172 nomothetic templates patient-focused research, 47
monitoring interventions, anchoring diagnosis, 69 perception, 43
52–62 individualization of, 70 Personalized Advantage Index
clinical significance of, non-attention strategies, 19 (PAI), 50–51
56–58 Notifiable Data Breaches person-centered mental health
Jacobson and Truax scheme, 185 systems, 168
method, 56–57 PHQ-9. See 9-Item Patient
Reliable Change Index, obsessive compulsive disorder Health Questionnaire
56–57 (OCD), 92, 94 physical status, in MSE, 40–41
efficacy studies for, 52 option talk, 152–153 appearance, 40–41
historical development of, orientation attitude, 41
52 in MSE, 42 behaviors, 40–41
Lambert and, 52–53 relational, 248 motor activity, 41
Lutz and, 53 orientation to time, 249 political issues, ethical
outcome, 53–58 orientations, for group practices and, practical
Daily Index-5, 54–58 treatment, approach to, 245–246
scales and measurement 160–162 positive reinforcement, 67
tools, 53–54 format clarification, 161 in contingency
Therapist Graphs, participation guidelines in, management, 99
55–56 161 positive reinforcers, 66
World Health patients as informed allies, PPOs. See Preferred Provider
Organization Well- 161 Organizations
Being Index, 54, 57–58 outcome monitoring practice research network
randomized control trials, interventions, 53–58 (PRN), 298
52 Daily Index-5, 54–58 practice-based evidence, in
Routine Outcomes scales and measurement interventions, 52
Monitoring, 58, 60 tools, 53–54 preferred mode of activity, 249
motivational interviewing, Therapist Graphs, Preferred Provider
102–103 55–56 Organizations (PPOs),
in Alcohol Use Disorders World Health Organization 10–11
Identification Test, Well-Being Index, 54, prescriptive authority, of
139 57–58 psychologists, 283–285
by psychologists, 279 outcomes prescriptive privileges of
therapy withdrawal and, Better Outcomes in Mental psychologists (RxP
225–231 Health Care program, movement), 283–285
motor activity, 41 1 prescriptive strategies, for
MSE. See Mental Status from group treatment, supervisory skills
Examination 163–165 acquisition, 215–216
through documentation, presenting problems
NA. See negative affect 165–166 assessment of, 34–35
National Institute of Health routine outcomes in psychologist
and Clinical Excellence monitoring, 58, 60 interventions, 277–278
(NICE), 1 in private practice, 292
https://avxhm.se/blogs/hill0 prevention paradox, 128
352 Index

privacy issues, in long- session frequency and, Project MATCH, 50

distance therapy, 261 291 psychiatrists, erosion of
private practice time costs of, 292–293 popularity, 2
assessment practices with, PRN. See practice research psychoanalytic theory
290 network countertransference in, 7–8
business sustainability pro forma, of interviews, 36 transference in, 7–8
strategies, 293–298 proactive evaluation, 171 psychological service delivery,
financial performance problem lists, cognitive evolution of, 272–274
indicators, 296 behavioral case accountability in, 272–274
case formulations with, 290 formulation, 69 evidence-based care, 272–274
client data in, 287–289 problem-focused approach, of patient-centered care,
costs of psychologists, 275 272–281
for marketing, 289 process dimension scientist-practitioner
for treatment planning application of, throughout approach to, 274
and measurement, therapy, 233 psychologists
292–293 with countertransference, accountability for outcomes,
evaluation mechanisms for, 239–244 282
297–298 definition and scope of, articulation of roles and
knowledge acquisition as 233–236 services, 281–282
element of, 289–290 in therapy, 244 communications skills for,
monitoring outcomes, 293 with transference, 236–239 280
for clients, 294–295 process indicators, for private educational role of, in rural
routine outcomes practices, 295 and remote settings,
measurement, 292 program evaluations 269
practical considerations for, clarificative evaluation, 171 ethical issues for, 282–283
286–288 co-design approaches to, confidentiality as,
professional development 168–170 282–283
in, 289–290 implementation of, 169 health service psychology
quality of treatment, 293 promotion of, 169–170 and, 271
client outcome indicators, stakeholders in, 170 in integrated care settings,
294–295 impact evaluation, 171–172 value of, 274–277
financial performance interactive evaluation, 171 in generalist models of
indicators, 296 monitoring evaluation, 171–172 care, 277
improvement strategies ongoing quality good enough treatment
for, 293–298 improvements and, 168 concept, 275
key performance for person-centered mental for hypertension,
indicators for, health systems, 168 275–276
294–295, 297 proactive evaluation, 171 for pain management,
process indicators, 295 questions as element of, 276
research strategies, 297–298 171–172 problem-focused
practice research for action approach, 275
network, 298 recommendations, in stepped care models,
scientist-practitioner model 174–175 275–276
for, 287 about data collection and interventions by, 277–279
training and, 289–290 analysis, 174 data collection and,
treatment implementation, about development, application of, 279
293 172–173 motivational interviewing
treatment planning and for promotion of as element of, 279
measurement in, recommended presenting problems,
290–293 changes, 175–177 277–278
expectation setting, 291 for written short-term treatment
financial costs of, recommendations, 175 strategies, 279
292–293 scope of, 169 medical knowledge for,
goal-setting, 291 skills training in, 170 parameters of, 280–281
routine outcome theoretical approach to, for health policy systems,
measurement, 292 168–171 281
 Index 353

reimbursement codes, trigger events, 212 role-play, in modeling, 105

281 reflective practices, in routine outcomes monitoring
prescriptive authority of, supervised practices, (ROM), 58, 60
283–285 209–211 in private practice, 292
RxP movement, 283–285 confirmation bias as result ruptures, in therapeutic
as team players, 280 of, 210 alliances
punishers, 66 data-driven, 211 case example of, 217–218
punishment. See contingent Dunning-Kruger effect, 210 causes of, 219
punishment science gap in, 209–211 therapeutic resistance,
self-reflective devices in, 210 219–220, 224, 228–229
quality assurance issues, for supervisory skills definition and scope of,
during intake phase, acquisition, 215 219–221
188 reflective strategies, for homework assignments
quality of treatment, in private supervisory skills and, 231–233
practices, 293 acquisition, 215 from interference in clinical
client outcome indicators, rehabilitation, 47 process, 219
294–295 reimbursement codes, 281 management of,
financial performance reinforcement. See automatic 221–225
indicators, 296 reinforcement; during assessment phase,
improvement strategies for, negative 221–222
293–298 reinforcement; positive for client engagement,
key performance indicators reinforcement 222
for, 294–295, 297 relational orientation, 248 during implementation
process indicators, 295 relationships between people, phase, 222–224
questions in culture-sensitive during termination
in program evaluations, practices, 249 phase, 224–225
171–172 and natural world, 249 Working Alliance
for action Reliable Change Index (RCI), Inventory and,
recommendations, 56–57 224–225
174–175 remediation, 47 model of, 218
about data collection and reminiscence issues, 252 process dimension and
analysis, 174 remoralization, 47 application of,
about program remote settings. See rural and throughout therapy,
development, 172–173 remote settings 233
for promotion of response costs with countertransference,
recommended in contingency 239–244
changes, 175–177 management, 100 definition and scope of,
for written in functional analysis, 233–236
recommendations, 175 66–67 in therapy, 244
in therapeutic alliances, RET. See Rational Emotive with transference,
16–19 Therapy 236–239
risk assessment and sequential process and,
randomized control trials, 52 management 219
Rational Emotive Therapy classification of risks, therapy withdrawal as result
(RET), 107 190–193 of, prevention
rationing, of health care, emergency procedures and, strategies for, 225–231
272–273 193–194 through argument
RCI. See Reliable Change during intake phase, avoidance, 228
Index 189–194 through empathy,
record keeping, in case in long-distance therapy, 226–227
management, 178–180 262 goal setting, through
reflection-in-action, 212–214 protective factors in, 189 discrepancy
during subsequent client of suicidal states, 189–193 acknowledgment,
sessions, 213–214 risky drinkers, in AUDIT, 227–228
before supervision, 212–213 135–136, 140–143 motivational
during supervision, 213 role transitions, 114
https://avxhm.se/blogs/hill0 interviewing, 225–231
354 Index

ruptures, in therapeutic rural fishbowl, 264–266 service users, in low intensity

alliances (cont.) RxP movement. See psychological
through self-efficacy prescriptive privileges interventions, 150–151
support, 229–230 of psychologists short-term group treatment,
with therapeutic 157
resistance, 228–229 Saving Normal (Frances), 2 short-term treatment
rural and remote settings, science gap, in reflective strategies, by
clinical therapy in practices, 209–211 psychologists, 279
compliance with local science-informed model, 5–8 silence, therapeutic alliances
regulations and accountability in, 6–7 and, 19
legislation, 260–261 client data linkages in, 6 skills training, in program
during COVID-19 countertransference and, evaluations, 170
pandemic, 260 7–8 smoking cessation programs,
educational role for error correcting group treatment and,
psychologists, 269 mechanisms in, 6 159, 164
effectiveness of, 260 transference and, 7–8 Tobacco Dependence
isolation issues, coping of treatment strategies, 97 Treatment Handbook,
strategies for, 268–270 scientist-practitioner model, 157–158
through evaluation 4–5 social issues, ethical aspects of
mechanisms, 269 clinical psychology practice and, 246
through multidisciplinary influenced by, 4–5 practical approach to,
collaborations, 268–269 for clinical therapy in rural 245–246
social contexts for, 268 and remote settings, 265 social learning theory, 102
management of multiple for private practice, 287 Socratic dialogue, in cognitive
relationships in, 266 for psychological service therapy, 109–111
boundary setting in, delivery, 274 speech, 44
266–267 purpose of clinical S-REF model. See Self-
through documentation, psychologist in, 4 Regulatory Executive
266 security issues, with long- Functioning model
informed consent in, distance therapy, 261 stakeholders
266–267 self-efficacy in clinical psychology, 8–11
monitoring mechanisms in Alcohol Use Disorders clients as, 8–9
in, 266–267 Identification Test, 140 clinical psychologists as,
mental health services in, 264 self-management and, 102 9–10
economic barriers to, 264 therapy withdrawal and, society as, 9
social contexts for, 264 229–230 specifications of, 10
practical approaches to, 260 self-focused attention, 116 Subjective Units of
practical guidelines for self-management, 102–104 Discomfort, 10
long-distance therapy, behavioral contracting, in co-design approaches to
261–264 103–104 program evaluations,
adaptation of therapeutic empathy in, 102 170
skills, 263–264 motivational interviewing, in supervised practices, 202
in digital space, 262–263 102–103 Standard Drink Chart, 133
privacy issues, 261 self-efficacy as element of, stepped-care approaches
risk management issues, 102 to clients, 11
262 social learning theory and, in low intensity
security issues, 261 102 psychological
tele-health work self-reflective devices, 210 interventions, 150
environment, 262–263 Self-Regulatory Executive for psychologists, in
professional boundaries in, Functioning (S-REF) integrated care
264–266 model, 125 settings, 275–276
in management of self-reports, in feedback, 60 structured interviews, 39
multiple relationships, semi-structured interviews, 39 structured problem-solving, in
266–267 sequential process, in ruptures culture-sensitive
scientist-practitioner in therapeutic practices, 253–259
approach in, 265 alliances, 219 brainstorming in, 253
 Index 355

definition of problem, 253 trigger events, 212 non-attention strategies, 19

in ethical decision-making, reflective practices in, paraphrasing as part of,
254–259 209–211 19–22
in Canadian Code of confirmation bias as questions as element of,
Ethics, 255 result of, 210 16–19
confidentiality in, data-driven, 211 repetition and restatement
258 Dunning-Kruger effect, as part of, 19–22
under “do no harm” 210 silence and, 19
principle, 256 science gap in, 209–211 troubleshooting in, 22–25
with dual relationships, self-reflective devices in, vocal tones, 17
258–259 210 therapeutic resistance,
worksheets for, 257–258 for supervisory skills 219–220, 224, 228–229
evaluation mechanisms in, acquisition, 215 Therapist Graphs, 55–56
253 supervisory skills therapy withdrawal, from
implementation options, acquisition, 214–216 ruptures, prevention
253 prescriptive strategies for, strategies for, 225–231
solution selection, 215–216 through argument
253 reflective strategies for, avoidance, 228
Subjective Units of Discomfort 215 through empathy,
(SUD), 10 supportive strategies for, 226–227
suicidal states, risk assessment 215 goal setting, through
and management of, theoretical approach to, 200 discrepancy
189–193 supervision record forms, 206 acknowledgment,
supervised practices supervisory skills acquisition, 227–228
accountability for, 205 214–216 motivational interviewing,
supervision record forms, prescriptive strategies for, 225–231
206 215–216 through self-efficacy
agenda setting, 202–203 reflective strategies for, 215 support, 229–230
with audio/video supportive strategies for, with therapeutic resistance,
recordings, 203–205 215 228–229
impression management, thought processes
204–205 tele-health work environment, form and content of,
segment of sessions, 262–263 42–43
selection of, 204 termination phase, of case in low intensity
stage setting with, 204 management, 197–199 psychological
competency-based after goal attainment, interventions, 153
approach to, 208–209 197–198 three-talk model, of shared
evaluation of, 208–209 termination reports, decision-making,
competency-based 198–199 152–153
approach to, 208–209 termination reports, 198–199 time-out from reinforcement,
formative, 208 therapeutic alliances, 15–25. 100
summative, 208 See also ruptures Tobacco Dependence
future challenges for, body language in, 17 Treatment Handbook,
207–208 clients in 157–158
goals of, 200–202, 207–208 assessment of, 22 transdiagnostic approaches
primary, 201–202 relations with, 15–19 to case formulation,
for stakeholders, 202 construction and 87–95
for groups, 205–207 development of, 15 modular approaches, 95
outcomes of, 205 destruction of, 25 for symptoms, 87–90
reflection-in-action, empathy as part of, 21 theoretical commonalities
212–214 congruence and, 21–22 in, 87–90
during subsequent client encouragement as part of, treatment commonalities
sessions, 213–214 19–22 in, 87–90
before supervision, flexibility of, 22 treatment planning,
212–213 hierarchies in, 22 90–95
during supervision, 213 location factors for, 24–25
https://avxhm.se/blogs/hill0 integration of, 126
356 Index

transdiagnostic approaches initiation of treatment, health care programs

(cont.) 195–197 Employee Assistance
in treatment interventions, efficacy studies, 49 Programs, 10–11
87–90, 119–126 evidence-based, 12, 115–119 Health Maintenance
anxiety sensitivity action tendencies, 116 Organizations,
therapy, 121–122 exposure to stimuli in, 10–11
for avoidance behaviors, 115–119 Individual Practice
122–123 inhibitory learning Associations,
with cognitive behavior approach in, 116 10–11
therapy, 119–123 for lack of control in, Preferred Provider
for emotion regulation, perception of, 116 Organizations,
123–125 self-focused attention in, 10–11
for false safety behavior 116 unresolved stressors,
elimination therapy, from low intensity dialectical behavior
122–123 psychological therapy with, 106
with interpersonal interventions, 153–156 U.S. See United States
psychotherapy, in psychotherapy literature,
119 96 very risky drinkers, in AUDIT,
intolerance of uncertainty science-informed model of, 135–136, 140–143
therapy, 121–122 97 vocal tones, in therapeutic
metacognitive therapy, theoretical approach to, 49, alliances, 17
125–126 96–98
for negative affect, treatment-focused research, 47 WAI. See Working Alliance
119–121 Trier Treatment Navigator Inventory
treatment planning, (TTN), 51–52 Well-Being Index
90–95 trigger events, 212 (World Health
transference TTN. See Trier Treatment Organization)
process dimension with, Navigator (WHO-5), 54, 57–58
236–239 Western-centered focus, in
in science-informed model, U.K. See United Kingdom clinical practices,
7–8 Uncertainty Model, 90 247
treatment strategies. See also unconscious thoughts, WHO. See World Health
behavior therapies; cognitive therapy and, Organization
group treatment; 109 WHO-5. See Well-Being Index
interventions; United Kingdom (U.K.) Working Alliance Inventory
transdiagnostic Improving Access to (WAI), 224–225
approaches; specific Psychological Therapies worksheets
therapies; specific program, 1, 38 for cognitive behavioral case
treatments 9-Item Patient Health formulation, 80
in case management, Questionnaire, for ethical decision-making,
186–194 38–39 257–258
documentation of National Institute of Health World Health Organization
progress, for goal and Clinical Excellence (WHO), 26
attainment, 194–196 in, 1 Mental Health Plan,
implementation of United States (U.S.) 271
treatment in, 194–197 Affordable Care Act, 1 Well-Being Index, 54