It has always puzzled me when I hear of new research that asserts again, that a manualized or evidenced-based treatment model produces better outcomes than an eclectic practice. I, like many if not all who are actually providing therapy find myself thinking, how could this possibly be true?

There are so many variables constantly impacting the therapeutic relationship, that defy being put in a box. Of course this includes the tricky variable of time and thus from one second to the next- everything constantly changes. How could one’s approach not be responsively flexible and eclectic?

For example:

If for the sake of my treatment modality (i.e. focusing only on the present and the immediate future when doing behavioral therapy), I steer someone away from disclosing details of past sexual abuse that are weighing on them and that they have never revealed to anyone, what kind of therapist am I? “Sorry, we can’t talk about that till session #6.”, is probably not going to go over very well. 

In the same vein, how damaging to this person would it be if upon such disclosure, I refer the person to someone who does that type of work or redirect them towards preparing for doing that work at a later date?   

What are they trying to prove? 

Ok, so funding. But let’s not sell our souls. Research that compares manualized or evidenced-based treatment approaches to eclectic approaches, misses the point and is damaging. Logic alone implies that our treatment approaches need to be as eclectic as the humans who seek us out.

Furthermore, how can one compare something that is well-defined to something that is not? Research that compares manualized or evidenced-based treatment approaches to eclectic approaches only muddies the water and leads us further from our goal: to provide effective therapy.

This problem is compounded by the likely scenario that the vast majority of people who are truly passionate about doing therapy, are doing actual therapy- not research. And with the stigma still connected to mental healthcare, our larger society has not historically cared about conducting such research. The system (of education, of government, healthcare system, etc…) is a mess.

In fairness to the few researchers out there, this is also difficult stuff to study. But we therapists know: research should focus more directly on developing evidence-based, eclectic models. Training should focus on helping therapists to learn and implement a combination of evidence-based models that in concert, produce desired outcomes.

This plays out poorly…

Since by and large this is not the case, therapists are left to just wing it. Often, this is more kindly referred to as looking at providing therapy as an art. So strengths-based! However the trouble is that beauty is in the eye of the beholder. Research shows that eclectic practice is not very effective because we therapists, in general way over-estimate our artistic abilities.

It’s understandable. Providing therapy is dynamic and challenging. We therapists are called to think in ways that defy the normal thought process. Using one’s brain and even the physical body in session in this way is more taxing than other, even highly stressful forms of work. This is why most organizations give starting therapists 4 weeks of paid vacation. Avoiding burnout is not even really realistic. Instead we must plan for it, in order to minimize its impact.

Add systemic and economic issues that result in poor training and lack of support and what kind of art is one producing? The good enough kind. And sometimes, (gasp!)… the bad kind. But our clients don’t just need protection from harm- they need more than good enough.

What do people do with good enough art? They throw it away, they sell it in a yard sale, they hang that impersonal piece on their wall in college and grow to hate it. Like the Ansel Adams print we’ve had on our wall since my husband’s bachelor days. I’ve been planning to donate that thing to the Good Will for years, but for now it’s filling a spot on our wall while we look for a piece of real art that we can now afford and that will mean something to us.

Good enough therapy is described to me way too often when a person comes to see me for the first time. “Tell me about your past experiences with therapy” is so often met with the person relaying that the therapist was very good at listening, but didn’t talk very much. So many explain that they liked the therapist, but that they didn’t really get a lot out of it. Frequently even further: I really wanted help, but it didn’t work and I was so frustrated that I stopped going. I’ve been struggling ever since. Things have gotten so bad, though- I’m willing to try again. The Ansel Adams analogy seems crass.

Let’s get on a better track.

Basic social work values dictate that we therapists must do an ongoing self-critique… always. Clients, supervisors and colleagues should be an active part of this process. This will consistently prompt us to seek out current research and training. In this vein, I’ve sought to hone my art through developing an evidence-based, eclectic practice.

It’s important that when the work is hard or overwhelming, one does not fall to good enough and rely on active listening and relationship building only. After-all, we know that the greatest potential for growth (for client and therapist!) is actually at these times. We need to prioritize taking good care of ourselves and through toiling– seek to grow.

I have been fortunate in my career to have had professors, supervisors, mentors, and most of all clients who have taught me how to accomplish these goals.

I’ve developed a dynamic, eclectic, evidence-based practice that my clients report (and with a critical eye, I observe) to be highly effective. This practice will continue to grow and change, as it should in response to an ever-changing, growing person and world. Does this mean that it cannot be measured? That it is ultimately just my own art? No. It is made up of principles that guide my work, as well as evidence-based strategies that I find essential for present day therapeutic delivery.

It is a rare talent, that doesn’t need art lessons. Even if you are a highly talented therapist – the nature of the work requires ongoing, well-informed learning and skill development.

In this series of posts, I will share with you the principles that guide my work, and discuss the evidence-based approaches that I use.

What does your practice look like? Call it art, call it eclectic practice, but let’s make it better. We need to first help ourselves and each other, in order to provide more meaningful and effective help to our clients.  

 

Bottom Line:

-We need to work together to develop and implement evidence-based, eclectic models for treatment.

-We need to address systemic and economic contributors that get in the way of therapists learning and consistently implementing evidence-based approaches.

-Read this series of posts to learn about my eclectic treatment model that is based on evidence-based approaches.

-Please contribute to the discussion by posting your thoughts and what approaches have been helpful for your clients.

 

Helpful mantras:

-Self-care always.

-Self-critique always.

-My artist’s tools are evidence-based.

 

 

Alisa Reed, LCSW-R

 

 

 

This is a question that more and more therapists have been asking themselves and earlier and earlier in their careers. Sure, there are some people who know that private practice is where they want to end up and sometimes they are looking to get there as quickly as possible. There may be nothing wrong with that, but there are external pressures that are currently pushing more and more therapists to go this route before they are ready or otherwise would. The reason for this situation is economic and systemic and it may come as no surprise that the system is being exploited by insurance companies and a government that just doesn’t work. Though the need for therapists has increased, by and large gone are the days (at least for now!) that one could obtain a full-time job as a clinician with benefits, especially right out of graduate school. If you are a new grad., someone at the beginning of their career, or a therapist at any point in your career: having been in your shoes, I’ll give you some inside info that can help you decide if private practice is right for you and if so, when.

The first thing to ask yourself and to answer honestly: have I had enough high quality supervision, training, and experience doing the type of therapy that I will be doing in private practice? If you read the above paragraph and your thoughts went to, wow this is a terrible situation for clients too! Your heart is definitely in the right place. And if it was the first thought that came to mind, bless you, social worker! But what about you? If you enter private practice without having put in some solid time working for an agency with excellent training and supervision, and doing the work! you and your career are also at risk.

After all, you want to do this work for 30+ years possibly, not burn out after 5, right? Of course, you want to avoid miss-steps and lawsuits! Who likes lawsuits? And I know, especially because you are reading this- you want to be a great therapist! Finally, if wanting to help people the best you can does not factor in, please go no further. I say this because some do. If it’s you, please don’t, this does nobody any good, you included! But I’ve seen well-meaning and skilled therapists struggle after jumping into private practice too soon and I’ve thanked my lucky stars countless times for my past supervisors and training, and some still current mentors and continuing ed..

Next, here’s a somewhat scary thought, but just like you help your clients to do, it’s one you must face: you will make mistakes. Are you ready to make mistakes when it’s all on your shoulders? The types of mistakes that even seasoned clinicians inevitably make, being human? Or are you at a point when you want the support of an organization that is set up in a way to safely enable therapists to learn and grow with an understanding that mistakes do happen?

Some less obvious, and just a few more fair questions that you may not have considered, but the type to think through: Are you prepared to properly assess and relatively quickly, the appropriateness of scheduling an evaluation with a potential client over the phone? Also, can you typically smell a subpoena a mile away? Like, in the first 10 minutes of an initial session? Or better yet, over the phone? If this question confuses you, you are not ready! If you get it, but haven’t developed this skill yet, you’re getting there… while some hopefully rare circumstances make this unavoidable, a courtroom is absolutely no place for a therapist. We do therapy! Not court! If you like a courtroom that’s fine- get advanced training as a forensic social worker (or the equivalent in your field) and add this to your practice, you will make a boatload of money and all joking aside provide an important service. But your average therapist- court- avoid!!! and refer to more appropriate resources.

If you are not stressed yet, you might be ready! If you are feeling discouraged or daunted, don’t worry, you will get there! Hopefully the information I’m presenting will help you figure out your next step- whether that’s reaching out to a therapist who can act as mentor, looking for work at an organization that provides better supervision and training, or calling on that ad for office space that you saw the other day. Things will click if you go about them in a mindful way. And some people are always more comfortable working for someone else and there’s nothing wrong with that! What matters is the same thing we tell our clients: that you trust yourself and access that voice deep down that knows what’s right for you.

The things that in my experience, were my biggest fears and ended up not mattering at all: how will I get referrals? How will I get in network with insurance companies? How will this all work? Will I feel too isolated? What if this doesn’t make financial sense? All of these questions are easily answered as you put one foot in front of the other. One route that makes sense for many: rent an office space for one day a week and start gradually. If you can’t find an office space for rent like this, call therapists in your area who may be willing to sublet an evening a week to you. A good therapist is not generally afraid of competition and might perk up at an opportunity for connection. A call from someone wanting to rent my office one day a week is a call I want to get!

Lastly, here’s a little secret that as a therapist, you probably already know but bears repeating now: everyone, even highly successful CEO’s, and the like, are afraid, at least a teeny bit, that everyone is going to find out they are incompetent. This is normal and healthy and part of why you are not a narcissist. But keep it in check. In considering going into private practice, keep your stress at a eu-stress level (admitted therapist nerd here) and let it motivate you to take the steps to make a well-informed and excellent decision.

If you are already in private practice and struggling, it’s ok! Use that struggle as a springboard for growth and rather than trigger shame or a shutting down, let it motivate you to figure out what to do next. And keep in mind: supervision and peer consultation should not go by the wayside just because you legally don’t need to have them anymore. A therapist in their late 70’s was a member of a private practice peer consultation group I used to attend! And while I provide supervision to others, I still seek it out myself and probably always will. Consider calling a sought-after therapist in your area who has a long wait list. They may welcome the opportunity to provide you supervision for payment, though they are short on space for clients. What a great opportunity! And at the very least an insurance policy against burn-out and the pitfalls of the work.

Bottom Line: Filter out the normal, healthy worries and hone in on what your gut is telling you. Have you had enough training and supervision and have things really clicked yet?

Helpful mantras: “Don’t let the perfect be the enemy of the good.” “One foot in front of the other.”

 

Alisa Reed, LCSW-R

 

 

-The opinions presented in this post are just that: solely opinions of this writer, and not professional recommendations. Statements are to be taken at your own discretion and resulting choices, at your own risk. Please seek the assistance of a licensed therapist of any kind if you would like help understanding any of the ideas presented here.