The book consists of 109 pages across 12 chapters that address frequent habits of regimented therapists.  Without a proper dose of personal, along with professional humility, the authors, both psychologists, believe it can be challenging to recognize these habits, let alone minimize them.  The book's target audience is comparable to one written 10 years ago by Jeffrey Kottler and Richard Hazler (What You Never Learned in Graduate School).  Both focus on clinicians who may have completed their formal training, but sense that something is missing that cannot be acquired through CEU seminars.  The present one differs in that it focuses more on methods that can establish whether clients will keep their next appointments, and whether those clients will ultimately progress.

  Schwartz and Flowers stress the pivotal role of assessment, and sharply criticize those who are cursory about the process.  Potential trouble can occur by overlooking a client's previous history with therapy.  If the previous outcomes were poor, is the clinician willing (and able) to implement alternative measures?  They also encourage healthy skepticism regarding previous diagnoses whether its from ER physicians or clients' themselves.  They specifically mention the use (or abuse) of ADHD, bipolar disorder, and repressed memories.  Indirectly, the authors allude to a parallel issue:  Diagnoses sometimes have a way of taking opportunities for insight off the table (Does the client have a learned pattern of verbal abuse? or is it just her "bipolar" acting up?).  

In later chapters, they see establishing rapport as paramount, but they do not see that as being compromised by clinical overkill during the first 90-minute encounter.  Maybe they should.  Additionally, it is implied that the initial encounter is the one and only time that assessment issues can be addressed.  They seemed to underestimate how numerous sessions can answer these questions a manner that is more relaxed and less intrusive.  Occasionally though, there will be no future sessions if an overly sterile assessment process limits that rapport. 

The authors are equally critical of those who ignore science.  While they concede that "eighty-five percent of patients with mild to moderate levels of distress recovered fairly well from virtually any credible therapeutic approach", they note empirical evidence regarding certain conditions requiring specialized interventions, such as OCD, PTSD, eating disorders and phobias.  They surmise that "theoretical rigor mortis" sets in early in some careers, and no amount of studies can reverse it.  The other side of this coin is when certain therapists captivate their peers no less than the culture at large ("From primal screaming to nude encounter groups, clinicians flocked to the feet of these self-proclaimed gurus, with sometimes disastrous results.").  For better or worse, the authors refrain from identifying contemporary quacks, but have two general caveats: 1. Apply the same standards of critical thinking regardless of a person's status or prior accomplishments.  2. Charisma is no substitute for data. 

In a convincing chapter, the authors highlight the strong treatment role of collaboration. The percentage of clinicians who will openly object to collaboration is probably lower than those who still use a couch.  However, they contend that many therapists do not do what they profess, or they are doing it in a manner that is largely symbolic, such as getting a client's signature on a treatment plan.  While peers and superiors may applaud a therapist for using the recommended 'standard of care', the average client is less likely to instantly grasp how this applies to their immediate well being ("Do not assume that what appears to be the 'obvious goal' is what the client has in mind as most significant."). One basic suggestion they make is to identify say, five problem areas, and probe as far as which one (if any) the client believes is priority.  They also encourage paying "attention to what clients are not saying as to what they are saying."  One of their case studies relates to a client involved in an abusive relationship.  While the client had a number of ideas about how to cope with the situation, ending the relationship was not one of them.  This led to disappointment on the part of the therapist when his unilateral decision to refer the client to a battered-women's shelter was ignored.  But as a therapeutic alliance solidifies, a client is more likely to reconsider some of the clinician's initial ideas, stated or not.  Finally, they mention the benefits of therapists shifting focus in response to shifts in motivation on the part of clients.

Another persuasive chapter is titled "How to Ruin the Therapist-Client Relationship."  Previously, it was mentioned that 15% of maladjustment requires very specific interventions.  This leaves 85% in which the clinicians are allowed maximum latitude in how best to instill hope, as well establishing trust and confidence.  Nevertheless, a sizable number of therapists squander this opportunity by focusing on specific techniques rather than (again) building the relationship.  The authors encourage genuineness by not behaving toward clients in a manner that is overly stilted or controlling.  While a therapist might feel good about winning a verbal power struggle, the feeling might be short-lived, if the client declines to return when they feel less than affirmed. 

However discouraged by the authors, it's a matter of when mortal clinicians will respond negatively to client criticism.  Therapists can fall into this in a variety of ways.  A Freudian might dismiss criticism as resistance.  A CBT might label it as unrealistic expectations.  The authors touch on ways to solicit client feedback before clients feel compelled to confront.  There are two issues that the authors may have shortchanged.  One is how liability questions have a chilling effect on therapists taking responsibility for any role they have in a wounded relationship.  Moreover, clinicians have been professionally conditioned to carefully guard their reputations with the insurance companies, agencies, etc.  While we are not discouraged from branding a dissatisfied client as an 'Axis II', it is dicey to say the following to that same client, let alone anyone else:   "Knowing what I now know, I would have done things differently."

Hopefully, we have more finesse in confronting clients than they sometimes have in confronting us. But the authors are not sure.  Frustrated with a client's reluctance to take responsibility, a therapist might get the impatience out of their system by responding in an aggressive or insensitive way.  While this might help the therapist to feel better, it's not clear if this is optimal for the client. At the other end are therapists who do not confront at all ("To focus only on the nurturing aspects of the therapeutic endeavor is to omit the basis for therapeutic growth, — and that is to change."). This leads to the question, are 100% of clients capable of change?  If not, is there virtue in merely learning to manage the most distressing thoughts and emotions?

One of the more debatable chapters focuses on how therapists can encourage clients to take psychotropic medication ("Knowing that most clients are going to resist the idea of medication, it is best to sow the seeds for this possibility as early in treatment as possible.").  This was probably the case 15 years ago before pharmaceutical salespeople set the tone for diagnoses and treatment.  Oddly, the authors do not elaborate on when (or if) psychotropics are clinically indicated. And this may also point to the ubiquity of those same pharmaceuticals   Anecdotally, for every client who resists taking medication, there are five who view it as a nonnegotiable condition for commencing therapy.  The authors encourage clinicians to state how "therapy can be assisted and made faster by a temporary adjustment of brain chemistry."  But the referring therapist is far less likely to be defining 'temporary' than the prescribing psychiatrist ('We all know depression is just like diabetes.').  Also surprising is that they do not remark on the less-than-positive ways medication can affect therapy, such as how clients will desire to spend more and more time during sessions talking about their symptoms and side effects, and less and less about their lives, assuming they continue with therapy at all. 

For this reviewer, who has a background in community mental health, there were no shortages of themes to identify with.  Although, there was little mention from the authors about the samples in the studies they were citing.  What was their range of income and education?  What percentage was insured?  Self-referred?  Out of the starting gates, they almost always see merit in presenting the theoretical framework of therapy to clients.  Depending on the education level, an abstract presentation can lose some clients cognitively, especially if it displaces the providing of some immediate emotional relief.  In turn, the client be might lost literally if they do not feel "helped" after the initial session.  Related to this is the chapter "Failing to Prepare Clients for the Variety of Emotions That Therapy Can Evoke".  The notion of repressed memories or overwhelming trauma propelled to the surface has been a staple of clinical and popular culture for at least a few decades.  Who among us has not seen at least one drama, using therapy as plot advancement, where the client curses the therapist for bringing the painful past back to awareness?  Solipsism aside, the reviewer has not witnessed this once in 18 years.

Paradoxically, this may be the book's greatest strength:  It compels the reader to do a little research of their own on how their professional experience compares and contrasts to their peers.  Is the population one works with typical?  Or a bizarre aberration?  In general, how is private practice similar or different from public agencies?

And where are the majority of clinicians making their living these days?  More valuable than the authors' directions for growth, may be the questions they have yet to answer.

© 2007 Eric Lindquist

Eric Lindquist, LCPC, CADC has worked in mental health for 18 years.  His employment has included a group home and psychiatric hospital.  For the past 12 years, he has worked in an outpatient setting in Chicago, where he also resides

Categories: Psychotherapy