In contrast, this second edition, and this chapter in particular, offers a broader framework for effective clinical decision making. This framework provides an overview of subsequent chapters in the book structured around the four core dimensions of the therapeutic process and the competencies that support each dimension. A basic premise of this book is that therapists who are able to make effective clinical decisions and implement them sufficiently with the necessary clinical competencies described in this book are likely to be practicing highly effective therapy. As such, the primary and most important of the core clinical competencies is to “make and implement effective clinical decisions.” The four other core clinical competencies are: relationship building and maintenance, intervention planning, intervention implementation, and intervention evaluation, and the 19 clinical competencies that support them are listed in Table 1.1.
The first part of this chapter introduces three criteria: evidence, circumstances, and ethics, for making and implementing effective clinical decisions. The second part sketches three common psychotherapy practice patterns that therapists employ today. Each of these practice patterns “reflect” and “require” specific supporting clinical competencies. The final section of this chapter discusses the value of the third pattern and the limitations of the first two patterns.
EFFECTIVE CLINICAL DECISION MAKING: THREE CRITERIA
Another basic premise of this book is that highly effective therapy is a result of effective clinical decision making throughout the course of treatment. Such decision making is a foundation for and informs the use of the other strategies and competencies described in this book.
So, what does it mean to “make and implement effective clinical decisions”? In the past, as noted earlier, it was common for therapists to base clinical decisions on their theoretical orientation. Or, they might have based such decisions on their professional experience or preference, or even on clinical lore, e.g., “never give advice,” “always follow the client’s lead,” “don’t ask questions, just respond.” This began to change in the 1990s with the advent of best practices, empirically supported treatments, and evidence-based practice. Along with evidence, at least two other criteria beyond evidence emerged as essential for making effective clinical decisions. Each will be briefly described.
Evidence. Originally, evidence-based practice was considered a process of assisting therapists in making important treatment decisions. In this process, a therapist would decide on interventions after considering research evidence, their experience, expertise, circumstances, available resources, and client values and preferences (Gambrill, 2011). Unfortunately, many have assumed that “evidence” means published empirical research, particularly the list of “empirically supported treatments” promoted by Division 12 of the American Psychological Association promoting. Rather, the originators of evidence-based practice (Sackett et al., 1996) described two kinds of evidence. External evidence refers to quality empirical research, while internal evidence or clinical expertise refers applying external evidence in a way specifically that matches client needs and wants. Unfortunately, there are many practicing therapists who reject evidence-based practice, despite increasing expectation for its use among third-party payers (Lilienfeld et al., 2013). Fortunately, a new generation of emerging therapists is receptive to empirically based treatment interventions (Williams et al., 2014).
Circumstances. I have observed that the therapy process tends to follow three different trajectories. Sometimes, therapy gets stuck and requires refocusing. Occasionally, therapy derails and can result in premature termination unless the therapist intervenes to prevent it. Fortunately, much of the time follows a third trajectory: it goes smoothly and results in effected change (Sperry, 2021). There are a unique set of clinical decisions and actions requiring specific competencies associated with each trajectory. Obviously, there are considerably more decisions and clinical competencies involved when therapists endeavor to refocus treatment that is stuck, or to prevent and deal with derailment and premature termination than when treatment is going smoothly.
Ethics. Usually, when thinking about ethical professional practice, four ethical standards come to mind: confidentiality, informed consent, therapist competence, and conflict of interests. In addition to these, there are three others that are specifically germane to therapeutic decision making.
Is it effective?
Is it safe?
Is it appropriate for this client? (Sperry, 2018)
Take the example of the empirically supported treatment of loving kindness, an increasingly utilized mindfulness intervention. Although researchers have demonstrated that this intervention is effective with a wide range of clients, including those with clinical depression, they have also reported significant concerns about its safety and appropriateness in individuals suffering with the form of clinical depression known as recurrent depression (Segal et al., 2013). In short, while this mindfulness intervention is effective and safe with many individuals, it is neither safe nor appropriate for some. Making the decision to utilize this intervention when it is inappropriate for a given client is not only ineffective and unethical, but it may also have serious medical and psychiatric consequences.
In short, these three ethical criteria are superior to decision making based on one’s professional experience or preference, clinical lore, and, particularly, theoretical orientation. It is noteworthy that justification for basing treatment decisions and recommendations primarily on theoretical orientation has been increasingly discounted. For instance, Sookman (2015) contends that “it is the ethical responsibility of all clinicians regardless of orientation to be guided by current empirical research as well as their own specific areas of competence, experience, and limitations when making treatment recommendation” (emphasis added, p. 1295).
For these reasons, “making and implementing effective clinical decisions” is designated as the primary clinical competency among the 20 clinical competencies described in this book. It is meant to serve as starting point and end point of all planning, implementing, and evaluating psychotherapeutic treatment. In the remainder of this chapter, we refer to these three criteria as “decisional criteria” and the decisional criteria dimension.