Sunday, August 3, 2014

Learner therapist (16)……What’s a good enough therapist

Torrey Orton
August 3, 2014

I set myself the goal for my CPD tasks two years ago to design a generic therapist competences framework. This is the first cut. It begins with the name – the good enough therapist – which intentionally borrows from Donald Winnicott’s ‘good enough mother’. We could do with a bit more good enough these days, and maybe I was thinking the same for therapists. My objective is to use this framework as a template for self-assessment, with elements of professional assessment added as possible – that is, as I can succeed in finding colleagues who are prepared to judge.

I have enquired around the formal psych fraternity – especially the APS and some of its associated colleges – to find so far that no one has a generic, or a context-specific, competence framework for therapists, even the CBT squad. So there is no agreed framework for evaluating anyone’s performance, apart from the “clinical psychologist” qualification standard of CBT masters and similar. Anyone with a slight degree of program evaluation experience knows that quals are only the starting place. It is therapeutic processes and outcomes that count for patients.

 And as for the processes and outcomes of therapy a few things are clear. First, the nature of the therapeutic relationship from both points of view is a major contributor to perceived therapeutic effectiveness. Second this effect stands without regard to the therapeutic system, modality, theory or fantasy which a therapist brings to the relationship. Third, therapeutic improvement can best be achieved by constant checking with patients about their continuing perceptions of effectiveness of the experience of being in therapy with one. Fourth, the generic therapist must be able to engage with any presenting patient, even if only long enough to identify that a referral to a specialist of some sort is appropriate (and have a resource of such specialists on hand).

Here are some competences, knowledge and skills: no special order. I am seeking all and any suggested additions to the following first. Then, I’ll entertain alteration or deletion suggestions to the items listed.

1)      Intercultural communication, which includes knowledge of relevant cultural differences affecting application of preferred treatment(s) and the capacity to negotiate the treatment process. The key test of this competence is the capacity to understand and accept that the suite of assumptions and practices which constitutes Anglo psychotherapy will not be wholly shared by cultures like Chinese, fundamentalist religious practitioners (Jewish, Christian, Moslem, Hindu….), etc. In the end this competence would be exhibited by not working with some cultures rather than assuming one can work with all which one doesn’t know enough to know they are immutably different from one’s own.


2)      In vivo, person to person negotiation of the therapeutic process, including review / evaluate each session with patients, without shielding oneself by a diagnostic stance presuming the therapist knows best. A test for this competence might be the holding of a patient who experiences themselves as sometimes ‘crazy’ or out of control and demonstrates that self-perception in the room.


3)      Knowledge of a full range of therapeutic approaches, techniques and work styles, including how these approaches integrate with each other at different times in the therapeutic engagement. E.g. – CBT, IPT, dynamic therapies, behavioural therapies, ACT, Mindfulness, etc.


4)      Experience being in therapy oneself, not just supervision, so the more permeable boundaries of one’s self are in view and acknowledged as such – as being in flux – and how affecting that flux is of one’s availability to patients under various personal circumstances and conditions.


5)      A theory of the self which is holistic, embracing at least the biopsychosociocultural paradigm’s domains, with awareness of the spiritual and economic.


6)      A theory of life span learning stages and the processes through which they are experienced by people, including micro learning processes and their integration into life span learning.


7)      A human needs construct like:

Elements of well-being (basic human needs)

*From: The Treatment of Sex Offenders: Risk Management and Good Lives.

Tony Ward, University of Melbourne, Claire A Stewart, Deakin University, 2005


Without specified needs we cannot decide how we are doing and what trade-offs are required to improve well-being. One approach to defining basic needs is this:


Wants specifications of needs
1) Life (including healthy living and functioning)
Adequate sleep, food, exercise
2) Knowledge
Knowing that…Knowing how to….knowing why…etc.
3) Excellence in play and work (including mastery experiences)
Play an instrument, a sport; Practice a profession, trade, art, hobby…
4) Excellence in agency (i.e., autonomy and self-directedness)
Cooperative activities; enlisting others in our activities
5) Inner peace (i.e., freedom from emotional turmoil and stress)
Meditation, martial arts,
6) Friendship (including intimate, romantic and family relationships)
Appropriate care, affection, connectedness….
7) Community
Authentic membership, identification, …
8) Spirituality (in the broad sense of finding meaning & purpose in life)
Relevant belief, imagery, contemplation….
9) Happiness
In my view this is not a need; it is one  outcome of well-being
10) Creativity
Opportunities to invent at whatever level or domain of life activity (also a doubtful need)


8)      Understanding of social systems and the individual’s place in them, especially family systems, workplace systems and social systems generally.


9)      Capability in leading patients through actual or virtual reconciliation cycles, including creating and sustaining the power to be heard within those systems.


10)   Ability to hold and contain intense feelings, with a view to building patient authenticity and authority about those feelings. Confronting high risk subjects: suicide, violence to others or self, crime, abuse and how to contain an emotional outburst of any kind.


11)   Ability to recognise and admit own mistakes appropriately as they happen… a continuing learner with specific development aims and goals.


12)   Understand what makes research good enough and what important emerging evidence-based research shows about good enough psychological processes. Neuropsychology presents as a must appreciate emerging field.


13)   Capacity to make good enough judgments in the room about:

Talking about possible need for medication

Knowing where patients are at, or up to

Managing exposure therapy at the right pace / depth

How far to pursue a patient who is loosely engaged in therapy

Appropriate self-disclosure

Quantity of therapist input required

Boundaries of contact: in the room only?


14)  Having workable definitions of the main therapeutic entities: person, couple, family….


15)  Knowing at least one therapeutic paradigm in depth and a number of others to level of workable confidence


16)  Supervision - peer and professional; one-to-one and group.


17)  Knowing when to refer and being free to do so


18)  Having a collegial support network


19)  Having had an ordeal to prove you’ve got the commitment to do therapy; mastery of personal suffering and success


20)  Wider life experience: jobs, vocations, volunteer work, etc.


21)  Having a workable theory of contemporary life: it’s challenges, rewards, distortions and distractions

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