How consciously do you adapt your approach to the way that you perceive the needs of your client? Do you occupy different roles or modes of working with different clients? I know I certainly do, but if you’d asked to me define those modes succinctly, I might have struggled. A recent paper has helped give me a framework for these different modes, as well as how their impact might be measured.
At the risk of stating the obvious, clients come with different needs and desired outcomes. Some want simply to feel ‘better’ and to be free of the various problems and symptoms that trouble them. Others may come to learn; about what makes them ‘tick’; about why they are stuck in self-defeating patterns and how to overcome them. Others may be on a journey of personal discovery, seeking to explore issues of meaning and purpose in their lives.
I’ve seen and worked with these different needs over the years, but never quite found the right framework to neatly conceptualise them. I’ve also known that in terms of quantifying the impact of the work in these different modes, there’s no one measure that measures up. No one size fits all. More on this later.
Sometimes the things we need drop into our lap when we’re not looking for them. And so it was that I came across the recent paper by Lars-Gunnar Lundh proposing a meta-framework for considering core therapeutic skills in the context of three distinct ‘modes’ of psychotherapy. Not only did it provide me with a more coherent framework for thinking about the different modes I operate from, it also provided some answers to how their outcomes might be measured. I’d recommend it to you, and if you’re a BACP member you can access it free as a Counselling and Psychotherapy Research article.
Three modes of psychotherapy
In his paper, titled Three modes of psychotherapy and their requisite core skills [i], Lars proposes that therapy can be conceived of as being delivered in three primary modes, each of which requires different core therapeutic skills. These modes are: (a) an educational mode, which requires teaching skills; (b) a reparative mode, which requires analytic-conceptualising skills to identify some kind of ‘disordered functioning’, as well as relational-technical skills to repair this dysfunction, and (c) a developmental mode, which requires us to engage with clients to facilitate their personal growth and requires non-directivity skills.
We could quibble over the core skills required in each of the modes, but I think that would be to miss the over-arching point I want to make. That is that clients are looking for different things from therapy and may therefore have different needs of us. To meet these needs may require that we occupy different roles, or as Lars calls them, different modes. Each mode has distinct aims and intentions, as well as specific skills. In his words:
“The reason for introducing the term mode is that a mode can be more straightforwardly defined in terms of specific therapeutic aims and intentions. The educational mode, for example, is characterised by a teaching intention and therefore first of all requires good teaching skills.”
In the paragraphs that follow I’ll briefly outline each of the three modes and relate each to my own practice. Maybe you’ll find them resonating with your experience. I’d love to know and you can leave a comment below.
The educational mode
In the educational mode the therapist takes the role of teacher to provide the client with new knowledge, skills or attitudes.
What is taught (e.g. new self-techniques, new understanding of psychological functioning or insights about the clients’ own intrapsychic and interpersonal functioning) as well as how it is taught (e.g. psychoeducation, skills training, didactic teaching, experiential learning) may vary. What underlies each, however, is an educational stance aimed at providing the clients with some kind of new knowledge or understanding. While the techniques may vary from one therapy to another, the skills required are essentially teaching skills.
There are undoubtedly elements of teaching in my work with clients, for example, when I’m offering the client a framework (e.g. the Drama Triangle or TA’s ego state model) that may help them make sense of their experience. I also know that I need to do more than simply impart the framework; to be truly helpful I need to help the client locate their experience within it so they can then use it to bring about some desired change. While it sounds simple, the more I think about it, the more I recognise that it’s a skill that I need to continually develop.
The reparative mode
Lars describes the role of the therapist in reparative mode as more like a craftsman than a teacher, whose role is to ‘repair’ something that has become ‘disordered’ or damaged in some way. This may be in the form of the client’s self-esteem or sense of themselves, their interpersonal functioning, or being traumatised and in need of some processing of their experience. How the ‘repair’ is attempted will depend on the therapeutic approach.
Common to all approaches, however, is that the therapist will use, first, analytic-conceptualising skills to form some kind of ‘diagnosis, analysis or conceptualisation of the client’s problems’. Second, he or she will use relational-technical skills, as appropriate, from their preferred model, to try and repair what is broken. Within the paper Lars offers an examination of where (if at all) the three modes sit within five perspectives on the therapeutic endeavour, namely the psychodynamic, cognitive-behavioural and humanistic-existential approaches, as well as the common factors and mindfulness perspectives.
While there are probably as many reparative therapeutic strategies as there are brand name therapies, what really resonated with my work was Lars’ description of the common factors approach as championed by individuals such as Jerome Frank and Bruce Wampold. [ii] [iii]
From this perspective most psychological problems are “due to what Frank refers to as emotional “demoralisation,” defined as a negative emotional state characterised by anxiety, depression, low self-esteem, meaninglessness and hopelessness.” To turn this negative emotional state into a more positive one (remoralisation) the therapist needs to:
(a) develop an emotionally charged, confiding relationship with the client
(b) instill new hope and expectations for change
c) offer the client new explanations of his or her problems, and
d) provide a method or procedure that affords the client new “success experiences.”
Both Frank and Wampold assert that the content of the new explanations and procedures are less important than that they serve as “myths” to believe in, and that the methods or procedures serve as convincing “rituals” to go through in order to experience successful outcomes. In the words of Bruce Wampold:
The essential aspect of psychotherapy is that a new, more adaptive explanation is acquired by the patient…the truth of the explanation is unimportant to the outcome of psychotherapy. The power of the treatment rests on the patient accepting the explanation rather than whether the explanation is ‘scientifically’ correct.
According to Lars, this standpoint exemplifies the reparative mode of psychotherapy: “what needs to be repaired is the patient’s dysfunctional emotional state (“demoralisation”), and this is to occur by means of a therapeutic relationship that provides the patient with new hope, new explanations and new success experiences. The educational and developmental modes are not emphasised—although some degree of teaching skill may be needed to persuade the client of new explanations, these explanations do not have to be based on any kind of facts.”
I could go on, but this really speaks to the core of how I work as a therapist. How I conceptualise the problem, and the methods or procedures that I think will help, and how I convey these to the client may vary. What is constant, at least when I am working in reparative mode, is the framework above.
The developmental mode
In the developmental role our focus is more on personal growth rather than restoring a healthy level of functioning. Lars refers to this role as being more akin to a gardener. In his paper he contrasts the reparative treatment of post-traumatic symptoms with the developmental fostering of post-traumatic growth.
From this mode the therapist is engaging with the client to foster their “personal growth, personal development or maturation.”
This mode is consistent with the aims and intentions of the person-centred tradition pioneered by Carl Rogers. Rather than counter-acting the state of demoralisation experienced by clients, the aim of the therapist is to promote the client’s personal development and self-actualisation.
Now, it may be connected to the way that I market myself, or where I take my referrals from, but when I look at my caseload over the years the proportion of clients that come to therapy solely for the purposes of their self-development or growth seems rather small. Most seem to be seeking some kind of ‘pain relief’.
That isn’t to say, however, that clients who start in this place don’t then go on to explore, in a developmental sense, issues of meaning and purpose in their lives. I can think of plenty of clients who I’ve trodden this path with, and a deeply satisfying transition it can be.
Different modes require different measures
To what extent are the measures of outcome most commonly used in psychological therapy fit for purpose when it comes to measuring impact in each of the three modes? I think the answer has to be; to a limited extent.
The most commonly used measures of outcome in therapy tend to be those that measure either problems or symptoms associated with common mental health problems, difficulties with life or social functioning, as well as risk. I’m thinking of measures such as CORE, GAD-7, PHQ-9, OQ-45 and the Outcome Rating Scale. They are going to be less suited to measuring the impact of working from an educational or developmental stance, unless perhaps the educational work takes place as part of a broader reparative focus.
As Lars suggests, if each mode is defined by the aims and intentions of the therapist, then it follows that what should by measured will differ depending on the mode of therapy in question. He elaborates further:
For treatments in a reparative mode, it may be quite sufficient to focus on measuring changes in symptoms or alliance. But for treatments in an educational mode, the outcome should also be studied in terms of insights, the acquisition of new skills, or attitude change (depending on what kind of change was aimed for). And for treatments in a developmental mode, the primary outcome should be studied in terms of changes of personality, or other more stable cognitive, emotional or motivational patterns.
Relating this to my own practice, when I work from within an educational mode, it is invariably in service of a wider reparative focus. In this case it feels appropriate to stay with those standard problem or symptom measures of outcome I’ve highlight above.
From a developmental perspective, however, I’m inclined to focus more on trying to measure progress towards the goals that the client has for therapy. While I see clarification of the client’s goals as a vital part of our early work together, however, I’ve not up until now been in the habit of recording these and measuring progress towards them. For a number of reasons, I’m beginning to think that may need to change.
First, I think that working with the client to capture the essence of what they are seeking can, of itself, be a therapeutic process. It also provides a shared clear understanding of the aims of the work. Second, it helps both myself and the client to hold those goals clearly in mind. Third, it helps us both to know how well we are progressing toward them.
We know the contribution of the therapeutic alliance to therapy outcomes. We also know that one of the cornerstones of the alliance is agreement on therapeutic goals. Why then would we not seek to make their clarification a more systematic process? I’ve been following Mick Cooper’s work on the development of a goal measure for some time now, and I think it’s about time that I took the plunge and trialled his goal based outcome measure in my practice. I’ll hope to report back in due course, but if you have your own experience of using a goal-based measure, please do post a comment below.
Lars’ framework of the three modes in which we may operate as therapists is something I’m trying to consciously hold in mind in my work with clients. This is providing me with a little more clarity about my aims and intentions as I work, how I may transition between the different modes, and perhaps most importantly, why.
It has also reminded me that goals are the starting point from which every therapeutic intervention should flow, and that I can make goal setting a more systematic process. And for that, I’m grateful.
If the notion of the three therapeutic modes resonates with your experience, we’d love to hear your comments below.
[i] Lundh LG. 2019. Three modes of psychotherapy and their requisite core skills. Counselling and Psychotherapy Research. https://onlinelibrary.wiley.com/doi/abs/10.1002/capr.12244
[iii] Wampold, B. E. (2007). Psychotherapy: The humanistic (and effective) treatment. American Psychologist, 62, 857–873. https://psycnet.apa.org/doiLanding?doi=10.1037%2F0003-066X.62.8.857
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