August 2008 Volume 1 Issue 2
The Center for Collaborative Psychology and Psychiatry
Steven A. Frankel, MD, Center Director
August 2008 Newsletter
The Newsletter is written in collaboration with
Philip Erdberg, Ph.D.
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Greetings.
We hope you will take a moment to comment on the content and
quality of the Newsletter, and if you have them, to make
suggestions for future issues. Our goal is to make the
Newsletter useful for practicing clinicians like yourself. Your
comments will be particularly valuable since our readership is
broad and comes from diverse theoretical and experiential
backgrounds. Just reply to this email and let us know what you
think.
Regarding confidentiality, all case material in the Newsletter
has been thoroughly disguised, and, in addition, is presented
in The Newsletter only after obtaining the patient's consent.
As an added layer of protection, the write-up has often been
done in collaboration with that person and frequently the write-
up is used therapeutically to facilitate the clinical work with
that person (see Engelman and Frankel 2002, Finn 2007).
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~ Clinical Judgment and Truth ~
Steven A. Frankel, M.D.
As mental health professionals, we are quite earnest and take pride in having assiduously high standards for delivering and
judging our own work. However, how often and in what ways are
we held accountable for our results?
Here is what I mean. In last quarter's newsletter, I discussed
Owen, our 21-year-old disheveled college drop-out who was in
treatment with me. There is no question that I desperately
wanted Owen to progress. How, though, could I have been
entirely objective about Owen's progress? If Owen remained
stuck in his life for the year he was in treatment with me,
pending his return to college, I could have comforted myself
with the notion that he hadn't been a good candidate for
psychotherapy or that I hadn't had enough time to work with
him. After all, I did all the right things and even got
psychological testing, although admittedly I waited until he
was well into treatment before doing that.
So, please give me a break. There was nothing more I could do.
Or was there?
Time to take out the magnifying glass. Well, OK, I did leave
out of my list the semi-formal personality evaluations that
clinicians can make by themselves as treatment progresses. I am
referring to the disciplined review available to any
practitioner in our field. These "truing measures" are a bit
time consuming and many clinicians, like myself in this
instance, may regard them as a an inconvenience. An example of
the kind of personal housekeeping available to the therapist is
the self-monitoring method I describe as an "SO analysis" in my
first three books, or the self-supervision that Patrick
Casement describes in his books. Using these techniques the
therapist becomes his or her own critic, momentarily stepping
back from the emotion generated in the treatment. It also took
a while for me to get a second clinical opinion, in this case
from the psychologist who would do the psychological or
neuropsychological testing. Again, these both are steps that
mental health professionals typically bypass either because
they are time consuming or not reimbursed.
Compare this approach to medical treatment. If the patient has
an anemia, what would you think of a doctor who didn't follow
up a complete blood count with an extensive search for occult
bleeding, or a screen to determine if nutritional factors such
as iron or vitamin B12 or maybe even a parasite could be
implicated in causing the anemia? Follow-through in medicine is
rarely accomplished in a single step. Multiple specialists may
need to be called in. In medicine, this level of rigor and
follow-through would not surprise any of us. It's not rocket
science. In our own fields, however....
This reasoning leads me to think about Eduardo, a patient I
discuss in "Evidence from Within: A Paradigm for Clinical
Practice" (2008). It's a bit embarrassing, but I worked with
Eduardo for several years off and on, always believing I knew
who he was diagnostically and personally. No reason to question
my clinical judgment, after all I had already been doing this
kind of stuff for 25 years when I began to work with him.
During the initial work we got along swimmingly and he clearly
progressed. As I saw it, at bottom he was a decent, albeit
somewhat moralistic, young man who had been scapegoated by his
parents. That was my clinical judgment. "Sociopath" was the
furthest diagnosis from my seasoned clinical mind. And yet that
turned out to be what he was: unattached, out for what he could
get. The testing clinched it.
Doctor Frankel! You shoulda gotten a second opinion and testing
years earlier. Careful of that ego, Doc.
Of course, it is no surprise that we are stuck with both the
comfort and uncertainty of opinion as we do our clinical work.
However, remembering that our clinical judgments -- even when
backed up by endless experience, good training, and even data -
are all ultimately reflections of our opinion, should keep us
on track. And, there are ways to repeatedly bring these
judgments into focus, making them progressively more true to
what will ultimately prove to be the clinical reality of that
treatment situation.
Here we must examine our methods of verification. In addition
to psychological and neuropsychological testing, we have the
powerful benefit of patient-therapist collaboration. Whatever
else we use for confirmation of our clinical hypotheses, this
process of deliberate collaboration between clinician and
patient and respect for the inadvertent yet continuous feedback
between the two, in fact, is at the heart of our clinical
philosophy at The Center for Collaborative Psychology and
Psychiatry. We believe that if the collaborative methods I
mention in "Making Psychotherapy Work: Collaborating
Effectively with Your Patient" (2007), namely, those involving
ongoing evaluation of progress with our patients, are attended
to regularly, most errors in clinical judgment will eventually
show up. One of you, therapist or patient, will catch them.
Apart from your discerning mind and clinical rigor, all you
need is collaboration with your patient in a truly bilateral
and open manner. You are then likely to succeed in your
clinical enterprise.
References:
Engelman, D. and Frankel, S. (2002) "The Three Person
Field: Collaborative Consultation to Psychotherapy."
The Humanistic Psychologist. 30:49-62
Finn, S (2007) "In Your Client's Shoes," New Jersey: LEA.
Henderson, R. and Keiding, N. (2005) J. Med. Ethics, 2005, 31:703-706.
Meyer, G. J., Finn, S. E., Eyde, L. D., Kay, G. G.,
Moreland, K. L., Dies, R. R., et al. (2001). "Psychological
testing and psychological assessment: A review of evidence and
issues." American Psychologist, 56, 128-165.
Meyer, G. (2004) "The Reliability and Validity of the
Rorschach and Thematic Apperception Test (TAT) Compared to
Other Psychological and Medical Procedures: An Analysis of
Systematically Gathered Evidence." In: M. Hilsenroth and D.
Segal (eds) Comprehensive Handbook of Psychological Assessment,
Hoboken, N. J., Wiley.
Viglone, D. and Meyer, G. "Handbook of Forensic
Rorschach Assessment, an overview of psychometrics," New York:
Routledge, 2008.
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~Joining with Us ~
Would you like to know more about the work of the Center? If
so, you may be interested in reading my book "Making
Psychotherapy Work: Collaborating Effectively with Your
Patient," published January 2007. My new book "Evidence from
Within: A New Paradigm for Clinical Practice," was published by
Rowman and Littlefield in March 2008. Information about both
books can be found on the Center website
http://www.collaborativepsychology.com .
Also, if you would like to learn about participating in one of
our bi-weekly consultation groups with Phil Erdberg and
myself, please visit
http://www.collaborativepsychology.com/workshops.html .
Participation will entitle you to receive continuing education
credit as a psychologist, social worker, or MFT.
We welcome your feedback and suggestions. You can email Steve
Frankel at steve@collaborativepsychology.com ..
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Thanks for reading,
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