Thursday, June 6, 2019

Disconnected: Where Did the Client’s Voice in Treatment Go?

By David S. Prescott, LICSW & Kieran McCartan, Ph.D

Mick Cooper, John Norcross, Brett Raymond-Barker, and Thomas Hogan just published a study in which they sought out what treatment providers believe is important in psychotherapy and how their answers compared with what clients felt was most helpful. Asking, “Whose therapy is it?”, the authors found that, “Robust differences were found between laypersons’ and professionals’ preferences on these two dimensions: Mental health professionals wanted less therapist directiveness than did laypersons … and more emotional intensity … These findings suggest that psychotherapists should be mindful of their own treatment preferences and ensure that these are not inappropriately generalized to patients.”

To some degree, these findings call to mind those of Beech & Fordham (1997), who found that professionals providing treatment to clients who had sexually abused often believe themselves to be more helpful than their clients perceive them to be. A common theme across the entire Criminal Justice sector, not just in respect to people who have been suspected or convicted of sexual offences are that we often don’t fully take into account the service users (our client’s) perspectives in developing and delivering services.  We (David & Kieran) with Danielle Harris, and have just published a study in this same area, finding that specific themes of problematic client experience emerged in three areas of their interface with the criminal just system. These include: (a) Interactions with the formal criminal justice system (police, courts, and custodial corrections), (b) Interactions with community corrections (probation and parole), and (c) Interactions with treatment providers (rehabilitation, therapists, and evaluators). They reflect broader issues in the “criminogenic” and social care systems where clients can best be characterized as “do to”, not “done with”; which reflects a position of expert knows best and that can contravene the therapeutic alliance. As just one example from his week, David and Kieran visited Bredtveit, an all-female prison in Oslo (Norway), and saw what a more empathetic, supportive and consideration system looked like; there was a balance between the clients’ voices, social care, understanding where they were coming from (in terms of past trauma and offences they committed) and how they could move forward,

From all of this, logical question follows: If one goal of treatment is to reduce risk, doesn’t it make sense to ensure that our understanding of our clients’ experiences is in line with theirs? Shouldn’t we take action to make sure that we are, in fact, understanding their experience so that we can better tailor our services to become more accessible to clients (in line with the responsivity principle of effective correctional treatment)?

If your answers to these questions is yes, then more questions follow: To what extent do we pay lip service to client experiences in treatment and supervision? Do we as individuals believe, as Beech and Fordham found, that we are more effective with our clients than we actually are, and therefore don’t need to be concerned with seeking out their feedback and input into treatment? Would we as individual professionals actually be able (first) to establish the environment where this kind of feedback is possible and (second) to handle the feedback that we might get? Are we afraid that the feedback we might get would be impossible to act on? Do we believe we already get feedback? And perhaps most importantly, do we harbor the belief that some feedback is not worth listening to? If the answer to this last question is yes, what does that say about us? Are we willing to admit that – in line with the research – that we are missing something?

These are not easy questions to answer. It often seems that our training in providing treatment can be a hindrance as well as a help. Many of us are trained to think in terms of adopting specific models or techniques and become so focused in these areas that we lose focus on whether or not these same approaches are actually working with our clients.

Bruce Wampold and Zac Imel have written extensively about the mechanisms by which treatment work. Central to all effective approaches to treatment is the therapeutic alliance itself. Brandy Blasko and Faye Taxman have found that this same alliance works with probation officers as well. This leaves us with even more questions. Perhaps it’s time to consider more deeply that our most cherished models and techniques work because they are delivered in the context of an effective alliance? Perhaps it’s also time to explore the many ways that we are not maintaining an alliance or truly listening to our clients’ experiences at the very times we are focused on implementing our models and techniques?

No comments:

Post a Comment