Personalized Psychotherapy: Effective Methods for Tailoring Therapy to Individual Clients with Dr. James Boswell Part 1

In this episode of Psychotherapy and Applied Psychology, Dan is joined by Dr. James Boswell as they chat tailoring psychotherapy treatments to clients.

Dan and Dr. Boswell explore the challenges and strategies of tailoring psychotherapy to individual clients. Dr. Boswell discusses his own experiences as a graduate student, the importance of having a supportive mentor and stresses the growing need for empathy and problem-solving when working with overwhelmed graduate students. Dr. Boswell also highlights the significance of collaboration and client preferences in therapy, as well as the role of outcome and process research in tailoring treatment. The two then discuss the use of routine outcome monitoring and the "if-then" approach of therapy.

Stay tuned for Part 2!

Special Guest:
Dr. James Boswell
Society for Psychotherapy Research

Keywords

tailoring psychotherapy, individual clients, challenges, strategies, graduate students, mentorship, empathy, problem-solving, collaboration, client preferences, outcome research, process research, routine outcome monitoring, if-then approach, markers

Takeaways

• Having a supportive mentor is crucial for graduate students who may feel overwhelmed by the demands of their program.
• Tailoring therapy to individual clients involves considering their preferences, expectations, and unique characteristics.
• Outcome research focuses on what works in therapy, while process research explores how and why therapy works.
• Routine outcome monitoring and the if-then approach can help therapists identify markers and adjust treatment accordingly.
• Collaboration and client feedback are essential in tailoring therapy and ensuring its effectiveness.

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Transcript

Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a Professor of Counseling Psychology at the University of British Columbia. Welcome to episode number 13 of Psychotherapy and Applied Psychology, where we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain, and hopefully have some fun along the way in an attempt to bring new ideas to practitioners, those training to be practitioners, and the applied psychology curious. Please reach out.
I'd love to hear from you. You can send me a text or leave me a voice message. Links to do both of these can be found in the episode show notes.
And if you're willing, let me know your name and where you're from. Today, I'm thrilled to have one of the world's foremost experts in tailoring psychotherapy to the individual client. He's a faculty member and clinical psychology program director at the University at Albany State University of New York, as well as the former president of the North American Chapter of the Society of Psychotherapy Research.
I provided a link in the show notes to the Society of Psychotherapy Research, and for full transparency, I am a member. But I will say that if you're interested in research on the process of psychotherapy, that is on questions such as how and why psychotherapy works, then this is the group for you. In this episode, which is part one of my conversation on tailoring psychotherapy to the individual client, we discuss process research versus outcome research, session level outcomes and processes, collaboration in treatment selection, client expectations and preferences, and addressing low motivation and diminished outcome expectations.
We begin this conversation with my guest answering my question about a time early in his career when he experienced self-doubt. So without further ado, it is my pleasure to welcome Dr. James Boswell.
Well, I definitely had many times when I had a question whether or not I could do this, because I think being in a PhD program that's obviously research focused, and a program that expects you to become a researcher, at least have that be a big part of your professional identity, I think there's a lot of pressure to really be excited about research. And I was, but I think the process was really intimidating. I mean, I was interested in psychotherapy process, which is why I applied to graduate school and did enough work in the lab that I worked in.
But just the intensity of the research and the process of writing and submitting it to peers and getting feedback and rejections and things like that, it all seemed like just a lot of, I guess a lot of rejection, sort of setting yourself up to just learn to be comfortable with rejection. And I think on top of tons of coursework and also starting to learn how to do psychotherapy, trying to build your research program is, there's just so much in clinical and counseling psychology graduate training that it becomes overwhelming at times. So I definitely had moments with my mentor where we would sit in his office and I would say, I don't, I'm not sleeping, I'm not on top of things, I don't know if I can do this.
And he was always extremely supportive, just saying, like, I totally understand, I know. I know how it is, it's really difficult if you want to be productive and be involved in research and contribute to the field. These are choices you make and it takes a lot of time and effort and late nights and weekends and things like that.
And ultimately, I think sort of reframing it kind of more humanistically as these are choices we make and it's up to you to decide whether or not this is something that you would want. But I think you can do it. You know, I've been there before.
And so I stuck with it. But I think that, yeah, the in the first manuscript that I submitted to a journal that will not be made was it was it was rejected. But but again, the the feedback was useful, you know, but then it also consulting with my with my mentor and thinking about how we can be responsive to the feedback and what can we do to make the manuscript better and where should we send it next and we send it to a different journal that was also a very good journal and it ended up being accepted.
And so that was, I think, maybe a turning point in some ways, was just having some initial success. That's sort of having having a reputable journal saying that this is this is decent enough work to publish and worth worth reading. And yeah, but but again, I think at every turn, I was very fortunate to have a supportive mentor.
So when I was feeling stuck, I guess it's in some ways, it's also a lot to say that that you have a relationship with a with a mentor in graduate school, who you can tell them these things, you know, that I'm struggling, because I know that might not be the case with every with every mentor, that that's the kind of thing you talk about.
So what do you so when a graduate student sits down and sort of says the same sort of thing to you, because it is a lot, when they say, you know, the theoretical graduate student, or if you were talking to a graduate student who was saying those same things to you, what would you say?
Well, I would try to be very empathic, because I can say, you know, from my direct experience that I've, I've been where you are now. In fact, in some ways, I've never really left that that space. But that, you know, let's talk through sort of what's going on and what your particular concerns are and how you're kind of managing your time and sort of think through what the priorities might be.
So in addition to just trying to be supportive, I think also being being problem oriented can be useful, too, because I think it's often the case, even for anybody, right? It's you have ideas about what you should be prioritizing, and you're putting a lot of effort and ruminating about a particular thing, and you just might need to have somebody telling you. It's not that this is unimportant.
It will need to be done, but actually I would be prioritizing these other things first. And as long as you're staying on top of those things, then you're actually in pretty good shape. And it ebbs and flows a bit.
I think that the years when you are really ramping up, say, a master's project, in addition to ramping up your clinical training caseload, and you're still taking core courses, that's when you're really getting hit from all sides. And so I think once you get a sense for what that's like to handle, it gets a little bit easier. I mean, I remember, again, probably around the same time I was initially having my, can I do this?
Kind of these thoughts to myself as a graduate student, talking to a more advanced graduate student, say that each year you tell yourself that you couldn't possibly do more. You couldn't take more on. This is the absolute limit.
In fact, you're past it. And then yet, the next year, you are taking more on and you're telling yourself, this is the most I can do. I could never do more.
I could never take on more. This is past my limit. And yet, the next year, and so you always end up, not always, but you can end up just recalibrating.
You just can get used to how busy things are and the competing demands on time and things like that.
Well, maybe I can use this selfishly for some mentorship from you, because this is something that I've often struggled with with graduate students, which is the prioritization, that oftentimes there are things that they, in their heads, and this isn't a critique of them because this is sort of a ubiquitous experience, but that they blow up to be really big and should take a lot of their time and attention. And then I try to communicate, listen, this is just a hurdle. This is what you need to do to study for this thing or to write, you know, to study for this comp, to write this whatever.
And then there are other things that are really big, right? So like when they're applying for internship and writing those letters and preparing for interviews, like that does take a tremendous amount of time, and that is really important. But there are other things where it's, listen, let's take this from a 10 to a 2, because that, like, is there a way that you found that is effective for communicating that?
Well, I think you really just laid it out already. Thank you.
It doesn't seem to cause any behavior change, but thank you.
No, I think you actually did a nice job of running it out. I think that that's a good frame, you know, to, you know, again, recalibrating, you know, expectations, what's helping people think through what the real priorities are, you know, what's the most time-sensitive thing versus something that maybe they can sort of take a breath and hold off on those sorts of things. I mean, some of it, I mean, these milestones that are major milestones, I do think that there is a potential, right, I think as a mentor who's been through it, you know, somebody who has the degree, who's completed the process, to maybe even minimize certain milestones.
You know, I sort of get the sense that sometimes it's like, well, you know, you're going to do this, but then you'll just move on and not sort of forgetting what it was like when you were in that position and just how important these things were. And they are important. You know, so I think you don't want to minimize the anxiety necessarily or concerns because, you know, obviously, dissertation, internship, things like that are really important.
Qualifying exam is very important. But for things like, you know, it's not surprising. I don't know if it's just me or my colleagues or where there are mixed messages around other parts of the training experience or around things like coursework.
Well, GPA doesn't matter as a doctoral student. You complete your courses. You have to get a B or higher in order to pass.
Just make sure you do that and you'll be fine. And you're spending too much time on your course. At the same time, like that's where the core of the conceptual foundation and the initial research foundation that everything's being built upon is introduced in these courses.
And when it's experimental methods, statistics, things like that, you want them to actually learn these things. And I think if you, for students who struggle, maybe, let's say in statistics, not necessarily in danger of failing, but are really anxious that they're not, say, getting an A, they're getting an A minus or something like that. I think the trying to emphasize the importance of taking on a learning orientation and that the level in graduate school is very different from undergraduate school.
And this is a learning opportunity, and it's kind of set up to be very difficult. These things are difficult. They will continue to be difficult.
The person who's teaching the course, I'm sure, probably still struggles with the basic things that are being covered in that particular course. And so trying not to get too discouraged.
Well, this leads actually rather well because right now we're talking about tailoring supervision or grad student supervision to the student. And now we're going to pivot and go and talk about tailoring therapy to the client. So before we dig too deep into it, what's your origin story?
How did you get into this, your work in this area?
Well, I mean, I applied to graduate school with a... I have learned now maybe somewhat of a strange interest in psychotherapy process. There aren't that many...
People are very interested in interventions in psychotherapy, but psychotherapy process, there aren't that many of us out there. But I was interested in how psychotherapy works. I was interested in for whom it works.
And so I applied to graduate school with an interest in trying to study those things. So I was fortunate to end up in a lab that was studying those questions. And it just happened to be at the time, among other things, one of the big projects that I...
I was not involved that started this, but what was ongoing within the lab was this multi-PI project focused on cognitive behavioral therapy for GAD. And in particular, it was taking the standard cognitive behavioral therapy that was considered to be the evidence-based standard in the treatment of GAD and comparing it with an integrative therapy that combined cognitive behavioral therapy with interpersonal and emotional processing therapy intervention. So combining elements of dynamic therapy and humanistic therapy.
And I mean, immediately there, right, there's a scientific and a conceptual sort of recognition that even though CBT is quote-unquote the first line treatment when it comes to psychotherapy for people with primary generalized anxiety disorder, at least that's what the research would indicate, there are so many people who do not respond to the textbook standard cognitive behavioral therapy for generalized anxiety disorder. In fact, I think it's still the case that GAD among all of the DSM disorders has the lowest response rates. On average, people get better, but there's a lot of room for improvement.
And so it's even the recognition that we need to develop a more effective approach. How do we determine that or how do we test that, how do we develop that? Well, that comes from understanding individual differences.
And for whom is the standard working and for whom is it not working? And so that's where you have the more process-focused studies, looking at interpersonal problem severity, being a moderator of outcome. And so maybe we can augment standard cognitive behavioral therapy by focusing more on interpersonal factors, hence this iterative therapy.
And so from the get-go, this is a long way of saying, from the get-go, I was involved in process-focused research that was really all motivated by this tailoring question. It was like, how do we take secondary findings from trials, and what can we learn from them to see how we might be able to augment existing treatments to pump up the effects? But even within that very particular context and looking at treatments, I think there's still, right, and ultimately in the comparative trial, there was no statistically significant difference between the groups that post-treatment or follow-up.
You know, it's, you know, I have this quote-unquote evidence-based treatment that I can use with my next patient who shows up and has primary GAD, but clearly there's no guarantee that this person is going to respond to that. And so, as an N of one, you know, this individual who is sitting in front of me, now I have to figure out as a clinician who's actually doing the work, you know, how is this going to work or be potentially beneficial or not for this particular client? You know, but, so I think it was initial clinical training and actually trying to apply some of these treatments while working in the lab studying them.
Just kind of just seeing how complex the process is and how much each client is just so unique.
Many of the listeners will know, but as you were talking, I was thinking, you know, we should probably take a moment just to say what outcome research is and what process research is and sort of differentiate them.
Yeah, yeah, sure. Yeah, and it's such a good question too, because I think once you get into particular examples, I mean, it can be a little bit of a fuzzy boundary, right? So the sort of thing about outcome, which ironically is kind of where my focus has ended up more in focusing on outcomes, but outcome research focused more on what works.
So we have this particular intervention, and we implemented, say, in a trial, or it could be open comparative trial, and we usually track symptoms, functioning, disorder status over time, and did people get better or not? So we have this intervention. Did it work?
Versus process, which is more about how it works, why it worked, for whom it worked. So the within treatment kinds of factors that could be what are the therapist variables that might predict better or worse outcome, patient variables, relational variables, within session or between session intervention variables. So not just what worked, but how it worked and for whom.
So with outcome research, it's kind of easy to use the analogy of more traditional medical health stuff. So some people get the active pill, some people get the placebo pill or no pill at all. Then we're going to see, does this reduce a specific cardiovascular disease or whatever.
But in psychotherapy, with outcome stuff, what's interesting is, when we do outcome research, we're usually saying this treatment, which is in a treatment manual, versus either some other treatment or a placebo treatment, which is very difficult in psychotherapy, or no treatment at all. But I always think what's interesting about that is, okay, so we know that this, for example, we know this treatment manual is more effective than this placebo or no treatment, but we don't actually know why. We don't know if it was effective because of what it purports to be effective, because of why it purports to be effective, or maybe it was just because, well, sessions were at 8 o'clock in the morning, and they got the client up and out of bed, and so then they were able to then, after that, they sort of went about and did stuff, rather than hitting the snooze and staying in and not actually getting out of bed until 11.
So we don't know if it's the change in their irrational beliefs, or if it's just that they happened to get out of bed, or maybe just that they had a friend who they found in their therapist, or a million other variables that could explain why the treatment was actually effective.
Yeah, I mean, the comparison with medication, I think, can be very useful, especially when introducing the distinction, and especially talking about methodology. I teach an advanced psychotherapy systems course for undergraduate majors in psychology here at the university, and I will frequently draw in, well, let's take medication, this particular medication for depression. I will often call on those sorts of examples, because I think to start, for whatever reason, maybe just because psychotherapies tend to be multi-session complex, multi-participant activities, that starting with, like, let's picture a pharmacotherapy trial is a good way to introduce some of what we're talking about.
And I think it's an effective way to introduce these things. It does, as I was saying before, it does end up getting a little bit tricky sometimes in terms of what process versus outcome and what one's particular interest might be, because depending on the level of analysis, depending on the complexity, that in one instance, something could be your dependent variable or outcome, but in another, it could be a process that's predicting something else. In general, we have this, we're often using variables or individual difference variables from therapists and patients that are occurring at the point at which they enter treatment to predict things that happen 12, 16 weeks later.
And many people have argued that it's not that you shouldn't look at those things, but that it might be more useful to actually look at, say, post-session level outcomes and sort of track how those progress or don't over time. And so, session level outcome, but it's also a process that's modeled that could itself then be used to predict follow-up outcome. It really does depend on the context.
Well, even the example that you gave when you first started, I think that's sort of difficult to tease apart too, because you're actually looking at two different treatments, one with some different components than the other one. Is that a process study because you're studying those sort of... Do these processes facilitate outcome or is it an outcome study because you have these two different treatments predicting outcome?
Can you give us a 30,000-foot overview of how you've come to think about tailoring psychotherapy for individual clients? Is that too much? Is that too big?
Well, I mean, I can start with the unsatisfying, very general. Let's start with the really unsatisfying, I guess. Well, I think that we have a number of effective therapies out there, therapies that have been shown to be on average effective for commonly presenting problems that have at least ostensibly very different theoretical assumptions and techniques.
I mean, without getting into some process research showing that maybe the differences aren't as stark as some people might argue in terms of what a dynamic therapy session looks like versus what a cognitive therapy session looks like. And so even taking, even if you pay attention to things like the Division 12 evidence-based treatment list, for commonly presenting problems, you will often have several different treatments that you could pull from. Some of them are within the same broad theoretical paradigm, but many of them are across the theoretical paradigms.
And so it's somebody sitting in front of me, and I'm basing this on presenting problem, then I have this list of things I could choose from. How do I decide what to do?
And so I think that it's a tailoring question. And even though there's a lot of research that still needs to be done, we do have some general principles floating around that have replicated across a few studies at least. But it ultimately does boil down to research identifying, let's say, what these tailoring variables are without getting into mechanisms per se, but more in terms of participant variables or moderator variables that tend to predict whether or not somebody responds to a particular treatment or not.
If research can elucidate those things, then I as a clinician hopefully will somehow come upon those findings, and I will sort of file that away and say, okay, the next person who shows up at my doorstep, who with this particular problem, I do some assessment that is trying to capture those variables that the literature is telling me are relevant for tailoring decisions, and depending on what those results are, I make my decision. And so that's a treatment selection issue, and it does require maybe asking questions that go beyond the typical diagnostic interview or initiative.
So you hit on something I didn't even think about that we might go in this conversation. So first of all, I just want to put an asterisk by this for anybody who's listening. Division 12, which is the Clinical Psychology Division of the American Psychological Association, they have a very useful website that you can go to, and I introduce it to students all the time, because most of the time people just don't know it's there, where they look at or they sort of catalog evidence-based treatments for specific problems.
And they sort of highlight how much evidence there is, and there's sort of variable nuance there. There's actually, you can spend a bit of time exploring it. It's updated sporadically, but it's still, I find a really useful resource just when you're like, I don't know what to do with this person, or I don't know how to work with this sort of a problem.
Where can I go and get some resources? And it's all free, it's all available, and I find it a lovely resource. But the other thing you're talking about here is thinking about treatment selection at the outset.
So if I'm working with somebody who has major depressive disorder, that if I go to that website, there's actually several evidence-based treatments for major depressive disorder. So then how should I, or how could I, based on the evidence, how could I as a clinician think about which one I should choose for this client? Above and beyond, I happen to have, which is not irrelevant, I happen to have training in this particular area.
But let's sort of say all of that is equal. How would you suggest someone think about going about making that decision? Should I use this approach or that approach with this client?
Sure, sure. I think in any instance when it comes to treatment selection, but then also as treatment progresses, I think it's important to be as collaborative as possible with the client. So I think a lot of this is driven by the client's experiences, expectations, preferences.
And so let's assume that I have some exposure, and I feel competent enough in a couple of different evidence-based approaches for major depressive disorder. I will probably pitch those options to the client. I'll say that your concerns are very consistent with this diagnosis, and there's a lot of research to show that we have a couple of treatment options available that involve slightly different ways of working and framing goals and et cetera.
And so if you're willing to listen, we can talk a little bit about what those options are, and you can tell me if one seems to strike you as being most relevant or worth doing or fit your expectations for what this is going to look like. Because there's quite a bit of evidence at this point in terms of outcome expectations being associated with ultimate outcome, less on task related expectations for therapy. So what do I actually expect the therapy to look like, and does it actually look like the thing I thought it was going to look like?
I think at least conceptually, you want to make sure that you proceed in a way that's fitting what the client wants to do or what they were coming into the process, expecting to get from you out of therapy. But then also, in thinking about preferences, there's quite a bit of research to show, at least if it's correlational, an association, a positive association between preference accommodation and outcome. And so I can get a sense of, like, am I introducing a way of working that fitting your worldview and expectations, I'm listening to you to help me make decisions about sort of moving in a particular direction, that it's going to be useful for you and keep you engaged.
There's a measure out now called the Cooper-Norcross Inventory of Preferences. I might have the I part of the afternoon wrong. And you could give it to the client as a self-report measure at the start of the therapy, or you could actually integrate it into session early on with a client.
And it has a number of dimensions, but it gives you a sense of, is this client, how motivated would they be to actually be skills-focused and have homework assigned week to week? Some clients from the get-go might say, I'm absolutely uninterested in that. I don't want to do that.
So better to know that than to jump in and say that, okay, we're going to do behavioral activation for your depression. Not to say that you couldn't flexibly apply a more structured, interactive treatment with clients who express that preference, but you should take it seriously and think about how that would fit or not. And so, what are the client's expectations?
What are their preferences which might steer me in? Like, are they thinking more insight-oriented? Are they thinking more action-oriented?
And then along those lines, too, I mean, there are some general principles for tailoring treatment selection based on some of the work that Butler and others have done around, you know, sort of coping styles and level of reactance. So, you know, the degree to which, you know, I am sort of sensitive to potential impingements on my autonomy or freedom of choice. You know, so if I'm high on reactance, I usually like to take direction myself.
I'm not really great at taking direction from other people. And so if I'm working with a client who likes to do their own thing and wants to take up, you know, most of the session doing the talking and steering the ship, et cetera, I want to be very sensitive to, you know, before I start to apply a treatment again, it's going to be more structured, action-oriented, skills-focused, because at least the research would show that somebody who's higher on this particular factor may not respond favorably to a more structured, directed treatment. So there are a few of those principles out there.
Well, I think that what you're saying is interesting, too, because it speaks to... So one, depending on their level of reactants, do I want it to be more therapist-guided or client-guided? So you can think about that at the level of the treatment you're choosing at the outset, but then there's also, this gets back to those fuzzy lines, that level of even if I'm doing some cognitive therapy treatment, that I can tailor that, if I'm a somewhat seasoned therapist, I can tailor that where I'm talking more over there talking more, where I'm using more there coming up with stuff, or I'm using more I'm coming up with stuff.
Yeah, I've never, and the research just isn't strong enough to draw this conclusion anyway, but I would never look at those findings and say, well, if somebody is high on reactants, you just throw out anything that's more CBT, just throw it out the window. It's not an option. And I don't think that that's true.
I think at the very least, I need to be very sensitive to make sure that I really, like the collaborative empiricism has a capital C in collaborative, that I'm making sure that we're working in a way that's always deferring in some ways to the client so that they really feel like they're having ownership over the direction of the work. And maybe even reminding myself to check in with them occasionally about like, am I being too heavy handed here? I feel like maybe I'm taking over in a way that is not useful for you.
What's your sense of how that's going?
So that's at the very sort of the, I sort of think of it as a macro level, like what approach am I going to take with this particular client? Let's dig into the micro a little bit. So, you know, session to session, what are some of the ways that you think about tailoring therapy?
Well, I mean, so that gets a little bit into the other area of work that we've done in I guess over the last 20 years since graduate school, looking more at routine progress and outcome monitoring. Now, again, this will not ultimately lead to any kind of satisfying answer, but I think it's kind of starting from the point of, okay, we've done everything we can to identify a starting point, provided a rationale, there's agreement on the approach that we're taking, at least initially that the plan makes sense to the client, they're on board, let's go do it, it's consistent with what the standard is in the field, but then, again, every striker talks about local clinical scientists, every client is going to be able to make a difference, so now you're kind of off to the races. And what's behind your question is that you can't just, psychotherapy isn't just a plug and play activity.
I can't just assume that this is going to work for the client because this is what the textbook tells me to do or what the researchers tell me to do. So that means I have to be very sensitive within and between sessions to picking up on what are the markers that actually things are progressing in a way that are consistent with what the goals are and what the expectations are for the therapy. And so some of that is based on observation within session process and trying to pick up on potential disruptions or ruptures within the collaborative working relationship or clients expressing concerns about the lack of helpfulness, whatever it might be.
So there's that, just being a careful observer who's willing to recognize when things aren't working. But then that's augmented in some of the work that we've done by routine outcome monitoring, which is to gather information based on the patient's own report at a session level or every other week, where we're actually asking them to tell us on standardized measures, although we can get into augmenting standardized measures with more person-specific measures, but tracking from the client's perspective how things are going. And using that feedback, that's then going to give me, again, a higher level compass in terms of trying to figure out whether or not we're moving in the right direction or not.
Until I gather more information, I don't know exactly what is contributing to the person benefiting as we would hope or not, but at least I have some indicator that things are improving, and if they're not improving, then I know I need to do something. And I think that what's difficult is that next step in the kind of, okay, there's a marker here, that something isn't working for the client based on this routine assessment, so I need to pay attention to that. What I do in response to that, kind of the then part of the if-then equation, it gets a little bit trickier.
It does, maybe there is some research out there to guide certain things. I think that there are systems available that involve standardized assessment, that have supplementary assessments, more assessment and assessment assessment, where you can sort of start to try to check off boxes. And so ask questions about motivation, ask questions about how our alliance is doing, ask questions about social supports, ask questions about recent life events that could be impacting the ability to engage or make use of therapy, those sorts of things.
And then based on the results of that follow up assessment, and then actually talking to the client, I might get a better sense from their perspective, what it is that's leading to this impasse. But it's hard to know. You have to gather more information to at least start to brainstorm what you might do differently.
And you sort of mentioned it, but I think it's worth highlighting. So in some of your writing, you've talked about sort of this if-then approach. And the way that I've read is sort of like, if this certain marker shows up, then I should go and sort of be responsive in this type of way.
And so one of the ifs has to do with routine outcome monitoring. And so for example, if it doesn't look like, based on the data that I'm getting back, I'm not on track with this client, then I should, that sort of thing. Is this sort of the general if-then approach, kind of the way that you think about tailoring therapy to the individual client?
Is that sort of like a meta framework that you use?
Absolutely, yeah, absolutely. I mean, I think that the, it's a general framework that's sort of built to be able to, I guess, accumulate whatever the research is starting to show us, because there are hundreds of different potential markers that could be identified as relevant. This is a sort of, it could be, we were talking about before, you could think about, it's at a micro level, but you can think about patient characteristics as potential tailoring variables as a marker.
It's just if a client has these characteristics, then you should probably select this approach. That's one way to start. But then within the treatment, there are, it could be feedback-related markers, which again tells you that you should be, you should consider doing something, something different or at least using that as an opportunity to have a conversation with the client.
But then other markers that exist include things like alliance ruptures. So am I noticing within session markers of alliance tears? If so, then I should probably consider engaging in resolution strategies.
If there are markers of resistance to the treatment or me as the therapist, then I might want to strongly consider shifting into using a more motivational interviewing informed approach. And so those are some of the if-then kinds of marker response strategies that have a bit more research support for them. But I think the whole idea is that as a field, we can start to come up with a list of what the relevant markers are going to be and the optimal ways of responding to those markers.
So I think in that way, yes, I think I use the if-then marker-driven decision-making framework when I supervise in the clinic, when I think about my own clinic work. But it's recognizing that we really only know a somewhat decent amount about probably four or five different if-then scenarios. And so there are a lot of things that we, there are a lot of quote-unquote markers out there that haven't really been identified or haven't replicated.
Right. So I know some of the ones, and you've hit on a couple of these, but you've talked about in your writing, clients ruptures, low patient motivation, when clients have diminished outcome expectations, missed cultural opportunities, when routine outcome monitoring indicates you're not on track. So I want to just hit on a couple of these, if you don't mind, maybe dig into a little bit, things that I sort of have less knowledge about.
I feel like the Alliance rupture thing, I've covered it in previous episodes of the podcast, and there's a ton out there on there, which is wonderful. And so if folks haven't dug into that, I should probably have somebody on to talk specifically about Alliance ruptures. But if folks are unfamiliar, Google it.
It's well worth your time. There's a lot there. But I think that that's more frequently talked about.
So I wanted to get into a couple of other things. So in particular, low patient motivation. This is such a ubiquitous experience.
What are some thoughts you have when you have about having a client who has low patient motivation?
Yeah, so low motivation.
That's a wrap on part one of my conversation with Dr. James Boswell. Please be sure to check out part two, which drops next week. And please reach out by sending a text or leaving a voice message.
I'd love to hear from you. Until next time!