On necessity and sufficiency in counseling and psychotherapy (revisited).

It seems to me that Carl Rogers (see record 2007-14639-002) was far too ambitious in trying to specify general conditions of necessity and sufficiency that would be relevant to the entire spectrum of problems and the diverse expectancies and personalities of the people who seek our help. Rogers' position and orientation almost totally overlook the array of problems under the rubric of "response deficits" that stem from misinformation and missing information and call for active correction, training, and retraining. Rogers also paid scant attention to problems with significant biological determinants. Nevertheless, as exemplified by his seminal 1957 article and many other articles and books, Rogers made major contributions within the domain of the therapeutic alliance. Today, the scientific emphasis looks at accountability, the need to establish various treatments of choice, and the need to understand their presumed mechanisms. Treatment efficacy and generalizability across different methodologies are now considered key issues. The efficacy narrowing and clinically self-limiting consequences of adhering to one particular school of thought are now self-evident to most. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

How certain boundaries and ethics diminish therapeutic effectiveness.

When taken too far, certain well-intentioned ethical guidelines can become transformed into artificial boundaries that serve as destructive prohibitions and thereby undermine clinical effectiveness. Rigid roles and strict codified rules of conduct between therapist and client can obstruct a clinician's artistry. Those anxious conformists who go entirely by the book, and who live in constant fear of malpractice suits, are unlikely to prove significantly helpful to a broad array of clients. It is my contention that one of the worst professional/ethical violations is to permit current risk-management principles to take precedence over humane interventions.

A multimodal behavioral approach to performance anxiety.

Cognitive-behavior therapy (CBT) stresses a trimodal assessment framework (affect, behavior, and cognition [ABC]), whereas the multimodal approach assesses seven discrete but interactive components--behavior, affect, sensation, imagery, cognition, interpersonal relationships, and drugs/biological factors (BASIC I.D.). Only complex or recalcitrant cases call for the entire seven-pronged range of multimodal interventions. Various case illustrations are offered as examples of how a clinician might proceed when confronted with problems that fall under the general heading of performance anxiety. The main example is of a violinist in a symphony orchestra whose career was in serious jeopardy because of his extreme fear of performing in public. He responded very well to a focused but elaborate desensitization procedure. The hierarchy that was eventually constructed contained many dimensions and subhierarchies featuring interlocking elements that evoked his anxiety. In addition to imaginal systematic desensitization, sessions were devoted to his actual performance in the clinical setting. As a homework assignment, he found it helpful to listen to a long-playing record of an actual rehearsal and to play along with the world-renowned orchestra and conductor. The subsequent disclosure by the client of an important sexual problem was dealt with concomitantly by using a fairly conventional counseling procedure. Therapy required 20 sessions over a 3-month period.