Tuesday, August 14, 2012

Goodness of Fit in Therapy

The Ecological Theory of human behavior in the social environment suggests that how well someone functions in life is the direct result of the "goodness of fit" between the person and their environment. So, for example, how well a student learns is heavily influenced by the degree of fit between the teacher's teaching style and temperament, and the student's learning style and temperament. Similarly, two children with different temperaments may respond very differently to the same parenting; for example, what one experiences as playful roughhousing the other may experience as overwhelming or threatening.

Goodness of Fit is also a factor in the therapeutic relationship. Different clients respond differently to different therapists' styles, manners of interacting, and intervention approaches. When the fit is good, outcomes may be better than when the fit is less good. It's also likely to be more satisfying for both client and therapist. In contrast, if it's a bad fit, the client is more likely to be guarded, defensive or resistance, and the therapist may be less likely to be empathic and patient. As a result, the process is less likely to be therapeutic, and may even be counter-therapeutic.

Working in agency settings, at least in the settings where I've worked, "fit" is rarely a consideration - or at least, not a deciding factor. The decision tends to be more about numbers - what clinician(s) have room in their schedule or a smaller caseload. Sure, if multiple clinicians are available, the person assigning cases may consider who may be a better fit. However, once the assignment is made (i.e., by the time the clinician and client meet for the first time), it's usually a "done deal" - clients and therapists are typically discouraged from requesting reassignment.

Private practice is a totally different ballgame. Both clients and clinicians have a lot more choices, and the ability to "shop around" for the right "fit." Granted, clinicians don't necessarily want to be too picky, especially starting out, and clients may also find the process of trying out various therapists (and repeating the intake process over and over) becomes onerous if they are too picky. Nevertheless, both have significantly more control over whom they see.

So, what makes for a good "fit" in therapy?

From the perspective of the client, trying to choose the right therapist, you should:

1) Feel comfortable enough to be open about what you're experiencing...without expecting that you'll feel totally comfortable. This is a stranger, after all, with whom you're sharing very personal information. If you expect total comfort from the beginning, you will discount providers who could actually be a really good fit for you. You want someone who challenges you in some way - that's what produces change. It should feel different than talking to a friend.

It's also common to experience whatever relationship issues you may have in life getting played out in relationships with therapists - this is actually good and productive, and helps resolve those issues if you can stick it out. Deciding that it's a sign the therapist isn't a good fit just means that you're putting off an issue that is likely to come up again with the next therapist.

2) Feel like the therapist can help you (i.e., they know something about what you're dealing with), and find their approach acceptable. You don't have to totally understand or believe in all aspects of someone's approach, but if you're operating from totally different worldviews, that can be an obstacle.

3) Consider the logistics - does the therapist's availability work for you? Does the location make sense for you? Is the therapist's financial policy acceptable to you (for example, whether they will go through your insurance, what your copayment or fee is), and do you understand no-show or cancellation policies? If these logistics aren't acceptable to you, they are bound to become barriers in treatment.

From the perspective of the therapist, the consideration of fit has to consider:

1) Our ethical obligation to clients. Specifically:Do you feel you can competently treat this client? Do you have knowledge and expertise with the client's presenting problem? And, although this piece is rarely acknowledged, do you feel able to empathize with the client? If you can't establish empathy, the treatment is not going to work, and while we probably all pride ourselves on our empathy, sometimes there really just is a bad fit, and our own "stuff" gets in the way. Our responsibility, when we don't have the expertise, or empathy for a particular client, is to make a referral to another professional who might be a better fit.

2) Workload balance. Our practice is only likely to feel manageable if we maintain some balance in the work we take on. If we already have several high risk clients, it may not be feasible to take another one. Similarly, there may be a limit to the number of clients with personality disorders we can manage, or the number of cases with a lot of collateral involvement, etc. We have to recognize and listen to our own limits.

3) Logistics: Like the client, we have to consider our schedule and availability (whether we are able to take a client during the time(s) the client is available), and financial agreement (whether we can take the client's insurance, for example).

There may be other considerations on either side. How do you think about finding the right fit between therapist and client?

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