11

TEACHING CLINICAL
DECISION MAKING
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GREGG HENRIQUES

When you look for it, it is everywhere—it permeates almost every aspect
of professional practice. Whether one is setting up one’s office, consulting on
a referral, deciding what assessment instrument to use, meeting a client for
the first time, reviewing and assessing the literature, or advocating for a par-
ticular treatment approach for a particular case, one is engaged in a form of
it. The “it” can be termed clinical decision making, and it’s not too much of a
stretch to say that the fundamental goal of doctoral training in professional
psychology or training in any advanced mental health discipline is to produce
budding clinicians who have the knowledge, skills, and attitudes that enable
them to make and carry out good clinical decisions.
Despite the centrality of this concept, professional psychologists are
generally less likely than some other health professionals, such as nurses and
physicians, to deliberately frame their work and teach their craft in terms of
clinical decision making, although there are exceptions (e.g., O’Donohue &

http://dx.doi.org/10.1037/14711-011
Clinical Decision Making in Mental Health Practice, J. J. Magnavita (Editor)
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273
 Henderson, 1999). The failure to explicitly frame our training in this manner
may be a function of the old debate about clinical versus empirical judgment
or the fact that “clinical” is still used to denote one of the three broad prac-
tice areas (with “counseling” and “school” being the other two) or the fact
that conflict remains between the romantic and empirical visions of profes-
sional psychology. Whatever the reasons, it is my hope that this volume will
change the current state of affairs. Emphasizing clinical decision making is
apt because it encourages a deliberate, reflective, and intentional stance with
regard to how to go about one’s work as a professional psychologist.
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Because clinical decision making is such a broad term, it has, not surpris-
ingly, many facets and can be approached from many different angles. For
example, Magnavita and Lilienfield (Chapter 2, this volume) offer a power­ful
analysis that deconstructs the key elements of the clinical decision-making
process from the vantage point of cognitive psychology (Kahneman, 2011).
Part of that analysis includes a review of how people make decisions in gen-
eral. Perhaps most central to understanding general decision making is that
human’s process information via two related but separable streams of menta-
tion. The first stream is a fast, relatively automatic, perceptual, holistic, affec-
tive system of processing that sizes up a situation via “thin slicing” (Gladwell,
2005) and forms quick, intuitive judgments. The second system is a slower,
more explicitly self-conscious and deliberate form of thought, mediated largely
by processes of verbal justification. From an educator’s perspective, this is a
basic and central feature of the human mind of which students of profes-
sional psychology should be very aware. For example, a training exercise that
I find useful when the class is viewing video is to stop the tape as soon as the
patient (or client) appears on the screen and ask students for their report of
their immediate perceptions, feelings, and intuitions about the client. Often
trainees are initially reticent to say anything, generally because they don’t
want to appear as though they “judge a book by its cover.” But once they are
given permission, the associations flow, and we see that many impressions are
formed almost instantaneously. They first notice the obvious demographics
of the patient. Then they will notice how attractive they perceive the client
to be and the manner of dress, hygiene, and body position, all which serve as
indicators of socioeconomic status. Following that, a host of more imagina-
tive wonderings will begin. These impressions are examples of thin slicing,
an inevitable aspect of being human, and students need to be aware that they
will then begin to form narratives and expectations on the basis of this very
brief exposure.
Building on this basic formulation of the human mind, Magnavita
and Lilienfeld (Chapter 2, this volume) further articulate how individuals
develop heuristics, the general rules of thumb that are acquired over time that
help consolidate the massive amounts of incoming information into relatively

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 reliable interpretations and guides. Although heuristics are necessary and cen-
tral features of our cognitive system that enable us to get along in our everyday
lives, it is also the case that they can be characterized as “lazy” and “miserly,”
meaning that in the service of efficiency they frequently result in inaccurate
and misinformed judgments. Because the biases and traps are so easy to fall
into, it is essential to teach clinical trainees about these cognitive mechanisms.
Students should be shown explicit examples of how such biases and traps can
lead practitioners astray and should be given training opportunities that allow
them to build self-reflective awareness regarding their own heuristic processing
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tendencies that might result in them deviating from best practice.

Because the mechanics of clinical decision making are well examined
elsewhere in this volume, I do not review them in detail here. From a training
perspective such processes can be subsumed within a broader context—that
is, within the identity and conceptual framework employed by the professional
practitioner. The foundational elements that ground the more microlevel and
situation-dependent cognitive processes can be considered, from the vantage
point of decision making, as the “frame” of the practitioner. The frame of the
practitioner refers to his or her worldview and practice orientation, and it is of
tremendous importance in clinical decision making.
Magnavita and Lilienfeld (Chapter 2, this volume) offer the example
that a psychoanalytic therapist will hear and respond to a patient’s symptoms
in a very different way than a psychopharmacologist. This gives rise to the
question “What is the appropriate frame for a professional psychologist?” My
position as an educator and scholar of the field is that practitioners should
operate from the most coherent and comprehensive frame possible for under-
standing the key elements of a particular situation that requires clinical deci-
sion making. Unfortunately, this is difficult because the field of psychology
is rife with competing, conflicting, overlapping, and somewhat redundant
models and paradigms that attempt to offer practitioners a frame for under-
standing their patients or clients. This chapter introduces a framework that
emphasizes key elements of the training of professional psychologists that
enable them to make good clinical decisions. This framework is grounded
in what is known as a combined–integrated approach to training professional
psychologists (Shealy, 2004) and a more unified approach to the field of psy-
chology as a whole (Henriques, 2011).
The first section of this chapter describes the general scientific human-
istic philosophical approach and key values that we attempt to instill in our
students, followed by a discussion regarding the implications for decision
making. The second section provides a brief overview of the field and articu-
lates why decision making needs to be grounded in a conceptual knowledge
base. Following that an integrative approach to conceptualizing people is
offered that directly informs budding clinicians in a wide variety of different

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 contexts, including consulting and assessing patients. The fourth section
addresses what is perhaps the most well-known and important frame of the
clinical decision making of professional psychologists, the position of the
American Psychological Association (APA) on evidence-based practice
(EBP; APA Presidential Task Force, 2006). The history of EBP is reviewed,
highlighting some of the major historical tensions that went into the emer-
gence of EBP and how we train our students to approach the issue. Finally, an
overview of a new unified approach to psychotherapy is offered that sets the
stage for a heuristic that we train our students to use to frame their decision
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making in psychotherapy, called “TEST RePP.”

CORE VALUES AND A SCIENTIFIC HUMANISTIC PHILOSOPHY

One of the most perplexing challenges for the field of professional psy-
chology has been its struggle to navigate the tensions between the cold logic
of science and the moral necessities of humanism. Indeed, in a seminal article,
Kimble (1984) empirically documented the split between science and human-
ism in the broader field. It is the obligation of professional psychologists to
understand the historical and epistemological issues that have contributed to
this split and to be informed by both scientific and humanistic lenses when
engaged in professional practice. First, by virtue of a core institutional identity,
professional psychology is grounded in science, which means that it embraces
the epistemic values and methods associated with science (Henriques &
Sternberg, 2004). As such, it is crucial that a scientific attitude is instilled in
budding professional psychologists. Some of the key ingredients of this atti-
tude are skepticism and critical thought, a worldview that frames cause and
effect with certain assumptions based on scientific plausibility, and reliance on
evidence acquired in a systematic way (see Lilienfeld & O’Donohue, 2012).
Although a scientific attitude is crucial, it is not all there is to being a
professional psychologist. Indeed, the primary identity of professional psychol-
ogy is as an applied health service profession, and this means that the primary
charge of professional psychology is prescriptive (Henriques & Sternberg,
2004). Ultimately, the function of professional psychologists is to change an
existing state. This can be conceived as having the goal to move individuals
or systems toward more valued states of being, which requires having a broadly
philosophical—some might say metaphysical (O’Donohue, 1989)—position
regarding the values that are guiding one’s actions. The ethical code offered
by the APA prescribes some of the key values that all psychologists need to
consider in their professional behavior but, although essential, leaves much
ambiguity in the details of how to be an ethical, values-driven practitioner.
Because an individual psychologist has the potential for great influence over

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 others, and because much clinical work and professional practice can be inher-
ently subjective, it is essential that students be willing and able to understand
and critically explore who they are; what they believe and why; and what they
must do—personally and professionally—to become highly knowledgeable,
skilled, and competent scientific practitioners. Thus, it is incumbent on the
practitioner to be self-reflective and aware of the assumptions and the broader
worldview that guides their actions. And there must be a narrative associated
with that view that ties together core moral values, such as promoting human
dignity and well-being with integrity (Henriques, 2011). These ingredients
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are fundamentally humanistic in nature.

To understand how training in a broad scientific humanistic philosophy
has implications for clinical decision making, consider the following case:
A 19-year-old college freshman is referred by the office of disability of her uni-
versity for an evaluation because she believes she might have attention-deficit/
hyperactivity disorder (ADHD). The scientific methodological perspective
should inform the clinician to approach this case in a number of different ways.
Specifically, a clinician should be informed regarding the empirical research
that discriminates this disorder from other possible presenting conditions and
be aware of the most reliable and valid assessment measures. Thus, a scientifi-
cally informed clinician would know that impressions formed in the course of
a brief interview are a poor way to diagnose ADHD. Instead, what is needed is
a detailed history of prior behavior patterns such as impulsivity, inattention,
hyperactivity, poor organization, and poor academic performance relative to
intellectual potential, supplemented via perspectives of an informant such as a
parent, coupled with records from past school performance. In addition, reliable
symptom inventories, both self- and observer report, a cognitive and academic
profile suggesting difficulties with attention and processing speed, clinical obser-
vations, and a detailed interview assessing the nature and trajectory of the symp-
toms are all essential to make a diagnosis that would be “scientifically” valid.
But a scientifically informed methodological approach to assessment,
although crucial, is not enough. Indeed, from the vantage point of a larger
metaphysical humanistic philosophical approach, a pristine application of the
scientific method that results in reliable diagnoses and points to evidence-based
interventions might be seriously problematic when viewed from a broader per-
spective. Why? Because diagnostic entities such as ADHD have huge socio-
logical implications. It carries meaning for how individuals understand their
very natures, and there are good reasons to be extremely concerned about
the “medicalization” of human experience. Indeed, the rising epidemic of
mental health concerns (i.e., depression, anxiety, ADHD, etc.) has been linked
by some scholars to the rise of the “disease–pill” model of human experience
(Whitaker, 2010). Because humans are meaning-making entities, a professional
psychologist in this context would be obligated to understand the personal

teaching clinical decision making      277

 significance of this diagnosis and its meaning in the context of this individual’s
social system. It is also the obligation of the professional psychologist to con-
sider his or her role in the context of a system that creates policies that have
broad social implications. There are no simple decision-making algorithms that
can be applied at this level of analysis. However, if we are teaching leaders in
mental health who will attempt to guide the system toward wise policies, it is
incumbent on us to instill in our students a broad awareness of the implica-
tions of our actions beyond the narrow application of the scientific method to
develop reliable, evidence-based answers in specific situations.
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IS SCIENTIFICALLY INFORMED DECISION MAKING GROUNDED

IN A METHOD OR A CONCEPTUAL KNOWLEDGE BASE?

When asked how he defined science, Robyn Dawes, well known for his
work on fostering empirically based decision making, answered,
I would define it as testing hypotheses through the systematic collection
and analysis of data whether via what are called “randomized trials,”
where we randomly assign people to be given a vaccine or not or to a
placebo group, all the way to informed observation. These are really the
two essences of science. (Gambrill & Dawes, 2003; cited in Lilienfeld &
O’Donohue, 2012, p. 59)
Dawes captured the methodological view of science. This view is
embraced by many psychologists, both researchers and practitioners alike.
Indeed, some argue that grounding psychology in the scientific method is
the defining and unifying feature of the discipline (see, e.g., Stam, 2004).
However, from the vantage point of a broad scientific humanistic philosophy,
the purely methodological view of science is inadequate. In isolation, the
scientific method (i.e., generating hypotheses and conducting studies) yields
data and information. However, the professional psychologist needs to oper-
ate first from knowledge and wisdom. The incompleteness of method is obvi-
ous on reflection. Consider the question of why we engage in the scientific
method in the first place. It generally is not solely for the specific data it yields
about the specific phenomena under investigation. Indeed, if the data gath-
ered were not generalizable at all, they would be largely irrelevant because
scientific findings from specific studies—in the absence of a nomological net-
work of scientific understanding—are essentially meaningless. The data and
information from scientific studies become meaningful only when they are
linked with data from other investigations and then placed within a network
of understanding. Thus, science must include attention to the conceptually
grounded meaning-making schema that organizes scientific knowledge.

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 A bit of probing of even the most committed methodologists reveals
this necessity. Consider, for example, the spirited call for the “clinical scien-
tist” model of training in professional psychology offered by Baker, McFall,
and Shoham (2009). Like Dawes, these authors have strongly equated sci-
ence with the scientific method. Yet they acknowledged that the informa-
tion gathered from science must be assessed for its external validity and
generalizability. How do we accomplish this? The authors proclaimed that
the “scientific plausibility” of the information gleaned from the scientific
method must be considered. Consider, for example, that on the basis of the
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authors’ articulation of scientific plausibility, it seems highly likely that they

would dismiss empirical data derived via the scientific method that pointed
to the existence of parapsychological phenomena (see, e.g., Radin, 2011) or
the utility of energy psychology methods in reducing psychological distress
(Feinstein, 2008).
All of this, of course, raises the question “What is ‘scientifically plau-
sible’?” We must have a way of answering this question or else we will simply
generate a mountain of data and information without genuine understanding.
To be a mature science, psychology must have an answer to the following:
Is there a scientifically grounded conception of the human condition that is
rich enough to speak to the complexities of the human experience while also
assimilating and integrating major lines of information gleaned from various
empirical investigations? To the extent that the answer is no, the field of pro-
fessional psychology is destined to be deeply divided. Those who are impressed
with the advances in the natural sciences will lean more toward the epistemic
values of accuracy, objectivity, and reliability of knowledge and will emphasize
the scientific method. In contrast, those who question the extent to which the
natural sciences have effectively elucidated the nature of the human condition
and who value meaning, relationships, subjectivity, and the unique and idio-
graphic nature of the human experience will view the empirical commitment
as sacrificing too much and missing the essence of what it means to be human.
This is the fundamental reason the field has been pulled into two cultures.
The argument here is that the field of professional psychology needs to
evolve from a conception of “science” as consisting solely of the method of
hypothesis testing and data collection as Dawes described it to thinking about
science as a knowledge system that provides a map of the human condition
and our place in the universe. To be a credible system, the map must make
sense out of the field of scientific psychology and point to a way of thinking
about human behavior that offers a sophisticated guide to the practitioner.
The construction of just such a formulation has been the focus of my efforts
over the past decade (Henriques, 2003, 2004, 2008, 2011, 2013a).
Consider that it is not uncommon for students, in the course of their
professional training, to be exposed to approaches such as person-centered

teaching clinical decision making      279

 therapy, cognitive–behavioral and emotion-focused therapy, family systems,
and psychodynamic frameworks. Each of these perspectives has “data” sup-
porting its views, yet they all have quite different fundamental assumptions
that can overwhelm a student (or even a seasoned practitioner!). In addi-
tion, the conceptual connection between the various therapeutic paradigms
and the science of human psychology as articulated by major domains of sci-
entific inquiry, such as evolutionary, personality, developmental, cognitive,
social, and cultural psychology, can easily result in contradictory messages
and confusion.
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For example, many ideas in evolutionary psychology seem to conflict

with a cultural psychological perspective (Henriques, 2011). Even domains
that seem like they should be obviously connected frequently are not. Consider
that as a graduate student I took a personality theories class that was followed
by a personality assessment class, and I found that the two courses were largely
independent from one another. This was so even though they were taught
by the same instructor! The main personality assessment instrument covered
was the Minnesota Multiphasic Personality Inventory—2, and that seemed to
introduce a whole different set of concepts than those that were covered in
the personality theories class, which itself consisted of a series of schools of
thought that were different and often disconnected and contradictory (e.g.,
radical behavioral, psychodynamic, humanistic, social cognitive). And when
I was taught psychotherapy, the perspectives I was introduced to there were
only loosely related to concepts in personality or personality assessment.
Given the enormous diversity, pluralism, and conceptual fragmentation
in the field of psychology, I became deeply concerned that psychology in gen-
eral and psychotherapy in particular were producing vast amounts of infor-
mation but little cumulative knowledge (Henriques, 2011). In the 1990s, I
began work on a project that sought to remedy this problem with a frame-
work that would ultimately become known as the unified theory (Henriques,
2003, 2008). Because the term unified theory might sound to some like an
all-encompassing idea that explains everything and makes precise predictions
about how humans behave, it can also be characterized as a unified approach,
which refers to an integrative metatheoretical framework that can define
the field of psychology; integrate key insights from the major paradigms; and
resolve long-standing philosophical disputes, such as the debates between
mentalists and behaviorists (Henriques, 2004).
The unified approach works via the introduction of several new broad
ideas (the tree of knowledge system, behavioral investment theory, the influ-
ence matrix, and the justification hypothesis) that allow for the key ideas of
the major domains of psychological inquiry (e.g., evolutionary, cognitive,
personality, social, cultural, developmental) and the major therapy paradigms
(e.g., psychodynamic and cognitive–behavioral therapy perspectives) to be

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 effectively assimilated and integrated into a more coherent whole. In short,
the unified theory allows for both the “vertical” integration of the biological,
psychological, and sociocultural dimensions of human functioning and the
“horizontal” integration of perspectives on the human mind and behavior
at the level of the individual (Henriques, 2013b).
The specific details of the unified approach are beyond the scope of
this chapter, and the reader is referred elsewhere for an overview of the ideas
that make up the system (see, e.g., Henriques, 2011, 2013a). What it offers
in terms of teaching good clinical decision making is the position that it is
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both possible and useful to pull together, in a conceptually sound way, the
primary lenses that are offered from the major perspectives in psychotherapy
(i.e., behavioral, cognitive, existential, humanistic, psychodynamic, and
family systems). In addition, it allows a foothold for organizing the vast data
that researchers have gathered about human nature under the broad head-
ing of psychology and the more specific research on psychotherapy such that
those data can be brought to bear on real-life clinical situations in a holistic,
nuanced, and effective way (see also Melchert, 2014).

AN INTEGRATIVE MODEL FOR CONCEPTUALIZING PEOPLE

THAT INFORMS CLINICAL DECISION MAKING

In this approach, concepts and theories are the bridges that link
data and information gleaned from the scientific method to wise practice.
Consequently, a major goal I have as a trainer of budding clinicians is to pro-
vide them with a broad framework that effectively maps the discipline, clears
up the current psychotherapy tower of Babel, and allows the key insights from
myriad perspectives and traditions to be coherently integrated into a whole.
Directly related to clinical decision making in a wide variety of contexts is
the approach to conceptualizing people based on analyzing five systems of
character adaptation and the biological, learning and developmental, and
sociocultural contexts in which the individual is immersed (Henriques, 2011;
see Figure 11.1). The systems of character adaptation refer to the hierarchical
arrangement of mental systems that enable an individual to respond to the
current situation. The character adaptation system theory (CAST) approach
refers to the hierarchical arrangement of mental systems that enable an indi-
vidual to respond to the current situation. From the most basic to the most
advanced, the five systems are as follows: (a) the habit system, which refers to
the basic procedural processes shaped by learning and stimulus control; (b) the
experiential system, which refers to the core of experiential consciousness that
is organized by the flow of perception, motivation, and emotional reactions;
(c) the relationship system, which is an outgrowth of the experiential system

teaching clinical decision making      281

 that tracks self–other exchanges in an intuitive way on the dimension of rela-
tional value and social influence; (d) the defensive system, which refers to the
ways the individual manages psychic equilibrium in the form of experiential
avoidance, dissonance reduction, and defense mechanisms; and (e) the justifi-
cation system, which refers to the verbally mediated explicit beliefs, values, and
attributions people use to make sense of themselves and others.
As articulated by Henriques and Stout (2012), the five systems of char-
acter adaptation provide a framework for assimilating and integrating the key
insights from major traditions in psychotherapy, placed in a biopsychosocial
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context. For example, behaviorists have historically tended to think and focus
on habits, whereas humanistic and experiential practitioners have focused on
core emotions and experiences; psychodynamic practitioners have focused on
underlying relationship patterns and psychological defenses, and cognitive
and narrative therapists have emphasized semantic meaning making in vari-
ous ways. The CAST approach provides a way to understand how these are
all component systems of adaptation that can be effectively woven together
in to a more coherent whole.
How does this system influence clinical decision making? As O’Donohue
and Henderson (1999; cited in Lilienfeld & O’Donohue, 2012) pointed out,
“choosing appropriate treatment methods involves knowing and instanti-
ating causal relations” (p. 51). To do this, a clinician needs to be able to
understand the key variables and their hypothesized causal relations, and the
CAST approach guides students on how to accomplish this. To see this, let’s
continue with the example that was introduced earlier, that of a college stu-
dent who receives a referral for assessing the presence of ADHD and possible
accommodations. Let’s add the following background to the formulation and
then apply the CAST approach to fostering a conceptualization:
Tina is a 19-year-old college freshman. She grew up in a small rural
town in southwestern Virginia. She is a first-generation college student
and entered college with hopes of being a physician. She did extremely
well in high school and has always been very driven and conscientious.
However, her first semester at college did not go very well. She expe-
rienced difficulty making friends, and she was uncomfortable with the
drinking and party atmosphere. She focused a lot on her studies and
studied several hours a day, but she struggled to get the As she expected
(her first semester grade point average was 3.2). Now she is reporting
problems taking tests and staying focused and is worried that she has
ADHD. She is starting to have trouble sleeping; she can’t fall asleep
because she is constantly worrying about what she needs to do the next
day. She is also having nightmares about failing out of school. She
also is reporting frequent stomachaches, and she is now considering
whether she should transfer to a different college because it is closer
to home.

teaching clinical decision making      283

 As O’Donohue and Henderson (1999) pointed out, people consult psy-
chologists because they possess a form of specialized expertise. Specifically, they
are able to understand key psychological variables and causal processes that
contribute to the situation, have knowledge about what might foster adaptive
change, and have a skill set that enables them assist with this process. Yet,
exactly what scientific and professional information is considered relevant,
and how psychologists are to maintain a reasonable level of awareness so that
they understand people’s presenting problems and make epistemologically
informed and ecologically valid clinical decisions, remain extremely difficult
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and contentious. The volume of information and the markedly disparate lines
of thought within our field makes this issue particularly daunting, and the
CAST approach offers a heuristic to delineate key psychological variables that
will enable the effective conceptualization of psychological problems. Here is
an example of a formulation that might emerge if one was to apply the CAST
approach:
Tina is at a key developmental time in her life and is experiencing signifi-
cant distress and psychological dysfunction due to a host of interrelated
variables. Perhaps most salient issue is that Tina seems to be struggling
with her identity and her sense of competence (Justification System),
which is generating significant levels of negative affect, especially anxiety
(Experiential System). It seems that her confusion is tied to her difficul-
ties in adjustment associated with the change in her social context, from
a rural setting to a university setting (Social Context). In the former con-
text, she likely shared many of the social values and was able to perform
in a way that was both personally and relationally affirming (i.e., she
achieved academically and had friends—Justification and Relationship
Systems). However, at college, the social values are deviating from hers
in a way that leaves her more likely to feel isolated and uncomfortable
(Experiential and Relational Systems). In addition, she is finding aca-
demic success more challenging than she expected. Thus, compared with
high school, she is having trouble in two key life domains, academic
and social. It seems that in an attempt to cope with her difficulties and
control what she could (Defensive System), she has tried to increase her
academic performance and has isolated herself a bit from her social con-
nections. Unfortunately, it seems likely that the intense pressure she has
placed on herself to succeed (Defense and Justification Systems) likely
created additional problems because her anxious arousal (Experiential
System) probably had the function of impairing her ability to perform in
high-stakes situations like taking tests, thus creating a vicious, anxiety-
producing cycle. As her general stress level increases, it seems likely that
her basic biological and habitual patterns (e.g., eating and sleeping) have
become disrupted, which will likely contribute to a dysfunctional spiral.
It will be crucial to assess Tina’s family history (past Social and Learning
and Developmental Contexts) and what her status as a first-generation

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 college student and desire to be a physician means in that context
(Justification System). It would also be important to assess for any history
of illnesses (in Tina or her family), especially for anxiety or depressive
disorders (Biological Context). From the vantage point of diagnosis, it
does not appear Tina has problems indicative of ADHD, but depending on
additional information, she might meet criteria for a generalized anxiety
disorder or an adjustment disorder with anxious features.
The CAST approach is a useful heuristic that is justified by its util-
ity, parsimony, and conceptual coherence and is based on the argument that
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clinicians need to be guided by rationally coherent systems, which brings us

to the point of exploring existing systems of decision making. It is helpful
to review the history of the concept of EBP and then offer a framework that
extends it on the basis of a metatheoretical approach to the field grounded in
a scientific humanistic philosophy.

A BRIEF HISTORY OF EVIDENCE-BASED PRACTICE

Professional psychology has long been torn between two visions, the
practice of psychology as an art versus an empirically based science. The artis-
tic vision promotes the image of the master clinician as a wise and insightful
healer guided by a deep intuitive knowledge. A prototype of such a clinician
was offered by Caldwell (2004; cited in Garb, 2005), who, on receiving an
award for his work in personality assessment, gave the following example of
successfully interpreting a Minnesota Multiphasic Personality Inventory:
We got a severe 4-6-8 profile on a young woman. I looked at the tortured
implications of the pattern and somehow said, “She will have something
like cigarette burn scars on her hands, where her father prepared her to
steel herself to the suffering of life.” The round burn marks were on her
hands and extended a little way up her arms. (Caldwell, 2004, p. 9)
In contrast to the vision of the master practitioner as a wise artisan, the
empiricist vision cautions psychologists against such ideals (Garb, 2005) and
emphasizes judgments and decision making based not on intuition and the
like but on existing empirical evidence. The practitioner’s skill is in know-
ing how to acquire, interpret, and apply good empirical data to the question
at hand. Empirically trained practitioners tend to dismiss with skepticism
anecdotes like the one in the previous paragraph and point out the incred-
ible biases of the human mind in seeing spurious patterns in nature. As a
consequence, proponents of the empirical tradition argue that there is a great
need to ground assessments and treatments in those validated by the scien-
tific method. As alluded to earlier, the empirical tradition is now explicitly
represented in “clinical science” training programs (Baker et al., 2009) that

teaching clinical decision making      285

 define clinical psychology solely as a science and generally reject the notion
that clinical practice is in any way an art form.
Historically, these two traditions have been framed as the competition
between the empirical and romantic visions of professional practice (Garb,
2005), but I believe this is an unfortunate way to characterize the split. In
philosophy, there are two broad positions on the mechanisms humans use to
achieve knowledge. The empirical tradition, epitomized by individuals like
John Locke and David Hume, posits that the most fundamental and reli-
able way to achieve knowledge comes from systematic observations and data
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collection. This accords very well with the methodological view of science
articulated by Dawes. The rationalist tradition, epitomized by individuals
like René Descartes and Immanuel Kant, argues that the best approach to
knowledge is achieved by using reason to arrive at conclusions about the most
justifiable claims. Whereas empiricists emphasize “show me the evidence,”
rationalists emphasize “show me the logic and rationale.” Consistent with
my emphasis on approaching human psychology and the profession from the
vantage point of conceptual coherence (Henriques, 2013a), my view is that
the rationalist position has not received enough attention in the identity of
professional psychology. This chapter can be characterized as a call for how to
teach clinical decision making grounded in a rationalist approach. Of course,
empirical data and the honed, artistic skills of the practitioner are valued, but
from this perspective, the central guiding key to wisdom that informs best
practice is a comprehensive system of justification.
Returning to the history of EBP, the competition for the core iden-
tity of practitioners and for the conceptual groundwork for making clini-
cal decisions in psychotherapy reached a fever pitch in the 1990s. Much
of it centered on the debate about the role and place of empirically sup-
ported treatments (ESTs) in psychological practice. For a host of reasons—
managed care being a primary one—pressure was mounting on the field
in the 1980s to demonstrate the effectiveness of psychotherapy interven-
tions. At the same time, there emerged interventions that offered models
and manuals for treatment that could be tested empirically relatively easily.
For example, A. T. Beck produced a model and treatment for depression,
the effectiveness of which he and his colleagues were able to test using a
randomized controlled design. Studies began to emerge that suggested that
cognitive therapy (or cognitive–behavioral therapy) was more effective in
reducing symptoms than either no treatment or control conditions like sup-
portive therapy. From the empirical–methodological perspective such find-
ings were exactly the kind of data needed to ground the field in science.
Many academics began to promote the idea that students of psychotherapy
must be taught empirical approaches and that such interventions ought to
be the first line of treatment in practice.

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 Given that virtually all agree that by virtue of its history and iden-
tity, professional psychology is tied in some way or another to science, one
might think at first glance that the EST movement would not inspire much
controversy. It seems to represent a straightforward scientific advance, and
indeed, from a pure methodological view of science and practice, ESTs are
a straightforward advance. However, from the vantage point of a rational-
ist informed by a broad scientific humanistic view of the field, the issues
are enormously complicated. I offer a brief discussion of just a few of them
and refer the reader to Marquis and Douthit (2006) and Wachtel (2010)
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for more detailed critiques. The overall point here is that from a broad sci-
entific, humanistic, philosophically informed view, it is naive and a form of
scientism (i.e., an overreliance on power of the procedures and methods of
science) to believe that data and information derived from studies empha-
sizing sound scientific methodology should be the sole guide in clinical
decision making.
We can start unpacking the debate surrounding ESTs by considering
that virtually all ESTs are grounded in concepts from the Diagnostic and
Statistical Manual of Mental Disorders (DSM). Many have criticized the DSM,
which was produced largely by the field of psychiatry, as offering an overly
simplistic, medicalized descriptive categorization of psychopathology that
ignores psychosocial etiology and, as such, does not lead to effective treat-
ment plans because it is blind to the dimensions of functioning that are cru-
cial to understand in psychotherapy. Psychodynamically oriented clinicians
were so frustrated by what the DSM failed to capture that they developed
their own Psychodynamic Diagnostic Manual to guide practitioners in assess-
ment and case formulation (PDM Task Force, 2006). Humanistic, critical,
and positive psychologists have all been critical of the DSM system in vari-
ous ways. Even biologically oriented scientists who study mental disorders
have started to abandon the DSM (including researchers at the National
Institute of Mental Health; see, e.g., Insel, 2013). The fact that the major
mental health research institution in the United States is abandoning the
DSM must raise a host of questions about the foundational validity of so
many EST research projects.
The conceptual structure of the EST movement does not implicitly
endorse just the DSM but also the medical model of treatment. By that I
mean that the EST model of psychotherapy assumes that psychological dis-
orders exist within individuals, are of a specific identifiable type, and are ame-
nable to specific interventions that result in helpful change. Conceptually,
the medical model places the disorder as the “figure” to be analyzed, along
with the impact of the specified and generalizable intervention. In the tradi-
tional medical model of researching disorder–intervention match, the per-
sonality of both the individual and the treating professional and the nature

teaching clinical decision making      287

 of their relationship become the “ground” and are generally treated as error
or noise, both in the way the interventions are presented and the way data
are analyzed in randomized controlled trials.
The potential problem with this framing is that many view psycho-
therapy as a psychosocial or human relational process. In this view, the
personality of both individuals in the therapy room and the nature of their
healing relationship are front and center. In his now classic work, The Great
Psychotherapy Debate, Bruce Wampold (2001) argued that the scientific data
were clear on the best way to conceptualize psychotherapy: It should be
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considered a human relational process rather than a depersonalized medi-

cal intervention. Why? According to Wampold, the scientific data strongly
support the notion that it is the quality of the therapeutic alliance that is
more closely associated with good outcomes than is the process of specifically
matching particular techniques to DSM-type problems.
To understand the differences between the two perspectives, consider an
individual diagnosed with clinical depression being treated with a behavioral
activation intervention (e.g., Martell, Dimidjian, & Herman-Dunn, 2010).
The EST approach focuses on the nature of depression as a state of behav-
ioral shutdown, and the key ingredient of change is considered increases in
mastery, pleasure, and rewarding activity. Randomized controlled trials focus
on comparing whether those in a behavioral activation condition show more
symptom relief than those in a different condition. The specific personalities
of the individual and the therapist and their relationship might be exam-
ined as moderating influences but generally are not considered central. In
contrast, the process approach emphasizes that the key ingredient is not the
specific intervention but the extent to which the therapist and client form a
positive, trusting relationship; agree on the formulation; and are able to set
tasks that foster change. This angle on psychotherapy research points out
that widely different approaches to thinking about conditions like depres-
sion (e.g., behavioral, cognitive–behavioral, emotion focused, interpersonal,
modern psychodynamic) tend to get very similar results. The key ingredients,
according to Wampold and other outcome-informed therapists (e.g., Duncan,
2013), are not the model of the disorder or intervention per se. Instead, these
scholars have argued that as long as the model is credible, the key ingredients
are whether the healing relationship is strong, the formulation of the prob-
lem is shared, and the work leads to change-oriented tasks in which both
individuals are invested. Thus, in this case, the key ingredients are whether
the individual is at a stage of change that makes him or her receptive to the
conceptualization of depression offered by behavioral activation, whether the
therapist is seen as trustworthy and knowledgeable, and whether the indi-
vidual is motivated to comply with the tasks designed to change the current
state of affairs. Wampold pointed out that if these ingredients are present, the

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 data suggest the outcomes are the same for all the credible kinds of therapy,
which raises serious questions about a host of issues.
In addition to debates about how to think about psychotherapy in gen-
eral (i.e., whether we approach it via a medical model or a psycho­social pro-
cess), there are many theoretical approaches to psychological treatment, and
when one takes a broad view of the field it must be noted that the EST debate
has been deeply entangled with the competition between the schools of
thought on the various ways to conceptualize people in general and psycho­
pathology and psychotherapy in particular. Compared with psychodynamic
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and humanistic approaches, cognitive and behavioral approaches were more

closely connected with empirical traditions in academic psychology and
were structured in a way to be more readily examined via traditional research
methods. Thus, historically, support for ESTs basically translated into support
for behavioral or cognitive approaches over psychodynamic and humanistic
ones. All these forces set the stage for a deep and complicated debate, which,
as is evident from the growth of “clinical science” programs, has yet to be
settled.
Largely in response to the conflict the EST debate sparked in the field,
the APA developed a broad framework for clinical decision making with
its position on EBP (APA Presidential Task Force, 2006). EBP is defined as
approaching practice via “the integration of the best available research with
clinical expertise in the context of patient characteristics, culture and prefer-
ences” (p. 273). Sometimes conceptualized as a three-legged stool, EBP thus
has three predominant elements that should go into considerations of best
practice: (a) the available research evidence applicable to the current situa-
tion, (b) the professional expertise of the practitioner, and (c) the values of
the client in the given cultural context. The EBP concept is broader than the
focus of ESTs and was issued in part by APA to provide a form of conceptual
rapprochement between the various factions in the debate over the relevance
and power of ESTs to influence practice. For example, the acknowledgement
of both available research and professional expertise in the unique context
of the specific client and culture attempts to speak to both sides of the issue.
The basic framing of EBP provides a generally useful heuristic to guide prac-
titioners in the key elements that should go into the decisions surrounding
assessments, interventions, and consultations. However, despite its usefulness
as a general framework, I have found as an educator that EBP requires more
clarification to serve as an effective guide.
Grounded in the same integrative metatheoretical approach that gener-
ated the CAST approach for conceptualizing individuals, we have developed
TEST RePP to provide students in behavioral and mental health programs
with a heuristic that informs them of how to make effective, holistic, clinical
decisions in a wide variety of professional contexts. It is a framework that is

teaching clinical decision making      289

 embedded in a course on integrative psychotherapy for adults, although it
could extend to other related domains of practice, such as consultation and
assessment. To apply it, we must first articulate a how a broad and general
view of psychotherapy can set the stage for resolving the great psychotherapy
debate and allow practitioners a truly comprehensive framework for ratio-
nally integrating research, professional wisdom, and unique contextual ele-
ments and client values into effective practice.
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A GENERAL, UNIFIED VIEW OF PSYCHOTHERAPY

The argument laid out so far is that if students are going to be informed
consumers of scientific research applied to professional practice, they must
operate from a broad scientific humanistic philosophy of the field. Such a
view will enable them to consolidate findings into meaningful information
that guides their decision making. Without such a framework, the field and
its practitioners are destined to endless debates because of foundational dis-
putes about assumptions that are not resolvable at the level of scientific data
gathering. Earlier I described how a broad scientific humanistic philosophy
is necessary to reflect on and make decisions about diagnoses and develop
holistic conceptualizations that elucidate key variables and their causal inter­
relations in a way that leads to informed clinical decision making. In this
section of this chapter, the focus turns to therapy and how the unified system
offers a new way to approach the field of psychotherapy, one that is quite dif-
ferent from other approaches.
The field of psychology in general and the practice of psychotherapy in
particular have been “pre-paradigmatic,” meaning that there was no avail-
able broad framework from which professional psychologists could operate.
This is apparent when one considers that the emergence of the major schools
of thought were generally through a master practitioner gaining insights
based on useful techniques in the therapy room. Although they were all
students of human nature, the founders of the great therapy endeavors like
Freud, Rogers, and Beck largely started with observations about the thera-
peutic process and generalized from there about insights for the field of psy-
chology. These gurus then generated a following of individuals who tried to
apply their insights and argue for the best approach to psychotherapy on the
basis of this process.
The unified approach advocated for here works in the opposite direc-
tion. It specifically concerns itself with the construction of an integrative
metatheoretical framework that then can be used to assimilate and inte-
grate key insights and findings from both the science of human psychology
(e.g., personality, cognitive, affective, developmental, neuroscience, social,

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 abnormal) and psychotherapy from a multitude of perspectives (e.g., cognitive–
behavioral therapy, psychodynamic). Thus, the unified approach enables
the psychotherapist to move beyond specific paradigms and toward a general
model of psychotherapy that is grounded in the science of human psychology
(Henriques & Stout, 2012; Magnavita & Anchin, 2014; Melchert, 2014).
Because the unified framework enables us to take a broad view of the
field, it is well positioned to advance the search for a more effective way to
approach psychotherapy integration. First, it can offer a general conception of
psychotherapy, one that other perspectives cannot do because they are not tied
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to a coherent conception of human psychology. Via the unified view, psycho­

therapy can be defined as a professional relationship between a patient (or
client) and a professional psychologist who is trained in applying psychologi-
cal knowledge toward improving human well-being. In addition, the integra-
tive metatheoretical perspective can also serve as a way to unify the various
approaches to psychotherapy integration. One such perspective that has been
quite influential has been the common factors approach, which is based on
the early work of Jerome Frank. This view, supported strongly by Wampold’s
(2001) analysis of the field, emphasizes the fact that generally speaking, the
different bona fide treatments yield very similar outcomes (the so-called dodo
bird effect) and thus the primary curative agents are likely in the “common
factors” of the various treatment protocols. One of the most robust findings
in the research on psychotherapy has been the association between a strong
working or therapeutic alliance and good outcomes. Consistent with Bordin’s
(1979) early formulation and much subsequent research, the working alli-
ance consists of three primary components: (a) the bond or quality of the
therapeutic relationship; (b) the shared goals of the therapy, which emerge
out of a shared conceptualization of the problems; and (c) the tasks, which
are the changes and interventions that are hopefully going to take place to
achieve the stated goals. In accordance with this view, students can be taught
to think about general psychotherapy as consisting of the three elements that
together make up the concept of the therapeutic alliance.
Although some tend to think about the therapeutic alliance only in
terms of the process and quality of the relationship, it is, of course, much
more than that. In addition to the human bond, it also involves develop-
ing an effective, shared narrative of the problem and useful tasks that foster
reaching specified therapeutic goals. This is where the CAST approach to
conceptualizing is placed in the system because it attempts to ensure that a
comprehensive, holistic picture of the individual can be formed and in a way
that is both systematic and that can be shared with clients (Henriques &
Stout, 2012). If successful, the conceptualization results in the collaborative
weaving together of the key forces and domains that tell a story of how the
person got to where they are and what will influence their trajectory in an

teaching clinical decision making      291

 adaptive as opposed to maladaptive way. The CAST approach is integrative
because, as mentioned earlier, the five systems of character adaptation align
with the dominant perspectives in individual psychotherapy. The conceptual
foundations that drive behavioral, experiential, modern, psychodynamic,
cognitive, and narrative approaches can now be integrated into a holistic
biopsychosocial formulation. Thus, students can now effectively transcend the
competing insights from these grand traditions and coherently integrate them
into a more cohesive framework.
If this is done well, the case formulation gives rise to the goals of the
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therapy, which can be framed as a description of what would influence the

ultimate outcome to be desirable and adaptive (e.g., if an individual could
be less negative in their self-talk, be more assertive in their relationships,
become aware of ways they defend against certain feelings). In this light,
the goals of therapy can be now framed as decreasing distress and dysfunc-
tion and increasing valued states of being. Finally, these goals can then
be matched with the empirical literature in psychotherapy, and a series of
therapeutic tasks can be developed that can be expected to have a positive
impact on the stated goals. In short, for the first time there is now a model
of psychotherapy that can be effectively corresponded with the science of
human psychology, allowing for much more unity and synergy between these
two branches of our field.

A FRAMEWORK FOR CLINICAL DECISION

MAKING IN PSYCHOTHERAPY

The three broad domains of a general psychotherapy (relationship,

case formulation, and intervention assessed via clear outcomes) grounded
in the conceptual map provided by the unified theory enables students to
disentangle the complicated process of psychotherapy into more discrete,
but clearly related, parts. To foster a deliberate working conception of the
kinds of thought processes that ought to be guiding them in their clinical
decision making, students are introduced to the mnemonic TEST RePP,
which stands for “Theoretically and Empirically Supported Treatment and
Relationship Processes and Principles.” It provides a heuristic that cap-
tures the key elements that evidence-based practitioners ought to be aware
of and adhering to. It is specifically organized in a way that allows the field
to transcend the current “midlevel” paradigms, build bridges between psy-
chotherapy research and meaningful practice, and move toward resolving
the great psychotherapy debate by holding both the “disorder–intervention”
and “healing relational process” perspectives in complementary relation to
one another.

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 TEST REPP APPLIED TO THE CASE OF TINA

Each element of TEST RePP is described in greater detail in the sub-

sections that follow. To help see how its elements have implications for clini-
cal decision making, it is applied to Tina, with the context being that she
has come to see a staff psychologist at a college counseling center, seeking
guidance on what she should do and greatly desiring to reduce her distress.
Note that TEST RePP guides the clinician within the context of an appropri-
ate, ethical, and professional therapeutic relationship, and the assumption is
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made here that the proper considerations have been taken in setting up the
frame for the relationship.

Theoretically Supported Treatment

A basic principle stemming from the argument thus far is that, as phi-
losophers often point out, “facts are theory laden.” Professional psychologists
must be aware that humans do not perceive the world directly as it truly is
(whatever that might mean), but we have perceptual and conceptual catego-
ries that enable us to actively make meaning out of the patterns in the world.
This is the first meaning of the word theory here. Because the background
conceptual structure “frames” what the practitioner sees in making decisions,
it is crucial that the practitioner be as fully aware of those structures as pos-
sible. This starts at the level of broad philosophy and worldview and includes
the views the professional psychologist has for how the world works, his or
her religious and political perspectives, beliefs about the nature of human
nature, and beliefs about humanity’s place in the universe at large. If these
sound deeply philosophical, they are. This is central because we relate to our
clients at the level of meaning and inevitably hear their stories through a
particular lens defined by our worldview.
Applied to Tina, consider how a Christian psychological practitioner
might hear and respond to her story differently than a secular skeptical prac-
titioner. To do so, let’s make the reasonable assumption, on the basis of Tina’s
story and the demographics of southern rural Virginia, that she was raised in
a socially conservative, Christian home. If so, it follows that some of her cur-
rent anxiety and confusion likely would stem from the potentially conflicting
messages she has received in the context of her transition from a socially and
religiously conservative environment where she felt comfortable to one that
is more secular and has looser mores regarding drinking and sexual activity. If
so, then it is highly likely that a socially conservative Christian psychological
practitioner will hear Tina’s story differently than a purely secular practitio-
ner. This is the case even when both practitioners are engaged in “secular”
psychotherapy and are appropriately ethical and sensitive about imposing

teaching clinical decision making      293

 their own personal beliefs on the therapy practice. The issue here regarding
clinical decision making is one of awareness as opposed to explicit formula-
tions regarding what one ought to do. Because these deep structures will have
a profound impact on how we practice, a foundational pillar of good prac-
tice is to have strong self-reflective awareness of one’s identity, deep-seated
beliefs, and values and the capacity to clearly identify the ways in which
those frames influence how one hears and responds to a client’s presentation.
The second meaning of the term theory refers to the practitioner’s
knowledge of human psychology. This consists of the biological, develop-
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mental, and social understanding of personality, psychopathology, relational,

and human change processes through which both the individual and the
process of intervention will be understood. Professional psychologists should
have basic knowledge of elements such as behavioral genetics and their influ-
ence on mental illnesses; personality traits (e.g., neuroticism and conscien-
tiousness); emotions and motivations; social psychological processes of first
impressions, stereotypes, attitudes, and attributions; and general knowledge
of intelligence and academic aptitude, along with categories and classifica-
tion of mental disorders (i.e., the DSM).
This second level of theory, knowledge of human psychology, is usu-
ally organized around and telescoped into the primary paradigm of practice
that the professional operates from (e.g., third wave cognitive–behavioral
therapy, eclectic therapy, emotion-focused therapy). A humanistic psychol-
ogist operating from a person-centered approach would likely emphasize the
external pressures that Tina is experiencing that “force” her to feel com-
pelled to fit into a specific socialized mode. The assumption that she has
within her an organizing growth force will position the humanistic prac-
titioner to make choices in the therapy room to focus on Tina’s internal
emotional experience and create a relational context of empathy, congru-
ence, and positive regard in which she can begin to discover and give voice
to her “true” self, which is seen as central to healthy development from the
vantage point of the humanistic tradition. In contrast, from a traditional
cognitive–behavioral perspective, a psychological practitioner will attend
to the interpretations and beliefs that Tina has about herself, others, and
her situation. These beliefs will be seen to be the key to understanding the
negative emotions and maladaptive behaviors that follow. Here the thera-
pist will listen for how Tina’s story indicates the presence of beliefs that she
is incompetent or that she must get all As in order to be successful. From the
current perspective, it is the obligation of the practitioner to be able to iden-
tify the general paradigm from which he or she is operating in understanding
Tina and explain how it is consistent with the body of human psychological
knowledge in general. This is deemed to be a basic requirement of doing
psychological therapy.

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 One of the distinguishing features of the unified approach that fos-
ters advances in this area is that because its starting point is a holistic view
of human psychology, it sets the stage for a much greater correspondence
between the body of psychological knowledge and the conceptual under-
standing of the current situation. For example, as articulated when describing
how Tina might be conceptualized, lenses from a wide variety of different
domains were combined in a holistic picture, including biology and behav-
ioral genetics, learning and development, interpersonal and sociological,
behavioral (habits), experiential and emotion focused, psychodynamic (i.e.,
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defenses and relational schema), and cognitive–narrative perspectives.

In short, to effectively decide how to frame the therapy with Tina, the
professional psychologist must be clear about his or her theoretical and con-
ceptual frame. The reason for this is that it guides how the psychologist sees
Tina, conceptualizes her problems, and inquires about and deciphers Tina’s
valued states of being. It also informs the psychologist of how to think about
the current condition, the key causal variables that led up to it, and the pro-
posed mechanisms of change. The argument here is that the more coherent,
clear, and comprehensive one’s approach is and the more it aligns with our
knowledge of human psychology, the better the decision making that will
ensue about a particular case. That said, I am not advocating for a “purely”
rationalist approach to intervention. Coherent and comprehensive formula-
tions must be buttressed and informed by the empirical literature that has
been done on cases similar, and that brings us to the next piece of TEST
RePP, the EST.

Empirically Supported Treatment

As valuable as theory is, it needs to connect to and correspond with

empirical research. Indeed, research and theory are complementary ingredi-
ents to growing our scientific knowledge. In this context, we can be reminded
of Eysenck’s (1952) famous early challenge to the field of psychotherapy,
which was an important motivator to examine whether psychotherapy is
actually helpful. Decades of empirical research have since demonstrated
that, generally speaking, psychotherapy is an effective health intervention
(Lambert & Bergin, 1994). In addition, much has been learned about the
elements that are effective and associated with positive outcomes, and prac-
titioners have an obligation to be aware of the research on the validity of the
assessment instruments and treatment interventions they use. In addition,
psychologists should be aware of their personal biases and seek to check their
beliefs against objective research, be cognizant of the way motives and needs
influence one’s beliefs and perceptions, and be aware of alternative perspec-
tives. They should also be aware of the way the research they are interpreting

teaching clinical decision making      295

 was conducted, be able to critique issues of methodology that might raise
questions of internal validity, and have a conceptual map that allows them
to consider issues of generalizability.
More concretely, practitioners operating in well-researched domains,
as when working with anxious adults like Tina, should be aware of empirical
findings associated with different treatment interventions, such as cognitive–
behavioral and psychodynamic approaches, as well as common medications.
Intervention principles that have consistent connections with good out-
comes, such as those involving exposure with response prevention, should be
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at least acknowledged and seriously considered in a case like Tina’s. Indeed,

if there is a clear desire by the patient to reduce his or her anxious symptoms
and there is good reason to believe that the levels of anxiety are contributing
to dysfunction in important areas (as in Tina’s case), it is the obligation of the
practitioner to provide guidance toward interventions that have been empiri-
cally shown to be effective at reducing anxiety and improving performance.
In the case of Tina, for example, it seems that the minimum a pro-
fessional psychologist should be aware of in terms of the broad empirical
literature on reducing anxiety is summed up well by the renowned cognitive–
behavioral psychotherapy researcher David Barlow. Reviewing a large litera-
ture on ESTs, Barlow and his colleagues have suggested that practitioners be
able to view depressive and anxiety disorders from the general perspective of
negative affect (Barlow, Allen, & Choate, 2004). From this, he argued that
research has demonstrated three broad principles that foster effective treat-
ment: (a) reducing catastrophic or overly pessimistic expectations for future
events, (b) reducing avoidance patterns and increasing the capacity to stay
with aversive emotions, and (c) training individuals to develop antithetical
emotional responses to their dominant response style (e.g., fostering general
relaxation skills for anxious individuals). Thus, high on the decision-making
list of the clinician working with Tina are the following questions: When
should Tina’s anxiety symptoms become the focus of the intervention, how
should they be conceptualized with her, how should she be motivated to
engage in interventions known to be effective, and how can the utility of
these interventions be tracked?
Generally speaking, the term treatment here evokes a “medical model”
conception, in which the individual is thought of as having an identifi-
able problem that can be matched with a set of interventions that will
alleviate the difficulty. This model is the dominant frame of thinking in
cognitive–behavioral literatures, and from our broad scientific humanistic
view of human psychology and psychotherapy, it is a useful framework. But it
is limited in scope. It often fails to consider deeply other issues of personality,
especially identity and relational functioning. And it frames psychotherapy
in a particular way that can blind practitioners to equally important aspects

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 of treatment. As mentioned earlier, referencing the great psychotherapy
debate, the other major perspective is to consider the process of psycho­
therapy as a psychosocial or relational one, whereby two individuals enter
into a meaningful professional relationship with the intent of relieving
distress and improving functioning. Students should be taught and profes-
sionals should be able to think about the psychotherapeutic process both
as matching a presentation to an intervention and as a unique human rela-
tionship process that unfolds between two individuals. This brings us to the
“Re” in TEST RePP.
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Relationship

Whereas the “EST” stands for thinking about systematic interventions

that might reduce suffering and improve functioning, with “relationship” the
focus shifts to the nature of the exchange between the practitioner and client
and their personalities as well as the broader social variables at play. At a
basic descriptive level, this would include attention to the gender, age, and
socioeconomic and ethnic background of both parties. But it is much more
than that. Every psychotherapy encounter consists of two unique individu-
als experiencing one another at a unique moment in time. The individual
uniqueness of both the therapist and the client tend to be considered either
error or noise in traditional treatment research. That is, for research purposes,
the treatment is standardized, a set of inclusion and exclusion criteria are
developed based on symptoms, and then the results are reported in aggregate
form, averaging across groups.
Humanistic and psychodynamic thinkers have done the most developed
systematic work on the therapeutic relationship and how it can be used to
foster healing. As noted previously, a strong empirical claim can be made that
the effectiveness of psychotherapy is related to and dependent on the qual-
ity of the therapeutic relationship. There are several crucial key relationship
variables. First, it is important that the therapist be seen as competent, trust-
worthy, and someone who has the best interests of the client at heart. The
client must experience positive regard from the therapist as well as empathy
and warmth. Moreover, therapists are expected to have inter­personal grace
and be able to understand how they feel about their clients and maintain a
helpful, professional stance.
Second, the unique interpersonal relationship provides a wonderful
opportunity for psychosocial learning. Thus, the therapist ought to be skilled
in the art of interpersonal process, and should be dialoguing, when appropri-
ate, about the way the exchange is unfolding and eliciting narrative from
the client about how his or her experience of the therapist relates to past
experiences. The opportunity for this kind of conversation should be present

teaching clinical decision making      297

 in all meaningful therapy, certainly not just analytic therapies that emphasize
working with transference.
Third, the therapist should be effective at tracking the nature of the
relationship and pacing it appropriately. Interpersonal process comments
need to be timed appropriately relative to the nature and development of the
relationship. For example, strong feelings toward the therapist are much less
likely to be present very early in the process. In addition, recognizing poten-
tial ruptures and subtle changes in the patient’s attitudes about either the
therapy or therapist is crucial to maintaining an effective working alliance.
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With regard to Tina, the relationship factors will likely be central in a

successful intervention. They are also likely to be complicated. It is reason-
able to surmise that Tina is both feeling extremely vulnerable and at the
same time desperately seeking guidance. In addition, given the context of
her emergence into the therapy system via a referral for ADHD, it is highly
likely that Tina will already feel frustrated with the system. If she wanted a
label, a pill, and accommodations to foster her academic performance and
she gets referred for the reflective work of psychotherapy, then there already
is a mismatch between what she anticipated and what she is receiving. And,
given that her anxiety symptoms are likely a function of the fact that her core
emotional self is feeling overwhelmed by deep existential conflicts, it seems
highly likely that she will be defensive about exploring such issues, espe-
cially when she is feeling the pressure to make a life decision quickly (i.e., to
transfer or not). Because of all of these factors, she likely will not have much
tolerance for a slowly developing therapy (i.e., a therapy that does not help
her feel grounded and better quickly). And yet there is the very real concern,
which many therapeutic perspectives would emphasize, that a therapy that
moves too quickly and a therapist who is too directive might short-circuit a
key developmental task, that Tina needs to sort these issues out for herself,
and that the job of therapy is to provide her with a context for doing so
but not necessarily to be an advice-giving guide. The point here is that the
decisions that will go into establishing a working relationship with Tina will
have a number of potentially competing considerations that require thought-
ful reflection. This point raises the question regarding the final elements of
TEST RePP, which involve a description of the key processes and principles
that ought to guide practitioners in their work.

Processes and Principles

The last two elements of TEST RePP remind practitioners of how to

be guided by their knowledge systems. Historically, the emphasis on empiri-
cism has been so strong in certain domains (i.e., academia) that the mes-
sage seemed to be that rigid adherence to specific procedures enacted by a

298       gregg henriques

 practitioner following a step-by-step treatment manual were the key to sci-
entific treatments. Thankfully, it now appears that the majority in the field
are moving away from the attempt to reduce the therapeutic process to a
series of prespecified steps, like what one would do when baking a cake, and
more toward a view that recognizes therapy as an organic process that should
not be overly structured like some algorithmic recipe. The latter has long
been the model of humanistic and psychodynamic practitioners and is now
becoming the general way many cognitive–behavioral practitioners operate.
For example, acceptance and commitment therapy, a new wave cognitive–
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behavioral treatment, emphasizes a set of guideposts for clinicians as they

form a relationship and foster commitments toward valued goal states (Hayes
& Spencer, 2005).
“Processes and principles” is an attempt to remind wise practitioners of
the guideposts that are shaping their work and orient them toward the rest
of the TEST RePP formulation. With regard to processes, I emphasize three
broad domains of process that I encourage students to keep in mind as
they make decisions about what to do in their psychological interventions:
(a) awareness, (b) acceptance, and (c) active change. Central to all therapeu-
tic encounters is assessment—problem formulation and fostering systematic
awareness in relative parties regarding the nature of the problem and the
variables that are contributing to it. Human behavior is enormously com-
plex, and humans notoriously are unaware of how much they do not know or
understand. Much of the work of a psychologist is the process of developing
a shared formulation that fosters clarity about the current situation. As such,
a key treatment process variable for the psychologist to keep in mind when
making decisions is awareness, in terms of understanding what level of aware-
ness the client has, how greater clarity might be achieved, and self-reflective
awareness of the psychologist.
Although traditionally psychoanalytic practitioners deemed awareness
(or insight) as fundamental to a successful intervention, it is now generally
understood that treatment must be geared to more than fostering awareness.
The other two process variables, acceptance and active change, are both quite
complicated, but they can serve as guideposts to the process of therapy. For
example, learning to accept the aspects of the world that cannot be controlled
is now broadly recognized as a key ingredient to mental health. The rise of
mindfulness as a key ingredient to many therapeutic perspectives is a testa-
ment to the centrality of enhancing capacities for acceptance. And for as long
as people have being doing therapy, acceptance of past losses, unfinished busi-
ness, failures, or traumas (usually via fostering a more compassionate attitude)
and of warded-off feelings have been salient aspects of the therapeutic process.
Of course, sometimes people need to actively learn how to be dif-
ferent so that they are in a better place to flourish and avoid the vicious,

teaching clinical decision making      299

 maladaptive cycles associated with their distress and impairment. When
this is the case, the focus of therapy is on fostering active change. Individuals
often need to learn to do things differently, whether this involves altering a
maladaptive habit, training themselves to think differently, or developing
a new relational skill. Here, understanding the process of human change is
crucial, including recognizing the client’s stage of change, how gradual and
dramatic change can happen, and how changes can be maintained. The
twin processes of acceptance on the one hand and active change on the
other can seem almost contradictory. However, it is worth noting that both
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psychodynamic (Wachtel, 2011) and cognitive–behaviorally oriented

(Linehan, 1987) practitioners have helpfully pointed out that acceptance
and change can be thought of as existing in dialectical relationship to one
another. This dialectical emphasis offers a more useful holistic view of
the two processes than when they are viewed separately or in conceptual
contrast to one another.
With regard to Tina, issues of awareness, acceptance, and change are
all very salient. Sooner rather than later she needs to develop a better way of
understanding her character and her situation and the origins and nature of
her anxious symptoms. It seems likely that she lacks awareness about many
of the features that are contributing to her distress, and if so, this needs to be
addressed. At the same time, she needs ways of coping with her immediate
problems that will help improve her functioning. My approach would be to
take an active stance, helping Tina in a fairly direct way to come as quickly as
possible to the understanding of her situation that is spelled out in the formu-
lation described earlier. That is, I would likely use the approach of a “thera-
peutic assessment” (Finn & Tonsager, 2002) to attempt to generate such an
understanding. From there, a shared plan could be developed that teaches
her evidence-based strategies to (a) reduce her test anxiety; (b) enable her
to increase her social support; and (c) adopt a longer term, hopeful perspec-
tive about what she might learn about herself in the context of this difficulty
with adjustment. If this stage was initially successful and her symptoms were
stabilized, then a focus on her core identity, purpose in life, and relational
style and needs could be employed to build a deeper, more aware and resilient
character structure that would enable her to make more adaptive interpreta-
tions and decisions, both in the short and long term.
The final “P” in TEST RePP stands for principles. It serves two related
functions. First, the goal is to remind budding practitioners that they are
guided by principles—values, goals, and knowledge bases—and that effec-
tive clinical decision making involves a frame that keeps these ideas salient
and keeps the practitioner reflective and aware of his or her actions. The
second function of “principles” is to help elucidate the more specific guid-
ing frames that inform practitioners regarding their practice. It encourages

300       gregg henriques

 them to consult both the literature and existing practice guidelines in their
work. A sample of key treatment principles is offered in Appendix 11.1.

SUMMARY

If we are to produce ethical, self-reflective, and effective professional

psychologists, we must be able to teach them the capacity to deeply answer
the questions “If this is the case, what should you do and why?” and “In that
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situation, why did you do what you did?” These basic questions provide the
frame for thinking about clinical decision making, and it is crucial that prac-
titioners of psychotherapy have solid justification systems that guide them.
The field of professional psychology has historically not attended
systematically to the process of clinical decision making as much as other
health care professions, such as nursing and medicine. In addition, the field
has often been characterized as being split between empirical and romantic
visions of practice, with the former emphasizing decisions grounded in data
derived from the scientific method and the latter emphasizing the deep, intui-
tive skills of the seasoned practitioner. It is time that we transcend this old
dichotomy and move toward a different conception of science and a more
rationalist approach to intervention. It has always been the case that the
only effective bridges between the worlds of research and practical knowledge
are found in concepts and theories. Thankfully, for the first time, there are
comprehensive, scientifically grounded visions for human psychology that
effectively bridge to the world of practice. Thus, we are set for a new era of
unification and synergistic growth between the fields of professional practice
and human psychology.
This chapter has outlined some of those emerging perspectives and
articulated how a unified view of practice and human psychology can give
rise to a scientific humanistic perspective on decision making that speaks
both to methodological issues of precision, reliability, and validity and to
broader philosophical questions. There is also now a model for conceptualiz-
ing the human condition that transcends the traditional midlevel paradigms
and affords practitioners a systematic approach to conceptualizing that is
grounded in scientific rationality.
APA attempted to bridge the disputes between clinical researchers and
practitioners with its guidelines for EBP, which emphasizes the three domains
of best available research, clinical experience, and patient values in the par-
ticular cultural and policy context as being the primary sources that practitio-
ners ought to be relying on when developing their interventions. However,
more specificity is needed in helping students approach their clinical deci-
sion making about psychotherapy interventions. The reason for this is that

teaching clinical decision making      301

 the vast field of psychotherapy is conceptually fragmented at a multitude of
levels. To address the conceptual fragmentation, a heuristic frame going by
the acronym TEST RePP, which stands for “Theoretically and Empirically
Supported Treatment and Relationship Processes and Principles,” was devel-
oped that attempts to delineate the key conceptual elements that ought to
guide decision making in developing and enacting such psychotherapeutic
interventions. This perspective allows future practitioners to address the
competing paradigms in the field, provides them with an integrative meta-
perspective, and allows them to appreciate and consider major debates in
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the field of psychotherapy research (e.g., medical model vs. psychosocial

process). We hope practitioners informed by this model will make more
effective clinical decisions.

302       gregg henriques

 APPENDIX 11.1

The following list offers some of the key principles that guide effec-
tive psychotherapy. This attempts to breakdown the elements of TEST RePP
in a way that is congruent with the empirical literatures in psychology and
psychotherapy.
1. Set an appropriate, ethical frame. Psychotherapy is a relationship
that is grounded in professional obligations and constraints,
and it is crucial that all stakeholders involved understand the
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purpose and function of the relationship; issues of confidenti-

ality; financial reimbursement; general focus of the work; and,
where appropriate, expected time frame.
2. Begin to foster a strong therapeutic relationship. It is crucial that
the psychologist exhibit a level of competence and respect
toward the client such that the client feels valued and heard
and believes the therapist can help where appropriate.
3. Identify cultural context variables. Consideration of the social
construction of identities is crucial for both the therapist and
the client. When the client and psychologist do not share the
same broader cultural background, particular attention should
be paid to how the influence of cultural context might lead to
differences in communication patterns, expectations of roles,
core values, and so forth.
4. Identify client values and hopes. The central goal of psychother-
apy is to enhance adaptive ways of living, a central element of
which is the client’s value states of being.
5. Identify risk of harm. A fundamental tenet of practice is to min-
imize the risk of harm. A practitioner must be reflective about
the possible ways an intervention might have unintended side
effects. If there is anticipated possible harm, all parties should
be informed, and that must be carefully weighed against prob-
able benefits.
6. Begin to formulate an ongoing case conceptualization. A compre-
hensive assessment includes a general categorization of the
major symptoms, character, key developmental factors, rel-
evant biological and sociocultural variables, current relational
context, and major stressors and affordances in the environ-
ment. In addition, a systematic approach to assessing rela-
tional style, identity, and presenting problem (i.e., diagnosis)
should be included.
7. Begin to identify realistic, adaptive treatment outcomes. The ther-
apist should work with the client to identify therapy goals in

teaching clinical decision making      303

 the context of the client’s values and stage of change within
a holistic, biopsychosocial, developmental conceptualization.
In cases of excessive maladaptive symptoms, these goals are
often straightforward (e.g., reducing levels of depressive symp-
toms). Sometimes, however, goals need to be more focused on
awareness (i.e., increasing values or clarifying identity issues)
or acceptance of past losses or current injury.
8. Tailor treatment to level of client functioning. More than any-
thing else, treatment outcomes are determined by the client’s
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history, level of impairment, and attitude about therapy. It is

crucial that the goals of therapy consider this fact. It is also
recommended that therapists increase their levels of direction
and guidance when impairment is high.
9. Consider therapy as a nonlinear process of fostering awareness,
acceptance, and compassion and of engaging in active efforts to
change. Although therapists should have a clear road map of
their work, it is also the case that therapy is rarely a simple,
linear, stepwise process. Instead, many times individuals have
symptoms that are the consequence of tangled and confused
psychological processes that require an unfolding of aware-
ness, acceptance, and active change, in varied sequences.
10. Reducing maladaptive levels of negative affect. When the major
treatment goals include reducing the levels of negative affect,
the treatment plan should consider the following: (a) altering
maladaptive antecedent cognitive appraisals, (b) identify­ing
layers of emotional–experiential processing and preventing
problematic avoidance (i.e., foster exposure and acceptance),
and (c) facilitating action tendencies antithetical to the dys-
regulated emotion (teaching clients to relax when they are
anxious or becoming active and to focus on mastery or pleasure
when they are depressed).
11. Altering problematic aspects of relationships and identity. When
the major treatment goals include altering aspects of iden-
tity and maladaptive relationship patterns, the practitioner
should consider (a) patterns between old relationships and
current relationships, looking especially for vicious relation-
ship cycles; (b) role functions and conflicts relative to core
relational needs; (c) developing awareness of purpose in life,
existential narratives, and problematic core beliefs and con-
sidering ways to renarrate self or life in a healthier way;
(d) fostering compassion for both self and other and flexibility
in human relating; (e) making conscious defense mechanisms

304       gregg henriques

 and working toward restructuring maladaptive defenses; and
(f) ways to increase agency, coherence in identity, or coping
self-efficacy.
12. Monitor changes in desired goals. Once problem areas and treat-
ment goals are identified, therapists should monitor changes
in symptoms and problem areas (e.g., with appropriate test
instruments).
13. Monitor client satisfaction and attitudes about the therapist. In
addition to monitoring symptom outcomes, it is crucial that
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regular feedback is solicited about the satisfaction the client

has with the therapist and the treatment. Ideally, there should
be intermittent opportunities designed to solicit authentic
opinions about the treatment.
14. When there are ruptures or failure to make adequate progress,
process this and be open to making changes.
15. Plan for termination, monitor changes, and taper therapy if neces-
sary. Therapy, especially when financed by an outside source,
should be conducted in a time-sensitive way. It is the obli-
gation of the health care professional to foster treatment
advances as efficiently as possible and not to extend treatment
beyond what is necessary.

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