Will Your Treatment Plans Actually Survive a Doomsday Scenario? By Lawrence Rubin, PhD, ABPP on 8/5/22 - 3:49 PM

As a practicing clinical supervisor, and when I have attempted to teach graduate counseling students the differences between the art and science of psychotherapy, I have been careful to flavor my guidance with what I hoped would be just the right amount of professional ethics. And sometimes for good luck, I would add a pinch of legal-speak. But what seems to have resounded most loudly from my lessons were those that were worst case scenario-infused examples of what to do in clinical work to avoid, or at least contend with what one of my supervisees called, “Dr. Rubin’s Doomsday Scenario.” And this particular form of supervision-by-terrorization centered around the simple question, “what if you had to defend your treatment plan and/or intervention on the stand to an overly aggressive plaintiff’s attorney whose aggrieved client claimed that your treatment had caused them harm?

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With the exception of those students/supervisees who were subsequently influenced to reconsider their professional trajectories, the rest learned the importance of justifying their treatment plan and techniques by locating their foundation in the quantitative research literature and/or the position statements/practice parameters/best practices guidelines of respectable and respected clinical organizations such as the American Psychological Association, American Counseling Association, National Association of Social Workers, American Association of Marriage and Family Therapy, American Academy of Child and Adolescent Psychiatry.

So, when I recently met with one of my clinical supervisees who had implemented what seemed to be a creative, and as he related, effective intervention around trauma in a therapy group, I asked him the simple question, “Where did this technique come from?” Quite pleased with himself and the apparent sweet fruits of his empathetic and creative labors, he couldn’t quite recall the source of the intervention. “I did my research….I found it somewhere online,” he said sheepishly, knowing from his experience with me, that such a response would likely be met with less than positivity, enthusiasm, and accolades for his clinical decision making.

“Somewhere online,” I mused inwardly. Oy! Where had my lessons gone? Had I failed him? Had he failed his clients? Would he fail on the stand if even one of the clients in that trauma group complained about his intervention or its unintended aftermath? So, I asked for more feedback to which he responded by saying that he had chosen the exercise for the group because after reviewing their clinical files and having worked with them both individually and in group, and due to their shared histories of trauma, the intervention made sense at that juncture. And because these clients had other group activities throughout the day that did not rely on creative/expressive media, he thought that inclusion of such would be particularly appealing to them and provide them with an alternative means of expressing their trauma-related feelings, memories, and somatic experiences. He added that he had tried using this exercise in the past but was not successful because those clients were far less open about their trauma and generally treatment resistant. Further, past therapy groups had not gelled as did the current one with which the intervention seemed so successful. He concluded his justification non-defensively by saying that group members responded very well to the exercise, seemed generally and genuinely grateful, were able to express their vulnerabilities, and had even highlighted each other's strengths during the debriefing.

Truth be told, I was pleased with what I heard. And I was quite proud with the way he had accumulated his “practice-based evidence” (as opposed to evidence-based practice), had taken the time to study the clients’ individual and collective histories, drew from his experience with each off them and as a cohort, and then tailor-made the intervention to their collective needs. And while that fictitious plaintiff’s attorney might have torn him to shreds on the stand, even if the counterargument was made that this was a well-researched, deliberated, and implemented intervention, he demonstrated a scientific and artistic approach to clinical service delivery. And isn’t that what we hope our interns and counseling students will be able to do some day?


I remember something David Nylund once said when presenting at the 2001 Pan-Pacific Brief Psychotherapy Conference in Japan. He mused, “I believe in evidence, but I am more interested in what constitutes evidence, and who gets to decide on what counts as evidence. Is it professionals, licensing boards, researchers, and journal editors? Or is it clients? If a young person can reclaim his life from ADHD, for example, and we create and circulate a therapeutic letter about his experience, I consider that just as compelling as a randomized clinical trial.”

Well, I don’t think that Nylund’s constructivist rejoinder would satisfy that attorney, but it works for me, as did the intervention and justification my intern demonstrated.   

File under: The Art of Psychotherapy, Musings and Reflections, Therapy Training