Practical Psychology: For Clinical Psychologists

Practical Psychology:

for

Clinical Psychologists

Author: Robert Jones AFBPsS

Chartered Psychologist

CCAPS Publishing

© 2018 Robert Jones

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Cardiff Counselling & Psychological Services

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Practical Psychology for

Clinical Psychologists

Robert Jones

About the Author

ROBERT JONES HAS HAD a varied career path. After leaving school at the age of fifteen years with no qualifications because, according to his teachers, he wasn't good enough to study for GCE 0 level qualifications, he embarked on an apprenticeship with the North Thames Gas Board, in Essex, UK. After a number of years during which he travelled to Australia and New Zealand and back to the UK; and also during which his career included gas fitting, plumbing, fire-fighting, teaching, and providing nutritional consultations Robert qualified as a Clinical and Counselling Psychologist and he is registered in both fields with the Health Care Professions Council (HCPC) in the UK. Robert is also a Chartered Member of the British Psychological Society (BPS) and he is an Associate Fellow of the BPS (AFBPsS).

Over the years Robert has developed a wide range of skills in performance fields. For example, while pursuing his teaching career he also was a professional puppeteer, part-time film and TV extra, and singer. These skills have become invaluable in his work as a psychologist, allowing him to extend himself when working as a therapist, particularly when working with children.

Robert's lowly beginning has availed him many opportunities to help his clients to recognise their own potentials. By expounding on a range of life experiences while giving the client the understanding that he is discussing another person, not himself, Robert is able to guide his clients while he is encouraging them to reach their goals and, thereby, further their own emotional development.

Having worked as a psychologist in hospitals both in Australia and various parts of the UK, Robert is now in private practice. He accepts referrals for clients with a wide range of psychological/emotional difficulties and his greatest delight is when he has to say goodbye because his clients have made progress and do not require his help any further.

About this Publication

This book began out of a desire to see newly qualified clinicians and psychologists in training, finding approaches to therapy that, perhaps, they have not had the opportunity to engage with within their training. Although training programs for Clinical Psychologists within the United Kingdom are held in high esteem it is my experience that face to face work with clients is, to a large degree, led by the experience and methodologies employed by supervising clinicians. Psychology training around the world differs not only from country to country but often from city to city. This has been found to be especially true in Australia where I began my clinical career.

When a psychologist bases his or her clinical approach on their supervisor's work this has the potential to not only bring about incredible growth, but also, to stunt the clinician's professional growth, and thus, hinder the healing process of their clients. Also, one of the key issues that should be recognised by newly qualified clinicians and clinicians in training; is the need for therapeutic relationship building skills, that are second to none. As part of these relationship building skills it is imperative that the clinician can very quickly, read their client, in order that they may adjust the therapeutic approach(s) used, and thereby, not lose the client's trust.

This book does not claim to answer the needs of every clinician. It is important, to recognise the personality differences between clinicians and how different personalities interact differently with their clients. It is also important to remember that with differing personalities, differing skill sets are likely to emerge. For example, one personality type may be drawn toward performance forms of approaches, thus,  if you do not have the skills or the inclination to build the necessary skill set to work in puppet therapy with children, then look for other approaches for working with this client group. If you do not feel comfortable working outside of the cognitive arena, then investigate how cognitive psychotherapy may be expanded for you to be more successful. If on the other hand you are able to be versatile in your clinical practice, then perhaps you will be helped by the approaches discussed and expounded upon within the pages of this book. This book, rather than being written totally for academia, is a practical approach for psychologists. Thus, I hope that the reader will find this book to be a pleasing and rewarding experience, and one that will prove to have  excellent outcomes for clients.

This book provides for the reader the reasons for approaching clients with an integrative methodology in psychological interventions. But not just any integrative methodology, one that works.

While other books related to therapy alone may provide suggestions of specific skills for integration, this book shows how to use the appropriate skills and the contexts in which to use them.

While other books are restrained within the parameters of psychology, Robert Jones recognises that we live in a real world and, thus, this book contains subject matter related to the field of sociology and its impact on the individual.

While other books and fields of study may leave the emerging clinician to flounder when working with other disciplines, this book introduces the reader to some of the complexities of working with other professionals.

While other books may propose skill sets for therapy alone, this book recognises that psychologists are more than therapists, we also conduct work with the courts, and much more. Thus, this book provides guidance on working within the legal system and particularly as an Expert Witness.

Contents

About the Author iii

About this Publication iv

Ch.1 A Common Response for Common Problems 4

Ch.2 The Reason and Evidence Base for this Publication  19

Ch.3 Multimodal and Integrative Psychotherapy 31

Ch.4 Humanistic Psychotherapy 41

Ch.5 Psychodynamic Psychotherapy 67

Ch.6 EMDR 86

Ch.7 REBT Introduction 103

Ch.8 REBT-The Snake Story 115

Ch.9 REBT Changing Our Feelings 124

Ch.10 REBT Mindfulness 134

Ch.11 REBT A Return to Changing Our Feelings 143

Ch.12 REBT Changing Our Thoughts 157

Ch.13 REBT Changing Our Behaviours 169

Ch.14 Problematic Behaviour Therapy 187

Ch.15 Adult Mental Health 192

Ch.16 The Sidewalk 203

Ch.17 Assertiveness for Climbing Out of Holes 208

Ch.18 Climbing Out of Sexual Grooming Holes 215

Ch.19 Couples Therapy 223

Ch.20 Working with Other Professionals 236

Ch.21 The Sociological Perspective 254

Ch.22 Religion and ASD Don't Mix 270

Ch.23 Ethical Issues 286

Ch.24 Expert Witnesses 305

The Report 313

Ch.25 Lateral Thinking 355

Ch.26 Helping Our Client through Grief 363

Ch.27 Continuing Professional Development (CPD) 372

Ch.28 Individuals with Weight Difficulties 380

Ch.29 Practical Psychology 398

Appendix 1 Timeline 407

Appendix 2 Completed Timeline 408

Appendix 3 Triangle of a Fire 409

Appendix 4 Partially Completed History 410

Appendix 5 History Chart 411

Appendix 6 Diagram of a Hard Drive 412

Appendix 7 Therapeutic Windows 413

References 414

Ch. 1 - A Common Response for Common Problems

In 2008 I conducted a project related to academic stress. At that time I don't think I made any huge discoveries. For example I found that stress could be found in the workplace, high schools, and with university teachers, information that only supported other researchers such as (Abel & Sewell, 2001; Blix, Cruise, Mitchell, & Blix, 1994). I was also able to establish that university students suffered stress, supporting researchers like (Abouserie, 1994; Akgun & Ciarrochi, 2003; Huan, Yeo, Ang, & Chong, 2006), and that geographic relocation for job purposes also created stress as discussed by (Anderson & Stark, 1988). I also discovered that stress in the workplace was found to be a specific difficulty for specific occupations such as farming (Walker & Walker, 1988), members of the police force (Richmond, Wodak, Kehoe, & Heather, 1998) and commonly with the beginning of a new technology, fear of using computers (Bloom, 1985). Back then, there was a great deal of worry in Government circles due to the huge financial burden on the public purse related directly to the overall cost of mental health, and at that time I was looking specifically at Australia (Australian Bureau of Statistics, 1997). The Australian Government at that time reported over a period of years that  stress was found in separated or divorced couples, losses in the employment market due to poor job training, and negative employer attitudes (Australian Bureau of Statistics, 1997; Keltner & Leung, 1995a). So what's new? We have known these things for years now.

What appeared new as I grew in experience as a Clinical and Counselling Psychologist, is the fact that most of the clients that we see over the years aren't aware of this! Our clients may be going through hell on earth and have no idea why they are feeling so low.

We know that people who suffer from stress are likely to experience fear, helplessness or horror in its acute form and may feel numb or detached (American Psychiatric Association, 2000; Mental Health Foundation of Australia, 2008). They may experience a tendency to lose perspective, feel restless, anxious or depressed (Cheng & Hamid, 1996). Alternatively, or in conjunction with these symptoms, they may experience somatic symptoms such as a sore throat, dizziness, blurred vision or sweaty palms or feet (Cheng & Hamid). It has also been  shown that differential experiences of symptoms to stress and particularly academic stress, is a predictor of suicide (Ang & Huan, 2006).

So if we have known all this for such a long period of time, why is it that therapists don't appear to be doing anything about it? Is it that people can't be helped? Is it that individuals for some reason or other don't want to be helped? Or is it perhaps that they don't realise that they need help?

It isn't as though science has been left on the back foot in this regard. For example we know that there is a relationship between the immune system and symptoms of stress. This was found by Ellard (2005) and his associates. They found that stressed individuals had significantly depressed natural killer (NK) cells (number of cells and cytotoxic activity) (Ellard, Barlow, & Mian). They reported that a depression of NK cells was heightened during student examination time. They also reported that polymorphonuclear neurophils (PMN), components of the non-specific immune system, comprise 60%-70% of the leukocyte population  and  are modulated even during short term stress, leading to conditions associated with upper respiratory infections (Ellard et al.). From these findings we may conclude that an individual in our consulting rooms who may appear to be  lacking  engagement, may also be experiencing these the somatic symptoms associated with stress. Thus, their apparent lack of engagement may be a symptom of the stress that they are under. Once again, however, we have known this for years. I wonder how many health professionals are able to take this on board when they see a new client. Occasionally we may find that a client calls at the last minute to postpone an appointment. How do we as therapists react to this? Is it incumbent upon us to make allowances for those clients. I am aware that some therapists demand payment for sessions missed when the amount of notice is short. However, should we not rather, put the client at ease when this occurs, and not demand payment. Thus, allaying their fears, and promoting a more speedy recovery?

According to Gray-Toft and Anderson (1981) stress may be defined as an internal cue in the physical, social, or psychological environment that threatens the homeostasis of an individual. How do we interpret this? Our internal mechanisms feel threatened and we react! We avoid emotionally focused interventions such as our partners, our parents, our work (Mitchell, Cronkite, & Moos, 1983;Nakano, 1991). Clearly, if avoidance occurs then a circle of avoidance strategies may be employed by the client, endangering the client to a lifetime (possibly) of avoiding and never becoming healed. This is, or course, where psychology comes in, if we have the skills!

High levels of self esteem have been shown to moderate stress and the lack of positive self esteem, and has been shown to correlate with depression (Barnett & Fanshaw, 1997). So if we feel good about ourselves we are less likely to become depressed but the reverse is true if we feel bad about ourselves. Hmmm, shouldn't this inform psychologists that perhaps a positive psychological intervention could be helpful here?

What is referred to as vulnerable self esteem predisposition is seen as a dormant state that may be triggered by life events according to (Roberts & Monroe, 1992). If this is the case, shouldn't we be looking with our clients to discover the reason for this predisposition? Surely, if an individual is predisposed to particular feelings, actions, or thoughts, that predisposition began somewhere. As I write these words I am reminded of an individual who was recently interviewed by the BBC (Coughlan, 2018). Coughlan reported that this young woman was brought up in a country area of America where she wasn't allowed to go to school. She was home schooled, but not much teaching went on. This young woman, it is reported, secretly bought text books, under a parental regime of obsession about the State, where even hospitals were seen as the enemy. As a child, this woman had been controlled by her parents to inhibit her hobby interests, and contact with others outside her family. Her father's paranoia even extended to having an extensive armoury to ward off potential federal agent penetration.

Even though this woman, brought up like a woodland animal appears to have her past under control, she allows her emotions to show with statements such as You can miss someone every day and still be glad you don't have to see them. How far this woman has come emotionally since she moved to the UK and became a Gates Scholar, and was conferred with her PhD from Cambridge University may be open to conjecture. This individual is discussed because her past has certainly affected who she is. And, one cannot help but wonder how much she has been affected when one reads her account of mainstream education where the biggest worry is that it sounds like such a passive, sterile process. A conveyor belt you stand on and you come out educated.

Another moderator to stress is level of optimism. Perhaps the woman discussed above is optimistic about her future. She has reason to be optimistic since she has a story to tell, her story has been published, and her story has been discussed by the BBC. This reason, however, is related to the likelihood of financial security. I wonder about her emotional security, I sincerely hope this also goes well for her. Vivien Huan and her associates in their discussion over dispositional optimism argue that even in the face of adversity, individuals may succeed in fulfilling desired goals (Huan et al., 2006). The opposite is true however when the disposition is one of pessimism. It is shown by Leung (2002) that achievement under these conditions has a negative effect, which stands to reason. From these researchers we may clearly see the need for building the psychological profile of our clients. The methodology employed for building the psychological profile, in my practice, is referred to as positive psychology.

Student medical doctors are recognised, more than others, as being subject to stress (Niemi & Vainiomaki, 1999). In 1999, a study by (Niemi & Vainiomaki) found that student doctors experienced emotional detachment, depression and other forms of psychological distress, though these forms weren't categorised other than the fact that they became cynical and that their views of the future were unrealistic. My own findings related to doctors, however, have shown that their stress levels do not abate upon finishing medical training. As an example, one doctor/client that came to my practice detached himself from his wife who also had been a doctor before they began a family. This person was a highly skilled surgeon who didn’t understand why his wife was considering leaving him. His narrative indicated that he was a good provider, they had a lovely home, their children attended a smart private school, they had everything going for them. The problem was, before he came to see me, he had no idea how to sit and talk with his wife. He was too stressed because of his work. This example informs us that education is not particularly a factor in communication, but stress almost certainly is.

Within the higher educational sector, seven key issues of influence on academic achievement were suggested by (Michie, Glachan, & Bray, 2001). These are: age, gender, past educational experiences, motivation, global self esteem, academic self concept and academic stress. These are affected by: home sickness, new relationships, and developing skills in finance, (e.g., student loans).  Michie et al., found that a high correlation existed between each of the above conflicts and academic stress. They also found that if a student is an adult (re-entry),  then a history of punitive teaching methods while at school equated to low self concept at university (Michie et al.). This last finding I can attest to. I remember leaving secondary school with no qualifications, entering a trade, and getting on with life with little self esteem, having received punitive measures at school. So how has this affected me as a clinician? I have compassion for all of my clients, but none more so than those that I learn have had similar experiences to myself. My question to my readers, therefore is, how has your past informed your present? What is your self esteem like? You may be an excellent student, but what is your confidence like? Do you really know how good you are, or is your confidence a facade for fooling others? If we know ourselves, then we are more able to help our clients.

Additionally, peer evaluation is also an element of self concept. When peer evaluations are found to be negative, negative continuity exists between study habits at high school and university. Thus in my own experience, because my peers looked down upon me because of my apparent inability to study, I shied away from further study. In later life as a school teacher and now as a psychologist I example to young clients what they are able to achieve, when given the opportunity.

Life events such as regular participation in sports, theatre or other recreational activities are recognised moderating variables associated with psychological health and positive self esteem and this has been recognised and demonstrated for many years, and by many researchers, for example (Barnett & Fanshaw, 1997). Thus, part of my approach from a positive psychological approach is to help my clients to engage in pursuits of this nature. It may be argued that this may also be true of students from the far east, for example. Leung (2002), reports that East Asian students do not see the playing of sports or generally having fun as important, though these same students report high levels of stress in their lives (Leung, 2002).Thus, we may be confident that whomever our clients may be, whether from European descent, or from the far east; and whether they be youths or older, their mental health will improve through recreation or sports. Hilsman and Garber (1995) reported on a test of the Cognitive Diathesis-Stress Model of Depression in children. According to this model, individuals who have a positive cognitive outlook on life are less likely to suffer depression due to stressful life events. Using a 15 point adjective checklist appropriate for fifth and sixth grade students, these researchers found that negative cognitions alone were able to produce a negative effect and depressive symptoms. It has also been shown that this may generalize to adolescents (Banez & Compas, 1990). Clearly from the perspective of youths, therefore, an approach to therapy that is cognitively based or contains cognitive exercises should be recommended in these cases, without forgetting the positive approach.

One concern which should be considered relevant when working with students from Asian backgrounds, however, is the propensity for Asian students to ignore or disclaim symptoms of stress as being associated with stress (Carr, Koyama, & Thiagarajan, 2003). It is suggested that a cultural enigma exists over exhibition of stress symptoms from Asian individuals. That exhibition of symptoms are a cause of shame or embarrassment (Carr et al., ; Cheng & Hamid, 1996) and the person experiencing symptoms, according to the social norm, needs to save face, rather than show such symptoms (Carr et al.). In this way it may be argued that self esteem may play a role in the outworking of stress suffered by East Asian students (Crocker & Luhtanen).

Among the usual identifiers of self esteem such as feelings of being loved or being attractive, and being good in school, may also be fundamental to some individual’s level of self esteem (Crocker & Luhtanen, 1990, 2003). Where some individuals spend time grooming, visits to the beauty parlour, exercising and dancing, others may find their self worth in studying (Crocker & Luhtanen). It may therefore be supposed that students from East Asia who spend great amounts of time studying, do so for reasons of self worth. This, therefore should be considered when working with individuals who originated from the east or who have eastern families of origin, since these students stress levels are likely to be driven by the need for self esteem, rather than high academic achievement per se (Barnett & Fanshaw, 1997; Crocker & Luhtanen).

The combination of low self esteem, and the exacerbation by the stress that is produced by the condition described above, is likely to lead to lower levels of academic achievement, thus completing the cycle. Thus, it is important that we as therapists are cognizant of these factors when working with Asian students; and not only university students but also high school (Dandy & Nettelbeck, 2002). These researchers tested 160 school children in the higher grades and found that Chinese and Vietnamese children achieved significantly higher grades than  Anglo-Celtic children, regardless of socio-economic status. It was also shown that this result was not due to higher intellect, therefore, a higher level of study participation appears to have been indicated in the Asian children.  So, what could we say about our work when it pertains to individuals whose origins are the far east? These individuals generally may present to you with a high level of pride in their achievements. Where you may be tempted to suggest to a European client that they may need to take things a little easier, this approach to an individual from the far east is not likely to work. Instead, perhaps it may be prudent to take the exercise and social interaction approach.

Reporting on the Third International Mathematics and Science Study (TIMSS), Leung (2002) stated that students from four East Asian countries; Hong Kong, Japan, Korea and Singapore, are arguably the highest achievers in the world, when measured on mathematical ability. It is reported that they all see mathematics as very important and necessary however, with the exception of Singapore, no students from the Asian community enjoyed mathematics (Leung). These researchers state that there is no correlation between the country participating in the study, and enjoyment of the subject. They also state that class sizes are not a variable in success, and students in this study did not think that they worked harder than students from other countries. They did, however feel under great pressure to succeed and many attended private cram schools after day school and at week-ends to ensure success (Huan et al., 2006). It was suggested that co-variants to these students stress may have been pressure from parents, teachers and themselves (Huan et al.). Another covariant described a lack or avoidance of healthier pursuits such as exercise and another issue that may impinge on post graduate students from the East is the rejection of their under-graduate qualifications, by registering authorities Hirschman (1996), leading to additional stress (Abouguendia & Noels, 2001).

From these findings we see that along with European or other Western clients, our Asian clients also suffer stress, though our Eastern clients are more likely to be driven by other pressures to succeed. Thus, when we connect with Asian clients it is important that our understanding of their culture, and their self infliction of pressure may be factors in their rehabilitation.

In 2008 I reported on a sample which was taken from a University in Queensland Australia. In this, I  measured a final sample of 295 students. A breakdown of the study showed that subjects consisted of 161 (54.6%) female and 134 (45.4%) male. of this sample 123 (41.7%) were Australian students and 172 (58.3%) were from other countries. 261 (88.5%) reported being single, 30 (10.2%) reported being married or living in a de-facto relationship and 4 (1.4%) reported being widowed or divorced. When questioned about their educational level, it was found that eight students (2.7%) were new to university and were studying prerequisite units, prior to commencing their degrees, 214 (72.5%) were engaged in under-graduate studies, and 73 (24.7%) were studying at post graduate level. It was shown that 91 (30.8%) students had a grade point average (GPA) of Pass (GPA =50%), that 95 (32.2%) received credits (GPA=65%), 83 (28.1%) received distinctions (GPA=75%) and 26 (8.8%) averaged a high distinction (GPA= over 85%). This university is recognised for its diverse multicultural student base. It was found that 118 (40%) of the sample were Australian, 2 (0.7%) were from New Zealand, 30 (10.2%) were from the USA, 8 (2.7%) were from Canada, 71 (24.1%) were from East Asian countries, 2 (0.7%) from other Asian countries, and 64 (21.7%) were from other countries in Europe. When questioned on how the students paid for their tuition and living costs, 195 (66.1%) said that they were supported by their families. The Australian government were reported to be supporters of 32 (10.8%) of the students, 18 received a scholarship, 53 (18%) were self sufficient and 1 (0.3%) received support from other means. The age given by this sample had a mean of: M = 22.98, and a standard deviation of SD = 5.33.

Given the findings from the other researchers discussed earlier, it is interesting to note that my findings indicated that the students that I assessed, engaged to almost the same level as the other nationalities in the various social strategies related to unwinding between and after lectures (M = 1.11, SD = 0.51) compared to (M = 1.19, SD = 0.55). From these mean scores it was shown that although the students had the potential for  enjoyment they all did so but some to a lower degree. Clearly there must be a reason.

In fact the university in question boasts considerable entertainment pursuits (Bond University, 2008) including a sports centre that provides volleyball, swimming, cricket and tennis, among others, promoting a reversal of empowerment deficits (Blinde & Taub, 1999). Thus increasing a sense of accomplishment and self-actualization, increased motivation to setting and realizing goals, bonding and broadening social skills, and promoting social inclusiveness (Blinde & McClung, 1997), as well as building psychological health (Trovato,1998). There are also on-campus restaurants and a tavern where students may dampen their responses to stress (Sher, Bartholow, Peuser, Erickson, & Wood, 2007) and thereby reduce tension (Cappell & Herman, 1972).

Here we may see the reasons for the differences between the study at this university, and the studies from the Eastern countries discussed earlier. We know that when an individual is able to relax, the worries of this world appear to disappear if only for a time. Why else do we take holidays each year? From these findings it is clear that regardless of cultural background, people enjoy taking a break from the norm. And, if everyone likes a rest now and again, we as therapists should be looking for the reasons why our clients are not taking time off. If indeed this is their problem.

It appears from our findings that the occasional libation or restaurant meal, may play a part in the general psychological health of, not only Westerners but also Asian individuals. It may also be considered that Asian students, once settled into student life in the west, assume a collective self esteem, related to their new group processes (Abrams & Hogg, 1988). That in many cases, differences between groups also elevates individuals self esteem (Crocker & Luhtanen, 1990) and that students protect themselves from low self esteem and the consequences of that low self esteem (stress, anxiety and depression), by assuming the social strategies of the dominant group (Long & Spears, 1997), and reducing uncertainty in their lives (Hogg, 2000). Thus we generalise, that stress, which relates strongly with anxiety and depression may be treated through encouraging our clients to participate in enjoyable pursuits and exercise in order to alleviate any tendency toward further ill health related to their psychology. This research also found that the East Asian students who were expected to be even more stressed due to an absence from their home environment, were indeed more stressed on arrival on campus, but by the end of the first trimester, their stress levels had reduced to the norm for the population. Thus, if the conditions are right, it doesn't take long to overcome some obstacles regardless of ethnicity.

We can therefore predict that our clients, whatever their national heritage whether American, Canadian, Australian, New Zealanders, British or other Europeans, or from the far east, will always benefit from taking part in sports, or other leisure activities including eating out or going to a bar. The problem that we as therapists have in some instances, is getting them to do some of these things.

I recently worked with a woman who was aged in her middle 60’s. Prior to her retirement from teaching she had been very active, cycling, skiing, running, tennis; but now she was totally inactive. She had become a couch potato. Her husband had joined her in this past-time of watching television. Together they had forgotten what it was like to be active. As part of a positive psychology approach (see later in this book), they were encouraged to get back into their healthy pursuits. And together they regained not only their physical health, but their psychological health also. Thus, from the findings from the study at the University just discussed, and from the findings encountered within a clinical setting over a number of years, it may be seen that a combination of a positive psychotherapeutic approach and exercise in various settings has the potential for extremely good therapeutic outcomes for each of our clients.

Ch.2- The Reason and evidence base for this Publication

Prior to beginning my work for this book I had recently attended a Continuing Professional Development (CPD) event where the presenters spoke about a given approach to therapy (Mindfulness) with a great deal of conviction but little evidence of its effectiveness, I thought about an earlier meeting I had attended. At this earlier meeting, Cognitive Behavioural Therapy (CBT) was lifted higher than the skies and Eye Movement Desensitization and Reprocessing (EMDR) Shapiro (2001), was considered the work of evangelists who were hoping for miracles. These two events caused me to consider the work of authors such as (Norcross, Beutler, & Levant, 2006). These authors remind us that Evidence Based Practices (EBP) will present the fundamental questions (in this fiercely contested debate) and will provide balanced, informed positions on the salient questions (Norcross et al., 2006, p. 11). So, what are these questions? The fundamentals in EBP demand that all effective therapeutic practice results from therapists using therapeutic approaches that work. In doing this we need to take on board the individual differences that exist between our clients, thus, a multimodal or technical eclectic approach may be (according to these authors) the most appropriate way to go, an approach which was also discussed by (Prochaska & Norcross, 1999).

It was from within this context that it was decided that a review of recent work within a private practice should be conducted. Because a number of variables exist within this practice such as instructing agencies insisting on particular assessment instruments, and the differences in presentations; it was considered important that only participants who were known to have suffered significant stress in