How Do You Determine the Right Therapeutic Modality for a Patient?

How Do You Determine the Right Therapeutic Modality for a Patient?

Selecting the right therapeutic modality is a nuanced process that requires careful consideration of various factors. To gain deeper insight, we've compiled seven expert opinions from leading Licensed Clinical Psychologists and Psychotherapists. They range from considering a client's self-reflection ability to matching the modality with clinical expertise.

• Consider Client's Self-Reflection Ability
• Evaluate Symptoms and History
• Collaborate and Adjust Therapy
• Understand Patient Needs First
• Integrate Multiple Therapeutic Approaches
• Use Stepped-Care Approach
• Match Modality with Clinical Expertise

Consider Client's Self-Reflection Ability

First of all, I'm a believer that it's the therapist themselves, not their 'modality,' that is the most important vehicle for change. However, one way I determine the right therapeutic modality is by listening for the client's observing ego strength. Some people have a really strong 'self-reflective' voice, while others do not. Those with good self-reflection (observing ego) need more help connecting with their feelings to grow, while those who are more reactive need help self-reflecting. This is one of the ways I try to listen to clients at the start of therapy to help tailor my approach.

Evaluate Symptoms and History

Not every therapeutic modality works for every client or client presentation. Psychologists, specifically, are skilled and trained in the brief evaluation of a client's symptoms and challenges, which psychologists then conceptualize to determine what therapeutic modality fits for that client.

During an initial intake with a client, I obtain a thorough history of the client's mental health symptoms and current problems, identify their goals, understand their therapy history, and highlight their strengths. With this information, I then determine which therapeutic modality (i.e., cognitive-behavioral therapy [CBT], dialectical behavior therapy [DBT], acceptance and commitment therapy [ACT], psychodynamic, behavioral) would be the best fit for the client.

For example, if a client is presenting with active suicidal ideation and self-injurious behaviors, I would recommend DBT. In contrast, for a client with high-functioning autism spectrum disorder and symptoms of depression, I would instead advise modified CBT or behavioral therapy. CBT or behavioral therapy would be a better fit than DBT for someone with autism because DBT uses a lot of metaphors to teach ways to manage and regulate emotions, and those with autism would struggle with these DBT concepts given their social communication challenges.

Toward the end of the intake, I would provide my therapeutic modality recommendations to the client and elicit their feedback to ensure that their concerns or hesitations about the recommendations are addressed.

Collaborate and Adjust Therapy

For me, therapy is always a collaborative process where I begin by building a strong relationship with my clients based on clearly understanding their concerns that brought them to therapy. We will often discuss my approach and their preferences for therapy in order to learn if they prefer a more direct, solution-focused approach or a more gradual process in therapy. Over time, based on their responses to therapeutic interventions, I learn more about their needs and personality to help inform which modality I will be using. I tend not to believe that therapy is one-size-fits-all, so I aim to mold my candid, down-to-earth, and warm approach into a style that will help that client achieve their goals.

Understand Patient Needs First

Choosing the 'right' modality for a patient is based on years of training and experience, being up-to-date on the current research about evidence-based methods, and knowing your patient well. For example, we know that eating disorders respond well to cognitive behavioral therapy (CBT), but a patient may have done CBT in the past and found it minimally useful, or has other co-occurring issues that might be better served with a different modality. Getting a really good background history is important for choosing an appropriate modality, as is knowing when a patient needs a modality that you are not qualified to provide and referring the patient out. Since I am not certified in EMDR, for example, I have another psychologist to whom I refer patients who need that modality. Keeping the patient's needs in mind is, first and foremost, the pivotal issue.

Integrate Multiple Therapeutic Approaches

Like many psychologists, I rarely use a single therapeutic approach. Rather, my work is informed by the Common Factors Model, and also the Multitheoretical Psychotherapy approach by Jeff E. Brooks-Harris to bring different therapy theories together while focusing on the process level of therapy. I work with my patient/client to identify what their understanding of the problem might be, and try to tailor the integrated approach and interventions to fit their understanding while expanding into other possible strategies.

For example, if I am working with a client who thinks about their depression as a biological problem with neurotransmitter imbalances, I will use my medical training to talk in those terms while also discussing how relationship and life stressors can activate epigenetic factors to change their biological functioning. I might suggest skills from DBT and Solution-Focused Therapy and medications in that case. If I have a client who believes their anxiety is a religious trial or from lack of religious faith, I will try to use a religiously accommodative and contextual approach that could also include relationship and attachment-building strategies from Interpersonal and Interpersonal Process Psychotherapies while confronting existential anxiety with Logotherapy and experiential avoidance with strategies from ACT and Emotion-Focused Therapy.

In the end, it is all about expanding the client’s understanding and skills with a common understanding of what we are working on and how we are working on it within a caring therapeutic alliance.

Use Stepped-Care Approach

At IAMH, we use the Vervulling Stepped-Care approach, which allows us to determine the intensity of the psychological difficulty an individual is facing. Each level of intensity has a corresponding intervention type. Stepped-care matrices were first made popular by the NHS in the United Kingdom and were also built upon in Canada. They offer an efficient way to match requirements with intervention without wasting an already sparse supply of mental health professionals and services.

The types of challenges a patient faces also play a role when making this determination, as certain challenges can be addressed better with specific therapeutic modalities.

Finally, the individual seeking support plays a major role too, as our intervention plans typically involve their input—are they interested in dealing with specific challenges in their daily life? Or is it a more overarching issue? A significant factor here is what works for the patient—do they like taking targeted action every day? Or perhaps they feel better reflecting on their journey and want to talk through their challenging feelings?

Match Modality with Clinical Expertise

Choosing the appropriate modality and therapeutic approach is one of the most important factors to consider when working with patients. As a psychologist, it is critical to be mindful of one's own clinical training and areas of expertise. Psychologists must determine if they are equipped with the necessary tools and training to appropriately and confidently treat the patient. Additionally, when deciding which modality to use, psychologists should be thoughtful about the presenting concerns and symptoms that bring a patient to therapy in order to decide if and how their therapeutic approach can be beneficial to the patient. In my role as a psychologist, my primary goal, in addition to focusing on building a strong therapeutic alliance with each patient, is to use a therapeutic approach that can help each patient foster individual growth, optimize therapeutic gains, and learn effective and adaptive coping mechanisms that support optimal functioning in their life and in their relationships. Furthermore, I seek to utilize an approach that allows me the opportunity to tailor treatment to meet the specific and diverse needs of each individual.