Walking the hallway of the Psychotherapy and Behavior Change Lab throughout the course of my graduate training, I often glanced at a paper that my mentor had taped to one of the doors, which cited Paul’s (1967) iconic question: ‘‘What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?’’ As I learned about evidence-based psychotherapies, I thought that treatment selection was at the core of Paul’s dilemma. Nonetheless, I soon began being exposed to clinical work at my initial clinical practicum, a community mental health clinic affiliated with my institution. Needless to say, none of my clients seemed to be a perfect match for any of the treatments that I had learned. The reality of clinical work, I learned, was much more complex than I had anticipated. I was particularly struck by the frequency of comorbid and co-occurring conditions, while also noticing that most of the specific problems that my clients wanted to address in therapy were nowhere to be found in DSM-5 (American Psychiatric Association, 2013). Over the course of my graduate training, I was also increasingly exposed to the medical model, completing several clinical practicums at medical centers. Although that symptom-based framework helped me communicate and collaborate with providers from other disciplines, it did not necessarily promote the conceptualization of my clients’ presenting problems. The work of therapists, I finally understood, required much more creativity than I could have ever imagined. As I began to devote more attention to treatment personalization, I noticed that tailoring interventions to the needs of each individual was a transactional process. Just like a salesperson displays paint swatches and suggests color combinations, therapists introduce strategies and approaches, but it is ultimately clients who determine which ones best fit their needs and context. The aptly named working alliance successfully captured this transactional nature of the therapeutic relationship that I was experiencing with my clients. Negotiating the selection and prioritization of treatment goals and tasks allowed me to draw connections between the underlying psychological processes I intended to target with interventions and my clients’ individual goals. Tracking clients’ progress toward the achievement of these idiographic goals also proved to serve as a much more valid compass than observing changes on symptom-based measures. These idiographic measures helped me navigate and respond to the ever-changing context of psychotherapy, supporting my ability to be flexible and responsive. It also afforded me with the opportunity to be creative, forcing me to survey my clinical repertoire to identify and adapt clinical interventions so that they could be relevant to my clients’ unique goals. These experiences support my current understanding of psychotherapy as a combination its two interdependent aspects of art and science. On the one hand, the creative therapist adapts evidence-based interventions to the context and needs of each client, while on the other, observing the process and outcomes produced by these creative adaptations can inspire future research endeavors, ultimately promoting the advancement of the field.

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Matteo Bugatti, Ph.D.

Dr. Bugatti is a postdoctoral research fellow at University of Denver. His research interests include measurement-based care and the personalization of evidence-based psychotherapies.