ninth edition

Theory and Practice

of Counseling

and Psychotherapy

G E R A L D C O R E Y

California State University, Fullerton

Diplomate in Counseling Psychology

American Board of Professional Psychology

$XVWUDOLDä%UD]LOä-DSDQä.RUHDä0H[LFRä6LQJDSRUHä6SDLQä8QLWHG.LQJGRPä8QLWHG6WDWHV

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About the Author

GERALD COREY is a Professor Emeritus of Human Serv-

ices at California State University at Fullerton and a licensed

psychologist. He received his doctorate in counseling from

the University of Southern California. He is a Diplomate

in Counseling Psychology, American Board of Professional

Psychology; a National Certified Counselor; a Fellow of the

American Psychological Association (Counseling Psychol-

Press

ogy); a Fellow of the American Counseling Association; and

Associated

a Fellow of the Association for Specialists in Group Work.

He also holds memberships in the American Group Psycho-

therapy Association; the American Mental Health Counselors Association; the As-

sociation for Spiritual, Ethical, and Religious Values in Counseling; the Associa-

tion for Counselor Education and Supervision; and the Western Association for

Coun selor Education and Supervision.

Along with Marianne Schneider Corey, Jerry received the Lifetime Achieve-

ment Award from the American Mental Health Counselors Association in 2011

and the Eminent Career Award from the Association for Specialists in Group

Work in 2001. Jerry was the recipient of the Outstanding Professor of the Year

Award from California State University at Fullerton in 1991. He teaches both

undergraduate and graduate courses in group counseling, as well as courses

in experiential groups, the theory and practice of counseling, theories of coun-

seling, and professional ethics. He is the author or coauthor of 16 textbooks

in counseling currently in print, 5 student videos/DVDs with workbooks, and

more than 60 articles in professional publications. Theory and Practice of Coun-

seling and Psychotherapy has been translated into the Arabic, Indonesian, Por-

tuguese, Korean, Chinese, and Turkish languages. Theory and Practice of Group

Counseling has been translated into Chinese, Korean, Russian, and Spanish.

Issues and Ethics in the Helping Professions has been translated into Korean, Japa-

nese, and Chinese.

Jerry and Marianne Corey often presents workshop in group counseling. In

the past 35 years the Coreys have conducted group counseling training workshops

for mental health professionals at many universities in the United States as well as

in Korea, Ireland, Germany, Belgium, Scotland, Mexico, China, Hong Kong, and

Canada. The Coreys also frequently give presentations and workshops at state and

national professional conferences. In his leisure time, Jerry likes to travel, hike and

bicycle in the mountains, and drive his 1931 Model A Ford.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Recent publications by Jerry Corey, all with Brooks/Cole, Cengage Learning,

include:

t Case Approach to Counseling and Psychotherapy, Eighth Edition (2013)

t The Art of Integrative Counseling, Third Edition (2013)

t Theory and Practice of Group Counseling (and Student Manual, Eighth Edition,

2012)

t Becoming a Helper, Sixth Edition (2011, with Marianne Schneider Corey)

t Issues in Ethics in the Helping Professions, Eighth Edition (2011, with Marianne

Schneider Corey and Patrick Callanan)

t Groups: Process and Practice, Eighth Edition (2010, with Marianne Schneider

Corey and Cindy Corey)

t I Never Knew I Had a Choice, Ninth Edition (2010, with Marianne Schneider

Corey)

t Group

Techniques, Third Edition (2004, with Marianne Schneider Corey,

Patrick Callanan, and J. Michael Russell)

Jerry is coauthor (with Barbara Herlihy) of Boundary Issues in Counseling: Multiple

Roles and Responsibilities, Second Edition (2006) and ACA Ethical Standards Case-

book, Sixth Edition (2006); he is coauthor (with Robert Haynes, Patrice Moulton,

and Michelle Muratori) of Clinical Supervision in the Helping Professions: A Practi-

cal Guide, Second Edition (2010); he is the author of Creating Your Professional

Path: Lessons From My Journey (2010). All four of these books are published by the

American Counseling Association.

He also has made several educational DVD and video programs on various as-

pects of counseling practice: DVD for Theory and Practice of Counseling and Psycho-

therapy: The Case of Stan and Lecturettes (2013); DVD for Integrative Counseling: The

Case of Ruth and Lecturettes (2013, with Robert Haynes); DVD—Theory and Practice

of Group Counseling (2012); Groups in Action: Evolution and Challenges—DVD and

Workbook (2006, with Marianne Schneider Corey and Robert Haynes); and Ethics

in Action: CD-ROM (2003, with Marianne Schneider Corey and Robert Haynes).

All of these programs are available through Brooks/Cole, Cengage Learning.

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

This is an electronic version of the print textbook. Due to electronic rights restrictions,

some third party content may be suppressed. Editorial review has deemed that any suppressed

content does not materially affect the overall learning experience. The publisher reserves the right

to remove content from this title at any time if subsequent rights restrictions require it. For

valuable information on pricing, previous editions, changes to current editions, and alternate

formats, please visit www.cengage.com/highered to search by ISBN#, author, title, or keyword for

materials in your areas of interest.

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Theory and Practice of Counseling

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and Psychotherapy, Ninth Edition

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Gerald Corey

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Printed in the United States of America

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To Terry Hendrix and in memory of Claire Verduin,

our first editors at Brooks/Cole; they had faith

in the potential of this book and encouraged us to

write early in our careers.

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Contents

P R E FAC E X I I

vii

C

ONTENT

PA RT 1

Basic Issues in Counseling Practice3

S

1 Introduction and Overview4

Introduction 5

Where I Stand 6

Suggestions for Using the Book 8

Overview of the Theory Chapters 9

Introduction to the Case of Stan 13

2 The Counselor: Person and Professional17

Introduction 18

The Counselor as a Therapeutic Person 18

Personal Therapy for the Counselor 20

The Counselor’s Values and the Therapeutic Process 22

Becoming an Effective Multicultural Counselor 24

Issues Faced by Beginning Therapists 28

Summary 34

3 Ethical Issues in Counseling Practice36

Introduction 37

Putting Clients’ Needs Before Your Own 37

Ethical Decision Making 38

The Right of Informed Consent 40

Dimensions of Confidentiality 41

Ethical Issues in a Multicultural Perspective 42

Ethical Issues in the Assessment Process 44

Ethical Aspects of Evidence-Based Practice 46

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Managing Multiple Relationships in Counseling Practice 48

Becoming an Ethical Counselor 51

Summary 52

Where to Go From Here 52

Recommended Supplementary Readings for Part 1 53

References and Suggested Readings for Part 1 55

PA RT 2

Theories and Techniques of Counseling 61

4 Psychoanalytic Therapy 62

Introduction 63

viii

Key Concepts 64

S

The Therapeutic Process 72

Application: Therapeutic Techniques and Procedures 78

ONTENT

C

Jung’s Perspective on the Development of Personality 83

Contemporary Trends: Object-Relations Theory,

Self Psychology, and Relational Psychoanalysis 85

Psychoanalytic Therapy From a Multicultural Perspective 91

Psychoanalytic Therapy Applied to the Case of Stan 92

Summary and Evaluation 94

Where to Go From Here 97

Recommended Supplementary Readings 98

References and Suggested Readings 99

5 Adlerian Therapy 101

Introduction 102

Key Concepts 103

The Therapeutic Process 109

Application: Therapeutic Techniques and Procedures 113

Adlerian Therapy From a Multicultural Perspective 123

Adlerian Therapy Applied to the Case of Stan 125

Summary and Evaluation 127

Where to Go From Here 129

Recommended Supplementary Readings 131

References and Suggested Readings 132

6 Existential Therapy 136

Introduction 139

Key Concepts 145

The Therapeutic Process 154

Application: Therapeutic Techniques and Procedures 157

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Existential Therapy From a Multicultural Perspective 160

Existential Therapy Applied to the Case of Stan 162

Summary and Evaluation 163

Where to Go From Here 166

Recommended Supplementary Readings 168

References and Suggested Readings 169

7 Person-Centered Therapy 172

Introduction 173

Key Concepts 178

The Therapeutic Process 179

Application: Therapeutic Techniques and Procedures 184

ix

Person-Centered Expressive Arts Therapy 189

C

ONTENT

Motivational Interviewing 191

Person-Centered Therapy From a Multicultural Perspective 194

Person-Centered Therapy Applied to the Case of Stan 196

S

Summary and Evaluation 197

Where to Go From Here 203

Recommended Supplementary Readings 205

References and Suggested Readings 206

8 Gestalt Therapy 210

Introduction 212

Key Concepts 213

The Therapeutic Process 219

Application: Therapeutic Techniques and Procedures 224

Gestalt Therapy From a Multicultural Perspective 233

Gestalt Therapy Applied to the Case of Stan 234

Summary and Evaluation 236

Where to Go From Here 239

Recommended Supplementary Readings 241

References and Suggested Readings 241

9 Behavior Therapy 244

Introduction 247

Key Concepts 250

The Therapeutic Process 252

Application: Therapeutic Techniques and Procedures 255

Behavior Therapy From a Multicultural Perspective 274

Behavior Therapy Applied to the Case of Stan 276

Summary and Evaluation 277

Where to Go From Here 281

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Recommended Supplementary Readings 282

References and Suggested Readings 282

10 Cognitive Behavior Therapy 287

Introduction 290

Albert Ellis’s Rational Emotive Behavior Therapy 291

Key Concepts 292

The Therapeutic Process 295

Application: Therapeutic Techniques and Procedures 297

Aaron Beck’s Cognitive Therapy 302

Donald Meichenbaum’s Cognitive Behavior Modification 310

Cognitive Behavior Therapy From a Multicultural Perspective 315

x

Cognitive Behavior Therapy Applied to the Case of Stan 318

S

Summary and Evaluation 320

Where to Go From Here 324

ONTENT

C

Recommended Supplementary Readings 327

References and Suggested Readings 327

11 Reality Therapy 333

Introduction 335

Key Concepts 336

The Therapeutic Process 340

Application: Therapeutic Techniques and Procedures 342

Reality Therapy From a Multicultural Perspective 349

Reality Therapy Applied to the Case of Stan 352

Summary and Evaluation 354

Where to Go From Here 356

Recommended Supplementary Readings 357

References and Suggested Readings 358

12 Feminist Therapy 360

Introduction 362

Key Concepts 367

The Therapeutic Process 370

Application: Therapeutic Techniques and Procedures 373

Feminist Therapy From a Multicultural and Social

Justice Perspective 380

Feminist Therapy Applied to the Case of Stan 382

Summary and Evaluation 384

Where to Go From Here 388

Recommended Supplementary Readings 390

References and Suggested Readings 391

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13 Postmodern Approaches 395

Introduction to Social Constructionism 397

Solution-Focused Brief Therapy 400

Narrative Therapy 410

Postmodern Approaches From a Multicultural Perspective 419

Postmodern Approaches Applied to the Case of Stan 421

Summary and Evaluation 423

Where to Go From Here 426

Recommended Supplementary Readings 429

References and Suggested Readings 429

14 Family Systems Therapy 432

xi

Introduction 434

C

ONTENT

Development of Family Systems Therapy and Personal

Development of the Family Therapist 437

A Multilayered Process of Family Therapy 445

S

Family Systems Therapy From a Multicultural Perspective 451

Family Systems Therapy Applied to the Case of Stan 452

Summary and Evaluation 456

Where to Go From Here 458

Recommended Supplementary Readings 458

References and Suggested Readings 459

PA RT 3

Integration and Application463

15 An Integrative Perspective464

Introduction 465

The Movement Toward Psychotherapy Integration 465

Issues Related to the Therapeutic Process 477

The Place of Techniques and Evaluation in Counseling 483

Summary 497

Where to Go From Here 498

Recommended Supplementary Readings 499

References and Suggested Readings 499

16 Case Illustration: An Integrative Approach

in Working With Stan 503

Counseling Stan: Integration of Therapies 504

Concluding Comments 521

AU T H O R I N D E X 523

S U B J E C T I N D E X 528

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Preface

This book is intended for counseling courses for undergraduate and graduate stu-

dents in psychology, counselor education, human services, and the mental health

professions. It surveys the major concepts and practices of the contemporary ther-

apeutic systems and addresses some ethical and professional issues in counseling

practice. The book aims to teach students to select wisely from various theories and

techniques and to begin to develop a personal style of counseling.

xii

I have found that students appreciate an overview of the divergent contem-

CE

porary approaches to counseling and psychotherapy. They also consistently say

A

that the first course in counseling means more to them when it deals with them

PREF

personally. Therefore, I stress the practical application of the material and encour-

age reflection. Using this book can be both a personal and an academic learning

experience.

In this ninth edition, every effort has been made to retain the major qualities

that students and professors have found helpful in the previous editions: the suc-

cinct overview of the key concepts of each theory and their implications for prac-

tice, the straightforward and personal style, and the book’s comprehensive scope.

Care has been taken to present the theories in an accurate and fair way. I have at-

tempted to be simple, clear, and concise. Because many students want suggestions

for supplementary reading as they study each therapy approach, I have included an

updated reading list at the end of each chapter.

This edition updates the material and refines existing discussions. Part 1 deals

tion update

with issues that are basic to the practice of counseling and psychotherapy. Chapter 1

with issues that are bas

puts the book into perspective, then students are introduced to the counselor—

puts the book into pe

as a person and a professional—in Chapter 2. This chapter addresses a number

as a person and a pro

of topics pertaining to the role of the counselor as a person and the therapeutic

of topics p

g

relationship. Chapter 3 introduces students to some key ethical issues in coun-

rela onship. Chapter 3 in

seling practice, and several of the topics in this chapter have been updated and

eling practice, and several

expanded.

Part 2 is devoted to a consideration of 11 theories of counseling. Each of the

Part 2 is devoted to a consid

n of 11 theo

f the

theory chapters follows a common organizational pattern, and students can easily

y

p

theory chapters follows a common

zational patt

nts can easily

compare and contrast the various models. This pattern includes core topics such

c mpare and cont st the various m

This pattern

ludes core topics such

as key concepts, the therapeutic process, therapeutic techniques and procedures,

a

oncepts, the t

key c

rapeutic proce

erapeutic techniques and procedures,

multicultural perspectives, theory applied to the case of Stan, and summary and

m lticultural perspectiv

theory applie to the ca e of Stan, and summary and

evaluation. In this ninth edition, all of the chapters in Part 2 have been revised,

e

uation. n this ninth

ion, all o he chapte s in Part 2 haave been revised,

updated, and expanded to reflect recent trends. Revisions were based on the rec-

up ated, and expanded to r

trends. Revisions were based on the rec-

ommendations of experts in each theory, all of whom are listed in the Acknowledg-

mendatio

om

s of experts in

, all of wh m are listed in the Acknowledg-

ments section. Both expert and general reviewers provided suggestions for adding,

ents sectio

m

Both expert a

eviewers rovide suggestions for adding,

uggestions for addin

replacing, and expanding material for this edition. Attention was given to current

replacing, an expanding m

al for t is edition. Atten

rent

on was given to curr

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

trends and recent developments in the practice of each theoretical approach. For

each chapter in Part 2, the citations have been updated.

Each of the 11 theory chapters summarizes key points and evaluates the con-

tributions, strengths, limitations, and applications of these theories. Special

attention is given to evaluating each theory from a multicultural perspective as

well, with a commentary on the strengths and shortcomings of the theory in

working with diverse client populations. The consistent organization of the sum-

mary and evaluation sections makes comparing theories easier. Students are

given recommendations regarding where to look for further training for all of the

approaches. Updated annotated lists of reading suggestions and extensive refer-

ences at the end of these chapters are offered to stimulate students to expand on

the material and broaden their learning through further reading. In addition, a

list of DVD resources has been added to the ninth edition for each of the theory

xiii

chapters.

PREF

A

CE

w h at ’s n e w i n t h i s e d i t i o n

Significant changes for the ninth edition for each of the theory chapters are out-

lined below:

c h a p t e r 4 Psychoanalytic

Therapy

t Increased emphasis on the role of the relationship in analytic therapy

t Increased coverage on contemporary psychodynamic therapy

t Broadened discussion of relational psychoanalysis

t A new perspective on therapist neutrality and anonymity

t More emphasis on the role of termination in analytic therapy

t New material on countertransference, its role in psychoanalytic therapy, and

guidelines for effectively dealing with countertransference

t Expanded discussion of resistance and how to work with it effectively

t Revised and expanded section on brief psychodynamic therapy

c h a p t e r 5 Adlerian

Therapy

t Revised material on the concept of lifestyle

t Expanded discussion of social interest

t New material on early recollections

t Streamlined discussion of some key concepts

c h a p t e r 6 Existential

Therapy

t Revised material on existential themes

t New and expanded coverage of the contributions of Irvin Yalom and James

Bugental to existential therapy

t More attention on international developments of existential therapy

t New material on main aims of existential therapy

t Revised section on the client–therapist relationship

t Revised discussion of strengths of the approach from a diversity perspective

t New discussion of integration of existential concepts in other therapies

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

c h a p t e r 7 Person-Centered

Therapy

t Expanded coverage on the contributions and influence of Carl Rogers on the

counseling profession

t New section on the Abraham Maslow’s contributions to humanistic philosophy

and psychology

t New material on Maslow’s concept of self-actualization and relation to person-

centered philosophy

t Broadened discussion of clients as active self-healers

t Updated coverage of the core conditions of congruence, unconditional positive

regard, and empathy

t Recent research on contextual factors as the main predictors of effective therapy

t New material on the limitations and criticisms of the approach

xiv

t New material on the diversity of styles of practicing person-centered therapy

t More emphasis on how the basic philosophy of the person-centered approach

CE

A

can be applied to other therapeutic modalities

t Inclusion of emotion-focused therapy, stressing the role of emotions as a route

PREF

to change

t Revised coverage on person-centered expressive arts

t New section on motivational interviewing (person-centered approach with a twist)

t Additional coverage of the stages of change as applied to motivational inter-

viewing

c h a p t e r 8 Gestalt

Therapy

t Revised discussion of the role of experiments in Gestalt therapy

t More emphasis on therapist presence

t Added description of emotion-focused therapy and its relationship to Gestalt

therapy

t More attention to the relational approach to Gestalt practice

c h a p t e r 9 Behavior

Therapy

t Increased attention to the trends in contemporary behavior therapy

t Broadened discussion of the role of the therapeutic relationship in behavior

therapy

t Expanded and updated discussion of social skills training

t Revision of multimodal therapy section

t Revised discussion of systematic desensitization and exposure procedures

t Revision of section on EMDR

t More attention to the role of mindfulness and acceptance strategies in contem-

porary behavior therapy

t New material on mindfulness-based cognitive therapy and stress reduction

t Expanded and revised treatment of dialectical behavior therapy

c h a p t e r 1 0 Cognitive Behavior Therapy

t Revised and expanded coverage of Aaron Beck’s cognitive therapy

t Increased coverage of Judith Beck’s role in the development of cognitive therapy

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

t Increased attention on Donald Meichenbaum’s influence in the development

of CBT

t New material on Meichenbaum’s stress inoculation training

t Revised section on Meichenbaum’s constructivist approach to CBT

t Increased coverage of relapse prevention

t Increased discussion of CBT from a multicultural perspective

t New material on the potential limitations of the multicultural applications of CBT

c h a p t e r 1 1 Reality

Therapy

t Revised discussion of the relationship of choice theory to reality therapy

t Expanded discussion of the role of questions in reality therapy

t Revision of section on the role of planning in reality therapy

t More emphasis on the value of reality therapy with reluctant clients

xv

t Additional material on reality therapy from a diversity perspective

PREF

A

c h a p t e r 1 2 Feminist Therapy

CE

t Updated treatment of the principles of feminist therapy

t Updated discussion of the role of assessment and diagnosis in feminist therapy

t Increased attention given to empowerment

t New example of applying feminist therapy interventions with the case of Alma

t Revised and expanded discussion on therapeutic techniques and strategies

c h a p t e r 1 3 Postmodern Approaches

t Additional material on parallels between solution-focused brief therapy and

positive psychology

t Broadened discussion of the key concepts of solution-focused brief therapy

(SFBT)

t More emphasis on the client-as-expert in the therapy relationship in postmod-

ern approaches

t Revision of material on techniques in the postmodern approaches

t New material on listening with an open mind in narrative therapy

t More emphasis on the collaborative nature of narrative therapy and SFBT

c h a p t e r 1 4 Family Systems Therapy

t A reconceptualization and streamlining of the chapter

t New section describing the multilayered process of family therapy

t More emphasis on the personal development of the family therapist

t Addition of reflection questions to assist in the personal application of family

theory

t New material on genogram work for understanding the self of the therapist

and clients

t Expanded section on recent developments in family therapy

t New material on the postmodern perspective on family therapy

t More attention given to feminism, multiculturalism, and postmodern constru-

ctionism as applied to family therapy

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

In Part 3 readers are helped to put the concepts together in a meaningful

way through a discussion of the integrative perspective and consideration of a

case study. Chapter 15 (“An Integrative Perspective”) pulls together themes from

all 11 theoretical orientations. This chapter has been revised to expand discus-

sion of the psychotherapy integration movement; revise treatment of the various

integrative approaches; update and expand the section on integration of multi-

cultural issues in counseling; revise the section on integration of spirituality in

counseling; add material on research demonstrating the importance of the thera-

peutic relationship; more discussion on the central role of the client in determin-

ing therapy outcomes; and update coverage of the conclusions from the research

literature on the effectiveness of psychotherapy. Chapter 15 develops the notion

that an integrative approach to counseling practice is in keeping with meeting

xvi

the needs of diverse client populations in many different settings. Numerous

tables and other integrating material help students compare and contrast the 11

CE

A

approaches.

The “Case of Stan” has been retained in Chapter 16 to help readers see the

PREF

application of a variety of techniques at various stages in the counseling process

with the same client. This chapter illustrates an integrative approach that draws

from all the therapies and applies a thinking, feeling, and behaving model in

counseling Stan. Applying the various theories to a single case example allows

for a comparison among the approaches. The video program ( DVD for Theory

and Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes) can

be used as an ideal supplement to this chapter. For each of the 13 sessions in the

DVD program in my counseling with Stan, I apply just a few selected techniques

designed to illustrate each theory in action. New to accompany this ninth edition

is a series of lecturettes that I present for each chapter in this textbook. This ex-

panded DVD program now includes both demonstrations of my counseling with

Stan and brief lectures that highlight my perspective on the practical applications

of each theory.

This text can be used in a flexible way. Some instructors will follow my se-

quencing of chapters. Others will prefer to begin with the theory chapters (Part 2)

and then deal later with the student’s personal characteristics and ethical issues.

The topics can be covered in whatever order makes the most sense. Readers are

offered some suggestions for using this book in Chapter 1.

In this edition I have made every effort to incorporate those aspects that have

worked best in the courses on counseling theory and practice that I regularly teach.

To help readers apply theory to practice, I have also revised the Student Manual,

which is designed for experiential work. The Student Manual for Theory and Prac-

tice of Counseling and Psychotherapy still contains open-ended questions, many new

cases for exploration and discussion, structured exercises, self-inventories, and a

variety of activities that can be done both in class and out of class. The ninth edition

features a structured overview, as well as a glossary, for each of the theories, and

chapter quizzes for assessing the level of student mastery of basic concepts.

CourseMate, a new online resource, is available to accompany this textbook. It

contains the video program for Theory and Practice of Counseling and Psychotherapy:

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

The Case of Stan and Lecturettes, as well as a glossary of key terms, interviews with ex-

perts (questions and answers by experts in the various theories), and case examples

for each of the theories illustrating ways of applying these concepts and techniques

to a counseling case.

The newly revised and enlarged Case Approach to Counseling and Psychotherapy

(Eighth Edition) features experts working with the case of Ruth from the vari-

ous therapeutic approaches. The casebook can either supplement this book or

stand alone. An additional chapter covering transactional analysis is available on

WebTutor.® This material is provided in the same format as the 11 theory chapters

in this book and includes experiential exercises that can be completed individually

or in small groups.

Accompanying this ninth edition of the text and Student Manual is a DVD for

Integrative Counseling: The Case of Ruth and Lecturettes, in which I demonstrate an

xvii

integrative approach in counseling Ruth (the central character in the casebook).

PREF

It contains lecturettes on how I draw from key concepts and techniques from the

A

various theories presented in the book. This DVD program has been developed for

CE

student purchase and use as a self-study program, and it makes an ideal learning

package that can be used in conjunction with this text and the Student Manual.

The Art of Integrative Counseling (Third Edition), which expands on the material in

Chapter 15 of the textbook, also complements this book.

Some professors have found the textbook and the Student Manual or the online

program (CourseMate) to be ideal companions and realistic resources for a single

course. Others like to use the textbook and the casebook as companions. With

this revision it is now possible to have a unique learning package of several books,

along with the DVD for Integrative Counseling: The Case of Ruth and Lecturettes. The

Case Approach to Counseling and Psychotherapy and the Art of Integrative Counseling

can also be used in a various classes, a few of which include case-management

practicum, fieldwork courses, or counseling techniques courses.

Also available is a revised and updated Instructor’s Resource Manual, which

includes suggestions for teaching the course, class activities to stimulate inter-

est, PowerPoint presentations for all chapters, and a variety of test questions

and final examinations. This instructor’s manual is now geared for the following

learning package: Theory and Practice of Counseling and Psychotherapy, Student

Manual for Theory and Practice of Counseling and Psychotherapy, Case Approach

to Counseling and Psychotherapy, The Art of Integrative Counseling, and two video

programs: DVD for Integrative Counseling: The Case of Ruth and Lecturettes, and

DVD for Theory and Practice of Counseling and Psychotherapy: The Case of Stan and

Lecturettes.

Acknowledgments

The suggestions I received from the many readers of prior editions who took the

time to complete the survey at the end of the book have been most helpful. Many

other people have contributed ideas that have found their way into this ninth

edition. I especially appreciate the time and efforts of the manuscript reviewers,

who offered constructive criticism and supportive commentaries, as well as those

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

professors who have used this book and provided me with feedback that has been

most useful in these revisions. Those who reviewed the complete manuscript of

the ninth edition are:

Sylinda Banks, Norfolk State University

Jayne Barnes, Nashua Community College

Eric Bruns, Campbellsville University

Joya Crear, George Mason University

Samantha Daniel, Fayetteville State University

Melodie Frick, West Texas A&M University

Amanda Healey, Sam Houston State University

Paula Nelson, Saint Leo University

Terence Patterson, University of San Francisco

xviii

Holly Seirup, Hofstra University

CE

Special thanks are extended to the chapter reviewers, who provided consulta-

A

tion and detailed critiques. Their insightful and valuable comments have generally

PREF

been incorporated into this edition:

t Chapter 4 (Psychoanalytic Therapy): William Blau, Copper Mountain College,

Joshua Tree, California; and J. Michael Russell of California State University,

Fullerton

t Chapter 5 (Adlerian Therapy): James Robert Bitter, East Tennessee State

University, and I coauthored Chapter 5

t Chapter 6 (Existential Therapy): Emmy van Deurzen, New School of Psy-

chotherapy and Counselling, London, England, and University of Sheffield;

J. Michael Russell of California State University, Fullerton; David N. Elkins,

Graduate School of Education and Psychology, Pepperdine University; Bryan

Farha, Oklahoma City College; Jamie Bludworth, private practice, Phoeniz,

Arizona; Kirk Schneider, the Existential-Humanistic Institute; and Victor

Yalom, president, Psychotherapy.Net

t Chapter 7 (Person-Centered Therapy): Natalie Rogers, Person-Centered Ex-

pressive Arts Associates, Cotati, California; David N. Elkins, Graduate School

of Education and Psychology, Pepperdine University; and David Cain, Cali-

fornia School of Professional Psychology at Alliant International University,

San Diego

t

Chapter 8 (Gestalt Therapy): Jon Frew, Private Practice, Vancouver, Washington,

and Pacific University, Oregon; Ansel Woldt, Kent State University

t Chapter 9 (Behavior Therapy): Sherry Cormier, West Virginia University;

Frank M. Dattilio, Harvard Medical School, and the University of Pennsylvania

School of Medicine; and Arnold A. Lazarus, Rutgers University, and the Lazarus

Institute

t Chapter 10 (Cognitive Behavior Therapy): Sherry Cormier, West Virginia

University; Frank M. Dattilio, Harvard Medical School, and the University of

Pennsylvania School of Medicine; Windy Dryden, Professor of Psychothera-

peutic Studies at Goldsmiths College, London; and Donald Meichenbaum,

Research Director of the Melissa Institute for Violence Prevention

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

t Chapter 11 (Reality Therapy): Robert Wubbolding, Center for Reality Therapy,

Cincinnati, Ohio

t Chapter 12 (Feminist Therapy): Carolyn Zerbe Enns, Cornell College; Barbara

Herlihy, University of New Orleans, and I coauthored Chapter 12

t Chapter 13 (Postmodern Approaches): John Winslade, California State Uni-

versity, San Bernardino; Linda Metcalf, Texas Women’s University, and the

Solution Focused Institute for Education and Training; and John Murphy, Uni-

versity of Central Arkansas

t Chapter 14 (Family Systems Therapy): Jon Carlson, Governors State Univer-

sity; James Robert Bitter, East Tennessee State University, and I coauthored

Chapter 14

I want to acknowledge those on the Brooks/Cole, Cengage Learning team who are

involved with our projects. These people include Seth Dobrin, editor of counseling,

xix

social work, and human services; Julie Martinez, consulting editor, who monitored

PREF

the review process; Caryl Gorska, for her work on the interior design and cover of

A

CE

this book; Elizabeth Momb, media editor; Naomi Dreyers, supplemental materials

for the book; Michelle Muratori, Johns Hopkins University, for her work on up-

dating the Instructor’s Resource Manual and assisting in developing the other sup-

plements; and Rita Jaramillo, project manager. We thank Ben Kolstad of Cenveo

Publisher Services, who coordinated the production of this book. Special recogni-

tion goes to Kay Mikel, the manuscript editor of this edition, whose exceptional

editorial talents continue to keep this book reader friendly. We appreciate Susan

Cunningham’s work in preparing the index. The efforts and dedication of all of

these people certainly contribute to the high quality of this edition.

– Gerald Corey

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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p a r t 1

Basic Issues in

Counseling Practice

1 Introduction and Overview 4

2 The Counselor: Person and Professional 17

3 Ethical Issues in Counseling Practice 36

R e c o m m e n d e d S u p p l e m e n ta r y R e a d i n g s

f o r Pa r t 1 53

R e f e r e n c e s a n d S u g g e s t e d R e a d i n g s

f o r Pa r t 1 55

3

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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c h a p t e r 1

Introduction and Overview

i n t r o d u c t i o n

w h e r e i s ta n d

s u g g e s t i o n s f o r u s i n g t h e b o o k

o v e r v i e w o f t h e t h e o ry c h a p t e r s

i n t r o d u c t i o n t o t h e c a s e o f s ta n

• Intake Interview and Stan’s Autobiography

• Overview of Some Key Themes in Stan’s Life

4

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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i n t r o d u c t i o n

Counseling students can begin to acquire a counseling style tailored to their own

personality by familiarizing themselves with the major approaches to therapeutic

practice. This book surveys 11 approaches to counseling and psychotherapy, pre-

senting the key concepts of each approach and discussing features such as the

therapeutic process (including goals), the client–therapist relationship, and spe-

cifi c procedures used in the practice of counseling. This information will help you

develop a balanced view of the major ideas of each of the theories and acquaint

you with the practical techniques commonly employed by counselors who adhere

to each approach. I encourage you to keep an open mind and to seriously consider

both the unique contributions and the particular limitations of each therapeutic

system presented in Part 2.

You do not gain the knowledge and experience needed to synthesize various

5

approaches by merely completing an introductory course in counseling theory.

INTR

This process will take many years of study, training, and practical counseling ex-

ODUC

perience. Nevertheless, I recommend a personal integration as a framework for

the professional education of counselors. The danger in presenting one model to

TION AND O

which all students are expected to subscribe is that it can limit their effectiveness

in working with a diverse range of future clients.

An undisciplined mixture of approaches, however, can be an excuse for

failing to develop a sound rationale for systematically adhering to certain con-

VER

cepts and to the techniques that are extensions of them. It is easy to pick and

VIEW

choose fragments from the various therapies because they support our biases

and preconceptions. By studying the models presented in this book, you will

have a better sense of how to integrate concepts and techniques from differ-

ent approaches when defi ning your own personal synthesis and framework for

counseling.

Each therapeutic approach has useful dimensions. It is not a matter of a theory

being “right” or “wrong,” as every theory offers a unique contribution to under-

standing human behavior and has unique implications for counseling practice.

Accepting the validity of one model does not necessarily imply rejecting other

models. There is a clear place for theoretical pluralism, especially in a society that

is becoming increasingly diverse.

Although I suggest that you remain open to incorporating diverse approaches

into your own personal synthesis—or integrative approach to counseling—let

me caution that you can become overwhelmed and confused if you attempt to

learn everything at once, especially if this is your introductory course in coun-

seling theories. A case can be made for initially getting an overview of the major

theoretical orientations, and then learning a particular approach by becoming

steeped in that approach for some time, rather than superfi cially grasping many

theoretical approaches. An integrative perspective is not developed in a random

fashion; rather, it is an ongoing process that is well thought out. Successfully

integrating concepts and techniques from diverse models requires years of refl ec-

tive practice and a great deal of reading about the various theories. In Chapter 15

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28549_ch01_rev01.indd 5

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I discuss in more depth some ways to begin designing your integrative approach

to counseling practice.

See the video program for Chapter 1, DVD for Theory and Practice of

Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest

that you view the brief lecturette for each chapter in this book prior to

reading the chapter.

w h e r e i s ta n d

My philosophical orientation is strongly infl uenced by the existential approach.

Because this approach does not prescribe a set of techniques and procedures, I

draw techniques from the other models of therapy that are presented in this book.

6

I particularly like to use role-playing techniques. When people reenact scenes from

their lives, they tend to become more psychologically engaged than when they

merely report anecdotes about themselves. I also incorporate many techniques

derived from cognitive behavior therapy.

The psychoanalytic emphasis on early psychosexual and psychosocial develop-

ment is useful. Our past plays a crucial role in shaping our current personality and

CHAPTER ONE

behavior. I challenge the deterministic notion that humans are the product of their

early conditioning and, thus, are victims of their past. But I believe that an explora-

tion of the past is often useful, particularly to the degree that the past continues to

infl uence present-day emotional or behavioral diffi culties.

I value the cognitive behavioral focus on how our thinking affects the way we

feel and behave. These therapies also emphasize current behavior. Thinking and

feeling are important dimensions, but it can be a mistake to overemphasize them

and not explore how clients are behaving. What people are doing often gives us a

good clue to what they really want. I also like the emphasis on specifi c goals and

on encouraging clients to formulate concrete aims for their own therapy sessions

and in life. Contracts between clients and therapists can be very useful. I frequently

suggest either specifi c homework assignments or ask my clients to devise their own

assignments, or together we develop goals and tasks that guide the therapy process.

More approaches have been developing methods that involve collaboration be-

tween therapist and client, making the therapeutic venture a shared responsibility.

This collaborative relationship, coupled with teaching clients ways to use what they

learn in therapy in their everyday lives, empowers clients to take an active stance

in their world. It is imperative that clients be active, not only in their counseling

sessions but in daily life as well. Homework can be a vehicle for assisting clients in

putting into action what they are learning in therapy.

A related assumption of mine is that we can exercise increasing freedom to cre-

ate our future. The acceptance of personal responsibility does not imply that we can

be anything that we want. Social, environmental, cultural, and biological realities

oftentimes limit our freedom of choice. Being able to choose must be considered

in the sociopolitical contexts that exert pressure or create constraints; oppression

is a reality that can restrict our ability to choose our future. We are also infl uenced

by our social environment, and much of our behavior is a product of learning and

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch01_rev01.indd 6

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conditioning. That being said, I believe an increased awareness of these contextual

forces enables us to address these realities. It is crucial to learn how to cope with

the external and internal forces that limit our decisions and behavior.

Feminist therapy has contributed an awareness of how environmental and

social conditions contribute to the problems of women and men and how gender-

role socialization leads to a lack of gender equality. Family therapy teaches us that

it is not possible to understand the individual apart from the context of the system.

Both family therapy and feminist therapy are based on the premise that to un-

derstand the individual it is essential to take into consideration the interpersonal

dimensions and the sociocultural context rather than focusing primarily on the

intrapsychic domain. Thus a comprehensive approach to counseling goes beyond

focusing on our internal dynamics and addresses those environmental and sys-

temic realities that infl uence us.

7

My philosophy of counseling does not include the assumption that therapy is

INTR

exclusively for the “sick” and is aimed at “curing” psychological “ailments.” Such

ODUC

a focus on the medical model restricts therapeutic practice because it stresses

defi cits rather than strengths. Instead, I agree with the postmodern approaches

TION AND O

(see Chapter 13), which are grounded on the assumption that people have both

internal and external resources to draw upon when constructing solutions to their

problems. Therapists will view these individuals quite differently if they acknowl-

edge that their clients possess competencies rather than pathologies. I view each

VER

individual as having resources and competencies that can be discovered and built

VIEW

upon in therapy.

Psychotherapy is a process of engagement between two people, both of whom

are bound to change through the therapeutic venture. At its best, this is a collabora-

tive process that involves both the therapist and the client in co-constructing

solutions to concerns. Most of the theories described in this book emphasize the

collaborative nature of the practice of psychotherapy.

Therapists are not in business to change clients, to give them quick advice, or

to solve their problems for them. Instead, counselors facilitate healing through

a process of genuine dialogue with their clients. The kind of person a therapist

is remains the most critical factor affecting the client and promoting change. If

practitioners possess wide knowledge, both theoretical and practical, yet lack

human qualities of compassion, caring, good faith, honesty, presence, realness,

and sensitivity, they are more like technicians. In my judgment those who func-

tion exclusively as technicians do not make a signifi cant difference in the lives of

their clients. It is essential that counselors explore their own values, attitudes, and

beliefs in depth and work to increase their own awareness. Throughout the book,

I encourage you to fi nd ways to personally relate to each of the therapies. Applying

this material to yourself personally takes you beyond a mere academic understand-

ing of theories.

With respect to mastering the techniques of counseling and applying them

appropriately and effectively, it is my belief that you are your own very best tech-

nique. Your reactions to your clients, including sharing how you are affected in

the relationship with them, are useful in moving the therapeutic process along.

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28549_ch01_rev01.indd 7

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It is impossible to separate the techniques you use from your personality and the

relationship you have with your clients.

Administering techniques to clients without regard for the relationship var-

iables is ineffective. Techniques cannot substitute for the hard work it takes to

develop a constructive client–therapist relationship. Although you can learn atti-

tudes and skills and acquire certain knowledge about personality dynamics and

the therapeutic process, much of effective therapy is the product of artistry. Coun-

seling entails far more than becoming a skilled technician. It implies that you are

able to establish and maintain a good working relationship with your clients, that

you can draw on your own experiences and reactions, and that you can identify

techniques suited to the needs of your clients.

As a counselor, you need to remain open to your own personal development

8

and to address your personal problems. The most powerful ways for you to teach

your clients is by the behavior you model and by the ways you connect with

them. I suggest you experience a wide variety of techniques yourself as a client.

Reading about a technique in a book is one thing; actually experiencing it from

the vantage point of a client is quite another. If you have practiced mindfulness

exercises, for example, you will have a much better sense for guiding clients in

CHAPTER ONE

the practice of becoming increasingly mindful in daily life. If you have carried

out real-life homework assignments as part of your own self-change program,

you can increase your empathy for clients and their potential problems. Your

own anxiety over self-disclosing and addressing personal concerns can be a most

useful anchoring point as you work with the anxieties of your clients. The cour-

age you display in your therapy will help you appreciate how essential courage is

for your clients.

Your personal characteristics are of primary importance in becoming a coun-

selor, but it is not suffi cient to be merely a good person with good intentions. To

be effective, you also must have supervised experiences in counseling and sound

knowledge of counseling theory and techniques. Further, it is essential to be well

grounded in the various theories of personality and to learn how they are related to

theories of counseling. Your conception of the person and the individual characteris-

tics of your client affect the interventions you will make. Differences between you

and your client may require modifi cation of certain aspects of the theories. Some

practitioners make the mistake of relying on one type of intervention (supportive,

confrontational, information giving) for most clients with whom they work. In

reality, different clients may respond better to one type of intervention than to

another. Even during the course of an individual’s therapy, different interventions

may be needed at different times. Practitioners should acquire a broad base of

counseling techniques that are suitable for individual clients rather than forcing

clients to fi t one approach to counseling.

s u g g e s t i o n s f o r u s i n g t h e b o o k

Here are some specifi c recommendations on how to get the fullest value from this

book. The personal tone of the book invites you to relate what you are reading to your

own experiences. As you read Chapter 2, “The Counselor: Person and Professional,”

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch01_rev01.indd 8

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begin the process of refl ecting on your needs, motivations, values, and life expe-

riences. Consider how you are likely to bring the person you are becoming into

your professional work. You will assimilate much more knowledge about the vari-

ous therapies if you make a conscious attempt to apply their key concepts and

techniques to your own personal life. Chapter 2 helps you think about how to use

yourself as your single most important therapeutic instrument, and it addresses a

number of signifi cant ethical issues in counseling practice.

Before you study each therapy in depth in Part 2, I suggest that you at least

briefl y read Chapter 15, which provides a comprehensive review of the key concepts

from all 11 theories presented in this textbook. I try to show how an integration of

these perspectives can form the basis for creating your own personal synthesis to

counseling. In developing an integrative perspective, it is essential to think holisti-

cally. To understand human functioning, it is imperative to account for the physi-

9

cal, emotional, mental, social, cultural, political, and spiritual dimensions. If any

INTR

of these facets of human experience is neglected, a theory is limited in explaining

ODUC

how we think, feel, and act.

To provide you with a consistent framework for comparing and contrasting

TION AND O

the various therapies, the 11 theory chapters share a common format. This format

includes a few notes on the personal history of the founder or another key fi gure;

a brief historical sketch showing how and why each theory developed at the time

it did; a discussion of the approach’s key concepts; an overview of the therapeutic

VER

process, including the therapist’s role and client’s work; therapeutic techniques

VIEW

and procedures; applications of the theory from a multicultural perspective;

application of the theory to the case of Stan; a summary and evaluation; sugges-

tions of how to continue your learning about each approach; and suggestions for

further reading.

Refer to the preface for a complete description of other resources that fi t as a

package and complement this textbook, including Student Manual for Theory and

Practice of Counseling and Psychotherapy and DVD for Integrative Counseling: The

Case of Ruth and Lecturettes. In addition, in DVD for Theory and Practice of Coun-

seling and Psychotherapy: The Case of Stan and Lecturettes, I demonstrate my way of

counseling Stan from the various theoretical approaches in 13 sessions and present

my perspective on the key concepts of each theory in a brief lecture, with emphasis

on the practical application of the theory.

o v e r v i e w o f t h e t h e o r y c h a p t e r s

I have selected 11 therapeutic approaches for this book. Table 1.1 presents an over-

view of these approaches, which are explored in depth in Chapters 4 through 14. I

have grouped these approaches into four general categories.

First are the psychodynamic approaches. Psychoanalytic therapy is based largely

on insight, unconscious motivation, and reconstruction of the personality. The

psychoanalytic model appears fi rst because it has had a major infl uence on all of

the other formal systems of psychotherapy. Some of the therapeutic models are ba-

sically extensions of psychoanalysis, others are modifi cations of analytic concepts

and procedures, and still others are positions that emerged as a reaction against

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TA B L E 1 .1 Overview of Contemporary Counseling Models

Psychodynamic Approaches

Psychoanalytic therapy

Founder: Sigmund Freud. A theory of personality

development, a philosophy of human nature, and a method

of psychotherapy that focuses on unconscious factors that

motivate behavior. Attention is given to the events of the fi rst

6 years of life as determinants of the later development of

personality.

Adlerian therapy

Founder: Alfred Adler. Key Figure: Following Adler, Rudolf

Dreikurs is credited with popularizing this approach in the

United States. This is a growth model that stresses assuming

10

responsibility, creating one’s own destiny, and fi nding meaning

and goals to create a purposeful life. Key concepts are used in

most other current therapies.

Experiential and Relationship-Oriented Therapies

CHAPTER ONE

Existential therapy

Key fi gures: Viktor Frankl, Rollo May, and Irvin Yalom.

Reacting against the tendency to view therapy as a system of

well-defi ned techniques, this model stresses building therapy

on the basic conditions of human existence, such as choice,

the freedom and responsibility to shape one’s life, and self-

determination. It focuses on the quality of the person-to-person

therapeutic relationship.

Person-centered therapy

Founder: Carl Rogers. Key fi gure: Natalie Rogers. This approach

was developed during the 1940s as a nondirective reaction

against psychoanalysis. Based on a subjective view of human

experiencing, it places faith in and gives responsibility to the

client in dealing with problems and concerns.

Gestalt therapy

Founders: Fritz and Laura Perls. Key fi gures: Miriam and

Erving Polster. An experiential therapy stressing awareness and

integration; it grew as a reaction against analytic therapy.

It integrates the functioning of body and mind.

Cognitive Behavioral Approaches

Behavior therapy

Key fi gures: B. F. Skinner, Arnold Lazarus, and Albert Bandura.

This approach applies the principles of learning to the

resolution of specifi c behavioral problems. Results are subject

to continual experimentation. The methods of this approach are

always in the process of refi nement.

Cognitive behavior therapy

Key fi gure: A. T. Beck founded cognitive therapy, which gives

a primary role to thinking as it infl uences behavior; Judith

Beck continues to develop CBT. Donald Meichenbaum is

a prominent contributor to the development of cognitive

behavior therapy.

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Rational emotive

Key fi gure: Albert Ellis founded rational emotive behavior

behavior therapy

therapy, a highly didactic, cognitive, action-oriented model of

therapy that stresses the role of thinking and belief systems as

the root of personal problems.

Reality therapy

Founder: William Glasser. Key fi gure: Robert Wubbolding. This

short-term approach is based on choice theory and focuses on

the client assuming responsibility in the present. Through the

therapeutic process, the client is able to learn more effective

ways of meeting her or his needs.

Systems and Postmodern Approaches

Feminist therapy

This approach grew out of the efforts of many women, a few

11

of whom are Jean Baker Miller, Carolyn Zerbe Enns, Oliva

INTR

Espin, and Laura Brown. A central concept is the concern

for the psychological oppression of women. Focusing on

ODUC

the constraints imposed by the sociopolitical status to which

women have been relegated, this approach explores women’s

TION AND O

identity development, self-concept, goals and aspirations, and

emotional well-being.

Postmodern approaches

A number of key fi gures are associated with the development of

VER

these various approaches to therapy. Steve de Shazer and Insoo

Kim Berg are the co-founders of solution-focused brief therapy.

VIEW

Michael White and David Epston are the major fi gures associated

with narrative therapy. Social constructionism, solution-focused

brief therapy, and narrative therapy all assume that there is

no single truth; rather, it is believed that reality is socially

constructed through human interaction. These approaches

maintain that the client is an expert in his or her own life.

Family systems therapy

A number of signifi cant fi gures have been pioneers of the

family systems approach, including Alfred Adler, Murray

Bowen, Virginia Satir, Carl Whitaker, Salvador Minuchin, Jay

Haley, and Cloé Madanes. This systemic approach is based

on the assumption that the key to changing the individual is

understanding and working with the family.

psychoanalysis. Many theories of counseling and psychotherapy have borrowed

and integrated principles and techniques from psychoanalytic approaches.

Adlerian therapy differs from psychoanalytic theory in many respects, but it can

broadly be considered an analytic perspective. Adlerians focus on meaning, goals,

purposeful behavior, conscious action, belonging, and social interest. Although

Adlerian theory accounts for present behavior by studying childhood experiences,

it does not focus on unconscious dynamics.

The second category comprises the experiential and relationship-oriented thera-

pies: the existential approach, the person-centered approach, and Gestalt therapy.

The existential approach stresses a concern for what it means to be fully human.

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It suggests certain themes that are part of the human condition, such as freedom

and responsibility, anxiety, guilt, awareness of being fi nite, creating meaning in

the world, and shaping one’s future by making active choices. This approach is not

a unifi ed school of therapy with a clear theory and a systematic set of techniques.

Rather, it is a philosophy of counseling that stresses the divergent methods of

understanding the subjective world of the person. The person-centered approach,

which is rooted in a humanistic philosophy, places emphasis on the basic attitudes

of the therapist. It maintains that the quality of the client–therapist relationship

is the prime determinant of the outcomes of the therapeutic process. Philosophi-

cally, this approach assumes that clients have the capacity for self-direction without

active intervention and direction on the therapist’s part. Another experiential ap-

proach is Gestalt therapy, which offers a range of experiments to help clients gain

12

awareness of what they are experiencing in the here and now—that is, the present.

In contrast to person-centered therapists, Gestalt therapists tend to take an active

role, yet they follow the leads provided by their clients. These approaches tend to

emphasize emotion as a route to bringing about change, and in a sense, they can

be considered emotion-focused therapies.

Third are the cognitive behavioral approaches, sometimes known as the action-

CHAPTER ONE

oriented therapies, because they all emphasize translating insights into behav-

ioral action. These approaches include reality therapy, behavior therapy, rational

emotive behavior therapy, and cognitive therapy. Reality therapy focuses on cli-

ents’ current behavior and stresses developing clear plans for new behaviors.

Like reality therapy, behavior therapy puts a premium on doing and on taking

steps to make concrete changes. A current trend in behavior therapy is toward

paying increased attention to cognitive factors as an important determinant of

behavior. Rational emotive behavior therapy and cognitive therapy highlight the

necessity of learning how to challenge inaccurate beliefs and automatic thoughts

that lead to behavioral problems. These cognitive behavioral approaches are used

to help people modify their inaccurate and self-defeating assumptions and to

develop new patterns of acting.

The fourth general approach encompasses the systems and postmodern perspec-

tives. Feminist therapy and family therapy are systems approaches, but they also

share postmodern notions. The systems orientation stresses the importance of

understanding individuals in the context of the surroundings that infl uence their

development. To bring about individual change, it is essential to pay attention to

how the individual’s personality has been affected by his or her gender-role sociali-

zation, culture, family, and other systems.

The postmodern approaches include social constructionism, solution-focused

brief therapy, and narrative therapy. These newer approaches challenge the basic

assumptions of most of the traditional approaches by assuming that there is no sin-

gle truth and that reality is socially constructed through human interaction. Both

the postmodern and the systemic theories focus on how people produce their own

lives in the context of systems, interactions, social conditioning, and discourse.

In my view, practitioners need to pay attention to what their clients are think-

ing, feeling, and doing, and a complete therapy system must address all three of

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28549_ch01_rev01.indd 12

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these facets. Some of the therapies included here highlight the role that cognitive

factors play in counseling. Others place emphasis on the experiential aspects of

counseling and the role of feelings. Still others emphasize putting plans into action

and learning by doing. Combining all of these dimensions provides the basis

for a comprehensive therapy. If any of these dimensions is excluded, the therapy

approach is incomplete.

i n t r o d u c t i o n t o t h e c a s e o f s ta n

You will learn a great deal by seeing a theory in action, preferably in a live

demonstration or as part of experiential activities in which you function in the

alternating roles of client and counselor. An online program (available in DVD

format as well) demonstrates one or two techniques from each of the theories.

13

As Stan’s counselor, I show how I would apply some of the principles of each

INTR

of the theories you are studying to Stan. Many of my students fi nd this case

ODUC

history of the hypothetical client (Stan) helpful in understanding how various

techniques are applied to the same person. Stan’s case, which describes his life

TION AND O

and struggles, is presented here to give you signifi cant background material to

draw from as you study the applications of the theories. Each of the 11 theory

chapters in Part 2 includes a discussion of how a therapist with the orientation

under discussion is likely to proceed with Stan. We examine the answers to

VER

questions such as these:

VIEW

• What themes in Stan’s life merit special attention in therapy?

• What concepts would be useful to you in working with Stan on his problems?

• What are the general goals of Stan’s therapy?

• What possible techniques and methods would best meet these goals?

• What are some characteristics of the relationship between Stan and his therapist?

• How might the therapist proceed?

• How might the therapist evaluate the process and treatment outcomes of therapy?

In Chapter 16 (which I recommend you read early) I present how I would work

with Stan, suggesting concepts and techniques I would draw on from many of the

models (forming an integrative approach).

A single case illustrates both contrasts and parallels among the approaches.

It also will help you understand the practical applications of the 11 models and

provide a basis for integrating them. A summary of the intake interview with Stan,

his autobiography, and some key themes in his life are presented next to provide

a context for making sense of the way therapists with various theoretical orienta-

tions might work with Stan. Try to fi nd attributes of each approach that you can

incorporate into a personalized style of counseling.

Intake Interview and Stan’s Autobiography

The setting is a community mental health agency where both individual and group

counseling are available. Stan comes to counseling because of his drinking. He

was convicted of driving under the infl uence, and the judge determined that he

needed professional help. Stan recognizes that he does have problems, but he is

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28549_ch01_rev01.indd 13

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not convinced that he is addicted to alcohol. Stan arrives for an intake interview

and provides the counselor with this information:

At the present time I work in construction. I like building houses, but probably won’t stay

in construction for the rest of my life. When it comes to my personal life, I’ve always had

diffi culty in getting along with people. I could be called a “loner.” I like people in my life,

but I don’t seem to know how to stay close to people. It probably has a lot to do with why I

drink. I’m not very good at making friends or getting close to people. Probably the reason I

sometimes drink a bit too much is because I’m so scared when it comes to socializing. Even

though I hate to admit it, when I drink, things are not quite so overwhelming. When I look

at others, they seem to know the right things to say. Next to them I feel dumb. I’m afraid

that people don’t fi nd me very interesting. I’d like to turn my life around, but I just don’t

know where to begin. That’s why I went back to school. I’m a part-time college student ma-

joring in psychology. I want to better myself. In one of my classes, Psychology of Personal

Adjustment, we talked about ourselves and how people change. We also had to write an

14

autobiographical paper.

That is the essence of Stan’s introduction. The counselor says that she would

like to read his autobiography. Stan hopes it will give her a better understanding

of where he has been and where he would like to go. He brings her the autobiog-

raphy, which reads as follows:

CHAPTER ONE

Where am I currently in my life? At 35 I feel that I’ve wasted most of my life. I should be

fi nished with college and into a career by now, but instead I’m only a junior. I can’t afford

to really commit myself to pursuing college full time because I need to work to support

myself. Even though construction work is hard, I like the satisfaction I get when I look at

what I have done.

I want to get into a profession where I could work with people. Someday, I’m hoping to get

a master’s degree in counseling or in social work and eventually work as a counselor with

kids who are in trouble. I know I was helped by someone who cared about me, and I would

like to do the same for someone else.

I have few friends and feel scared around most people. I feel good with kids. But I wonder

if I’m smart enough to get through all the classes I’ll need to become a counselor. One of

my problems is that I frequently get drunk. This happens when I feel alone and when I’m

scared of the intensity of my feelings. At fi rst drinking seemed to help, but later on I felt

awful. I have abused drugs in the past also.

I feel overwhelmed and intimidated when I’m around attractive women. I feel cold, sweaty,

and terribly nervous. I think they may be judging me and see me as not much of a man.

I’m afraid I just don’t measure up to being a real man. When I am sexually intimate with a

woman, I am anxious and preoccupied with what she is thinking about me.

I feel anxiety much of the time. I often feel as if I’m dying inside. I think about committing

suicide, and I wonder who would care. I can see my family coming to my funeral feeling

sorry for me. I feel guilty that I haven’t worked up to my potential, that I’ve been a failure,

that I’ve wasted much of my time, and that I let people down a lot. I get down on myself and

wallow in guilt and feel very depressed. At times like this I feel hopeless and that I’d be better

off dead. For all these reasons, I fi nd it diffi cult to get close to anyone.

There are a few bright spots. I did put a lot of my shady past behind me, and did get into

college. I like this determination in me—I want to change. I’m tired of feeling the way I do.

I know that nobody is going to change my life for me. It’s up to me to get what I want. Even

though I feel scared at times, I like that I’m willing to take risks.

What was my past like? A major turning point for me was the confi dence my supervisor

had in me at the youth camp where I worked the past few summers. He helped me get my

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28549_ch01_rev01.indd 14

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job, and he also encouraged me to go to college. He said he saw a lot of potential in me for

being able to work well with young people. That was hard for me to believe, but his faith

inspired me to begin to believe in myself. Another turning point was my marriage and

divorce. This marriage didn’t last long. It made me wonder about what kind of man I was!

Joyce was a strong and dominant woman who kept repeating how worthless I was and how

she did not want to be around me. We had sex only a few times, and most of the time I was

not very good at it. That was hard to take. It made me afraid to get close to a woman. My

parents should have divorced. They fought most of the time. My mother (Angie) constantly

criticized my father (Frank Sr.). I saw him as weak and passive. He would never stand up

to her. There were four of us kids. My parents compared me unfavorably with my older

sister (Judy) and older brother (Frank Jr.). They were “perfect” children, successful honors

students. My younger brother (Karl) and I fought a lot. They spoiled him. It was all very

hard for me.

In high school I started using drugs. I was thrown into a youth rehabilitation facility for

stealing. Later I was expelled from regular school for fi ghting, and I landed in a continua-

15

INTR

tion high school, where I went to school in the mornings and had afternoons for on-the-job

training. I got into auto mechanics, was fairly successful, and even managed to keep myself

ODUC

employed for 3 years as a mechanic.

I can still remember my father asking me: “Why can’t you be like your sister and brother?

TION AND O

Why can’t you do anything right?” And my mother treated me much the way she treated my

father. She would say: “Why do you do so many things to hurt me? Why can’t you grow up

and be a man? Things are so much better around here when you’re gone.” I recall crying

myself to sleep many nights, feeling terribly alone. There was no talk of religion in my house,

VER

nor was there any talk of sex. In fact, I fi nd it hard to imagine my folks ever having sex.

VIEW

Where would I like to be 5 years from now? What kind of person do I want to become? Most

of all, I would like to start feeling better about myself. I would like to be able to stop drink-

ing altogether and still feel good. I want to like myself much more than I do now. I hope

I can learn to love at least a few other people, most of all, a woman. I want to lose my fear

of women. I would like to feel equal with others and not always have to feel apologetic for

my existence. I want to let go of my anxiety and guilt. I want to become a good counselor

for kids. I’m not certain how I’ll change or even what all the changes are I hope for. I do

know that I want to be free of my self-destructive tendencies and learn how to trust people

more. Perhaps when I begin to like myself more, I’ll be able to trust that others will fi nd

something about me to like.

Effective therapists, regardless of their theoretical orientation, would pay atten-

tion to suicidal thoughts. In his autobiography Stan says, “I think about commit-

ting suicide.” At times he doubts that he will ever change and wonders if he’d be

“better off dead.” Before embarking on the therapeutic journey, the therapist would

need to make an assessment of Stan’s current ego strength (or his ability to manage

life realistically), which would include a discussion of his suicidal thoughts.

Overview of Some Key Themes in Stan’s Life

A number of themes appear to represent core struggles in Stan’s life. Here are

some of the statements we can assume that he may make at various points in his

therapy and themes that will be addressed from the theoretical perspectives in

Chapters 4 through 14:

• Although I’d like to have people in my life, I just don’t seem to know how to go

about making friends or getting close to people.

• I’d like to turn my life around, but I have no sense of direction.

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28549_ch01_rev01.indd 15

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• I want to make a difference.

• I am afraid of failure.

• I know that when I feel alone, scared, and overwhelmed, I drink heavily to feel

better.

• I am afraid of women.

• Sometimes at night I feel a terrible anxiety and feel as if I’m dying.

• I often feel guilty that I’ve wasted my life, that I’ve failed, and that I’ve let people

down. At times like this, I get depressed.

• I like it that I have determination and that I really want to change.

• I’ve never really felt loved or wanted by my parents.

• I’d like to get rid of my self-destructive tendencies and learn to trust people more.

• I put myself down a lot, but I’d like to feel better about myself.

16

In Chapters 4 through 14, I write about how I would apply selected concepts

and techniques of the particular theory in counseling Stan. In addition, in these

chapters you are asked to think about how you would continue counseling Stan

from each of these different perspectives. In doing so, refer to the introductory

material given here and to Stan’s autobiography as well. To make the case of Stan

CHAPTER ONE

come alive for each theory, I highly recommend that you view and study the video

program, DVD for Theory and Practice of Counseling and Psychotherapy: The Case of

Stan and Lecturettes. In this video program I counsel Stan from each of the various

theories and provide brief lectures that highlight each theory.

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28549_ch01_rev01.indd 16

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c h a p t e r 2

The Counselor: Person

and Professional

i n t r o d u c t i o n

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17

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

i n t r o d u c t i o n

One of the most important instruments you have to work with as a counselor is

yourself as a person. In preparing for counseling, you will acquire knowledge about

the theories of personality and psychotherapy, learn assessment and intervention

techniques, and discover the dynamics of human behavior. Such knowledge and

skills are essential, but by themselves they are not suffi cient for establishing and

maintaining effective therapeutic relationships. To every therapy session we bring

our human qualities and the experiences that have infl uenced us. In my judg-

ment, this human dimension is one of the most powerful infl uences on the thera-

peutic process.

A good way to begin your study of contemporary counseling theories is by

refl ecting on the personal issues raised in this chapter. By remaining open to self-

18

evaluation, you not only expand your awareness of self but also build the founda-

O

tion for developing your abilities and skills as a professional. The theme of this

chapter is that the person and the professional are intertwined facets that cannot be

separated in reality. We know, clinically and scientifi cally, that the person of the

therapist and the therapeutic relationship contribute to therapy outcome at least

CHAPTER TW

as much as the particular treatment method used (Duncan, Miller, Wampold, &

Hubble, 2010; Norcross, 2011; Norcross & Guy, 2007).

See the DVD program for Chapter 2, DVD for Theory and Practice of Counseling

and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view

the brief lecture for each chapter prior to reading the chapter.

t h e c o u n s e lo r a s a

t h e r a p e u t i c p e r s o n

Because counseling is an intimate form of learning, it demands a practitioner who

is willing to be an authentic person in the therapeutic relationship. It is within the

context of such a person-to-person connection that the client experiences growth.

If we hide behind the safety of our professional role, our clients will likely keep

themselves hidden from us. If we strive for technical expertise alone, and leave our

own reactions and self out of our work, the result is likely to be ineffective coun-

seling. Our own genuineness can have a signifi cant effect on our relationship with

our clients. If we are willing to look at our lives and make the changes we want, we

can model that process by the way we reveal ourselves and respond to our clients.

If we are inauthentic, our clients will probably pick that up and be discouraged

by it. Our clients can be encouraged by our way of being with them. If we model

authenticity by engaging in appropriate self-disclosure, our clients will tend to be

honest with us as well.

I believe that who the psychotherapist is directly relates to his or her ability

to establish and maintain effective therapy relationships with clients. But what

does the research reveal about the role of the counselor as a person and the thera-

peutic relationship on psychotherapy outcome? Abundant research indicates the

centrality of the person of the therapist as a primary factor in successful therapy

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28549_ch02_rev01.indd 18

20/09/11 2:49 PM

(Norcross & Lambert, 2011; Norcross & Wampold, 2011). Clients place more value

on the personality of the therapist than on the specifi c techniques used (Lambert,

2011). Norcross and Lambert (2011) cite considerable evidence indicating that the

person of the psychotherapist is inextricably intertwined with the outcome of psy-

chotherapy. Indeed, evidence-based psychotherapy relationships are critical to the

psychotherapy endeavor.

Techniques themselves have limited importance in the therapeutic process.

Wampold (2001) conducted a meta-analysis of many research studies on therapeu-

tic effectiveness and found that the personal and interpersonal components are es-

sential to effective psychotherapy, whereas techniques have relatively little effect on

therapeutic outcome. The contextual factors—the alliance, the relationship, the per-

sonal and interpersonal skills of the therapist, client agency, and extra-therapeutic

factors—are the primary determinants of therapeutic outcome. This research sup-

19

ports what humanistic psychologists have maintained for years: “It is not theories

THE C

and techniques that heal the suffering client but the human dimension of therapy

OUNSEL

and the ‘meetings’ that occur between therapist and client as they work together”

(Elkins, 2009, p. 82). In short, both the therapy relationship and the therapy methods

used infl uence the outcomes of treatment, but it is essential that the methods used

OR: PERSON AND PR

support the therapeutic relationship being formed with the client.

Personal Characteristics of Effective Counselors

Particular personal qualities and characteristics of counselors are signifi cant in

creating a therapeutic alliance with clients. My views regarding these personal

characteristics are supported by research on this topic (Norcross, 2011; Skovholt &

OFES

Jennings, 2004). I do not expect any therapist to fully exemplify all the traits de-

SIONAL

scribed in the list that follows. Rather, the willingness to struggle to become a

more therapeutic person is the crucial variable. This list is intended to stimulate

you to examine your own ideas about what kind of person can make a signifi cant

difference in the lives of others.

• Effective therapists have an identity. They know who they are, what they are capa-

ble of becoming, what they want out of life, and what is essential.

• Effective therapists respect and appreciate themselves. They can give and receive

help and love out of their own sense of self-worth and strength. They feel ad-

equate with others and allow others to feel powerful with them.

• Effective therapists are open to change. They exhibit a willingness and courage to

leave the security of the known if they are not satisfi ed with the way they are.

They make decisions about how they would like to change, and they work

toward becoming the person they want to become.

• Effective therapists make choices that are life oriented. They are aware of early

decisions they made about themselves, others, and the world. They are not the

victims of these early decisions, and they are willing to revise them if necessary.

They are committed to living fully rather than settling for mere existence.

• Effective therapists are authentic, sincere, and honest. They do not hide behind rigid

roles or facades. Who they are in their personal life and in their professional

work is congruent.

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• Effective therapists have a sense of humor. They are able to put the events of life

in perspective. They have not forgotten how to laugh, especially at their own

foibles and contradictions.

• Effective therapists make mistakes and are willing to admit them. They do not dis-

miss their errors lightly, yet they do not choose to dwell on them, either.

• Effective therapists generally live in the present. They are not riveted to the past, nor

are they fi xated on the future. They are able to experience and be present with

others in the “now.”

• Effective therapists appreciate the infl uence of culture. They are aware of the ways

in which their own culture affects them, and they respect the diversity of values

espoused by other cultures. They are sensitive to the unique differences arising

out of social class, race, sexual orientation, and gender.

20

• Effective therapists have a sincere interest in the welfare of others. This concern is

based on respect, care, trust, and a real valuing of others.

O

• Effective therapists possess effective interpersonal skills. They are capable of entering

the world of others without getting lost in this world, and they strive to create

collaborative relationships with others. They readily entertain another person’s

perspective and can work together toward consensual goals.

CHAPTER TW

• Effective therapists become deeply involved in their work and derive meaning from it.

They can accept the rewards fl owing from their work, yet they are not slaves to

their work.

• Effective therapists are passionate. They have the courage to pursue their dreams

and passions, and they radiate a sense of energy.

• Effective therapists are able to maintain healthy boundaries. Although they strive to

be fully present for their clients, they don’t carry the problems of their clients

around with them during leisure hours. They know how to say no, which ena-

bles them to maintain balance in their lives.

This picture of the characteristics of effective therapists might appear unreal-

istic. Who could be all those things? Certainly I do not fi t this bill! Do not think of

these personal characteristics from an all-or-nothing perspective; rather, consider

them on a continuum. A given trait may be highly characteristic of you, at one

extreme, or it may be very uncharacteristic of you, at the other extreme. I have pre-

sented this picture of the therapeutic person with the hope that you will examine

it and develop your own concept of what personality traits you think are essential

to strive for to promote your own personal growth. For a more detailed discussion

of the person of the counselor and the role of the therapeutic relationship in out-

comes of treatments, see Psychotherapy Relationships That Work (Norcross, 2011)

and Master Therapists: Exploring Expertise in Therapy and Counseling (Skovholt &

Jennings, 2004).

p e r s o n a l t h e r a p y f o r t h e c o u n s e lo r

Discussion of the counselor as a therapeutic person raises another issue debated

in counselor education: Should people be required to participate in counseling or

therapy before they become practitioners? My view is that counselors can benefi t

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greatly from the experience of being clients at some time, a view that is supported

by research. Some type of self-exploration can increase your level of self-aware-

ness. This experience can be obtained before your training, during it, or both, but I

strongly support some form of personal exploration as vital preparation in learning

to counsel others.

The vast majority of mental health professionals have experienced personal

therapy, typically on several occasions (Geller, Norcross, & Orlinsky, 2005b). A

review of research studies on the outcomes and impacts of the psychotherapist’s

own psychotherapy revealed that more than 90% of mental health professionals

report satisfaction and positive outcomes from their own counseling experiences

(Orlinsky, Norcross, Ronnestad, & Wiseman, 2005). Orlinsky and colleagues sug-

gest that personal therapy contributes to the therapist’s professional work in the

following three ways: (1) as part of the therapist’s training, personal therapy offers

21

a model of therapeutic practice in which the trainee experiences the work of a more

THE C

experienced therapist and learns experientially what is helpful or not helpful; (2) a

OUNSEL

benefi cial experience in personal therapy can further enhance a therapist’s inter-

personal skills that are essential to skillfully practicing therapy; and (3) successful

personal therapy can contribute to a therapist’s ability to deal with the ongoing

OR: PERSON AND PR

stresses associated with clinical work.

In his research on personal therapy for mental health professionals, Norcross

(2005) states that lasting lessons practitioners learn from their personal therapy

experiences pertain to interpersonal relationships and the dynamics of psycho-

therapy. Some of these lessons learned are the centrality of warmth, empathy, and

the personal relationship; having a sense of what it is like to be a therapy client;

OFES

valuing patience and tolerance; and appreciating the importance of learning how

SIONAL

to deal with transference and countertransference. By participating in personal

therapy, counselors can prevent their potential future countertransference from

harming clients.

Through our work as therapists, we can expect to confront our own unexplored

personal blocks such as loneliness, power, death, and intimate relationships. This

does not mean that we need to be free of confl icts before we can counsel others, but

we should be aware of what these confl icts are and how they are likely to affect us

as persons and as counselors. For example, if we have great diffi culty dealing with

anger or confl ict, we may not be able to assist clients who are dealing with anger or

with relationships in confl ict.

When I began counseling others, old wounds were opened, and feelings I had

not explored in depth came to the surface. It was diffi cult for me to encounter a cli-

ent’s depression because I had failed to come to terms with the way I had escaped

from my own depression. I did my best to cheer up depressed clients by talking

them out of what they were feeling, mainly because of my own inability to deal

with such feelings. In the years I worked as a counselor in a university counseling

center, I frequently wondered what I could do for my clients. I often had no idea

what, if anything, my clients were getting from our sessions. I couldn’t tell if they

were getting better, staying the same, or getting worse. It was very important to me

to note progress and see change in my clients. Because I did not see immediate

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results, I had many doubts about whether I could become an effective counselor.

What I did not understand at the time was that my clients needed to struggle to

fi nd their own answers. To see my clients feel better quickly was my need, not

theirs, for then I would know that I was helping them. It never occurred to me

that clients often feel worse for a time as they give up their defenses and open

themselves to their pain. My early experiences as a counselor showed me that I

could benefi t by participating in further personal therapy to better understand how

my personal issues were affecting my professional work. I realized that periodic

therapy, especially early in one’s career, can be most useful.

Personal therapy can be instrumental in healing the healer. If student coun-

selors are not actively involved in the pursuit of healing their psychological wounds,

they will probably have considerable diffi culty entering the world of a client. As

22

counselors, can we take our clients any further than we have gone ourselves? If we

are not committed personally to the value of examining our own life, how can we

O

inspire clients to examine their lives? By becoming clients ourselves, we gain an

experiential frame of reference with which to view ourselves. This provides a basis

for understanding and compassion for our clients, for we can draw on our own

memories of reaching impasses in our therapy, of both wanting to go farther and

CHAPTER TW

at the same time resisting change. Our own therapy can help us develop patience

with our patients! We learn what it feels like to deal with anxieties that are aroused

by self-disclosure and self-exploration and how to creatively facilitate deeper levels

of self-exploration in clients. Through our own therapy, we can gain increased

appreciation for the courage our clients display in their therapeutic journey. Being

willing to participate in a process of self-exploration can reduce the chances of

assuming an attitude of arrogance or of being convinced that we are totally healed.

Our own therapy helps us avoid assuming a stance of superiority over others and

makes it less likely that we would treat people as objects to be pitied or disre-

spected. Indeed, experiencing counseling as a client is very different from merely

reading about the counseling process.

For a comprehensive discussion of personal therapy for counselors, see

The Psychotherapist’s Own Psychotherapy: Patient and Clinician Perspectives (Geller,

Norcross, & Orlinsky, 2005a).

t h e c o u n s e lo r ’s va l u e s

a n d t h e t h e r a p e u t i c p r o c e s s

As alluded to in the previous section, the importance of self-exploration for coun-

selors carries over to the values and beliefs they hold. My experience in teaching

and supervising students of counseling shows me how crucial it is that students

be aware of their values, of where and how they acquired them, and of how their

values can infl uence their interventions with clients.

The Role of Values in Counseling

Our values are core beliefs that infl uence how we act, both in our personal and

our professional lives. Personal values infl uence how we view counseling and

the manner in which we interact with clients, including the way we conduct client

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assessments, our views of the goals of counseling, the interventions we choose, the

topics we select for discussion in a counseling session, how we evaluate progress,

and how we interpret clients’ life situations.

Although total objectivity cannot be achieved, we can strive to avoid being en-

capsulated by our own worldview. As counselors we need to guard against the

tendency to use our power to infl uence the client to accept our values because it is

not our function to persuade clients to accept or adopt our value system From my

perspective, the counselor’s role is to create a climate in which clients can examine

their thoughts, feelings, and actions and to empower them to arrive at their own

solutions to problems they face. The counseling task is to assist individuals in fi nd-

ing answers that are most congruent with their own values. It is not benefi cial to

provide advice or to give clients your answers to their questions.

You may not agree with certain of your clients’ values, but you need to respect

23

their right to hold divergent values from yours. This is especially true when coun-

THE C

seling clients who have a different cultural background and perhaps do not share

OUNSEL

your own core cultural values. Your role is to provide a safe and inviting context in

which clients can explore the congruence between their values and their behavior.

If clients acknowledge that what they are doing is not getting them what they want,

OR: PERSON AND PR

it is appropriate to assist them in developing new ways of thinking and behaving to

help them move closer to their goals. This is done with full respect for their right

to decide which values they will use as a framework for living. Individuals seeking

counseling need to clarify their own values and goals, make informed decisions,

choose a course of action, and assume responsibility and accountability for the

decisions they make.

OFES

There is a difference between exposing our values and imposing our values

SIONAL

on clients. Value imposition refers to counselors directly attempting to defi ne a

client’s values, attitudes, beliefs, and behaviors. It is possible for counselors to

impose their values either actively or passively. Counselors are cautioned about

not imposing their values on their clients. On this topic, the American Counseling

Association’s Code of Ethics (ACA, 2005) has this standard:

Personal Values. Counselors are aware of their own values, attitudes, beliefs, and behaviors

and avoid imposing values that are inconsistent with counseling goals and respect for the

diversity of clients, trainees, and research participants. (A.4.b.)

Even though therapists should not directly teach the client or impose spe-

cifi c values, therapists do implement a philosophy of counseling, which is, in

effect, a philosophy of life. Counselors communicate their values by the thera-

peutic goals to which they subscribe and by the procedures they employ to reach

these goals.

The Role of Values in Developing Therapeutic Goals

Who should establish the goals of counseling? Almost all theories are in agree-

ment that it is largely the client’s responsibility to decide upon goals, collaborating

with the therapist as therapy proceeds. Counselors have general goals, which are

refl ected in their behavior during the therapy session, in their observations of the

client’s behavior, and in the interventions they make. The general goals of coun-

selors must be congruent with the personal goals of the client.

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Setting goals is inextricably related to values. The client and the counselor need

to explore what they hope to obtain from the counseling relationship, whether

they can work with each other, and whether their goals are compatible. Even more

important, it is essential that the counselor be able to understand, respect, and

work within the framework of the client’s world rather than forcing the client to fi t

into the therapist’s scheme of values.

In my view, therapy ought to begin with an exploration of the client’s expecta-

tions and goals. Clients initially tend to have vague ideas of what they expect from

therapy. They may be seeking solutions to problems, they may want to stop hurt-

ing, they may want to change others so they can live with less anxiety, or they may

seek to be different so that some signifi cant persons in their lives will be more

accepting of them. In some cases clients have no goals; they are in the therapist’s

24

offi ce simply because they were sent for counseling by their parents, probation

offi cer, or teacher.

O

So where can a counselor begin? The initial interview can be used most pro-

ductively to focus on the client’s goals or lack of them. The therapist may begin

by asking any of these questions: “What do you expect from counseling? Why are

you here? What do you want? What do you hope to leave with? How is what you

CHAPTER TW

are currently doing working for you? What aspects of yourself or your life situation

would you most like to change?”

When a person seeks a counseling relationship with you, it is important to

cooperatively discover what this person is expecting from the relationship. If you

try to fi gure out in advance how to proceed with a client, you may be depriving the

client of the opportunity to become an active partner in her or his own therapy.

Why is this person coming in for counseling? It is the client’s place to decide on

the goals of therapy. It is important to keep this focus in mind so that the client’s

agenda is addressed rather than an agenda of your own.

b e c o m i n g a n e f f e c t i v e

m u lt i c u lt u r a l c o u n s e lo r

Part of the process of becoming an effective counselor involves learning how to

recognize diversity issues and shaping one’s counseling practice to fi t the client’s

worldview. It is an ethical obligation for counselors to develop sensitivity to cultural

differences if they hope to make interventions that are consistent with the values

of their clients. The therapist’s role is to assist clients in making decisions that are

congruent with their worldview, not to live by the therapist’s values.

Diversity in the therapeutic relationship is a two-way street. As a counselor,

you bring your own heritage with you to your work, so you need to recognize the

ways in which cultural conditioning has infl uenced the directions you take with

your clients. Unless the social and cultural context of clients and counselors

are taken into consideration, it is diffi cult to appreciate the nature of clients’

struggles. Counseling students often hold values—such as making their own

choices, expressing what they are feeling, being open and self-revealing, and

striving for independence—that differ from the values of clients from different

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cultural backgrounds. Some clients may be very slow to disclose and have dif-

ferent expectations about counseling than the therapist has. Counselors need

to become aware of how clients from diverse cultures may perceive them as

therapists, as well as how clients may perceive the value of formal helping. It is

the task of counselors to determine whether the assumptions they have made

about the nature and functioning of therapy are appropriate for culturally di-

verse clients.

Clearly, effective counseling must take into account the impact of culture on

the client’s functioning, including the client’s degree of acculturation. Culture is,

quite simply, the values and behaviors shared by a group of individuals. It is im-

portant to realize that culture refers to more than ethnic or racial heritage; culture

also includes factors such as age, gender, religion, sexual orientation, physical and

mental ability, and socioeconomic status.

25

THE C

Acquiring Competencies in Multicultural Counseling

OUNSEL

Effective counselors understand their own cultural conditioning, the condition-

ing of their clients, and the sociopolitical system of which they are a part. Acquir-

ing this understanding begins with counselors’ awareness of the cultural origins

OR: PERSON AND PR

of any values, biases, and attitudes they may hold. Counselors from all cultural

groups must examine their expectations, attitudes, biases, and assumptions about

the counseling process and about persons from diverse groups. Recognizing our

biases and prejudices takes courage because most of us do not want to acknowl-

edge that we have cultural biases. Everyone has biases, but being unaware of the

biased attitudes we hold is an obstacle to client care. It takes a concerted effort and

OFES

vigilance to monitor our biases, attitudes, and values so that they do not interfere

SIONAL

with establishing and maintaining successful counseling relationships.

A major part of becoming a diversity-competent counselor involves challeng-

ing the idea that the values we hold are automatically true for others. We also need

to understand how our values are likely to infl uence our practice with diverse cli-

ents who embrace different values. Furthermore, becoming a diversity-competent

practitioner is not something that we arrive at once and for all; rather, it is an

ongoing process.

Sue, Arredondo, and McDavis (1992) and Arredondo and her colleagues

(1996) have developed a conceptual framework for competencies and standards

in multicultural counseling. Their dimensions of competency involve three areas:

(1) beliefs and attitudes, (2) knowledge, and (3) skills. For an in-depth treatment of

multicultural counseling and therapy competence, refer to Counseling the Cultur-

ally Diverse: Theory and Practice (D. W. Sue & Sue, 2008).

b e l i e f s a n d at t i t u d e s First, effective counselors have moved from being

culturally unaware to ensuring that their personal biases, values, or problems will

not interfere with their ability to work with clients who are culturally different from

them. They believe cultural self-awareness and sensitivity to one’s own cultural her-

itage are essential for any form of helping. Counselors are aware of their positive and

negative emotional reactions toward persons from other racial and ethnic groups

that may prove detrimental to establishing collaborative helping relationships.

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They seek to examine and understand the world from the vantage point of their

clients. They respect clients’ religious and spiritual beliefs and values. They are

comfortable with differences between themselves and others in terms of race, eth-

nicity, culture, and beliefs. Rather than maintaining that their cultural heritage

is superior, they are able to accept and value cultural diversity. They realize that

traditional theories and techniques may not be appropriate for all clients or for all

problems. Culturally skilled counselors monitor their functioning through consul-

tation, supervision, and further training or education.

k n o w l e d g e Second, culturally effective practitioners possess certain knowl-

edge. They know specifi cally about their own racial and cultural heritage and

how it affects them personally and professionally. Because they understand the

dynamics of oppression, racism, discrimination, and stereotyping, they are in a

26

position to detect their own racist attitudes, beliefs, and feelings. They understand

O

the worldview of their clients, and they learn about their clients’ cultural back-

grounds. They do not impose their values and expectations on their clients from

differing cultural backgrounds and avoid stereotyping clients. Culturally skilled

counselors understand that external sociopolitical forces infl uence all groups, and

CHAPTER TW

they know how these forces operate with respect to the treatment of minorities.

These practitioners are aware of the institutional barriers that prevent minorities

from utilizing the mental health services available in their communities. They pos-

sess knowledge about the historical background, traditions, and values of the client

populations with whom they work. They know about minority family structures,

hierarchies, values, and beliefs. Furthermore, they are knowledgeable about com-

munity characteristics and resources. Those who are culturally skilled know how

to help clients make use of indigenous support systems. In areas where they are

lacking in knowledge, they seek resources to assist them. The greater their depth

and breadth of knowledge of culturally diverse groups, the more likely they are to

be effective practitioners.

s k i l l s a n d i n t e r v e n t i o n s t r at e g i e s Third, effective counselors

have acquired certain skills in working with culturally diverse populations. Coun-

selors take responsibility for educating their clients about the therapeutic process,

including matters such as setting goals, appropriate expectations, legal rights, and

the counselor’s orientation. Multicultural counseling is enhanced when practition-

ers use methods and strategies and defi ne goals consistent with the life experiences

and cultural values of their clients. Such practitioners modify and adapt their in-

terventions to accommodate cultural differences. They do not force their clients

to fi t within one counseling approach, and they recognize that counseling tech-

niques may be culture-bound. They are able to send and receive both verbal and

nonverbal messages accurately and appropriately. They become actively involved

with minority individuals outside the offi ce (community events, celebrations, and

neighborhood groups). They are willing to seek out educational, consultative, and

training experiences to enhance their ability to work with culturally diverse client

populations. They consult regularly with other multiculturally sensitive profession-

als regarding issues of culture to determine whether referral may be necessary.

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Incorporating Culture in Counseling Practice

It is unrealistic to expect a counselor to know everything about the cultural back-

ground of a client, but some understanding of the client’s cultural and ethnic

background is essential. There is much to be said for letting clients teach coun-

selors about relevant aspects of their culture. It is a good idea for counselors to

ask clients to provide them with the information they will need to work effectively.

Incorporating culture into the therapeutic process is not limited to working with

clients from a certain ethnic or cultural background. It is critical that therapists

take into account the worldview and background of every client. Failing to do this

seriously restricts the potential impact of the therapeutic endeavor.

In the case of individuals who have lived in more than one culture, it is useful

to assess the degree of acculturation and identity development that has taken place.

Clients often have allegiance to their culture of origin, and yet they may fi nd cer-

27

THE C

tain characteristics of their new culture attractive. They may experience confl icts

in integrating the two cultures in which they live. Different rates of acculturation

OUNSEL

among family members is a common complaint of clients who are experiencing

family problems. These core struggles can be explored productively in the thera-

peutic context if the counselor understands and respects this cultural confl ict.

OR: PERSON AND PR

w e lc o m i n g d i v e r s i t y Counseling is by its very nature diverse in a multi-

cultural society, so it is easy to see that there are no ideal therapeutic approaches.

Instead, different theories have distinct features that have appeal for different cul-

tural groups. Some theoretical approaches have limitations when applied to certain

populations. Effective multicultural practice demands an open stance on the part

OFES

of the practitioner, fl exibility, and a willingness to modify strategies to fi t the needs

and the situation of the individual client. Practitioners who truly respect their cli-

SIONAL

ents will be aware of clients’ hesitations and will not be too quick to misinterpret

this behavior. Instead, they will patiently attempt to enter the world of their clients

as much as they can. Although practitioners may not have had the same experi-

ences as their clients, the empathy shown by counselors for the feelings and strug-

gles of their clients is essential to good therapeutic outcomes. We are more often

challenged by our differences than by our similarities to look at what we are doing.

p r a c t i c a l g u i d e l i n e s i n a d d r e s s i n g c u lt u r e If the counseling

process is to be effective, it is essential that cultural concerns be addressed with all

clients. Here are some guidelines that may increase your effectiveness when work-

ing with clients from diverse backgrounds:

• Learn more about how your own cultural background has infl uenced your think-

ing and behaving. Take steps to increase your understanding of other cultures.

• Identify your basic assumptions, especially as they apply to diversity in culture,

ethnicity, race, gender, class, spirituality, religion, and sexual orientation. Think

about how your assumptions are likely to affect your professional practice.

• Examine where you obtained your knowledge about culture.

• Remain open to ongoing learning of how the various dimensions of culture

may affect therapeutic work. Realize that this skill does not develop quickly or

without effort.

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28549_ch02_rev01.indd 27

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• Be willing to identify and examine your own personal worldview and any preju-

dices you may hold about other racial/ethnic groups.

• Learn to pay attention to the common ground that exists among people of diverse

backgrounds.

• Be

fl exible in applying the methods you use with clients. Don’t be wedded to a

specifi c technique if it is not appropriate for a given client.

• Remember that practicing from a multicultural perspective can make your job

easier and can be rewarding for both you and your clients.

It takes time, study, and experience to become an effective multicultural coun-

selor. Multicultural competence cannot be reduced simply to cultural awareness

and sensitivity, to a body of knowledge, or to a specifi c set of skills. Instead, it re-

quires a combination of all of these factors.

28

i s s u e s fa c e d b y b e g i n n i n g

O

t h e r a p i s t s

In this section I identify some of the major issues that most of us typically face,

particularly during the beginning stages of learning how to be therapists. When

CHAPTER TW

you complete formal course work and begin facing clients, you will be challenged

to integrate and to apply what you have learned. At that point some real concerns

are likely to arise about your adequacy as a person and as a professional. Here are

some useful guidelines for your refl ection on becoming an effective counselor.

Dealing With Your Anxieties

Most beginning counselors have ambivalent feelings when meeting their fi rst cli-

ents. A certain level of anxiety demonstrates that you are aware of the uncertainties

of the future with your clients and of your abilities to really be there for them. A

willingness to recognize and deal with these anxieties, as opposed to denying them,

is a positive sign. That we have self-doubts is normal; it is how we deal with them

that matters. One way is to openly discuss our self-doubts with a supervisor and

peers. The possibilities are rich for meaningful exchanges and for gaining support

from fellow interns who probably have many of the same concerns and anxieties.

Being Yourself and Self-Disclosure

Because you may be self-conscious and anxious when you begin counseling, you

may have a tendency to be overly concerned with what the books say and with the

mechanics of how to proceed. Inexperienced therapists too often fail to appreciate

the values inherent in simply being themselves. If we are able to be ourselves in

our therapeutic work and appropriately disclose our reactions in counseling ses-

sions, we increase the chances of being authentic. It is this level of genuineness

and presence that enables us to connect with our clients and to establish an effec-

tive therapeutic relationship with them.

It is possible to err by going to extremes in two different directions. At one end

are counselors who lose themselves in their fi xed role and hide behind a profes-

sional facade. These counselors are so caught up in maintaining stereotyped role

expectations that little of their personal selves shows through. Counselors who

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28549_ch02_rev01.indd 28

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adopt this behavior will likely remain anonymous to clients, and clients may per-

ceive them as hiding behind a professional role.

At the other end of the spectrum is engaging in too much self-disclosure. Some

counselors make the mistake of inappropriately burdening their clients with their

spontaneous impressions about their clients. Judging the appropriate amount of

self-disclosure can be a problem even for seasoned counselors, and it is often espe-

cially worrisome for new counselors. In determining the appropriateness of self-

disclosure, consider what to reveal, when to reveal, and how much to reveal. It may

be useful to mention something about ourselves from time to time, but we must

be aware of our motivations for making ourselves known in this way. Assess the

readiness of a client to hear these disclosures as well as the impact doing so might

have on the client. Remain observant during any self-disclosure to get a sense of

how the client is being affected by it.

29

The most productive form of self-disclosure is related to what is going on

THE C

between the counselor and the client within the counseling session. The skill of

OUNSEL

immediacy involves revealing what we are thinking or feeling in the here and now

with the client, but be careful to avoid pronouncing judgments about the client.

When done in a timely way, sharing persistent reactions can facilitate therapeutic

OR: PERSON AND PR

progress and improve the quality of our relationship with the client. Even when

we are talking about reactions based on the therapeutic relationship, caution is

necessary, and discretion and sensitivity are required in deciding what reactions

we might share.

Avoiding Perfectionism

OFES

Perhaps one of the most common self-defeating beliefs with which we burden

ourselves is that we must never make a mistake. Although we may well know inte-

SIONAL

llectually that humans are not perfect, emotionally we often feel that there is little

room for error. To be sure, you will make mistakes, whether you are a beginning or

a seasoned therapist. If our energies are tied up presenting an image of perfection,

this will affect our ability to be present for our clients. I tell students to question

the notion that they should know everything and be perfectly skilled. I encourage

them to share their mistakes or what they perceive as errors during their supervi-

sion meetings. Students willing to risk making mistakes in supervised learning

situations and willing to reveal their self-doubts will fi nd a direction that leads

to growth.

Being Honest About Your Limitations

You cannot realistically expect to succeed with every client. It takes honesty to

admit that you cannot work successfully with every client. It is important to learn

when and how to make a referral for clients when your limitations prevent you

from helping them. However, there is a delicate balance between learning your

realistic limits and challenging what you sometimes think of as being “limits.”

Before deciding that you do not have the life experiences or the personal qualities

to work with a given population, try working in a setting with a population you do

not intend to specialize in. This can be done through diversifi ed fi eld placements

or visits to agencies.

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Understanding Silence

Silent moments during a therapeutic session may seem like silent hours to a

beginning therapist, yet this silence can have many meanings. The client may be

quietly thinking about some things that were discussed earlier or evaluating some

insight just acquired. The client may be waiting for the therapist to take the lead

and decide what to say next, or the therapist may be waiting for the client to do

this. Either the client or the therapist may be distracted or preoccupied, or neither

may have anything to say for the moment. The client and the therapist may be

communicating without words. The silence may be refreshing, or the silence may

be overwhelming. Perhaps the interaction has been on a surface level, and both

persons have some fear or hesitancy about getting to a deeper level. When silence

occurs, acknowledge and explore with your client the meaning of the silence.

30

Dealing With Demands From Clients

O

A major issue that puzzles many beginning counselors is how to deal with clients

who seem to make constant demands. Because therapists feel they should extend

themselves in being helpful, they often burden themselves with the unrealistic

idea that they should give unselfi shly, regardless of how great clients’ demands

CHAPTER TW

may be. These demands may manifest themselves in a variety of ways. Clients

may want to see you more often or for a longer period than you can provide.

They may want to see you socially. Some clients may expect you to continually

demonstrate how much you care or demand that you tell them what to do and

how to solve a problem. One way of heading off these demands is to make your

expectations and boundaries clear during the initial counseling sessions or in the

disclosure statement.

Dealing With Clients Who Lack Commitment

Involuntary clients may be required by a court order to obtain therapy, and you

may be challenged in your attempt to establish a working relationship with them.

It is possible to do effective work with mandated clients, but practitioners must

begin by openly discussing the nature of the relationship. Counselors who omit

preparation and do not address clients’ thoughts and feelings about coming to

counseling are likely to encounter resistance. It is critical that therapists not prom-

ise what they cannot or will not deliver. It is good practice to make clear the limits

of confi dentiality as well as any other factors that may affect the course of therapy.

In working with involuntary clients, it is especially important to prepare them for

the process; doing so can go a long way toward lessening resistance.

Tolerating Ambiguity

Many beginning therapists experience the anxiety of not seeing immediate results.

They ask themselves: “Am I really doing my client any good? Is the client perhaps

getting worse?” I hope you will learn to tolerate the ambiguity of not knowing for

sure whether your client is improving, at least during the initial sessions. Realize

that oftentimes clients may seemingly “get worse” before they show therapeutic

gains. Also, realize that the fruitful effects of the joint efforts of the therapist and

the client may manifest themselves after the conclusion of therapy.

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Becoming Aware of Your Countertransference

Working with clients can affect you in personal ways, and your own vulnerabili-

ties and countertransference are bound to surface. If you are unaware of your

personal dynamics, you are in danger of being overwhelmed by a client’s emo-

tional experiences. Beginning counselors need to learn how to “let clients go”

and not carry around their problems until we see them again. The most thera-

peutic thing is to be as fully present as we are able to be during the therapy hour,

but to let clients assume the responsibility of their living and choosing outside of

the session. If we become lost in clients’ struggles and confusion, we cease being

effective agents in helping them fi nd solutions to their problems. If we accept

responsibility for our clients’ decisions, we are blocking rather than fostering

their growth.

Countertransference, defi ned broadly, includes any of our projections that in-

31

THE C

fl uence the way we perceive and react to a client. This phenomenon occurs when

we are triggered into emotional reactivity, when we respond defensively, or when

OUNSEL

we lose our ability to be present in a relationship because our own issues become

involved. Recognizing the manifestations of our countertransference reactions is

an essential step in becoming competent counselors. Unless we are aware of our

OR: PERSON AND PR

own confl icts, needs, assets, and liabilities, we can use the therapy hour more for

our own purposes than for being available for our clients. Because it is not appro-

priate for us to use clients’ time to work through our reactions to them, it is all the

more important that we be willing to work on ourselves in our own sessions with

another therapist, supervisor, or colleague. If we do not engage in this kind of self-

exploration, we increase the danger of losing ourselves in our clients and using

OFES

them to meet our unfulfi lled needs.

SIONAL

The emotionally intense relationships we develop with clients can be expected

to tap into our own unresolved problem areas. Our clients’ stories and pain are

bound to affect us; we will be touched by their stories and can express compassion

and empathy. However, we have to realize that it is their pain and not carry it for

them lest we become overwhelmed by their life stories and thus render ourselves

ineffective in working with them. Although we cannot completely free ourselves

from any traces of countertransference or ever fully resolve all personal confl icts

from the past, we can become aware of ways these realities infl uence our profes-

sional work. Our personal therapy can be instrumental in enabling us to recognize

and manage our countertransference reactions.

Developing a Sense of Humor

Therapy is a responsible endeavor, but it need not be deadly serious. Both clients

and counselors can enrich a relationship through humor. What a welcome relief

when we can admit that pain is not our exclusive domain. It is important to recog-

nize that laughter or humor does not mean that clients are not respected or work

is not being accomplished. There are times, of course, when laughter is used to

cover up anxiety or to escape from the experience of facing threatening material.

The therapist needs to distinguish between humor that distracts and humor that

enhances the situation.

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Sharing Responsibility With the Client

You might struggle with fi nding the optimum balance in sharing responsibility

with your clients. One mistake is to assume full responsibility for the direction

and outcomes of therapy. This will lead to taking from your clients their rightful

responsibility of making their own decisions. It could also increase the likelihood

of your early burnout. Another mistake is for you to refuse to accept the responsi-

bility for making accurate assessments and designing appropriate treatment plans

for your clients. How responsibility will be shared should be addressed early in

the course of counseling. It is your responsibility to discuss specifi c matters such

as length and overall duration of the sessions, confi dentiality, general goals, and

methods used to achieve goals. (Informed consent is discussed in Chapter 3.)

It is important to be alert to your clients’ efforts to get you to assume respon-

32

sibility for directing their lives. Many clients seek a “magic answer” as a way of

escaping the anxiety of making their own decisions. It is not your role to assume

O

responsibility for directing your clients’ lives. Collaboratively designing contracts

and homework assignments with your clients can be instrumental in your clients’

increasingly fi nding direction within themselves. Perhaps the best measure of our

effectiveness as counselors is the degree to which clients are able to say to us,

CHAPTER TW

“I appreciate what you have been to me, and because of your faith in me, and what

you have taught me, I am confi dent that I can go it alone.” Eventually, if we are

effective, we will be out of business!

Declining to Give Advice

Quite often clients who are suffering come to a therapy session seeking and even

demanding advice. They want more than direction; they want a wise counselor to

make a decision or resolve a problem for them. However, counseling should not be

confused with dispensing information. Therapists help clients discover their own

solutions and recognize their own freedom to act. Even if we, as therapists, were

able to resolve clients’ struggles for them, we would be fostering their dependence

on us. They would continually need to seek our counsel for every new twist in their

diffi culties. Our task is to help clients make independent choices and accept the

consequences of their choices. The habitual practice of giving advice does not work

toward this end.

Defining Your Role as a Counselor

One of your challenges as a counselor will be to defi ne and clarify your professional

role. As you read about the various theoretical orientations in Part 2, you will discover

the many different roles of counselors that are related to these diverse theories. As a

counselor, you will likely be expected to function with a diverse range of roles.

From my perspective, the central function of counseling is to help clients rec-

ognize their own strengths, discover what is preventing them from using their

resources, and clarify what kind of life they want to live. Counseling is a process by

which clients are invited to look honestly at their behavior and make certain deci-

sions about how they want to modify the quality of their life. In this framework

counselors provide support and warmth yet care enough to challenge clients so that

they will be able to take the actions necessary to bring about signifi cant change.

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Keep in mind that the professional roles you assume are likely to be dependent

on factors such as the client populations with whom you are working, the specifi c

therapeutic services you are providing, the particular stage of counseling, and the

setting in which you work. Your role will not be defi ned once and for all. You will

have to reassess the nature of your professional commitments and redefi ne your

role at various times.

Learning to Use Techniques Appropriately

When you are at an impasse with a client, you may have a tendency to look for a

technique to get the sessions moving. As discussed in Chapter 1, relying on tech-

niques too much can lead to mechanical counseling. Ideally, therapeutic tech-

niques should evolve from the therapeutic relationship and the material presented,

and they should enhance the client’s awareness or suggest possibilities for experi-

33

menting with new behavior. Know the theoretical rationale for each technique you

THE C

use, and be sure the techniques are appropriate for the goals of therapy. This does

not mean that you need to restrict yourself to drawing on procedures within a sin-

OUNSEL

gle model; quite the contrary. However, it is important to avoid using techniques

in a hit-or-miss fashion, to fi ll time, to meet your own needs, or to get things mov-

OR: PERSON AND PR

ing. Your methods need to be thoughtfully chosen as a way to help clients make

therapeutic progress.

Developing Your Own Counseling Style

Be aware of the tendency to copy the style of a supervisor, therapist, or some other

model. There is no one way to conduct therapy, and wide variations in approach

OFES

can be effective. You will inhibit your potential effectiveness in reaching others if

you attempt to imitate another therapist’s style or if you fi t most of your behavior

SIONAL

during the session into the procrustean bed of some expert’s theory. Your coun-

seling style will be infl uenced by your teachers, therapists, and supervisors, but

don’t blur your potential uniqueness by trying to imitate them. I advocate borrow-

ing from others, yet at the same time, doing it in a way that is distinctive to you.

Maintaining Your Vitality as a Person and as a Professional

Ultimately, your single most important instrument is the person you are, and your

most powerful technique is your ability to model aliveness and realness. It is of

paramount importance that we take care of ourselves, for how can we take care of

others if we are not taking care of ourselves? We need to work at dealing with those

factors that threaten to drain life from us and render us helpless. I encourage you

to consider how you can apply the theories you will be studying to enhance your

life from both a personal and a professional standpoint.

Learn to look within yourself to determine what choices you are making (and not

making) to keep yourself vital. If you are aware of the factors that sap your vitality

as a person, you are in a better position to prevent the condition known as profes-

sional burnout. You have considerable control over whether you become burned out

or not. You cannot always control stressful events, but you do have a great deal of

control over how you interpret and react to these events. It is important to realize

that you cannot continue to give and give while getting little in return. There is a

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28549_ch02_rev01.indd 33

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price to pay for always being available and for assuming responsibility over the

lives and destinies of others. Become attuned to the subtle signs of burnout rather

than waiting for a full-blown condition of emotional and physical exhaustion to

set in. You would be wise to develop your own strategy for keeping yourself alive

personally and professionally.

Self-monitoring is a crucial fi rst step in self-care. If you make an honest

inventory of how well you are taking care of yourself in specifi c domains, you will

have a framework for deciding what you may want to change. By making periodic

assessments of the direction of your own life, you can determine whether you are

living the way you want to live. If not, decide what you are willing to actually do to

make changes occur. By being in tune with yourself, by having the experience of

centeredness and solidness, and by feeling a sense of personal power, you have

34

the foundation for integrating your life experiences with your professional experi-

ences. Such an awareness can provide the basis for retaining your physical and

O

psychological vitality and for being an effective professional.

Counseling professionals tend to be caring people who are good at taking care

of others, but often we do not treat ourselves with the same level of care. Self-care

is not a luxury but an ethical mandate. If we neglect to care for ourselves, our cli-

CHAPTER TW

ents will not be getting the best of us. If we are physically drained and psychologi-

cally depleted, we will not have much to give to those with whom we work. It is not

possible to provide nourishment to our clients if we are not nourishing ourselves.

Mental health professionals often comment that they do not have time to take

care of themselves. My question to them is, “Can you afford not to take care of

yourself?” To successfully meet the demands of our professional work, we must

take care of ourselves physically, psychologically, intellectually, socially, and spir-

itually. Ideally, our self-care should mirror the care we provide for others. If we

hope to have the vitality and stamina required to stay focused on our professional

goals, we need to incorporate a wellness perspective into our daily living. Wellness

is the result of our conscious commitment to a way of life that leads to zest, peace,

vitality, and happiness.

Wellness and self-care are being given increased attention in professional jour-

nals (see Counseling Today, January 2011) and at professional conferences. When

reading about self-care and wellness, refl ect on what you can do to put what you

know into action. If you are interested in learning more about therapist self-care,

I highly recommend Leaving It at the Offi ce: A Guide to Psychotherapist Self-Care

(Norcross & Guy, 2007) and Empathy Fatigue: Healing the Mind, Body, and Spirit

of Professional Counselors (Stebnicki, 2008). For more on the topic of the counselor

as a person and as a professional, see Creating Your Professional Path: Lessons From

My Journey (Corey, 2010).

s u m m a r y

One of the basic issues in the counseling profession concerns the signifi cance

of the counselor as a person in the therapeutic relationship. In your professional

work, you are asking people to take an honest look at their lives and to make choices

concerning how they want to change, so it is critical that you do this in your own

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life. Ask yourself questions such as “What do I personally have to offer others who

are struggling to fi nd their way?” and “Am I doing in my own life what I may be

urging others to do?”

You can acquire an extensive theoretical and practical knowledge and can make

that knowledge available to your clients. But to every therapeutic session you also

bring yourself as a person. If you are to promote change in your clients, you need

to be open to change in your own life. This willingness to attempt to live in accord-

ance with what you teach and thus to be a positive model for your clients is what

makes you a “therapeutic person.”

35

THE C

OUNSEL

OR: PERSON AND PR

OFES

SIONAL

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c h a p t e r 3

Ethical Issues in

Counseling Practice

i n t r o d u c t i o n

e t h i c a l i s s u e s i n t h e

a s s e s s m e n t p r o c e s s

p u t t i n g c l i e n t s ’ n e e d s

• The Role of Assessment and Diagnosis in

b e f o r e y o u r o w n

Counseling

e t h i c a l d e c i s i o n m a k i n g

e t h i c a l a s p e c t s o f e v i d e n c e -

• The Role of Ethics Codes as a Catalyst for

b a s e d p r a c t i c e

Improving Practice

• Some Steps in Making Ethical Decisions

m a n a g i n g m u lt i p l e r e l at i o n s h i p s

i n c o u n s e l i n g p r a c t i c e

t h e r i g h t o f i n f o r m e d c o n s e n t

• Perspectives on Multiple Relationships

d i m e n s i o n s o f c o n f i d e n t i a l i t y

b e c o m i n g a n e t h i c a l c o u n s e lo r

e t h i c a l i s s u e s i n a m u lt i c u lt u r a l

s u m m a ry

p e r s p e c t i v e

• Are Current Theories Adequate in Working

w h e r e t o g o f r o m h e r e

Are Current Theories Adeq

With Culturally Diverse Populations?

With Culturally Diverse Pop

•

• Is Counseling Culture Bound?

Is Counseling Culture Bou

•

• Focusing on Both Individual and

Focusing on oth Individu

Environmental Factors

Enviro mental Factors

36

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28549_ch03_rev01.indd 36

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i n t r o d u c t i o n

This chapter introduces some of the ethical principles and issues that will be a ba-

sic part of your professional practice. Its purpose is to stimulate you to think about

ethical practice so that you can form a sound basis for making ethical decisions.

To help you make these decisions, you can consult with colleagues, keep yourself

informed about laws affecting your practice, keep up to date in your specialty fi eld,

stay abreast of developments in ethical practice, refl ect on the impact your values

have on your practice, and be willing to engage in honest self-examination. Top-

ics addressed include balancing clients’ needs against your own needs, ways of

making good ethical decisions, educating clients about their rights, parameters

of confi dentiality, ethical concerns in counseling diverse client populations, ethi-

cal issues involving diagnosis, evidence-based practice, and dealing with multiple

37

relationships.

ETHIC

At times students think of ethics in a negative way, merely as a list of rules

and prohibitions that result in sanctions and malpractice actions if practitioners

AL IS

do not follow them. Mandatory ethics is the view of ethical practice that deals with

SUES IN C

the minimum level of professional practice, whereas aspirational ethics is a higher

level of ethical practice that addresses doing what is in the best interests of clients.

Ethics is more than a list of things to avoid for fear of punishment. Ethics is a way

of thinking about becoming the best practitioner possible. Positive ethics is an ap-

OUNSELING PRA

proach taken by practitioners who want to do their best for clients rather than sim-

ply meet minimum standards to stay out of trouble (Knapp & VandeCreek, 2006).

See the video program for Chapter 3, DVD for Theory and Practice of

Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that

C

you view the brief lecture for each chapter prior to reading the chapter.

TICE

p u t t i n g c l i e n t s ’ n e e d s

b e f o r e yo u r o w n

As counselors we cannot always keep our personal needs completely separate from

our relationships with clients. Ethically, it is essential that we become aware of

our own needs, areas of unfi nished business, potential personal problems, and

especially our sources of countertransference. We need to realize how such factors

could interfere with effectively and ethically serving our clients.

Our professional relationships with our clients exist for their benefi t. A useful

question to frequently ask yourself is this: “Whose needs are being met in this

relationship, my client’s or my own?” It takes considerable professional maturity

to make an honest appraisal of how your behavior affects your clients. It is not

unethical for us to meet our personal needs through our professional work, but it

is essential that these needs be kept in perspective. An ethical problem exists when

we meet our needs, in either obvious or subtle ways, at the expense of our clients’

needs. It is crucial that we avoid exploiting or harming clients.

We all have certain blind spots and distortions of reality. As helping profes-

sionals, we have responsibilities to work actively toward expanding our own

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self-awareness and to learn to recognize areas of prejudice and vulnerability. If

we are aware of our personal problems and are willing to work through them,

there is less chance that we will project them onto clients. If certain problem

areas surface and old confl icts become reactivated, we have an ethical obligation

to do whatever it takes to avoid harming our clients.

We must also examine other, less obviously harmful personal needs that can

get in the way of creating growth-producing relationships, such as the need for

control and power; the need to be nurturing and helpful; the need to change others

in the direction of our own values; the need for feeling adequate, particularly when

it becomes overly important that the client confi rm our competence; and the need

to be respected and appreciated. It is crucial that we do not meet our needs at the

expense of our clients. For an expanded discussion of this topic, see M. Corey and

38

Corey (2011, chap. 1).

e t h i c a l d e c i s i o n m a k i n g

The ready-made answers to ethical dilemmas provided by professional organiza-

tions typically contain only broad guidelines for responsible practice. As a practi-

CHAPTER THREE

tioner, ultimately you will have to apply the ethics codes of your profession to the

many practical problems you face. Professionals are expected to exercise prudent

judgment when it comes to interpreting and applying ethical principles to specifi c

situations. Although you are responsible for making ethical decisions, you do not

have to do so alone. Part of the process of making ethical decisions involves learn-

ing about the resources from which you can draw when you are dealing with an

ethical question. You should also be aware of the consequences of practicing in

ways that are not sanctioned by organizations of which you are a member or the

state in which you are licensed to practice.

The Role of Ethics Codes as a Catalyst

for Improving Practice

Professional codes of ethics serve a number of purposes. They educate counseling

practitioners and the general public about the responsibilities of the profession.

They provide a basis for accountability, and through their enforcement, clients

are protected from unethical practices. Perhaps most important, ethics codes can

provide a basis for refl ecting on and improving your professional practice. Self-

monitoring is a better route for professionals to take than being policed by an

outside agency (Herlihy & Corey, 2006a).

From my perspective, one of the unfortunate trends is for ethics codes to in-

creasingly take on legalistic dimensions. Many practitioners are so anxious to

avoid becoming embroiled in a lawsuit that they gear their practices mainly toward

fulfi lling legal minimums rather than thinking of what is right for their clients. If

we are too concerned with being sued, it is unlikely that we will be very creative

or effective in our work. In this era of litigation, it makes sense to be aware of the

legal aspects of practice and to do what is possible to reduce a malpractice suit, but

it is a mistake to equate behaving legally with being ethical. Although following

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the law is part of ethical behavior, being an ethical practitioner involves far more.

One of the best ways to prevent being sued for malpractice rests in demonstrating

respect for clients, having their welfare as a central concern, and practicing within

the framework of professional codes.

No code of ethics can delineate what would be the appropriate or best course

of action in each problematic situation a professional will face. In my view, ethics

codes are best used as guidelines to formulate sound reasoning and serve practi-

tioners in making the best judgments possible. A number of professional organi-

zations and their websites are listed at the end of this chapter; each has its own

code of ethics, which you can access through its website. Compare your profes-

sional organization’s code of ethics to several others to understand their similari-

ties and differences.

39

Some Steps in Making Ethical Decisions

ETHIC

There are a number of different models for ethical decision making; most tend to

focus on the application of principles to ethical dilemmas. After reviewing a few

AL IS

of these models, my colleagues and I have identifi ed a series of procedural steps

SUES IN C

to help you think through ethical problems (see Corey, Corey, & Callanan, 2011):

• Identify the problem or dilemma. Gather information that will shed light on the

nature of the problem. This will help you decide whether the problem is mainly

OUNSELING PRA

ethical, legal, professional, clinical, or moral.

• Identify the potential issues. Evaluate the rights, responsibilities, and welfare of

all those who are involved in the situation.

• Look at the relevant ethics codes for general guidance on the matter. Consider

whether your own values and ethics are consistent with or in confl ict with the

C

TICE

relevant guidelines.

• Consider the applicable laws and regulations, and determine how they may have

a bearing on an ethical dilemma.

• Seek consultation from more than one source to obtain various perspectives on

the dilemma, and document in the client’s record what suggestions you received

from this consultation.

• Brainstorm various possible courses of action. Continue discussing options

with other professionals. Include the client in this process of considering

options for action. Again, document the nature of this discussion with your

client.

• Enumerate the consequences of various decisions, and refl ect on the implica-

tions of each course of action for your client.

• Decide on what appears to be the best possible course of action. Once the course

of action has been implemented, follow up to evaluate the outcomes and to

determine whether further action is necessary. Document the reasons for the

actions you took as well as your evaluation measures.

In reasoning through any ethical dilemma, there is rarely just one course of

action to follow, and practitioners may make different decisions. The more sub-

tle the ethical dilemma, the more complex and demanding the decision-making

process.

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Professional maturity implies that you are open to questioning and discussing

your quandaries with colleagues. In seeking consultation, it is generally possible to

protect the identity of your client and still get useful input that is critical to making

sound ethical decisions. Because ethics codes do not make decisions for you, it is a

good practice to demonstrate a willingness to explore various aspects of a problem,

raise questions, discuss ethical concerns with others, and continually clarify your

values and examine your motivations. To the degree that it is possible, include the

client in all phases of the ethical decision-making process. Again, it is essential

to document how you included your client as well as the steps you took to ensure

ethical practice.

t h e r i g h t o f i n f o r m e d c o n s e n t

40

Regardless of your theoretical framework, informed consent is an ethical and legal

requirement that is an integral part of the therapeutic process. It also establishes

a basic foundation for creating a working alliance and a collaborative partnership

between the client and the therapist. Informed consent involves the right of clients

to be informed about their therapy and to make autonomous decisions pertaining to

it. Providing clients with information they need to make informed choices tends to

CHAPTER THREE

promote the active cooperation of clients in their counseling plan. By educating

your clients about their rights and responsibilities, you are both empowering them

and building a trusting relationship with them. Seen in this light, informed con-

sent is something far broader than simply making sure clients sign the appropriate

forms. It is a positive approach that helps clients become active partners and true

collaborators in their therapy. Some aspects of the informed consent process in-

clude the general goals of counseling, the responsibilities of the counselor toward

the client, the responsibilities of clients, limitations of and exceptions to confi den-

tiality, legal and ethical parameters that could defi ne the relationship, the qualifi ca-

tions and background of the practitioner, the fees involved, the services the client

can expect, and the approximate length of the therapeutic process. Further areas

might include the benefi ts of counseling, the risks involved, and the possibility

that the client’s case will be discussed with the therapist’s colleagues or supervi-

sors. This process of educating the client begins with the initial counseling session

and continues for the duration of counseling.

The challenge of fulfi lling the spirit of informed consent is to strike a balance

between giving clients too much information and giving them too little. For exam-

ple, it is too late to tell minors that you intend to consult with their parents after

they have disclosed that they are considering an abortion. In such a case the young

people involved have a right to know about the limitations of confi dentiality before

they make such highly personal disclosures. Clients can be overwhelmed, how-

ever, if counselors go into too much detail initially about the interventions they are

likely to make. It takes both intuition and skill for practitioners to strike a balance.

Informed consent in counseling can be provided in written form, orally, or

some combination of both. If it is done orally, therapists must make an entry in

the client’s clinical record documenting the nature and extent of informed consent

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(Nagy, 2011). I think it is a good idea to have basic information about the therapy

process in writing, as well as to discuss with clients topics that will enable them to

get the maximum benefi t from their counseling experience. Written information

protects both clients and therapists and enables clients to think about the informa-

tion and bring up questions at the following session. For a more complete discus-

sion of informed consent and client rights, see Issues and Ethics in the Helping

Professions (Corey, Corey, & Callanan, 2011, chap. 5), Ethical, Legal, and Professional

Issues in Counseling (Remley & Herlihy, 2010), and Essential Ethics for Psychologists

(Nagy, 2011, chap. 5).

d i m e n s i o n s o f c o n f i d e n t i a l i t y

Confi dentiality and privileged communication are two related but somewhat dif-

41

ferent concepts. Both of these concepts are rooted in a client’s right to privacy.

ETHIC

Confi dentiality is an ethical concept, and in most states it is the legal duty of thera-

pists not to disclose information about a client. Privileged communication is a

AL IS

legal concept that generally bars the disclosure of confi dential communications

SUES IN C

in a legal proceeding (Committee on Professional Practice and Standards, 2003).

All states have enacted into law some form of psychotherapist–client privilege, but

the specifi cs of this privilege vary from state to state. These laws ensure that disclo-

OUNSELING PRA

sures clients make in therapy will be protected from exposure by therapists in legal

proceedings. Generally speaking, the legal concept of privileged communication

does not apply to group counseling, couples counseling, family therapy, or child

and adolescent therapy. However, the therapist is still bound by confi dentiality

with respect to circumstances not involving a court proceeding.

C

Confi dentiality is central to developing a trusting and productive client–therapist

TICE

relationship. Because no genuine therapy can occur unless clients trust in the privacy

of their revelations to their therapists, professionals have the responsibility to defi ne

the degree of confi dentiality that can be promised. Counselors have an ethical and

legal responsibility to discuss the nature and purpose of confi dentiality with their

clients early in the counseling process. In addition, clients have a right to know that

their therapist may be discussing certain details of the relationship with a supervisor

or a colleague.

Although most counselors agree on the essential value of confi dentiality, they

realize that it cannot be considered an absolute. There are times when confi dential

information must be divulged, and there are many instances in which keeping or

breaking confi dentiality becomes a cloudy issue. In determining when to breach

confi dentiality, therapists must consider the requirements of the law, the institu-

tion in which they work, and the clientele they serve. Because these circumstances

are frequently not clearly defi ned by accepted ethics codes, counselors must exer-

cise professional judgment.

There is a legal requirement to break confi dentiality in cases involving child

abuse, abuse of the elderly, abuse of dependent adults, and danger to self or oth-

ers. All mental health practitioners and interns need to be aware of their duty

to report in these situations and to know the limitations of confi dentiality. Here

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are some other circumstances in which information must legally be reported by

counselors:

• When the therapist believes a client under the age of 16 is the victim of incest,

rape, child abuse, or some other crime

• When the therapist determines that the client needs hospitalization

• When information is made an issue in a court action

• When clients request that their records be released to them or to a third party

In general, the counselor’s primary obligation is to protect client disclosures

as a vital part of the therapeutic relationship. Informing clients about the limits of

confi dentiality does not necessarily inhibit successful counseling.

For a more complete discussion of confi dentiality, see Issues and Ethics in the

Helping Professions (Corey, Corey, & Callanan, 2011, chap. 6), The Ethical and Pro-

42

fessional Practice of Counseling and Psychotherapy (Sperry, 2007, chap. 6), and Es-

sential Ethics for Psychologists (Nagy, 2011, chap. 6).

e t h i c a l i s s u e s i n a

m u lt i c u lt u r a l p e r s p e c t i v e

CHAPTER THREE

Ethical practice requires that we take the client’s cultural context into account in

counseling practice. In this section we look at how it is possible for practitioners to

practice unethically if they do not address cultural differences in counseling practice.

Are Current Theories Adequate in Working

With Culturally Diverse Populations?

I believe current theories need to be, and can be, expanded to include a multicul-

tural perspective. With respect to many of the traditional theories, assumptions

made about mental health, optimum human development, the nature of psycho-

pathology, and the nature of effective treatment may have little relevance for some

clients. For traditional theories to be relevant in a multicultural and diverse soci-

ety, they must incorporate an interactive person-in-the-environment focus. That is,

individuals are best understood by taking into consideration salient cultural and

environmental variables. It is essential for therapists to create therapeutic strate-

gies that are congruent with the range of values and behaviors that are characteris-

tic of a pluralistic society.

Is Counseling Culture Bound?

Historically, therapists have relied on Western therapeutic models to guide their

practice and to conceptualize problems that clients present in mental health set-

tings. Value assumptions made by culturally different counselors and clients have

resulted in culturally biased counseling and have led to underuse of mental health

services by diverse populations (Pedersen, 2000; D. W. Sue & Sue, 2008). Mul-

ticultural specialists have asserted that theories of counseling and psychotherapy

represent different worldviews, each with its own values, biases, and assump-

tions about human behavior. Some of these approaches may not be applicable to

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clients from different racial, ethnic, and cultural backgrounds. Western models

of counseling have some limitations when applied to special populations and

cultural groups such as Asian and Pacifi c Islanders, Latinos, Native Americans,

and African Americans. A therapist’s methods often need to be modifi ed when

working with clients from diverse cultural backgrounds.

Contemporary therapy approaches are grounded on a core set of values,

which are neither value-neutral nor applicable to all cultures. For example, the

values implicit in most traditional counseling theories include an emphasis on

individualism, the separate existence of the self, individuation as the foundation

for maturity, and decision making and responsibility resting with the individual

rather than the group. These values of individual choice and autonomy do not

have universal applicability. In some cultures the key values are collectivist, and

primary consideration is given to what is good for the group. Regardless of the

43

therapist’s orientation, it is crucial to listen to clients and determine why they

ETHIC

are seeking help and how best to deliver the help that is appropriate for them.

AL IS

Unskilled clinicians may inappropriately apply certain techniques that are not

relevant to particular clients. Competent therapists understand themselves as

SUES IN C

social and cultural beings and possess at least a minimum level of knowledge

and skill that they can bring to bear on any counseling situation. These prac-

titioners understand what their clients need and avoid forcing clients into a

OUNSELING PRA

preconceived mold.

The attitudes, values, and behaviors counselors and clients bring to the therapy

relationship can vary widely. Denying the importance of these cultural variables

or overemphasizing cultural differences both can result in counselors losing their

spontaneity and failing to be present for their clients. Counselors need to under-

C

TICE

stand and accept clients who have a different set of assumptions about life, and

they need to be alert to the possibility of imposing their own worldview. In working

with clients from different cultural backgrounds and life experiences, it is impor-

tant that counselors resist making value judgments for them.

Focusing on Both Individual and Environmental Factors

A theoretical orientation provides practitioners with a map to guide them in a

productive direction with their clients. It is hoped that the theory orients them

but does not control what they attend to in the therapeutic venture. Counselors

who operate from a multicultural framework also have certain assumptions and a

focus that guides their practice. They view individuals in the context of the family

and the culture, and their aim is to facilitate social action that will lead to change

within the client’s community rather than merely increasing the individual’s

insight. Both multicultural practitioners and feminist therapists maintain that

therapeutic practice will be effective only to the extent that interventions are tai-

lored toward social action aimed at changing those factors that are creating the

client’s problem rather than blaming the client for his or her condition. These

topics are developed in more detail in later chapters.

An adequate theory of counseling does deal with the social and cultural factors

of an individual’s problems. However, there is something to be said for helping

clients deal with their response to environmental realities. Counselors may well be

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28549_ch03_rev01.indd 43

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at a loss in trying to bring about social change when they are sitting with a client

who is in pain because of social injustice. By using techniques from many of the

traditional therapies, counselors can help clients increase their awareness of their

options in dealing with barriers and struggles. However, it is essential to focus on

both individual and social factors if change is to occur, as the feminist, postmod-

ern, and family systems approaches to therapy teach us. Indeed, the person-in-the-

environment perspective acknowledges this interactive reality. For a more detailed

treatment of the ethical issues in multicultural counseling, see Corey, Corey, and

Callanan (2011, chap. 4).

e t h i c a l i s s u e s i n t h e

a s s e s s m e n t p r o c e s s

44

Both clinical and ethical issues are associated with the use of assessment and

diagnostic procedures. As you will see when you study the various theories of

counseling, some approaches place heavy emphasis on the role of assessment as

a prelude to the treatment process; other approaches fi nd assessment less useful

in this regard.

CHAPTER THREE

The Role of Assessment and Diagnosis in Counseling

Assessment and diagnosis are integrally related to the practice of counseling

and psychotherapy, and both are often viewed as essential for planning treat-

ment. For some approaches, a comprehensive assessment of the client is the

initial step in the therapeutic process. The rationale is that specifi c counseling

goals cannot be formulated and appropriate treatment strategies cannot be

designed until a client’s past and present functioning is understood. Regardless

of their theoretical orientation, therapists need to engage in assessment, which

is generally an ongoing part of the therapeutic process. This assessment may be

subject to revision as the clinician gathers further data during therapy sessions.

Some practitioners consider assessment as a part of the process that leads to a

formal diagnosis.

Assessment consists of evaluating the relevant factors in a client’s life to iden-

tify themes for further exploration in the counseling process. Diagnosis, which is

sometimes part of the assessment process, consists of identifying a specifi c mental

disorder based on a pattern of symptoms. Both assessment and diagnosis can be

understood as providing direction for the treatment process.

Diagnosis may include an explanation of the causes of the client’s diffi cul-

ties, an account of how these problems developed over time, a classifi cation of

any disorders, a specifi cation of preferred treatment procedure, and an estimate

of the chances for a successful resolution. The purpose of diagnosis in coun-

seling and psychotherapy is to identify disruptions in a client’s present behavior

and lifestyle. Once problem areas are clearly identifi ed, the counselor and client

are able to establish the goals of the therapy process, and then a treatment plan

can be tailored to the unique needs of the client. A diagnosis provides a working

hypothesis that guides the practitioner in understanding the client. The therapy

sessions provide useful clues about the nature of the client’s problems. Thus

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28549_ch03_rev01.indd 44

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diagnosis begins with the intake interview and continues throughout the dura-

tion of therapy.

The classic book for guiding practitioners in making diagnostic assessments is

the fourth edition of the American Psychiatric Association’s (2000) Diagnostic and

Statistical Manual of Mental Disorders, Text Revision (also known as the DSM-IV-TR),

which is presently being revised. The DSM-5 is scheduled to be published in 2013.

Clinicians who work in community mental health agencies, private practice, and

other human service settings are generally expected to assess client problems

within this framework. This manual advises practitioners that it represents only

an initial step in a comprehensive evaluation and that it is necessary to gain infor-

mation about the person being evaluated beyond that required for a DSM-IV-TR

diagnosis.

Although some clinicians view diagnosis as central to the counseling process,

45

others view it as unnecessary, as a detriment, or as discriminatory against ethnic

ETHIC

minorities and women. As you will see when you study the therapeutic models in

AL IS

this book, some approaches do not use diagnosis as a precursor to treatment.

c o n s i d e r i n g e t h n i c a n d c u lt u r a l fa c t o r s i n a s s e s s m e n t

SUES IN C

a n d d i a g n o s i s A danger of the diagnostic approach is the possible failure

of counselors to consider ethnic and cultural factors in certain patterns of behav-

ior. The DSM-IV-TR emphasizes the importance of being aware of unintentional

OUNSELING PRA

bias and keeping an open mind to the presence of distinctive ethnic and cultural

patterns that could infl uence the diagnostic process. Unless cultural variables are

considered, some clients may be subjected to erroneous diagnoses. Certain be-

haviors and personality styles may be labeled neurotic or deviant simply because

they are not characteristic of the dominant culture. Counselors who work with

C

TICE

diverse client populations may erroneously conclude that a client is repressed,

inhibited, passive, and unmotivated, all of which are seen as undesirable by West-

ern standards.

a s s e s s m e n t a n d d i a g n o s i s f r o m va r i o u s t h e o r e t i c a l

p e r s p e c t i v e s The theory from which you operate infl uences your thinking

about the use of a diagnostic framework in your therapeutic practice. Many practi-

tioners who use the cognitive behavioral approaches and the medical model place

heavy emphasis on the role of assessment as a prelude to the treatment process.

The rationale is that specifi c therapy goals cannot be designed until a clear picture

emerges of the client’s past and present functioning. Counselors who base their prac-

tices on the relationship-oriented approaches tend to view the process of assessment

and diagnosis as external to the immediacy of the client– counselor relationship,

impeding their understanding of the subjective world of the client. As you will see

in Chapter 12, feminist therapists contend that traditional diagnostic practices are

often oppressive and that such practices are based on a White, male-centered, West-

ern notion of mental health and mental illness. Both the feminist perspective and

the postmodern approaches (Chapter 13) charge that these diagnoses ignore societal

contexts. Therapists with a feminist, social constructionist, solution-focused, or nar-

rative therapy orientation challenge many DSM-IV-TR diagnoses. However, these

practitioners do make assessments and draw conclusions about client problems and

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28549_ch03_rev01.indd 45

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strengths. Regardless of the particular theory espoused by a therapist, both clinical

and ethical issues are associated with the use of assessment procedures and possibly

a diagnosis as part of a treatment plan.

a c o m m e n ta r y o n a s s e s s m e n t a n d d i a g n o s i s Most practition-

ers and many writers in the fi eld consider assessment and diagnosis to be a contin-

uing process that focuses on understanding the client. The collaborative perspec-

tive that involves the client as an active participant in the therapy process implies

that both the therapist and the client are engaged in a search-and-discovery process

from the fi rst session to the last. Even though some practitioners may avoid formal

diagnostic procedures and terminology, making tentative hypotheses and sharing

them with clients throughout the process is a form of ongoing diagnosis. This per-

spective on assessment and diagnosis is consistent with the principles of feminist

46

therapy, an approach that is critical of traditional diagnostic procedures.

Ethical dilemmas may be created when diagnosis is done strictly for insur-

ance purposes, which often entails arbitrarily assigning a client to a diagnostic

classifi cation. However, it is a clinical, legal, and ethical obligation of therapists to

screen clients for life-threatening problems such as organic disorders, schizophre-

nia, bipolar disorder, and suicidal types of depression. Students need to learn the

CHAPTER THREE

clinical skills necessary to do this type of screening, which is a form of diagnostic

thinking.

It is essential to assess the whole person, which includes assessing dimensions

of mind, body, and spirit. Therapists need to take into account the biological proc-

esses as possible underlying factors of psychological symptoms and work closely

with physicians. Clients’ values can be instrumental resources in the search for

solutions to their problems, and spiritual and religious values often illuminate cli-

ent concerns.

For a more detailed discussion of assessment and diagnosis in counseling

practice as it is applied to a single case, consult Case Approach to Counseling and

Psychotherapy (Corey, 2013b), in which theorists from 12 different theoretical ori-

entations share their diagnostic perspectives on the case of Ruth.

e t h i c a l a s p e c t s o f

e v i d e n c e - b a s e d p r a c t i c e

Mental health practitioners are faced with the task of choosing the best interven-

tions with a particular client. For many practitioners this choice is based on their

theoretical orientation. In recent years, however, a shift has occurred toward pro-

moting the use of specifi c interventions for specifi c problems or diagnoses based

on empirically supported treatments (APA Presidential Task Force on Evidence-

based Practice, 2006; Cukrowicz et al., 2005; Deegear & Lawson, 2003; Edwards,

Dattilio, & Bromley, 2004).

This trend toward specifi c, empirically supported treatment is referred to as

evidence-based practice (EBP): “the integration of the best available research with

clinical expertise in the context of patient characteristics, culture, and prefer-

ences” (APA Presidential Task Force on Evidence-based Practice, 2006, p. 273).

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28549_ch03_rev01.indd 46

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Increasingly, those practitioners who work in a behavioral health care system

must cope with the challenges associated with evidence-based practice. Norcross,

Hogan, and Koocher (2008) advocate for inclusive evidence-based practices that

incorporate the three pillars of EBP: looking for the best available research, rely-

ing on clinical expertise, and taking into consideration the client’s characteristics,

culture, and preferences. The central aim of evidence-based practice is to require

psychotherapists to base their practice on techniques that have empirical evidence

to support their effi cacy. Research studies empirically analyze the most effective

and effi cient treatments, which then can be widely implemented in clinical prac-

tice (Norcross, Beutler, & Levant, 2006).

Evidence-based practice is a potent force in psychotherapeutic practice today,

and it may mandate the types of treatments therapists can offer in the future

(Wampold & Bhati, 2004). In many mental health settings, clinicians are pres-

47

sured to use interventions that are both brief and standardized. In such settings,

ETHIC

treatments are operationalized by reliance on a treatment manual that identifi es

AL IS

what is to be done in each therapy session and how many sessions will be required

(Edwards et al., 2004). Edwards and his colleagues point out that psychological

SUES IN C

assessment and treatment is a business involving fi nancial gain and reputation.

In seeking to specify the treatment for a specifi c diagnosis as precisely as possi-

ble, health insurance companies are concerned with determining the minimum

OUNSELING PRA

amount of treatment that can be expected to be effective. This raises ethical ques-

tions about whether the insurance company’s need to save money is being placed

above the needs of clients.

Many practitioners believe this approach is mechanistic and does not take into

full consideration the relational dimensions of the psychotherapy process and indi-

C

TICE

vidual variability. Indeed, relying exclusively on standardized treatments for specifi c

problems may raise another set of ethical concerns because the reliability and valid-

ity of these empirically based techniques is questionable. Human change is com-

plex and diffi cult to measure beyond such a simplistic level that the change may be

meaningless. Furthermore, not all clients come to therapy with clearly defi ned psy-

chological disorders. Many clients have existential concerns that do not fi t with any

diagnostic category and do not lend themselves to clearly specifi ed symptom-based

outcomes. EBP may have something to offer mental health professionals who work

with individuals with specifi c emotional, cognitive, and behavioral disorders, but it

does not have a great deal to offer practitioners working with individuals who want

to pursue more meaning and fulfi llment in their lives.

Counseling is not merely a technique that needs to be empirically validated.

Many aspects of treatment—the therapy relationship, the therapist’s personality

and therapeutic style, the client, and environmental factors—are vital contribu-

tors to the success of psychotherapy. Evidence-based practices tend to emphasize

only one of these aspects—interventions based on the best available research.

Norcross and his colleagues (2006) argue for the centrality of the therapeutic rela-

tionship as a determinant of therapy outcomes. They add, however, that the client

actually accounts for more of the treatment outcome than either the relationship

or the method employed.

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Norcross and his colleagues (2006) believe the call for accountability in mental

health care is here to stay and that all mental health professionals are challenged

by the mandate to demonstrate the effi ciency, effi cacy, and safety of the services

they provide. They emphasize that the overarching goal of EBP is to enhance the

effectiveness of client services and to improve public health and warn that mental

health professionals need to take a proactive stance to make sure this goal is kept

in focus. They realize there is potential for misuse and abuse by third-party payers

who could selectively use research fi ndings as cost-containment measures rather

than ways of improving the quality of services delivered.

Miller, Duncan, and Hubble (2004) are critical of the EBP movement and

argue that “signifi cant improvements in client retention and outcome have been

shown where therapists have feedback on the client’s experience of the alliance

48

and progress in treatment. Rather than evidence-based practice, therapists tailor

their work through practice-based evidence” (p. 2). Practice-based evidence involves

using data generated during treatment to inform the process and outcome of treat-

ment. This topic is discussed in more detail in Chapter 15.

For further reading on the topic of evidence-based practice, I recommend

Clinician’s Guide to Evidence-based Practice (Norcross, Hogan, & Koocher, 2008).

CHAPTER THREE

m a n a g i n g m u lt i p l e r e l at i o n s h i p s

i n c o u n s e l i n g p r a c t i c e

Dual or multiple relationships, either sexual or nonsexual, occur when coun-

selors assume two (or more) roles simultaneously or sequentially with a client.

This may involve assuming more than one professional role or combining pro-

fessional and nonprofessional roles. The term multiple relationship is more often

used than the term dual relationship because of the complexities involved in these

relationships. The terms dual relationships and multiple relationships are used

interchangeably in various professional codes of ethics, and the ACA (2005) uses

the term nonprofessional relationships. In this section I use the broader term of

multiple relationships to encompass both dual relationships and nonprofessional

relationships.

When clinicians blend their professional relationship with another kind of

relationship with a client, ethical concerns must be considered. Many forms of

nonprofessional interactions or nonsexual multiple relationships pose a challenge

to practitioners. Some examples of nonsexual dual or multiple relationships are

combining the roles of teacher and therapist or of supervisor and therapist; barter-

ing for goods or therapeutic services; borrowing money from a client; providing

therapy to a friend, an employee, or a relative; engaging in a social relationship with

a client; accepting an expensive gift from a client; or going into a business venture

with a client. Some multiple relationships are clearly exploitative and do serious

harm both to the client and to the professional. For example, becoming emotionally

or sexually involved with a current client is clearly unethical, unprofessional, and

illegal. Sexual involvement with a former client is unwise, can be exploitative, and is

generally considered unethical.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

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Because nonsexual multiple relationships are necessarily complex and multi-

dimensional, there are few simple and absolute answers to resolve them. It is not

always possible to play a single role in your work as a counselor, nor is it always

desirable. You may have to deal with managing multiple roles, regardless of the

setting in which you work or the client population you serve. It is a wise practice to

give careful thought to the complexities of multiple roles and relationships before

embroiling yourself in ethically questionable situations.

Ethical reasoning and judgment come into play when ethics codes are applied

to specifi c situations. The ACA Code of Ethics (ACA, 2005) stresses that counseling

professionals must learn how to manage multiple roles and responsibilities in

an ethical way. This entails dealing effectively with the power differential that is

inherent in counseling rela tionships and training relationships, balancing bound-

ary issues, addressing nonprofessional relationships, and striving to avoid using

49

power in ways that might cause harm to clients, students, or super visees (Herlihy &

ETHIC

Corey, 2006b).

AL IS

Although multiple relationships do carry inherent risks, it is a mistake to con-

clude that these relationships are always unethical and necessarily lead to harm

SUES IN C

and exploitation. Some of these relationships can be benefi cial to clients if they are

implemented thoughtfully and with integrity (Zur, 2007). An excellent resource

on the ethical and clinical dimensions of multiple relationships is Boundaries in

OUNSELING PRA

Psychotherapy: Ethical and Clinical Explorations (Zur, 2007).

Perspectives on Multiple Relationships

What makes multiple relationships so problematic? Herlihy and Corey (2006b)

contend that some of the problematic aspects of engaging in multiple relation-

C

TICE

ships are that they are pervasive; they can be diffi cult to recognize; they are una-

voidable at times; they are potentially harmful, but not necessarily always harmful;

they can be benefi cial; and they are the subject of confl icting advice from various

experts. A review of the literature reveals that dual and multiple relationships are

hotly debated. Except for sexual intimacy with current clients, which is unequivo-

cally unethical, there is not much consensus regarding the appropriate way to deal

with multiple relationships.

Some of the codes of the professional organizations advise against forming

multiple relationships, mainly because of the potential for misusing power, ex-

ploiting the client, and impairing objectivity. When multiple relationships exploit

clients, or have signifi cant potential to harm clients, they are unethical. The eth-

ics codes do not mandate avoidance of all such relationships, however; nor do

the codes imply that nonsexual multiple relationships are unethical. The current

focus of ethics codes is to remain alert to the possibilities of harm to clients and

to develop safeguard to protect clients. Although codes can provide some gener-

al guidelines, good judgment, the willingness to refl ect on one’s practices, and

being aware of one’s motivations are critical dimensions of an ethical practitioner.

It bears repeating that multiple relationship issues cannot be resolved with ethics

codes alone; counselors must think through all of the ethical and clinical dimen-

sions involved in a wide range of boundary concerns.

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28549_ch03_rev01.indd 49

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A consensus of many writers is that multiple relationships are inevitable and

unavoidable in some situations and that a global prohibition is not a realistic

answer. Because interpersonal boundaries are not static but undergo redefi nition

over time, the challenge for practitioners is to learn how to manage boundary fl uc-

tuations and to deal effectively with overlapping roles (Herlihy & Corey, 2006b).

One key to learning how to manage multiple relationships is to think of ways to

minimize the risks involved.

w ay s o f m i n i m i z i n g r i s k In determining whether to proceed with a

multiple relationship, it is critical to consider whether the potential benefi t to the

client of such a relationship outweighs its potential harm. Some relationships may

have more potential benefi ts to clients than potential risks. It is your responsibility

to develop safeguards aimed at reducing the potential for negative consequences.

50

Herlihy and Corey (2006b) identify the following guidelines:

• Set healthy boundaries early in the therapeutic relationship. Informed consent

is essential from the beginning and throughout the therapy process.

• Involve clients in ongoing discussions and in the decision-making process, and

document your discussions. Discuss with your clients what you expect of them

CHAPTER THREE

and what they can expect of you.

• Consult with fellow professionals as a way to maintain objectivity and identify

unanticipated diffi culties. Realize that you don’t need to make a decision alone.

• When multiple relationships are potentially problematic, or when the risk for

harm is high, it is always wise to work under supervision. Document the nature

of this supervision and any actions you take in your records.

• Self-monitoring is critical throughout the process. Ask yourself whose needs are

being met and examine your motivations for considering becoming involved in

a dual or multiple relationship.

In working through a multiple relationship concern, it is best to begin by ascertain-

ing whether such a relationship can be avoided. Nagy (2011) points out that multi-

ple relationships cannot always be avoided, especially in small towns. Nor should

every multiple relationship be considered unethical. However, when a therapist’s

objectivity and competence are compromised, the therapist may fi nd that personal

needs surface and diminish the quality of the therapist’s professional work. Some-

times nonprofessional interactions are avoidable and your involvement would put

the client needlessly at risk. In other cases multiple relationships are unavoidable.

One way of dealing with any potential problems is to adopt a policy of completely

avoiding any kind of nonprofessional interaction. As a general guideline, Nagy

(2011) recommends avoiding multiple relationships to the extent this is possi-

ble. Therapists should document precautions taken to protect clients when such

relationships are unavoidable. Another alternative is to deal with each dilemma

as it develops, making full use of informed consent and at the same time seeking

consultation and supervision in dealing with the situation. This second alternative

includes a professional requirement for self-monitoring. It is one of the hallmarks

of professionalism to be willing to grapple with these ethical complexities of day-

to-day practice.

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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establishing personal and professional boundaries Establish-

ing and maintaining consistent yet fl exible boundaries is necessary if you are to

effectively counsel clients. If you have diffi culty establishing and maintaining

boundaries in your personal life, you are likely to fi nd that you will have diffi -

culty when it comes to managing boundaries in your professional life. Developing

appropriate and effective boundaries in your counseling practice is the fi rst step

to learning how to manage multiple relationships. There is a relationship between

developing appropriate boundaries in the personal and professional realms. If you

are successful in establishing boundaries in various aspects of your personal life,

you have a good foundation for creating sound boundaries with clients.

One important aspect of maintaining appropriate professional boundaries is to

recognize boundary crossings and prevent them from becoming boundary viola-

tions. A boundary crossing is a departure from a commonly accepted practice that

51

could potentially benefi t a client. For example, attending the wedding of a client

ETHIC

may be extending a boundary, but it could be benefi cial for the client. In contrast,

AL IS

a boundary violation is a serious breach that harms the client and is therefore

unethical. A boundary violation is a boundary crossing that takes the practitioner

SUES IN C

out of the professional role, which generally involves exploitation and results in

harm to a client (Gutheil & Brodsky, 2008). Flexible boundaries can be useful in the

counseling process when applied ethically. Some boundary crossings pose no ethi-

OUNSELING PRA

cal problems and may enhance the counseling relationship. Other boundary cross-

ings may lead to a pattern of blurred professional roles and become problematic.

b e c o m i n g a n e t h i c a l c o u n s e lo r

C

Knowing and following your profession’s code of ethics is part of being an ethi-

TICE

cal practitioner, but these codes do not make decisions for you. As you become

involved in counseling, you will fi nd that interpreting the ethical guidelines of your

professional organization and applying them to particular situations demand the

utmost ethical sensitivity. Even responsible practitioners differ over how to apply

established ethical principles to specifi c situations. In your professional work you

will deal with questions that do not always have obvious answers. You will have

to assume responsibility for deciding how to act in ways that will further the best

interests of your clients.

Throughout your professional life you will need to reexamine the ethical ques-

tions raised in this chapter. You can benefi t from both formal and informal op-

portunities to discuss ethical dilemmas during your training program. Even if you

resolve some ethical matters while completing a graduate program, there is no guar-

antee that these matters have been settled once and for all. These topics are bound

to take on new dimensions as you gain more experience. Oftentimes students bur-

den themselves unnecessarily with the expectation that they should resolve all poten-

tial ethical problem areas before they begin to practice. Throughout your profession-

al life, seek consultation from trusted colleagues and supervisors whenever you face

an ethical dilemma. Ethical decision-making is an evolutionary process that requires

you to be continually open and self-refl ective. Becoming an ethical practitioner is not

a fi nal destination but a journey that will continue throughout your career.

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s u m m a r y

It is essential that you learn a process for thinking about and dealing with ethical

dilemmas, keeping in mind that most ethical issues are complex and defy simple

solutions. A sign of good faith is your willingness to share your struggles with

colleagues. Such consultation can be helpful in clarifying issues by giving you an-

other perspective on a situation. The task of developing a sense of professional

and ethical responsibility is never really fi nished, and new issues are constantly

surfacing. Positive ethics demands periodic refl ection and an openness to change.

If there is one fundamental question that can serve to tie together all the issues

discussed in this chapter, it is this: “Who has the right to counsel another person?”

This question can be the focal point of your refl ection on ethical and professional

issues. It also can be the basis of your self-examination each day that you meet with

52

clients. Continue to ask yourself: “What makes me think I have a right to counsel oth-

ers?” “What do I have to offer the people I’m counseling?” “Am I doing in my own life

what I’m encouraging my clients to do?” At times you may feel that you have no ethi-

cal right to counsel others, perhaps because your own life isn’t always the model you

would like it to be for your clients. More important than resolving all of life’s issues is

knowing what kinds of questions to ask and remaining open to refl ection.

CHAPTER THREE

This chapter has introduced you to a number of ethical issues that you are

bound to face at some point in your counseling practice. I hope your interest has

been piqued and that you will want to learn more. For further reading on this

important topic, choose some of the books listed in the Recommended Supplemen-

tary Readings section for further study.

w h e r e t o g o f r o m h e r e

The following professional organizations provide helpful information about what

each group has to offer, including the code of ethics for the organization.

American Association for Marriage and

www.aamft.org

Family Therapy (AAMFT)

American Counseling Association (ACA)

www.counseling.org

American Mental Health Counselors

www.amhca.org

Association (AMHCA)

American Music Therapy Association

www.musictherapy.org

American Psychological Association (APA) www.apa.org

American School Counselor

www.schoolcounselor.org

Association (ASCA)

Commission on Rehabilitation Counselor www.crccertifi cation.com

Certifi cation (CRCC)

National Association of Alcohol and

www.naadac.org

Drug Abuse Counselors (NAADAC)

National Association of Social Workers

www.socialworkers.org

(NASW)

National Organization for Human

www.nationalhumanservices.org

Services (NOHS)

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch03_rev01.indd 52

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Free Podcasts for ACA Members

You can download ACA Podcasts (prerecorded interviews) relevant to topics

discussed in Chapter 3 by going to www.counseling.org, clicking on the Resource

button, and selecting the Podcast Series:

Multicultural and Diversity (Dr. Courtland Lee)

The Counselor and the Law: A Guide to Legal and Ethical Practice

(Drs. Nancy Wheeler and Burt Bertram)

The Ethics of Confi dentiality, Who Needs to Know What?

(Larry Freeman)

The Death of Dual Relationships, or Relationships with Clients, Benefi cial

Versus Harmful (Dr. Rocco Cottone)

Clinical Supervision in the Helping Professions (Drs. Gerald Corey, Robert

53

Haynes, Patrice Moulton, and Michelle Muratori)

ETHIC

For interviews on topics introduced in subsequent chapters, see the following

podcasts:

AL IS

Chapter 5: Adlerian Theory and Practice (Dr. Jon Carlson)

SUES IN C

Chapter 6: Existential Therapy (Dr. Gerald Corey)

Chapter 7: Carl Rogers and the Person-Centered Approach (Dr. Howard

Kirschenbaum)

OUNSELING PRA

Chapter 11: Reality Therapy, Choice Theory: What’s the Difference?

(Dr. Robert Wubbolding)

Chapter 13: Solution-Focused Counseling in Schools (Dr. John Murphy)

Chapter 13: Narrative Therapy: Remembering Lives, Conversations With

the Dying and Bereaved (Lorraine Hedtke, MSW, LCSW, and Dr. John

C

TICE

Winslade)

Recommended Supplementary

Readings for Part 1

Leaving It at the Offi ce: A Guide to Psychotherapist Self-Care (Norcross & Guy,

2007) addresses 12 self-care strategies that are supported by empirical evidence.

The authors develop the position that self-care is personally essential and profes-

sionally ethical. This is one of the most useful books on therapist self-care and on

prevention of burnout.

Psychotherapy Relationships That Work: Evidence-based Responsiveness (Norcross,

2011) is a comprehensive treatment of the effective elements of the therapy

relationship. Many different contributors address ways of tailoring the therapy

relationship to individual clients. Implications from research for effective clinical

practice are presented.

Ethics Desk Reference for Counselors (Barnett & Johnson, 2010) is a practical guide

to understanding and applying the ACA Code of Ethics. It is a reference that is

easy to read, interesting, and has appeal for both students and practitioners.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch03_rev01.indd 53

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The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their

Patients (Yalom, 2003) is a highly readable, insightful, and useful resource. It

includes 85 short chapters on a wide variety of topics that pertain to the counselor

as a person and as a professional.

ACA Ethical Standards Casebook (Herlihy & Corey, 2006a) contains a variety of

useful cases that are geared to the ACA Code of Ethics. The examples illustrate and

clarify the meaning and intent of the standards.

Boundary Issues in Counseling: Multiple Roles and Responsibilities (Herlihy & Corey,

2006b) puts the multiple-relationship controversy into perspective. The book

focuses on dual relationships in a variety of work settings.

Boundaries in Psychotherapy: Ethical and Clinical Explorations (Zur, 2007) ex-

54

amines the complex nature of boundaries in professional practice by offering a

decision-making process to help practitioners deal with a range of topics such as

gifts, nonsexual touch, home visits, bartering, and therapist self-disclosure.

Issues and Ethics in the Helping Professions (Corey, Corey, & Callanan, 2011) is devoted

entirely to the issues that were introduced briefl y in Chapter 3. The book is designed

CHAPTER THREE

to involve readers in a personal and active way, and many open-ended cases are pre-

sented to help readers formulate their thoughts on a wide range of ethical issues.

Becoming a Helper (M. Corey & Corey, 2011) has separate chapters that expand

on issues dealing with the personal and professional lives of helpers and ethical

issues in counseling practice.

Ethics in Action: CD-ROM (Corey, Corey, & Haynes, 2003) is a self-instructional

program divided into three parts: (1) ethical decision making, (2) values and the

helping relationship, and (3) boundary issues and multiple relationships. The

program includes video clips of vignettes demonstrating ethical situations aimed

at stimulating discussion.

Student Manual for Theory and Practice of Counseling and Psychotherapy (Corey,

2013c) is designed to help you integrate theory with practice and to make the

concepts covered in this book come alive. It consists of self-inventories, overview

summaries of the theories, a glossary of key concepts, study questions, issues

and questions for personal application, activities and exercises, comprehension

checks and quizzes, and case examples. The manual is fully coordinated with the

textbook to make it a personal study guide.

Case Approach to Counseling and Psychotherapy (Corey, 2013b) provides case ap-

plications of how each of the theories presented in this book works in action.

A hypothetical client, Ruth, experiences counseling from all of the therapeutic

vantage points.

The Art of Integrative Counseling (Corey, 2013a) is a presentation of concepts and

techniques from the various theories of counseling. The book provides guidelines

for readers in developing their own approaches to counseling practice.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch03_rev01.indd 54

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DVD for Theory and Practice of Counseling and Psychotherapy: The Case of Stan

and Lecturettes (Corey, 2013) is an interactive self-study tool that consists of two

programs. Part 1 includes 13 sessions in which Gerald Corey counsels Stan us-

ing a few selected techniques from each theory. Part 2 consists of brief lectures

by the author for each chapter in Theory and Practice of Counseling and Psycho-

therapy. Both programs emphasize the practical applications of the various

theories.

DVD for Integrative Counseling: The Case of Ruth and Lecturettes (Corey & Haynes,

2013) is an interactive self-study tool that contains video segments and interac-

tive questions designed to teach students ways of working with a client (Ruth)

by drawing concepts and techniques from diverse theoretical approaches. The

topics in this video program parallel the topics in the book The Art of Integrative

55

Counseling.

ETHIC

Creating Your Professional Path: Lessons From My Journey (Corey, 2010) is a per-

sonal book that deals with a range of topics pertaining to the counselor as a person

AL IS

and as a professional. In addition to the author’s discussion of his personal and

SUES IN C

professional journey, 18 contributors share their personal stories regarding turn-

ing points in their lives and lessons they learned.

The Counselor as Person and Professional (DVD) elaborates on the themes in Chap-

OUNSELING PRA

ter 2 and is available from the American Counseling Association. This program is

a keynote address that was given by Gerald Corey at the ACA conference in 2010

in Pittsburgh.

References and Suggested Readings

C

TICE

for Part 1

American Counseling Association.

*American Psychological Association

(2005). ACA code of ethics. Alexandria,

Presidential Task Force on Evidence-Based

VA: Author.

Practice. (2006). Evidence-based practice in

psychology. American Psychologist, 61, 271–285.

American Psychiatric Association. (2000).

Diagnostic and statistical manual of mental

Arredondo, P., Toporek, R., Brown, S., Jones,

disorders, text revision (4th ed.). Washington,

J., Locke, D., Sanchez, J., & Stadler, H. (1996).

DC: Author.

Operationalization of multicultural counseling

competencies. Journal of Multicultural Coun-

American Psychological Association. (2002).

seling and Development, 24(1), 42–78.

Ethical principles of psychologists and code

of conduct . American Psychologist, 57(12),

*Baker, E. K. (2003). Caring for ourselves: A

1060–1073.

therapist’s guide to personal and professional

well-being. Washington, DC: American

American Psychological Association. (2003).

Psychological Association.

Guidelines on multicultural education, training,

research, practice, and organizational change

*Barnett, J. E., & Johnson, W. B. (2008). Ethics

for psychologists. American Psychologist, 58(5),

desk reference for psychologists. Washington, DC:

377–402.

American Psychological Association.

*Books and articles marked with an asterisk are suggested for further study.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch03_rev01.indd 55

20/09/11 1:33 PM

*Barnett, J. E., & Johnson, W. B. (2010). Ethics

*Corey, M., & Corey, G. (2011). Becoming a

desk reference for counselors. Alexandria, VA:

helper (6th ed.). Belmont, CA: Brooks/Cole,

American Counseling Association.

Cengage Learning.

Cardemil, E. V., & Battle, C. L. (2003). Guess

Cukrowicz, K. C., White, B. A., Reitzel, L. R.,

who’s coming to therapy? Getting comfortable

Burns, A. B., Driscoll, K. A., Kemper, T. S., &

with conversations about race and ethnic-

Joiner, T. E. (2005). Improved treatment out-

ity in psychotherapy. Professional Psychology:

come associated with the shift to empirically

Research and Practice, 34(3), 278–286.

supported treatments in a graduate training

clinic. Professional Psychology: Research and

Codes of Ethics for the Helping Professions

Practice, 36(3), 330–337.

(4Th Ed.). (2011). Belmont, CA: Brooks/Cole,

Cengage Learning.

Deegear, J., & Lawson, D. M. (2003). The

utility of empirically supported treatments.

Comas-Diaz, L. (2011). Multicultural ap-

Professional Psychology: Research and Practice,

proaches to psychotherapy. In J. C. Norcross,

56

34(3), 271–277.

G. R. Vandenbos, & D. K. Freedheim (Eds.),

History of psychotherapy (2nd ed., pp. 243–

*Duncan, B. L., Miller, S. D., & Sparks, J. A.

268). Washington, DC: American

(2004). The heroic client: A revolutionary way

Psychological Association.

to improve effectiveness through client-directed,

outcome-informed therapy. San Francisco:

Committee on Professional Practice and

Jossey-Bass.

Standards. (2003). Legal issues in the profes-

CHAPTER THREE

sional practice of psychology. Professional Psy-

*Duncan, B. L., Miller, S. D., Wampold, B. E. &

chology: Research and Practice, 34(6), 595–600.

Hubble, M. A. (Eds.). (2010). The heart and

soul of change: Delivering what works in therapy

*Corey, G. (2010). Creating your professional

(2nd ed.). Washington, DC: American Psycho-

path: Lessons from my journey. Alexandria,

logical Association.

Va: American Counseling Association.

Edwards, J. A., Dattilio, F. M., & Bromley,

*Corey, G. (2013a). The art of integrative coun-

D. B. (2004). Developing evidence-based

seling (3rd ed.). Belmont, CA: Brooks/Cole,

practice: The role of case-based research.

Cengage Learning.

Professional Psychology: Research and Practice,

*Corey, G. (2013b). Case approach to counseling

35(6), 589–597.

and psychotherapy (8th ed.). Belmont, CA:

Elkins, D. N. (2009). Humanistic psychology:

Brooks/Cole, Cengage Learning.

A clinical manifesto. Colorado Springs, CO:

*Corey, G. (2013c). Student manual for theory

University of the Rockies Press.

and practice of counseling and psychotherapy

*Falender, C. A., & Shafranske, E. P. (2004).

(9th ed.). Belmont, CA: Brooks/Cole,

Clinical supervision: A competency-based

Cengage Learning.

approach. Washington, DC: American

*Corey, G., & Corey, M. (2010). I never knew

Psychological Association.

I had a choice (9th ed.). Belmont, CA: Brooks/

*Geller, J. D., Norcross, J. C., & Orlinsky,

Cole, Cengage Learning.

D. E. (Eds.). (2005a). The psychotherapist’s

*Corey, G., Corey, M., & Callanan, P. (2011).

own psychotherapy: Patient and clinician

Issues and ethics in the helping professions (8th ed.).

perspectives. New York: Oxford

Belmont, CA: Brooks/Cole, Cengage Learning.

University Press.

*Corey, G., Corey, M., & Haynes, R. (2003).

*Geller, J. D., Norcross, J. C., & Orlinsky, D. E.

Ethics in action: CD-ROM. Belmont, CA: Brooks/

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psychotherapist’s own psychotherapy: Patient

grative counseling: The case of Ruth and

and clinician perspectives (pp. 3–11). New York:

lecturettes. Belmont, CA: Brooks/Cole,

Oxford University Press.

Cengage Learning.

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*Herlihy, B., & Corey, G. (2006a). ACA ethical

standards casebook (6th ed.). Alexandria, VA:

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*Herlihy, B., & Corey, G. (2006b). Boundary

issues in counseling: Multiple roles and respon-

*Norcross, J. C., Hogan, T. P., & Koocher,

sibilities (2nd ed.). Alexandria, VA: American

G. P. (2008). Clinician’s guide to evidence-based

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*Knapp, S. J., & Vandecreek, L. (2006).

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Lambert, M. J. (2011). Psychotherapy research

and its achievements. In J. C. Norcross, G. R.

Norcross, J. C., Vandenbos, G. R., &

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ships and psychotherapy. New York: Springer.

Research conclusions and clinical practices. In

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that work: Evidence-based responsiveness

framework for understanding diverse groups and

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justice issues (4th ed.). Belmont, CA: Brooks/

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M. H., & Wiseman, H. (2005). Outcomes

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and impacts of the psychotherapists’ own

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*Nagy, T. F. (2011). Essential ethics for psycholo-

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*Pedersen, P. (2000). A handbook for develop-

*Norcross, J. C. (2005). The psychotherapist’s

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psychologists. American Psychologist, 60(8),

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legal, and professional issues in counseling

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personal values. Counseling Today, 53(5), 32–34.

logical Association.

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Shallcross, L. (2011). Taking care of

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ing to the omissions: A historical examina-

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Sue, D. W., Arredondo, P., & Mcdavis, R. J.

*Yalom, I. D. (2003). The gift of therapy: An

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Ethical and clinical explorations. Washington,

culturally diverse: Theory and practice (5th ed.).

CHAPTER THREE

DC: American Psychological Association.

New York: Wiley.

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28549_ch03_rev01.indd 58

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p a r t 2

Theories and Techniques

of Counseling

59

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p a r t 2

Theories and Techniques

of Counseling

4 Psychoanalytic Therapy 62

5 Adlerian Therapy 101

6 Existential Therapy 136

7 Person-Centered Therapy 172

8 Gestalt Therapy 210

9 Behavior Therapy 244

10 Cognitive Behavior Therapy 287

11 Reality Therapy 333

12 Feminist Therapy 360

13 Postmodern Approaches 395

14 Family Systems Therapy 432

61

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c h a p t e r 4

Psychoanalytic Therapy

i n t r o d u c t i o n

c o n t e m p o r a ry t r e n d s : o b j e c t-

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d e v e lo p m e n t o f p e r s o n a l i t y

62

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Sigmund Freud

SIGMUND FREUD (1856–

of personality development. He first examined his

1939) was the firstborn in

childhood memories and came to realize the intense

a Viennese family of three

hostility he had felt for his father. He also recalled his

boys and five girls. His father,

childhood sexual feelings for his mother, who was

like many others of his time

attractive, loving, and protective. He then clinically

and place, was very authori-

formulated his theory as he observed his patients

tarian. Freud’s family back-

work through their own problems in analysis.

Imagery/PhotoLibrary

ground is a factor to consider

Freud had very little tolerance for colleagues

Stock

in understanding the devel-

who diverged from his psychoanalytic doctrines.

Index

opment of his theory.

He attempted to keep control over the movement

Even though Freud’s family had limited financ-

by expelling those who dared to disagree. Carl

63

es and was forced to live in a crowded apartment,

Jung and Alfred Adler, for example, worked closely

PS

his parents made every effort to foster his obvious

with Freud, but each founded his own therapeutic

Y

CHO

intellectual capacities. Freud had many interests,

school after repeated disagreements with Freud on

but his career choices were restricted because of

theoretical and clinical issues.

ANAL

his Jewish heritage. He finally settled on medicine.

Freud was highly creative and productive,

YTIC THERAP

Only 4 years after earning his medical degree from

frequently putting in 18-hour days. His col-

the University of Vienna at the age of 26, he at-

lected works fill 24 volumes. Freud’s productivity

tained a prestigious position there as a lecturer.

remained at this prolific level until late in his life

Freud devoted most of his life to formulat-

when he contracted cancer of the jaw. During his

ing and extending his theory of psychoanalysis.

last two decades, he underwent 33 operations and

Y

Interestingly, the most creative phase of his life

was in almost constant pain. He died in London

corresponded to a period when he was experienc-

in 1939.

ing severe emotional problems of his own. During

As the originator of psychoanalysis, Freud

his early 40s, Freud had numerous psychosomatic

distinguished himself as an intellectual giant. He

disorders, as well as exaggerated fears of dying and

pioneered new techniques for understanding

other phobias, and was involved in the difficult task

human behavior, and his efforts resulted in the

of self-analysis. By exploring the meaning of his

most comprehensive theory of personality and

own dreams, he gained insights into the dynamics

psychotherapy ever developed.

i n t r o d u c t i o n

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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OUR

See the DVD program for Chapter 4, DVD for Theory and Practice of Counseling

and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view

the brief lecture for each chapter prior to reading the chapter.

CHAPTER F

k e y c o n c e p t s

View of Human Nature

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Structure of Personality

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Consciousness and the Unconscious

1FSIBQT'SFVETHSFBUFTUDPOUSJCVUJPOTBSFIJTDPODFQUTPGUIFVODPOTDJPVTBOEPG

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MPXJOH ESFBNT XIJDI BSF TZNCPMJD SFQSFTFOUBUJPOT PG VODPOTDJPVT OFFET

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

XJTIFT BOEDPOnJDUT TMJQTPGUIFUPOHVFBOEGPSHFUUJOH GPSFYBNQMF BGBNJM

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FYJTUT CFMPX UIF TVSGBDF PG BXBSFOFTT 5IF unconscious TUPSFT BMM FYQFSJFODFT

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66

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OUR

UPNT UIFDBVTFTPGCFIBWJPS BOEUIFSFQSFTTFENBUFSJBMTUIBUJOUFSGFSFXJUIIFBMUIZ

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UIFTZNQUPN5IFDMJFOUTOFFEUPDMJOHUPPMEQBUUFSOT SFQFUJUJPO NVTUCFDPOGSPOUFE

CHAPTER F

CZXPSLJOHUISPVHIUSBOTGFSFODFEJTUPSUJPOT BQSPDFTTEJTDVTTFEMBUFSJOUIJTDIBQUFS

Anxiety

"MTPFTTFOUJBMUPUIFQTZDIPBOBMZUJDBQQSPBDIJTJUTDPODFQUPGBOYJFUZAnxietyJTB

GFFMJOHPGESFBEUIBUSFTVMUTGSPNSFQSFTTFEGFFMJOHT NFNPSJFT EFTJSFT BOEFYQF

SJFODFUIBUFNFSHFUPUIFTVSGBDFPGBXBSFOFTT*UDBOCFDPOTJEFSFEBTBTUBUFPG

UFOTJPOUIBUNPUJWBUFTVTUPEPTPNFUIJOH*UEFWFMPQTPVUPGBDPOnJDUBNPOHUIF

JE FHP BOETVQFSFHPPWFSDPOUSPMPGUIFBWBJMBCMFQTZDIJDFOFSHZ5IFGVODUJPOPG

BOYJFUZJTUPXBSOPGJNQFOEJOHEBOHFS

5IFSF BSF UISFF LJOET PG BOYJFUZ SFBMJUZ OFVSPUJD BOE NPSBM Reality anxiety

JTUIFGFBSPGEBOHFSGSPNUIFFYUFSOBMXPSME BOEUIFMFWFMPGTVDIBOYJFUZJTQSP

QPSUJPOBUFUPUIFEFHSFFPGSFBMUISFBU/FVSPUJDBOENPSBMBOYJFUJFTBSFFWPLFECZ

UISFBUTUPUIFiCBMBODFPGQPXFSwXJUIJOUIFQFSTPO5IFZTJHOBMUPUIFFHPUIBUVOMFTT

BQQSPQSJBUFNFBTVSFTBSFUBLFOUIFEBOHFSNBZJODSFBTFVOUJMUIFFHPJTPWFSUISPXO

Neurotic anxietyJTUIFGFBSUIBUUIFJOTUJODUTXJMMHFUPVUPGIBOEBOEDBVTFPOFUP

EPTPNFUIJOHGPSXIJDIPOFXJMMCFQVOJTIFEMoral anxietyJTUIFGFBSPGPOFTPXO

DPOTDJFODF1FPQMFXJUIBXFMMEFWFMPQFEDPOTDJFODFUFOEUPGFFMHVJMUZXIFOUIFZEP

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Ego-Defense Mechanisms

Ego-defense mechanisms IFMQ UIF JOEJWJEVBM DPQF XJUI BOYJFUZ BOE QSFWFOU UIF

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EFTDSJQUJPOTPGTPNFDPNNPOFHPEFGFOTFT

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

TA B L E 4 .1 Ego-Defense Mechanisms

D E F E N S E

U S E S F O R B E H A V I O R

Repression

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SFNPWBMPGTPNFUIJOHGSPNDPOTDJPVTOFTT

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Denial

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67

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PS

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Y

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CHO

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ANAL

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YTIC THERAP

Reaction

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formation

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Y

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Projection

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Displacement

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TIJGUJOHGSPNBUISFBUFOJOHPCKFDUUPBiTBGFS

QFSTPOJTJOBDDFTTJCMF

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GFFMTJOUJNJEBUFECZIJTCPTTDPNFTIPNF

BOEVOMPBETJOBQQSPQSJBUFIPTUJMJUZPOUPIJT

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Rationalization .BOVGBDUVSJOHiHPPEw

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SFBMMZEJEOPUXBOUUIFQPTJUJPOBOZXBZ

( continues)

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

TA B L E 4 .1 Ego-Defense Mechanisms ( continued)

D E F E N S E

U S E S F O R B E H A V I O R

Sublimation

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Regression

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68

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OUR

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Introjection

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CHAPTER F

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PUIFST

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Identification

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DBVTFT PSHBOJ[BUJPOT PS

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XPSUIXIJMF

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XIFOVTFECZQFPQMFXIPGFFMCBTJDBMMZ

JOGFSJPS

Compensation

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BDDPNQMJTINFOUTw

Development of Personality

i m p o r ta n c e o f e a r ly d e v e lo p m e n t "TJHOJmDBOUDPOUSJCVUJPOPGUIF

QTZDIPBOBMZUJDNPEFMJTEFMJOFBUJPOPGUIFTUBHFTPGQTZDIPTFYVBMBOEQTZDIPTPDJBM

TUBHFTPGEFWFMPQNFOUGSPNCJSUIUISPVHIBEVMUIPPE5IFpsychosexual stagesSF

GFSUPUIF'SFVEJBODISPOPMPHJDBMQIBTFTPGEFWFMPQNFOU CFHJOOJOHJOJOGBODZ

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

'SFVEQPTUVMBUFEUISFFFBSMZTUBHFTPGEFWFMPQNFOUUIBUPGUFOCSJOHQFPQMFUP

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BTBQFSTPOBOEUIFMBDLPGBTFOTFPGBVUPOPNZ5IJSEJTUIFphallic stage, XIJDI

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69

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PS

Y

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CHO

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ANAL

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YTIC THERAP

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Y

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)FEFTDSJCFTEFWFMPQNFOUJOUFSNTPGUIFFOUJSFMJGFTQBO EJWJEFECZTQFDJmDDSJTFT

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&SJLTPOJTPGUFODSFEJUFEXJUICSJOHJOHBOFNQIBTJTPOTPDJBMGBDUPSTUPDPO

UFNQPSBSZQTZDIPBOBMZTJTClassical psychoanalysis JTHSPVOEFEPOid psychol-

ogy, BOEJUIPMETUIBUJOTUJODUTBOEJOUSBQTZDIJDDPOnJDUTBSFUIFCBTJDGBDUPST

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psychoanalysisUFOETUPCFCBTFEPOego psychology, XIJDIEPFTOPUEFOZUIF

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CPUIQTZDIPTFYVBMBOEQTZDIPTPDJBMGBDUPSTJTVTFGVM&SJLTPOCFMJFWFE'SFVEEJE

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

OPUHPGBSFOPVHIJOFYQMBJOJOHUIFFHPTQMBDFJOEFWFMPQNFOUBOEEJEOPUHJWF

FOPVHIBUUFOUJPOUPTPDJBMJOnVFODFTUISPVHIPVUUIFMJGFTQBO"DPNQBSJTPOPG

'SFVETQTZDIPTFYVBMWJFXBOE&SJLTPOTQTZDIPTPDJBMWJFXPGUIFTUBHFTPGEFWFM

PQNFOUJTQSFTFOUFEJO5BCMF

TA B L E 4 . 2 Comparison of Freud’s Psychosexual Stages and Erikson’s

Psychosocial Stages

P E R I O D

O F L I F E

F R E U D

E R I K S O N

First year of life

Oral stage

Infancy: Trust versus mistrust

4VDLJOHBUNPUIFSTCSFBTUTTBUJTmFT *GTJHOJmDBOUPUIFSTQSPWJEFGPSCBTJD

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70

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OUR

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CHAPTER F

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Ages 1–3

Anal stage

Early childhood: Autonomy versus

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shame and doubt

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Ages 3–6

Phallic stage

Preschool age: Initiative versus guilt

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Ages 6–12

Latency stage

School age: Industry versus inferiority

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Ages 12–18

Genital stage

Adolescence: Identity versus role confusion

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71

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Ages 18–35

Genital stage continues

Young adulthood: Intimacy versus

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isolation.

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Ages 35–60

Genital stage continues

Middle age: Generativity versus

stagnation.

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Ages 60+

Genital stage continues

Later life: Integrity versus despair

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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72

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CHAPTER F

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t h e t h e r a p e u t i c p r o c e s s

Therapeutic Goals

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Therapist’s Function and Role

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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73

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PS

Y

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CHO

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ANAL

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Y

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Client’s Experience in Therapy

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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74

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OUR

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CHAPTER F

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

lose their objectivity in a relationship because their own conflicts are triggered.

Wolitzky (2011b) states that over the years this traditional view of countertrans-

ference has broadened to include all of the therapist’s reactions, not only to the

client’s transference but to all aspects of the client’s personality and behavior.

In this broader perspective, countertransference involves the therapist’s total

emotional response to a client. In today’s psychoanalytic practice, countertrans-

ference is manifested in the form of subtle nonverbal, tonal, and attitudinal

actions that inevitably affect clients, either consciously or unconsciously (Curtis &

Hirsch, 2011).

It is critical that therapists become aware of their countertransference so that

their reactions toward clients do not interfere with their objectivity. For example,

a male client may become excessively dependent on his female therapist. The cli-

ent may look to her to direct him and tell him how to live, and he may look to her

77

for the love and acceptance that he felt he was unable to secure from his mother.

PS

Y

The therapist herself may have unresolved needs to nurture, to foster a dependent

CHO

relationship, and to be told that she is significant, and she may be meeting her

ANAL

own needs by in some way keeping her client dependent. Unless she is aware of

her own needs as well as her own dynamics, it is very likely that her dynamics will

YTIC THERAP

interfere with the progress of therapy.

Not all countertransference reactions are detrimental to therapeutic progress.

Indeed, countertransference reactions are often the strongest source of data for

understanding the world of the client and for self-understanding on the therapist’s

Y

part. The therapist’s countertransference reactions are inevitable because all ther-

apists have unresolved conflicts, personal vulnerabilities, and unconscious “soft

spots” that are activated through their professional work (Curtis & Hirsch, 2011;

Hayes, Gelso, & Hummel, 2011; Wolitkzy, 2011a). Hayes (2004) reports that most

research on countertransference has dealt with its deleterious effects and how to

manage these reactions. Hayes adds that it would be useful to undertake system-

atic study of the potential therapeutic benefits of countertransference.

Although countertransference can greatly benefit the therapeutic work, this

is true only if therapists study their internal reactions and use them to under-

stand their clients (Ainslie, 2007; Gelso & Hayes, 2002; Wolitzky, 2011a, 2011b).

It is critical that therapists monitor their own feelings during therapy sessions and

use their responses as a source for increased self-awareness and understanding of

their clients.

A therapist who pays attention to his or her countertransference reactions and

observations to a particular client may use this as a part of the therapy. The thera-

pist who notes a countertransference mood of irritability, for instance, may learn

something about a client’s pattern of being demanding, which can be explored in

therapy. Viewed in this more positive way, countertransference can become a key

avenue for helping the client gain self-understanding.

Psychoanalytic therapists vary in the manner in which they use their observa-

tions of countertransference. In some instances the feelings may be shared with

the client, but traditional analytic therapists strive to minimize their expression of

countertransference while silently learning from its inevitable occurrence. Hayes,

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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78

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CHAPTER F

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a p p l i c at i o n : t h e r a p e u t i c

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Interpretation

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80

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CHAPTER F

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Dream Analysis

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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81

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Analysis and Interpretation of Resistance

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Analysis and Interpretation of Transference

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82

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CHAPTER F

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Application to Group Counseling

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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83

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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84

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CHAPTER F

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archetypes"NPOHUIFNPTUJNQPSUBOUBSDIFUZQFTBSFUIFQFSTPOB UIFBOJNBBOE

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Reflections +VOH BOE Living With Paradox: An Introduction to Jungian Psy-

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c o n t e m p o r a r y t r e n d s : o b j e c t-

r e l at i o n s t h e o r y, s e l f p s yc h o lo g y,

a n d r e l at i o n a l p s yc h o a n a ly s i s

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Object-relations theory FODPNQBTTFT UIF XPSL PG B OVNCFS PG SBUIFS EJGGFS

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86

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CHAPTER F

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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87

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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88

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CHAPTER F

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Psychotherapy for Borderline Personality $MBSLJO :FPNBOT ,FSOCFSH

some directions of contemporary psychodynamic therapy4USVQQ

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the trend toward brief, time-limited psychodynamic therapy

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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CHAPTER F

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Brief Dynamic Therapy -FWFOTPO

p s yc h o a n a ly t i c t h e r a p y f r o m a

m u lt i c u lt u r a l p e r s p e c t i v e

Strengths From a Diversity Perspective

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Shortcomings From a Diversity Perspective

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Psychoanalytic Therapy Applied to the Case of Stan

In each of the chapters in Part 2, the

mother was the strong, domineering force who

case of Stan is used to demonstrate

could and did hurt men. Stan generalized his fear

the practical applications of the theory

of his mother to all women. It could be further

in question. To give you a focus on Stan’s central

hypothesized that the woman he married was

concerns, refer to the end of Chapter 1, where

similar to his mother, both of whom reinforced

his biography is given. I also recommend that

his feelings of impotence.

you at least skim Chapter 16, which deals with

The opportunity to develop a transference

an integrative approach as applied to Stan.

relationship and work through it is the core of

The psychoanalytic approach focuses on the

the therapy process. Stan will eventually relate to

unconscious psychodynamics of Stan’s behavior.

me, as his therapist, as he did to his father, and

Considerable attention is given to material that

this process will be a valuable means of gaining

he has repressed. At the extreme Stan demon-

insight into the origin of Stan’s difficulties in

strated a self-destructive tendency, which is a

relating to others. The analytic process stresses

way of inflicting punishment on himself. Instead

an intensive exploration of Stan’s past. Stan

of directing his hostility toward his parents and

devotes much therapy time to reliving and

siblings, he turned it inward toward himself.

exploring his early past. As he talks, he gains

Stan’s preoccupation with drinking could be

increased understanding of the dynamics of his

hypothesized as evidence of an oral fixation.

behavior. He begins to see connections between

Because he never received love and acceptance

his present problems and early experiences in his

during his early childhood, he is still suffering

childhood. Stan explores memories of relation-

from this deprivation and continues to desper-

ships with his siblings and with his mother and

ately search for approval and acceptance from

father and also explores how he has generalized

others. Stan’s gender-role identification was

his view of women and men from his view of

fraught with difficulties. He learned the basis

these family members. It is expected that he will

of female–male relationships through his early

reexperience old feelings and uncover buried

experiences with his parents. What he saw was

feelings related to traumatic events. From anoth-

fighting, bickering, and discounting. His father

er perspective, apart from whatever conscious

was the weak one who always lost, and his

insight Stan may acquire, the goal is for him to

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

have a more integrated self, where feelings split

psychology can shed light on his difficulties in

off as foreign (the id) become more a part of what

forming intimate relationships.

he is comfortable with (the ego). In Stan’s relation-

ship with me, his old feelings can have different

Follow-Up: You Continue as

outcomes from his past experiences with significant

Stan’s Psychoanalytic Therapist

others and can result in deep personality growth.

With each of the 11 theoretical orientations, you

I am likely to explore some of these ques-

will be encouraged to try your hand at applying

tions with Stan: “What did you do when you felt

the principles and techniques you have just stud-

unloved?” “As a child, what did you do with your

ied in the chapter to working with Stan from that

negative feelings?” “As a child, could you express

particular perspective. The information presented

your anger, hurt, and fears?” “What effects did your

about Stan from each of these theory chapters will

relationship with your mother and father have on

provide you with some ideas of how you might

you?” “What did this teach you about women and

continue working with him if he were referred to

about men?” Brought into the here and now of the

you. Do your best to stay within the general spirit

93

transference relationship, I might ask, “When have

of each theory by identifying specific concepts

PS

you felt anything like you felt with your parents?”

you would draw from and techniques that you

Y

CHO

The analytic process focuses on key influ-

might use in helping him explore the struggles he

ences in Stan’s developmental years, some-

identifies. Here are a series of questions to provide

ANAL

times explicitly, sometimes in terms of how those

some structure in your thinking about his case:

YTIC THERAP

earlier events are being relived in the present

t How much interest would you have in Stan’s

analytic relationship. As he comes to understand

early childhood? What are some ways you’d

how he has been shaped by these past experi-

help him see patterns between his childhood

ences, he is increasingly able to exert control

issues and his current problems?

over his present functioning. Many of Stan’s fears

t

Y

Consider the transference relationship that is

become conscious, and then his energy does not

likely to be established between you and Stan.

have to remain fixed on defending himself from

How might you react to his making you into a

unconscious feelings. Instead, he can make new

significant person in his life?

decisions about his current life. He can do this

t In working with Stan, what countertransfer-

only if he works through the transference rela-

ence issues might arise for you?

tionship, however, for the depth of his endeav-

t What resistances and defenses might you

ors in therapy largely determine the depth and

predict in your work with Stan? From a psy-

extent of his personality changes.

choanalytic perspective, how would you inter-

If I am operating from a contemporary

pret and work with this resistance?

object-relations psychoanalytic orientation,

my focus may well be on Stan’s developmental

t Which of the various forms of psychoanalytic

sequences. Particular attention is paid to un-

therapy—classical, relational, or object relations—

derstanding his current behavior in the world as

would you be most inclined to apply in work-

largely a repetition of one of his earlier develop-

ing with Stan?

mental phases. Because of his dependency, it is

useful in understanding his behavior to see that

See DVD for Theory and Practice of

he is now repeating patterns that he formed

Counseling and Psychotherapy: The Case

with his mother during his infancy. Viewed from

of Stan and Lecturettes (Session 1, an initial

this perspective, Stan has not accomplished the

session with Stan, and Session 2, on psycho-

task of separation and individuation. He is still

analytic therapy) for a demonstration of my

“stuck” in the symbiotic phase on some levels.

approach to counseling Stan from this perspec-

He is unable to obtain his confirmation of worth

tive. The first session consists of the intake

from himself, and he has not resolved the

and assessment process. The second session

dependence–independence struggle. Looking

focuses on Stan’s resistance and dealing with

at his behavior from the viewpoint of self

transference.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

s u m m a r y a n d e va l u at i o n

Summary

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CHAPTER F

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UISPVHIUIFDMJFOUoUIFSBQJTUSFMBUJPOTIJQ

Contributions of the Psychoanalytic Approach

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Contributions of Modern Psychoanalytic Approaches

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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CHAPTER F

Limitations and Criticisms of the Psychoanalytic Approach

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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UIJTDIBQUFS5IFZJODMVEF Psychoanalytic Therapy /.D8JMMJBNT Relational

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American Psychoanalytic Association

309 East 49th Street, New York, NY 10017-1601

CHAPTER F

Telephone: (212) 752-0450

Fax: (212) 593–0571

Website: www.apsa.org

Recommended Supplementary Readings

Psychoanalytic Theory: An Introduction &MMJPUU QSPWJEFTUIPSPVHIDPWFSBHF

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Psychodynamic Psychiatry in Clinical Practice (BCCBSE PGGFSTBOFYDFMMFOU

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References and Suggested Readings

*Ainslie, R. (2007). Psychoanalytic psycho-

In J. C. Norcross (Ed.), Psychotherapy relation-

therapy. In A. B. Rochlen (Ed.), Applying coun-

ships that work (pp. 267–283). New York:

seling theories: An online case-based approach

Oxford University Press.

(pp. 5–20). Upper Saddle River, NJ: Pearson

*Harris, A. S. (1996). Living with paradox: An

Prentice-Hall.

introduction to Jungian psychology. Belmont,

Atkinson, D. R., Thompson, C. E., & Grant,

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S. K. (1993). A three-dimensional model for

Hayes, J. A., (2004). Therapist know thyself:

counseling racial/ethnic minorities. The Coun-

Recent research on countertransference. Psy-

seling Psychologist, 2(2), 257–277.

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Clarkin, J., Yeomans, F., & Kernberg, O.

Hayes, J. A., Gelso, C. J., & Hummel, A. M.

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University Press.

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*Elliot, A. (1994). Psychoanalytic theory: An

Kernberg, O. F. (1997). Convergences and

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cure? Chicago: University of Chicago Press.

agement of countertransference.

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

*Levenson, H. (2007). Time-limited dynamic

Prochaska, J. O., & Norcross, J. C. (2010).

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CHAPTER F

Learning.

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open letter to a new generation of therapists and

Mitchell, S. A., & Black, M. J. (1995). Freud

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thought. New York: Basic Books.

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c h a p t e r 5

Adlerian Therapy

Coauthored by Gerald Corey and James Robert Bitter

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101

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Alfred Adler

ALFRED ADLER (1870–

rology and psychiatry, and he had a keen interest in

1937) grew up in a Vienna

incurable childhood diseases.

family of six boys and two

Adler had a passionate concern for the com-

girls. His younger brother

mon person and was outspoken about child-rearing

died at a very young age

practices, school reforms, and prejudices that

Images

in the bed next to Alfred.

resulted in conflict. He spoke and wrote in simple,

Adler’s early childhood was

nontechnical language so that the general popula-

Archive/Getty

not a happy time. He was

tion could understand and apply the principles

Hulton

sickly and very much aware

of his approach in a practical way, which helped

of death. At age 4 he almost died of pneumonia.

people meet the challenges of daily life. Adler’s

He heard the doctor tell his father that “Alfred is

(1927/1959) Understanding Human Nature was

102

lost.” Adler associated this time with his decision

the first major psychology book to sell hundreds

to become a physician. Because he was ill so much

of thousands of copies in the United States. After

during the first few years of his life, Adler was

serving in World War I as a medical officer, Adler

pampered by his mother. He developed a trusting

created 32 child guidance clinics in the Vienna

relationship with his father, but did not feel very

public schools and began training teachers, social

close to his mother. He was extremely jealous of

workers, physicians, and other professionals. He

CHAPTER FIVE

his older brother, Sigmund, which led to a strained

pioneered the practice of teaching profession-

relationship between the two during childhood and

als through live demonstrations with parents and

adolescence. When we consider Adler’s strained

children before large audiences, now called “open-

relationship with Sigmund Freud, one cannot help

forum” family counseling. The clinics he founded

but suspect that patterns from his early family

grew in number and in popularity, and he was inde-

constellation were repeated in this relationship

fatigable in lecturing and demonstrating his work.

with Freud.

Although Adler had an overcrowded work

Adler’s early childhood experiences had an

schedule most of his professional life, he still

impact on the formation of his theory. Adler is an

took some time to sing, enjoy music, and be with

example of a person who shaped his own life as

friends. In the mid-1920s he began lecturing in the

opposed to having it determined by fate. Adler

United States, and he later made frequent visits

was a poor student. His teacher advised his father

and tours. He ignored the warning of his friends

to prepare Adler to be a shoemaker, but not much

to slow down, and on May 28, 1937, while taking

else. With determined effort Adler eventually rose

a walk before a scheduled lecture in Aberdeen,

to the top of his class. He went on to study medi-

Scotland, Adler collapsed and died of heart failure.

cine at the University of Vienna, entering private

If you have an interest in learning more about

practice as an ophthalmologist, and then shifting to

Adler’s life, see Edward Hoffman’s (1996) excellent

general medicine. He eventually specialized in neu-

biography, The Drive for Self.

i n t r o d u c t i o n

Along with Freud and Jung, Alfred Adler was a major contributor to the initial

development of the psychodynamic approach to therapy. After 8 to 10 years of col-

laboration, Freud and Adler parted company, with Freud taking the position that

Adler was a heretic who had deserted him. Adler resigned as president of the Vien-

na Psychoanalytic Society in 1911 and founded the Society for Individual Psychology

in 1912. Freud then asserted that it was not possible to support Adlerian concepts

and still remain in good standing as a psychoanalyst.

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28549_ch05_rev01.indd 102

20/09/11 3:19 PM

Later, a number of other psychoanalysts deviated from Freud’s orthodox

position (see Chapter 4). These Freudian revisionists—including Karen Horney,

Erich Fromm, and Harry Stack Sullivan—agreed that relational, social, and cul-

tural factors were of great signifi cance in shaping personality. Even though these

three therapists are typically called neo-Freudians, it would be more appropri-

ate, as Heinz Ansbacher (1979) has suggested, to refer to them as neo-Adlerians

because they moved away from Freud’s biological and deterministic point of view

and toward Adler’s social-psychological and teleological (or goal-oriented) view of

human nature.

Adler stresses the unity of personality, contending that people can only be

understood as integrated and complete beings. This view also espouses the pur-

poseful nature of behavior, emphasizing that where we have come from is not as

important as where we are striving to go. Adler saw humans as both the creators

103

and the creations of their own lives; that is, people develop a unique style of liv-

ADLERIAN THERAP

ing that is both a movement toward and an expression of their selected goals. In

this sense, we create ourselves rather than merely being shaped by our childhood

experiences.

After Adler’s death in 1937, Rudolf Dreikurs was the most signifi cant fi gure

in bringing Adlerian psychology to the United States, especially as its principles

Y

applied to education, individual and group therapy, and family counseling.

Dreikurs is credited with giving impetus to the idea of child guidance centers and

to training professionals to work with a wide range of clients.

See the DVD program for Chapter 5, DVD for Theory and Practice of Coun-

seling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you

view the brief lecture for each chapter prior to reading the chapter.

k e y c o n c e p t s

View of Human Nature

Adler abandoned Freud’s basic theories because he believed Freud was exces-

sively narrow in his emphasis on biological and instinctual determination. Adler

believed that the individual begins to form an approach to life somewhere in the

fi rst 6 years of living. He focused on the person’s past as perceived in the present

and how an individual’s interpretation of early events continued to infl uence that

person’s present behavior. According to Adler, humans are motivated primarily

by social relatedness rather than by sexual urges; behavior is purposeful and goal-

directed; and consciousness, more than unconsciousness, is the focus of therapy.

Adler stressed choice and responsibility, meaning in life, and the striving for suc-

cess, completion, and perfection. Adler and Freud created very different theories,

even though both men grew up in the same city in the same era and were educated

as physicians at the same university. Their individual and distinct childhood

experiences, their personal struggles, and the populations with whom they worked

were key factors in the development of their particular views of human nature

(Schultz & Schultz, 2009).

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28549_ch05_rev01.indd 103

20/09/11 3:19 PM

Adler’s theory starts with a consideration of inferiority feelings, which he saw

as a normal condition of all people and as a source of all human striving. Rather

than being considered a sign of weakness or abnormality, inferiority feelings can

be the wellspring of creativity. They motivate us to strive for mastery, success

(superiority), and completion. We are driven to overcome our sense of inferiority

and to strive for increasingly higher levels of development (Ansbacher & Ansbacher,

1956/1964). Indeed, at around 6 years of age our fi ctional vision of ourselves as

perfect or complete begins to form into a life goal. The life goal unifi es the person-

ality and becomes the source of human motivation; every striving and every effort

to overcome inferiority is now in line with this goal.

From the Adlerian perspective, human behavior is not determined solely by

heredity and environment. Instead, we have the capacity to interpret, infl uence,

104

and create events. Adler asserted that genetics and heredity are not as important

as what we choose to do with the abilities and limitations we possess. Although

Adlerians reject a deterministic stance, they do not go to the other extreme and

maintain that individuals can become whatever they want to be. Adlerians recog-

nize that biological and environmental conditions limit our capacity to choose and

to create.

CHAPTER FIVE

Adlerians put the focus on reeducating individuals and reshaping society.

Adler was the forerunner of a subjective approach to psychology that focuses on

internal determinants of behavior such as values, beliefs, attitudes, goals, interests,

and the individual perception of reality. He was a pioneer of an approach that is

holistic, social, goal oriented, systemic, and humanistic. Adler also was the fi rst

systemic therapist: he maintained that it is essential to understand people within

the systems in which they live.

Subjective Perception of Reality

Adlerians attempt to view the world from the client’s subjective frame of reference,

an orientation described as phenomenological. Paying attention to the individual

way in which people perceive their world, referred to as “subjective reality,” includes

the individual’s perceptions, thoughts, feelings, values, beliefs, convictions, and

conclusions. Behavior is understood from the vantage point of this subjective per-

spective. From the Adlerian perspective, objective reality is less important than how

we interpret reality and the meanings we attach to what we experience.

As you will see in subsequent chapters, many contemporary theories have

incorporated this notion of the client’s subjective worldview as a basic factor ex-

plaining behavior, including existential therapy, person-centered therapy, Gestalt

therapy, the cognitive behavioral therapies, reality therapy, feminist therapy, and

the postmodern approaches.

Unity and Patterns of Human Personality

Adler chose the name Individual Psychology (from the Latin individuum, meaning

indivisible) for his theoretical approach because he wanted to avoid reductionism.

Adler emphasized the unity and indivisibility of the person and stressed under-

standing the whole person in the context of his or her life—how all dimensions

of a person are interconnected components, and how all of these components

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch05_rev01.indd 104

20/09/11 3:19 PM

are unifi ed by the individual’s movement toward a life goal. This holistic concept

implies that we cannot be understood in parts; rather, all aspects of ourselves must

be understood in relationship (Carlson & Englar-Carlson, 2008). The focus is on

understanding whole persons within their socially embedded contexts of family,

culture, school, and work. We are social, creative, decision-making beings who act

with purpose and cannot be fully known outside the contexts that have meaning in

our lives (Sherman & Dinkmeyer, 1987).

The human personality becomes unifi ed through development of a life goal.

An individual’s thoughts, feelings, beliefs, convictions, attitudes, character, and

actions are expressions of his or her uniqueness, and all refl ect a plan of life that

allows for movement toward a self-selected life goal. An implication of this holistic

view of personality is that the client is an integral part of a social system. There is

more emphasis on interpersonal relationships than on the individual’s internal

105

psychodynamics.

ADLERIAN THERAP

b e h a v i o r a s p u r p o s e f u l a n d g o a l o r i e n t e d Individual Psychol-

ogy assumes that all human behavior has a purpose. The concept of the purposeful

nature of behavior is perhaps the cornerstone of Adler’s theory. Adler replaced

deterministic explanations with teleological (purposive, goal-oriented) ones. A basic

assumption of Individual Psychology is that we can only think, feel, and act in rela-

Y

tion to our goal; we can be fully understood only in light of knowing the purposes

and goals toward which we are striving. Although Adlerians are interested in the

future, they do not minimize the importance of past infl uences. They assume that

most decisions are based on the person’s experiences, on the present situation, and

on the direction in which the person is moving—with the latter being the most

important. They look for continuity by paying attention to themes running through

a person’s life.

Adler was infl uenced by the philosopher Hans Vaihinger (1965), who noted

that people often live by fi ctions (or views of how the world should be). Many Adle-

rians use the term fi ctional fi nalism to refer to an imagined life goal that guides a

person’s behavior. It should be noted, however, that Adler ceased using this term

and replaced it with “guiding self-ideal” and “goal of perfection” to account for our

striving toward superiority or perfection (Watts & Holden, 1994). Very early in life,

we begin to envision what we might be like if we were successful, complete, whole,

or perfect. Applied to human motivation, a guiding self-ideal might be expressed

in this way: “Only when I am perfect can I be secure” or “Only when I am impor-

tant can I be accepted.” The guiding self-ideal represents an individual’s image of

a goal of perfection, for which he or she strives in any given situation. Because of

our subjective fi nal goal, we have the creative power to choose what we will accept

as truth, how we will behave, and how we will interpret events.

s t r i v i n g f o r s i g n i f i c a n c e a n d s u p e r i o r i t y Adler stressed that

the recognition of inferiority feelings and the consequent striving for perfection

or mastery are innate (Ansbacher & Ansbacher, 1979)—they are two sides of the

same coin. To understand human behavior, it is essential to grasp the ideas of

basic inferiority and compensation. From our earliest years, we recognize that

we are helpless in many ways, which is characterized by feelings of inferiority.

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This inferiority is not a negative factor in life. According to Adler, the moment we

experience inferiority we are pulled by the striving for superiority. He maintained

that the goal of success pulls people forward toward mastery and enables them to

overcome obstacles. The goal of superiority contributes to the development of hu-

man community. However, it is important to note that “superiority,” as used by

Adler, does not necessarily mean superiority over others. Rather, it means moving

from a perceived lower (or minus) position to a perceived better (or plus) position.

People cope with feelings of helplessness by striving for competence, mastery,

and perfection. They can seek to change a weakness into a strength, for example,

or strive to excel in one area to compensate for defects in other areas. The unique

ways in which people develop a style of striving for competence is what constitutes

individuality or lifestyle. The manner in which Adler reacted to his childhood and

106

adolescent experiences is a living example of this aspect of his theory.

l i f e s t y l e The movement from a felt minus to a desired plus results in the devel-

opment of a life goal, which in turn unifi es the personality and the individual’s core

beliefs and assumptions. These core beliefs and assumptions guide each person’s

movement through life and organize his or her reality, giving meaning to life events.

CHAPTER FIVE

Adler called this life movement the individual’s “lifestyle.” Synonyms for this term

include “plan of life,” “style of life,” “strategy for living,” and “road map of life.” Life-

style includes the connecting themes and rules of interaction that give meaning to

our actions. Lifestyle is often described as our perceptions regarding self, others, and

the world. It includes an individual’s characteristic way of thinking, acting, feeling,

living, and striving toward long-term goals (Mosak & Maniacci, 2011).

Adler saw us as actors, creators, and artists. Understanding one’s lifestyle is

somewhat like understanding the style of a composer: “We can begin wherever

we choose: every expression will lead us in the same direction—toward the one

motive, the one melody, around which the personality is built” (Adler, as cited in

Ansbacher & Ansbacher, 1956/1964, p. 332).

People are viewed as adopting a proactive, rather than a reactive, approach

to their social environment. Although events in the environment infl uence the

development of personality, such events are not the causes of what people become;

rather, it is our interpretation of these events that shape personality. Faulty in-

terpretations may lead to mistaken notions in our private logic, which will sig-

nifi cantly infl uence present behavior. Once we become aware of the patterns and

continuity of our lives, we are in a position to modify those faulty assumptions and

make basic changes. We can reframe childhood experiences and consciously create

a new style of living.

Social Interest and Community Feeling

Social interest and community feeling ( Gemeinschaftsgefühl) are probably Adler’s

most signifi cant and distinctive concepts (Ansbacher, 1992). These terms refer to

individuals’ awareness of being part of the human community and to individuals’

attitudes in dealing with the social world.

Social interest is the action line of one’s community feeling, and it involves

being as concerned about others as one is about onself. This concept involves the

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capacity to cooperate and contribute (Milliren & Clemmer, 2006). Social interest

requires that we have enough contact with the present to make a move toward a

meaningful future, that we are willing to give and to take, and that we develop our

capacity for contributing to the welfare of others and striving for the betterment of

humanity. The socialization process associated with social interest begins in child-

hood and involves helping children to fi nd a place in society and acquire a sense of

belonging, as well as the ability to make a contribution (Kefi r, 1981). While Adler

considered social interest to be innate, he also believed that it must be learned,

developed, and used.

Adler equated social interest with a sense of identifi cation and empathy

with others: “to see with the eyes of another, to hear with the ears of another, to feel

with the heart of another” (as cited in Ansbacher & Ansbacher, 1979, p. 42). Social

interest is the central indicator of mental health. Those with social interest tend to

107

direct the striving toward the healthy and socially useful side of life. From the Adle-

ADLERIAN THERAP

rian perspective, as social interest develops, feelings of inferiority and alienation

diminish. People express social interest through shared activity and mutual respect.

Individual Psychology rests on a central belief that our happiness and success

are largely related to this social connectedness. Because we are embedded in a

society, and indeed in the whole of humanity, we cannot be understood in isola-

Y

tion from that social context. We are primarily motivated by a desire to belong.

Community feeling embodies the feeling of being connected to all of humanity—

past, present, and future—and to being involved in making the world a better place.

Those who lack this community feeling become discouraged and end up on the

useless side of life. We seek a place in the family and in society to fulfi ll basic needs

for security, acceptance, and worthiness. Many of the problems we experience are

related to the fear of not being accepted by the groups we value. If our sense of

belonging is not fulfi lled, anxiety is the result. Only when we feel united with oth-

ers are we able to act with courage in facing and dealing with our problems (Adler,

1938/1964).

Adler taught that we must successfully master three universal life tasks: build-

ing friendships (social task), establishing intimacy (love–marriage task), and con-

tributing to society (occupational task). All people need to address these tasks,

regardless of age, gender, time in history, culture, or nationality. Each of these

tasks requires the development of psychological capacities for friendship and be-

longing, for contribution and self-worth, and for cooperation (Bitter, 2006). These

basic life tasks are so fundamental to human living that impairment in any one of

them is often an indicator of a psychological disorder (American Psychiatric As-

sociation, 2000). More often than not, when people seek therapy, it is because they

are struggling unsuccessfully to meet one or more of these life tasks. The aim of

therapy is to assist clients in modifying their lifestyle so they can more effectively

navigate each of these tasks (Carlson & Englar-Carlson, 2008).

Birth Order and Sibling Relationships

The Adlerian approach is unique in giving special attention to the relationships

between siblings and the psychological birth position in one’s family. Adler

identifi ed fi ve psychological positions, or vantage points, from which children

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tend to view life: oldest, second of only two, middle, youngest, and only. Birth

order is not a deterministic concept but does increase an individual’s probability

of having a certain set of experiences. Actual birth order is less important than

the individual’s interpretation of his or her place in the family. Because Adle-

rians view most human problems as social in nature, they emphasize relation-

ships within the family as our earliest and, perhaps, our most infl uential social

system.

Adler (1931/1958) observed that many people wonder why children in the

same family often differ so widely, and he pointed out that it is a fallacy to assume

that children of the same family are formed in the same environment. Although

siblings share aspects in common in the family constellation, the psychological

situation of each child is different from that of the others due to birth order. The

108

following description of the infl uence of birth order is based on Ansbacher and

Ansbacher (1964), Dreikurs (1953), and Adler (1931/1958).

1. The oldest child generally receives a good deal of attention, and during the time

she is the only child, she is typically somewhat spoiled as the center of attention.

She tends to be dependable and hard working and strives to keep ahead. When a

CHAPTER FIVE

new brother or sister arrives on the scene, however, she fi nds herself ousted from

her favored position. She is no longer unique or special. She may readily believe

that the newcomer (or intruder) will rob her of the love to which she is accustomed.

Most often, she reasserts her position by becoming a model child, bossing younger

children, and exhibiting a high achievement drive.

2. The second child of only two is in a different position. From the time she is born,

she shares the attention with another child. The typical second child behaves as

if she were in a race and is generally under full steam at all times. It is as though

this second child were in training to surpass the older brother or sister. This com-

petitive struggle between the fi rst two children infl uences the later course of their

lives. The younger child develops a knack for fi nding out the elder child’s weak

spots and proceeds to win praise from both parents and teachers by achieving

successes where the older sibling has failed. If one is talented in a given area, the

other strives for recognition by developing other abilities. The second-born is often

opposite to the fi rstborn.

3. The middle child often feels squeezed out. This child may become convinced

of the unfairness of life and feel cheated. This person may assume a “poor me”

attitude and can become a problem child. However, especially in families charac-

terized by confl ict, the middle child may become the switchboard and the peace-

maker, the person who holds things together. If there are four children in a family,

the second child will often feel like a middle child and the third will be more easy-

going, more social, and may align with the fi rstborn.

4. The youngest child is always the baby of the family and tends to be the most

pampered one. Because of being pampered or spoiled, he may develop helpless-

ness into an art form and become expert at putting others in his service. Youngest

children tend to go their own way, often developing in ways no others in the family

have attempted and may outshine everyone.

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5. The only child has a problem of her own. Although she shares some of the char-

acteristics of the oldest child (for example, a high achievement drive), she may not

learn to share or cooperate with other children. She will learn to deal with adults

well, as they make up her original familial world. Often, the only child is pampered

by her parents and may become dependently tied to one or both of them. She may

want to have center stage all of the time, and if her position is challenged, she will

feel it is unfair.

Birth order and the interpretation of one’s position in the family have a great

deal to do with how adults interact in the world. Individuals acquire a certain style

of relating to others in childhood and form a defi nite picture of themselves that

they carry into their adult interactions. In Adlerian therapy, working with family

dynamics, especially relationships among siblings, assumes a key role. Although

109

it is important to avoid stereotyping individuals, it does help to see how certain

ADLERIAN THERAP

personality trends that began in childhood as a result of sibling rivalry infl uence

individuals throughout life.

t h e t h e r a p e u t i c p r o c e s s

Therapeutic Goals

Y

Adlerian counseling rests on a collaborative arrangement between the client and

the counselor. In general, the therapeutic process includes forming a relationship

based on mutual respect; a holistic psychological investigation or lifestyle assess-

ment; and disclosing mistaken goals and faulty assumptions within the person’s style

of living. This is followed by a reeducation or reorientation of the client toward

the useful side of life. The main aim of therapy is to develop the client’s sense

of belonging and to assist in the adoption of behaviors and processes character-

ized by community feeling and social interest. This is accomplished by increasing

the client’s self-awareness and challenging and modifying his or her fundamental

premises, life goals, and basic concepts (Dreikurs, 1967, 1997). Milliren, Evans,

and Newbauer (2007), identify this goal of Adlerian therapy: “to assist clients to

understand their unique lifestyles . . . and to act in such a way as to meet the tasks

of life with courage and social interest” (p. 145).

Adlerians do not view clients as being “sick” and in need of being “cured.”

They favor the growth model of personality rather than the medical model. As

Mosak and Maniacci (2011) put it: “The Adlerian is interested not in curing sick

individuals or a sick society but in reeducating individuals and in reshaping soci-

ety” (p. 78). Rather than being stuck in some kind of pathology, Adlerians contend

that clients are often discouraged. The counseling process focuses on providing

information, teaching, guiding, and offering encouragement to discouraged cli-

ents. Encouragement is the most powerful method available for changing a per-

son’s beliefs, for it helps clients build self-confi dence and stimulates courage.

Courage is the willingness to act even when fearful in ways that are consistent with

social interest. Fear and courage go hand in hand; without fear, there would be no

need for courage. The loss of courage, or discouragement, results in mistaken and

dysfunctional behavior. Discouraged people do not act in line with social interest.

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Adlerian counselors provide clients with an opportunity to view things from

a different perspective, yet it is up to the clients to decide whether to accept an

alternative perspective. Adlerians work collaboratively with clients to help them

reach their self-defi ned goals. Adlerians educate clients in new ways of looking at

themselves, others, and life. Through the process of providing clients with a new

“cognitive map,” a fundamental understanding of the purpose of their behavior,

counselors assist them in changing their perceptions. Mosak and Maniacci (2011)

lists these goals for the educational process of therapy:

• Fostering social interest

• Helping clients overcome feelings of discouragement and inferiority

• Modifying clients’ views and goals—that is, changing their lifestyle

• Changing faulty motivation

110

• Encouraging the individual to recognize equality among people

• Helping people to become contributing members of society

Therapist’s Function and Role

Adlerian counselors realize that clients can become discouraged and function

CHAPTER FIVE

ineffectively because of mistaken beliefs, faulty values, and useless or self-absorbed

goals. These therapists operate on the assumption that clients will feel and behave

better once they discover and correct their basic mistakes. Therapists tend to look

for major mistakes in thinking and valuing such as mistrust, selfi shness, unrealis-

tic ambitions, and lack of confi dence.

Adlerians assume a nonpathological perspective and thus do not label clients

with pathological diagnoses. One way of looking at the role of Adlerian therapists

is that they assist clients in better understanding, challenging, and changing their

life story. “When individuals develop a life story that they fi nd limiting and prob-

lem saturated, the goal is to free them from that story in favor of a preferred and

equally viable alternative story” (Disque & Bitter, 1998, p. 434).

A major function of the therapist is to make a comprehensive assessment of

the client’s functioning. Therapists often gather information about the individual’s

style of living by means of a questionnaire on the client’s family constellation,

which includes parents, siblings, and others living in the home, life tasks, and

early recollections. When summarized and interpreted, this questionnaire gives a

picture of the individual’s early social world. From this information on the family

constellation, the therapist is able to get a perspective on the client’s major areas

of success and failure and on the critical infl uences that have had a bearing on the

role the client has assumed in the world.

The counselor also uses early recollections as an assessment procedure. Early

recollections (ERs) are defi ned as “stories of events that a person says occurred

[one time] before he or she was 10 years of age” (Mosak & Di Pietro, 2006, p. 1).

ERs are specifi c incidents that clients recall, along with the feelings and thoughts

that accompanied these childhood incidents. These recollections are quite useful

in getting a better understanding of the client (Clark, 2002). After these early rec-

ollections are summarized and interpreted, the therapist identifi es some of the

major successes and mistakes in the client’s life. The aim is to provide a point of

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departure for the therapeutic venture. ERs are particularly useful as a functional

assessment device because they indicate what clients do and how they think in

both adaptive and maladaptive ways (Mosak & Di Pietro, 2006). The process of

gathering early memories is part of what is called a lifestyle assessment, which

involves learning to understand the goals and motivations of the client. When this

process is completed, the therapist and the client have targets for therapy.

Mosak and Maniacci (2011) consider dreams to be a useful part of the assess-

ment process. Freud assumed that dreams were wish fulfi llment, or, in some

instances, an attempt at solving an old problem; Adler, on the other hand, viewed

dreams as a rehearsal for possible future actions. Just as early recollections refl ect

a client’s long-range goals, dreams suggest possible answers to a client’s present

problems. In interpreting dreams, the therapist considers their purposive func-

tion. Mosak and Maniacci (2011) assert that “dreams serve as weather vanes for

111

treatment, bringing problems to the surface and pointing to the patient’s move-

ADLERIAN THERAP

ment” (p. 88).

Client’s Experience in Therapy

How do clients maintain their lifestyle, and why do they resist changing it? A per-

son’s style of living serves the individual by staying stable and constant. In other

Y

words, it is predictable. It is, however, also resistant to change throughout most of

one’s life. Generally, people fail to change because they do not recognize the errors

in their thinking or the purposes of their behaviors, do not know what to do differ-

ently, and are fearful of leaving old patterns for new and unpredictable outcomes.

Thus, even though their ways of thinking and behaving are not successful, they

tend to cling to familiar patterns (Sweeney, 2009). Clients in Adlerian counseling

focus their work on desired outcomes and a resilient lifestyle that can provide a

new blueprint for their actions.

In therapy, clients explore what Adlerians call private logic, the concepts about

self, others, and life that constitute the philosophy on which an individual’s life-

style is based. Private logic involves our convictions and beliefs that get in the way

of social interest and that do not facilitate useful, constructive belonging (Carlson,

Watts, & Maniacci, 2006). Clients’ problems arise because the conclusions based

on their private logic often do not conform to the requirements of social living. The

heart of therapy is helping clients to discover the purposes of behaviors or symp-

toms and the basic mistakes associated with their personal coping. Learning how

to correct faulty assumptions and conclusions is central to therapy.

To provide a concrete example, think of a chronically depressed middle-aged

man who begins therapy. After a lifestyle assessment is completed, these basic

mistakes are identifi ed:

• He has convinced himself that nobody could really care about him.

• He rejects people before they have a chance to reject him.

• He is harshly critical of himself, expecting perfection.

• He has expectations that things will rarely work out well.

• He burdens himself with guilt because he is convinced he is letting everyone

down.

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Even though this man may have developed these mistaken ideas about himself and

life when he was young, he is still clinging to them as rules for living. His expecta-

tions, most of which are pessimistic, tend to be fulfi lled because on some level he

is seeking to validate his beliefs. Indeed, his depression will eventually serve the

purpose of helping him avoid contact with others, a life task at which he expects

to fail. In therapy, this man will learn how to challenge the structure of his private

logic. In his case the syllogism goes as follows:

• “I am basically unlovable.”

• “The world is fi lled with people who are likely to be rejecting.”

• “Therefore, I must keep to myself so I won’t be hurt.”

This person holds onto several basic mistakes, and his private logic offers a psy-

chological focus for treatment. A central theme or convictions in this client’s life

112

might be: “I must control everything in my life.” “I must be perfect in everything

I do.”

It is easy to see how depression might follow from this thinking, but Adlerians

also know that the depression serves as an excuse for this man’s retreat from life.

It is important for the therapist to listen for the underlying purposes of this cli-

CHAPTER FIVE

ent’s behavior. Adlerians see feelings as being aligned with thinking and as the

fuel for behaving. First we think, then we feel, and then we act. Because emotions

and cognitions serve a purpose, a good deal of therapy time is spent in discover-

ing and understanding this purpose and in reorienting the client toward effective

ways of being. Because the client is not perceived by the therapist to be mentally

ill or emotionally disturbed, but as mainly discouraged, the therapist will offer the

client encouragement so that change is possible. Through the therapeutic proc-

ess, the client will discover that he or she has resources and options to draw on in

dealing with signifi cant life issues and life tasks.

Relationship Between Therapist and Client

Adlerians consider a good client–therapist relationship to be one between equals

that is based on cooperation, mutual trust, respect, confi dence, collaboration, and

alignment of goals. They place special value on the counselor’s modeling of com-

munication and acting in good faith. From the beginning of therapy, the relation-

ship is a collaborative one, characterized by two persons working equally toward

specifi c, agreed-upon goals. Adlerian therapists strive to establish and maintain

an egalitarian therapeutic alliance and a person-to-person relationship with their

clients. Developing a strong therapeutic relationship is essential to successful out-

comes (Carlson et al., 2006). Dinkmeyer and Sperry (2000) maintain that at the

outset of counseling clients should begin to formulate a plan, or contract, detailing

what they want, how they plan to get where they are heading, what is preventing

them from successfully attaining their goals, how they can change nonproductive

behavior into constructive behavior, and how they can make full use of their assets

in achieving their purposes. This therapeutic contract sets forth the goals of the

counseling process and specifi es the responsibilities of both therapist and client.

Developing a contract is not a requirement of Adlerian therapy, but a contract can

bring a tight focus to therapy.

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a p p l i c at i o n : t h e r a p e u t i c

t e c h n i q u e s a n d p r o c e d u r e s

Adlerian counseling is structured around four central objectives that correspond to

the four phases of the therapeutic process (Dreikurs, 1967). These phases are not

linear and do not progress in rigid steps; rather, they can best be understood as a

weaving that leads to a tapestry. These phases are as follows:

1. Establish the proper therapeutic relationship.

2. Explore the psychological dynamics operating in the client (an assessment).

3. Encourage the development of self-understanding (insight into purpose).

4. Help the client make new choices (reorientation and reeducation).

Dreikurs (1997) incorporated these phases into what he called minor psycho-

113

therapy in the context and service of holistic medicine. His approach to therapy

ADLERIAN THERAP

has been elaborated in what is now called Adlerian brief therapy, or ABT (Bitter,

Christensen, Hawes, & Nicoll, 1998). This way of working is discussed in the fol-

lowing sections.

Phase 1: Establish the Relationship

The Adlerian practitioner works in a collaborative way with clients, and this rela-

Y

tionship is based on a sense of interest that grows into caring, involvement, and

friendship. Therapeutic progress is possible only when there is an alignment of

clearly defi ned goals between therapist and client. The counseling process, to be

effective, must deal with the personal issues the client recognizes as signifi cant

and is willing to explore and change. The therapeutic effi cacy in the later phases of

Adlerian therapy is predicated upon the development and continuation of a solid

therapeutic relationship during this fi rst phase of therapy (Watts, 2000; Watts &

Pietrzak, 2000).

Adlerian therapists focus on making person-to-person contact with clients

rather than starting with “the problem.” Clients’ concerns surface rather quickly

in therapy, but the initial focus should be on the person, not the problem. One way

to create effective contact is for counselors to help clients become aware of their

assets and strengths rather than dealing continually with their defi cits and lia-

bilities. During the initial phase, a positive relationship is created by listening;

responding; demonstrating respect for clients’ capacity to understand purpose and

seek change; and exhibiting faith, hope, and caring. When clients enter therapy,

they typically have a diminished sense of self-worth and self-respect. They lack faith

in their ability to cope with the tasks of life. Therapists provide support, which is

an antidote to despair and discouragement. For some people, therapy may be one

of the few times in which they have truly experienced a caring human relationship.

Adlerians pay more attention to the subjective experiences of the client than

they do to using techniques. They fi t their techniques to the needs of each client.

During the initial phase of counseling, the main techniques are attending and

listening with empathy, following the subjective experience of the client as closely

as possible, identifying and clarifying goals, and suggesting initial hunches about

purpose in client’s symptoms, actions, and interactions. Adlerian counselors are

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generally active, especially during the initial sessions. They provide structure and

assist clients to defi ne personal goals, they conduct psychological assessments,

and they offer interpretations (Carlson et al., 2006). Adlerians attempt to grasp

both the verbal and nonverbal messages of the client; they want to access the core

patterns in the client’s life. If the client feels deeply understood and accepted, the

client is likely to focus on what he or she wants from therapy and thus establish

goals. At this stage the counselor’s function is to provide a wide-angle perspective

that will eventually help the client view his or her world differently.

Phase 2: Explore the Individual’s Psychological Dynamics

The aim of the second phase of Adlerian counseling is to get a deeper understand-

ing of an individual’s lifestyle. During this assessment phase, the focus is on the

individual’s social and cultural context. Rather than attempting to fi t clients into a

114

preconceived model, Adlerian practitioners allow salient cultural identity concepts

to emerge in the therapy process, and these issues are then addressed (Carlson &

Englar-Carlson, 2008). This assessment phase proceeds from two interview forms:

the subjective interview and the objective interview (Dreikurs, 1997). In the subjective

interview, the counselor helps the client to tell his or her life story as completely as

CHAPTER FIVE

possible. This process is facilitated by a generous use of empathic listening and

responding. Active listening, however, is not enough. The subjective interview

must follow from a sense of wonder, fascination, and interest. What the client

says will spark an interest in the counselor and lead, naturally, to the next most

signifi cant question or inquiry about the client and his or her life story. Indeed,

the best subjective interviews treat clients as experts in their own lives, allowing

clients to feel completely heard. Throughout the subjective interview, the Adlerian

counselor is listening for clues to the purposive aspects of the client’s coping and

approaches to life. “The subjective interview should extract patterns in the person’s

life, develop hypotheses about what works for the person, and determine what

accounts for the various concerns in the client’s life” (Bitter et al., 1998, p. 98).

Toward the end of this part of the interview, Adlerian brief therapists ask, “Is there

anything else you think I should know to understand you and your concerns?”

An initial assessment of the purpose that symptoms, actions, or diffi culties

serve in a person’s life can be gained from what Dreikurs (1997) calls “The Ques-

tion.” Adlerians often end a subjective interview with this question: “How would

your life be different, and what would you be doing differently, if you did not have

this symptom or problem?” Adlerians use this question to help with differential

diagnosis. More often, the symptoms or problems experienced by the client help

the client avoid something that is perceived as necessary but from which the per-

son wishes to retreat, usually a life task: “If it weren’t for my depression, I would

get out more and see my friends.” Such a statement betrays the client’s concern

about the possibility of being a good friend or being welcomed by his or her friends.

“I need to get married, but how can I with these panic attacks?” indicates the per-

son’s worry about being a partner in a marriage. Depression can serve as the cli-

ent’s solution when faced with problems in relationships. If a client reports that

nothing would be different, especially with physical symptoms, Adlerians suspect

that the problem may be organic and require medical intervention.

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The objective interview seeks to discover information about (a) how problems

in the client’s life began; (b) any precipitating events; (c) a medical history, includ-

ing current and past medications; (d) a social history; (e) the reasons the client

chose therapy at this time; (f) the person’s coping with life tasks; and (g) a lifestyle

assessment. Mozdzierz and his colleagues (1986) describe the counselor as a “life-

style investigator” during this phase of therapy. Based on interview approaches

developed by Adler and Dreikurs, the lifestyle assessment starts with an investiga-

tion of the person’s family constellation and early childhood history (Powers &

Griffi th, 1987; Shulman & Mosak, 1988). Counselors also interpret the person’s

early memories, seeking to understand the meaning that she or he has attached

to life experiences. They operate on the assumption that it is the interpretations

people develop about themselves, others, the world, and life that govern what they

do. Lifestyle assessment seeks to develop a holistic narrative of the person’s life, to

115

make sense of the way the person copes with life tasks, and to uncover the private

ADLERIAN THERAP

interpretations and logic involved in that coping. For example, if Jenny has lived

most of her life in a critical environment, and now she believes she must be perfect

to avoid even the appearance of failure, the assessment process will highlight the

restricted living that fl ows from this perspective.

t h e fa m i ly c o n s t e l l at i o n Adler considered the family of origin as having

Y

a central impact on an individual’s personality. Adler suggested that it was through

the family constellation that each person forms his or her unique view of self, others,

and life. Factors such as cultural and familial values, gender-role expectations, and

the nature of interpersonal relationships are all infl uenced by a child’s observation

of the interactional patterns within the family. Adlerian assessment relies heavily on

an exploration of the client’s family constellation, including the client’s evaluation

of conditions that prevailed in the family when the person was a young child (family

atmosphere), birth order, parental relationship and family values, and extended fam-

ily and culture. Some of these questions are almost always explored:

• Who was the favorite child?

• What was your father’s relationship with the children? Your mother’s?

• Which child was most like your father? Your mother? In what respects?

• Who among the siblings was most different from you? In what ways?

• Who among the siblings was most like you? In what ways?

• What were you like as a child?

• How did your parents get along? In what did they both agree? How did they

handle disagreements? How did they discipline the children?

An investigation of family constellation is far more comprehensive than these few

questions, but these questions give an idea of the type of information the counselor

is seeking. The questions are always tailored to the individual client with the goal

of eliciting the client’s perceptions of self and others, of development, and of the

experiences that have affected that development.

e a r ly r e c o l l e c t i o n s As you will recall, another assessment procedure used

by Adlerians is to ask the client to provide his or her earliest memories, including the

age of the person at the time of the remembered events and the feelings or reactions

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associated with the recollections. Early recollections are one-time occurrences, usu-

ally before the age of 9, pictured by the client in clear detail. Adler reasoned that out

of the millions of early memories we might have we select those special memories

that project the essential convictions and even the basic mistakes of our lives. Early

recollections are a series of small mysteries that can be woven together into a tapes-

try that leads to an understanding of how we view ourselves, how we see the world,

what our life goals are, what motivates us, what we value and believe in, and what we

anticipate for our future (Clark, 2002; Mosak & Di Pietro, 2006).

Early memories cast light on the “story of our life” because they represent met-

aphors for our current views. From the thousands of experiences we have before

the age of 9, we tend to remember only 6 to 12 memories. By understanding why

we retain these memories and what they tell us about how we see ourselves, others,

116

and life in the present, it is possible to get a clear sense of our mistaken notions,

present attitudes, social interests, and possible future behavior. Early recollections

are specifi c instances that clients tell therapists, and they are very useful in under-

standing those who are sharing a story (Mosak & Di Pietro, 2006). Exploring early

recollections involves discovering how mistaken notions based on faulty goals and

values continue to create problems in a client’s life.

CHAPTER FIVE

To tap such recollections, the counselor might proceed as follows: “I would like

to hear about your early memories. Think back to when you were very young, as

early as you can remember (before the age of 10), and tell me something that hap-

pened one time. ” After receiving each memory, the counselor might also ask: “What

part stands out to you? What was the most vivid part of your early memory? If

you played the whole memory like a movie and stopped it at one frame, what would

be happening? Putting yourself in that moment, what are you feeling? What’s your

reaction?” Three memories are usually considered a minimum to assess a pattern,

and some counselors ask for as many as a dozen memories.

Adlerian therapists use early recollections as a projective technique (Clark, 2002;

Hood & Johnson, 2007) and to (a) assess the client’s convictions about self, others,

life, and ethics; (b) assess the client’s stance in relation to the counseling session

and the counseling relationship; (c) verify the client’s coping patterns; and (d) assess

individual strengths, assets, and interfering ideas (Bitter et al., 1998, p. 99).

In interpreting these early recollections, Adlerians may consider questions

such as these:

• What part does the client take in the memory? Is the client an observer or a

participant?

• Who else is in the memory? What position do others take in relation to the client?

• What are the dominant themes and overall patterns of the memories?

• What feelings are expressed in the memories?

• Why does the client choose to remember this event? What is the client trying to

convey?

i n t e g r at i o n a n d s u m m a r y Once material has been gathered from both

subjective and objective interviews with the client, integrated summaries of the

data are developed. Different summaries are prepared for different clients, but

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common ones are a narrative summary of the person’s subjective experience and

life story; a summary of family constellation and developmental data; a summa-

ry of early recollections, personal strengths or assets, and interfering ideas; and

a summary of coping strategies. The summaries are presented to the client and

discussed in the session, with the client and the counselor together refi ning

specifi c points. This information provides the client with the chance to discuss

specifi c topics and to raise questions.

Mosak and Maniacci (2011) believe lifestyle can be conceived of as a personal

mythology. People behave as if the myths were true because, for them, they are

true. Mosak and Maniacci list fi ve basic mistakes in what is essentially an integra-

tion of Adlerian psychology and cognitive behavioral theory: overgeneralizations,

false or impossible goals of security, misperceptions of life and life’s demands,

minimization or denial of one’s basic worth, and faulty values.

117

In addition to the concept of basic mistakes, Adlerian theory is useful in as-

ADLERIAN THERAP

sisting clients to identify and examine some of their common fears. These fears

include being imperfect, being vulnerable, being disapproved of, and suffering

from past regrets (Carlson & Englar-Carlson, 2008).

The Student Manual that accompanies this textbook includes a concrete

example of the lifestyle assessment as it is applied to the case of Stan. In Case

Y

Approach to Counseling and Psychotherapy (Corey, 2013, chap. 3), Drs. Jim Bitter

and Bill Nicoll present a lifestyle assessment of another hypothetical client, Ruth.

Phase 3: Encourage Self-Understanding and Insight

During this third phase, Adlerian therapists interpret the fi ndings of the assess-

ment as an avenue for promoting self-understanding and insight. Mosak and

Maniacci (2011) defi ne insight as “understanding translated into constructive action”

(p. 89). When Adlerians speak of insight, they are referring to an understanding of

the motivations that operate in a client’s life. Self-understanding is only possible

when hidden purposes and goals of behavior are made conscious. Adlerians con-

sider insight as a special form of awareness that facilitates a meaningful understand-

ing within the therapeutic relationship and acts as a foundation for change. Insight

is a means to an end, and not an end in itself. People can make rapid and signifi cant

changes without much insight.

Disclosure and well-timed interpretations are techniques that facilitate the proc-

ess of gaining insight. Interpretation deals with clients’ underlying motives for

behaving the way they do in the here and now. Adlerian disclosures and interpreta-

tions are concerned with creating awareness of one’s direction in life, one’s goals

and purposes, one’s private logic and how it works, and one’s current behavior.

Adlerian interpretations are suggestions presented tentatively in the form of

open-ended questions that can be explored in the sessions. They are hunches or

guesses, and they often begin with phrases such as “I could be wrong, but I am

wondering if . . . ,” “Could it be that . . . ,” or “Is it possible that . . .” Because inter-

pretations are presented in this manner, clients are not led to defend themselves,

and they feel free to discuss and even argue with the counselor’s hunches and

impressions. Through this process, both counselor and client eventually come to

understand the client’s motivations, the ways in which these motivations are now

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contributing to the maintenance of the problem, and what the client can do to

correct the situation. During this phase of therapy, the counselor helps the client

understand the limitations of the style of life the client has chosen.

Phase 4: Reorientation and Reeducation

The fi nal stage of the therapeutic process is the action-oriented phase known as

reorientation and reeducation: putting insights into practice. This phase focuses

on helping clients discover a new and more functional perspective. Clients are

both encouraged and challenged to develop the courage to take risks and make

changes in their life. During this phase, clients can choose to adopt a new style of

life based on the insights they gained in the earlier phases of therapy.

Adlerians are interested in more than changes in behavior. Reorientation

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involves shifting rules of interaction, process, and motivation. These shifts are

facilitated through changes in awareness, which often occur during the therapy ses-

sion and which are transformed into action outside of the therapy offi ce (Bitter &

Nicoll, 2004). In addition, especially at this phase of therapy, Adlerians focus on

reeducation (see the section on therapeutic goals).

In some cases, signifi cant changes are needed if clients are to overcome discour-

CHAPTER FIVE

agement and fi nd a place for themselves in this life. More often, however, clients

merely need to be reoriented toward the useful side of life. The useful side involves a

sense of belonging and being valued, having an interest in others and their welfare,

courage, the acceptance of imperfection, confi dence, a sense of humor, a willing-

ness to contribute, and an outgoing friendliness. The useless side of life is charac-

terized by self-absorption, withdrawal from life tasks, self-protection, or acts against

one’s fellow human beings. People acting on the useless side of life become less

functional and are more susceptible to psychopathology. Adlerian therapy stands

in opposition to self-depreciation, isolation, and retreat, and it seeks to help clients

gain courage and to connect to strengths within themselves, to others, and to life.

Throughout this phase, no intervention is more important than encouragement.

t h e e n c o u r a g e m e n t p r o c e s s Encouragement is the most distinctive

Adlerian procedure, and it is central to all phases of counseling and therapy. It

is especially important as people consider change in their lives. Encouragement

literally means “to build courage.” Courage develops when people become aware

of their strengths, when they feel they belong and are not alone, and when they

have a sense of hope and can see new possibilities for themselves and their daily

living. Encouragement entails showing faith in people, expecting them to assume

responsibility for their lives, and valuing them for who they are (Carlson et al.,

2006). Carlson and Englar-Carlson (2008) note that encouragement involves

acknowledging that life can be diffi cult, yet it is critical to instill a sense of faith in

clients that they can make changes in life. Milliren, Evans, and Newbauer (2007)

consider encouragement key in promoting and activating social interest. They add

that encouragement is the universal therapeutic intervention for Adlerian coun-

selors, that it is a fundamental attitude rather than a technique. Because clients

often do not recognize or accept their positive qualities, strengths, or internal

resources, one of the counselor’s main tasks is to help them do so.

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Adlerians believe discouragement is the basic condition that prevents people

from functioning, and they see encouragement as the antidote. As a part of the

encouragement process, Adlerians use a variety of relational, cognitive, behavioral,

emotional, and experiential techniques to help clients identify and challenge self-

defeating cognitions, generate perceptional alternatives, and make use of assets,

strengths, and resources (Ansbacher & Ansbacher, 1964; Dinkmeyer & Sperry,

2000; Watts & Pietrzak, 2000; Watts & Shulman, 2003).

Encouragement takes many forms, depending on the phase of the coun-

seling process. In the relationship phase, encouragement results from the mutual

respect the counselor seeks to engender. In the assessment phase, which is partially

designed to illuminate personal strengths, clients are encouraged to recognize that

they are in charge of their own lives and can make different choices based on new

understandings. During reorientation, encouragement comes when new possibili-

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ties are generated and when clients are acknowledged and affi rmed for taking posi-

ADLERIAN THERAP

tive steps to change their lives for the better.

c h a n g e a n d t h e s e a r c h f o r n e w p o s s i b i l i t i e s During the reo-

rientation phase of counseling, clients make decisions and modify their goals. They

are encouraged to act as if they were the people they want to be, which can serve

to challenge self-limiting assumptions. Clients are asked to catch themselves in the

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process of repeating old patterns that have led to ineffective behavior. Commitment

is an essential part of reorientation. If clients hope to change, they must be willing

to set tasks for themselves in everyday life and do something specifi c about their

problems. In this way, clients translate their new insights into concrete actions. Bit-

ter and Nicoll (2004) emphasize that real change happens between sessions, and

not in therapy itself. They state that arriving at a strategy for change is an important

fi rst step, and stress that it takes courage and encouragement for clients to apply

what they have learned in therapy to daily living.

This action-oriented phase is a time for solving problems and making deci-

sions. The counselor and the client consider possible alternatives and their con-

sequences, evaluate how these alternatives will meet the client’s goals, and decide

on a specifi c course of action. The best alternatives and new possibilities are those

generated by the client, and the counselor must offer the client a great deal of sup-

port and encouragement during this stage of the process.

m a k i n g a d i f f e r e n c e Adlerian counselors seek to make a difference in the

lives of their clients. That difference may be manifested by a change in behavior or

attitude or perception. Adlerians use many different techniques to promote change,

some of which have become common interventions in other therapeutic models.

Techniques that go by the names of immediacy, advice, humor, silence, paradoxi-

cal intention, acting as if, spitting in the client’s soup, catching oneself, the push-

button technique, externalization, reauthoring, avoiding the traps, confrontation, use

of stories and fables, early recollection analysis, lifestyle assessment, encouraging,

task setting and commitment, giving homework, and terminating and summariz-

ing have all been used (Carlson & Slavik, 1997; Carlson et al., 2006; Dinkmeyer &

Sperry, 2000; Disque & Bitter, 1998; Mosak & Maniacci, 2011; Mozdzierz, Peluso, &

Lisiecki, 2009). Adlerian practitioners can creatively employ a wide range of other

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techniques, as long as these methods are philosophically consistent with the basic

theoretical premises of Adlerian psychology (Milliren et al., 2007). Adlerians are prag-

matic when it comes to using techniques that are appropriate for a given client. In

general, however, Adlerian practitioners focus on motivation modifi cation more than

behavior change and encourage clients to make holistic changes on the useful side of

living. All counseling is a cooperative effort, and making a difference depends on the

counselor’s ability to win the client’s cooperation.

Areas of Application

Adler anticipated the future direction of the helping professions by calling upon

therapists to become social activists and by addressing the prevention and reme-

diation of social conditions that were contrary to social interest and resulted in

human problems. Adler’s pioneering efforts on prevention services in mental health

120

led him to increasingly advocate for the role of Individual Psychology in schools and

families. Because Individual Psychology is based on a growth model, not a medical

model, it is applicable to such varied spheres of life as child guidance; parent–child

counseling; couples counseling; family counseling and therapy; group counseling

and therapy; individual counseling with children, adolescents, and adults; cultural

CHAPTER FIVE

confl icts; correctional and rehabilitation counseling; and mental health institutions.

Adler’s basic ideas have been incorporated into the practices of school psychology,

school counseling, the community mental health movement, and parent education.

Adlerian principles have been widely applied to substance abuse programs, social

problems to combat poverty and crime, problems of the aged, school systems, reli-

gion, and business.

a p p l i c at i o n t o e d u c at i o n Adler (1930/1978) advocated training both

teachers and parents in effective practices that foster the child’s social interests and

result in a sense of competence and self-worth. Adler had a keen interest in apply-

ing his ideas to education, especially in fi nding ways to remedy faulty lifestyles of

schoolchildren. He initiated a process to work with students in groups and to edu-

cate parents and teachers. By providing teachers with ways to prevent and correct

basic mistakes of children, he sought to promote social interest and mental health.

Adler was ahead of his time in advocating for schools to take an active role in de-

veloping social skills and character education as well as teaching the basics. Many

of the major teacher education models are based on principles of Adlerian psychol-

ogy (see Albert, 1996). Besides Adler, the main proponent of Individual Psychol-

ogy as a foundation for the teaching–learning process was Dreikurs (1968, 1971).

a p p l i c at i o n t o pa r e n t e d u c at i o n Parent education seeks to im-

prove the relationship between parent and child by promoting greater understand-

ing and acceptance. Parents are taught how to recognize the mistaken goals of chil-

dren and to use logical and natural consequences to guide children toward more

productive behavior. Adlerian parent education also stresses listening to children,

helping children accept the consequences of their behavior, applying emotion

coaching, holding family meetings, and using encouragement. Two of the leading

parent education programs in the United States—STEP (Dinkmeyer & McKay,

1997) and Active Parenting (Popkin, 1993)—are based on Adlerian principles.

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a p p l i c at i o n t o c o u p l e s c o u n s e l i n g Adlerian therapy with couples

is designed to assess a couple’s beliefs and behaviors while educating them in

more effective ways of meeting their relational goals. Clair Hawes has developed

an approach to couples counseling within the Adlerian brief therapy model. In addi-

tion to addressing the compatibility of lifestyles, Hawes looks at the early recollections

of the marriage and each partner’s relationship to a broad set of life tasks, including

occupation, social relationships, intimate relationships, spirituality, self-care, and

self-worth (Bitter et al., 1998; Hawes, 1993; Hawes & Blanchard, 1993). Carlson,

Watts, and Maniacci (2006) describe how Adlerians achieve the goals of brief

couples therapy: they foster social interest, assist couples in decreasing feelings

of inferiority and overcoming discouragement, help couples modify their views

and goals, help couples to feel a sense of quality in their relationships, and pro-

vide skill-building opportunities. Therapists aim to create solutions for problems,

121

increase choices of couples, and help clients discover and use their individual and

ADLERIAN THERAP

collective resources.

The full range of techniques applicable to other forms of counseling can be used

when working with couples. In couples counseling, couples are taught specifi c

techniques that enhance communication and cooperation. Some of these tech-

niques are listening, paraphrasing, giving feedback, having marriage conferences,

Y

listing expectations, doing homework, and enacting problem solving. Adlerians

use psychoeducational methods and skills training in counseling couples. For use-

ful books on this topic, see Carlson and Dinkmeyer (2003) and Sperry, Carlson,

and Peluso (2006).

Adlerians will sometimes see clients as a couple, sometimes individually, and

then alternately as a couple and as individuals. Rather than looking for who is at fault

in the relationship, the therapist considers the lifestyles of the partners and the inter-

action of the two lifestyles. Emphasis is given to helping them decide if they want to

maintain their relationship, and, if so, what changes they are willing to make.

a p p l i c at i o n t o fa m i ly c o u n s e l i n g With its emphasis on the fam-

ily constellation, holism, and the freedom of the therapist to improvise, Adler’s

approach contributed to the foundation of the family therapy perspective. Adleri-

ans working with families focus on the family atmosphere, the family constellation,

and the interactive goals of each member (Bitter, 2009). The family atmosphere is

the climate characterizing the relationship between the parents and their attitudes

toward life, gender roles, decision making, competition, cooperation, dealing with

confl ict, responsibility, and so forth. This atmosphere, including the role models

the parents provide, infl uences the children as they grow up. The therapeutic proc-

ess seeks to increase awareness of the interaction of the individuals within the

family system. Those who practice Adlerian family therapy strive to understand

the goals, beliefs, and behaviors of each family member and the family as an entity

in its own right. Adler’s and Dreikurs’s infl uence on family therapy is covered in

more depth in Chapter 14.

a p p l i c at i o n t o g r o u p c o u n s e l i n g Adler and his coworkers used

a group approach in their child guidance centers in Vienna as early as 1921

(Dreikurs, 1969). Dreikurs extended and popularized Adler’s work with groups

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and used group psychotherapy in his private practice for more than 40 years.

Although Dreikurs introduced group therapy into his psychiatric practice as a way

to save time, he quickly discovered some unique characteristics of groups that

made them an effective way of helping people change. Inferiority feelings can be

challenged and counteracted effectively in groups, and the mistaken concepts and

values that are at the root of social and emotional problems can be deeply infl u-

enced because the group is a value-forming agent (Sonstegard & Bitter, 2004).

The rationale for Adlerian group counseling is based on the premise that our

problems are mainly of a social nature. The group provides the social context in

which members can develop a sense of belonging, social connectedness, and com-

munity. Sonstegard and Bitter (2004) write that group participants come to see

that many of their problems are interpersonal in nature, that their behavior has

122

social meaning, and that their goals can best be understood in the framework

of social purposes.

The use of early recollections is a unique feature of Adlerian group counseling.

As mentioned earlier, from a series of early memories, individuals can get a clear

sense of their mistaken notions, current attitudes, social interests, and possible fu-

ture behavior. Through the mutual sharing of these early recollections, members

CHAPTER FIVE

develop a sense of connection with one another, and group cohesion is increased.

The group becomes an agent of change because of the improved interpersonal

relationships among members and the emergence of hope.

We particularly value the way Adlerian group counselors implement action

strategies at each of the group sessions and especially during the reorientation

stage when new decisions are made and goals are modifi ed. To challenge self-

limiting assumptions, members are encouraged to act as if they were the persons

they want to be. They are asked to “catch themselves” in the process of repeating

old patterns that have led to ineffective or self-defeating behavior. The mem-

bers come to appreciate that if they hope to change, they need to set tasks for

themselves, apply group lessons to daily life, and take steps in fi nding solutions

to their problems. This fi nal stage is characterized by group leaders and mem-

bers working together to challenge erroneous beliefs about self, life, and others.

During this stage, members are considering alternative beliefs, behaviors, and

attitudes.

Adlerian group counseling can be considered a brief approach to treatment.

The core characteristics associated with brief group therapy include rapid estab-

lishment of a strong therapeutic alliance, clear problem focus and goal alignment,

rapid assessment, emphasis on active and directive therapeutic interventions, a

focus on strengths and abilities of clients, an optimistic view of change, a focus

on both the present and the future, and an emphasis on tailoring treatment to

the unique needs of clients in the most time-effi cient manner possible (Carlson

et al., 2006).

Adlerian brief group therapy is addressed by Sonstegard, Bitter, Pelonis-

Peneros, and Nicoll (2001). For more on the Adlerian approach to group coun-

seling, refer to Theory and Practice of Group Counseling (Corey, 2012, chap. 7) and

Sonstegard and Bitter (2004).

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a d l e r i a n t h e r a p y f r o m

a m u lt i c u lt u r a l p e r s p e c t i v e

Strengths From a Diversity Perspective

Adlerian theory addressed social equality issues and social embeddedness of

humans long before multiculturalism assumed central importance in the profes-

sion (Watts & Pietrzak, 2000). Adler introduced notions with implications toward

multiculturalism that have as much or more relevance today as they did during

Adler’s time (Pedersen, as cited in Nystul, 1999b). Some of these ideas include

(1) the importance of the cultural context, (2) the emphasis on health as opposed

to pathology, (3) a holistic perspective on life, (4) the value of understanding indi-

viduals in terms of their core goals and purposes, (5) the ability to exercise freedom

123

within the context of societal constraints, and (6) the focus on prevention and the

ADLERIAN THERAP

development of a proactive approach in dealing with problems. Adler’s holistic per-

spective is an articulate expression of what Pedersen calls a “culture-centered” or

multicultural approach to counseling. Carlson and Englar-Carlson (2008) maintain

that Adlerian theory is well suited to counseling diverse populations and doing so-

cial justice work. They assert: “Perhaps Adler’s greatest contribution is that he de-

veloped a theory that recognizes and stresses the effects of social class, racism, sex,

Y

and gender on the behavior of individuals. His ideas, therefore, are well received by

those living in today’s global society” (p. 134).

Although the Adlerian approach is called Individual Psychology, its focus is on

the person in a social context. Thus clients are encouraged to defi ne themselves

within their social environments. Adlerians allow broad concepts of age, ethnicity,

lifestyle, sexual/affectional orientations, and gender differences to emerge in ther-

apy. The therapeutic process is grounded within a client’s culture and worldview

rather than attempting to fi t clients into preconceived models.

In their analysis of the various theoretical approaches to counseling, Arciniega

and Newlon (2003) state that Adlerian theory holds a great deal of promise for

addressing diversity issues. They note a number of characteristics of Adlerian the-

ory that are congruent with the values of many racial, cultural, and ethnic groups,

including the emphasis on understanding the individual in a familial and socio-

cultural context; the role of social interest and contributing to others; and the focus

on belonging and the collective spirit. Cultures that stress the welfare of the social

group and emphasize the role of the family will fi nd the basic assumptions of Adle-

rian psychology to be consistent with their values.

Adlerian therapists tend to focus on cooperation and socially oriented values

as opposed to competitive and individualistic values (Carlson & Carlson, 2000).

Native American clients, for example, tend to value cooperation over competition.

One such client told a story about a group of boys who were in a race. When one

boy got ahead of the others, he would slow down and allow the others to catch up,

and they all made it to the fi nish line at the same time. Although the coach tried

to explain that the point of the race was for an individual to fi nish fi rst, these boys

were socialized to work together cooperatively as a group. Adlerian therapy is easily

adaptable to cultural values that emphasize community.

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Not only is Adlerian theory congruent with the values of people from diverse

cultural groups, but the approach offers fl exibility in applying a range of cognitive

and action-oriented techniques to helping clients explore their practical problems

in a cultural context. Adlerian practitioners are not wedded to any particular set

of procedures. Instead, they are conscious of the value of fi tting their techniques

to each client’s situation. Although they utilize a diverse range of methods, most

of them do conduct a lifestyle assessment. This assessment is heavily focused on

the structure and dynamics within the client’s family. Because of their cultural

background, many clients have been conditioned to respect their family heritage

and to appreciate the impact of their family on their own personal development. It

is essential that counselors be sensitive to the confl icting feelings and struggles of

their clients. If counselors demonstrate an understanding of these cultural values,

124

it is likely that these clients will be receptive to an exploration of their lifestyle.

Such an exploration will involve a detailed discussion of their own place within

their family.

It should be noted that Adlerians investigate culture in much the same way

that they approach birth order and family atmosphere. Culture is a vantage point

from which life is experienced and interpreted; it is also a background of values,

CHAPTER FIVE

history, convictions, beliefs, customs, and expectations that must be addressed by

the individual. Culture provides a way of grasping the subjective and experien-

tial perspective of an individual. Although culture infl uences each person, it is

expressed within each individual differently, according to the perception, evalua-

tion, and interpretation of culture that the person holds. Contemporary Adlerians

appreciate the role of spirituality and religion in the lives of clients because these

factors are manifestations of social interest and responsibility to others (Carlson &

Englar-Carlson, 2008).

Adler was one of the fi rst psychologists at the turn of the century to advocate

equality for women. He recognized that men and women were different in many

ways, but he felt that the two genders were deserving of equal value and respect.

This respect and appreciation for difference extends to culture as well as gender.

Adlerians fi nd in different cultures opportunities for viewing the self, others, and

the world in multidimensional ways.

Shortcomings From a Diversity Perspective

As is true of most Western models, the Adlerian approach tends to focus on the

self as the locus of change and responsibility. Because other cultures have differ-

ent conceptions, this primary emphasis on changing the autonomous self may be

problematic for many clients. Assumptions about the Western nuclear family are

built into the Adlerian concepts of birth order and family constellation. For people

brought up in extended family contexts, some of these ideas may be less relevant

or at least may need to be reconfi gured.

Adlerian theory has some potential drawbacks for clients from those cultures

who are not interested in exploring past childhood experiences, early memories,

family experiences, and dreams. This approach also has limited effectiveness with

clients who do not understand the purpose of exploring the details of a lifestyle

analysis when dealing with life’s current problems (Arciniega & Newlon, 2003).

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In addition, the culture of some clients may contribute to their viewing the coun-

selor as the “expert” and expecting that the counselor will provide them with solu-

tions to their problems. For these clients, the role of the Adlerian therapist may

pose problems because Adlerian therapists are not experts in solving other people’s

problems. Instead, they view it as their function to collaboratively teach people

alternative methods of coping with life concerns.

Many clients who have pressing problems are likely to be hesitant to discuss

areas of their lives that they may not see as connected to the struggles that bring

them into therapy. Individuals may believe that it is inappropriate to reveal family

information. On this point Carlson and Carlson (2000) suggest that a therapist’s

sensitivity and understanding of a client’s culturally constructed beliefs about dis-

closing family information are critical. If the therapist is able to demonstrate an

understanding of a client’s cultural values, it is likely that this person will be more

125

open to the assessment and treatment process.

Adlerian Therapy Applied to the Case of Stan

The basic aims of an Adlerian thera-

early years, especially his experiences in his

pist working with Stan are fourfold

family. (See the Student Manual for Theory and

and correspond to the four stages

Practice of Counseling and Psychotherapy for a

of counseling: (1) establishing and maintain-

complete description of this lifestyle assessment

ing a good working relationship with Stan,

form as it is applied to Stan.) This assessment

(2) exploring Stan’s dynamics, (3) encouraging

includes a determination of whether he poses

Stan to develop insight and understanding, and

a danger to himself because Stan did mention

(4) helping Stan see new alternatives and make

suicidal ideation. During the assessment phase,

new choices.

which might take a few sessions, I explore with

To develop mutual trust and respect, I pay

Stan his social relationships, his relationships

close attention to Stan’s subjective experience

with members of his family, his work responsi-

and attempt to get a sense of how he has

bilities, his role as a man, and his feelings about

reacted to the turning points in his life. During

himself. I place considerable emphasis on Stan’s

the initial session, Stan reacts to me as the

goals in life and his priorities. I do not pay a great

expert who has the answers. He is convinced

deal of attention to his past, except to show him

that when he makes decisions he generally ends

the consistency between his past and present as

up regretting the results. Stan approaches me

he moves toward the future.

out of desperation. Because I view counseling

As an Adlerian counselor, I place value on

as a relationship between equals, I initially focus

exploring early recollections as a source of

on his feeling of being unequal to most other

understanding his goals, motivations, and

people. A good place to begin is exploring his

values. I ask Stan to report his earliest

feelings of inferiority, which he says he feels in

memories. He replies as follows:

most situations. The goals of counseling are

I was about 6. I went to school, and I was

developed mutually, and I avoid deciding for

scared of the other kids and the teacher. When I

Stan what his goals should be. I also resist

came home, I cried and told my mother I didn’t

giving Stan the simple formula he is

want to go back to school. She yelled at me and

requesting.

called me a baby. After that I felt horrible and

I prepare a lifestyle assessment based on a

even more scared.

questionnaire that taps information about Stan’s

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Another of Stan’s early recollections was at

this phase of the process, I make interpretations

age 8:

centering on his lifestyle, his current direction,

his goals and purposes, and how his private logic

My family was visiting my grandparents. I was

works. Of course, Stan is expected to carry out

playing outside, and some neighborhood kid

homework assignments that assist him in trans-

hit me for no reason. We started fighting, and

lating his insights into new behavior. In this way

my mother came out and scolded me for being

he is an active participant in his therapy.

such a rough kid. She wouldn’t believe me when

In the reorientation phase of therapy, Stan

I told her he started the fight. I felt angry and

and I work together to consider alternative atti-

hurt that she didn’t believe me.

tudes, beliefs, and actions. By now Stan sees that

Based on these early recollections, I suggest

he does not have to be locked into past patterns,

that Stan sees life as frightening and unpredict-

feels encouraged, and realizes that he has the

ably hostile and that he feels he cannot count on

power to change his life. He accepts that he will

women; they are likely to be harsh, unbelieving,

not change merely by gaining insights and knows

126

and uncaring.

that he will have to make use of these insights by

Having gathered the data based on the lifestyle

carrying out an action-oriented plan. Stan begins

assessment about his family constellation and his

to feel that he can create a new life for himself

early recollections, I assist Stan in the process of

and not remain the victim of circumstances.

summarizing and interpreting this information. I

CHAPTER FIVE

give particular attention to identifying basic mis-

Follow-Up: You Continue as

takes, which are faulty conclusions about life and

Stan’s Adlerian Therapist

self-defeating perceptions. Here are some of the

Use these questions to help you think about how

mistaken conclusions Stan has reached:

you would counsel Stan using an Adlerian approach:

• “I must not get close to people, because they

• What are some ways you would attempt to

will surely hurt me.”

establish a relationship with Stan based on trust

• “Because my own parents didn’t want me and

and mutual respect? Can you imagine any diffi-

didn’t love me, I’ll never be desired or loved by

culties in developing this relationship with him?

anybody.”

• What aspects of Stan’s lifestyle particularly

• “If only I could become perfect, maybe people

interest you? In counseling him, how would

would acknowledge and accept me.”

these be explored?

• “Being a man means not showing emotions.”

• The Adlerian therapist identified four of Stan’s

mistaken conclusions. Can you identify with

The information I summarize and interpret

any of these basic mistakes? If so, do you think

leads to insight and increased self-understanding

this would help or hinder your therapeutic

on Stan’s part. He gains increased awareness of

effectiveness with him?

his need to control his world so that he can keep

painful feelings in check. He sees more clearly

• How might you assist Stan in discovering his

some of the ways he tries to gain control over

social interest and going beyond a preoccupa-

his pain: through the use of alcohol, avoiding

tion with his own problems?

interpersonal situations that are threatening, and

• What strengths and resources in Stan might

being unwilling to count on others for psycholog-

you draw on to support his determination and

ical support. Through continued emphasis on his

commitment to change?

beliefs, goals, and intentions, Stan comes to see

how his private logic is inaccurate. In his case, a

See the DVD for Theory and Practice

syllogism for his style of life can be explained in

of Counseling and Psychotherapy: The

this way: (1) “I am unloved, insignificant, and do

Case of Stan and Lecturettes (Session 3 on

not count”; (2) “The world is a threatening place

Adlerian therapy) for a demonstration of my

to be, and life is unfair”; (3) “Therefore, I must

approach to counseling Stan by focusing on his

find ways to protect myself and be safe.” During

early recollections.

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s u m m a r y a n d e va l u at i o n

Summary

Adler was far ahead of his time, and most contemporary therapies have incorpo-

rated at least some of his ideas. Individual Psychology assumes that people are

motivated by social factors; are responsible for their own thoughts, feelings, and

actions; are the creators of their own lives, as opposed to being helpless victims;

and are impelled by purposes and goals, looking more toward the future than back

to the past.

The basic goal of the Adlerian approach is to help clients identify and change

their mistaken beliefs about, self, others, and life and thus to participate more

fully in a social world. Clients are not viewed as psychologically sick but as dis-

couraged. The therapeutic process helps individuals become aware of their pat-

127

terns and make some basic changes in their style of living, which lead to changes

ADLERIAN THERAP

in the way they feel and behave. The role of the family in the development of the

individual is emphasized. Therapy is a cooperative venture that challenges clients

to translate their insights into action in the real world. Contemporary Adlerian

theory is an integrative approach, combining cognitive, constructivist, existential,

psychodynamic, and systems perspectives. Some of these common characteristics

include an emphasis on establishing a respectful client–therapist relationship,

Y

an emphasis on clients’ strengths and resources, and an optimistic and future

orientation.

The Adlerian approach gives practitioners a great deal of freedom in work-

ing with clients. Major Adlerian contributions have been made in the following

areas: elementary education, consultation groups with teachers, parent education

groups, couples and family therapy, and group counseling.

Contributions of the Adlerian Approach

A strength of the Adlerian approach is its fl exibility and its integrative nature.

Adlerian therapists can be both theoretically integrative and technically eclectic

(Watts & Shulman, 2003). This therapeutic approach allows for the use of a variety

of relational, cognitive, behavioral, emotive, and experiential techniques. Adlerian

therapists are resourceful and fl exible in drawing on many methods, which can be

applied to a diverse range of clients in a variety of settings and formats. Therapists

are mainly concerned with doing what is in the best interests of clients rather than

squeezing clients into one theoretical framework (Watts, 1999, 2000; Watts &

Pietrzak, 2000; Watts & Shulman, 2003).

Another contribution of the Adlerian approach is that it is suited to brief, time-

limited therapy. Adler was a proponent of time-limited therapy, and the techniques

used by many contemporary brief therapeutic approaches are very similar to

interventions created by or commonly used by Adlerian practitioners (Carlson et

al., 2006). Adlerian therapy and contemporary brief therapy have in common a

number of characteristics, including quickly establishing a strong therapeutic alli-

ance, a clear problem focus and goal alignment, rapid assessment and application

to treatment, an emphasis on active and directive intervention, a psychoeducational

focus, a present and future orientation, a focus on clients’ strengths and abilities

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and an optimistic expectation of change, and a time sensitivity that tailors treatment

to the unique needs of the client (Carlson et al., 2006). According to Mosak and

Di Pietro (2006), early recollections are a signifi cant assessment intervention in

brief therapy. They claim that early recollections are often useful in minimizing

the number of therapy sessions. This procedure takes little time to administer and

interpret and provides a direction for therapists to pursue.

Bitter and Nicoll (2000) identify fi ve characteristics that form the basis for an

integrative framework in brief therapy: time limitation, focus, counselor directive-

ness, symptoms as solutions, and the assignment of behavioral tasks. Bringing a

time-limitation process to therapy conveys to clients the expectation that change

will occur in a short period of time. When the number of sessions is specifi ed,

both client and therapist are motivated to stay focused on desired outcomes and

128

to work as effi ciently as possible. Because there is no assurance that a future ses-

sion will occur, brief therapists tend to ask themselves this question: “If I had only

one session to be useful in this person’s life, what would I want to accomplish?”

(p. 38).

The Adlerian concepts I (Jerry Corey) draw on most in my professional work are

(1) the importance of looking to one’s life goals, including assessing how these goals

CHAPTER FIVE

infl uence an individual; (2) the focus on the individual’s interpretation of early expe-

riences in the family, with special emphasis on their current impact; (3) the clinical

use of early recollections in both assessment and treatment; (4) the use of dreams as

rehearsals for future action; (5) the need to understand and confront basic mistakes;

(6) the cognitive emphasis, which holds that emotions and behaviors are largely

infl uenced by one’s beliefs and thinking processes; (7) the idea of working out an

action plan designed to help clients make changes; (8) the collaborative relation-

ship, whereby the client and therapist work toward mutually agreed-upon goals;

and (9) the emphasis given to encouragement during the entire counseling proc-

ess. Several Adlerian concepts have implications for personal development. One

of these notions that has helped me to understand the direction of my life is the

assumption that feelings of inferiority are linked to a striving for superiority

(Corey, 2010).

It is diffi cult to overestimate the contributions of Adler to contemporary thera-

peutic practice. Many of his ideas were revolutionary and far ahead of his time. His

infl uence went beyond counseling individuals, extending into the community men-

tal health movement (Ansbacher, 1974). Abraham Maslow, Viktor Frankl, Rollo

May, Paul Watzlawick, Karen Horney, Erich Fromm, Aaron T. Beck, and Albert Ellis

have all acknowledged their debt to Adler. Both Frankl and May see him as a fore-

runner of the existential movement because of his position that human beings

are free to choose and are entirely responsible for what they make of themselves.

This view also makes him a forerunner of the subjective approach to psychology,

which focuses on the internal determinants of behavior: values, beliefs, attitudes,

goals, interests, personal meanings, subjective perceptions of reality, and strivings

toward self-realization. Bitter (2008) and his colleagues (Bitter, Robertson, Healey, &

Cole, 2009) have drawn attention to the link between Adlerian thinking and femi-

nist therapy approaches.

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One of Adler’s most important contributions was his infl uence on other therapy

systems. Many of his basic ideas have found their way into most of the other psy-

chological schools, a few of which include existential therapy, cognitive behavior

therapy, rational emotive behavior therapy, reality therapy, solution-focused ther-

apy, and family therapy. In many respects, Adler seems to have paved the way for

current developments in both the cognitive and constructivist therapies (Watts,

2003). Adlerians’ basic premise is that if clients can change their thinking then

they can change their feelings and behavior. A study of contemporary counseling

theories reveals that many of Adler’s notions have reappeared in these modern

approaches with different nomenclature, and often without giving Adler the credit

that is due to him (Watts, 1999; Watts & Pietrzak, 2000; Watts & Shulman, 2003).

It is clear that there are signifi cant linkages between Adlerian theory and most of

the present-day theories, especially those that view the person as purposive, self-

129

determining, and striving for growth. Carlson and Englar-Carlson (2008) assert

ADLERIAN THERAP

that Adlerians face the challenge of continuing to develop their approach so that it

meets the needs of contemporary global society: “Whereas Adlerian ideas are alive

in other theoretical approaches, there is a question about whether Adlerian theory

as a stand-alone approach is viable in the long term” (p. 133). These authors believe

that for the Adlerian model to survive and thrive it will be necessary to fi nd ways

Y

to strive for signifi cance.

Limitations and Criticisms of the

Adlerian Approach

Adler had to choose between devoting his time to formalizing his theory and teach-

ing others the basic concepts of Individual Psychology. He placed practicing and

teaching before organizing and presenting a well-defi ned and systematic theory.

As a result, his written presentations are often diffi cult to follow, and many of

them are transcripts of lectures he gave. Initially, many people considered his ide-

as somewhat loose and too simplistic.

Research supporting the effectiveness of Adlerian theory is limited but has

improved over the last 25 years (Watts & Shulman, 2003). However, a large part of

the theory still requires empirical testing and comparative analysis. This is especial-

ly true in the conceptual areas that Adlerians accept as axiomatic: for example, the

development of lifestyle; the unity of the personality and an acceptance of a sin-

gular view of self; the rejection of the prominence of heredity in determining

behavior, especially pathological behavior; and the usefulness of the multiple inter-

ventions used by various Adlerians.

w h e r e t o g o f r o m h e r e

Refer to the DVD for Integrative Counseling: The Case of Ruth and Lecturettes, Ses-

sion 6 (“Cognitive Focus in Counseling”), which illustrates Ruth’s striving to live

up to expectations and measure up to perfectionist standards. In this particular

therapy session with Ruth, you will see how I draw upon cognitive concepts and

apply them in practice.

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Free Podcasts for ACA Members

You can download ACA Podcasts (prerecorded interviews) by going to www.

counseling.org and then clicking on the Resource button, and then the Podcast

Series. For Chapter 5, look for Podcast 11, Adlerian Therapy, by Dr. Jon Carlson.

Other Resources

Videos from Psychotherapy.net demonstrate Adlerian therapy with adults, fami-

lies, and children, and are available to students and professionals at their website,

www.Psychotherapy.net. New articles, interviews, blogs, therapy cartoons, and vid-

eos are published monthly. For this chapter, see the following:

Carlson, J. (1997). Adlerian Therapy (Psychotherapy with the Experts Series)

Carlson, J. (2001). Adlerian Parent Consultation (Child Therapy with the Experts

130

Series)

Kottman, T. (2001). Adlerian Play Therapy (Child Therapy with the Experts Series)

If your thinking is allied with the Adlerian approach, you might consider seeking

training in Individual Psychology or becoming a member of the North American

Society of Adlerian Psychology (NASAP). To obtain information on NASAP and a

list of Adlerian organizations and institutes, contact:

CHAPTER FIVE

North American Society of Adlerian Psychology (NASAP)

614 Old West Chocolate Avenue

Hershey, PA 17033

Telephone: (717) 579-8795

Fax: (717) 533-8616

E-mail: nasap@msn.com

Website: www.alfredadler.org

The society publishes a newsletter and a quarterly journal and maintains a list of

institutes, training programs, and workshops in Adlerian psychology. The Jour-

nal of Individual Psychology presents current scholarly and professional research.

Columns on counseling, education, and parent and family education are regular

features. Information about subscriptions is available by contacting the society.

If you are interested in pursuing training, postgraduate study, continuing edu-

cation, or a degree, contact NASAP for a list of Adlerian organizations and institutes.

A few training institutes are listed here:

Adler School of Professional Psychology

65 East Wacker Place, Suite 2100

Chicago, IL 60601-7298

Telephone: (312) 201-5900

Fax: (312) 201-5917

E-mail: admissions@adler.edu

Website: www.adler.edu

Adler Graduate School

1550 East 78th Street

Richfield, MN 55423

Telephone: 612-861-7554

Fax: 612-861-7559

E-mail:info@alfredadler.edu

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Adler School of Professional Psychology, Vancouver Campus

595 Burrard Street, Suite 753

P.O. Box 49104

Vancouver, BC, Canada V7X 1G4

Telephone: (604) 482-5510

Fax: (604) 874-4634

Adlerian Training Institute, Inc.

Dr. Bill Nicoll, Coordinator

P.O. Box 881581

Port St. Lucie, FL 34988

Telephone/Fax: (772) 807-4141

Cell Phone: (954) 650-0637

E-mail: adleriantraining@aol.com

Website: www.adleriantraining.com

131

The Alfred Adler Institute of Northwestern Washington

ADLERIAN THERAP

2565 Mayflower Lane

Bellingham, WA 98226

Telephone: (360) 647-5670

E-mail: HTStein@att.net

Website: http://ourworld.compuserv.com/homepages/hstein/

Y

Alfred Adler Institute of San Francisco

266 Bemis Street

San Francisco, CA 94131

Telephone: (415) 584-3833

E-mail: DPienkow@msn.com

The International Committee of Adlerian

Summer Schools and Institutes

Michael Balla, ICASSI Administrator

257 Billings Avenue

Ottawa, Ontario, Canada K1H 5L1

Fax: (613) 733-0289

E-mail: mjballa@sympatico.ca

Website: www.icassi.net

Recommended Supplementary Readings

Adlerian Therapy: Theory and Practice (Carlson, Watts, & Maniacci, 2006) clearly

presents a comprehensive overview of Adlerian therapy in contemporary practice.

There are chapters on the therapeutic relationship, brief individual therapy, brief

couples therapy, group therapy, play therapy, and consultation. This book lists

Adlerian intervention videos that are available.

Adlerian Counseling and Psychotherapy: A Practitioner’s Approach (Sweeney, 2009)

is one of the most comprehensive books written on the wide range of Adlerian

applications to therapy and wellness.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch05_rev01.indd 131

20/09/11 3:19 PM

Adlerian Psychotherapy: An Advanced Approach to Individual Psychology (Oberst &

Stewart, 2003) is an up-to-date and in-depth presentation of Adlerian psychother-

apeutic process, including chapters on family therapy and the relevance of this

model to postmodern approaches.

Early Recollections: Interpretative Method and Application (Mosak & Di Pietro,

2006) is an extensive review of the use of early recollections as a way to under-

stand an individual’s dynamics and behavioral style. This book addresses the

theory, research, and clinical applications of early recollections.

Understanding Life-Style: The Psycho-Clarity Process (Powers & Griffi th, 1987) is a

useful source of information for doing a lifestyle assessment. Separate chapters

deal with interview techniques, lifestyle assessment, early recollections, the fam-

132

ily constellation, and methods of summarizing and interpreting information.

References and Suggested Readings

Adler, A. (1958). What life should mean to you.

*Ansbacher, H. L. (1992). Alfred Adler’s

CHAPTER FIVE

New York: Capricorn. (Original work published

concepts of community feeling and social

1931)

interest and the relevance of community

feeling for old age. Individual Psychology,

Adler, A. (1959). Understanding human nature.

48(4), 402–412.

New York: Premier Books. (Original work

published 1927)

*Ansbacher, H. L., & Ansbacher, R. R. (Eds.).

(1964). The individual psychology of Alfred Adler.

Adler, A. (1964). Social interest. A challenge to

New York: Harper & Row/Torchbooks.

mankind. New York: Capricorn. (Original work

(Original work published 1956)

published 1938)

*Ansbacher, H. L., & Ansbacher, R. R. (Eds.).

Adler, A. (1978). The education of children.

(1979). Superiority and social interest. Alfred

Chicago: Regnery Publishing. (Original work

Adler: A collection of his later writings

published 1930)

(3rd rev. ed.). New York: Norton.

Albert, L. (1996). Cooperative discipline. Circle

Arciniega, G. M., & Newlon, B. J. (2003).

Pines, MN: American Guidance Service.

Counseling and psychotherapy: Multicultural

American Psychiatric Association. (2000).

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Diagnostic and statistical manual of mental

(Eds.), Counseling and psychotherapy: Theories

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DC: Author.

Upper Saddle River, NJ: Merrill/

Prentice-Hall.

Ansbacher, H. L. (1974). Goal-oriented individ-

ual psychology: Alfred Adler’s theory. In

Bitter, J. R. (2006, May 25). Am I an Adlerian?

A. Burton (Ed.), Operational theories of

Ansbacher Lecture, 54th annual convention

personality (pp. 99–142). New York: Brunner/

of the North American Society of Adlerian

Mazel.

Psychology (NASAP), Chicago, IL.

*Ansbacher, H. L. (1979). The increasing

Bitter, J. R. (2008). Reconsidering narcissism:

recognition of Adler. In. H. L. Ansbacher & R. R.

An Adlerian-feminist response to the articles

Ansbacher (Eds.), Superiority and social interest.

in the special section of the Journal of Individu-

Alfred Adler, A collection of his later writings

al Psychology, volume 63, number 2. Journal of

(3rd rev. ed., pp. 3–20). New York: Norton.

Individual Psychology, 64(3), 270–279.

*Books and articles marked with an asterisk are suggested for further study.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Bitter, J. R. (2009). Theory and practice of

*Corey, G. (2013). Case approach to counseling

family therapy and counseling. Belmont, CA:

and psychotherapy (8th ed.). Belmont, CA:

Brooks/Cole, Cengage Learning.

Brooks/Cole, Cengage Learning.

*Bitter, J. R., Christensen, O. C., Hawes, C., &

Dinkmeyer, D. C., & Mc Kay, G. D. (1997).

Nicoll, W. G. (1998). Adlerian brief therapy

Systematic training for effective parenting [STEP].

with individuals, couples, and families.

Circle Pines, MN: American Guidance Service.

Directions in Clinical and Counseling Psychology,

Dinkmeyer, D., Jr., & Sperry, L. (2000).

8(8), 95–111.

Counseling and psychotherapy: An integrated

*Bitter, J. R., & Nicoll, W. G. (2000). Adlerian

Individual Psychology approach (3rd ed.). Upper

brief therapy with individuals: Process and

Saddle River, NJ: Merrill/Prentice-Hall.

practice. Journal of Individual Psychology, 56(1),

*Disque, J. G., & Bitter, J. R. (1998). Integrat-

31–44.

ing narrative therapy with Adlerian lifestyle

*Bitter, J. R., & Nicoll, W. G. (2004). Relational

assessment: A case study. Journal of Individual

133

strategies: Two approaches to Adlerian brief

Psychology, 54(4), 431–450.

ADLERIAN THERAP

therapy. Journal of Individual Psychology, 60(1),

Dreikurs, R. (1953). Fundamentals of Adlerian

42–66.

psychology. Chicago: Alfred Adler Institute.

Bitter, J. R., Robertson, P. E., Healey, A., &

Dreikurs, R. (1967). Psychodynamics, psy-

Cole, L. (2009). Reclaiming a pro-feminist

chotherapy, and counseling. Collected papers.

orientation in Adlerian therapy. Journal of

Chicago: Alfred Adler Institute.

Individual Psychology, 65(1), 13–33.

Y

Dreikurs, R. (1968). Psychology in the class-

*Carlson, J. M., & Carlson, J. D. (2000). The

room (2nd ed.). New York: Harper & Row.

application of Adlerian psychotherapy with

Asian-American clients. Journal of Individual

Dreikurs, R. (1969). Group psychotherapy from

Psychology, 56(2), 214–225.

the point of view of Adlerian psychology. In

H. M. Ruitenbeck (Ed.), Group therapy today: Styles,

Carlson, J., & Dinkmeyer, D. (2003). Time

methods, and techniques (pp. 37–48). New York:

for a better marriage. Atascadero, CA: Impact

Aldine-Atherton. (Original work published 1957)

Publishers.

Dreikurs, R. (1971). Social equality: The chal-

*Carlson, J. D., & Englar-Carlson, M. (2008).

lenge of today. Chicago: Regnery.

Adlerian therapy. In J. Frew & M. D. Spiegler

(Eds.), Contemporary psychotherapies for a

Dreikurs, R. (1997). Holistic medicine.

diverse world (pp. 93–140). Boston: Lahaska Press.

Individual Psychology, 53(2), 127–205.

*Carlson, J., & Slavik, S. (Eds.). (1997). Tech-

Hawes, E. C. (1993). Marriage counseling

niques in Adlerian psychology. Philadelphia, PA:

and enrichment. In O. C. Christensen (Ed.),

Taylor & Francis.

Adlerian family counseling (Rev. ed., pp.

125–163). Minneapolis, MN: Educational

*Carlson, J., Watts, R. E., & Maniacci, M.

Media Corporation.

(2006). Adlerian therapy: Theory and practice.

Washington DC: American Psychological

Hawes, C., & Blanchard, L. M. (1993). Life

Association.

tasks as an assessment technique in marital

counseling. Individual Psychology, 49, 306–317.

Clark, A. (2002). Early recollections: Theory

and practice in counseling and psychotherapy.

Hoffman, E. (1996). The drive for self: Alfred

New York: Brunner Routledge.

Adler and the founding of Individual Psychology.

Reading, MA: Addison-Wesley.

*Corey, G. (2010). Creating your professional

path: Lessons from my journey. Alexandria, VA:

Hood, A. B., & Johnson, R. W. (2007).

American Counseling Association.

Assessment in counseling: A guide to the use of

psychological assessment procedures (4th ed.).

*Corey, G. (2012). Theory and practice of group

Alexandria, VA: American Counseling

counseling (8th ed.). Belmont, CA: Brooks/

Association.

Cole, Cengage Learning.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Kefir, N. (1981). Impasse/priority therapy. In

*Powers, R. L., & Griffith, J. (1987). Under-

R. J. Corsini (Ed.), Handbook of innovative psy-

standing life-style. The psycho-clarity process.

chotherapies (pp. 401–415). New York: Wiley.

Chicago: Americas Institute of Adlerian

Studies.

Milliren, A. P., & Clemmer, F. (2006). Intro-

duction to Adlerian psychology: Basic princi-

Powers, R. L., & Griffith, J. (1995). IPCW: The

ples and methodology. In S. Slavik & J. Carlson

individual psychology client workbook with sup-

(Eds.), Readings in the theory and practice of

plements. Chicago: Americas Institute of

Individual Psychology (pp. 17–43). New York:

Adlerian Studies. (Original work published

Routledge (Taylor & Francis).

1986)

Milliren, A. P., Evans, T. D., & Newbauer, J. F.

Schultz, D., & Schultz, S. E. (2009). Theories of

(2007). Adlerian theory. In D. Capuzzi & D.

personality (9th ed.). Belmont, CA: Wadsworth,

R. Gross (Eds.), Counseling and psychotherapy:

Cengage Learning.

Theories and interventions (4th ed., pp. 123–163).

Sherman, R., & Dinkmeyer, D. (1987). Systems

134

Upper Saddle River, NJ: Merrill Prentice-Hall.

of family therapy. An Adlerian integration.

*Mosak, H. H., & Di Pietro, R. (2006). Early rec-

New York: Brunner/Mazel.

ollections: Interpretative method and application.

Shulman, B. H., & Mosak, H. H. (1988).

New York: Routledge.

Manual for life style assessment. Muncie,

*Mosak, H. H., & Maniacci, M. P. (2011).

IN: Accelerated Development.

Adlerian psychotherapy. In R. J. Corsini & D.

CHAPTER FIVE

*Sonstegard, M. A., & Bitter, J. R. (with

Wedding (Eds.), Current psychotherapies

Pelonis, P.). (2004). Adlerian group counseling

(9th ed., pp. 67–112). Belmont, CA: Brooks/

and therapy: Step-by-step. New York: Brunner/

Cole, Cengage Learning.

Routledge (Taylor & Francis).

Mosak, H. H., & Shulman, B. H. (1988).

Sonstegard, M. A., Bitter, J. R., Pelonis-

Lifestyle inventory. Muncie, IN: Accelerated

Peneros, P. P., & Nicoll, W. G. (2001). Adlerian

Development.

group psychotherapy: A brief therapy

Mozdzierz, G. J., Lisiecki, J., Bitter, J. R., &

approach. Directions in Clinical and Counseling

Williams, A. L. (1986). Role-functions for

Psychology, 11(2), 11–12.

Adlerian therapists. Individual Psychology,

*Sperry, L., Carlson, J., & Peluso, P. (2006).

42(2), 154–177.

Couples therapy. Denver, CO: Love.

Mozdzierz, G. J., Peluso, P. R., & Lisiecki, J.

Sweeney, T. J. (2009). Adlerian counseling

(2009). Principles of counseling and psycho-

and psychotherapy: A practitioner’s approach

therapy: Learning the essential domains and

(5th ed.). New York: Routledge (Taylor &

non-linear thinking of master practitioners.

Francis).

New York: Routledge.

Vaihinger, H. (1965). The philosophy of “as if.”

Nystul, M. S. (1999a). An interview with

London: Routledge & Kegan Paul.

Gerald Corey. Journal of Individual Psychology,

55(1), 15–25.

Watts, R. E. (1999). The vision of Adler: An

introduction. In R. E. Watts & J. Carlson (Eds.),

Nystul, M. S. (1999b). An interview with

Interventions and strategies in counseling and

Paul Pedersen. Journal of Individual Psychology,

psychotherapy (pp. 1–13). Philadelphia, PA:

55(2), 216–224.

Accelerated Development (Taylor & Francis).

Oberst, U. E., & Stewart, A. E. (2003).

Watts, R. E. (2000). Entering the new millen-

Adlerian psychotherapy: An advanced approach

nium: Is Individual Psychology still relevant?

to individual psychology. New York: Brunner-

Journal of Individual Psychology, 56(1), 21–30.

Routledge.

Watts, R. E. (2003). Adlerian, cognitive, and

Popkin, M. (1993). Active parenting today.

constructivist therapies: An integrative dialogue.

Atlanta, GA: Active Parenting.

New York: Springer.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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*Watts, R. E., & Holden, J. M. (1994). Why

of solution-focused brief therapy. Journal

continue to use “fictional finalism”? Individual

of Counseling and Development, 78(4),

Psychology, 50, 161–163.

442–447.

Watts, R. E., Peluso, P. R., & Lewis, T. F.

Watts, R. E., & Shulman, B. H. (2003). Inte-

(2005). Expanding the acting as if technique:

grating Adlerian and constructive therapies:

An Adlerian/constructive integration. Journal

An Adlerian perspective. In R. E. Watts (Ed.),

of Individual Psychology, 61(4), 380–387.

Adlerian, cognitive, and constructivist therapies:

An integrative dialogue (pp. 9–37). New York:

Watts, R. E., & Pietrzak, D. (2000). Adlerian

Springer.

“encouragement” and the therapeutic process

135

ADLERIAN THERAP

Y

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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c h a p t e r 6

Existential Therapy

i n t r o d u c t i o n

a p p l i c at i o n : t h e r a p e u t i c

• Historical Background in Philosophy

t e c h n i q u e s a n d p r o c e d u r e s

and Existentialism

• Phases of Existential Counseling

• Key Figures in Contemporary Existential

• Clients Appropriate for Existential Counseling

Psychotherapy

• Application to Brief Therapy

• Application to Group Counseling

k e y c o n c e p t s

e x i s t e n t i a l t h e r a p y f r o m a

• View of Human Nature

m u lt i c u lt u r a l p e r s p e c t i v e

• Proposition 1: The Capacity for Self-Awareness

• Proposition 2: Freedom and Responsibility

• Strengths From a Diversity Perspective

• Proposition 3: Striving for Identity and

• Shortcoming From a Diversity Perspective

Relationship to Others

e x i s t e n t i a l t h e r a p y a p p l i e d t o

• Proposition 4: The Search for Meaning

t h e c a s e o f s ta n

• Proposition 5: Anxiety as a Condition

a C

of Living

s u m m a ry a n d e va l u at i o n

Living

•

• Proposition 6: Awareness of Death and

Proposition 6: Awareness o

• Summary

Nonbeing

Nonbeing

• Contributions of the Existential Approach

• Limitations and Criticisms of the Existential

t h e t h e r a p e u t i c p r o c e s s

Approach

•

• Therapeutic

Thera

Goals

eutic Goals

•

• Therapist’s Function and Role

w h e r e t o g o f r o m h e r e

Th rapist’s Function and Role

•

• Client’s Experience in Therapy

C ent’s Experience in Therapy

•

• Recommended Supplementary Readings

y Read

•

• Relationship Between Therapist and Client

Relationship Between Therapist and Cl

•

• References and Suggested Readings

Refer

ed Readings

136

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch06_rev01.indd 136

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Viktor Frankl / Rollo May / Irvin Yalom

VIKTOR FRANKL (1905–

terrible circumstances, he believed, we could

1997) was born and educat-

preserve a vestige of spiritual freedom and inde-

ed in Vienna. He founded the

pendence of mind. He learned experientially that

Youth Advisement Centers

everything could be taken from a person except

Archiv

there in 1928 and directed

one thing: “the last of human freedoms—to choose

them until 1938. From 1942

one’s attitude in any given set of circumstances, to

Frankl

to 1945 Frankl was a pris-

choose one’s own way” (p. 104). ). Frankl believed

oner in the Nazi concentra-

that the essence of being human lies in searching

IMAGNO/Viktor

tion camps at Auschwitz

for meaning and purpose. He believed that love

and Dachau, where his parents, brother, wife, and

is the highest goal to which humans can aspire and

children died. He vividly remembered his horrible

that our salvation is through love. We can discover

experiences in these camps, yet he was able to

this meaning through our actions and deeds, by

137

EXIS

use them in a constructive way and did not allow

experiencing a value (such as love or achievements

them to dampen his love and enthusiasm for life.

through work), and by suffering.

TENTIAL THERAP

He traveled all around the world, giving lectures

Frankl knew and read Freud and attended

in Europe, Latin America, Southeast Asia, and the

some of the meetings of Freud’s psychoanalytic

United States.

group. Frankl acknowledged his indebtedness

Frankl received his MD in 1930 and his PhD

to Freud, although he disagreed with the rigidity

in philosophy in 1949, both from the University of

of Freud’s psychoanalytic system. Frankl often

Y

Vienna. He became an associate professor at the

remarked that Freud was a depth psychologist and

University of Vienna and later was a distinguished

that he is a height psychologist who built

speaker at the United States International University

on Freud’s foundations. Reacting against most of

in San Diego. He was a visiting professor at Har-

Freud’s deterministic notions, Frankl developed

vard, Stanford, and Southern Methodist universi-

his own theory and practice of psychotherapy,

ties. Frankl’s works have been translated into more

which emphasized the concepts of freedom,

than 20 languages, and his ideas continue to have

responsibility, meaning, and the search for values.

a major impact on the development of existential

He established his international reputation as the

therapy. His compelling book Man’s Search for Mean-

founder of what has been called “The Third School

ing (1963) has been a best-seller around the world.

of Viennese Psychoanalysis,” the other two being

Although Frankl had begun to develop an exis-

Sigmund Freud’s psychoanalysis and Alfred Adler’s

tential approach to clinical practice before his grim

Individual Psychology.

years in the Nazi death camps, his experiences

I have selected Frankl as one of the key figures

there confirmed his views. Frankl (1963) observed

of the existential approach because of the dramatic

and personally experienced the truths expressed

way in which his theories were tested by the trag-

by existential philosophers and writers who hold

edies of his life. His life was an illustration of his

that we have choices in every situation. Even in

theory, for he lived what his theory espouses.

ROLLO MAY (1909–1994)

ogy and counseling. In his personal life May

first lived in Ohio and then

struggled with his own existential concerns and the

moved to Michigan as a

failure of two marriages.

young child along with his

Despite his unhappy life experiences, he gradu-

five brothers and a sister.

ated from Oberlin College in 1930 and then went

Images

He remembered his home

to Greece as a teacher. During his summers in

life as being unhappy, a

Greece he traveled to Vienna to study with Alfred

Archive/Getty

situation that contributed

Adler. After receiving a degree in theology from

to his interest in psychol-

Union Theological Seminary, May decided that the

Hulton

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch06_rev01.indd 137

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best way to reach out and help people was through

writings reflect a concern with the nature of

psychology instead of theology. He completed his

human experience, such as recognizing and deal-

doctorate in clinical psychology at Columbia Uni-

ing with power, accepting freedom and respon-

versity and started a private practice in New York;

sibility, and discovering one’s identity. He draws

he also became a supervisory training analyst for

from his rich knowledge based on the classics and

the William Alanson Institute.

his existential perspective.

While May was pursuing his doctoral program,

Rollo May was one of the main proponents

he came down with tuberculosis, which resulted in

of humanistic approaches to psychotherapy, and

a 2-year stay in a sanitarium. During his recovery

he was the principal American spokesperson of

period, May spent much time learning firsthand

European existential thinking as it is applied to

about the nature of anxiety. He also spent time

psychotherapy. He believed psychotherapy should

reading, and he studied the works of Søren Kierke-

be aimed at helping people discover the mean-

gaard, which was the catalyst for his recognizing

ing of their lives and should be concerned with

138

the existential dimensions of anxiety. This study

the problems of being rather than with problem

resulted in his book The Meaning of Anxiety (1950).

solving. Questions of being include learning to

His popular book Love and Will (1969) reflects his

deal with issues such as sex and intimacy, growing

own personal struggles with love and intimate rela-

old, facing death, and taking action in the world.

tionships and mirrors Western society’s question-

According to May, the real challenge is for people

ing of its values pertaining to sex and marriage.

to be able to live in a world where they are alone

CHAPTER SIX

The greatest personal influence on Rollo May

and where they will eventually have to face death.

was the existential theologian Paul Tillich (author

He contends that our individualism should be

of The Courage to Be, 1952), who became his men-

balanced by what Adler refers to as social inter-

tor and a personal friend. The two spent much

est. It is the task of therapists to help individuals

time together discussing philosophical, religious,

find ways to contribute to the betterment of the

and psychological topics. Most of May’s

society in which they live.

IRVIN YALOM (b. 1931- )

since publication in 1970 of his influential book

was born of parents who

The Theory and Practice of Group Psychotherapy

immigrated from Russia

(1970/2005), which has been translated into 12

shortly after World War I.

languages and is currently in its fifth edition. His

Siroker.

During his early childhood,

pioneering work, Existential Psychotherapy, written

Joseph

Yalom lived in the inner city

in 1980, is a classic and authoritative textbook on

of

of Washington, D.C., in a

existential therapy. Drawing on his clinical experi-

courtesy

poor neighborhood. Life on

ence and on empirical research, philosophy, and

Photo

the streets was perilous,

literature, Yalom developed an existential approach

and Yalom took refuge indoors reading novels and

to psychotherapy that addresses four “givens of

other works. Twice a week he made the hazardous

existence” or ultimate human concerns: freedom

bicycle trek to the library to stock up on reading

and responsibility, existential isolation, meaning-

supplies. He found an alternative and satisfying

lessness, and death. These existential themes deal

world in reading fiction, which was a source of

with the client’s existence, or being-in-the-world.

inspiration and wisdom to him. Early in his life he

Yalom urges all therapists, regardless of theoretical

decided that writing a novel was the very finest

orientation, to develop a sensibility to existential

thing a person could do, and subsequently he has

issues because generally these issues emerge in all

written several teaching novels.

courses of therapy.

Irvin Yalom is professor emeritus of psychia-

Psychotherapy has been endlessly intriguing

try at the Stanford University School of Medicine.

for Yalom, who has approached all of his patients

A psychiatrist and author, Yalom has been a

with a sense of wonderment at the stories they

major figure in the field of group psychotherapy

reveal. He believes that a different therapy must be

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch06_rev01.indd 138

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designed for each client because each has a unique

Overcoming the Terror of Death, is a treatise on the

story. He advocates using the here and now of

role of death anxiety in psychotherapy, illustrating

the therapeutic relationship to explore the client’s

how death and the meaning of life are foundational

interpersonal world, and he believes the therapist

themes associated with in-depth therapeutic

must be transparent, especially regarding his or

work. Yalom’s works, translated into more than 20

her experience of the client. His basic philosophy

languages, have been widely read by therapists and

is existential and interpersonal, which he applies to

laypeople alike.

both individual and group therapy.

Yalom’s wife, Marilyn, has a PhD in compara-

Irvin Yalom has authored many stories and

tive literature and has had a successful career as

novels related to psychotherapy, including Love’s

a university professor and writer. His four children

Executioner (1987), When Nietzsche Wept (1992),

have chosen a variety of careers—medicine, pho-

Lying on the Couch (1997), Momma and the Meaning

tography, creative writing, theater directing, and

of Life (2000), and The Schopenhauer Cure (2005a).

clinical psychology. He has five grandchildren and

His 2008 nonfiction book, Staring at the Sun:

is still counting.

139

EXIS

TENTIAL THERAP

i n t r o d u c t i o n

Existential therapy is more a way of thinking, or an attitude about psychotherapy,

than a particular style of practicing psychotherapy. It is neither an independent

nor separate school of therapy, nor is it a clearly defi ned model with specifi c tech-

Y

niques. Existential therapy can best be described as a philosophical approach that

infl uences a counselor’s therapeutic practice. Yalom and Josselson (2011) capture

the essence of this approach:

Existential psychotherapy is an attitude toward human suffering [that] has no manual. It

asks deep questions about the nature of the human being and the nature of anxiety, despair,

grief, loneliness, isolation, and anomie. It also deals centrally with the questions of mean-

ing, creativity, and love. (p. 310)

Existential therapy focuses on exploring themes such as mortality, meaning, free-

dom, responsibility, anxiety, and aloneness as these relate to a person’s current

struggle. The goal of existential therapy is to assist clients in their exploration of

the existential “givens of life,” how these are sometimes ignored or denied, and

how addressing them can ultimately lead to a deeper, more refl ective and mean-

ingful existence. Clients are invited to refl ect on life, to recognize their range of

alternatives, and to decide among them.

The existential approach rejects the deterministic view of human nature es-

poused by traditional psychoanalysis and radical behaviorism. Psychoanalysis sees

the individual as primarily determined by unconscious forces, irrational drives,

and past events; behaviorists see the individual as primarily determined by socio-

cultural conditioning. Although deterministic forces affect us and we sometimes

cannot control external events thrust upon us, existential therapists believe we

retain the freedom to choose how we respond to such events. Existential therapy

is grounded on the assumption that we are free and therefore responsible for our

choices and actions. We are the authors of our lives, and we design the pathways

we follow. This chapter addresses some of the existential concepts and themes that

have signifi cant implications for the existentially oriented practitioner.

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A basic existential premise is that we are not victims of circumstance because,

to a large extent, we are what we choose to be. Once clients begin the process of

recognizing the ways in which they have passively accepted circumstances and

surrendered control, they can start down a path of consciously shaping their own

lives. The fi rst step in the therapeutic journey is for clients to accept responsibility.

As Yalom (2003) puts it, “Once individuals recognize their role in creating their

own life predicament, they also realize that they, and only they, have the power to

change that situation” (p. 141). One of the aims of existential therapy is to challenge

people to stop deceiving themselves regarding their lack of responsibility for what

is happening to them and their excessive demands on life (van Deurzen, 2002b).

Emmy van Deurzen (2002a), a key contributor to British existential psychol-

ogy, writes that existential counseling is not designed to “cure” people of illness in

140

the tradition of the medical model. She does not view clients as being sick, but as

“sick of life or clumsy at living” (p. 18) and unable to live a productive life.

See the DVD program for Chapter 6, DVD for Theory and Practice of Counseling

and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view

the brief lecture for each chapter prior to reading the chapter.

CHAPTER SIX

Historical Background in Philosophy and Existentialism

The existential therapy movement was not founded by any particular person or

group; many streams of thought contributed to it. Drawing from a major orienta-

tion in philosophy, existential therapy arose spontaneously in different parts of Eu-

rope and among different schools of psychology and psychiatry in the 1940s and

1950s. Many Europeans found that their lives had been devastated by World War

II, and they struggled with existential issues including feelings of isolation, aliena-

tion, and meaninglessness. Early writers focused on the individual’s experience

of being alone in the world and facing the anxiety of this situation. The European

existential perspective focused on human limitations and the tragic dimensions of

life (Sharp & Bugental, 2001).

The thinking of existential psychologists and psychiatrists was infl uenced by a

number of philosophers and writers during the 19th century. To understand the

philosophical underpinnings of modern existential psychotherapy, one must have

some awareness of such fi gures as Søren Kierkegaard, Friedrich Nietzsche, Martin

Heidegger, Jean-Paul Sartre, and Martin Buber. These major fi gures of existential-

ism and existential phenomenology and their cultural, philosophical, and religious

writings provided the basis for the formation of existential therapy. Ludwig Bin-

swanger and Medard Boss are also included in this section because both were early

existential psychoanalysts who contributed key ideas to existential psychotherapy.

s ø r e n k i e r k e g a a r d ( 1 8 1 3 – 1 8 5 5 ) A Danish philosopher and Chris-

tian theologian, Kierkegaard was particularly concerned with angst—a Danish and

German word whose meaning lies between the English words dread and anxiety—

and he addressed the role of anxiety and uncertainty in life. Existential anxiety

is associated with making basic decisions about how we want to live, and it is

not pathological. Kierkegaard believed that anxiety is the school in which we are

educated to be a self. Without the experience of angst, we may go through life as

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sleepwalkers. But many of us, especially in adolescence, are awakened into real life

by a terrible uneasiness. Life is one contingency after another, with no guarantees

beyond the certainty of death. This is by no means a comfortable state, but it is

necessary to our becoming human. Kierkegaard believed that “the sickness unto

death” arises when we are not true to ourselves. What is needed is the willingness

to risk a leap of faith in making choices. Becoming human is a project, and our task

is not so much to discover who we are as to create ourselves.

f r i e d r i c h n i e t z s c h e ( 1 8 4 4 – 1 9 0 0 ) The German philosopher Nietzsche

is the iconoclastic counterpart to Kierkegaard, expressing a revolutionary approach to

the self, to ethics, and to society. Like Kierkegaard, he emphasized the importance

of subjectivity. Nietzsche set out to prove that the ancient defi nition of humans

as rational was entirely misleading. We are far more creatures of will than we are

141

impersonal intellects. But where Kierkegaard emphasized the “subjective truth” of

EXIS

an intense concern with God, Nietzsche located values within the individual’s “will to

TENTIAL THERAP

power.” We give up an honest acknowledgment of this source of value when society

invites us to rationalize powerlessness by advocating other worldly concerns. If, like

sheep, we acquiesce in “herd morality,” we will be nothing but mediocrities. But if

we release ourselves by giving free rein to our will to power, we will tap our poten-

tiality for creativity and originality. Kierkegaard and Nietzsche, with their pioneer-

ing analyses of anxiety, depression, subjectivity, and the authentic self, together are

Y

generally considered to be the originators of the existential perspective (Sharp &

Bugental, 2001).

m a r t i n h e i d e g g e r ( 1 8 8 9 – 1 9 7 6 ) Heidegger’s phenomenological exis-

tentialism reminds us that we exist “in the world” and should not try to think of

ourselves as beings apart from the world into which we are thrown. The way we

fi ll our everyday life with superfi cial conversation and routine shows that we often

assume we are going to live forever and can afford to waste day after day. Our

moods and feelings (including anxiety about death) are a way of understanding

whether we are living authentically or whether we are inauthentically constructing

our lives around the expectations of others. When we translate this wisdom from

vague feeling to explicit awareness, we may develop a more positive resolve about

how we want to be. Phenomenological existentialism, as presented by Heidegger,

provides a view of human history that does not focus on past events but motivates

individuals to look forward to “authentic experiences” that are yet to come.

m a r t i n b u b e r ( 1 8 7 8 – 1 9 6 5 ) Leaving Germany to live in the new state of

Israel, Buber took a less individualistic stand than most of the other existentialists.

He said that we humans live in a kind of betweenness; that is, there is never just an

I, but always an other. The I, the person who is the agent, changes depending on

whether the other is an it or a Thou. But sometimes we make the serious mistake

of reducing another person to the status of a mere object, in which case the rela-

tionship becomes I/it. Although Buber recognizes that of necessity we must have

many I/it interactions (in everyday life), we are seriously limited if we live only in

the world of the I/it. Buber stresses the importance of presence, which has three

functions: (1) it enables true I/Thou relationships; (2) it allows for meaning to exist

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in a situation; and (3) it enables an individual to be responsible in the here and now

(Gould, 1993). In a famous dialogue with Carl Rogers, Buber argued that the thera-

pist and client could never be on the same footing because the latter comes to the

former for help. When the relationship is fully mutual, we have become “dialogic,”

a fully human condition.

l u d w i g b i n s w a n g e r ( 1 8 8 1 – 1 9 6 6 ) An existential analyst, Binswanger

proposed a holistic model of self that addresses the relationship between the per-

son and his or her environment. He used a phenomenological approach to explore

signifi cant features of the self, including choice, freedom, and caring. He based his

existential approach largely on the ideas of Heidegger and accepted Heidegger’s

notion that we are “thrown into the world.” However, this “thrown-ness” does not

release us from the responsibility of our choices and for planning for the future

142

(Gould, 1993). Existential analysis ( dasein analyse) emphasizes the subjective and

spiritual dimensions of human existence. Binswanger (1975) contended that crises

in therapy were typically major choice points for the client. Although he originally

looked to psychoanalytic theory to shed light on psychosis, he moved toward an exis-

tential view of his patients. This perspective enabled him to understand the worldview

CHAPTER SIX

and immediate experience of his patients, as well as the meaning of their behavior, as

opposed to superimposing his view as a therapist on their experience and behavior.

m e d a r d b o s s ( 1 9 0 3 – 1 9 9 1 ) Both Binswanger and Boss were early existen-

tial psychoanalysts and signifi cant fi gures in the development of existential psycho-

therapy. They made reference to dasein or being-in-the-world, which pertains to our

ability to refl ect on life events and attribute meaning to these events. They believed

that the therapist must enter the client’s subjective world without presuppositions

that would get in the way of this experiential understanding. Both Binswanger

and Boss were signifi cantly infl uenced by Heidegger’s seminal work, Being and

Time (1962), which provided a broad basis for understanding the individual (May,

1958). Boss was deeply infl uenced by Freudian psychoanalysis, but even more so

by Heidegger. Boss’s major professional interest was applying Heidegger’s phil-

osophical notions to therapeutic practice, and he was especially concerned with

integrating Freud’s methods with Heidegger’s concepts, as described in his book

Daseinanalysis and Psychoanalysis (1963) .

j e a n - pa u l s a r t r e ( 1 9 0 5 – 1 9 8 0 ) A philosopher and novelist, Sartre was

convinced, in part by his years in the French Resistance in World War II, that

humans are even more free than earlier existentialists had believed. The existence

of a space—nothingness—between the whole of our past and the now frees us to

choose what we will. Our values are what we choose. The failure to acknowledge

our freedom and choices results in emotional problems. This freedom is hard to

face, so we tend to invent an excuse by saying, “I can’t change now because of

my past conditioning.” Sartre called excuses “bad faith.” No matter what we have

been, we can make choices now and become something quite different. We are

condemned to be free. To choose is to become committed; this is the responsibility

that is the other side of freedom. Sartre’s view was that at every moment, by our

actions, we are choosing who we are being. Our existence is never fi xed or fi nished.

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Every one of our actions represents a fresh choice. When we attempt to pin down

who we are, we engage in self-deception (Russell, 2007).

Key Figures in Contemporary Existential Psychotherapy

Viktor Frankl, Rollo May, Irvin Yalom, and James Bugental all developed their

existential approaches to psychotherapy from strong backgrounds in both existen-

tial and humanistic psychology. Some of their contributions to psychotherapy are

illustrated in the brief sketches that follow.

v i k t o r f r a n k l ( 1 9 0 5 – 1 9 9 7 ) Viktor Frankl was a central fi gure in de-

veloping existential therapy in Europe and also in bringing it to the United States.

As a youth, Frankl was deeply infl uenced by Freud, but he became a student of

Adler. Later, he was infl uenced by the writings of existential philosophers, and he

began developing his own existential philosophy and psychotherapy. He was fond

143

EXIS

of quoting Nietzsche: “He who has a why to live for can bear with almost any how”

(as cited in Frankl, 1963, pp. 121, 164). Frankl contended that those words could

TENTIAL THERAP

be the motto for all psychotherapeutic practice. Another quotation from Nietzsche

seems to capture the essence of his own experience and his writings: “That which

does not kill me, makes me stronger” (as cited in Frankl, 1963, p. 130).

Frankl developed logotherapy, which means “therapy through meaning.”

Frankl’s philosophical model sheds light on what it means to be fully alive. The

Y

central themes running through his works are life has meaning, under all circum-

stances; the central motivation for living is the will to meaning; we have the freedom

to fi nd meaning in all that we think; and we must integrate body, mind, and spirit to be

fully alive. Frankl said that Freud viewed humans as motivated by the “will to pleas-

ure” and that Adler focused on the “will to power.” For Frankl, the most powerful

motivation for humans is the “will to meaning.” Frankl’s writings refl ect the theme

that the modern person has the means to live, but often has no meaning to live for.

The therapeutic process is aimed at challenging individuals to fi nd meaning and

purpose through, among other things, suffering, work, and love (Frankl, 1965).

(For more background information on Viktor Frankl, see his biography at the

beginning of this chapter).

r o l lo m ay ( 1 9 0 9 – 1 9 9 4 ) Along with Frankl, psychologist Rollo May was

deeply infl uenced by the existential philosophers, by the concepts of Freudian psy-

chology, and by many aspects of Alfred Adler’s Individual Psychology. May was

one of the key fi gures responsible for bringing existentialism from Europe to the

United States and for translating key concepts into psychotherapeutic practice. His

writings have had a signifi cant impact on existentially oriented practitioners. Of

primary importance in introducing existential therapy to the United States was

the book Existence: A New Dimension in Psychiatry and Psychology (May, Angel, &

Ellenberger, 1958). According to May, it takes courage to “be,” and our choices

determine the kind of person we become. There is a constant struggle within us.

Although we want to grow toward maturity and independence, we realize that

expansion is often a painful process. Hence, the struggle is between the security of

dependence and the joys and pains of growth. (For more background information

on Rollo May, see his biography at the beginning of this chapter).

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i r v i n ya lo m ( 1 9 3 1 - ) Irvin Yalom is a signifi cant contemporary existential

therapist in the United States. He acknowledges the contributions of both Euro-

pean and American psychologists and psychiatrists who have infl uenced the devel-

opment of existential thinking and practice (Yalom, 1980). Yalom has developed

his approach to individual and group psychotherapy based on the notion that

existentialism deals with basic “givens of existence”: isolation and relationship with

others; death and living fully; and meaninglessness and meaning. Yalom believes

the vast majority of experienced therapists, regardless of their theoretical orienta-

tion, employ many of the core existential themes. He also contends that how we

address these existential themes has a good deal to do with the design and quality

of our lives. Yalom recognizes Frankl as an eminently pragmatic thinker who has

had an impact on his writing and practice. He also acknowledges the infl uence on

144

his writings of several novelists and philosophers. More specifi cally, he draws on

the following themes from those philosophers discussed earlier:

• From Kierkegaard: creative anxiety, despair, fear and dread, guilt, and nothingness

• From Nietzsche: death, suicide, and will

• From Heidegger: authentic being, caring, death, guilt, individual responsibility,

CHAPTER SIX

and isolation

• From Sartre: meaninglessness, responsibility, and choice

• From Buber: interpersonal relationships, I/Thou perspective in therapy, and

self-transcendence

(For more background information on Irvin Yalom, see his biography at the

beginning of this chapter.)

j a m e s b u g e n ta l ( 1 9 1 5 – 2 0 0 8 ) James Bugental coined the term “existen-

tial-humanistic” psychotherapy, and he was a leading spokesman for this approach.

His philosophical and therapeutic approach included a curiosity and focus that

moved him away from the traditional therapeutic milieu of labeling and diagnos-

ing clients. His work emphasized the cultivation of both client and therapist pres-

ence. He developed techniques to assist the client in deepening inner exploration,

or searching. The therapist’s primary task involved helping clients to make new dis-

coveries about themselves in the living moment, as opposed to merely talking about

themselves.

Central to Bugental’s approach is his view of resistance, which from an existential-

humanistic perspective is not resistance to therapy per se but rather to being fully

present both during the therapy hour and in life. Resistance is seen as part of

the self-and-world construct —how a person understands his or her being and rela-

tionship to the world at large. Forms of resistance include intellectualizing, being

argumentative, always seeking to please, and any other life-limiting pattern. As re-

sistance emerges in the therapy sessions, the therapist repeatedly notes, or “tags,”

the resistance so the client increases his or her awareness and ultimately has an

increased range of choices.

Bugental’s theory and practice emphasized the distinction between therapeutic

process and content. He became known for being a masterful teacher and psycho-

therapist, primarily because he lived his work. He was an existentialist at heart,

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which made him a great model and mentor, not only for clients but also for stu-

dents and professionals. In his workshops, he developed many exercises to help

therapists refi ne and practice their skills. He frequently brought his techniques

to life with live demonstrations, which emphasized therapeutic work taking place

in the moment, impromptu here-and-now dialogue, and exploring in the context

of self as client or therapist. Bugental’s (1987) classic text, The Art of the Psycho-

therapist, is widely recognized for deconstructing the therapy process and moving

beyond theory and generalizations to show what actually occurs moment-to-

moment in the therapeutic encounter. Psychotherapy Isn’t What You Think (Bugental,

1999) is the last book he wrote before he died in 2008, at the age of 93.

o t h e r c o n t r i b u t o r s t o e x i s t e n t i a l t h e r a p y A more recent in-

fl uential fi gure in contemporary existential psychology is Kirk Schneider, who with

145

colleagues Orah Krug, David Elkins, and Ken Bradford are helping to extend exis-

EXIS

tential principles to a new generation of practitioners. Schneider and his colleagues

developed an existential-integrative therapy (see Schneider, 2008, 2011; Schneider &

TENTIAL THERAP

Krug, 2010) mainly because of the need to address today’s ethnically and diagnosti-

cally diverse clinical populations. The existential-integrative approach emphasizes

such areas as personal and interpersonal presence, the working through of resist-

ance, the rediscovery of meaning and awe, and contemplative practices. These

themes are increasingly being incorporated into the therapeutic mainstream.

Y

Signifi cant developments in the existential approach are also occurring in

Britain, largely due to the efforts of Emmy van Deurzen, who is developing aca-

demic and training programs at the New School of Psychotherapy and Counselling

(see Other Resources at the end of the chapter for details). In the past decades the

existential approach has spread rapidly in Britain and is now an alternative to tra-

ditional methods (van Deurzen, 2002b). For a description of the historical context

and development of existential therapy in Britain, see van Deurzen (2002b) and

Cooper (2003); for an excellent overview of the theory and practice of existential

therapy, see van Deurzen (2002a) and Schneider and Krug (2010).

k e y c o n c e p t s

View of Human Nature

The crucial signifi cance of the existential movement is that it reacts against the

tendency to identify therapy with a set of techniques. Instead, it bases therapeu-

tic practice on an understanding of what it means to be human. The existential

movement stands for respect for the person, for exploring new aspects of human

behavior, and for divergent methods of understanding people. It uses numerous

approaches to therapy based on its assumptions about human nature.

The existential tradition seeks a balance between recognizing the limits and

tragic dimensions of human existence on one hand and the possibilities and

opportunities of human life on the other hand. It grew out of a desire to help people

engage the dilemmas of contemporary life, such as isolation, alienation, and mean-

inglessness. The current focus of the existential approach is on the individual’s

experience of being in the world alone and facing the anxiety of this isolation.

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“No relationship can eliminate existential isolation, but aloneness can be shared in

such a way that love compensates for its pain” (Yalom & Josselson, 2011, p. 326).

The existential view of human nature is captured, in part, by the notion that the

signifi cance of our existence is never fi xed once and for all; rather, we continually

recreate ourselves through our projects. Humans are in a constant state of transi-

tion, emerging, evolving, and becoming in response to the tensions, contradictions,

and confl icts in our lives. Being a person implies that we are discovering and mak-

ing sense of our existence. We continually question ourselves, others, and the world.

Although the specifi c questions we raise vary in accordance with our developmental

stage in life, the fundamental themes do not vary. We pose the same questions

philosophers have pondered throughout Western history: “Who am I?” “What can I

know?” “What ought I to do?” “What can I hope for?” “Where am I going?”

146

The basic dimensions of the human condition, according to the existential

approach, include (1) the capacity for self-awareness; (2) freedom and responsi-

bility; (3) creating one’s identity and establishing meaningful relationships with

others; (4) the search for meaning, purpose, values, and goals; (5) anxiety as a con-

dition of living; and (6) awareness of death and nonbeing. I develop these proposi-

CHAPTER SIX

tions in the following sections by summarizing themes that emerge in the writings

of existential philosophers and psychotherapists, and I also discuss the implica-

tions for counseling practice of each of these propositions.

Proposition 1: The Capacity for Self-Awareness

Freedom, choice, and responsibility constitute the foundation of self-awareness. The

greater our awareness, the greater our possibilities for freedom (see Proposition 2).

Schneider (2008) explains that the core existential position is that we are both free (will-

ful, creative, and expressive) and limited (by environmental and social constraints). We

increase our capacity to live fully as we expand our awareness in the following areas:

• We are fi nite and do not have unlimited time to do what we want in life.

• We have the potential to take action or not to act; inaction is a decision.

• We choose our actions, and therefore we can partially create our own destiny.

• Meaning is the product of discovering how we are “thrown” or situated in the

world and then, through commitment, living creatively.

• As we increase our awareness of the choices available to us, we also increase our

sense of responsibility for the consequences of these choices.

• We are subject to loneliness, meaninglessness, emptiness, guilt, and isolation.

• We are basically alone, yet we have an opportunity to relate to other beings.

We can choose either to expand or to restrict our consciousness. Because self-

awareness is at the root of most other human capacities, the decision to expand it is

fundamental to human growth. Here are some areas of emerging awareness that

individuals may experience in the counseling process:

• They see how they are trading the security of dependence for the anxieties that

accompany choosing for themselves.

• They begin to see that their identity is anchored in someone else’s defi nition of

them; that is, they are seeking approval and confi rmation of their being in others

instead of looking to themselves for affi rmation.

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• They learn that in many ways they are keeping themselves prisoner by some of

their past decisions, and they realize that they can make new decisions.

• They learn that although they cannot change certain events in their lives they

can change the way they view and react to these events.

• They learn that they are not condemned to a future similar to the past, for they

can learn from their past and thereby reshape their future.

• They realize that they are so preoccupied with suffering, death, and dying that

they are not appreciating living.

• They are able to accept their limitations yet still feel worthwhile, for they under-

stand that they do not need to be perfect to feel worthy.

• They come to realize that they are failing to live in the present moment because

of preoccupation with the past, planning for the future, or trying to do too many

things at once.

147

EXIS

Increasing self-awareness—which includes awareness of alternatives, motivations,

TENTIAL THERAP

factors infl uencing the person, and personal goals—is an aim of all counseling.

Clients need to learn that a price must be paid for increased awareness. As we

become more aware, it is more diffi cult to “go home again.” Ignorance of our

condition may have brought contentment along with a feeling of partial deadness,

but as we open the doors in our world, we can expect more turmoil as well as the

potential for more fulfi llment.

Y

Proposition 2: Freedom and Responsibility

A characteristic existential theme is that people are free to choose among alterna-

tives and therefore play a large role in shaping their own destiny. Schneider and

Krug (2010) write that existential therapy embraces three values: (1) the freedom to

become within the context of natural and self-imposed limitations; (2) the capacity

to refl ect on the meaning of our choices; and (3) the capacity to act on the choices we

make. A central existential concept is that although we long for freedom, we often try

to escape from our freedom by defi ning ourselves as a fi xed or static entity (Russell,

2007). We have no choice about being thrust into the world, yet the manner in

which we live and what we become are the result of our choices. Because of the real-

ity of this freedom, our task is to accept responsibility for directing our lives. How-

ever, it is possible to avoid this reality by making excuses. In speaking about “bad

faith,” the existential philosopher Jean-Paul Sartre (1971) refers to the inauthenticity

of not accepting personal responsibility. Here are two statements that reveal bad

faith: “Since that’s the way I’m made, I couldn’t help what I did” or “Naturally I’m

this way, because I grew up in a dysfunctional family.” An inauthentic mode of

existence consists of lacking awareness of personal responsibility for our lives and

passively assuming that our existence is largely controlled by external forces. Sartre

claims we are constantly confronted with the choice of what kind of person we are

becoming, and to exist is never to be fi nished with this kind of choosing.

Freedom implies that we are responsible for our lives, for our actions, and

for our failures to take action. From Sartre’s perspective people are condemned

to freedom. He calls for a commitment to choosing for ourselves. Existential guilt

is being aware of having evaded a commitment, or having chosen not to choose.

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This guilt is a condition that grows out of a sense of incompleteness, or a realiza-

tion that we are not what we might have become. Guilt may be a sign that we have

failed to rise to the challenge of our anxiety and that we have tried to evade it by

not doing what we know is possible for us to do (van Deurzen, 2002a). This condi-

tion is not viewed as neurotic, nor is it seen as a symptom that needs to be cured.

Instead, the existential therapist explores it to see what clients can learn about the

ways in which they are living their life. This guilt also results from allowing others

to defi ne us or to make our choices for us. Sartre said, “We are our choices.”

Authenticity implies that we are living by being true to our own evaluation of what

is a valuable existence for ourselves; it is the courage to be who we are.

For existentialists, then, being free and being human are identical. Freedom

and responsibility go hand in hand. We are the authors of our lives in the sense

148

that we create our destiny, our life situation, and our problems (Russell, 1978).

Assuming responsibility is a basic condition for change. Clients who refuse to

accept responsibility by persistently blaming others for their problems are not

likely to profi t from therapy.

Frankl (1978) also links freedom with responsibility. He suggested that the

CHAPTER SIX

Statue of Liberty on the East Coast should be balanced with a Statue of Respon-

sibility on the West Coast. His basic premise is that freedom is bound by certain

limitations. We are not free from conditions, but we are free to take a stand against

these restrictions. Ultimately, these conditions are subject to our decisions, which

means we are responsible.

The therapist assists clients in discovering how they are avoiding freedom

and encourages them to learn to risk using it. Not to do so is to cripple clients

and make them dependent on the therapist. Therapists have the task of teaching

clients that they can explicitly accept that they have choices, even though they may

have devoted most of their life to evading them. Those who are in therapy often

have mixed feelings when it comes to choice. As Russell (2007) puts it: “We resent

it when we don’t have choices, but we get anxious when we do! Existentialism is all

about broadening the vision of our choices” (p. 111).

People often seek psychotherapy because they feel that they have lost control

of how they are living. They may look to the counselor to direct them, give them

advice, or produce magical cures. They may also need to be heard and understood.

Two central tasks of the therapist are inviting clients to recognize how they have

allowed others to decide for them and encouraging them to take steps toward

choosing for themselves. In inviting clients to explore other ways of being that are

more fulfi lling than their present restricted existence, some existential counselors

ask, “Although you have lived in a certain pattern, now that you recognize the price

of some of your ways, are you willing to consider creating new patterns?” Others

may have a vested interest in keeping the client in an old pattern, so the initiative

for changing it will have to come from the client.

Cultural factors need to be taken into account in assisting clients in the process

of examining their choices. A person who is struggling with feeling limited by her

family situation can be invited to look at her part in this process and values that

are a part of her culture. For example, Meta, a Norwegian American, is working to

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attain a professional identity as a social worker, but her family thinks she is being

selfi sh and neglecting her primary duties. The family is likely to exert pressure on

her to give up her personal interests in favor of what they feel is best for the wel-

fare of the entire family. Meta may feel trapped in the situation and see no way out

unless she rejects what her family wants. In cases such as this, it is useful to

explore the client’s underlying values and to help her determine whether her values

are working for her and for her family. Clients such as Meta have the challenge of

weighing values and balancing behaviors between two cultures. Ultimately, Meta

must decide in what ways she might change her situation, and she needs to assess

values based on her culture. The existential therapist will invite Meta to begin to

explore what she can do and to realize that she can be authentic in spite of pres-

sures on her by her situation. According to Vontress (2008), we can be authentic

in any society, whether we are a part of an individualistic or collectivistic society.

149

It is essential to respect the purpose that people have in mind when they initiate

EXIS

therapy. If we pay careful attention to what our clients tell us about what they want,

TENTIAL THERAP

we can operate within an existential framework. We can encourage individuals to

weigh the alternatives and to explore the consequences of what they are doing with

their lives. Although oppressive forces may be severely limiting the quality of their

lives, we can help people see that they are not solely the victims of circumstances

beyond their control. Even though we sometimes cannot control things that hap-

Y

pen to us, we have complete control over how we choose to perceive and handle

them. Although our freedom to act is limited by external reality, our freedom to

be relates to our internal reality. At the same time that people are learning how to

change their external environment, they can be challenged to look within them-

selves to recognize their own contributions to their problems. Through the therapy

experience, clients may be able to discover new courses of action that will lead to a

change in their situation.

Proposition 3: Striving for Identity

and Relationship to Others

People are concerned about preserving their uniqueness and centeredness, yet at

the same time they have an interest in going outside of themselves to relate to other

beings and to nature. Each of us would like to discover a self or, to put it more authen-

tically, to create our personal identity. This is not an automatic process, and creating

an identity takes courage. As relational beings, we also strive for connectedness with

others. Many existential writers discuss loneliness, uprootedness, and alienation,

which can be seen as the failure to develop ties with others and with nature.

The trouble with so many of us is that we have sought directions, answers,

values, and beliefs from the important people in our world. Rather than trusting

ourselves to search within and fi nd our own answers to the confl icts in our life, we

sell out by becoming what others expect of us. Our being becomes rooted in their

expectations, and we become strangers to ourselves.

t h e c o u r a g e t o b e Paul Tillich (1886–1965), a leading Protestant theolo-

gian of the 20th century, believes awareness of our fi nite nature gives us an appre-

ciation of ultimate concerns. It takes courage to discover the true “ground of our

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being” and to use its power to transcend those aspects of nonbeing that would de-

stroy us (Tillich, 1952). Courage entails the will to move forward in spite of anxiety-

producing situations, such as facing our death (May, 1975). We struggle to discover,

to create, and to maintain the core deep within our being. One of the greatest fears

of clients is that they will discover that there is no core, no self, no substance, and

that they are merely refl ections of everyone’s expectations of them. A client may

say, “My fear is that I’ll discover I’m nobody, that there really is nothing to me.

I’ll fi nd out that I’m an empty shell, hollow inside, and nothing will exist if I shed

my masks.” If clients demonstrate the courage to confront these fears, they might

well leave therapy with an increased tolerance for the uncertainty of life. By assist-

ing clients in facing the fear that their lives or selves are empty and meaningless,

therapists can help clients to create a self that has meaning and substance that they

150

have chosen.

Existential therapists may begin by asking their clients to allow themselves to

intensify the feeling that they are nothing more than the sum of others’ expecta-

tions and that they are merely the introjects of parents and parent substitutes.

How do they feel now? Are they condemned to stay this way forever? Is there a way

CHAPTER SIX

out? Can they create a self if they fi nd that they are without one? Where can they

begin? Once clients have demonstrated the courage to recognize this fear, to put it

into words and share it, it does not seem so overwhelming. I fi nd that it is best to

begin work by inviting clients to accept the ways in which they have lived outside

themselves and to explore ways in which they are out of contact with themselves.

t h e e x p e r i e n c e o f a lo n e n e s s The existentialists postulate that part

of the human condition is the experience of aloneness. But they add that we can

derive strength from the experience of looking to ourselves and sensing our sepa-

ration. The sense of isolation comes when we recognize that we cannot depend on

anyone else for our own confi rmation; that is, we alone must give a sense of mean-

ing to life, and we alone must decide how we will live. If we are unable to tolerate

ourselves when we are alone, how can we expect anyone else to be enriched by our

company? Before we can have any solid relationship with another, we must have a

relationship with ourselves. We are challenged to learn to listen to ourselves. We

have to be able to stand alone before we can truly stand beside another.

There is a paradox in the proposition that humans are existentially both alone

and related, but this very paradox describes the human condition. To think that

we can cure the condition, or that it should be cured, is erroneous. Ultimately we

are alone, yet our aloneness is set in the context of our inevitable relatedness to

other people.

t h e e x p e r i e n c e o f r e l at e d n e s s We humans depend on relationships

with others. We want to be signifi cant in another’s world, and we want to feel that

another’s presence is important in our world. When we are able to stand alone and

tap into our own strength, our relationships with others are based on our fulfi ll-

ment, not our deprivation. If we feel personally deprived, however, we can expect

little but a clinging and symbiotic relationship with someone else.

Perhaps one of the functions of therapy is to help clients distinguish between a

neurotically dependent attachment to another and a life-affi rming relationship in

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which both persons are enhanced. The therapist can challenge clients to examine

what they get from their relationships, how they avoid intimate contact, how they

prevent themselves from having equal relationships, and how they might create

therapeutic, healthy, and mature human relationships. Existential therapists speak

of intersubjectivity, which is the fact of our interrelatedness with others and the

need for us to struggle with this in a creative way.

s t r u g g l i n g w i t h o u r i d e n t i t y Because of our fear of dealing with

our aloneness, Farha (1994) points out that some of us get caught up in ritualis-

tic behavior patterns that cement us to an image or identity we acquired in early

childhood. He writes that some of us become trapped in a doing mode to avoid the

experience of being.

Part of the therapeutic journey consists of the therapist challenging clients

151

to begin to examine the ways in which they have lost touch with their identity,

EXIS

especially by letting others design their life for them. The therapy process itself

is often frightening for clients when they realize that they have surrendered their

TENTIAL THERAP

freedom to others and that in the therapy relationship they will have to assume

their freedom again. By refusing to give easy solutions or answers, existential

therapists confront clients with the reality that they alone must fi nd their own

answers.

Y

Proposition 4: The Search for Meaning

A distinctly human characteristic is the struggle for a sense of signifi cance and

purpose in life. In my experience the underlying confl icts that bring people into

counseling and therapy are centered in these existential questions: “Why am I

here?” “What do I want from life?” “What gives my life purpose?” “Where is the

source of meaning for me in life?”

Existential therapy can provide the conceptual framework for helping clients

challenge the meaning in their lives. Questions that the therapist might ask are,

“Do you like the direction of your life?” “Are you pleased with what you now are

and what you are becoming?” “If you are confused about who you are and what you

want for yourself, what are you doing to get some clarity?”

t h e p r o b l e m o f d i s c a r d i n g o l d va l u e s One of the problems in

therapy is that clients may discard traditional (and imposed) values without creat-

ing other, suitable ones to replace them. What does the therapist do when clients

no longer cling to values that they never really challenged or internalized and now

experience a vacuum? Clients may report that they feel like a boat without a rudder.

They seek new guidelines and values that are appropriate for the newly discovered

facets of themselves, and yet for a time they are without them. One of the tasks of

the therapeutic process is to help clients create a value system based on a way of

living that is consistent with their way of being.

The therapist’s job is to trust in the capacity of clients to eventually create an

internally derived value system that provides the foundation for a meaningful life.

They will no doubt fl ounder for a time and experience anxiety as a result of the

absence of clear-cut values. The therapist’s trust is important in helping clients

trust their own capacity to create a new source of values.

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m e a n i n g l e s s n e s s When the world they live in seems meaningless, clients

may wonder whether it is worth it to continue struggling or even living. Faced with

the prospect of our mortality, we might ask, “Is there any point to what I do now,

since I will eventually die? Will what I do be forgotten when I am gone? Given the

fact of mortality, why should I busy myself with anything?” A man in one of my

groups captured precisely the idea of personal signifi cance when he said, “I feel

like another page in a book that has been turned quickly, and nobody bothered to

read the page.” For Frankl (1978) such a feeling of meaninglessness is the major

existential neurosis of modern life.

Meaninglessness in life can lead to emptiness and hollowness, or a condition

that Frankl calls the existential vacuum. This condition is often experienced when

people do not busy themselves with routine or with work. Because there is no

152

preordained design for living, people are faced with the task of creating their own

meaning. At times people who feel trapped by the emptiness of life withdraw from

the struggle of creating a life with purpose. Experiencing meaninglessness and

establishing values that are part of a meaningful life are issues that become the

heart of counseling.

CHAPTER SIX

c r e at i n g n e w m e a n i n g Logotherapy is designed to help clients fi nd

meaning in life. The therapist’s function is not to tell clients what their particular

meaning in life should be but to point out that they can create meaning even in suf-

fering (Frankl, 1978). This view holds that human suffering (the tragic and negative

aspects of life) can be turned into human achievement by the stand an individual

takes when faced with it. Frankl also contends that people who confront pain, guilt,

despair, and death can effectively deal with their despair and thus triumph.

Yet meaning is not something that we can directly search for and obtain. Para-

doxically, the more rationally we seek it, the more likely we are to miss it. Frankl

(1978) and Yalom and Josselson (2011) are in basic agreement that, like pleasure,

meaning must be pursued obliquely. Finding satisfaction and meaning in life is

a by-product of engagement, which is a commitment to creating, loving, working,

and building. Meaning is created out of an individual’s engagement with what is

valued, and this commitment provides the purpose that makes life worthwhile

(van Deurzen, 2002a). I like the way Vontress (2008) captures the idea that mean-

ing in life is an ongoing process we struggle with throughout our lives: “What

provides meaning one day may not provide meaning the next, and what has been

meaningful to a person throughout life may be meaningless when a person is on

his or her deathbed” (p. 158).

Proposition 5: Anxiety as a Condition of Living

Anxiety arises from one’s personal strivings to survive and to maintain and as-

sert one’s being, and the feelings anxiety generates are an inevitable aspect of the

human condition. Existential anxiety is the unavoidable result of being confronted

with the “givens of existence”—death, freedom, choice, isolation, and meaningless-

ness (Vontress, 2008; Yalom, 1980; Yalom & Josselson, 2011). Existential anxiety

arises as we recognize the realities of our mortality, our confrontation with pain and

suffering, our need to struggle for survival, and our basic fallibility. We experience

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this anxiety as we become increasingly aware of our freedom and the consequenc-

es of accepting or rejecting that freedom. In fact, when we make a decision that

involves reconstruction of our life, the accompanying anxiety can be a signal that we

are ready for personal change and can be a stimulus for growth. If we learn to listen

to the subtle messages of anxiety, we can dare to take the steps necessary to change

the direction of our lives.

Existential therapists differentiate between normal and neurotic anxiety, and

they see anxiety as a potential source of growth. Normal anxiety is an appropriate

response to an event being faced. Further, this kind of anxiety does not have to

be repressed, and it can be used as a motivation to change. Because we could not

survive without some anxiety, it is not a therapeutic goal to eliminate normal anxi-

ety. Existential philosophers have argued that at the root of our normal (or ontic)

anxiety, which is an appropriate anxiety that relates to concrete things in the world,

153

is a more fundamental existential (or ontological) anxiety, which is based on our

EXIS

awareness of our own temporality and is present even when we do not have to face

TENTIAL THERAP

particularly diffi cult situations. Neurotic anxiety, in contrast, is anxiety about con-

crete things that is out of proportion to the situation. Neurotic anxiety is typically

out of awareness, and it tends to immobilize the person. Being psychologically

healthy entails living with as little neurotic anxiety as possible, while accepting and

struggling with the unavoidable existential anxiety that is a part of living.

Y

Many people who seek counseling want solutions that will enable them to elimi-

nate anxiety. Attempts to avoid anxiety by creating the illusion that there is security

in life may help us cope with the unknown, yet we really know on some level that

we are deceiving ourselves when we think we have found fi xed security. Facing

existential anxiety involves viewing life as an adventure rather than hiding behind

imagined securities that seem to offer protection. Opening up to new life means

opening up to anxiety. We pay a steep price when we short-circuit anxiety.

People who have the courage to face themselves are, nonetheless, frightened. I

am convinced that those who are willing to live with their anxiety for a time profi t

from personal therapy. Those who fl ee too quickly into comfortable patterns might

experience temporary relief but in the long run seem to experience the frustration

of being stuck in old ways.

The existential therapist can help clients recognize that learning how to tolerate

ambiguity and uncertainty and how to live without props can be a necessary phase in

the journey from dependence to autonomy. The therapist and client can explore the

possibility that although breaking away from crippling patterns and building new

ways of living will be fraught with anxiety for a while, anxiety will diminish as the cli-

ent experiences more satisfaction with newer ways of being. When a client becomes

more self-confi dent, the anxiety that results from an expectation of catastrophe is

likely to decrease.

Proposition 6: Awareness of Death and Nonbeing

The existentialist does not view death negatively but holds that awareness of death

as a basic human condition gives signifi cance to living. A distinguishing human

characteristic is the ability to grasp the reality of the future and the inevitability of

death. It is necessary to think about death if we are to think signifi cantly about life.

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Death should not be considered a threat; death provides the motivation for us to

take advantage of appreciating the present moment. Instead of being frozen by the

fear of death, death can be viewed as a positive force that enables us to live as fully

as possible. Although the notion of death is a wake-up call, it is also something

that we strive to avoid (Russell, 2007). If we defend ourselves against the reality

of our eventual death, life becomes insipid and meaningless. But if we realize that

we are mortal, we know that we do not have an eternity to complete our projects

and that the present is crucial. Our awareness of death is the source of zest for life

and creativity. Death and life are interdependent, and though physical death de-

stroys us, the idea of death saves us (Yalom, 1980, 2003).

Yalom (2008) recommends that therapists talk directly to clients about the

reality of death. He believes the fear of death percolates beneath the surface and

154

haunts us throughout life. Death is a visitor in the therapeutic process, and Yalom

believes that ignoring its presence sends the message that death is too overwhelm-

ing to explore. Confronting this fear can be the factor that helps us transform an

inauthentic mode of living into a more authentic one. Accepting the reality of our

personal death can result in a massive shift in the way we live in the world (Yalom &

CHAPTER SIX

Josselson, 2011). We can turn our fear of death into a positive force when we accept

the reality of our mortality. In Staring at the Sun: Overcoming the Terror of Death,

Yalom (2008) develops the idea that confronting death enables us to live in a more

compassionate way.

One focus in existential therapy is on exploring the degree to which clients

are doing the things they value. Without being morbidly preoccupied by the ever-

present threat of nonbeing, clients can develop a healthy awareness of death as a

way to evaluate how well they are living and what changes they want to make in

their lives. Those who fear death also fear life. When we emotionally accept the

reality of our eventual death, we realize more clearly that our actions do count, that

we do have choices, and that we must accept the ultimate responsibility for how

well we are living (Corey & Corey, 2010).

t h e t h e r a p e u t i c p r o c e s s

Therapeutic Goals

Existential therapy is best considered as an invitation to clients to recognize the

ways in which they are not living fully authentic lives and to make choices that

will lead to their becoming what they are capable of being. An aim of therapy is to

assist clients in moving toward authenticity and learning to recognize when they

are deceiving themselves (van Deurzen, 2002a). The existential orientation holds

that there is no escape from freedom as we will always be held responsible. We can

relinquish our freedom, however, which is the ultimate inauthenticity. Existential

therapy aims at helping clients face anxiety and engage in action that is based on

the authentic purpose of creating a worthy existence.

May (1981) contends that people come to therapy with the self-serving illu-

sion that they are inwardly enslaved and that someone else (the therapist) can free

them. Existential therapists are mainly concerned about helping people to reclaim

and reown their lives. The task of existential therapy is to teach clients to listen to

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what they already know about themselves, even though they may not be attend-

ing to what they know. Schneider and Krug (2010) identify four essential aims of

existential-humanistic therapy: (1) to help clients become more present to both

themselves and others; (2) to assist clients in identifying ways they block them-

selves from fuller presence; (3) to challenge clients to assume responsibility for de-

signing their present lives; and (4) to encourage clients to choose more expanded

ways of being in their daily lives.

Increased awareness is the central goal of existential therapy, which allows

clients to discover that alternative possibilities exist where none were recognized

before. Clients come to realize that they are able to make changes in their way of

being in the world.

Therapist’s Function and Role

155

Existential therapists are primarily concerned with understanding the subjective

EXIS

world of clients to help them come to new understandings and options. Existen-

TENTIAL THERAP

tial therapists are especially concerned about clients avoiding responsibility; they

consistently invite clients to accept personal responsibility. When clients complain

about the predicaments they are in and blame others, the therapist is likely to ask

them how they contributed to their situation.

Therapists with an existential orientation usually deal with people who have

Y

what could be called a restricted existence. These clients have a limited aware-

ness of themselves and are often vague about the nature of their problems. They

may see few, if any, options for dealing with life situations, and they tend to feel

trapped, helpless, and stuck. For Bugental (1997), a therapist’s function is to assist

clients in seeing the ways in which they constrict their awareness and the cost of

such constrictions. The therapist may hold up a mirror, so to speak, so that clients

can gradually engage in self-confrontation. In this way clients can see how they be-

came the way they are and how they might enlarge the way they live. Once clients

are aware of factors in their past and of stifl ing modes of their present existence,

they can begin to accept responsibility for changing their future.

Existential practitioners may make use of techniques that originate from

diverse theoretical orientations, yet no set of techniques is considered essen-

tial. The therapeutic journey is creative and uncertain and different for each cli-

ent. Russell (2007) captures this notion well when he writes: “There is no one

right way to do therapy, and certainly no rigid doctrine for existentially rooted

techniques. What is crucial is that you create your own authentic way of being

attuned to your clients” (p. 123). Existential therapists encourage experimenta-

tion not only within the therapy offi ce but also outside of the therapy setting,

based on the belief that life outside therapy is what counts. Practitioners often

ask clients to refl ect on or write about problematic events they encounter in daily

life (Schneider, 2011).

Client’s Experience in Therapy

Clients in existential therapy are clearly encouraged to assume responsibility for

how they are currently choosing to be in their world. Effective therapy does not stop

with this awareness itself, for the therapist encourages clients to take action on the

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basis of the insights they develop through the therapeutic process. Experimentation

with new ways of behaving in the outside world is necessary if clients are to change.

Further, clients must be active in the therapeutic process, for during the sessions

they must decide what fears, guilt feelings, and anxieties they will explore.

Merely deciding to enter psychotherapy is itself a frightening prospect for most

people. The experience of opening the doors to oneself can be frightening, excit-

ing, joyful, depressing, or a combination of all of these. As clients wedge open the

closed doors, they also begin to loosen the deterministic shackles that have kept

them psychologically bound. Gradually, they become aware of what they have been

and who they are now, and they are better able to decide what kind of future they

want. Through the process of their therapy, individuals can explore alternatives for

making their visions real.

156

When clients plead helplessness and attempt to convince themselves that they

are powerless, May (1981) reminds them that their journey toward freedom began

by putting one foot in front of the other to get to his offi ce. As narrow as their range

of freedom may be, individuals can begin building and augmenting that range by

taking small steps. The therapeutic journey that opens up new horizons is poeti-

CHAPTER SIX

cally described by van Deurzen (2010):

Embarking on our existential journey requires us to be prepared to be touched and shaken by

what we fi nd on the way and to not be afraid to discover our own limitations and weaknesses,

uncertainties and doubts. It is only with such an attitude of openness and wonder that we can

encounter the impenetrable everyday mysteries, which take us beyond our own preoccupa-

tions and sorrows and which by confronting us with death, make us rediscover life. (p. 5)

Another aspect of the experience of being a client in existential therapy is confront-

ing ultimate concerns rather than coping with immediate problems. Rather than

being solution-oriented, existential therapy is aimed toward removing roadblocks

to meaningful living and helping clients assume responsibility for their actions

(Yalom & Josselson, 2011). Existential therapists assist people in facing life with

courage, hope, and a willingness to fi nd meaning in life.

Relationship Between Therapist and Client

Existential therapists give central prominence to their relationship with the client.

The relationship is important in itself because the quality of this person-to-person

encounter in the therapeutic situation is the stimulus for positive change. Atten-

tion is given to the client’s immediate, ongoing experience, especially what is go-

ing on in the interaction between the therapist and the client. Therapy is viewed

as a social microcosm in the sense that the interpersonal and existential problems

of the client will become apparent in the here and now of the therapy relationship

(Yalom & Josselson, 2011).

Therapists with an existential orientation believe their basic attitudes toward the

client and their own personal characteristics of honesty, integrity, and courage are

what they have to offer. Therapy is a journey taken by therapist and client that delves

deeply into the world as perceived and experienced by the client. But this type of quest

demands that therapists also be in contact with their own phenomenological world.

Existential therapy is a voyage into self-discovery and a journey of life-discovery

for both client and therapist (van Deurzen, 2010; Yalom & Josselson, 2011).

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Buber’s (1970) conception of the I/Thou relationship has signifi cant implica-

tions here. His understanding of the self is based on two fundamental relation-

ships: the “I/it” and the “I/Thou.” The I/it is the relation to time and space, which

is a necessary starting place for the self. The I/Thou is the relationship essential

for connecting the self to the spirit and, in so doing, to achieve true dialogue. This

form of relationship is the paradigm of the fully human self, the achievement of

which is the goal of Buber’s existential philosophy. Relating in an I/Thou fashion

means that there is direct, mutual, and present interaction. Rather than prizing

therapeutic objectivity and professional distance, existential therapists strive to cre-

ate caring and intimate relationships with clients.

The core of the therapeutic relationship is respect, which implies faith in

clients’ potential to cope authentically with their troubles and in their ability to

discover alternative ways of being. Existential therapists share their reactions to

157

clients with genuine concern and empathy as one way of deepening the therapeu-

EXIS

tic relationship. Therapists invite clients to grow by modeling authentic behavior.

TENTIAL THERAP

If therapists keep themselves hidden during the therapeutic session or if they en-

gage in inauthentic behavior, clients will also remain guarded and persist in their

inauthentic ways.

Bugental (1987) emphasizes the crucial role the presence of the therapist plays

in the therapeutic relationship. In his view many therapists and therapeutic sys-

Y

tems overlook its fundamental importance. He contends that therapists are too

often so concerned with the content of what is being said that they are not aware of

the distance between themselves and their clients:

The therapeutic alliance is the powerful joining of forces which energizes and supports the

long, diffi cult, and frequently painful work of life-changing psychotherapy. The conception

of the therapist here is not of a disinterested observer-technician but of a fully alive human

companion for the client. (p. 49)

Schneider (2011) believes that the therapist’s presence is both a condition and a goal

of therapeutic change. Presence serves the dual functions of reconnecting people

to their pain and to attuning them to the opportunities to transform their pain.

a p p l i c at i o n : t h e r a p e u t i c

t e c h n i q u e s a n d p r o c e d u r e s

The existential approach is unlike most other therapies in that it is not technique-

oriented. Although existentially oriented therapists may incorporate many tech-

niques from other models, these interventions are made within the context of striv-

ing to understand the subjective world of the client. The interventions existential

practitioners employ are based on philosophical views about the nature of human

existence. These practitioners prefer description, understanding, and exploration

of the client’s subjective reality, as opposed to diagnosis, treatment, and prognosis

(van Deurzen, 2002b). As Vontress (2008) puts it: “Existential therapists prefer

to be thought of as philosophical companions, not as people who repair psyches”

(p. 161). Yalom and Josselson (2011) assert that existential therapists are “fel-

low travelers” (p. 332), willing to make themselves known through appropriate

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self-disclosure. As mentioned earlier, existential therapists are free to draw from

techniques that fl ow from many other orientations. However, they do not employ an

array of unintegrated techniques; they have a set of assumptions and attitudes that

guide their interventions with clients. See Case Approach to Counseling and Psycho-

therapy (Corey, 2013, chap. 4) for an illustration of how Dr. J. Michael Russell works

in an existential way with some key themes in the case of Ruth.

Van Deurzen (2010) identifi es as a primary ground rule of existential work the

openness to the individual creativity of the therapist and the client. She maintains

that existential therapists need to adapt their interventions to their own person-

ality and style, as well as being sensitive to what each client requires. The main

guideline is that the existential practitioner’s interventions are responsive to the

uniqueness of each client.

158

Van Deurzen (2002a, 2002b) believes that the starting point for existential

work is for practitioners to clarify their views on life and living. She stresses the

importance of therapists reaching suffi cient depth and openness in their own lives

to venture into clients’ murky waters without getting lost. The nature of existential

work is assisting people in the process of living with greater expertise and ease.

CHAPTER SIX

Van Deurzen (2010) identifi es how therapists make a difference with clients: “We

help them to get better at refl ecting on their situation, deal with their dilemma,

face their predicament and think for themselves” (p. 236). Van Deurzen reminds

us that existential therapy is a collaborative adventure in which both client and

therapist will be transformed if they allow themselves to be touched by life. When

the deepest self of the therapist meets the deepest part of the client, the counseling

process is at its best. Therapy is a creative, evolving process of discovery that can be

conceptualized in three general phases.

Phases of Existential Counseling

During the initial phase of counseling, therapists assist clients in identifying

and clarifying their assumptions about the world. Clients are invited to defi ne and

question the ways in which they perceive and make sense of their existence. They

examine their values, beliefs, and assumptions to determine their validity. This is

a diffi cult task for many clients because they may initially present their problems

as resulting almost entirely from external causes. They may focus on what other

people “make them feel” or on how others are largely responsible for their actions

or inaction. The counselor teaches them how to refl ect on their own existence and

to examine their role in creating their problems in living.

During the middle phase of existential counseling, clients are assisted in more

fully examining the source and authority of their present value system. This proc-

ess of self-exploration typically leads to new insights and some restructuring of

values and attitudes. Individuals get a better idea of what kind of life they consider

worthy to live and develop a clearer sense of their internal valuing process.

The fi nal phase of existential counseling focuses on helping people take what

they are learning about themselves and put it into action. Transformation is not

limited to what takes place during the therapy hour. The therapeutic hour is a

small contribution to a person’s renewed engagement with life, or a rehearsal

for life (van Deurzen, 2002b). The aim of therapy is to enable clients to discover

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ways of implementing their examined and internalized values in a concrete way

between sessions and after therapy has terminated. Clients typically discover their

strengths and fi nd ways to put them to the service of living a purposeful existence.

Clients Appropriate for Existential Counseling

Existential practice has been applied in a variety of settings and with a diverse pop-

ulation of clients, including those with substance abuse issues, ethnic and racial

minorities, gay and lesbian clients, and psychiatric inpatients (Schneider, 2011). A

strength of the perspective is its focus on available choices and pathways toward

personal growth. For people who are coping with developmental crises, experienc-

ing grief and loss, confronting death, or facing a major life decision, existential

therapy is especially appropriate. Some examples of these critical turning points

that mark passages from one stage of life into another are the struggle for identity

159

in adolescence, coping with possible disappointments in middle age, adjusting to

EXIS

children leaving home, coping with failures in marriage and work, and dealing

TENTIAL THERAP

with increased physical limitations as one ages. These developmental challenges

involve both dangers and opportunities. Uncertainty, anxiety, and struggling with

decisions are all part of this process.

Van Deurzen (2002b) suggests that this form of therapy is most appropriate

for clients who are committed to dealing with their problems about living, for peo-

ple who feel alienated from the current expectations of society, or for those who

Y

are searching for meaning in their lives. It tends to work well with people who

are at a crossroads and who question the state of affairs in the world and are will-

ing to challenge the status quo. It can be useful for people who are on the edge of

existence, such as those who are dying or contemplating suicide, who are working

through a developmental or situational crisis, who feel that they no longer belong

in their surroundings, or who are starting a new phase of life.

Application to Brief Therapy

The existential approach can focus clients on signifi cant areas such as assuming

personal responsibility, making a commitment to deciding and acting, and ex-

panding their awareness of their current situation. It is possible for a time-limited

approach to serve as a catalyst for clients to become actively and fully involved in

each of their therapy sessions. Strasser and Strasser (1997), who are connected to

the British school of existential analysis, maintain that there are clear benefi ts to

time-limited therapy, which mirrors the time-limited reality of human existence.

Sharp and Bugental (2001) maintain that short-term applications of the existential

approach require more structuring and clearly defi ned and less ambitious goals.

At the termination of short-term therapy, it is important for individuals to evaluate

what they have accomplished and what issues may need to be addressed later. It is

essential that both therapist and client determine that short-term work is appropri-

ate, and that benefi cial outcomes are likely.

Application to Group Counseling

An existential group can be described as people making a commitment to a lifelong

journey of self-exploration with these goals: (1) enabling members to become honest

with themselves, (2) widening their perspectives on themselves and the world

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around them, and (3) clarifying what gives meaning to their present and future life

(van Deurzen, 2002b). An open attitude toward life is essential, as is the willingness

to explore unknown territory. Recurring universal themes evolve in many groups

and challenge members to seriously explore existential concerns such as choice,

freedom and anxiety, awareness of death, meaning in life, and living fully.

Yalom (1980) contends that the group provides the optimal conditions for

therapeutic work on responsibility. The members are responsible for the way they

behave in the group, and this provides a mirror for how they are likely to act in

the world. A group represents a microcosm of the world in which participants live

and function. Over time the interpersonal and existential problems of the partici-

pants become evident in the here-and-now interactions within the group (Yalom &

Josselson, 2011). Through feedback, members learn to view themselves through

160

others’ eyes, and they learn the ways in which their behavior affects others. Build-

ing on what members learn about their interpersonal functioning in the group,

they can take increased responsibility for making changes in everyday life. The

group experience provides the opportunity to participants to relate to others in

meaningful ways, to learn to be themselves in the company of other people, and to

CHAPTER SIX

establish rewarding, nourishing relationships.

In existential group counseling, members come to terms with the paradoxes of

existence: that life can be undone by death, that success is precarious, that we are

determined to be free, that we are responsible for a world we did not choose, that

we must make choices in the face of doubt and uncertainty. Members experience

anxiety when they recognize the realities of the human condition, including pain

and suffering, the need to struggle for survival, and their basic fallibility. Clients

learn that there are no ultimate answers for ultimate concerns. Through the sup-

port that is within a group, participants are able to tap the strength needed to create

an internally derived value system that is consistent with their way of being.

A group provides a powerful context to look at oneself, and to consider what

choices might be more authentically one’s own. Members can openly share their

fears related to living in unfulfi lling ways and come to recognize how they have

compromised their integrity. Members can gradually discover ways in which they

have lost their direction and can begin to be more true to themselves. Members

learn that it is not in others that they fi nd the answers to questions about signifi -

cance and purpose in life. Existential group leaders help members live in authentic

ways and refrain from prescribing simple solutions. For a more detailed discus-

sion of the existential approach to group counseling, see Corey (2012, chap. 9).

e x i s t e n t i a l t h e r a p y f r o m a

m u lt i c u lt u r a l p e r s p e c t i v e

Strengths From a Diversity Perspective

Because the existential approach does not dictate a particular way of viewing or relat-

ing to reality, and because of its broad perspective, this approach is highly relevant in

working in a multicultural context (van Deurzen, 2002a). Vontress and colleagues

(1999) write about the existential foundation of cross-cultural counseling: “Existential

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counseling is probably the most useful approach to helping clients of all cultures fi nd

meaning and harmony in their lives, because it focuses on the sober issues each of us

must inevitably face: love, anxiety, suffering, and death” (p. 32). These are the human

experiences that transcend the boundaries that separate cultures.

Existential therapy is useful in working with culturally diverse clients because

of its focus on universality, or the common ground that we all share. This approach

emphasizes presence, the I/Thou relationship, and courage. As such, it can be

effectively applied with diverse client populations with a range of specifi c problems

and in a wide array of settings (Schneider, 2008, 2011; Schneider & Krug, 2010).

Schneider’s (2008) “existential-integrative” model of practice coordinates a variety

of therapeutic modes within an overarching existential or experiential framework.

Vontress (1996) points out that all people are multicultural in the sense that they

are all products of many cultures. He encourages counselors-in-training to focus

161

on the universal commonalities of clients fi rst and secondarily on areas of differ-

EXIS

ences. In working with cultural diversity, it is essential to recognize simultaneously

TENTIAL THERAP

the commonalities and differences of human beings: “Cross-cultural counseling,

in short, does not intend to teach specifi c interventions for each culture, but to

infuse the counselor with a cultural sensitivity and tolerant philosophical outlook

that will befi t all cultures” (p. 164).

The focus on subjective experience, or phenomenology, is a strength from a

Y

multicultural perspective. Another strength of the existential approach is that it

enables clients to examine the degree to which their behavior is being infl uenced

by social and cultural conditioning. Clients can be challenged to look at the price

they are paying for the decisions they have made. Although it is true that some

clients may not feel a sense of freedom, their freedom can be increased if they

recognize the social limits they are facing. Their freedom can be hindered by insti-

tutions and limited by their family. In fact, it may be diffi cult to separate individual

freedom from the context of their family structure.

There is wide-ranging international interest in the existential approach. Several

Scandinavian societies, an East European society (encompassing Estonia, Latvia,

Lithuania, Russia, Ukraine, and Belarus), and Mexican and South American socie-

ties are thriving. In addition, an Internet course, SEPTIMUS, is taught in Ireland,

Iceland, Sweden, Poland, Czech Republic, Romania, Italy, Portugal, France, Belgium,

the United Kingdom, Israel, and Australia. Most recently, the First International East-

West Existential Psychology conference was held in Nanjing, China, with representa-

tives from the United States, Korea, and Japan. These international developments, as

well as the creation of the International Collaborative of Existential Counselors and

Psychotherapists, which has members from all over the world, reveal that existential

therapy has wide appeal to diverse populations in many parts of the world.

Shortcomings From a Diversity Perspective

For those who hold a systemic perspective, the existentialists can be criticized on the

grounds that they are excessively individualistic and that they ignore the social factors

that cause human problems. However, with the advent of the “existential-integrative”

model of practice (Schneider, 2008), this situation is beginning to change. According

to Schneider (2011), existential practitioners are not only concerned with facilitating

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individual change but with promoting an in-depth inquiry that has implications for

social change: “One cannot simply heal individuals to the neglect of the social con-

text within which they are thrust. To be a responsible practitioner, one must develop

a vision of responsible social change alongside and in coordination with one’s vision

of individual transformation” (p. 281).

Some individuals who seek counseling may operate on the assumption that

they have very little choice because environmental circumstances severely restrict

their ability to infl uence the direction of their lives. Even if they change internal-

ly, they see little hope that the external realities of racism, discrimination, and

oppression will change. They are likely to experience a deep sense of frustration and

feelings of powerlessness when it comes to making changes outside of themselves.

As you will see in Chapter 12, feminist therapists maintain that therapeutic practice

162

will be effective only to the extent that therapists intervene with some form of social

action to change those factors that are creating clients’ problems. In working with

people of color who come from the barrio or ghetto, for example, it is important to

engage their survival issues. If a counselor too quickly puts across the message to

these clients that they have a choice in making their lives better, they may feel pa-

CHAPTER SIX

tronized and misunderstood. These real-life concerns can provide a good focus for

counseling, assuming the therapist is willing to deal with them.

A potential problem within existential theory is that it is highly focused on the

philosophical assumption of self-determination, which may not take into account

the complex factors that many people who have been oppressed must deal with. In

many cultures it is not possible to talk about the self and self-determination apart

from the context of the social network and environmental conditions. However,

a case can be made for the existential approach being instrumental in enabling

clients to make conscious choices when it comes to the values they live by. Existen-

tial therapists do not push autonomy apart from a client’s culture. They do assist

clients in critically evaluating the source of their values and making a choice rather

than uncritically accepting the values of their culture and family.

Many clients expect a structured and problem-oriented approach to counseling

that is not found in the conventional existential approach. Although clients may

feel better if they have an opportunity to talk and to be understood, they are likely to

expect the counselor to do something to bring about a change in their life situation.

A major task for the counselor who practices from an existential perspective is to

provide enough concrete direction for these clients without taking the responsibility

away from them.

Existential Therapy Applied to the Case of Stan

As an existentially oriented therapist, I

the victim of his past conditioning but can be the

counsel Stan with the assumption that

architect in redesigning his future. He can free

he has the capacity to increase his

himself of his deterministic shackles and

self-awareness and decide for himself the future

accept the responsibility that comes with

direction of his life. I want him to realize more

directing his own life. This approach emphasizes

than anything else that he does not have to be

the importance of my understanding of Stan’s

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world, primarily by establishing an authentic

experience of aloneness. He is not, however,

relationship as a means to a fuller degree of

condemned to a life of isolation, alienation from

self-understanding.

others, and loneliness. I hope to help Stan dis-

Stan is demonstrating what Sartre would call

cover his own centeredness and live by the values

“bad faith” by not accepting personal respon-

he chooses and creates for himself. By doing so,

sibility. I confront Stan with the ways in which

Stan can become a more substantial person and

he is attempting to escape from his freedom

come to appreciate himself more. When he does,

through alcohol and drugs. Eventually, I chal-

the chances are lessened that he will have a need

lenge Stan’s passivity. I reaffirm that he is now

to secure approval from others, particularly his

entirely responsible for his life, for his actions,

parents and parental substitutes. Instead of form-

and for his failure to take action. I do this in a

ing a dependent relationship, Stan could choose

supportive yet firm manner.

to relate to others out of his strength. Only then

I do not see Stan’s anxiety as something

would there be the possibility of overcoming his

negative, but as a vital part of living with uncer-

feelings of separateness and isolation.

163

tainty and freedom. Because there are no guar-

EXIS

antees and because the individual is ultimately

Follow-Up: You Continue as

TENTIAL THERAP

alone, Stan can expect to experience some degree

Stan’s Existential Therapist

of healthy anxiety, aloneness, guilt, and even

Use these questions to help you think about

despair. These conditions are not neurotic in

how you would counsel Stan using an existential

themselves, but the way in which Stan orients

approach:

himself and copes with these conditions is critical.

• If Stan resisted your attempts to help him see

Stan sometimes talks about his suicidal feel-

that he is responsible for the direction of his

Y

ings. Certainly, I investigate further to determine

life, how might you intervene?

if he poses an immediate threat to himself. In

• Stan experiences a great deal of anxiety. From

addition to this assessment to determine lethality,

an existential perspective, how do you view his

I view his thoughts of “being better off dead” as

anxiety? How might you work with his anxiety

symbolic. Could it be that Stan feels he is dying

in helpful ways?

as a person? Is Stan using his human potential?

• If Stan talks with you about suicide as a re-

Is he choosing a way of merely existing instead

sponse to despair and a life without meaning,

of affirming life? Is Stan mainly trying to elicit

how would you respond?

sympathy from his family? I invite Stan to explore

the meaning and purpose in his life. Is there any

reason for him to want to continue living? What

See the DVD for Theory and Practice of

are some of the projects that enrich his life? What

Counseling and Psychotherapy: The Case

can he do to find a sense of purpose that will

of Stan and Lecturettes (Session 4 on existential

make him feel more significant and alive?

therapy) for a demonstration of my approach

Stan needs to accept the reality that he may

to counseling Stan from this perspective. This

at times feel alone. Choosing for oneself and

session focuses on the themes of death and the

living from one’s own center accentuates the

meaning of life.

s u m m a r y a n d e va l u at i o n

Summary

As humans, according to the existentialist view, we are capable of self-awareness,

which is the distinctive capacity that allows us to refl ect and to decide. With this

awareness we become free beings who are responsible for choosing the way we live,

and we infl uence our own destiny. This awareness of freedom and responsibility

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28549_ch06_rev01.indd 163

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gives rise to existential anxiety, which is another basic human characteristic. Wheth-

er we like it or not, we are free, even though we may seek to avoid refl ecting on this

freedom. The knowledge that we must choose, even though the outcome is not cer-

tain, leads to anxiety. This anxiety is heightened when we refl ect on the reality that

we are mortal. Facing the inevitable prospect of eventual death gives the present

moment signifi cance, for we become aware that we do not have forever to accom-

plish our projects. Our task is to create a life that has meaning and purpose. As

humans we are unique in that we strive toward fashioning purposes and values that

give meaning to living. Whatever meaning our life has is developed through free-

dom and a commitment to make choices in the face of uncertainty.

Existential therapy places central prominence on the person-to-person relation-

ship. It assumes that client growth occurs through this genuine encounter. It is not

164

the techniques a therapist uses that make a therapeutic difference; rather, it is the

quality of the client–therapist relationship that heals. It is essential that therapists

reach suffi cient depth and openness in their own lives to allow them to venture

into their clients’ subjective world without losing their own sense of identity. Pres-

ence is both a condition for therapy to occur and a goal of therapy. Existential thera-

CHAPTER SIX

pists are fellow travelers, and as such they strive to be authentic and self-disclosing

in their therapy work. Because this approach focuses on the goals of therapy, ba-

sic conditions of being human, and therapy as a shared journey, practitioners are

not bound by specifi c techniques. Although existential therapists may apply tech-

niques from other orientations, their interventions are guided by a philosophical

framework about what it means to be human.

Contributions of the Existential Approach

The existential approach has helped bring the person back into central focus. It

concentrates on the central facts of human existence: self-consciousness and our

consequent freedom. To the existentialist goes the credit for providing a new view

of death as a positive force, not a morbid prospect to fear, for death gives life mean-

ing. Existentialists have contributed a new dimension to the understanding of anx-

iety, guilt, frustration, loneliness, and alienation.

I particularly appreciate the way van Deurzen (2002a) views the existential

practitioner as a mentor and fellow traveler who encourages people to refl ect upon

the problems they encounter in living. What clients need is “some assistance in

surveying the terrain and in deciding on the right route so that they can again fi nd

their way” (p. 18). According to van Deurzen, the existential approach encourages

people to live life by their own standards and values: “The aim of existential work is

to assist people in developing their talents in their own personal way, helping them

in being true to what they value” (p. 21).

One of the major contributions of the existential approach is its emphasis on

the human quality of the therapeutic relationship. This aspect lessens the chances

of dehumanizing psychotherapy by making it a mechanical process. Existential

counselors reject the notions of therapeutic objectivity and professional distance,

viewing them as being unhelpful.

I very much value the existential emphasis on freedom and responsibility

and the person’s capacity to redesign his or her life by choosing with awareness.

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28549_ch06_rev01.indd 164

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This perspective provides a sound philosophical base on which to build a personal

and unique therapeutic style because it addresses itself to the core struggles of the

contemporary person.

contributions to the integration of psychotherapies

From my perspective, the key concepts of the existential approach can be inte-

grated into most therapeutic schools. Regardless of a therapist’s orientation, the

foundation for practice can be based on existential themes. Existential psychother-

apy continues to have an enduring impact on a variety of psychological practices.

“Indeed, existential psychotherapy is in the ironic position of being one of the most

widely infl uential yet least offi cially embraced orientations on the professional

scene” (Schneider, 2008, p. 1). Bruce Wampold (2008), a leading researcher in the

psychotherapy fi eld, agrees “that an understanding of the principles of existential

165

therapy is needed by all therapists, as it adds a perspective that might . . . form the

EXIS

basis for all effective treatments” (p. 6).

TENTIAL THERAP

A key contribution is the possibility of a creative integration of the concep-

tual propositions of existential therapy with many other therapeutic orientations

(Bugental & Bracke, 1992; Schneider, 2008, 2011; Schneider & Krug, 2010). One

example of such a creative integration is provided by Dattilio (2002), who inte-

grates cognitive behavioral techniques with the themes of an existential approach.

As a cognitive behavior therapist and author, Dattilio maintains that he directs

Y

much of his efforts to “helping clients make a deep existential shift—to a new

understanding of the world” (p. 75). He uses techniques such as restructuring

of belief systems, relaxation methods, and a variety of cognitive and behavioral

strategies, but he does so within an existential framework that can begin the proc-

ess of real-life transformation. Many of his clients suffer from panic attacks or

depression. Dattilio often explores with these people existential themes of mean-

ing, guilt, hopelessness, anxiety—and at the same time he provides them with cog-

nitive behavioral tools to cope with the problems of daily living. In short, he grounds

symptomatic treatment in an existential approach.

Some people have argued that the new trend toward positive psychology is

similar to the existential approach, but this rests on a superfi cial comparison of

these two approaches. Existential therapists favor intensity and passionate experi-

ence, including that of happiness, but they equally value the darker side of human

nature and would encourage clients to learn to value both sides of their experience

(van Deurzen, 2009).

Limitations and Criticisms of the Existential Approach

A major criticism often aimed at this approach is that it lacks a systematic state-

ment of the principles and practices of psychotherapy. Some practitioners have

trouble with what they perceive as its mystical language and concepts. Some thera-

pists who claim adherence to an existential orientation describe their therapeutic

style in vague and global terms such as self-actualization, dialogic encounter, au-

thenticity, and being in the world. This particular use of language causes confusion

at times and makes it diffi cult to conduct research on the process or outcomes of

existential therapy.

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28549_ch06_rev01.indd 165

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Both beginning and advanced practitioners who are not of a philosophical turn

of mind tend to fi nd many of the existential concepts lofty and elusive. As we have

seen, this approach places primary emphasis on a subjective understanding of the

world of clients. It is assumed that techniques follow understanding. The fact that

few techniques are generated by this approach makes it essential for practitioners

to develop their own innovative procedures or to borrow from other schools of

therapy. For counselors who believe they need a specifi c set of techniques to coun-

sel effectively, this approach has limitations (Vontress, 2008).

Practitioners who prefer a counseling practice based on research contend that

the concepts should be empirically sound, that defi nitions should be operational,

that the hypotheses should be testable, and that therapeutic practice should be

based on the results of research into both the process and outcomes of counseling.

166

Certainly, the notions of manualized therapy and evidence-based practice are not

part of the existential perspective because every psychotherapy experience is unique

(Walsh & McElwain, 2002). According to Cooper (2003), existential practitioners

generally reject the idea that the therapeutic process can be measured and evalu-

ated in quantitative and empirical ways. Although existential practices are gener-

CHAPTER SIX

ally upheld by recent research on therapeutic effectiveness (see Elkins, 2009), few

studies directly evaluate and examine the existential approach. To a large extent,

existential therapy makes use of techniques from other theories, which makes it

diffi cult to apply research to this approach to study its effectiveness (Sharf, 2012).

According to van Deurzen (2002b), the main limitation of this approach is

that of the level of maturity, life experience, and intensive training required of

practitioners. Existential therapists need to be wise and capable of profound and

wide-ranging understanding of what it means to be human. Authenticity is a

cardinal characteristic of a competent existential practitioner, which is certainly

more involved than mastering a body of knowledge and acquiring technical skills.

Russell (2007) puts this notion nicely: “Authenticity means being able to sign your

own name on your work and your life. It means you will want to take responsibility

for creating your own way of being a therapist” (p.123).

w h e r e t o g o f r o m h e r e

Refer to the DVD for Integrative Counseling: The Case of Ruth and Lecturettes, Ses-

sion 11 (“Understanding How the Past Infl uences the Present and the Future”),

for a demonstration of ways I utilize existential notions in counseling Ruth. We

engage in a role play where Ruth becomes the voice of her church and I take on

a new role as Ruth—one in which I have been willing to challenge certain beliefs

from church. This segment illustrates how I assist Ruth in fi nding new values.

In Session 12 (“Working Toward Decisions and Behavioral Changes”) I challenge

Ruth to make new decisions, which is also an existential concept.

Free Podcasts for ACA Members

You can download ACA Podcasts (prerecorded interviews) at www.counseling.org;

click on the Resource button and then the Podcast Series. For Chapter 6, Existen-

tial Therapy, look for Podcast 14 by Dr. Gerald Corey.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

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28549_ch06_rev01.indd 166

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Other Resources

The American Psychological Association offers a DVD by K. J. Schneider (2009)

titled Existential-Humanistic Therapy in their Systems of Psychotherapy Video Series.

Psychotherapy.net is a comprehensive resource for students and profession-

als that offers videos and interviews on existential therapy featuring Irvin Yalom,

James Bugental, and Rollo May. New video and editorial content is made available

monthly. DVDs relevant to this chapter are available at www.psychotherapy.net

and include the following:

Bugental, J.F.T. (1995). Existential-Humanistic Psychotherapy in Action

Bugental, J. (1997). Existential-Humanistic Psychotherapy (Psychotherapy

with the Experts Series)

Bugental, J. (2008). James Bugental: Live Case Consultation

167

May, R. (2007). Rollo May on Existential Psychotherapy

EXIS

Yalom, I. (2002) The Gift of Therapy: A Conversation with Irvin Yalom, M.D.

TENTIAL THERAP

Yalom, I. (2006). Irvin Yalom: Live Case Consultation

Yalom, I. (2011) Confronting Death and Other Existential Issues in

Psychotherapy

If you are interesting in further information on Irvin Yalom, check out his website

at www.yalom.com.

Y

The Existential-Humanistic Institute, Dr. Kirk Schneider, Orah Krug, and Nader

Shabahangi

Website:www.ehinstitute.org

The Existential-Humanistic Institute’s (EHI) primary focus is training; offering

courses, and in conjunction with Saybrook University, a new certifi cate program

in existential-humanistic therapy and theory. A secondary focus is community

building. EHI was formed as a nonprofi t organization under the auspices of the

Pacifi c Institute in 1997 and provides a home for those mental health profession-

als, scholars, and students who seek in-depth training in existential-humanistic

theory and practice. EHI’s year-long certifi cate program offers graduate and post-

graduate students an opportunity to gain a basic foundation in the theory and

practice of existential-humanistic therapy. EHI offers courses on the principles of

existential-humanistic practice and case seminars in existential-humanistic theory

and practice. Most of EHI’s instructors have studied extensively with such masters

as James Bugental, Irvin Yalom, and Rollo May, and are, like Kirk Schneider and

Orah Krug, acknowledged leaders of the existential-humanistic movement today.

Society for Existential Analysis

Website: www.existentialanalysis.co.uk/

Additional Information: www.dilemmas.org

The Society for Existential Analysis is a professional organization devoted to

exploring issues pertaining to an existential/phenomenological approach to coun-

seling and therapy. Membership is open to anyone interested in this approach

and includes students, trainees, psychotherapists, philosophers, psychiatrists,

counselors, and psychologists. Members receive a regular newsletter and an

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch06_rev01.indd 167

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annual copy of the Journal of the Society for Existential Analysis. The society provides

a list of existentially oriented psychotherapists for referral purposes. The School of

Psychotherapy and Counselling at Regent’s College in London offers an advanced

diploma in existential psychotherapy as well as short courses in the fi eld.

International Society for Existential Psychotherapy and Counselling

Website: www.existentialpsychotherapy.net

The International Society for Existential Psychotherapy and Counselling was cre-

ated in London in July 2006 and was renamed International Collaborative of Exis-

tential Counselors and Psychotherapists soon after (www.icecap.org.uk). It brings

together the existing national societies as well as providing a forum for the devel-

opment and accreditation of the approach.

168

Psychotherapy Training on the Net: SEPTIMUS

Website: www.septimus.info

Additional Information: www.psychotherapytraining.net

SEPTIMUS is an Internet-based course taught in Ireland, Iceland, Sweden, Po-

land, Czech Republic, Romania, Italy, Portugal, Austria, Belgium, France, Israel,

CHAPTER SIX

Australia, and the United Kingdom.

New School of Psychotherapy and Counselling

Royal Waterloo House

51-55 Waterloo Road

London, England SE1 8TX

Telephone: +44 (0) 20 7928 43 44

E-mail: Admin@nspc.org.uk

Website: www.nspc.org.uk

The New School of Psychotherapy and Counselling (NSPC) is set up especially for

training existential therapists. It offers an MA and doctoral program in Existen-

tial Psychotherapy and Counseling together with Middlesex University, as well as

an MSC and professional doctorate in Existential Counseling Psychology and Psy-

chotherapy also jointly with Middlesex University. NSPC offers intensive courses

for distance learners (worldwide student body), including e-learning.

Recommended Supplementary Readings

Everyday Mysteries: A Handbook of Existential Psychotherapy (van Deurzen, 2010) pro-

vides a framework for practicing counseling from an existential perspective. The au-

thor puts into clear perspective topics such as anxiety, authentic living, clarifying one’s

worldview, determining values, discovering meaning, and coming to terms with life.

Existential Therapies (Cooper, 2003) provides a useful and clear introduction to

the existential therapies. There are separate chapters on logotherapy, the British

school of existential analysis, the U.S. existential-humanistic approach, dimen-

sions of existential therapeutic practice, and brief existential therapies.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch06_rev01.indd 168

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Existential Psychotherapy (Yalom, 1980) is a superb treatment of the ultimate

human concerns of death, freedom, isolation, and meaninglessness as these

issues relate to therapy. This book has depth and clarity, and it is rich with clini-

cal examples that illustrate existential themes.

Existential-Humanistic Therapy (Schneider & Krug, 2010) is a clear presentation

of the theory and practice of existential-humanistic therapy. This approach incor-

porates techniques from other contemporary therapeutic approaches.

Existential-Integrative Psychotherapy: Guideposts to the Core of Practice (Schneider,

2008) is an edited book that offers recent and future trends in existential-

integrative therapy and case illustrations of this model.

I Never Knew I Had a Choice (Corey & Corey, 2010) is a self-help book written

169

from an existential perspective. Topics include our struggle to achieve autonomy;

EXIS

the meaning of loneliness, death, and loss; and how we choose our values and

philosophy of life.

TENTIAL THERAP

References and Suggested Readings

Binswanger, L. (1975). Being-in-the-world:

integrative psychotherapy: Guideposts to the

Y

Selected papers of Ludwig Binswanger. London:

core of practice (pp. 165–168). New York:

Souvenir Press.

Routledge.

Boss, M. (1963). Daseinanalysis and psychoa-

Bugental, J.F.T., & Bracke, P. E. (1992). The fu-

nalysis. New York: Basic Books.

ture of existential-humanistic psychotherapy.

Psychotherapy, 29(l), 28–33.

Buber, M. (1970). I and thou (W. Kaufmann,

Trans.). New York: Scribner’s.

*Cooper, M. (2003). Existential therapies.

London: Sage.

Bugental, J.F.T. (1986). Existential-humanistic

psychotherapy. In I. L. Kutash & A. Wolf (Eds.),

Corey, G. (2012). Theory and practice of group

Psychotherapist’s casebook (pp. 222–236). San

counseling (8th ed.). Belmont, CA: Brooks/

Francisco: Jossey-Bass.

Cole, Cengage Learning.

*Bugental, J.F.T. (1987). The art of the psycho-

*Corey, G. (2013). Case approach to counseling

therapist. New York: Norton.

and psychotherapy (8th ed.). Belmont, CA:

Brooks/Cole, Cengage Learning.

Bugental, J.F.T. (1997). There is a fundamental

division in how psychotherapy is conceived. In

*Corey, G., & Corey, M. (2010). I never knew I

J. K. Zeig (Ed.), The evolution of psychotherapy:

had a choice (9th ed.). Belmont, CA: Brooks/

The third conference (pp. 185–196). New York:

Cole, Cengage Learning.

Brunner/Mazel.

Dattilio, F. M. (2002, January-February).

*Bugental, J.F.T. (1999). Psychotherapy isn’t

Cognitive-behaviorism comes of age: Ground-

what you think: Bringing the psychotherapeutic

ing symptomatic treatment in an existential

engagement into the living moment. Phoenix,

approach. The Psychotherapy Networker, 26(1),

AZ: Zeig, Tucker.

75–78.

Bugental, J.F.T. (2008). Preliminary sketches

*Deurzen, E., van. (2002a). Existential counsel-

for a short-term existential-humanistic

ling and psychotherapy in practice (2nd ed.).

therapy. In K. J. Schneider (Ed.), Existential-

London: Sage.

*Books and articles marked with an asterisk are suggested for further study.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch06_rev01.indd 169

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*Deurzen, E., van. (2002b). Existential therapy.

May, R., Angel, E., & Ellenberger, H. F. (Eds.).

In W. Dryden (Ed.), Handbook of individual

(1958). Existence: A new dimension in psychiatry

therapy (4th ed., pp. 179–208). London: Sage.

and psychology. New York: Basic Books.

Deurzen, E., van. (2009). Psychotherapy and

Russell, J. M. (1978). Sartre, therapy, and

the quest for happiness. London: Sage.

expanding the concept of responsibility.

American Journal of Psychoanalysis, 38, 259–269.

*Deurzen, E., van. (2010). Everyday mysteries: A

handbook of existential psychotherapy (2nd ed).

*Russell, J. M. (2007). Existential psychother-

London: Routledge.

apy. In A. B. Rochlen (Ed.), Applying coun-

seling theories: An online case-based approach

*Elkins, D. N. (2009). Humanistic psychology:

(pp. 107–125). Upper Saddle River, NJ: Pear-

A clinical manifesto. Colorado Springs, CO:

son Prentice-Hall.

University of the Rockies Press.

Sartre, J. P. (1971). Being and nothingness.

Farha, B. (1994). Ontological awareness: An

New York: Bantam Books.

170

existential/cosmological epistemology. The

Person-Centered Periodical, 1(1), 15–29.

*Schneider, K. J. (Ed.). (2008). Existential-

integrative psychotherapy: Guideposts to the core

*Frankl, V. (1963). Man’s search for meaning.

of practice. New York: Routledge.

Boston: Beacon.

*Schneider, K. J. (2011). Existential-humanistic

*Frankl, V. (1965). The doctor and the soul.

psychotherapies. In S. B. Messer & A. S.

CHAPTER SIX

New York: Bantam Books.

Gurman, (Eds.), Essential psychotherapies:

*Frankl, V. (1978). The unheard cry for

Theory and practice (3rd ed., pp. 261–294).

meaning. New York: Simon & Schuster

New York: Guilford Press.

(Touchstone).

*Schneider, K. J., & Krug, O. T. (2010). Exis-

Gould, W. B. (1993). Viktor E. Frankl: Life with

tential-humanistic therapy. Washington, DC:

meaning. Pacific Grove, CA: Brooks/Cole.

American Psychological Association.

Heidegger, M. (1962). Being and time.

*Schneider, K. J., & May, R. (Eds.). (1995). The

New York: Harper & Row.

psychology of existence: An integrative, clinical

perspective. New York: McGraw-Hill.

May, R. (1950). The meaning of anxiety.

New York: Ronald Press.

Sharf, R. S. (2012). Theories of psychotherapy

and counseling: Concepts and cases (5th ed.).

*May, R. (1953). Man’s search for himself.

Belmont, CA: Brooks/Cole, Cengage

New York: Dell.

Learning.

May, R. (1958). The origins and significance

*Sharp, J. G., & Bugental, J.F.T. (2001). Existen-

of the existential movement in psychology. In

tial-humanistic psychotherapy. In R. J. Corsini

R. May, E. Angel, & H. R. Ellenberger (Eds.),

(Ed.), Handbook of innovative therapies (2nd ed.,

Existence: A new dimension in psychiatry and

pp. 206–217). New York: Wiley.

psychology. New York: Basic Books.

*Strasser, F., & Strasser, A. (1997). Existential

*May, R. (Ed.). (1961). Existential psychology.

time-limited therapy: The wheel of existence.

New York: Random House.

Chichester: Wiley.

May, R. (1969). Love and will. New York: Norton.

Tillich, P. (1952). The courage to be. New

May, R. (1975). The courage to create.

Haven, CT: Yale University Press.

New York: Norton.

*Vontress, C. E. (1996). A personal retrospec-

May, R. (1981). Freedom and destiny. New York:

tive on cross-cultural counseling. Journal

Norton.

of Multicultural Counseling and Development,

24(3), 156–166.

*May, R. (1983). The discovery of being:

Writings in existential psychology. New York:

*Vontress, C. E. (2008). Existential therapy. In

Norton.

J. Frew & M. D. Spiegler (Eds.), Contemporary

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch06_rev01.indd 170

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psychotherapies for a diverse world

*Yalom, I. D. (1987). Love’s executioner: And

(pp. 141–176). Boston: Lahaska Press.

other tales of psychotherapy. New York: Harper

Perennial.

*Vontress, C. E., Johnson, J. A., & Epp, L. R.

(1999). Cross-cultural counseling: A casebook.

Yalom, I. D. (1992). When Nietzche wept.

Alexandria, VA: American Counseling

New York: Basic Books.

Association.

*Yalom, I. D. (1997). Lying on the couch: A novel.

*Walsh, R. A., & McElwain, B. (2002). Existen-

New York: Harper Perennial.

tial psychotherapies. In D. J. Cain & J. Seeman

*Yalom, I. D. (2000). Momma and the meaning

(Eds.), Humanistic psychotherapies: Handbook

of life: Tales of psychotherapy. New York: Harper

of research and practice (pp. 253–278).

Perennial.

Washington, DC: American Psychological

Association.

*Yalom, I. D. (2003). The gift of therapy: An open

letter to a new generation of therapists and their

*Watson, J. C., Goldman, R. N., & Greenberg,

patients. New York: HarperCollins (Perennial).

171

L. S. (2011). Humanistic and experiential

EXIS

theories in psychotherapy. In J. C. Norcross, G.

Yalom, I. D. (2005a). The Schopenhauer cure: A

R. Vandenbos, & D. K. Freedheim (Eds.), History

novel. New York: HarperCollins.

TENTIAL THERAP

of psychotherapy (2nd ed., pp. 141–172).

*Yalom, I. D. (with Leszcz, M). (2005b). The

Washington, DC: American Psychological

theory and practice of group psychotherapy (5th

Association.

ed.). New York: Basic Books. (Original work

Wampold, B. (2008, February 6). Existential-

published 1970)

integrative psychotherapy comes of age

*Yalom, I. D. (2008). Staring at the sun: Overcom-

Y

[Review of Existential-integrative psycho-

ing the terror of death. San Francisco: Jossey-Bass.

therapy: Guideposts to the core of

practice]. PsycCritiques, 53, Release 6,

*Yalom, I. D., & Josselson, R. (2011). Existential

Article 1, p. 6.

psychotherapy. In R. Corsini & D. Wedding (Eds.),

Current psychotherapies (9th ed., pp. 310–341).

*Yalom, I. D. (1980). Existential psychotherapy.

Belmont, CA: Brooks/Cole, Cengage Learning.

New York: Basic Books.

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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c h a p t e r 7

Person-Centered Therapy

i n t r o d u c t i o n

m o t i vat i o n a l i n t e r v i e w i n g

• Four Periods of Development of the Approach

• The MI Spirit

• Existentialism and Humanism

• The Basic Principles of Motivational

• Abraham Maslow’s Contributions to

Interviewing

Humanistic Psychology

• The Stages of Change

k e y c o n c e p t s

p e r s o n - c e n t e r e d t h e r a p y f r o m

• View of Human Nature

a m u lt i c u lt u r a l p e r s p e c t i v e

• Strengths From a Diversity Perspective

t h e t h e r a p e u t i c p r o c e s s

• Shortcomings From a Diversity

• Therapeutic Goals

Perspective

• Therapist’s Function and Role

• Client’s Experience in Therapy

p e r s o n - c e n t e r e d t h e r a p y a p p l i e d

• Relationship Between Therapist and Client

t o t h e c a s e o f s ta n

a p p l i c at i o n : t h e r a p e u t i c

s u m m a ry a n d e va l u at i o n

t e c h n i q u e s a n d p r o c e d u r e s

• Summary

•

• Early Emphasis on Refl ection of Feelings

Early Emphasis on Refl ecti

• Contributions of the Person-Centered

•

• Evolution of Person-Centered Methods

Evolution of Pe

Approach

•

• The Role of Assessment

The Rol

f Assessment

• Limitations and Criticisms of the Person-

•

• Application of the Philosophy of the

App cation of the Philosophy of th

Centered Approach

Person-Centered Approach

Pe son-Centered Approach

w h e r e t o g o f r o m h e r e

•

• Application to Crisis Intervention

A plication to Crisis Intervention

•

• Recommended Supplementary Readings

Recom

mentary Read

• Application to Group Counseling

App cation to Gro

plication to Group Counseling

•

• References and Suggested Readings

Referenc

and Suggested Readings

p e r s o n - c e n t e r e d e x p r e s s i v e

a r t s t h e r a p y

•

• Principles of Expressive Arts Therapy

Princ

es of Exp essive Arts Th

•

• Creativity and Offering Stimulating Experiences

Creati

y and Of ring Stimulati

es

•

• Contributions of Natalie Rogers

Contr

C

butions of atalie Rogers

172

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch07_rev01.indd 172

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Carl Rogers

CARL ROGERS (1902–1987),

have far-reaching effects on the field of psycho-

a major spokesperson for

therapy (Cain, 2010).

humanistic psychology, led a

It is difficult to overestimate the significance

life that reflected the ideas he

of Rogers’s contributions to clinical and counseling

developed for half a century.

psychology. He was a courageous pioneer who

He showed a questioning

“was about 50 years ahead of his time and has

stance, a deep openness to

been waiting for us to catch up” (Elkins, 2009,

Ressmeyer/Corbis

change, and the courage to

p. 20). Often called the “father of psychotherapy

Roger

©

forge into unknown territory

research,” Rogers was the first to study the coun-

both as a person and as a professional. In writ-

seling process in depth by analyzing the transcripts

ing about his early years, Rogers (1961) recalled

of actual therapy sessions; he was the first clinician

his family atmosphere as characterized by close

to conduct major studies on psychotherapy using

173

PERSON-CENTERED THERAP

and warm relationships but also by strict religious

quantitative methods; he was the first to formulate

standards. Play was discouraged, and the virtues

a comprehensive theory of personality and psy-

of the Protestant ethic were extolled. His boyhood

chotherapy grounded in empirical research; and he

was somewhat lonely, and he pursued scholarly

contributed to developing a theory of psychother-

interests instead of social ones. Rogers was an

apy that de-emphasized pathology and focused on

introverted person, and he spent a lot of time

the strengths and resources of individuals. He was

reading and engaging in imaginative activity and

not afraid to take a strong position and challenged

reflection. During his college years his interests and

the status quo throughout his professional career.

academic major changed from agriculture to history,

During the last 15 years of his life, Rogers ap-

plied the person-centered approach to world peace

Y

then to religion, and finally to clinical psychology.

Rogers held academic positions in various

by training policymakers, leaders, and groups in

fields, including education, social work, coun-

conflict. Perhaps his greatest passion was directed

seling, psychotherapy, group therapy, peace, and

toward the reduction of interracial tensions and

interpersonal relations, and he earned recognition

the effort to achieve world peace, for which he was

around the world for originating and developing

nominated for the Nobel Peace Prize.

the humanistic movement in psychotherapy. His

For a detailed video presentation of the life and

foundational ideas, especially the central role of the

works of Carl Rogers, see Carl Rogers: A Daughter’s

client–therapist relationship as a means to growth

Tribute (CD ROM, 2002) , which is described at the

and change, have been incorporated by many other

end of this chapter. See also Carl Rogers: The Quiet

theoretical approaches. Rogers was a pioneer

Revolutionary (Rogers & Russell, 2002) and The Life

whose groundbreaking discoveries continue to

and Work of Carl Rogers (Kirschenbaum, 2009).

i n t r o d u c t i o n

Of all the pioneers who have founded a therapeutic approach, for me Carl Rogers

stands out as one of the most infl uential fi gures in revolutionizing the direction of

counseling theory and practice. Rogers has become known as a “quiet revolution-

ary” who both contributed to theory development and whose infl uence continues to

shape counseling practice today (see Cain, 2010; Kirschenbaum, 2009; Rogers &

Russell, 2002).

The person-centered approach shares many concepts and values with the

existential perspective presented in Chapter 6. Rogers’s basic assumptions are

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28549_ch07_rev01.indd 173

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that people are essentially trustworthy, that they have a vast potential for under-

standing themselves and resolving their own problems without direct interven-

tion on the therapist’s part, and that they are capable of self-directed growth if

they are involved in a specifi c kind of therapeutic relationship. From the begin-

ning, Rogers emphasized the attitudes and personal characteristics of the thera-

pist and the quality of the client–therapist relationship as the prime determi-

nants of the outcome of the therapeutic process. He consistently relegated to

a secondary position matters such as the therapist’s knowledge of theory and

techniques. This belief in the client’s capacity for self-healing is in contrast with

many theories that view the therapist’s techniques as the most powerful agents

that lead to change (Bohart & Tallman, 2010). Clearly, Rogers revolutionized the

fi eld of psychotherapy by proposing a theory that centered on the client as the

174

primary agent for constructive self-change (Bohart & Tallman, 2010; Bozarth,

Zimring, & Tausch, 2002).

Contemporary person-centered therapy is the result of an evolutionary process

that continues to remain open to change and refi nement (see Cain, 2010; Cain &

Seeman, 2002). Rogers did not present the person-centered theory as a fi xed and

completed approach to therapy. He hoped that others would view his theory as

CHAPTER SEVEN

a set of tentative principles relating to how the therapy process develops, not as

dogma. Rogers expected his model to evolve and was open and receptive to change.

See the video program for Chapter 7, DVD for Theory and Practice of Counseling

and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view

the brief lecture for each chapter prior to reading the chapter.

Four Periods of Development of the Approach

In tracing the major turning points in Rogers’s approach, Zimring and Raskin

(1992) and Bozarth, Zimring, and Tausch (2002) have identifi ed four periods of

development. In the fi rst period, during the 1940s, Rogers developed what was

known as nondirective counseling, which provided a powerful and revolutionary

alternative to the directive and interpretive approaches to therapy then being prac-

ticed. While he was a professor at Ohio State University, Rogers (1942) published

Counseling and Psychotherapy: Newer Concepts in Practice, which described the phi-

losophy and practice of nondirective counseling. Rogers’s theory emphasized the

counselor’s creation of a permissive and nondirective climate. His theory took

power away from the therapist and honored the inherent power of the client. When

he challenged the basic assumption that “the counselor knows best,” he realized

this radical idea would affect the power dynamics and politics of the counseling

profession, and indeed it caused a great furor (Elkins, 2009).

Rogers also challenged the validity of commonly accepted therapeutic proce-

dures such as advice, suggestion, direction, persuasion, teaching, diagnosis, and

interpretation. Based on his conviction that diagnostic concepts and procedures

were inadequate, prejudicial, and often misused, Rogers omitted them from his

approach. Nondirective counselors avoided sharing a great deal about themselves

with clients and instead focused mainly on refl ecting and clarifying the clients’

verbal and nonverbal communications.

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In the second period, during the 1950s, Rogers (1951) wrote Client-Centered

Therapy and renamed his approach client-centered therapy, to refl ect its emphasis

on the client rather than on nondirective methods. In addition, he started the Coun-

seling Center at the University of Chicago. This period was characterized by a shift

from clarifi cation of feelings to a focus on the phenomenological world of the client.

Rogers assumed that the best vantage point for understanding how people behave

was from their own internal frame of reference. He focused more explicitly on the

actualizing tendency as the basic motivational force that leads to client change.

The third period, which began in the late 1950s and extended into the 1970s,

addressed the necessary and suffi cient conditions of therapy. Rogers (1957) set

forth a hypothesis that resulted in three decades of research. A signifi cant pub-

lication was On Becoming a Person (Rogers, 1961), which addressed the nature of

“becoming the self that one truly is,” an idea he borrowed from Kierkegaard. Rogers

175

published this work during the time that he held joint appointments in the depart-

PERSON-CENTERED THERAP

ments of psychology and psychiatry at the University of Wisconsin. In this book he

described the process of “becoming one’s experience,” which is characterized by

an openness to experience, a trust in one’s experience, an internal locus of evalua-

tion, and the willingness to be in process. During the 1950s and 1960s, Rogers and

his associates continued to test the underlying hypotheses of the client-centered

approach by conducting extensive research on both the process and the outcomes

of psychotherapy. He was interested in how people best progress in psychotherapy,

and he studied the qualities of the client–therapist relationship as a catalyst lead-

Y

ing to personality change. On the basis of this research the approach was further

refi ned and expanded (Rogers, 1961). For example, client-centered philosophy was

applied to education and was called student-centered teaching (Rogers & Freiberg,

1994). The approach was also applied to encounter groups (Rogers, 1970).

The fourth phase, during the 1980s and the 1990s, was marked by considerable

expansion to education, couples and families, industry, groups, confl ict resolution,

politics, and the search for world peace. Because of Rogers’s ever-widening scope

of infl uence, including his interest in how people obtain, possess, share, or surren-

der power and control over others and themselves, his theory became known as the

person-centered approach. This shift in terms refl ected the broadening application

of the approach. Although the person-centered approach has been applied mainly

to individual and group counseling, important areas of further application include

education, family life, leadership and administration, organizational development,

health care, cross-cultural and interracial activity, and international relations. It

was during the 1980s that Rogers directed his efforts toward applying the person-

centered approach to politics, especially to efforts related to the achievement of

world peace.

In a comprehensive review of the research on person-centered therapy over a

period of 60 years, Bozarth, Zimring, and Tausch (2002) concluded the following:

• In the earliest years of the approach, the client rather than the therapist deter-

mined the direction and goals of therapy and the therapist’s role was to help

the client clarify feelings. This style of nondirective therapy was associated with

increased understanding, greater self-exploration, and improved self-concepts.

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• Later a shift from clarifi cation of feelings to a focus on the client’s lived experi-

ences took place. Many of Rogers’s hypotheses were confi rmed, and there was

strong evidence for the value of the therapeutic relationship and the client’s

resources as the crux of successful therapy.

• As person-centered therapy developed further, research centered on the core

conditions assumed to be both necessary and suffi cient for successful therapy.

The attitude of the therapist—an empathic understanding of the client’s world

and the ability to communicate a nonjudgmental stance to the client—along

with the therapist’s genuineness were found to be basic to a successful therapy

outcome.

• The main source of successful psychotherapy is the client. The therapist’s atten-

tion to the client’s frame of reference fosters the client’s utilization of inner and

176

outer resources.

Existentialism and Humanism

In the 1960s and 1970s there was a growing interest among counselors in a “third

force” in therapy as an alternative to the psychoanalytic and behavioral approaches.

Under this heading fall existential therapy (Chapter 6), person-centered therapy

(Chapter 7), Gestalt therapy (Chapter 8), and certain other experiential and rela-

CHAPTER SEVEN

tionship-oriented approaches.

Partly because of this historical connection and partly because representatives

of existentialist thinking and humanistic thinking have not always clearly sorted

out their views, the connections between the terms existentialism and humanism

have tended to be confusing for students and theorists alike. The two viewpoints

have much in common, yet there also are signifi cant philosophical differences

between them. They share a respect for the client’s subjective experience, the

uniqueness and individuality of each client, and a trust in the capacity of the cli-

ent to make positive and constructive conscious choices. They have in common

an emphasis on concepts such as freedom, choice, values, personal responsibility,

autonomy, purpose, and meaning. Both approaches place little value on the role

of techniques in the therapeutic process and emphasize instead the importance of

genuine encounter. They differ in that existentialists take the position that we are

faced with the anxiety of choosing to create an identity in a world that lacks intrinsic

meaning. Existentialists tend to acknowledge the stark realities of human experi-

ence, and their writings often focus on death, anxiety, depression, and isolation.

The humanists, in contrast, take the somewhat less anxiety-evoking position and

more optimistic view that each of us has a natural potential that we can actualize

and through which we can fi nd meaning. Many contemporary existential therapists

refer to themselves as existential-humanistic practitioners, indicating that their roots

are in existential philosophy but that they have incorporated many aspects of North

American humanistic psychotherapies (Cain, 2002a; Schneider & Krug, 2010).

As will become evident in this chapter, the existential and person-centered

approaches have parallel concepts with regard to the client–therapist relationship at

the core of therapy. The phenomenological emphasis that is basic to the existentialist

approach is also fundamental to person-centered theory. Both approaches focus on

the client’s perceptions and call for the therapist to be fully present with the client

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28549_ch07_rev01.indd 176

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so that it is possible to understand the client’s subjective world, and they both em-

phasize the client’s capacity for self-awareness and self-healing. The therapist aims

to provide the client with a safe, responsive, and caring relationship to facilitate self-

exploration, growth, and healing (Watson, Goldman, & Greenberg, 2011).

Abraham Maslow’s Contributions

to Humanistic Psychology

Abraham Maslow (1970) was a pioneer in the development of humanistic psychol-

ogy and was infl uential in furthering the understanding of self-actualizing indi-

viduals. Many of Carl Rogers’s ideas, especially on the positive aspects of being

human and the fully functioning person, are built on Maslow’s basic philosophy.

Maslow criticized Freudian psychology for what he saw as its preoccupation with

the sick and negative side of human nature. Maslow believed too much research

177

was being conducted on anxiety, hostility, and neuroses and too little into joy, crea-

PERSON-CENTERED THERAP

tivity, and self-fulfi llment. Self-actualization was the central theme of the work

of Abraham Maslow (1968, 1970, 1971). The positive psychology movement that

recently has come into prominence shares many concepts on the healthy side of

human existence with the humanistic approach.

Maslow studied what he called “self-actualizing people” and found that they

differed in important ways from so-called normal individuals. The core character-

istics of self-actualizing people are self-awareness, freedom, basic honesty and car-

ing, and trust and autonomy. Other characteristics of self-actualizing individuals

Y

include a capacity to welcome uncertainty in their lives, acceptance of themselves

and others, spontaneity and creativity, a need for privacy and solitude, autonomy,

a capacity for deep and intense interpersonal relationships, a genuine caring for

others, an inner-directedness (as opposed to the tendency to live by others’ expec-

tations), the absence of artifi cial dichotomies within themselves (such as work/

play, love/hate, and weak/strong), and a sense of humor (Maslow, 1970). All of

these personal characteristics have been identifi ed by Rogers as being central to

the person-centered philosophy.

Maslow postulated a hierarchy of needs as a source of motivation, with the most

basic needs being physiological needs. If we are hungry and thirsty, our attention

is riveted on meeting these basic needs. Next are the safety needs, which include

a sense of security and stability. Once our physical and safety needs are fulfi lled,

we become concerned with meeting our needs for belonging and love, followed by

working on our need for esteem, both from self and others. We are able to strive

toward self-actualization only after these four basic needs are met. The key factor

determining which need is dominant at a given time is the degree to which those

below it are satisfi ed. We cannot strive toward self-actualization, for example, if our

self-esteem is low.

t h e v i s i o n o f h u m a n i s t i c p h i lo s o p h y The underlying vision of

humanistic philosophy is captured by the metaphor of how an acorn, if provided

with the appropriate conditions, will “automatically” grow in positive ways, pushed

naturally toward its actualization as an oak. In contrast, for many existentialists

there is nothing that we “are,” no internal “nature” we can count on. We are faced

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28549_ch07_rev01.indd 177

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at every moment with a choice about what to make of this condition. Maslow’s em-

phasis on the healthy side of being human and the emphasis on joy, creativity, and

self-fulfi llment are part of the person-centered philosophy. The humanistic phi-

losophy on which the person-centered approach rests is expressed in attitudes and

behaviors that create a growth-producing climate. According to Rogers (1986b),

when this philosophy is lived, it helps people develop their capacities and stimu-

lates constructive change in others. Individuals are empowered, and they are able

to use this power for personal and social transformation.

k e y c o n c e p t s

View of Human Nature

178

A common theme originating in Rogers’s early writing and continuing to permeate

all of his works is a basic sense of trust in the client’s ability to move forward in a

constructive manner if conditions fostering growth are present. His professional

experience taught him that if one is able to get to the core of an individual, one fi nds

a trustworthy, positive center (Rogers, 1987a). In keeping with the philosophy of

humanistic psychology, Rogers fi rmly maintained that people are trustworthy, re-

CHAPTER SEVEN

sourceful, capable of self-understanding and self-direction, able to make construc-

tive changes, and able to live effective and productive lives. When therapists are able

to experience and communicate their realness, support, caring, and nonjudgmental

understanding, signifi cant changes in the client are most likely to occur.

Rogers maintained that three therapist attributes create a growth-promoting

climate in which individuals can move forward and become what they are capable

of becoming: (1) congruence (genuineness, or realness), (2) unconditional positive

regard (acceptance and caring), and (3) accurate empathic understanding (an ability to

deeply grasp the subjective world of another person). According to Rogers, if thera-

pists communicate these attitudes, those being helped will become less defensive

and more open to themselves and their world, and they will behave in prosocial

and constructive ways.

Brodley (1999) writes about the actualizing tendency, a directional process of

striving toward realization, fulfi llment, autonomy, and self-determination. This nat-

ural inclination of humans is based on Maslow’s (1970) studies of self-actualizing

people. This growth force within us provides an internal source of healing, but it

does not imply a movement away from relationships, interdependence, connec-

tion, or socialization. This humanistic view of human nature has signifi cant im-

plications for the practice of therapy. Because of the belief that the individual has

an inherent capacity to move away from maladjustment and toward psychological

health and growth, the therapist places the primary responsibility on the client.

The person-centered approach rejects the role of the therapist as the authority who

knows best and of the passive client who merely follows the beliefs of the therapist.

Therapy is rooted in the client’s capacity for awareness and self-directed change in

attitudes and behavior.

In the person-centered approach the emphasis is on how clients act in their

world with others, how they can move forward in constructive directions, and how

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28549_ch07_rev01.indd 178

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they can successfully deal with obstacles (both from within themselves and outside

of themselves) that are blocking their growth. By promoting self-awareness and

self-refl ection, clients learn to exercise choice. Humanistic therapists emphasize

a discovery-oriented approach in which clients are the experts on their own inner

experience (Watson, Goldman, & Greenberg, 2011), and they encourage clients to

make changes that will lead to living fully and authentically, with the realization

that this kind of existence demands a continuing struggle. Maslow taught us that

becoming self-actualizing individuals is an ongoing process rather than a fi nal

destination.

t h e t h e r a p e u t i c p r o c e s s

Therapeutic Goals

179

The person-centered approach aims toward the client achieving a greater degree

PERSON-CENTERED THERAP

of independence and integration. Its focus is on the person, not on the person’s

presenting problem. Rogers did not believe the goal of therapy was merely to solve

problems. Rather, the goal is to assist clients in their growth process so clients can

better cope with problems as they identify them.

Rogers (1961) wrote that people who enter psychotherapy often ask: “How can

I discover my real self? How can I become what I deeply wish to become? How can

I get behind my facades and become myself?” The underlying aim of therapy is to

provide a climate conducive to helping the individual strive toward self-actualiza-

Y

tion. Before clients are able to work toward that goal, they must fi rst get behind the

masks they wear, which they develop through the process of socialization. Clients

come to recognize that they have lost contact with themselves by using facades. In

a climate of safety in the therapeutic session, they also come to realize that there

are more authentic ways of being.

When the facades are put aside during the therapeutic process, what kind of

person emerges from behind the pretenses? Rogers (1961) described people who

are becoming increasingly actualized as having (1) an openness to experience,

(2) a trust in themselves, (3) an internal source of evaluation, and (4) a willingness

to continue growing. Encouraging these characteristics is the basic goal of person-

centered therapy.

These four characteristics provide a general framework for understanding the

direction of therapeutic movement. The therapist does not choose specifi c goals

for the client. The cornerstone of person-centered theory is the view that clients

in a relationship with a facilitating therapist have the capacity to defi ne and clarify

their own goals. Person-centered therapists are in agreement on the matter of not

setting goals for what clients need to change, yet they differ on the matter of how to

best help clients achieve their own goals and to fi nd their own answers (Bohart &

Watson, 2011).

Therapist’s Function and Role

The role of person-centered therapists is rooted in their ways of being and atti-

tudes, not in techniques designed to get the client to “do something.” Research on

person-centered therapy seems to indicate that the attitude of therapists, rather than

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28549_ch07_rev01.indd 179

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their knowledge, theories, or techniques, facilitate personality change in the client

(Rogers, 1961). Basically, therapists use themselves as an instrument of change.

When they encounter the client on a person-to-person level, their “role” is to be

without roles. They do not get lost in a professional role. It is the therapist’s attitude

and belief in the inner resources of the client that creates the therapeutic climate for

growth (Bozarth et al., 2002).

Thorne (2002a) reinforces the importance of therapists encountering clients

in a person-to-person way, as opposed to being overly reliant on a professional con-

tract. He cautions about retreating into a stance of pseudo-professionalism charac-

terized by presenting a detailed contract to clients, rigid observation of boundaries,

and the commitment to empirically validated methods. He suggests that this over-

emphasis on professionalism is aimed at protecting therapists from overinvolve-

180

ment with clients, which often results in underinvolvement with them.

Person-centered theory holds that the therapist’s function is to be present and

accessible to clients and to focus on their immediate experience. First and fore-

most, the therapist must be willing to be real in the relationship with clients. By

being congruent, accepting, and empathic, the therapist is a catalyst for change. In-

stead of viewing clients in preconceived diagnostic categories, the therapist meets

CHAPTER SEVEN

them on a moment-to-moment experiential basis and enters their world. Through

the therapist’s attitude of genuine caring, respect, acceptance, support, and un-

derstanding, clients are able to loosen their defenses and rigid perceptions and

move to a higher level of personal functioning. When these therapist attitudes are

present, clients then have the necessary freedom to explore areas of their life that

were either denied to awareness or distorted.

Client’s Experience in Therapy

Therapeutic change depends on clients’ perceptions both of their own experience

in therapy and of the counselor’s basic attitudes. If the counselor creates a cli-

mate conducive to self-exploration, clients have the opportunity to explore the full

range of their experience, which includes their feelings, beliefs, behavior, and

worldview. What follows is a general sketch of clients’ experiences in therapy.

Clients come to the counselor in a state of incongruence; that is, a discrepancy

exists between their self-perception and their experience in reality. For example,

Leon, a college student, may see himself as a future physician, yet his below-aver-

age grades could exclude him from medical school. The discrepancy between how

Leon sees himself (self-concept) or how he would like to view himself (ideal self-

concept) and the reality of his poor academic performance may result in anxiety

and personal vulnerability, which can provide the necessary motivation to enter

therapy. Leon must perceive that a problem exists or, at least, that he is uncomfort-

able enough with his present psychological adjustment to want to explore possibili-

ties for change.

One reason clients seek therapy is a feeling of basic helplessness, powerless-

ness, and an inability to make decisions or effectively direct their own lives. They

may hope to fi nd “the way” through the guidance of the therapist. Within the per-

son-centered framework, however, clients soon learn that they can be responsible

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for themselves in the relationship and that they can learn to be more free by using

the relationship to gain greater self-understanding.

As counseling progresses, clients are able to explore a wider range of beliefs and

feelings. They can express their fears, anxiety, guilt, shame, hatred, anger, and other

emotions that they had deemed too negative to accept and incorporate into their

self-structure. With therapy, people distort less and move to a greater acceptance and

integration of confl icting and confusing feelings. They increasingly discover aspects

within themselves that had been kept hidden. As clients feel understood and accepted,

they become less defensive and become more open to their experience. Because they

feel safer and are less vulnerable, they become more realistic, perceive others with

greater accuracy, and become better able to understand and accept others. Individuals

in therapy come to appreciate themselves more as they are, and their behavior shows

more fl exibility and creativity. They become less concerned about meeting others’

181

expectations, and thus begin to behave in ways that are truer to themselves. These

PERSON-CENTERED THERAP

individuals direct their own lives instead of looking outside of themselves for

answers. They move in the direction of being more in contact with what they are

experiencing at the present moment, less bound by the past, less determined, freer to

make decisions, and increasingly trusting in themselves to manage their own lives.

In short, their experience in therapy is like throwing off the self-imposed shackles

that had kept them in a psychological prison. With increased freedom they tend to

become more mature psychologically and move toward increased self-actualization.

Person-centered therapy is grounded on the assumption that it is clients who

Y

heal themselves, who create their own self-growth, and who are active self-healers

(Bohart & Tallman, 1999, 2010; Bohart & Watson, 2011). The therapy relationship

provides a supportive structure within which clients’ self-healing capacities are

activated. What clients value most is being understood and accepted, which results

in creating a safe place to explore feelings, thoughts, behaviors, and experiences;

clients also value support for trying out new behaviors (Bohart & Tallman, 2010).

Relationship Between Therapist and Client

Rogers (1957) based his hypothesis of the “necessary and suffi cient conditions for

therapeutic personality change” on the quality of the relationship: “If I can provide

a certain type of relationship, the other person will discover within himself or her-

self the capacity to use that relationship for growth and change, and personal devel-

opment will occur” (Rogers, 1961, p. 33). Rogers (1967) hypothesized further that

“signifi cant positive personality change does not occur except in a relationship”

(p. 73). Rogers’s hypothesis was formulated on the basis of many years of his pro-

fessional experience, and it remains basically unchanged to this day. This hypoth-

esis (cited in Cain 2002a, p. 20) is stated thusly:

1. Two persons are in psychological contact.

2. The fi rst, whom we shall term the client, is in a state of incongruence, being

vulnerable or anxious.

3.

The second person, whom we term the therapist, is congruent (real or genuine)

in the relationship.

4. The therapist experiences unconditional positive regard for the client.

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5. The therapist experiences an empathic understanding of the client’s internal

frame of reference and endeavors to communicate this experience to the client.

6. The communication to the client of the therapist’s empathic understanding and

unconditional positive regard is to a minimal degree achieved.

Rogers hypothesized that no other conditions were necessary. If the therapeutic

core conditions exist over some period of time, constructive personality change

will occur. The core conditions do not vary according to client type. Further, they

are both necessary and suffi cient for therapeutic change to occur.

From Rogers’s perspective the client–therapist relationship is characterized by

equality. Therapists do not keep their knowledge a secret or attempt to mystify the

therapeutic process. The process of change in the client depends to a large degree

on the quality of this equal relationship. As clients experience the therapist listen-

182

ing in an accepting way to them, they gradually learn how to listen acceptingly to

themselves. As they fi nd the therapist caring for and valuing them (even the as-

pects that have been hidden and regarded as negative), clients begin to see worth

and value in themselves. As they experience the realness of the therapist, clients

drop many of their pretenses and are real with both themselves and the therapist.

This humanistic approach is perhaps best characterized as a way of being and as

CHAPTER SEVEN

a shared journey in which therapist and client reveal their humanness and partici-

pate in a growth experience. The therapist can be a relational guide on this journey

because he or she is usually more experienced and more psychologically experienced

in this role than the client. Thorne (2002b) delivered this message: “Therapists can-

not confi dently invite their clients to travel further than they have journeyed them-

selves, but for person-centred therapists the quality, depth and continuity of their

own experiencing becomes the very cornerstone of the competence they bring to

their professional activity” (p. 144). Therapists are invested in broadening their own

life experiences and are willing to do what it takes to deepen their self-knowledge.

Rogers admitted that his theory was striking provocative and radical. His for-

mulation has generated considerable controversy, for he maintained that many

conditions other therapists commonly regard as necessary for effective psychother-

apy were nonessential. The core therapist conditions of congruence, unconditional

positive regard, and accurate empathic understanding subsequently have been em-

braced by many therapeutic schools as essential in facilitating therapeutic change.

These core qualities of therapists, along with the therapist’s presence, work holis-

tically to create a safe environment for learning (Cain, 2010). Regardless of theo-

retical orientation, most therapists strive to listen fully and empathically to clients,

especially during the initial stages of therapy. We now turn to a detailed discussion

of how these core conditions are an integral part of the therapeutic relationship.

c o n g r u e n c e , o r g e n u i n e n e s s implies that therapists are real; that is,

they are genuine, integrated, and authentic during the therapy hour. They are with-

out a false front, their inner experience and outer expression of that experience

match, and they can openly express feelings, thoughts, reactions, and attitudes that

are present in the relationship with the client. This communication is done with

careful refl ection and considered judgment on the therapist’s part (Kolden, Klein,

Wang, & Austin, 2011).

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Through authenticity the therapist serves as a model of a human being strug-

gling toward greater realness. Being congruent might necessitate expressing a

range of feelings including anger, frustration, liking, concern, and annoyance.

This does not mean that therapists should impulsively share all their reactions, for

self-disclosure must be appropriate, well timed, and have a constructive therapeu-

tic intent. Counselors can try too hard to be genuine; sharing because one thinks

it will be good for the client, without being genuinely moved to express something

regarded as personal, can be incongruent. Person-centered therapy stresses that

counseling will be inhibited if the counselor feels one way about the client but acts

in a different way. For example, if the practitioner dislikes or disapproves of the

client but feigns acceptance, therapy will be impaired. Cain (2010) stresses that

therapists need to be attuned to the emerging needs of the client and to respond in

ways that are in the best interests of the individual. If therapists keep this in mind,

183

they are likely to make sound clinical decisions most of the time.

PERSON-CENTERED THERAP

Rogers’s concept of congruence does not imply that only a fully self-actualized

therapist can be effective in counseling. Because therapists are human, they can-

not be expected to be fully authentic. Congruence exists on a continuum from

highly congruent to very incongruent. This is true of all three characteristics.

u n c o n d i t i o n a l p o s i t i v e r e g a r d a n d a c c e p ta n c e The second

attitude therapists need to communicate is deep and genuine caring for the client

as a person, or a condition of unconditional positive regard, which can best be

achieved through empathic identifi cation with the client (Farber & Doolin, 2011).

Y

The caring is nonpossessive and is not contaminated by evaluation or judgment of

the client’s feelings, thoughts, and behavior as good or bad. Therapists value and

warmly accept clients without placing stipulations on their acceptance. It is not

an attitude of “I’ll accept you when . . .”; rather, it is one of “I’ll accept you as you

are.” Therapists communicate through their behavior that they value their clients

as they are and that clients are free to have feelings and experiences. Acceptance

is the recognition of clients’ rights to have their own beliefs and feelings; it is not

the approval of all behavior. All overt behavior need not be approved of or accepted.

According to Rogers’s (1977) research, the greater the degree of caring, priz-

ing, accepting, and valuing of the client in a nonpossessive way, the greater the

chance that therapy will be successful. He also makes it clear that it is not possible

for therapists to genuinely feel acceptance and unconditional caring at all times.

However, if therapists have little respect for their clients, or an active dislike or

disgust, it is not likely that the therapeutic work will be fruitful. If therapists’ caring

stems from their own need to be liked and appreciated, constructive change in the

client is inhibited. This notion of positive regard has implications for all therapists,

regardless of their theoretical orientation (Farber & Doolin, 2011).

acc u r at e e m pat h i c u n d e r sta n d i n g One of the main tasks of the ther-

apist is to understand clients’ experience and feelings sensitively and accurately as they

are revealed in the moment-to-moment interaction during the therapy session. The

therapist strives to sense clients’ subjective experience, particularly in the here and

now. The aim is to encourage clients to get closer to themselves, to feel more deeply

and intensely, and to recognize and resolve the incongruity that exists within them.

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Empathy is a deep and subjective understanding of the client with the client.

Empathy is not sympathy, or feeling sorry for a client. Therapists are able to share the

client’s subjective world by drawing from their own experiences that may be similar

to the client’s feelings. Yet therapists must not lose their own separateness. Rogers

asserts that when therapists can grasp the client’s private world as the client sees

and feels it—without losing the separateness of their own identity—constructive

change is likely to occur. Empathy, particularly emotionally focused empathy,

helps clients (1) pay attention to and value their experiencing, (2) process their

experience both cognitively and bodily, (3) view prior experiences in new ways, and

(4) increase their confi dence in making choices and in pursuing a course of action

(Cain, 2010).

Clark (2010) describes an integral model of empathy in the counseling process

184

that is based on three ways of knowing: (1) subjective empathy enables practition-

ers to experience what it is like to be the client; (2) interpersonal empathy pertains

to understanding a client’s internal frame of reference and conveying a sense of

the private meanings to the person; and (3) objective empathy relies on knowledge

sources outside of a client’s frame of reference. By using a multiple-perspective

model of empathy, counselors have a broader way to understand clients.

CHAPTER SEVEN

Accurate empathy is the cornerstone of the person-centered approach, and it

is a necessary ingredient of any effective therapy (Cain, 2010). Accurate empathic

understanding implies that the therapist will sense clients’ feelings as if they were

his or her own without becoming lost in those feelings. It is a way for therapists

to hear the meanings expressed by their clients that often lie at the edge of their

awareness. A primary means of determining whether an individual experienc-

es a therapist’s empathy is to secure feedback from the client (Norcross, 2010).

According to Watson (2002), full empathy entails understanding the meaning and

feeling of a client’s experiencing. Therapists need to understand clients on both

emotional and cognitive levels. Empathy is an active ingredient of change that fa-

cilitates clients’ cognitive processes and emotional self-regulation. Watson (2002)

states that 60 years of research has consistently demonstrated that empathy is the

most powerful determinant of client progress in therapy.

Clients’ perceptions of feeling understood by their therapists relate favorably to

outcome. Empathic therapists strive to discover the meaning of the client’s experi-

ence, understand the overall goals of the client, and tailor their responses to the

particular client. Effective empathy is grounded in authentic caring for the client

(Elliott, Bohart, Watson, & Greenberg, 2011).

a p p l i c at i o n : t h e r a p e u t i c

t e c h n i q u e s a n d p r o c e d u r e s

Early Emphasis on Reflection of Feelings

Rogers’s original emphasis was on grasping the world of the client and refl ecting

this understanding. As his view of psychotherapy developed, however, his focus

shifted away from a nondirective stance and emphasized the therapist’s relation-

ship with the client. Many followers of Rogers simply imitated his refl ective style,

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and client-centered therapy has often been identifi ed primarily with the technique

of refl ection despite Rogers’s contention that the therapist’s relational attitudes

and fundamental ways of being with the client constitute the heart of the change

process. Rogers and other contributors to the development of the person-centered

approach have been critical of the stereotypic view that this approach is basically a

simple restatement of what the client just said.

Evolution of Person-Centered Methods

Contemporary person-centered therapy is the result of an evolutionary process of

more than 70 years, and it continues to remain open to change and refi nement.

One of Rogers’s main contributions to the counseling fi eld is the notion that the

quality of the therapeutic relationship, as opposed to administering techniques,

is the primary agent of growth in the client. The therapist’s ability to establish a

185

strong connection with clients is the critical factor determining successful coun-

PERSON-CENTERED THERAP

seling outcomes.

No techniques are basic to the practice of person-centered therapy; “being with”

clients and entering imaginatively into their world of perceptions and feelings is

suffi cient for facilitating a process of change. Person-centered therapists are not

prohibited from suggesting techniques, but how these suggestions are presented is

crucial. Techniques may be suggested when doing so fosters the process of client

and therapist being together in an empathic way. Techniques are not attempts at

“doing anything” to a client (Bohart & Watson, 2011).

Y

The person-centered philosophy is based on the assumption that clients have

the resourcefulness for positive movement without the counselor assuming an

active, directive, or problem-solving role. Traditional person-centered therapists

would not tend to suggest a technique (Bohart & Watson, 2011). What is essential

for clients’ progress is the therapist’s presence, being completely attentive to and

immersed in the client as well as in the client’s expressed concerns (Cain, 2010).

This way of being is far more powerful than any technique a therapist might use

to bring about change. Qualities and skills such as listening, accepting, respect-

ing, understanding, and responding must be honest expressions by the therapist.

As discussed in Chapter 2, counselors need to evolve as persons, not just acquire

a repertoire of therapeutic strategies. Therapists mainly stay within the client’s

frame of reference and strive to understand and refl ect the client’s communication

and experience.

Rogers expected person-centered therapy to continue to evolve and supported

others in breaking new ground. One of the main ways in which person-centered

therapy has evolved is the diversity, innovation, and individualization in practice.

There is no longer one way of practicing person-centered therapy (Cain, 2010), and

there has been increased latitude for therapists to share their reactions, to confront

clients in a caring way, and to participate more actively and fully in the therapeutic

process (Bozarth et al., 2002). Immediacy, or addressing what is going on between

the client and therapist, is highly valued in this approach. This development en-

courages the use of a wider variety of methods and allows for considerable diversity

in personal style among person-centered therapists. The shift toward genuineness

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enables person-centered therapists both to practice in more fl exible and integra-

tive ways that suit their personalities and to have greater fl exibility in tailoring the

counseling relationship to suit different clients (Bohart & Watson, 2011).

Cain (2008, 2010) believes it is essential for therapists to adapt their therapeu-

tic style to accommodate the unique needs of each client. Person-centered thera-

pists have the freedom to use a variety of responses and methods to assist their

clients; a guiding question therapists need to ask is, “Does it fi t?” Cain contends

that, ideally, therapists will continually monitor whether what they are doing fi ts,

especially whether their therapeutic style is compatible with their clients’ way of

viewing and understanding their problems. For an illustration of how Dr. David

Cain works with the case of Ruth in a person-centered style, see Case Approach to

Counseling and Psychotherapy (Corey, 2013, chap. 5).

186

Today, those who practice a person-centered approach work in diverse ways

that refl ect both advances in theory and practice and a plethora of personal styles.

This is appropriate and fortunate, for none of us can emulate the style of Carl

Rogers and still be true to ourselves. If we strive to model our style after Rogers,

and if that style does not fi t for us, we are not being ourselves and we are not being

fully congruent.

CHAPTER SEVEN

The Role of Assessment

Assessment is frequently viewed as a prerequisite to the treatment process. Many

mental health agencies use a variety of assessment procedures, including diagnos-

tic screening, identifi cation of clients’ strengths and liabilities, and various tests.

Person-centered therapists generally do not fi nd traditional assessment and diag-

nosis to be useful because these procedures encourage an external and expert per-

spective on the client (Bohart & Watson, 2011). What matters is not how the coun-

selor assesses the client but the client’s self-assessment. From a person-centered

perspective, the best source of knowledge about the client is the individual client.

In the early development of nondirective therapy, Rogers (1942) recommend-

ed caution in using psychometric measures or in taking a complete case history

at the outset of counseling. If a counseling relationship began with a battery of

psychological tests and a detailed case history, he believed clients could get the

impression that the counselor would be providing the solutions to their problems.

Assessment seems to be gaining in importance in short-term treatments in most

counseling agencies, and it is imperative that clients be involved in a collaborative

process in making decisions that are central to their therapy. Today it may not be a

question of whether to incorporate assessment into therapeutic practice but of how

to involve clients as fully as possible in their assessment and treatment process.

Application of the Philosophy of the

Person-Centered Approach

The person-centered approach has been applied to working with individuals, groups,

and families. Bozrath, Zimring, and Tausch (2002) cite studies done through the

1990s that revealed the effectiveness of person-centered therapy with a wide range

of client problems including anxiety disorders, alcoholism, psychosomatic problems,

agoraphobia, interpersonal diffi culties, depression, cancer, and personality disorders.

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Person-centered therapy has been shown to be as viable as the more goal-oriented

therapies. Furthermore, outcome research conducted in the 1990s revealed that

effective therapy is based on the client–therapist relationship in combination

with the inner and external resources of the client (Duncan, Miller, Wampold, &

Hubble, 2010).

The person-centered approach has been applied extensively in training both

professionals and paraprofessionals who work with people in a variety of settings.

This approach emphasizes staying with clients as opposed to getting ahead of

them with interpretations. People without advanced psychological education are

able to benefi t by translating the therapeutic conditions of genuineness, empathic

understanding, and unconditional positive regard into both their personal and pro-

fessional lives. Learning to listen with acceptance to oneself is a valuable life skill

that enables individuals to be their own therapists. The basic concepts are straight-

187

forward and easy to comprehend, and they encourage locating power in the person

PERSON-CENTERED THERAP

rather than fostering an authoritarian structure in which control and power are

denied to the person. These core skills also provide an essential foundation for

virtually all of the other therapy systems covered in this book. If counselors are

lacking in these relationship and communication skills, they will not be effective

in carrying out a treatment program for their clients.

The person-centered approach demands a great deal of the therapist. An ef-

fective person-centered therapist must be grounded, centered, genuine, respect-

ful, caring, present, a focused and astute listener, patient, and accepting in a way

Y

that involves maturity. Without a person-centered way of being, mere application

of skills is likely to be hollow. Natalie Rogers (2011) points out that the person-

centered approach is a way of being that is easy to understand intellectually but

is very diffi cult to put into practice. She continues to fi nd the core conditions of

genuineness, positive regard, and empathy most important in developing trust,

safety, and growth in a group.

Application to Crisis Intervention

The person-centered approach is especially applicable in crisis intervention such as

an unwanted pregnancy, an illness, a disastrous event, or the loss of a loved one. Peo-

ple in the helping professions (nursing, medicine, education, the ministry) are often

fi rst on the scene in a variety of crises, and they can do much if the basic attitudes

described in this chapter are present. When people are in crisis, one of the fi rst steps

is to give them an opportunity to fully express themselves. Sensitive listening, hear-

ing, and understanding are essential at this point. Being heard and understood helps

ground people in crises, helps to calm them in the midst of turmoil, and enables

them to think more clearly and make better decisions. Although a person’s crisis is

not likely to be resolved by one or two contacts with a helper, such contacts can pave

the way for being open to receiving help later. If the person in crisis does not feel

understood and accepted, he or she may lose hope of “returning to normal” and may

not seek help in the future. Genuine support, caring, and nonpossessive warmth can

go a long way in building bridges that can motivate people to do something to work

through and resolve a crisis. Communicating a deep sense of understanding should

always precede other more problem-solving interventions.

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In crisis situations person-centered therapists may need to provide more struc-

ture and direction than would be the case for clients who are not experiencing a

crisis. Suggestions, guidance, and even direction may be called for if clients are

not able to function effectively. For example, in certain cases it may be necessary

to take action to hospitalize a suicidal client to protect this person from self-harm.

Application to Group Counseling

The person-centered approach emphasizes the unique role of the group counselor

as a facilitator rather than a leader. The primary function of the facilitator is to cre-

ate a safe and healing climate—a place where the group members can interact in

honest and meaningful ways. In this climate members become more appreciative

and trusting of themselves as they are and are able to move toward self-direction

and empowerment. Ultimately, group members make their own choices and bring

188

about change for themselves. Yet with the presence of the facilitator and the sup-

port of other members, participants realize that they do not have to experience

the struggles of change alone and that groups as collective entities have their own

source of transformation. The facilitator’s way of being can create a productive

climate within a group:

Facilitators cannot make participants trust the group process. Facilitators earn trust by

CHAPTER SEVEN

being respectful, caring, and even loving. Being an effective group facilitator has much to

do with one’s “way of being.” No method or technique can evoke trust unless the facilitator

herself has a capacity to be fully present, considerate, caring, authentic, and responsive.

This includes the ability to challenge people constructively (N. Rogers, 2011, p. 57)

Rogers (1970) clearly believed that groups tend to move forward if the facilitator

exhibits a deep sense of trust in the members and refrains from using techniques

or exercises to get a group moving. The core conditions of person-centered therapy

apply to the process of a group. The role of the facilitator is to empathically under-

stand what an individual is communicating within the group. Instead of leading

the members toward specifi c goals, the group facilitator assists members in de-

veloping attitudes and behaviors of genuineness, acceptance, and empathy, which

enables the members to interact with each other in therapeutic ways to fi nd their

own sense of direction as a group.

From Rogers’s perspective, facilitators should avoid making interpretive com-

ments or group process observations because such comments are apt to make

the group self-conscious and slow the process down. Group process observations

should come from members, a view that is consistent with Rogers’s philosophy of

placing the responsibility for the direction of the group on the members. Accord-

ing to Raskin, Rogers, and Witty (2008), groups are fully capable of articulating

and pursuing their own goals. They assert, “when the therapeutic conditions are

present in a group and when the group is trusted to fi nd its own way of being,

group members tend to develop processes that are right for them and to resolve

confl icts within time constraints in the situation” (p. 143).

Regardless of a group leader’s theoretical orientation, the core conditions that

have been described here are highly applicable to any leader’s style of group facili-

tation. Only when the leader is able to create a person-centered climate will move-

ment take place within a group. All of the theories discussed in this book depend

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on the quality of the therapeutic relationship as a foundation. As you will see, the

cognitive behavioral approaches to group work place emphasis on creating a work-

ing alliance and collaborative relationships. In this way, most effective approaches

to group work share key elements of a person-centered philosophy. For a more

detailed treatment of person-centered group counseling, see Corey (2012, chap.

10). Also see Natalie Rogers’s (2011), The Creative Connection for Groups: Person-

Centered Expressive Arts for Healing and Social Change.

p e r s o n - c e n t e r e d e x p r e s s i v e

a r t s t h e r a p y *

Natalie Rogers (1993, 2011) expanded on her father, Carl Rogers’s (1961), theory

of creativity using the expressive arts to enhance personal growth for individuals

189

and groups. Rogers’s approach, known as expressive arts therapy, extends the per-

PERSON-CENTERED THERAP

son-centered approach to spontaneous creative expression, which symbolizes deep

and sometimes inaccessible feelings and emotional states. Counselors trained in

person-centered expressive arts offer their clients the opportunity to create move-

ment, visual art, journal writing, sound, and music to express their feelings and

gain insight from these activities.

Principles of Expressive Arts Therapy

Expressive arts therapy uses various artistic forms—movement, drawing, painting,

Y

sculpting, music, writing, and improvisation—toward the end of growth, healing,

and self-discovery. This is a multimodal approach integrating mind, body, emo-

tions, and inner spiritual resources. Methods of expressive arts therapy are based on

humanistic principles but giving fuller form to Carl Rogers’s notions of creativity.

These principles include the following (N. Rogers, 1993):

• All people have an innate ability to be creative.

• The creative process is transformative and healing. The healing aspects involve

activities such as meditation, movement, art, music, and journal writing.

• Personal growth and higher states of consciousness are achieved through self-

awareness, self-understanding, and insight.

• Self-awareness, understanding, and insight are achieved by delving into our

feelings of grief, anger, pain, fear, joy, and ecstasy.

• Our feelings and emotions are an energy source that can be channeled into the

expressive arts to be released and transformed.

• The expressive arts lead us into the unconscious, thereby enabling us to express

previously unknown facets of ourselves and bring to light new information and

awareness.

• One art form stimulates and nurtures the other, bringing us to an inner core or

essence that is our life energy.

*Much of the material in this section is based on key ideas that are more fully developed in two of Natalie

Rogers’s books, The Creative Connection: Expressive Arts as Healing (Rogers, 1993) and The Creative Connec-

tion for Groups: Person-Centered Expressive Arts for Healing and Social Change (Rogers, 2011). This section was written in close collaboration with Natalie Rogers.

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• A connection exists between our life force—our inner core, or soul—and the

essence of all beings.

• As we journey inward to discover our essence or wholeness, we discover our

relatedness to the outer world, and the inner and outer become one.

The various art modes interrelate in what Natalie Rogers calls the “creative connec-

tion.” When we move, it affects how we write or paint. When we write or paint, it

affects how we feel and think.

Natalie Rogers’s approach is based on a person-centered theory of individual

and group process. The same conditions that Carl Rogers and his colleagues found

basic to fostering a facilitative client–counselor relationship also help support crea-

tivity. Personal growth takes place in a safe, supportive environment created by

counselors or facilitators who are genuine, warm, empathic, open, honest, congru-

190

ent, and caring—qualities that are best learned by fi rst being experienced. Taking

time to refl ect on and evaluate these experiences allows for personal integration at

many levels—intellectual, emotional, physical, and spiritual.

Creativity and Offering Stimulating Experiences

According to Natalie Rogers, this deep faith in the individual’s innate drive to

become fully oneself is basic to the work in person-centered expressive arts. Indi-

CHAPTER SEVEN

viduals have a tremendous capacity for self-healing through creativity if given the

proper environment. When one feels appreciated, trusted, and given support to

use individuality to develop a plan, create a project, write a paper, or to be authen-

tic, the challenge is exciting, stimulating, and gives a sense of personal expansion.

N. Rogers believes the tendency to actualize and become one’s full potential, in-

cluding innate creativity, is undervalued, discounted, and frequently squashed in

our society. Traditional educational institutions tend to promote conformity rather

than original thinking and the creative process.

Person-centered expressive arts therapy utilizes the arts for spontaneous cre-

ative expression that symbolizes deep and sometimes inaccessible feelings and

emotional states. The conditions that foster creativity require acceptance of the

individual, a nonjudgmental setting, empathy, psychological freedom, and availa-

bility of stimulating and challenging experiences. With this type of environment in

place, the facilitative internal conditions of the client are encouraged and inspired:

a nondefensive openness to experience and an internal locus of evaluation that

receives but is not overly concerned with the reactions of others. N. Rogers (1993)

believes that we cheat ourselves out of a fulfi lling and joyous source of creativity if

we cling to the idea that an artist is the only one who can enter the realm of creativ-

ity. Art is not only for the few who develop a talent or master a medium. We all can

use various art forms to facilitate self-expression and personal growth.

Contributions of Natalie Rogers

As is clear from this brief section, Natalie Rogers has built upon a person-centered

philosophy and incorporated expressive and creative arts as a basis for personal

growth. Cain (2010) believes “Natalie Rogers’s expressive arts therapy represents

a major innovation in practice and helped open the way for other person-centered

therapists to expand the variety and range of practice” (p. 60). Sommers-Flanagan

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(2007) notes that person-centered expressive arts therapy may be a solution for

clients who are stuck in linear and rigid ways of being. He concludes: “Using her

own love of creativity and art in combination with her father’s renowned thera-

peutic approach, Natalie Rogers developed a form of therapy that extends person-

centered counseling into a new and exciting domain” (p. 124). Rogers continues

her active professional life, conducting workshops in the United States, Europe,

Japan, Hong Kong, Latin America, and Russia. At the end of this chapter are some

resources for those interested in training in the person-centered approach to ex-

pressive arts therapy.

m o t i vat i o n a l i n t e r v i e w i n g

Motivational Interviewing (MI) is a humanistic, client-centered, psychosocial, di-

191

rective counseling approach that was developed by William R. Miller and Stephen

PERSON-CENTERED THERAP

Rollnick in the early 1980s. The clinical and research applications of motivational

interviewing have received increased attention in recent years, and MI has been

shown to be effective as a relatively brief intervention (Levensky, Kersh, Cavasos, &

Brooks, 2008). MI has been defi ned as “a directive, client centered counseling

style for eliciting behavior change by helping clients to explore and resolve am-

bivalence” (Rollnick & Miller, 1995, p. 326). Motivational interviewing is based on

humanistic principles, has some basic similarities with person-centered therapy,

and expands the traditional person-centered approach.

Y

Motivational interviewing was initially designed as a brief intervention for

problem drinking, but more recently this approach has been applied to a wide

range of clinical problems including substance abuse, compulsive gambling, eat-

ing disorders, anxiety disorders, depression, suicidality, chronic disease manage-

ment, and health behavior change practices (Arkowitz & Miller, 2008; Arkowitz &

Westra, 2009). MI stresses client self-responsibility and promotes an invitational

style for working cooperatively with clients to generate alternative solutions to

behavioral problems. MI therapists avoid arguing with clients, avoid assuming a

confrontational stance, reframe resistance as a healthy response, express empathy,

and listen refl ectively. MI therapists do not view clients as opponents to be de-

feated but as allies who play a major role in their present and future success. Both

MI and person-centered practitioners believe in the client’s abilities, strengths,

resources, and competencies. The underlying assumption is that clients want to be

healthy and desire positive change.

The MI Spirit

MI is rooted in the philosophy of person-centered therapy, but with a “twist.”

Unlike the nondirective and unstructured person-centered approach, MI is delib-

erately directive and is aimed at reducing client ambivalence about change and

increasing intrinsic motivation (Arkowitz & Miller, 2008). It is essential that thera-

pists function within the spirit of MI, rather than simply applying the strategies of

the approach (Levensky et al., 2008). The attitudes and skills in MI are based on a

person-centered philosophy and include using open-ended questions, employing

refl ective listening, affi rming and supporting the client, responding to resistance

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28549_ch07_rev01.indd 191

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in a nonconfrontational manner, guiding a discussion of ambivalence, summariz-

ing and linking at the end of sessions, and eliciting and reinforcing change talk.

MI works by activating clients’ own motivation for change and adherence to treat-

ment. Practitioners assist clients in becoming their own advocates for change and

the primary agents of change in their lives.

In both person-centered therapy and MI, the counselor provides the condi-

tions for growth and change by communicating attitudes of accurate empathy

and unconditional positive regard. In MI, the therapeutic relationship is as impor-

tant in achieving successful outcomes as the specifi c theoretical model or school

of psychotherapy from which the therapist operates (Miller & Rollnick, 2002).

Both MI and person-centered therapy are based on the premise that individuals

have within themselves the capacity to generate intrinsic motivation to change.

192

Responsibility for change rests with clients, not with the counselor, and therapist

and client share a sense of hope and optimism that change is possible. Once cli-

ents believe that they have the capacity to change and heal, new possibilities open

up for them.

The Basic Principles of Motivational Interviewing

Miller and Rollnick (2002) formulated fi ve basic principles of MI, which are sum-

CHAPTER SEVEN

marized below:

1. Therapists practicing motivational interviewing strive to experience the world

from the client’s perspective without judgment or criticism. MI emphasizes refl ec-

tive listening, which is a way for practitioners to better understand the subjective

world of clients. Expressing empathy is foundational in creating a safe climate for

clients to explore their ambivalence for change. When clients are slow to change,

it may be assumed that they have compelling reasons to remain as they are as well

as having reasons to change.

2. MI is designed to evoke and explore both discrepancies and ambivalence. Coun-

selors using MI refl ect discrepancies between the behaviors and values of clients to

increase the motivation to change. Counselors pay particular attention to clients’

arguments for changing compared to their arguments for not changing. Thera-

pists elicit and reinforce change talk by employing specifi c strategies to strengthen

discussion about change. MI therapists assume a directive stance by steering the

conversation in the direction of considering change without persuading clients to

change. Clinicians encourage clients to determine whether change will occur, and

if so, what kinds of changes will occur and when.

3. Reluctance to change is viewed as a normal and expected part of the therapeutic

process. Although individuals may see advantages to making life changes, they

also may have many concerns and fears about changing. People who seek therapy

are often ambivalent about change, and their motivation may ebb and fl ow dur-

ing the course of therapy. A central goal of MI is to increase internal motivation

to change based on the personal goals and values of clients (Arkowitz & Miller,

2008). MI therapists assume a respectful view of resistance and work therapeuti-

cally with any reluctance or caution on the part of clients.

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4. Practitioners operating from an MI orientation support clients’ self-effi cacy,

mainly by encouraging them to use their own resources to take necessary actions

that can lead to success in changing. MI clinicians strive to enhance client agency

about change and emphasize the right and inherent ability of clients to formulate

their own personal goals and to make their own decisions. MI focuses on present

and future conditions and empowers clients to fi nd ways to achieve their goals.

5. When clients show signs of readiness to change through decreased resistance

to change and increased talk about change, a critical phase of MI begins. In this

stage, clients may express a desire and ability to change, show an interest in ques-

tions about change, experiment with making changes between sessions, and envi-

sion a future picture of how their life will be different once the desired changes

have been made. At this time therapists shift their focus toward strengthening

193

clients’ commitments to change and helping them implement a change plan.

PERSON-CENTERED THERAP

The Stages of Change

The stages of change model assumes that people progress through a series of fi ve

identifi able stages in the counseling process. In the precontemplation stage, there is

no intention of changing a behavior pattern in the near future. In the contemplation

stage, people are aware of a problem and are considering overcoming it, but they

have not yet made a commitment to take action to bring about the change. In the

preparation stage, individuals intend to take action immediately and report some

small behavioral changes. In the action stage, individuals are taking steps to modify

Y

their behavior to solve their problems. During the maintenance stage, people work

to consolidate their gains and prevent relapse.

People do not pass neatly through these fi ve stages in linear fashion, and a cli-

ent’s readiness can fl uctuate throughout the change process. If change is initially

unsuccessful, individuals may return to an earlier stage (Prochaska & Norcross,

2010). MI therapists strive to match specifi c interventions with whatever stage of

change clients are experiencing. If there is a mismatch between process and stage,

movement through the stage will be impeded and is likely to be manifested in

reluctant behavior. When clients demonstrate any form of reluctance or resistance,

this could be due to a therapist’s misjudgment of a client’s readiness to change.

Certain behaviors on a therapist’s part may lead to a client feeling invalidated or

misunderstood, which is likely to result in what appears to be a client’s resistive

behavior (Levensky et al., 2008).

Working within the framework of the stages of change model has implica-

tions for the therapist’s role at the different stages. Norcross, Krebs, and Prochaska

(2011) describe the relational stances and roles taken by therapists during the

course of therapy. With clients in the precontemplation stage, the role assumed

is that of a nurturing parent. With clients in contemplation, therapists function as

a Socratic teacher who encourages them to achieve their own insights. For clients

who are in the preparation stage, therapists take the stance of an experienced coach.

With clients who are progressing into action and maintenance, therapists function

in the role of a consultant. As termination approaches, therapists are consulted less

often as a way to foster client autonomy.

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Motivational interviewing is but one example of how therapeutic strategies

have been developed based on the foundational principles and philosophy of the

person-centered approach. Indeed, most of the therapeutic models illustrate how

the core therapeutic conditions are necessary aspects leading to client change.

Where many therapeutic approaches, including motivational interviewing, diverge

from traditional person-centered therapy is the assumption that the therapeu-

tic factors are both necessary and suffi cient in bringing about change. Many other

models employ specifi c intervention strategies to address specifi c concerns clients

bring to therapy.

p e r s o n - c e n t e r e d t h e r a p y f r o m

a m u lt i c u lt u r a l p e r s p e c t i v e

194

Strengths From a Diversity Perspective

One of the strengths of the person-centered approach is its impact on the fi eld of

human relations with diverse cultural groups. Person-centered philosophy and prac-

tice can now be studied in several European countries, South America, and Japan.

Here are some examples of ways in which this approach has been incorporated in

various countries and cultures:

CHAPTER SEVEN

• In several European countries person-centered concepts have had a signifi cant

impact on the practice of counseling as well as on education, cross-cultural com-

munication, and reduction of racial and political tensions. In the 1980s Rogers

(1987b) elaborated on a theory of reducing tension among antagonistic groups

that he began developing in 1948.

• In the 1970s Rogers and his associates began conducting workshops promoting

cross-cultural communication. Well into the 1980s he led large workshops in

many parts of the world. International encounter groups have provided partici-

pants with multicultural experiences.

• Japan, Australia, South America, Mexico, and the United Kingdom have all

been receptive to person-centered concepts and have adapted these practices to

fi t their cultures.

• Shortly before his death, Rogers conducted intensive workshops with profes-

sionals in the former Soviet Union.

Cain (1987c) sums up the reach of the person-centered approach to cultural diver-

sity: “Our international family consists of millions of persons worldwide whose

lives have been affected by Carl Rogers’s writings and personal efforts as well as

his many colleagues who have brought his and their own innovative thinking and

programs to many corners of the earth” (p. 149).

There is no doubt that Carl Rogers has had a global impact. His work has reached

more than 30 countries, and his writings have been translated into 12 languages.

In addition to this global impact, the emphasis on the core conditions makes the

person-centered approach useful in understanding diverse worldviews. The under-

lying philosophy of person-centered therapy is grounded on the importance of hear-

ing the deeper messages of a client. Empathy, being present, and respecting the

values of clients are essential attitudes and skills in counseling culturally diverse

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28549_ch07_rev01.indd 194

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clients. Cain (2008, 2010) contends that although person-centered therapists are

aware of diversity factors, they do not make initial assumptions about individuals.

They realize that each client’s journey is unique and take steps to tailor their meth-

ods to fi t each individual.

Several writers consider person-centered therapy as being ideally suited to cli-

ents in a diverse world. Cain (2008, 2010) views this approach as being a potent

way of working with individuals representing a wide range of cultural backgrounds

because the core therapeutic conditions are qualities that are universal. Bohart and

Watson (2011) claim that the person-centered philosophy is particularly appropri-

ate for working with diverse client populations because the counselor does not

assume the role of expert who is going to impose a “right way of being” on the cli-

ent. Instead, the therapist is a “fellow explorer” who attempts to understand the cli-

ent’s phenomenological world in an interested, accepting, and open way and checks

195

with the client to confi rm that the therapist’s perceptions are accurate. Motivational

PERSON-CENTERED THERAP

interviewing, which is based on the philosophy of person-centered therapy, is a cul-

turally sensitive approach that can be effective across population domains, includ-

ing gender, age, ethnicity, and sexual orientation (Levensky et al., 2008).

Shortcomings From a Diversity Perspective

Although the person-centered approach has made signifi cant contributions to

counseling people from diverse social, political, and cultural backgrounds, there

are some shortcomings to practicing exclusively within this framework. Many cli-

ents who come to community mental health clinics or who are involved in outpa-

Y

tient treatment want more structure than this approach provides. Some clients

seek professional help to deal with a crisis, to alleviate emotional problems, or to

learn coping skills in dealing with everyday problems. Because of certain cultural

messages, when these clients do seek professional help, it may be as a last resort.

They often expect a directive counselor and can be put off by a professional who

does not provide suffi cient structure.

A second shortcoming of the person-centered approach is that it is diffi cult to

translate the core therapeutic conditions into actual practice in certain cultures.

Communication of these core conditions must be consistent with the client’s cul-

tural framework. Consider, for example, the expression of therapist congruence

and empathy. Clients accustomed to indirect communication may not be comfort-

able with direct expressions of empathy or self-disclosure on the therapist’s part.

For some clients the most appropriate way to express empathy is for the therapist

to demonstrate it indirectly through respecting their need for distance or through

suggesting task-focused interventions (Bohart & Greenberg, 1997).

A third shortcoming in applying the person-centered approach with clients

from diverse cultures pertains to the fact that this approach extols the value of

an internal locus of evaluation. The humanistic foundation of person-centered

therapy emphasizes dimensions such as self-awareness, freedom, autonomy, self-

acceptance, inner-directedness, and self-actualization. In collectivist cultures, cli-

ents are likely to be highly infl uenced by societal expectations and not simply mo-

tivated by their own personal preferences. The focus on development of individual

autonomy and personal growth may be viewed as being selfi sh in a culture that

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28549_ch07_rev01.indd 195

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stresses the common good. Cain (2010) contends that “persons from collectivistic

cultures are oriented less toward self-actualization and more toward intimacy, con-

nection, and harmony with others and toward what is best for the community and

the common good” (p. 143).

Consider Lupe, a Latina client who values the interests of her family over her

self-interests. From a person-centered perspective she could be viewed as being in

danger of “losing her own identity” by being primarily concerned with her role in

taking care of others in the family. Rather than pushing her to make her personal

wants a priority, the counselor will explore Lupe’s cultural values and her level of

commitment to these values in working with her. It would be inappropriate for the

counselor to impose a vision of the kind of woman she should be. (This topic is

discussed more extensively in Chapter 12.)

196

Although there may be particular shortcomings in practicing exclusively with-

in a person-centered perspective, it should not be concluded that this approach is

unsuitable for working with clients from diverse cultures. There is great diversity

among any group of people, and therefore, there is room for a variety of thera-

peutic styles. According to Cain (2010), rigid insistence on a nondirective style of

counseling for all clients, regardless of their cultural background or personal pref-

CHAPTER SEVEN

erence, may be perceived as an imposition that does not fi t the client’s interper-

sonal and therapeutic needs. Counseling a culturally different client may require

more activity and structuring than is usually the case in a person-centered frame-

work, but the potential positive impact of a counselor who responds empathically

to a culturally different client cannot be overestimated.

Person-Centered Therapy Applied to the Case of Stan

Stan’s autobiography indicates that

times. I attempt to create an atmosphere of

he has a sense of what he wants

freedom and security that will encourage Stan

for his life. As a person-centered

to explore the threatening aspects of his

therapist, I rely on his self-report of the way he

self-concept.

views himself rather than on a formal assess-

Stan has a low evaluation of his self-worth.

ment and diagnosis. My concern is with under-

Although he finds it difficult to believe that

standing him from his internal frame of refer-

others really like him, he wants to feel loved.

ence. Stan has stated goals that are meaningful

He says, “I hope I can learn to love at least a

for him. He is motivated to change and seems

few people, most of all, women.” He wants to

to have sufficient anxiety to work toward these

feel equal to others and not have to apologize

desired changes. I have faith in Stan’s ability

for his existence, yet most of the time he feels

to find his own way, and I trust that he has the

inferior. By creating a supportive, trusting, and

necessary resources for reaching his therapy

encouraging atmosphere, I can help Stan learn

goals. I encourage Stan to speak freely about

to be more accepting of himself, with both his

the discrepancy between the person he sees

strengths and limitations. He has the opportu-

himself as being and the person he would like

nity to openly express his fears of women, of

to become; about his feelings of being a failure,

not being able to work with people, and of feel-

being inadequate; about his fears and uncer-

ing inadequate and stupid. He can explore how

tainties; and about his hopelessness at

he feels judged by his parents and by

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28549_ch07_rev01.indd 196

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authorities. He has an opportunity to express

Follow-Up: You Continue as Stan’s Person-

his guilt—that is, his feelings that he has not

Centered Therapist

lived up to his parents’ expectations and that

Use these questions to help you think about how

he has let them and himself down. He can

you would counsel Stan using a person-centered

also relate his feelings of hurt over not having

approach:

ever felt loved and wanted. He can express the

• How would you respond to Stan’s deep feelings

loneliness and isolation that he so often feels,

of self-doubt? Could you enter his frame of ref-

as well as the need to numb these feelings with

erence and respond in an empathic manner that

alcohol or drugs.

lets Stan know you hear his pain and struggle

Stan is no longer totally alone, for he is taking

without needing to give advice or suggestions?

the risk of letting me into his private world of

• How would you describe Stan’s deeper strug-

feelings. Stan gradually gets a sharper focus on

gles? What sense do you have of his world?

his experiencing and is able to clarify his own

feelings and attitudes. He sees that he has the

• To what extent do you think that the relation-

197

capacity to make his own decisions. In short, our

ship you would develop with Stan would help

PERSON-CENTERED THERAP

therapeutic relationship frees him from his self-

him move forward in a positive direction?

defeating ways. Because of the caring and faith

What, if anything, might get in your way—

he experiences from me in our relationship, Stan

either with him or in yourself—in establishing

is able to increase his own faith and confidence

a therapeutic relationship?

in himself.

My empathy assists Stan in hearing him-

See DVD for Theory and Practice of

self and accessing himself at a deeper level.

Counseling and Psychotherapy: The Case

Stan gradually becomes more sensitive to his

of Stan and Lecturettes (Session 5 on person-

own internal messages and less dependent on

centered therapy) for a demonstration of my

Y

confirmation from others around him. As a result

approach to counseling Stan from this perspec-

of the therapeutic venture, Stan discovers that

tive. This session focuses on exploring the

there is someone in his life whom he can depend

immediacy of our relationship and assisting

on—himself.

Stan in finding his own way.

s u m m a r y a n d e va l u at i o n

Summary

Person-centered therapy is based on a philosophy of human nature that postulates

an innate striving for self-actualization. Further, Rogers’s view of human nature

is phenomenological; that is, we structure ourselves according to our perceptions

of reality. We are motivated to actualize ourselves in the reality that we perceive.

Rogers’s theory rests on the assumption that clients can understand the fac-

tors in their lives that are causing them to be unhappy. They also have the capacity

for self-direction and constructive personal change. Change will occur if a con-

gruent therapist makes psychological contact with a client in a state of anxiety or

incongruence. It is essential for the therapist to establish a relationship the cli-

ent perceives as genuine, accepting, and understanding. Therapeutic counseling

is based on an I/Thou, or person-to-person, relationship in the safety and accept-

ance of which clients drop their defenses and come to accept and integrate aspects

that they have denied or distorted. The person-centered approach emphasizes this

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personal relationship between client and therapist; the therapist’s attitudes are

more critical than are knowledge, theory, or techniques employed. In the context

of this relationship, clients unleash their growth potential and become more of the

person they are capable of becoming.

This approach places primary responsibility for the direction of therapy on the

client. In the therapeutic context, individuals have the opportunity to decide for

themselves and come to terms with their own personal power. The underlying

assumption is that no one knows the client better than the client; in short, the cli-

ent is viewed as an expert on his or her own life (Cain, 2010). The general goals

of therapy are becoming more open to experience, achieving self-trust, developing

an internal source of evaluation, and being willing to continue growing. Specifi c

goals are not suggested for clients; rather, clients choose their own values and

198

goals. Current applications of the theory emphasize more active participation by

the therapist than was the case earlier. Counselors are now encouraged to be fully

involved as persons in the therapeutic relationship. More latitude is allowed for

therapists to express their reactions and feelings as they are appropriate to what is

occurring in therapy. Person-centered practitioners are willing to be transparent

about persistent feelings that exist in their relationships with clients (Watson et al.,

CHAPTER SEVEN

2011). It is the therapist’s job to adapt and accommodate in a manner that works

best for each client, which means being fl exible in the application of methods in

the counseling process (Cain, 2010).

Contributions of the Person-Centered Approach

When Rogers founded nondirective counseling more than 70 years ago, there

were very few other therapeutic models. The longevity of this approach is certainly

a factor to consider in assessing its infl uence. Cain (2008) states: “An extensive

body of research has been generated and provides support for the effectiveness

of person-centered therapy with a wide range of clients and problems of all age

groups” (p. 214).

Rogers had, and his theory continues to have, a major impact on the fi eld of

counseling and psychotherapy. When he introduced his revolutionary ideas in the

1940s, he provided a powerful and radical alternative to psychoanalysis and to the

directive approaches then practiced. Rogers was a pioneer in shifting the therapeu-

tic focus from an emphasis on technique and reliance on therapist authority to that

of the power of the therapeutic relationship.

Kirschenbaum (2009) contends that the scope and infl uence of Rogers’s work

has continued well beyond his death; the person-centered approach is alive, well,

and expanding. Today there is not one version of person-centered therapy, but a

number of continuously evolving person-centered psychotherapies (Cain, 2010).

Although few psychotherapists claim to have an exclusive person-centered theo-

retical orientation, the philosophy and principles of this approach permeate the

practice of most therapists. Other schools of therapy are increasingly recogniz-

ing the centrality of the therapeutic relationship as a route to therapeutic change

(Kirschenbaum, 2009).

Person-centered therapy is strongly represented in Europe, and there is con-

tinuing interest in this approach in both South America and the Far East. The

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person-centered approach has established a fi rm foothold in British universities.

According to Natalie Rogers (2011), some of the most in-depth training of person-

centered counselors is in the United Kingdom. In addition, British scholars includ-

ing Fairhurst (1999), Keys (2003), Lago and Smith (2003), Mearns and Cooper

(2005), Mearns and Thorne (2000, 2007), Merry (1999), Natiello (2001), Thorne

(2002a, 2002b), and Watson (2003) continue to expand and refi ne this approach.

As we have seen, Natalie Rogers has made a signifi cant contribution to the

application of the person-centered approach by incorporating the expressive arts as

a medium to facilitate healing and social change, primarily in a group setting. She

has been instrumental in the evolution of the person-centered approach by using

nonverbal methods to enable individuals to heal and to develop. Many individu-

als who have diffi culty expressing themselves verbally can fi nd new possibilities

for self-expression through nonverbal channels and through the expressive arts

199

(N. Rogers, 2011).

PERSON-CENTERED THERAP

e m p h a s i s o n r e s e a r c h One of Rogers’s contributions to the fi eld of psy-

chotherapy was his willingness to state his concepts as testable hypotheses and to

submit them to research. He literally opened the fi eld to research. He was truly a

pioneer in his insistence on subjecting the transcripts of therapy sessions to criti-

cal examination and applying research technology to counselor–client dialogues

(Combs, 1988). Rogers’s basic hypothesis gave rise to a great deal of research and

debate in the fi eld of psychotherapy, perhaps more than any other school of ther-

apy (Cain, 2002a). According to Cain (2010), an enormous body of research, con-

Y

ducted over a period of 70 years, supports the effectiveness of the person-centered

approach. This research is ongoing in many parts of the world and continues to

expand and refi ne our understanding of what constitutes effective psychotherapy.

Cain (2010) concludes, “person centered therapy is as vital and effective as it has

ever been and continues to develop in ways that will make it increasingly so in the

years to come” (p. 169).

Even his critics give Rogers credit for having conducted and inspired others to

conduct extensive studies of counseling process and outcome. Rogers presented a

challenge to psychology to design new models of scientifi c investigation capable of

dealing with the inner, subjective experiences of the person. His theories of ther-

apy and personality change have had a tremendous heuristic effect, and though

much controversy surrounds this approach, his work has challenged practitioners

and theoreticians to examine their own therapeutic styles and beliefs.

t h e i m p o r ta n c e o f e m pat h y Among the major contributions of person-

centered therapy are the implications of empathy for the practice of counseling.

More than any other approach, person-centered therapy has demonstrated that

therapist empathy plays a vital role in facilitating constructive change in the client.

Watson’s (2002) comprehensive review of the research literature on therapeutic

empathy has consistently demonstrated that therapist empathy is the most potent

predictor of client progress in therapy. Indeed, empathy is an essential component

of successful therapy in every therapeutic modality.

Person-centered research has been conducted predominantly on the hypoth-

esized necessary and suffi cient conditions of therapeutic personality change (Cain,

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1986, 1987b). Most of the other counseling approaches covered in this book have

incorporated the importance of the therapist’s attitude and behavior in creating a

therapeutic relationship that is conducive to the use of their techniques. For in-

stance, the cognitive behavioral approaches have developed a wide range of strate-

gies designed to help clients deal with specifi c problems, and they recognize that

a trusting and accepting client–therapist relationship is necessary for successful

application of these procedures. In contrast to the person-centered approach, how-

ever, cognitive behavioral practitioners contend that the working relationship is

not suffi cient to produce change. They contend that active procedures, in combina-

tion with a collaborative relationship, are needed to bring about change.

i n n o vat i o n s i n p e r s o n - c e n t e r e d t h e r a p y One of the strengths

of the person-centered approach is “the development of innovative and sophisti-

200

cated methods to work with an increasingly diffi cult, diverse, and complex range

of individuals, couples, families, and groups” (Cain, 2002b, p. xxii). A number of

people have made signifi cant advancements that are compatible with the essential

values and concepts of person-centered therapy. Table 7.1 describes some of the

innovators who have played a role in the evolution of person-centered therapy.

Rogers consistently opposed the institutionalization of a client-centered

CHAPTER SEVEN

“school.” Likewise, he reacted negatively to the idea of founding institutes, grant-

ing certifi cates, and setting standards for membership. He feared this institution-

alization would lead to an increasingly narrow, rigid, and dogmatic perspective. If

Rogers (1987a) were to give students-in-training advice it would be: “There is one

best school of therapy. It is the school of therapy you develop for yourself based on

a continuing critical examination of the effects of your way of being in the relation-

ship” (p. 185).

e m o t i o n - f o c u s e d t h e r a p y One of the developments associated with

the person-centered approach is the emergence of emotion-focused therapy (EFT).

Leslie Greenberg (2011) is a prominent fi gure in the development of this integra-

tive approach. Emotion-focused therapy is rooted in a person-centered philosophy,

but it is integrative in that it synthesizes aspects of Gestalt therapy and existential

therapy. EFT is a therapeutic practice informed by an understanding of the role of

emotion in psychotherapeutic change. A number of strategies in EFT are aimed

at the goal of strengthening the self, regulating affect, and creating new mean-

ing. Many traditional therapies emphasize conscious understanding and cognitive

and behavioral change, yet they often neglect the foundational role of emotional

change. EFT emphasizes the importance of awareness, acceptance, and under-

standing of emotion and the visceral experience of emotion. In EFT, clients are

assisted to identify, experience, accept, explore, transform, and manage their emo-

tions. A premise of EFT is that we can change only when we accept ourselves as

we are. This approach has a good deal to offer with respect to teaching us about the

role of emotion in personal change and how emotional change can be a primary

pathway to cognitive and behavioral change.

Other therapeutic approaches are increasingly focusing on emotions. For

example, both psychoanalytic and cognitive behavioral approaches are giving more

attention to the role of emotions and are rapidly assimilating many aspects of EFT.

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TA B L E 7.1 Therapists Who Contributed to the Evolution

of Person-Centered Theory

I N N O V A T O R

C O N T R I B U T I O N

Natalie Rogers (1993, 1995, 2011)

Expanded the theory by developing person-centered

expressive arts therapy in groups.

Virginia Axline (1964, 1969)

Made signifi cant contributions to client-centered

therapy with children and play therapy.

Eugene Gendlin (1996)

Developed experiential techniques, such as focusing, as

a way to enhance client experiencing.

Laura Rice (Rice & Greenberg,

Taught therapists to be more evocative in re-creating

201

1984)

crucial experiences that continue to trouble the client.

PERSON-CENTERED THERAP

Peggy Natiello (2001)

Works on collaborative power and gender issues.

Art Combs (1988, 1989, 1999)

Developed perceptual psychology.

Leslie Greenberg (2011); Greenberg Contributed to the development of emotion-focused

and colleagues (Greenberg,

therapy. Focused on the importance of facilitating

Korman, & Paivio, 2002;

emotional change in therapy and advanced person-

Greenberg, Rice, & Elliott, 1993)

centered theory and methods. Demonstrated that the

emotional route can be a key to changing cognitions

Y

and behavior.

David Rennie (1998)

Provided a glimpse at the inner workings of the

therapeutic process.

Art Bohart (Bohart & Greenberg,

Contributed to a deeper understanding of empathy in

1997; Bohart & Tallman, 1999;

therapeutic practice and the active role of the client.

2010; Bohart & Watson, 2011)

Jeanne Watson (2002)

Demonstrated that when empathy is operating on the

cognitive, affective, and interpersonal levels it is one of

the therapist’s most powerful tools.

Dave Mearns and Brian Thorne

Contributed to understanding new frontiers in the

(2000, 2007)

theory and practice of the person-centered approach

and have been signifi cant fi gures in teaching and

supervising in the United Kingdom.

C. H. Patterson (1995)

Showed that client-centered therapy is a universal

system of psychotherapy.

Barry Duncan, Scott Miller, Bruce

Demonstrated that the client-centered relationship

Wampold, & Mark Hubble (2010)

and the core conditions are essential to all therapeutic

approaches.

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A strength of EFT is that it is an evidence-based approach, an idea that is increas-

ingly being emphasized in graduate programs (Greenberg, 2011).

Limitations and Criticisms of the Person-Centered Approach

Although I applaud person-centered therapists for their willingness to subject their

hypotheses and procedures to empirical scrutiny, some researchers have been crit-

ical of the methodological errors contained in some of these studies. Accusations

of scientifi c shortcomings involve using control subjects who are not candidates

for therapy, failing to use an untreated control group, failing to account for placebo

effects, relying on self-reports as a major way to assess the outcomes of therapy,

and using inappropriate statistical procedures.

There is a similar limitation shared by both the person-centered and existential

(experiential) approaches. Neither of these therapeutic modalities emphasizes the

202

role of techniques aimed at bringing about change in clients’ behavior. Proponents

of psychotherapy manuals, or manualized treatment methods for specifi c disor-

ders, fi nd serious limitations in the experiential approaches due to their lack of

attention to proven techniques and strategies. Those who call for accountability as

defi ned by evidence-based practices within the fi eld of mental health also are quite

critical of the experiential approaches.

CHAPTER SEVEN

I do not believe manualized treatment methods can be considered the gold

standard in psychotherapy, however. There is good research demonstrating that

techniques account for only 15% of client outcome (see Duncan et al., 2010), whereas

contextual factors have powerful effects on what happens in therapy (Elkins, 2009).

Research points to relational and client factors as the main predictors of effective

therapy. Furthermore, the evaluation of evidence-based practices should be broad-

ened to include best available research, the expertise of the clinician, and client char-

acteristics, culture, and preferences (see Norcross, Hogan, & Koocher, 2008).

A potential limitation of the person-centered approach is that some students-in-

training and practitioners with this orientation may have a tendency to be very support-

ive of clients without being challenging. Out of their misunderstanding of the basic

concepts of the approach, some have limited the range of their responses and coun-

seling styles mainly to refl ections and empathic listening. Although there is value in

really hearing a client and in refl ecting and communicating understanding, counseling

entails more than this. I believe that the therapeutic core conditions are necessary for

therapy to succeed, yet I do not see them as being suffi cient conditions for change for

all clients at all times. From my perspective, these basic attitudes are the foundation on

which counselors must then build the skills of therapeutic intervention. Motivational

interviewing rests on the therapeutic core conditions, for example, but MI employs a

range of strategies that enable clients to develop action plans leading to change.

A related challenge for counselors using this approach is to truly support

clients in fi nding their own way. Counselors sometimes experience diffi culty in

allowing clients to decide their own specifi c goals in therapy. It is easy to give lip

service to the concept of clients’ fi nding their own way, but it takes considerable

respect for clients and faith on the therapist’s part to encourage clients to listen to

themselves and follow their own directions, particularly when they make choices

that are not what the therapist hoped for.

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More than any other quality, the therapist’s genuineness determines the power

of the therapeutic relationship. If therapists submerge their unique identity and style

in a passive and nondirective manner, they are not likely to affect clients in powerful

ways. Therapist authenticity and congruence are so vital to this approach that those

who practice within this framework must feel natural in doing so and must fi nd a

way to express their own reactions to clients. If not, a real possibility is that person-

centered therapy will be reduced to a bland, safe, and ineffectual approach.

w h e r e t o g o f r o m h e r e

In the DVD for Integrative Counseling: The Case of Ruth and Lecturettes, you will see

a concrete illustration of how I view the therapeutic relationship as the foundation

for our work together. Refer especially to Session 1 (“Beginning of Counseling”),

203

Session 2 (“The Therapeutic Relationship”), and Session 3 (“Establishing Thera-

PERSON-CENTERED THERAP

peutic Goals”) for a demonstration of how I apply principles from the person-

centered approach to my work with Ruth.

Free Podcasts for ACA Members

You can download ACA Podcasts (prerecorded interviews) by going to www.coun-

seling.org; click on the Resource button and then select the Podcast Series. For

Chapter 7, Carl Rogers and the Person-Centered Approach, look for Podcast 7 by

by Dr. Howard Kirschenbaum.

Y

Other Resources

The American Psychological Association offers the following DVDs in their Psy-

chotherapy Video Series:

Greenberg, L. S. (2010). Emotion-Focused Therapy Over Time

Cain, D. J. (2010). Person-Centered Therapy Over Time

Psychotherapy.net is a comprehensive resource for students and professionals that

offers videos and interviews featuring Natalie Rogers, Rollo May, and more. New

articles, interviews, blogs, therapy cartoons, and videos are published monthly.

DVDs relevant to this chapter are available at www.psychotherapy.net and include

the following:

Rogers, N. (1997). Person-Centered Expressive Arts Therapy

May, R. (2007). Rollo May on Existential Psychotherapy

Association for the Development of the Person-Centered Approach, Inc. (ADPCA)

P. O. Box 3876

Chicago, IL 60690-3876

E-mail: enquiries@adpca.org

Website: www.adpca.org

Journal Editor: jonmrose@aol.com

The Association for the Development of the Person-Centered Approach (ADPCA)

is an interdisciplinary and international organization that consists of a network of

individuals who support the development and application of the person-centered

approach. Membership includes a subscription to the Person-Centered Journal, the

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch07_rev01.indd 203

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association’s newsletter, a membership directory, and information about the an-

nual meeting. ADPCA also provides information about continuing education and

supervision and training in the person-centered approach. For information about

the Person-Centered Journal, contact the editor (Jon Rose).

Association for Humanistic Psychology

1516 Oak Street #320A

Alameda, CA 94501-2947

Telephone: (510) 769-6495

Fax: (510) 769-6433

E-mail: AHPOffice@aol.com

Website: www.ahpweb.org

Journal website: http://jhp.sagepub.com

204

The Association for Humanistic Psychology (AHP) is devoted to promoting per-

sonal integrity, creative learning, and active responsibility in embracing the chal-

lenges of being human in these times. Information about the Journal of Human-

istic Psychology is available from the Association for Humanistic Psychology or at

publisher’s website.

Society for Humanistic Psychology

CHAPTER SEVEN

Website: http://www.societyforhumanisticpsychology.com/

Division 32 of APA, Society for Humanistic Psychology, represents a constellation

of “humanistic psychologies” that includes the earlier Rogerian, transpersonal,

and existential orientations as well as the more recently developing perspectives.

Division 32 seeks to contribute to psychotherapy, education, theory, research, epis-

temological diversity, cultural diversity, organization, management, social respon-

sibility, and change. The division has been at the forefront in the development of

qualitative research methodologies. The Society for Humanistic Psychology offers

journal access to The Humanistic Psychologist. Information about membership,

conferences, and journals is available from the website of Division 32.

Carl Rogers: A Daughter’s Tribute

Website: www.nrogers.com

The Carl Rogers CD-ROM is a visually beautiful and lasting archive of the life

and works of the founder of humanistic psychology. It includes excerpts from his

16 books, over 120 photographs spanning his lifetime, and award-winning video

footage of two encounter groups and Carl’s early counseling sessions. It is an es-

sential resource for students, teachers, libraries, and universities. It is a profound

tribute to one of the most important thinkers, infl uential psychologists, and peace

activists of the 20th century. Developed for Natalie Rogers, PhD, by Mindgarden

Media, Inc.

Center for Studies of the Person

1150 Silverado, Suite #112

La Jolla, CA 92037

Telephone: (858) 459-3861

E-mail: centerfortheperson@yahoo.com

Website: www.centerfortheperson.org

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch07_rev01.indd 204

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The Center for Studies of the Person (CSP) offers workshops, training seminars, ex-

periential small groups, residential workshops, and sharing of learning in community

meetings. The Distance Learning Project and the Carl Rogers Institute for Psychother-

apy Training and Supervision provide experiential and didactic training and supervi-

sion for professionals interested in developing their own person-centered orientation.

Saybrook Graduate School

E-mail: admissions@saybrook.edu

Website: www.nrogers.com

For training in expressive art therapy, you could join Natalie Rogers, PhD, and Shel-

lee Davis, MA, faculty of the certifi cate program at Saybrook Graduate School in

their course, “Expressive Arts for Healing and Social Change: A Person-Centered

Approach.” A 16-unit certifi cate program includes 6 separate weeks spread over 2

205

years at a retreat center north of San Francisco. Rogers and Davis offer expressive

PERSON-CENTERED THERAP

arts within a person-centered counseling framework. They use counseling demon-

strations, practice counseling sessions, readings, discussions, papers, and a creative

project to teach experiential and theoretical methods.

Recommended Supplementary Readings

On Becoming a Person (Rogers, 1961) is one of the best primary sources for fur-

Y

ther reading on person-centered therapy. This is a collection of Rogers’s articles

on the process of psychotherapy, its outcomes, the therapeutic relationship, edu-

cation, family life, communication, and the nature of the healthy person.

A Way of Being (Rogers, 1980) contains a series of writings on Rogers’s personal

experiences and perspectives, as well as chapters on the foundations and applica-

tions of the person-centered approach.

The Creative Connection: Expressive Arts as Healing (N. Rogers, 1993) is a practical,

spirited book lavishly illustrated with color and action photos and fi lled with fresh

ideas to stimulate creativity, self-expression, healing, and transformation. Natalie

Rogers combines the philosophy of her father with the expressive arts to enhance

communication between client and therapist.

The Life and Work of Carl Rogers (Kirschenbaum, 2009) is a defi nitive biography

of Carl Rogers that follows his life from his early childhood through his death.

This book illustrates the legacy of Carl Rogers and shows his enormous infl uence

on the fi eld of counseling and psychotherapy.

Person-Centered Psychotherapies (Cain, 2010) contains a clear discussion of person-

centered theory, the therapeutic process, evaluation of the approach, and future

developments.

Humanistic Psychology: A Clinical Manifesto (Elkins, 2009) offers an insightful

critique of the medical model of psychotherapy and the myth of empirically

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch07_rev01.indd 205

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supported treatments. The author calls for a relationship-based approach to psy-

chotherapy that can provide both individual and social transformation.

References and Suggested Readings

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*Arkowitz, H., Westra, H. A., Miller, W. R., &

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CHAPTER SEVEN

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*Norcross, J. C., Hogan, T. P., & Koocher, G. P.

Rogers, C. (1986a). Carl Rogers on the de-

(2008). Clinician’s guide to evidence-based prac-

CHAPTER SEVEN

velopment of the person-centered approach.

tices. New York: Oxford University Press.

Person-Centered Review, 1(3), 257–259.

Norcross, J. C., Krebs, P. M., & Prochaska, J. O.

Rogers, C. (1986b). Client-centered therapy.

(2011). Stages of change. In J.C. Norcross (Ed.),

In I. L. Kutash & A. Wolf (Eds.), Psychothera-

Psychotherapy relationships that work: Evidence-

pists casebook (pp. 197–208). San Francisco:

based responsiveness (2nd ed., pp. 279–300).

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Rogers, C. R. (1987a). Rogers, Kohut, and

Patterson, C. H. (1995). A universal system

Erickson: A personal perspective on some

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similarities and differences. In J. K. Zeig (Ed.),

2(1), 54–62.

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New York: Brunner/Mazel.

of psychotherapy: A transtheoretical analysis

Rogers, C. R. (1987b). Steps toward world

(7th ed.). Belmont, CA: Brooks/Cole, Cengage

peace, 1948–1986: Tension reduction in theory

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dom to learn (3rd ed.). Upper Saddle River, NJ:

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c h a p t e r 8

Gestalt Therapy

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210

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Fritz Perls / LAURA PERLS

FREDERICK S. (“FRITZ”) PERLS, MD, PhD

Perls and several of his colleagues established

(1893–1970), was the main originator and devel-

the New York Institute for Gestalt Therapy in 1952.

oper of Gestalt therapy. Born in Berlin, Germany,

Eventually Fritz left New York and settled in Big

into a lower-middle-class Jewish family, he later

Sur, California, where he conducted workshops and

identified himself as a source of much trouble for

seminars at the Esalen Institute, carving out his

his parents. Although he failed the seventh grade

reputation as an innovator in psychotherapy. Here

twice and was expelled from school because of

he had a great impact on people, partly through his

difficulties with the authorities, his brilliance was

professional writings, but mainly through personal

never quashed, and he returned—not only to

contact in his workshops.

complete high school but to earn his medical

Personally, Perls was both vital and perplexing.

degree (MD) with a specialization in psychiatry.

People typically either responded to him in awe

In 1916 he joined the German Army and served

or found him harshly confrontational and saw him

211

GES

as a medic in World War I. His experiences with

as meeting his own needs through showmanship.

soldiers who were gassed on the front lines led to

Having a predilection for the theater since child-

T

AL

his interest in mental functioning, which led him to

hood, he loved being on stage and putting on a

T THERAP

Gestalt psychology.

show. He was viewed variously as insightful, witty,

After the war Perls worked with Kurt Goldstein

bright, provocative, manipulative, hostile, demand-

at the Goldstein Institute for Brain-Damaged

ing, and inspirational. Unfortunately, some of the

Y

Soldiers in Frankfurt. It was through this associa-

people who attended his workshops went on to

tion that he came to see the importance of viewing

mimic the less attractive side of Perls’s personality.

humans as a whole rather than as a sum of dis-

Even though Perls was not happy with this, he did

cretely functioning parts. It was also through this

little to discourage it.

association that he met his wife, Laura, who was

For a firsthand account of the life of Fritz Perls,

earning her PhD with Goldstein. Later he moved to

I recommend his autobiography, In and Out of the

Vienna and began his psychoanalytic training.

Garbage Pail (1969b). For a well-researched chap-

Perls was in analysis with Wilhelm Reich, a

ter on the history of Gestalt therapy, see Bowman

psychoanalyst who pioneered methods of self-

(2005).

understanding and personality change by working

with the body.

L AU R A P O S N E R P E R L S , P h D (1905–1990),

already had a rich background when she met

was born in Pforzheim, Germany, the daughter

Fritz in 1926 and they began their collaboration,

of well-to-do parents. She began playing the

which resulted in the theoretical foundations

piano at the age of 5 and played with profes-

of Gestalt therapy. Laura and Fritz were married

sional skill by the time she was 18. From the

in 1930 and had two children while living and

age of 8 she was involved in modern dance, and

practicing in South Africa. Laura continued to

both music and modern dance remained vital

be the mainstay for the New York Institute

parts of her adult life and were incorporated

for Gestalt Therapy after Fritz abandoned his

into her therapy with some clients. By the time

family to become internationally famous as the

Laura began her practice as a psychoanalyst she

traveling minstrel for Gestalt therapy. Laura

had prepared for a career as a concert pianist,

also made significant contributions to the

had attended law school, achieved a doctoral

development and maintenance of the Gestalt

degree in Gestalt psychology, and made an

therapy movement in the United States and

intensive study of existential philosophy with

throughout the world (although in very different

Paul Tillich and Martin Buber. Clearly, Laura

ways) from the late 1940s until her death

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

in 1990. Laura’s own words make it clear that

of being responsive at a time when the popular

Fritz was a generator, not a developer or organ-

notion of Gestalt therapy was that it fostered

izer. At the 25th anniversary of the New York

responsibility only to oneself. She corrected

Institute for Gestalt Therapy, Laura Perls (1990)

some of the excesses committed in the name

stated, “Without the constant support from

of Gestalt therapy and adhered to the basic

his friends, and from me, without the constant

principles of Gestalt therapy theory as

encouragement and collaboration, Fritz would

written in Gestalt Therapy: Excitement and

never have written a line, nor founded

Growth in the Human Personality (Perls, Heffer-

anything” (p. 18).

line, & Goodman, 1951). She taught that every

Laura paid a great deal of attention to

Gestalt therapist needs to develop his or her

contact and support, which differed from Fritz’s

own therapeutic style. From her perspective,

attention to intrapsychic phenomena and his

whatever is integrated in our personality

focus on awareness. Her emphasis on contact

becomes support for what we use technically

212

underscored the role of the interpersonal and

(Humphrey, 1986).

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See the video program for Chapter 8, DVD for Theory and Practice of Counseling

and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view

the brief lecture for each chapter prior to reading the chapter.

k e y c o n c e p t s

View of Human Nature

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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CHAPTER EIGHT

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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CHAPTER EIGHT

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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219

t h e t h e r a p e u t i c p r o c e s s

GES

Therapeutic Goals

T

AL

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Therapist’s Function and Role

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220

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CHAPTER EIGHT

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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221

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GES

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T

t Language that denies power. 4PNFDMJFOUTIBWFBUFOEFODZUPEFOZUIFJSQFS

AL

T THERAP

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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222

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CHAPTER EIGHT

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Client’s Experience in Therapy

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

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a p p l i c at i o n : t h e r a p e u t i c

CHAPTER EIGHT

t e c h n i q u e s a n d p r o c e d u r e s

The Experiment in Gestalt Therapy

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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The Role of Confrontation

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Gestalt Therapy Interventions

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CHAPTER EIGHT

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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CHAPTER EIGHT

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Application to Group Counseling

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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232

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CHAPTER EIGHT

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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g e s ta lt t h e r a p y f r o m a

m u lt i c u lt u r a l p e r s p e c t i v e

Strengths From a Diversity Perspective

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Shortcomings From a Diversity Perspective

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234

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CHAPTER EIGHT

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Gestalt Therapy Applied to the Case of Stan

Gestalt-oriented therapy focuses on the

Although the focus is on Stan’s present

unfinished business Stan has with his

behavior, I guide him toward becoming aware

parents, siblings, and ex-wife. It appears

of how he is carrying old baggage around and

that this unfinished business consists mainly of

how it interferes with his life today. My task is to

feelings of resentment, and Stan turns this resent-

assist him in re-creating the context in which he

ment on himself. His present life situation is

made creative adjustments during his childhood

spotlighted, but he may also need to reexperience

years that no longer serving him well. One of

past feelings that could be interfering with his

his cardinal introjections was, “I’m stupid, and it

present attempts to develop intimacy with others.

would be better if I did not exist.”

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Stan has been influenced by cultural mes-

Although I have no agenda to get Stan to experi-

sages that he has accepted. I am interested in

ence his feelings at this point, it is important for

exploring his cultural background, including

him to increase his awareness of his reluctance

his values and the values characteristic of his

and to explore the meaning it holds for him.

culture. With this focus, I assist Stan in identify-

If Stan decides that he wants to experience

ing some of the following cultural introjections:

his emotions rather than deny them, I ask: “What

“Don’t talk about your family with strangers,

are you aware of now having said what you did?”

and don’t hang your dirty linen in public.” “Don’t

Stan says that he can’t get his ex-wife out of his

confront your parents because they deserve re-

mind. He tells me about the pain he feels over

spect.” “Don’t be too concerned about yourself.”

that relationship and how he is frightened of get-

“Don’t show your vulnerabilities; hide your feel-

ting involved again lest he be hurt again. I con-

ings and weaknesses.” I invite Stan to examine

tinue to ask him to focus inward and get a sense

those introjections to assess their utility in his

of what stands out for him at this very moment.

present circumstances. Although he can decide

Stan replies: “I’m hurt and angry over all the pain

235

to retain those aspects of his culture that he

that I’ve allowed her to inflict on me.” I ask him to

GES

prizes, he is in a position to modify or reject

imagine himself in earlier scenes with his ex-wife,

T

AL

other cultural expectations. Of course, this will

as though the painful situation were occurring

T THERAP

be done when these issues emerge in the fore-

in the here and now. He symbolically relives and

ground of his work.

reexperiences the situation by talking “directly”

I ask Stan to attend to what he becomes

to his wife. By expressing his resentments and

Y

aware of as the session begins: “What are you

hurts directly, Stan can begin to complete some

experiencing as we are getting started today?”

unfinished business that is interfering with his

As I encourage Stan to tune in to his present

current functioning. By participating in this

experience and selectively make observations, a

experiment, Stan is attaining more awareness of

number of figures will emerge. The goal is to

what he is now doing and how he keeps himself

focus on a figure of interest, one that seems to

locked into his past.

hold the most energy or relevance for Stan. When

a figure is identified, my task is to deepen Stan’s

Follow-Up: You Continue as Stan’s

awareness of this thought, feeling, body sensa-

Gestalt Therapist

tion, or insight through related experiments.

Use these questions to help you think about how

In typical Gestalt fashion, Stan deals with

to work with Stan using the Gestalt approach:

his present struggles within the context of our

t How might you begin a session with Stan?

relationship and through experimentation. One

Would you suggest a direction he should pur-

possible experiment would involve Stan becom-

sue? Would you wait for him to initiate work?

ing some of those individuals who told him how

Would you ask him to continue from where he

to think, feel, and behave as a child. He can then

left off in the previous session? Would you at-

become the child that he was and respond to

tend to whatever theme or issue becomes fig-

them from the place where he feels the most

ural to him?

confusion or pain. He experiences in new ways

t What unfinished business can you identify in

the feelings that accompany his beliefs about

Stan’s case? Does any of his experience of be-

himself, and he comes to a deeper appreciation

ing stuck remind you of yourself? How might

of how his feelings and thoughts influence what

you work with Stan if he did bring up your own

he is doing today.

unfinished business?

Stan has learned to hide his emotions rather

t What kind of an experiment might you pro-

than to reveal them. Understanding this about

pose to assist Stan in learning more about his

him, we explore his objections and concerns about

hesitation and reluctance to access and ex-

“getting into feelings.” The figure of interest now

press his feelings?

is his hesitation to experience or express emotion.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

t Stan participated in an experiment to deal

an assessment of some of the ways in which

with pain, resentment, and hurt over situa-

his culture is affecting him today?

tions with his ex-wife. How might you have

worked with the material Stan brought up?

See DVD for Theory and Practice of

What kind of experiment might you design?

Counseling and Psychotherapy: The Case

How would you decide what kind of experi-

of Stan and Lecturettes (Session 6 on Gestalt

ment to create?

therapy) for a demonstration of my approach

t How might you work with Stan’s cultural mes-

to counseling Stan from this perspective. This

sages? Would you be able to respect his cul-

session consists of Stan exploring one of his

tural values and still encourage him to make dreams in Gestalt fashion.

236

s u m m a r y a n d e va l u at i o n

Summary

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CHAPTER EIGHT

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Other Resources

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Gestalt Institute of Cleveland. Inc.

1588 Hazel Drive

Cleveland, OH 44106-1791

Telephone: (216) 421-0468

Fax: (216) 421-1729

E-mail: registrar@gestaltcleveland.org

Website: www.gestaltcleveland.org

Pacific Gestalt Institute

1626 Westwood Blvd., Suite 104

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Los Angeles, CA 90024

Telephone: (310) 446-9720

Fax: (310) 475-4704

E-mail: info@gestalttherapy.org

Website: www.gestalttherapy.org

Gestalt Center for Psychotherapy and Training

220 Fifth Avenue, Suite 802

New York, NY 10001

Telephone: (212) 387-9429

E-mail: info@gestaltnyc.org

Website: www.gestaltnyc.org

Gestalt International Study Center

1035 Cemetery Road

240

South Wellfleet, Cape Cod, MA 02667

Telephone: (508) 349-7900

E-mail: office@gisc.org

Website: www.GISC.org

Gestalt Therapy Training Center Northwest

757 SE 34th Avenue

CHAPTER EIGHT

Portland, OR 97214

Telephone: (503) 230-0900

E-mail: gttcnw@aol.com

Website: www.gttcnw.org

Gestalt Associates Training, Los Angeles

1460 Seventh Street, Suite 300

Santa Monica, CA 90401

Telephone/Fax: (310) 395-6844

E-mail: ritaresnick@gatla.org

Website: www.gatla.org

5IFNPTUQSPNJOFOUQSPGFTTJPOBMBTTPDJBUJPOTGPS(FTUBMUUIFSBQZUIBUIPMEJOUFS

OBUJPOBMDPOGFSFODFTGPMMPX

Association for the Advancement of Gestalt Therapy (AAGT)

Website: www.AAGT.org

European Association for Gestalt Therapy (EAGT)

Website: www.EAGT.org

Gestalt Review

Website: www.gestaltreview.com

British Gestalt Journal

Website: www.britishgestaltjournal.com

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Recommended Supplementary Readings

Gestalt Therapy Verbatim (Perls, 1969a) provides a firsthand account of the way Fritz Perls

worked. It contains many verbatim transcripts of workshop demonstrations.

Gestalt Therapy: History, Theory, and Practice (Woldt & Toman, 2005) introduces the historical

underpinnings and key concepts of Gestalt therapy and features applications of those concepts

to therapeutic practice. This is a significant recent publication in the field of Gestalt therapy that

contains pedagogical learning activities and experiments, review questions, and photographs of

all contributors.

Gestalt Therapy Integrated: Contours of Theory and Practice (Polster & Polster, 1973) is a classic in

the field and an excellent source for those who want a more advanced and theoretical treatment

of this model.

241

References and Suggested Readings

GES

T

*Barber, P. (2006). Becoming a practitioner

counseling (8th ed.). Belmont, CA: Brooks/

AL

T THERAP

researcher: A Gestalt approach to holistic inquiry.

Cole, Cengage Learning.

London: Middlesex University Press.

*Corey, G. (2013). Case approach to counseling

Beisser, A. R. (1970). The paradoxical theory

and psychotherapy (8th ed.). Belmont, CA:

Y

of change. In J. Fagan & I. L. Shepherd (Eds.),

Brooks/Cole, Cengage Learning.

Gestalt therapy now (pp. 77–80). New York:

Elliott, R., Watson, J. C., Goldman, R. N., &

Harper & Row (Colophon).

Greenberg, L. S. (2004). Learning emotion-

*Bowman, C. (2005). The history and develop-

focused therapy: A process-experiential approach

ment of Gestalt therapy. In A. Woldt & S. To-

to change. Washington, DC: American Psycho-

man (Eds.), Gestalt therapy: History, theory, and

logical Association.

practice (pp. 3–20). Thousand Oaks, CA: Sage.

*Feder. B. (2006). Gestalt group therapy: A prac-

Breshgold, E. (1989). Resistance in Gestalt

tical guide. New Orleans: Gestalt Institute Press.

therapy: An historical theoretical perspective.

*Feder, B., & Frew, J. (Eds.). (2008). Beyond the

The Gestalt Journal, 12(2), 73–102.

hot seat revisited: Gestalt approaches to group.

*Brown, J. R. (2007). Gestalt therapy. In A. B.

New Orleans: Gestalt Institute Press.

Rochlen (Ed.), Applying counseling theories: An

Feder, B., & Ronall, R. (Eds.). (1996). A living

online case-based approach (pp. 127–141).

legacy of Fritz and Laura Perls: Contemporary

Upper Saddle River, NJ: Pearson Prentice-Hall.

case studies. Montclair, NJ: Walden.

*Brownell, P. (2008). Handbook for theory,

Fernbacher, S., & Plummer, D. (2005).

research and practice in Gestalt therapy.

Cultural influences and considerations in

Newcastle, UK: Cambridge Scholar Publishing.

Gestalt therapy. In A. Woldt & S. Toman (Eds.),

*Cain, D. J. (2002). Defining characteristics,

Gestalt therapy: History, theory, and practice (pp.

history, and evolution of humanistic psycho-

117–132). Thousand Oaks, CA: Sage.

therapies. In D. J. Cain & J. Seeman (Eds.),

Frew, J. E. (1986). The functions and patterns

Humanistic psychotherapies: Handbook of

of occurrence of individual contact styles

research and practice (pp. 3–54). Washington,

during the development phase of the Gestalt

DC: American Psychological Association.

group. The Gestalt Journal, 9(l), 55–70.

Clarkson, P., & Mackewn, J. (1993). Fritz Perls.

Frew, J. E. (1997). A Gestalt therapy theory

Newbury Park, CA: Sage.

application to the practice of group leadership.

Corey, G. (2012). Theory and practice of group

Gestalt Review, 1(2), 131–149.

#PPLTBOEBSUJDMFTNBSLFEXJUIBOBTUFSJTLBSFTVHHFTUFEGPSGVSUIFSTUVEZ

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

*Frew, J. (2008). Gestalt therapy. In J. Frew &

Perls, L. (1976). Comments on new direc-

M. D. Spiegler (Eds.), Contemporary psychother-

tions. In E.W.L. Smith (Ed.), The growing edge

apies for a diverse world (pp. 228–274). Boston:

of Gestalt therapy (pp. 221–226). New York:

Lahaska Press.

Brunner/Mazel.

*Greenberg, L. S. (2011). Emotion-focused

Perls, L. (1990). A talk for the 25th anniver-

therapy. Washington, DC: American Psycho-

sary. The Gestalt Journal, 13(2), 15–22.

logical Association.

Polster, E. (1987a). Escape from the present:

Humphrey, K. (1986). Laura Perls: A biograph-

Transition and storyline. In J. K. Zeig (Ed.), The

ical sketch. The Gestalt Journal, 9(l), 5–11.

evolution of psychotherapy (pp. 326–340). New

York: Brunner/Mazel.

*Hycner, R., & Jacobs, L. (1995). The healing

relationship in Gestalt therapy. Highland, NY:

*Polster, E. (1987b). Every person’s life is worth

Gestalt Journal Press.

a novel: How to cut through emotional pain and

discover the fascinating core of life. New York:

Jacobs, L. (1989). Dialogue in Gestalt theory

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*Polster, E. (1995). A population of selves: A

*Latner, J. (1986). The Gestalt therapy book.

therapeutic exploration of personality diversity.

Highland, NY: Center for Gestalt Development.

San Francisco: Jossey-Bass.

*Lee, R. G. (Ed.). (2004). The values of connec-

*Polster, E., & Polster, M. (1973). Gestalt

tion: A relational approach to ethics. Cambridge,

therapy integrated: Contours of theory and prac-

CHAPTER EIGHT

MA: Gestalt Press.

tice. New York: Brunner/Mazel.

Levitsky, A., & Perls, F. (1970). The rules and

Polster, E., & Polster, M. (1976). Therapy with-

games of Gestalt therapy. In J. Fagan & I.

out resistance: Gestalt therapy. In A. Burton

Shepherd (Eds.), Gestalt therapy now (pp. 140–

(Ed.), What makes behavior change possible?

149). New York: Harper & Row (Colophon).

(pp. 259–277). New York: Brunner/Mazel.

Maurer, R. (2005). Gestalt approaches with

Polster, M. (1987). Gestalt therapy: Evolution

organizations and large systems. In A. Woldt

and application. In J. K. Zeig (Ed.), The evolu-

& S. Toman (Eds.), Gestalt therapy: History,

tion of psychotherapy (pp. 312–325). New York:

theory, and practice. (pp. 237–256). Thousand

Brunner/Mazel.

Oaks, CA: Sage.

Polster, M., & Polster, E. (1990). Gestalt thera-

Melnick, J., & Nevis, S. (2005). Gestalt

py. In J. K. Zeig & W. M. Munion (Eds.), What

therapy methodology. In A. Woldt & S. Toman

is psychotherapy? Contemporary perspectives

(Eds.), Gestalt therapy: History, theory, and prac-

(pp. 103–107). San Francisco: Jossey-Bass.

tice. (pp. 101–116). Thousand Oaks, CA: Sage.

*Strumpfel, U., & Goldman, R. (2002). Con-

Parlett, M. (2005). Contemporary Gestalt

tacting Gestalt therapy. In D. J. Cain & J.

therapy: Field theory. In A. Woldt & S. Toman

Seeman (Eds.), Humanistic psychotherapies:

(Eds.), Gestalt therapy: History, theory, and prac-

Handbook of research and practice (pp. 189–

tice (pp. 41–64). Thousand Oaks, CA: Sage.

219). Washington, DC: American Psychologi-

Passons, W. R. (1975). Gestalt approaches in

cal Association.

counseling. New York: Holt, Rinehart & Winston.

Watson, J. C., Goldman, R. N., & Greenberg,

*Perls, F. (1969a). Gestalt therapy verbatim.

L. S. (2011). Humanistic and experiential theo-

Moab, UT: Real People Press.

ries in psychotherapy. In J. C. Norcross, G. R.

Vandenbos, & D. K. Freedheim (Eds.), History of

Perls, F. (1969b). In and out of the garbage pail.

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ton, DC: American Psychological Association.

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Gestalt therapy: Excitement and growth in the

therapy: History, theory, and practice. Thousand

human personality. New York: Dell.

Oaks, CA: Sage.

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

*Yontef, G. M. (1993). Awareness, dialogue and

Gestalt therapy: History, theory, and practice

process: Essays on Gestalt therapy. Highland,

(pp. 81–100). Thousand Oaks, CA: Sage.

NY: Gestalt Journal Press.

*Yontef, G., & Jacobs, L. (2011). Gestalt

*Yontef, G. (1995). Gestalt therapy. In A. S.

therapy. In R. Corsini & D. Wedding (Eds.),

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Zahm, S. (1998). Therapist self-disclosure in

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the practice of Gestalt therapy. The Gestalt

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*Zinker, J. (1978). Creative process in Gestalt

*Yontef, G. M. (2005). Gestalt therapy theory

therapy. New York: Random House (Vintage).

of change. In A. Woldt & S. Toman (Eds.),

243

GES

T

AL

T THERAP

Y

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c h a p t e r 9

Behavior Therapy

i n t r o d u c t i o n

• Self-Management Programs and Self-Directed

• Historical Background

Behavior

• Four Areas of Development

• Multimodal Therapy: Clinical Behavior

Therapy

k e y c o n c e p t s

• Mindfulness and Acceptance-Based Cognitive

• View of Human Nature

Behavior Therapy

• Basic Characteristics and Assumptions

• Application to Group Counseling

t h e t h e r a p e u t i c p r o c e s s

b e h a v i o r t h e r a p y f r o m a

m u lt i c u lt u r a l p e r s p e c t i v e

• Therapeutic Goals

• Therapist’s Function and Role

• Strengths From a Diversity Perspective

• Client’s Experience in Therapy

• Shortcomings From a Diversity Perspective

• Relationship Between Therapist and Client

b e h a v i o r t h e r a p y a p p l i e d t o t h e

c a s e o f s ta n

a p p l i c at i o n : t h e r a p e u t i c

t e c h n i q u e s a n d p r o c e d u r e s

s u m m a ry a n d e va l u at i o n

•

• Applied Behavioral Analysis: Operant

Applied Behavioral Analysi

• Summary

Conditioning Techniques

• Contributions of Behavior Therapy

•

• Progressive Muscle Relaxation

Progressive Muscle Relaxati

• Limitations and Criticisms of Behavior

•

• Systematic Desensitization

atic Desensitization

System

Therapy

•

• In Vivo Exposure and Flooding

In ivo Exposure and Flooding

•

• Eye Movement Desensitization and

w h e r e t o g o f r o m h e r e

Eye Movement Desensitization and

Reprocessing

Reprocessing

•

• Recommended Supplementary Readings

Recomm

ntary Readin

•

• Social Skills Training

Socia Skills Training

•

• References and Suggested Readings

References

Suggested Readings

244

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B. F. Skinner / Albert Bandura / Arnold Lazarus

B. F. SKINNER (1904–

mind and motives, which cannot be observed and

1990) reported that he was

changed directly, and that too little focus had been

brought up in a warm, stable

given to environmental factors that can be directly

family environment.* As he

observed and changed. He was extremely inter-

was growing up, Skinner was

ested in the concept of reinforcement, which he

greatly interested in building

applied to his own life. For example, after working

all sorts of things, an interest

for many hours, he would go into his constructed

that followed him through-

cocoon (like a tent), put on headphones, and listen

Photo

AP

out his professional life. He

to classical music (Frank Dattilio, personal commu-

received his PhD in psychol-

nication, September 24, 2010).

ogy from Harvard University in 1931 and eventu-

Most of Skinner’s work was of an experimental

245

ally returned to Harvard after teaching in several

nature in the laboratory, but others have applied his

BEHA

universities. He had two daughters, one of whom is

ideas to teaching, managing human problems, and

an educational psychologist and the other an artist.

social planning. Science and Human Behavior

VIOR THERAP

Skinner was a prominent spokesperson for

(Skinner, 1953) best illustrates how Skinner thought

behaviorism and can be considered the father of

behavioral concepts could be applied to every

the behavioral approach to psychology. Skinner

domain of human behavior. In Walden II (1948)

championed radical behaviorism, which places

Skinner describes a utopian community in which

Y

primary emphasis on the effects of environment

his ideas, derived from the laboratory, are applied

on behavior. Skinner was also a determinist; he

to social issues. His 1971 book, Beyond Freedom and

did not believe that humans had free choice. He

Dignity, addressed the need for drastic changes if

acknowledged that feelings and thoughts exist, but

our society was to survive. Skinner believed that

he denied that they caused our actions. Instead,

science and technology held the promise for a

he stressed the cause-and-effect links between

better future.

objective, observable environmental conditions

*This biography is based largely on Nye’s (2000)

and behavior. Skinner maintained that too much

discussion of B. F. Skinner’s radical behaviorism.

attention had been given to internal states of

ALBERT BANDURA

and demonstrated that modeling is a powerful

(b. 1925) was born in a

process that explains diverse forms of learning

small town in northern

(see Bandura 1971a, 1971b; Bandura & Walters,

Alberta, Canada; he was

1963). In his research programs at Stanford

Stanford

the youngest of six children

University, Bandura and his colleagues explored

Bandura,

CA

in a family of Eastern Eu-

social learning theory and the prominent role of

Alto,

Albert

ropean descent.* Bandura

observational learning and social modeling in

Dr.

Palo

spent his elementary and

human motivation, thought, and action. By the

high school years in the one

mid-1980s Bandura had renamed his theoretical

Courtesy,

University,

school in town, which was

approach social cognitive theory, which shed light

short of teachers and resources. These meager

on how we function as self-organizing, proactive,

educational resources proved to be an asset

self-reflective, and self-regulating beings (see

rather than a liability as Bandura early on learned

Bandura, 1986). This notion that we are not simply

the skills of self-directedness, which would later

reactive organisms shaped by environmental

become one of his research themes. He earned his

forces or driven by inner impulses represented

PhD in clinical psychology from the University of

a dramatic shift in the development of behavior

Iowa in 1952, and a year later he joined the faculty

therapy. Bandura broadened the scope of behavior

at Stanford University. Bandura and his colleagues

therapy by exploring the inner cognitive-affective

did pioneering work in the area of social modeling

forces that motivate human behavior.

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28549_ch09_rev01.indd 245

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There are some existential qualities inherent

depressions are caused. Bandura has created one

in Bandura’s social cognitive theory. Bandura has

of the few mega-theories that still thrive at the

produced a wealth of empirical evidence that dem-

beginning of the 21st century. He has shown that

onstrates the life choices we have in all aspects

people need a sense of self-efficacy and resilience

of our lives. In Self-Efficacy: The Exercise of Control

to create a successful life and to meet the inevita-

(Bandura, 1997), Bandura shows the compre-

ble obstacles and adversities they encounter.

hensive applications of his theory of self-efficacy

To date Bandura has written nine books, many

to areas such as human development, psychol-

of which have been translated into various lan-

ogy, psychiatry, education, medicine and health,

guages. In 2004 he received the Outstanding Life-

athletics, business, social and political change, and

time Contribution to Psychology Award from the

international affairs.

American Psychological Association. In his early

Bandura has concentrated on four areas of

80s, Bandura continues to teach and do research

research: (1) the power of psychological modeling

at Stanford University and to travel throughout the

246

in shaping thought, emotion, and action; (2) the

world. He still makes time for hiking, opera, being

mechanisms of human agency, or the ways people

with his family, and wine tasting in the Napa and

influence their own motivation and behavior

Sonoma valleys.

through choice; (3) people’s perceptions of their

*This biography is based largely on Pajares’s

efficacy to exercise influence over the events that

(2004) discussion of Bandura’s life and work.

affect their lives; and (4) how stress reactions and

CHAPTER NINE

ARNOLD A. LAZARUS

clinical psychology in 1960, and then went into full-

(b. 1932) was born and

time private practice in Johannesburg. In 1963 he

educated in Johannesburg,

was invited by Albert Bandura to teach at Stanford

South Africa. The young-

University. Later he held teaching positions at

Institute

est of four children, he

Temple University Medical School, Yale University,

Lazarus

grew up in a neighborhood

and Rutgers University.

the

of

where there were very few

He has received many honors and won numer-

children, and he remembers

ous awards, including two Distinguished Profes-

Courtesy

being lonely and frightened.

sional Contributions Awards from the American

He learned to play the piano at an early age and

Psychological Association and the prestigious

recalls, “When I was 7 I used to play like a talented

Cummings PSYCHE AWARD. Lazarus has written

12-year-old, but when I turned 14 and still played

17 books and more than 300 professional articles.

like a 12-year-old, I decided to quit!” His interests

He is a pioneer in clinical behavior therapy and

then changed to bodybuilding, weight lifting, box-

the developer of multimodal therapy, which is

ing, and wrestling. He adds, “I was a pathetically

a comprehensive, systematic, holistic approach

skinny kid, often beaten up and bullied, so I started

to behavior therapy. Although the assessment

training rather frantically” (personal communica-

process is multimodal, the treatment is cognitive

tion, April 15, 2011). Through sheer determination

behavioral and draws on empirically supported

he ended up winning boxing and weight-lifting

methods. In terms of clinical practice, behavior

competitions and planned to own and operate a

therapy and multimodal therapy are very similar.

gym or health center.

He is recognized as an authority on brief, efficient,

Although Lazarus grew up in South Africa,

and effective psychotherapy.

he strongly identified with the United States. At

In addition to his contribution to the develop-

an early age he felt that racism and discrimina-

ment of behavior therapy, Lazarus has shown a

tion were totally unacceptable. He entered col-

keen interest in the subject of dual and multiple

lege intending to major in English with a view to

relationships in psychotherapy. Through his writing

journalism as a career but soon switched majors

and lecturing on this topic, he has done a great deal

to psychology. He obtained his master’s degree

to challenge the rigidity of a rule-based approach

in experimental psychology in 1957 and a PhD in

to practicing psychotherapy. One significant book

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28549_ch09_rev01.indd 246

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is Dual Relationships and Psychotherapy, (Lazarus &

is the executive director and his daughter-in-law

Zur, 2002). Arnold Lazarus is currently the presi-

(Donna Astor-Lazarus, MSW, LCSW) is the

dent of The Lazarus Institute in Skillman, New

clinical director.

Jersey, where his son (Clifford N. Lazarus, PhD)

i n t r o d u c t i o n

Behavior therapy practitioners focus on directly observable behavior, current de-

terminants of behavior, learning experiences that promote change, tailoring treat-

ment strategies to individual clients, and rigorous assessment and evaluation.

Behavior therapy has been used to treat a wide range of psychological disorders

247

with different client populations. Anxiety disorders, depression, posttraumatic

BEHA

stress disorder, substance abuse, eating and weight disorders, sexual problems,

pain management, and hypertension have all been successfully treated using this

VIOR THERAP

approach (Wilson, 2011). Behavioral procedures are used in the fi elds of develop-

mental disabilities, mental illness, education and special education, community

psychology, clinical psychology, rehabilitation, business, self-management, sports

psychology, health-related behaviors, medicine, and gerontology (Miltenberger,

Y

2012; Wilson, 2011).

Historical Background

The behavioral approach had its origin in the 1950s and early 1960s, and it was

a radical departure from the dominant psychoanalytic perspective. The behavior

therapy movement differed from other therapeutic approaches in its application of

principles of classical and operant conditioning (which will be explained shortly)

to the treatment of a variety of problem behaviors. Today, it is diffi cult to fi nd

a consensus on the defi nition of behavior therapy because the fi eld has grown,

become more complex, and is marked by a diversity of views. Contemporary

behavior therapy is no longer limited to treatments based on traditional learning

theory (Antony & Roemer, 2011b). Indeed, as behavior therapy has evolved and

developed, it has increasingly overlapped in some ways with other psychotherapeutic

approaches (Wilson, 2011). Behavior therapists now use a variety of evidence-based

techniques in their practices, including cognitive therapy, social skills training,

relaxation training, and mindfulness strategies—all of which are discussed in this

chapter. The following historical sketch of behavior therapy is largely based on

Spiegler and Guevremont (2010).

Traditional behavior therapy arose simultaneously in the United States, South

Africa, and Great Britain in the 1950s. In spite of harsh criticism and resistance

from psychoanalytic psychotherapists, the approach has survived. Its focus was on

demonstrating that behavioral conditioning techniques were effective and were a

viable alternative to psychoanalytic therapy.

In the 1960s Albert Bandura developed social learning theory, which combined

classical and operant conditioning with observational learning. Bandura made

cognition a legitimate focus for behavior therapy. During the 1960s a number of

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28549_ch09_rev01.indd 247

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cognitive behavioral approaches sprang up, which focus on cognitive representations

of the environment rather than on characteristics of the objective environment.

Contemporary behavior therapy emerged as a major force in psychology during

the 1970s, and it had a signifi cant impact on education, psychology, psychotherapy,

psychiatry, and social work. Behavioral techniques were expanded to provide solu-

tions for business, industry, and child-rearing problems as well. Behavior therapy

techniques were viewed as the treatment of choice for many psychological problems.

The 1980s were characterized by a search for new horizons in concepts and

methods that went beyond traditional learning theory. Behavior therapists con-

tinued to subject their methods to empirical scrutiny and to consider the impact

of the practice of therapy on both their clients and the larger society. Increased

attention was given to the role of emotions in therapeutic change, as well as to the

248

role of biological factors in psychological disorders. Two of the most signifi cant

developments in the fi eld were (1) the continued emergence of cognitive behavior

therapy as a major force and (2) the application of behavioral techniques to the

prevention and treatment of health-related disorders.

By the late 1990s the Association for Behavioral and Cognitive Therapies (ABCT)

(formerly known as the Association for Advancement of Behavior Therapy) claimed

CHAPTER NINE

a membership of about 4,500. Currently, ABCT includes approximately 6,000

mental health professionals and students who are interested in empirically based

behavior therapy or cognitive behavior therapy. This name change and description

reveals the current thinking of integrating behavioral and cognitive therapies.

By the early 2000s, the behavioral tradition had broadened considerably, which

involved enlarging the scope of research and practice. This newest development,

sometimes known as the “third wave” of behavior therapy, includes dialectical

behavior therapy (DBT), mindfulness-based stress reduction (MBSR), mindfulness-

based cognitive therapy (MBCT), and acceptance and commitment therapy (ACT).

See the video program for Chapter 9, DVD for Theory and Practice of Counseling

and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view

the brief lecture for each chapter prior to reading the chapter.

Four Areas of Development

Contemporary behavior therapy can be understood by considering four major

areas of development: (1) classical conditioning, (2) operant conditioning, (3) social-

cognitive theory, and (4) cognitive behavior therapy.

Classical conditioning (respondent conditioning) refers to what happens prior

to learning that creates a response through pairing. A key fi gure in this area is

Ivan Pavlov who illustrated classical conditioning through experiments with dogs.

Placing food in a dog’s mouth leads to salivation, which is respondent behavior.

When food is repeatedly presented with some originally neutral stimulus (some-

thing that does not elicit a particular response), such as the sound of a bell, the dog

will eventually salivate to the sound of the bell alone. However, if a bell is sounded

repeatedly but not paired again with food, the salivation response will eventually

diminish and become extinct. An example of a procedure that is based on the clas-

sical conditioning model is Joseph Wolpe’s systematic desensitization, which is

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch09_rev01.indd 248

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described later in this chapter. This technique illustrates how principles of learn-

ing derived from the experimental laboratory can be applied clinically. Desensiti-

zation can be applied to people who, through classical conditioning, developed an

intense fear of fl ying after having a frightening experience while fl ying.

Technically one can develop an intense fear of fl ying without having a frighten-

ing experience personally. For example, someone may see visual images of a plane

crashing off the coast of Brazil and develop a fear of fl ying even though that person

has never fl own anywhere. Some researchers hold a different view and believe

that fear of fl ying may be due primarily to claustrophobia (Frank Dattilio, personal

communication, September 24, 2010).

Most of the signifi cant responses we make in everyday life are examples of

operant behaviors, such as reading, writing, driving a car, and eating with uten-

sils. Operant conditioning involves a type of learning in which behaviors are infl u-

249

enced mainly by the consequences that follow them. If the environmental changes

BEHA

brought about by the behavior are reinforcing—that is, if they provide some reward

VIOR THERAP

to the organism or eliminate aversive stimuli—the chances are increased that the

behavior will occur again. If the environmental changes produce no reinforcement

or produce aversive stimuli, the chances are lessened that the behavior will recur.

Positive and negative reinforcement, punishment, and extinction techniques, de-

Y

scribed later in this chapter, illustrate how operant conditioning in applied settings

can be instrumental in developing prosocial and adaptive behaviors. Operant tech-

niques are used by behavioral practitioners in parent education programs and with

weight management programs.

The behaviorists of both the classical and operant conditioning models excluded

any reference to mediational concepts, such as the role of thinking processes,

attitudes, and values. This focus is perhaps due to a reaction against the insight-

oriented psychodynamic approaches. The social learning approach (or the social-

cognitive approach) developed by Albert Bandura and Richard Walters (1963) is

interactional, interdisciplinary, and multimodal (Bandura, 1977, 1982). Social-

cognitive theory involves a triadic reciprocal interaction among the environment,

personal factors (beliefs, preferences, expectations, self-perceptions, and interpre-

tations), and individual behavior. In the social-cognitive approach the environmen-

tal events on behavior are mainly determined by cognitive processes governing

how environmental infl uences are perceived by an individual and how these events

are interpreted (Wilson, 2011). A basic assumption is that people are capable of self-

directed behavior change and that the person is the agent of change. For Bandura

(1982, 1997), self-effi cacy is the individual’s belief or expectation that he or she can

master a situation and bring about desired change. An example of social learning

is ways people can develop effective social skills after they are in contact with other

people who effectively model interpersonal skills.

Cognitive behavior therapy (CBT) represents the mainstream of contemporary

behavior therapy and is a popular theoretical orientation among psychologists.

Cognitive behavioral therapy operates on the assumption that what people believe

infl uences how they act and feel. Since the early 1970s, the behavioral movement

has conceded a legitimate place to thinking, even to the extent of giving cognitive

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28549_ch09_rev01.indd 249

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factors a central role in understanding and treating emotional and behavioral prob-

lems. By the mid-1970s cognitive behavior therapy had replaced behavior therapy as

the accepted designation, and the fi eld began emphasizing the interaction among

affective, behavioral, and cognitive dimensions (Lazarus, 2008a; Wilson, 2011).

Today only the integrative therapies are more popular than CBT (Hollon &

DiGiuseppe, 2011). A good example of this more integrative approach of cognitive

and behavioral dimensions is multimodal therapy, which is discussed later in this

chapter. Many techniques, particularly those developed within the last three dec-

ades, emphasize cognitive processes that involve private events such as the client’s

self-talk as mediators of behavior change (see Bandura, 1969, 1986; Beck, 1976;

Beck & Weishaar, 2011).

Contemporary behavior therapy has much in common with cognitive behavior

250

therapy in which the mechanism of change is both cognitive (modifying thoughts

to change behaviors) and behavioral (altering external factors that lead to behav-

ior change) (Follette & Callaghan, 2011). Considered broadly, the term “behavior

therapy” refers to practices based primarily on social-cognitive theory and encom-

passes a range of cognitive principles and procedures (Wilson, 2011). This chapter

goes beyond the traditional behavioral perspective and deals mainly with applied

CHAPTER NINE

aspects of this model. Chapter 10 is devoted to the cognitive behavioral approaches,

which focus on changing clients’ cognitions (thoughts and beliefs) that maintain

psychological problems.

k e y c o n c e p t s

View of Human Nature

Modern behavior therapy is grounded on a scientifi c view of human behavior that

accommodates a systematic and structured approach to counseling. This view does

not rest on a deterministic assumption that humans are a mere product of their

sociocultural conditioning. Rather, the current view is that the person is the pro-

ducer and the product of his or her environment.

The current trend in behavior therapy is toward developing procedures that

give control to clients and thus increase their range of freedom. Behavior therapy

aims to increase people’s skills so that they have more options for responding. By

overcoming debilitating behaviors that restrict choices, people are freer to select

from possibilities that were not available to them earlier, which increases individ-

ual freedom. People have the capacity to choose how they will respond to external

events in their environment, which makes it possible for therapists to use behavio-

ral methods to attain humanistic ends (Kazdin, 1978, 2001).

Basic Characteristics and Assumptions

Seven key characteristics of behavior therapy are described below.

1. Behavior therapy is based on the principles and procedures of the scientifi c meth-

od. Experimentally derived principles of learning are systematically applied to help

people change their maladaptive behaviors. The distinguishing characteristic of

behavioral practitioners is their systematic adherence to precision and to empirical

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evaluation. Behavior therapists state treatment goals in concrete objective terms

to make replication of their interventions possible. Treatment goals are agreed

upon by the client and the therapist. Throughout the course of therapy, the thera-

pist assesses problem behaviors and the conditions that are maintaining them.

Evaluation methods are used to discern the effectiveness of both assessment and

treatment procedures. Therapeutic techniques employed must have demonstrated

effectiveness. In short, behavioral concepts and procedures are stated explicitly,

tested empirically within a conceptual framework, and revised continually.

2. Behavior is not limited to overt actions a person engages in that we can observe;

behavior also includes internal processes such as cognitions, images, beliefs, and

emotions. The key characteristic of a behavior is that it is something that can be

operationally defi ned.

251

3. Behavior therapy deals with the client’s current problems and the factors

BEHA

infl uencing them, as opposed to an analysis of possible historical determinants.

VIOR THERAP

Emphasis is on specifi c factors that infl uence present functioning and what fac-

tors can be used to modify performance. At times understanding of the past may

offer useful information about environmental events related to present behavior.

Behavior therapists look to the current environmental events that maintain prob-

Y

lem behaviors and help clients produce behavior change by changing environmen-

tal events, through a process called functional assessment, or what Wolpe (1990)

referred to as a “behavioral analysis.” Behavior therapy recognizes the importance

of the individual, the individual’s environment, and the interaction between the

person and the environment in facilitating change.

4. Clients involved in behavior therapy are expected to assume an active role by en-

gaging in specifi c actions to deal with their problems. Rather than simply talking

about their condition, clients are required to do something to bring about change.

Clients monitor their behaviors both during and outside the therapy sessions,

learn and practice coping skills, and role-play new behavior. Therapeutic tasks that

clients carry out in daily life, or homework assignments, are a basic part of this ap-

proach. Behavior therapy is an action-oriented and an educational approach, and

learning is viewed as being at the core of therapy. Clients learn new and adaptive

behaviors to replace old and maladaptive behaviors.

5. This approach assumes that change can take place without insight into underly-

ing dynamics and without understanding the origins of a psychological problem.

Behavior therapists operate on the premise that changes in behavior can occur prior

to or simultaneously with understanding of oneself, and that behavioral chang-

es may well lead to an increased level of self-understanding. While it is true that

insight and understanding about the contingencies that exacerbate one’s problems

can supply motivation to change, knowing that one has a problem and knowing

how to change it are two different things (Martell, 2007).

6. Assessment is an ongoing process of observation and self-monitoring that

focuses on the current determinants of behavior, including identifying the problem

and evaluating the change; assessment informs the treatment process. Therapists

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also assess their clients’ cultures as part of their social environments, including

social support networks relating to target behaviors (Tanaka-Matsumi, Higgin-

botham, & Chang, 2002). Critical to behavioral approaches is the careful assess-

ment and evaluation of the interventions used to determine whether the behavior

change resulted from the procedure.

7. Behavioral treatment interventions are individually tailored to specifi c prob-

lems experienced by the client. Several therapy techniques may be used to treat an

individual client’s problems. An important question that serves as a guide for this

choice is, “What treatment, by whom, is the most effective for this individual with

that specifi c problem and under which set of circumstances?” (Paul, 1967, p. 111).

252

t h e t h e r a p e u t i c p r o c e s s

Therapeutic Goals

Goals occupy a place of central importance in behavior therapy. The general goals

of behavior therapy are to increase personal choice and to create new conditions

for learning. The client, with the help of the therapist, defi nes specifi c treatment

CHAPTER NINE

goals at the outset of the therapeutic process. Although assessment and treatment

occur together, a formal assessment takes place prior to treatment to determine

behaviors that are targets of change. Continual assessment throughout therapy

determines the degree to which identifi ed goals are being met. It is important to

devise a way to measure progress toward goals based on empirical validation.

Contemporary behavior therapy stresses clients’ active role in deciding about

their treatment. The therapist assists clients in formulating specifi c measurable

goals. Goals must be clear, concrete, understood, and agreed on by the client and

the counselor. The counselor and client discuss the behaviors associated with the

goals, the circumstances required for change, the nature of subgoals, and a plan of

action to work toward these goals. This process of determining therapeutic goals

entails a negotiation between client and counselor that results in a contract that

guides the course of therapy. Behavior therapists and clients alter goals throughout

the therapeutic process as needed.

Therapist’s Function and Role

Behavior therapists conduct a thorough functional assessment (or behavioral anal-

ysis) to identify the maintaining conditions by systematically gathering informa-

tion about situational antecedents (A), the dimensions of the problem behavior

(B), and the consequences (C) of the problem. This is known as the ABC model,

and the goal of a functional assessment of a client’s behavior is to understand the

ABC sequence. This model of behavior suggests that behavior (B) is infl uenced by

some particular events that precede it, called antecedents (A), and by certain events

that follow it, called consequences (C). Antecedent events cue or elicit a certain

behavior. For example, with a client who has trouble going to sleep, listening to a

relaxation tape may serve as a cue for sleep induction. Turning off the lights and

removing the television from the bedroom may elicit sleep behaviors as well. Con-

sequences are events that maintain a behavior in some way, either by increasing

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or decreasing it. For example, a client may be more likely to return to counseling

after the counselor offers verbal praise or encouragement for having come in or

for having completed some homework. A client may be less likely to return if

the counselor is consistently late to sessions. In doing a behavioral assessment

interview, the therapist’s task is to identify the particular antecedent and conse-

quent events that infl uence, or are functionally related to, an individual’s behavior

(Cormier, Nurius, & Osborn, 2013).

Behaviorally oriented practitioners tend to be active and directive and to func-

tion as consultants and problem solvers. They rely heavily on empirical evidence

about the effi cacy of the techniques they apply to particular problems. Behavio-

ral practitioners must possess intuitive skills and clinical judgment in selecting

appropriate treatment methods and in determining when to implement specifi c

techniques (Wilson, 2011). They pay close attention to the clues given by clients,

253

and they are willing to follow their clinical hunches. They use some techniques

BEHA

common to other approaches, such as summarizing, refl ection, clarifi cation, and

VIOR THERAP

open-ended questioning. However, behavioral clinicians perform other functions

as well (Miltenberger, 2012; Spiegler & Guevremont, 2010):

• The therapist strives to understand the function of client behaviors, including

how certain behaviors originated and how they are sustained. With this under-

Y

standing, the therapist formulates initial treatment goals and designs and

implements a treatment plan to accomplish these goals.

• The behavioral clinician uses strategies that have research support for use with

a particular kind of problem. These evidence-based strategies promote generali-

zation and maintenance of behavior change. A number of these strategies are

described later in this chapter.

• The clinician evaluates the success of the change plan by measuring progress

toward the goals throughout the duration of treatment. Outcome measures are

given to the client at the beginning of treatment (called a baseline) and collected

again periodically during and after treatment to determine whether the strategy

and treatment plan are working. If not, adjustments are made in the strategies

being used.

• A key task of the therapist is to conduct follow-up assessments to see whether

the changes are durable over time. Clients learn how to identify and cope with

potential setbacks. The emphasis is on helping clients maintain changes over

time and acquire behavioral and cognitive coping skills to prevent relapses.

Let’s examine how a behavior therapist might perform these functions. A client

comes to therapy to reduce her anxiety, which is preventing her from leaving the

house. The therapist is likely to begin with a specifi c analysis of the nature of her

anxiety. The therapist will ask how she experiences the anxiety of leaving her house,

including what she actually does in these situations. Systematically, the therapist

gathers information about this anxiety. When did the problem begin? In what

situations does it arise? What does she do at these times? What are her feelings

and thoughts in these situations? Who is present when she experiences anxiety?

What does she do to reduce the anxiety? How do her present fears interfere with

living effectively? After this assessment, specifi c behavioral goals are developed,

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and strategies such as relaxation training, systematic desensitization, and exposure

therapy are designed to help the client reduce her anxiety to a manageable level.

The therapist will get a commitment from the client to work toward the specifi ed

goals, and the two of them will evaluate the client’s progress toward meeting these

goals throughout the duration of therapy.

For a description of applying a behavioral approach to the assessment and treat-

ment of an individual client, see Dr. Sherry Cormier’s behavioral interventions

with Ruth in Case Approach to Counseling and Psychotherapy (Corey, 2013a, chap. 7).

Client’s Experience in Therapy

One of the unique contributions of behavior therapy is that it provides the therapist

with a well-defi ned system of procedures to employ. Both therapist and client have

clearly defi ned roles, and the importance of client awareness and participation in

254

the therapeutic process is stressed. Behavior therapy is characterized by an active

role for both therapist and client. A large part of the therapist’s role is to teach

concrete skills through the provision of instructions, modeling, and performance

feedback. The client engages in behavioral rehearsal with feedback until skills are

well learned and generally receives active homework assignments (such as self-

CHAPTER NINE

monitoring of problem behaviors) to complete between therapy sessions. Behavior

clinicians emphasize that changes clients make in therapy need to be translated

into their daily lives. It is important for clients to be motivated to change, and they

are expected to cooperate in carrying out therapeutic activities, both during therapy

sessions and in everyday life. If clients are not involved in this way, the chances

are slim that therapy will be successful. However, if clients are not motivated, an-

other behavioral strategy that has considerable empirical support is motivational

interviewing (Miller & Rollnick, 2002). This strategy involves honoring the client’s

resistance in such a way that his or her motivation to change is increased over time

(Cormier et al., 2013).

Clients are encouraged to experiment for the purpose of enlarging their rep-

ertoire of adaptive behaviors. Counseling is not complete unless actions follow

verbalizations. Behavioral practitioners make the assumption that it is only when

the transfer of changes is made from the sessions to everyday life that the effects

of therapy can be considered successful. Clients are as aware as the therapist is

regarding when the goals have been accomplished and when it is appropriate to

terminate treatment. It is clear that clients are expected to do more than merely

gather insights; they need to be willing to make changes and to continue imple-

menting new behavior once formal treatment has ended.

Relationship Between Therapist and Client

The charge is often made that the importance of the relationship between client

and therapist is discounted in behavior therapy. Antony and Roemer (2011b) ac-

knowledge that examining the effi cacy of particular behavioral techniques has been

given more emphasis than the quality of the therapeutic relationship in behavior

therapy. However, behavioral practitioners have increasingly recognized the role

of the therapeutic relationship and therapist behavior as critical factors related to

the process and outcome of treatment. Today, most behavioral practitioners stress

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the value of establishing a collaborative working relationship with their clients. For

example, Lazarus (1993) believes a fl exible repertoire of relationship styles, plus a

wide range of techniques, enhances treatment outcomes. He emphasizes the need

for therapeutic fl exibility and versatility above all else. Lazarus contends that the

cadence of client–therapist interaction differs from individual to individual and

even from session to session. The skilled behavior therapist conceptualizes prob-

lems behaviorally and makes use of the client–therapist relationship in facilitating

change.

As you will recall, the experiential therapies (existential therapy, person-centered

therapy, and Gestalt therapy) place primary emphasis on the nature of the en-

gagement between counselor and client. In contrast, most behavioral practitioners

contend that factors such as warmth, empathy, authenticity, permissiveness, and

acceptance are necessary, but not suffi cient, for behavior change to occur. The client–

255

therapist relationship is a foundation on which therapeutic strategies are built to

BEHA

help clients change in the direction they wish.

VIOR THERAP

a p p l i c at i o n : t h e r a p e u t i c

t e c h n i q u e s a n d p r o c e d u r e s

Y

A strength of the behavioral approaches is the development of specifi c therapeutic

procedures that must be shown to be effective through objective means. The re-

sults of behavioral interventions become clear because therapists receive continual

direct feedback from their clients. A hallmark of the behavioral approaches is that

the therapeutic techniques are empirically supported and evidence-based practice

is highly valued. To its credit, the effectiveness of behavior therapy has been re-

searched with different populations and a wide array of disorders.

According to Lazarus (1989, 1992b, 1996b, 1997a, 2005, 2008a, 2008b),

behavioral practitioners can incorporate into their treatment plans any technique

that can be demonstrated to effectively change behavior. Lazarus advocates the

use of diverse techniques, regardless of their theoretical origin. It is clear that

behavior therapists do not have to restrict themselves only to methods derived from

learning theory. Likewise, behavioral techniques can be incorporated into other

approaches. This is illustrated later in this chapter in the sections on the incorpora-

tion of mindfulness and acceptance-based approaches into the practice of behavior

therapy.

The therapeutic procedures used by behavior therapists are specifi cally designed

for a particular client rather than being randomly selected from a “bag of tech-

niques.” Therapists are often quite creative in their interventions. In the following

sections I describe a range of behavioral techniques available to the practitioner:

applied behavioral analysis, relaxation training, systematic desensitization, expo-

sure therapies, eye movement desensitization and reprocessing, social skills train-

ing, self-management programs and self-directed behavior, multimodal therapy,

and mindfulness and acceptance-based approaches. These techniques do not

encompass the full spectrum of behavioral procedures, but they do represent a

sample of the approaches used in the practice of contemporary behavior therapy.

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Applied Behavioral Analysis: Operant

Conditioning Techniques

This section describes a few key principles of operant conditioning: positive rein-

forcement, negative reinforcement, extinction, positive punishment, and negative

punishment. For a detailed treatment of the wide range of operant conditioning

methods that are part of contemporary behavior modifi cation, I recommend

Miltenberger (2012).

In applied behavior analysis, operant conditioning techniques and methods of

assessment and evaluation are applied to a wide range of problems in many differ-

ent settings (Kazdin, 2001). The most important contribution of applied behavior

analysis is that it offers a functional approach to understanding clients’ problems

and addresses these problems by changing antecedents and consequences (the

256

ABC model).

Behaviorists believe we respond in predictable ways because of the gains we

experience (positive reinforcement) or because of the need to escape or avoid

unpleasant consequences (negative reinforcement). Once clients’ goals have been

assessed, specifi c behaviors are targeted. The goal of reinforcement, whether posi-

tive or negative, is to increase the target behavior. Positive reinforcement involves

CHAPTER NINE

the addition of something of value to the individual (such as praise, attention,

money, or food) as a consequence of certain behavior. The stimulus that follows

the behavior is the positive reinforcer. For example, a child earns excellent grades

and is praised for studying by her parents. If she values this praise, it is likely that

she will have an investment in studying in the future. When the goal of a program

is to decrease or eliminate undesirable behaviors, positive reinforcement is often

used to increase the frequency of more desirable behaviors, which replace undesir-

able behaviors. In the above example, the parental praise functions as the positive

reinforcer and makes it more likely that the child will maintain or even increase

the frequency of studying and earning good grades. Note that if a child did not

value parental praise, this would not serve as a reinforcer. The reinforcer is not

defi ned by the form or substance that it takes but rather by the function it serves:

namely, to maintain or increase the frequency of a desired behavior.

Negative reinforcement involves the escape from or the avoidance of aversive

(unpleasant) stimuli. The individual is motivated to exhibit a desired behavior to

avoid the unpleasant condition. For example, a friend of mine does not appreci-

ate waking up to the shrill sound of an alarm clock. She has trained herself to

wake up a few minutes before the alarm sounds to avoid the aversive stimulus of

the alarm buzzer.

Another operant method of changing behavior is extinction, which refers to

withholding reinforcement from a previously reinforced response. In applied

settings, extinction can be used for behaviors that have been maintained by posi-

tive reinforcement or negative reinforcement. For example, in the case of chil-

dren who display temper tantrums, parents often reinforce this behavior by the

attention they give to it. An approach to dealing with problematic behavior is

to eliminate the connection between a certain behavior (tantrums) and positive

reinforcement (attention). In this example a parent uses extinction when during

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and after a child’s temper tantrum, the parent ignores the child’s tantrum-related

behaviors. Doing so can decrease or eliminate such behaviors through the ex-

tinction process. It should be noted that extinction might well have negative side

effects, such as anger and aggression. Also note that initially when using extinc-

tion that unwanted behaviors may increase temporarily. Extinction can reduce or

eliminate certain behaviors, but extinction does not replace those responses that

have been extinguished. For this reason, extinction is most often used in behav-

ior modifi cation programs in conjunction with various reinforcement strategies

(Kazdin, 2001).

Another way behavior is controlled is through punishment, sometimes re-

ferred to as aversive control, in which the consequences of a certain behavior result

in a decrease of that behavior. The goal of reinforcement is to increase target behav-

ior, but the goal of punishment is to decrease target behavior. Miltenberger (2012)

257

describes two kinds of punishment that may occur as a consequence of behavior:

BEHA

positive punishment and negative punishment. In positive punishment an aver-

VIOR THERAP

sive stimulus is added after the behavior to decrease the frequency of a behavior

(such as a time-out procedure with a child who is displaying misbehavior).

In negative punishment a reinforcing stimulus is removed following the behav-

ior to decrease the frequency of a target behavior (such as deducting money from

Y

a worker’s salary for missing time at work, or taking television time away from a

child for misbehavior). In both kinds of punishment, the behavior is less likely to

occur in the future. These four operant procedures form the basis of behavior ther-

apy programs for parent skills training and are also used in the self-management

procedures that are discussed later in this chapter.

Some behavioral practitioners are opposed to using aversive control or punish-

ment, and recommended substituting positive reinforcement. The key principle in

the applied behavior analysis approach is to use the least aversive means possible

to change behavior, and positive reinforcement is known to be the most powerful

change agent. In everyday life, punishment often is used as a means of getting

revenge or expressing frustration. However, as Kazdin (2001) has noted, “punish-

ment in everyday life is not likely to teach lessons or suppress intolerable behavior

because of the specifi c punishments that are used and how they are applied” (p. 231).

Even in those cases when punishment suppresses undesirable responses, punish-

ment does not result in teaching desirable behaviors. Punishment should be used

only after nonaversive approaches have been implemented and found to be inef-

fective in changing problematic behavior (Kazdin, 2001; Miltenberger, 2012). It is

essential that reinforcement be used as a way to develop appropriate behaviors that

replace the behaviors that are suppressed.

Progressive Muscle Relaxation

Progressive muscle relaxation has become increasingly popular as a method of

teaching people to cope with the stresses produced by daily living. It is aimed at

achieving muscle and mental relaxation and is easily learned. After clients learn

the basics of relaxation procedures, it is essential that they practice these exercises

daily to obtain maximum results.

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Jacobson (1938) is credited with initially developing the progressive muscle

relaxation procedure. It has since been refi ned and modifi ed, and relaxation pro-

cedures are frequently used in combination with a number of other behavioral

techniques. These include systematic desensitization, assertion training, self-

management programs, audiotape recordings of guided relaxation procedures,

computer simulation programs, biofeedback-induced relaxation, hypnosis, medi-

tation, and autogenic training (teaching control of bodily and imaginal functions

through autosuggestion).

Progressive muscle relaxation involves several components. Clients are given

a set of instructions that teaches them to relax. They assume a passive and

relaxed position in a quiet environment while alternately contracting and relax-

ing muscles. This progressive muscle relaxation is explicitly taught to the client

258

by the therapist. Deep and regular breathing also is associated with producing

relaxation. At the same time clients learn to mentally “let go,” perhaps by focus-

ing on pleasant thoughts or images. Clients are instructed to actually feel and

experience the tension building up, to notice their muscles getting tighter and

study this tension, and to hold and fully experience the tension. It is useful for

clients to experience the difference between a tense and a relaxed state. The

CHAPTER NINE

client is then taught how to relax all the muscles while visualizing the various

parts of the body, with emphasis on the facial muscles. The arm muscles are

relaxed fi rst, followed by the head, the neck and shoulders, the back, abdo-

men, and thorax, and then the lower limbs. Relaxation becomes a well-learned

response, which can become a habitual pattern if practiced daily for about

25 minutes each day.

Relaxation procedures have been applied to a variety of clinical problems, ei-

ther as a separate technique or in conjunction with related methods. The most

common use has been with problems related to stress and anxiety, which are often

manifested in psychosomatic symptoms. Relaxation training has benefi ts in areas

such as preparing patients for surgery, teaching clients how to cope with chron-

ic pain, and reducing the frequency of migraine attacks (Ferguson & Sgambati,

2008). Some other ailments for which progressive muscle relaxation is helpful

include asthma, headache, hypertension, insomnia, irritable bowel syndrome, and

panic disorder (Cormier et al., 2013).

For an exercise of the phases of the progressive muscle relaxation procedure

that you can apply to yourself, see Student Manual for Theory and Practice of Coun-

seling and Psychotherapy (Corey, 2013b). For an excellent audiotape demonstration

of progressive muscle relaxation, see Dattilio (2006). For a more detailed discus-

sion of progressive muscle relaxation, see Ferguson and Sgambati (2008).

Systematic Desensitization

Systematic desensitization, which is based on the principle of classical condition-

ing, is a basic behavioral procedure developed by Joseph Wolpe, one of the pio-

neers of behavior therapy. Clients imagine successively more anxiety-arousing

situations at the same time that they engage in a behavior that competes with

anxiety. Gradually, or systematically, clients become less sensitive (desensitized) to

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the anxiety-arousing situation. This procedure can be considered a form of expo-

sure therapy because clients are required to expose themselves to anxiety-arousing

images as a way to reduce anxiety.

Systematic desensitization is an empirically researched behavior therapy pro-

cedure that is time consuming, yet it is clearly effective and effi cient in reducing

maladaptive anxiety and treating anxiety-related disorders, particularly in the area

of specifi c phobias (Cormier et al., 2013; Head & Gross, 2008; Spiegler & Guevre-

mont, 2010). Before implementing the desensitization procedure, the therapist

conducts an initial interview to identify specifi c information about the anxiety

and to gather relevant background information about the client. This interview,

which may last several sessions, gives the therapist a good understanding of who

the client is. The therapist questions the client about the particular circumstances

that elicit the conditioned fears. For instance, under what circumstances does the

259

client feel anxious? If the client is anxious in social situations, does the anxiety

BEHA

vary with the number of people present? Is the client more anxious with women

VIOR THERAP

or men? The client is asked to begin a self-monitoring process consisting of

observing and recording situations during the week that elicit anxiety responses.

Some therapists also administer a questionnaire to gather additional data about

situations leading to anxiety.

Y

If the decision is made to use the desensitization procedure, the therapist gives

the client a rationale for the procedure and briefl y describes what is involved. Once

it has been determined that systematic desensitization is an appropriate form of

treatment, a three-step process unfolds: (1) relaxation training, (2) development

of a graduated anxiety hierarchy, and (3) systematic desensitization proper that

involves the presentation of hierarchy items while the client is in a deeply relaxed

state (Head & Gross, 2008).

The steps in progressive muscle relaxation, which were described earlier, are pre-

sented to the client. The therapist uses a very quiet, soft, and pleasant voice to teach

progressive muscular relaxation. The client is asked to create imagery of previously

relaxing situations, such as sitting by a lake or wandering through a beautiful fi eld.

It is important that the client reach a state of calm and peacefulness. The client is

instructed to practice relaxation both as a part of the desensitization procedure and

also outside the session on a daily basis.

The therapist then works with the client to develop an anxiety hierarchy for

each of the identifi ed areas. Stimuli that elicit anxiety in a particular area, such as

rejection, jealousy, criticism, disapproval, or any phobia, are analyzed. The thera-

pist constructs a ranked list of situations that elicit increasing degrees of anxiety

or avoidance. The hierarchy is arranged in order from the most anxiety-provoking

situation the client can imagine down to the situation that evokes the least anxiety.

If it has been determined that the client has anxiety related to fear of rejection, for

example, the highest anxiety-producing situation might be rejection by the spouse,

next, rejection by a close friend, and then rejection by a coworker. The least dis-

turbing situation might be a stranger’s indifference toward the client at a party.

Desensitization does not begin until several sessions after the initial interview

has been completed. Enough time is allowed for clients to learn relaxation in therapy

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sessions, to practice it at home, and to construct their anxiety hierarchy. The de-

sensitization process begins with the client reaching complete relaxation with eyes

closed. A neutral scene is presented, and the client is asked to imagine it. If the

client remains relaxed, he or she is asked to imagine the least anxiety-arousing

scene on the hierarchy of situations that has been developed. The therapist moves

progressively up the hierarchy until the client signals that he or she is experiencing

anxiety, at which time the scene is terminated. Relaxation is then induced again,

and the scene is reintroduced again until little anxiety is experienced to it. Treat-

ment ends when the client is able to remain in a relaxed state while imagining

the scene that was formerly the most disturbing and anxiety-producing. The core

of systematic desensitization is repeated exposure in the imagination to anxiety-

evoking situations without experiencing any negative consequences.

260

Homework and follow-up are essential components of successful desensiti-

zation. Clients are encouraged to practice selected relaxation procedures daily, at

which time they visualize scenes completed in the previous session. Gradually,

they can expose themselves to daily-life situations as a further way to manage their

anxieties. Clients tend to benefi t the most when they have a variety of ways to cope

with anxiety-arousing situations that they can continue to use once therapy has

CHAPTER NINE

ended (Head & Gross, 2008).

Systematic desensitization is among the most empirically supported therapy

methods available, especially for the treatment of anxiety (Head & Gross, 2008).

Not only does systematic desensitization have a good track record in dealing with

fears, it also has been used to treat a variety of conditions including anger, asth-

matic attacks, insomnia, motion sickness, nightmares, and sleepwalking (Spiegler,

2008). Systematic desensitization is often acceptable to clients because they are

gradually and symbolically exposed to anxiety-evoking situations.

For a more detailed discussion of systematic desensitization, see Head and

Gross (2008) and Cormier et al. (2013).

In Vivo Exposure and Flooding

Exposure therapies are designed to treat fears and other negative emotional

responses by introducing clients, under carefully controlled conditions, to the situ-

ations that contributed to such problems. Exposure is a key process in treating a

wide range of problems associated with fear and anxiety. Exposure therapy involves

systematic confrontation with a feared stimulus, either through imagination or in

vivo (live). Imaginal exposure can be used prior to implementing in vivo exposure

when a client’s fears are so severe that the client is unable to participate in live

exposure (Hazlett-Stevens & Craske, 2008). Whatever route is used, exposure in-

volves contact by clients with what they fi nd fearful. Desensitization is one type

of exposure therapy, but there are others. Two variations of traditional systematic

desensitization are in vivo exposure and fl ooding.

i n v i v o e x p o s u r e In vivo exposure involves client exposure to the ac-

tual anxiety-evoking events rather than simply imagining these situations. Live

exposure has been a cornerstone of behavior therapy for decades. Hazlett-

Stevens and Craske (2008) describe the key elements of the process of in vivo

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exposure. Typically, treatment begins with a functional analysis of objects or situ-

ations a person avoids or fears. Together, the therapist and the client generate a

hierarchy of situations for the client to encounter in ascending order of diffi culty.

In vivo exposure involves repeated systematic exposure to fear items, beginning

from the bottom of the hierarchy. Clients engage in a brief, graduated series

of exposures to feared events. As is the case with systematic desensitization,

clients learn responses incompatible with anxiety, such as responses involving

muscle relaxation. Clients are encouraged eventually to experience their full fear

response during exposure without engaging in avoidance. Between therapy ses-

sions, clients carry out self-directed exposure exercises. Clients’ progress with

home practice is reviewed, and the therapist provides feedback on how the client

could deal with any diffi culties encountered.

In some cases the therapist may accompany clients as they encounter feared

261

situations. For example, a therapist could go with clients in an elevator if they had

BEHA

phobias of using elevators. Of course, when this kind of out-of-offi ce procedure is

VIOR THERAP

used, matters of safety and appropriate ethical boundaries are always considered.

People who have extreme fears of certain animals could be exposed to these ani-

mals in real life in a safe setting with a therapist. Self-managed in vivo exposure—a

procedure in which clients expose themselves to anxiety-evoking events on their

Y

own—is an alternative when it is not practical for a therapist to be with clients in

real-life situations.

f lo o d i n g Another form of exposure therapy is fl ooding, which refers to either

in vivo or imaginal exposure to anxiety-evoking stimuli for a prolonged period of

time. As is characteristic of all exposure therapies, even though the client experi-

ences anxiety during the exposure, the feared consequences do not occur.

In vivo fl ooding consists of intense and prolonged exposure to the actual anxiety-

producing stimuli. Remaining exposed to feared stimuli for a prolonged period

without engaging in any anxiety-reducing behaviors allows the anxiety to decrease

on its own. Generally, highly fearful clients tend to curb their anxiety through the

use of maladaptive behaviors. In fl ooding, clients are prevented from engaging in

their usual maladaptive responses to anxiety-arousing situations. In vivo fl ooding

tends to reduce anxiety rapidly.

Imaginal fl ooding is based on similar principles and follows the same proce-

dures except the exposure occurs in the client’s imagination instead of in daily life.

An advantage of using imaginal fl ooding over in vivo fl ooding is that there are no re-

strictions on the nature of the anxiety-arousing situations that can be treated. In vivo

exposure to actual traumatic events (airplane crash, rape, fi re, fl ood) is often not

possible nor is it appropriate for both ethical and practical reasons. Imaginal fl ood-

ing can re-create the circumstances of the trauma in a way that does not bring about

adverse consequences to the client. Survivors of an airplane crash, for example, may

suffer from a range of debilitating symptoms. They are likely to have nightmares

and fl ashbacks to the disaster; they may avoid travel by air or have anxiety about

travel by any means; and they probably have a variety of distressing symptoms such

as guilt, anxiety, and depression. In vivo and imaginal exposure, as well as fl ooding,

are frequently used in the behavioral treatment for anxiety-related disorders, specifi c

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phobia, social phobia, panic disorder, obsessive-compulsive disorder, posttraumatic

stress disorder, and agoraphobia (Hazlett-Stevens & Craske, 2008).

Because of the discomfort associated with prolonged and intense exposure,

some clients may not elect these exposure treatments. It is important for the behav-

ior therapist to work with the client to create motivation and readiness for exposure.

From an ethical perspective, clients should have adequate information about pro-

longed and intense exposure therapy before agreeing to participate. It is important

that they understand that anxiety will be induced as a way to reduce it. Clients need

to make informed decisions after considering the pros and cons of subjecting them-

selves to temporarily stressful aspects of treatment. Clients should be informed that

they can terminate exposure if they experience a high level of anxiety.

The repeated success of exposure therapy in treating various disorders has re-

262

sulted in exposure being used as a part of most behavioral treatments for anxiety

disorders. Spiegler and Guevremont (2010) conclude that exposure therapies are

the single most potent behavioral procedures available for anxiety-related disor-

ders, and they can have long-lasting effects. However, they add, using exposure as

a sole treatment procedure is not always suffi cient. In cases involving severe and

multifaceted disorders, more than one behavioral intervention is often required.

CHAPTER NINE

Increasingly, imaginal and in vivo exposure are being used in combination, which

fi ts with the trend in behavior therapy to use treatment packages as a way to en-

hance the effectiveness of therapy.

Eye Movement Desensitization and Reprocessing

Eye movement desensitization and reprocessing (EMDR) is a form of exposure

therapy that entails assessment and preparation, imaginal fl ooding, and cognitive

restructuring in the treatment of individuals with traumatic memories. The treat-

ment involves the use of rapid, rhythmic eye movements and other bilateral stimu-

lation to treat clients who have experienced traumatic stress. Developed by Francine

Shapiro (2001), this therapeutic procedure draws from a wide range of behavio-

ral interventions. Designed to assist clients in dealing with posttraumatic stress

disorders, EMDR has been applied to a variety of populations including children,

couples, sexual abuse victims, combat veterans, victims of crime, rape survivors,

accident victims, and individuals dealing with anxiety, panic, depression, grief, ad-

dictions, and phobias. The treatment consists of three basic phases involving as-

sessment and preparation, imaginal fl ooding, and cognitive restructuring.

Shapiro (2001) emphasizes the importance of the safety and welfare of the

client when using this approach. EMDR may appear simple to some, but the

ethical use of the procedure demands training and clinical supervision, as is

true of using exposure therapies in general. Because of the powerful reactions

from clients, it is essential that practitioners know how to safely and effectively

manage these occurrences. Therapists should not use this procedure unless they

receive proper training and supervision from an authorized EMDR instructor. A

more complete discussion of this behavioral procedure can be found in Shapiro

(2001, 2002a).

There is some controversy over whether the eye movements themselves create

change or the application of cognitive techniques paired with eye movements act

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as change agents. The role of lateral eye movements has yet to be clearly demon-

strated, and some evidence indicates that the eye movement component may not

be integral to the treatment (Prochaska & Norcross, 2010; Spiegler & Guevremont,

2010). In a review of controlled studies of EMDR in the treatment of trauma, Sha-

piro (2002b) reports that EMDR clearly outperforms no treatment and achieves

similar or superior results as other methods of treating trauma. When it comes

to the overall effectiveness of EMDR, Prochaska and Norcross (2010) note that

“in its 20-year history, EMDR has garnered more controlled research than any

other method used to treat trauma” (p. 236). In writing about the future of EMDR,

Prochaska and Norcross make several predictions: increasing numbers of practi-

tioners will receive training in EMDR; outcome research will shed light on EMDR’s

effectiveness compared to other current therapies for trauma; and further research

and practice will provide a sense of its effectiveness with disorders besides post-

263

traumatic stress disorder.

BEHA

Social Skills Training

VIOR THERAP

Social skills training is a broad category that deals with an individual’s ability to

interact effectively with others in various social situations; it is used to help clients

develop and achieve skills in interpersonal competence. Social skills involve being

able to communicate with others in a way that is both appropriate and effective.

Y

Individuals who experience psychosocial problems that are partly caused by inter-

personal diffi culties are good candidates for social skills training. Typically, social

skills training involves various behavioral techniques such as psychoeducation,

modeling, behavior rehearsal, and feedback (Antony & Roemer, 2011b). Social

skills training is effective in treating psychosocial problems by increasing clients’

interpersonal skills (Segrin, 2008). Social skills involve the ability to relate to oth-

ers in appropriate and effective ways. Some of the desirable aspects of this training

are that it has a very broad base of applicability and that it can easily be tailored to

suit the particular needs of individual clients.

Segrin (2008) identifi es these key elements of social skills training, which entail

a collection of techniques: assessment, direct instruction and coaching, modeling,

role-playing, and homework assignments. Clients learn information that they can

apply to various interpersonal situations, and skills are modeled for them so they

can actually see how skills can be used. A key step involves the necessity of clients

putting into action the information they are acquiring. It is through role-playing

that individuals actively practice desired behaviors that are observed. Segrin notes

that by monitoring clients’ successes and failures therapists can fi ne-tune clients’

performances. The feedback and reinforcement clients receive assists them in con-

ceptualizing and using a new set of social skills that enables them to communicate

more effectively. A follow-up phase is critical for clients in establishing a range of

effective behaviors that can be applied to many social situations.

A few examples of evidence-based applications of social skills training include

alcohol/substance abuse, attention-defi cit/hyperactivity disorder, bullying, social

anxiety, emotional and behavioral problems in children, behavioral treatment for

couples, and depression (Antony & Roemer, 2011b; Segrin, 2008). A popular vari-

ation of social skills training is anger management training, which is designed for

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individuals who have trouble with aggressive behavior. Assertion training, which is

described next, is useful for people who lack assertive skills.

a s s e r t i o n t r a i n i n g One specialized form of social skills training consists

of teaching people how to be assertive in a variety of social situations. Many people

have diffi culty feeling that it is appropriate or right to assert themselves. People

who lack social skills frequently experience interpersonal diffi culties at home, at

work, at school, and during leisure time. Assertion training can be useful for those

(1) who have diffi culty expressing anger or irritation, (2) who have diffi culty saying

no, (3) who are overly polite and allow others to take advantage of them, (4) who

fi nd it diffi cult to express affection and other positive responses, (5) who feel they

do not have a right to express their thoughts, beliefs, and feelings, or (6) who have

social phobias.

264

The basic assumption underlying assertion training is that people have the

right (but not the obligation) to express themselves. One goal of assertion train-

ing is to increase people’s behavioral repertoire so that they can make the choice

of whether to behave assertively in certain situations. It is important that clients

replace maladaptive social skills with new skills. Another goal is teaching people

to express themselves in ways that refl ect sensitivity to the feelings and rights of

CHAPTER NINE

others. Assertion does not mean aggression; truly assertive people do not stand up

for their rights at all costs, ignoring the feelings of others.

Generally, the therapist both teaches and models desired behaviors the client

wants to acquire. These behaviors are practiced in the therapy offi ce and then en-

acted in everyday life. Most assertion training programs focus on clients’ negative

self-statements, self-defeating beliefs, and faulty thinking. People often behave in

unassertive ways because they don’t think they have a right to state a viewpoint or

ask for what they want or deserve. Thus their thinking leads to passive behavior.

Effective assertion training programs do more than give people skills and techniques

for dealing with diffi cult situations. These programs challenge people’s beliefs that

accompany their lack of assertiveness and teach them to make constructive self-state-

ments and to adopt a new set of beliefs that will result in assertive behavior.

Assertion training is often conducted in groups. When a group format is used,

the modeling and instructions are presented to the entire group, and members

rehearse behavioral skills in role-playing situations. After the rehearsal, the mem-

ber is given feedback that consists of reinforcing the correct aspects of the behavior

and instructions on how to improve the behavior. Each member engages in fur-

ther rehearsals of assertive behaviors until the skills are performed adequately in a

variety of simulated situations (Miltenberger, 2012).

Because assertion training is based on Western notions of the value of assert-

iveness, it may not be suited for clients with a cultural background that places

more emphasis on harmony than on being assertive. This approach is not a pana-

cea, but it can be an effective treatment for clients who have skill defi cits in asser-

tive behavior or for individuals who experience diffi culties in their interpersonal

relationships. Although counselors can adapt this form of social skills training

procedures to suit their own style, it is important to include behavioral rehearsal

and continual assessment as basic aspects of the program. If you are interested in

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learning more assertion training, consult Your Perfect Right: A Guide to Assertive

Behavior (Alberti & Emmons, 2008).

Self-Management Programs and Self-Directed Behavior

For some time there has been a trend toward “giving psychology away.” This involves

psychologists being willing to share their knowledge so that “consumers” can

increasingly lead self-directed lives and not be dependent on experts to deal with

their problems. Psychologists who share this perspective are primarily concerned

with teaching people the skills they will need to manage their own lives effectively.

An advantage of self-management techniques is that treatment can be extended

to the public in ways that cannot be done with traditional approaches to therapy.

Another advantage is that costs are minimal. Because clients have a direct role in

their own treatment, techniques aimed at self-change tend to increase involvement

265

and commitment to their treatment.

BEHA

Self-management strategies include self-monitoring, self-reward, self-contract-

ing, and stimulus control. The basic idea of self-management assessments and in-

VIOR THERAP

terventions is that change can be brought about by teaching people to use coping

skills in problematic situations. Generalization and maintenance of the outcomes are

enhanced by encouraging clients to accept the responsibility for carrying out these

strategies in daily life.

Y

In self-management programs people make decisions concerning specifi c behav-

iors they want to control or change. People frequently discover that a major reason

they do not attain their goals is the lack of certain skills or unrealistic expectations of

change. Hope can be a therapeutic factor that leads to change, but unrealistic hope

can pave the way for a pattern of failures in a self-change program. A self-directed

approach can provide the guidelines for change and a plan that will lead to change.

For people to succeed in such a program, a careful analysis of the context of the

behavior pattern is essential, and people must be willing to follow some basic steps

such as those provided by Watson and Tharp (2007):

1. Selecting goals. Goals should be established one at a time, and they should be

measurable, attainable, positive, and signifi cant for you. It is essential that expecta-

tions be realistic.

2. Translating goals into target behaviors. Identify behaviors targeted for change.

Once targets for change are selected, anticipate obstacles and think of ways to

negotiate them.

3. Self-monitoring. Deliberately and systematically observe your own behavior, and

keep a behavioral diary, recording the behavior along with comments about the

relevant antecedent cues and consequences.

4. Working out a plan for change. Devise an action program to bring about actual

change. Various plans for the same goal can be designed, each of which can be

effective. Some type of self-reinforcement system is necessary in this plan because

reinforcement is the cornerstone of modern behavior therapy. Self-reinforcement

is a temporary strategy used until the new behaviors have been implemented in

everyday life. Take steps to ensure that the gains made will be maintained.

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5. Evaluating an action plan. Evaluate the plan for change to determine whether

goals are being achieved, and adjust and revise the plan as other ways to meet goals

are learned. Evaluation is an ongoing process rather than a one-time occurrence,

and self-change is a lifelong practice.

Self-management strategies have been successfully applied to many popula-

tions and problems, a few of which include coping with panic attacks, helping

children to cope with fear of the dark, increasing creative productivity, managing

anxiety in social situations, encouraging speaking in front of a class, increasing

exercise, control of smoking, and dealing with depression (Watson & Tharp, 2007).

Research on self-management has been conducted in a wide variety of health prob-

lems, a few of which include arthritis, asthma, cancer, cardiac disease, substance

abuse, diabetes, headaches, vision loss, depression, nutrition, and self-health care

266

(Cormier et al., 2013).

Multimodal Therapy: Clinical Behavior Therapy

Multimodal therapy is a comprehensive, systematic, holistic approach to behav-

ior therapy developed by Arnold Lazarus (1989, 1997a, 2005, 2008a). Lazarus

(2008a) claims that the term “multimodal behavior therapy” is somewhat of a mis-

CHAPTER NINE

nomer. Although the assessment process is multimodal, the treatment is cognitive

behavioral and draws upon empirically supported methods. In terms of clinical

practice, behavior therapy and multimodal therapy are very similar (Wilson, 2011).

Multimodal therapy is grounded in social-cognitive theory and applies diverse be-

havioral techniques to a wide range of problems. This approach serves as a major

link between some behavioral principles and the cognitive behavioral approach

that has largely replaced traditional behavioral therapy.

Multimodal therapy is an open system that encourages technical eclecticism in

that it applies diverse behavioral techniques to a wide range of problems. Multi-

modal therapists borrow techniques from many other therapy systems (Lazarus,

2008b). New techniques are constantly being introduced and existing techniques

refi ned, but they are never used in a shotgun manner. Multimodal therapists take

great pains to determine precisely what relationship and what treatment strategies

will work best with each client and under which particular circumstances. The

underlying assumption of this approach is that because individuals are troubled

by a variety of specifi c problems it is appropriate that a multitude of treatment

strategies be used in bringing about change. Therapeutic fl exibility and versatility,

along with breadth over depth, are highly valued, and multimodal therapists are

constantly adjusting their procedures to achieve the client’s goals. Therapists need

to decide when and how to be challenging or supportive and how to adapt their

relationship style to the needs of the client (Lazarus, 1993, 1997a). Multimodal

therapists tend to be very active during therapist sessions, functioning as train-

ers, educators, consultants, coaches, and role models. They provide information,

instruction, and feedback as well as modeling assertive behaviors. They offer sug-

gestions, positive reinforcements, and are appropriately self-disclosing.

t h e b a s i c i . d . The essence of Lazarus’s multimodal approach is the premise

that the complex personality of human beings can be divided into seven major areas

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of functioning: B 5 behavior; A 5 affective responses; S 5 sensations; I 5 images; C

5 cognitions; I 5 interpersonal relationships; and D 5 drugs, biological functions,

nutrition, and exercise (Lazarus, 1989, 1992a, 1992b, 1997a, 1997b, 2000, 2006).

Multimodal therapy begins with a comprehensive assessment of the seven mo-

dalities of human functioning and the interaction among them. A complete assess-

ment and treatment program must account for each modality of the BASIC I.D.,

which is the cognitive map linking each aspect of personality. Table 9.1 outlines

this process using questions Lazarus typically asks.

TA B L E 9.1 The BASIC I.D. Assessment Process

M O D A L I T Y

B E H A V I O R S

Q U E S T I O N S T O A S K

Behavior

Overt behaviors,

What would you like to change?

267

including acts, habits,

How active are you?

BEHA

and reactions that

What would you like to start doing?

are observable and

What would you like to stop doing?

VIOR THERAP

measurable

What are some of your main strengths?

What specifi c behaviors keep you from getting

what you want?

Affect

Emotions, moods, and

What emotions do you experience most often?

Y

strong feelings

What makes you laugh?

What makes you cry?

What makes you sad, mad, glad, scared?

What emotions are problematic for you?

Sensation

Basic senses of touch,

Do you suffer from unpleasant sensations,

taste, smell, sight, and

such as pains, aches, dizziness, and so forth?

hearing

What do you particularly like or dislike in the

way of seeing, smelling, hearing, touching,

and tasting?

Imagery

How we picture

What are some bothersome recurring dreams

ourselves, including

and vivid memories?

memories, dreams, and

Do you have a vivid imagination?

fantasies

How do you view your body?

How do you see yourself now?

How would you like to be able to see yourself

in the future?

Cognition

Insights, philosophies,

What are some ways in which you meet your

ideas, opinions, self-

intellectual needs?

talk, and judgments

How do your thoughts affect your emotions?

that constitute one’s

What are the values and beliefs you most

fundamental values,

cherish?

attitudes, and beliefs

What are some negative things you say to

yourself?

What are some of your central faulty beliefs?

What are the main ‘shoulds,’ ‘oughts,’ and

‘musts’ in your life? How do they get in the

way of effective living?

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Interpersonal

Interactions with other

How much of a social being are you?

relationships

people

To what degree do you desire intimacy with

others?

What do you expect from the signifi cant

people in your life?

What do they expect from you?

Are there any relationships with others that

you would hope to change?

If so, what kinds of changes do you want?

Drugs/biology

Drugs, nutritional

Are you healthy and health conscious?

habits, and exercise

Do you have any concerns about your health?

patterns

Do you take any prescribed drugs?

What are your habits pertaining to diet,

268

exercise, and physical fi tness?

Source: Lazarus 1989, 1997a, 2000.

A major premise of multimodal therapy is that breadth is often more important

CHAPTER NINE

than depth. The more coping responses a client learns in therapy, the less chance

there is for a relapse. Therapists identify one specifi c issue from each aspect of the

BASIC I.D. framework as a target for change and teach clients a range of tech-

niques they can use to combat faulty thinking, to learn to relax in stressful situ-

ations, and to acquire effective interpersonal skills. Clients can then apply these

skills to a broad range of problems in their everyday lives.

The preliminary investigation of the BASIC I.D. framework brings out some

central and signifi cant themes that can be productively explored using a detailed

life-history questionnaire. (See Lazarus and Lazarus, 2005, for the Multimodal

Life-History Inventory.) Once the main profi le of a person’s BASIC I.D. has been

established, the next step consists of an examination of the interactions among

the different modalities. It is essential that therapists start where the client is and

then move into other productive areas for exploration. Failure to comprehend the

client’s situation can easily leave the client feeling alienated and misunderstood

(Lazarus, 2000). For an illustration of how Dr. Lazarus applies the BASIC I.D.

assessment model to the case of Ruth, along with examples of various techniques

he uses, see Case Approach to Counseling and Psychotherapy (Corey, 2013a, chap. 7).

Mindfulness and Acceptance-Based

Cognitive Behavior Therapy

Over the last decade behavior therapy has evolved, resulting in an expansion of the

behavioral tradition. Newer facets of cognitive behavior therapy, labeled the “third

wave” of behavior therapy, emphasize considerations that were considered off

limits for behavior therapists until recently, including mindfulness, acceptance,

the therapeutic relationship, spirituality, values, meditation, being in the present

moment, and emotional expression (Hayes, Follette, & Linehan, 2004; Herbert &

Forman, 2011). Third-generation behavior therapies have been developed that

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center around fi ve interrelated core themes: (1) an expanded view of psychologi-

cal health, (2) a broad view of acceptable outcomes in therapy, (3) acceptance, (4)

mindfulness, and (5) creating a life worth living (Spiegler & Guevremont, 2010).

Mindfulness involves being aware of our experiencing in a receptive way and

engaging in activity based on this nonjudgmental awareness (Robins & Rosenthal,

2011). In mindfulness practice, clients train themselves to intentionally focus on their

present experience while at the same time achieving a distance from it. Mindfulness

involves developing an attitude of curiosity and compassion to present experience.

Clients learn to focus on one thing at a time and to bring their attention back to the

present moment when distractions arise.

As a clinical intervention, mindfulness shows promise across a broad range of

clinical problems, including for depression, generalized anxiety disorder, relation-

ship problems, and borderline personality disorder (Dimidjian & Linehan, 2008)

269

as well as being useful in the treatment of posttraumatic stress disorder among

BEHA

military veterans. Through mindfulness exercises, veterans may be better able to

VIOR THERAP

observe repetitive negative thinking and prevent extensive engagement with mala-

daptive ruminative processes (Vujanovic, Niles, Pietrefesa, Schmertz, & Potter,

2011). Many therapeutic approaches are incorporating mindfulness, meditation,

and other Eastern practices in the counseling process, and this trend seems likely

Y

to continue (Worthington, 2011).

Acceptance is a process involving receiving one’s present experience without

judgment or preference, but with curiosity and kindness, and striving for full

awareness of the present moment (Germer, 2005b). Acceptance is not resigning

oneself to life’s problems; rather, it is an active process of self-affi rmation (Wilson,

2011). Acceptance is an alternative way of responding to our internal experience.

By replacing judgment, criticism, and avoidance with acceptance, the likely result

is increased adaptive functioning (Antony & Roemer, 2011b). The mindfulness and

acceptance approaches are good avenues for the integration of spirituality in the

counseling process.

The subjects of mindfulness and acceptance are only briefl y described in this

chapter. For a useful and extensive discussion of these topics, see Herbert and For-

man (2011), Acceptance and Mindfulness in Cognitive Behavior Therapy: Understand-

ing and Applying the New Therapies.

The four major approaches in the recent development of the behavioral tra-

dition include (1) dialectical behavior therapy (Linehan, 1993a, 1993b), which has

become a recognized treatment for borderline personality disorder; (2) mindfulness-

based stress reduction (Kabat-Zinn, 1990, 2003), which involves an 8- to 10-week

group program applying mindfulness techniques to coping with stress and pro-

moting physical and psychological health; (3) mindfulness-based cognitive therapy

(Segal et al., 2002), which is aimed primarily at treating depression; and (4) accept-

ance and commitment therapy (Hayes, Strosahl, & Houts, 2005; Hayes, Strosahl, &

Wilson, 2011), which is based on encouraging clients to accept, rather than

attempt to control or change, unpleasant sensations. All four of these approaches

use mindfulness strategies that have been subjected to empirical scrutiny, which

is a hallmark of the behavioral tradition.

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d i a l e c t i c a l b e h a v i o r t h e r a p y ( d b t ) Formulated by Linehan

(1993a, 1993b), DBT is a promising blend of behavioral and psychoanalytic tech-

niques for treating borderline personality disorders. Like analytic therapy, DBT

emphasizes the importance of the psychotherapeutic relationship, validation of the

client, the etiologic importance of the client having experienced an “invalidating

environment” as a child, and confrontation of resistance.

DBT treatment strategies include both acceptance- and change-oriented strate-

gies. The treatment program is geared toward helping clients make changes in

their behavior and environment, and at the same time communicating accept-

ance of their current state (Robins & Rosenthal, 2011). To help clients who have

particular problems with emotional regulation, DBT teaches clients to recognize

and accept the existence of simultaneous, opposing forces. By acknowledging this

270

fundamental dialectic relationship—such as not wanting to engage in a certain

behavior, yet knowing they have to engage in the behavior if they want to achieve

a desired goal—clients can learn to integrate the opposing notions of acceptance

and change, and the therapist can teach clients how to regulate their emotions and

behaviors. Mindfulness procedures are taught and practiced to develop an attitude

of acceptance (Fishman, Rego, & Muller, 2011).

CHAPTER NINE

DBT employs behavioral and cognitive behavioral techniques, including a form

of exposure therapy in which the client learns to tolerate painful emotions without

enacting self-destructive behaviors. DBT integrates its cognitive behaviorism not

only with analytic concepts but also with the mindfulness training of “Eastern psy-

chological and spiritual practices (primarily Zen practice)” (Linehan, 1993b, p. 6).

Many of the treatment strategies used and skills taught in DBT have roots in Zen

Buddhist principles and practices. These include being aware of the present

moment, seeing reality without distortion, accepting reality without judgment, let-

ting go of attachments that result in suffering, developing a greater degree of accept-

ance of self and others, and entering fully into present activities without separating

oneself from ongoing events and interactions (Robins & Rosenthal, 2011).

DBT is highly structured, but goals are tailored to each individual. Therapists

assist clients in using whatever skills they possess or are learning to navigate crises

more effectively and to address problem behaviors (Robins & Rosenthal, 2011).

Skills are taught in four modules: mindfulness, interpersonal effectiveness, emo-

tional regulation, and distress tolerance (Simpson, 2011). Mindfulness is a funda-

mental skill in DBT and is considered the basis for other skills taught. Mindful-

ness helps clients to embrace and tolerate the intense emotions they experience

when facing distressing situations. Interpersonal effectiveness involves learning to

ask for what one needs and learning to cope with interpersonal confl ict. This skill

entails increasing the chances that a client’s goals will be met, while at the same

time not damaging the relationship. Emotion regulation includes identifying emo-

tions, identifying obstacles to changing emotions, reducing vulnerability, and in-

creasing positive emotions. Clients learn the benefi ts of regulating emotions such

as anger, depression, and anxiety. Distress tolerance is aimed at helping individuals

to calmly recognizing emotions associated with negative situations without be-

coming overwhelmed by these situations. Clients learn how to tolerate pain or

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discomfort skillfully. These skills are the route clients can take in achieving their

goals. “The therapy aims to assist clients to learn to control behavior, fully experi-

ence emotions, improve daily living skills, and achieve a sense of completeness”

(Simpson, 2011, p. 230).

DBT skills training is not a “quick fi x” approach. It generally involves a mini-

mum of one year of treatment and includes both individual therapy and skills train-

ing done in a group. DBT requires a behavioral contract. To competently practice

DBT, it is essential to obtain training in this approach. Because DBT places heavy

emphasis on didactic instruction and teaching mindfulness skills, therapists must

be competent in applying these skills and be able to model specifi c strategies and

attitudes for clients. Therapists who want to employ mindfulness strategies must

also have personal understanding and experience of these interventions to be able

to effectively use them with clients (Dimidjian & Linehan, 2008). A useful resource

271

for a more detailed discussion of DBT is Robins and Rosenthal (2011).

BEHA

m i n d f u l n e s s - b a s e d s t r e s s r e d u c t i o n ( m b s r ) The essence of

VIOR THERAP

mindfulness-based stress reduction (MBSR) consists of the notion that much of

our distress and suffering results from continually wanting things to be different

from how they actually are (Salmon, Sephton, & Dreeben, 2011). MBSR aims to

assist people in learning how to live more fully in the present rather than ruminating

Y

about the past or being overly concerned about the future. MBSR does not actively

teach cognitive modifi cation techniques, nor does it label certain cognitions as

“dysfunctional,” because this is not consistent with the nonjudgmental attitude

one strives to cultivate in mindfulness practice.

The approach adopted in the MBSR program is to develop the capacity for

sustained directed attention through formal meditation practice. The skills taught

include sitting meditation and mindful yoga, which are aimed at cultivating mind-

fulness. The program includes a body scan meditation, which helps clients to

observe all the sensations in their body. Clients are encouraged to bring mindful-

ness into all of their daily activities, including standing, walking, and eating. Those

who are involved in the program are encouraged to practice formal mindfulness

meditation for 45 minutes daily. The MBSR program is designed to teach partici-

pants to relate to external and internal sources of stress in constructive ways. MBSR

places a heavy emphasis on experiential learning and the process of client self-

discovery (Dimidjian & Linehan, 2008). MBSR has many clinical applications, and

it is expected that the approach will evolve to address a range of negative psychologi-

cal states, such as anxiety, stress, and depression. This approach has many applica-

tions in the area of health and wellness and in promoting healthy lifestyle changes.

An excellent resource for a more detailed treatment of MBSR is Salmon, Sephton,

and Dreeben (2011).

m i n d f u l n e s s - b a s e d c o g n i t i v e t h e r a p y ( m b c t ) This program

is a comprehensive integration of the principles and skills of mindfulness applied

to the treatment of depression (Segal, Williams, & Teasdale, 2002). MBCT is an

8-week group treatment program adapted from Kabat-Zinn’s (1990) mindfulness-

based stress reduction program, and it includes components of cognitive behavior

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therapy. MBCT represents an integration of techniques from MBSR and teaching

cognitive behavioral interventions to clients. The primary aim is to change clients’

awareness of and relation to their negative thoughts. Participants are taught how

to respond in skillful and intentional ways to their automatic negative thought pat-

terns. Fesco, Flynn, Mennin, and Haigh (2011) describe the essence of the seven

sessions in the MBCT program:

• Therapy begins by identifying negative automatic thinking of people experienc-

ing depression and by introducing some basic mindfulness practices.

• In the second session, participants learn about the reactions they have to life

experiences and learn more about mindfulness practices.

• The third session is devoted to teaching breathing techniques and focused atten-

tion on their present experiencing.

272

• In session four, the emphasis is on learning to experience the moment without

becoming attached to outcomes as a way to prevent relapse.

• The

fi fth session teaches participants how to accept their experiencing without

holding on.

• Session six is used to describe thoughts as “merely thoughts;” clients learn that

they do not have to act on their thoughts. They can tell themselves, “I am not my

CHAPTER NINE

thoughts” and “Thoughts are not facts.”

• In the fi nal sessions, participants learn how to take care of themselves, to pre-

pare for relapse, and to generalize their mindfulness practices to daily life.

MBCT emphasizes experiential learning, in-session practice, learning from feed-

back, completing homework assignments, and applying what is learned in the pro-

gram to challenging situations encountered outside of the sessions. The brevity of

MBCT makes this approach an effi cient and cost-effective treatment. For a more

detailed review of MBCT, see Fresco, Flynn, Mennin, and Haigh (2011).

acceptance and commitment therapy (act) Another mindfulness-

based approach is acceptance and commitment therapy (Hayes et al., 2005, 2011),

which involves fully accepting present experience and mindfully letting go of ob-

stacles. In this approach “acceptance is not merely tolerance—rather it is the active

nonjudgmental embracing of experience in the here and now” (Hayes, 2004, p.

32). Acceptance is a stance or posture from which to conduct therapy and from

which a client can conduct life that provides an alternative to contemporary forms

of cognitive behavioral therapy (Eifert & Forsyth, 2005). In contrast to the cognitive

behavioral approaches discussed in Chapter 10, in which dysfunctional thoughts

are identifi ed and challenged, in ACT there is little emphasis on changing the

content of a client’s thoughts. Instead, the emphasis is on acceptance (nonjudg-

mental awareness) of cognitions. The goal is for individuals to become aware of

and examine their thoughts. Clients learn how to change their relationship to their

thoughts. They learn how to accept and distance themselves from the thoughts

and feelings they may have been trying to deny. Hayes has found that confronting

maladaptive cognitions actually strengthens rather than reduces these cognitions.

The goal of ACT is to allow for increased psychological fl exibility. Values are a basic

part of the therapeutic process, and ACT practitioners might ask clients, “What do

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you want your life to stand for?” Therapy involves assisting clients to choose values

they want to live by, designing specifi c goals, and taking steps to achieve their goals

(Wilson, 2011).

In addition to acceptance, commitment to action is essential. Commitment

involves making mindful decisions about what is important in life and what the

person is willing to do to live a valued and meaningful life (Wilson, 2011). ACT

makes use of concrete homework and behavioral exercises as a way to create larger

patterns of effective action that will help clients live by their values (Hayes, 2004).

For example, one form of homework given to clients is asking them to write down

life goals or things they value in various aspects of their lives. The focus of ACT is

allowing experience to come and go while pursuing a meaningful life.

ACT is an effective form of therapy (Eifert & Forsyth, 2005) that continues to

infl uence the practice of behavior therapy. Germer (2005a) suggests “mindfulness

273

might become a construct that draws clinical theory, research, and practice closer

BEHA

together, and helps integrate the private and professional lives of therapists” (p. 11).

VIOR THERAP

According to Wilson (2011), ACT emphasizes common processes across clinical

disorders, which makes it easier to learn basic treatment skills. Practitioners can

then implement basic principles in diverse and creative ways. ACT has been effec-

tive for treatment of a variety of disorders, including for substance abuse, depres-

Y

sion, anxiety, phobias, posttraumatic stress disorder, and panic disorder (Eifert &

Forsyth, 2005).

For an in-depth discussion of the role of mindfulness in psychotherapeutic prac-

tice, three highly recommended readings are Acceptance and Mindfulness in Cognitive

Behavior Therapy: Understanding and Applying the New Therapies (Herbert & Forman,

2011), Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition (Hay-

es et al., 2004), and Mindfulness and Psychotherapy (Germer et al., 2005).

Application to Group Counseling

Group-based behavioral approaches emphasize teaching clients self-management

skills and a range of new coping behaviors, as well as how to restructure their

thoughts. Clients can learn to use these techniques to control their lives, deal ef-

fectively with present and future problems, and function well after they complete

their group experience. Many groups are designed primarily to increase the cli-

ent’s degree of control and freedom in specifi c aspects of daily life.

Group leaders who function within a behavioral framework may develop tech-

niques from various theoretical viewpoints. Behavioral practitioners make use of a

brief, active, directive, structured, collaborative, psychoeducational model of ther-

apy that relies on empirical validation of its concepts and techniques. The leader

follows the progress of group members through the ongoing collection of data be-

fore, during, and after all interventions. Such an approach provides both the group

leader and the members with continuous feedback about therapeutic progress.

Today, many groups in community agencies demand this kind of accountability.

Behavioral group therapy has some unique characteristics that set it apart from

most of the other group approaches. A distinguishing characteristic of behavioral

practitioners is their systematic adherence to specifi cation and measurement. The

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specifi c unique characteristics of behavioral group therapy include (1) conducting

a behavioral assessment, (2) precisely spelling out collaborative treatment goals,

(3) formulating a specifi c treatment procedure appropriate to a particular problem,

and (4) objectively evaluating the outcomes of therapy. Behavior therapists tend to

utilize short-term, time-limited interventions aimed at effi ciently and effectively

solving problems and assisting members in developing new skills.

Behavioral group leaders assume the role of teacher and encourage members to

learn and practice skills in the group that they can apply to everyday living. Group

leaders typically assume an active, directive, and supportive role in the group and

apply their knowledge of behavioral principles and skills to the resolution of prob-

lems. They model active participation and collaboration by their involvement with

members in creating an agenda, designing homework, and teaching skills and

274

new behaviors. Leaders carefully observe and assess behavior to determine the

conditions that are related to certain problems and the conditions that will facili-

tate change. Members in behavioral groups identify specifi c skills that they lack

or would like to enhance. Assertiveness and social skills training fi t well into a

group format (Wilson, 2011). Relaxation procedures, behavioral rehearsal, mod-

eling, coaching, meditation, and mindfulness techniques are often incorporated

CHAPTER NINE

in behavioral groups. The experience of being mindful is expanded in the group

setting where people meditate and are still in the presence of others. Most of the

other techniques described earlier in this chapter can be applied to group work.

There are many different types of groups with a behavioral twist, or groups that

blend both behavioral and cognitive methods for specifi c populations. Structured

groups, with a psychoeducational focus, are especially popular in various settings

today. At least fi ve general approaches can be applied to the practice of behavioral

groups: (1) social skills training groups, (2) psychoeducational groups with spe-

cifi c themes, (3) stress management groups, (4) multimodal group therapy, and

(5) mindfulness and acceptance-based behavior therapy in groups.

For a more detailed discussion of cognitive behavioral approaches to groups,

see Corey (2012, chap.13).

b e h a v i o r t h e r a p y f r o m a

m u lt i c u lt u r a l p e r s p e c t i v e

Strengths From a Diversity Perspective

Behavior therapy has some clear advantages over many other theories in coun-

seling culturally diverse clients. Because of their cultural and ethnic backgrounds,

some clients hold values that are contrary to the free expression of feelings and the

sharing of personal concerns. Behavioral counseling does not generally place em-

phasis on experiencing catharsis. Rather, it stresses changing specifi c behaviors

and developing problem-solving skills. Some potential strengths of the behavioral

approaches in working with diverse client populations include its specifi city, task

orientation, focus on objectivity, focus on cognition and behavior, action orienta-

tion, dealing with the present more than the past, emphasis on brief interventions,

teaching coping strategies, and problem-solving orientation. The attention given to

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transfer of learning and the principles and strategies for maintaining new behavior

in daily life are crucial. Clients who are looking for action plans and specifi c behav-

ioral change are likely to cooperate with this approach because they can see that it

offers them concrete methods for dealing with their problems of living.

Behavior therapy focuses on environmental conditions that contribute to a client’s

problems. Social and political infl uences can play a signifi cant role in the lives of

people of color through discriminatory practices and economic problems, and the

behavioral approach takes into consideration the social and cultural dimensions of

the client’s life. Behavior therapy is based on an experimental analysis of behavior in

the client’s own social environment and gives special attention to a number of spe-

cifi c conditions: the client’s cultural conception of problem behaviors, establishing

specifi c therapeutic goals, arranging conditions to increase the client’s expectation of

successful therapeutic outcomes, and employing appropriate social infl uence agents

275

(Tanaka-Matsumi et al., 2002). The foundation of ethical practice involves a thera-

BEHA

pist’s familiarity with the client’s culture, as well as the competent application of this

VIOR THERAP

knowledge in formulating assessment, diagnostic, and treatment strategies.

The behavioral approach has moved beyond treating clients for a specifi c symptom

or behavioral problem. Instead, it stresses a thorough assessment of the person’s life

circumstances to ascertain not only what conditions give rise to the client’s problems

Y

but also whether the target behavior is amenable to change and whether such a change

is likely to lead to a signifi cant improvement in the client’s total life situation.

In designing a change program for clients from diverse backgrounds, effective

behavioral practitioners conduct a functional analysis of the problem situation.

This assessment includes the cultural context in which the problem behavior

occurs, the consequences both to the client and to the client’s sociocultural envi-

ronment, the resources within the environment that can promote change, and the

impact that change is likely to have on others in the client’s social surroundings.

Assessment methods should be chosen with the client’s cultural background in

mind (Spiegler & Guevremont, 2010; Tanaka-Matsumi et al., 2002). Counselors

must be knowledgeable as well as open and sensitive to issues such as these: What

is considered normal and abnormal behavior in the client’s culture? What are the

client’s culturally based conceptions of his or her problems? What is the potential

role of spirituality or religion in the client’s life? What kind of information about

the client is essential in making an accurate assessment?

Shortcomings From a Diversity Perspective

According to Spiegler and Guevremont (2010), a future challenge for behavior ther-

apists is to develop empirically based recommendations for how behavior therapy

can optimally serve culturally diverse clients. Although behavior therapy is sensi-

tive to differences among clients in a broad sense, behavior therapists need to be-

come more responsive to specifi c issues pertaining to all forms of diversity. Because

race, gender, ethnicity, and sexual orientation are critical variables that infl uence

the process and outcome of therapy, it is essential that behavior therapists pay

careful attention to these factors and address social justice issues as they arise in a

client’s therapy.

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Some behavioral counselors may focus on using a variety of techniques in nar-

rowly treating specifi c behavioral problems. Instead of viewing clients in the con-

text of their sociocultural environment, these practitioners concentrate too much

on problems within the individual. In doing so they may overlook signifi cant

issues in the lives of clients. Such practitioners are not likely to bring about benefi -

cial changes for their clients.

The fact that behavioral interventions often work well raises an interesting

issue in multicultural counseling. When clients make signifi cant personal changes,

it is very likely that others in their environment will react to them differently.

Before deciding too quickly on goals for therapy, the counselor and client need to

discuss the complexity inherent in change. It is essential for therapists to conduct a

thorough assessment of the interpersonal and cultural dimensions of the problem.

276

Clients should be helped in assessing the possible consequences of some of their

newly acquired social skills. Once goals are determined and therapy is under way,

clients should have opportunities to talk about the problems they encounter as they

bring new skills and behaviors into their home and work settings.

Behavior Therapy Applied to the Case of Stan

In Stan’s case many specific and

the purposes of his behavior. I then educate Stan

interrelated problems can be identi-

about how the therapy sessions (and his work

fied through an assessment process.

outside of the sessions) can help him reach his

Behaviorally, he is defensive, avoids eye contact,

goals. Early during treatment I help Stan trans-

speaks hesitantly, uses alcohol excessively, has a

late some of his general goals into concrete and

poor sleep pattern, and displays various avoid-

measurable ones. When Stan says, “I want to

ance behaviors in social and interpersonal situ-

feel better about myself,” I help him define more

ations. In the emotional area, Stan has a number

specific goals. When he says, “I want to get rid

of specific problems, some of which include

of my inferiority complex,” I reply: “What exactly

anxiety, panic attacks, depression, fear of criti-

do you mean by this?” “What are some situa-

cism and rejection, feeling worthless and stupid,

tions in which you feel inferior?” “What do you

and feeling isolated and alienated. He experi-

actually do that leads to feelings of inferiority?”

ences a range of physiological complaints such

Stan’s concrete aims include his desire to func-

as dizziness, heart palpitations, and headaches.

tion without drugs or alcohol. I suggest that he

Cognitively, he worries about death and dying,

keep a record of when he drinks and what events

has many self-defeating thoughts and beliefs, is

lead to drinking. My hope is that Stan will estab-

governed by categorical imperatives (“shoulds,”

lish goals that are based on positive markers, not

“oughts,” “musts”), engages in fatalistic thinking,

negative goals. Instead of focusing on what Stan

and compares himself negatively with others. In

would like to get rid of, I am more interested in

the interpersonal area, Stan is unassertive, has an

what he would like to acquire and develop.

unsatisfactory relationship with his parents, has

Stan indicates that he does not want to

few friends, is afraid of contact with women and

feel apologetic for his existence. I introduce

fears intimacy, and feels socially inferior.

behavioral skills training because he has trouble

After completing this assessment, I focus on

talking with his boss and coworkers. I demon-

helping Stan define the specific areas where he

strate specific skills that he can use in

would like to make changes. Before developing

approaching them more directly and confidently.

a treatment plan, I assist Stan in understanding

This procedure includes modeling, role playing,

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28549_ch09_rev01.indd 276

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and behavior rehearsal. He then tries more

Stan’s presenting symptoms decrease, and he

effective behaviors with me as I play the role of

reports a greater degree of satisfaction.

the boss. I give him feedback on how strong or

apologetic he seemed.

Follow-Up: You Continue as Stan’s

Imaginal exposure and systematic desensi-

Behavior Therapist

tization are appropriate in working with Stan’s

Use these questions to help you think about how

fear of failing. Before using these procedures,

you would work with Stan using a behavioral

I explain the procedure to Stan and get his in-

approach:

formed consent. Stan first learns relaxation pro-

• How would you collaboratively work with Stan

cedures during the sessions and then practices

in identifying specific behavioral goals to give

them daily at home. Next, he lists his specific

a direction to your therapy?

fears relating to failure, and he then generates a

• What behavioral techniques might be most

hierarchy of fear items. Stan identifies his great-

appropriate in helping Stan with his problems?

est fear as fear of dating and interacting with

• Stan indicates that he does not want to feel

277

women. The least fearful situation he identifies

apologetic for his existence. How might you

BEHA

is being with a female student for whom he does

help him translate this wish into a specific

not feel an attraction. I first do some systematic

VIOR THERAP

behavioral goal? What behavioral techniques

desensitization on Stan’s hierarchy. Stan begins

might you draw on in helping him in this area?

repeated, systematic exposure to items that

• What homework assignments are you likely to

he finds frightening, beginning at the bottom

suggest for Stan?

of the fear hierarchy. He continues with

Y

repeated exposure to the next fear hierarchy

item when exposure to the previous item gener-

See DVD for Theory and Practice of

ates only mild fear. Part of the process involves

Counseling and Psychotherapy: The Case

exposure exercises for practice in various

of Stan and Lecturettes (Session 7 on behavior

situations away from the therapy office.

therapy) for a demonstration of my approach

The goal of therapy is to help Stan modify the

to counseling Stan from this perspective. This

behavior that results in his feelings of guilt and

session involves collaboratively working on

anxiety. By learning more appropriate coping

homework and behavior rehearsals to experi-

behaviors, eliminating unrealistic anxiety and

ment with assertive behavior.

guilt, and acquiring more adaptive responses,

s u m m a r y a n d e va l u at i o n

Summary

Behavior therapy is diverse with respect not only to basic concepts but also to tech-

niques that can be applied in coping with specifi c problems with a wide range of

clients. The behavioral movement includes four major areas of development: clas-

sical conditioning, operant conditioning, social-cognitive theory, and increasing

attention to the cognitive factors infl uencing behavior (see Chapter 10). A unique

characteristic of behavior therapy is its strict reliance on the principles of the sci-

entifi c method. Concepts and procedures are stated explicitly, tested empirically,

and revised continually. Treatment and assessment are interrelated and occur si-

multaneously. Research is considered to be a basic aspect of the approach, and

therapeutic techniques are continually refi ned.

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A cornerstone of behavior therapy is identifying specifi c goals at the outset of

the therapeutic process. In helping clients achieve their goals, behavior therapists

typically assume an active and directive role. Although the client generally deter-

mines what behavior will be changed, the therapist typically determines how this

behavior can best be modifi ed. In designing a treatment plan, behavior therapists

employ techniques and procedures from a wide variety of therapeutic systems and

apply them to the unique needs of each client.

Contemporary behavior therapy places emphasis on the interplay between the

individual and the environment. Behavioral strategies can be used to attain both

individual goals and societal goals. Because cognitive factors have a place in the

practice of behavior therapy, techniques from this approach can be used to attain

humanistic ends. It is clear that bridges can connect humanistic and behavioral

278

therapies, especially with the current focus of attention on self-management ap-

proaches and also with the incorporation of mindfulness and acceptance-based

approaches into behavioral practice. Mindfulness practices rely of experiential

learning as opposed to didactic instruction and client discovery rather than formal

teaching (Dimidjian & Linehan, 2008).

CHAPTER NINE

Contributions of Behavior Therapy

Behavior therapy challenges us to reconsider our global approach to counseling.

Some may assume they know what a client means by the statement, “I feel unloved;

life has no meaning.” A humanist might nod in acceptance to such a statement,

but the behaviorist may respond with: “Who specifi cally do you feel is not loving

you?” “What is going on in your life to make you think it has no meaning?” “What

are some specifi c things you might be doing that contribute to the state you are in?”

“What would you most like to change?” The specifi city of the behavioral approaches

helps clients translate unclear goals into concrete plans of action, and it helps both

the counselor and the client to keep these plans clearly in focus. Ledley and col-

leagues (2010) state that therapists can help clients to learn about the contingencies

that maintain their problematic thoughts and behaviors and then teach them ways

to make the changes they want. Techniques such as role playing, relaxation proce-

dures, behavioral rehearsal, coaching, guided practice, modeling, feedback, learning

by successive approximations, mindfulness skills, and homework assignments can

be included in any therapist’s repertoire, regardless of theoretical orientation.

An advantage behavior therapists have is the wide variety of specifi c behavioral

techniques at their disposal. Because behavior therapy stresses doing, as opposed

to merely talking about problems and gathering insights, practitioners use many

behavioral strategies to assist clients in formulating a plan of action for chang-

ing behavior. The basic therapeutic conditions stressed by person-centered thera-

pists—active listening, accurate empathy, positive regard, genuineness, respect,

and immediacy—need to be integrated in a behavioral framework.

A major contribution of behavior therapy is its emphasis on research into

and assessment of treatment outcomes. It is up to practitioners to demonstrate

that therapy is working. If progress is not being made, therapists look carefully

at the original analysis and treatment plan. Of all the therapies presented in this

book, this approach and its techniques have been subjected to the most empirical

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28549_ch09_rev01.indd 278

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research. Behavioral practitioners are put to the test of identifying specifi c inter-

ventions that have been demonstrated to be effective. Fishman, Rego, and Muller

(2011) acknowledge the evolving nature of these therapies but conclude:

We believe the core of behavior therapy will endure in a commitment to theory that is

scholarly, logically clear, directly linked to data, and primarily rooted in the interactional

worldview; to therapy principles and procedures that are evidenced-based; to measurement

methods designed to ensure accountability; and to a focus on outcomes that result in con-

crete improvement in patients’ lives. (p. 135)

Evidence-based therapies (EBT) are a hallmark of both behavior therapy and cog-

nitive behavior therapy. To their credit, behavior therapists are willing to examine

the effectiveness of their procedures in terms of the generalizability, meaningful-

ness, and durability of change. Most studies show that behavior therapy methods

are more effective than no treatment. Moreover, a number of behavioral and cogni-

279

tive behavioral procedures are currently the best treatment strategies available for

BEHA

depression, obsessive-compulsive disorder, panic disorder, social phobia, hypochon-

VIOR THERAP

driasis, generalized anxiety disorder, posttraumatic stress disorder, eating disorders,

borderline personality disorder, bipolar disorder, and childhood disorders (Hollon &

DiGiuseppe, 2011).

A strength of the behavioral approaches is the emphasis on ethical accountabil-

Y

ity. Behavior therapy is ethically neutral in that it does not dictate whose behavior

or what behavior should be changed. At least in cases of voluntary counseling, the

behavioral practitioner only specifi es how to change those behaviors the client tar-

gets for change. Clients have a good deal of control and freedom in deciding what

the goals of therapy will be.

Limitations and Criticisms of Behavior Therapy

Behavior therapy has been criticized for a variety of reasons. Let’s examine four

common criticisms and misconceptions people often have about behavior therapy,

together with my reactions.

1. Behavior therapy may change behaviors, but it does not change feelings. Some critics

argue that feelings must change before behavior can change. Behavioral practition-

ers hold that empirical evidence has not shown that feelings must be changed fi rst,

and behavioral clinicians do in actual practice deal with feelings as an overall part

of the treatment process. A general criticism of both the behavioral and the cogni-

tive approaches is that clients are not encouraged to experience their emotions. In

concentrating on how clients are behaving or thinking, some behavior therapists

tend to play down the working through of emotional issues. Generally, I favor

initially focusing on what clients are feeling and then working with the behavioral

and cognitive dimensions. My reasoning here is that I fi nd when clients are feeling

they are engaged and this seems to me to be a good point of departure. I can still

tie a discussion of what clients are feeling with how this is affecting their behavior

and I can later inquire about their cognitions.

2. Behavior therapy does not provide insight. If this assertion is indeed true, behav-

ior therapists would probably respond that insight is not a necessary requisite for

behavior change. Follette and Callaghan (2011) state that contemporary behavior

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28549_ch09_rev01.indd 279

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therapists tend to be leery of the role of insight in favor of alterable, controllable,

causal variables. It is possible for therapy to proceed without a client knowing how

change is taking place. Although change may be taking place, clients often can-

not explain precisely why. Furthermore, insights may result after clients make a

change in behavior. Behavioral shifts often lead to a change in understanding or to

insight, which may lead to emotional changes as well.

3. Behavior therapy treats symptoms rather than causes. The psychoanalytic assumption

is that early traumatic events are at the root of present dysfunction. Behavior therapists

may acknowledge that deviant responses have historical origins, but they contend that

history is less important in the maintenance of current problems than environmental

events such as antecedents and consequences. However, behavior therapists empha-

size changing current environmental circumstances to change behavior.

280

Related to this criticism is the notion that, unless historical causes of present

behavior are therapeutically explored, new symptoms will soon take the place of

those that were “cured.” Behaviorists rebut this assertion on both theoretical and

empirical grounds. They contend that behavior therapy directly changes the main-

taining conditions, which are the causes of problem behaviors (symptoms). Fur-

CHAPTER NINE

thermore, they assert that there is no empirical evidence that symptom substitution

occurs after behavior therapy has successfully eliminated unwanted behavior be-

cause they have changed the conditions that give rise to those behaviors (Kazdin &

Wilson, 1978; Spiegler & Guevremont, 2010).

4. Behavior therapy involves control and social infl uence by the therapist. All thera-

pists have a power relationship with the client and thus have control. According to

Wilson (2011), all forms of therapy involve social infl uence; the ethical issue relates

to the therapist’s degree of awareness of this infl uence and how it is addressed in

therapy. Behavior therapy recognizes the importance of making the social infl u-

ence process explicit, and it emphasizes client-oriented behavioral goals. Thera-

pists collaborate with clients to make sure there is a mutual agreement regarding

treatment goals (Antony & Roemer, 2011b), and the client is encouraged to become

an active participant in his or her therapy. Therapy progress is continually assessed

and treatment is modifi ed to ensure that the client’s goals are being met.

Behavior therapists address ethical issues by stating that therapy is basically

a psychoeducational process (Tanaka-Matsumi et al., 2002). At the outset of be-

havior therapy, clients learn about the nature of counseling, the procedures that

may be employed, and the benefi ts and risks. Clients are given information about

the specifi c therapy procedures appropriate for their particular problems. To some

extent, they also participate in the choice of techniques that will be used in dealing

with their problems. With this information clients become informed, fully enfran-

chised partners in the therapeutic venture.

The literature in the fi eld of behavior therapy is so extensive and diverse that it is not

possible in one brief survey chapter to present a comprehensive, in-depth discussion

of behavioral techniques. I hope I have encouraged you to examine any misconcep-

tions you may hold about behavior therapy. I urge you to examine some of the selected

sources in the following section to further your knowledge of this complex approach.

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w h e r e t o g o f r o m h e r e

In the DVD for Integrative Counseling: The Case of Ruth and Lecturettes, Session 8

(“Behavioral Focus in Counseling”), I demonstrate a behavioral way to assist Ruth

in developing an exercise program. It is crucial that Ruth makes her own decisions

about specifi c behavioral goals she wants to pursue. This applies to my attempts

to work with her in developing methods of relaxation, increasing her self-effi cacy,

and designing an exercise plan.

Other Resources

DVDs offered by the American Psychological Association that are relevant to this

chapter include the following:

Antony, M. M. (2009). Behavioral Therapy Over Time (APA Psychotherapy

Video Series)

281

BEHA

Hayes, S. C. (2011). Acceptance and Commitment Therapy (Systems of Psy-

chotherapy Video Series)

VIOR THERAP

Psychotherapy.net is a comprehensive resource for students and professionals that

offers videos and interviews on behavior therapy. New video and editorial content

is made available monthly. DVDs relevant to this chapter are available at www.

psychotherapy.net and include the following:

Y

Stuart, R. (1998). Behavioral Couples Therapy (Couples Therapy With the

Experts Series)

Association for Behavioral and Cognitive Therapies (ABCT)

305 Seventh Avenue, 16th Floor

New York, NY 10001-6008

Telephone: (212) 647-1890

Fax: (212) 647-1865

E-mail: membership@abct.org

Website: www.abct.org

If you have an interest in further training in behavior therapy, the Association

for Behavioral and Cognitive Therapies (ABCT) is an excellent resource. ABCT

(formerly AABT) is a membership organization of more than 4,500 mental health

professionals and students who are interested in behavior therapy, cognitive

behavior therapy, behavioral assessment, and applied behavioral analysis. Full and

associate memberships are $199 and include one journal subscription (to either

Behavior Therapy or Cognitive and Behavioral Practice), and a subscription to the

Behavior Therapist (a newsletter with feature articles, training updates, and associa-

tion news). Membership also includes reduced registration and continuing educa-

tion course fees for ABCT’s annual convention held in November, which features

workshops, master clinician programs, symposia, and other educational presenta-

tions. Student memberships are $49. Members receive discounts on all ABCT

publications, some of which are:

• Directory of Graduate Training in Behavior Therapy and Experimental-Clinical

Psychology is an excellent source for students and job seekers who want infor-

mation on programs with an emphasis on behavioral training.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch09_rev01.indd 281

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• Directory of Psychology Internships: Programs Offering Behavioral Training describes

training programs having a behavioral component.

• Behavior Therapy is an international quarterly journal focusing on original

experimental and clinical research, theory, and practice.

• Cognitive and Behavioral Practice is a quarterly journal that features clinically

oriented articles.

Recommended Supplementary Readings

Contemporary Behavior Therapy (Spiegler & Guevremont, 2010) is a comprehen-

sive and up-to-date treatment of basic principles and applications of the behavior

282

therapies, as well as a fi ne discussion of ethical issues. Specifi c chapters deal with

procedures that can be usefully applied to a range of client populations: behavio-

ral assessment, modeling therapy, systematic desensitization, exposure therapies,

cognitive restructuring, and cognitive coping skills.

Interviewing and Change Strategies for Helpers (Cormier, Nurius, & Osborn, 2013)

CHAPTER NINE

is a comprehensive and clearly written textbook dealing with training experiences

and skill development. Its excellent documentation offers practitioners a wealth

of material on a variety of topics, such as assessment procedures, selection of

goals, development of appropriate treatment programs, and methods of evaluat-

ing outcomes.

Cognitive Behavior Therapy: Applying Empirically Supported Techniques in Your

Practice (O’Donohue & Fisher, 2008) is a useful collection of edited short chap-

ters describing empirically supported techniques for working with a wide range

of presenting problems.

Behavior Therapy (Antony & Roemer, 2011a) offers a useful and updated overview

of behavior therapy.

Behavior Modifi cation: Principles and Procedures (Miltenberger, 2012) is an excel-

lent resource for learning more about basic principles such as reinforcement,

extinction, punishment, and procedures to establish new behavior.

Acceptance and Mindfulness in Cognitive Behavior Therapy: Understanding and

Applying the New Therapies (Herbert & Forman, 2011) is one of the best resources

for discussion of new developments in the behavior therapy tradition and the

future trends of these therapies.

References and Suggested Readings

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perfect right: A guide to assertive behavior

Behavior therapy. Washington, DC: American

(9th ed.). Atascadero, CA: Impact.

Psychological Association.

*Books and articles marked with an asterisk are suggested for further study.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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(2011). Mindfulness-based stress reduction.

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In J. D. Hebert & E. M. Forman (Eds.),

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c h a p t e r 1 0

Cognitive Behavior Therapy

i n t r o d u c t i o n

d o n a l d m e i c h e n b a u m ’s c o g n i t i v e

b e h a v i o r m o d i f i c at i o n

a l b e r t e l l i s ’s r at i o n a l e m o t i v e

• Introduction

b e h a v i o r t h e r a p y

• How Behavior Changes

• Stress Inoculation Training

k e y c o n c e p t s

• The Constructivist Approach to Cognitive

• View of Human Nature

Behavior Therapy

• View of Emotional Disturbance

• A-B-C Framework

c o g n i t i v e b e h a v i o r t h e r a p y f r o m

a m u lt i c u lt u r a l p e r s p e c t i v e

t h e t h e r a p e u t i c p r o c e s s

• Strengths From a Diversity Perspective

• Therapeutic Goals

• Shortcomings From a Diversity Perspective

• Therapist’s Function and Role

• Client’s Experience in Therapy

c o g n i t i v e b e h a v i o r t h e r a p y

• Relationship Between Therapist and Client

a p p l i e d t o t h e c a s e o f s ta n

hip Bet

a p p l i c at i o n : t h e r a p e u t i c

s u m m a ry a n d e va l u at i o n

t e c h n i q u e s a n d p r o c e d u r e s

• Summary

•

• The Practice of Rational Emotive Behavior

The P

• Contributions of the Cognitive Behavioral

Therapy

Approaches

•

• Applications of REBT to Various Settings

Applications of REBT

• Limitations and Criticisms of the Cognitive

•

• Application of REBT as a Brief Therapy

Application of REBT as a

Behavioral Approaches

•

• Application to Group Counseling

Application to Group Coun

w h e r e t o g o f r o m h e r e

a a r o n b e c k ’s c o g n i t i v e t h e r a p y

•

• Recommended Supplementary Readings

commended Supplemen

•

• Introduction

ntroduction

• References and Suggested Readings

References and Suggested

•

• Basic Principles of Cognitive Therapy

Bas c Principles o

ognitive Thera y

•

• The Client–Therapist Relationship

The lient–Therapi

elationsh

•

• Applications of Cognitive Therapy

Appli tions of Cogn

287

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28549_ch10_rev01.indd 287

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Albert Ellis / Aaron T. Beck / Judith S. Beck /

Donald Meichenbaum

ALBERT ELLIS (1913–2007)

his youth. At one point in his life, for example, he

was born in Pittsburgh but

had exaggerated fears of speaking in public. Dur-

Institute

escaped to the wilds of New

ing his adolescence he was extremely shy around

Ellis

York at the age of 4 and lived

young women. At age 19 he forced himself to talk

Albert

there (except for a year in

to 100 different women in the Bronx Botanical

of

New Jersey) for the rest of

Gardens over a period of one month. Although

Courtesy

his life. He was hospitalized

he never managed to get a date from these brief

Photo

nine times as a child, mainly

encounters, he does report that he desensitized

with nephritis, and developed renal glycosuria at

himself to his fear of rejection by women. By apply-

the age of 19 and diabetes at the age of 40. Despite

ing rational and behavioral methods, he managed

288

his many physical challenges, he lived an unusu-

to conquer some of his strongest emotional blocks

ally robust, active, and energetic life until his death

(Ellis, 1994, 1997).

at age 93. As he put it, “I am busy spreading the

People who heard Ellis lecture often com-

gospel according to St. Albert.”

mented on his abrasive, humorous, and flamboy-

Realizing that he could counsel people skillfully

ant style. In his workshops it seemed that he took

CHAPTER TEN

and that he greatly enjoyed doing so, Ellis decided

delight in giving vent to his eccentric side, such as

to become a psychologist. Believing psychoanalysis

peppering his speech with four-letter words. He

to be the deepest form of psychotherapy, Ellis was

greatly enjoyed his work and teaching REBT, which

analyzed and supervised by a training analyst. He

was his passion and primary commitment in life.

then practiced psychoanalytically oriented psycho-

It seems that his work was his life, and he gave

therapy, but eventually he became disillusioned

workshops wherever he went in his travels. Ellis

with the slow progress of his clients. He observed

proclaimed, “I wouldn’t go to the Taj Mahal unless

that they improved more quickly once they

they asked me to do a workshop there!”

changed their ways of thinking about themselves

Ellis married Australian psychologist Debbie

and their problems. Early in 1955 he developed

Joffe in November 2004, whom he has called “the

an approach to psychotherapy he called rational

greatest love of my life” (Ellis, 2008). They shared

therapy and later rational emotive therapy, and

the same life goals and ideals, and they worked as a

which is now known as rational emotive behavior

team presenting workshops. If you are interested in

therapy (REBT). Ellis has rightly been referred to as

learning more about the life and work of Albert Ellis, I

the grandfather of cognitive behavior therapy.

recommend two of his books: Rational Emotive Behav-

To some extent Ellis developed his approach as

ior Therapy: It Works for Me—It Can Work for You (Ellis,

a method of dealing with his own problems during

2004a) and All Out! An Autobiography (Ellis, 2010).

AARON TEMKIN BECK

A graduate of Brown University and Yale

(b. 1921) was born in Provi-

School of Medicine, Beck initially was trained as a

PA.

Cognitive

dence, Rhode Island. His

neurologist, but he switched to psychiatry during

for

Cynwyd,

childhood, although happy,

his residency. Beck attempted to validate Freud’s

Institute

Bala

was interrupted by a life-

theory of depression, but his research resulted

Beck

threatening illness when

in his parting company with Freud’s motivational

of

Therapy,

he was 8 years old. As a

model and the explanation of depression as self-

Courtesy

Behavior

consequence, he experi-

directed anger. As a result of this decision, Beck

enced blood injury fears, fear of suffocation, and

endured isolation and rejection from many in the

anxiety about his health. Beck used his personal

psychiatric community for many years. Through

problems as a basis for understanding others and

his research, Beck developed a cognitive theory

for developing his cognitive theory.

of depression, which represents one of the most

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28549_ch10_rev01.indd 288

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comprehensive conceptualizations. He found the

depression. He has successfully applied cognitive

cognitions of depressed individuals to be charac-

therapy to depression, generalized anxiety and

terized by errors in interpretation that he called

panic disorders, suicide, alcoholism and drug abuse,

“cognitive distortions.” For Beck, negative thoughts

eating disorders, marital and relationship problems,

reflect underlying dysfunctional beliefs and

psychotic disorders, and personality disorders. He

assumptions. When these beliefs are triggered by

has developed assessment scales for depression,

situational events, a depressive pattern is put in

suicide risk, anxiety, self-concept, and personality.

motion. Beck believes clients can assume an

He is the founder of the Beck Institute, which is

active role in modifying their dysfunctional thinking

a research and training center directed by one of his

and thereby gain relief from a range of psychiatric

four children, Dr. Judith Beck. He has eight grand-

conditions. His continuous research in the areas

children and two great-grandchildren and has been

of psychopathology and the utility of cognitive

married for more than 60 years. To his credit, Aaron

therapy has earned him a place of prominence in

Beck has focused on developing the cognitive ther-

the scientific community in the United States. Beck

apy skills of thousands of clinicians throughout the

289

is the pioneering figure in cognitive therapy, one of

world. In turn, many of them have established their

C

OGNITIVE BEHA

the most influential and empirically validated

own cognitive therapy centers. Beck has a vision

approaches to psychotherapy.

for the cognitive therapy community that is global,

Beck joined the Department of Psychiatry of

inclusive, collaborative, empowering, and benevo-

the University of Pennsylvania in 1954, where he

lent. He continues to remain active in writing and

currently holds the position of University Professor

research; he has published 21 books and more than

VIOR THERAP

(Emeritus) of Psychiatry. Beck’s pioneering research

450 articles and book chapters. For more on the life

established the efficacy of cognitive therapy for

of Aaron T. Beck, see Aaron T. Beck (Weishaar, 1993).

JUDITH S. BECK (b. 1954)

and supervision programs for students and faculty,

was born in Philadelphia,

deployed and returning military families, health

Y

PA.

the second of four children.

and mental health professionals at all levels, and

Cognitive

for

Both her parents were quite

organizations.

Cynwyd,

notable in their fields: her

Beck travels extensively in the United States

Institute

Bala

father, as “the father of

and abroad, teaching and disseminating cognitive

Beck

of

Therapy,

cognitive therapy,” and her

behavior therapy and assisting a wide variety of

mother, as the first female

organizations in developing or strengthening their

Courtesy

Behavior

judge on the appellate court

CT programs. She writes a number of CT-oriented

of the Commonwealth of Pennsylvania. From an

blogs and edits “Cognitive Therapy Today,” an

early age, Beck wanted to be an educator, and she

e-newsletter. She is coauthor of the widely adopted

began her professional career teaching children

self-report scales, the Personality Belief Question-

with learning disabilities. Her ability to break down

naire and the Beck Youth Inventories II, which

complex subjects into easily understandable ideas,

screens children aged 7–18 for symptoms of

so critical in the education of children with learning

depression, anxiety, disruptive behavior, self-

differences, is characteristic of all her work.

concept, and anger.

Beck later returned to graduate school, studied

Beck is Clinical Associate Professor at the

education and psychology, and completed a

University of Pennsylvania and was instrumental

postdoctoral fellowship at the Center for Cognitive

in founding the Academy of Cognitive Therapy,

Behavior Therapy at the University of Pennsylvania.

the “home” organization for cognitive therapists

In 1994 she and her father opened the nonprofit

worldwide. She has written nearly a hundred

Beck Institute for Cognitive Therapy in suburban

articles and chapters on a variety of CT topics

Philadelphia, and she is currently president of

and authored several books on cognitive therapy,

the institute. A premier training organization, the

including Cognitive Behavior Therapy: Basics and

institute is devoted to national and international

Beyond (2011a), Cognitive Therapy for Challenging

training in cognitive therapy through workshop

Problems: What to Do When the Basics Don’t Work

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28549_ch10_rev01.indd 289

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(2005), and the Cognitive Therapy Worksheet

nance. Judith Beck has been married for 34 years

Packet (2011b), as well as trade books with a

and has three adult children, one of whom is a

cognitive behavioral program for diet and mainte-

social worker specializing in CT.

DONALD MEICHEN-

about her daily activities that were peppered with

of

BAUM (b. 1940) was born

her thoughts, feelings, and a running commentary.

University

in New York City

This childhood experience contributed to Meichen-

(the Bronx) and learned

baum’s psychotherapeutic approach of construc-

Psychology

of

early to be “street smart”

tivist narrative therapy, in which clients to tell their

Meichenbaum,

and to be on the lookout

stories and describe what they did to “survive and

Donald

Department

for high-risk situations. He

cope.” Meichenbaum’s recent work with returning

of

attended City College of

service members using iPod technology to bolster

Courtesy

Waterloo,

New York and received his

resilience is modeled on this approach. When

290

PhD in clinical psychology from the University of

therapy is successful, Meichenbaum ensures

Illinois. At the University of Waterloo in Ontario,

that clients take credit for the changes they have

Canada, he conducted research on the develop-

achieved. As he observes, “I am at my therapeutic

ment of cognitive behavior therapy (CBT). He is the

best when the clients I see are one step ahead of

recipient of a Lifetime Achievement Award from

me offering the observations or suggestions that

the Clinical Division of the American Psychological

I would otherwise offer” (Donald Meichenbaum,

CHAPTER TEN

Association for his work on suicide prevention. In

personal communication, October 21, 2010).

1995 Meichenbaum retired from the University of

Meichenbaum has published extensively,

Waterloo to become the research director of the

including Cognitive Behavior Modification: An Integra-

Melissa Institute for Violence Prevention, which is

tive Approach (1977), Stress Inoculation Training (1985),

designed to “give science away” in order to reduce

and Treatment of Individuals with Anger-Control

violence and to treat victims of violence.

Problems and Aggressive Behaviors (2002). He has

Meichenbaum attributes the origin of CBT

lectured and consulted internationally and frequently

to his mother, who had a knack for telling stories

presents workshops at professional conferences.

i n t r o d u c t i o n

As you saw in Chapter 9, traditional behavior therapy has broadened and largely

moved in the direction of cognitive behavior therapy. Several of the more promi-

nent cognitive behavioral approaches are featured in this chapter, including Al-

bert Ellis’s rational emotive behavior therapy (REBT), Aaron T. Beck’s and Judith

Beck’s cognitive therapy (CT), and Donald Meichenbaum’s cognitive behavior

therapy (CBT). The cognitive behavior therapies, which combine both cognitive

and behavioral principles and methods in a short-term treatment approach, have

generated more empirical research than any other psychotherapy model (Dattilio,

2000a). These approaches all fall under the general umbrella of cognitive behavior

therapies, which is the reason they are grouped together in this chapter.

All of the cognitive behavioral approaches share the same basic characteristics

and assumptions as traditional behavior therapy described in Chapter 9. Although

the approaches are quite diverse, they do share these attributes: (1) a collabora-

tive relationship between client and therapist, (2) the premise that psychological

distress is largely a function of disturbances in cognitive processes, (3) a focus

on changing cognitions to produce desired changes in affect and behavior, (4)

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28549_ch10_rev01.indd 290

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a present-centered, time-limited focus, (5) an active and directive stance by the

therapist, and (6) an educational treatment focusing on specifi c and structured

target problems (Beck & Weishaar, 2011). In addition, both cognitive therapy and

the cognitive behavioral therapies are based on a structured psychoeducation-

al model, emphasize the role of homework, place responsibility on the client to

assume an active role both during and outside therapy sessions, emphasize develop-

ing a strong therapeutic alliance, and draw from a variety of cognitive and behav-

ioral strategies to bring about change. Therapists help clients to examine the manner

in which they understand themselves and their world and to experiment with new

ways of behaving (Dienes, Torres-Harding, Reinecke, Freeman, & Sauer, 2011).

To a large degree, both cognitive therapy and cognitive behavior therapy are

based on the assumption that a reorganization of one’s self-statements will result

in a corresponding reorganization of one’s behavior. Behavioral techniques such

291

as operant conditioning, modeling, and behavioral rehearsal can be applied to the

C

OGNITIVE BEHA

more subjective processes of thinking and internal dialogue. Cognitive therapy

and the cognitive behavioral approaches include a variety of behavioral strategies

(discussed in Chapter 9) as a part of their integrative repertoire.

See the video program for Chapter 10, DVD for Theory and Practice of Coun-

VIOR THERAP

seling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you

view the brief lecture for each chapter prior to reading the chapter.

a l b e r t e l l i s ’s r at i o n a l e m o t i v e

Y

b e h a v i o r t h e r a p y

Rational emotive behavior therapy (REBT) was the fi rst of the cognitive behavior

therapies, and today it continues to be a major cognitive behavioral approach.

REBT has a great deal in common with the therapies that are oriented toward

cognition and behavior as it also stresses thinking, judging, deciding, analyzing,

and doing. The basic assumption of REBT is that people contribute to their own

psychological problems, as well as to specifi c symptoms, by the rigid and extreme

beliefs they hold about events and situations. REBT is based on the assumption

that cognitions, emotions, and behaviors interact signifi cantly and have a recip-

rocal cause-and-effect relationship. REBT has consistently emphasized all three

of these modalities and their interactions, thus qualifying it as an integrative

approach (Ellis, 2001a, 2001b, 2002, 2011; Ellis & Dryden, 2007; Wolfe, 2007).

Although REBT is generally conceded to be the parent of today’s cognitive be-

havioral approaches, it was preceded by earlier schools of thought. Ellis gave credit

to Alfred Adler as an infl uential precursor of REBT, and Karen Horney’s (1950)

ideas on the “tyranny of the shoulds” are apparent in the conceptual framework of

REBT. Ellis also acknowledged his debt to the ancient Greeks, especially the Stoic

philosopher Epictetus, who said around 2,000 years ago: “People are disturbed

not by events, but by the views which they take of them” (as cited in Ellis, 2001a,

p. 16). Ellis’s reformulation of Epictetus’s dictum can be stated as, “People disturb

themselves by the rigid and extreme beliefs they hold about events.”

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch10_rev01.indd 291

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REBT’s basic hypothesis is that our emotions stem mainly from our beliefs,

which infl uence the evaluations and interpretations we make of the reactions we

have to life situations. Through the therapeutic process, clients learn skills that

give them the tools to identify and dispute irrational beliefs that have been ac-

quired and self-constructed and are now maintained by self-indoctrination. They

learn how to replace such ineffective ways of thinking with effective and rational

cognitions, and as a result they change their emotional reactions to situations. The

therapeutic process allows clients to apply REBT principles of change not only to

a particular presenting problem but also to many other problems in life or future

problems they might encounter.

Several therapeutic implications fl ow from these assumptions: The focus is on

working with thinking and acting rather than primarily with expressing feelings.

292

Therapy is seen as an educational process. The therapist functions in many ways like

a teacher, especially in collaborating with a client on homework assignments and

in teaching strategies for straight thinking; and the client is a learner who practices

these new skills in everyday life.

REBT differs from many other therapeutic approaches in that it does not place

much value on free association, working with dreams, focusing on the client’s past

CHAPTER TEN

history, expressing and exploring feelings, or dealing with transference phenomena.

Ellis (2011) maintains that transference is not encouraged, and when it does occur,

the therapist is likely to confront it. Ellis believes the transference relationship is

based on the irrational belief that the client must be liked and loved by the therapist,

or parent fi gure. Although transference and countertransference may spontaneously

occur in therapy, Ellis claims “they are quickly analyzed, the philosophies behind

them are revealed, and they tend to evaporate in the process” (p. 221). Furthermore,

when a client’s deep feelings emerge, “the client is not given too much chance to

revel in these feelings or abreact strongly about them” (p. 221). Ellis believes that

such cathartic work may result in clients feeling better, but it will rarely aid them in

getting better.

k e y c o n c e p t s

View of Human Nature

Rational emotive behavior therapy is based on the assumption that human beings

are born with a potential for both rational, or “straight,” thinking and irrational, or

“crooked,” thinking. People have predispositions for self-preservation, happiness,

thinking and verbalizing, loving, communion with others, and growth and self-

actualization. They also have propensities for self-destruction, avoidance of thought,

procrastination, endless repetition of mistakes, superstition, intolerance, perfection-

ism and self-blame, and avoidance of actualizing growth potentials. REBT encour-

ages people accept themselves even though they will make mistakes.

View of Emotional Disturbance

REBT is based on the premise that we learn irrational beliefs from signifi cant oth-

ers during childhood and then re-create these irrational beliefs throughout our

lifetime. We actively reinforce our self-defeating beliefs through the processes of

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch10_rev01.indd 292

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autosuggestion and self-repetition, and we then behave in ways that are consistent

with these beliefs. Hence, it is largely our own repetition of early-indoctrinated

irrational beliefs, rather than a parent’s repetition, that keeps dysfunctional atti-

tudes alive and operative within us.

Ellis contends that people do not need to be accepted and loved, even though

this may be highly desirable. The therapist teaches clients how to feel sad, but not

depressed, even when they are unaccepted and unloved by signifi cant others. A

major goal of the REBT therapist is to encourage clients to be less emotionally re-

active, for example, by feeling sadness and disappointment about life’s adversities

rather than by feeling anxiety, depression, and shame.

Ellis insists that blame is at the core of most emotional disturbances. If we want

to become psychologically healthy, we had better stop blaming ourselves and others

and learn to fully and unconditionally accept ourselves despite our imperfections.

293

Ellis (Ellis & Blau, 1998; Ellis & Harper, 1997) hypothesizes that we have strong ten-

C

OGNITIVE BEHA

dencies to transform our desires and preferences into dogmatic “shoulds,” “musts,”

“oughts,” demands, and commands. When we are disturbed, it is a good idea to look

to our hidden dogmatic “musts” and absolutist “shoulds.” Such demands underpin

disruptive feelings and dysfunctional behaviors (Ellis, 2001a, 2004a).

Here are three basics musts (or irrational beliefs) that we internalize that inevita-

VIOR THERAP

bly lead to self-defeat (Ellis & Dryden, 2007):

• “I must do well and win the approval of others for my performances or else I am

no good.”

Y

• “Other

people

must treat me considerately, fairly, kindly, and in exactly the way

I want them to treat me. If they don’t, they are no good and they deserve to be

condemned and punished.”

• “I

must get what I want, when I want it; and I must not get what I don’t want. If I

don’t get what I want, it’s terrible, I can’t stand it, and life is no good for depriv-

ing me of what I must have.”

We have a strong tendency to make and keep ourselves emotionally disturbed by inter-

nalizing and perpetuating self-defeating beliefs such as these, which is why it is a real

challenge to achieve and maintain good psychological health (Ellis, 2001a, 2001b).

A-B-C Framework

The A-B-C framework is central to REBT theory and practice. This model provides

a useful tool for understanding the client’s feelings, thoughts, events, and behavior

(Wolfe, 2007). A is the existence of a fact, or an activating event, or an inference

about an event, of an individual. C is the emotional and behavioral consequence or

reaction of the individual; the reaction can be either healthy or unhealthy. A (the

activating event) does not cause C (the emotional consequence). Instead, B, which

is the person’s belief about A, largely creates C, the emotional reaction.

The interaction of the various components can be diagrammed like this:

A (activating event)  B (belief) ® C (emotional and behavioral consequence)

D (disputing intervention) ® E (effect) ® F (new feeling)

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If a person experiences depression after a divorce, for example, it may not be

the divorce itself that causes the depressive reaction nor his inference that he has

failed, but the person’s beliefs about his divorce or about his failure. Ellis maintains

that the beliefs about the rejection and failure (at point B) are what mainly cause

the depression (at point C)—not the actual event of the divorce or the person’s in-

ference of failure (at point A). Believing that human beings are largely responsible

for creating their own emotional reactions and disturbances and showing people

how they can change their irrational beliefs that directly “cause” their disturbed

emotional consequences is at the heart of REBT (Ellis & Dryden, 2007; Ellis &

Harper, 1997).

How is an emotional disturbance fostered? It is fed by the self-defeating sen-

tences clients continually repeat to themselves, such as “I am totally to blame for

294

the divorce,” “I am a miserable failure, and everything I did was wrong,” “I am a

worthless person.” Ellis repeatedly makes the point that “you mainly feel the way

you think.” Disturbed emotional reactions such as depression and anxiety are initi-

ated and perpetuated by clients’ self-defeating belief systems, which are based on

irrational ideas clients have incorporated and invented.

After A, B, and C comes D (disputing). Essentially, D is the application of meth-

CHAPTER TEN

ods to help clients challenge their irrational beliefs. There are three components

of this disputing process: detecting, debating, and discriminating. First, clients

learn how to detect their irrational beliefs, particularly their absolutist “shoulds”

and “musts,” their “awfulizing,” and their “self-downing.” Then clients debate their

dysfunctional beliefs by learning how to logically and empirically question them

and to vigorously argue themselves out of and act against believing them. Finally,

clients learn to discriminate irrational (self-defeating) beliefs from rational (self-

helping) beliefs (Ellis, 1994, 1996). Cognitive restructuring is a central technique

of cognitive therapy that teaches people how to improve themselves by replacing

irrational beliefs with rational beliefs (Ellis, 2008). Restructuring involves helping

clients learn to monitor their self-talk, identify maladaptive self-talk, and substitute

adaptive self-talk for their negative self-talk (Spiegler, 2008).

Ellis (1996, 2001b) maintains that we have the capacity to signifi cantly change our

cognitions, emotions, and behaviors. We can best accomplish this goal by avoiding

preoccupying ourselves with A and by acknowledging the futility of dwelling end-

lessly on emotional consequences at C. Rather, we can choose to examine, challenge,

modify, and uproot B—the irrational beliefs we hold about the activating events at A.

Although REBT uses many other cognitive, emotive, and behavioral methods

to help clients minimize their irrational beliefs, it stresses the process of disput-

ing (D) such beliefs both during therapy sessions and in everyday life. Eventually

clients arrive at E, an effective philosophy, which has a practical side. A new and

effective belief system consists of replacing unhealthy thoughts with healthy ones.

If we are successful in doing this, we also create F, a new set of feelings. Instead of

feeling seriously anxious and depressed, we feel healthily sorry and disappointed

in accord with a situation.

In sum, philosophical restructuring to change our dysfunctional personality involves

these steps: (1) fully acknowledging that we are largely responsible for creating our

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own emotional problems; (2) accepting the notion that we have the ability to change

these disturbances signifi cantly; (3) recognizing that our emotional problems largely

stem from irrational beliefs; (4) clearly perceiving these beliefs; (5) seeing the value of

disputing such self-defeating beliefs; (6) accepting the fact that if we expect to change

we had better work hard in emotive and behavioral ways to counteract our beliefs and

the dysfunctional feelings and actions that follow; (7) understanding what the rational

alternative to these irrational beliefs are; and (8) practicing REBT methods of uprooting

or changing disturbed consequences and practicing their healthy alternatives for the

rest of our life (Ellis, 1999, 2001b, 2002).

t h e t h e r a p e u t i c p r o c e s s

Therapeutic Goals

295

According to Ellis (2001b; Ellis & Harper, 1997), we have a strong tendency not only

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OGNITIVE BEHA

to rate our acts and behaviors as “good” or “bad,” “worthy” or “unworthy,” but also to

rate ourselves as a total person on the basis of our performances. These ratings consti-

tute one of the main sources of our emotional disturbances. Therefore, most rational

emotive behavior therapists have the general goal of teaching clients how to separate

the evaluation of their behaviors from the evaluation of themselves—their essence and

VIOR THERAP

their totality—and how to accept themselves in spite of their imperfections.

The many roads taken in rational emotive behavior therapy lead toward the

destination of clients minimizing their emotional disturbances and self-defeating

behaviors by acquiring a more realistic and workable philosophy of life. The proc-

Y

ess of REBT involves a collaborative effort on the part of both the therapist and the

client in choosing realistic and self-enhancing therapeutic goals. The therapist’s

task is to help clients differentiate between realistic and unrealistic goals and also

self-defeating and self-enhancing goals (Dryden, 2007). A basic goal is to teach cli-

ents how to change their dysfunctional emotions and behaviors into healthy ones.

Ellis (2001b) states that two of the main goals of REBT are to assist clients in

the process of achieving unconditional self-acceptance (USA) and unconditional other

acceptance (UOA), and to see how these are interrelated. As clients become more

able to accept themselves, they are more likely to unconditionally accept others.

Therapist’s Function and Role

The therapist has specifi c tasks, and the fi rst step is to show clients how they have

incorporated many irrational absolute “shoulds,” “oughts,” and “musts.” The ther-

apist disputes clients’ irrational beliefs and encourages clients to engage in activi-

ties that will counter their self-defeating beliefs and to replace their rigid “musts”

with preferences.

A second step in the therapeutic process is to demonstrate how clients are

keeping their emotional disturbances active by continuing to think illogically and

unrealistically. In other words, because clients keep reindoctrinating themselves,

they are largely responsible for their own psychological problems.

To get beyond mere recognition of irrational thoughts, the therapist takes a third

step—helping clients modify their thinking and minimize their irrational ideas.

Although it is unlikely that we can entirely eliminate the tendency to think irrationally,

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we can reduce the frequency of such thinking. The therapist encourages clients to

identify the irrational beliefs they originally unquestioningly accepted and demon-

strates how they are continuing to indoctrinate themselves with these beliefs.

The fourth step in the therapeutic process is to challenge clients to develop a

rational philosophy of life so that in the future they can avoid becoming the victim

of other irrational beliefs. Tackling only specifi c problems or symptoms can give

no assurance that new illogical fears will not emerge. It is desirable, then, for the

therapist to dispute the core of the irrational thinking and to teach clients how to

substitute rational beliefs and behaviors for irrational ones.

The therapist takes the mystery out of the therapeutic process, teaching clients

about the cognitive hypothesis of disturbance and showing how rigid and extreme

irrational beliefs lead to disturbed negative consequences. Insight alone does not

296

typically lead to psychotherapeutic change, but it helps clients to see how they are

continuing to sabotage themselves and what they can do to change.

Client’s Experience in Therapy

Once clients begin to accept that their beliefs underpin their emotions and behav-

iors, they are able to participate effectively in the cognitive restructuring process

CHAPTER TEN

(Ellis, Gordon, Neenan, & Palmer, 1997; Ellis & MacLaren, 2005). Because psy-

chotherapy is viewed as a reeducative process, clients learn how to apply logical

thought, participate in experiential exercises, and carry out behavioral homework

as a way to bring about change. Clients can realize that life does not always work

out the way that they would like it to. Even though life is not always pleasant, cli-

ents learn that life can be bearable and that even suffering can be honorable.

The therapeutic process largely focuses on clients’ experiences in the present.

Like the person-centered and existential approaches to therapy, REBT mainly em-

phasizes here-and-now experiences and clients’ present ability to change the pat-

terns of thinking and emoting that they constructed earlier. The therapist does

not devote much time to exploring clients’ early history and making connections

between their past and present behavior unless doing so will aid the therapeutic

process. Nor does the therapist usually explore clients’ early relationships with

their parents or siblings. Instead, the therapeutic process stresses to clients that

they are presently disturbed because they still believe in and act upon their self-

defeating view of themselves, other people, and the world.

Clients are expected to actively work outside the therapy sessions. By working

hard and carrying out behavioral homework assignments, clients can learn to mini-

mize faulty thinking, which leads to disturbances in feeling and behaving. Home-

work is carefully designed and agreed upon and is aimed at getting clients to carry

out positive actions that induce emotional and attitudinal change. These assign-

ments are checked in later sessions, and clients learn effective ways to dispute self-

defeating thinking. Toward the end of therapy, clients review their progress, make

plans, and identify strategies for dealing with continuing or potential problems.

Relationship Between Therapist and Client

Because REBT is essentially a cognitive and directive behavioral process, a warm re-

lationship between therapist and client is not required. As with the person-centered

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therapy of Rogers, REBT practitioners strive to unconditionally accept all clients

and to teach them to unconditionally accept others and themselves. However,

Ellis believes that too much warmth and understanding can be counterproductive

and foster a sense of dependence for approval from the therapist. REBT prac-

titioners accept their clients as imperfect beings who can be helped through a

variety of techniques such as teaching, bibliotherapy, and behavior modifi cation

(Ellis, 2011).

Rational emotive behavior therapists are often open and direct in disclosing

their own beliefs and values. Some are willing to share their own imperfections as

a way of disputing clients’ unrealistic notions that therapists are “completely put

together” persons. On this point, Wolfe (2007) claims “it is important to establish

as much as possible an egalitarian relationship, as opposed to presenting yourself

as a nondisclosing authority fi gure” (p. 186).

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OGNITIVE BEHA

a p p l i c at i o n : t h e r a p e u t i c

t e c h n i q u e s a n d p r o c e d u r e s

The Practice of Rational Emotive Behavior Therapy

Rational emotive behavior therapists are multimodal and integrative. REBT gener-

VIOR THERAP

ally starts with clients’ disturbed feelings and intensely explores these feelings in

connection with thoughts and behaviors. REBT practitioners tend to use a number of

different modalities (cognitive, imagery, emotive, behavioral, and interpersonal) to

dispel these self-defeating cognitions and to teach people how to acquire a rational

Y

approach to living. Therapists are encouraged to be fl exible and creative in their

use of methods, making sure to tailor the techniques to the unique needs of each

client (Dryden, 2007).

For a concrete illustration of how Dr. Ellis works with the client Ruth, drawing

from cognitive, emotive, and behavioral techniques, see Case Approach to Coun-

seling and Psychotherapy (Corey, 2013a, chap. 8). What follows is a brief summary

of the major cognitive, emotive, and behavioral techniques Ellis describes (Ellis,

2004a; Ellis & Crawford, 2000; Ellis & Dryden, 2007; Ellis & MacLaren, 2005).

c o g n i t i v e m e t h o d s REBT practitioners usually incorporate a persuasive

cognitive methodology in the therapeutic process. They demonstrate to clients in a

quick and direct manner what it is that they are continuing to tell themselves. Then

they teach clients how to deal with these self-statements so that they no longer

believe them, encouraging them to acquire a philosophy based on reality. REBT

relies heavily on thinking, disputing, debating, challenging, interpreting, explain-

ing, and teaching. The most effi cient way to bring about lasting emotional and

behavioral change is for clients to change their way of thinking (Dryden, 2007).

Here are some cognitive techniques available to the therapist.

• Disputing irrational beliefs. The most common cognitive method of REBT con-

sists of the therapist actively disputing clients’ irrational beliefs and teaching them

how to do this challenging on their own. Clients go over a particular “must,” absolute

“should,” or “ought” until they no longer hold that irrational belief, or at least until it

is diminished in strength. Here are some examples of questions or statements clients

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learn to tell themselves: “Why must people treat me fairly?” “How do I become a total

fl op if I don’t succeed at important tasks I try?” “If I don’t get the job I want, it may be

disappointing, but I can certainly stand it.” “If life doesn’t always go the way I would

like it to, it isn’t awful, just inconvenient.”

• Doing cognitive homework. REBT clients are expected to make lists of their

problems, look for their absolutist beliefs, and dispute these beliefs. They often

fi ll out the REBT Self-Help Form, which is reproduced in Corey’s (2013b) Stu-

dent Manual for Theory and Practice of Counseling and Psychotherapy. They can

bring this form to their therapy sessions and critically evaluate the disputation

of some of their beliefs. Homework assignments are a way of tracking down the

“shoulds” and “musts” that are part of their internalized self-messages. Part of

this homework consists of applying the A-B-C model to many of the problems

298

clients encounter in daily life. Work in the therapy session can be designed in

such a way that out-of-offi ce tasks are feasible and the client has the skills to

complete these tasks.

In carrying out homework, clients are encouraged to put themselves in risk-

taking situations that will allow them to challenge their self-limiting beliefs. For

CHAPTER TEN

example, a client with a talent for acting who is afraid to act in front of an audience

because of fear of failure may be asked to take a small part in a stage play. The client

is helped to replace irrational beliefs—“If I look foolish, this proves I am a fool.”

“If I am not liked, that would be awful.” “I will fail and therefore be a failure.”—

with more positive messages such as these: “Even if I do behave foolishly at times,

this does not make me a foolish person. ” “I can act.” “I will do the best I can.” “It’s

nice to be liked, but not everybody has to like me, and if they don’t, that isn’t the

end of the world.” “If I fail, I am human, not a failure.”

The theory behind this and similar assignments is that clients often create

a negative, self-fulfi lling prophecy and actually fail because they told themselves

in advance that they would. Clients are encouraged to carry out specifi c assign-

ments during the sessions and, especially, in everyday situations between sessions.

Clients are expected to take the time to record and think about how their beliefs

contribute to their personal problems. In addition, they need to work hard at up-

rooting these self-defeating cognitions. In this way clients gradually learn to deal

with anxiety and to challenge basic irrational thinking. Making changes is hard

work, and doing work outside the sessions is of real value in revising clients’ think-

ing, feeling, and behaving.

• Bibliotherapy. REBT, and other CBT approaches, can be delivered to some

degree in a bibliotherapeutic format. It is probably best to utilize bibliotherapy as

an adjunctive form of treatment. There are advantages of bibliotherapy, such as

cost-effectiveness, widespread availability, and the potential of reaching a broad

spectrum of populations. Bibliotherapeutic approaches have empirical support for

the treatment of depression, for a variety of anxiety disorders, and for a range of

clinical problems (Jacobs, 2008). Because therapy is seen as an educational proc-

ess, clients are encouraged to read REBT self-help books such as Rational Emotive

Behavior Therapy: It Works for Me—It Can Work for You (Ellis, 2004a) and other

books by Ellis (1999, 2000, 2001a, 2001b).

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• Changing one’s language. REBT rests on the premise that imprecise language

is one of the causes of distorted thinking processes. Clients learn that “musts,”

“oughts,” and absolute “shoulds” can be replaced by preferences. Instead of saying “It

would be absolutely awful if . . .”, they learn to say “It would be inconvenient if . . .”.

Clients who use language patterns that refl ect helplessness and self-condemnation

can learn to employ new self-statements, which help them think and behave differ-

ently. As a consequence, they also begin to feel differently.

• Psychoeducational methods. REBT programs introduce clients to various edu-

cational materials. Therapists educate clients about the nature of their problems

and how treatment is likely to proceed. They ask clients how particular concepts

apply to them. Clients are more likely to cooperate with a treatment program if

they understand how the therapy process works and if they understand why par-

ticular techniques are being used (Ledley, Marx, & Heimberg, 2010).

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OGNITIVE BEHA

e m o t i v e t e c h n i q u e s REBT practitioners use a variety of emotive proce-

dures, including unconditional acceptance, rational emotive role playing, modeling,

rational emotive imagery, and shame-attacking exercises. Clients are taught the val-

ue of unconditional self-acceptance. Even though their behavior may be diffi cult to

accept, they can decide to see themselves as fallible human beings. Clients are taught

VIOR THERAP

how destructive it is to engage in “putting oneself down” for perceived defi ciencies.

Although REBT employs a variety of emotive techniques, which tend to be

vivid and evocative in nature, the main purpose is to dispute clients’ irrational

beliefs (Dryden, 2007). These strategies are used both during the therapy sessions

Y

and as homework assignments in daily life. Their purpose is not simply to provide

a cathartic experience but to help clients change some of their thoughts, emotions,

and behaviors (Ellis, 2001b, 2011; Ellis & Dryden, 2007). Let’s look at some of

these evocative and emotive therapeutic techniques in more detail.

• Rational emotive imagery. This technique is a form of intense mental practice

designed to establish new emotional patterns (see Ellis, 2001a, 2001b). Using the

technique of rational emotive imagery (REI), clients are asked to vividly imagine

one of the worst things that might happen to them. They imagine themselves in

specifi c situations where they experience disturbing feelings. Then they are shown

how to train themselves to develop healthy emotions in place of disruptive ones.

As clients change their feelings about adversities, they stand a better chance of

changing their behavior in the situation. Such a technique can be usefully applied

to interpersonal and other situations that are problematic for the individual. Ellis

(2001a, 2011) maintains that if we keep practicing rational emotive imagery several

times a week for a few weeks, we can reach the point that we no longer feel upset

over negative events.

• Using humor. REBT contends that emotional disturbances often result from

taking oneself too seriously, thus, this approach employs a good deal of humor.

One appealing aspect of REBT is that it fosters the development of a better sense

of humor and helps put life into perspective (Wolfe, 2007). Humor has both cogni-

tive and emotional benefi ts in bringing about change. Humor shows the absurdity

of certain ideas that clients steadfastly maintain, and it can be of value in helping

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clients take themselves much less seriously. It teaches clients to laugh—not at

themselves, but at their self-defeating ways of thinking.

• Role playing. Role playing has emotive, cognitive, and behavioral compo-

nents, and the therapist often interrupts to show clients what they are telling them-

selves to create their disturbances and what they can do to change their unhealthy

feelings to healthy ones. Clients can rehearse certain behaviors to bring out what

they feel in a situation. The focus is on working through the underlying irrational

beliefs that are related to unpleasant feelings. For example, Dawson may put off

applying to a graduate school because of his fears of not being accepted. Just the

thought of not being accepted to the school of his choice brings out intense feel-

ings of “being stupid.” Dawson role-plays an interview with the dean of graduate

students, notes his anxiety and the specifi c beliefs leading to it, and challenges his

300

conviction that he absolutely must be accepted and that not gaining such accept-

ance means that he is a stupid and incompetent person.

• Shame-attacking exercises. The rationale underlying shame-attacking exercis-

es is that emotional disturbance related to the self is often characterized by feel-

ings of shame, guilt, anxiety, and depression. Ellis (1999, 2000, 2001a, 2001b)

CHAPTER TEN

developed exercises to help people reduce shame and anxiety over behaving in

certain ways. Ellis asserts that we can stubbornly refuse to feel ashamed by telling

ourselves that it is not catastrophic if someone thinks we are foolish. The exercises

are aimed at increasing self-acceptance and mature responsibility, as well as help-

ing clients see that much of what they think of as being shameful has to do with the

way they defi ne reality for themselves. Clients may accept a homework assignment

to take the risk of doing something that they are ordinarily afraid to do because of

what others might think. For example, clients may wear “loud” clothes designed

to attract attention, sing loudly, ask a silly question at a lecture, or ask for a left-

handed monkey wrench in a grocery store. By carrying out such assignments, cli-

ents are likely to fi nd out that other people are not really that interested in their

behavior. They work on themselves so that they do not feel ashamed or humiliated,

even when they acknowledge that some of their acts will lead to judgments by oth-

ers. They continue practicing these exercises until they realize that their feelings

of shame are self-created and until they are able to behave in less inhibited ways.

Clients eventually learn that they often have no reason for continuing to let others’

reactions or possible disapproval stop them from doing the things they would like

to do. Note that these exercises do not involve illegal activities or acts that will be

harmful to oneself or to others or that will unduly alarm other people.

behavioral techniques REBT practitioners use most of the standard behav-

ior therapy procedures, especially operant conditioning, self-management princi-

ples, systematic desensitization, relaxation techniques, and modeling. Behavioral

homework assignments to be carried out in real-life situations are particularly im-

portant. These assignments are done systematically and are recorded and analyzed

on a form. Homework gives clients opportunities to practice new skills outside

of the therapy session, which may be even more valuable for clients than work

done during the therapy hour (Ledley et al., 2010). Doing homework may involve

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desensitization and live exposure in daily life situations. Clients can be encouraged

to desensitize themselves gradually but also, at times, to perform the very things

they dread doing implosively. For example, a person with a fear of elevators may

decrease this fear by going up and down in an elevator 20 or 30 times in a day.

Clients actually do new and diffi cult things, and in this way they put their insights

to use in the form of concrete action. By acting differently, they also tend to incor-

porate functional beliefs.

Applications of REBT to Various Settings

With its clear structure (A-B-C framework), REBT is applicable to a wide range of

settings and populations, including elementary and secondary schools. REBT can

be applied to couples counseling and family therapy. In working with couples, the

partners are taught the principles of REBT so that they can work out their differ-

301

ences or at least become less disturbed about them. In family therapy, individual

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OGNITIVE BEHA

family members are encouraged to consider letting go of the demand that others

in the family behave in ways they would like them to. Instead, REBT teaches family

members that they are primarily responsible for their own actions and for chang-

ing their own reactions to the family situation.

VIOR THERAP

Application of REBT as a Brief Therapy

REBT is well suited as a brief form of therapy, whether it is applied to individuals,

groups, couples, or families. Ellis originally developed REBT to try to make psycho-

therapy shorter and more effi cient than most other systems of therapy, and it is often

Y

used as a brief therapy. Ellis has always maintained that the best therapy is effi cient,

quickly teaching clients how to tackle practical problems of living. Clients learn how to

apply REBT techniques to their present as well as future problems. A distinguishing

characteristic of REBT that makes it a brief form of therapy is that it is a self-help ap-

proach (Vernon, 2007). The A-B-C approach to changing basic disturbance-creating

attitudes can be learned in 1 to 10 sessions and then practiced at home.

Application to Group Counseling

Cognitive behavior therapy (CBT) groups are among the most popular in clinics

and community agency settings. Two of the most common CBT group approaches

are based on the principles and techniques of REBT and cognitive therapy (CT).

REBT practitioners employ an active role in getting members to commit them-

selves to practicing in everyday situations what they are learning in the group sessions.

They view what goes on during the group as being valuable, yet they know that the con-

sistent work between group sessions and after a group ends is even more crucial. The

group context provides members with tools they can use to become self-reliant and

to accept themselves unconditionally as they encounter new problems in daily living.

REBT is also suitable for group therapy because the members are taught to ap-

ply its principles to one another in the group setting. Ellis recommends that most

clients experience group therapy as well as individual therapy at some point. This

form of group therapy focuses on specifi c techniques for changing a client’s self-

defeating thoughts in various concrete situations. In addition to modifying beliefs,

this approach helps group members see how their beliefs infl uence what they feel

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and what they do. This model aims to minimize symptoms by bringing about a

profound change in philosophy. Ellis (2011) contends that REBT is particularly

applicable to group therapy and is frequently the treatment of choice. Group

work affords many opportunities to agree on homework assignments, to practice

assertiveness skills, to take risks by practicing different behaviors, to challenge

self-defeating thinking, to learn from the experiences of others, and to interact

therapeutically and socially with each other in after-group sessions. All of the

cognitive, emotive, and behavioral techniques described earlier are applicable

to group counseling as are the techniques covered in Chapter 9 on behavior

therapy. Behavioral homework and skills training are just two useful methods

for a group format.

A major strength of REBT and cognitive behavioral groups is the emphasis

302

placed on education and prevention. Because CBT and REBT are based on broad

principles of learning, these approaches can be used to meet the requirements

of a wide variety of groups with a range of different purposes. The specifi city of

CBT allows for links among assessment, treatment, and evaluation strategies. CBT

groups have targeted problems ranging from anxiety and depression to parent ed-

ucation and relationship enhancement. Cognitive behavioral group therapy has

CHAPTER TEN

been demonstrated to have benefi cial applications for some of the following specif-

ic problems: depression, anxiety, panic and phobia, obesity, eating disorders, dual

diagnoses, dissociative disorders, and adult attention defi cit disorders (see White &

Freeman, 2000). Based on his survey of outcome studies of cognitive behavioral

group therapy, Petrocelli (2002) concludes that this approach to groups is effec-

tive for treating a wide range of emotional and behavioral problems. For a more

detailed discussion of REBT applied to group counseling, see Corey (2012, chap. 14).

a a r o n b e c k ’s c o g n i t i v e t h e r a p y

Introduction

Aaron T. Beck developed an approach known as cognitive therapy (CT) as a re-

sult of his research on depression (Beck 1963, 1967). Beck developed cognitive

therapy about the same time that Ellis was developing REBT, yet they appear to

have created their approaches independently. Beck’s observations of depressed

clients revealed that they had a negative bias in their interpretation of certain life

events, which contributed to their cognitive distortions (Beck, 1967). Cognitive

therapy has a number of similarities to both rational emotive behavior therapy and

behavior therapy. All of these therapies are active, directive, time-limited, present-

centered, problem-oriented, collaborative, structured, and empirical. They make

use of homework and require explicit identifi cation of problems and the situations

in which they occur (Beck & Weishaar, 2011).

Cognitive therapy (CT) perceives psychological problems as stemming from com-

monplace processes such as faulty thinking, making incorrect inferences on the basis

of inadequate or incorrect information, and failing to distinguish between fantasy

and reality. Like REBT, CT is an insight-focused therapy with a strong psychoedu-

cational component that emphasizes recognizing and changing unrealistic nega-

tive thoughts and maladaptive beliefs. Cognitive therapy is highly collaborative and

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involves designing specifi c learning experiences to help clients monitor their auto-

matic thoughts; examine the validity of their automatic thoughts; understand the

relationship among cognition, feelings, and behavior; develop more accurate and

realistic cognitions; and change underlying beliefs and assumptions (Dobson &

Dozois, 2010; Dozois & Beck, 2011). Cognitive therapy is based on the theoretical

rationale that the way people feel and behave is infl uenced by how they perceive

and structure their experience. The theoretical assumptions of cognitive therapy

are (1) that people’s internal communication is accessible to introspection, (2) that

clients’ beliefs have highly personal meanings, and (3) that these meanings can

be discovered by the client rather than being taught or interpreted by the therapist

(Weishaar, 1993).

Basic Principles of Cognitive Therapy

303

Beck, formerly a practicing psychoanalytic therapist for many years, grew inter-

C

OGNITIVE BEHA

ested in his clients’ automatic thoughts (personalized notions that are triggered by

particular stimuli that lead to emotional responses). As a part of a psychoanalytic

research study, he was examining the dream content of depressed clients for anger

that they were turning back on themselves. He began to notice that rather than

retrofl ected anger, as Freud theorized with depression, clients exhibited a negative

VIOR THERAP

bias in their interpretation or thinking. Beck asked clients to observe their nega-

tive automatic thoughts that persisted even though they were contrary to objective

evidence, and from this beginning he developed one of the most comprehensive

theories of psychopathology in the world.

Y

Individuals tend to maintain their core beliefs about themselves, their world,

and their future. A primary focus of cognitive therapy is to assist clients in ex-

amining and restructuring their core beliefs (or core schema) (Dozois & Beck,

2011). By encouraging clients to gather and weigh the evidence in support of their

beliefs, therapists help clients bring about enduring changes in their mood and

their behavior.

Beck contends that people with emotional diffi culties tend to commit char-

acteristic “logical errors” that distort objective reality. Let’s examine some of the

systematic errors in reasoning that lead to faulty assumptions and misconceptions,

which are termed cognitive distortions (J. Beck, 2011; Beck & Weishaar, 2011).

• Arbitrary inferences refer to making conclusions without supporting and rel-

evant evidence. This includes “catastrophizing,” or thinking of the absolute worst

scenario and outcomes for most situations. You might begin your fi rst job as a

counselor with the conviction that you will not be liked or valued by either your

colleagues or your clients. You are convinced that you fooled your professors

and somehow just managed to get your degree, but now people will certainly see

through you!

• Selective abstraction consists of forming conclusions based on an isolated

detail of an event. In this process other information is ignored, and the signifi -

cance of the total context is missed. The assumption is that the events that matter

are those dealing with failure and deprivation. As a counselor, you might measure

your worth by your errors and weaknesses, not by your successes.

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• Overgeneralization is a process of holding extreme beliefs on the basis of a

single incident and applying them inappropriately to dissimilar events or settings.

If you have diffi culty working with one adolescent, for example, you might con-

clude that you will not be effective counseling any adolescents. You might also

conclude that you will not be effective working with any clients!

• Magnifi cation and minimization consist of perceiving a case or situation in a

greater or lesser light than it truly deserves. You might make this cognitive error

by assuming that even minor mistakes in counseling a client could easily create a

crisis for the individual and might result in psychological damage.

• Personalization is a tendency for individuals to relate external events to them-

selves, even when there is no basis for making this connection. If a client does not

return for a second counseling session, you might be absolutely convinced that

304

this absence is due to your terrible performance during the initial session. You

might tell yourself, “This situation proves that I really let that client down, and now

she may never seek help again.”

• Labeling and mislabeling involve portraying one’s identity on the basis of

imperfections and mistakes made in the past and allowing them to defi ne one’s

CHAPTER TEN

true identity. Thus, if you are not able to live up to all of a client’s expectations,

you might say to yourself, “I’m totally worthless and should turn my professional

license in right away.”

• Dichotomous thinking involves categorizing experiences in either-or ex-

tremes. With such polarized thinking, events are labeled in black or white terms.

You might give yourself no latitude for being an imperfect person and imperfect

counselor. You might view yourself as either being the perfectly competent coun-

selor (which means you always succeed with all clients) or as a total fl op if you are

not fully competent (which means there is no room for any mistakes).

The cognitive therapist operates on the assumption that an important way to

produce lasting change in dysfunctional emotions and behaviors is to modify inac-

curate and dysfunctional thinking. The cognitive therapist teaches clients how to

identify these distorted and dysfunctional cognitions through a process of evalua-

tion. Through a collaborative effort, clients learn the infl uence that cognition has

on their feelings and behaviors and even on environmental events. In cognitive

therapy, clients learn to engage in more realistic thinking, especially if they con-

sistently notice times when they tend to get caught up in catastrophic thinking.

After they have gained insight into how their unrealistic negative thoughts are

affecting them, clients are taught to test these automatic thoughts against reality

by examining and weighing the evidence for and against them. They can begin to

monitor the frequency with which these beliefs intrude in situations in everyday life.

The frequently asked question is, “What is the evidence for _____?” This process of

critically examining their automatic thoughts and core beliefs involves empirically

testing them by actively engaging in a Socratic dialogue with the therapist, carry-

ing out homework assignments, doing behavioral experiments, gathering data on

assumptions they make, and forming alternative interpretations (Dattilio, 2000a;

Freeman & Dattilio, 1994; Tompkins, 2004, 2006). From the start of treatment,

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clients learn to employ specifi c problem-solving and coping skills. Through a proc-

ess of guided discovery, clients acquire insight about the connection between their

thinking and the ways they act and feel.

Cognitive therapy is focused on present problems, regardless of a client’s di-

agnosis. The past may be brought into therapy when the therapist considers it es-

sential to understand how and when certain core dysfunctional beliefs originated

and how these ideas have a current impact on the client’s specifi c schema (Dattilio,

2002a). The goals of this brief therapy include providing symptom relief, assist-

ing clients in resolving their most pressing problems, and teaching clients relapse

prevention strategies.

s o m e d i f f e r e n c e s b e t w e e n c t a n d r e b t In both CT and REBT,

reality testing is highly organized. Clients come to realize on an experiential level

305

that they have misconstrued situations. Yet there are some important differences

C

OGNITIVE BEHA

between these two approaches, especially with respect to therapeutic methods

and style.

REBT is often highly directive, persuasive, and confrontational; it also focus-

es on the teaching role of the therapist. The therapist models rational thinking

and helps clients to identify and dispute irrational beliefs. In contrast, CT uses a

VIOR THERAP

Socratic dialogue by posing open-ended questions to clients with the aim of getting

clients to refl ect on personal issues and arrive at their own conclusions. CT places

more emphasis on helping clients identify their misconceptions for themselves

than does REBT. Through this refl ective questioning process, the cognitive thera-

Y

pist attempts to collaborate with clients in testing the validity of their cognitions

(a process termed collaborative empiricism). Therapeutic change is the result of

clients confronting faulty beliefs with contradictory evidence that they have gath-

ered and evaluated.

There are also differences in how Ellis and Beck view faulty thinking. Through

a process of rational disputation, Ellis works to persuade clients that certain of their

beliefs are irrational and nonfunctional. Beck views his clients’ beliefs as being

more inaccurate than irrational and asks his clients to conduct behavioral experi-

ments to test the accuracy of their beliefs (Hollon & DiGiuseppe, 2011). Cognitive

therapists view dysfunctional beliefs as being problematic when they are irrational,

or when they are too absolute, broad, and extreme (Beck & Weishaar, 2011). For

Beck, people live by rules (premises or formulas); they get into trouble when they

label, interpret, and evaluate by a set of rules that are unrealistic or when they use

the rules inappropriately or excessively. If clients make the determination that they

are living by rules that are likely to lead to misery, the therapist may suggest alter-

native rules for them to consider, without indoctrinating them. Although cognitive

therapy often begins by recognizing the client’s frame of reference, the therapist

continues to ask for evidence for a belief system.

The Client–Therapist Relationship

One of the main ways the practice of cognitive therapy differs from the practice of

rational emotive behavior therapy is its emphasis on the therapeutic relationship.

As you will recall, Ellis views the therapist largely as a teacher and does not think

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that a warm personal relationship with clients is essential. In contrast, Beck (1987)

emphasizes that the quality of the therapeutic relationship is basic to the applica-

tion of cognitive therapy. Through his writings, it is clear that Beck believes that

effective therapists must combine empathy and sensitivity, along with techni-

cal competence. The core therapeutic conditions described by Rogers in his

person-centered approach are viewed by cognitive therapists as being necessary,

but not suffi cient, to produce optimum therapeutic effect. A therapeutic alliance

is a necessary fi rst step in cognitive therapy, especially in counseling diffi cult-

to-reach clients. Without a working alliance, applying techniques will not be

effective (Dienes et al., 2011). Therapists must also have a cognitive conceptu-

alization of cases, be creative and active, be able to engage clients through a

process of Socratic questioning, and be knowledgeable and skilled in the use

306

of cognitive and behavioral strategies aimed at guiding clients in signifi cant

self-discoveries that will lead to change (Beck & Weishaar, 2011). Macy (2007)

states that effective cognitive therapists strive to create “warm, empathic rela-

tionships with clients while at the same time effectively using cognitive therapy

techniques that will enable clients to create change in their thinking, feeling,

and behaving” (p. 171).

CHAPTER TEN

Cognitive therapists are continuously active and deliberately interactive with

clients, helping clients frame their conclusions in the form of testable hypotheses.

Therapists engage clients’ active participation and collaboration throughout all

phases of therapy, including deciding how often to meet, how long therapy should

last, what problems to explore, and setting an agenda for each therapy session

(J. Beck & Butler, 2005).

Aaron and Judith Beck conceptualize a partnership to devise personally mean-

ingful evaluations of the client’s negative assumptions (J. Beck, 2005, 2011a). The

therapist functions as a catalyst and a guide who helps clients understand how

their beliefs and attitudes infl uence the way they feel and act. Clients are expected

to identify the distortions in their thinking, summarize important points in the

session, and collaboratively devise homework assignments that they agree to carry

out. Cognitive therapists emphasize the client’s role in self-discovery. The assump-

tion is that lasting changes in the client’s thinking and behavior will be most likely

to occur with the client’s initiative, understanding, awareness, and effort (J. Beck,

2005, 2011a; J. Beck & Butler, 2005; Beck & Weishaar, 2011).

In cognitive therapy, the aim is to identify specifi c, measurable goals and to

move directly into the areas that are causing the most diffi culty for clients (Dienes

et al. 2011). Cognitive therapists aim to teach clients how to be their own thera-

pist. Typically, a therapist will educate clients about the nature and course of their

problem, about the process of cognitive therapy, and how thoughts infl uence their

emotions and behaviors. The educative process includes providing clients with in-

formation about their presenting problems and about relapse prevention. One way

of educating clients is through bibliotherapy, in which clients complete readings

dealing with the philosophy of cognitive therapy. These readings are assigned as

an adjunct to therapy and are designed to enhance the therapeutic process by pro-

viding an educational focus (Dattilio & Freeman, 2007; Jacobs, 2008). Cognitive

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therapy self-help books also provide an educational focus, such as The Beck Diet

Solution: Train Your Brain to Think Like a Thin Person (J. Beck, 2007a) and The

Complete Beck Diet for Life (J. Beck, 2008).

Homework is often used as a part of cognitive therapy because practicing cog-

nitive behavioral skills outside of the offi ce facilitates more rapid gains (Dienes

et al., 2011). Homework is tailored to the client’s specifi c problem and arises out of

the collaborative therapeutic relationship. Tompkins (2004, 2006) outlines the key

steps to successful homework assignments and the steps involved in collaboratively

designing homework. The purpose of homework is not merely to teach clients new

skills but also to enable them to test their beliefs and experiment with different

behaviors in daily-life situations. Homework is generally presented to clients as an

experiment, which increases the openness of clients to get involved in an assign-

ment. Emphasis is placed on self-help assignments that serve as a continuation

307

of issues addressed in a therapy session (Dattilio, 2002b). Cognitive therapists

C

OGNITIVE BEHA

realize that clients are more likely to complete homework if it is tailored to their

needs, if they participate in designing the homework, if they begin the homework

in the therapy session, and if they talk about potential problems in implementing

the homework (J. Beck, 2005). Tompkins (2006) points out that there are clear

advantages to the therapist and the client working in a collaborative manner in

VIOR THERAP

negotiating mutually agreeable homework tasks. One indicator of a good therapeu-

tic alliance is whether homework is done and done well.

Applications of Cognitive Therapy

Y

Cognitive therapy initially gained recognition as an approach to treating depres-

sion, but extensive research has also been devoted to the study and treatment of

many other psychiatric disorders. One of the reasons for the popularity of cognitive

therapy is due to “strong empirical support for its theoretical framework and to

the large number of outcome studies with clinical populations” (Beck & Weishaar,

2011, p. 305). According to J. Beck (personal communication, January 1, 2011),

hundreds of research studies have confi rmed the theoretical underpinnings of CT,

and hundreds of outcome trials have established its effi cacy for a wide range of

psychiatric disorders, psychological problems, and medical conditions with psy-

chological components.

Cognitive therapy has been successfully used to treat phobias, psychosomatic

disorders, eating disorders, anger, panic disorders, and generalized anxiety disor-

ders (Chambless & Peterman, 2006; Dattilio & Kendall, 2007; Riskind, 2006);

posttraumatic stress disorder, suicidal behavior, borderline personality disorders,

narcissistic personality disorders, and schizophrenic disorders (Dattilio & Freeman,

2007); personality disorders (Pretzer & Beck, 2006); substance abuse (Newman,

2006); chronic pain (Beck, 1987); medical illness (Dattilio & Castaldo, 2001); crisis

intervention (Dattilio & Freeman, 2007); couples and families therapy (Dattilio,

1993, 1998, 2001, 2005, 2010; Dattilio & Padesky, 1990; Epstein, 2006); child

abusers, divorce counseling, skills training, and stress management (Dattilio, 1998;

Granvold, 1994; Reinecke, Dattilio, & Freeman, 2002). Clearly, cognitive therapy

programs have been designed for all ages and for a variety of client populations.

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For an excellent resource on the clinical applications of cognitive therapy to a wide

range of disorders and populations, see Contemporary Cognitive Therapy (Leahy,

2006a).

a p p ly i n g c o g n i t i v e t e c h n i q u e s Beck and Weishaar (2011) describe

both cognitive and behavioral techniques that are part of the overall strategies used

by cognitive therapists. Cognitive techniques focus on identifying and examining

a client’s beliefs, exploring the origins of these beliefs, and modifying them if the

client cannot support these beliefs. Examples of behavioral techniques typically

used by cognitive therapists include activity scheduling, behavioral experiments,

skills training, role playing, behavioral rehearsal, and exposure therapy. Regard-

less of the nature of the specifi c problem, the cognitive therapist is mainly in-

terested in applying procedures that will assist individuals in making alternative

308

interpretations of events in their daily living. Think about how you might apply the

principles of CT to yourself in this classroom situation and change your feelings

surrounding the situation:

Your professor does not call on you during a particular class session. You feel depressed.

Cognitively, you are telling yourself: “My professor thinks I’m stupid and that I really don’t

CHAPTER TEN

have much of value to offer the class. Furthermore, she’s right, because everyone else is

brighter and more articulate than I am. It’s been this way most of my life!”

Some possible alternative interpretations are that the professor wants to include oth-

ers in the discussion, that she is short on time and wants to move ahead, that she

already knows your views, or that she believes you are self-conscious about being

singled out or called on.

The therapist would have you become aware of the distortions in your thinking

patterns by examining your automatic thoughts. The therapist would ask you to

look at your inferences, which may be faulty, and may investigate whether these

inferences can be traced back to earlier experiences in your life. Then the therapist

would help you see how you sometimes come to a conclusion (your decision that

you are stupid, with little of value to offer) when evidence for such a conclusion is

either lacking or based on distorted information from the past.

As a client in cognitive therapy, you would also learn about the process of mag-

nifi cation or minimization of thinking, which involves either exaggerating the

meaning of an event (you believe the professor thinks you are stupid because she

did not acknowledge you on this one occasion) or minimizing it (you belittle your

value as a student in the class). The therapist would assist you in learning how you

disregard important aspects of a situation, engage in overly simplifi ed and rigid

thinking, and generalize from a single incident of failure. Can you think of other

situations where you could apply CT procedures?

t r e at m e n t o f d e p r e s s i o n Based on his research, Beck (1963) chal-

lenged the notion that depression results from anger turned inward. Instead, he

focuses on the content of the depressive’s negative thinking and biased interpreta-

tion of events. Beck (1987) writes about the cognitive triad as a pattern that triggers

depression. In the fi rst component of the triad, clients hold a negative view of them-

selves. They blame their setbacks on personal inadequacies without considering

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circumstantial explanations. They are convinced that they lack the qualities essen-

tial to bring them happiness. The second component of the triad consists of the

tendency to interpret their personal world in a negative manner. Depressed people

focus on certain facts that conform to their negative conclusions, a process referred

to as selective abstraction by Beck. The third component of the triad pertains to

depressed clients’ gloomy vision and projections about the future. They expect

their present diffi culties to continue, and they anticipate only failure in the future.

Depression-prone people often set rigid, perfectionist goals for themselves

that are impossible to attain. Their negative expectations are so strong that even

if they experience success in specifi c tasks they anticipate failure the next time.

They screen out successful experiences that are not consistent with their nega-

tive self-concept. The thought content of depressed individuals often centers on

a sense of irreversible loss that results in emotional states of sadness, disappoint-

309

ment, and apathy.

C

OGNITIVE BEHA

The cognitive therapy approach to treating depressed clients focuses on spe-

cifi c problem areas and the reasons clients give for their symptoms. To assess the

depth of depression, Beck (1967) designed a standardized device known as the

Beck Depression Inventory (BDI). Some of the behavioral symptoms of depres-

sion are inactivity, withdrawal, and avoidance. The therapist is likely to probe with

VIOR THERAP

Socratic questioning such as this: “What would be lost by trying a specifi c activity?

Will you feel worse if you are passive? How do you know that it is pointless to try?”

Therapy procedures include setting up an activity schedule with graded tasks to

be completed. Clients are asked to complete easy tasks fi rst, so that they will meet

Y

with some success and become slightly more optimistic. The point is to enlist the

client’s cooperation with the therapist on the assumption that doing something is

more likely to lead to feeling better than doing nothing.

A central characteristic of most depressive people is self-criticism. Underneath

the person’s negative self-attitudes are themes of weakness, inadequacy, and lack

of responsibility. A number of therapeutic strategies can be used. Clients can be

asked to identify and provide reasons for their excessively self-critical thinking. The

therapist may ask the client, “If your friend were to make a mistake the way you

do, would you be as critical of her as you are of yourself?” The therapist may also

discuss with the client how the “tyranny of shoulds” can lead to increased distress.

Depressed clients typically experience painful emotions. They may say that they

cannot stand the pain or that nothing can make them feel better. One procedure

that may be helpful is to ask them to speak more conversationally about events in

the past week in which their mood lifted even just a little.

Another specifi c characteristic of depressed people is an exaggeration of exter-

nal demands, problems, and pressures. They may express thoughts of being over-

whelmed and that there is so much to accomplish that they can never do it. A cognitive

therapist might ask clients to list things that need to be done, set priorities, check off

tasks that have been accomplished, and break down an external problem into man-

ageable units. When problems are discussed, clients often become aware of how they

are magnifying the importance of these diffi culties. Through rational exploration,

clients are able to regain a perspective on defi ning and accomplishing tasks.

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The therapist typically has to take the lead in helping clients make a list of their

responsibilities, set priorities, and develop a realistic plan of action. Because carry-

ing out such a plan is often inhibited by negative automatic thoughts, it is well for

therapists to use cognitive rehearsal techniques in both identifying and changing

negative thoughts. If clients can learn to combat their self-doubts in the therapy

session, they may be able to apply their newly acquired cognitive and behavioral

skills in real-life situations.

a p p l i c at i o n t o fa m i ly t h e r a p y The cognitive behavioral approach

focuses on family interaction patterns, and family relationships, cognitions, emo-

tions, and behavior are viewed as exerting a mutual infl uence on one another. A

cognitive inference can evoke emotion and behavior, and emotion and behavior

can likewise infl uence cognition in a reciprocal process that sometimes serves to

310

maintain the dysfunction of the family unit.

Cognitive therapy, as set forth by Beck (1976), places a heavy emphasis on sche-

ma, or what have elsewhere been defi ned as core beliefs. A key aspect of the therapeu-

tic process involves restructuring distorted beliefs (or schema), which has a pivotal

impact on changing dysfunctional behaviors. Some cognitive behavior therapists place

CHAPTER TEN

a strong emphasis on examining cognitions among individual family members as well

as on what may be termed the “family schemata” (Dattilio, 1993, 1998, 2001, 2010).

These are jointly held beliefs about the family that have formed as a result of years of

integrated interaction among members of the family unit. It is the experiences and

perceptions from the family of origin that shape the schema about both the immedi-

ate family and families in general. These schemata have a major impact on how the

individual thinks, feels, and behaves in the family system (Dattilio, 2001, 2005, 2010).

For a concrete illustration of how Dr. Dattilio applies cognitive principles and

works with family schemata, see his cognitive behavioral approach with Ruth in

Case Approach to Counseling and Psychotherapy (Corey, 2013a, chap. 8). For a discus-

sion of myths and misconceptions of cognitive behavior family therapy, see Dattilio

(2001); for a concise presentation on the cognitive behavioral model of family ther-

apy, see Dattilio (2010). Also, for an expanded treatment of applications of cognitive

behavioral approaches to working with couples and families, see Dattilio (1998).

d o n a l d m e i c h e n b a u m ’s c o g n i t i v e

b e h a v i o r m o d i f i c at i o n

Introduction

Another major alternative to rational emotive behavior therapy is Donald Meichen-

baum’s cognitive behavior modifi cation (CBM), which focuses on changing the cli-

ent’s self-verbalizations. Meichenbaum’s cognitive behavioral approach combines

some of the best elements of behavior therapy and cognitive therapy. According to

Meichenbaum (1977), self-statements affect a person’s behavior in much the same

way as statements made by another person. A basic premise of CBM is that clients,

as a prerequisite to behavior change, must notice how they think, feel, and behave

and the impact they have on others. For change to occur, clients need to interrupt

the scripted nature of their behavior so that they can evaluate their behavior in vari-

ous situations (Meichenbaum, 1993, 2007).

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This approach shares with REBT and Beck’s cognitive therapy the assumption that

distressing emotions are typically the result of maladaptive thoughts. REBT is more

direct and confrontational in uncovering and disputing irrational thoughts, whereas

Meichenbaum’s self-instructional training focuses more on helping clients become

aware of their self-talk and the stories they tell about themselves. Both REBT and CT

focus on changing thinking processes, but Meichenbaum suggests that it may be easi-

er and more effective to behave our way into a new way of thinking rather than to think

our way into a new way of behaving. Furthermore, our emotions and thinking are two

sides of the same coin: the way we feel can affect our way of thinking, just as how we

think can infl uence how we feel. The therapeutic process consists of teaching clients to

make self-statements and training clients to modify the instructions they give to them-

selves so that they can cope more effectively with the problems they encounter. Cogni-

tive restructuring plays a central role in Meichenbaum’s (1977, 1993) self-instructional

311

training. He describes cognitive structure as the organizing aspect of thinking, which

C

OGNITIVE BEHA

seems to monitor and direct the choice of thoughts through an “executive processor”

that “holds the blueprints of thinking” that determine when to continue, interrupt,

or change thinking. Together, therapist and client practice the self-instructions and

the desirable behaviors in role-play situations that simulate problem situations in the

client’s daily life. The emphasis is on acquiring practical coping skills for problematic

VIOR THERAP

situations such as impulsive and aggressive behavior, anxiety in social situations, fear

of taking tests, eating problems, and fear of public speaking.

How Behavior Changes

Y

Meichenbaum (1977) proposes that “behavior change occurs through a sequence

of mediating processes involving the interaction of inner speech, cognitive struc-

tures, and behaviors and their resultant outcomes” (p. 218). He describes a three-

phase process of change in which those three aspects are interwoven. According to

him, focusing on only one aspect will probably prove insuffi cient.

Phase 1: Self-observation. The beginning step in the change process consists of clients

learning how to observe their own behavior. When clients begin therapy, their in-

ternal dialogue is characterized by negative self-statements and imagery. A critical

factor is their willingness and ability to listen to themselves. This process involves an

increased sensitivity to their thoughts, feelings, actions, physiological reactions, and

ways of reacting to others. If depressed clients hope to make constructive changes, for

example, they must fi rst realize that they are not “victims” of negative thoughts and

feelings. Rather, they are actually contributing to their depression through the things

they tell themselves. Although self-observation is necessary if change is to occur, it is

not suffi cient for change. As therapy progresses, clients acquire new cognitive struc-

tures that enable them to view their problems in a new light. This reconceptualization

process comes about through a collaborative effort between client and therapist.

Phase 2: Starting a new internal dialogue. As a result of the early client–therapist

contacts, clients learn to notice their maladaptive behaviors, and they begin to see

opportunities for adaptive behavioral alternatives. If clients hope to change what

they are telling themselves, they must initiate a new behavioral chain, one that

is incompatible with their maladaptive behaviors. Clients learn that psychological

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distress is a function of the interdependence of cognitions, emotions, behaviors,

and resultant consequences. In therapy, clients learn to change their internal dia-

logue, which serves as a guide to new behavior.

Phase 3: Learning new skills. The third phase of the modifi cation process consists of

helping clients interrupt the downward spiral of thinking, feeling, and behaving

and teaching them more adaptive ways of coping using the resources they bring to

therapy. Clients learn more effective coping skills, which are practiced in real-life

situations. For example, clients who can’t cope with failure may avoid appealing

activities for fear of not succeeding at them. Cognitive restructuring can help them

change their negative view, thus making them more willing to engage in desired

activities. At the same time, clients continue to focus on telling themselves new

sentences and observing and assessing the outcomes. As they behave differently

312

in situations, they typically get different reactions from others. The stability of what

they learn is greatly infl uenced by what they say to themselves about their newly

acquired behavior and its consequences.

Stress Inoculation Training

CHAPTER TEN

A particular application of a coping skills program is teaching clients stress man-

agement techniques by way of a strategy known as stress inoculation training

(SIT) . Using cognitive techniques, Meichenbaum (1985, 2007, 2008) has devel-

oped stress inoculation procedures that are a psychological and behavioral ana-

log to immunization on a biological level. Individuals are given opportunities to

deal with relatively mild stress stimuli in successful ways, so that they gradually

develop a tolerance for stronger stimuli. This training is based on the assumption

that we can affect our ability to cope with stress by modifying our beliefs and self-

statements about our performance in stressful situations. Meichenbaum’s stress

inoculation training is concerned with more than merely teaching people specifi c

coping skills. His program is designed to prepare clients for intervention and

motivate them to change, and it deals with issues such as resistance and relapse.

Stress inoculation training consists of a combination of information giving,

Socratic discovery-oriented inquiry, cognitive restructuring, problem solving, relaxa-

tion training, behavioral rehearsals, self-monitoring, self-instruction, self-reinforce-

ment, and modifying environmental situations (Meichenbaum, 2008). SIT involves

collaborative goal setting that nurtures hope, direct-action skills, and acceptance-based

coping skills. These coping skills are designed to be applied to both present problems

and future diffi culties. Clients are assisted in generalizing what they learn in the

training to daily living, and relapse prevention strategies are taught. Meichenbaum

(2008) describes stress inoculation training as a complex, multifaceted cognitive be-

havioral intervention that is both a preventive and a treatment approach.

Clients can acquire more effective strategies in dealing with stressful situations

by learning how to modify their cognitive “set,” or core beliefs. The following pro-

cedures are designed to teach these coping skills:

• Expose clients to anxiety-provoking situations by means of role playing and

imagery

• Require clients to evaluate their anxiety level

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• Teach clients to become aware of the anxiety-provoking cognitions they experi-

ence in stressful situations

• Help clients examine these thoughts by reevaluating their self-statements

• Have clients note the level of anxiety following this reevaluation

t h e p h a s e s o f s t r e s s i n o c u l at i o n t r a i n i n g Meichenbaum

(2007, 2008) has designed a three-stage model for stress inoculation training:

(1) the conceptual-educational phase, (2) the skills acquisition and consolidation

phase, and (3) the application and follow-through phase.

During the conceptual-educational phase, the primary focus is on creating a

working relationship and therapeutic alliance with clients. This is mainly done by

helping them gain a better understanding of the nature of stress and reconceptual-

izing it in social-interactive terms. The therapist enlists the client’s collaboration

313

during this early phase and together they rethink the nature of the problem or

C

the individual’s stress concerns. Initially, clients are provided with a conceptual

OGNITIVE BEHA

framework in simple terms designed to educate them about ways of responding to

a variety of stressful situations. They learn about the role cognitions and emotions

play in creating and maintaining stress through didactic presentations, by curious

questioning, and by a process of guided self-discovery.

VIOR THERAP

Clients often begin treatment feeling that they are the victims of external cir-

cumstances, thoughts, feelings, and behaviors over which they have no control.

As a way to understand the subjective world of clients, the therapist generally

elicits stories that clients tell themselves. Training includes teaching clients to

Y

become aware of their own role in creating their stress and their life stories. They

acquire this awareness by systematically observing the statements they make

internally as well as by monitoring the maladaptive behaviors that fl ow from this

inner dialogue. Such self-monitoring continues throughout all the phases. As is

true in cognitive therapy, clients typically keep an open-ended diary in which they

systematically monitor and record their specifi c thoughts, feelings, and behav-

iors. In teaching these coping skills, therapists strive to be fl exible in their use of

techniques and to be sensitive to the individual, cultural, and situational circum-

stances of their clients.

During the skills acquisition and consolidation phase, the focus is on giving cli-

ents a variety of behavioral and cognitive coping skills to apply to stressful situa-

tions. This phase involves direct actions, such as gathering information about their

fears, learning specifi cally what situations bring about stress, arranging for ways to

lessen the stress by doing something different, and learning methods of physical and

psychological relaxation. The training involves cognitive coping; clients are taught

that adaptive and maladaptive behaviors are linked to their inner dialogue. Through

this training, clients acquire and rehearse a new set of self-statements. Meichenbaum

(1986) provides some examples of coping statements that are rehearsed in this

phase of SIT:

• “How can I prepare for a stressor?” (“What do I have to do? Can I develop a plan

to deal with the stress?”)

• “How can I confront and deal with what is stressing me?” (“What are some ways

I can handle a stressor? How can I meet this challenge?”)

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• “How can I cope with feeling overwhelmed?” (“What can I do right now? How

can I keep my fears in check?”)

• “How can I make reinforcing self-statements?” (“How can I give myself credit?”)

Clients also are exposed to various behavioral interventions, such as relaxation

training, social skills training, time-management instruction, and self-instructional

training. They are helped to make lifestyle changes by reevaluating priorities,

developing support systems, and taking direct action to alter stressful situations.

Through teaching, demonstration, and guided practice, clients learn the skills of

progressive relaxation and practice them regularly to decrease arousal due to stress.

During the application and follow-through phase, the focus is on carefully arranging

for transfer and maintenance of change from the therapeutic situation to everyday

life. Clients practice their new self-statements and apply their new skills to everyday

314

life. To consolidate the lessons learned in the training sessions, clients participate in a

variety of activities, including imagery and behavior rehearsal, role playing, modeling,

and graded in vivo exposure. Once clients have become profi cient in cognitive and

behavioral coping skills, they practice behavioral assignments, which become increas-

ingly demanding. They are asked to write down the homework assignments they are

CHAPTER TEN

willing to complete. The outcomes of these assignments are carefully checked at sub-

sequent meetings, and if clients do not follow through with them, the therapist and

the client collaboratively consider the reasons for the failure.

Relapse prevention, which consists of procedures for dealing with the inevitable

setbacks clients are likely to experience as they apply what they are learning to daily

life, is taught at this stage (Marlatt & Donovan, 2005). Part of relapse prevention

involves teaching clients to view any lapses that occur as “learning opportunities”

rather than “catastrophic failures.” Clients explore a variety of possible high-risk

stressful situations that they may reexperience. Then they rehearse and practice in

a collaborative fashion with the therapist, and with other clients in a group, ways

of applying skills they have learned in the training to maintain the gains they have

made. Follow-up and booster sessions typically take place at 3-, 6-, and 12-month

periods as an incentive for clients to continue practicing and refi ning their coping

skills. SIT can be considered part of an ongoing stress management program that

extends the benefi ts of training into the future.

Stress inoculation training has potentially useful applications for a wide vari-

ety of problems and clients and for both remediation and prevention. The clinical

application of SIT has been individually tailored to specifi c target populations

and includes anger control, anxiety management, assertion training, improving

creative thinking, treating depression, and dealing with health problems. Stress

inoculation training has been employed with medical patients and with psychiat-

ric patients. SIT has been successfully used with children, adolescents, and adults

who have anger problems, anxiety disorders, phobias, social incompetence,

addictions, alcoholism, sexual dysfunctions, social withdrawal, or posttraumatic

stress disorder (PTSD), including use with veterans who experience combat-

related PTSD (Meichenbaum, 1993, 1994a, 1994b, 2007, 2008). Meichenbaum

(2007) contends that the fl exibility of the SIT format has contributed to its robust

effectiveness.

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The Constructivist Approach

to Cognitive Behavior Therapy

Meichenbaum (1997) has developed his approach by incorporating the construc-

tivist narrative perspective (CNP), which focuses on the stories people tell about

themselves and others regarding signifi cant events in their lives. Therapists elicit

stories from their clients that are explored in the therapy process. This approach

begins with the assumption that there are multiple realities. One of the therapeutic

tasks is to help clients appreciate how they construct their realities and how they

author their own stories (see Chapter 13). Meichenbaum describes the constructiv-

ist approach to cognitive behavior therapy as less structured and more discovery-

oriented than standard cognitive therapy. The constructivist approach gives more

emphasis to past development, tends to target deeper core beliefs, and explores

the behavioral impact and emotional toll a client pays for clinging to certain root

315

C

metaphors.

OGNITIVE BEHA

Meichenbaum (personal communication, October 21, 2010) claims that we are

all “story tellers” and that we should beware of the stories that we tell ourselves and

others. For example, victimized clients might see themselves as “prisoners of the

past” or as “stubborn victims.” These phrases are not idle metaphors; they are the

organizing schemas that color the ways individuals view themselves, their world,

VIOR THERAP

and their future. Therapists help clients appreciate how they construct reality (story

tell) and examine the implications and conclusions clients draw from their stories.

Telling the “rest of the story”—what they did to survive and cope—bolsters clients’

strengths and helps them develop resilient-engendering behaviors. In this way,

Y

clients can move from being ”stubborn victims” to becoming “tenacious survivors”

and perhaps “impressive thrivers.”Meichenabum works in a collaborative fashion

with clients to develop the coping skills necessary to achieve these treatment goals.

He uses a Socratic discovery-oriented approach and the art of questioning to assist

clients in reaching their goals.

Meichenbaum (1997) uses these questions to evaluate the outcomes of therapy:

• Are clients now able to tell a new story about themselves and the world?

• Do clients now use more positive metaphors to describe themselves?

• Are clients able to predict high-risk situations and employ coping skills in deal-

ing with emerging problems?

• Are clients able to take credit for the changes they have been able to bring about?

In successful therapy clients develop their own voices, take pride in what they

have accomplished, and take ownership of the changes they are bringing about. In

short, clients become their own therapists and take the therapists’ voice with them.

cognitive behavior therapy

from a multicultural perspective

Strengths From a Diversity Perspective

There are several strengths of cognitive behavioral approaches in working with

individuals from diverse cultural, ethnic, and racial backgrounds. If therapists un-

derstand the core values of their culturally diverse clients, they can help clients

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explore these values and gain a full awareness of their confl icting feelings. Then

the client and the therapist can work together to modify selected beliefs and prac-

tices. Cognitive behavior therapy tends to be culturally sensitive because it uses the

individual’s belief system, or worldview, as part of the method of self-exploration.

Because counselors with a cognitive behavioral orientation function as teachers,

clients are actively involved in learning skills to deal with the problems of living. In

speaking with colleagues who work with culturally diverse populations, I have learned

that their clients tend to appreciate the emphasis on cognition and action, as well as

the stress on relationship issues. The collaborative approach of CBT offers clients

the structure they may want, yet the therapist still makes every effort to enlist clients’

active cooperation and participation. According to Spiegler (2008), because of its basic

nature and the way CBT is practiced, it is inherently suited to treating diverse clients.

316

Some of the factors that Spiegler identifi es that makes CBT diversity effective include

individualized treatment, focusing on the external environment, active nature, empha-

sis on learning, reliance on empirical evidence, concern with present behavior, and

brevity. A strength of CBT is integrating assessment throughout therapy, which com-

municates respect for clients’ viewpoints regarding their progress.

According to Hays (2009), there is an “almost perfect fi t” between cognitive

CHAPTER TEN

behavior therapy and multicultural therapy because these perspectives share com-

mon assumptions that make integration possible. Some aspects that contribute to

an integrative framework follow:

• Interventions are tailored to the unique needs and strengths of the individual.

• Clients are empowered by learning specifi c skills they can apply in daily life

(CBT) and by the emphasis on cultural infl uences that contribute to clients’

uniqueness (multicultural therapy).

• Inner resources and strengths of clients are activated to bring about change.

• Clients make changes that minimize stressors, increase personal strengths and

supports, and establish skills for dealing more effectively with their physical and

social (cultural) environments.

Shortcomings From a Diversity Perspective

Exploring values and core beliefs plays an important role in all of the cognitive

behavioral approaches, and it is crucial for therapists to have some understand-

ing of the cultural background of clients and to be sensitive to their struggles.

Therapists would do well to use caution in confronting clients about their be-

liefs and behaviors until they clearly understand their cultural context. On this

matter, Wolfe (2007) suggests that the therapist’s job is to help clients examine

and challenge long-standing cultural assumptions only if they result in dysfunc-

tional emotions or behaviors. She writes that the therapist assists clients in criti-

cally thinking about “potential confl icts with the values of the dominant culture

so they can work toward achieving their own personal goals within their own

sociocultural context” (p. 188).

A potential limitation of REBT is its negative view of dependency. Many cul-

tures view interdependence as necessary to good mental health. According to Ellis

(1994), REBT is aimed at inducing people to examine and change some of their

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most basic values. Clients with certain long-cherished cultural values pertaining

to interdependence are not likely to respond favorably to such forceful methods

of persuasion toward independence. “REBT practitioners often employ a rapid-

fi re active-directive-persuasive philosophical methodology. In most instances, they

quickly pin clients down to a few basic dysfunctional beliefs” (Ellis, 2011, p. 214).

This style may intimidate or alienate clients who value being refl ective. Modifi ca-

tions in a therapist’s style need to be made depending on the client’s culture.

Hays (2009) suggests that therapists avoid challenging the core cultural beliefs

of clients, unless the client is clearly open to this. By emphasizing collaboration over

confrontation, the therapist can avoid seeming to be disrespectful. Hays recom-

mends drawing on the client’s culturally related strengths in developing helpful

ways of thinking to replace unhelpful cognitions. For example, consider an Asian

American client, Sung, from a culture that stresses values such as doing one’s best,

317

cooperation, interdependence, and working hard. It is likely that Sung may feel that

C

OGNITIVE BEHA

she is bringing shame to her family if she is going through a divorce, and she may

feel guilt if she perceives that she is not living up to the expectations and standards

set for her by her family and her community. The rules for Sung are likely to be

different than are the rules for a male member of her culture. The counselor could

assist Sung in understanding and exploring how both her gender and her culture

VIOR THERAP

are factors to consider in her situation. If Sung is confronted too quickly on living

by the expectations or rules of others, the results are likely to be counterproductive.

Sung might even leave counseling feeling that she has been misunderstood.

Cormier, Nurius, and Osborn (2013) suggest that therapists refrain from jargon

Y

and use of disrespectful language when describing clients’ cognitions, avoiding terms

such as rational and irrational, or maladaptive and dysfunctional. This is especially important when interacting with individuals who feel marginalized by the mainstream

culture. They recommend adapting the language presented in cognitive restructur-

ing to the client’s primary language, age, and educational level. These guidelines can

certainly be applied to REBT practitioners who might do well to refl ect on the words

they use and their tone, especially when zeroing in on a client’s core beliefs.

The emphasis of CBT on assertiveness, independence, verbal ability, rationality,

cognition, and behavioral change may limit its use in cultures that value subtle com-

munication over assertiveness, interdependence over personal independence, listen-

ing and observing over talking, and acceptance over behavior change (Hayes, 2009).

In CBT the focus is on the present, which can result in the therapist failing to recog-

nize the role of the past in a client’s development. Cognitive behavioral assessments

involve the investigation of a client’s personal history. If the therapist is unaware of

a client’s cultural beliefs, which are rooted in the past, the therapist may have dif-

fi culty interpreting the client’s personal experiences accurately. Another limitation

of CBT from a multicultural perspective involves its individualistic orientation. An

inexperienced therapist may overemphasize cognitive restructuring to the neglect of

environmental interventions. Hays points out that these potential limitations do not

preclude the integration of CBT and multicultural counseling. Instead, being aware

of these limitations “presents opportunities for rethinking, refi ning, adapting and

increasing the relevance and effectiveness of psychotherapy” (p. 356).

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Cognitive Behavior Therapy Applied to the Case of Stan

From a cognitive behavioral perspec-

he has accepted without questioning. Work-

tive, I want Stan to critically evaluate

ing with Stan as a collaborative partner in his

and modify his self-defeating beliefs,

therapy, I guide him in discovering some basic

which will likely result in Stan acquiring more

cognitions that influence what he tells himself

effective behavior. As his therapist, I am both

and how he feels and acts. This is some of his

goal oriented and problem focused. From the

self-talk:

initial session, I ask Stan to identify his prob-

• “I always have to be strong, tough, and perfect.”

lems and formulate specific goals and help him

• “I’m not a man if I show any signs of weakness.”

reconceptualize his problems in a way that will

• “If everyone didn’t love me and approve of me,

increase his chances of finding solutions.

things would be catastrophic.”

I follow a clear structure for every session.

318

The basic procedural sequence includes

• “If a woman rejected me, I really would be re-

(1) preparing him by providing a cognitive ration-

duced to a ‘nothing.’”

ale for treatment and demystifying treatment;

• “If I fail, I am then a failure as a person.”

(2) encouraging him to monitor the thoughts

• “I’m apologetic for my existence because

that accompany his distress; (3) implementing

I don’t feel equal to others.”

CHAPTER TEN

behavioral and cognitive techniques;

Second, I assist Stan in monitoring and evalu-

(4) assisting him in identifying and examining

ating the ways in which he keeps telling himself

some basic beliefs and ideas; (5) teaching him

these self-defeating sentences. I assist him in

ways to examine his beliefs and assumptions

clarifying specific problems and learning how to

by testing them in reality; and (6) teaching him

critically evaluate some of his faulty thinking:

basic coping skills that will enable him to avoid

You’re not your father. I wonder why you con-

relapsing into old patterns.

tinue telling yourself that you’re just like him? Do

As a part of the structure of the therapy

you think you need to continue accepting without

sessions, I ask Stan for a brief review of the

question your parents’ value judgments about your

week, elicit feedback from the previous session,

worth? Where is the evidence that they were right

review homework assignments, collaboratively

in their assessment of you? You say you’re such a

create an agenda for the session, discuss topics

failure and that you feel inferior. Do your present

on the agenda, and set new homework for the

activities support this? If you were not so hard on

week. I encourage Stan to perform personal

yourself, how might your life be different?

experiments and practice coping skills in daily life.

Third, once Stan more fully understands the

Stan tells me that he would like to work on

nature of his cognitive distortions and his self-

his fear of women and would hope to feel far

defeating beliefs, I draw on a variety of cognitive

less intimidated by them. He reports that he

and behavioral techniques to help Stan make

feels threatened by most women, but especially

the changes he most desires. Through various

by women he perceives as powerful. In work-

cognitive techniques, he learns to identify, evalu-

ing with Stan’s fears, I proceed with four steps:

ate, and respond to his dysfunctional beliefs.

educating him about his self-talk; having him

I rely heavily on cognitive techniques such as

monitor and evaluate his faulty beliefs; using

Socratic questioning, guided discovery, and cogni-

cognitive and behavioral interventions; and

tive restructuring to assist Stan in examining the

collaboratively designing homework with Stan

evidence that seems to support or contradict his

that will give him opportunities to practice new

core beliefs. I work with Stan so he will view his

behaviors in daily life.

basic beliefs and automatic thinking as hypoth-

First, I educate him about the importance of

eses to be tested. In a way, he will become a

examining his automatic thoughts, his self-talk,

personal scientist by checking out the validity of

and the many “shoulds,” “oughts,” and “musts”

many of the conclusions and basic assumptions

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that contribute to his personal difficulties. By the

Follow-Up: You Continue as Stan’s

use of guided discovery, Stan learns to evaluate

Cognitive Behavior Therapist

the validity and functionality of his beliefs and

Use these questions to help you think about

conclusions. Stan can also profit from cognitive

how to counsel Stan using a cognitive behavior

restructuring, which would entail his observ-

approach:

ing his own behavior in various situations. For

• My therapeutic style is characterized as an in-

example, during the week he can take a particu-

tegrative form of cognitive behavioral therapy.

lar situation that is problematic for him, paying

I borrow concepts and techniques from the

particular attention to his automatic thoughts

approaches of Ellis, Beck, and Meichenbaum.

and internal dialogue. What is he telling himself

In your work with Stan, what specific concepts

as he approaches a difficult situation? How is he

would you borrow from these approaches?

setting himself up for failure with his self-talk?

What cognitive behavioral techniques would

As he learns to attend to his maladaptive behav-

you use? What possible advantages do you

iors, he begins to see that what he tells himself

see, if any, in applying an integrative cognitive

319

has as much impact as others’ statements about

behavioral approach in your work with Stan?

C

OGNITIVE BEHA

him. He also sees the connections between his

• What are some things you would most want to

thinking and his behavioral problems. With this

teach Stan about how cognitive behavior ther-

awareness he is in an ideal place to begin to

apy works? How would you explain to him the

learn a new, more functional internal dialogue.

therapeutic alliance and the collaborative thera-

Fourth, I work collaboratively with him in

peutic relationship?

creating specific homework assignments to

VIOR THERAP

help him deal with his fears. It is expected

• What are some of Stan’s most prominent

that Stan will learn new coping skills, which he

faulty beliefs that get in the way of his living

can practice first in the sessions and then in

fully? What cognitive and behavioral tech-

daily life situations. It is not enough for him to

niques might you use in helping him examine

Y

merely say new things to himself; Stan needs to

his core beliefs?

apply his new cognitive and behavioral coping

• Stan lives by many “shoulds” and “oughts.”

skills in various daily situations. At one point,

His automatic thoughts seem to impede him

for instance, I ask Stan to explore his fears of

from getting what he wants. What techniques

powerful women and his reasons for continuing

would you use to encourage guided discovery

to tell himself: “They expect me to be strong and

on his part?

perfect. If I’m not careful, they’ll dominate me.”

• What are some homework assignments that

His homework includes approaching a woman

would be useful for Stan to carry out? How

for a date. If he succeeds in getting the date, he

would you collaboratively design homework

can think about his catastrophic expectations of

with Stan? How would you encourage him to

what might happen. What would be so terrible if

develop action plans to test the validity of his

she did not like him or if she refused the

thinking and his conclusions?

date? Stan tells himself over and over that he

must be approved of by women and that if any

See the DVD for Theory and Practice of

woman rebuffs him the consequences are more

Counseling and Psychotherapy: The Case

than he can bear. With practice, he learns to

of Stan and Lecturettes (Session 8 on cogni-

label distortions and is able to automatically

tive behavior therapy) for a demonstration

identify his dysfunctional thoughts and moni-

of my approach to counseling Stan from this

tor his cognitive patterns. Through a variety of

perspective. This session focuses on exploring

cognitive and behavioral strategies, he is able

some of Stan’s faulty beliefs through the use

to acquire new information, change his basic

of role-reversal and cognitive restructuring

beliefs, and implement new and more effective

techniques.

behavior.

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s u m m a r y a n d e va l u at i o n

Summary

REBT has evolved into a comprehensive and integrative approach that emphasizes

thinking, judging, deciding, and doing. This approach is based on the premise of

the interconnectedness of thinking, feeling, and behaving. Therapy begins with cli-

ents’ problematic behaviors and emotions and disputes the thoughts that directly

create them. To block the self-defeating beliefs that are reinforced by a process

of self-indoctrination, REBT therapists employ active and directive techniques

such as teaching, suggestion, persuasion, and homework assignments, and

they challenge clients to substitute a rational belief system for an irrational one.

Therapists demonstrate how and why dysfunctional beliefs lead to negative emo-

tional and behavioral results. They teach clients how to dispute self-defeating

320

beliefs and behaviors that might occur in the future. REBT stresses action—doing

something about the insights one gains in therapy. Change comes about mainly

by a commitment to consistently practice new behaviors that replace old and

ineffective ones.

Rational emotive behavior therapists are typically eclectic in selecting thera-

CHAPTER TEN

peutic strategies. They have the latitude to develop their own personal style and to

exercise creativity; they are not bound by fi xed techniques for particular problems.

Cognitive therapists also practice from an integrative stance, using many methods

to assist clients in modifying their self-talk. The working alliance is given special

importance in cognitive therapy as a way of forming a collaborative partnership.

Although the client–therapist relationship is viewed as necessary, it is not suffi -

cient for successful outcomes. In cognitive therapy, it is presumed that clients are

helped by the skillful use of a range of cognitive and behavioral interventions and

by their willingness to perform homework assignments between sessions.

All of the cognitive behavioral approaches stress the importance of cognitive proc-

esses as determinants of behavior. It is assumed that how people feel and what they

actually do is largely infl uenced by their subjective assessment and interpretation of

situations. Because this appraisal of life situations is infl uenced by beliefs, attitudes, as-

sumptions, and internal dialogue, such cognitions become the major focus of therapy.

Contributions of the Cognitive Behavioral Approaches

Most of the therapies discussed in this book can be considered “cognitive,” in a

general sense, because they have the aim of changing clients’ subjective views

of themselves and the world. The cognitive behavioral approaches focus on un-

dermining faulty assumptions and beliefs and teaching clients the coping skills

needed to deal with their problems. Both Ellis’s REBT and Beck’s CT represent

the most systematic applications of cognitive behavior therapy. Both REBT and CT

are based on a wide range of cognitive behavioral techniques and follow a defi ned

plan of action; they are relatively brief and structured treatments in keeping with

the spirit of cost effectiveness and evidence-based practice (Hollon & DiGiuseppe,

2011). The psychoeducational aspect of CBT is a clear strength that can be applied

to many clinical problems and used effectively in many settings with diverse client

populations.

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ellis’s rebt I fi nd aspects of REBT very valuable in my work because I be-

lieve we are responsible for maintaining self-destructive ideas and attitudes that

infl uence our daily transactions. I see value in asking clients questions such as

“What are your assumptions and basic beliefs?” and “Have you examined the

core ideas you live by to determine if they are your own values or merely in-

trojects?” REBT has built on the Adlerian notion that events themselves do not

have the power to determine us; rather, it is our interpretation of these events

that is crucial. The A-B-C framework simply and clearly illustrates how human

disturbances occur and the ways in which problematic behavior can be changed.

Rather than focusing on events themselves, therapy stresses how clients inter-

pret and react to what happens to them and the necessity of actively disputing a

range of faulty beliefs.

One of the strengths of REBT is the focus on teaching clients ways to carry on

321

their own therapy without the direct intervention of a therapist. I particularly like

C

OGNITIVE BEHA

the emphasis that REBT puts on supplementary and psychoeducational approaches

such as listening to tapes, reading self-help books, keeping a record of what they

are doing and thinking, carrying out homework assignments, and attending work-

shops. In this way clients can further the process of change in themselves without

becoming excessively dependent on a therapist.

VIOR THERAP

b e c k ’s c o g n i t i v e t h e r a p y Beck’s key concepts share similarities with

REBT, but differ in underlying philosophy, the process by which therapy proceeds,

and the formulation and treatment for different disorders. Beck made pioneering

Y

efforts in the treatment of anxiety, phobias, and depression. Today, empirically

validated treatments for both anxiety and depression have revolutionized thera-

peutic practice; research has demonstrated the effi cacy of cognitive therapy for a

variety of problems (Leahy, 2002; Scher, Segal, & Ingram, 2006). Beck developed

specifi c cognitive procedures to help depressive clients evaluate their assumptions

and beliefs and to create a new cognitive perspective that can lead to optimism

and changed behavior. The effects of cognitive therapy on depression and hope-

lessness have been demonstrated through research to be maintained for at least

one year after treatment. Cognitive therapy has been applied to a wide range of

clinical populations that Beck did not originally believe were appropriate for this

model, including treatment for posttraumatic stress disorder, schizophrenia, delu-

sional disorders, bipolar disorder, and various personality disorders (Leahy, 2002,

2006a). The credibility of the cognitive model grows out of the fact that many of

its propositions have been empirically tested.

Beck demonstrated that a structured therapy that is present centered and

problem oriented can be very effective in treating depression and anxiety in a

relatively short time. One of Beck’s major theoretical contributions has been

bringing private experience back into the realm of legitimate scientifi c inquiry

(Weishaar, 1993). A strength of cognitive therapy is its focus on developing a

detailed case conceptualization as a way to understand how clients view their

world.

A key strength of all the cognitive behavioral therapies is that they are integra-

tive forms of psychotherapy, and this is particularly true of cognitive therapy. Beck

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considers cognitive therapy to be the integrative psychotherapy because it draws

from so many different modalities of psychotherapy (Alford & Beck, 1997).

m e i c h e n b a u m ’s c o g n i t i v e b e h a v i o r m o d i f i c at i o n Meichen-

baum’s work in self-instruction and stress inoculation training has been applied

successfully to a variety of client populations and specifi c problems. Of special note

is his contribution to understanding how stress is largely self-induced through

inner dialogue. Meichenbaum’s integration of the constructivist perspective is a

key strength in that he is able to combine elements of the postmodern interest in

stories clients tell with assisting clients in changing their cognitions, feelings, and

behaviors by drawing on a cognitive behavioral conceptual framework.

A contribution of all of the cognitive behavioral approaches is the emphasis on

putting newly acquired insights into action. Homework assignments are well suited

322

to enabling clients to practice new behaviors and assisting them in the process of

learning more effective coping skills. Adlerian therapy, reality therapy, behavior

therapy, and solution-focused brief therapy all share with the cognitive behavioral

approaches this action orientation. It is important that homework be a natural out-

growth of what is taking place in the therapy session. Clients are more likely to carry

CHAPTER TEN

out their homework if the assignments are collaboratively created. Meichenbaum’s

stress inoculation training places special emphasis on practicing new skills both in

the training itself and in daily life, and homework is a key part of the training proc-

ess. Clients learn how to generalize coping skills to various problem situations and

acquire relapse prevention strategies to ensure that their gains are consolidated.

A major contribution made by Ellis, the Becks, and Meichenbaum is the de-

mystifi cation of the therapy process. The cognitive behavioral approaches are

based on an educational model that stresses a working alliance between therapist

and client. The models encourage self-help, provide for continuous feedback from

the client on how well treatment strategies are working, and provide a structure

and direction to the therapy process that allows for evaluation of outcomes. Clients

are active, informed, and responsible for the direction of therapy because they are

partners in the enterprise.

Limitations and Criticisms of the Cognitive

Behavioral Approaches

The cognitive behavioral approaches focus only limited attention on the role of

emotions in treatment. Although Dattilio (2001) admits that CBT places central

emphasis on cognition and behavior, he maintains that emotion is not ignored in

the therapy process; rather, he believes that emotion is a by-product of cognition

and behavior and is addressed in a different fashion. Some potential limitations of

the various CBT approaches follow.

e l l i s ’s r e b t I value paying attention to a client’s past without getting lost in

this past and without assuming a fatalistic stance about earlier traumatic experi-

ences. I question the REBT assumption that exploring the past is ineffective in

helping clients change faulty thinking and behavior. From my perspective, explor-

ing past childhood experiences can have a great deal of therapeutic power if the

discussion is connected to our present functioning.

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Another potential limitation involves the misuse of the therapist’s power

by imposing ideas of what constitutes rational thinking. Due to the active and

directive nature of this approach, it is particularly important for practitioners

to know themselves well and to avoid imposing their own philosophy of life on

their clients. Because the therapist has a large amount of power by virtue of

persuasion, psychological harm is more possible in REBT than in less directive

approaches.

As Ellis practiced it, REBT is a forceful and confrontational therapy. Some

clients will have trouble with a confrontational style, especially if a strong ther-

apeutic alliance has not been established. It is well to underscore that REBT

can be effective when practiced in a style different from Ellis’s. Indeed, a thera-

pist can be soft-spoken and gentle and still use REBT concepts and methods

effectively. Janet Wolfe, who has supervised hundreds of practitioners in her

323

30 years at the Albert Ellis Institute, makes the point that therapists do not

C

OGNITIVE BEHA

need to emulate Ellis’s style to effectively incorporate REBT into their own rep-

ertoire of interventions. Wolfe (2007) encourages practitioners to embrace this

useful therapy approach, but to develop a style that is consistent with their own

personality.

For practitioners who value a spiritual dimension of psychotherapy, Ellis’s views

VIOR THERAP

on religion and spirituality are likely to raise some problems. Historically, Ellis has

declared himself as an atheist and has long been critical of dogmatic religions that

instill guilt in people. Ellis (2004b) has written about the core philosophies that

can either improve our mental health or can lead to disturbances. Although his

Y

tone softened over the years, he was still critical of any philosophies that promoted

rigid beliefs. Personally, I think that a spiritual and a religious orientation can be

incorporated into the practice of REBT if this is meaningful to the client and if

this is done in a thoughtful manner by the therapist. Throughout his life, Ellis was

driven by his passion to teach people about REBT, and he always chuckled when

he said in his workshops that his mission was to spread the gospel according to

St. Albert. Indeed, I would say that his “religion” is embodied in the principles and

practices of REBT. For more on this topic, see The Road to Tolerance (Ellis, 2004b).

b e c k ’s c o g n i t i v e t h e r a p y Cognitive therapy has been criticized for fo-

cusing too much on the power of positive thinking; being too superfi cial and sim-

plistic; denying the importance of the client’s past; being too technique oriented;

failing to use the therapeutic relationship; working only on eliminating symptoms,

but failing to explore the underlying causes of diffi culties; ignoring the role of un-

conscious factors; and neglecting the role of feelings (Freeman & Dattilio, 1992;

Weishaar, 1993).

Freeman and Dattilio (1992, 1994; Dattilio, 2001) do a good job of debunking

the myths and misconceptions about cognitive therapy. Weishaar (1993) concisely

addresses a number of criticisms leveled at the approach. Although the cognitive

therapist is straightforward and looks for simple rather than complex solutions,

this does not imply that the practice of cognitive therapy is simple. Cognitive thera-

pists do not explore the unconscious or underlying confl icts but work with cli-

ents in the present to bring about changes in their core beliefs. However, they do

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recognize that clients’ current problems are often a product of earlier life experi-

ences, and thus, they may explore with clients, especially those with Axis II disor-

ders, the ways their past is presently infl uencing them.

m e i c h e n b a u m ’s c o g n i t i v e b e h a v i o r m o d i f i c at i o n Some

practitioners who apply stress inoculation training focus more on techniques to

change a client’s reaction to stress or pay too much attention to the client’s inter-

nal dialogue. Meichenbaum is a high-energy person and is very charismatic in his

workshop presentations. I suspect that much of the success of his approach has to

do with his level of caring and his creativity in implementing CBT interventions.

Practitioners without his wit, energy, personal fl air, and direct therapeutic style

may not get the same results even though they follow his treatment protocol. This

emphasizes the importance of each therapist developing his or her own unique

324

therapeutic style. Meichenbaum (1986) cautions cognitive behavioral practitioners

against the tendency to become overly preoccupied with techniques. If progress

is to be made, he suggests that cognitive behavior therapy must develop a test-

able theory of behavior change. He reports that some attempts have been made to

formulate a cognitive social learning theory that will explain behavior change and

CHAPTER TEN

specify the best methods of intervention.

A potential limitation of any of the cognitive behavioral approaches is the

therapist’s level of personal development, training, knowledge, skill, and percep-

tiveness. Although this is true of all therapeutic approaches, it is especially true

for CBT practitioners because they tend to be active, highly structured, and offer

clients psychoeducational information and teach life skills. According to Judith

Beck (personal communication, May 27, 2011), a limitation in learning cognitive

therapy is that therapists need to learn the specifi c cognitive formulation for each

disorder they treat and learn how to address the key cognitions and behavioral

strategies for each disorder. Macy (2007) stresses that the effective use of cogni-

tive behavior therapy interventions requires extensive study, training, and practice:

“Effective implementation of these interventions requires that the practitioner be

fully grounded in the therapy’s theory and premises, and be able to use a range of

associated techniques and interventions” (p. 159).

w h e r e t o g o f r o m h e r e

In the DVD for Integrative Counseling: The Case of Ruth and Lecturettes, I work with Ruth

from a cognitive behavioral perspective in a number of therapy sessions. In Sessions

6, 7, and 8, I demonstrate my way of working with Ruth from a cognitive, emotive, and

behavioral focus. See also Session 9 (“Integrative Perspective”), which illustrates the

interactive nature of working with Ruth on thinking, feeling, and doing levels.

Other Resources

DVDs relevant to this chapter offered by the American Psychological Association

from their Systems of Psychotherapy Video Series include the following:

Beck, J. (2005). Cognitive Therapy

Meichenbaum, D. (2007). Cognitive Behavioral Therapy With Donald

Meichenbaum

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch10_rev01.indd 324

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Vernon, A. (2010). Rational Emotive Behavior Therapy Over Time

Dobson, K. S. (2010). Cognitive Therapy Over Time

Persons, J. (2006). Cognitive-Behavior Therapy

Dobson, K. S. (2008). Cognitive-Behavioral Therapy for Perfectionism Over Time

Dobson, K. S. (2011). Cognitive-Behavioral Therapy Strategies

Psychotherapy.net is a comprehensive resource for students and professionals that

offers videos and interviews on cognitive behavior therapy. New video and editorial

content is made available monthly. DVDs relevant to this chapter are available at

www.psychotherapy.net and include the following:

Beck, J. (2010). Cognitive Therapy for Weight Loss: A Coaching Session

Ellis, A. (1996). Rational-Emotive Therapy for Addictions

Ellis, A. (1996). Coping With the Suicide of a Loved One: An REBT

325

Approach

C

OGNITIVE BEHA

Freeman, A. (1994). Depression: A Cognitive Therapy Approach

Krumboltz, J. (1997). Cognitive-Behavioral Therapy With John Krumboltz

(Psychotherapy With the Experts Series)

Lazarus, A. (1997). Multimodal Therapy (Psychotherapy With the Experts

Series)

VIOR THERAP

Liese, B. (2000). Cognitive Therapy for Addictions (Brief Therapy for

Addictions Series)

Masek, B. (2002). Cognitive-Behavioral Child Therapy (Child Therapy

With the Experts Series)

Y

Meichenbaum, D. (1996). Mixed Anxiety and Depression: A Cognitive-

Behavioral Approach

Meichenbaum, D. (2000). Cognitive-Behavioral Therapy With Donald

Meichenbaum (Psychotherapy With the Experts Series)

The Journal of Rational-Emotive and Cognitive-Behavior Therapy is published by

Kluwer Academic/Human Sciences Press. This quarterly journal is an excellent

way to keep informed of a wide variety of cognitive behavioral specialists.

For information about the work of Albert Ellis, and current training oppor-

tunities, contact:

Debbie Joffe

Telephone: (917) 887-2006

Website: www.rebtnetwork.org/

The International Journal of Cognitive Therapy, edited by John Riskind, also pro-

vides information on theory, practice, and research in cognitive behavior therapy.

Information about the journal is available from the International Association of

Cognitive Psychotherapy or by contacting John Riskind directly.

Dr. John Riskind

George Mason University

Department of Psychology, MSN 3F5

Fairfax, VA 22030-4444

Telephone: (703) 993-4094

Private Practice Telephone: (703) 280-8060

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28549_ch10_rev01.indd 325

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Fax: (703) 993-1359

E-mail: jriskind@gmu.edu

Website: www.the-iacp.com

The Center for Cognitive Therapy, Newport Beach, California, maintains a website

for mental health professionals. They list cognitive therapy books, audio and video

training tapes, current advanced training workshops, and other cognitive therapy

resources and information.

Center for Cognitive Therapy

E-mail: mooney@padesky.com

Website: http://www.padesky.com

For more information about CBT workshops, supervision, a CBT blog, and news-

326

letter, contact the Beck Institute.

Beck Institute for Cognitive Behavior Therapy

One Belmont Avenue, Suite 700

Bala Cynwyd, PA 19004-1610

Telephone: (610) 664-3020

Fax: (610) 709-5336

CHAPTER TEN

E-mail: info@beckinstitute.org

Website: www.beckinstitute.org

The “home” organization for cognitive therapists worldwide is the Academy of Cogni-

tive Therapy, which Judith S. Beck was instrumental in founding.

Academy of Cognitive Therapy

Website: www.academyofct.org

The American Institute for Cognitive Therapy is an internationally recognized group

of clinical psychologists and psychotherapists who provide the highest quality cogni-

tive behavioral treatment for depression, anxiety, phobias, eating disorders, person-

ality disorders, child and adolescent problems, and family and marital problems.

American Institute for Cognitive Therapy

Robert L. Leahy, PhD

136 E 57th St., Suite 1101

New York, NY 10022

Telephone: (212) 308-2440

Fax: (212) 308-3099

E-mail: AICT@aol.com

Website: www.cognitivetherapynyc.com

Donald Meichenbaum is research director of the Melissa Institute for Violence

Prevention, a nonprofi t organization designed to “give science away” in order to

reduce violence and to treat victims of violence. The institute is dedicated to the

study and prevention of violence through education, community service, research

support, and consultation.

Melissa Institute for Violence Prevention

Website: www.melissainstitute.org

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Recommended Supplementary Readings

Rational Emotive Behavior Therapy: It Works for Me—It Can Work for You

(Ellis, 2004a) is a personal book that describes the many challenges Ellis has faced

in his life and how he has coped with these realities by applying REBT principles.

The Road to Tolerance: The Philosophy of Rational Emotive Behavior Therapy

(Ellis, 2004b) is a companion book to the book listed above. In this book Ellis

demonstrates that tolerance is a deliberate, rational choice that we can make, both

for the good of ourselves and for others.

Cognitive Behavior Therapy: Basics and Beyond (J. Beck, 2011a) is a main text in

cognitive therapy that presents a comprehensive overview of the approach. An

earlier edition of this book was translated into 20 languages.

327

C

OGNITIVE BEHA

Cognitive Therapy for Challenging Problems (J. Beck, 2005) is a comprehensive

account of cognitive therapy procedures applied to clients who present a multi-

plicity of diffi cult behaviors. It covers the nuts and bolts of cognitive therapy with

various populations and cites important research on cognitive therapy since its

inception. There are chapters dealing with topics such as the therapeutic alliance,

VIOR THERAP

setting goals, structuring sessions, homework, identifying cognitions, modifying

thoughts and images, modifying assumptions, and modifying core beliefs.

Cognitive Behavior Therapy: Applying Empirically Supported Techniques in Your Prac-

tice (O’Donohue & Fisher, 2008) is a useful collection of short chapters on applying

Y

empirically supported techniques in working with a wide range of presenting prob-

lems. Most of these chapters can be applied to both individual and group therapy.

Mind Over Mood: Change How You Feel by Changing the Way You Think

(Greenberger & Padesky, 1995) provides step-by-step worksheets to identify

moods, solve problems, and test thoughts related to depression, anxiety, anger,

guilt, and shame. This is a popular self-help workbook and a valuable tool for

therapists and clients learning cognitive therapy skills.

Clinician’s Guide to Mind Over Mood (Padesky & Greenberger, 1995) shows

therapists how to integrate Mind Over Mood in therapy and use cognitive therapy

treatment protocols for specifi c diagnoses. This succinct overview of cognitive

therapy has troubleshooting guides, reviews cultural issues, and offers guidelines

for individual, couples, and group therapy.

References and Suggested Readings

*Alford, B. A., & Beck, A. T. (1997). The inte-

D. K. Freedheim (Ed.), History of psychotherapy:

grative power of cognitive therapy. New York:

A century of change (pp. 657–694). Washing-

Guilford Press.

ton, DC: American Psychological Association.

Arnkoff, D. B., & Glass, C. R. (1992). Cognitive

Beck, A. T. (1963). Thinking and depression:

therapy and psychotherapy integration. In

Idiosyncratic content and cognitive

*Books and articles marked with an asterisk are suggested for further study.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch10_rev01.indd 327

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distortions. Archives of General Psychiatry,

*Bond, F., & Flaxman, P. (2010). Acceptance

9, 324–333.

and commitment therapy: Distinctive features.

New York: Routledge (Taylor & Francis Group).

Beck, A. T. (1967). Depression: Clinical,

experimental, and theoretical aspects. New York:

*Burns, D. (1988). Feeling good: The new mood

Harper & Row. (Republished as Depression:

therapy. New York: Signet.

Causes and treatment. Philadelphia: University

Burns, D. (1989). The feeling good handbook.

of Pennsylvania Press, 1972)

New York: Morrow.

*Beck, A. T. (1976). Cognitive therapy and

Chambless, D. L., & Peterman, M. (2006).

emotional disorders. New York: International

Evidence on cognitive-behavioral therapy

Universities Press.

for generalized anxiety disorder and panic

Beck, A. T. (1987). Cognitive therapy. In J. K.

disorder. In R. L. Leahy (Ed.), Contemporary

Zeig (Ed.), The evolution of psychotherapy

cognitive therapy: Theory, research, and practice

(pp. 149–178). New York: Brunner/

(pp. 86–115). New York: Guilford Press.

328

Mazel.

*Corey, G. (2012). Theory and practice of group

*Beck, A. T., Rush, A., Shaw, B., & Emery, G.

counseling (8th ed.). Belmont, CA: Brooks/

(1979). Cognitive therapy of depression.

Cole, Cengage Learning.

New York: Guilford Press.

*Corey, G. (2013a). Case approach to counseling

*Beck, A. T., & Weishaar, M. E. (2011). Cogni-

and psychotherapy (8th ed.). Belmont, CA:

CHAPTER TEN

tive therapy. In R. J. Corsini & D. Wedding

Brooks/Cole, Cengage Learning.

(Eds.), Current psychotherapies (9th ed.,

Corey, G. (2013b). Student manual for Theory and

pp. 276–309). Belmont, CA: Brooks/Cole,

Practice of Counseling and Psychotherapy (9th ed.).

Cengage Learning.

Belmont, CA: Brooks/Cole, Cengage Learning.

Beck, A., Wright, E. D., Newman, C. E., &

*Cormier, S., Nurius, P. S., & Osborn, C. J.

Liese, B. (1993). Cognitive therapy of substance

(2013). Interviewing and change strategies

abuse. New York: Guilford Press.

for helpers: Fundamental skills and cognitive

*Beck, J. S. (2005). Cognitive therapy for chal-

behavioral interventions (7th ed.). Belmont, CA:

lenging problems: What to do when the basics

Brooks/Cole, Cengage Learning.

don’t work. New York: Guilford Press.

*Crane, R. (2008). Mindfulness-based cogni-

Beck, J. S. (2007a). The Beck diet solution: Train

tive therapy: Distinctive features. New York:

your brain to think like a thin person. New York:

Routledge (Taylor & Francis Group).

Oxmoor House.

*Craske, M. G. (2010). Cognitive-behavioral

Beck, J. S. (2007b). Beck diet solution weight

therapy. Washington, DC: American Psycho-

loss workbook. New York: Oxmoor House.

logical Association.

Beck, J. S. (2008). The complete Beck diet for

*Dattilio, F. M. (1993). Cognitive techniques

life. New York: Oxmoor House.

with couples and families. The Family Journal,

1(1), 51–65.

*Beck, J. S. (2011a). Cognitive behavior therapy:

Basics and beyond (2nd ed.). New York:

*Dattilio, F. M. (Ed.). (1998). Case studies in

Guilford Press.

couple and family therapy: Systemic and cogni-

tive perspectives. New York: Guilford Press.

*Beck, J. S. (2011b). Cognitive therapy worksheet

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CHAPTER TEN

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c h a p t e r 1 1

Reality Therapy

i n t r o d u c t i o n

• The “WDEP” System

• Application to Group Counseling

k e y c o n c e p t s

r e a l i t y t h e r a p y f r o m a

• View of Human Nature

m u lt i c u lt u r a l p e r s p e c t i v e

• Choice Theory Explanation of Behavior

• Characteristics of Reality Therapy

• Strengths From a Diversity Perspective

• Shortcomings From a Diversity Perspective

t h e t h e r a p e u t i c p r o c e s s

r e a l i t y t h e r a p y a p p l i e d t o t h e

• Therapeutic Goals

c a s e o f s ta n

• Therapist’s Function and Role

• Client’s Experience in Therapy

s u m m a ry a n d e va l u at i o n

• Relationship Between Therapist

• Summary

and Client

• Contributions of Reality Therapy

a p p l i c at i o n : t h e r a p e u t i c

• Limitations and Criticisms of Reality Therapy

t e c h n i q u e s a n d p r o c e d u r e s

w h e r e t o g o f r o m h e r e

•

• The Practice of Reality Therapy

The Practice of

• Recommended Supplementary Readings

•

• The Counseling Environment

The Counseling

• References and Suggested Readings

•

• Procedures That Lead to Change

Pro

333

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William Glasser / Robert E. Wubbolding

WILLIAM GLASSER

the audience. Most of those attending were educators,

(b. 1925), currently retired, was

social workers, counselors, and correctional workers,

educated at Case Western

so Glasser changed the name of his system to “reality

Institute,

Reserve University in Cleve-

therapy,” which became the title of his groundbreaking

Glasser

land, Ohio. Initially a chemical

book published in 1965. Educators found the principles

William

engineer, he turned to psychol-

of reality therapy helpful, and he was asked to apply

The

CA

ogy (MA, Clinical Psychology,

it to the classroom and the school as an organiza-

of

1948) and then to psychiatry,

tion. As a result of this experience, he wrote Schools

Courtesy

Chatsworth,

attending medical school

Without Failure in 1968, which had a major impact on

(MD, 1953) with the intention of becoming a psychia-

the administration of schools, the training of teachers,

trist. By 1957 he had completed his psychiatric training

and the way learning is conducted in schools. Glasser

334

at the Veterans Administration and UCLA in Los

took the position that schools needed to be structured

Angeles and in 1961 was board certified in psychiatry.

in ways to help students achieve a success identity as

Glasser was married to Naomi for 47 years, and

opposed to a failure identity. He advocated for a

she was very involved with the William Glasser Insti-

curriculum geared to the lives of learners. Glasser

tute until her death in 1992. In 1995 Glasser married

made significant contributions through in-service

Carleen, who is an instructor at the institute. Glasser

workshops for teachers and administrators. Since the

played tennis often until recently, and now, at age 86,

late 1960s, reality therapy has been further applied

CHAPTER ELEVEN

he enjoys watching basketball on television.

to education and to virtually all other human relation-

Very early Glasser rejected the Freudian model,

ships, especially intimate relationships.

partly due to his observation of psychoanalytically

Glasser became convinced that it was of

trained therapists who did not seem to be imple-

paramount importance that clients accept personal

menting Freudian principles. Rather, they tended to

responsibility for their behavior. By the early 1980s,

hold people responsible for their behavior. Early in

Glasser was looking for a theory that could explain

his career, Glasser was a psychiatrist at the Ventura

all his work. Glasser learned about control theory

School, a prison and school for girls operated by the

from William Powers, and he believed this theory

California Youth Authority. He became convinced

had great potential. He spent the next 10 years ex-

that his psychoanalytic training was of limited utility

panding, revising, and clarifying what he was initially

in counseling these young people. From these obser-

taught. By 1996 Glasser had become convinced that

vations, Glasser thought it best to talk to the sane

these revisions had so changed the theory that it

part of clients, not their disturbed side. Glasser was

was misleading to continue to call it control theory,

also influenced by G. L. Harrington, a psychiatrist and

and he changed the name to choice theory to reflect

mentor. Harrington believed in getting his patients

all that he had developed. The essence of reality

involved in projects in the real world, and by the end

therapy, now taught all over the world, is that we

of his residency Glasser began to put together ideas

are all responsible for what we choose to do. We

that would later be known as reality therapy.

are internally motivated by current needs and

In 1962 Glasser began to present public lectures

wants, and we control our present behavioral

on “reality psychiatry,” but few psychiatrists were in

choices.

ROBERT E. WUBBOLD-

professional organizations, and has licenses as a

ING, EdD (b. 1936), born

counselor and as a psychologist. He taught high

and raised in Cincinnati,

school history, worked as a high school and ele-

Ohio, is the youngest of six

mentary school counselor, and served as a consult-

children. He received his

ant to drug and alcohol abuse programs of the U.S.

WubboldingE.

doctorate in counseling from

Army and Air Force. In addition, Bob Wubbolding

Robert

the University of Cincinnati,

began a career in the Catholic priesthood but later

of

is a member of several

“left the clergy freely and honorably.” He is married

Courtesy

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28549_ch11_rev01.indd 334

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to Sandra Trifilio, a former French teacher, who

fulfilling his lifelong desire to travel and to live in

shares his passion for his work and is administrator

other countries. He has become an internationally

of the Center for Reality Therapy, as well as editor

known teacher, author, and practitioner of real-

of his writings.

ity therapy and has introduced choice theory and

He is now the director of the Center for Reality

reality therapy in Europe, Asia, and the Middle

Therapy in Cincinnati and professor emeritus of

East. Among his specialties is adapting choice

Xavier University, where he taught counselor edu-

theory and reality therapy to various cultures and

cation for 32 years. He loved teaching and viewed

ethnic groups. He received the Gratitude Award

his students as being highly motivated, eager to

(2009) for Initiating Reality Therapy in the United

learn, and experienced. One of his most meaningful

Kingdom and the Certificate of Reality Therapy

experiences was teaching graduate students in the

Psychotherapist by the European Association for

counseling department at Xavier University.

Psychotherapy (2009).

After completing his doctorate, Wubbolding

Wubbolding has extended the theory and

attended training sessions representing a wide

practice of reality therapy with his conceptualiza-

335

range of counseling approaches, yet he found

tion of the WDEP system, which is described later

REALITY THERAP

reality therapy to be best suited to his interests.

in the chapter. He has written 11 books and more

He attended many intensive training workshops

than 145 articles, essays, and chapters in textbooks

conducted by William Glasser in Los Angeles, and

as well as preparing 12 videos/DVDs, some of

in 1988 Glasser appointed him director of training

which are referenced in this chapter. His religious

for the William Glasser Institute.

commitment and his life of service to others are

Y

Wubbolding served as visiting professor at the

apparent in his work, and he continues his voca-

University of Southern California in their overseas

tion of teacher, counselor, psychologist, and active

programs in Japan, Korea, and Germany, thus

member of his church.

i n t r o d u c t i o n

Reality therapists believe the underlying problem of most clients is the same: they

are either involved in a present unsatisfying relationship or lack what could even

be called a relationship. Many of the problems of clients are caused by their inabil-

ity to connect, to get close to others, or to have a satisfying or successful relation-

ship with at least one signifi cant person in their lives. The therapist guides clients

toward a satisfying relationship and teaches them more effective ways of behaving.

The more clients are able to connect with people, the greater chance they have to

experience happiness.

Few clients understand that their problem, which is unhappiness, results from

the way they are choosing to behave. What they do know is that they feel a great

deal of pain or that they are unhappy because they have been sent for counseling

by someone with authority who is not satisfi ed with their behavior—typically a

court offi cial, a school administrator, an employer, a spouse, or a parent. Reality

therapists recognize that clients choose their behaviors as a way to deal with the

frustrations caused by unsatisfying relationships.

Glasser (2003) contends that clients should not be labeled with a diagnosis

except when it is necessary for insurance purposes. From Glasser’s perspective,

diagnoses are descriptions of the behaviors people choose in their attempt to deal

with the pain and frustration that is endemic to their unsatisfying present relation-

ships. Labeling these ineffective behaviors as mental illness is inaccurate. Glasser

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believes mental illnesses are conditions such as Alzheimer’s disease, epilepsy, head

trauma, and brain infections—conditions associated with tangible brain damage.

Because these people are suffering from a brain abnormality, he contends they

should be treated primarily by neurologists.

Reality therapy is based on choice theory as it is explained in several of Glasser’s

(1998, 2001, 2003) books. (In this chapter, the discussion of Glasser’s ideas pertains

to these three books, unless otherwise specifi ed.) Choice theory is the theoretical

basis for reality therapy; it explains why and how we function. Reality therapy pro-

vides a delivery system for helping individuals take more effective control of their

lives. If choice theory is the highway, reality therapy is the vehicle delivering the

product (Wubbolding, 2011a). Therapy consists mainly of helping and sometimes

teaching clients to make more effective choices as they deal with the people they

336

need in their lives. Glasser maintains that it is essential for the therapist to estab-

lish a satisfying relationship with clients as a prerequisite for effective therapy.

Once this relationship is developed, the skill of the therapist as a teacher assumes

a central role.

Reality therapy has been used in a variety of settings. The approach is appli-

cable to counseling, social work, education, crisis intervention, corrections and

rehabilitation, institutional management, and community development. Reality

CHAPTER ELEVEN

therapy is popular in schools, general hospitals, state mental hospitals, halfway

houses, and alcohol and drug abuse centers. Many of the military clinics that treat

substance abusers use reality therapy as their preferred therapeutic approach.

See the video program for Chapter 11, DVD for Theory and Practice of Counseling

and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the

brief lecture for each chapter prior to reading the chapter.

k e y c o n c e p t s

View of Human Nature

Choice theory posits that we are not born blank slates waiting to be externally mo-

tivated by forces in the world around us. Rather, we are born with fi ve genetically

encoded needs that drive us all our lives: survival, or self-preservation ; love and

belonging; power, or inner control ; freedom, or independence ; and fun, or enjoyment.

Each of us has all fi ve needs, but they vary in strength. For example, we all have a

need for love and belonging, but some of us need more love than others. Choice

theory is based on the premise that because we are by nature social creatures

we need to both receive and give love. Glasser (2001, 2005) believes the need to

love and to belong is the primary need because we need people to satisfy the other

needs. It is also the most diffi cult need to satisfy because we must have a coopera-

tive person to help us meet it.

Our brain functions as a control system. It continually monitors our feelings

to determine how well we are doing in our lifelong effort to satisfy these needs.

Whenever we feel bad, one or more of these fi ve needs is unsatisfi ed. Although

we may not be aware of our needs, we know that we want to feel better. Driven by

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pain, we try to fi gure out how to feel better. Reality therapists teach clients choice

theory, sometimes subtly and indirectly, so clients can identify unmet needs and

try to satisfy them.

Choice theory teaches that we do not satisfy our needs directly. What we do,

beginning shortly after birth and continuing all our lives, is to keep close track of

anything we do that feels very good. We store information inside our minds and

build a fi le of wants, called our quality world, which is at the core of our life. It is

our personal Shangri-la—the world we would like to live in if we could. It is com-

pletely based on our wants and needs, but unlike the needs, which are general,

it is very specifi c. The quality world consists of specifi c images of people, activi-

ties, events, beliefs, possessions, and situations that fulfi ll our needs (Wubbolding,

2000, 2011a). Our quality world is like a picture album. We develop an inner

picture album of specifi c wants as well as precise ways to satisfy these wants. We

337

are attempting to behave in a way that gives us the most effective control over our

REALITY THERAP

lives. Some pictures may be blurred, and the therapist’s role is to help the client

clarify them. Pictures exist in priority for most people, yet clients may have dif-

fi culty identifying their priorities. Part of the process of reality therapy is assisting

clients in prioritizing their wants and uncovering what is most important to them

(Wubbolding, 2011a).

Y

People are the most important component of our quality world, and these are

the people we most want to connect with. It contains the people we are closest to

and most enjoy being with. Those who enter therapy generally have no one in their

quality world or, more often, someone in their quality world that they are unable

to relate to in a satisfying way. For therapy to have a chance of success, a therapist

must be the kind of person that clients would consider putting in their quality

world. Getting into the clients’ quality world is the art of therapy. It is from this

relationship with the therapist that clients begin to learn how to get close to the

people they need.

Choice Theory Explanation of Behavior

Choice theory explains that all we ever do from birth to death is behave and, with

rare exceptions, everything we do is chosen. Every total behavior is our best at-

tempt to get what we want to satisfy our needs. Total behavior teaches that all

behavior is made up of four inseparable but distinct components— acting, thinking,

feeling, and physiology—that necessarily accompany all of our actions, thoughts,

and feelings. Choice theory emphasizes thinking and acting, which makes this a

general form of cognitive behavior therapy. The primary emphasis is on what the

client is doing on and how the doing component infl uences the other aspects of to-

tal behavior. Behavior is purposeful because it is designed to close the gap between

what we want and what we perceive we are getting. Specifi c behaviors are always

generated from this discrepancy. Our behaviors come from the inside, and thus

we choose our destiny.

Glasser says that to speak of being depressed, having a headache, being angry,

or being anxious implies passivity and lack of personal responsibility, and it is in-

accurate. It is more accurate to think of these as parts of total behaviors and to use

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the verb forms depressing, headaching, angering, and anxietying to describe them. It

is more accurate to think of people depressing or angering themselves rather than

being depressed or being angry. When people choose misery by developing a range

of “paining” behaviors, it is because these are the best behaviors they are able to

devise at the time, and these behaviors often get them what they want.

When a reality therapist starts teaching choice theory, the client will often pro-

test and say, “I’m suffering; don’t tell me I’m choosing to suffer like this.” As

painful as depressing is, the therapist explains that people do not choose pain and

suffering directly; rather, it is an unchosen part of their total behavior. The behavior

of the person is the best effort, ineffective as it is, to satisfy needs.

Robert Wubbolding (personal communication, September 7, 2010) has added a

new idea to choice theory. He believes that behavior is a language, and that we send

338

messages by what we are doing. The purpose of behavior is to infl uence the world

to get what we want. Therapists ask clients what messages they are sending to the

world by way of their actions: “What message do you want others to get?” “What

message are others getting whether or not you intended to send them?” By consid-

ering the messages that clients send to others, counselors can help clients indirectly

gain a greater appreciation of messages they unintentionally send to others.

CHAPTER ELEVEN

Characteristics of Reality Therapy

Contemporary reality therapy focuses quickly on the unsatisfying relationship or

the lack of a relationship, which is often the cause of clients’ problems. Glasser has

given increasing attention to the role of meaningful relationships in fostering emo-

tional health. Clients may complain of a problem such as not being able to keep

a job, not doing well in school, or not having a meaningful relationship. When

clients complain about how other people are causing them pain, the therapist does

not get involved with fi nding fault. Reality therapists ask clients to consider how

effective their choices are, especially as these choices affect their relationships with

signifi cant people in their lives. Choice theory teaches that talking about what cli-

ents cannot control is of minimal value; the emphasis is on what clients can control

in their relationships. The basic axiom of choice theory, which is crucial for clients

to understand, is this: “The only person you can control is yourself.” Two books

devoted to how choice theory can help people deal with their relationship problems

and enhance their relationships are Getting Together and Staying Together (Glasser &

Glasser, 2000) and Eight Lessons for a Happier Marriage (Glasser & Glasser, 2007).

Reality therapists do not listen very long to complaining, blaming, and criti-

cizing, for these are the most ineffective behaviors in our behavioral repertoire.

Because reality therapists give little attention to these self-defeating total behaviors,

Glasser maintains that they tend to disappear from therapy. What do reality thera-

pists focus on? Here are some underlying characteristics of reality therapy.

e m p h a s i z e c h o i c e a n d r e s p o n s i b i l i t y If we choose all we do, we

must be responsible for what we choose. This does not mean we should be blamed

or punished, unless we break the law, but it does mean the therapist should never

lose sight of the fact that clients are responsible for what they do. Choice theory

changes the focus of responsibility to choice and choosing.

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Reality therapists deal with people “as if” they have choices. Therapists focus

on those areas where clients have choice, for doing so gets them closer to the peo-

ple they need. For example, being involved in meaningful activities, such as work,

is a good way to gain the respect of other people, and work can help clients fulfi ll

their need for power. It is very diffi cult for adults to feel good about themselves

if they don’t engage in some form of meaningful activity. As clients begin to feel

good about themselves, it is less necessary for them to continue to choose ineffec-

tive and self-destructive behaviors.

r e j e c t t r a n s f e r e n c e Reality therapists strive to be themselves in their

professional work. By being themselves, therapists can use the relationship to

teach clients how to relate to others in their lives. Glasser contends that transfer-

ence is a way that both therapist and client avoid being who they are and owning

339

what they are doing right now. It is unrealistic for therapists to go along with the

REALITY THERAP

idea that they are anyone but themselves. Assume the client claims, “I see you as

my father or mother and this is why I’m behaving the way I am.” In such a situ-

ation a reality therapist is likely to say clearly and fi rmly, “I am not your mother,

father, or anyone but myself.”

k e e p t h e t h e r a p y i n t h e p r e s e n t Some clients come to counseling

Y

convinced that they must revisit the past if they are to be helped. Many thera-

peutic models teach that to function well in the present people must understand

and revisit their past. Glasser (2001) disagrees with this assumption and contends

that whatever mistakes were made in the past are not pertinent now. An axiom of

choice theory is that the past may have contributed to a current problem but that

the past is never the problem. To function effectively, people need to live and plan

in the present and take steps to create a better future. We can only satisfy our needs

in the present.

The reality therapist does not totally reject the past. If the client wants to talk

about past successes or good relationships in the past, the therapist will listen

because these may be repeated in the present. Reality therapists will devote only

enough time to past failures to assure clients that they are not rejecting them. As

soon as possible, therapists tell clients, “What has happened is over; it can’t be

changed. The more time we spend looking back, the more we avoid looking for-

ward.” Although the past has propelled us to the present, reality therapists contend

that it does not have to determine our future. We are free to make choices, even

though our external world limits our choices (Wubbolding, 2011b).

a v o i d f o c u s i n g o n s y m p t o m s In traditional therapy a great deal of

time is spent focusing on symptoms by asking clients how they feel and why they

are obsessing. Focusing on the past “protects” clients from facing the reality of un-

satisfying present relationships, and focusing on symptoms does the same thing.

Glasser (2003) contends that people who have symptoms believe that if they could

only be symptom-free they would fi nd happiness. Whether people are depress-

ing or paining, they tend to think that what they are experiencing is happening

to them. They are reluctant to accept the reality that their suffering is due to the

total behavior they are choosing. Their symptoms can be viewed as the body’s way

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of warning them that the behavior they are choosing is not satisfying their basic

needs. The reality therapist spends as little time as he or she can on the symptoms

because they will last only as long as they are needed to deal with an unsatisfying

relationship or the frustration of basic needs.

According to Glasser, if clients believe that the therapist wants to hear about

their symptoms or spend time talking about the past, they are more than willing

to comply. Engaging in long journeys into the past or exploring symptoms results

in lengthy therapy. Glasser (2005) maintains that almost all symptoms are caused

by a present unhappy relationship. By focusing on present problems, especially

interpersonal concerns, therapy can generally be shortened considerably.

c h a l l e n g e t r a d i t i o n a l v i e w s o f m e n ta l i l l n e s s Choice the-

ory rejects the traditional notion that people with problematic physical and psycho-

340

logical symptoms are mentally ill. Glasser (2003) has warned people to be cautious

of psychiatry, which can be hazardous to both one’s physical and mental health.

He criticizes the traditional psychiatric establishment for relying heavily on the

DSM-IV-TR (American Psychiatric Association, 2000) for both diagnosis and

treatment. Glasser (2003) challenges the traditionally accepted views of mental ill-

ness and treatment by the use of medication, especially the widespread use of psy-

CHAPTER ELEVEN

chiatric drugs that often result in negative side effects both physically and psycho-

logically. Wubbolding (personal communication, September 7, 2010) emphasizes

that reality therapy is a mental health system rather than a remediating system. He

incorporates the Ericksonian principle that “people don’t have problems, they have

solutions that have not worked.” By reframing diagnostic categories and negative

behaviors, the counselor helps the client to perceive his or her behaviors in a very

different light, which facilitates the search for more effective solutions and choices.

t h e t h e r a p e u t i c p r o c e s s

Therapeutic Goals

A primary goal of contemporary reality therapy is to help clients get connected

or reconnected with the people they have chosen to put in their quality world.

In addition to fulfi lling this need for love and belonging, a basic goal of reality

therapy is to help clients learn better ways of fulfi lling all of their needs, includ-

ing achievement, power or inner control, freedom or independence, and fun. The

basic human needs serve to focus treatment planning and setting both short- and

long-term goals. Reality therapists assist clients in making more effective and

responsible choices related to their wants and needs.

In many instances, clients come voluntarily for therapy, and these clients are the

easiest to help. However, another goal entails working with an increasing number

of involuntary clients who may actively resist the therapist and the therapy process.

These individuals often engage in violent behavior, addictions, and other kinds of

antisocial behaviors. It is essential for counselors to do whatever they can to get con-

nected with involuntary clients. If the counselor is unable to make a connection, there

is no possibility of providing signifi cant help. If the counselor can make a connection,

the goal of teaching the client how to fulfi ll his or her needs can slowly begin.

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Therapist’s Function and Role

Therapy is often considered as a mentoring process in which the therapist is the

teacher and the client is the student. Reality therapists teach clients how to engage

in self-evaluation, which is done by raising the question, “Is what you are choosing

to do getting you what you want and need?” Here are some other questions that

therapists tend to ask clients:

• How would you most like to change your life?

• What do you want in your life that you are not getting?

• What would you have in your life if you were to change?

• What do you have to do now to make the changes happen?

The role of the reality therapist is not to make the evaluation for clients but to

challenge clients to examine what they are doing. Reality therapists assist clients

341

in evaluating their own behavioral direction, specifi c actions, wants, perceptions,

REALITY THERAP

level of commitment, possibilities for new directions, and action plans. Clients

then decide what to change and formulate a plan to facilitate the desired changes.

The outcome is better relationships, increased happiness, and a sense of inner

control of their lives (Wubbolding, 2011b).

It is the job of therapists to convey the idea that no matter how bad things are

Y

there is hope. If therapists are able to instill this sense of hope, clients feel that

they are no longer alone and that change is possible. The therapist functions as an

advocate, or someone who is on the client’s side. Together they can creatively

address a range of concerns and options.

Client’s Experience in Therapy

Clients are not expected to backtrack into the past or get sidetracked into talking

about symptoms. Neither will much time be spent talking about feelings separate

from the acting and thinking that are part of the total behaviors over which clients

have direct control. The emphasis in on actions. When clients change what they

are doing, they often change how they are feeling and thinking.

Therapists will gently, but fi rmly confront clients. Reality therapists often ask

clients questions such as these: “Is what you are choosing to do bringing you closer

to the people you want to be closer to right now?” “Is what you are doing get-

ting you closer to a new person if you are presently disconnected from everyone?”

These questions are part of the self-evaluation process, which is the cornerstone

of reality therapy.

Clients can expect to experience some urgency in therapy. Time is important,

as each session may be the last. Clients should be able to say to themselves, “I can

begin to use what we talked about today in my life. I am able to bring my present

experiences to therapy as my problems are in the present, and my therapist will not

let me escape from that fact.”

Relationship Between Therapist and Client

Reality therapy emphasizes an understanding and supportive relationship, or

therapeutic alliance, which is the foundation for effective outcomes (Wubbolding &

Brickell, 2005; Wubbolding, Robey, & Brickell, 2010). The therapist’s skill in

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establishing a trusting relationship is critical. It is also important that the client

perceives the therapist as being skilled and knowledgeable. Although the therapeu-

tic relationship is paramount, it is not an end in itself, and it is not automatically

curative or healing (Wubbolding, 2011a).

For involvement between the therapist and the client to occur, the counselor

must have certain personal qualities, including warmth, sincerity, congruence, un-

derstanding, acceptance, concern, respect for the client, openness, and the willing-

ness to be challenged by others. (For other personal characteristics, see Chapter 2.)

Wubbolding (2010, 2011a, 2011b) identifi es specifi c ways for counselors to create

a climate that leads to involvement with clients. Some of these ways entail using

attending behavior, listening to clients, suspending judgment, doing the unexpected,

using humor appropriately, being oneself as a counselor, engaging in facilitative

342

self-disclosure, listening for metaphors in the client’s mode of self-expression,

listening for themes, summarizing and focusing, allowing consequences, allowing

silence, and being an ethical practitioner. The basis for therapeutic interventions

to work effectively rests on a fair, fi rm, friendly, and trusting environment. Once

involvement has been established, the counselor assists clients in gaining a deeper

understanding of the consequences of their current behavior.

CHAPTER ELEVEN

a p p l i c at i o n : t h e r a p e u t i c

t e c h n i q u e s a n d p r o c e d u r e s

The Practice of Reality Therapy

The practice of reality therapy can best be conceptualized as the cycle of counseling,

which consists of two major components: (1) creating the counseling environment

and (2) implementing specifi c procedures that lead to changes in behavior. The art

of counseling is to weave these components together in ways that lead clients to

evaluate their lives and decide to move in more effective directions.

How do these components blend in the counseling process? The cycle of

counseling begins with creating a working relationship with clients, which was

described in the previous section. The process proceeds through an exploration

of clients’ wants, needs, and perceptions. Clients explore their total behavior and

make their own evaluation of how effective they are in getting what they want. If

clients decide to try new behavior, they make plans that will lead to change, and

they commit themselves to those plans. The cycle of counseling includes following

up on how well clients are doing and offering further consultation as needed.

It is important to keep in mind that although the concepts may seem simple as

they are presented here, being able to translate them into actual therapeutic prac-

tice takes considerable skill and creativity. Although the principles will be the same

when used by any counselor who is certifi ed in reality therapy, the manner in which

these principles are applied does vary depending on the counselor’s style and per-

sonal characteristics. These principles are applied in a progressive manner, but they

should not be thought of as discrete and rigid categories. The art of practicing real-

ity therapy involves far more than following procedures in a step-by-step, cookbook

fashion. Although these procedures are described in jargon-free language, they can

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be challenging to implement (Wubbolding, 2007, 2011b). Counseling is not a sim-

plistic method that is applied in the same way with every client. With choice theory

in the background of practice, the counselor tailors the counseling to what the client

presents. Although the counselor is prepared to work in a way that is meaningful

to the client, the move toward satisfying relationships remains in the foreground.

Robert Wubbolding is a reality therapist who has extended the practice of real-

ity therapy (WDEP system) for both implementing and teaching reality therapy

(Wubbolding, 2009). Over the years he has played a major role in the development

of reality therapy. I especially value Wubbolding’s contributions to teaching reality

therapy and to conceptualizing therapeutic procedures. His ideas render choice

theory practical and useable by counselors, and his system provides a basis for con-

ceptualizing and applying the theory. Although reality therapists operate within

the spirit of choice theory, they practice in their own unique ways and develop their

343

own individual therapeutic style. This section is based on an integrated summary

REALITY THERAP

and adaptation of material from various sources (Glasser, 1992, 1998, 2001; Wub-

bolding, 1988, 1991, 2000, 2007, 2008, 2011a, 2011b; Wubbolding et al., 1998,

2004). The Student Manual that accompanies this textbook contains Wubbolding’s

(2010) chart, which highlights issues and tasks to be accomplished throughout the

cycle of counseling.

Y

The Counseling Environment

The practice of reality therapy rests on the assumption that a supportive and chal-

lenging environment allows clients to begin making life changes. The therapeutic

relationship is the foundation for effective practice; if this is lacking, there is little

hope that the system can be successfully implemented. Counselors who hope to

create a therapeutic alliance strive to avoid behaviors such as arguing, attacking,

accusing, demeaning, bossing, criticizing, fi nding fault, coercing, encouraging ex-

cuses, holding grudges, instilling fear, and giving up easily (Wubbolding, 2010,

2011a, 2011b). In a short period of time, clients generally begin to appreciate the

caring, accepting, noncoercive choice theory environment. It is from this mildly

confrontive yet always noncriticizing, nonblaming, noncomplaining, caring envi-

ronment that clients learn to create the satisfying environment that leads to success-

ful relationships. In this coercion-free atmosphere, clients feel free to be creative

and to begin to try new behaviors.

Procedures That Lead to Change

Reality therapists operate on the assumption that we are motivated to change (1)

when we are convinced that our present behavior is not meeting our needs and

(2) when we believe we can choose other behaviors that will get us closer to what

we want. Reality therapists begin by asking clients what they want from therapy.

Therapists take the mystery and uncertainty out of the therapeutic process. They

also inquire about the choices clients are making in their relationships. In most in-

stances, there is a major unsatisfi ed relationship, and clients usually do not believe

they have any choice in what is going on in this relationship. In the beginning the

client may deny this is the case. For example, the client might say, “I’m depressed.

My depression is the problem. Why are you talking about my relationships?” The

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client often does not want to talk about the real problem, which is the unsatisfying

relationship or lack thereof.

In the fi rst session a skilled therapist looks for and defi nes the wants of the cli-

ent. The therapist also looks for a key unsatisfying present relationship—usually

with a spouse, a child, a parent, or an employer. The therapist might ask, “Whose

behavior can you control?” This question may need to be asked several times during

the next few sessions to deal with the client’s resistance to looking at his or her own

behavior. The emphasis is on encouraging clients to focus on what they can control.

When clients begin to realize that they can control only their own behavior,

therapy is under way. The rest of therapy focuses on how clients can make better

choices. There are more choices available than clients realize, and the therapist

explores these possible choices. Clients may be stuck in misery, blaming, and the

344

past, but they can choose to change—even if the other person in the relationship

does not change. Wubbolding (2011a) makes the point that clients can learn that

they are not at the mercy of others, are not victims, are capable of gaining a sense

of inner control, and have a range of choices open to them. In short, clients in real-

ity therapy often acquire a sense of hope for a better future.

Reality therapists explore the tenets of choice theory with clients, helping cli-

ents identify basic needs, discovering clients’ quality world, and fi nally, helping

CHAPTER ELEVEN

clients understand that they are choosing the total behaviors that are their symp-

toms. In every instance when clients make a change, it is their choice. With the

therapist’s help, clients learn to make better choices than they did when they were

on their own. Through choice theory, clients can acquire and maintain successful

relationships.

The “WDEP” System

Wubbolding (2000) uses the acronym WDEP to describe key procedures in the

practice of reality therapy. The WDEP system of reality therapy can be described as

“effective, practical, usable, theory-based, cross-cultural, and founded on universal

human principles” (Wubbolding, 2007, p. 204). The WDEP system can be used

to help clients explore their wants, possible things they can do, opportunities for

self-evaluation, and design plans for improvement (Wubbolding, 2007, 2011a, 2011b).

Grounded in choice theory, the WDEP system assists people in satisfying their ba-

sic needs. Each of the letters refers to a cluster of strategies: W 5 wants, needs, and

perceptions; D 5 direction and doing; E 5 self-evaluation; and P 5 planning. These

strategies are designed to promote change. Let’s look at each one in more detail.

w a n t s ( e x p lo r i n g w a n t s , n e e d s , a n d p e r c e p t i o n s ) Reality

therapists assist clients in discovering their wants and hopes. All wants are related

to the fi ve basic needs. The key question asked is, “What do you want?” Through

the therapist’s skillful questioning, clients are assisted in defi ning what they want

from the counseling process and from the world around them. It is useful for cli-

ents to defi ne what they expect and want from the counselor and from themselves.

Part of counseling consists of exploring the “picture album,” or quality world, of

clients and how their behavior is aimed at moving their perception of the external

world closer to their inner world of wants.

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Clients are given the opportunity to explore every facet of their lives, including

what they want from their family, friends, and work. Furthermore, this exploration

of wants, needs, and perceptions should continue throughout the counseling proc-

ess as clients’ pictures change.

Here are some useful questions to help clients pinpoint what they want:

• If you were the person that you wish you were, what kind of person would you be?

• What would your family be like if your wants and their wants matched?

• What would you be doing if you were living as you want to?

• Do you really want to change your life?

• What is it you want that you don’t seem to be getting from life?

• What do you think stops you from making the changes you would like?

Wubbolding and Brickell (2009) now include questions focusing on perceptions:

345

“How do you look at the situation?” “Where do you see your control?” (p. 51). Peo-

REALITY THERAP

ple have a great deal more control than they often perceive, and these questions

help clients move from a sense of external control to a sense of internal control.

This line of questioning sets the stage for applying other procedures in reality

therapy. It is an art for counselors to know what questions to ask, how to ask them,

and when to ask them. Relevant questions help clients gain insights and arrive at

Y

plans and solutions. Although well-timed, open-ended questions can help clients

identify their counseling goals, excessive questioning can result in resistance and

defensiveness. Part of this phase of counseling involves eliciting a commitment to

counseling. Personal growth will occur to the degree that clients are committed to

making changes in their actions (Wubbolding, 2011b).

d i r e c t i o n a n d d o i n g The focus on the present is characterized by the

key question asked by the reality therapist: “What are you doing?” Even though

problems may be rooted in the past, clients need to learn how to deal with them in

the present by learning better ways of getting what they want. Problems must be

solved either in the present or through a plan for the future. The therapist’s chal-

lenge is to help clients make more need-satisfying choices.

Early in counseling it is essential to discuss with clients the overall direction of

their lives, including where they are going and where their behavior is taking them.

This exploration is preliminary to the subsequent evaluation of whether it is a desir-

able direction. The therapist holds a mirror before the client and asks, “What do you

see for yourself now and in the future?” It often takes some time for this refl ection

to become clearer to clients so they can verbally express their perceptions.

Reality therapy focuses on gaining awareness of and changing current total be-

havior. To accomplish this, reality therapists focus on questions like these: “What

are you doing now?” “What did you actually do yesterday?” “What did you want to

do differently this past week?” “What stopped you from doing what you said you

wanted to do?” “What will you do tomorrow?”

Listening to clients talk about feelings can be productive, but only if it is linked

to what they are doing. When an emergency light on the car dashboard lights up,

the driver is alerted that something is wrong and that immediate action is neces-

sary to remedy a problem. In a similar way, when clients talk about problematic

feelings, most reality therapists affi rm and acknowledge these feelings. Rather than

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focusing mainly on these feelings, however, reality therapists encourage clients to

take action by changing what they are doing and thinking. It is easier to change

what we are doing and thinking than to change our feelings. From a choice theory

perspective, discussions centering on feelings, without strongly relating them to

what people are doing and thinking, are counterproductive.

s e l f - e va l u at i o n Self-evaluation is the cornerstone of reality therapy pro-

cedures. The core of reality therapy, as we have seen, is to ask clients to make

the following self-evaluation: “Does your present behavior have a reasonable

chance of getting you what you want now, and will it take you in the direction

you want to go?” Specifi cally, evaluation involves the client examining behav-

ioral direction, specifi c actions, wants, perceptions, new directions, and plans

(Wubbolding, 2011b). According to Wubbolding (2007), clients often present

346

a problem with a signifi cant relationship, which is at the root of much of their

dissatisfaction. The counselor can help clients evaluate their behavior by ask-

ing this question: “Is your current behavior bringing you closer to people im-

portant to you or is it driving you further apart?” Through skillful questioning,

the counselor helps clients determine if what they are doing is helping them.

Artful questioning assists clients in evaluating their present behavior and the

CHAPTER ELEVEN

direction this is taking them. Wubbolding (2000, 2011a) suggests questions

like these:

• Is what you are doing helping or hurting you?

• Is what you are doing now what you want to be doing?

• Is your behavior working for you?

• Is there a healthy congruence between what you are doing and what you believe?

• Is what you are doing against the rules?

• Is what you want realistic or attainable?

• Does it help you to look at it that way?

• Is it really true that you have no control over your situation?

• How committed are you to the therapeutic process and to changing your life?

• After carefully examining what you want, does it appear to be in your best inter-

ests and in the best interest of others?

Asking clients to evaluate each component of their total behavior is a major task

in reality therapy. It is the counselor’s task to assist clients in evaluating the qual-

ity of their actions and to help them make responsible choices and devise effective

plans. Individuals will not change until they fi rst decide that a change would be

more advantageous. Without an honest self-assessment, it is unlikely that clients

will change. Reality therapists are relentless in their efforts to help clients con-

duct explicit self-evaluations of each behavioral component. When therapists ask a

depressing client if this behavior is helping in the long run, they introduce the idea

of choice to the client. The process of evaluation of the doing, thinking, feeling,

and physiological components of total behavior is within the scope of the client’s

responsibility.

Reality therapists may be directive with certain clients at the beginning of

treatment. This is done to help clients recognize that some behaviors are not

effective. In working with clients who are in crisis, for example, it is sometimes

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necessary to suggest straightforwardly what will work and what will not. Other

clients, such as alcoholics and children of alcoholics, need direction early in

the course of treatment, for they often do not have the thinking behaviors in

their control system to be able to make consistent evaluations of when their

lives are seriously out of effective control. These clients are likely to have blurred

pictures and, at times, to be unaware of what they want or whether their wants

are realistic. As they grow and continue to interact with the counselor, they

learn to make evaluations with less and less help from the counselor (Wubbold-

ing, 2011a; Wubbolding & Brickell, 2005).

p l a n n i n g a n d a c t i o n Much of the signifi cant work of the counseling proc-

ess involves helping clients identify specifi c ways to fulfi ll their wants and needs.

Once clients determine what they want to change, they are generally ready to

347

explore other possible behaviors and formulate an action plan. The key question

REALITY THERAP

is, “What is your plan?” The process of creating and carrying out plans enables

people to begin to gain effective control over their lives. If the plan does not work,

for whatever reason, the counselor and client work together to devise a different

plan. The plan gives the client a starting point, a toehold on life, but plans can be

modifi ed as needed. Throughout this planning phase, the counselor continually

Y

urges the client to be willing to accept the consequences for his or her own choices

and actions. Not only are plans discussed in light of how they can help the client

personally, but plans are also designed in terms of how they are likely to affect oth-

ers in the client’s life.

Wubbolding (2000, 2007, 2008, 2011a, 2011b) discusses the central role of plan-

ning and commitment. The culmination of the cycle of counseling rests with a plan

of action. Although planning is important, it is effective only if the client has made a

self-evaluation and determined that he or she wants to change a behavior. Wubbolding

uses the acronym SAMIC to capture the essence of a good plan: simple, attainable,

measurable, immediate, involved, controlled by the planner, committed to, and con-

sistently done. Wubbolding contends that clients gain more effective control over

their lives with plans that have the following characteristics:

• The plan is within the limits of the motivation and capacities of the client.

Skillful counselors help clients identify plans that involve greater need-fulfi lling

payoffs. Clients may be asked, “What plans could you make now that would

result in a more satisfying life?”

• Good plans are simple and easy to understand. They are realistically doable, pos-

itive rather than negative, dependent on the planner, specifi c, immediate, and

repetitive. Although they need to be specifi c, concrete, and measurable, plans

should be fl exible and open to revision as clients gain a deeper understanding

of the specifi c behaviors they want to change.

• The plan involves a positive course of action, and it is stated in terms of what the

client is willing to do. Even small plans can help clients take signifi cant steps

toward their desired changes.

• Counselors encourage clients to develop plans that they can carry out independ-

ently of what others do. Plans that are contingent on others lead clients to sense

that they are not steering their own ship but are at the mercy of the ocean.

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• Effective plans are repetitive and, ideally, are performed daily.

• Plans are carried out as soon as possible. Counselors can ask the question,

“What are you willing to do today to begin to change your life?”

• Plans involve process-centered activities. For example, clients may plan to do

any of the following: apply for a job, write a letter to a friend, take a yoga class,

substitute nutritious food for junk food, devote 2 hours a week to volunteer

work, or take a vacation that they have been wanting.

• Before clients carry out their plan, it is a good idea for them to evaluate it with

their therapist to determine whether it is realistic and attainable and whether

it relates to what they need and want. After the plan has been carried out

in real life, it is useful to evaluate it again and make any revisions that may be

necessary.

348

• To help clients commit themselves to their plan, it is useful for them to fi rm it

up in writing.

Resolutions and plans are empty unless there is a commitment to carry them out.

It is up to clients to determine how to take their plans outside the restricted world

of therapy and into the everyday world. Effective therapy can be the catalyst that

leads to self-directed, responsible living.

CHAPTER ELEVEN

Asking clients to determine what they want for themselves, to make a self-

evaluation, and to follow through with action plans includes assisting them in

determining how intensely they are willing to work to attain the changes they

desire. Commitment is not an all-or-nothing matter; it exists in degrees. Wub-

bolding (2007, 2011a, 2011b) maintains that it is important for a therapist to

express concern about clients’ level of commitment, or how much they are will-

ing to work to bring about change. This communicates in an implicit way to

clients that they have within them the power to take charge of their lives. It is

essential that those clients who are reluctant to make a commitment be helped

to express and explore their fears of failing. Clients are helped by a therapist

who does not easily give up believing in their ability to make better choices, even

if they are not always successful in completing their plans. In his workshops,

Wubbolding often mentions this axiom of reality therapy: “To fail to plan is

to plan to fail.”

Application to Group Counseling

With the emphases on connection and interpersonal relationships, reality therapy

is well suited for various kinds of group counseling. Groups provide members

with many opportunities for exploring ways to meet their needs through the

relationships formed within the group. In particular, the WDEP system can be

applied to helping group members satisfy their basic needs. If members talk

about their past experiences or make excuses for their current behavior, the group

leader redirects them to what they are presently doing. From the very beginning

of a group, the members can be asked to take an honest look at what they are

doing and to clarify whether their behavior is getting them what they say they

want. Once group members get a clearer picture of what they have in their lives

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now and what they want to be different, they can use the group as a place to

explore an alternative course of behavior.

This model lends itself to expecting the members to carry out homework

assignments between the group meetings. However, it is the members, with the

help of the leader, who evaluate their own behavior and decide whether they want

to change. Members also take the lead in deciding what kinds of homework tasks

they will set for themselves as a way to achieve their goals. Group leaders often

meet with resistance if they make poorly timed suggestions and plans for how the

members should best live their lives. To their credit, reality therapists keep asking

the members to evaluate for themselves whether what they are doing is getting

them what they want. If the members concede that what they are doing is not

working for them, their resistance is much more likely to melt, and they tend to be

more open to trying different behaviors.

349

Once the members make some changes, reality therapy provides the struc-

REALITY THERAP

ture for them to formulate specifi c plans for action and to evaluate their level

of success. Feedback from the members and the leader can help individuals

design realistic and attainable plans. Considerable time is devoted during the

group sessions for developing and implementing plans. If people don’t carry out

a plan, it is important to discuss with them what stopped them. Perhaps they

Y

set their goals unrealistically high, or perhaps there is a discrepancy between

what they say they want to change and the steps they are willing to take to bring

about change.

I also like reality therapy’s insistence that change will not come by insight alone;

rather, members have to begin doing something different once they determine

that their behavior is not working for them. I am skeptical about the value of ca-

tharsis as a therapeutic vehicle unless the release of pent-up emotions is eventually

put into some kind of cognitive framework and is followed up with an action plan.

In the groups that I facilitate, group members are challenged to look at the futil-

ity of waiting for others to change. I ask members to assume that the signifi cant

people in their life may never change, which means that they will have to take a

more active stance in shaping their own destiny. I appreciate the emphasis of real-

ity therapy on teaching clients that the only life they can control is their own and

the focus placed on helping group members change their own patterns of acting

and thinking.

For a more detailed discussion of reality therapy in groups, see Corey (2012,

chap. 15).

r e a l i t y t h e r a p y f r o m a

m u lt i c u lt u r a l p e r s p e c t i v e

Strengths From a Diversity Perspective

The core principles of choice theory and reality therapy have much to offer in the

area of multicultural counseling. In cross-cultural therapy it is essential that coun-

selors respect the differences in worldview between themselves and their clients.

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Counselors demonstrate their respect for the cultural values of their clients by

helping them explore how satisfying their current behavior is both to themselves

and to others. Once clients make this assessment, they can formulate realistic

plans that are consistent with their cultural values. It is a further sign of respect

that the counselor refrains from deciding what behavior should be changed.

Through skillful questioning on the counselor’s part, clients from diverse ethnic

backgrounds can be helped to determine the degree to which they have become

acculturated into the dominant society. Is it possible for them to fi nd a balance,

retaining their ethnic identity and values while integrating some of the values and

practices of the dominant group? Again, the counselor does not determine this

balance for clients, but works with them to arrive at their own answers. With this

focus on thinking and acting rather than on exploring feelings, many clients are

350

less likely to display resistance to counseling.

Glasser (1998) contends that reality therapy and choice theory can be applied both

individually and in groups to anyone with any psychological problem in any cultural

context. We are all members of the same species and have the same genetic struc-

ture; therefore, relationships are the problem in all cultures. Wubbolding (2007,

2011a, 2011b) asserts that the principles underlying choice theory are universal,

which makes choice theory applicable to all people. All of us have internal needs,

CHAPTER ELEVEN

we all make choices, and we all seek to infl uence the world around us. Putting the

principles of choice theory into action demands creativity, sensitivity to cultures

and individuals, and fl exibility in implementing the procedures of reality therapy.

Reality therapy principles and procedures need to be applied differently in various

cultures and must be adapted to the psychological and developmental levels pre-

sented by individuals (Wubbolding, 2011b).

Based on the assumption that reality therapy must be modifi ed to fi t the cultural

context of people other than North Americans, Wubbolding (2000, 2011a) and Wub-

bolding and colleagues (1998, 2004) have expanded the practice of reality therapy

to multicultural situations. Wubbolding’s experience in conducting reality therapy

workshops in Japan, Taiwan, Hong Kong, Singapore, Korea, India, Kuwait, Australia,

Slovenia, Croatia, and countries in western Europe has taught him the diffi culty of

generalizing about other cultures. Growing out of these multicultural experiences,

Wubbolding (2000) has adapted the cycle of counseling in working with Japanese

clients. He points to some basic language differences between Japanese and Western

cultures. North Americans are inclined to say what they mean and to be assertive. In

Japanese culture, assertive language is not appropriate between a child and a parent

or between an employee and a supervisor. Ways of communicating are more indirect.

To ask some Japanese clients what they want may seem harsh and intrusive to them.

Because of these style differences, adaptations such as those listed below are needed to

make the practice of reality therapy relevant to Japanese clients:

• The reality therapist’s tendency to ask direct questions may need to be softened,

with questions being raised more elaborately and indirectly. It may be a mistake

to ask individualistic questions built around whether specifi c behaviors meet

the client’s need. Confrontation should be done only after carefully considering

the context.

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• There is no exact Japanese translation for the word “plan,” nor is there an exact

word for “accountability,” yet both of these are key dimensions in the practice of

reality therapy and are central to Japanese culture.

• In asking clients to make plans and commit to them, Western counselors do not

settle for a response of “I’ll try.” Instead, they tend to push for an explicit pledge

to follow through. In Japanese culture, however, the counselor is likely to accept

“I’ll try” as a fi rm commitment.

These are but a few illustrations of ways in which reality therapy might be adapted

to non-Western clients. Although this approach assumes that all people have the

same basic needs (survival, love and belonging, power, freedom, and fun), the

way these needs are expressed depends largely on the cultural context. In working

with culturally diverse clients, the therapist must allow latitude for a wide range

351

of acceptable behaviors to satisfy these needs. As with other theories and the tech-

REALITY THERAP

niques that fl ow from them, fl exibility is a foremost requirement.

A key strength of reality therapy is that it provides clients with tools to make

the changes they desire. This is especially true during the planning phase, which

is central to the process of reality therapy. The focus is on positive steps that can be

taken, not on what cannot be done. Clients identify those problems that are caus-

Y

ing them diffi culty, and these problems become the targets for change. This type of

specifi city and the direction that is provided by an effective plan are certainly assets

in working with diverse client groups.

Reality therapy needs to be used artfully and to be applied in different ways

with a variety of clients. Many of its principles and concepts can be incorporated

in a dynamic and personal way in the style of counselors, and there is a basis for

integrating these concepts with most of the other therapeutic approaches covered

in this book.

Shortcomings From a Diversity Perspective

One of the shortcomings of reality therapy in working with clients from cer-

tain ethics groups is that it may not take fully into account some very real

environmental forces that operate against them in their everyday lives. Reality

therapy gives only limited attention to helping people address environmental

and social problems. Discrimination, racism, sexism, homophobia, heterosex-

ism, ageism, negative attitudes toward disabilities, and other social injustices

are unfortunate realities, and these forces do limit many individuals in getting

what they want from life. It is important that therapists acknowledge that peo-

ple do not choose to be the victims of various forms of discrimination and op-

pression. If therapists do not accept these environmental restrictions or are not

interested in bringing about social justice as well as individual change, clients

are likely to feel misunderstood. There is a danger that some reality therapists

may overstress the ability of these clients to take charge of their lives and not

pay enough attention to systemic and environmental factors that can limit the

potential for choice.

Some reality therapists may make the mistake of too quickly or too forcefully

stressing the ability of their clients to take charge of their lives. On this point,

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Wubbolding (2008) maintains that because of oppression and discrimination,

some people have fewer choices available to them, yet they do have choices. Wub-

bolding sees reality therapy as helping clients to focus on those choices they do

have. Although focusing on choices clients do have is useful, I believe clients

may need to talk about the ways their choices are restricted by environmental cir-

cumstances. Therapists would do well to consider how both they and their clients

could take even small steps toward bringing about societal changes, as do femi-

nist therapists (see Chapter 12).

Another shortcoming associated with reality therapy is that some clients are

very reluctant to directly verbally express what they need. Their cultural values

and norms may not reinforce them in assertively asking for what they want. In

fact, they may be socialized to think more of what is good for the social group than

352

of their individual wants. In working with people with these values, counselors

must “soften” reality therapy somewhat. If reality therapy is to be used effectively

with clients from other cultures, the procedures must be adapted to the life experi-

ences and values of members from various cultures (Wubbolding, 2000, 2011a;

Wubbolding et al., 2004).

Reality Therapy Applied to the Case of Stan

As a reality therapist, I am guided by

Stan learns that even though most of his prob-

the key concepts of choice theory to

lems did indeed begin in childhood, there is

identify Stan’s behavioral dynamics,

little he can now do to undo his childhood. He

to provide a direction for him to work toward,

eventually recognizes that all of his symptoms

and to teach him about better alternatives for

and avoidances keep him from getting what he

achieving what he wants. Stan has not been

most wants. He eventually realizes that he has

effective in getting what he needs—a satisfying

a great deal of control over what he can do for

relationship.

himself now.

Stan has fallen into a victim role, blam-

I have Stan describe how his life would be

ing others, and looking backward instead of

different if he were symptom free. I am inter-

forward. Initially, he wants to tell me about the

ested in knowing what he would be doing if he

negative aspects of his life, which he does by

were meeting his needs for belonging, achieve-

dwelling on his major symptoms: depression,

ment, power, freedom, and fun. I explain to him

anxiety, inability to sleep, and other psycho-

that he has an ideal picture of what he wants

somatic symptoms. I listen carefully to his

his life to be, yet he does not possess effec-

concerns, but I hope he will come to realize that

tive behaviors for meeting his needs. I talk to

he has many options for acting differently. I

him about all of his basic psychological needs

operate on the premise that therapy will offer

and how this type of therapy will teach him to

the opportunity to explore with Stan what he

satisfy them in effective ways. I also explain that

can build on—successes, productive times,

his total behavior is made up of acting, thinking,

goals, and hopes for the future.

feeling, and physiology. Even though he says

After creating a relationship with Stan, I

he hates feeling anxious most of the time, Stan

am able to show him that he does not have to

learns that much of what he is doing and think-

be a victim of his past unless he chooses to be,

ing is directly leading to his unwanted feelings

and I assure him that he has rehashed his past

and physiological reactions. When he complains

miseries enough. As counseling progresses,

of feeling depressed much of the time, anxious

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at night, and overcome by panic attacks, I let him

Counseling With Choice Theory: The New Reality

know that I am more interested in what he is

Therapy (Glasser, 2001) and A Set of Directions

doing and thinking because these are the behav-

for Putting and Keeping Yourself Together

ioral components that can be directly changed.

(Wubbolding & Brickell, 2001). Stan brings

I help Stan understand that his depressing is

some of what he is learning from his reading

the feeling part of his choice. Although he may

into his sessions, and eventually he is able to

think he has little control over how he feels, over

achieve some of his goals. The combination of

his bodily sensations, and over his thoughts, I

working with a reality therapist, his reading,

want him to understand that he can begin to

and his willingness to put what he is learning

take different action, which is likely to change

into practice by engaging in new behaviors in

his depressing experience. I frequently ask this

the world assist him in replacing ineffective

question, “Is what you are choosing to do get-

choices with life-affirming choices. Stan comes

ting you what you want?” I lead Stan to begin

to accept that he is the only person who can

to recognize that he does have some, indirect

control his own destiny.

353

control over his feelings. This is best done after

REALITY THERAP

he has made some choices about doing some-

Follow-Up: You Continue as Stan’s

thing different from what he has been doing. At

Reality Therapist

this point he is in a better place to see that the

Use these questions to help you think about how

choice to take action has contributed to feeling

you would counsel Stan using reality therapy:

better, which helps him realize that he has some

• If Stan complains of feeling depressed most

power to change.

Y

of the time and wants you to “fix” him, how

Stan tells me about the pictures in his head,

would you proceed?

a few of which are becoming a counselor, act-

• If Stan persists, telling you that his mood is

ing confident in meeting people, thinking of

getting the best of him and that he wants you

himself as a worthwhile person, and enjoying

to work with his physician in getting him on

life. Through therapy he makes the evaluation

an antidepressant drug, what would you say

that much of what he is doing is not getting

or do?

him closer to these pictures or getting him

• What are some of Stan’s basic needs that are

what he wants. After he decides that he is

not being met? What action plans can you

willing to work on himself to be different, the

think of to help Stan find better ways of get-

majority of time in the sessions is devoted to

ting what he wants?

making plans and discussing their implementa-

• Would you be inclined to do a checklist on al-

tion. We both focus on the specific steps he

coholism with Stan? Why or why not? If you

can take right now to begin the changes he

determined that he was addicted to alcohol,

would like.

would you insist that he attend a program

As Stan continues to carry out plans in the

such as Alcoholics Anonymous in conjunction

real world, he gradually begins to experience

with therapy with you? Why or why not?

success. When he does backslide, I do not put

him down but help him refocus. We then de-

• What interventions would you make to help

velop a new plan that we both feel more confi-

Stan explore his total behavior?

dent about. I am not willing to give up on Stan

even when he does not make major progress,

See DVD for Theory and Practice of

and Stan lets me know that my support is a

Counseling and Psychotherapy: The Case

source of real inspiration for him to keep working

of Stan and Lecturettes (Session 9 on reality

on himself.

therapy) for a demonstration of my approach

I teach Stan about choice theory, and, if he

to counseling Stan from this perspective. This

is willing to engage in some reading, I sug-

session deals with assisting Stan in forming an

gest that he read and reflect on the ideas in

action plan.

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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s u m m a r y a n d e va l u at i o n

Summary

The reality therapist functions as a teacher, a mentor, and a model, confronting cli-

ents in ways that help them evaluate what they are doing and whether their behavior

is fulfi lling their basic needs without harming themselves or others. The heart of

reality therapy is learning how to make better and more effective choices and gain

more effective control. People take charge of their lives rather than being the victims

of circumstances beyond their control. Practitioners of reality therapy focus on what

clients are able and willing to do in the present to change their behavior. Practitioners

teach clients how to make signifi cant connections with others. Therapists continue

to ask clients to evaluate the effectiveness of what they are choosing to do to deter-

mine if better choices are possible.

354

The practice of reality therapy weaves together two components, the counseling

environment and specifi c procedures that lead to changes in behavior. This thera-

peutic process enables clients to move in the direction of getting what they want.

The goals of reality therapy include behavioral change, better decision making, im-

proved signifi cant relationships, enhanced living, and more effective satisfaction

of all the psychological needs.

CHAPTER ELEVEN

Contributions of Reality Therapy

Among the advantages of reality therapy are its relatively short-term focus and

the fact that it deals with conscious behavioral problems. Insight and awareness

are not enough; the client’s self-evaluation, a plan of action, and a commitment

to following through are the core of the therapeutic process. I like the focus

on strongly encouraging clients to engage in self-evaluation, to decide if what

they are doing is working or not, and to commit themselves to doing what is

required to make changes. The existential underpinnings of choice theory are

a major strength of this approach, which accentuates taking responsibility for

what we are doing. People are not viewed as being hopelessly and helplessly

depressed. Instead, people are viewed as doing the best they can, or making

the choices they hope will result in fulfi lling their needs. With the emphasis on

responsibility and choice, individuals can acquire a sense of self-direction and

empowerment.

Too often counseling fails because therapists have an agenda for clients. The

reality therapist helps clients conduct a searching inventory of what they are do-

ing. If clients determine that their present behavior is not working, they are then

much more likely to consider acquiring a new behavioral repertoire. Many clients

approach counseling with a great deal of skepticism. Reality therapy can be used

effectively with individuals who manifest reluctance and who are often highly re-

sistant. For example, in working with people with addictions, reality therapy strate-

gies can be used to help clients evaluate where their behavior is leading them and

to provide clients with options to bring about positive changes in their behavior.

Reality therapy has been effectively used in addiction treatment and recovery pro-

grams for more than 30 years (Wubbolding & Brickell, 2005). In many situations

with these populations, it would be inappropriate to embark on long-term therapy

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch11_rev01.indd 354

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that delves into unconscious dynamics and an intensive exploration of one’s past.

Reality therapy focuses on making changes in the present and is an effective, short-

term approach, often in 10 sessions or less.

Limitations and Criticisms of Reality Therapy

From my perspective, one of the main limitations of reality therapy is that it does

not give adequate emphasis to the role of the following aspects of the counseling

process: the role of insight, the unconscious, the power of the past and the effect

of traumatic experiences in early childhood, the therapeutic value of dreams, and

the place of transference. Because reality therapy focuses almost exclusively on

consciousness, it does not take into account factors such as repressed confl icts

and the power of the unconscious in infl uencing how we think, feel, behave,

and choose.

355

Dealing with dreams is not part of the reality therapist’s repertoire. Accord-

REALITY THERAP

ing to Glasser (2001), it is not therapeutically useful to explore dreams. For him,

spending time discussing dreams can be a defense used to avoid talking about

one’s behavior and, thus, is time wasted. From my perspective, dreams are pow-

erful tools in helping people recognize their internal confl icts. I believe that

there is richness in dreams, which can be a shorthand message of clients’ central

Y

struggles, wants, hopes, and visions of the future. Asking clients to recall, report,

share, and relive their dreams in the here and now of the therapeutic session can

help unblock them and can pave the way for clients to take a different course

of action.

Similarly, I have a diffi cult time accepting Glasser’s view of transference as a

misleading concept, for I fi nd that clients are able to learn that signifi cant people

in their lives have a present infl uence on how they perceive and react to others. To

rule out an exploration of transference that distorts accurate perception of others

seems narrow in my view.

As you will recall, Glasser (2001, 2003) contends that chronic depression and pro-

found psychosis are chosen behaviors. Apart from specifi c brain pathology, Glasser

argues that mental illness is the result of an individual’s unsatisfying present rela-

tionships or general unhappiness. I have trouble viewing all psychological disorders

as behavioral choices. People suffering from chronic depression or schizophrenia

are struggling to cope with a real illness. In reality therapy these people may have ad-

ditional guilt to carry if they accept the premise that they are choosing their condition.

I believe reality therapy is vulnerable to the practitioner who assumes the

role of an expert in deciding for others how life should be lived and what consti-

tutes responsible behavior. Wubbolding (2008) admits that reality therapy can

lend itself to fi xing problems and imposing a therapist’s values on clients, es-

pecially by inexperienced or inadequately trained counselors. Wubbolding adds

that it is not the therapist’s role to evaluate the behavior of clients. Generally, cli-

ents need to engage in a process of courageous self-evaluation to determine how

well certain behaviors are working and what changes they may want to make.

It is critical that therapists monitor any tendency to judge clients’ behavior, but

instead to do all that is possible to get clients to make their own evaluation of

their behavior.

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Finally, reality therapy makes use of concrete language and simple concepts.

This can erroneously be viewed as a simple approach that does not require a high

level of competence. Because reality therapy is easily understood, it might appear

to be easy to implement. However, the effective practice of reality therapy requires

practice, supervision, and continuous learning (Wubbolding, 2007b, 2011a). Com-

petent reality therapists have a thorough understanding of choice theory and have

mastered the art of applying reality therapy procedures to working with diverse

clients with a range of clinical problems.

w h e r e t o g o f r o m h e r e

In the DVD for Integrative Counseling: The Case of Ruth and Lecturettes, Session 8

(“Behavioral Focus in Counseling”), you will note ways that I attempt to assist Ruth

356

in specifying concrete behaviors that she will target for change. In this session I

am drawing heavily from principles of reality therapy in assisting Ruth to develop

an action plan to make the changes she desires.

Free Podcasts for ACA Members

You can download ACA Podcasts (prerecorded interviews) at www.counseling.org;

CHAPTER ELEVEN

click on the Resource button and then the Podcast Series. For Chapter 11, Reality

Therapy, look for Podcast 18, “Reality Therapy, Choice Theory: What’s the Differ-

ence?” by Dr. Robert Wubbolding.

Other Resources

DVDs offered by the American Psychological Association that are relevant to this

chapter include the following:

Wubbolding, R. (2007). Reality Therapy

Psychotherapy.net is a comprehensive resource for students and professionals

that offers videos and interviews on demonstrating reality therapy working with

addictions, adults, and children. New video and editorial content is made available

monthly. DVDs relevant to this chapter are available at www.psychotherapy.net

and include the following:

Wubbolding, R. (2000). Reality Therapy (Psychotherapy With the Experts Series)

Wubbolding, R. (2000). Reality Therapy for Addictions (Brief Therapy for

Addictions Series)

Wubbolding, R. (2002). Reality Therapy With Children (Child Therapy With

the Experts Series)

The programs offered by the William Glasser Institute are designed to teach the

concepts of choice theory and the practice of reality therapy. More than 7,800 thera-

pists have completed the training in reality therapy and choice theory. The institute

offers a certifi cation process, which starts with a 3-day introductory course known

as “basic training” in which participants are involved in discussions, demonstra-

tions, and role playing. For those wishing to pursue more extensive training, the

institute offers a fi ve-part sequential course of study leading to certifi cation in real-

ity therapy, which includes basic training, a basic practicum, advanced training,

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch11_rev01.indd 356

20/09/11 3:55 PM

an advanced practicum, and a certifi cation week. This 18-month training program

culminates in a Certifi cate of Completion. Complete information on this program

can be obtained directly from the institute.

The William Glasser Institute

William Glasser, MD, President and Founder

Attention: Executive Director

22024 Lassen Street, Suite #118

Chatsworth, CA 91311-3600

Telephone: (818) 700-8000

Toll free: (800) 899-0688

Fax: (818) 818-700-0555

E-mail: wginst@wglasser.com

Website: www.wglasser.com

357

Center for Reality Therapy

REALITY THERAP

Dr. Robert E. Wubbolding, Director

7672 Montgomery Road #383

Cincinnati, OH 45236-4204

Telephone: (513) 561-1911

Fax: (513) 561-3568

E-mail: wubsrt@fuse.net

Y

Website: www.realitytherapywub.com

The International Journal of Choice Theory and Reality Therapy (online journal) fo-

cuses on concepts of internal control psychology, with particular emphasis on re-

search, development, and practical applications of choice theory and reality therapy

principles in various settings. To subscribe, contact:

Dr. Tom Parish

International Journal of Choice Theory and Reality Therapy

4606 SW Moundview Drive

Topeka, Kansas 66610

Telephone: (785) 862-1379

E-mail: Parishts@gmail.com

Recommended Supplementary Readings

Counseling With Choice Theory: The New Reality Therapy (Glasser, 2001) repre-

sents the author’s latest thinking about choice theory and develops the existen-

tial theme that we choose all of our total behaviors. Case examples demonstrate

how choice theory principles can be applied in helping people establish better

relationships.

Reality Therapy (Wubbolding, 2011a) updates and extends previous publications on

choice theory and reality therapy. As a part of the APA theories of psychotherapy se-

ries, this is a well-written and comprehensive overview of reality therapy and choice

theory.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch11_rev01.indd 357

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Case Approach to Counseling and Psychotherapy (Corey, 2013) illustrates how

prominent reality therapists Drs. William Glasser and Robert Wubbolding

would counsel Ruth from their different perspectives of choice theory and real-

ity therapy.

References and Suggested Readings

American Psychiatric Association. (2000).

*Wubbolding, R. E. (1988). Using reality

Diagnostic and statistical manual of mental

therapy. New York: Harper & Row

disorders, text revision, (4th ed.). Washington,

(Perennial Library).

DC: Author.

*Wubbolding, R. E. (1991). Understanding reality

Corey, G. (2012). Theory and practice of group

therapy. New York: Harper & Row (Perennial

counseling (8th ed.). Belmont, CA: Brooks/

Library).

358

Cole, Cengage Learning.

*Wubbolding, R. E. (2000). Reality therapy for

*Corey, G. (2013). Case approach to counseling

the 21st century. Philadelphia, PA: Brunner-

and psychotherapy (8th ed.). Belmont, CA:

Routledge.

Brooks/Cole, Cengage Learning.

Wubbolding, R. E. (2007). Reality therapy.

Glasser, W. (1965). Reality therapy: A new

In A. B. Rochlen (Ed.), Applying counseling

approach to psychiatry. New York: Harper & Row.

theories: An online case-based approach

CHAPTER ELEVEN

(pp. 193–207). Upper Saddle River, NJ:

Glasser, W. (1968) . Schools without failure.

Pearson Prentice-Hall.

New York: Harper & Row.

Wubbolding, R. E. (2008). Reality therapy.

Glasser, W. (1992). Reality therapy. New York

In J. Frew & M. D. Spiegler (Eds.), Contempo-

State Journal for Counseling and Development,

rary psychotherapies for a diverse world

7(l), 5–13.

(pp. 360–396). Boston: Houghton

*Glasser, W. (1998). Choice theory: A new psychol-

Mifflin.

ogy of personal freedom. New York: HarperCollins.

Wubbolding, R. E. (2009). Headline or foot-

*Glasser, W. (2001). Counseling with choice

note? Mainstream or backwater? Cutting

theory: The new reality therapy. New York:

edge or trailing edge? Included or excluded

HarperCollins.

from the professional world? International

Journal of Reality Therapy, 29(1), 26–29.

Glasser, W. (2003). Warning: Psychiatry can

be hazardous to your mental health. New York:

Wubbolding, R. E. (2010). Cycle of psycho-

HarperCollins.

therapy, counseling, coaching, managing and

supervising (chart, 17th revision). Cincinnati,

Glasser, W. (2005). Defining mental health as a

OH: Center for Reality Therapy.

public health issue: A new leadership role for the

helping and teaching professions. Chatsworth,

*Wubbolding, R. E. (2011a). Reality therapy.

CA: William Glasser Institute.

Washington, DC: American Psychological

Association.

Glasser, W., & Glasser, C. (2000). Getting

together and staying together. New York:

*Wubbolding, R. E. (2011b). Reality therapy/

HarperCollins.

choice theory. In D. Capuzzi & D. R. Gross (Eds.),

Counseling and psychotherapy: Theories and inter-

Glasser, W., & Glasser, C. (2007). Eight

ventions (5th ed., pp. 263–285). Alexandria, VA:

lessons for a happier marriage. New York:

American Counseling Association.

HarperCollins.

*Books and articles marked with an asterisk are suggested for further study.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch11_rev01.indd 358

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*Wubbolding, R. E., & Brickell, J. (2001). A

Wubbolding, R. E., & Colleagues. (1998).

set of directions for putting and keeping yourself

Multicultural awareness: Implications for

together. Minneapolis, MN: Educational Media

reality therapy and choice theory. International

Corporation.

Journal of Reality Therapy, 17(2), 4–6.

Wubbolding, R. E., & Brickell, J. (2005).

Wubbolding, R. E., Brickell, J., Imhof, L., Kim, R.,

Reality therapy in recovery. Directions in

Lojk, L., & Al-Rashidi, B. (2004). Reality therapy:

Addiction Treatment and Prevention, 9(1),

A global perspective. International Journal for the

1–10. New York: The Hatherleigh

Advancement of Counselling, 26(3), 219–228.

Company.

Wubbolding, R. E., Robey, P., & Brickell, J.

Wubbolding, R. E., & Brickell, J. (2009).

(2010). A partial and tentative look at the

Perception: The orphaned component of

future of choice theory, reality therapy and lead

choice theory. International Journal of Reality

management. International Journal of Choice

Therapy, 28(2), 50–54.

Theory and Reality Therapy, 19(2), 25–34.

359

REALITY THERAP

Y

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch11_rev01.indd 359

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c h a p t e r 1 2

Feminist Therapy

Coauthored by Barbara Herlihy and Gerald Corey

i n t r o d u c t i o n

f e m i n i s t t h e r a p y f r o m a

• History and Development

m u lt i c u lt u r a l a n d s o c i a l

j u s t i c e p e r s p e c t i v e

k e y c o n c e p t s

• Strengths From a Diversity Perspective

• View of Human Nature

• Shortcomings From a Diversity Perspective

• Feminist Perspective on Personality

f e m i n i s t t h e r a p y a p p l i e d

Development

t o t h e c a s e o f s ta n

• Principles of Feminist Therapy

t h e t h e r a p e u t i c p r o c e s s

s u m m a ry a n d e va l u at i o n

• Therapeutic Goals

• Summary

• Therapist’s Function and Role

• Contributions of Feminist Therapy

• Client’s Experience in Therapy

• Limitations and Criticisms of Feminist

• Relationship Between Therapist and Client

Therapy

a p p l i c at i o n : t h e r a p e u t i c

w h e r e t o g o f r o m h e r e

t e c h n i q u e s a n d p r o c e d u r e s

• Recommended Supplementary Readings

•

• The Role of Assessment and Diagnosis

The Role of Assessment an

• References and Suggested Readings

•

• Techniques and Strategies

Techniques and

•

• The Role of Men in Feminist Therapy

The Rol of Men in Feminist T

360

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Some Contemporary Feminist Therapists

Feminist therapy does not have a single founder.

inclusion here, recognizing full well that many other

Rather, it has been a collective effort by many. We

equally influential scholar-practitioners could have

have selected a few individuals who have made

appeared in this space. Feminist therapy is truly

significant contributions to feminist therapy for

founded on a theory of inclusion.

Jean Baker Miller / Carol Zerbe Enns /

Oliva M. Espin / Lauara S. Brown

JEAN BAKER MILLER, MD

thored The Healing Connection: How Women Form

(1928–2006), was a clinical

Relationships in Therapy and in Life (Miller & Stiver,

Institute

361

professor of psychiatry at

1997) and Women’s Growth in Connection (Jordan

FEMINIS

Training

Boston University School of

et al., 1991) . Dr. Miller collaborated with diverse

Miller

Medicine and director of the

groups of scholars and colleagues on the develop-

Baker

Jean Baker Miller Training

ment of relational-cultural theory. She made im-

T THERAP

Jean

Institute at the Stone Center,

portant contributions toward expanding this theory

of

Wellesley College. She wrote

and exploring new applications to complex issues

Courtesy

Toward a New Psychology of

in psychotherapy and beyond, including issues of

Y

Women (1986) and coau-

diversity, social action, and workplace change.

CAROLYN ZERBE ENNS,

and Feminist Psychotherapies: Origins, Themes, and

PhD, is Professor of Psy-

Diversity (2004). The relationship of theory to

chology and participant in

feminist pedagogy is another major interest area

Enns

the Women’s Studies and

and is the topic of a co-edited book (with Ada

Zerbe

Ethnic Studies programs at

Sinacore) of Teaching and Social Justice: Integrating

Cornell College in Mt.

Multicultural and Feminist Theories in the Classroom

Carolyn

of

Vernon, Iowa. Enns became

(2005) . Dr. Enns was one of three co-chairs

interested in feminist

(with Roberta Nutt and Joy Rice) of the task force

Courtesy

therapy while she was

that developed APA’s (2007) “Guidelines for

completing her PhD in Counseling Psychology at

Psychological Practice with Girls and Women.” Her

the University of California, Santa Barbara. She

most recent efforts are directed toward articu-

devotes much of her work to exploring the pro-

lating the importance of multicultural feminist

found impact feminist theory has on the manner in

therapy, exploring the practice of feminist therapy

which therapists implement therapeutic practices,

around the world (especially in Japan), and writing

and she discusses this impact in Feminist Theories

about multicultural feminist pedagogies.

OLIVA M. ESPIN, PhD,

University of Florida, specializing in counseling

State

is Professor Emerita in the

and therapy with women from different cultures

Diego

Department of Women’s

and in Latin American Studies. She is a pioneer in

San

Professor

Studies at San Diego State

the theory and practice of feminist therapy with

Espin,

Studies,

University and at the

women from different cultural backgrounds and

Oliva

California School of Profes-

has done extensive research, teaching, and train-

Dr.

Women’s

of

sional Psychology of Alliant

ing on multicultural issues in psychology. Dr. Espin

of

International University. A

has published on psychotherapy with Latinas,

Courtesy

Emerita

University

native of Cuba, she did her

women immigrants and refugees, the sexuality of

undergraduate work in psychology at the Universidad

Latinas, language in therapy with fluent bilinguals,

de Costa Rica and received her PhD from the

and training clinicians to work with multicultural

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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populations. Espin co-edited Refugee Women and

Migration, and Sexuality (1997) , and Women Cross-

Their Mental Health: Shattered Societies, Shattered

ing Boundaries: A Psychology of Immigration and the

Lives (Cole, Espin, & Rothblum, 1992) and has

Transformation of Sexuality (1999) , which is based

written Latina Healers: Lives of Power and Tradition

on a study of women immigrants from all over the

(1996) , Latina Realities: Essays on Healing,

world.

LAURA S. BROWN, PhD,

practice in psychotherapy and counseling, and

is a founding member

Subversive Dialogues: Theory in Feminist Therapy

of the Feminist Therapy

(1994) is considered by many to be the founda-

Institute, an organization

tion book addressing how theory informs

dedicated to the support

practice in feminist therapy. Her most recent

Brown

S.

of advanced practice in

book is Feminist Therapy (2010). Dr. Brown has

Laura

feminist therapy, and a

made particular contributions to thinking about

Dr.

of

member of the theory

ethics and boundaries, and the complexities of

362

workgroup at the National

ethical practice in small communities. Her cur-

Courtesy

VE

Conference on Education

rent interests include feminist forensic psychol-

and Training in Feminist Practice. She has writ-

ogy and the application of feminist principles to

ten several books considered core to feminist

treatment of trauma survivors.

CHAPTER TWEL

i n t r o d u c t i o n

This chapter provides an alternative perspective to the models considered thus far

in this book.* As you will see, feminist therapy puts intersections of gender, social

location, and power at the core of the therapeutic process. Feminist therapy is

built on the premise that it is essential to consider the social, cultural, and political

context that contributes to a person’s problems in order to understand that per-

son. This perspective has signifi cant implications for the development of coun-

seling theory and for how practitioners intervene with diverse client populations.

A central concept in feminist therapy is the importance of understanding and

acknowledging the psychological oppression of women and the constraints im-

posed by the sociopolitical status to which women have been relegated. The fem-

inist perspective offers a unique approach to understanding the roles that both

women and men have been socialized to accept and to bringing this understanding

into the therapeutic process. The socialization of women inevitably affects their

identity development, self-concept, goals and aspirations, and emotional well-

being (Belenky, Clinchy, Goldberger, & Tarule, 1987/1997; Gilligan, 1982; Turner &

Werner-Wilson, 2008). As Natalie Rogers (1995) has observed, socialization

patterns tend to result in women giving away their power in relationships, often

without being aware of it. Feminist therapy keeps knowledge about gender sociali-

zation in mind in the work with all clients.

The majority of clients in counseling are women, and the majority of psycho-

therapy practitioners at the master’s level are women. However, most theories that

*I invited a colleague and friend, Barbara Herlihy, a professor of counselor education at the University of

New Orleans, to coauthor this chapter. We have coauthored two books (Herlihy & Corey, 2006a, 2006b),

which seems like a natural basis for collaboration on a project that we both consider valuable.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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are traditionally taught—including all of the other theories in this book—were

founded by White males from Western (American or European) cultures, with

only Adler taking a pro-feminist stance in early theory development. The need for

a theory that evolves from the thinking and experiencing of women seems self-

evident. Theories are developed from the experiences of the “developer,” and femi-

nist theory is the fi rst therapeutic theory from a female perspective.

Feminist therapists have challenged male-oriented assumptions regarding

what constitutes a mentally healthy individual. Early feminist therapy efforts

focused on valuing women’s experiences, political realities, and the unique issues

facing women within a patriarchal system. Current feminist practice emphasizes

a diverse approach that includes an understanding of multiple oppressions, mul-

ticultural competence, and social justice (American Psychological Association,

2007; Beardsley, Morrow, Castillo, & Weitzman, 1998; Brown & Root, 1990;

363

Enns & Byars-Winston, 2010). Today’s feminists believe that gender cannot be

FEMINIS

considered apart from other identities related to race, ethnicity, socioeconomic

class, and sexual orientation. The contemporary version of feminist therapy and

T THERAP

the multicultural and social justice approaches to counseling practice have a

great deal in common (Crethar, Torres Rivera, & Nash, 2008). All three of these

approaches provide a systemic perspective based on understanding the social

Y

context of clients’ lives and are aimed toward affecting social change as well as

individual change.

See the video program for Chapter 12, DVD for Theory and Practice of Counseling

and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the

brief lecture for each chapter prior to reading the chapter.

History and Development

Feminist therapy has developed in a grassroots manner, responding to challenges

and to the emerging needs of women (Brabeck & Brown, 1997). No single indi-

vidual can be identifi ed as the founder of this approach, refl ecting a central theme

of feminist collaboration. Its history is relatively brief. The beginnings of feminism

can be traced to the late 1800s, but it is the women’s movement of the 1960s

that laid the foundation for the development of feminist therapy. In the 1960s

women began uniting their voices to express their dissatisfaction with the limiting

and confi ning nature of traditional female roles. Consciousness-raising groups, in

which women came together to share their experiences and perceptions, helped

individual women become aware that they were not alone. A sisterhood developed,

and some of the services that evolved from women’s collective desires to improve

society included shelters for battered women, rape crisis centers, and women’s

health and reproductive health centers.

Changes in psychotherapy occurred when women therapists participated in

consciousness-raising groups and were changed by their experiences. They formed

feminist therapy groups that operated from the same norms as consciousness-

raising groups, including nonhierarchical structures, equal sharing of resources

and power, and empowerment of women. These women also realized in their

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sharing that they were already working with clients from a feminist lens that had

never been formally defi ned.

Believing that personal counseling was a legitimate means to effect change,

they viewed therapy as a partnership between equals and built mutuality into the

therapeutic process. They took the stance that therapy needed to move away from

an intrapsychic perspective on psychopathology (in which the sources of a wom-

an’s unhappiness reside within her) to a focus on understanding the social, politi-

cal, and cultural forces in society that damage and constrain girls and women, as

well as boys and men.

A profusion of research on gender-bias emerged in the 1970s, which helped

further feminist therapy ideas, and formal organizations began to foster the devel-

opment and defi nition of feminist therapy. Among them were the Association for

364

Women in Psychology (AWP) and various efforts by the American Psychological

Association (APA).

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The 1980s were marked by efforts to defi ne feminist therapy as an entity in

its own right (Enns, 1993), and individual therapy became the most frequently

practiced form of feminist therapy (Kaschak, 1981). Gilligan’s (1982) work on the

development of a morality of care in women, and the work of Miller (1986) and

the Stone Center scholars in developing the self-in-relation model (now called the

CHAPTER TWEL

“relational-cultural” model) were infl uential in the evolution of a feminist person-

ality theory. New theories emerged that honored the relational and cooperative

dimensions of women’s experiencing (Enns, 1991, 2000, 2004; Enns & Sinacore,

2001). Feminist therapists began to formally examine the relationship of feminist

theory to traditional psychotherapy systems, and integrations with various existing

systems were proposed.

By the 1980s feminist group therapy had changed dramatically, becoming more

diverse as it focused increasingly on specifi c problems and issues such as body im-

age, abusive relationships, eating disorders, incest, and other forms of sexual abuse

(Enns, 1993). The feminist philosophies that guided the practice of therapy also

became more diverse. According to Enns (2004), in the fi eld of feminist therapy

“there is room for diversity of practice and the opportunity for individuals to

articulate a set of beliefs which are personally meaningful and which guide trans-

formational practice” (p. 10). Brown (2010) maintains that feminist therapy is a

technically integrative approach that stresses tailoring interventions to meet clients

with their strengths. Feminist therapists also draw upon strategies from many oth-

er therapy models. There are feminists who identify themselves as person-centered,

Gestalt, Adlerian, cognitive, cognitive-behavioral, existential, and psychoanalytic,

but most feminist therapists do not feel a need to position themselves in a particu-

lar philosophical place.

Enns (1993, 2004; Enns & Sinacore, 2001) identifi es four enduring feminist

philosophies, which are often described as the “second wave” of feminism: liberal,

cultural, radical, and socialist feminism. These philosophies all advocate social

activism and changing society as goals in feminist practice.

Liberal feminists focus on helping individual women overcome the limits and

constraints of traditional gender-role socialization patterns. Liberal feminists argue

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for a transformation from accepting traditional gender roles to creating equal oppor-

tunities for both women and men. These feminists tend to believe the differences

between women and men will be less problematic as work and social environments

become increasingly bias free. For liberal feminists, the major goals of therapy in-

clude personal empowerment of individual women, dignity, self-fulfi llment, shared

power in decision making in relationships, and equality. Another key goal is to

eliminate psychotherapy practices that have supported traditional socialization and

are based on biased views about women and men (Enns, 2004).

Cultural feminists believe oppression stems from society’s devaluation of wom-

en’s strengths, values, and roles. They emphasize the differences between women

and men and believe the solution to oppression lies in feminization of the cul-

ture so that society becomes more nurturing, intuitive, subjective, cooperative, and

relational. Cultural feminism highlights the value of interdependence over indi-

365

vidualism (Enns, 2004). For cultural feminists, the major goal of therapy is so-

FEMINIS

cial transformation through the infusion of feminine values (such as cooperation,

altruism, and connectedness) into the culture.

T THERAP

Radical feminists focus on the oppression of women that is embedded in pa-

triarchy and seek to change society through activism and equalizing power. Radi-

cal feminists strive to identify and question the many ways in which patriarchy

Y

dominates every area of life including household chores, paid employment, inti-

mate partnerships, violence, and parenting. They challenge the many ways that

women are denied power. The major goals are to transform gender relationships,

transform societal institutions, and increase women’s sexual and procreative self-

determination.

Socialist feminists share with radical feminists the goal of societal change. Their

emphasis differs, however, in that they focus on multiple oppressions and believe

solutions to society’s problems must include considerations of class, race, sexual

orientation, economics, nationality, and history. Socialist feminists pay close at-

tention to the ways that work, education, and family roles affect their lives. For

socialist feminists, the major goal of therapy is to transform social relationships

and institutions.

During the past 20 years feminist women of color and postmodern feminists

have found classic feminist theories wanting and have offered new theoretical

perspectives focused on issues of diversity, the complexity of sexism, and the

centrality of social context in understanding gender issues. In 1993 psychologists

who embraced a diversity of feminist perspectives met at the National Confer-

ence on Education and Training in Feminist Practice. They reached consensus

on basic themes and premises underlying feminist practice, thus taking a signifi -

cant step toward integration of a number of feminist perspectives. Enns (2004)

states that this “third wave” of feminism embraces diversity with its inclusion

of women of color, lesbians, and the postmodern and constructivist viewpoints

espoused by many of the most recent generation of feminist women. New devel-

opments in feminism also include global and international perspectives. Enns

(2004) describes some of the key characteristics associated with contemporary

feminist approaches.

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Postmodern feminists provide a model for critiquing other traditional and fem-

inist approaches, addressing the issue of what constitutes reality and proposing

multiple truths as opposed to a single truth. The postmodern perspective is based

on the assumption that “reality is embedded in social relationships and histori-

cal contexts, is socially created or invented, and is reproduced through power

relationships” (Enns, 2004, p. 271). This approach calls attention to the limita-

tion of knowledge and the fallibility of “knowers.” Polarities such as masculine–

feminine are deconstructed, which involves an analysis of how such constructs

are created.

Women of color feminists believe it is essential that feminist theory be broadened

and made more inclusive. Women of color have criticized some White feminists

who overgeneralize the experiences of White women to fi t the experiences of all

366

women. They challenge feminist theory to include an analysis of the intersections

of multiple oppressions, an assessment of access to privilege and power, to rec-

VE

ognize the importance of the spiritual dimension of human experience, and to

emphasize activism.

Lesbian feminists share commonalities with many aspects of radical femi-

nism. Both perspectives view women’s oppression as related to heterosexism

and sexualized images of women. Lesbians who defi ne themselves as feminists

CHAPTER TWEL

sometimes feel excluded by heterosexual feminists who do not understand dis-

crimination based on sexual orientation. This perspective calls for feminist theory

to include an analysis of the intersections of a person’s multiple identities and

their relationship to oppression and to recognize the diversity that exists among

lesbians. In recent years, lesbian feminism has been enriched through interac-

tion with queer theory, which emphasizes the fl uidity, fl exibility, and multiple

meanings associated with sex, sexual orientation, and gender. Some individuals

identify “lesbian feminism” with 1970s and 1980s movements. Although queer

theory and lesbian theory are not identical, queer theory seems to be increasingly

integrated with lesbian feminism.

Global international feminists take a worldwide perspective and seek to under-

stand the ways in which racism, sexism, economics, and classism affect women

in different countries. Western feminists are challenged to recognize their eth-

nocentrism and stereotyping of women in different parts of the world. Global

feminists assume that each woman lives under unique systems of oppression.

They see a need to address those cultural differences that directly contribute to

women’s oppression.

The variety in feminist theories provides a range of different but overlapping

perspectives from which to work (Enns & Sinacore, 2001). Brown (2010) defi nes

feminist therapy as a postmodern, technically integrative approach that emphasizes

the analysis of gender, power, and social location as strategies for facilitating

change. Feminist therapists, both male and female, believe that understanding

and confronting gender-role stereotypes and power are central to therapeutic prac-

tice and that addressing a client’s problems requires adopting a sociocultural per-

spective: namely, understanding the impact of the society and culture in which a

client lives.

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k e y c o n c e p t s

View of Human Nature

The feminist view of human nature is fundamentally different from that of most

other therapeutic models. Many of the traditional theories grew out of a historical

period in which social arrangements were assumed to be rooted in one’s biologi-

cally based gender. Men were assumed to be the norm and were the only group

studied or understood within the normative construct. It also was assumed that

because of biological gender differences women and men would pursue differ-

ent directions in life. Worell and Remer (2003) are critical of traditional theories

for being androcentric (using male-oriented constructs to draw conclusions about

human, including female, nature), gendercentric (proposing two separate paths

of development for women and men), heterosexist (viewing a heterosexual orien-

367

tation as normative and desirable and devaluing lesbian, gay male, and bisexual

FEMINIS

orientations), deterministic (assuming that personality patterns and behavior are

fi xed at an early stage of development), and having an intrapsychic orientation (at-

T THERAP

tributing behavior to internal causes, which often results in blaming the victim and

ignoring sociocultural and political factors). To the degree that traditional theories

contain these biased elements, they have clear limitations for counseling females

Y

and members of marginalized groups.

Worell and Remer (2003) describe the constructs of feminist theory as being gen-

der fair, fl exible–multicultural, interactionist, and life-span-oriented. Gender-fair

approaches explain differences in the behavior of women and men in terms of

socialization processes rather than on the basis of our “innate” natures, thus avoid-

ing stereotypes in social roles and interpersonal behavior. A fl exible–multicultural

perspective uses concepts and strategies that apply equally to individuals and

groups regardless of age, race, culture, gender, ability, class, or sexual orientation.

The interactionist view contains concepts specifi c to the thinking, feeling, and

behaving dimensions of human experience and accounts for contextual and envi-

ronmental factors. A life-span perspective assumes that human development is a

lifelong process and that personality and behavioral changes can occur at any time

rather than being fi xed during early childhood.

Feminist Perspective on Personality Development

Feminist therapists emphasize that societal gender-role expectations profoundly

infl uence a person’s identity from the moment of birth and become deeply in-

grained in adult personality. Because gender politics are embedded in the fabric

of American society, they infl uence how we see ourselves as girls and boys and

as women and men throughout the course of our lives. Prochaska and Norcross

(2010) point out that gender-role expectations tend to generate a false sense of self

and force women to accept stereotyped gender roles. “Women are expected to be a

lady, to never swear, hit, or get angry. They should strive to please men and, above

all, never offend or best a man” (p. 379).

Gilligan (1977) recognized that theories of moral development were based

almost exclusively on research with males. As a result of her studies on women’s

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moral and psychosocial development, Gilligan came to believe women’s sense of

self and morality is based in issues of responsibility and care for other people and is

embedded in a cultural context. She posited that the concepts of connectedness and

interdependence—virtually ignored in male-dominated developmental theories—

are central to women’s development.

Most models of human growth and development emphasize a struggle toward

independence and autonomy, but feminists recognize that women are searching

for a connectedness with others. In feminist therapy women’s relational qualities

are seen as strengths and as pathways for healthy growth and development instead

of being identifi ed as weaknesses or defects.

The founding scholars of relational-cultural theory have elaborated on the vital

role that relationships and connectedness with others play in the lives of women

368

(Jordan, Kaplan, Miller, Stiver, & Surrey, 1991; Miller, 1986, 1991; Miller et al., 1999;

Miller & Stiver, 1997; Surrey, 1991; Trepal, 2010). These scholars suggest that

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a woman’s sense of identity and self-concept develop in the context of relation-

ships. They describe a process of relational movement in which women move

through connections, disconnections, and enhanced transformative relationships

throughout their lives (Comstock et al., 2008). As you will see, many of the tech-

niques of feminist therapy foster mutuality, relational capacities, and growth in

CHAPTER TWEL

connection.

Bem (1993) posits that even very young children develop gender schemas, which

are internalizations of the gender roles perpetuated in a sexist society. In a similar

vein, Kaschak (1992) used the term engendered lives to describe her belief that gen-

der is the organizing principle in people’s lives. She has studied the role gender

plays in shaping the identities of females and males and believes the masculine

defi nes the feminine. For instance, because men pay great attention to women’s

bodies, women’s appearance is given tremendous importance in Western society.

It is easy to see how this perspective gets reifi ed in both eating disorders and vari-

ous forms of depression. Men, as the dominant group, defi ne and determine the

roles that women play. Because women occupy a subordinate position, to survive

and thrive in society they must be able to interpret the needs and behaviors of

the dominant group. To that end, women have developed “women’s intuition”

and have included in their gender schema an internalized belief that women are

less important than men. Females are raised in a culture grounded in sexism, and

they internalize the oppression. Understanding and acknowledging internalized

oppression is central in feminist work.

Feminist therapists remind us that traditional gender stereotypes of women

are still prevalent in cultures throughout the world. They teach their clients that

uncritical acceptance of traditional roles can greatly restrict their range of freedom.

Today many women and men are resisting being so narrowly defi ned. Women and

men in therapy learn that, if they choose to, they can experience mutual behavioral

characteristics such as accepting themselves as being interdependent, giving to

others, being open to receiving, thinking and feeling, and being tender and tough.

Rather than being cemented to a single behavioral style, women and men who

reject traditional roles are saying that they are entitled to express the complex range

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of characteristics that are appropriate for different situations and that they are open

to their vulnerability as human beings.

Principles of Feminist Therapy

A number of feminist writers have articulated core principles that form the foun-

dation for the practice of feminist therapy. These principles are interrelated and

overlapping.

1. The personal is political. This principle is based on the assumption that the per-

sonal or individual problems that individuals bring to counseling originate in a

political and social context. For females this is often a context of marginalization,

oppression, subordination, and stereotyping. Acknowledgment of the political and

societal impact on an individual’s life is perhaps the most fundamental tenet that

lies at the core of feminist therapy. Although feminist therapists emphasize social

369

FEMINIS

context, they also work from a biopsychosocial perspective, attending to the inter-

section of the biological, psychological, and social aspects of people’s lives (Brown,

1994).

T THERAP

2. Commitment to social change. Feminist therapy aims not only for individual

change but for social change. Feminists view their therapy practice as existing not

Y

only to help individual clients in their struggles but also to advance a transforma-

tion in society. Direct action for social change is part of their responsibility as

therapists. It is important that women who engage in the therapy process—clients

and therapists alike—recognize that they have suffered from oppression as mem-

bers of a subordinate group and that they can join with other women to right these

wrongs. The goal is to advance a different vision of societal organization that frees

both women and men from the constraints imposed by gender-role expectations.

This vision of counseling, which moves away from the traditional focus on change

from within the individual out into the realm of social activism, distinguishes fem-

inist therapy from other historically accepted approaches.

3. Women’s and girl’s voices and ways of knowing are valued and their experiences

are honored. Women’s perspectives are considered central in understanding their

distress. Traditional therapies that operate on androcentric norms compare women

to the male norm and fi nd them deviant. Much of psychological theory and research

tends to conceptualize women and men in a polarized way, forcing a male–female

split in most aspects of human experience (Bem, 1993). A goal of feminist ther-

apy is to replace patriarchal “objective truth” with feminist consciousness, which

acknowledges diverse ways of knowing. Women are encouraged to value their

emotions and their intuition and to use their personal experience as a touchstone

for determining what is “reality.” Their voices are acknowledged as authoritative

and invaluable sources of knowledge. The valuing and facilitation of women’s voic-

es in or out of therapy directly counteracts the often forced silence of women and

contributes to an ultimate change in the body politic of society.

4. The counseling relationship is egalitarian. Attention to power is central in femi-

nist therapy. Feminist therapists recognize that there is a power imbalance in the

therapeutic relationship, so they strive for an egalitarian relationship, keeping in

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mind that clients are the experts on their own lives. The intent is to shift power

and privilege to the voices and experiences of those who come to counseling

and away from those who deliver it (Brown, 2010). An open discussion of power

and role differences in the therapeutic relationship helps clients to understand

how power dynamics infl uence both counseling and other relationships and also

invites a dialogue about ways to reduce power differentials (Enns, 2004). Finding

ways to share power with clients and to demystify therapy is essential because

feminist therapists believe all relationships should strive for equality, or mutuality

(a condition of authentic connection between the client and the therapist).

5. A focus on strengths and a reformulated defi nition of psychological distress. Feminist

therapy has a “confl icted and ambivalent relationship” with diagnostic labeling

and the “disease model” of mental illness (Brown, 2010, p. 50). Psychological dis-

370

tress is reframed, not as disease but as a communication about unjust systems.

When contextual variables are considered, symptoms can be reframed as survival

VE

strategies. Feminist therapists talk about problems in the context of living and cop-

ing skills rather than pathology (Enns, 2004; Worell & Remer, 2003). If a formal

diagnosis is used, it is arrived at collaboratively with the client.

6. All types of oppression are recognized. Clients can best be understood in the context

CHAPTER TWEL

of their sociocultural environments. Feminist therapists acknowledge that social

and political inequities have a negative effect on all people. Feminist therapists

work to help individuals make changes in their lives, but they also are commit-

ted to working toward social change that will liberate all members of society from

stereotyping, marginalization, and oppression. Diverse sources of oppression, not

simply gender, are identifi ed and interactively explored as a basis for understand-

ing the concerns that clients bring to therapy. Framing clients’ issues within a

cultural context leads to empowerment, which can be fully realized only through

social change (Worell & Remer, 2003).

t h e t h e r a p e u t i c p r o c e s s

Therapeutic Goals

According to Enns (2004), some goals of feminist therapy include empowerment,

valuing and affi rming diversity, striving for change rather than adjustment, equality,

balancing independence and interdependence, social change, and self-nurturance.

Enns adds that a key goal of feminist therapy is to assist individuals in viewing

themselves as active agents on their own behalf and on behalf of others. A goal of

feminist therapy is to empower all people to create a world of equality that is refl ected

at individual, interpersonal, institutional, national, and global levels (Enns & Byars-

Winston, 2010). Perhaps the ultimate goal of this approach is to create the kind

of society where sexism and other forms of discrimination and oppression are no

longer a reality (Worell & Remer, 2003). Feminist therapy strives for transforma-

tion for both the individual client and society as a whole.

At the individual level, feminist therapists work to help females and males

recognize, claim, and embrace their personal power. Empowering the client is

at the heart of feminist therapy, which is the overarching long-term therapeutic

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goal (Gilbert & Rader, 2007). Through this empowerment, clients are able to free

themselves from the constraints of their gender-role socialization and to challenge

ongoing institutional oppression.

According to Worell and Remer (2003), feminist therapists help clients:

• Become aware of their own gender-role socialization process

•

Identify their internalized messages and replace them with more self-enhancing

beliefs

• Understand how sexist and oppressive societal beliefs and practices infl uence

them in negative ways

• Acquire skills to bring about change in the environment

• Restructure institutions to rid them of discriminatory practices

• Develop a wide range of behaviors that are freely chosen

371

• Evaluate the impact of social factors on their lives

FEMINIS

• Develop a sense of personal and social power

• Recognize the power of relationships and connectedness

• Trust their own experience and their intuition

T THERAP

Feminist therapists also work toward reinterpreting women’s mental health.

Their aim is to depathologize women’s experiencing and to infl uence society so

Y

that female voices are honored and relational qualities are valued. Women’s and

girls’ experiences are examined without the bias of patriarchal values, and their life

skills and accomplishments are acknowledged.

Therapist’s Function and Role

Feminist therapy rests on a set of philosophical assumptions that can be applied to var-

ious theoretical orientations. Any theory can be evaluated against the criteria of being

gender fair, fl exible–multicultural, interactionist, and life-span-oriented. The therapist’s

role and functions will vary to some extent depending on the particular therapist and

client in the therapeutic relationship. In Case Approach to Counseling and Psychotherapy

(Corey, 2013, chap. 10) three feminist therapists (Drs. Evans, Kincade, and Seem) team

up to demonstrate a variety of feminist interventions in their work with Ruth. They also

conceptualize the case of Ruth from a feminist therapy perspective.

Feminist therapists have integrated feminism into their approach to therapy

and into their lives. Their actions and beliefs and their personal and professional

lives are congruent. They are committed to monitoring their own biases and distor-

tions, especially the social and cultural dimensions of women’s experiences. Femi-

nist therapists are also committed to understanding oppression in all its forms—

including but not limited to sexism, racism, heterosexism—and they consider the

impact of oppression and discrimination on psychological well-being. They value

being emotionally present for their clients, being willing to share themselves dur-

ing the therapy hour, modeling proactive behaviors, and being committed to their

own consciousness-raising process. Finally, although feminist therapists may use

techniques and strategies from other theoretical orientations, they are unique in

the feminist assumptions they hold.

Feminists share common ground with Adlerian therapists in their emphasis

on social equality and social interest, and with existential therapists who emphasize

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therapy as a shared journey, one that is life changing for both client and therapist,

and with their basic trust in the client’s ability to move forward in a positive and

constructive manner (Bitter, Robertson, Healey, & Cole, 2009). Feminist thera-

pists believe the therapeutic relationship should be a nonhierarchical, person-to-

person relationship, and they aim to empower clients to live according to their own

values and to rely on an internal (rather than external or societal) locus of control

in determining what is right for them. Like person-centered therapists, feminist

therapists convey their genuineness and strive for mutual empathy between client

and therapist. Unlike person-centered therapists, however, feminist therapists do

not see the therapeutic relationship alone as being suffi cient to produce change.

Insight, introspection, and self-awareness are springboards to action.

Some feminist therapists share with postmodern therapists (see Chapter 13) an

372

emphasis on the politics and power relationships in the therapy process and a con-

cern about power relations in the world in general. Both feminist and postmodern

VE

thought asserts that psychotherapists must not replicate societal power imbalances

or foster dependency in the client. Rather, therapist and client take active and equal

roles, working together to determine goals and procedures. A common denomina-

tor of both feminist and postmodern approaches is the avoidance of assuming a

therapist role of all-knowing expert.

CHAPTER TWEL

Client’s Experience in Therapy

Clients are active participants in the therapeutic process. Feminist therapists are

committed to ensuring that this does not become another arena in which women

remain passive and dependent. It is important that clients tell their stories and give

voice to their experiencing.

Appropriate self-disclosure is affi rmed within feminist therapy. The female thera-

pist may share some of her own experiences including gender-role oppression. As an

analysis of gender-role stereotyping is conducted, the client’s consciousness is raised.

Feminist therapists do not restrict their practice to female clients; they also

work with males, couples, families, and children. The therapeutic relationship is

always a partnership, and the client, male or female, will be the expert in determin-

ing what he or she needs and wants from therapy. A male client will explore ways in

which he has been limited by his gender-role socialization, becoming more aware

of how he is constrained in his ability to express a range of emotions. In the safe

environment of the therapeutic sessions, he may be able to fully experience such

feelings as sadness, tenderness, uncertainty, and empathy. As he transfers these

ideas to daily living, he may fi nd that relationships change in his family, his social

world, and at work.

As mentioned earlier, a major goal of feminist therapy is empowerment, which

involves acquiring a sense of self-acceptance, self-confi dence, joy, and authentic-

ity. Worell and Remer (2003) write that clients acquire a new way of looking at

and responding to their world. They add that the shared journey of empower-

ment can be both frightening and exciting—for both client and therapist. Clients

need to be prepared for major shifts in their way of viewing the world around

them, changes in the way they perceive themselves, and transformed interper-

sonal relationships.

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Relationship Between Therapist and Client

Feminist therapists view the therapeutic relationship as being based on mutuality,

equality, and empowerment (Evans, Kincade, & Seem, 2011). The very structure

of the client–therapist relationship models how to identify and use power respon-

sibly. Feminist therapists clearly state their values to reduce the chance of value

imposition. This allows clients to make a choice regarding whether or not to work

with the therapist. It also is a step in demystifying the process.

As mentioned, although there is an inherent power differential in the therapy

relationship, feminist therapists work to equalize the power base in the relation-

ship by employing a number of strategies (Thomas, 1977). First, they are acutely

sensitive to ways they might abuse their own power in the relationship, such as by

diagnosing unnecessarily, by interpreting or giving advice, by staying aloof behind

an “expert” role, or by discounting the impact the power imbalance between thera-

373

FEMINIS

pist and client has on the relationship.

Second, therapists actively focus on the power their clients have in the therapeu-

tic relationship and make this part of their informed consent processes. Therapists

T THERAP

encourage clients to identify and express their feelings, to become aware of the

ways they relinquish power in relationships with others as a result of socialization

or as a means for survival, and to make decisions with this knowledge as the basis.

Y

Third, feminist therapists work to demystify the counseling relationship by

sharing with the client their own perceptions about what is going on in the re-

lationship, by making the client an active partner in determining any diagnosis,

and by making use of appropriate self-disclosure. Some feminist therapists use

contracts as a way to make the goals and processes of therapy overt rather than

covert and mysterious.

A defi ning theme of the client–counselor relationship is the inclusion of clients

in both the assessment and the treatment process, keeping the therapeutic rela-

tionship as egalitarian as possible. Walden (2006) emphasizes the value of edu-

cating and empowering clients. When counselors keep their clients uninformed

about the nature of the therapeutic process, they deny them the potential for active

participation in their therapy. When counselors make decisions about a client for

the client rather than with the client, they rob the client of power in the therapeutic

relationship. Collaboration with the client in all aspects of therapy leads to a genu-

ine partnership with the client.

a p p l i c at i o n : t h e r a p e u t i c

t e c h n i q u e s a n d p r o c e d u r e s

The Role of Assessment and Diagnosis

Feminist therapists have been sharply critical of the DSM classifi cation system,

and research indicates that gender, culture, and race may infl uence assessment of

clients’ symptoms (Enns, 2000; Eriksen & Kress, 2005). To the degree that assess-

ment is infl uenced by subtle forms of sexism, racism, ethnocentrism, heterosexism,

ageism, or classism, it is extremely diffi cult to arrive at a meaningful assessment

or diagnosis. For a thoughtful discussion of feminist challenges to DSM diagnosis,

see Eriksen and Kress (2005, 2008) and Evans, Kincade, and Seem (2011).

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From the perspective of feminist therapy, diagnostic criteria were established

through a system that views male gender-role traits as “normative.” Thus women’s

behaviors are more prone to becoming pathologized. Feminist therapists refer

to distress rather than psychopathology (Brown, 2010), and they use diagnostic

labels quite carefully, if at all. They believe diagnostic labels are severely limiting

for these reasons: (1) they focus on the individual’s symptoms and not the social

factors that cause dysfunctional behavior; (2) as part of a system developed main-

ly by White male psychiatrists, they may represent an instrument of oppression;

(3) they (especially the personality disorders) may reinforce gender-role stereotypes

and encourage adjustment to the norms of the status quo; (4) they may refl ect

the inappropriate application of power in the therapeutic relationship; (5) they can

lead to an overemphasis on individual solutions rather than social change; and

374

(6) they have the potential to dehumanize the client through the label. Using diag-

nostic categories may contribute to a victim-blaming stance and dull the therapist’s

VE

sensitivity to external factors that contribute to a client’s symptoms (Enns, 2000;

Eriksen & Kress, 2005).

The feminist approach emphasizes the importance of considering the gender-

normative context of men and women’s lives and points out that many symp-

toms can be understood as coping or survival strategies rather than as evidence of

CHAPTER TWEL

pathology (Bitter, 2008; Worell & Remer, 2003). Due to the cultural and gender

limitations of diagnoses, Eriksen and Kress (2005) encourage therapists “to be

tentative in diagnosing those from diverse backgrounds, and to, as a part of a more

egalitarian relationship, co-construct an understanding of the problem with the

client, rather than imposing a diagnosis on the client” (p. 104). In keeping with

the focus on client empowerment, diagnosis is a shared process in which clients

are the experts on the meaning of their distress. Reframing symptoms as resist-

ance to oppression and as coping skills or strategies for survival and shifting the

etiology of the problem to the environment avoids “blaming the victim” for her

or his problems. Assessment is viewed as an ongoing process between client and

therapist and is connected to treatment interventions (Enns, 2000). In the femi-

nist therapy process, diagnosis of distress becomes secondary to identifi cation and

assessment of strengths, skills, and resources (Brown, 2010). If a DSM diagnosis

is discussed, feminist therapists may ask questions aimed at deconstructing the

diagnosis: “Who benefi ts from using this label?” “How might this label contribute

to disempowering the person to whom it is assigned?”

Using the DSM-IV-TR (American Psychiatric Association, 2000), depression

is diagnosed twice as often in women as in men. Feminist therapists believe

women have many more reasons to experience depression than do men, and they

often frame depression as a normative experience for women. Women are often

fi nancially disadvantaged or dependent, relationally submissive, and strive to

please others by anticipating their needs. Depression may result from women’s

sense of powerlessness in their subordinate position, along with their experiences

of domestic violence, sexual abuse, poverty, or sexual harassment in the workplace.

Similarly, with eating disorders feminist therapists focus on messages given by

society, and by the mass media in particular, about women’s bodies. The therapist

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uses a gender-role analysis to help clients who suffer from anorexia or bulimia to

examine these societal injunctions and how they have come to accept them. Thera-

pist and client work together on ways to challenge and change these messages.

Perhaps the potentially most damaging diagnosis is borderline personality disor-

der (American Psychiatric Association, 2000), a diagnosis usually assigned to and

critical of women (Bitter, 2008). Since very few women who receive this diagnosis

have escaped physical abuse or sexual molestation, Herman (1992) has argued

that the more appropriate diagnosis would be complex posttraumatic stress disor-

der. The latter diagnosis would certainly generate more compassion and sympathy

in therapists than does the diagnosis of borderline personality disorder.

Feminist therapists do not refuse to use the DSM-IV-TR in this age of managed

care and the prevalence of the medical model of mental health, but therapists who

participate in the process of diagnosis have a responsibility to challenge the current

375

diagnostic system (Eriksen & Kress, 2008). Diagnosis, when used, results from

FEMINIS

a shared dialogue between client and therapist. The therapist is careful to review

with the client any implications of assigning a diagnosis so the client can make an

T THERAP

informed choice, and discussion focuses on helping the client understand the role

of socialization and culture in the etiology of her problems.

Y

Techniques and Strategies

Feminist therapy does not prescribe any particular set of interventions; rather, femi-

nist therapists tailor interventions to clients’ strengths with the goal of empowering

clients while evoking their feminist consciousness (Brown, 2010). Nonetheless, they

have developed several unique techniques, and have borrowed others from tradi-

tional approaches. Particularly important are consciousness-raising techniques that

help women to differentiate between what they have been taught is socially accept-

able or desirable and what is actually healthy for them. Some of the techniques

described by Worell and Remer (2003) and Enns (1993, 2004) are discussed in this

section, using the case example of Alma to illustrate how these techniques might

be applied.

Alma, age 22, comes to counseling reporting general anxiety about a new job she began a

month ago. She states that she has struggled with depression off and on throughout her life

because of bullying as a child and rejection from much of her family after coming out as a

lesbian at age 14. Alma identifi es as Dominican and continues to struggle with the loss of

her place within her family of origin. She now believes coming out was a selfi sh mistake

and is trying to make amends by keeping her feelings regarding her sexual and affectional

orientation hidden. Due in part to past experiences, she is worried that if she comes out to

her coworkers the company might fi nd a reason to fi re her. Alma says, “I would like to cut

my hair short again because it is more manageable and I also prefer to wear what is con-

sidered to be more masculine clothing, but I am worried this will cause people at work to

question my femininity. I really like my job, and I worked very hard to get it. I am afraid if

I show them who I really am, they won’t want me there anymore.”

e m p o w e r m e n t Enns and Byars-Winston (2010) point out that many of the

strategies of multicultural feminist therapy are part of the general umbrella of em-

powerment, which enables people to see themselves as active agents on behalf of

themselves and others. At the heart of feminist strategies is the goal of empowering

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the client. Feminist therapists work in an egalitarian manner and use empower-

ment strategies that are tailored to each client (Brown, 2010; Evans, Kincade, &

Seem, 2011). Alma’s therapist will pay careful attention to informed consent issues,

discussing ways Alma can get the most from the therapy session, clarifying expec-

tations, identifying goals, and working toward a contract that will guide the thera-

peutic process.

The process of feminist therapy begins with the informed consent process,

which Brown (2010) refers to as “empowerment consent.” Informed consent

offers a place to begin a relationship that is egalitarian and collaborative. By explain-

ing how therapy works and enlisting Alma as an active partner in the therapeutic

venture, the therapy process is demystifi ed and Alma becomes an equal partici-

pant. Alma will learn that she is in charge of the direction, length, and procedures

376

of her therapy. Alma’s therapist might ask her, “What is the most powerful thing

you could do right now?” The intent of this question is to “interrupt the trance

VE

of powerlessness” (Brown, 2010, p. 35) by inviting Alma to notice how power is

actually available to her. Given Alma’s cultural background, it may be particularly

important to address power within the therapeutic relationship because Alma may

view the therapist as an expert who holds the answers she is seeking. In addition,

Alma may view counseling as a weakness and may feel shame associated with her

CHAPTER TWEL

need for help.

s e l f - d i s c lo s u r e Feminist therapists use therapeutic self-disclosure in the

best interests of the client to equalize the client–therapist relationship, to provide

modeling, to normalize women’s collective experiences, to empower clients, and

to establish informed consent. Believing that there is no such thing as therapist

neutrality or objectivity, therapists who disown the reality of being knowable and

known to clients are at greater risk of abusing their power (Brown, 2010). For

example, Alma’s therapist may disclose her own diffi culties in relating to members

of her family of origin, acknowledging that at times hiding information seems im-

portant in order to keep the peace. The therapist can share how she decides when

to be open about her personal life and how to balance relating in a less open way.

The counselor could then discuss with Alma ways in which they have both experi-

enced cultural and social pressures to conform to a hetero-normative ideal. Alma

benefi ts from this modeling by a woman who does not meet society’s expectations

for female behavior and appearance but is comfortable with the image she has

developed and how it has worked for her, not against her.

Self-disclosure is not just sharing information and experiences. It also involves

a certain quality of presence the therapist brings to the therapeutic sessions. Effec-

tive therapist self-disclosure is grounded in authenticity and a sense of mutuality.

The therapist considers how the disclosures may affect the client by using what

relational-cultural theorists refer to as “anticipatory empathy.” Feminist therapists,

like counselors who subscribe to other theoretical orientations, are ethically com-

mitted to using self-disclosure appropriately to enhance the therapeutic process.

The therapist also clearly states her relevant values and beliefs about society

to allow Alma to make an informed choice about whether or not to enter into a

professional relationship with this therapist. The therapist explains to Alma the

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therapeutic interventions that are likely to be employed. Alma, as an informed

consumer, will be involved in evaluating how well these strategies are working and

the degree to which her personal goals in therapy are being met.

g e n d e r - r o l e a n a ly s i s A hallmark of feminist therapy, gender-role analy-

sis explores the impact of gender-role expectations on the client’s psychological

well-being and draws upon this information to make decisions about future gender-

role behaviors (Enns, 2004). Some feminist therapists prefer the term “social iden-

tity analysis” because it refl ects the importance of assessing all relevant aspects of

a client’s identity, including multiple memberships in both socially disempowered

and privileged groups. Hayes (2008) proposes an ADDRESSING model that in-

cludes the elements of age, disability status, religion, ethnicity, race, social class,

and sexual orientation along with gender.

377

Gender-role analysis begins with clients identifying the societal messages they

FEMINIS

received about how women and men should be and act (Remer, 2008). The thera-

pist begins by asking Alma to identify messages she has received related to sexual-

ity and appearance from her culture, society, her peers, the media, and her family.

T THERAP

The therapist talks about how body image expectations differ between females

and males in our culture and how they may differ in other cultures. The therapist

explains how expectations related to appearance could intersect with beliefs about

Y

what it means to be gay or straight in Alma’s culture, family, and society as it

relates to her working environment. Alma decides what messages she would pre-

fer to have in her mind and keeps an open awareness when the discounting mes-

sages play in her head.

g e n d e r - r o l e i n t e rv e n t i o n Using this technique, the therapist responds

to Alma’s concern by placing it in the context of society’s role expectations for wom-

en. The aim is to provide Alma with insight into the ways social issues are affecting

her. Alma’s therapist responds to her statement with, “Our society really focuses

on sometimes unrealistic beauty ideals with females. The media bombards girls

and women with the message that they must be thin, have long straight hair, and

wear attractive clothing. The message is so ingrained that many girls are struggling

with self-esteem issues related to their appearance as early as elementary school to

avoid being bullied or to fi t in.” By placing Alma’s concern in the context of societal

expectations, the therapist gives Alma insight into how these expectations have af-

fected her psychological condition and have contributed to her feeling depressed

and anxious about judgment from others. The therapist’s statement also paves the

way for Alma to think more positively about her unity with other women and even

to think about how she might contribute as a role model for girls and young women

in the future.

p o w e r a n a ly s i s Power analysis refers to the range of methods aimed at

helping clients understand how unequal access to power and resources can infl u-

ence personal realities. Together therapists and clients explore how inequities or

institutional barriers often limit self-defi nition and well-being (Enns, 2004). With

this technique, Alma will become aware of the power difference between men and

women as well as the power differences associated with sexual orientation in our

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society. Specifi c issues related to Alma’s cultural perspective also are explored. In

Alma’s case the power analysis may focus on helping Alma identify alternate kinds

of power she may exercise and to challenge the gender-role messages that prohibit

the exercise of that kind of power. Interventions are aimed at helping Alma learn

to appreciate herself as she is, regain her self-confi dence based on the personality

attributes she possesses, and set goals that will be fulfi lling to her within the con-

text of her cultural values.

b i b l i o t h e r a p y Nonfi ction books, psychology and counseling textbooks, au-

tobiographies, self-help books, educational videos, fi lms, and even novels can all be

used as bibliotherapy resources. Reading about feminist perspectives on common

issues in women’s lives (incest, rape, battering, and sexual harassment) may chal-

lenge a woman’s tendency to blame herself for these problems (Remer, 2008). The

378

therapist describes a number of books that address issues of relevance to Alma, and

she selects one to read over the next few weeks. Providing Alma with reading ma-

VE

terial increases knowledge and decreases the power difference between Alma and

her therapist. Reading can supplement what is learned in the therapy sessions, and

Alma can enhance her therapy by exploring her reactions to what she is reading.

a s s e r t i v e n e s s t r a i n i n g By teaching and promoting assertive behavior,

CHAPTER TWEL

women become aware of their interpersonal rights, transcend stereotypical gender

roles, change negative beliefs, and implement changes in their daily lives. The

therapist and client consider what is culturally appropriate, and the client makes

decisions about when and how to use the new skill of assertion.

Through learning and practicing assertive behaviors and communication,

Alma may increase her own power, which will ameliorate her depression and

anxiety. Alma learns that it is her right to ask for what she wants and needs in the

workplace. The therapist helps Alma to evaluate and anticipate the consequences

of behaving assertively, which might range from criticism to actually getting what

she wants.

r e f r a m i n g a n d r e l a b e l i n g Like bibliotherapy, therapist self-disclosure,

and assertiveness training, reframing is not unique to feminist therapy. However,

reframing is applied uniquely in feminist therapy. Reframing includes a shift

from “blaming the victim” to a consideration of social factors in the environ-

ment that contribute to a client’s problem. In reframing, rather than dwelling

exclusively on intrapsychic factors, the focus is on examining societal or political

dimensions. Alma may come to understand that her depression and anxiety are

linked to social pressures to behave within hetero-normative gender-role expecta-

tions and to develop an appearance that matches these culturally and societally

prescribed ideals.

Relabeling is an intervention that changes the label or evaluation applied to

some behavioral characteristic. Alma can change certain labels she has attached

to herself, such as being inadequate or socially unwanted because she does not

conform to ideals commonly associated with feminism. An example might be that

Alma is encouraged to talk about herself as a strong and healthy woman rather

than as being “selfi sh” or too “masculine.”

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s o c i a l a c t i o n Social action, or social activism, is an essential quality of femi-

nist therapy (Enns, 2004). As clients become more grounded in their understanding

of feminism, therapists may suggest that clients become involved in activities such

as volunteering at a rape crisis center, lobbying lawmakers, or providing commu-

nity education about gender issues. Participating in such activities can empower

clients and help them see the link between their personal experiences and the

sociopolitical context in which they live. Alma might decide to join and partici-

pate in organizations that are working to change societal stereotypes about beauty

expectations for women or social groups that affi rm people who identify with a

variety of sexual and affectional orientations. Taking this kind of social action is

another way for Alma to feel more empowered.

g r o u p w o r k Group work became popular as a way for women to discuss their

379

lack of voice in many aspects of society. Historically, group work has been used for

FEMINIS

both consciousness-raising and support (Herlihy & McCollum, 2011). Conscious-

ness-raising groups initially provided an avenue for women to share their experi-

ences of oppression and powerlessness. Eventually, these groups evolved into self-

T THERAP

help groups that empowered women and challenged many of the social patterns

of the time (Evans, Kincade, Marbley, & Seem, 2005; Evans et al., 2011). Feminist

therapists often encourage their clients to make the transition from individual ther-

Y

apy to a group format such as joining a support group or a political action group as

soon as this is realistic (Herlihy & McCollum, 2011). Although these groups are as

diverse as the women who comprise them, they share a common denominator em-

phasizing support for the experience of women. The literature reveals that women

who join these groups eventually realize that they are not alone and gain validation

for their experiences by participating in the group. These groups can provide wom-

en with a social network, decrease feelings of isolation, create an environment that

encourages sharing of experiences, and help women realize that they are not alone

in their experiences (Eriksen & Kress, 2005). Groups provide a supportive context

where women can share and begin to critically explore the messages they have in-

ternalized about their self-worth and their place in society. The self-disclosures of

both the members and the leader foster deeper self-exploration, a sense of univer-

sality, and increased levels of cohesion. Members learn to use power effectively by

providing support to one another, practicing behavioral skills, considering social/

political actions, and by taking interpersonal risks in a safe setting (Enns, 2004).

Through their group participation, women learn that their individual experiences

are frequently rooted in problems within the system. In conjunction with the group

members, the group facilitator’s job is to design a group that results in both indi-

vidual and systemic change (Kees & Leech, 2004). Participation in a group experi-

ence can inspire women to take up some form of social action. Indeed, a form of

homework can be to carry out what women are learning in the group to bring about

changes in their lives outside of the group.

Alma and her therapist will likely discuss the possibility of Alma joining a

women’s support group, a gay-straight alliance, or another type of group as a part

of the process of terminating individual therapy. By joining a group Alma will have

opportunities to discover that she is not alone in her struggles. Other women can

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provide her with nurturance and support, and Alma will have the chance to be sig-

nifi cant to other women as they engage in their healing process.

The Role of Men in Feminist Therapy

Men can be feminist therapists, and feminist therapy can be practiced with male

clients. It is an erroneous perception that feminist therapy is conducted only by

women and for women, or that feminist therapy is anti-men because it is pro-women

(Herlihy & McCollum, 2011). Although the original feminist therapists were exclu-

sively women, men are now included among their ranks. Male feminist therapists

are willing to understand and “own” their male privilege, confront sexist behavior

in themselves and others, redefi ne masculinity and femininity according to other

than traditional values, work toward establishing egalitarian relationships, and ac-

tively support women’s efforts to create a just society.

380

The principles and practices of feminist psychotherapy are useful in working

VE

with male clients, individuals from diverse racial and cultural backgrounds, and

people who are committed to addressing social justice issues in counseling practice

(Enns, 2000, 2004; Worell & Remer, 2003). Social mandates about masculinity

such as restrictive emotionality, overvaluing power and control, the sexualization

of emotion, and obsession with achievement can be limiting to males (Gilbert &

CHAPTER TWEL

Scher, 1999; Pleck, 1995; Pollack, 1995, 1998; Real, 1998).

Some feminist therapists routinely work with men, especially with abusive

men and in batterers’ groups. According to Ganley (1988), issues that men can

deal with productively in feminist therapy include learning how to increase their

capacity for intimacy, expressing their emotions and learning self-disclosure, bal-

ancing achievement and relationship needs, accepting their vulnerabilities, and

creating collaborative relationships at work and with signifi cant others that are not

based on a “power-over” model of relating. Any presenting issue can be dealt with

from a feminist perspective.

f e m i n i s t t h e r a p y f r o m a

m u lt i c u lt u r a l a n d s o c i a l

j u s t i c e p e r s p e c t i v e

Strengths From a Diversity Perspective

Of all the theoretical approaches to counseling and psychotherapy in this book,

feminist therapy has the most in common with the multicultural and social justice

perspectives. Historically, multicultural approaches evolved in response to societal

oppression, discrimination, and marginalization faced by people of color. Over time,

multicultural counseling has become more inclusive, and contemporary multicul-

tural counselors work to address inequities created not only by racism but also by

other “isms” that limit full participation in society. Social justice counseling aims

to empower the individual as well as to confront injustice and inequality in society.

Although multicultural, feminist, and social justice counseling have been

viewed as disparate models, they have many common threads (Crethar, Torres

Rivera, & Nash, 2008). All three approaches emphasize the need to promote

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social, political, and environmental changes within the counseling context.

Practitioners of all three theories strive to create an egalitarian relationship in

which counselor and client co-construct the client’s problems from a contextual

perspective and collaborate in setting goals and choosing strategies. All three

approaches reject the “disease model” of psychopathology; they view clients’

problems as symptoms of their experiences of living in an unjust society rather

than as having an intrapsychic origin.

The “personal is political” principle is embraced equally in each of the ap-

proaches. None of the approaches rests solely on individual change; they all em-

phasize direct action for social change as a part of the role of therapists.

Culture encompasses the sociopolitical reality of people’s lives, including how

the privileged dominant group (in Western societies: White, Protestant, hetero-

sexual, rich males) treats those who are different from them. Feminist therapists

381

believe psychotherapy is inextricably bound to culture, and, increasingly, they are

FEMINIS

being joined by thoughtful leaders in the fi eld of counseling practice. All cultures

include feminist voices from within them today.

T THERAP

The women’s movement and the multicultural movement, and more recently

the social justice movement, have called to our attention the negative effects of dis-

crimination and oppression on their targets and also on those doing the discrimi-

Y

nating and oppressing. Culturally competent feminist therapists look for ways to

work within the client’s culture by exploring consequences and alternatives. They

appreciate the complexities involved in changing within one’s culture but do not

view culture as sacrosanct (Worell & Remer, 2003). It is important to understand

and respect diverse cultures, but most cultural contexts have both positive and

toxic aspects. Feminist therapists are committed to taking a critical look at cultural

beliefs and practices that discriminate against, subordinate, and restrict the poten-

tial of groups of individuals, which can be either a strength or a shortcoming.

Shortcomings From a Diversity Perspective

Feminist therapists advocate for change in the social structure, especially in the

areas of inequality, power in relationships, the right to self-determination, freedom

to pursue a career outside or inside the home, and the right to an education. This

agenda could pose some problems when working with women who do not share

these beliefs. Remer (2008) acknowledges this practice of critically evaluating soci-

etal values and structures that subordinate certain groups as a shortcoming of the

approach. If therapists do not fully understand and respect the cultural values of

clients from diverse groups, they run the risk of imposing their own values. Remer

claims “a potential danger inherent in feminist counseling is that counselors’ val-

ues will too strongly infl uence clients or will confl ict with clients’ values” (p. 431).

Being aware of the cultural context is especially important when feminist ther-

apists work with women from cultures that endorse culturally prescribed roles that

keep women in a subservient place or that are grounded in patriarchy. Consider

this scenario. You are a feminist therapist working with a Vietnamese woman who

is struggling to fi nd a way to be true to her culture and also to follow her own

educational and career aspirations. Your client is a student in a helping profession

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who is being subjected to extreme pressure from her father to return home and

take care of her family. Although she wants to complete a degree and eventually

help others in the Vietnamese community, she feels a great deal of guilt when she

considers “selfi shly” pursuing her education when her family at home needs her.

In this complex situation, the therapist is challenged to work together with the

client to fi nd a path that enables her to consider her own individual goals without

ignoring or devaluing her collectivistic cultural values. The therapist’s job is not

to take away her pain or struggle, nor to choose for the client, but to be present in

such a way that the client will truly be empowered to make signifi cant decisions.

The feminist counselor must remain aware that the price may be very high if this

woman chooses to go against what is culturally expected of her, and that the cli-

ent is the one to ultimately decide which path to follow. As can be seen from this

382

example, to minimize this potential shortcoming of imposing cultural values on

a client, it is essential that therapists understand how their own cultural perspec-

VE

tives are likely to infl uence their interventions, especially when they are working

with culturally diverse clients. A safeguard against value imposition is for feminist

therapists to clearly present their values to clients early in the course of the coun-

seling relationship so that clients can make an informed choice about continuing

this relationship (Remer, 2008).

CHAPTER TWEL

Feminist Therapy Applied to the Case of Stan

Stan’s fear of women and his gender-

ship, conveying to Stan that he is in charge of the

role socialization experiences make

direction of his therapy. I spend time explaining

him an excellent candidate to benefit

my view of the therapy process and how it works.

from feminist therapy. A therapeutic relationship

A gender-role analysis is conducted to help

that is egalitarian will be a new kind of experi-

Stan become aware of the influence of gender-

ence for Stan.

role expectations in the development of his

Stan has indicated that he is willing and even

problems. First, I ask him to identify gender-role

eager to change. Despite his low self-esteem and

messages he received while growing up from a

negative self-evaluations, he is able to identify

variety of societal sources including his parents,

some positive attributes. These include his deter-

teachers, the media, faith community, and peers.

mination, his ability to articulate his feelings, and

In his autobiography Stan has written about

his gift for working with children. Stan knows what

some of the messages his parents gave him,

he wants out of therapy and has clear goals: to

and this provides a natural starting point for his

stop drinking, to feel better about himself, to relate

analysis. He remembers his father calling him

to women on an equal basis, and to learn to love

“dumb” and his mother saying, “Why can’t you

and trust himself and others. Operating from a

grow up and be a man?” Stan wrote about his

feminist orientation, I will build on these strengths.

mother “continually harping at” his father and

In the first session I focus on establishing an

telling Stan how she wished she hadn’t had him.

egalitarian working relationship to help Stan begin

He describes his father as weak, passive, and

to regain his personal power. It is important that

mousy in relating to his mother and remembers

the therapeutic relationship does not replicate

that his father compared him unfavorably with

other relationships Stan has had with significant

his siblings. Stan internalized these messages,

figures in his life. I consciously work to demystify

often crying himself to sleep and feeling very

the therapeutic process and equalize the relation-

hopeless.

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I ask Stan to identify the damaging self-

First, he is beginning to believe he doesn’t need

statements he makes now that are based on

to keep blaming himself. He knows that many

these early experiences. As we review his

of the messages he has received from his

writings, Stan sees how societal messages he

parents and from society about what it means

received about what a man “should” be were

to be a man have been undesirable and one-

reinforced by parental messages and have

dimensional. He acknowledges that he has

shaped his view of himself today. For example,

been limited and constrained by his gender-role

he wrote that he feels sexually inadequate. It

socialization. Second, he feels hopeful because

appears that he has introjected the societal

there are alternatives to those parental and

notion that men should always initiate sex, be

societal definitions—people he admires have

ready for sex, and be able to achieve and sustain

been able to successfully combine “masculine”

an erection. Stan also sees that he has already

and “feminine” traits. If they can do it, so can he.

identified and written about how he wants to

I ask Stan whether he chooses to return for

change those messages, as exemplified in his

another session. When he answers in the

383

statements that he wants to “feel equal with

affirmative, I give him W. S. Pollack’s (1998)

FEMINIS

others” and not “feel apologetic” for his existence

book Real Boys to read. I explain that this book

and develop a loving relationship with a woman.

descriptively captures the gender-role socializa-

Stan begins to feel capable and empowered as I

tion that many boys experience.

T THERAP

acknowledge the important work he has already

Stan comes to the following session eager to

done, even before he entered therapy.

talk about his homework assignment. He tells me

I follow this gender-role analysis with a

that he gained some real insights into his own

Y

gender-role intervention to place Stan’s con-

attitudes and beliefs by reading Real Boys. What

cerns in the context of societal role expectations.

Stan learned from reading this book leads to a

I say, “Indeed, it is a burden to try to live up to

further exploration of his relationship with his

society’s notion of what it means to be a man,

mother. He finds it helpful to understand his par-

always having to be strong and tough. Those

ents’ behavior in the context of societal expecta-

aspects of yourself that you would like to value—

tions and stereotypes rather than continuing to

your ability to feel your feelings, being good with

blame them. I help Stan to see how our culture

children—are qualities society tends to label as

tends to hold extreme positions about mothers—

‘feminine.’” Stan replies wistfully, “Yeah, it would

that they are either perfect or wicked—and that

be a better world if women could be strong

neither of these extremes is true. As Stan learns

without being seen as domineering and if men

to reframe his relationship with his mother,

could be sensitive and nurturing without being

he develops a more realistic picture of her. He

seen as weak.” I raise the question, “Are you sure

comes to realize, too, that his father has been

that’s not possible? Have you ever met a woman

oppressed by his own socialization experiences

or a man who was like that?” Stan ponders for a

and by an idealistic view of masculinity that he

minute and then with some animation describes

may have felt unable to achieve.

the college professor who taught his Psychology

Stan continues to work at learning to value

of Adjustment class. Stan saw her as very

the nurturing and sensitive aspects of himself.

accomplished and strong but also as someone

He is learning to value the “feminine” aspects

who empowered him by encouraging him to find

of himself as well as the “masculine” side of

his own voice through writing his autobiography.

his personality. He also continues to monitor

He also remembers a male counselor at the

and make changes in his self-talk about what

youth rehabilitation facility where he spent part

it means to be a man. He is involved in gaining

of his adolescence as a man who was strong as

ongoing awareness of these messages that come

well as sensitive and nurturing.

from current sources such as the media and

As the first session draws to a close, I invite

friends. Since a number of Stan’s sessions were

Stan to talk about what he learned from our time

devoted to exploring his relationship with his

together. Stan says two things stand out for him.

mother, along with his resentment toward her, I

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suggest another reading assignment—

focus on, and what alternatives might

Caplan’s (1989) book, Don’t Blame Mother.

you offer?

The aim of this assignment is to assist

• In what ways could you integrate cog-

Stan in exploring alternatives to blaming

nitive behavior therapy with feminist

his mother for his present problems.

therapy in Stan’s case? What possibili-

Throughout our therapeutic relation-

ties do you see for integrating Gestalt

ship, we discuss with immediacy how

therapy methods with feminist thera-

we are communicating and relating to

py? What other therapies might you

each other during the sessions. I am

combine with a feminist approach?

self-disclosing and treat Stan as an equal,

• I used bibliotherapy as a form of home-

continually acknowledging that he is the

work assignment. Would you suggest

“expert” on his life.

books or films for Stan? If so, which

ones? What other homework might

Follow-Up: You Continue as Stan’s

384

you suggest to Stan? What other femi-

Feminist Therapist

nist therapy strategies would you utilize

VE

Use these questions to help you think

in counseling Stan?

about how you would counsel Stan using

a feminist therapy model:

See DVD for Theory and Practice of

• What unique values do you see in work-

Counseling and Psychotherapy: The

ing with Stan from a feminist perspective

Case of Stan and Lecturettes (Session 10

CHAPTER TWEL

as opposed to working from the other on feminist therapy) for a demonstra-

therapeutic approaches you’ve studied tion of my approach to counseling Stan

thus far?

from this perspective. This session deals

• If you were to continue working with with Stan’s exploration of his gender-role

Stan, what self-statements regarding identity and messages he has incorpo-

his view of himself as a man might you

rated about being a man.

s u m m a r y a n d e va l u at i o n

Summary

The origins of feminist therapy are connected with the women’s movements of the

late 1800s and the 1960s, when women united in vocalizing their dissatisfaction

over the restrictive nature of traditional female roles. Feminist therapy largely grew

out of the recognition by women that the traditional models of therapy suffer from

basic limitations due to the inherent bias of earlier theoreticians. Feminist therapy

emphasizes these concepts:

• Viewing problems in a sociopolitical and cultural context rather than on an

individual level

• Recognizing that clients know what is best for their lives and are experts on

their own lives

•

Striving to create a therapeutic relationship that is egalitarian through the proc-

ess of self-disclosure and informed consent

• Demystifying the therapeutic process by including the client as much as

possible in all phases of assessment and treatment, which increases client

empowerment

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• Viewing women’s experiences from a unique perspective

• Understanding and appreciating the lives and perspectives of diverse women

• Understanding that gender never exists in isolation from other aspects of identity

• Challenging traditional ways of assessing the psychological health of women

• Emphasizing the role of the therapist as advocate as well as facilitator

• Encouraging clients to get involved in social action to address oppressive

aspects of the environment

Feminist therapy is aimed at both personal and social change. The theory is not

static but is continually evolving and maturing. The major goal is to replace the

current patriarchal system with feminist consciousness and thus create a society

that values equality in relationships, values diversity, stresses interdependence

rather than dependence, and encourages both women and men to defi ne them-

385

selves rather than being defi ned by societal demands.

FEMINIS

Instead of being a singular and unifi ed approach to psychotherapy, feminist

practice tends to be diverse. As feminist therapy has matured, it has become more

self-critical and varied. Feminist therapists share a number of basic assumptions

T THERAP

and roles: they engage in appropriate self-disclosure; they make their values and

beliefs explicit so that the therapy process is clearly understood; they establish egal-

itarian roles with clients; they work toward client empowerment; they emphasize

Y

the commonalities among women while honoring their diverse life experiences;

and they all have an agenda to bring about social change.

Feminist therapists are committed to actively breaking down the hierarchy of

power in the therapeutic relationship through the use of various interventions.

Some of these strategies are unique to feminist therapy, such as gender-role analy-

sis and intervention, power analysis, assuming a stance of advocate in challenging

conventional attitudes toward appropriate roles for women, and encouraging cli-

ents to take social action. Other therapeutic strategies are borrowed from various

therapy models, including bibliotherapy, assertiveness training, cognitive restruc-

turing, reframing and relabeling, counselor self-disclosure, role playing, identify-

ing and challenging untested beliefs, and journal writing. Feminist therapy prin-

ciples and techniques can be applied to a range of therapeutic modalities such

as individual therapy, couples counseling, family therapy, group counseling, and

community intervention. Regardless of the specifi c techniques used, the overrid-

ing goals are client empowerment and social transformation.

Contributions of Feminist Therapy

One of the major contributions feminists have made to the fi eld of counseling and

psychotherapy is paving the way for gender-sensitive practice and an awareness of

the impact of the cultural context and multiple oppressions. By focusing attention

on our attitudes and biases pertaining to gender and culture, feminist therapists

have expanded the awareness of therapists of all theoretical orientations regarding

how social justice issues may touch clients. Feminists have had a major infl uence

on therapeutic practice with women and girls; for example, feminist perspectives

are refl ected throughout the American Psychological Association’s Guidelines for

Psychological Practice with Girls and Women (2007). A signifi cant contribution of

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28549_ch12_rev01.indd 385

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feminist therapy is the emphasis on social change, which can lead to a transforma-

tion in society. Therapists with a feminist orientation understand how important it

is to be fully aware of typical gender-role messages clients have grown up with, and

they are skilled in helping clients identify and examine these messages (Philpot,

Brooks, Lusterman, & Nutt, 1997).

According to Gilbert and Rader (2007), feminist therapists have brought about

signifi cant theoretical and professional advances in counseling practice. Some of

these contributions include power sharing with clients, cultural critiques of both

assessment and treatment approaches, and the validation of women and their nor-

mative experiences. Feminist therapists have also made important contributions

by questioning traditional counseling theories and models of human development.

Most theories place the cause of problems within individuals rather than with

386

external circumstances and the environment. This has led to holding individuals

responsible for their problems and not giving full recognition to social and politi-

VE

cal realities that create problems. A key contribution feminists continue to make

is reminding all of us that the proper focus of therapy includes addressing oppres-

sive factors in society rather than expecting individuals to merely adapt to expected

role behaviors. This emphasis on social justice issues has expanded the role of

therapists to be advocates for clients. For a discussion of adaptations to traditional

CHAPTER TWEL

approaches to counseling women, see Enns (2003).

Another major contribution of the feminist movement is in the areas of ethics in

psychology and counseling practice (Brabeck, 2000) and ethical decision making in

therapy (Rave & Larsen, 1995). The unifi ed feminist voice called attention to the extent

and implications of child abuse, incest, rape, sexual harassment, and domestic vio-

lence. Feminists pointed out the consequences of failing to recognize and take action

when children and women were victims of physical, sexual, and psychological abuse.

Feminist therapists work with male clients who are abusive, and increasing numbers

of groups composed of male batterers are led or co-led by feminist therapists.

Feminist therapists demanded action in cases of sexual misconduct at a time

when male therapists misused the trust placed in them by their female clients. Not

too long ago the codes of ethics of all the major professional organizations were

silent on the matter of therapist and client sexual liaisons. Now, virtually all of the

professional codes of ethics prohibit sexual intimacies with current clients and

with former clients for a specifi ed time period. Furthermore, the professions agree

that a sexual relationship cannot later be converted into a therapeutic relationship.

Largely due to the efforts and input of women on ethics committees, the existing

codes are explicit with respect to sexual harassment and sexual relationships with

clients, students, and supervisees (Herlihy & Corey, 2006b).

Feminist therapy principles have been applied to supervision, teaching, con-

sultation, ethics, research, and theory building as well as to the practice of psycho-

therapy. Building community, providing authentic mutual empathic relationships,

creating a sense of social awareness, and addressing social injustices are all signifi -

cant strengths of this approach.

The principles and techniques of feminist therapy can be incorporated in many

other contemporary therapy models and vice versa (Enns, 2003). Both feminist and

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Adlerian therapists view the therapeutic relationship as egalitarian. Both feminist

and person-centered therapists agree on the importance of therapist authenticity,

modeling, and self-disclosure; empowerment is the basic goal of both orientations.

When it comes to making choices about one’s destiny, existential and feminist

therapists are speaking the same language—both emphasize choosing for oneself

instead of living a life determined by societal dictates.

Although feminist therapists have been critical of psychoanalysis as a sexist

orientation, a number of feminist therapists believe psychoanalysis can be an

appropriate approach to helping women. Object-relations theory may help clients

examine internalized object representations that are based on their relationships

with their parents. Therapy might include an examination of unconscious learn-

ing about women’s roles through the mother–daughter relationship to provide in-

sights into why gender roles are so deeply ingrained and diffi cult to change.

387

Gestalt therapy and feminist therapy share the goal of increasing the client’s

FEMINIS

awareness of personal power. Gestalt therapy also is useful for increasing a wom-

an’s sense of herself as a powerful person (Enns, 2003). In many ways the dialogic,

T THERAP

relational, and collaborative model of Gestalt therapy fi ts well with the philosophy

of a feminist perspective (Enns, 1987, 2004).

Cognitive behavioral therapies and feminist therapy are compatible in that they

Y

view the therapeutic relationship as a collaborative partnership, with the client

being in charge of setting goals and selecting strategies for change. These approach-

es are committed to demystifying therapy, and both aim to help clients take charge

of their own lives. Both the cognitive behavior therapist and the feminist therapist

assume a range of information-giving and teaching functions so clients can become

active partners in the therapy process. A feminist therapist could employ action-

oriented strategies such as assertiveness training and behavioral rehearsal, and sug-

gest homework assignments for clients to practice in their everyday lives. A useful

source for further discussion of feminist cognitive behavior therapy is Worell and

Remer (2003).

Limitations and Criticisms of Feminist Therapy

Feminist therapists do not take a neutral stance; they believe therapy is a value-

oriented process. They emphasize the importance of counselors clarifying their

personal and professional values and being aware of the potential impact of these

values on clients. However, there is a danger that therapists may unduly infl u-

ence clients, especially those who lack a strong sense of their own values. Feminist

therapists must remain aware of their own values and explicitly share these values

with clients in an appropriate, timely, and respectful manner to reduce the risk of

value imposition.

Feminist therapists call attention to clients’ unexamined choices, but they must

honor clients’ choices as long as those choices are indeed informed. Once clients

understand the impact of gender and cultural factors on their choices, the therapist

must guard against providing specifi c directions for client growth. Feminist thera-

pists are committed to helping clients weigh the costs and benefi ts of their current

life choices but should not push clients too quickly toward changes they feel are

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28549_ch12_rev01.indd 387

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beyond their reach. Lenore Walker (1994) raised this issue with regard to working

with abused women. Although Walker focuses on the importance of asking ques-

tions that enable women to think through their situations in new ways and of help-

ing women develop “safety plans,” she emphasizes how critical it is to understand

those factors in a woman’s life that often pose diffi culties for her in making changes.

Looking at contextual or environmental factors that contribute to a woman’s

problems and moving away from exploring the intrapsychic domain can be both a

strength and a limitation. Instead of being blamed for her depression, the client is

able to come to an understanding of external realities that are indeed oppressive.

However, viewing the source of a client’s problem as being in the environment

could contribute to the client not taking personal responsibility to act in the face

of an unfair world. A client can make some internal changes even in those cir-

388

cumstances where external realities may largely be contributing to her problems.

Therapists must balance an exploration of the outer and inner worlds of the client

VE

if the client is to fi nd a way to take action in her own life.

Because feminist therapists do not assume a neutral stance, they need to iden-

tify any sources of bias and work toward restructuring or eliminating biased

aspects in any theories or techniques they employ. This is indeed a demanding

endeavor, and it should be considered an ongoing process.

CHAPTER TWEL

Factors that inhibit the growth of feminist therapy include training that is often

offered only sporadically in a nonsystematic way (Brown, 2010) and the lack of qual-

ity control. No credentialing organization confers offi cial status as a qualifi ed femi-

nist therapist, so formalized training and credentialing need to be addressed in the

future. In addition, evidence-based research on the effi cacy of feminist therapy is

lacking, as is an understanding of feminist therapy as an integrative approach that

can inform therapeutic practice for counselors of varied theoretical orientations.

w h e r e t o g o f r o m h e r e

The DVD for Integrative Counseling: The Case of Ruth and Lecturettes is especially

useful as a demonstration of interventions I make with Ruth that illustrate some

principles and procedures of feminist therapy. For example, in Session 1 (“Begin-

ning of Counseling”) I ask Ruth about her expectations and initiate the informed

consent process. I attempt to engage Ruth as a collaborative partner in the thera-

peutic venture, and I teach her how counseling works. Clearly, Ruth is the expert

on her own life and my job is to assist her in attaining the goals we collabora-

tively identify as a focus of therapy. In Session 4 (“Understanding and Addressing

Diversity”) Ruth brings up gender differences, and she also mentions our differ-

ences in religion, education, culture, and socialization. Ruth and I explore the

degree to which she feels comfortable with me and trusts me.

Other Resources

DVDs offered by the American Psychological Association that are relevant to this

chapter include the following:

Brown, L. S. (2009). Feminist Therapy Over Time (APA Psychotherapy Video

Series)

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Psychotherapy.net is a comprehensive resource for students and professionals that

offers videos and interviews on feminist therapy. New video and editorial content

is made available monthly. DVDs relevant to this chapter are available at www.

psychotherapy.net and include the following:

Walker, L.(1994). The Abused Woman: A Survivor Therapy Approach

Walker, L. (1997). Feminist Therapy (Psychotherapy With the Experts

Series)

The Jean Baker Miller Training Institute offers workshops, courses, professio-

nal training, publications, and ongoing projects that explore applications of the

relational-cultural approach and integrate research, psychological theory, and social

action. This relational-cultural model is based on the assumption that growth-

fostering relationships and disconnections are constructed within specifi c cultural

389

FEMINIS

contexts.

Jean Baker Miller Training Institute

Stone Center, Wellesley College

T THERAP

106 Central Street

Wellesley, MA 02481

Telephone: (781) 283-3800

Y

Fax: (781) 283-3646

Website: www.wellesley.edu/JBMTI/

The American Psychological Association has two divisions devoted to special inter-

ests in women’s issues: Division 17 (Counseling Psychology’s Section on Women)

and Division 35 (Psychology of Women).

American Psychological Association

750 First Street, N.E.

Washington, DC 20002-4242

Telephone: (202) 336-5500 or (800) 374-2721

Fax: (202) 336-5568

Association Website: www.apa.org

Division 17 Website: www.div17.org

Division 35 Website: www.apa.org/divisons/div35

The Association for Women in Psychology (AWP) sponsors an annual confer-

ence dealing with feminist contributions to the understanding of life experiences

of women. AWP is a scientifi c and educational feminist organization devoted

to reevaluating and reformulating the role that psychology and mental health

research generally play in women’s lives.

Association for Women in Psychology

Website: www.awpsych.org

The Psychology of Women Resource List, or POWR online, is cosponsored by APA

Division 35, Society for the Psychology of Women, and the Association for Women

in Psychology. This public electronic network facilitates discussion of current top-

ics, research, teaching strategies, and practice issues among people interested in

the discipline of psychology of women. Most people with computer access to Bitnet

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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or the Internet can subscribe to POWR-L at no cost. To subscribe, send the com-

mand below via e-mail to:

LISTSERV@URIACC (Binet) or LISTSERV@URIACC.URI.EDU

Subscribe POWR-L Your name (Use first and last name)

The University of Kentucky offers a minor specialty area in counseling women

and feminist therapy within the Counseling Psychology graduate programs. For

information, contact:

Dr. Pam Remer

University of Kentucky

Department of Educational and Counseling Psychology

251-C Dickey Hall

Lexington, KY 40506-0017

390

Telephone: (859) 257-4158

E-mail: Premer@uky.edu

VE

Website: www.uky.edu/Education/edphead.html

Texas Women’s University offers a training program with emphasis in women’s

issues, gender issues, and family psychology. For information, contact:

Dr. Roberta Nutt

CHAPTER TWEL

Texas Women’s University

Counseling Psychology Program

P. O. Box 425470

Denton, Texas 76204-5470

Telephone: (940) 898-2313

E-mail: rnutt@mail.twu.edu

Website: www.twu.edu/as/psyphil/Counseling_Home.htm

Recommended Supplementary Readings

Feminist Perspectives in Therapy: Empowering Diverse Women (Worell & Remer,

2003) is an outstanding text that clearly outlines the foundations of empower-

ment feminist therapy. The book covers a range of topics such as integrating

feminist and multicultural perspectives on therapy, changing roles for women,

feminist views of counseling practice, feminist transformation of counseling

theories, and a feminist approach to assessment and diagnosis. There also are

excellent chapters dealing with depression, surviving sexual assault, confronting

abuse, choosing a career path, and lesbian and ethnic minority women.

Feminist Theories and Feminist Psychotherapies: Origins, Themes, and Diversity

(Enns, 2004) describes the wide range of feminist theories that inform and infl u-

ence feminist practice. The book includes short self-assessment questionnaires

designed to help readers clarify their feminist theoretical perspective.

Feminist Therapy (Brown, 2010) provides an interesting perspective on the history

of feminist therapy and speculates about future developments of the approach.

Brown clearly explains key concepts of feminist theory and the therapeutic process.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch12_rev01.indd 390

20/09/11 3:46 PM

Introduction to Feminist Therapy: Strategies for Social and Individual Change (Evans,

Kincade, & Seem, 2011) emphasizes the practical applications of feminist theory

to clinical practice. They provide useful information on social change and empow-

erment, the importance of establishing an egalitarian relationship, and interven-

tion strategies when working with people from diverse cultural backgrounds.

The Healing Connection: How Women Form Relationships in Therapy and Life

(Miller & Stiver, 1997) describes how connections are formed between people

and how this leads to strong, healthy individuals. The authors also deal with dis-

connections between people that lead to anxiety, isolation, and depression.

Women’s Growth in Diversity: More Writings From the Stone Center (Jordan, 1997)

builds on the foundations laid by Women’s Growth in Connection (Jordan et al.,

1991) . This work offers insights on issues such as sexuality, shame, anger, de-

391

pression, power relations between women, and women’s experiences in therapy.

FEMINIS

References and Suggested Readings

T THERAP

American Psychiatric Association. (2000).

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Diagnostic and statistical manual of mental

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*Books and articles marked with an asterisk are suggested for further study.

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*Eriksen, K., & Kress, V. E. (2005). Beyond the

CHAPTER TWEL

DSM story: Ethical quandaries, challenges, and

Enns, C. Z. (1987). Gestalt therapy and femi-

best practices. Thousand Oaks, CA: Sage.

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Counseling and Development, 66, 93–95.

*Eriksen, K., & Kress, V. E. (2008). Gender

and diagnosis: Struggles and suggestions for

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counselors. Journal of Counseling & Develop-

models of women’s identity: A review and

ment, 86, 152–162.

critique for counselors. Journal of Counseling

and Development, 69, 209–217.

Espín, O. M. (1996). Latina healers: Lives of

power and tradition. Encino, CA: Floricanto

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counseling and therapy: From naming biases

to implementing multifaceted practice. The

Espín, O. M. (1997). Latina realities: Essays on

Counseling Psychologist, 21(1), 3–87.

healing, migration, and sexuality. Boulder, CO:

Westview Press.

Enns, C. Z. (2000). Gender issues in coun-

seling. In S. D. Brown & R. W. Lent (Eds.),

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*Enns, C. Z. (2003). Contemporary adapta-

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*Enns, C. Z. (2004). Feminist theories and

Evans, K. M., Kincade, E. A., & Seem, S. R.

feminist psychotherapies: Origins, themes, and

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Psychology: Research and Practice, 41(4),

therapy code of ethics (revised, 1999). San

333–339.

Francisco: Feminist Therapy Institute.

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Kaschak, E. (1992). Engendered lives.

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In J. L. DeLucia-Waack, D. Gerrity, C. R.

*Gilbert, L. A., & Rader, J. (2007). Feminist

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group counseling and psychotherapy

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issues in counseling: Multiple roles and respon-

worlds: Why men and women clash and how

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therapists can bring them together. Washington,

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*Herlihy, B., & Mccollum, V. J. (2011).

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paradigm: An update. In R. R. Levant & W. S.

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*Real, T. (1998). I don’t want to talk about it:

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CHAPTER TWEL

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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c h a p t e r 1 3

Postmodern Approaches

i n t r o d u c t i o n t o s o c i a l

p o s t m o d e r n a p p r o a c h e s f r o m a

c o n s t r u c t i o n i s m

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Some Contemporary Founders of Postmodern Therapies

The postmodern approaches do not have a single

focused brief therapy and two cofounders of nar-

founder. Rather, it has been a collective effort by

rative therapy who have had a major impact on the

many. I have highlighted two cofounders of solution-

development of these therapeutic approaches.

Insoo Kim Berg / Steve de Shazer / Michael White / David Epston

INSOO KIM BERG (1935–

practice of solution-focused brief therapy (SFBT),

2007) was a co-developer

she provided workshops in the United States,

of the solution-focused

Japan, South Korea, Australia, Denmark, England,

Center

approach. Until her death in

and Germany. Among her writings are Family Based

396

Therapy

2007, she was the director

Services: A Solution-Focused Approach (1994), Work-

Family

of the Brief Family Therapy

ing With the Problem Drinker: A Solution-Focused

Brief

Center in Milwaukee,

Approach (Berg & Miller, 1992), and Interviewing for

TEEN

of

Wisconsin. As a leader in the

Solutions (De Jong & Berg, 2008).

Courtesy

STEVE de SHAZER

brief therapy was developed. He wrote several

(1940–2005) was one of the

books on SFBT, including Keys to Solutions in Brief

CHAPTER THIR

Center

pioneers of solution-focused

Therapy (1985), Clues: Investigating Solutions in Brief

brief therapy. For many

Therapy (1988), Putting Difference to Work (1991), and

Therapy

years he was the director of

Words Were Originally Magic (1994). He presented

Family

research at the Brief Family

workshops, trained, and consulted widely in North

Brief

of

Therapy Center in Milwaukee,

America, Europe, Australia, and Asia. He died in

where solution-focused

September 2005 while on a teaching tour in Europe.

Courtesy

MICHAEL WHITE (1949–

has attracted widespread international interest.

2008) was the cofounder,

Among his many books are Narrative Means to

Centre,

with David Epston, of the

Therapeutic Ends (White & Epston, 1990), Reau-

narrative therapy move-

thoring Lives: Interviews and Essays (1995), Narrative

Dulwich

ment. He founded the

of Therapists’ Lives (1997), and Maps of Narrative

White,

Dulwich Centre in Adelaide,

Practice (2007). Michael White died in April 2008

Cheryl

Australia, and his work with

while visiting San Diego for a teaching workshop.

of

Australia

families and communities

Courtesy

Adelaide,

DAVID EPSTON (b. 1944)

North America. He is a coauthor of Narrative Means

is one of the co-developers

to Therapeutic Ends (White & Epston, 1990) and

of narrative therapy. He is

Playful Approaches to Serious Problems: Narrative

co-director of the Family

Therapy With Children and Their Families (Freeman,

Therapy Centre in Auckland,

Epston, & Lobovits, 1997). He is well known for his

Epston

New Zealand. He is an inter-

work with persons affected by eating disorders and

David

national traveler, presenting

was a coauthor of Biting the Hand That Starves You

of

lectures and workshops

(Maisel, Epston, & Borden, 2004).

Courtesy

in Australia, Europe, and

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch13_rev01.indd 396

20/09/11 3:57 PM

i n t r o d u c t i o n t o s o c i a l

c o n s t r u c t i o n i s m

Each of the models of counseling and psychotherapy we have studied so far has

its own version of “reality.” The simultaneous existence of multiple and often con-

fl icting “truths” has led to increasing skepticism of the possibility that a singular,

universal theory will one day explain human beings and the systems in which they

live. We have entered a postmodern world in which truth and reality are often

understood as points of view bounded by history and context rather than as objec-

tive, immutable facts.

Modernists believe in objective reality and assume that it can be observed and

systematically known through the scientifi c method. They further believe reality

exists independent of any attempt to observe it. Modernists believe people seek

397

therapy for a problem when they have deviated too far from some objective norm.

POS

For example, clients may think they are abnormally depressed when they experi-

T

MODERN APPR

ence sadness for longer than they think is normal. They might then seek help to

return to “normal” behavior.

Postmodernists, in contrast, believe that realities do not exist independent of

observational processes. Social constructionism is a psychological expression of this

postmodern worldview; it values the client’s reality without disputing whether it is

O

A

accurate or rational (Gergen, 1991, 1999; Weishaar, 1993). To social construction-

CHES

ists, any understanding of reality is based on the use of language and is largely a

function of the situations in which people live. Our knowledge about realities is so-

cially constructed. A person is depressed when he or she adopts a defi nition of self

as depressed. Once a defi nition of self is adopted, it is hard to recognize behaviors

counter to that defi nition; for example, it is hard for someone who is suffering from

depression to acknowledge the value of a periodic good mood in his or her life.

In postmodern thinking, forms of language and the use of language in stories

create meaning. There may be as many meanings as there are people to tell the

stories, and each of these stories expresses a truth for the person telling it. Every

person involved in a situation has a perspective on the “reality” of that situation,

but the range of truths is limited due to the effects of specifi c historical events and

the language uses that dominate particular social contexts. In practice, therefore,

the range of possible meanings is not infi nite. When Kenneth Gergen (1985, 1991,

1999) and others began to emphasize the ways in which people make meaning in

social relationships, the fi eld of social constructionism was born. Berger and Luck-

man (1967) are reputed to be the fi rst who used the term social constructionism, and

it signaled a shift in emphasis for individual and family systems psychotherapy.

In social constructionism the therapist disavows the role of expert, preferring a

more collaborative or consultative stance. Clients are viewed as experts about their

own lives. De Jong and Berg (2008) put this notion about the therapist’s task well:

We do not view ourselves as expert at scientifi cally assessing client problems and then inter-

vening. Instead, we strive to be expert at exploring clients’ frames of reference and identify-

ing those perceptions that clients can use to create more satisfying lives. (p. 19)

The collaborative partnership in the therapeutic process is considered more impor-

tant than assessment or technique. Understanding narratives and deconstructing

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language processes (linguistics) are the focus for both understanding individuals

and helping them construct desired change.

Social constructionist theory is grounded on four key assumptions (Burr, 2003),

which form the basis of the difference between postmodernism and traditional psycho-

logical perspectives. First, social constructionist theory invites a critical stance toward

taken-for-granted knowledge. Social constructionists challenge conventional knowl-

edge that has historically guided our understanding of the world, and they caution us to

be suspicious of assumptions of how the world appears to be. Second, social construc-

tionists believe the language and concepts we use to generally understand the world are

historically and culturally specifi c. Knowledge is time- and culture-bound, and our ways

of understanding are not necessarily better than other ways. Third, social construction-

ists assert that knowledge is constructed through social processes. What we consider to

398

be “truth” is a product of daily interactions between people in daily life. Thus there is

not a single or “right” way to live one’s life. Fourth, negotiated understandings (social

constructions) are considered to be practices that affect social life rather than being

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abstractions from it. Therefore, knowledge and social action go together.

See the video program for Chapter 13, DVD for Theory and Practice of Counseling

and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the

brief lecture for each chapter prior to reading the chapter.

CHAPTER THIR

Historical Glimpse of Social Constructionism

A mere hundred years ago, Freud, Adler, and Jung were part of a major paradigm

shift that transformed psychology as well as philosophy, science, medicine, and

even the arts. In the 21st century, postmodern constructions of alternative knowl-

edge sources seem to be one of the paradigm shifts most likely to affect the fi eld

of psychotherapy. Postmodernist thought is infl uencing the development of many

psychotherapy theories and contemporary psychotherapeutic practice. The creation

of the self, which so dominated the modernist search for human essence and truth,

is being replaced with the concept of socially storied lives. Diversity, multiple frame-

works, and integration—collaboration of the knower with the known—are all part

of this new social movement, which provides a wider range of perspectives in coun-

seling practice. For some social constructionists, the process of “knowing” includes

a distrust of the dominant cultural positions that permeate families and society today

(White & Epston, 1990), particularly when the dominant culture exerts a destructive

impact on the lives of those who live beyond the margins of what is generally consid-

ered normal. Change begins by deconstructing the power of cultural narratives and

then proceeds to the co-construction of a new life of meaning.

Among the best-known postmodern perspectives on therapy practice are the

collaborative language systems approach (Anderson & Goolishian, 1992), solution-

focused brief therapy (de Shazer, 1985, 1988, 1991, 1994), solution-oriented ther-

apy (Bertolino & O’Hanlon, 2002; O’Hanlon & Weiner-Davis, 2003), narrative

therapy (White & Epston, 1990), and feminist therapy (Brown, 2010). The next sec-

tion examines the collaborative language systems approach, but the heart of this

chapter addresses two of the most signifi cant postmodern approaches: solution-

focused brief therapy and narrative therapy.

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The Collaborative Language Systems Approach

A relatively unstructured social constructionist dialogue has been suggested

by Harlene Anderson and the late Harold Goolishian (1992) of the Houston

Galveston Institute. Rejecting the more therapist-controlled and theory-based

interventions of other North American therapeutic approaches, Anderson

and Goolishian developed a therapy of caring and being with the client. Their

stance is similar to the person-centered way of being that originated with Carl

Rogers, but without the theory of self-actualization. Informed by and contrib-

uting to the fi eld of social constructionism, they came to believe human life is

constructed in personal and family narratives that maintain both process and

meaning in people’s lives. These narratives are constructed in social interac-

tion over time. The sociocultural systems in which people live are a product

of social interaction, not the other way around. In this sense, therapy is also a

399

POS

system process created in the therapeutic conversations of the client and the

listener-facilitator.

T

MODERN APPR

When people seek therapy, they are often “stuck” in a dialogic system that

has a unique language, meaning, and process related to “the problem.” Therapy

is another conversational system that becomes therapeutic through its “problem-

organizing, problem-dissolving” nature (Anderson & Goolishian, 1992, p. 27).

O

It is therapists’ willingness to enter the therapeutic conversation from a “not-

A

CHES

knowing” position that facilitates this caring relationship with the client. In

the not-knowing position, therapists still retain all of the knowledge and person-

al, experiential capacities they have gained over years of living, but they allow

themselves to enter the conversation with curiosity and with an intense interest

in discovery. The aim here is to enter a client’s world as fully as possible.

Clients become the experts who are informing and sharing with the therapist

the signifi cant narratives of their lives. The not-knowing position is empathic

and is most often characterized by questions that “come from an honest, con-

tinuous therapeutic posture of not understanding too quickly” (Anderson, 1993,

p. 331).

Based on the referral or intake process, the therapist enters the session with

some sense of what the client may wish to address. The questions the therapist

asks are always informed by the answers the client-expert has provided. The client’s

answers provide information that stimulates the interest of the therapist, still in a

posture of inquiry, and another question proceeds from each answer given. The

process is similar to the Socratic method without any preconceived idea about

how or in which direction the development of the stories should go. The intent of

the conversation is not to confront or challenge the narrative of the client but to

facilitate the telling and retelling of the story until opportunities for new meaning

and new stories develop: “Telling one’s story is a representation of experience; it

is constructing history in the present” (Anderson & Goolishian, 1992, p. 37). By

staying with the story, the therapist–client conversation evolves into a dialogue of

new meaning, constructing new narrative possibilities. This not-knowing position

of the therapist has been infused as a key concept for both the solution-focused and

the narrative therapeutic approaches.

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s o l u t i o n - f o c u s e d b r i e f t h e r a p y

Introduction

Solution-focused brief therapy (SFBT) is a future-focused, goal-oriented therapeu-

tic approach to brief therapy developed initially by Steve de Shazer and Insoo Kim

Berg at the Brief Family Therapy Center in Milwaukee in the early 1980s. SFBT

emphasizes strengths and resiliencies of people by focusing on exceptions to their

problems and their conceptualized solutions.

Having grown dissatisfi ed with the constraints of the strategic model, in the

1980s de Shazer collaborated with a number of therapists, including Eve Lipchik,

John Walter, Jane Peller, Michelle Weiner-Davis, and Bill O’Hanlon, who each

wrote extensively about solution-focused therapy and started their own solution-

focused training institutes. Both O’Hanlon and Weiner-Davis were infl uenced

400

by de Shazer and Berg’s original work, and they expanded on this foundation to

create what they called solution-oriented therapy. In this chapter when I discuss

TEEN

solution-focused brief therapy, solution-focused therapy, and solution-oriented therapy,

I am focusing on what these approaches have in common rather than looking at

their differences.

Key Concepts

CHAPTER THIR

u n i q u e f o c u s o f s f b t Solution-focused brief therapy (SFBT) differs from

traditional therapies by eschewing the past in favor of both the present and the

future. Therapists focus on what is possible, and they have little or no interest

in gaining an understanding of how the problem emerged. Behavior change

is viewed as the most effective approach to assisting people in enhancing their

lives. De Shazer (1988, 1991) suggests that it is not necessary to know the cause

of a problem to solve it and that there is no necessary relationship between the

causes of problems and their solutions. Assessing problems is not necessary for

change to occur. If knowing and understanding problems are unimportant, so

is searching for “right” or absolute solutions. Any person might consider mul-

tiple solutions, and what is right for one person may not be right for others. In

solution-focused brief therapy, clients choose the goals they wish to accomplish;

little attention is given to diagnosis, history taking, or exploring the emergence

of the problem (Berg & Miller, 1992; Gingerich & Eisengart, 2000; O’Hanlon &

Weiner-Davis, 2003).

p o s i t i v e o r i e n tat i o n Solution-focused brief therapy is grounded on the

optimistic assumption that people are healthy and competent and have the abil-

ity to construct solutions that can enhance their lives. An underlying assumption

of SFBT is that we already have the ability to resolve the challenges life brings us,

but at times we lose our sense of direction or our awareness of our competencies.

Regardless of what shape clients are in when they enter therapy, solution-focused

therapists believe clients are competent. The therapist’s role is to help clients recog-

nize the competencies they already possess and apply them toward solutions. The

essence of therapy involves building on clients’ hope and optimism by creating posi-

tive expectations that change is possible. SFBT is a nonpathologizing approach that

emphasizes competencies rather than defi cits, and strengths rather than weaknesses

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(Metcalf, 2001). The solution-focused model requires a philosophical stance of ac-

cepting people where they are and assisting them in creating solutions. Solution-

focused brief therapy has parallels with positive psychology, which concentrates

on what is right and what is working for people rather than dwelling on defi cits,

weaknesses, and problems (Murphy, 2008). By emphasizing positive dimensions,

clients quickly become involved in resolving their problems, which makes this a

very empowering approach.

Because clients often come to therapy in a “problem-oriented” state, even the

few solutions they have considered are wrapped in the power of the problem orien-

tation. Clients often have a story that is rooted in a deterministic view that what has

happened in their past will certainly shape their future. Solution-focused practi-

tioners counter this negative client presentation with optimistic conversations that

highlight a belief in achievable and usable goals. Therapists can be instrumental in

401

assisting clients in making a shift from a fi xed problem state to a world with new

POS

possibilities. One of the goals of SFBT is to shift clients’ perceptions by reframing

T

MODERN APPR

what White and Epston (1990) refer to as clients’ problem-saturated stories through

the counselor’s skillful use of language.

lo o k i n g f o r w h at i s w o r k i n g The emphasis of SFBT is to focus on

what is working in clients’ lives, which stands in stark contrast to the traditional

O

models of therapy that tend to be problem-focused. Individuals bring stories to

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therapy. Some stories are used to justify the client’s belief that life can’t be changed

or, worse, that life is moving them further and further away from their goals.

Solution-focused brief therapists assist clients in paying attention to the excep-

tions to their problem patterns. They promote hope by helping clients discover-

ing exceptions, or times when the problem is less intrusive in their life (Metcalf,

2001). SFBT focuses on fi nding out what people are doing that is working and then

helping them apply this knowledge to eliminate problems in the shortest amount

of time possible. Identifying what is working and encouraging clients to replicate

these patterns is extremely important (Murphy, 2008). A key concept is, “Once you

know what works, do more of it.” If something is not working, clients are encour-

aged to do something different, which typically involves drawing on their unique

strengths and successes.

There are various ways to assist clients in thinking about what has worked

for them. De Shazer (1991) prefers to engage clients in conversations that lead to

progressive narratives whereby people create situations in which they can make

steady gains toward their goals. De Shazer might say, “Tell me about times when

you felt a little better and when things were going your way.” It is in these stories

of life worth living that the power of problems is deconstructed and new solutions

are manifest and made possible.

b a s i c a s s u m p t i o n s g u i d i n g p r a c t i c e Walter and Peller (1992,

2000) think of solution-focused therapy as a model that explains how people

change and how they can reach their goals. Here are some of their basic assump-

tions about solution-focused therapy:

• Individuals who come to therapy do have the capability of behaving effectively, even

though this effectiveness may be temporarily blocked by negative cognitions. Prob-

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lem-focused thinking prevents people from recognizing effective ways they have

dealt with problems.

• There are advantages to a positive focus on solutions and on the future. If clients

can reorient themselves in the direction of their strengths using solution-talk,

there is a good chance therapy can be brief.

• There are exceptions to every problem, or times when the problem was absent.

By talking about these exceptions, clients can get clues to effective solutions

and can gain control over what had seemed to be an insurmountable personal

diffi culty. Rapid changes are possible when clients identify exceptions to their

problems and begin to organize their thinking around these exceptions instead

of around the problem.

• Clients often present only one side of themselves. Solution-focused therapists

402

invite clients to examine another side of the story they are presenting.

• No problem is constant, and change is inevitable. What people need to do is

become aware of any positive changes that are happening. Small changes pave

TEEN

the way for larger changes. Oftentimes, small changes are all that are needed

to resolve problems that clients bring to therapy. Like tipping the fi rst domino,

one small change leads to another, then another, and so on until the “solution

momentum” outweighs the problem momentum.

CHAPTER THIR

• Clients want to change, have the capacity to change, and are doing their best to

make change happen. Therapists should adopt a cooperative stance with clients

rather than devising strategies to control resistive patterns. When therapists

fi nd ways to cooperate with people, resistance does not occur.

• Clients can be trusted in their intention to solve their problems. Therapists as-

sume that clients want to change, can change, and will change under coopera-

tive and empowering therapeutic conditions. There are no “right” solutions to

specifi c problems that can be applied to all people. Each individual is unique

and so, too, is each solution.

Walter and Peller (2000) have moved away from the term therapy and refer to

what they do as personal consultation. They facilitate conversations around the pref-

erences and possibilities of their clients to help them create a positive future. By

avoiding the stance of the expert, Walter and Peller believe they can be interested,

curious, and encouraging in jointly exploring the desires of their clients.

The Therapeutic Process

Bertolino and O’Hanlon (2002) stress the importance of creating collaborative

therapeutic relationships and see doing so as necessary for successful therapy.

Acknowledging that therapists have expertise in creating a context for change, they

stress that clients are the experts on their own lives and often have a good sense

of what has or has not worked in the past and, as well, what might work in the

future. Solution-focused counseling assumes a collaborative approach with clients

in contrast to the educative stance that is typically associated with most traditional

models of therapy. If clients are involved in the therapeutic process from begin-

ning to end, the chances are increased that therapy will be successful. In short, col-

laborative and cooperative relationships tend to be more effective than hierarchical

relationships in therapy.

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Walter and Peller (1992) describe four steps that characterize the process of

SFBT: (1) Find out what clients want rather than searching for what they do not

want. (2) Do not look for pathology, and do not attempt to reduce clients by giv-

ing them a diagnostic label. Instead, look for what clients are doing that is already

working and encourage them to continue in that direction. (3) If what clients are

doing is not working, encourage them to experiment with doing something differ-

ent. (4) Keep therapy brief by approaching each session as if it were the last and

only session. Although these steps seem fairly obvious, the collaborative process of

the client and therapist constructing solutions is not merely a matter of mastering

a few techniques.

De Shazer (1991) believes clients can generally build solutions to their prob-

lems without any assessment of the nature of their problems. Given this frame-

work, the structure of solution building differs greatly from traditional approaches

403

to problem solving as can be seen in this brief description of the steps involved

POS

(De Jong & Berg, 2008):

T

MODERN APPR

1. Clients are given an opportunity to describe their problems. The therapist lis-

tens respectfully and carefully as clients answer the therapist’s question, “How

can I be useful to you?”

2. The therapist works with clients in developing well-formed goals as soon as

O

possible. The question is posed, “What will be different in your life when your

A

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problems are solved?”

3. The therapist asks clients about those times when their problems were not

present or when the problems were less severe. Clients are assisted in exploring

these exceptions, with special emphasis on what they did to make these events

happen.

4. At the end of each solution-building conversation, the therapist offers clients

summary feedback, provides encouragement, and suggests what clients might

observe or do before the next session to further solve their problem.

5. The therapist and clients evaluate the progress being made in reaching satisfac-

tory solutions by using a rating scale. Clients are asked what needs to be done

before they see their problem as being solved and also what their next step will be.

t h e r a p e u t i c g o a l s SFBT refl ects some basic notions about change, about

interaction, and about reaching goals. The solution-focused therapist believes peo-

ple have the ability to defi ne meaningful personal goals and that they have the

resources required to solve their problems. Goals are unique to each client and are

constructed by the client to create a richer future (Prochaska & Norcross, 2010). A

lack of clarity regarding client preferences, goals, and desired outcomes can result

in a rift between therapist and client. During the early phase of therapy, it is impor-

tant that clients be given the opportunity to express what they want from therapy

and what concerns they are willing to explore. From the fi rst contact with clients,

the therapist strives to create a climate that will facilitate change and encourage

clients to think in terms of a range of possibilities.

Solution-focused therapists concentrate on small, realistic, achievable changes

that can lead to additional positive outcomes. Because success tends to build

upon itself, modest goals are viewed as the beginning of change. Solution-focused

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practitioners join with the language of their clients, using similar words, pacing,

and tone. Therapists use questions such as these that presuppose change, posit

multiple answers, and remain goal-directed and future-oriented: “What did you

do, and what has changed since last time?” or “What did you notice that went bet-

ter?” (Bubenzer & West, 1993).

Walter and Peller (1992) and Murphy (2008) emphasize the importance of

assisting clients in creating well-defi ned goals that are (1) stated positively in the

client’s language; (2) are process- or action-oriented; (3) are structured in the here

and now; (4) are attainable, concrete, specifi c, and measurable; and (5) are control-

led by the client. Counselors should not too rigidly impose an agenda of getting

precise goals before clients have a chance to express their concerns. Clients must

feel that their concerns are heard and understood before they can formulate mean-

404

ingful personal goals. In a therapist’s zeal to be solution-focused, it is possible to

get lost in the mechanics of therapy and not attend suffi ciently to the interpersonal

aspects.

TEEN

Solution-oriented therapy offers several forms of goals: changing the viewing

of a situation or a frame of reference, changing the doing of the problematic situa-

tion, and tapping client strengths and resources (O’Hanlon & Weiner-Davis, 2003).

Therapists note the language they use, so they can increase their clients’ hope and

CHAPTER THIR

optimism and their openness to possibilities and change. Clients are encouraged

to engage in change- or solution-talk, rather than problem-talk, on the assumption

that what we talk about most will be what we produce. Talking about problems can

produce ongoing problems. Talk about change can produce change.

t h e r a p i s t ’s f u n c t i o n a n d r o l e Clients are much more likely to fully

participate in the therapeutic process if they perceive themselves as determining

the direction and purpose of the conversation (Walter & Peller, 1996). Much of

what the therapeutic process is about involves clients’ thinking about their future

and what they want to be different in their lives. Consistent with the postmodern

and social constructionist perspective, solution-focused brief therapists adopt a not-

knowing position to put clients in the position of being the experts about their own

lives. Therapists do not assume that by virtue of their expert frame of reference

they know the signifi cance of the client’s actions and experiences (Anderson &

Goolishian, 1992). This model casts the role and function of a therapist in quite

a different light from traditionally oriented therapists who view themselves as

experts in assessment and treatment. The therapist-as-expert is replaced by the

client-as-expert, especially when it comes to what the client wants in life and in

therapy. It is important that therapists actually believe that their clients are the

true experts on their own lives. According to Guterman (2006), therapists have

expertise in the process of change, but clients are the experts on what they want

changed. The therapist’s task is to point clients in the direction of change without

dictating what to change.

Therapists strive to create a climate of mutual respect, dialogue, and affi rma-

tion in which clients experience the freedom to create, explore, and coauthor their

evolving stories. A key therapeutic task consists of helping clients imagine how they

would like life to be different and what it would take to make this transformation

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happen. One of the functions of the therapist is to ask questions and, based on the

answers, generate further questions. Examples of some useful questions are “What

do you hope to gain from coming here?” “If you were to make the changes you de-

sire, how would that make a difference in your life?” and “What steps can you take

now that will lead to these changes?”

t h e t h e r a p e u t i c r e l at i o n s h i p The quality of the relationship between

therapist and client is a determining factor in the outcomes of SFBT, so relation-

ship building or engagement is a basic step in SFBT. The attitude of the therapist

is crucial to the effectiveness of the therapeutic process. It is essential to create a

sense of trust so clients will return for further sessions and will follow through on

homework suggestions. The therapeutic process works best when clients become

actively involved, when they experience a positive relationship with the therapist,

405

and when counseling addresses what clients see as being important (Murphy,

POS

2008). One way of creating an effective therapeutic partnership is for the therapist

T

to show clients how they can use the strengths and resources they already have to

MODERN APPR

construct solutions. Clients are encouraged to do something different and to be

creative in thinking about ways to deal with their present and future concerns.

De Shazer (1988) has described three kinds of relationships that may develop

between therapists and their clients:

O

A

1. Customer: the client and therapist jointly identify a problem and a solution to

CHES

work toward. The client realizes that to attain his or her goals, personal effort

will be required.

2. Complainant: the client describes a problem but is not able or willing to assume

a role in constructing a solution, believing that a solution is dependent on some-

one else’s actions. In this situation, the client generally expects the therapist to

change the other person to whom the client attributes the problem.

3. Visitor: the client comes to therapy because someone else (a spouse, parent,

teacher, or probation offi cer) thinks the client has a problem. This client may

not agree that he or she has a problem and may be unable to identify anything

to explore in therapy.

De Jong and Berg (2008) recommend using caution so that therapists do not box

clients into static identities. These three roles are only starting points for conversa-

tion. Rather than categorizing clients, therapists can refl ect on the kinds of rela-

tionships that are developing between their clients and themselves. For example,

clients who tend to place the cause of their problems on another person or persons

in their lives (complainants) may be helped by skilled intervention to begin to see

their own role in their problems and the necessity for taking active steps in creat-

ing solutions. A visitor client may be willing to work with the therapist to create a

customer relationship by exploring what the client needs to do to satisfy the other

person or “get them off their back.” Initially, some clients will feel powerless and

overwhelmed by their problems. Even clients who are unable to articulate a prob-

lem may change as the result of developing an effective therapeutic alliance. How

the therapist responds to different behaviors of clients has a lot to do with bringing

about a shift in the relationship. In short, both complainants and visitors have the

capacity for becoming customers.

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Application: Therapeutic Techniques and Procedures

Some of the key techniques that solution-focused practitioners are likely to employ

include looking for differences in doing, exception questions, scaling questions,

and the miracle question. If these techniques are used in a routine way without

developing a collaborative working alliance, they will not lead to effective results.

Murphy (2008) reminds us that these solution-focused techniques should be used

fl exibly and tailored to the unique circumstances of each client. Therapy is best

guided by the client’s goals, perceptions, resources, and feedback. Therapy should

not be determined by any absolutes or rigid standards outside the therapeutic rela-

tionship (namely, evidence-based treatments).

p r e t h e r a p y c h a n g e Simply scheduling an appointment often sets positive

change in motion. During the initial therapy session, it is common for solution-

406

focused therapists to ask, “What have you done since you called for the appointment

that has made a difference in your problem?” (de Shazer, 1985, 1988). By asking

TEEN

about such changes, the therapist can elicit, evoke, and amplify what clients have

already done by way of making positive change. These changes cannot be attrib-

uted to the therapy process itself, so asking about them tends to encourage clients

to rely less on their therapist and more on their own resources to accomplish their

treatment goals (McKeel, 1996; Weiner-Davis, de Shazer, & Gingerich, 1987).

CHAPTER THIR

e x c e p t i o n q u e s t i o n s SFBT is based on the notion that there were times in

clients’ lives when the problems they identify were not problematic. These times are

called exceptions and represent news of difference (Bateson, 1972). Solution-focused

therapists ask exception questions to direct clients to times when the problem did

not exist, or when the problem was not as intense. Exceptions are those past experi-

ences in a client’s life when it would be reasonable to have expected the problem

to occur, but somehow it did not (de Shazer, 1985; Murphy, 2008). By helping

clients identify and examine these exceptions, the chances are increased that they

will work toward solutions (Guterman, 2006). Once identifi ed by an individual,

these instances of success can be useful in making further changes. Change-focused

questions explore what clients believe to be important goals and how they can tap

their strengths and resources to reach their goals (Murphy, 2008). This exploration

reminds clients that problems are not all-powerful and have not existed forever; it

also provides a fi eld of opportunity for evoking resources, engaging strengths, and

positing possible solutions. The therapist asks clients what has to happen for these

exceptions to occur more often.

t h e m i r a c l e q u e s t i o n Therapy goals are developed by using what de

Shazer (1988) calls the miracle question, which is a main SFBT technique . The

therapist asks, “If a miracle happened and the problem you have was solved over-

night, how would you know it was solved, and what would be different?” Clients

are then encouraged to enact “what would be different” in spite of perceived prob-

lems. If a client asserts that she wants to feel more confi dent and secure, the thera-

pist might say: “Let yourself imagine that you leave the offi ce today and that you

are on track to acting more confi dently and securely. What will you be doing differ-

ently?” This process of considering hypothetical solutions refl ects O’Hanlon and

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Weiner-Davis’s (2003) belief that changing the doing and viewing of the perceived

problem changes the problem.

De Jong and Berg (2008) identify several reasons the miracle question is a

useful technique. Asking clients to consider that a miracle takes place opens up a

range of future possibilities. Clients are encouraged to allow themselves to dream

as a way of identifying the kinds of changes they most want to see. This question

has a future focus in that clients can begin to consider a different kind of life that

is not dominated by a particular problem. This intervention shifts the emphasis

from both past and current problems toward a more satisfying life in the future.

s c a l i n g q u e s t i o n s Solution-focused therapists also use scaling questions

when change in human experiences are not easily observed, such as feelings,

moods, or communication, and to assist clients in noticing that they are not com-

407

pletely defeated by their problem (de Shazer & Berg, 1988). For example, a woman

POS

reporting feelings of panic or anxiety might be asked: “On a scale of zero to 10,

T

with zero being how you felt when you fi rst came to therapy and 10 being how you

MODERN APPR

feel the day after your miracle occurs and your problem is gone, how would you

rate your anxiety right now?” Even if the client has only moved away from zero to

1, she has improved. How did she do that? What does she need to do to move an-

other number up the scale? Scaling questions enable clients to pay closer attention

O

to what they are doing and how they can take steps that will lead to the changes

A

CHES

they desire.

f o r m u l a f i r s t s e s s i o n ta s k The formula fi rst session task (FFST) is

a form of homework a therapist might give clients to complete between their fi rst

and second sessions. The therapist might say: “Between now and the next time we

meet, I would like you to observe, so that you can describe to me next time, what

happens in your (family, life, marriage, relationship) that you want to continue

to have happen” (de Shazer, 1985, p. 137). At the second session, clients can be

asked what they observed and what they would like to have happen in the future.

This kind of assignment offers clients hope that change is inevitable. It is not a

matter of if change will occur, but when it will happen. According to de Shazer,

this intervention tends to increase clients’ optimism and hope about their present

and future situation. The FFST technique emphasizes future solutions rather than

past problems (Murphy, 2008). Bertolino and O’Hanlon (2002) suggest that the

FFST intervention be used after clients have had a chance to express their present

concerns, views, and stories. It is important that clients feel understood before they

are directed to make changes.

t h e r a p i s t f e e d b a c k t o c l i e n t s Solution-focused practitioners gen-

erally take a break of 5 to 10 minutes toward the end of each session to compose

a summary message for clients. During this break therapists formulate feed-

back that will be given to clients after the break. De Jong and Berg (2008) de-

scribe three basic parts to the structure of the summary feedback: compliments,

a bridge, and suggesting a task. Compliments are genuine affi rmations of what

clients are already doing that is leading toward effective solutions. It is impor-

tant that complimenting is not done in a routine or mechanical way, but in an

encouraging manner that creates hope and conveys the expectation to clients

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that they can achieve their goals by drawing on their strengths and successes.

Second, a bridge links the initial compliments to the suggested tasks that will be

given. The bridge provides the rationale for the suggestions. The third aspect

of feedback consists of suggesting tasks to clients, which can be considered as

homework. Observational tasks ask clients to simply pay attention to some

aspect of their lives. This self-monitoring process helps clients note the differ-

ences when things are better, especially what was different about the way they

thought, felt, or behaved. Behavioral tasks require that clients actually do some-

thing the therapist believes would be useful to them in constructing solutions.

De Jong and Berg (2008) stress that a therapist’s feedback to clients addresses

what they need to do more of and do differently in order to increase the chances of

obtaining their goals.

408

t e r m i n at i n g From the very fi rst solution-focused interview, the therapist

is mindful of working toward termination. Once clients are able to construct a

TEEN

satisfactory solution, the therapeutic relationship can be terminated. The initial

goal-formation question that a therapist often asks is, “What needs to be different

in your life as a result of coming here for you to say that meeting with me was

worthwhile?” Another question to get clients thinking is, “When the problem is

solved, what will you be doing differently?” Through the use of scaling questions,

CHAPTER THIR

therapists can assist clients in monitoring their progress so clients can determine

when they no longer need to come to therapy (De Jong & Berg, 2008). Prior to end-

ing therapy, therapists assist clients in identifying things they can do to continue

the changes they have already made into the future. Clients can also be helped to

identify hurdles or perceived barriers that could get in the way of maintaining the

changes they have made.

Guterman (2006) maintains that the ultimate goal of solution-focused coun-

seling is to end treatment. He adds, “If counselors are not proactive in making

their treatment brief by design, then in many cases counseling will be brief by

default” (p. 67). Because this model of therapy is brief, present-centered, and

addresses specifi c complaints, it is very possible that clients will experience other

developmental concerns at a later time. Clients can ask for additional sessions

whenever they feel a need to get their life back on track or to update their story.

Dr. John Murphy puts many SFBT techniques into action as he illustrates assess-

ment and treatment from a solution-focused brief therapy approach in the case

of Ruth in Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 11).

a p p l i c at i o n t o g r o u p c o u n s e l i n g The solution-focused group prac-

titioner believes that people are competent, and that given a climate where they

can experience their competency, they are able to solve their own problems, ena-

bling them to live a richer life. From the beginning, the group facilitator sets a

tone of focusing on solutions (Metcalf, 1998) in which group members are given

an opportunity to describe their problems briefl y. A facilitator might begin a new

group by requesting, “I would like each of you to introduce yourself. As you do,

give us a brief idea as to why you are here and tell us what you would like for us

to know about you.” Facilitators help members to keep the problem external in

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conversations, which tends to be a relief because it gives members an opportunity

to see themselves as less problem-saturated. It is the facilitator’s role to create

opportunities for the members to view themselves as being resourceful. Because

SFBT is designed to be brief, the leader has the task of keeping group members

on a solution track rather than a problem track, which helps members to move in

a positive direction.

The group leader works with members in developing well-formed goals as

soon as possible. Leaders concentrate on small, realistic, achievable changes that

may lead to additional positive outcomes. Because success tends to build upon

itself, modest goals are viewed as the beginning of change. Questions used to as-

sist members in formulating clear goals might include “What will be different in

your life when each of your problems is solved?” and “What will be going on in

the future that will tell you and the rest of us in the group that things are better for

409

you?” Sometimes members talk about what others will be doing or not doing and

POS

forget to pay attention to their own goals or behavior. At times such as this they

T

MODERN APPR

can be asked, “And what about yourself? What will you be doing differently in that

picture? As a result of your doing things differently, how would you imagine others

responding to you?”

The facilitator asks members about times when their problems were not present

or when the problems were less severe. The members are assisted in exploring

O

A

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these exceptions, and special emphasis is placed on what they did to make these

events happen. The participants engage in identifying exceptions with each other.

This improves the group process and promotes a solution focus, which can become

quite powerful. Exceptions are real events that take place outside of the problem

context. In individual counseling, only the therapist and the client are observers of

competency. An advantage of group counseling is that the audience widens and

more input is possible (Metcalf, 1998).

The art of questioning is a main intervention used in solution-focused groups.

Questions are asked from a position of respect, genuine curiosity, sincere inter-

est, and openness. Group leaders use questions such as these that presuppose

change and remain goal-directed and future-oriented: “What did you do and what

has changed since last time?” or “What did you notice that went better?” Other

group members are encouraged to respond along with the group leader to promote

group interaction. Facilitators may pose questions like these: “Someday, when the

problems that brought you to this group are less problematic to you, what will you

be doing?” “As each of you listened to others today, is there someone in our group

who could be a source of encouragement for you to do something different?” The

leader is attempting to help the members identify exceptions and begin to recog-

nize personal resiliency and competency. Creating a group context in which the

members are able to learn more about their personal abilities is key to members

learning to resolve their own concerns.

Solution-focused group counseling offers a great deal of promise for practition-

ers who want a practical and time-effective approach to interventions in school set-

tings. As a cooperative approach, SFBT shifts the focus from what’s wrong in stu-

dents’ lives to what’s working for them (Murphy, 2008; Sklare, 2005). Rather than

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being a cookbook of techniques for removing students’ problems, this approach of-

fers school counselors a collaborative framework aimed at achieving small, concrete

changes that enable students to discover a more productive direction. This model has

much to offer to school counselors who are responsible for serving large caseloads

of students in a K–12 school system. For a more detailed treatment of how SFBT

can be applied to group work in the schools, see Sklare (2005) and Murphy (2008).

They give special attention to the process of goal setting and provides many concrete

examples of how counselors can assist students in identifying well-established goals.

For a more detailed discussion of SFBT in groups, see Corey (2012, chap. 16).

n a r r at i v e t h e r a p y

Introduction

410

Of all the social constructionists, Michael White and David Epston (1990) are best

known for their use of narrative in therapy. According to White (1992), individu-

TEEN

als construct the meaning of life in interpretive stories, which are then treated

as “truth.” Because of the power of dominant culture narratives, individuals tend

to internalize the messages from these dominant discourses, which often work

against the life opportunity of the individual.

Adopting a postmodern, narrative, social constructionist view sheds light on

CHAPTER THIR

how power, knowledge, and “truth” are negotiated in families and other social and

cultural contexts (Freedman & Combs, 1996). Therapy is, in part, a reestablish-

ment of personal agency from the oppression of external problems and the domi-

nant stories of larger systems.

Key Concepts

The key concepts and therapeutic process sections are adapted from several differ-

ent works, but primarily from these sources: Winslade and Monk (2007), Monk

(1997), Winslade, Crocket, and Monk (1997), McKenzie and Monk (1997), and

Freedman and Combs (1996).

f o c u s o f n a r r at i v e t h e r a p y The narrative approach involves adopt-

ing a shift in focus from most traditional theories. Therapists are encouraged to

establish a collaborative approach with a special interest in listening respectfully

to clients’ stories; to search for times in clients’ lives when they were resourceful;

to use questions as a way to engage clients and facilitate their exploration; to avoid

diagnosing and labeling clients or accepting a totalizing description based on a

problem; to assist clients in mapping the infl uence a problem has had on their

lives; and to assist clients in separating themselves from the dominant stories they

have internalized so that space can be opened for the creation of alternative life

stories (Freedman & Combs, 1996).

t h e r o l e o f s t o r i e s We live our lives by stories we tell about ourselves

and that others tell about us. These stories actually shape reality in that they con-

struct and constitute what we see, feel, and do. The stories we live by grow out of

conversations in a social and cultural context. Therapy clients do not assume the

role of pathologized victims who are leading hopeless and pathetic lives; rather,

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they emerge as courageous victors who have vivid stories to recount. The stories

not only change the person telling the story, but also change the therapist who is

privileged to be a part of this unfolding process (Monk, 1997).

l i s t e n i n g w i t h a n o p e n m i n d All social constructionist theories em-

phasize listening to clients without judgment or blame, affi rming and valuing

them. Narrative practice goes further in deconstructing the systems of normal-

izing judgment that are found in medical, psychological, and educational dis-

course. Normalizing judgment is any kind of judgment that locates a person on a

normal curve and is used to assess intelligence, mental health, or normal behavior.

Because these kinds of judgments claim to be objective measures, they are diffi cult

for individuals to resist and usually are internalized. Narrative therapists argue that

suspending personal judgment is of little value if you participate in normalizing

411

judgment. Deconstruction involves turning the tables and inquiring what clients

POS

think of the judgments they have been assigned. Narrative practitioners might be

T

said to invite people to pass judgment on the judgments that have been working

MODERN APPR

them over.

Lindsley (1994) emphasizes that therapists can encourage their clients to

reconsider absolutist judgments by moving toward seeing both “good” and “bad”

elements in situations. Narrative therapists make efforts to enable clients to modify

O

painful beliefs, values, and interpretations without imposing their value systems

A

CHES

and interpretations. They want to create meaning and new possibilities from the

stories clients share rather than out of a preconceived and ultimately imposed

theory of importance and value.

Although narrative therapists bring to the therapy venture certain attitudes

such as optimism, respectful curiosity and persistence, and a valuing for the cli-

ent’s knowledge, they seek to listen to the problem-saturated story of the client

without getting stuck. As narrative therapists listen to the client’s story, they stay

alert for details that give evidence of the client’s competence in taking stands

against oppressive problems. Winslade and Monk (2007) maintain that the thera-

pist believes that clients have abilities, talents, positive intentions, and life experi-

ences that can be the catalysts for new possibilities for action. The counselor needs

to demonstrate faith that these strengths and competencies can be identifi ed, even

when the client is having diffi culty seeing them.

During the narrative conversation, attention is given to avoiding totalizing lan-

guage, which reduces the complexity of the individual by assigning an all-embracing,

single description to the essence of the person. Therapists begin to separate the

person from the problem in their mind as they listen and respond (Winslade &

Monk, 2007).

The narrative perspective focuses on the capacity of humans for creative and

imaginative thought, which is often found in their resistance to dominant dis-

course. Narrative practitioners do not assume that they know more about the lives

of clients than their clients do. Clients are the primary interpreters of their own

experiences. People are viewed as active agents who are able to derive meaning

from their experiential world, and they are encouraged to join with others who

might share in the development of a counter story.

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The Therapeutic Process

This brief overview of the steps in the narrative therapeutic process illustrates the

structure of the narrative approach (O’Hanlon, 1994, pp. 25–26):

• Collaborate with the client to come up with a mutually acceptable name for the

problem.

• Personify the problem and attribute oppressive intentions and tactics to it.

• Investigate how the problem has been disrupting, dominating, or discouraging

to the client.

• Invite the client to see his or her story from a different perspective by offering

alternative meanings for events.

• Discover moments when the client wasn’t dominated or discouraged by the

problem by searching for exceptions to the problem.

412

• Find historical evidence to bolster a new view of the client as competent enough

to have stood up to, defeated, or escaped from the dominance or oppression

of the problem. (At this phase the person’s identity and life story begin to be

TEEN

rewritten.)

• Ask the client to speculate about what kind of future could be expected from

the strong, competent person who is emerging. As the client becomes free of

problem-saturated stories of the past, he or she can envision and plan for a less

CHAPTER THIR

problematic future.

• Find or create an audience for perceiving and supporting the new story. It is

not enough to recite a new story. The client needs to live the new story outside

of therapy. Because the person’s problem initially developed in a social context,

it is essential to involve the social environment in supporting the new life story

that has emerged in the conversations with the therapist.

Winslade and Monk (2007) stress that narrative conversations do not follow the

linear progression described here; it is better to think of these steps in terms of

cyclical progression containing the following elements:

• Move problem stories toward externalized descriptions of problems

• Map the effects of a problem on the individual

• Listen to signs of strength and competence in an individual’s problem-saturated

stories

• Build a new story of competence and document these achievements

t h e r a p y g o a l s A general goal of narrative therapy is to invite people to

describe their experience in new and fresh language. In doing this, they open up

new vistas of what is possible. This new language enables clients to develop new

meanings for problematic thoughts, feelings, and behaviors (Freedman & Combs,

1996). Narrative therapy almost always includes an awareness of the impact of

various aspects of dominant culture on human life. Narrative practitioners seek

to enlarge the perspective and focus and facilitate the discovery or creation of new

options that are unique to the people they see.

t h e r a p i s t ’s f u n c t i o n a n d r o l e Narrative therapists are active fa-

cilitators. The concepts of care, interest, respectful curiosity, openness, empathy,

contact, and even fascination are seen as a relational necessity. The not-knowing

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position, which allows therapists to follow, affi rm, and be guided by the stories of

their clients, creates participant-observer and process-facilitator roles for the thera-

pist and integrates therapy with a postmodern view of human inquiry.

A main task of the therapist is to help clients construct a preferred story line.

The narrative therapist adopts a stance characterized by respectful curiosity and

works with clients to explore both the impact of the problem on them and what

they are doing to reduce the effects of the problem (Winslade & Monk, 2007). One

of the main functions of the therapist is to ask questions of clients and, based on

the answers, to generate further questions.

White and Epston (1990) start with an exploration of the client in relation to

the presenting problem. It is not uncommon for clients to present initial stories in

which they and the problem are fused, as if one and the same. White uses questions

aimed at separating the problem from the people affected by the problem. This

413

shift in language begins the deconstruction of the original narrative in which the

POS

person and the problem were fused; now the problem is objectifi ed as external to

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MODERN APPR

the client.

Like the solution-focused therapist, the narrative therapist assumes the client

is the expert when it comes to what he or she wants in life. The narrative therapist

tends to avoid using language that embodies diagnosis, assessment, treatment,

and intervention. Functions such as diagnosis and assessment often grant prior-

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CHES

ity to the practitioner’s “truth” over clients’ knowledge about their own lives. The

narrative approach gives emphasis to understanding clients’ lived experiences and

de-emphasizes efforts to predict, interpret, and pathologize. Narrative practition-

ers are careful not to ascribe the major role of taking initiative in another per-

son’s life or usurping the agency (power) of the client in bringing about change

(Winslade et al., 1997).

When it comes to the effective practice of narrative therapy, there are no set for-

mulas or recipes to follow (Freedman & Combs, 1996; Monk, Winslade, Crocket, &

Epston, 1997; Winslade & Monk, 2007). Monk (1997) emphasizes that narrative

therapy will vary with each client because each person is unique. For Monk, narra-

tive conversations are based on a way of being, and if narrative counseling “is seen

as a formula or used as a recipe, clients will have the experience of having things

done to them and feel left out of the conversation” (p. 24).

t h e t h e r a p e u t i c r e l at i o n s h i p Narrative therapists place great im-

portance on the values and ethical commitments a therapist brings to the therapy

venture. Some of these attitudes include optimism and respect, curiosity and per-

sistence, valuing the client’s knowledge, and creating a special kind of relation-

ship characterized by a real power-sharing dialogue (Winslade & Monk, 2007).

Collaboration, compassion, refl ection, and discovery characterize the therapeutic

relationship. If this relationship is to be truly collaborative, the therapist needs to

be aware of how power manifests itself in his or her professional practice. This

does not mean that the therapist does not have authority as a professional. He or

she uses this authority, however, by treating clients as experts in their own lives.

Furthermore, the therapist is interested in facilitating the articulation of the values

and ethical commitments of the client.

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Winslade, Crocket, and Monk (1997) describe this collaboration as coauthor-

ing or sharing authority. Clients function as authors when they have the authority

to speak on their own behalf. In the narrative approach, the therapist-as-expert

is replaced by the client-as-expert. This notion challenges the stance of the thera-

pist as being an all-wise and all-knowing expert. Winslade and Monk (2007) state:

“The integrity of the counseling relationship is thus maintained while the client

is honored as the senior author in the construction of an alternative narrative

(pp. 57–58).

Clients are often stuck in a pattern of living a problem-saturated story that

does not work. When a client has a limited perception of his or her capacities

due to being saturated in problem thinking, it is the job of the therapist to elic-

it other strength-related stories to modify the client’s perception. The therapist

414

assists the client in this pursuit by entering into a dialogue and asking questions in

an effort to elicit the perspectives, resources, and unique experiences of the client.

The past is history, but it sometimes provides a foundation for understanding and

TEEN

discovering news of differences or unique outcomes that will make a difference.

The history of the problem often dominates understanding, but there is another

history that narrative therapists argue should not be neglected. It is the history of

the counter story to the problem story, which is constructed in conversation and

CHAPTER THIR

becomes the foundation for a different future. The narrative therapist supplies the

optimism and sometimes a process, but the client generates what is possible and

contributes the movement that actualizes it.

Application: Therapeutic Techniques and Procedures

The effective application of narrative therapy is more dependent on therapists’

attitudes or perspectives than on techniques. In the practice of narrative therapy,

there is no recipe, no set agenda, and no formula that the therapist can follow to

assure positive results (Drewery & Winslade, 1997). When externalizing questions

are approached mainly as a technique, the intervention will be shallow, forced, and

unlikely to produce signifi cant therapeutic effects (Freedman & Combs, 1996;

O’Hanlon, 1994).

Narrative therapists are in agreement with Carl Rogers on the notion of the

therapist’s way of being as opposed to being technique driven. A narrative approach

to counseling is more than the application of skills; it is based on the therapist’s

personal characteristics that create a climate that encourages clients to see their

stories from different perspectives. However, a series of “maps” of narrative con-

versational trajectories can help give structure and direction to a therapeutic conver-

sation (White, 2007). The approach is also an expression of an ethical stance, which

is grounded in a postmodern framework. It is from this conceptual framework that

practices are applied to assist clients in fi nding new meanings and new possibilities

in their lives (Winslade & Monk, 2007).

q u e s t i o n s . . . a n d m o r e q u e s t i o n s The questions narrative thera-

pists ask may seem embedded in a unique conversation, part of a dialogue about

earlier dialogues, a discovery of unique events, or an exploration of dominant cul-

ture processes and imperatives. Whatever the purpose, the questions are often

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circular, or relational, and they seek to empower clients in new ways. To use

Gregory Bateson’s (1972) famous phrase, they are questions in search of a differ-

ence that will make a difference.

Narrative therapists use questions as a way to generate experience rather than

to gather information. The aim of questioning is to progressively discover or con-

struct the client’s experience so that the client has a sense of a preferred direction.

Questions are always asked from a position of respect, curiosity, and openness.

Therapists ask questions from a not-knowing position, meaning that they do not

pose questions that they think they already know the answers to. Monk (1997)

describes this stance as follows:

In contrast to the normative, knowing stance, a narrative way of working invites the coun-

selor to take up the investigative, exploratory, archaeological position. She demonstrates to

the client that being a counselor does not imply any privileged access to the truth. The coun-

415

selor is consistently in the role of seeking understanding of the client’s experience. (p. 25)

POS

Through the process of asking questions, therapists provide clients with an op-

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MODERN APPR

portunity to explore various dimensions of their life situations. This questioning

process helps bring out the unstated cultural assumptions that contribute to the

original construction of the problem. The therapist is interested in fi nding out how

the problems fi rst became evident, and how they have affected clients’ views of

themselves (Monk, 1997). Narrative therapists attempt to engage people in decon-

O

A

structing problem-saturated stories, identifying preferred directions, and creating

CHES

alternative stories that support these preferred directions (Freedman & Combs,

1996). For a more complete discussion of the use of questions in narrative thera-

py, see Madigan (2011).

e x t e r n a l i z at i o n a n d d e c o n s t r u c t i o n Narrative therapists believe

it is not the person that is the problem, but the problem that is the problem (White,

1989). These problems often are products of the cultural world or of the power

relations in which this world is located. Living life means relating to problems, not

being fused with them.. Narrative therapists help clients deconstruct these prob-

lematic stories by disassembling the taken-for-granted assumptions that are made

about an event, which then opens alternative possibilities for living (Winslade &

Monk, 2007).

Externalization is one process for deconstructing the power of a narrative. This

process separates the person from identifi cation with the problem. When clients

view themselves as “being” the problem, they are limited in the ways they can effec-

tively deal with the problem. When clients experience the problem as being located

outside of themselves, they create a relationship with the problem. For example,

there is quite a difference between labeling someone an alcoholic and indicating

that alcohol has invaded his or her life. Separating the problem from the individual

facilitates hope and enables clients to take a stand against specifi c story lines, such

as self-blame. By understanding the cultural invitations to blame oneself, clients

can deconstruct this story line and generate a more positive, healing story.

The method used to separate the person from the problem is referred to

as externalizing conversation, which opens up space for new stories to emerge.

This method is particularly useful when people have internalized diagnoses and

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labels that have not been validating or empowering of the change process

(Bertolino & O’Hanlon, 2002). Externalizing conversations counteract oppressive,

problem-saturated stories and empower clients to feel competent to handle the

problems they face. Two stages of structuring externalizing conversations are (1) to

map the infl uence of the problem in the person’s life, and (2) to map the infl uence

of the person’s life back on the problem (McKenzie & Monk, 1997).

Mapping the infl uence of the problem on the person generates a great deal of

useful information and often results in people feeling less shamed and blamed.

People feel listened to and understood when the problem’s infl uences are explored

in a systematic fashion. A common question is, “When did this problem fi rst

appear in your life?” When this mapping is done carefully, it lays the foundation

for coauthoring a new story line for the client. Often clients feel outraged when

416

they see for the fi rst time how much the problem is affecting them. The job of the

therapist is to assist clients in tracing the problem from when it originated to the

present. Therapists may put a future twist on the problem by asking, “If the prob-

TEEN

lem were to continue for a month (or any time period), what would this mean

for you?” This question can motivate the client to join with the therapist in com-

bating the impact of the problem’s effects. Other useful questions are “To what

extent has this problem infl uenced your life?” and “How deeply has this problem

CHAPTER THIR

affected you?”

It is important to identify instances when the problem did not completely dom-

inate a client’s life. This kind of mapping can help the client who is disillusioned

by the problem see some hope for a different kind of life. Therapists look for these

“sparkling moments” as they engage in externalizing conversations with clients

(White & Epston, 1990).

The case of Brandon illustrates an externalizing conversation. Brandon says

that he gets angry far too much, especially when he feels that his wife is criticizing

him unjustly: “I just fl are! I pop off, get upset, fi ght back. Later, I wish I hadn’t, but

it’s too late. I’ve messed up again.” Questions about how his anger occurs, com-

plete with specifi c examples and events, can help chart the infl uence of the prob-

lem. However, it is questions like the ones that follow that externalize the problem:

“What is the mission of the anger, and how does it recruit you into this mission?”

“How does the anger get you, and how does it trick you into letting it become so

powerful?” “What does the anger require of you, and what happens to you when

you meet its requirements?” “What cultural supports (in your family/community/

world) have shaped the role that anger plays for you?”

s e a r c h f o r u n i q u e o u t c o m e s In the narrative approach, external-

izing questions are followed by questions searching for unique outcomes. The

therapist talks to the client about moments of choice or success regarding the

problem. This is done by selecting for attention any experience that stands apart

from the problem story, regardless of how insignifi cant it might seem to the cli-

ent. The therapist may ask: “Was there ever a time in which anger wanted to take

you over, and you resisted? What was that like for you? How did you do it?” These

questions are aimed at highlighting moments when the problem has not oc-

curred or when the problem has been dealt with successfully. Unique outcomes

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can often be found in the past or the present, but they can also be hypothesized

for the future: “What form would standing up against your anger take?” Explor-

ing questions such as these enables clients to see that change is possible. Linking

a series of such unique outcomes together starts to form a counter story. It is

within the account of unique outcomes that a gateway is provided for alternative

versions of a person’s life (White, 1992).

Following the description of a unique outcome, White (1992) suggests posing

questions, both direct and indirect, that lead to the elaboration of preferred identity

stories:

• What do you think this tells me about what you have wanted for your life and

about what you have been trying for in your life?

• How do you think knowing this has affected my view of you as a person?

417

• Of all those people who have known you, who would be least surprised that

POS

you have been able to take this step in addressing your problem’s infl uence in

T

your life?

MODERN APPR

• What actions might you commit yourself to if you were to more fully embrace

this knowledge of who you are? (p. 133)

The development of unique outcome stories into solution stories is facilitated by

what Epston and White (1992) call “circulation questions”:

O

A

• Now that you have reached this point in life, who else should know about it?

CHES

• I guess there are a number of people who have an outdated view of who you are

as a person. What ideas do you have about updating these views?

• If other people seek therapy for the same reasons you did, can I share with them

any of the important discoveries you have made? (p. 23)

These questions are not asked in a barrage-like manner. Questioning is an integral

part of the context of the narrative conversation, and each question is sensitively

attuned to the responses brought out by the previous question (White, 1992).

McKenzie and Monk (1997) suggest that therapists seek permission from the

client before asking a series of questions. By letting a client know that they do not

have answers to the questions they raise, therapists are putting the client in control

of the therapeutic process. Asking permission of the client to use persistent ques-

tioning tends to minimize the risk of inadvertently pressuring the client.

a lt e r n at i v e s t o r i e s a n d r e a u t h o r i n g Constructing new stories

goes hand in hand with deconstruction, and the narrative therapist listens for open-

ings to new stories. People can continually and actively reauthor their lives, and

narrative therapists invite clients to author alternative stories through “unique out-

comes,” defi ned as events that could not be predicted from listening to the domi-

nant problem-saturated story. The narrative therapist asks for openings: “Have you

ever been able to escape the infl uence of the problem?” The therapist listens for

clues to competence in the midst of a problematic story and builds a story of compe-

tence around it. Madigan (2011) suggests that a person’s life story is probably much

more interesting than the story being told. He maintains a therapist’s main task

is “to help people to remember, reclaim and reinvent a richer, thicker, and more

meaningful alternative story” (p. 159).

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A turning point in the narrative interview comes when clients make the choice

of whether to continue to live by a problem-saturated story or create an alternative

story (Winslade & Monk, 2007). Through the use of unique possibility questions,

the therapist moves the focus into the future. For example: “Given what you have

learned about yourself, what is the next step you might take?” “When you are act-

ing from your preferred identity, what actions will it lead you to do more of?” Such

questions encourage people to refl ect upon what they have presently achieved and

what their next steps might be.

The therapist works with clients collaboratively by helping them construct

more coherent and comprehensive stories (Neimeyer, 1993). Whether involved

in a free-fl owing conversation or engaged in a series of questions in a relatively

consistent process, narrative therapists seek to elicit new possibilities and em-

418

bed them in the life narratives and processes of the people they serve. White and

Epston’s (1990) inquiry into unique outcomes is similar to the exception ques-

tions of solution-focused therapists. Both seek to build on the competence already

TEEN

present in the person. The development of alternative stories, or narratives, is an

enactment of ultimate hope: Today is the fi rst day of the rest of your life. Refer to

Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 11) for two con-

crete examples of a narrative approach to working with Ruth from the perspectives

CHAPTER THIR

of Dr. Gerald Monk and Dr. John Winslade.

d o c u m e n t i n g t h e e v i d e n c e Narrative practitioners believe that new

stories take hold only when there is an audience to appreciate and support them.

Gaining an audience for the news that change is taking place needs to occur if

alternative stories are to stay alive (Andrews & Clark, 1996), and an appreciative

audience to new developments is consciously sought.

One technique for consolidating the gains a client makes is by writing let-

ters. Narrative therapists have pioneered the development of therapeutic letter

writing. These letters that the therapist writes provide a record of the session

and may include an externalizing description of the problem and its infl uence

on the client, as well as an account of the client’s strengths and abilities that are

identifi ed in a session. Letters can be read again at different times, and the story

that they are part of can be reinspired. The letter highlights the struggle the

client has had with the problem and draws distinctions between the problem-

saturated story and the developing new and preferred story (McKenzie & Monk,

1997).

Epston has developed a special facility for carrying on therapeutic dialogues

between sessions through the use of letters (White & Epston, 1990). His letters

may be long, chronicling the process of the interview and the agreements reached,

or short, highlighting a meaning or understanding reached in the session and

asking a question that has occurred to him since the end of the previous therapy

visit. These letters are used to encourage clients, noting their accomplishments in

relation to handling problems or speculating on the meaning of their accomplish-

ments for others in their community. Letters documenting the changes clients

have achieved tend to strengthen the signifi cance of the changes, both for the cli-

ent and for others in the client’s life (Winslade & Monk, 2007).

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David Nylund, a clinical social worker, uses narrative letters as a basic part of

his practice. Nylund describes a conceptual framework he has found useful in

structuring letters to his clients (Nylund & Thomas, 1994):

• The introductory paragraph reconnects the client to the previous therapy session.

• Statements summarize the infl uence the problem has had and is having on the

client.

• Questions the therapist thought about after the session that pertain to the alter-

native story that is developing may be posed to the client.

• The letter documents unique outcomes or exceptions to the problematic story

that emerged during the session. Where possible, the client’s words are quoted

verbatim. Using the client’s words enhances the therapeutic relationship,

resulting in the client feeling empowered and understood. This connection

419

leads to a more comfortable opportunity for the client to rethink descriptions

POS

and stories and to create new images, leading to change.

T

Nylund and Thomas (1994) contend that narrative letters reinforce the importance

MODERN APPR

of carrying what is being learned in the therapy offi ce into everyday life. The mes-

sage conveyed is that participating fully in the world is more important than being

in the therapy offi ce. In an informal survey of the perceptions of the value of narra-

tive letters by past clients, the average worth of a letter was equal to more than three

O

A

individual sessions. This fi nding is consistent with McKenzie and Monk’s (1997)

CHES

statement: “Some narrative counselors have suggested that a well-composed letter

following a therapy session or preceding another can be equal to about fi ve regular

sessions” (p. 113).

a p p l i c at i o n t o g r o u p c o u n s e l i n g Many of the techniques described

in this chapter can be applied to group counseling. Winslade and Monk (2007)

claim that the narrative emphasis on creating an appreciative audience for new

developments in an individual’s life lends itself to group counseling. They state:

“Groups provide a ready-made community of concern and many opportunities for

the kind of interaction that opens possibilities for new ways of living. New identi-

ties can be rehearsed and tried out into a wider world” (p. 135). They give several

examples of working in a narrative way with groups in schools: getting back on

track in schoolwork; an adventure-based program; an anger management group;

and a grief counseling group. For a detailed description of these narrative groups,

see Winslade and Monk (2007, chap. 5).

p o s t m o d e r n a p p r o a c h e s f r o m

a m u lt i c u lt u r a l p e r s p e c t i v e

Strengths From a Diversity Perspective

Social constructionism is congruent with the philosophy of multiculturalism.

One of the problems that culturally diverse clients often experience is the expecta-

tion that they should conform their lives to the truths and reality of the dominant

society of which they are a part. With the emphasis on multiple realities and the

assumption that what is perceived to be a truth is the product of social construc-

tion, the postmodern approaches are a good fi t with diverse worldviews.

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The social constructionist approach to therapy provides clients with a frame-

work to think about their thinking and to determine the impact stories have on

what they do. Clients are encouraged to explore how their realities are being con-

structed out of cultural discourse and the consequences that follow from such con-

structions. Within the framework of their cultural values and worldview, clients

can explore their beliefs and provide their own reinterpretations of signifi cant life

events. The practitioner with a social constructionist perspective can guide clients

in a manner that respects their underlying values. This dimension is especially im-

portant in those cases where counselors are from a different cultural background

or do not share the same worldview as their clients.

Narrative therapy is grounded in a sociocultural context, which makes this

approach especially relevant for counseling culturally diverse clients. Narrative ther-

420

apists operate on the premise that problems are identifi ed within social, cultural,

political, and relational contexts rather than existing within individuals. They are

very much concerned with considering the specifi cations of gender, ethnicity, race,

TEEN

disability, sexual orientation, social class, and spirituality and religion as therapeutic

issues. Furthermore, therapy becomes a place to reauthor the social constructions

and identity narratives that clients are fi nding problematic.

Narrative therapy is a relational and anti-individualistic practice. Michael White

CHAPTER THIR

believes that to address a person’s struggles in therapy without a relational and con-

textual understanding of his or her story is entirely absurd (Madigan, 2011). Narrative

therapists concentrate on problem stories that dominate and subjugate at the personal,

social, and cultural levels. The sociopolitical conceptualization of problems sheds light

on those cultural notions and practices that produce dominant and oppressive narra-

tives. From this orientation, practitioners take apart the cultural assumptions that are

a part of a client’s problem situation. People are able to come to an understanding of

how oppressive social practices have affected them. This awareness can lead to a new

perspective on dominant themes of oppression that have been such an integral part of

a client’s story, and with this cultural awareness new stories can be generated.

In their discussion of the multicultural infl uences on clients, Bertolino and O’Hanlon

(2002) make the point that they do not approach clients with a preconceived notion

about their experience. Instead, they learn from their clients about their experiential

world. Bertolino and O’Hanlon practice multicultural curiosity by listening respect-

fully to their clients, who become their best teachers. Here are some questions these

authors suggest as a way to more fully understand multicultural infl uences on a client:

• Tell me more about the infl uence that [some aspect of your culture] has played

in your life.

• What can you share with me about your background that will enable me to more

fully understand you?

• What challenges have you faced growing up in your culture?

• What, if anything, about your background has been diffi cult for you?

• How have you been able to draw on strengths and resources from your culture?

What resources can you draw from in times of need?

Questions such as these can shed light on specifi c cultural infl uences that have

been sources of support or that contributed to a client’s problem.

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Shortcomings From a Diversity Perspective

A potential shortcoming of the postmodern approaches pertains to the not-knowing

stance the therapist assumes, along with the assumption of the client-as-expert.

Individuals from many different cultural groups tend to elevate the professional as

the expert who will offer direction and solutions for the person seeking help. If the

therapist is telling the client, “I am not really an expert; you are the expert; I trust

in your resources for you to fi nd solutions to your problems,” then this may engen-

der lack of confi dence in the therapist. To avoid this situation, the therapist using

a solution-focused or a narrative orientation needs to convey to clients that he or

she has expertise in the process of therapy but clients are the experts in knowing

what they want in their lives. The postmodern approaches stress being transparent

with clients and honoring their hopes and expectations in therapy. This emphasis

creates a context for providing culturally responsive services.

421

Postmodern Approaches Applied to the Case of Stan

I operate from an integrative perspective

Soon after this orientation to how therapy

by combining concepts and techniques

works, I inquire about some specific goals that

from the solution-focused and narrative

Stan would like to reach through the therapy

approaches. From this framework, I am philo-

sessions. Stan gives clear signs that he is will-

sophically opposed to assessment and diagnosis

ing and eager to change. However, he adds that

using the DSM-IV-TR model, and I do not begin

he has become convinced that he suffers from

therapy with a formal assessment. Instead,

low self-esteem. I begin to externalize the idea

I engage Stan in collaborative conversations

of low self-esteem and inquire into its effects in

centered on change, competence, preferences,

his life. Then I start to focus Stan on looking for

possibilities, and ideas for making changes in the

exceptions to the problem of low self-esteem.

future.

I pose an exception question (solution-focused

I begin my work with Stan by inviting him

therapy): “What is different about the contexts

to tell me about the concerns that brought him

or times when you have not experienced low

to therapy and what he expects to accomplish

self-esteem?” Stan is able to identify some

in his sessions. I also provide Stan with a brief

positive characteristics: his courage, deter-

orientation of some of the basic ideas that guide

mination, and willingness to try new things in

my practice and describe my view of counseling

spite of his self-doubts, and his gift for working

as a collaborative partnership in which he is the

with children. Stan knows what he wants out

senior partner. Stan is somewhat surprised by

of therapy and has clear goals: to achieve his

this because he expected that I was the person

educational goals, to enhance his belief in him-

with the experience and expertise. He informs

self, to relate to women without fear, and to feel

me that he has very little confidence in knowing

more joy instead of sadness and anxiety.

how to proceed with his life, especially since he

I invite Stan to talk more about how he has

has “messed up” so often. I am aware that he has

managed to make the gains he has in spite of

self-doubts when it comes to assuming the role

struggling with the problem of self-doubt and

of senior partner. However, I work to demystify

low self-esteem.

the therapeutic process and establish a collabo-

I allow Stan to share his problem-saturated

rative relationship, conveying to Stan that he is in

story, but I do not get stuck in this narrative. I

charge of the direction his therapy will take.

invite Stan to think of his problems as external

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to the core of his selfhood. I help him to notice

of mapping the effects of the problem on his life.

the cultural forces that have recruited him into a

This process involves exploring how long the

story of thinking less about himself. Even during

problem has been around, the extent to which

the early sessions, I encourage Stan to separate

the problem has influenced various aspects of

his being from his problems by posing questions

his life, and how deeply the problem continues

that externalize his problem.

to affect him.

Although Stan presents several problem

As the sessions progress, there is a col-

areas that are of concern to him, I work with him

laborative effort aimed at investigating how the

on identifying one particular problem. Stan says

problem has been a disrupting, dominating, and

he is depressed a great deal of the time, and

discouraging influence. Stan comes to view his

he worries that his depression might someday

story from a different perspective. I continue

overwhelm him. After listening to Stan’s fears

talking with Stan about those moments when

and concerns, I ask Stan the miracle question

he has not been dominated or discouraged by

422

(solution-focused technique): “Let’s suppose

depression and anxiety and continue to search

that a miracle were to happen while you are

for exceptions to these problematic experi-

asleep tonight. When you wake up tomorrow,

ences. Stan and I participate in conversations

TEEN

the problems you are mentioning are gone.

about unique outcomes, or occasions when he

What would be the signs to you that this miracle

has demonstrated courage and persistence in

actually occurred and that your problems were

the face of discouraging events. Some of these

solved? How would your life be different?”

“sparkling moments” include Stan’s accomplish-

With this intervention, I am shifting the focus

ments in college, volunteer work with children,

CHAPTER THIR

from talking about problems to talking about

progress in curbing his tendencies to abuse

solutions. I explain to Stan that much of his ther-

alcohol, willingness to challenge his fears and

apy will deal with finding both present and future

make new acquaintances, talking back to self-

solutions rather than dwelling on past problems.

defeating internal messages, accomplishments

Together we engage in a conversation that fea-

in securing employment, and his willingness to

tures change-talk rather than problem-talk.

create a vision of a productive future.

To a great extent, Stan has linked his identity

With my help, Stan accumulates evidence

with his problems, especially depression. He

from his past to bolster a new view of himself

doesn’t think of his problems as being sepa-

as competent enough to have escaped from the

rate from himself. I want Stan to realize that he

dominance of problematic stories. At this phase

personally is not his problem, but instead that

in his therapy, Stan makes a decision to create

the problem is the problem. When I ask Stan to

an alternative narrative. Several sessions are

give a name to his problem, he eventually comes

devoted to reauthoring Stan’s story in ways that

up with “Disabling depression!” He then relates

are lively, creative, and colorful. Along with the

how his depression has kept him from function-

process of creating an alternative story, I explore

ing the way he would like in many areas of his

with Stan the possibilities of recruiting an audi-

life. I then use externalizing questions (narrative

ence who will reinforce his positive changes. I

technique) as a way to separate Stan from his

ask, “Who do you know who would be least sur-

problem: “How long has depression gotten the

prised to hear of your recent changes, and what

best of you?” “What has depression cost you?”

would this person know about you that would

“Have there been times when you stood up to

lead to him or her not being so surprised?”

depression and did not let it win?” Of course, I

Stan identifies one of his early teachers who

briefly explain to him what I am doing by using

served as a mentor to him and who believed in

externalizing language, lest he think this is a

him when Stan had little belief in himself. Some

strange way to counsel. I talk more about the ad-

therapy time is devoted to discussing how new

vantages of engaging in externalizing conversa-

stories take root only when there is an audience

tions. I also talk with Stan about the importance

to appreciate them.

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After five therapy sessions, Stan brings up

solution-focused and narrative models in your

the matter of termination. At the sixth and final

work with Stan?

session, I introduce scaling questions, ask-

• What unique values, if any, do you see in work-

ing Stan to rate his degree of improvement on

ing with Stan from a postmodern perspective as

a range of problems we explored in the past

opposed to working with Stan from the other

weeks. On a scale of zero to 10, Stan ranks how

therapeutic approaches you’ve studied thus far?

he saw himself prior to his first session and

• I asked many questions of Stan. List some

how he sees himself today on various specific

additional questions you would be particularly

dimensions. We also talked about Stan’s goals

interested in pursuing with Stan.

for his future and what kinds of improvements

• In what ways could you integrate SFBT and

he will need to make to attain what he wants. I

narrative therapy with feminist therapy in

then give Stan a letter I wrote summarizing both

Stan’s case? What other therapies might you

the problem story and its effects and also the

combine with the postmodern approaches?

counter story that we have been developing in

What other therapies would not combine so

423

therapy. In my narrative letter, I describe Stan’s

well with these postmodern therapies?

POS

determination and cooperation in his own words

• At this point, you are very familiar with the

T

and encourage him to circulate the news of the

MODERN APPR

themes in Stan’s life. If you were to write a nar-

differences he has brought about in his life. I also

rative letter that you would then give to Stan,

ask some questions that invite him to develop

what would you most want to include? What

the new story of identity more fully.

would you want to talk to him about regarding

Follow-Up: You Continue as Stan’s

his future?

O

A

Postmodern Therapist

CHES

Use these questions to help you think about how

See DVD for Theory and Practice of

to counsel Stan from a postmodernist approach:

Counseling and Psychotherapy: The Case

of Stan and Lecturettes (Session 11 on SFBT and

• As Stan’s therapist, I borrowed key concepts Session 12 on narrative therapy) for a demon-

and techniques common to both solution-fo-

stration of my approach to counseling Stan

cused and narrative orientations. In your work

from this perspective. Session 11 illustrates

with Stan, what specific concepts would you techniques such as identifying exceptions,

borrow from each of these approaches? What

the miracle question, and scaling. Session 12

techniques would you draw from each of the focuses on Stan’s work in creating a new story

approaches? What possible advantages do of his life.

you see, if any, in applying an integration of

s u m m a r y a n d e va l u at i o n

Summary

In social constructionist theory the therapist-as-expert is replaced by the client-

as-expert. Although clients are viewed as experts on their own lives, they are often

stuck in patterns that are not working well for them. Both solution-focused and nar-

rative therapists enter into dialogues in an effort to elicit the perspectives, resources,

and unique experiences of their clients. The therapeutic endeavor is a highly col-

laborative relationship in which the client is the senior partner. The qualities of

the therapeutic relationship are at the heart of the effectiveness of both SFBT and

narrative therapy. This has resulted in many therapists giving increased attention

to creating a collaborative relationship with clients. Collaborative therapists adjust

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their approach to each client or group instead of requiring clients to adapt to their

approach. Thus therapy may look very different for one client than for another.

The not-knowing position of the therapist has been infused as a key concept of

both the solution-focused and narrative therapeutic approaches. The not-knowing

position, which allows therapists to be curious about, affi rm, and be guided by the

stories of their clients, creates participant-observer and process-facilitator roles for the

therapist and integrates therapy with a postmodern perspective of human inquiry.

Both solution-focused brief therapy and narrative therapy are based on the

optimistic assumption that people are healthy, competent, resourceful, and pos-

sess the ability to construct solutions and alternative stories that can enhance their

lives. In SFBT the therapeutic process provides a context whereby individuals fo-

cus on creating solutions rather than talking about their problems. Some common

424

techniques include the use of miracle questions, exception questions, and scaling

questions. In narrative therapy the therapeutic process attends to the sociocultural

context wherein clients are assisted in separating themselves from their problems

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and are afforded the opportunity of authoring new stories.

Practitioners with solution-focused or narrative orientations tend to engage cli-

ents in conversations that lead to progressive narratives that help clients make steady

gains toward their goals. Therapists often ask clients: “Tell me about times when your

CHAPTER THIR

life was going the way you wanted it to.” These conversations illustrate stories of life

worth living. On the basis of these conversations, the power of problems is taken apart

(deconstructed) and new directions and solutions are manifest and made possible.

Contributions of Postmodern Approaches

Social constructionism, SFBT, and narrative therapy are making many contributions

to the fi eld of psychotherapy. I especially value the optimistic orientation of these post-

modern approaches that rest on the assumptions that people are competent and can

be trusted to use their resources in creating better solutions and more life-affi rming

stories. Many postmodern practitioners and writers have found that clients are able

to make signifi cant moves toward building more satisfying lives in a relatively short

period of time (Bertolino & O’Hanlon, 2002; De Jong & Berg, 2008; de Shazer, 1991;

Freedman & Combs, 1996; Miller, Hubble, & Duncan, 1996; O’Hanlon & Weiner-

Davis, 2003; Walter & Peller, 1992, 2000; Winslade & Monk, 2007).

To its credit, solution-focused therapy is a brief approach, of about fi ve sessions,

that seems to show promising results (de Shazer, 1991). In de Shazer’s summary

of two outcome studies at the Brief Family Therapy Center, he reports that 91% of

the clients who attended four or more sessions were successful in achieving their

treatment goals. SFBT tends to be very brief, even among the time-limited thera-

pies. In one study, Rothwell (2005) reports the average number of solution-focused

sessions to be two, in comparison to fi ve sessions for cognitive therapy. Brevity is

a main appeal of SFBT in an era of managed care, which places a premium on

short-term therapy. It should be noted that the brevity comes from the client being

in charge of goal setting and determining which issues are of immediate concern.

This differs from many other models in which the therapist determines the direc-

tion therapy should take. The narrative approach to counseling also tends to be

based on brief methods.

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I think the nonpathologizing stance characteristic of practitioners with a social

constructionist, solution-focused, or narrative orientation is a major contribution

to the counseling profession. Rather than dwelling on what is wrong with a per-

son, these approaches view the client as being competent and resourceful. People

cannot be reduced to a specifi c problem nor accurately labeled and identifi ed with

a disorder. Even practitioners who are expected to formulate a diagnosis can learn

the value of a respectful way to relate to clients.

Research from an “empirical generalizable” perspective is somewhat antithetical

to the social constructionist approach, but how effective is solution-focused brief ther-

apy? Regardless of the specifi c theoretical orientation of the therapist, brief therapy

has been shown to be effective for a wide range of clinical problems. Studies that have

compared brief therapies with long-term therapies have generally found no difference

in outcomes (McKeel, 1996). In a review of research of SFBT, McKeel concludes that

425

when SFBT techniques have been tested, the results are generally favorable. Although

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only a few studies of SFBT exist, outcome studies generally show that most clients

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receiving SFBT report accomplishing their treatment goals.

One particular area where the solution-focused approach shows promise

is in group treatment with domestic violence offenders . Lee, Sebold, and Uken

(2003) describe a cutting-edge treatment approach that seems to create effective,

positive change in domestic violence offenders. This approach is dramatically dif-

O

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ferent from traditional approaches in that there is virtually no emphasis on the

presenting problem of domestic violence. The approach focuses on holding

offenders accountable and responsible for building solutions rather than empha-

sizing their problems and defi cits. The process described by Lee and colleagues

is brief when measured against traditional program standards, lasting only eight

sessions over a 10- to 12-week period. Lee, Sebold, and Uken report research that

indicates a recidivism rate of 16.7% and completion rates of 92.9%. In contrast,

more traditional approaches typically generate recidivism rates between 40 and

60% and completion rates of less than 50%.

In their review of 15 outcome studies of SFBT, Gingerich and Eisengart (2000)

found that 5 studies were well controlled, and all showed positive outcomes. The

other 10 studies, which were only moderately controlled, supported a hypothesis

of the effectiveness of SFBT. The review of these studies provided preliminary sup-

port for the idea that SFBT may be benefi cial to clients, but methodological fl aws

did not permit a defi nitive conclusion. For a more detailed review of early research

and outcome measurement of SFBT, see De Jong and Berg (2008, chap. 11).

A major strength of both solution-focused and narrative therapies is the use of

questioning, which is the centerpiece of both approaches. Open-ended questions

about the client’s attitudes, thoughts, feeling, behaviors, and perceptions are one

of the main interventions. Especially useful are future-oriented questions that get

clients thinking about how they are likely to solve potential problems in the future.

Questions can assist clients in developing their story and discovering better ways

to deal with their concerns. Effective questioning can help individuals examine

their story and fi nd new ways to present their story. Winslade and Monk (2007)

note that a therapist’s careful questioning about clients’ early experiences of their

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch13_rev01.indd 425

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capabilities and resources tends to strengthen the foundation for clients in build-

ing a new sense of direction and for them to create alternative stories.

Limitation and Criticisms of Postmodern Approaches

To effectively practice solution-focused brief therapy, it is essential that therapists

are skilled in brief interventions. Although it may appear that SFBT is simple and

easy to implement, therapists practicing within this framework must be able to

make assessments, assist clients in formulating specifi c goals, and effectively use

a range of appropriate interventions. Some inexperienced or untrained therapists

may be enamored by the variety of techniques: the miracle question, scaling ques-

tions, the exception question, and externalizing questions. But effective therapy

is not simply a matter of relying on any of these interventions. The attitudes of

the therapist and his or her ability to use questions that are refl ective of genuine

426

respectful interest are crucial to the therapeutic process.

McKenzie and Monk (1997) express their concerns over those counselors who

TEEN

attempt to employ narrative ideas in a mechanistic fashion. They caution that

a risk in describing a map of a narrative orientation lies in the fact that some

beginners will pay more attention to following the map than they will to following

the lead of the client. In such situations, McKenzie and Monk are convinced that

mechanically using techniques will not be effective. They add that although nar-

CHAPTER THIR

rative therapy is based on some simple ideas, it is a mistake to assume that the

practice is simple.

McKeel (1996) observes that recent research on the importance of the thera-

peutic relationship is consistent with the SFBT view that positive treatment out-

comes are linked to therapists developing effective and collaborative working

relationships with clients. He cautions practitioners that losing sight of the po-

tency of the therapeutic relationship “will only doom SFBT to be remembered as a

disembodied set of clever techniques” (p. 265). Some solution-focused practition-

ers now acknowledge the problem of relying too much on a few techniques, and

they are placing increased importance on the therapeutic relationship and the

overall philosophy of the approach (Lipchik, 2002; Nichols, 2013).

Despite these limitations, the postmodern approaches have much to offer prac-

titioners, regardless of their theoretical orientation. Many of the basic concepts

and techniques of both solution-focused brief therapy and narrative therapy can be

integrated into the other therapeutic orientations discussed in this book.

w h e r e t o g o f r o m h e r e

Free Podcasts for ACA Members

You can download ACA Podcasts (prerecorded interviews) at www.counseling.org;

click on the Resource button and then the Podcast Series. For Chapter 13, Post-

modern Approaches, look for the following:

Interview with Dr. John Murphy on Solution-Focused Counseling in Schools

(Podcast 5) Lorraine Hedtke, L. & Winslade, J., Remembering Lives, Conversa-

tions With the Dying and Bereaved

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch13_rev01.indd 426

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Other Resources

Psychotherapy.net is a comprehensive resource for students and professionals that

offers videos and interviews on the postmodern approaches. New video and edito-

rial content is made available monthly. DVDs relevant to this chapter are available

at www.psychotherapy.net and include the following:

Madigan, S. (2002). Narrative Therapy With Children (Child Therapy With

the Experts)

Madigan, S. (1998). Narrative Family Therapy (Family Therapy With the Experts)

If you are interested in keeping up to date with the developments in brief therapy,

the Journal of Brief Therapy is a useful resource. It is devoted to developments,

innovations, and research related to brief therapy with individuals, couples, fami-

lies, and groups. The articles deal with brief therapy related to all theoretical

427

approaches, but especially to social constructionism, solution-focused therapy, and

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narrative therapy. For subscription information, contact:

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Springer Publishing Company

11 West 42nd Street, 15th Floor

New York, NY 10036

Toll-Free Telephone: (877) 687-7476

Website: www.springerpub.com

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A

Another useful journal is the International Journal of Narrative Therapy and Commu-

CHES

nity Work. For more information, contact:

Dulwich Centre

345 Carrington Street

Adelaide, South Australia 5000

Website: www.dulwichcentre.com.au/

Training in Solution-Focused Therapy Approaches

Center for Solution-Focused Brief Therapy

John Walter and Jane Peller

2320 Thayer Street

Evanston, IL 60201

Telephone: (847) 475-2691

E-mail: John Walter@aol.com

O’Hanlon and O’Hanlon Inc.

223 N. Guadalupe #278

Santa Fe, NM 87501

Telephone: (505) 983-2843

Fax: (505) 983-2761

E-mail: PossiBill@brieftherapy.com

Website: www.brief.org.uk

The Solution Focused Institute (SFI) at Texas Wesleyan University was founded in

January 2009 in Fort Worth, Texas, to provide training to mental health practition-

ers and school teachers and counselors who want to implement a solution-focused

approach in their work. The institute provides training on- and off-site in solution-

focused therapy and offers supervision to individuals and groups. For information

on SFI services, contact:

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch13_rev01.indd 427

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Linda Metcalf, PhD

Solution Focused Institute

3001 Avenue D

Fort Worth, TX 76105

Telephone: (817) 690-2229

Fax: (817) 531-4935

E-mail: lmetcalf@txwes.edu

Website:www.Solutionfocusedinstitute.com

Change-Focused Practice in Schools (CFPS) was initiated by John Murphy in 2005

to translate psychotherapy research into practical applications in schools and oth-

er settings. CFPS offers international training, supervision, and consultation on

solution-focused/outcome-informed approaches to helping young people change

in ways that honor their strengths and resources. For more information, contact:

428

John Murphy, PhD

Department of Psychology & Counseling

TEEN

University of Central Arkansas

Conway, AR 72035-0001

Telephone: (501) 450-5450

Fax: (501) 450-5424

E-mail: jmurphy@uca.edu

CHAPTER THIR

Website: www.drjohnmurphy.com

Training in Narrative Therapy

Evanston Family Therapy Institute

Jill Freedman and Gene Combs

820 Davis Street, Suite 504

Evanston, Illinois 60201

Dulwich Centre

Cheryl White

345 Carrington Street

Adelaide, South Australia 5000

http://www.dulwichcentre.com.au/

Bay Area Family Therapy Training Associates

Jeffrey L. Zimmerman and Marie-Nathalie Beaudoin

21760 Stevens Creek Blvd., Suite 102

Cupertino, CA 95015

Telephone: (408) 257-6881

Fax: (408) 257-0689

E-mail: baftta@aol.com

Website: www.baftta.com

The Houston-Galveston Institute

3316 Mount Vernon

Houston, TX 77006

Telephone: (713) 526-8390

Fax: (713) 528-2618

E-mail: admin@talkhgi.com

Website: www.talkhgi.com

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch13_rev01.indd 428

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Recommended Supplementary Readings

Interviewing for Solutions (De Jong & Berg, 2008) is a practical text aimed at

teaching and learning solution-focused skills. It is written in a conversational and

informal style and contains many examples to solidify learning of skills.

Solution-Focused Counseling in Schools (Murphy, 2008) is a clearly written and

practical book that offers effi cient strategies for addressing a range of problems

from preschool through high school. Numerous case examples illustrate the

foundations, tasks, and techniques of solution-focused counseling. The book also

describes how the principles of client-directed, outcome-informed practice can be

integrated in solution-focused counseling.

Narrative Means to Therapeutic Ends (White & Epston, 1990) is the most widely

429

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known book on narrative therapy.

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Maps of Narrative Practice (White, 2007) is Michael White’s fi nal book, which

brings together much of his work over several decades in one accessible volume.

Narrative Therapy (Madigan, 2011) provides an updated discussion of the theory

and therapeutic process of narrative therapy.

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A

Narrative Counseling in Schools (Winslade & Monk, 2007) is a basic and easy-

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to-read guide to applying concepts and techniques of narrative therapy to school

settings.

Narrative Therapy: The Social Construction of Preferred Realities (Freedman & Combs,

1996) is an exceptionally clear explanation of the basic ideas of narrative therapy.

The authors emphasize key concepts and the application of specifi c clinical prac-

tices. This is one of the best sources on the theory and practice of narrative therapy.

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Thousand Oaks, CA: Corwin Press.

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c h a p t e r 1 4

Family Systems Therapy

Coauthored by James Robert Bitter and Gerald Corey

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432

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Contributors to Family Systems Theory

Family systems therapy is represented by a variety

the individuals most closely associated with

of theories and approaches, all of which focus on

the origins of these systemic approaches are

the relational aspects of human problems. Some of

featured here.

Alfred Adler / Murray Bowen / Virginia Satir / Carl

Whitaker / Salvador Minuchin / Jay Haley and Cloé Madanes

ALFRED ADLER (1870–

family counseling sessions in an open public forum,

1937) was the first psy-

educating parents and professionals in greater

chologist of the modern era

numbers; they believed the problems of any one

to do family therapy using

family were common to all others in the commu-

Images

a systemic approach. He

nity (Christensen, 2004). As we have seen in the

433

F

set up more than 30 child

chapter on Adlerian therapy, the focus of interven-

AMIL

guidance clinics in Vienna

tions is on the purposes or goals of behavior—and

Archive/Getty

Y S

after World War I, and later

Adlerian family therapists extend this teleological

Hulton

Y

Rudolf Dreikurs brought this

focus to family interactions and patterns of com-

S

TEMS THERAP

concept to the United States in the form of family

munication.

education centers. Adler and Dreikurs conducted

MURRAY BOWEN

bers across generations. Two of his objectives in

of

(1913–1990) was one

therapy were to help family members develop a

Y

Study

of the original develop-

rational, nonreactive approach to living (called

the

for

ers of mainstream family

a differentiation of self) and to de-tangle family

Schara

therapy. Much of his theory

interactions that involved two people pulling a third

Center

Andrea

and practice grew out of

person into the couples’ problems and arguments

by

Bowen

his work at the National

(or triangulation). Bowen’s emphasis on a multi-

The

photo

of

Institute of Mental Health

generational perspective led to the development of

Family;

(and later at Georgetown

genograms (McGoldrick, Gerson, & Petry, 2008),

Courtesy

the

University) with schizo-

family life cycle development (McGoldrick, Carter,

phrenic individuals in families. He believed families

& Garcia-Preto, 2011), and a comprehensive focus

could best be understood when analyzed from a

on a multicultural perspective in family therapy

three-generation perspective because patterns of

(McGoldrick, Giordano, & Garcia-Preto, 2005).

interpersonal relationships connect family mem-

VIRGINIA SATIR (1916–

family to achieve change. The core of Satir’s model

1988) developed conjoint

relied on the power of congruence to help family

Network

family therapy, a human vali-

members communicate with emotional honesty.

Global

dation process model that

Her presence with people encouraged them to get in

Satir

emphasizes communication

touch with what was significant within, to become

Virginia

and emotional experienc-

more fully human, to share the individual’s best self

The

of

ing. Like Bowen, she used an

with a significant other: Satir called this experience

intergenerational model, but

“making contact,” and she believed that it extended

Courtesy

she worked to bring family

the peace one had within to a peace between peo-

patterns to life in the present through sculpting and

ple, and eventually, to a peace among people. From

family reconstructions. Claiming that techniques

Satir, family therapy gets it model for empathic lis-

were secondary to relationship, she concentrated

tening, therapeutic presence, and nurturance (Satir,

on the personal relationship between therapist and

Banmen, Gerber, & Gomori, 1991).

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

CARL WHITAKER

a sense of belonging in the family. He saw the

(1912–1995) is the creator

therapist as an active participant and coach who

of symbolic-experiential

enters the family process with creativity, putting

family therapy, a freewheel-

enough pressure on this process to produce change

Archives

ing, intuitive approach to

in the status quo. From Whitaker, the field of family

Madison

helping families open chan-

therapy learned to tolerate and sometimes create

nels of interaction. His goal

anxiety in families—and then how to join families

Wisconsin

was to facilitate individual

in their struggle to become more real and more

of

autonomy while retaining

transparent.

University

SALVADOR MINUCHIN

organization, of the family, the therapist helps

Family

(b. 1921) began to develop

the family modify its stereotyped patterns and

the

for

structural family therapy

redefine relationships among family members.

434

Center

in the 1960s through his

He believes structural changes in families must

work with delinquent boys

occur before individual members’ symptoms

TEEN

Minuchin

from poor families at the

can be reduced or eliminated. From Minuchin

Theof

OUR

Wiltwyck School in New

and his colleagues, family therapy developed

York. Working with col-

an understanding of power, organization,

Courtesy

leagues at the Philadelphia

and alignments in family life, and family thera-

Child Guidance Clinic in the 1970s, Minuchin

pists learned how to use themselves to set

CHAPTER F

refined the theory and practice of structural

boundaries and even unbalance dysfunctional

family therapy. Focusing on the structure, or

family systems.

JAY HALEY (1923–2007)

interventions. Madanes contributed to the

and CLOÉ MADANES

development of a brief, solution-oriented ther-

(b. 1941) founded the

apy approach. The strategic interventions most

Washington School of

favored by Haley and Madanes were reframing,

strategic family therapy

family directives, and paradoxical interven-

Madanes

in the 1970s, after Haley

tions. Strategic family therapy became the

Chloe

had left the Mental

most popular family therapy approach in the

of

Research Institute in

1980s. It is a pragmatic approach that focuses

Courtesy

Palo Alto, California, and

on solving problems in the present; understand-

later the Philadelphia

ing and insight are neither required nor sought.

Child Guidance Center, where he spent a brief

The problem brought by the family to therapy

period with Salvador Minuchin and colleagues.

is treated as “real”—not a symptom of underly-

Haley blended structural family therapy with

ing issues—and is solved. When the problem is

the concepts of hierarchy, power, and strategic

solved, therapy is finished.

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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See the video program for Chapter 14, DVD for Theory and Practice of Coun-

seling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you

view the brief lecture for each chapter prior to reading the chapter.

Differences Between Systemic and Individual Approaches

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CHAPTER F

The individual therapist may:

The systemic therapist may:

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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CHAPTER F

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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CHAPTER F

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

His Parents

Her Parents

John

Mary

Age 30

m. 2010

Age 29

2/27/86

12/22/87

John, Jr.

Ann

Age 5

Age 2

4/20/11

3/12/14

448

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CHAPTER F

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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CHAPTER F

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Shortcomings From a Diversity Perspective

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CHAPTER F

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Family Therapy Applied to the Case of Stan

In our work with Stan in this modal-

some possible ways to work with Stan from a

ity, we include examples of forming a

multilayered perspective.

relationship and joining, reading Stan’s

At an intake interview, a family therapist

genogram, a multilayered assessment, refram-

meets with Stan to explore his issues and con-

ing, boundary setting in therapy, and facilitating

cerns and to learn more about him and his life

change. There are many useful models and ways

situation. As they talk, the therapist brings an

to work with families; this discussion represents

intense interest and curiosity to the interview

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

and wonders out loud about the familial roots of

him. This initial conversation involves the devel-

some of Stan’s problems. It does not take much

opment of a genogram of Stan’s family of origin

of an inquiry to learn that Stan is still very much

(see Figure 14.1). This map will serve both Stan

engaged with his parents and siblings, no matter

and the therapist as a guide to the people and

how difficult these relationships have been for

the processes that influence Stan’s life.

d. 1977

(Cancer)

Tom

Martha

Joseph

m. 1937

Emma

b. 1920

m. 1940

b. 1921

b. 1907

b. 1917

Margie

Oris

Seth

d. 1968

b. 1944

453

b. 1938

b. 1942

(Vietnam)

F

AMIL

Y S

Y

Frank Sr.

m. 1962

S

b. 1940

Angie

TEMS THERAP

b. 1942

Matt

Y

b. 1960

Judy

Frank Jr.

Karl

Mary

b. 1963

b. 1966

b. 1972

b. 1963

Matthew

Stan

Stan

b. 1988

b. 1970

= Problem with alcohol

'JH V S F 5ISFF(FOFSBUJPO(FOPHSBNPG4UBOT'BNJMZ

Stan’s genogram is really a family picture,

through Alcoholics Anonymous. Stan’s maternal

or map, of his family-of-origin system. In this

grandmother always drank a little socially and

genogram, we learn that Stan’s grandparents

with her husband, but she never considered her-

tend to have lived fairly long lives. Stan’s maternal

self to have a problem. In her later years, however,

grandparents are both alive. The shaded lower half

she seems to secretly use alcohol more and more,

of their square and circle indicates that each had

and it is a source of distress in her marriage. Stan

some problem with alcohol. In the case of Tom,

also knows that Margie drinks a lot, because he

Stan reports that he was an admitted alcoholic

has been drinking with his aunt for years. She is

who recommitted himself to Christ and found help

the one who gave him his first drink.

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Angie, Stan’s mother, married Frank Sr. after

That’s what Stan needs to do. He just needs to

he had stopped drinking, also with the help of

stop.

AA. He still goes to meetings. Angie is suspi-

THERAPIST: So I’m hearing that life is better for

cious of all men around alcohol. She is especially

you without alcohol, and you would like Stan’s life

upset with Stan and with Judy’s husband, Matt,

to be better too. [ Reframing]

who “also drinks too much.” The genogram

FRANK SR.: Yeah. I’d like his life to be better in a lot

makes it easy to see the pattern of alcohol prob-

of different ways.

lems in this family.

THERAPIST: Angie, what about you? What is it like

The jagged lines /\/\/\/\ between Frank Sr.

for you to be here? [ Forming a relationship with each

and Angie indicate conflict in the relationship.

member]

The three solid lines === between Frank Sr. and

ANGIE: It’s heartbreaking. It’s always heartbreak-

Frank Jr., and between Angie and Karl, indicate a

ing. He [ Referring to Frank Sr. ] makes it sound as if

very close or even fused relationship. The double

he just summoned up his own personal power and

lines ==== between Karl and Stan are used to

454

quit drinking through his own strength of charac-

note a close relationship only. As we will see,

ter. That’s a laugh. I threatened to leave him. That’s

Karl actually looks up to Stan in this family. The

what really happened. I was ready to get a divorce!

TEEN

dotted lines . . . . . between Frank Sr. and Stan

And we’re Catholics. We don’t get divorced.

OUR

and between Frank Jr. and Stan indicate a distant

[ Possible face-to-face sequence around family stress

or even disengaged relationship.

and coping]

Since the family therapist believes that the

THERAPIST: So you’ve been through this before.

whole family is involved in Stan’s use of alco-

ANGIE: Oh my, yes. My father and mother drank.

CHAPTER F

hol, she spends a good part of the first session

Dad still does. My sister won’t admit it, but she

exploring with Stan processes for asking his

drinks too much. She goes crazy with it. Judy’s

other family members to join him in therapy.

husband has a problem. I’m surrounded by alco-

Stan may have many difficulties, but at the mo-

holics. I get so angry. I wish they would all just

ment his difficulty with alcohol is the primary

die or go away. [ Possible transgenerational family

focus. Alcohol is a negative part of his life, and

sequence: an entry point for exploring values, beliefs,

as such it has systemic meaning. It may have

and rules]

started out as a symptom of other problems,

THERAPIST: So this is something the whole family

but now the alcohol is a problem in itself. From

has been dealing with for a long time.

a systemic perspective, the questions are “How

ANGIE: Not everyone. I don’t drink. Frankie and

does this problem affect the family?” and “Is the

Judy don’t drink. And Karl doesn’t seem to have a

family using this problem to serve some other

problem.

purpose?”

THERAPIST: Is that how the family gets divided:

In the first therapy session with the family,

into those who drink and those who don’t?

the therapist’s main focus is in forming a

[ Possible organization perspective]

relationship with each of the family members,

JUDY: Drinking isn’t the only problem we have. It’s

but even here, a variety of approaches present

probably not even the most important.

themselves.

THERAPIST: Say more about that.

THERAPIST [ to Frank sr.]: I know coming here was

an inconvenience for you, but I want you to know

JUDY: Stan has always had it hard. I feel sorry

for him. Frankie is clearly Dad’s favorite [ Frank Sr.

how appreciative I am that you came. Can you tell

protests, saying he doesn’t have favorites], and things

me what it’s like for you to be here? [ Forming a

have always come easily for me. And Karl, he gets

relationship through joining]

whatever he wants. He’s Mom’s favorite. Mom and

FRANK SR.: Well, I have to tell you that I don’t like

Dad have fought a lot over the years. None of us

it much. [ Pause] Things are a lot different today

have been that happy, but Stan seems to have the

than they used to be. We didn’t have counseling

worst of it. [ Again, possible sequence and organiza-

20 years ago. I had a problem with drinking at

tion perspectives]

one point, but I got over it. I just quit—on my own.

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FRANK JR.: As I remember it, Stan gave Dad and

3. Stan has been reduced to a single part (his

Mom a lot to fight about. He was always messing

alcoholic part), and his description and ex-

up in one way or another.

perience of himself needs to be enlarged—

THERAPIST: Frankie, when your father was talk-

both for his own perspective and in the

ing earlier, I sensed he had some disappointment

eyes of others.

about Stan too, but he also wanted to see things

work out better for him. Is that true for you too?

A new place for Stan in the family, a better

[ Reframing Frankie’s comment, maintaining a focus

way of relating, and an ability to access “lost”

on new possibilities and new relations that might be

parts of his internal system are all critical to

developed]

winning his battle with alcohol. As therapy

FRANK JR.: Yes. I would like his life to be better.

continues, it becomes clear that two separate

relational–organization hypotheses must be

The initial part of this counseling session

explored. One is that the spousal relationship

has been devoted to meeting family members,

has been defined by the problem of alcohol

listening intently to the multiple perspectives

455

too, and it has not evolved or developed in any

they present, and reframing Stan’s problem into

F

kind of positive way over the years. Second,

AMIL

a family desire for a positive outcome. Although

the transgenerational sequences have targeted

there is a long way to go, the seeds of change

Y S

Stan and assigned him to a fixed role that he

have already been planted. There is evidence

Y

has been expected to play that has blocked de-

in these early interactions that Stan’s problem

S

TEMS THERAP

velopment past his middle to late adolescence,

has a multigenerational context. If this context

which was the period in which he started

is explored, family sequences that support and

drinking.

maintain alcohol as a problem may be identified.

It is possible to track these interactions and to

Follow-Up: You Continue as Stan’s

work toward more congruent communications.

Y

Family Therapist

Evolving relational, organizational, developmen-

Use these questions to help you think about how

tal sequences might be explored as a means of

you would counsel Stan from a family systems

freeing family members for new possibilities in

perspective:

their life together. Among other possibilities still

to be explored are perspectives related to gender

t What unique values do you see in working with

and culture. If the therapist were just listening

Stan from a multilayered, systemic perspective

to Stan, only one point of view would be evident.

as opposed to an individual therapy approach?

In this family session, multiple perspectives and

t What internal parts might Stan re-access as

the entire interactive process become clear in a

he continues in therapy? What parts of him

very short time.

might be polarized?

As the family interview proceeds, a number of

t Assuming that Stan was successful in getting

possibilities are presented for consideration. The

at least some of his family members to an-

therapist considers and may structure therapy

other session, where would you begin? Would

around any or all of the following possibilities:

you get everyone involved in the sessions? If

so, how would you do that?

1.

Stan’s parents have not been a well-

functioning leadership team for a long time,

t What are some specific ways to explore other

and both their spousal relationship and

perspectives with this family?

their parenting have suffered.

t What hypotheses are you developing, and

2. The adult siblings need a new opportunity

how would you share them with the family?

to function together without the influence t Are there systemic interventions that you would

and distractions continually imposed by the

find hopeful in terms of facilitating change?

parents.

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

s u m m a r y a n d e va l u at i o n

Summary

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CHAPTER F

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Limitations and Criticisms of Family Systems Approaches

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PS GPS B NBYJNVN PG ZFBST .FNCFST SFDFJWF UIF Journal of Marital and Fam-

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American Association for Marriage and Family Therapy

112 South Alfred Street

Alexandria, VA 22314-3061

Telephone: (703) 838-9808

Fax: (703) 838-9805

Website: www.aamft.org

Recommended Supplementary Readings

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practice. New York: Jason Aronson.

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tailoring treatment. Belmont, CA: Brooks/Cole,

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*Kerr, M. E., & Bowen, M. (1988). Family evalu-

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adjustment. In R. Dreikurs, Psychodynamics,

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native knowledges. In Experience, contradiction,

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David Epston and Michael White, 1989–1991

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Dulwich Centre.

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(3rd ed.). New York: Guilford Press.

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therapy techniques. Cambridge, MA: Harvard

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Prentice-Hall.

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ed.). Upper Saddle River, NJ: Prentice-Hall.

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therapy (Rev. ed.). New York: Norton.

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Richeport-Haley, M., & Carlson, J. (2010). Jay

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Haley revisited. New York: Routledge Books.

art of strategic therapy. New York: Brunner

Routledge.

Rogers, C. R. (1980). A way of being. Boston:

Houghton Mifflin.

*Hanna, S. M. (2007). The practice of family

therapy: Key elements across models (4th ed.).

*Satir, V. (1983). Conjoint family therapy

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(3rd ed.). Palo Alto, CA: Science and Behavior

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Satir, V. (1988). The new peoplemaking. Palo

and family counseling. Alexandria, VA: ACA/

Alto, CA: Science and Behavior Books.

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Satir, V., & Baldwin, M. (1983). Satir: Step-

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Gardner Press.

*Satir, V. M., Banman, J., Gerber, J., & Gamori,

M. (1991). The Satir model: Family therapy and

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beyond. Palo Alto, CA: Science and Behavior

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Books.

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Satir, V. M., & Bitter, J. R. (2000). The

White, M. (1997). Narratives of therapists’ lives.

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Adelaide, South Australia: Dulwich Centre.

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(5th ed.). Upper Saddle River, NJ: Merrill/

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch15_rev01.indd 462

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p a r t 3

Integration and

Application

15 An Integrative Perspective 464

16 Case Illustration: An Integrative Approach

i n Wo r k i n g Wi t h S ta n 503

463

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28549_ch15_rev01.indd 463

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c h a p t e r 1 5

An Integrative Perspective

i n t r o d u c t i o n

• Client’s Experience in Therapy

• Relationship Between Therapist

t h e m o v e m e n t t o w a r d

and Client

p s yc h o t h e r a p y i n t e g r at i o n

• Pathways Toward Psychotherapy Integration

t h e p l a c e o f t e c h n i q u e s a n d

e va l u at i o n i n c o u n s e l i n g

• Advantages of Psychotherapy Integration

• Integration of Multicultural Issues in

• Drawing on Techniques From Various

Counseling

Approaches

• Integration of Spirituality and Religion in

• Evaluating the Effectiveness of

Counseling

Counseling and Therapy

• The Challenge of Developing an Integrative

s u m m a ry

Perspective

w h e r e t o g o f r o m h e r e

i s s u e s r e l at e d t o t h e

t h e r a p e u t i c p r o c e s s

• Recommended Supplementary

Readings

•

• Therapeutic

Therapeu

Goals

• References and Suggested Readings

•

• Therapist’s Function and Role

Therapis

464

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28549_ch15_rev01.indd 464

20/09/11 4:00 PM

i n t r o d u c t i o n

This chapter will help you think about areas of convergence and divergence among

the 11 therapeutic systems covered in this book. Although these approaches all

have some goals in common, they have many differences when it comes to the best

route to achieve these goals. Some therapies call for an active and directive stance

on the therapist’s part, and others place value on clients being the active agent.

Some therapies focus on experiencing feelings, others stress identifying cognitive

patterns, and still others concentrate on actual behavior. The key task is to fi nd ways

to integrate certain features of each of these approaches so that you can work with

clients on all three levels of human experience.

The fi eld of psychotherapy is characterized by a diverse range of specialized

models. With all this diversity, is there any hope that a practitioner can develop

skills in all of the existing techniques? How does a student decide which theories

465

are most relevant to practice? Looking for commonalities among the systems of

AN INTE

psychotherapy is relatively new (Norcross & Beutler, 2011). Practitioners have been

battling over the “best” way to bring about personality change dating back to the

GRA

work of Freud. For decades, counselors resisted integration, often to the point of

TIVE PERSPE

denying the validity of alternative theories and of ignoring effective methods from

other theoretical schools. The early history of counseling is full of theoretical wars.

Since the early 1980s, psychotherapy integration has developed into a clearly

delineated fi eld. It is now an established and respected movement that is based

C

TIVE

on combining the best of differing orientations so that more complete theoreti-

cal models can be articulated and more effi cient treatments developed (Goldfried,

Pachankis, & Bell, 2005). The Society for the Exploration of Psychotherapy Inte-

gration, formed in 1983, is an international organization whose members are pro-

fessionals working toward the development of therapeutic approaches that tran-

scend single theoretical orientations. As the fi eld of psychotherapy has matured,

the concept of integration has emerged as a mainstay (Norcross & Beutler, 2011).

In this chapter I consider the advantages of developing an integrative per-

spective for counseling practice. I also present a framework to help you begin to

integrate concepts and techniques from various approaches. As you read, start to

formulate your own personal perspective for counseling. Look for ways to synthe-

size diverse elements from different theoretical perspectives. As much as possible,

be alert to how these systems can function in harmony.

See the video program for Chapter 15, DVD for Theory and Practice of Counseling

and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the

brief lecture for each chapter prior to reading the chapter.

t h e m o v e m e n t t o w a r d

p s yc h o t h e r a p y i n t e g r at i o n

A large number of therapists identify themselves as “eclectic,” and this category

covers a broad range of practice. At its worst, eclectic practice consists of haphaz-

ardly picking techniques without any overall theoretical rationale. This is known

as syncretism, wherein the practitioner, lacking in knowledge and skill in selecting

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch15_rev01.indd 465

20/09/11 4:00 PM

interventions, looks for anything that seems to work, often making little attempt

to determine whether the therapeutic procedures are indeed effective. Such an un-

critical and unsystematic combination of techniques is no better than a narrow and

dogmatic orthodoxy. This pulling of techniques from many sources without a sound

rationale results in syncretistic confusion (Lazarus, 1996b; Norcross & Beutler, 2011).

Pathways Toward Psychotherapy Integration

Psychotherapy integration is best characterized by attempts to look beyond and

across the confi nes of single-school approaches to see what can be learned from

other perspectives and how clients can benefi t from a variety of ways of conducting

therapy. The majority of psychotherapists do not claim allegiance to a particular

therapeutic school but prefer, instead, some form of integration (Norcross, 2005;

466

Norcross & Beutler, 2011). In a survey conducted by the Psychotherapy Networker

(2007), only 4.2% of respondents identifi ed themselves as being aligned with one

therapy model exclusively. The remaining 95.8% claimed to be integrative, mean-

ing they combined a variety of methods or approaches in their counseling practice.

The integrative approach is characterized by openness to various ways of in-

tegrating diverse theories and techniques, and there is a decided preference for

the term integrative over eclectic (Norcross, Karpiak, & Lister, 2005). Although

CHAPTER FIFTEEN

different terms are sometimes used—eclecticism, integration, convergence, and

rapprochement—the goals are very similar. The ultimate goal of integration is to en-

hance the effi ciency and applicability of psychotherapy. Norcross and Beutler (2011)

and Stricker (2010) describe four of the most common pathways toward the inte-

gration of psychotherapies: technical integration, theoretical integration, assimilative

integration, and common factors approach. All of these approaches to integration look

beyond the restrictions of single approaches, but they do so in distinctive ways.

Technical integration aims at selecting the best treatment techniques for the

individual and the problem. It tends to focus on differences, chooses from many

approaches, and is a collection of techniques. This path calls for using techniques

from different schools without necessarily subscribing to the theoretical posi-

tions that spawned them. For those who practice from the perspective of technical

integration, there is no necessary connection between conceptual foundations and

techniques. One of the best-known forms of technical integration, which he refers

to as technical eclecticism, is Lazarus’s (1997a) multimodal therapy (see Chapter 9).

Multimodal therapists borrow from many other therapeutic models, using tech-

niques that have been demonstrated to be effective in dealing with specifi c clinical

problems. Whenever feasible, multimodal therapists employ empirically support-

ed techniques (Lazarus, 2008a).

In contrast, theoretical integration refers to a conceptual or theoretical crea-

tion beyond a mere blending of techniques. This route has the goal of producing a

conceptual framework that synthesizes the best aspects of two or more theoretical

approaches under the assumption that the outcome will be richer than either theory

alone. This approach emphasizes integrating the underlying theories of therapy

along with techniques from each. Examples of this form of integration are dialecti-

cal behavior therapy (DBT) and acceptance and commitment therapy (ACT), both of

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch15_rev01.indd 466

20/09/11 4:00 PM

which were described in Chapter 9. Emotion-focused therapy (EFT), which is in-

formed by the role of emotion in psychotherapeutic change, also can be considered

a form of theoretical integration. Greenberg (2011), a key fi gure of the development

of EFT, conceptualizes the model as an empirically supported, integrative, experi-

ential approach to treatment. EFT synthesizes concepts of person-centered thera-

py, Gestalt therapy, experiential therapy, and existential therapy, viewed through

the lens of modern cognitive and emotion theory.

The assimilative integration approach is grounded in a particular school of

psychotherapy, along with an openness to selectively incorporate practices from

other therapeutic approaches. Assimilative integration combines the advantages

of a single coherent theoretical system with the fl exibility of a variety of interven-

tions from multiple systems. An example of this form of integration is mindfulness-

based cognitive therapy (MBCT), which integrates aspects of cognitive therapy and

467

mindfulness-based stress reduction procedures. As you may recall from Chapter 9,

AN INTE

MBCT is a comprehensive integration of the principles and skills of mindfulness

applied to the treatment of depression (Segal, Williams, & Teasdale, 2002).

GRA

The common factors approach searches for common elements across different

TIVE PERSPE

theoretical systems. Despite many differences among the theories, a recognizable

core of counseling practice is composed of nonspecifi c variables common to all

therapies. Lambert (2011) concludes that common factors can be a basis for psy-

chotherapy integration:

C

TIVE

The common factors explanation for the general equivalence of diverse therapeutic inter-

ventions has resulted in the dominance of integrative practice in routine care by implying

that the dogmatic advocacy of a particular theoretical school is not supported by research.

Research also suggests that common factors can become the focal point for integration of

seemingly diverse therapy techniques. (p. 314)

Some of these common factors include empathic listening, developing a working al-

liance, opportunity for catharsis, practicing new behaviors, positive expectations of

clients, working through one’s own confl icts, understanding interpersonal and intrap-

ersonal dynamics, and learning to be self-refl ective about one’s work (Norcross & Beut-

ler, 2011; Prochaska & Norcross, 2010). Other common factors that have been shown to

be curative include support, warmth, feedback, reassurance, and credibility (Lambert,

2011). These common factors are thought to be at least as important in accounting for

therapeutic outcomes as the unique factors that differentiate one theory from another.

Among the approaches to psychotherapy integration, the common factors approach

has the strongest empirical support (Duncan, Miller, Wampold, & Hubble, 2010).

Of all of the common factors investigated in psychotherapy, none has re-

ceived more attention and confi rmation than a facilitative therapeutic relationship

(Lambert, 2011). The importance of the therapeutic alliance is a well-established

critical component of effective therapy, and research confi rms that the client–

therapist relationship is central to therapeutic change.

Advantages of Psychotherapy Integration

One reason for the movement toward psychotherapy integration is the recognition

that no single theory is comprehensive enough to account for the complexities

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch15_rev01.indd 467

20/09/11 4:00 PM

of human behavior, especially when the range of client types and their specifi c

problems are taken into consideration. Because no one theory contains all the

truth, and because no single set of counseling techniques is always effective in

working with diverse client populations, integrative approaches hold promise for

counseling practice. Norcross and Wampold (2011b) maintain that effective clini-

cal practice requires a fl exible and integrative perspective. Psychotherapy should

be fl exibly tailored to the unique needs and contexts of the individual client. Nor-

cross and Wampold contend that using an identical therapy relationship style and

treatment method for all clients is inappropriate and can be unethical.

The 11 systems discussed in this book have evolved in the direction of broaden-

ing their theoretical and practical bases and have become less restrictive in their

focus. Many practitioners who claim allegiance to a particular system of therapy

468

are expanding their theoretical outlook and developing a wider range of therapeu-

tic techniques to fi t a more diverse population of clients. There is a growing recog-

nition that psychotherapy can be most effective when contributions from various

approaches are integrated (Goldfried, Glass, & Arnkoff, 2011). Although to date

the bulk of psychotherapy integration has been based on theoretical and clinical

foundations, Goldfried and colleagues suggest that evidence-based practice will

increasingly become the organizing force for integration. Empirical pragmatism,

CHAPTER FIFTEEN

not theory, will be the integrative theme of the 21st century.

Practitioners who are open to an integrative perspective will fi nd that several

theories play a crucial role in their personal counseling approach. Each theory has

its unique contributions and its own domain of expertise. By accepting that each

theory has strengths and weaknesses and is, by defi nition, “different” from the oth-

ers, practitioners have some basis to begin developing a theory that fi ts for them

and their clients. It takes considerable time to learn the various theories in depth. It

is not realistic for any of us to expect that we can integrate all the theories. Instead,

integration of some aspects of some of the theories is a more realistic goal. Devel-

oping an integrative perspective is a lifelong endeavor that is refi ned with clinical

experience, refl ection, reading, and discourse with colleagues.

Integration of Multicultural Issues in Counseling

Multiculturalism is a reality that cannot be ignored by practitioners if they hope

to meet the needs of diverse client groups. I believe current theories, to varying

degrees, can and should be expanded to incorporate a multicultural dimension.

I have consistently pointed out that if contemporary theories do not account

for the cultural dimension, they will have limited applicability in working with

diverse client populations. For some theories, this transition is easier than for

others.

Clients can be harmed if they are expected to fi t all the specifi cations of a given

theory, whether or not the values espoused by the theory are consistent with their

own cultural values. Rather than stretching the client to fi t the dimensions of a

single theory, practitioners need to tailor their theory and practice to fi t the unique

needs of the client. This calls for counselors to possess knowledge of various cul-

tures, to be aware of their own cultural heritage, and to have skills to assist a wide

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spectrum of clients in dealing with the realities of their culture. Psychotherapy

integration stresses tailoring interventions to the individual client rather than to

an overarching theory, making this approach particularly well suited to consider-

ing cultural factors and the unique perspective of each client. Comas-Diaz (2011)

asserts that cultural competence enables counselors to work effectively in most

clinical settings. Practitioners demonstrate their cultural competence by becoming

aware of their own and their clients’ worldviews, and by being able to use cultur-

ally appropriate interventions to refl ect their cultural beliefs, knowledge, and skills.

She adds:

Culturally competent therapists develop the capacities to value diversity and manage the

dynamics of difference. They also acquire and incorporate cultural knowledge into their

interventions, plus adapt to diversity and the cultural contexts of their clients. (p. 251)

This is a good time to review the discussion of the culturally skilled counselor in

469

AN INTE

Chapter 2 and to consult Tables 15.7 and 15.8, which appear later in this chapter.

In your role as a counselor, you need to be able to assess the special needs

of clients. Depending on the client’s ethnicity and culture and on the concerns

GRA

that bring this person to counseling, you are challenged to develop fl exibility in

TIVE PERSPE

utilizing an array of therapeutic strategies. Some clients will need more direction,

and even advice. Others will be very hesitant in talking about themselves in per-

sonal ways, especially during the early phase of the counseling process. What you

may see as resistance could be the client’s response to years of cultural condition-

C

TIVE

ing and respect for certain values and traditions. Basically, it comes down to your

familiarity with a variety of theoretical approaches and your ability to employ and

adapt your techniques to fi t the person-in-the-environment. It is not enough to

merely assist your clients in gaining insight, expressing suppressed emotions, or

making certain behavioral changes. The challenge is to fi nd practical strategies

for adapting the techniques you have developed to enable clients to examine the

impact their culture continues to have on their lives and to make decisions about

what, if anything, they want to change.

Being an effective counselor involves refl ecting on how your own culture infl u-

ences you and your interventions in your counseling practice. This awareness is

critical in becoming more sensitive to the cultural backgrounds of the clients who

seek your help. Using an integrative perspective, therapists can encompass social,

cultural, spiritual, and political dimensions in their work with clients.

Integration of Spirituality and Religion in Counseling

The counseling process can help clients gain insight into the ways their core be-

liefs and values are refl ected in their behavior. Current interest in spiritual and

religious beliefs has implications for how such beliefs might be incorporated in

therapeutic relationships (Young & Cashwell, 2011a; Frame, 2003). Survey data

from members of both the American Psychological Association and the American

Counseling Association indicate that spiritual and religious matters are therapeuti-

cally relevant, ethically appropriate, and potentially signifi cant topics for the prac-

tice of counseling in secular settings (Delaney, Miller, & Bisono, 2007; Young,

Wiggins-Frame, & Cashwell, 2007).

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Worthington (2011) asserts that the increasing openness of therapists to clients’

spiritual and religious concerns and interests has been fueled by the multicultur-

al evolution. The emphasis on multiculturalism has empowered people to defi ne

themselves from a cultural perspective, which includes their spiritual, religious,

and ethnic contexts.

Clients who are experiencing a crisis situation may fi nd a source of comfort,

support, and strength in drawing upon their spiritual resources. For some clients

spirituality entails embracing a religion, which can have many different meanings.

Other clients value spirituality, yet do not have any ties to a formal religion. What-

ever one’s particular view of spirituality, it is a force that can help the individual

to fi nd a purpose (or purposes) for living. Spirituality or religious beliefs can be

a major sustaining power that supports clients when all else fails. Other clients

470

may be affected by depression and a sense of worthlessness due to guilt, anger, or

sadness created by their unexamined acceptance of spiritual or religious dogma.

Counselors must remain open and nonjudgmental in conversations about reli-

gion or spirituality. Furthermore, counselors cannot ignore a client’s spiritual and

religious perspectives if they want to practice in a culturally sensitive and ethical

manner (Young & Cashwell, 2011a; 2011b).

c o m m o n g o a l s In some ways spirituality and counseling have similar goals.

CHAPTER FIFTEEN

Both emphasize learning to accept oneself, forgiving others and oneself, learn-

ing to love oneself and others, admitting one’s shortcomings, accepting personal

responsibility, letting go of hurts and resentments, dealing with guilt, and learning

to let go of self-destructive patterns of thinking, feeling, and acting.

Spiritual/religious values have a major part to play in human life and strug-

gles, which means that exploring these values has a great deal to do with providing

solutions for clients’ struggles. Because spiritual and therapeutic paths converge in

some ways, integration is possible, and dealing with a client’s spirituality will often

enhance the therapy process. Themes that have healing infl uences include loving,

caring, learning to listen with compassion, challenging clients’ basic life assump-

tions, accepting human imperfection, and going outside of self-oriented interests

(social interest). Both religion and counseling help people ponder questions of

“Who am I?” and “What is the meaning of my life?” At their best, both counseling

and religion can foster healing.

i m p l i c at i o n s f o r a s s e s s m e n t a n d t r e at m e n t Traditionally,

when clients come to a therapist with a problem, the therapist explores all the factors

that contributed to the development of the problem. A background of involvement

in religion can be part of clients’ history, and thus it can be a part of the intake as-

sessment and can be explored in counseling sessions. Frame (2003) presents many

reasons for including spirituality in the assessment process: understanding clients’

worldviews and the contexts in which they live, assisting clients in grappling with

questions regarding the purpose of their lives and what they most value, exploring

religion and spirituality as client resources, and uncovering religious and spiritual

problems. This information will assist the therapist in choosing appropriate interven-

tions. Young and Cashwell (2011a) maintain that counselors must assess clients’ spir-

itual or religious beliefs if they may be exacerbating clients’ psychological problems.

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yo u r r o l e a s a c o u n s e lo r It is critical that counselors not be judgmen-

tal when it comes to their clients’ beliefs and that they create an inviting and safe

climate for clients to explore their values and beliefs. There are many paths toward

fulfi lling spiritual needs, and it is not your role as a counselor to prescribe any par-

ticular pathway. By conducting a thorough assessment on a client’s background,

you will obtain many clues regarding personal themes for potential exploration. If

you remain fi nely tuned to clients’ stories and to the purpose for which they sought

therapy, clients’ concerns about spiritual or religious values, beliefs, and practices

will surface.

To assist clients in clarifying their values and in making their own decisions

requires that you have a clear sense of your own spiritual perspective. Spiritual

self-awareness is the basis for competence in dealing with the worldviews of your

clients (Hagedorn & Moorhead, 2011). Worthington (2011) reminds therapists of

471

their responsibility to provide informed and sensitive care to all clients, whether or

AN INTE

not they embrace a spiritual or religious worldview:

Given the social changes and openness of both clients and therapists to religion and spiritu-

GRA

ality, it is a reasonable supposition that spirituality tailored therapies will increase to meet

TIVE PERSPE

clients’ needs. There will also need to be continuing sensitivity to clients who do not want

to attend religiously or spiritually tailored therapy. (p. 541)

Robertson and Young (2011) stress the need to work with a client’s spiritual and

religious concerns, and state that “failure to address these issues, may, in some

C

TIVE

cases, be incompetent or unethical practice” (p. 38).

If you are to effectively serve diverse client populations, it is essential that you

pay attention to your training and competence in addressing spiritual and religious

concerns your clients bring to therapy. Ethically, it is important to monitor yourself

for subtle ways that you might be inclined to infl uence clients to embrace a spir-

itual perspective or to give up certain religious beliefs that you think are no longer

functional for them. It is important to keep in mind that clients should determine

the specifi c values they want to retain, replace, or modify.

From my vantage point, the emphasis on spirituality will continue to be impor-

tant in counseling practice, which makes it imperative that you prepare yourself to

work competently with the spiritual and religious concerns that your clients bring

up. For further reading on the topic of integrating spirituality and religion into

counseling, I highly recommend Integrating Spirituality and Religion into Coun-

seling: A Guide to Competent Practice (Cashwell & Young, 2011).

The Challenge of Developing an Integrative Perspective

A survey of approaches to counseling and psychotherapy reveals that no common

philosophy unifi es them. Many of the theories have different basic philosophies

and views of human nature (Table 15.1). As the postmodern therapists remind

us, our philosophical assumptions are important because they infl uence which

“reality” we perceive, and they direct our attention to the variables that we are “set”

to see. A word of caution, then: Beware of subscribing exclusively to any one view

of human nature. Remain open and selectively incorporate a framework for coun-

seling that is consistent with your own personality and your belief system.

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TA B L E 1 5 .1 The Basic Philosophies

Psychoanalytic therapy

Human beings are basically determined by psychic energy and

by early experiences. Unconscious motives and confl icts are

central in present behavior. Early development is of critical

importance because later personality problems have their roots

in repressed childhood confl icts.

Adlerian therapy

Humans are motivated by social interest, by striving toward

goals, by inferiority and superiority, and by dealing with the

tasks of life. Emphasis is on the individual’s positive capacities

to live in society cooperatively. People have the capacity to

interpret, infl uence, and create events. Each person at an

early age creates a unique style of life, which tends to remain

relatively constant throughout life.

472

Existential therapy

The central focus is on the nature of the human condition, which

includes a capacity for self-awareness, freedom of choice to

decide one’s fate, responsibility, anxiety, the search for meaning,

being alone and being in relation with others, striving for

authenticity, and facing living and dying.

Person-centered therapy

CHAPTER FIFTEEN

Positive view of people; we have an inclination toward

becoming fully functioning. In the context of the therapeutic

relationship, the client experiences feelings that were

previously denied to awareness. The client moves toward

increased awareness, spontaneity, trust in self, and inner-

directedness.

Gestalt therapy

The person strives for wholeness and integration of thinking,

feeling, and behaving. Some key concepts include contact with

self and others, contact boundaries, and awareness. The view

is nondeterministic in that the person is viewed as having the

capacity to recognize how earlier infl uences are related to present

diffi culties. As an experiential approach, it is grounded in the

here and now and emphasizes awareness, personal choice, and

responsibility.

Behavior therapy

Behavior is the product of learning. We are both the product and

the producer of the environment. Traditional behavior therapy

is based on classical and operant principles. Contemporary

behavior therapy has branched out in many directions.

Cognitive behavior therapy

Individuals tend to incorporate faulty thinking, which leads

to emotional and behavioral disturbances. Cognitions are the

major determinants of how we feel and act. Therapy is primarily

oriented toward cognition and behavior, and it stresses the role

of thinking, deciding, questioning, doing, and redeciding. This

is a psychoeducational model, which emphasizes therapy as a

learning process, including acquiring and practicing new skills,

learning new ways of thinking, and acquiring more effective

ways of coping with problems.

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Reality therapy

Based on choice theory, this approach assumes that we need

quality relationships to be happy. Psychological problems

are the result of our resisting the control by others or of our

attempt to control others. Choice theory is an explanation of

human nature and how to best achieve satisfying interpersonal

relationships.

Feminist therapy

Feminists criticize many traditional theories to the degree

that they are based on gender-biased concepts, such as being

androcentric, gendercentric, ethnocentric, heterosexist, and

intrapsychic. The constructs of feminist therapy include being

gender fair, fl exible, interactionist, and life-span-oriented.

Gender and power are at the heart of feminist therapy. This

is a systems approach that recognizes the cultural, social, and

political factors that contribute to an individual’s problems.

473

AN INTE

Postmodern approaches

Based on the premise that there are multiple realities and

multiple truths, postmodern therapies reject the idea that

GRA

reality is external and can be grasped. People create meaning in

their lives through conversations with others. The postmodern

TIVE PERSPE

approaches avoid pathologizing clients, take a dim view of

diagnosis, avoid searching for underlying causes of problems,

and place a high value on discovering clients’ strengths and

resources. Rather than talking about problems, the focus of

C

therapy is on creating solutions in the present and the future.

TIVE

Family systems therapy

The family is viewed from an interactive and systemic

perspective. Clients are connected to a living system; a change

in one part of the system will result in a change in other

parts. The family provides the context for understanding how

individuals function in relationship to others and how they

behave. Treatment deals with the family unit. An individual’s

dysfunctional behavior grows out of the interactional unit of the

family and out of larger systems as well.

Despite the divergences in the various theories, creative syntheses among some

models are possible. For example, an existential orientation does not necessarily

preclude using techniques drawn from behavior therapy or from some of the cog-

nitive theories. Each point of view offers a perspective for helping clients in their

search for self. I encourage you to study all the major theories and to remain open

to what you might take from the various orientations as a basis for an integrative

perspective that will guide your practice.

In developing a personal integrative perspective, it is important to be alert

to the problem of attempting to mix theories with incompatible underlying as-

sumptions. Lazarus (1995) asks, “How is it possible to blend two systems that

rest on totally different assumptions about the meaning, origins, development,

maintenance, signifi cance, and management of problems?” (p. 156). An advocate

of technical eclecticism, Lazarus (2008b) has consistently emphasized that a blend

of different theories is likely to result in confusion and argued against the notion

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28549_ch15_rev01.indd 473

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of theoretical integration. He adds that basic concepts that may seem compatible

often are, upon closer scrutiny, quite irreconcilable (see Table 15.2). Lazarus stress-

es that psychotherapy integration does not have to rely on a theoretical amalgama-

tion. Clinicians can be technically eclectic (or technically integrative) in that they

can select methods from any discipline without necessarily endorsing any of the

theories that spawned them.

TA B L E 1 5 . 2 Key Concepts

Psychoanalytic therapy

Normal personality development is based on successful

resolution and integration of psychosexual stages of

development. Faulty personality development is the result of

inadequate resolution of some specifi c stage. Anxiety is a result

of repression of basic confl icts. Unconscious processes are

474

centrally related to current behavior.

Adlerian therapy

Key concepts include the unity of personality, the need to view

people from their subjective perspective, and the importance of

life goals that give direction to behavior. People are motivated

by social interest and by fi nding goals to give life meaning.

Other key concepts are striving for signifi cance and superiority,

developing a unique lifestyle, and understanding the family

CHAPTER FIFTEEN

constellation. Therapy is a matter of providing encouragement

and assisting clients in changing their cognitive perspective and

behavior.

Existential therapy

Essentially an experiential approach to counseling rather than

a fi rm theoretical model, it stresses core human conditions.

Interest is on the present and on what one is becoming. The

approach has a future orientation and stresses self-awareness

before action.

Person-centered therapy

The client has the potential to become aware of problems

and the means to resolve them. Faith is placed in the client’s

capacity for self-direction. Mental health is a congruence of ideal

self and real self. Maladjustment is the result of a discrepancy

between what one wants to be and what one is. In therapy

attention is given to the present moment and on experiencing

and expressing feelings.

Gestalt therapy

Emphasis is on the “what” and “how” of experiencing in the

here and now to help clients accept all aspects of themselves. Key

concepts include holism, fi gure-formation process, awareness,

unfi nished business and avoidance, contact, and energy.

Behavior therapy

Focus is on overt behavior, precision in specifying goals of

treatment, development of specifi c treatment plans, and

objective evaluation of therapy outcomes. Present behavior is

given attention. Therapy is based on the principles of learning

theory. Normal behavior is learned through reinforcement and

imitation. Abnormal behavior is the result of faulty learning.

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Cognitive behavior therapy

Although psychological problems may be rooted in childhood,

they are reinforced by present ways of thinking. A person’s

belief system is the primary cause of disorders. Internal

dialogue plays a central role in one’s behavior. Clients focus

on examining faulty assumptions and misconceptions and on

replacing these with effective beliefs.

Reality therapy

The basic focus is on what clients are doing and how to get

them to evaluate whether their present actions are working

for them. People are mainly motivated to satisfy their needs,

especially the need for signifi cant relationships. The approach

rejects the medical model, the notion of transference, the

unconscious, and dwelling on one’s past.

475

Feminist therapy

Core principles of feminist therapy are that the personal is

AN INTE

political, therapists have a commitment to social change,

women’s voices and ways of knowing are valued and women’s

experiences are honored, the counseling relationship is

GRA

egalitarian, therapy focuses on strengths and a reformulated

defi nition of psychological distress, and all types of oppression

TIVE PERSPE

are recognized.

Postmodern approaches

Therapy tends to be brief and addresses the present and the

future. The person is not the problem; the problem is the

C

problem. The emphasis is on externalizing the problem and

TIVE

looking for exceptions to the problem. Therapy consists of a

collaborative dialogue in which the therapist and the client

co-create solutions. By identifying instances when the problem

did not exist, clients can create new meanings for themselves

and fashion a new life story.

Family systems therapy

Focus is on communication patterns within a family, both

verbal and nonverbal. Problems in relationships are likely to

be passed on from generation to generation. Key concepts vary

depending on specifi c orientation but include differentiation,

triangles, power coalitions, family-of-origin dynamics,

functional versus dysfunctional interaction patterns, and

dealing with here-and-now interactions. The present is more

important than exploring past experiences.

By remaining theoretically consistent, but technically integrative, practi-

tioners can spell out precisely the interventions they will employ with various

clients, as well as the means by which they will select these procedures. Lazarus

(1997a, 1997b) contends that therapists who hope to be effective with a wide

range of problems and with different client populations must be flexible and

versatile. Therapists should ask these basic questions when devising a treat-

ment program: “What works for whom under which particular circumstances?”

“Why are some procedures helpful and others unhelpful?” “What can be done

to ensure long-term success and positive follow-ups?” Lazarus (1993) believes

some clients respond to warm, informal counselors but that others want more

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28549_ch15_rev01.indd 475

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formal counselors. Some clients work well with therapists who are quiet and

nonforceful, whereas others work best with directive and outgoing therapists.

Furthermore, the same client may respond favorably to various therapeutic

techniques and styles at different times.

Lazarus (1996a) mentions the value of a therapist assuming an active role

in blending a fl exible repertoire of relationship styles with a wide range of tech-

niques as a way to enhance therapeutic outcomes. He maintains that a skilled

therapist is able to determine when to be confrontational, when to be directive,

when to allow the client to struggle, when to be formal or informal, when to

self-disclose or remain anonymous, and when to be gentle or tough. Lazarus

(1993) asserts that relationships of choice are at least as important as techni-

ques of choice. (For a review of multimodal procedures and their rationale, see

476

Chapter 9.)

One of the challenges you will face as a counselor is to deliver therapeutic

services in a brief, comprehensive, effective, and fl exible way. Many of the theoreti-

cal orientations addressed in this book can be applied to brief forms of therapy.

One of the driving forces of the psychotherapy integration movement has been

the increase of brief therapies and the pressures to do more for a variety of client

populations within the limitations of 6 to 20 sessions. Most forms of short-term

CHAPTER FIFTEEN

psychotherapy are active in nature, collaborative in relationship, and integrative in

orientation (Norcross & Beutler, 2011).

The main goal of brief therapy is to help clients resolve problems and to move

forward as quickly as possible. Some of the defi ning characteristics of brief therapy

include the following (Hoyt, 2011):

• Rapid working alliance between therapist and client

• Clear

specifi cation of achievable treatment goals

•

Clear division of responsibilities between client and therapist, with active client

participation and a high level of therapist activity

• Emphasis on client’s strengths, competencies, and adaptive capacities

• Expectation that change is possible and realistic

• Here-and-now orientation with a primary focus on current functioning in

thinking, feeling, and behaving

• Specifi c, integrated, and eclectic techniques

• Time sensitive, including making the most of each session and ending therapy

as soon as possible

The core task is for integrative practitioners to learn how to rapidly and system-

atically identify problems, create a collaborative relationship with clients, and

intervene with a range of specifi c methods. Hoyt puts the challenge to therapists

concisely: “The simple truth is that most therapy is brief therapy and will be

increasingly so; for the sake of our patients and our profession, we should learn to

practice it well” (p. 419).

An integrative perspective at its best entails a systematic integration of underly-

ing principles and methods common to a range of therapeutic approaches. The

strengths of systematic integration are based on its ability to be taught, replicated,

and evaluated (Norcross & Beutler, 2011). To develop this kind of integration, you

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will eventually need to be thoroughly conversant with a number of theories, be

open to the idea that these theories can be connected in some ways, and be will-

ing to continually test your hypotheses to determine how well they are working.

Developing a systematic integrative perspective is the product of a great deal of

study, clinical practice, research, and theorizing.

i s s u e s r e l at e d t o t h e

t h e r a p e u t i c p r o c e s s

Therapeutic Goals

The goals of counseling are almost as diverse as are the theoretical approaches.

Some goals include restructuring the personality, uncovering the unconscious,

477

creating social interest, fi nding meaning in life, curing an emotional disturbance,

AN INTE

examining old decisions and making new ones, developing trust in oneself, be-

coming more self-actualizing, reducing anxiety, reducing maladaptive behavior

and learning adaptive patterns, becoming grounded in the present moment, man-

GRA

aging intense emotions, gaining more effective control of one’s life, and reauthor-

TIVE PERSPE

ing the story of one’s life (Table 15.3). Is there a common denominator in this range

of goals?

C

TA B L E 1 5 . 3 Goals of Therapy

TIVE

Psychoanalytic therapy

To make the unconscious conscious. To reconstruct the basic

personality. To assist clients in reliving earlier experiences and

working through repressed confl icts. To achieve intellectual and

emotional awareness.

Adlerian therapy

To challenge clients’ basic premises and life goals. To offer

encouragement so individuals can develop socially useful goals

and increase social interest. To develop the client’s sense of

belonging.

Existential therapy

To help people see that they are free and to become aware of

their possibilities. To challenge them to recognize that they

are responsible for events that they formerly thought were

happening to them. To identify factors that block freedom.

Person-centered therapy

To provide a safe climate conducive to clients’ self-exploration,

so that they can recognize blocks to growth and can experience

aspects of self that were formerly denied or distorted. To enable

them to move toward openness, greater trust in self, willingness

to be a process, and increased spontaneity and aliveness. To fi nd

meaning in life and to experience life fully. To become more

self-directed.

Gestalt therapy

To assist clients in gaining awareness of moment-to-moment

experiencing and to expand the capacity to make choices. To

foster integration of the self.

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Behavior therapy

To eliminate maladaptive behaviors and learn more effective

behaviors. To identify factors that infl uence behavior and fi nd

out what can be done about problematic behavior. To encourage

clients to take an active and collaborative role in clearly setting

treatment goals and evaluating how well these goals are

being met.

Cognitive behavior therapy

To teach clients to confront faulty beliefs with contradictory

evidence that they gather and evaluate. To help clients seek out

their faulty beliefs and minimize them. To become aware of

automatic thoughts and to change them.

Reality therapy

To help people become more effective in meeting all of their

psychological needs. To enable clients to get reconnected with

478

the people they have chosen to put into their quality worlds and

teach clients choice theory.

Feminist therapy

To bring about transformation both in the individual client and

in society. To assist clients in recognizing, claiming, and using

their personal power to free themselves from the limitations of

gender-role socialization. To confront all forms of institutional

policies that discriminate or oppress on any basis.

CHAPTER FIFTEEN

Postmodern approaches

To change the way clients view problems and what they can do

about these concerns. To collaboratively establish specifi c, clear,

concrete, realistic, and observable goals leading to increased

positive change. To help clients create a self-identity grounded

on competence and resourcefulness so they can resolve present

and future concerns. To assist clients in viewing their lives in

positive ways, rather than being problem saturated.

Family systems therapy

To help family members gain awareness of patterns of

relationships that are not working well and to create new ways

of interacting.

This diversity can be simplifi ed by considering the degree of generality or spe-

cifi city of goals. Goals exist on a continuum from specifi c, concrete, and short term

on one end, to general, global, and long term on the other. The cognitive behavioral

approaches stress the former; the relationship-oriented therapies tend to stress the

latter. The goals at opposite ends of the continuum are not necessarily contradic-

tory; it is a matter of how specifi cally they are defi ned.

Therapist’s Function and Role

In working toward an integrative perspective, ask yourself these questions:

• How do the counselor’s functions change depending on the stage of the coun-

seling process?

• Does the therapist maintain a basic role, or does this role vary in accordance

with the characteristics of the client?

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• How does the counselor determine how active and directive to be?

• How is structuring handled as the course of therapy progresses?

•

What is the optimum balance of responsibility in the client–therapist relationship?

• What is the most effective way to monitor the therapeutic alliance?

• What, when, and how much does the counselor self-disclose?

As you saw through your study of the 11 therapeutic approaches, a central issue

of each system is the degree to which the therapist exercises control over clients’

behavior both during and outside the session. Cognitive behavior therapists and

reality therapists, for example, operate within a present-centered, directive, didac-

tic, structured, and psychoeducational context. As a collaborative endeavor, they

frequently design homework assignments to assist clients in practicing new behav-

ior outside therapy sessions. In contrast, person-centered therapists operate with a

479

much looser and less defi ned structure. Solution-focused and narrative therapists

AN INTE

view the client as the expert on his or her own life; they assist clients in refl ection

outside of the session that might result in self-directed change. Although they are

active questioners, they are not prescriptive in their practice.

GRA

Structuring depends on the particular client and the specifi c circumstances he

TIVE PERSPE

or she brings to the therapy situation. From my perspective, clear structure is most

essential during the early phase of counseling because it encourages the client to

talk about the problems that led to seeking therapy. In a collaborative way, it is

useful for both counselor and client to make some initial assessment that can pro-

C

TIVE

vide a focus for the therapy process. As soon as possible, the client should be given

a signifi cant share of the responsibility for deciding on the content and agenda of

the sessions. From early in the therapy process the client can be empowered if the

counselor expects the client to become an active participant in the process.

Client’s Experience in Therapy

Most clients share some degree of suffering, pain, or at least discontent. There

is a discrepancy between how they would like to be and how they are. Some in-

dividuals initiate therapy because they hope to cure a specifi c symptom or set of

symptoms. They want to get rid of migraine headaches, free themselves of chronic

anxiety attacks, lose weight, or get relief from depression. They may have confl ict-

ing feelings and reactions, may struggle with low self-esteem, or may have limited

information and skills. Many seek to resolve confl icts in their close relationships.

I believe people are increasingly entering therapy with existential problems. Their

complaints often relate to the these existential issues: a sense of emptiness, mean-

inglessness in life, routine ways of living, unsatisfying personal relationships,

anxiety over uncertainty, a lack of intense feelings, and a loss of their sense of self.

The initial expectation of many clients is that results will come quickly. They

often have great hope for major changes in their life and rely on direction from the

therapist. As therapy progresses, clients discover that they must be active in the

process, selecting their own goals and working toward them, both in the sessions

and in daily living. Some clients can benefi t from recognizing and expressing pent-

up feelings, others will need to examine their beliefs and thoughts, others will

most need to begin behaving in different ways, and others will benefi t from talking

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with you about their relationships with the signifi cant people in their lives. Most

clients will need to do some work in all three dimensions—feelings, thoughts, and

behaviors—because these dimensions are interrelated.

In deciding what interventions are most likely to be helpful, it is important

to take into account the client’s cultural, ethnic, and socioeconomic background.

Moreover, the focus of counseling may change as clients enter different phas-

es in the counseling process. Although some clients initially feel a need to be

listened to and allowed to express deep feelings, they can profi t later from ex-

amining the thought patterns that are contributing to their psychological pain.

Certainly at some point in therapy it is essential that clients translate what they

are learning about themselves into concrete action. The client’s given situation

in the environment provides a framework for selecting interventions that are

480

most appropriate.

Listening to client feedback about the therapy process is of the utmost im-

portance. One of the best ways to improve the effectiveness of psychotherapy is

through client-directed, outcome-informed therapy (Duncan, Miller, & Sparks,

2004). Therapists need to take direction from their clients. If therapists learn to

listen to clients’ feedback throughout the therapeutic process, clients can become

full and equal participants in all aspects of their therapy. In their book, The Heroic

CHAPTER FIFTEEN

Client, Duncan and his colleagues (2004) emphasize that “it is time to recast the

client as not only the hero or heroine of the therapy drama but also the director of

the change endeavor” (p. 12). Client strengths and perceptions are the foundation

of therapy work, and these authors advocate for systematic and consistent assess-

ment of the client’s perceptions of progress, which allows the therapist to tailor

the therapy to the individual needs and characteristics of each client. Using client

feedback, therapists can adjust and accommodate to maximize benefi cial outcomes.

In essence, Duncan and colleagues are arguing for practice-based evidence rather

than evidence-based practice: “Becoming outcome informed not only amplifi es the

client’s voice but offers the most viable, research-tested method to improve clinical

effectiveness” (p. 16).

Relationship Between Therapist and Client

Most approaches share common ground in accepting the importance of the thera-

peutic relationship. The existential, person-centered, Gestalt, Adlerian, and post-

modern views emphasize the personal relationship as the crucial determinant of

treatment outcomes. Rational emotive behavior therapy, reality therapy, cognitive

behavior therapy, and behavior therapy certainly do not ignore the relationship fac-

tor, yet they place less emphasis on the relationship and more on the effective use

of techniques (Table 15.4).

Counseling is a personal matter that involves a personal relationship, and evi-

dence indicates that honesty, sincerity, acceptance, understanding, and spontaneity

are basic ingredients for successful outcomes. Therapists’ degree of caring, their

interest and ability in helping their clients, and their genuineness infl uence the

relationship. Norcross and Wampold (2011a) stress that psychotherapy is primarily

a human relationship. Both client and therapist bring origins, culture, expecta-

tions, biases, defenses, and strengths to this relationship. They claim that how we

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TA B L E 1 5 .4 The Therapeutic Relationship

Psychoanalytic therapy

The classical analyst remains anonymous, and clients

develop projections toward him or her. Focus is on

reducing the resistances that develop in working with

transference and on establishing more rational control.

Clients undergo long-term analysis, engage in free

association to uncover confl icts, and gain insight by

talking. The analyst makes interpretations to teach clients

the meaning of current behavior as it relates to the past.

In contemporary relational psychoanalytic therapy, the

relationship is central and emphasis is given to here-and-

now dimensions of this relationship.

Adlerian therapy

The emphasis is on joint responsibility, on mutually

determining goals, on mutual trust and respect, and

481

AN INTE

on equality. Focus is on identifying, exploring, and

disclosing mistaken goals and faulty assumptions within

the person’s lifestyle.

GRA

Existential therapy

The therapist’s main tasks are to accurately grasp

TIVE PERSPE

clients’ being in the world and to establish a personal

and authentic encounter with them. The immediacy

of the client–therapist relationship and the authenticity

of the here-and-now encounter are stressed. Both

C

client and therapist can be changed by the

TIVE

encounter.

Person-centered therapy

The relationship is of primary importance. The qualities

of the therapist, including genuineness, warmth,

accurate empathy, respect, and nonjudgmentalness—

and communication of these attitudes to clients—are

stressed. Clients use this genuine relationship with the

therapist to help them transfer what they learn to other

relationships.

Gestalt therapy

Central importance is given to the I/Thou relationship

and the quality of the therapist’s presence. The therapist’s

attitudes and behavior count more than the techniques

used. The therapist does not interpret for clients but

assists them in developing the means to make their own

interpretations. Clients identify and work on unfi nished

business from the past that interferes with current

functioning.

Behavior therapy

The therapist is active and directive and functions

as a teacher or mentor in helping clients learn

more effective behavior. Clients must be active in the

process and experiment with new behaviors. Although

a quality client–therapist relationship is not viewed

as suffi cient to bring about change, it is considered

essential for implementing behavioral procedures.

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Cognitive behavior therapy

In REBT the therapist functions as a teacher and the client

as a student. The therapist is highly directive and teaches

clients an A-B-C model of changing their cognitions. In

CT the focus is on a collaborative relationship. Using a

Socratic dialogue, the therapist assists clients in identifying

dysfunctional beliefs and discovering alternative rules for

living. The therapist promotes corrective experiences that

lead to learning new skills. Clients gain insight into their

problems and then must actively practice changing self-

defeating thinking and acting.

Reality therapy

A fundamental task is for the therapist to create a good

relationship with the client. Therapists are then able to

engage clients in an evaluation of all their relationships

482

with respect to what they want and how effective they

are in getting this. Therapists fi nd out what clients want,

ask what they are choosing to do, invite them to evaluate

present behavior, help them make plans for change,

and get them to make a commitment. The therapist is a

client’s advocate, as long as the client is willing to attempt

to behave responsibly.

CHAPTER FIFTEEN

Feminist therapy

The therapeutic relationship is based on empowerment

and egalitarianism. Therapists actively break down

the hierarchy of power and reduce artifi cial barriers by

engaging in appropriate self-disclosure and teaching

clients about the therapy process. Therapists strive to

create a collaborative relationship in which clients can

become their own expert.

Postmodern approaches

Therapy is a collaborative partnership. Clients are viewed

as the experts on their own life. Therapists use questioning

dialogue to help clients free themselves from their

problem-saturated stories and create new life-affi rming

stories. Solution-focused therapists assume an active role

in guiding the client away from problem-talk and toward

solution-talk. Clients are encouraged to explore their

strengths and to create solutions that will lead to a richer

future. Narrative therapists assist clients in externalizing

problems and guide them in examining self-limiting

stories and creating new and more liberating stories.

Family systems therapy

The family therapist functions as a teacher, coach,

model, and consultant. The family learns ways to detect

and solve problems that are keeping members stuck,

and it learns about patterns that have been transmitted

from generation to generation. Some approaches focus

on the role of therapist as expert; others concentrate on

intensifying what is going on in the here and now of the

family session. All family therapists are concerned with

the process of family interaction and teaching patterns of

communication.

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create and nurture this powerful human relationship can be guided by the fruits

of research.

As you think about developing your personal counseling perspective, give con-

sideration to the issue of the match between client and counselor. I certainly do

not advocate changing your personality to fi t your perception of what each client

is expecting; it is important that you be yourself as you meet clients. You also need

to consider the reality that you will probably not be able to work effectively with

every client. Some clients will work better with counselors who have another type

of personal and therapeutic style than yours. Be sensitive in assessing what your

client needs, and use good judgment when determining the appropriateness of the

match between you and a potential client.

Although you do not have to be like your clients or have experienced the same

problems to be effective with them, it is critical that you be able to understand

483

their world and respect them. Ask yourself how well prepared you are to counsel

AN INTE

clients from a different cultural background. To what degree do you think you

can successfully establish a therapeutic relationship with a client of a different

GRA

race? Ethnic group? Gender? Age? Sexual orientation? Spiritual/religious orienta-

TIVE PERSPE

tion? Socioeconomic group? Do you see any potential barriers that would make it

diffi cult for you to form a working relationship with certain clients? It is also im-

portant to consider the client’s diagnosis, resistance level, treatment preferences,

and stages of change. Different types of clients respond better to different types of

C

treatments and relationship styles. Therapeutic techniques and styles should be

TIVE

selected to fi t the client’s personal characteristics. Norcross and Beutler (2011) sug-

gest that therapists create a new therapy for each client:

We believe that the purpose of integrative psychotherapy is not to create a single or uni-

tary treatment. Rather, we select different treatment methods according to the patient’s

response to the treatment goals, following an established set of integrative principles. The

result is a more effi cient and effi cacious therapy—and one that fi ts both the client and the

clinician. (p. 509)

t h e p l a c e o f t e c h n i q u e s

a n d e va l u at i o n i n c o u n s e l i n g

Drawing on Techniques From Various Approaches

Effective therapists incorporate a wide range of procedures into their therapeutic

style. Much depends on the purpose of therapy, the setting, the personality and

style of the therapist, the qualities of the particular client, and the problems selected

for intervention. Regardless of the therapeutic model you may be working with,

you must decide what relationship style to adopt, what techniques, procedures, or

intervention methods to use, when to use them, and with which clients. Take time

to review Table 15.5 and Table 15.6 on therapeutic techniques and applications of

techniques. Pay careful attention to the focus of each type of therapy and how that

focus might be useful in your practice.

It is critical to be aware of how clients’ cultural backgrounds contribute to their

perceptions of their problems. Each of the 11 therapeutic approaches has both

strengths and limitations when applied to culturally diverse client populations

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TA B L E 1 5 . 5 Techniques of Therapy

Psychoanalytic therapy

The key techniques are interpretation, dream analysis, free

association, analysis of resistance, analysis of transference,

and countertransference. Techniques are designed to help

clients gain access to their unconscious confl icts, which

leads to insight and eventual assimilation of new material

by the ego.

Adlerian therapy

Adlerians pay more attention to the subjective

experiences of clients than to using techniques.

Some techniques include gathering life-history data

(family constellation, early recollections, personal

priorities), sharing interpretations with clients, offering

encouragement, and assisting clients in searching for

484

new possibilities.

Existential therapy

Few techniques fl ow from this approach because it

stresses understanding fi rst and technique second. The

therapist can borrow techniques from other approaches

and incorporate them in an existential framework.

Diagnosis, testing, and external measurements are not

deemed important. Issues addressed are freedom and

CHAPTER FIFTEEN

responsibility, isolation and relationships, meaning and

meaninglessness, living and dying.

Person-centered therapy

This approach uses few techniques but stresses the

attitudes of the therapist and a “way of being.” Therapists

strive for active listening, refl ection of feelings,

clarifi cation, “being there” for the client, and focusing on

the moment-to-moment experiencing of the client. This

model does not include diagnostic testing, interpretation,

taking a case history, or questioning or probing for

information.

Gestalt therapy

A wide range of experiments are designed to intensify

experiencing and to integrate confl icting feelings.

Experiments are co-created by therapist and client through

an I/Thou dialogue. Therapists have latitude to creatively

invent their own experiments. Formal diagnosis and

testing are not a required part of therapy.

Behavior therapy

The main techniques are reinforcement, shaping,

modeling, systematic desensitization, relaxation methods,

fl ooding, eye movement and desensitization reprocessing,

cognitive restructuring, assertion and social skills training,

self-management programs, mindfulness and acceptance

methods, behavioral rehearsal, coaching, and various

multimodal therapy techniques. Diagnosis or assessment

is done at the outset to determine a treatment plan.

Questions concentrate on “what,” “how,” and “when” (but

not “why”). Contracts and homework assignments are also

typically used.

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Cognitive behavior therapy

Therapists use a variety of cognitive, emotive, and

behavioral techniques; diverse methods are tailored to suit

individual clients. This is an active, directive, time-limited,

present-centered, psychoeducational, structured therapy.

Some techniques include engaging in Socratic dialogue,

collaborative empiricism, debating irrational beliefs,

carrying out homework assignments, gathering data on

assumptions one has made, keeping a record of activities,

forming alternative interpretations, learning new coping

skills, changing one’s language and thinking patterns,

role playing, imagery, confronting faulty beliefs, self-

instructional training, and stress inoculation training.

Reality therapy

This is an active, directive, and didactic therapy. Skillful

questioning is a central technique used for the duration of

485

the therapy process. Various techniques may be used to get

AN INTE

clients to evaluate what they are presently doing to see if

they are willing to change. If clients decide that their present

behavior is not effective, they develop a specifi c plan for

GRA

change and make a commitment to follow through.

TIVE PERSPE

Feminist therapy

Although techniques from traditional approaches are

used, feminist practitioners tend to employ consciousness-

raising techniques aimed at helping clients recognize the

impact of gender-role socialization on their lives. Other

C

techniques frequently used include gender-role analysis

TIVE

and intervention, power analysis and intervention,

demystifying therapy, bibliotherapy, journal writing,

therapist self-disclosure, assertiveness training, reframing

and relabeling, cognitive restructuring, identifying and

challenging untested beliefs, role playing, psychodramatic

methods, group work, and social action.

Postmodern approaches

In solution-focused therapy the main technique involves

change-talk, with emphasis on times in a client’s life

when the problem was not a problem. Other techniques

include creative use of questioning, the miracle

question, and scaling questions, which assist clients

in developing alternative stories. In narrative therapy,

specifi c techniques include listening to a client’s problem-

saturated story without getting stuck, externalizing and

naming the problem, externalizing conversations, and

discovering clues to competence. Narrative therapists

often write letters to clients and assist them in fi nding an

audience that will support their changes and new stories.

Family systems therapy

A variety of techniques may be used, depending on the

particular theoretical orientation of the therapist. Techniques

include genograms, teaching, asking questions, joining the

family, tracking sequences, issuing directives, use of

countertransference, family mapping, reframing, restructuring,

enactments, and setting boundaries. Techniques may be

experiential, cognitive, or behavioral in nature. Most are

designed to bring about change in a short time.

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TA B L E 1 5 . 6 Applications of the Approaches

Psychoanalytic therapy

Candidates for analytic therapy include professionals who

want to become therapists, people who have had intensive

therapy and want to go further, and those who are in

psychological pain. Analytic therapy is not recommended for

self-centered and impulsive individuals or for people with

psychotic disorders. Techniques can be applied to individual

and group therapy.

Adlerian therapy

Because the approach is based on a growth model, it is

applicable to such varied spheres of life as child guidance,

parent–child counseling, marital and family therapy,

individual counseling with all age groups, correctional and

rehabilitation counseling, group counseling, substance

486

abuse programs, and brief counseling. It is ideally suited to

preventive care and alleviating a broad range of conditions that

interfere with growth.

Existential therapy

This approach is especially suited to people facing a

developmental crisis or a transition in life and for those with

existential concerns (making choices, dealing with freedom

and responsibility, coping with guilt and anxiety, making

CHAPTER FIFTEEN

sense of life, and fi nding values) or those seeking personal

enhancement. The approach can be applied to both individual

and group counseling, and to couples and family therapy,

crisis intervention, and community mental health work.

Person-centered therapy

Has wide applicability to individual and group counseling.

It is especially well suited for the initial phases of crisis

intervention work. Its principles have been applied to couples

and family therapy, community programs, administration

and management, and human relations training. It is a

useful approach for teaching, parent–child relations, and

for working with groups of people from diverse cultural

backgrounds.

Gestalt therapy

Addresses a wide range of problems and populations: crisis

intervention, treatment of a range of psychosomatic disorders,

couples and family therapy, awareness training of mental

health professionals, behavior problems in children, and

teaching and learning. It is well suited to both individual and

group counseling. The methods are powerful catalysts for

opening up feelings and getting clients into contact with their

present-centered experience.

Behavior therapy

A pragmatic approach based on empirical validation of results.

Enjoys wide applicability to individual, group, couples, and

family counseling. Some problems to which the approach is

well suited are phobic disorders, depression, trauma, sexual

disorders, children’s behavioral disorders, stuttering, and

prevention of cardiovascular disease. Beyond clinical practice,

its principles are applied in fi elds such as pediatrics, stress

management, behavioral medicine, education, and geriatrics.

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Cognitive behavior therapy

Has been widely applied to treatment of depression, anxiety,

relationship problems, stress management, skill training,

substance abuse, assertion training, eating disorders, panic

attacks, performance anxiety, and social phobias. CBT is

especially useful for assisting people in modifying their

cognitions. Many self-help approaches utilize its principles.

CBT can be applied to a wide range of client populations with

a variety of specifi c problems.

Reality therapy

Geared to teaching people ways of using choice theory in

everyday living to increase effective behaviors. It has been

applied to individual counseling with a wide range of clients,

group counseling, working with youthful law offenders, and

couples and family therapy. In some instances it is well suited

to brief therapy and crisis intervention.

487

AN INTE

Feminist therapy

Principles and techniques can be applied to a range

of therapeutic modalities such as individual therapy,

GRA

relationship counseling, family therapy, group counseling,

and community intervention. The approach can be applied

TIVE PERSPE

to both women and men with the goal of bringing about

empowerment.

Postmodern approaches

Solution-focused therapy is well suited for people with

C

adjustment disorders and for problems of anxiety and

TIVE

depression. Narrative therapy is now being used for a broad

range of human diffi culties including eating disorders,

family distress, depression, and relationship concerns.

These approaches can be applied to working with children,

adolescents, adults, couples, families, and the community in

a wide variety of settings. Both solution-focused and narrative

approaches lend themselves to group counseling and to

school counseling.

Family systems therapy

Useful for dealing with marital distress, problems of

communicating among family members, power struggles,

crisis situations in the family, helping individuals attain

their potential, and enhancing the overall functioning of the

family.

(Table 15.7 and Table 15.8). Although it is unwise to stereotype clients because of

their cultural heritage, it is useful to assess how the cultural context has a bearing

on their concerns. Some techniques may be contraindicated because of a client’s

socialization. The client’s responsiveness (or lack of it) to certain techniques is a

critical barometer in judging the effectiveness of these methods.

Effective counseling involves profi ciency in a combination of cognitive, affec-

tive, and behavioral techniques. Such a combination is necessary to help clients

think about their beliefs and assumptions, to experience on a feeling level their

confl icts and struggles, and to translate their insights into action programs by

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TA B L E 1 5 .7 Contributions to Multicultural Counseling

Psychoanalytic therapy

Its focus on family dynamics is appropriate for working

with many cultural groups. The therapist’s formality appeals

to clients who expect professional distance. Notion of ego

defense is helpful in understanding inner dynamics and

dealing with environmental stresses.

Adlerian therapy

Its focus on social interest, helping others, collectivism,

pursuing meaning in life, importance of family, goal

orientation, and belonging is congruent with the values of

many cultures. Focus on person-in-the-environment allows

for cultural factors to be explored.

Existential therapy

Focus is on understanding client’s phenomenological world,

488

including cultural background. This approach leads to

empowerment in an oppressive society. Existential therapy can

help clients examine their options for change within the context

of their cultural realities. The existential approach is particularly

suited to counseling diverse clients because of the philosophical

foundation that emphasizes the human condition.

Person-centered therapy

CHAPTER FIFTEEN

Focus is on breaking cultural barriers and facilitating open

dialogue among diverse cultural populations. Main strengths

are respect for clients’ values, active listening, welcoming

of differences, nonjudgmental attitude, understanding,

willingness to allow clients to determine what will be

explored in sessions, and prizing cultural pluralism.

Gestalt therapy

Its focus on expressing oneself nonverbally is congruent

with those cultures that look beyond words for messages.

Provides many experiments in working with clients who

have cultural injunctions against freely expressing feelings.

Can help to overcome language barrier with bilingual clients.

Focus on bodily expressions is a subtle way to help clients

recognize their confl icts.

Behavior therapy

Focus on behavior, rather than on feelings, is compatible

with many cultures. Strengths include a collaborative

relationship between counselor and client in working

toward mutually agreed-upon goals, continual assessment

to determine if the techniques are suited to clients’ unique

situations, assisting clients in learning practical skills, an

educational focus, and stress on self-management strategies.

Cognitive behavior therapy

Focus is on a collaborative approach that offers clients

opportunities to express their areas of concern. The

psychoeducational dimensions are often useful in exploring

cultural confl icts and teaching new behavior. The emphasis on

thinking (as opposed to identifying and expressing feelings) is

likely to be acceptable to many clients. The focus on teaching

and learning tends to avoid the stigma of mental illness. Clients

may value the active and directive stance of the therapist.

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Reality therapy

Focus is on clients making their own evaluation of behavior

(including how they respond to their culture). Through

personal assessment clients can determine the degree to

which their needs and wants are being satisfi ed. They can

fi nd a balance between retaining their own ethnic identity

and integrating some of the values and practices of the

dominant society.

Feminist therapy

Focus is on both individual change and social transformation.

A key contribution is that both the women’s movement and

the multicultural movement have called attention to the

negative impact of discrimination and oppression for both

women and men. Emphasizes the infl uence of expected

cultural roles and explores client’s satisfaction with and

knowledge of these roles.

489

AN INTE

Postmodern approaches

Focus is on the social and cultural context of behavior.

Stories that are being authored in the therapy offi ce need

GRA

to be anchored in the social world in which the client lives.

Therapists do not make assumptions about people and

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honor each client’s unique story and cultural background.

Therapists take an active role in challenging social and

cultural injustices that lead to oppression of certain groups.

Therapy becomes a process of liberation from oppressive

C

cultural values and enables clients to become active agents of

TIVE

their destinies.

Family systems therapy

Focus is on the family or community system. Many ethnic

and cultural groups place value on the role of the extended

family. Many family therapies deal with extended family

members and with support systems. Networking is a part

of the process, which is congruent with the values of many

clients. There is a greater chance for individual change if

other family members are supportive. This approach offers

ways of working toward the health of the family unit and the

welfare of each member.

TA B L E 1 5 . 8 Limitations in Multicultural Counseling

Psychoanalytic therapy

Its focus on insight, intrapsychic dynamics, and long-term

treatment is often not valued by clients who prefer to learn

coping skills for dealing with pressing daily concerns.

Internal focus is often in confl ict with cultural values that

stress an interpersonal and environmental focus.

Adlerian therapy

This approach uses a detailed interview about one’s

family background; this can confl ict with cultures that

have injunctions against disclosing family matters. Some

clients may view the counselor as an authority who will

provide answers to problems, which confl icts with the

egalitarian, person-to-person spirit as a way to reduce

social distance.

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Existential therapy

Values of individuality, freedom, autonomy, and

self-realization often confl ict with cultural values of

collectivism, respect for tradition, deference to authority,

and interdependence. Some may be deterred by the

absence of specifi c techniques. Others will expect more

focus on surviving in their world.

Person-centered therapy

Some of the core values of this approach may not be

congruent with the client’s culture. Lack of counselor

direction and structure are unacceptable for clients

who are seeking help and immediate answers from a

knowledgeable professional.

Gestalt therapy

Clients who have been culturally conditioned to

490

be emotionally reserved may not embrace Gestalt

experiments. Some may not see how “being aware of

present experiencing” will lead to solving their problems.

Behavior therapy

Family members may not value clients’ newly acquired

assertive style, so clients must be taught how to cope

with resistance by others. Counselors need to help

clients assess the possible consequences of making

CHAPTER FIFTEEN

behavioral changes.

Cognitive behavior therapy

Before too quickly attempting to change the beliefs

and actions of clients, it is essential for the therapist

to understand and respect their world. Some clients

may have serious reservations about questioning their

basic cultural values and beliefs. Clients could become

dependent on the therapist for deciding what are

appropriate ways to solve problems.

Reality therapy

This approach stresses taking charge of one’s own life,

yet some clients are more interested in changing their

external environment. Counselor needs to appreciate the

role of discrimination and racism and help clients deal

with social and political realities.

Feminist therapy

This model has been criticized for its bias toward the

values of White, middle-class, heterosexual women,

which are not applicable to many other groups of women

nor to men. Therapists need to assess with their clients

the price of making signifi cant personal change, which

may result in isolation from extended family as clients

assume new roles and make life changes.

Postmodern approaches

Some clients come to therapy wanting to talk about their

problems and may be put off by the insistence on talking

about exceptions to their problems. Clients may view the

therapist as an expert and be reluctant to view themselves

as experts. Certain clients may doubt the helpfulness of a

therapist who assumes a “not-knowing” position.

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Family systems therapy

Family therapy rests on value assumptions that are

not congruent with the values of clients from some

cultures. Western concepts such as individuation,

self-actualization, self-determination, independence,

and self-expression may be foreign to some clients. In

some cultures, admitting problems within the family is

shameful. The value of “keeping problems within the

family” may make it diffi cult to explore confl icts openly.

behaving in new ways in day-to-day living. Table 15.9 and Table 15.10 outline the

contributions and limitations of the various therapeutic approaches. These tables

will help you identify elements from the various approaches that you may want to

incorporate in your own counseling perspective.

491

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Evaluating the Effectiveness of Counseling and Therapy

Mental health providers must be accountable and be able to demonstrate the effi cacy

GRA

of their services. In the era of managed care, it is even more essential for practitioners

to demonstrate the degree to which their interventions are both clinically sound and

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cost-effective. Does therapy make a signifi cant difference? Are people substantially bet-

ter after therapy than they were without it? Can therapy actually be more harmful than

helpful? A thorough discussion of these questions is beyond the scope of this book, but

C

I will address a few basic issues related to evaluating the effectiveness of counseling.

TIVE

TA B L E 1 5 .9 Contributions of the Approaches

Psychoanalytic therapy

More than any other system, this approach has generated

controversy as well as exploration and has stimulated

further thinking and development of therapy. It has

provided a detailed and comprehensive description of

personality structure and functioning. It has brought

into prominence factors such as the unconscious as a

determinant of behavior and the role of trauma during the

fi rst 6 years of life. It has developed several techniques for

tapping the unconscious and shed light on the dynamics

of transference and countertransference, resistance,

anxiety, and the mechanisms of ego defense.

Adlerian therapy

A key contribution is the infl uence that Adlerian

concepts have had on other systems and the integration

of these concepts into various contemporary therapies.

This is one of the fi rst approaches to therapy that was

humanistic, unifi ed, holistic, and goal-oriented and that

put an emphasis on social and psychological factors.

Existential therapy

Its major contribution is recognition of the need for a

subjective approach based on a complete view of the human

condition. It calls attention to the need for a philosophical

statement on what it means to be a person. Stress on the I/

Thou relationship lessens the chances of dehumanizing

therapy. It provides a perspective for understanding anxiety,

guilt, freedom, death, isolation, and commitment.

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Person-centered therapy

Clients take an active stance and assume responsibility

for the direction of therapy. This unique approach has

been subjected to empirical testing, and as a result

both theory and methods have been modifi ed. It is an

open system. People without advanced training can

benefi t by translating the therapeutic conditions to both

their personal and professional lives. Basic concepts

are straightforward and easy to grasp and apply. It

is a foundation for building a trusting relationship,

applicable to all therapies.

Gestalt therapy

The emphasis on direct experiencing and doing rather than

on merely talking about feelings provides a perspective

on growth and enhancement, not merely a treatment of

492

disorders. It uses clients’ behavior as the basis for making

them aware of their inner creative potential. The approach

to dreams is a unique, creative tool to help clients discover

basic confl icts. Therapy is viewed as an existential

encounter; it is process-oriented, not technique-oriented. It

recognizes nonverbal behavior as a key to understanding.

Behavior therapy

Emphasis is on assessment and evaluation techniques,

CHAPTER FIFTEEN

thus providing a basis for accountable practice. Specifi c

problems are identifi ed, and clients are kept informed

about progress toward their goals. The approach has

demonstrated effectiveness in many areas of human

functioning. The roles of the therapist as reinforcer,

model, teacher, and consultant are explicit. The approach

has undergone extensive expansion, and research

literature abounds. No longer is it a mechanistic

approach, for it now makes room for cognitive factors and

encourages self-directed programs for behavioral change.

Cognitive behavior therapy

Major contributions include emphasis on a comprehensive

and eclectic therapeutic practice; numerous cognitive,

emotive, and behavioral techniques; an openness to

incorporating techniques from other approaches; and a

methodology for challenging and changing faulty thinking.

Most forms can be integrated into other mainstream

therapies. REBT makes full use of action-oriented

homework, various psychoeducational methods, and

keeping records of progress. CT is a structured therapy

that has a good track record for treating depression and

anxiety in a short time.

Reality therapy

This is a positive approach with an action orientation

that relies on simple and clear concepts that are easily

grasped in many helping professions. It can be used by

teachers, nurses, ministers, educators, social workers,

and counselors. Due to the direct methods, it appeals to

many clients who are often seen as resistant to therapy.

It is a short-term approach that can be applied to a

diverse population, and it has been a signifi cant force in

challenging the medical model of therapy.

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Feminist therapy

The feminist perspective is responsible for encouraging

increasing numbers of women to question gender

stereotypes and to reject limited views of what a woman

is expected to be. It is paving the way for gender-

sensitive practice and bringing attention to the gendered

uses of power in relationships. The unifi ed feminist

voice brought attention to the extent and implications

of child abuse, incest, rape, sexual harassment, and

domestic violence. Feminist principles and interventions

can be incorporated in other therapy approaches.

Postmodern approaches

The brevity of these approaches fi t well with the

limitations imposed by a managed care structure. The

emphasis on client strengths and competence appeals to

clients who want to create solutions and revise their life

493

stories in a positive direction. Clients are not blamed for

AN INTE

their problems but are helped to understand how they

might relate in more satisfying ways to such problems.

A strength of these approaches is the question format

GRA

that invites clients to view themselves in new and more

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effective ways.

Family systems therapy

From a systemic perspective, neither the individual nor

the family is blamed for a particular dysfunction. The

C

family is empowered through the process of identifying

TIVE

and exploring interactional patterns. Working with an

entire unit provides a new perspective on understanding

and working through both individual problems and

relationship concerns. By exploring one’s family of

origin, there are increased opportunities to resolve other

confl icts in systems outside of the family

TA B L E 1 5 .1 0 Limitations of the Approaches

Psychoanalytic therapy

Requires lengthy training for therapists and much

time and expense for clients. The model stresses

biological and instinctual factors to the neglect of

social, cultural, and interpersonal ones. Its methods

are less applicable for solving specifi c daily life

problems of clients and may not be appropriate for

some ethnic and cultural groups. Many clients lack

the degree of ego strength needed for regressive and

reconstructive therapy. It may be inappropriate for

certain counseling settings.

Adlerian therapy

Weak in terms of precision, testability, and empirical

validity. Few attempts have been made to validate

the basic concepts by scientifi c methods. Tends to

oversimplify some complex human problems and is

based heavily on common sense.

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Existential therapy

Many basic concepts are fuzzy and ill-defi ned, making

its general framework abstract at times. Lacks a

systematic statement of principles and practices of

therapy. Has limited applicability to lower functioning

and nonverbal clients and to clients in extreme crisis

who need direction.

Person-centered therapy

Possible danger from the therapist who remains

passive and inactive, limiting responses to refl ection.

Many clients feel a need for greater direction, more

structure, and more techniques. Clients in crisis may

need more directive measures. Applied to individual

counseling, some cultural groups will expect more

counselor activity.

494

Gestalt therapy

Techniques lead to intense emotional expression; if

these feelings are not explored and if cognitive work is

not done, clients are likely to be left unfi nished and will

not have a sense of integration of their learning. Clients

who have diffi culty using imagination may not profi t

from certain experiments.

CHAPTER FIFTEEN

Behavior therapy

Major criticisms are that it may change behavior but not

feelings; that it ignores the relational factors in therapy;

that it does not provide insight; that it ignores historical

causes of present behavior; that it involves control by the

therapist; and that it is limited in its capacity to address

certain aspects of the human condition.

Cognitive behavior therapy

Tends to play down emotions, does not focus on exploring

the unconscious or underlying confl icts, de-emphasizes

the value of insight, and sometimes does not give enough

weight to the client’s past. REBT, being a confrontational

therapy, might lead to premature termination. CBT might

be too structured for some clients.

Reality therapy

Discounts the therapeutic value of exploration of the

client’s past, dreams, the unconscious, early childhood

experiences, and transference. The approach is limited

to less complex problems. It is a problem-solving

therapy that tends to discourage exploration of deeper

emotional issues.

Feminist therapy

A possible limitation is the potential for therapists

to impose a new set of values on clients—such as

striving for equality, power in relationships, defi ning

oneself, freedom to pursue a career outside the home,

and the right to an education. Therapists need to keep

in mind that clients are their own best experts, which

means it is up to them to decide which values to

live by.

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Postmodern approaches

There is little empirical validation of the effectiveness

of therapy outcomes. Some critics contend that these

approaches endorse cheerleading and an overly positive

perspective. Some are critical of the stance taken by

most postmodern therapists regarding assessment

and diagnosis, and also react negatively to the

“not-knowing” stance of the therapist. Because some

of the solution-focused techniques are relatively easy

to learn, practitioners may use these interventions

in a mechanical way or implement these techniques

without a sound rationale.

Family systems therapy

Limitations include problems in being able to involve

all the members of a family in the therapy. Some family

members may be resistant to changing the structure of

495

the system. Therapists’ self-knowledge and willingness

AN INTE

to work on their own family-of-origin issues is crucial,

for the potential for countertransference is high. It is

essential that the therapist be well trained, receive quality

GRA

supervision, and be competent in assessing and treating

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individuals in a family context.

Evaluating how well psychotherapy works is far from simple. Therapeutic

C

TIVE

systems are applied by practitioners who have unique individual characteristics,

and clients themselves have much to do with therapeutic outcomes. For example,

effects resulting from unexpected and uncontrollable events in the environment

can lessen the impact of gains made in psychotherapy. Moreover, practitioners

who adhere to the same approach are likely to use techniques in various ways and

to relate to clients in diverse fashions, functioning differently with different clients

and in different clinical settings. Norcross and Beutler (2011) note that evidence-

based practice refl ects a commitment on “what works, not on what theory applies”

(p. 510).

Most of the outcome studies have been done by two divergent groups: (1) the

behavior and cognitive therapists, who have based their therapeutic practice on

empirical studies, and (2) the person-centered researchers, who have made sig-

nifi cant contributions to understanding both process and outcome variables. Sig-

nifi cant empirical research dealing with how well the therapy works has not been

produced for most of the other models covered in this book.

How effective is psychotherapy? A meta-analysis of psychotherapy outcome

literature conducted by Smith, Glass, and Miller (1980) concluded that psycho-

therapy was highly effective. Prochaska and Norcross (2010) note that controlled

outcome research consistently supports the effectiveness of psychotherapy. They

point out that more than 5,000 individual studies and 500 meta-analyses have

been conducted on the effectiveness of psychotherapy; these studies demonstrate

that well-developed therapy interventions have meaningful, positive effects on

the intended outcome variables. In short, not only does psychotherapy work, but

research demonstrates that therapy is remarkably effective.

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A summary of the research data shows that the various treatment approaches

achieve roughly equivalent results (Duncan et al., 2004). Lambert’s (2011) re-

view of psychotherapy research makes it clear that the similarities rather than

the differences among models account for the effectiveness of psychothera-

py. Reviews of comparative outcome studies reveal the same general conclu-

sion: there is relative equivalence among the various therapeutic approaches.

Interpersonal, social, and affective factors common across therapeutic orienta-

tions are more critical than techniques employed when it comes to facilitat-

ing therapeutic gains. Lambert believes the future direction of theory, practice,

and training will see (1) the decline of single-theory practice and the growth

of integrative therapies, and (2) the increase in short-term, time-limited, and

group treatments that seem to be as effective as long-term individual treatments

496

with many client populations.

Although it is clear that therapy works, there are no simple explanations of

how it works, and it appears that we must look to factors that are common to all

therapeutic approaches. Hubble, Duncan, Miller, and Wampold (2010) summa-

rized research studies in the fi eld and found that the following four factors account

for change in therapy:

• Client factors: 40%

CHAPTER FIFTEEN

• Alliance factors (the therapeutic relationship): 30%

• Expectancy factors (hope and allegiance): 15%

• Theoretical models and techniques: 15%

Common factors that are part of all theoretical orientations are critical to thera-

peutic outcome. Wampold (2010) concludes that “there is little evidence that the

specifi c ingredients of any treatment are responsible for the benefi ts of therapy”

(p. 71). Research indicates that a variety of treatments are equally effective—when

administered by therapists who believe in them and when they are accepted by

the client.

The various therapy approaches and techniques work equally well because they

share the most important ingredient accounting for change—the client. Data point

to the conclusion that the engine of change is the client (Bohart & Tallman, 2010),

and we can most productively direct our efforts toward ways of employing the cli-

ent in the process of change (Duncan et al., 2004). Duncan and colleagues further

state that therapists can translate this research into their clinical work by purpose-

fully working to do the following:

• Enhance the common factors across all theories that account for successful

outcomes

• Focus on the client’s perspective and theory of change as a guide to selecting

techniques and integrating various therapy models

• Obtain systematic client feedback regarding the client’s experience of the proc-

ess and outcome of therapy

Hubble, Duncan, Miller, and Wampold (2010) note that monitoring outcome

and adjusting accordingly on the basis of feedback from the client must become

routine practice. Duncan and colleagues (2004) claim that the client’s theory of

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change can be used as a basis for determining which approach, by whom, can be

most effective for this person, with his or her specifi c problem, under this particu-

lar set of circumstances. This approach to practicing therapy places emphasis on

continuous client input into the therapy process. Doing this increases the chances

of active client participation in therapy, which is the most important determinant

of the outcome of treatment.

s u m m a r y

Creating an integrative stance is truly a challenge. Therapists cannot simply pick

bits and pieces from theories in a random and fragmented manner. In forming an

integrated perspective, it is important to ask: Which theories provide a basis for

understanding the cognitive dimensions? What about the feeling aspects? And how

497

about the behavioral dimension? Most of the 11 therapeutic orientations discussed

AN INTE

here focus on one of these dimensions of human experience. Although the other

dimensions are not necessarily ignored, they are often given short shrift.

Developing an integrated theoretical perspective requires an accurate, in-

GRA

depth knowledge of the various theories. Without such knowledge, you cannot

TIVE PERSPE

formulate a true synthesis. Simply put, you cannot integrate what you do not know

(Norcross & Beutler, 2011). A central message of this book has been to remain

open to each theory, to do further reading, and to refl ect on how the key concepts

of each approach fi t your personality. Building your personalized orientation to

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TIVE

counseling, which is based on what you consider to be the best features of several

theories, is a long-term venture.

Besides considering your own personality, think about what concepts and tech-

niques work best with a range of clients. It requires knowledge, skill, art, and experi-

ence to be able to determine what techniques are suitable for particular problems.

It is also an art to know when and how to use a particular therapeutic intervention.

Although refl ecting on your personal preferences is important, I would hope that

you also balance your preferences with evidence from the research studies. Devel-

oping a personal approach to counseling practice does not imply that anything goes.

Indeed, in this era of managed care and evidence-based practice, your personal pref-

erences will not likely be the sole determinant of your psychotherapy practice. In

counseling clients with certain clinical problems (such as depression and gener-

alized anxiety), specifi c techniques have demonstrated their effectiveness. For in-

stance, behavior therapy, cognitive behavior therapy, mindfulness-based cognitive

therapy, and short-term psychodynamic therapy have repeatedly proved successful

in treating depression. Your use of techniques must be grounded on solid theoreti-

cal constructs. Ethical practice implies that you employ effi cacious procedures in

dealing with clients and their problems, and that you are able to provide a theoreti-

cal rationale for the interventions you make in your clinical work.

This is a good time to review what you have learned about counseling theory

and practice. Identify a particular theory that you might adopt as a foundation

for establishing your counseling perspective. Consider from which therapies you

would be most inclined to draw (1) underlying assumptions, (2) major concepts,

(3) therapeutic goals, (4) therapeutic relationship, and (5) techniques and procedures.

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Also, consider the major applications of each of the therapies as well as their basic

limitations and major contributions. The tables presented in this chapter are de-

signed to assist you in conceptualizing your view of the counseling process.

w h e r e t o g o f r o m h e r e

In the DVD for Integrative Counseling: The Case of Ruth and Lecturettes (Session 9,

“An Integrative Perspective”) you will view my ways of working with Ruth by draw-

ing on techniques from various theoretical models. I demonstrate how the founda-

tion of my integrative approach rests on existential therapy. In this session I am

drawing heavily from principles of the action-oriented therapies.

Other Resources

498

DVDs offered by the American Psychological Association that are relevant to this

chapter include the following:

Stricker, G. (2009). Psychotherapy Integration Over Time (Psychotherapy

Video Series)

A private group of clinicians and researchers is dedicated to studying “what

works” in behavioral mental health. Members and associates translate the latest

CHAPTER FIFTEEN

research into guidelines for clinical practice and publish the information in clini-

cally friendly terms on their website. The Institute for the Study of Therapeutic

Change has also developed an outcome management system that uses ongoing

client feedback to monitor and improve retention in therapy and improve outcome

of treatment services.

Scott D. Miller, PhD, Co-director

Institute for the Study of Therapeutic Change

P. O. Box 180147

Chicago, IL 60618-0573

Telephone: (773) 404-5130

Fax: (847) 841-4874

Mobile: (773) 454-8511

Website: www.talkingcure.com

The International Center for Clinical Excellence (ICCE) is a worldwide commu-

nity of practitioners, health care managers, educators, and researchers dedicated

to promoting excellence in behavioral health care services. This online community

facilitates sharing of best practices and innovative ideas specifi cally designed to

improve behavioral health care practice and enable practitioners and managers to

achieve their personal best as helping professionals.

The International Center for Clinical Excellence

www.centerforclinicalexcellence.com

Scott D. Miller’s website has additional information on workshops on clinical

excellence:

Scott D. Miller

Website: www.scottdmiller.com

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Recommended Supplementary Readings

Psychotherapy Integration (Stricker, 2010) is a concise presentation that deals with

the theory, therapeutic process, evaluation, and future developments of integra-

tive approaches.

A Casebook of Psychotherapy Integration (Stricker & Gold, 2006) features master

therapists who demonstrate how they successfully apply their own integrative

approaches.

Handbook of Psychotherapy Integration (Norcross & Goldfried, 2005) is an excel-

lent resource for conceptual and historical perspectives on therapy integration.

This edited volume gives a comprehensive overview of the major current

approaches, such as theoretical integration and technical eclecticism.

499

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The Art of Integrative Counseling (Corey, 2013a) is designed to assist students in devel-

oping their own integrative approach to counseling. This book is complemented by

GRA

the DVD for Integrative Counseling: The Case of Ruth and Lecturettes (Corey, 2013c).

TIVE PERSPE

Case Approach to Counseling and Psychotherapy (Corey, 2013b) illustrates each of

the 11 contemporary theories by applying them to the single case of Ruth. I also

demonstrate my integrative approach in counseling Ruth in the fi nal chapter.

This book also is designed to fi t well with the DVD for Integrative Counseling: The

C

TIVE

Case of Ruth and Lecturettes (Corey, 2013c).

Integrating Spirituality and Religion into Counseling: A Guide to Competent Prac-

tice (Cashwell & Young, 2011) offers a concrete perspective on how to provide

counseling in an ethical manner, consistent with a client’s spiritual beliefs and

practices. The authors help practitioners develop a respectful stance that honors

the client’s worldview and works within this framework in a collaborative fashion

to achieve the client’s goals.

References and Suggested Readings

*Bohart, A. C., & Tallman, K. (2010). Cli-

Comas-Diaz, L. (2011). Multicultural approach-

ents: The neglected common factor in

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psychotherapy. In B. L. Duncan, S. D. Miller,

Vandenbos, & D. K. Freedheim (Eds.), His-

B. E. Wampold, & M. A. Hubble (Eds.), The

tory of psychotherapy (2nd ed., pp. 243–268).

heart and soul of change: Delivering what

Washington, DC: American Psychological

works in therapy (2nd ed., pp. 83–111).

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seling (3rd ed.). Belmont, CA: Brooks/Cole,

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*Books and articles marked with an asterisk are recommended for further study.

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psychotherapies: Theory and practice (3rd ed.,

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(2007). Religiosity and spirituality among

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Lambert, M. J. (2011). Psychotherapy research

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CHAPTER FIFTEEN

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c h a p t e r 1 6

Case Illustration: An

Integrative Approach in

Working With Stan

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

c o u n s e l i n g s ta n : i n t e g r at i o n

o f t h e r a p i e s

The purpose of this chapter is to bring together in an integrative fashion the 11

approaches you have studied by combining thinking, feeling, and acting models

in counseling Stan. The material in Chapter 15 provides a conceptual framework

for my way of counseling from an integrative perspective. Many of the key points

made in Chapter 15 will become clearer as you read about the interventions I am

making with Stan in this chapter. At this point it would be helpful for you to review

the background material and themes in Stan’s life presented in Chapter 1. In addi-

tion, I suggest you consult the Student Manual for Theory and Practice of Counseling

and Psychotherapy (Chapter 16) for an overview and review of the major areas I

focus on for each of the theoretical approaches in my work with Stan.

504

In this section, I describe how I would integrate concepts and techniques from

the 11 theoretical perspectives in counseling Stan on the levels of thinking, feeling,

TEEN

and doing. I use information presented in Stan’s autobiography, and I indicate

what aspects from the various theories I would draw on in working with Stan at

the various stages of his therapy. As you read, think about the interventions you

would make with Stan that would be either similar to or different from mine.

CHAPTER SIX

Questions in the “Follow-Up” section near the end of the chapter will guide you

as you refl ect on being Stan’s counselor and working with him from your own

integrative perspective.

See the video program for Chapter 16, DVD for Theory and Practice of Counseling

and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the

brief lecture for each chapter prior to reading the chapter.

A Place to Begin

I start by giving Stan a chance to say how he feels about coming to the initial ses-

sion. To begin to understand why Stan has sought therapy, I might explore his

thoughts regarding any of the following questions:

• What brings you here? What has been going on in your life recently that made

you want to seek professional help?

• What expectations do you have of therapy? Of me? What are your hopes, fears,

and any reservations? What goals do you have for yourself through therapy?

• Give me a picture of some signifi cant turning points in your life? Who have

been the important people in your life? What signifi cant decisions have you

made? What are some of the struggles you’ve dealt with, and what are some of

these issues that are current for you?

• How would you describe your life in your family? How did you view your par-

ents? How did they react to you? What do you remember about your early

years? (It would be useful to administer the Adlerian lifestyle questionnaire.)

Clarifying the Therapeutic Relationship

I will work with Stan to develop a contract, which involves a discussion of our mu-

tual responsibilities and a clear statement of what he wants from these sessions

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28549_ch16_rev01.indd 504

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and what he is willing to do to obtain his goals. I believe it is important to discuss

any factors that might perpetuate a client’s dependency on the therapist, so I invite

Stan’s questions about this therapeutic relationship. One goal is to demystify the

therapy process; another is to get some focus for the direction of our sessions by

developing clear goals for the therapy.

In establishing the therapeutic relationship, I am infl uenced by the person-

centered, existential, Gestalt, feminist, postmodern, and Adlerian approaches.

They do not view therapy as something that the therapist does to a passive client.

I will apply my knowledge of these therapies to establish a working relationship

with Stan that is characterized by mutual trust and respect. I will ask myself these

questions: “To what degree am I able to listen to and hear Stan in a nonjudgmen-

tal way? Am I able to respect and care for him? Do I have the capacity to enter his

subjective world without losing my own identity? Am I able to share with him my

505

own thoughts and reactions as they pertain to our relationship?” I begin by being

APPR

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as honest as I can be with Stan as the basis for creating this relationship. This rela-

O

tionship is critical at the initial stages of therapy, but it must be maintained during

A

CH IN W

US

all stages if therapy is to be effective. I operate on the assumption that the quality

TRA

of our relationship will be critical to the therapeutic outcome.

TION: AN INTE

ORKING WITH S

Clarifying the Goals of Therapy

It is not enough to simply ask Stan what he hopes to gain by the conclusion of thera-

py. Clients are oftentimes vague, global, and unfocused about what they want. With

respect to goals, precision and clarity are essential. There is no progress when you

GRA

T

have directionless sessions. Thus, specifi city is a must. Once we have identifi ed some

AN

TIVE

goals, Stan can begin to observe and measure his own behavior, both in the sessions

and in his daily life. This self-monitoring is a vital step in any effort to bring about

change. I will be asking for Stan’s feedback throughout the therapeutic process and

will use his feedback as a basis for making modifi cations in our therapeutic alliance.

Here are a few interchanges that focus on the process of defi ning goals that will

give direction to Stan’s therapy:

JERRY: What would you most hope for, through our work together?

STAN: Well, I know I put myself down a lot. I’d like to feel better about myself.

JERRY: If you had what you want in your life today, what would that be like? What

would it take for you to feel good about yourself?

STAN: For one thing, I’d have people in my life, and I would be closer to people.

JERRY: Is this an area you’d be willing to explore in our sessions?

STAN: Yes.

JERRY: I’ll be glad to provide suggestions of ways to begin, if I know what you want.

STAN: For sure I’d like to get over my dumb fears of being with people.

JERRY: I like it that you’re willing to challenge your fears. Are you aware that you just

put yourself down by labeling your fears as dumb?

STAN: It’s almost a refl ex response for me. But I would like to feel more comfortable

when I’m with others.

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JERRY: How is it for you to be here with me now?

STAN: It’s not like me to do something like this, but I feel good. I’m talking, and I’m

saying what’s on my mind.

JERRY: I hope you will continue to give yourself credit for being different in our con-

versation right now.

Goal setting is not accomplished in a single session. Throughout our time to-

gether, I ask Stan to decide time and again what he wants from his therapy and to

assess the degree to which our work together is resulting in his meeting his goals.

As his therapist, I expect to be active, yet it is important that Stan provide the direc-

tion in which he wants to travel on his journey. Once I have a clear sense of the

specifi c ways Stan wants to change how he is thinking, feeling, and acting, I am

likely to take an active role in co-creating experiments with Stan that he can do both

506

in the therapy sessions and on his own away from our sessions.

Working With Stan’s Past, Present, and Future

TEEN

d e a l i n g w i t h t h e pa s t Reality therapy, solution-focused brief therapy,

behavior therapy, and rational emotive behavior therapy place very little emphasis

on the client’s history. The rationale for this lack of attention to the past is that

early childhood experiences do not necessarily have much to do with the mainte-

CHAPTER SIX

nance of present ineffective behavior. My inclination, in contrast, is to give weight

to understanding, exploring, and working with Stan’s early history and to connect

his past with what he is doing today. My view is that themes running through our

life can become evident if we come to terms with signifi cant experiences in our

childhood. The use of an Adlerian lifestyle questionnaire would indicate some of

these themes that originate from Stan’s childhood. The psychoanalytic approach,

of course, emphasizes uncovering and reexperiencing traumas in early childhood,

working through the places where we have become “stuck,” and resolving confl icts

that are often out of our awareness.

Although I agree that Stan’s childhood experiences were infl uential in contrib-

uting to his present personality (including his ways of thinking, feeling, and behav-

ing), it does not make sense to me to assume that these factors have determined him.

I favor the Gestalt approach of asking Stan to bring into the here and now those peo-

ple in his life with whom he feels unfi nished. A variety of role-playing techniques in

which Stan addresses signifi cant others through symbolic work in our sessions will

bring Stan’s past intensely to life in the present moment of our sessions.

d e a l i n g w i t h t h e p r e s e n t Being interested in Stan’s past does not

mean that we get lost in history or that we dwell on reliving traumatic situations.

By paying attention to what is going on in the here and now during the counseling

session, I get excellent clues about what is unfi nished from Stan’s past. He and

I can direct attention to his immediate feelings as well as to his thoughts and

actions. It seems essential to me that we work with all three dimensions—what

he is thinking, what he is actually doing, and how his thoughts and behaviors

affect his feeling states. Again, by directing Stan’s attention to what is going on

with him during our sessions, I can show him how he interacts in his world apart

from therapy.

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d e a l i n g w i t h t h e f u t u r e Adlerians are especially interested in where

the client is heading. Humans are pulled by goals, strivings, and aspirations. It

would help to know what Stan’s goals in life are. What does he want for himself?

If he decides that his present behavior is not getting him what he wants, he is in

a good position to think ahead about the changes he would like to make and what

he can do now to actualize his aspirations. The present-oriented behavioral focus

of reality therapy is a good reference point for getting Stan to dream about what

he would like to say about his life 5 years hence. Connecting present behavior with

future plans is an excellent way to help Stan formulate a concrete plan of action.

He will actually create his future.

Identifying Feelings

The person-centered approach stresses the fi rst stage in the therapy process, which

507

involves identifying, clarifying, and learning how to express feelings. Because of

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the therapeutic relationship I have built with Stan, I expect him to feel increasingly

O

free to talk about feelings that he has kept to himself. In some cases these feelings

A

CH IN W

US

are out of his awareness, and I encourage Stan to talk about any feelings that are a

TRA

source of diffi culty.

TION: AN INTE

During the early stages of our sessions, I rely on empathic listening. I need

ORKING WITH S

to do more than merely refl ect what I hear Stan saying; I need to share with him

my reactions as I listen to him because doing so helps to build a good therapeutic

alliance. When Stan senses that he is being understood and accepted for the feel-

ings he has, he has less need to deny or distort his feelings. His capacity for clearly

GRA

identifying what he is feeling at any moment will gradually increase.

T

AN

TIVE

There is a great deal of value in letting Stan tell his story in a way he chooses.

The way he walks into the offi ce, his gestures, his style of speech, the details he

chooses to go into, and what he decides to relate and not to relate—to mention just

a few elements—provide me with clues to his world. If I do too much structuring

too soon, I will interfere with his typical style of presenting himself.

Expressing and Exploring Feelings

The authenticity of my relationship with Stan encourages him to begin to identify

and share with me a range of feelings. But I do not believe an open and trusting

relationship between us is suffi cient to change Stan’s personality and behavior. I

must also use my knowledge, skills, and experiences although my clinical expertise

is not the sole determinant of therapeutic change. Stan is the best expert on his

own life, and I will assist him in coming to value the ways in which he is the expert

in the therapeutic endeavor.

As a way of helping Stan express and explore his feelings, I draw heavily on

Gestalt experiments. Eventually, I ask him to avoid merely talking about situations

and about feelings. Rather, I encourage him to bring whatever reactions he is hav-

ing into the present. For instance, if Stan reports feeling tense, I ask him how he

experiences this tension right now and where it is located in his body. I encourage

him to “be that feeling.” Thus, if he has a knot in his stomach, he can intensify

his feeling of tension by “becoming the knot, giving it voice and personality.” If I

notice tears in his eyes, I may direct him to “be his tears now.” By putting words

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to his tears, he avoids abstract intellectualization about all the reasons he is sad or

tense. Before he can change his feelings, Stan must allow himself to fully experi-

ence them. The experiential therapies provide valuable tools for guiding him to the

expression of his feelings.

Here are some segments of our dialogue in a session where Stan becomes

quite aware of what he is feeling as he talks about his relationship with his

father:

JERRY: You mentioned that your father often compared you with your brother Frank

and your sister Judy. What was that like for you?

STAN: I hated it! He told me that I’d never amount to anything.

JERRY: And when he said that, how did that affect you?

508

STAN: It made me feel that I could never measure up to all the great things that Judy

and Frank were accomplishing. I felt like a failure. [ As he says this, he begins to tear up,

and his voice changes. ]

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JERRY: Stan, what is going on right now?

STAN: All of a sudden a wave of sadness is coming over me. I’m getting all choked

up. This is hard!

JERRY: Stay with your feeling. What’s going on?

CHAPTER SIX

STAN: My chest is tight, like something wants to come out.

JERRY: Say more.

STAN: I’m feeling very sad and hurt.

JERRY: Would you be willing to try something? I’d like you to talk to me as though I

were your father. Are you willing to do that?

STAN: Well, you’re not mean the way he was, but I can try.

JERRY: How old are you feeling now?

STAN: Oh, maybe 12 years old—just like when I had to be around my father and

listen to all the stuff he told me about how useless I was.

JERRY: Let yourself be 12 again, and tell me what it’s like for you to be you—speaking

to me as your father.

STAN: There was nothing that I could ever do that was good enough for you. No mat-

ter how hard I tried, I couldn’t get you to notice me. [ Crying] Why didn’t I count, and

why did you ignore me?

JERRY: Stan, I’ll just let you talk for a while, and I’ll listen. So keep on telling me all

the things you may be feeling as that 12-year-old now.

STAN: All I ever wanted was to know that I mattered to you. But no matter how

hard I tried, all you’d do was put me down. Nothing I did was worth anything. I just

wanted you to love me. Why didn’t you ever do anything with me? [ Stan stops talking

and just cries for a while. ]

JERRY: What’s happening with you now?

STAN: I’m feeling so sad. As if it’s hopeless. Nothing I can do will ever get his approval.

JERRY: At 12 it was important for you to get his acceptance and his love. There is still

that part in you that wants his love.

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STAN: Yes, and I don’t think I’ll ever get it.

JERRY: Tell him more of what that’s like.

Stan continues talking to his “father” and recounts some of the ways in which

he tried to live up to his expectations. No matter what he did, there was no way to

get the acceptance that Frank and Judy got from him.

JERRY: Having said all that, what are you aware of now?

STAN: I’m feeling embarrassed.

JERRY: You say you’re embarrassed. Whom are you aware of now?

STAN: Well, right now of you. I feel like a wimp. You’re probably thinking that I’m

weak and dumb for letting this get to me.

JERRY: Tell me more about feeling weak and dumb.

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Stan expresses that he should be stronger and that he is afraid I’ll think he is

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hopeless. He goes into some detail in belittling himself for what he has just expe-

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rienced and expressed. I avoid quickly reassuring him that he “shouldn’t feel that

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way.” Instead, I let him express whatever he is feeling. After telling me many of

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the ways in which he is feeling embarrassed, he wonders if I still want to work with

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him. At this point I let him know that I respect his struggle and encourage him to

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continue revealing aspects that he typically keeps hidden. Because this session is

coming to an end, I talk with Stan about the value of releasing feelings that he has

been carrying around for a long time, suggesting that this is a good beginning. I

am also interested in getting him to do some homework before the next session.

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By focusing on his feelings both in the therapy offi ce and in daily life, I hope Stan

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can eventually learn to avoid judging himself so harshly.

JERRY: Stan, I’d like to suggest that you write a letter to your father . . .

STAN: [ Interrupting] Oh no! I’m not going to give that guy the satisfaction of knowing

that I need anything from him!

JERRY: Wait. I was about to say that I hope you’ll write him a letter that you don’t mail.

STAN: What’s the point of a letter that won’t be sent?

JERRY: Writing him a letter is an opportunity for further release and to gain some

new insights. I hope you’ll let yourself write about all the ways you tried to live up

to his expectations. Let him know what it felt like to be around him. Tell him more

about you, especially how it felt in not getting those things that you so much wanted.

STAN: OK, I’ll do that.

In this session I might have made many different interventions. For the mo-

ment, I chose to let him “borrow my eyes” and talk to me as his father while he was

12 years old. I asked him to stay with whatever he was experiencing, paying par-

ticular attention to his body and to the emotions that were welling up within him.

It would be premature to suggest problem-solving strategies or to attempt to fi gure

everything out. My intent in offering him the homework assignment of writing a

letter is to provide an avenue for Stan to continue thinking about the impact his

father has had on him and to further promote his work during the week. Writing

the letter may trigger memories, and he may experience further emotional release.

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At our next session I will ask Stan about the letter and what it was like for him

to write it. What did he say to his father? How was it to read the letter later? Is

there anything that he wants to share with me? The direction of our next session

will depend on his response. Again, Stan will provide clues to where he needs to

go next.

The Thinking Dimension in Therapy

Once Stan has experienced some intense feelings and perhaps released pent-up

feelings, some cognitive work is essential. To bring in this cognitive dimension,

I focus Stan’s attention on messages he incorporated as a child and on the deci-

sions he made. I get him to think about the reason he made certain early decisions.

Finally, I challenge Stan to look at these decisions about life, about himself, and

about others and to make necessary revisions that can lead him to creating a life of

510

his own choosing.

After getting basic information about Stan’s life history (by means of the Adle-

TEEN

rian lifestyle assessment form), I summarize and interpret it with Stan in a ses-

sion. For example, I fi nd some connections between his present fears of developing

intimate relationships and his history of rejection by his siblings and his parents.

I am interested in his family constellation and his early recollections. Rather than

CHAPTER SIX

working exclusively with his feelings, I want Stan to begin to understand (cog-

nitively) how these early experiences affected him then and how they still infl u-

ence him today. My emphasis is on having Stan begin to question the conclusions

he came to about himself, others, and life. What is his private logic? What are some

of his mistaken, self-defeating perceptions that grew out of his family experiences?

An Adlerian perspective provides tools for doing some productive cognitive work

both in and out of the therapy sessions.

From rational emotive behavior therapy I especially value the emphasis on

learning to think rationally and am interested in having Stan assess whether or

not his thoughts are rational. I am not imposing my views of rational thinking;

rather, I hope to help Stan examine his behavior and his beliefs about his behavior.

I look for the ways in which Stan contributes to his painful feelings by the process

of self-indoctrination with faulty beliefs that no longer serve him well. I ask him to

test the validity of the dire consequences he predicts. I value the stress put on do-

ing hard work in demolishing beliefs that have no validity and replacing them with

sound and rational beliefs. I do not think Stan can merely think his way through

life or that examining his faulty logic is enough by itself for personality change. But

I do see this process as an essential component of therapy.

The cognitive behavioral therapies have a range of cognitive techniques that

can help Stan recognize connections between his cognitions and his behaviors.

He should also learn about his inner dialogue and the impact it has on his day-to-

day behavior. Eventually, our goal is some cognitive restructuring work by which

Stan can learn new ways to think, new things to tell himself, and new assumptions

about life. This provides a basis for change in his behavior.

I have given Stan a number of homework assignments aimed at helping him

identify a range of feelings and thoughts that may be problematic for him. Follow-

ing are sample pieces of a session in which we focus on his cognitions.

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JERRY: Several times now you’ve brought up how you’re sure you’d be judged

critically if you allowed yourself to get close to a woman. Is this a topic you want to

explore in more depth?

STAN: Yes. I’m tired of avoiding women, but I’m still scared of approaching a woman.

I’m convinced that if any woman gets to know me, she’ll eventually reject me.

JERRY: Have you checked out this assumption? How many women have you

approached, and how many of them have actually rejected you?

STAN: They never tell me these things. But in my head I keep telling myself that

if they get to know the real me they’ll be turned off by my weakness, and then they

wouldn’t want anything to do with me.

JERRY: How about telling me some of the things you tell yourself when you think of

meeting a woman? Just let yourself free associate, listing out loud some of the state-

ments you make to yourself internally. Ready?

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STAN: So often I say to myself that I’m not worth knowing. [ Pause]

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JERRY: Just rattle off as many of these self-statements as you can. Don’t worry about

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how it sounds.

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STAN: What a nerd! Every time you open your mouth, you put your foot in it. Why

don’t you just shut up and hide? When you do talk to people, you freeze up. They’re

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judging you, and if you say much of anything, they’ll fi nd out what a complete and

utter failure you are. Anything you try, you fail in. You are not very interesting. You’re a

weak and a scared kid. Why don’t you keep to yourself so that others won’t reject you?

Stan continues with this list, and I listen. After he seems fi nished, I tell him

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how I’m affected by hearing his typical self-talk. I let him know that it saddens me.

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Although I like Stan, I don’t have the sense that he will emotionally believe that I

care about him. I let him know that I respect the way he doesn’t run from his fears

and that I admire his willingness to talk openly about his troubles.

Stan has acquired a wide range of critical internal dialogues that he has practiced

for many years. As he begins to challenge those thoughts, he will discover that his

thinking is grossly inaccurate. Eventually I hope he will change many of the beliefs

that are resulting in problems for him. Along this line, I work with him to pinpoint

specifi c beliefs and then do my best to get him to examine them. I am infl uenced by

the constructivist trend in cognitive behavior therapy. Applied to Stan, constructiv-

ism holds that his subjective framework and interpretations are far more important

than the objective bases that may be at the origin of his faulty beliefs. Thus, rather

than imposing my version of what may constitute faulty, irrational, and dysfunc-

tional beliefs on his part, I pursue a line of Socratic questioning whereby I get Stan

to evaluate his own thinking processes and his conclusions.

JERRY: Let’s take one statement that you’ve made a number of times: “When I’m

with other people, I feel stupid.” What goes on within you when you say this?

STAN: I hear critical voices, like people are in my head or are sitting on my shoulder.

JERRY: Name one person who often sits on your shoulder and tells you you’re stupid.

STAN: My dad, for one. I hear his voice in my head a lot.

JERRY: Let me be Stan for a moment, and you be your dad, saying to me some of

those critical things that you hear him saying inside your head.

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STAN: Why are you going to college? Why don’t you quit and give your seat to some-

one who deserves it? You’re not a good student. You’re wasting your time and the

taxpayers’ money by pretending to be a college student. Do yourself a favor and wake

up to the fact that you are just a dumb kid.

JERRY: How much truth is there in what you just said as your dad?

STAN: You know, it sounds stupid that I let him convince me that I’m totally stupid.

JERRY: Instead of saying that you’re stupid for letting him tell you that you’re stupid,

can you give yourself credit for being smart enough to come to this realization?

STAN: OK, but he’s right that I’ve failed at most of the things I’ve tried.

JERRY: Does failing at a task mean that you’re right holding to the label of being a

failure in life? I’d like to hear you produce the evidence that supports your interpreta-

tion of being stupid and of being a failure.

512

STAN: How about the failure in my marriage? I couldn’t make it work, and I was

responsible for the divorce. That’s a pretty big failure.

TEEN

JERRY: And were you totally responsible for the divorce? Did your wife have any part in it?

STAN: She always told me that no woman could ever live with me. She convinced me

that I couldn’t have a satisfying relationship with her or any other woman.

JERRY: Although she could speak for herself, I’m wondering what qualifi es her to

CHAPTER SIX

determine your future with all women. What study did she conduct that proves that

Stan is utterly destined to be allergic to all women forever?

STAN: I suppose I just bought into what she told me. After all, if I couldn’t live with

her, what makes me think I could have a satisfying life with any woman?

At this point, there are many directions to go with Stan to explore the origin of his

beliefs and to assess the validity of his interpretations about life situations and his con-

clusions about his basic worth. In this and other sessions, we explore what cognitive

therapists call “cognitive distortions.” Here are some of Stan’s cognitive distortions:

• Arbitrary inferences. Stan makes conclusions without supporting and relevant evi-

dence. He often engages in “catastrophizing,” or thinking about the worst pos-

sible scenario for a given situation.

• Overgeneralization. Stan holds extreme beliefs based on a single incident and

applies them inappropriately to other dissimilar events or settings. For in-

stance, because he and his wife divorced, he is convinced he is destined to be a

failure with any woman.

• Personalization. Stan has a tendency to relate external events to himself, even

when there is no basis for making the connection. He relates an incident in

which a female classmate did not show up for a lunch date. He agonized over

this event and convinced himself that she would have been humiliated to be

seen in his presence. He did not consider any other possible explanations for

her absence.

• Labeling and mislabeling. Stan presents himself in light of his imperfections

and mistakes. He allows his past failures to defi ne his total being.

• Polarized thinking. Stan frequently engages in thinking and interpreting in all-

or-nothing terms. Through this process of dichotomous thinking, he has cre-

ated self-defeating labels that keep him restricted.

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Over a number of sessions we work on specifi c beliefs. The aim is for Stan to criti-

cally evaluate the evidence for many of his conclusions. My role is to promote cor-

rective experiences that will lead to changes in his thinking. I am striving to create

a collaborative relationship, one in which he will discover for himself how to dis-

tinguish between functional and dysfunctional beliefs. He can learn this by testing

his conclusions.

Doing: Another Essential Component of Therapy

Stan can spend countless hours gathering interesting insights about why he is the

way he is. He can learn to express feelings that he kept hidden for many years. He

can think about the things he tells himself that lead to defeat. Yet in my view feel-

ing and thinking are not a complete therapy process. Doing is a way of bringing

these feelings and thoughts together by applying them to real-life situations in vari-

513

ous action programs. I am indebted to Adlerian therapy, behavior therapy, reality

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therapy, rational emotive behavior therapy, cognitive therapy, narrative therapy,

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and solution-focused brief therapy, all of which give central emphasis to the role of

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action as a prerequisite for change.

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Behavior therapy offers a multitude of techniques for behavioral change. In

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Stan’s case I am especially inclined to work with him in developing self-management

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programs. For example, he complains of often feeling tense and anxious. Daily

relaxation procedures are one way Stan can gain more control of his physical and

psychological tension. I have been teaching him a variety of mindfulness tech-

niques, including a combination of meditation and relaxation procedures. Through

GRA

mindfulness practice, Stan can get himself centered before he goes to his classes,

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meets women, or talks to friends. He can also begin to monitor his behavior in

everyday situations to gain increased awareness of what he tells himself, what he

does, and then how he feels. When he gets depressed, he tends to drink to alleviate

his symptoms. He can carry a small notebook with him and actually record events

that lead up to his feeling depressed (or anxious or hurt). He might also record

what he actually did in these situations and what he might have done differently.

By paying attention to what he is doing in daily life, he is already beginning to gain

more control of his behavior.

This behavioral monitoring can be coupled with both Adlerian and cognitive

approaches. My guess is that Stan gets depressed, engages in self-destructive be-

havior (drinking, for one), and then feels even worse. I work very much on both his

behaviors and cognitions and show him how many of his actions are infl uenced

by what he is telling himself. Together we work on how he is setting himself up

for failure by his self-defeating expectations. True to the spirit of rational emotive

behavior therapy, we explore his faulty assumptions that he must be perfect and

that if he does not get the job, life will be unbearable. There are many opportunities

for Stan to see connections between his cognitive processes and his daily behavior.

I encourage him to begin to behave differently and then look for changes in his

feeling states and his thinking.

With this in mind, I ask Stan to think of as many ways as possible of actually

bringing into his daily living the new learning he is acquiring in our sessions. Prac-

tice is essential. Homework assignments (preferably ones that Stan gives himself)

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are an excellent way for Stan to become an active agent in his therapy. He must

do something himself for change to occur. The degree to which he will change is

directly proportional to his willingness to experiment. I want Stan to learn from

his new behavior in life. Thus, each week we discuss his progress toward meeting

his goals, and we review how well he is completing his assignments. If he does not

like the way he carried out an assignment, we can use this as an opportunity to talk

about how he can adjust his behavior. I hold fi rm about expecting a commitment

from him to have an action plan for change and to continually look at how well his

plan is working.

In the following dialogue, our interchanges deal primarily with Stan learning a

more assertive style of behavior with one of his professors. Although this session

focuses on Stan’s behavior, we are also dealing with what he is thinking and feel-

514

ing. These three dimensions are interactive.

JERRY: Last week we role-played different ways you could approach a professor with

whom you were having a diffi culty. You learned several assertive skills that you used

TEEN

quite effectively when I assumed the role of the critical professor. Before you left last

week, you agreed to set up a time to meet with your professor and let her know about

your diffi culty. When we did the role playing, you were very clear about what you

wanted to say and strong in staying with your feelings. Did you carry out your plan?

CHAPTER SIX

STAN: The next day I tried to talk to her before class. She said she didn’t have time to

talk but that we could talk after class.

JERRY: And how did that go?

STAN: After class all I wanted to do was make an appointment with her so that I

could talk in private and without feeling hurried. When I tried to make the appoint-

ment, she very brusquely said that she had to go to a meeting and that I should see

her during her offi ce hours.

JERRY: How did that affect you?

STAN: I was mad. All I wanted to do was make an appointment.

JERRY: Did you go to her offi ce hours?

STAN: I did, that very afternoon. She was 20 minutes late for her offi ce hours, and

then some students were waiting to ask her questions. All I got to do was make an

appointment with her in a couple of days.

JERRY: Did that appointment actually take place?

STAN: Yes, but she was 10 minutes late and seemed preoccupied. I had a hard time

at the beginning.

JERRY: How so? Tell me more.

STAN: I feel stupid in her class, and I wanted to talk to her about it. When I ask ques-

tions, she gets a funny look on her face—as if she’s impatient.

JERRY: Did you check out these assumptions with her?

STAN: Yes I did, and I feel proud of myself. She told me that at times she does get

a bit impatient because I seem to need a lot of her time and reassurance. Then I let

her know how much I was studying for her class and how serious I was about doing

well in my major. It was good for me to challenge my fears, instead of avoiding her

because I felt she was judgmental.

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JERRY: It’s good to hear you give yourself credit for the steps you took. Even though

it was tough, you hung in there and said what you wanted to say. Is there anything

about this exchange with her that you wish you could have changed?

STAN: For the most part, I was pretty assertive. Generally, I blame people in author-

ity like her for making me feel stupid. I give them a lot of power in judging me. But

this time I remembered what we worked on in our session, and I stayed focused on

myself rather than telling her what she was doing or not doing.

JERRY: How did that go?

STAN: The more I talked about myself, the less defensive she became. I learned

that part of how she reacts to me is infl uenced by my behavior and when I changed

she also changed. I can still feel good about myself, even if the other person doesn’t

change. That was powerful.

JERRY: Great! Did you notice any difference in how you felt in her class after you had

515

this talk?

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STAN: For a change, I didn’t feel so self-conscious, especially when I asked questions

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or took part in class discussions. I was not so concerned about what she might think

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about me, and she seemed more at ease with me.

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JERRY: What did your meeting with her teach you about yourself?

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STAN: For one thing, I’m learning to check out my assumptions. That freed me up to

act much more spontaneously. Also, I learned that I could be clear, direct, and asser-

tive without getting nasty. It was possible for me to take care of myself without being

critical of her. Normally, I’d just swallow all my feelings and walk away feeling dumb.

This time I was assertive and was able to let her know that I needed some unhurried

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time from her.

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Practicing assertive behavior is associated with working with the feeling and

thinking domains. Had Stan not done as well as he did in engaging his professor,

we could have examined what had gone wrong from his vantage point. We could

have continued role-playing various approaches in our sessions, and then with

new knowledge and skills and more practice, he could have tried again. It is essen-

tial that Stan be willing to experiment with new ways of acting, especially outside of

the therapy sessions. In a sense, counseling can be like a dress rehearsal for living.

He exhibited courage and determination in carrying out a specifi c action plan, and

change did take place.

Working Toward Revised Decisions

When Stan has identifi ed and explored both his feelings and his faulty beliefs

and thinking processes, it does not mean that therapy is over. Becoming aware of

early decisions, including some of his basic mistakes and his self-defeating ideas,

is the starting point for change. It is essential that Stan fi nd ways to translate his

emotional and cognitive insights into new ways of thinking, feeling, and behaving.

Therefore, as much as possible I structure situations in the therapy sessions that

will facilitate new decisions on his part on both the emotional and cognitive levels.

In encouraging Stan to make these new decisions, I draw on cognitive, emotive, and

behavioral techniques. A few techniques I employ are role playing, imagery work,

assertion training procedures, and behavioral rehearsals. Both reality therapy and

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Adlerian therapy have a lot to offer on getting clients to decide on a plan of action

and then make a commitment to carry out their program for change.

Here are some examples of experiments I suggest for Stan during the therapy

sessions and homework assignments.

• I engage in reverse role-playing situations in which I “become” Stan and have

Stan assume the role of his mother, father, former wife, sister, older brother, and

a professor. Through this process Stan gets a clearer picture of ways in which he

allowed others to defi ne him, and he acquires some skills in arguing back to self-

defeating voices.

• To help Stan deal with his anxiety, I teach him meditation and other mindful-

ness techniques and encourage him to practice them daily. Stan learns to employ

these relaxation strategies in anxiety-arousing situations. I also teach him a range

516

of coping skills, such as assertiveness and disputing faulty beliefs. Stan is able to

apply these skills in several life situations.

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• Stan agrees to keep a journal in which he records impressions and experi-

ences. After encountering diffi cult situations, he writes about his reactions, both

on a thinking and a feeling level. He also records how he behaved in these situa-

tions, how he felt about his actions, and how he might have behaved differently. He

CHAPTER SIX

also agrees to read a few self-help books in areas that are particularly problematic

for him.

• As a homework assignment that we collaboratively design, Stan agrees to

meet with people whom he would typically avoid. For instance, he is highly anxious

over his performance in a couple of his classes. He decides to make an appoint-

ment with each professor to discuss his progress. In one case, a professor took an

increased interest in him, and now he does very well in her class. In the other case,

the professor is rather abrupt and not too helpful. He is able to recognize that this

is more the professor’s problem than anything he is doing.

• Stan wants to put himself in situations where he can make new friends. To-

gether we work on a clear plan of action that involves joining a club, going to social

events, and asking a woman in his class for a date. Although he is anxious in each

of these situations, he follows through with his plans. In our sessions we explore

some of his self-talk and actions at these events.

Encouraging Stan to Work With His Family of Origin

After working with Stan for a time, I suggest that he take the initiative to invite his

entire family for a session. My assumption is that many of his problems stem from

his family-of-origin experiences and that he is still being affected by these experi-

ences. I think it will be useful to have at least one session with the family so that I

can get a better idea of the broader context. The following dialogue illustrates my

attempt to introduce this idea to Stan.

JERRY: Our sessions are certainly revealing a good deal of diffi culties with several

members of your family. I think it would be useful to bring in as many of them as

you can for a session.

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STAN: No way! That’s way too much.

JERRY: Are you willing to talk with me more about this idea?

STAN: I’ll talk, but I don’t think it will change my mind.

JERRY: Why is that?

STAN: They already think I’m nutty, and if they fi nd out I’m seeing a psychologist,

that will be one more thing they can throw in my face.

JERRY: Would they use this against you?

STAN: Yes. Besides, I can’t see how it would help much. My mother and father don’t

think they have any problems. I don’t see them wanting to change much.

JERRY: Changing them is not my goal. It is more to give you a chance to express

yourself respectfully to people who are still an important part of your life.

517

STAN: Maybe, but I’m not ready for that one yet!

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JERRY: I can respect that you don’t feel ready yet. I hope you’ll remain open to the

O

idea, and if you change your mind, let me know.

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My rationale for including at least some of Stan’s family members is to pro-

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vide him with a context for understanding how his behavior is being infl uenced

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by what he learned as a child. He is a part of this system, and as he changes, it

is bound to infl uence others in his family with whom he has contact. From what

he has told me, I am assuming that his unclear boundaries with his mother have

had an impact on his relationships with other women. If he can gain a clearer

understanding of his relationship with his mother, he may be able to apply some

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of these insights with other women. In many ways Stan has allowed himself to

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be intimidated by his father, and he still hears Dad’s voice in his head a lot. In

much of his present behavior, Stan compares himself unfavorably with others,

which is a pattern that was established in early childhood with his siblings. If he is

able to deal with the members of his family about some of their past and present

struggles, there is a good chance that he will be able to form the kind of intimate

relationships that he says he would like to have in his life. (For a more complete

description of working with Stan from a family systems perspective, see Stan’s

case in Chapter 14.)

The Spiritual Dimension

Although I do not have an agenda to impose religious or spiritual values on Stan, I

want to assess the role spirituality plays, if any, in his life currently—and to assess

beliefs, attitudes, and practices from his earlier years. When I ask Stan if religion

was a factor in his childhood or adolescence, he informs me that his mother was

a practicing Lutheran and his father was rather indifferent to religion. His mother

made sure that he went to church each week. He tells me what he mainly remem-

bers from his church experiences is feeling a sense of guilt. Stan recalls that his

attitudes about religion fi t in with his low self-esteem. Not only was he not good

enough in the eyes of his parents, but he was also not good enough in the eyes of

God. He also adds that when he went to college he developed a new interest in

spirituality.

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Although formal religion does not seem to play a key role for Stan now, he is

struggling to fi nd a spiritual core as this is missing in his life. He also lets me know

that he is pleasantly surprised that I am even mentioning religion and spirituality.

He was under the impression that counselors would not be too interested in these

areas. Upon further discussion of this area, he informs me of his intention to bring

up his concerns about his spirituality at a future session.

Working With Stan’s Drinking Problem

Although each of the 11 therapeutic approaches address drug and alcohol abuse

in different ways, all probably agree that it is imperative at some point in Stan’s

therapy to confront him on the probability that he is a chemically dependent per-

son. In this section, I describe my approach to working with his dependence as

well as giving some brief background information on the alcoholic personality and

518

on treatment approaches.

s o m e b a s i c a s s u m p t i o n s Stan has given me a number of signifi cant

TEEN

clues suggesting that he is a chemically dependent person. From the information

he has provided, it is clear that Stan has many of the personality traits typically as-

sociated with addictions, including low self-concept, anxiety, underachievement,

feelings of social isolation, inability to receive love from others, hypersensitivity,

CHAPTER SIX

impulsivity, dependence, fear of failure, feelings of guilt, and suicidal ideation. He

has used drugs and alcohol as a way of blunting anxiety and attempting to control

what he perceives as a painful reality.

Once our therapeutic relationship is fi rmly established, I confront Stan (in a

caring and concerned manner) on the self-deception that drinking is less problem-

atic than taking drugs. He needs to see that alcohol is a drug. I think it is important

that he make an honest evaluation of his behavior so that he can recognize the

degree to which his drinking is interfering in his living.

a s u p p l e m e n ta r y t r e at m e n t p r o g r a m Stan eventually recognizes

and acknowledges that he does indeed have a problem with alcoholism, and he

says he is willing to do something about this problem. Stan needs to know that

long-term recovery is based on the principle of total abstinence from all drugs

and alcohol and that such abstinence is a prerequisite to effective counseling. In

addition to his weekly individual therapy sessions with me, I provide Stan with a

referral to deal with his chemical dependence.

I encourage Stan to join Alcoholics Anonymous and attend their meetings.

The 12-step program of AA has worked very well for many alcoholics. Once Stan

understands the nature of his chemical dependence and no longer uses drugs, the

chances are greatly increased that we can focus on the other aspects of his life that

he sees as problematic and would like to change. In short, it is possible to treat his

alcoholism and at the same time carry out a program of individual therapy geared

to changing Stan’s ways of thinking, feeling, and behaving.

Moving Toward Termination of Therapy

The process I have been describing will probably take months. During this time, I

will continue to draw simultaneously on a variety of therapeutic systems in working

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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with Stan’s thoughts, feelings, and behaviors. Eventually this process will lead to a

time when Stan can continue what he has learned in therapy without my assistance.

Termination of therapy is as important as the initial phase, for now the key

task is to put into practice what he has learned in the sessions by applying new

skills and attitudes to daily social situations without professional assistance.

When Stan brings up a desire to “go it alone,” we talk about his readiness to

end therapy and his reasons for thinking about termination. I also share with

him my perceptions of the directions I have seen him take. This is a good time

to talk about where he can go from here. We spend time developing an action

plan and talking about how he can best maintain his new learning. He may

want to join a therapeutic group. He could fi nd support in a variety of social

networks. In essence, he can continue to challenge himself by doing things that

are diffi cult for him yet at the same time broaden his range of choices. Now he

519

can take the risk and be his own therapist, dealing with feelings as they arise in

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new situations.

O

In a behavioral spirit, evaluating the process and outcomes of therapy seems

A

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essential. This evaluation can take the form of devoting some time to discussing

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Stan’s specifi c changes in therapy. A few questions for focus are: “What stands

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out the most for you, Stan? What did you learn that you consider the most valu-

ORKING WITH S

able? How did you learn these lessons? What can you do now to keep practicing

new behaviors? What will you do if you experience a setback?” We explore poten-

tial diffi culties he expects to face when he no longer comes to weekly counseling

sessions. At this point, I introduce some relapse prevention strategies to help Stan

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cope constructively with future problems. By addressing potential problems and

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stumbling blocks that he might have to deal with, Stan is less likely to become

discouraged if he experiences any setbacks. If any relapses do occur, we talk about

seeing these as “learning opportunities” rather than as signs that he has failed. I

let Stan know that his termination of formal therapy does not mean that he can-

not return for a visit or session when he considers it appropriate. Rather than

coming for weekly sessions, Stan might well decide to come in at irregular inter-

vals for follow-up sessions.

Encouraging Stan to Join a Therapy Group

As Stan and I talk about termination, he gives me clear indications that he has

learned a great deal about himself through individual counseling. Although Stan

has been doing well on his own, I believe he would benefi t from a group experi-

ence. I suggest that Stan consider joining a 16-week therapy group that will begin

in 2 months.

To me, progressing from individual therapy to a group seems useful for a cli-

ent like Stan. Because many of his problems are interpersonal, a group is an ideal

place for him to deal with them. The group will give Stan a context for practicing

the very behaviors he says he wants to acquire. Stan wants to feel freer in being

himself, to be able to approach people even when he is fearful, and to be able to

trust people more fully. In addition to a group experience, I will be working with

Stan to fi nd some other ways to continue his growth.

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Commentary on the Thinking, Feeling, and Doing Perspective

In applying my integrative perspective to Stan, I’ve dealt separately with the cog-

nitive, affective, and behavioral dimensions of human experience. Although the

steps I outlined may appear relatively structured and even simple, actually working

with clients is more complex and less predictable. If you are practicing from an in-

tegrative perspective, it would be a mistake to assume that it is best to always begin

working with what clients are thinking (or feeling or doing). Effective counseling

begins where the client is, not where a theory indicates a client should be.

In summary, depending on what clients need at the moment, I may focus initially

on what they are thinking and how this is affecting them, or I may focus on how they

feel, or I may choose to direct them to pay attention to what they are doing. Think-

ing and feeling are two sides of the same coin, and if Stan can change his thoughts,

520

I believe he is likely to change some of his behaviors and his feelings. If he changes

his feelings, he might well begin to think and act differently. If he changes certain

behaviors, he may begin thinking and feeling differently. Because these facets of hu-

TEEN

man experience are interrelated, one route generally leads to the other dimensions.

A person-centered focus respects the wisdom within the client and uses it as a

lead for where to go next. My guess is that counselors often make the mistake of

getting too far ahead of their clients, thinking, “What should I do next?” By staying

CHAPTER SIX

with our clients and asking them what they want, they will tell us which direction

to take either directly or indirectly. We can learn to pay attention to our own reac-

tions to our clients and to our own energy. By doing so we can engage in a thera-

peutic connection that is helpful for both parties in the relationship.

Follow-Up: You Continue Working With Stan

in an Integrative Style

Think about these questions to help you decide how to counsel Stan from your

own integrative approach:

• What themes in Stan’s life do you fi nd most signifi cant, and how might you

draw on these themes during the initial phase of counseling?

• What

specifi c concepts from the various theoretical orientations would you be

most inclined to utilize in your work with Stan?

• Identify some key techniques from the various therapies that you are most

likely to employ in your therapy with Stan.

• How would you develop experiments for Stan to carry out both inside and out-

side the therapy sessions?

• Knowing what you do about Stan, what do you imagine it would be like to be

his therapist? What problems, if any, might you expect to encounter in your

counseling relationship with him?

See DVD for Theory and Practice of Counseling and Psychotherapy: The Case of

Stan and Lecturettes (Session 13 on an integrative approach) for a demonstra-

tion of my approach to counseling Stan from this perspective. This session

deals with termination and takes an integrative view of Stan’s work. This is also

a good time to review the entire program of the 13 sessions with Stan as a way

to think about how you might counsel Stan from your integrative perspective.

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c o n c l u d i n g c o m m e n t s

At the beginning of the introductory course in counseling, my students typically

express two reactions: “How will I ever be able to learn all these theories?” and

“How can I make sense out of all this information?” By the end of the course, these

students are often surprised by how much work they have done and by how much

they have learned. Although an introductory survey course will not turn students

into accomplished counselors, it generally provides the basis for selecting from

among the many models to which they are exposed.

At this point you may be able to begin putting the theories together in some

meaningful way for yourself. This book will have served its central purpose if it

has encouraged you to read further and to expand your knowledge of the theories

that most caught your interest. I hope you have seen something of value that you

521

can use from each of the approaches described. You will not be in a position to

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conceptualize a completely developed integrative perspective after your fi rst course

in counseling theory, but you now have the tools to begin the process of integra-

O

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tion. With additional study and practical experience, you will be able to expand and

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refi ne your emerging personal philosophy of counseling.

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Finally, the book will have been put to good use if it has stimulated you to think

TION: AN INTE

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about the ways in which your philosophy of life, your values, your life experiences,

and the person you are becoming are vitally related to the caliber of counselor you

can become. This book and your course may have raised questions for you regard-

ing your decision to become a counselor. Seeking out at least one of your profes-

GRA

sors to explore these questions can be the next step.

T

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Now that you have fi nished this book, I would be very interested in hearing

about your experience with it and with your course. The comments readers have

sent me over the years have been helpful in revising each edition, and I welcome

your feedback. You can complete the reaction sheet at the end of the book and mail

it to Brooks/Cole, Cengage Learning, 20 Davis Drive, Belmont, California 94002.

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch16_rev01.indd 521

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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch16_rev01.indd 522

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Name Index

Adler, A., 10–11, 63, 84, 102–103,

Beck, A. T., 10, 128, 250, 288–289,

Brooks, G., 386

106–108, 115, 120, 128, 143, 291,

291, 302–303, 305–310, 322

Brooks, J., 191, 193, 195

433, 437

Beck, J., 10, 289, 303, 306–307, 324

Brown, J., 212, 214, 223

Ainslie, R., 75–77, 85

Becvar, D., 434–435, 441

Brown, L., 11, 362–364, 366, 369–

Alberti, R., 265

Becvar, R., 434–435, 441

370, 372, 374–376, 388, 398

Alford, B., 322

Beisser, A., 214

Brown, S., 25

Al-Rashidi, B., 343, 350, 352

Belenky, M., 362

Brownell, P., 237

523

American Counseling Association

Bell, A., 465

Breunlin, D., 445, 450

NAME INDEX

(ACA), 23, 48–49

Bem, S., 368–369

Bubenzer, D., 441

American Psychiatric Association,

Berg, I., 11, 396–397, 400, 403, 405,

Buber, M., 140–141, 157, 211

45, 107, 340, 374–375, 436

407–408, 424–425

Bugental, J., 140–141, 144–145, 155,

American Psychological Association,

Berger, P., 397

157, 159, 165

363, 385

Bertolino, B., 398, 402, 407, 416,

Bumberry, W., 440

American Psychological Associa-

420, 424

Burns, A., 46

tion Presidential Task Force on

Beutler, L., 47–48, 465–467, 476,

Burr, V., 398

Evidence-Based Practice, 46

483, 495, 497

Butler, A., 306

Andersen, T., 445

Bhati, K., 47

Byars-Winsston, A., 363, 370, 375

Anderson, C., 439, 451

Binswanger, L., 140, 142

Anderson, H., 398–399, 404, 442,

Bisono, A., 469

Cain, D., 173–174, 176, 181–186, 190,

445

Bitter, J., 101, 107, 110, 113–114, 115–

194–196, 198–200, 212

Andrews, J., 418

119, 121–122, 128, 372, 374–375,

Callaghan, G., 250, 279

Angel, E., 143

438–441, 445–446, 449, 456

Callanan, P., 39, 41–42, 44

Ansbacher, H., 103–108, 119, 128

Black, M., 89

Cannon, K., 368

Ansbacher, R., 104–108, 119

Blanchard, L., 121

Caplan, P., 384

Antony, M., 247, 254, 263, 269,

Blau, S., 293

Carlson, J. D., 123, 125, 445

280

Blau, W., 79

Carlson, J. M., 105, 107, 111–112, 114,

Arciniega, G., 123–124

Bohart, A., 174, 179, 181, 185–186,

117–119, 121–125, 127–130

Arkowitz, H., 191–192

195, 201, 496

Carter, B., 433, 439

Arlow, J., 73–75, 96–97

Borden, A., 396

Cashwell, C., 469–471

Arnkoff, D., 468

Boscolo, L., 457

Castaldo, J., 307

Arredondo, P., 25

Boss, M., 140, 142

Castillo, L., 363

Astor-Lazarus, D., 247

Bowen, M., 11, 433, 438, 438

Cavasos, L., 191, 193, 195

Atkinson, D., 91

Bowman, C., 211, 227

Cecchin, F., 457

Austin, S., 182

Bozarth, J., 174–175, 180, 185–186

Chambless, D., 307

Axline, V., 201

Brabeck, M., 363, 386

Chang, R., 252, 275, 280

Bracke, P., 165

Christensen, O., 113–114, 116, 121,

Baldwin, M., 446

Breshgold, E., 227, 236

433, 437

Bandura, A., 10, 245–247, 249–250

Brickell, J., 341, 343, 345, 347, 350,

Clark, A., 110, 116, 184

Banman, J., 433

352–354

Clark, D., 418

Barber, P., 237

Brodley, B., 178

Clarkin, J., 89

Bateson, G., 406, 415

Brodsky, A., 51

Clemmer, F., 107

Beardsley, B., 363

Bromley, D., 46–47

Clinchy, B., 362

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Cole, E., 362

Drewery, W., 414

Fresco, D., 272

Cole, L., 128, 372

Driscoll, K., 46

Freud, S., 10, 63, 70, 83–84, 94, 102

Comas-Diaz, L., 469

Dryden, W., 291, 293–295, 297, 299

Frew, J., 215, 218, 223–224, 227,

Combs, A., 199, 201

Duncan, B., 18, 48, 187, 201–202,

233

Combs, G., 410, 412–415, 424

424, 467, 480, 496

Fromm, E., 103, 128

Committee on Professional Practice

Fulton, P., 273

and Standards, 41

Edwards, J., 46–47

Comstock, D., 368

Eifert, G., 272–273

Gamori, M., 433

Cooper, M., 166, 199, 232

Eisengart, S., 400, 425

Ganley, A., 380

Corey, G., 34, 38–39, 41–42, 44, 46,

Eldridge, N., 368

Garcia-Preto, N., 433, 439

49–50, 79, 83, 101, 117, 122, 128,

Elkins, D., 19, 166, 173–174, 202

Geller, J., 21–22

154, 158, 160, 186, 189, 224, 233,

Ellenberger, H., 143

Gelso, C., 77–78

254, 258, 268, 274, 297–298, 302,

Elliott, R., 201, 213

Gendlin, E., 201

310, 349, 371, 386, 408, 410, 418

Ellis, A., 11, 128, 288, 291–300, 302,

Gerber, J., 433

524

Corey, M., 38–39, 41–42, 44, 154

316–317, 323

Gergen, K., 397, 442

Cormier, S., 253–254, 258–260, 266,

Emmons, M., 265

Germer, C., 269, 273

317

Englar-Carlson, M., 105, 107, 114,

Gerson, R., 433, 439, 446

Counseling Today, 34

117–118, 123–124, 129

Gilbert, L., 371, 380, 386

Craske, M., 260, 262

Enns, C., 11, 97, 361, 363–366, 370,

Gilligan, C., 362, 364, 367–368

NAME INDEX

Crawford, T., 297

373–375, 377, 379–380, 386–387

Gingerich, W., 400, 406, 425

Crethar, H., 363, 380

Epp, L., 160

Giordano, J., 433

Crocket, K., 410, 413–414

Epstein, N., 307

Gladding, S., 445–446

Cukrowicz, K., 46

Epston, D., 11, 396, 398, 401, 410,

Glass, C., 468

Curtis, R., 75, 77, 79–81

413, 416–418, 442, 445

Glass, G., 495

Eriksen, K., 373–375, 379

Glasser, C., 338

Erikson, E., 64, 69–70, 94

Dattilio, F., 46–47, 165, 245, 249,

Glasser, W., 11, 334, 336, 339–340,

258, 304–307, 310, 322–323

Espin, O., 11, 361–362

343, 350, 353, 355

Deegear, J., 46

Evans, K., 373, 376, 379

Goldberg, N., 362

De Jong, P., 396–397, 403, 405,

Evans, T., 109, 118, 120

Goldenberg, H., 435, 456

407–408, 424–425

Goldenberg, I., 435, 456

Delaney, H., 469

Fairhurst, I., 199

Goldfried, M., 465, 468

De Shazer, S., 11, 396, 398, 400–401,

Farber, B., 183

Goldman, R., 177, 179, 198, 213, 220,

403, 405–408, 424, 442

Farha, B., 151

225, 237

Deurzen, E., van, 140, 145, 148, 152,

Feder, B., 233

Goldstein, K., 211

154, 156–160, 164–166

Ferguson, K., 258

Goodman, R., 212, 220

Dienes, K., 291, 306

Fernbacher, S., 233

Goolishian, H., 398–399, 404, 442,

Digiuseppe, R., 250, 279, 305

Fishman, D., 270, 279

445

Dimidjian, S., 269, 271, 278

Fishman, H., 457

Gordon, J., 296

Dinkmeyer, D., 105, 120–121

Flynn, J., 272

Gottman, J., 446

Dinkmeyer, D., Jr., 112, 119

Follette, V., 268, 273

Gould, W., 142

Di Pietro, R., 110–111, 116, 128

Follette, W., 250, 279

Grant, S., 91

Disque, J., 110, 119

Forman, E., 268, 273

Granvold, D., 307

Dobson, K., 303

Forsyth, J., 272–273

Greenberg, L., 177, 179, 195, 198,

Donovan, D., 314

Frame, M., 469–470

200–202, 213, 220, 467

Doolin, E., 183

Frankl, V., 10, 128, 137, 143, 148, 152

Griffith, J., 115

Dozois, D., 303

Freedman, J., 396, 410, 412–415, 424

Gross, A., 259–260

Dreeben, S., 271

Freeman, A., 291, 302, 304,

Guevremont, D., 247, 253, 259,

Dreikurs, R., 10, 103, 108–109,

306–307, 323

262–263, 269, 275, 280

113–114, 120, 433, 437, 450

Freiberg, H., 175

Guterman, J., 404, 408

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Gutheil, T., 51

Johnson, R., 116

Leech, N., 379

Guy, J., 18, 34

Joiner, T., 46

Levant, R., 47–48

Jones, J., 25

Levensky, E., 191, 193, 195

Hagedorn, W., 471

Jordan, J., 361, 368

Levenson, H., 90–91

Haigh, A., 272

Josselson, R., 139, 146, 152, 154,

Levitsky, A., 228

Haley, J., 11, 434, 440–441, 457

156–157, 160

Lewis, J., 445

Hammer, T., 368

Jung, C., 63, 83–85, 94, 102

Lindsley, J., 411

Hanna, S., 445

Linehan, M., 97, 268–269, 269–271,

Hardy, K., 451

Kabat-Zinn, J., 269, 271

273, 278

Harper, R., 293–295

Kaplan, A., 361, 368

Lipckik, E., 400

Harris, A., 85

Karpiak, C., 466

Lisiecki, J., 115, 119

Hawes, C., 113–114, 116, 121

Kaschak, E., 364, 368

Lister, K., 466

Hayes, J., 77–78

Kazdin, A., 250, 256–257, 280

Lobovits, D., 396

Hayes, S., 268–269, 272–273

Kees, N., 379

Locke, D., 25

525

Hays, P., 316–317, 377

Kefir, N., 107

Lojk, L., 343, 350, 352

NAME INDEX

Hazlett-Stevens, H., 260, 262

Kemper, T., 46

Luborsky, E., 73–75, 96–97

Head, L., 259–260

Kendall, P., 307

Luckman, T., 397

Healey, A., 128, 372

Kernberg, O., 86, 88–89

Luepnitz, D., 445

Hedges, L., 87–88

Kerr, M., 438

Lusterman, D., 386

Hefferline, R., 212, 220

Kersh, B., 191, 193, 195

Heidegger, M., 140–142

Keys, S., 199

MacKune-Karrer, B., 445, 450

Heimberg, R., 278, 299–300

Kierkegaard, S., 138, 140

MacLaren, C., 296–297

Herbert, J., 268, 273

Kim, R., 343, 350, 352

Macy, R., 306, 324

Herlihy, B., 38, 41, 49–50, 379–380,

Kincade, E., 373, 376, 379

Madanes, C., 11, 434

386

Kirschenbaum, H., 173, 198

Madigan, S., 415, 417, 420

Herman, J., 375

Klein, M., 87, 182

Mahler, M., 87–88

Higginbotham, H., 252, 275, 280

Knapp, S., 37

Maisel, R., 396

Hirsch, I., 75, 77, 79–81

Kohut, H., 86, 88–89

Maniacci, M., 106, 109–112, 114,

Hogan, T., 47–48, 202

Koldon, G., 182

117–119, 121–122, 127–128

Holden, J., 105

Koocher, G., 47–48, 202

Marbley, A., 379

Hollon, S., 250, 279, 305

Korman, L., 201

Marlatt, G., 314

Hood, A., 116

Kottman, T., 130

Martell, C., 251

Horney, K., 103, 128, 291

Krebs, P., 193

Marx, B., 278, 299–300

Houts, A., 269, 272

Kress, V., 373–375, 379

Maslow, A., 128, 177–179

Hoyt, M., 476

Krug, O., 145, 147, 155, 161, 165,

Masterson, J., 89

Hubble, M., 18, 48, 187, 201–202,

176

Maurer, R., 227

424, 467, 496

May, R., 10, 128, 137–138, 143, 150,

Hummel, A., 77–78

Lago, C., 199

154, 156

Humphrey, K., 212

Lambert, M., 19, 467, 496

McCollum, V., 379–380

Larsen, C., 386

McDavis, R., 25

Imhof, L., 343, 350, 352

Latner, J., 215

McElwain, B., 166

Ingram, R., 321

Lawson, D., 46

McGoldrick, M., 433, 439, 446,

Lazarus, A., 10, 246–247, 250, 255,

451

Jacobs, L., 212, 220, 223–224, 227,

266–268, 466, 473, 476

McKay, G., 120

232, 236, 238

Lazarus, C., 247, 268

McKeel, A., 406, 425–426

Jacobs, N., 298, 306

Leahy, R., 308, 321

McKenzie, W., 410, 416–419, 426

Jacobson, E., 258

Ledley, D., 278, 299–300

Mearns, D., 199, 201

Jennings, L., 19–20

Lee, M., 425

Meichenbaum, D., 10, 290, 310–315,

Johnson, J., 160

Lee, R., 223

324

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Melnick, J., 219, 223–225

O’Hanlon, B., 398, 400, 402, 404,

Real, T., 380

Mennin, D., 272

406–407, 412, 414, 416, 420, 424,

Rego, S., 270, 279

Merry, T., 199

442

Reinecke, M., 291, 306–307

Messer, S., 90

O’Reilly-Landry, M., 73–75, 96–97

Reitzel, L., 46

Metcalf, L., 401, 408–409

Orlinsky, D., 21–22

Remer, P., 376, 370–372, 374–375,

Miller, J. B., 11, 361, 364, 368

Osborn, C., 253–254, 258–260, 266,

377–378, 380–382, 387

Miller, S., 18, 48, 187, 201–202, 396,

317

Remley, T., 41

400, 424, 467, 480, 496

Rennie, D., 201

Miller, T., 495

Pachankis, J., 465

Rice, L., 201

Miller, W., 191–192, 254, 469

Padesky, C., 307

Richeport-Haley, M., 441

Milliren, A., 107, 109, 118, 120

Paivio, S., 201

Riskind, J., 307

Miltenberger, R., 247, 253, 256–257,

Palmer, S., 296

Roberts, A., 438

264

Panjares, F., 246

Robertson, L., 471

Minuchin, S., 11, 434, 440, 457

Parlett, M., 223

Robertson, P., 128, 372

526

Mitchell, S., 86, 89

Parsons, J., 368

Robey, P., 341

Monk, G., 410–419, 424–426

Patterson, C., 201

Robins, C., 270–271

Moorhead, H., 471

Paul, G., 252

Roemer, L., 247, 254, 263, 269, 280

Morrow, S., 363

Pedersen, P., 42

Rogers, C., 10, 142, 173–175, 177–181,

Mosak, H., 106, 109–111, 115–117, 119,

Peller, J., 400–404, 424

183, 186, 188–190, 194, 200, 399,

NAME INDEX

128

Pelonis-Peneros, P., 122

414, 445

Mozdzierz, G., 115, 119

Peluso, P., 119, 121

Rogers, N., 10, 187–191, 199–201, 362

Muller, K., 270, 279

Perls, F., 10, 211–213, 220, 222,

Rollnick, S., 191–192, 254

Murphy, J., 401, 404–407, 409

227–228, 230, 238

Ronnestad, M., 21

Perls, L., 10, 211–212, 222–223

Root, M., 363

Nagy, T., 40–42, 50

Peterman, M., 307

Rosenthal, M., 270–271

Nash, S., 363, 380

Petrocelli, J., 302

Rothblum, E., 362

Natiello, P., 199, 201

Petry, S., 433, 439, 446

Russell, D., 173

Neenan, M., 296

Philpot, C., 386

Russell, J., 143, 147–148, 154–155,

158, 166

Neimeyer, 418

Pietrefesa, A., 269

Rutan, J., 83

Nevis, S., 219, 223–225

Pietrzak, D., 113, 119, 123, 127, 129

Newbauer, J., 109, 118, 120

Pleck, J., 380

Salazar, G., 368

Newlon, B., 123–124

Plummer, D., 233

Salmon, P., 270

Newman, C., 307

Pollack, W., 380, 383

Sanchez, J., 25

Nichols, M., 445, 456

Polster, E., 10, 212, 215–217, 221–225,

227

Sartre, J., 140, 142, 147

Nicoll, W., 113–114, 116, 117–119,

121–122, 128

Polster, M., 10, 212, 215–217,

Satir, V., 11, 433, 439, 446, 449

222–225, 227

Nietzsche, F., 140–141

Sauer, A., 291, 306

Popkin, M., 120

Niles, B., 269

Scher, C., 321

Potter, C., 269

Norcross, J., 18–22, 34, 47–48, 90,

Scher, M., 380

184, 193, 202, 263, 367, 403,

Powers, R., 115

Schmertz, S., 269

465–468, 476,480, 483, 495, 497

Prata, G., 457

Schneider, K., 145–147, 155, 157, 159,

North American Society of Adlerian

Pretzer, J., 307

161, 165, 176

Psychology (NASAP), 130

Prochaska, J., 90, 193, 263, 367, 403,

Schultz, D., 83–85, 103

Nurius, P., 253–254, 258–260, 266,

467, 495

Schultz, S., 83–85, 103

317

Psychotherapy Networker, 466

Schwartz, R., 445, 450

Nutt, R., 386

Sebold, J., 425

Nye, R., 245

Rader, J., 371, 386

Seem, S., 373, 376, 379

Nylund, D., 419

Raskin, N., 174, 188

Seeman, J., 174

Nystul, M., 123

Rave, E., 386

Segal, Z., 271, 321, 467

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

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Segrin, C., 263

Tallman, K., 174, 181, 201, 496

406–407, 424, 442

Selvini Palazzoli, M., 457

Tanaka-Matsumi, J., 252, 275, 280

Weishaar, M., 250, 289, 291,

Sephton, S., 271

Tarule, J., 362

302–303, 305–308, 321, 323, 397

Sgambati, R., 258

Tausch, R., 174–175, 180, 185–186

Weitzman, L., 363

Shapiro, F., 262–263

Teasdale, J., 271, 467

Werner-Wilson, R., 362

Sharf, R., 166

Tharp, R., 265–266

West, J., 441

Sharp, J., 140–141, 159

Thomas, J., 419

Westra, H., 191

Shay, J., 83

Thomas, S., 373

Whitaker, C., 11, 434, 440

Sherman, R., 105

Thompson, C., 91

White, B., 46

Shulman, B., 115, 119, 127, 129

Thorne, B., 180, 182, 199, 201

White, J., 302

Siegel, R., 273

Tillich, P., 138, 149–150, 211

White, M., 11, 396, 398, 401, 410,

Simpson, L., 270–271

Tompkind, M., 304, 307

413, 415–418, 442, 445, 450

Sinacore, A., 364, 366

Toporek, R., 25

Wiggins-Frame, M., 469

Skinner, B., 10, 245

Torres-Harding, S., 291, 306

Williams, A., 115

527

Sklare, G., 409–410

Torres Rivera, E., 363, 380

Williams, J., 271, 467

NAME INDEX

Skovholt, T., 19–20

Trepal, H., 368

Wilson, G., 247, 249–250, 253, 266,

Slavik, S., 119

Turner, L., 362

269, 273–274, 280

Smith, B., 199

Wilson, K., 269, 272

Smith, L., 92

Uken, A., 425

Winslade, J., 410–415, 418–419,

424–425

Smith, M., 495

Wiseman, H., 21

Sommers-Flanagan, J., 190–191

Vaihinger, H., 105

Witty, M., 188

Sonstegard, M., 122, 438

Vandecreek, L., 37

Wolfe, J., 291, 293, 297, 299, 316,

Sparks, J., 480, 496

Vernon, A., 301

323

Sperry, L., 42, 112, 119, 121, 445

Vontress, C., 149, 152, 157, 160–161,

Wolitzsky, D., 64, 72–77, 81–82, 89,

Spiegler, M., 247, 253, 259–260,

166

96

262–263, 269, 275, 280, 294,

Vujanovic, A., 269

Wolpe, J., 248, 251, 258

316

Worell, J., 367, 370–372, 374–375,

St. Clair, M., 86–86

Walden, S., 373

380–381, 387

Stadler, H., 25

Walker, L., 388

Worthington, E., 269, 470–471

Stebnicki, M., 34

Walker, M., 368

Wubbolding, R., 11, 334, 336–348,

Stern, D., 87

Walsh, F., 439, 451

350, 352–356

Stiver, I., 361, 368

Walsh, R., 166

Stone, W., 83

Walter, J., 400–404, 424

Yalom, I., 10, 97, 138–140, 144, 146,

Strasser, A., 159

Walters, R., 245, 249

152, 154, 156–157, 160

Strasser, F., 159

Wampold, B., 18–19, 47, 165, 187,

Yeomans, F., 89

Strentzsch, J., 368

201–202, 467–468, 480, 496

Yontef, G., 212, 214, 220, 223–225,

Stricker, G., 466

Wang, C., 182

227, 232, 236, 238

Strosahl, K., 269, 272

Warren, C., 90

Young, J., 469–471

Strumpfel, U., 225, 237

Watson, D., 265–266

Young, M., 471

Strupp, H., 89, 96

Watson, J., 177, 179, 181, 184–186,

Sue, D., 25, 42

195, 198–199, 201, 213, 220

Zahm, S., 236

Sue, D. W., 25, 42

Watts, R., 105, 111–114, 118–119,

Zimring, F., 174–175, 180, 185–186

Sullivan, H., 103

121–123, 127–129

Zinker, J., 212, 217, 219, 225, 238

Surrey, J., 361, 368

Watzlawick, P., 128

Zur, O., 49, 247

Sweeney, T., 111

Weiner-Davis, M., 398, 400, 404,

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Subject Index

A-B-C framework, 293–294, 301

Androcentric, 367

Aspirational ethics, 37

ABC model, 252, 482

Anger management training, 263

Assertion training, 264

Acceptance, 183, 188, 269, 295

Angst, 140

Assertiveness, 274, 378

Acceptance and commitment

Anima, 85

Assessment, 44–46, 186, 373–375,

therapy, 272–273, 466

Animus, 85

438, 446–449, 470

Accommodation, 222

Antecedent events, 252

Assessment process, ethical issues

Accurate empathic understanding,

528

Anxiety, 28, 66, 73, 81, 140, 152–153,

in, 44–46

184–185

176–177, 181, 230, 261, 262

Assimilation, 223

Action, planning and, 347–348

Anxiety, existential, 152

Assimilative integration, 467

Actualizing tendency, 178

Anxiety hierarchy, 259–260

Authenticity, 148, 165

T INDEX

Adlerian brief therapy, 113

Application and follow-through

Automatic thoughts, 303

C

Adlerian family therapy, 437–438

phase, 314

Autonomy, 176

Adlerian therapy, 101–135, 472

Approaches, theoretical

Autonomy versus shame and

SUBJE

application, 120–122, 486

Adlerian therapy, 101–135, 472,

doubt, 70

applied to the case of Stan,

477, 486, 488–489, 491, 493

Awareness, 66, 76, 81, 153–154,

125–126

behavior therapy, 244–286, 472,

212–213, 217, 219, 225, 232,

client’s experience, 111–112

478, 486, 488, 490, 492, 494

236, 316

contributions, 127–129, 488, 491

cognitive behavior therapy,

key concepts, 103–109, 474

287–332, 472, 478, 487–488,

Basic assumptions, 401–402,

limitations and criticisms, 129,

490, 492, 494

456, 518

489, 493

existential therapy, 136–171, 472,

Basic ID, 266–268

multicultural perspective, 123–125

477, 486, 488, 490–491, 494

Basic philosophies, 472–473

relationship between therapist

family systems therapy, 432–461,

en therapis

Behavior, 105, 267, 465

and client, 112, 481

473, 478, 487, 489, 491, 493,

and client, 112, 481

Behavior therapy, 244–286, 472

495

shortcomings, 12

tc

4–

omings, 12

125

4–

application, 255–274, 486

feminist therapy, 360–394, 473,

streng

str

ths, 123–12

ths, 123– 4

12

applied to the case of Stan,

478, 487, 489–490, 493, 494

therapeutic g

ther

oals, 109–

apeutic goals

110, 477

276–277

gestalt therapy, 210–243, 472,

therapeutic pr

therapeu

oc

pr

ess, 109–

oc

112

ess, 109–

areas of development, 248–250

477, 486, 488, 490, 492, 494

ther

the apeutic techniques and proc

eutic techniques and pr

e-

oc

basic characteristics and assump-

integrative perspective, 464–521

dures, 113–

dur

12

es, 113– 2, 484

12

tions, 250–252

person-centered therapy,

therapist’

her

s function and r

apist’

ole,

s function and role,

client’s experience, 254

254

172–209, 4

9

7

, 4 2, 4

7

77

2, 4

, 486, 488,

77,

110–

110 111

–111

contributions, 278–

278 2

– 79

27 , 488, 4

9,

92

490, 492, 494

494

Adolesc

Adoles ence, 7

enc

1

historical background, 2

cal backgr

4

ound, 2 7

4 –248

postmodern appr

post

oaches, 39

pr

5–431,

oaches, 395–4

Advice, 32

Advic

2

ke

k y c

e

onc

y c

epts, 250–

onc

252, 4

epts, 250–252, 74

473, 4

473

78, 487, 489–490

489–4

, 4

90

9

, 4 3,

93

Aff

A ect, 2

ffect

67

26

limitations and criticisms,

limitations and criticism

495

49

Aloneness, 150

Alone

s, 150

279–

2

280

79–

, 4

280

90

, 4

, 4

90

9

, 4 4

9

psy

ps choanalytic ther

ychoanal

ap

c ther

y

ap , 62

y, 6 –100

–

,

100,

Alternativ

Altern

e interpretations, 308

e interpr ations, 308

multicultur

mu

al per

cultur

spectiv

al per

e, 2

spective, 74–276

472, 4

472

77, 486, 488–489

486, 488–4

, 4

9

91,

, 491,

Ambiguit

Amb gu y, 30

493

relationship bet

r

w

elationship bet een ther

w

apist

een ther

Anal stag

Anal st

e, 69–

e, 6

7

9– 0

7

and client, 254–255, 481

and client, 254–

reality therapy

ap , 333–35

y

9

, 333–35 , 473,

4

Analytic fr

Analy

ame

fr

w

ame ork, maintaining

work,

intaining

478, 487, 489–490

, 489–4

, 4

90, 92, 4

9

9

2, 4 4

shortcomings, 2

tc

7

omings, 2 5–

7

2

5– 7

2 6

94

76

the, 79

he, 79

Arbitrary inf

y

erences, 5

enc

12

streng

str

ths, 27

ths, 2 4–

7

2

4– 7

2 5

es, 512

7

Analytic ps

A

y

alytic ps chology

y

, 83

chology

3

Archetypes, 84

therapeutic g

ther

oals, 252, 4

apeutic goals

7

252, 4 8

7

chetypes, 84

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

therapeutic process, 252–255

limitations and criticisms,

Cultural conditioning, 25

therapeutic techniques and proce-

322–324, 490, 494

Cultural feminists, 365

dures, 255–274, 484

multicultural perspective, 315–317

Culture, 25, 27–28

therapist’s function and role,

relationship between therapist

Customer, 405

252–254

and client, 297, 306–307, 482

Cybernetics, 441

Behavior, total, 337

shortcomings, 316–317

Cycle of counseling, 342

Behavioral analysis, 251–252

strengths, 315–316

Behavioral assessment

therapeutic goals, 295, 478

Death and nonbeing, 153–154

interview, 253

therapeutic process, 295–297

Death instincts, 64

Beliefs and attitudes, 25–26

therapeutic techniques and proce-

Decision making, ethical, 38–40

Beliefs, self-defeating, 29

dures, 297–302, 485

Decisions, revised, 515–516

Belonging, 107

therapist’s function and role,

Deconstruction, 415–416

Bibliotherapy, 298, 378

295–296

Defense mechanisms, 66–68, 74

Birth order, 107–109

Cognitive distortions, 303

Deflection, 218

529

Blaming, 439

Cognitive patterns, 465

Demands, 30

SUBJE

Blank-screen approach, 73

Cognitive restructuring, 294

Denial, 67

Blocks to energy, 218–219

Cognitive therapy, 302–310, 321–324

Depression, treatment of,

C

T INDEX

Borderline personality disorder,

Cognitive triad, 308

308–310

88–89

Collaborative empiricism, 305

Desensitization, 259

Boundaries, 51

Collaborative language systems ap-

Despair, integrity versus, 71

Boundary crossing, 51

proach, 399

Deterministic, 367

Boundary disturbance, 218

Collective unconscious, 84

Development, summary of stages of,

Boundary violation, 51

Commitment, 273

87–89

Bridge, 408

Common factors approach, 467

Diagnosis, 44–46, 373–375

Brief psychodynamic therapy, 90

Communication, privileged, 41

Dialectical behavior therapy,

Burnout, professional, 33

Community feelings, 107, 109

269–271, 466

Compensation, 68

Dialogic encounter, 165

Change, 119, 193–194, 343–344,

Complainant, 405

Dichotomous thinking, 304

450–451

Compliments, 407

Differentiation of self, 438

Change-focused questions, 406

Conceptual-educational phase, 313

Direction and doing, 345–346

Characteristics, personal, 19

Confidentiality, 41–42

Displacement, 67

Choice, 212, 264, 339

Confluence, 218

Distress tolerance, 270

Choice theory, 336

Confrontation, 227–228

Diversity, 24, 27

Circulation questions, 417

Congruence (genuineness), 182–183,

Doing, direction and, 345–346

Classical conditioning, 248

439

Dread, 140

Classical psychoanalysis, 69, 74

Consciousness, 65–66, 146

Dream analysis, 80–81

Client-centered therapy, 175

Consequences, 252

Dream work, 230

Cognition, 267

Constructivist narrative perspective,

Drugs, 268

Cognitive behavior modification, 310,

315

Dual relationships, 48

322, 324

Contact, 217–218

Cognitive behavior therapy, 249,

Contemporary psychoanalysis, 69

Early childhood, 70

287–332, 472

Contextual factors, 19

Early recollections, 110, 115–116

application, 297–302, 307–310,

Cooperation, 107

Egalitarian relationship, 369

487

Countertransference, 31, 76–78, 82

Ego, 64–66

applied to the case of Stan,

Courage, 149

Ego-defense mechanisms, 66–68, 82

318–319

Crisis, 69

Ego psychology, 69, 85

client’s experience, 296

Crisis intervention, 187–188

Electra complex, 70

contributions, 320–322, 488, 492

Criticisms, limitations and, 489–491,

EMDR. See Eye movement desensiti-

key concepts, 292–295, 475

493–495

zation and reprocessing

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).

Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Emotion-focused therapy, 200,

Existentialism and humanism,

client’s experience, 372

213, 467

176–177

contributions, 385–387, 489, 493

Emotional disturbance, 292–293

Experiential family therapy, 440

history and development,

Emotional regulation, 270

Experiments, 224

363–366

Empathy, 185, 199–200

Exposure therapies, 260

key concepts, 367–370, 475

Empowerment, 376–377

Expressive arts therapy, 189–191

limitations and criticisms,

Empty-chair technique, 228

Externalization, 415–416

387–388, 490, 494

Encouragement, 118–119

Externalizing conversations, 416

multicultural and social justice

Energy, 218–219

Externalizing questions, 422

perspective, 380–382

Engendered lives, 368

Extinction, 256

principles of, 369–370

Ethical decision making, 38–40

Extinction process, 257

relationship between therapist

Ethical issues, 36–58

Eye movement desensitization and

and client, 373, 482

Ethical issues, assessment process,

reprocessing (EMDR), 262–263

shortcomings, 381–382

44–46

strengths, 380–381

530

Ethical issues, multicultural per

Factors, contextual, 19

techniques and strategies,

spective, 42–44

Family constellation, 110, 115

375–380

Ethical obligation, 24

Family systems perspective, 435

therapeutic goals, 370–371, 478

T INDEX

Ethics, 37

Family systems therapy, 432–461,

therapeutic process, 370–373

C

Evidence-based practice, 46–48

473

therapeutic techniques and proce-

Exaggeration exercise, 230

Adlerian, 437–438

dures, 373–380, 485

SUBJE

Exception questions, 406

application, 487

therapist’s function and role,

371–372

Exceptions, 406

applied to the case of Stan,

Fictional finalism, 105

Exercises, 224

452–455

Field, 213

Existential analysis, 142

contributions, 457, 489, 493

Field theory, 215

Existential anxiety, 152

development of, 437–445

Figure, 214

Existential guilt, 147

experiential, 440

Figure-formation process, 215,

Existential therapy, 136–171, 472

goals and values, 456, 478

225, 237

application, 157–160, 486

human validation process model,

Flexible-multicultural perspective,

applied to the case of Stan,

439–440

367

162–163

key concepts, 475

Flooding, 261–262

client’s experience, 155–156

limitations and criticisms,

Formula first session task, 407

contributions, 164–165, 488, 491

457–458, 491, 495

Free association, 73, 79, 292

key concepts, 145–154, 474

multicultural perspective, 451–452

Freedom, 147–149, 176–177, 336

key figures, 143–145

multigenerational, 438–439

Friendship, 107

limitations and criticisms,

multilayered process, 445–451

Functional assessment, 251–252

165–166, 490, 494

postmodern perspectives,

Fundamental rule, 73

multicultural perspective,

442–445

160–162

shortcomings, 452

Future, 507

relationship between therapist

strengths, 451–452

and client, 156–157, 481

structural-strategic, 440–441

Gender-fair approaches, 367

shortcomings, 161–162

systemic viewpoints in, 443–444

Gender-role analysis, 377

strengths, 160–161

techniques, 456–457, 485

Gender-role intervention, 377

therapeutic goals, 154–155, 477

therapeutic relationship, 482

Gender schemas, 368

therapeutic process, 154–157

Faulty assumptions, 109

Gendercentric, 367

therapeutic techniques and

Feeling, 230, 465, 507–510

Generativity versus stagnation, 71

procedures, 157–160, 484

Feminist therapy, 360–394, 473

Genital stage, 71

therapist’s function and role, 155

application, 373–380, 487

Genogram, 446–448

Existential tradition, 145

applied to the case of Stan,

Genuineness (congruence), 182–183

Existential vacuum, 152

382–384

Gestalt therapy, 210–243, 472

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application, 224–233, 486

Holism, 214

applied to the case of Stan,

applied to the case of Stan,

Holistic concept, 105

503–521

234–236

Homework, 260, 263, 296, 298,

challenge of developing, 471–477

client’s experience, 222–223

300, 307, 479, 510

client’s experience, 479–480

contributions, 236–237, 488, 492

Honesty, 73, 177

integration of multicultural issues,

interventions, 228–231

Human behavior, 105

468–469

key concepts, 213–219, 474

Human nature, view of

integration of spirituality and

limitations and criticisms,

Adlerian therapy, 103–104

religion, 469–471

237–239, 490, 494

behavior therapy, 250

movement toward psychotherapy

multicultural perspective,

cognitive behavior therapy, 292

integration, 465–477

233–234

existential therapy, 145–146

relationship between therapist

relational, 212

and client, 480–483

feminist therapy, 367

relationship between therapist

techniques and evaluation,

gestalt therapy, 213–214

and client, 223–224, 481

483–497

person-centered therapy,

531

shortcomings, 234

therapeutic goals, 477–478

178–179

SUBJE

strengths, 233–234

therapeutic process, 477–483

psychoanalytic therapy, 64

therapeutic goals, 219–220, 477

therapist’s function and role,

reality therapy, 336–337

C

therapeutic process, 219–224

478–479

Human personality, 104–106

T INDEX

therapeutic techniques and proce-

Integrity versus despair, 71

Human validation process model,

dures, 224–233, 484

Internal dialogue, 228–229, 311–312

439–440

therapist’s function and role,

Interpersonal effectiveness, 270

Humanism, existentialism and,

220–222

176–177

Interpersonal empathy, 184

Global international feminists, 366

Humanistic psychology, 177–178

Interpersonal relationships, 268

Goal oriented, 105

Humor, 31, 299–300

Interpretation, 80, 117

Goals, 23–24, 470, 476, 505–506

Hypothesizing, 449–450

Interruptions in contact, 218

Adlerian therapy, 109–110, 477

Intervention strategies, skills and, 26

behavior therapy, 252, 478

Id, 64–66

Interventions, gestalt therapy,

cognitive behavior therapy,

Id psychology, 69

228–231

295, 478

Ideal self-concept, 180

Intimacy versus isolation, 71

existential therapy, 154–155, 477

Identification, 68

Intrapsychic orientation, 367

family systems therapy, 456, 478

Identity, 149–151

Introjection, 68, 217

feminist therapy, 370–371, 478

Identity versus role confusion, 71

In vivo exposure, 260–261

gestalt therapy, 219–220, 477

Imagery, 267

In vivo flooding, 261

integrative perspective, 477–478

Immediacy, 185

Involuntary clients, 30

person-centered therapy, 179, 477

Impasse, 216

Irrational beliefs, 297–298

postmodern approaches,

Inauthenticity, 147

Isolation, intimacy versus, 71

403–404, 412, 478

Individual psychology, 104, 107

It talk, 221

psychoanalytic therapy, 72, 477

Individual therapy, 436

reality therapy, 340, 478

Individuation, 84

Judgment, normalizing, 411

Goals, mistaken, 109

Industry versus inferiority, 71

Ground, 214

Infancy, 70

Key concepts

Group work, 379–380

Inferiority feelings, 104

Adlerian therapy, 103–109, 474

Guilt, existential, 147

Inferiority, industry versus, 71

behavior therapy, 250–252, 474

Guilt, initiative versus, 70

Informed consent, 40–41, 376

cognitive behavior therapy,

Initiative versus guilt, 70

292–295, 475

Here-and-now, 145, 216, 219–

Insight, 117–118

existential therapy, 145–154, 474

220, 231

Integrative perspective, 464–521

family systems therapy, 475

Heterosexist, 367

advantages of psychotherapy

feminist therapy, 367–370, 475

Hierarchy of needs, 177

integration, 467–468

gestalt therapy, 213–219, 474

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Key concepts ( continued)

Mistaken goals, 109

Person-centered approach, 175

person-centered therapy,

Mistrust, trust versus, 70

Person-centered therapy,

178–179, 474

Moral anxiety, 66

172–209, 472

postmodern approaches,

Motivational interviewing, 191–194

application, 184–189, 486

400–402, 410–411, 475

Multicultural counseling, 25–26

applied to the case of Stan,

psychoanalytic therapy,

Multicultural issues, integration of,

196–197

64–72, 474

468–469

client’s experience, 180–181

reality therapy, 336–340, 475

Multicultural perspective, ethical

contributions, 177–178, 198–202,

issues in, 42–44

488, 492

Labeling and mislabeling, 304, 512

Multigenerational family therapy,

development of the approach,

Language, 221

438–439

174–176

Latency stage, 71

Multilayered process of family

key concepts, 178–179, 474

Latent content, 80

therapy, 445–451

limitations and criticisms,

Later life, 71

Multimodal therapy, 266

202–203, 490, 494

532

Lesbian feminists, 366

Multiple relationships, 48–50

multicultural perspective, 194–196

Liberal feminists, 364

Muscle relaxation, progressive,

relationship between therapist

Libido, 64

257–258

and client, 181–184, 481

shortcomings, 195–196

T INDEX

Life instincts, 64

C

Narcissistic personality, 88–89

Life-span perspective, 367

strengths, 194–195

Narrative therapy, 410–419, 442

Lifestyle, 106

therapeutic goals, 179, 477

SUBJE

Negative punishment, 257

Lifestyle assessment, 111, 115

therapeutic process, 179–184

Negative reinforcement, 256

Limitations, 29

therapeutic techniques and proce-

Negative self-talk, 294

Limitations and criticisms, 489–491,

dures, 184–189, 484

Neurotic anxiety, 66, 153

493–495

therapist’s function and role,

Nonbeing, death and, 153–154

Listening, 411

180–181

Nondirective counseling, 174

Logotherapy, 143, 152

Persona, 85

Nonprofessional relationships, 48

Personal characteristics, 19

Normal anxiety, 153

Magnification and minimization, 304

Personal consultation, 402

Normal infantile autism, 87

Maintaining the analytic

Personal therapy, 20–22

framework, 79

Normalizing judgment, 411

Personality, 64–65

Making the rounds, 229

Not-knowing position, 399,

Personality, development of, 68–71,

404, 412–413, 415, 424,

Mandatory ethics, 37

83–85

441–442

Manifest content, 80

Personality, human, 104–106

Now, the, 215–216

Mapping, 416

Personalization, 304, 512

Meaning, 176

Phallic stage, 69–70

Object-relations theory, 86

Meaning, search for, 151–152

Phenomenological, 104

Objective empathy, 184

Meaninglessness, 152

Phenomenological awareness, 213

Objective interview, 115

Metaphors, 221

Phenomenological inquiry, 215

Oedipus complex, 70

Middle age, 71

Philosophical approach, 139

Oldest child, 108

Middle child, 108

Philosophical restructuring, 294

Only child, 109

Mindfulness, 269–270

Picture album, 337

Operant conditioning, 249, 300

Mindfulness-based cognitive

Placating, 439

Operationally defined, 251

therapy, 271–272, 467

Planning and action, 347–348

Oral stage, 69–70

Mindfulness-based stress reduction,

Pleasure principle, 65

Organismic self-regulation, 215

269, 271

Polarized thinking, 512

Overgeneralization, 304, 512

Minimization, magnification and, 304

Positive ethics, 37

Minor psychotherapy, 113

Paradoxical theory of change, 214, 219

Positive orientation, 400–401

Miracle question, 406–407

Past, 506

Positive psychology, 177, 401

Mislabeling, labeling and, 304, 512

Perfectionism, 29

Positive punishment, 257

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Positive reinforcement, 256

contributions, 94–96, 488, 491

multicultural perspective,

Postmodern approaches, 395–431,

counseling implications, 72

349–352

473

key concepts, 64–72, 474

relationship between therapist

application, 406–410, 414–419, 487

limitations and criticisms, 96–97,

and client, 341–342, 482

applied to the case of Stan,

489, 493

shortcomings, 351–352

421–423

multicultural perspective, 91–92

strengths, 349–351

contributions, 424–426, 489, 493

relationship between therapist

therapeutic goals, 340, 478

key concepts, 400–402,

and client, 75–78, 481

therapeutic process, 340–342

410–411, 475

shortcomings, 91–92

therapeutic techniques and

limitations and criticisms, 426,

strengths, 91

procedures, 342–349, 485

490, 495

therapeutic goals, 72, 477

therapist’s function and role, 341

multicultural perspective, 419–421

therapeutic process, 72–78

REBT. See Rational emotive behavior

narrative therapy, 410–419

therapeutic techniques and

therapy

shortcomings, 421

procedures, 78–83, 484

Reframing, 378

533

social constructionism, 397–399

therapist’s function and role,

Regression, 68, 74

SUBJE

solution-focused brief therapy,

72–73

Rehearsal exercise, 230–231

400–410

Psychological dynamics, 114–117

Relabeling, 378

C

T INDEX

strengths, 419–420

Psychological investigation, 109

Relapse prevention, 314

therapeutic goals, 403–404,

Psychosexual stages, 68, 70–71

Relatedness, 150–151

412, 478

Psychosocial stages, 69–71

Relational-cultural theory, 368

therapeutic process, 402–405,

Psychotherapy integration, 465–477

Relational Gestalt therapy, 212

412–414

Punishment, 257

Relational model, 86–87

therapeutic relationship, 405,

Purpose, 176

Relationship, 113–114, 445–446

413–414, 482

Relationship therapy, 435

therapeutic techniques and proce-

Quality world, 337, 344

Relationships, dual, 48

dures, 406–410, 414–419, 485

Questioning, art of, 409

Relationships, multiple, 48–50

therapist’s function and role,

Questions, 221, 406–407, 409–410,

Relationships, nonprofessional, 48

404–405, 412–413

414–417, 420, 422, 425

Relaxation, 260, 300

Postmodern feminists, 366

Religion, integration of spirituality

Postmodern perspectives, 442–445

Radical feminists, 365

and, 469–471

Power analysis, 377

Rational emotive behavior therapy

Reorientation, 118

Practice-based evidence, 480

(REBT), 291–292, 297–302,

Repression, 67

Preschool age, 70

321–323

Research, 199

Presence, 185

Rational emotive imagery, 299

Resistance, 81–82, 144, 227,

Present, 339, 506

Rationalization, 67

218–219, 227

Pretherapy change, 406

Reaction formation, 67

Responsibility, 32, 176, 212, 339

Private logic, 111

Reality, 104, 397

Restructuring, 294

Privileged communication, 41

Reality anxiety, 66

Retroflection, 218

Problem-saturated stories, 401

Reality principle, 65

Reversal exercise, 229

Professional burnout, 33

Reality therapy, 333–359, 472

Revised decisions, 515–516

Professional role, 32–33

application, 342–349, 487

Role confusion, identity

Progressive muscle relaxation,

applied to the case of Stan,

versus, 71

257–259

352–353

Role playing, 300

Projection, 67, 73, 217

client’s experience, 341

Psychoanalytic therapy,

contributions, 354–355,

Scaling questions, 407

62–100, 472

489, 492

Schema, 310

application, 82–83, 486

key concepts, 336–340, 475

School age, 71

applied to the case of Stan, 92–93

limitations and criticisms,

Search for meaning, 151–152

client’s experience, 73–75

355–356, 490, 494

Second child, 108

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Self- acceptance, 213

cognitive behavior therapy,

feminist therapy, 360–394,

Self-actualization, 165, 177, 179

318–319

473, 478, 487, 489–490,

Self-awareness, 38, 73, 109,

existential therapy, 162–163

493, 494

146–147, 177

family systems therapy, 452–455

gestalt therapy, 210–243, 472,

Self-care, 34

feminist therapy, 382–384

477, 486, 488, 490, 492, 494

Self-concept, 180

gestalt therapy, 234–236

integrative perspective, 464–502

Self-consciousness, 164

integrative approach, 503–521

person-centered therapy,

Self-defeating behavior, 216

person-centered therapy, 196–197

172–209, 472, 477, 486, 488,

490, 492, 494

Self-defeating beliefs, 29

postmodern approaches, 421–423

postmodern approaches,

Self-disclosure, 28–29, 158, 376, 385

psychoanalytic therapy, 92–93

395–431, 473, 478, 487,

Self-efficacy, 249

reality therapy, 352–353

489–490, 493, 495

Self-evaluation, 346–347, 354

Storied lives, 398

psychoanalytic therapy, 62–100,

Self-exploration, 22, 177

Stories, role of, 410–411

472, 477, 486, 488–489,

Self-instructional training, 311

Stress inoculation training, 312–314

534

491, 493

Self-management, 265

Structural-strategic family therapy,

reality therapy, 333–359,

Self-monitoring, 34, 265

440–441

473, 478, 487, 489–490,

Self-observation, 311

Student-centered teaching, 175

492, 494

T INDEX

Self-psychology, 86

Subjective empathy, 184

Theoretical integration, 466

C

Self-understanding, 117–118

Subjective interview, 114

Therapeutic core conditions, 182

Self-worth, 107

Sublimation, 68

SUBJE

Therapeutic relationship, 34, 226,

Sensation, 267

Suggesting tasks, 408

405, 413–414, 481–482,

Separation-individuation, 88

Superego, 65–66

504–505

Shadow, 85

Superiority, 105–106

Therapeutic techniques, 33

Shame and doubt, autonomy

Symbiosis, 87

Therapist feedback, 407–408

versus, 70

Systematic desensitization,

Therapy, personal, 20–22

Shame-attacking exercises, 300

258–260, 300

Total behavior, 337

Sibling relationships, 107–109

Systematic integration, 476

Transference, 73, 75–76, 82,

Significance, 105–106

Systemic therapy, 436

339, 355

Silence, 30

Systemic viewpoints in family

Triangulation, 438

Skills acquisition and consolidation

systems therapy, 443–444

Trust versus mistrust, 70

phase, 313

Technical eclecticism, 266

Skills and intervention strategies, 26

Unconditional other acceptance, 295

Technical integration, 466

Social action, 379

Unconditional positive regard,

Techniques, therapeutic, 33

Social constructionism, 397–399

182–183

Terminating, 408

Social interest, 106, 109

Unconditional self-acceptance, 295

Termination, 518–519

Social learning approach, 249

Unconscious, 65–66, 79, 231

Theoretical approaches

Social skills training, 263–265

Unconscious, collective, 84

Adlerian therapy, 101–135, 472,

Socialist feminists, 365

Unfinished business, 216–217

477, 486, 488–489, 491, 493

Socialization, 179

behavior therapy, 244–286,

Value imposition, 23

Solution-focused brief therapy,

472, 478, 486, 488, 490,

Values, 22–24, 43, 151, 176, 272

400–410, 442

492, 494

Visitor, 405

Spirituality and religion, integration

cognitive behavior therapy,

of, 469–471

287–332, 472, 478, 487–488,

Wants, 344–345

Spiritual dimension, 517–518

490, 492, 494

WDEP system, 344–348

Stages of development, 87–89

existential therapy, 136–171, 472,

Wellness, 34

Stagnation, generativity versus, 71

477, 486, 488, 490–491, 494

Working-through, 75

Stan, case of

family systems therapy, 432–461,

Adlerian therapy, 125–126

473, 478, 487, 489, 491, 493,

You talk, 221

behavior therapy, 276–277

495

Young adulthood, 71

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Document Outline

About the Author

Contents

Preface

Part 1: Basic Issues in Counseling Practice

Ch 1: Introduction and Overview

Introduction

Where I Stand

Suggestions for Using the Book

Overview of the Theory Chapters

Introduction to the Case of Stan

Ch 2: The Counselor: Person and Professional

Introduction

The Counselor as a Therapeutic Person

Personal Therapy for the Counselor

The Counselor's Values and the Therapeutic Process

Becoming an Effective Multicultural Counselor

Issues Faced by Beginning Therapists

Summary

Ch 3: Ethical Issues in Counseling Practice

Introduction

Putting Clients' Needs before Your Own

Ethical Decision Making

The Right of Informed Consent

Dimensions of Confidentiality

Ethical Issues in a Multicultural Perspective

Ethical Issues in the Assessment Process

Ethical Aspects of Evidence-Based Practice

Managing Multiple Relationships in Counseling Practice

Becoming an Ethical Counselor

Summary

Where to Go from Here

Recommended Supplementary Readings for Part 1

References and Suggested Readings for Part 1

Part 2: Theories and Techniques of Counseling

Ch 4: Psychoanalytic Therapy

Introduction

Key Concepts

The Therapeutic Process

Application: Therapeutic Techniques and Procedures

Jung's Perspective on the Development of Personality

Contemporary Trends: Object-Relations Theory, Self Psychology, and Relational Psychoanalysis

Psychoanalytic Therapy from a Multicultural Perspective

Psychoanalytic Therapy Applied to the Case of Stan

Summary and Evaluation

Where to Go from Here

Recommended Supplementary Readings

References and Suggested Readings

Ch 5: Adlerian Therapy

Introduction

Key Concepts

The Therapeutic Process

Application: Therapeutic Techniques and Procedures

Adlerian Therapy from a Multicultural Perspective

Adlerian Therapy Applied to the Case of Stan

Summary and Evaluation

Where to Go from Here

Recommended Supplementary Readings

References and Suggested Readings

Ch 6: Existential Therapy

Introduction

Key Concepts

The Therapeutic Process

Application: Therapeutic Techniques and Procedures

Existential Therapy from a Multicultural Perspective

Existential Therapy Applied to the Case of Stan

Summary and Evaluation

Where to Go from Here

Recommended Supplementary Readings

References and Suggested Readings

Ch 7: Person-Centered Therapy

Introduction

Key Concepts

The Therapeutic Process

Application: Therapeutic Techniques and Procedures

Person-Centered Expressive Arts Therapy

Motivational Interviewing

Person-Centered Therapy from a Multicultural Perspective

Person-Centered Therapy Applied to the Case of Stan

Summary and Evaluation

Where to Go from Here

Recommended Supplementary Readings

References and Suggested Readings

Ch 8: Gestalt Therapy

Introduction

Key Concepts

The Therapeutic Process

Application: Therapeutic Techniques and Procedures

Gestalt Therapy from a Multicultural Perspective

Gestalt Therapy Applied to the Case of Stan

Summary and Evaluation

Where to Go from Here

Recommended Supplementary Readings

References and Suggested Readings

Ch 9: Behavior Therapy

Introduction

Key Concepts

The Therapeutic Process

Application: Therapeutic Techniques and Procedures

Behavior Therapy from a Multicultural Perspective

Behavior Therapy Applied to the Case of Stan

Summary and Evaluation

Where to Go from Here

Recommended Supplementary Readings

References and Suggested Readings

Ch 10: Cognitive Behavior Therapy

Introduction

Albert Ellis's Rational Emotive Behavior Therapy

Key Concepts

The Therapeutic Process

Application: Therapeutic Techniques and Procedures

Aaron Beck's Cognitive Therapy

Donald Meichenbaum's Cognitive Behavior Modification

Cognitive Behavior Therapy from a Multicultural Perspective

Cognitive Behavior Therapy Applied to the Case of Stan

Summary and Evaluation

Where to Go from Here

Recommended Supplementary Readings

References and Suggested Readings

Ch 11: Reality Therapy

Introduction

Key Concepts

The Therapeutic Process

Application: Therapeutic Techniques and Procedures

Reality Therapy from a Multicultural Perspective

Reality Therapy Applied to the Case of Stan

Summary and Evaluation

Where to Go from Here

Recommended Supplementary Readings

References and Suggested Readings

Ch 12: Feminist Therapy

Introduction

Key Concepts

The Therapeutic Process

Application: Therapeutic Techniques and Procedures

Feminist Therapy from a Multicultural and Social Justice Perspective

Feminist Therapy Applied to the Case of Stan

Summary and Evaluation

Where to Go from Here

Recommended Supplementary Readings

References and Suggested Readings

Ch 13: Postmodern Approaches

Introduction to Social Constructionism

Solution-Focused Brief Therapy

Narrative Therapy

Postmodern Approaches from a Multicultural Perspective

Postmodern Approaches Applied to the Case of Stan

Summary and Evaluation

Where to Go from Here

Recommended Supplementary Readings

References and Suggested Readings

Ch 14: Family Systems Therapy

Introduction

Development of Family Systems Therapy and Personal Development of the Family Therapist

A Multilayered Process of Family Therapy

Family Systems Therapy from a Multicultural Perspective

Family Systems Therapy Applied to the Case of Stan

Summary and Evaluation

Where to Go from Here

Recommended Supplementary Readings

References and Suggested Readings

Part 3: Integration and Application

Ch 15: An Integrative Perspective

Introduction

The Movement toward Psychotherapy Integration

Issues Related to the Therapeutic Process

The Place of Techniques and Evaluation in Counseling

Summary

Where to Go from Here

Recommended Supplementary Readings

References and Suggested Readings

Ch 16: Case Illustration: An Integrative Approach in Working with Stan

Counseling Stan: Integration of Therapies

Concluding Comments

Name Index

Subject Index