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Models of Helping
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rofessional preparation programs are often structured according to two basic approaches. In the first option, you may be studying helping skills before you take a course in theory. It is reasoned that these professional behaviors are so universal among practitioners that it is not necessary to understand their theoretical base before you begin practicing them. Because they take consider- able time to learn well and become part of your interpersonal repertoire, the idea is that you should have as much time as possible to master them. Although some of the skills may be learned proficiently in a matter of weeks, mastery of others will take you the rest of your life. A second training approach requires you to study theories before you learn applied skills. In this approach you postpone learning how to do counseling and therapy until you are fully exposed to the conceptual base that supports practice. Of course, other possibilities are that you are taking both classes concurrently or as part of an integrated unit in which theory and skills are linked. In any of the scenarios, the outcome is the same: It is necessary to master both the underlying conceptual base of the profession, including the major theore- tical approaches (see Corey, 2006; Ivey, D’Andrea, Ivey, & Simek-Morgan, 2006; Seligman, 2005) and the applied interventions that emerged from these models (see, e.g., De Jong & Berg, 2007). There are distinct advantages and disadvantages to each preparation method and no clear consensus as to which is best. The purpose of this chapter is to help you understand the ways that theory influences and shapes the application of therapeutic skills. This relates not only to choice of which skills are considered most potent and useful, but also when and how they provide optimal effectiveness. Historically, the evolution of theory in our field has emerged in three move- ments (Dryden & Mytton, 1999). You would easily guess that Sigmund Freud’s con- tributions to developing psychoanalytic theory form the first stage. Freud and his collaborators developed the first comprehensive treatment model that explored unconscious motives, instinctual urges, defense mechanisms, and experiences from the past that continue to have an impact on present behavior. Some of Freud’s contemporaries, like Alfred Adler, helped to shape the second wave of psychological theory, which took the form of humanism, an approach later developed by Carl Rogers and others. These theorists emphasized the importance of the relationship in helping encounters, especially the kind of relationship that is
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characterized by empathy, caring, and respect. Emotional expression is often valued and encouraged in this second set of theories. The third movement focused more on how current thinking (rather than past experiences or feelings) impacts behavior. These theories value the exploration of thoughts and values that can be changed in order to help clients more easily alter negative emotions. There is a fourth movement currently growing that is primarily focused on con- textual factors that influence the process of working with clients, such as taking eth- nic culture, social class background, and gender into consideration, to name a few (Enns & Sinacore, 2005). This new approach to theory is influenced by those who seek cultural sensitivity and awareness of social factors that may inhibit a client’s ability to feel well. Corollary theorists who are also becoming increasingly influen- tial identify strongly as “postmodern,” “constructivist” (Neimyer & Mahoney, 2000), “feminist” (Hill & Ballou, 2005; Worrell & Remer, 2002), or “relational” (Jordan, Walker, & Harling, 2004; Miller &, Stiver, 1998; Walker & Rosen, 2004) therapists. All of them share an interest in issues related to marginalization, oppression, social justice, language, and culture as they impact client experiences. As you increase your exposure to theories, you will find that most practitioners use techniques and skills from all of these theories since they all have something useful to offer. For example, it is reasonable to assume that you might use active lis- tening skills from humanistic theory, challenging and disputing from cognitive the- ory, reframing from solution-focused theory, re-storying from narrative theory, interpretation from psychoanalytic theory, realigning coalitions from systemic the- ory, empowerment from feminist theory, and so on. The wonderful thing about a skills training experience is that you will be exposed to all the most important ther- apeutic interventions that are accepted as being most useful.
Theories and Their Offspring
Theories of counseling and psychotherapy provide several distinct uses for practi- tioners. First, they give you a foundation for understanding what you are doing. Second, they provide an organized framework for diagnosis and treatment. Third, theories help you to articulate your values about why clients come to therapy and how clients change. Table 3.1 provides a list of some theories and their major goals. You should understand that trying to state a general goal in a single sentence is dif- ficult, at best. You should also be aware that each author who studies a theory may differ subtly in his or her understanding of the theory. All this is to say that the stated goals are subjective interpretations of each of these theories. Finally, every theory supplies an inventory of techniques, skills, and interven- tions that become the means by which the model is applied. For instance, you have probably heard that psychoanalytic theory stresses that it is important to help clients uncover their unconscious desires and repressed wishes (Freud, 1936). This means essentially that the therapist’s job is to increase client awareness, especially of things in the past that have been buried, as well as internal thoughts and feelings that are not currently accessible. It is reasoned that bringing such material into view will help
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Many counseling skills did not emerge from a single theory, but rather resulted from observing what therapists actually do with their clients in sessions. It is one of the paradoxes of our profession that it is often difficult to tell which theory a clini- cian is using just by watching what is going on; often, a theory is more an organiz- ing set of assumptions rather than a blueprint for how to behave. Examples of these universal skills include open-ended questions in which you might elicit information, or summarizations in which you tie things together.
What Using a Theory Looks Like
Throughout your studies, you will probably hear how important it is to align yourself with one theoretical orientation. This may seem like a challenging task because so many theories have clear strengths. In addition, you may think that being eclectic can serve you just as well. A theory, however, provides you with a structure, a foundation that explains why people do what they do and how people change. Each theory will offer something useful, and you can actually use any technique in any theory. For example, people often assume that Gestalt theory is primarily about focus- ing on emotions and works only in the here and now. Some practitioners, however, also work with the client’s thoughts and may have clients reflect on the past. Clients who are particularly emotional but do not have a good understanding of why a feel- ing is particularly intense or seems disproportionate to the situation are encouraged to think back to the first time they first remembered feeling this way. Clients and therapist may explore the beliefs that underlie the feelings as well as the origins of those beliefs. Because this is based on exploring the past, it might sound psychoan- alytical. This could also seem to be cognitive since it’s based on the exploration of beliefs. A Gestalt therapist, however, would encourage the client to bring that moment into the present and then speak from that experience to gain this knowl- edge. In Gestalt therapy, the therapist assumes that unfinished business creates an incomplete gestalt. Unless you have studied Gestalt therapy, you might not follow the language, but you still could get the point that techniques from any theory can be used to help your clients. What your professors are advocating when they want you to use a theory (and by the way, many state licensure exams also expect you to align with one) is that you
Exercise in Brainstorming
Skills and Common Concepts
Those who have taken a theories course or are taking one now can form groups of four or five people and list concepts and skills that are found in each of the theories. See if you can connect some common concepts or skills from one theory to another. For example, the term projection is found in both psychoanalytic and Gestalt therapy.
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have a direction in therapy. Everything you say directs the session. When a client tells you a story that includes many different important facets, which one do you focus on? Your theory may help you answer this. To further illustrate the use of theories, we’ll conceptualize several models from the perspective of a character that almost everyone will be familiar with: Anakin Skywalker, also known as Darth Vader, from Star Wars. As you may recall, Darth Vader was the villain in the original trilogy of these movies. The more recent Star Wars films portray him during his younger years, before he “went over to the Dark Side.” We look at Darth Vader’s life through the lenses of three very different the- oretical orientations: psychoanalytic, person-centered, and cognitive. These are by no means the only theories we could have selected, but they are ones that have had a great deal of historical influence.
Darth Vader: A Brief Biography
Many of you may know Darth Vader from Star Wars, but that was only after his “transformation.” Before he became Darth Vader, Anakin Skywalker was raised by his single mother in an implied immaculate conception. During his formative years he lived in slavery, but had a loving mother who fostered his interests and natural ability to become a talented pilot. At age 9, he was given the opportunity to fulfill his dream of becoming a Jedi warrior, but had to leave his mother behind in order to undergo rigorous training. He left his home and mother in great sorrow, relieved at having escaped his own fate as a slave but still feeling guilty that his mother had been left behind. As you probably realize, 9 years old would have been a rather trau- matic time to be separated from your only living parent. We see Anakin again when he is 19 and still mourning the loss of his mother. In the past 10 years he has found love in the arms of a woman senator, and also found a mentor and father figure in Obi-Wan Kenobi. As much as he loved and respected his mentor, Anakin became rebellious (typical of later adolescence), feel- ing that Obi-Wan did not appreciate his abilities as a Jedi knight. Meanwhile, Lord Sith capitalized on Anakin’s rebellion by convincing him of how powerful he could be if he followed Lord Sith. Anakin’s rebellion evolved more deeply into anger after the death of his mother, where we see, for the first time, his rage take control of him. He eventually suffered a traumatic physical injury in a battle against his men- tor, Obi-Wan, that resulted in the loss of his arms and legs. Just before the battle, the love of his life became his wife, and became pregnant shortly thereafter; Anakin was thrilled with the idea of being a father. His wife tried to connect with Anakin, but found him pulling farther and farther away because of fears of intimacy as well as influence from Lord Sith, who felt threatened by Anakin’s attachment to another. His wife felt extremely stressed by his erratic behav- ior. While Anakin was having surgery for his prosthetic arms and legs, he learned that the love of his life had died giving birth. This was too much pain and suffering for him. Anakin eventually suffered a number of other experiences that moved him far- ther toward the “Dark Side.” He became embittered, filled with rage, vengeful, and in the course of time sustained additional injuries that required mechanical parts. At some point he became more cyborg than man. Anakin eventually “died,” and Darth
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been further complicated by the fact that Obi-Wan was someone he respected early in their relationship so much that he perceived Obi-Wan as a father figure. His need to please his mentor/father figure was incongruent with his own wants and needs, enhancing the gap between his ideal self and his self-concept. Thus, his organismic valuing process was externally driven, causing him to have a regard complex. As a result, Anakin was unable to symbolize positive experiences accurately, causing a breakdown and dis- organization in his self-structure, and eventually leading him to feel confused and anxious. This anxiety and confusion consequently made the Dark Side more tempting with its lure of enhancing his perceived self-worth. If Anakin had been able to express his feelings in a trusting relationship where he experienced unconditional positive regard, warmth, genuineness, and empathy, he might have been able to cope with the loss of his mother and his body image in a more fully functioning way, releasing his natural self-actualizing tendency to support good, rather than dark forces. As a result, if Rogers had seen Anakin, he would have provided him the opti- mal conditions of therapy, providing empathy, caring, respect, and unconditional positive regard in a genuine way. He would have developed trust with Anakin (admittedly a very chal- lenging goal) and exhibited warmth to enhance the relationship. By providing these conditions, the conditions of worth would lead to greater congruence between his ideal self and his self-concept. This, in turn, would release a greater actualizing tendency allow- ing Anakin to become a more fully functioning person and to be drawn to good instead of to the Dark Side.
Beck’s Cognitive Therapy
Conceptualization of Darth Vader
Beck (1976) might have conceptualized Anakin as having several cognitive distor- tions. First, Anakin made an arbitrary inference that he could have prevented his mother’s death. In addition, he made another arbitrary inference that Obi-Wan’s inten- tions were not in his, Anakin’s, best interest. Anakin overgeneralized his negative expe- rience of his mother’s death and the loss of his arms and legs, believing that the world was a bad place where he must become powerful in order prevent feeling hurt. He magnified Emperor Palpatine’s position and minimized the power of the Jedi Council, especially his mentor, Obi-Wan. Furthermore, he personalized Obi-Wan’s criticisms as trying to decrease his personal value rather than seeing Obi-Wan’s influ- ence as educational and helpful. He evidenced dichotomous thinking by seeing people in one of two ways: powerless or powerful. Thus, wanting to be powerful, he aligned with the Dark Side. After the death of his mother and the loss of his arms and legs, he probably was clinically depressed. His probable automatic thoughts with regard to his cognitive triad were that he was worthless without power; that the world was out to get him; and that the future would be bleak unless he aligned with the Dark Side. These beliefs in his triad and his cognitive distortions were probably related to a dysfunctional underlying schema that he must be all-powerful to be worthy of love. Beck might have started his work with Anakin by developing a trusting relation- ship through empathic listening. While Anakin shared his story, Beck probably would have listened for cognitive distortions, and would have identified them as Anakin was speaking. He would have amplified Anakin’s distorted thinking by repeating what he was hearing, and giving Anakin new, more functional language. For example, if
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Anakin said that he “ had to become all-powerful,” Beck might have said, “you want to become all-powerful.” This clarity of language would empower Anakin to take responsibility for his choices and decisions in life. Concurrently, Beck would have attempted to identify the underlying schemas that contributed to Anakin’s distorted cognitions. He would have worked with Anakin to help him to be more objective about how he viewed himself, the world, and the future. You may notice a difference in the use of language. You may also observe some commonalities. In all three scenarios, Anakin’s negative experiences (mom’s death and his own physical injuries) contributed to his angst. Furthermore, he was unable to or not given the right conditions to cope with these losses in a healthier way, leading him to make the poor decision to join the Dark Side. We believe that if he had undergone counseling, Anakin might never have needed to become Darth Vader. But if that had happened, there would have been no Star Wars movies, and what fun is there in that? You may also notice how each of these theories provides a direction for the therapist’s work with Anakin. Each practitioner would focus on different aspects of the presenting issue, whether this was the transference and id impulses, the conditions of worth and self-concept, or cognitive distortions and schemas. If you were to watch contemporary therapists use these theoretical orientations as they have developed, you would notice a lot of empathic responses, questioning, and clarity of language. They would be thinking in the language of their theory, but, ultimately, they would probably look fairly similar and arrive at similar outcomes. You can see that although these three theories are quite different in language and what they emphasize, they also use common sense to determine what went wrong with this client, Anakin Skywalker, aka Darth Vader. We hope this encourages you to find a theory or two that emphasize what you think are important contributors to behavior, and we hope that you will become familiar with them so they can help guide you in conceptualization and treatment planning as you work with clients.
The Limitations of Some Theories
In Chapter 2, we discussed some of the major cultural constructs that must be taken into consideration when working with clients. One of the challenges when choosing a theory is that not all theories are culturally sensitive. Many of the older theories (the ones we used with Anakin) were developed by Western- European/American men who were raised in privileged backgrounds. If you study their personal histories, you’ll realize that much of their theories come from their own experiences, which also include the values of the times. For instance, Freud lived during the Victorian era, which valued the inhibition of sexuality—and all behavior, for that matter. In contrast, some of Rogers’s work was developed from the early 1960s to the 1970s, when society’s inhibitions and limitations were being challenged. In addition, some of Rogers’s theory was in reaction to Freud’s work. Add their personal backgrounds to the formula, and you have theories constructed within sets of cultural assumptions. It would be nearly impossible to develop a the- ory that would work for everyone. This is why so many of the classical theories may fit privileged individuals—or at least middle-class individuals who are from the dominant American/Western European culture—very well, especially men. This is the foundation of the fourth
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In one of the first systematic attempts to teach counseling skills in a sequential, problem-solving way, Robert Carkhuff (1969) combined the skills that emerged from Carl Rogers’s person-centered approach with a series of studies undertaken to identify the behaviors most often associated with positive therapeutic outcomes (Carkhuff & Berenson, 1967). The model that emerged from these efforts is one in which helpers were taught a very structured problem-solving approach that moved from one stage to the next, with each stage composed of a series of steps and related skills (Carkhuff & Anthony, 1979). Thomas Gordon took much of the same material and in 1970 developed a sys- tem for teaching parents and later, in 1974, a system for teaching teachers the major skills of helping. Parent effectiveness training and teacher effectiveness training thus introduced a whole generation of nonprofessional “therapists” to the value of active listening and reflecting skills. Students were taught the basics of several specific interventions:
- Active listening. This set of skills involves learning how to listen effectively, “decode” underlying affective messages, and then reflect back to the client what was heard. The goal is to promote deeper exploration of issues and lead clients to solve their own problems.
- “I” messages. If active listening works well when the client “owns” the prob- lem, then using the pronoun “I” is appropriate when it is the teacher, thera- pist, or parent who has a problem with what others are doing. If a student is carving his initials in a desk, for example, the teacher might first try saying something like this in a rather stern, scolding voice: “Young man, do you have a problem?”
Exercise in Active Listening
For each of the following statements made by a client, try to decode the mes- sage by finishing the sentence, “You feel.. .”
- “My mother is always telling me what to do! Does she think I’m stupid or something?!?!?!?!!!”
- “My son is using drugs, and he won’t listen to me.” (with tears in her eyes)
- “I really do like this guy, but I’m not sure I can handle that he dates other people.”
- “I didn’t get much sleep last night; I kept thinking about the exam I have to take today.”
The student, of course, doesn’t have a problem at all. He likes defacing the desk with his initials. About the only problem that he has is that the teacher is in his face. In fact, it is the teacher who has a problem. And until the teacher is willing to rec- ognize that, any intervention is not likely to be very useful. The teacher can punish
the child, send him to the office, make him clean up his mess, but there are consid- erable side effects of this way of “solving” the problem. Instead, the teacher might have used an “I” message sounding something like this: “Excuse me. I have a prob- lem with what you are doing to that desk. I appreciate that you are expressing your artistic talents, but I am the one responsible for this property. So we have a problem that we need to work out.” This may not sound much different to you from the first statement, but its approach clarifies who owns the problem. If it is the student’s problem, then active listening is indicated; on the other hand, if it is the teacher’s or parent’s problem, then active listening is not going to be particularly helpful. Note the use of both skills in the conversation that follows between a father and his 9-year-old daughter:
Daughter: No I won’t get dressed! I hate this dress. And I hate these shoes. And besides, you said I could stay home and I didn’t have to go.
Father: I can see you’re really upset right now. You’re mad at me for making you do something that you’d rather not do. [Active listening]
Daughter: Well, you told me before that if I didn’t want to go, I didn’t have to. And I sure don’t want to go. So that’s the end of it.
Father: So, if I understand what you’re saying, this argument isn’t really about which dress to wear, but our disagreement about whether you have to go to dinner or not. [Active listening]
Daughter: That’s right! I don’t want to go. And that’s it.
Father: Okay. I’m in a bit of a bind and I need your help. I did tell you that you didn’t have to go if you didn’t want to. You’re right. But if you don’t go to dinner, then I can’t go either. And then your mother and brother will be pretty disappointed. So, I wonder if there is something we can do to help me with my problem? [“I” message]
You can see in this brief interaction that the father starts out by resisting the urge to scold, to use power and discipline to enforce his will over his daughter. Instead, he decides to listen carefully and compassionately to her, trying to sort out what is really going on. He reflects back to her what he hears her saying. Once he thinks he has a handle on what might be going on (since this is only a tentative hypothesis, it must be checked out), he then “owns” his share of the problem. Notice he does not become defensive or accusatory. He does not argue with his daughter. He does not yell at her. He simply maintains an active listening stance until the point that he realizes that he is the one with the problem, and until he articulates this reality, he isn’t going to get much cooperation from his daughter. The models introduced by Carkhuff and Gordon revolutionized the ways that counseling skills could be taught. A very complex process was reduced to a few basic skills and a half dozen progressive stages. This made it possible to teach a method previously restricted to psychiatrists and psychologists to a host of other helping professionals: nurses, crisis intervention workers, supervisors, teachers, parents, and more. It also made it possible to take a similar systematic approach to teaching skills for therapists and counselors.
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account for the development of moral thinking. Erik Erikson’s (1950) influential theory of psychosocial development was organized around a series of struggles between polar opposites (i.e., trust vs. mistrust, or integrity vs. despair). Following the “golden age” of stage theory, several more stage theories were developed to describe career development, gender development, sexual development, and cultural identity development. It will therefore come as no surprise to you that counseling and therapy have also been organized according to stages.
An Integrated Model
We have synthesized many of the different models that have been used over the past few decades into a generic outline that we believe most practitioners could live with. What you need most at this point in your development is a framework that helps you accomplish several critical tasks:
- Assess what is going on with your clients. This includes but is not limited to their presenting complaints, other symptomology that is operating behind the scenes, family history and background, cultural identities and personal values, and anything else that helps you to understand their worlds.
- Formulate a diagnosis and treatment plan. This becomes the outline for organiz- ing the work you will do. Diagnoses can be developed according to a number of different models, which might concentrate on personality attrib- utes, behavioral descriptions, developmental functioning, systemic patterns, or other factors. The treatment plan addresses systematically whatever you identified as clinically significant in the diagnosis.
- Establish a solid working alliance. This is the therapeutic relationship that allows you to develop trust and reach treatment goals. The relationship may be structured differently depending on client needs and preferences, the nature of the presenting complaint, the length of the treatment, and the particular stage in which you might be operating. Therapeutic relationships evolve over time according to what is needed.
- Make good choices about which skills and interventions to use in which situations. As we have said before, the major problem you will face is not a scarcity of choices but far too many to sort out in the time you have available. A client says or does something and you must respond—immediately. You need some way to simplify and organize your choice efforts.
- Figure out where you are in relationship to where you wish to be. Regardless of which model you are following, you still will need some way to assess accurately the impact of your interventions. In any given moment you must have at least a rough idea of the stage you are operating in and what your goals are. It is also a very good idea to have a defensible rationale for anything you do or say, one that you can explain if called on by a client or supervisor.
Of course, the kind of model you use to organize your work depends on your own stage of development as a professional. These stages are represented in a series of questions related to a beginner’s fear of failure (Kottler & Blau, 1989):
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- Stage 1: What if I don’t have what it takes to be a therapist? Hopefully, you are now past the point where you question constantly whether you have the stuff it takes to make it in this profession. You may have some doubts and insecurities about how good you will be as a practitioner, especially when you compare yourself to others who seem more poised, confident, and experienced, but deep in your heart you trust that with sufficient training, practice, and hard work, eventually you will reach a point where you can do somebody some good. On a good day, you will notice a few things you do very well; on a not-so-good day, you will question all over again whether you made the right career choice. If you are still feeling stuck in this very first stage because you are having seri- ous reservations about whether being a therapist is a good fit for you, then the help- ing model you choose should be one that is very basic and simple to operate. You already have enough to worry about without adding to your stress by making things unnecessarily complicated.
- Stage 2: What if I don’t know what to do with a client? Once you are comfortable with your ability to function as a relatively skilled practitioner, you’ll reach the stage of being afraid of making a mistake. The usual fantasy is that you will say or do the wrong thing, resulting in the client becoming so distraught by your ineptitude that he or she immediately jumps out the window, cursing your name all the way down. As a beginner, of course you won’t know what do with a client. We [Jeffrey and Leah] have been doing this work for many decades and we often still don’t know what to do a lot of the time. Doing therapy means living continuously with ambi- guity, complexity, and uncertainty. Just when you think you might be helping some- one, you discover later that the effects didn’t last, or that the person was just deceiving you and himself. Other times you will be sure that you have screwed up big-time only to discover later that what you thought were misguided efforts turned out to be a brilliant strategy. Then there will be other times when the client thanks you profusely for your masterful interventions—only you will have no recall what- soever of what you supposedly did. The question is not whether you will feel uncer- tain at times, but rather how you will handle these doubts.
- Stage 3: What if my treatment harms a client? If in the previous stage you are wracked with doubts about not knowing what to do in a given situation, in this stage you are concerned more with the consequences—most of them negative—of mak- ing a huge mistake. At this point you recognize the awesome power of what you have learned; your concern is how to harness this power. If you get inside the head of a therapist at this stage, you might hear something like the following:
Therapist: Where would you like to begin? [What a stupid way to say that. I should have just asked what he wants to talk about today.] Client: Um. I don’t know. Therapist: You don’t know? [What am I, a parrot? All I can think of to say is to repeat what he says?] Client: Remember last time what I was talking about things my supervisor said? Therapist: Sure. You were talking about how angry you were feeling because she wasn’t being fair to you. [Oh no. I’m putting words in his mouth. I don’t think he was saying that at all; rather, that was where I wanted to lead him.]
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You have four main tasks to accomplish in this first stage:
- Establish a working alliance.
- Complete an assessment and formulate a diagnosis.
- Conduct a treatment plan.
- Negotiate a contract and mutual goals.
The major skills that you will be learning and using that are linked to this stage include questioning and reflective listening. These are behaviors that are specifically designed to elicit information efficiently, as well as to develop relationships with clients that build trust, intimacy, and respect. This is what the beginning stage looks and sounds like in the middle of the first session with a new client, about 20 minutes into the interview.
Therapist: When did you first begin to notice that you were having difficulty sleep- ing? [Open-ended question to elicit more information on the symptoms of anxiety] Client: I can’t really recall. It seems like it’s always been like this. Therapist: So your sleep has been disrupted for some time. [Restatement] Client: I guess so. I don’t really know. All of this is just so overwhelming that I can’t remember things anymore. I don’t even know what I’m doing here. Therapist: You’re having some doubts about your decision to come for help and you’re feeling like things may be hopeless for you. [Reflection of client’s most terrifying feelings] Client: (nods head) So, what do you think I should do? Can you help me or not? Therapist: I think that your decision to seek help at this time is a sign of your resilience and strength. [Reassurance and support] You have been feel- ing so alone and already you will notice that some of that has dimin- ished. [Instilling confidence and planting favorable expectations] Yes, I can help you. I’ve worked with issues like this many times before. Before we proceed further, I’d like to ask you: What would you like to have happen as a result of our work together? [Question about expecta- tions and treatment goals]
The therapist is trying to accomplish several things simultaneously. At the same time, he or she is learning as much as possible about the client’s symptoms and when they occur, while also offering support and reassurance. There is a lot more the ther- apist will want to explore: what the anxiety feels like, when it first occurred, what has worked and not worked in dealing with it, whether these symptoms have occurred before, whether there is a history of this disorder in the family, what the conse- quences are of having these symptoms, and so on. Yet gathering all this important information to satisfy the therapist’s curiosity and needs is worthless unless the client feels heard and understood. It is absolutely crucial that the initial exploration of the problem is balanced with sufficient efforts to build a good working relationship.
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Building a good working relationship involves reflecting—reflecting not only the content and the feelings expressed by the client, but the meaning and emotions beneath what is presented. We are not the only people who believe that a good working alliance is a necessary condition of therapy. All of the primary theorists believe it is the foun- dation of therapy (Planalp, 2003). As stated before, if clients do not like you or have confidence in what you do, why would they be motivated to return for more sessions? It is difficult enough for most clients to make it to the first session. If they can find an excuse not to return, they may not. This means you have to create a strong working alliance and maintain this relationship throughout the therapeutic process.
Exercise in Building the Relationship
Get into pairs and have one person talk for 5 minutes about an emotionally charged issue, either positive or negative (client role). The other person (ther- apist role) is to reflect a feeling and some content, in a single sentence, of what is most essential about what the “client” said. Have the client respond with agreement or a correction, and repeat until the reflection is accurate. When complete, switch roles.
Exploring and Understanding
What you began in the first stage is continued as things develop. The relation- ship is deepened. More and more data are collected about the client’s presenting complaints and annoying symptoms, preexisting conditions, relevant family and cul- tural background, and other important areas of personal functioning. Essentially, you are exploring what is going on now and what has been going on in the past. This is not an activity that is taken solely for the therapist’s comfort and curiosity; rather, the very process of getting significant background information is also related to helping promote greater awareness and understanding in the client. Just as you might expect, there are as many ways of promoting this under- standing as there are approaches to therapy. Some systems—like behavior therapy or brief treatments—minimize this stage, believing that insight is at best needlessly time-consuming and irrelevant, and at worst is downright dangerous. We would cer- tainly agree that the realities of contemporary practice sometimes require us to shorten treatment to a few sessions. However, we also find that when it is feasible to include some component of insight, even such efforts often help clients to gen- eralize what they learned to other areas of their lives. Insight can be promoted in a number of different ways, depending on your own therapeutic style and theoretical allegiances. Cognitive therapists concentrate on help- ing clients understand that problems are the result of distorted and irrational think- ing patterns. Insight work is focused on helping clients identify the dysfunctional beliefs that are getting in the way and teaching them to substitute alternative percep- tions that are more reality based (Beck, 1976; Laposa & Rector, 2006; Tarrier, 2006).
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Exercise in Insight
With partners or on your own, develop a plan for the kinds of insight that you might promote for each of the clients presented in the above scenarios. Role- play each scenario.
We don’t wish to give the impression that we are “selling” you insight as a nec- essary and sufficient condition for change to take place. The phrase necessary and sufficient was exactly the wording Rogers (1961) used in his research, where he believed that it was quite enough to help clients access, understand, and express their feelings (i.e., insight). However, like Rogers, many of the great theorists believe that insight is an important condition of therapy. For example, Freud (1936) proposed that “good” therapy helps people to understand their pasts as a way to free them from dysfunctional behavior in the present. Rogers believed that most of the action took place in the realm of feelings, while Freud was far more concerned with understanding unconscious and repressed desires. Cognitive ther- apists also subscribe to the philosophy that insight is critical for change, but, as we mentioned, they are concentrating on underlying belief structures (Beck, 1976). Existential therapists also place high value on insight, but they are interested in uncovering the meanings of life (May, 1953; Yalom, 1980). Gestalt therapists are interested in enhancing awareness so that clients can fully experience an incom- plete gestalt, creating an insight not only at a cognitive level, but at a full mind, body, and spirit level (Perls, 1969). Within individual psychology, insight is the final stage of therapy where a change occurs not only in awareness, but also in the way a person thinks and behaves externally (Adler, 1963). It is our position, and the one we take throughout this book, that insight is important and valuable but it is often not sufficient to promote lasting changes. You probably know several people who have been in therapy for a long time, may under- stand perfectly why they are so screwed up, but still persist in their self-defeating behavior. It is therefore entirely possible to understand what is going on but still be unable to do much to change the situation. A particularly good example of this has to do with addiction. A substance abuser knows that doing drugs or drinking all the time is not a good thing to do, but he or she is still unable to stop. An even more common example has to do with smoking. Every smoker today understands all too well the health risks of continuing to engage in this behavior. Most people would love to break this habit, but they still can’t stop. When there is time to foster some kind of insight, this stage offers a number of advantages:
- It satisfies the human urge to make sense of life.
- It helps people to generalize what they learn to other areas of their life.
- It teaches skills for working systematically to deal with problems in the future.
- It can sometimes foster change.
Given the variety of ways that different therapeutic systems use insight and understanding, you can appreciate that there is a wide variety in the skills that are used most often. If the skills in the previous stage are centered around exploration, then the ones at this juncture are designed to increase awareness and help move clients to a different level of understanding of themselves and the world. This means that people often must be provoked and challenged before they will give up comfortable but ineffective coping strategies in favor of others that are more fully functioning. The major skills employed include confrontation, challenging, reflect- ing discrepancies, and information giving. In the following vignette, some of the major features of the insight stage are evident.
Client: I guess the anxiety that I’ve been feeling is nothing new for me. When I was much younger—I think when I was in elementary school—I had problems going to school. And my parents tell me I was always afraid of strangers. Therapist: So what you are experiencing right now is part of an ongoing pattern in your life that began when you were quite young. The risks that you avoid at work, and in your most important relationships, represent your best efforts to protect yourself from being hurt. Client: Yeah. I’d say that is probably true. Therapist: You think of yourself as rather fragile, as if you can’t take much stress or you’d fall apart. Client: (nods head) Therapist: But if that was really the case then how could you possibly have learned to live with your anxiety for so long? Client: What do you mean? Therapist: I think you are a lot tougher than you give yourself credit for. You are amazingly resourceful in the ways you have learned to live with your fears. Somehow you’ve managed to keep your job and your friendships. You strike me as pretty competent in a lot of areas—in spite of your handicap. Client: You really think so? Therapist: Well, what do you think? Let’s look at the evidence.
This gentle confrontation is intended to help the client examine alternative ways of looking at his or her situation. The therapist is introducing another way of viewing the situation: Instead of weakness, things have been reframed as a kind of strength. The client has not yet agreed to this interpretation, but this con- versation is typical of the negotiations that take place in therapy. In part, our job is to teach clients alternative ways of looking at their lives. We do this through an assortment of different skills that are all designed to challenge thinking, clarify feelings, and provoke people to consider alternative viewpoints that are more helpful. And all of this must be accomplished while still being mindful of the relationship with the client.
82 FOUNDATIONS FOR SKILLS
