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15An Integrative Perspective

1. Explain psychotherapy integration and why it is increasing in popularity.

2. Identify some specific advantages of psychotherapy integration.

3. Examine some of the main challenges of developing an integrative approach.

4. Discuss how multicultural issues can be addressed in counseling practice.

5. Discuss how spiritual and religious values can ethically and effectively

be integrated into counseling practice.

6. Understand a basis for effectively drawing techniques from various theories.

7. Examine what research generally shows about the effectiveness of psychotherapy.

8. Describe feedback-informed treatment and explain how this is related to enhanced therapeutic outcomes.

L e a r n i n g O b j e c t i v e s

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Copyright 2017 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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Introduction 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 ther- apies focus on experiencing feelings, others stress identifying cognitive patterns, and still others concentrate on actual behavior. The key task is to find 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 field 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 are most relevant to practice? Looking for commonalities among the systems of psychotherapy is relatively new (Norcross & Beutler, 2014). Practitioners have been battling over the “best” way to bring about personality change dating back to the work of Freud. For decades, counselors resisted integration, often to the point of 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 field. It is now an established and respected movement that is based on combining the best of differing orientations so that more complete theoretical mod- els can be articulated and more efficient treatments developed (Goldfried, Pachan- kis, & Bell, 2005). The Society for the Exploration of Psychotherapy Integration, formed in 1983, is an international organization whose members are professionals working toward the development of therapeutic approaches that transcend single theoretical orientations. As the field of psychotherapy has matured, the concept of integration has emerged as a mainstay (Norcross & Beutler, 2014).

In this chapter I consider the advantages of developing an integrative perspec- tive 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 synthesize diverse elements from different theoretical perspectives. As much as possible, be alert to how these systems can function in harmony.

Visit CengageBrain.com or watch the DVD for the video program on Chapter 15, 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.

The Movement Toward Psychotherapy Integration 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 interventions, looks for anything that seems to work, often making little attempt to

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determine whether the therapeutic procedures are indeed effective. Such an uncriti- cal and unsystematic combination of techniques is no better than a narrow and dogmatic orthodoxy. Pulling techniques from many sources without a sound ratio- nale results in syncretistic confusion, which is detrimental to the successful treat- ment of clients (Corey, 2015; Neukrug, 2016; Norcross & Beutler, 2014).

Pathways Toward Psychotherapy Integration Psychotherapy integration is best characterized by attempts to look beyond and across the confines of single-school approaches to see what can be learned from other perspectives and how clients can benefit from a variety of ways of conduct- ing therapy. The majority of psychotherapists do not claim allegiance to a particular therapeutic school but prefer, instead, some form of integration (Norcross, 2005; Norcross & Beutler, 2014). In a 2007 survey, only 4.2% of respondents identified themselves as being aligned with one therapy model exclusively. The remaining 95.8% claimed to be integrative, meaning they combined a variety of methods or approaches in their counseling practice (Psychotherapy Networker, 2007). A panel of psychotherapy experts has predicted an increase in the popularity of integrative therapies in the next decade, particularly with regard to mindfulness, cognitive behavioral, multicultural, and integrative theories (Norcross, Pfund, & Prochaska, 2013).

The integrative approach is characterized by openness to various ways of inte- grating diverse theories and techniques, and there is a decided preference for the term integrative over eclectic (Norcross, Karpiak, & Lister, 2005). The ultimate goal of integration is to enhance the efficiency and applicability of psychotherapy. Norcross and Beutler (2014) and Stricker (2010) describe four of the most common path- ways toward the integration 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 positions that spawned them. For those who practice from the perspective of technical inte- gration, there is no necessary connection between conceptual foundations and tech- niques. Therapists have a variety of tools in their toolkit to use with clients. One of the best-known forms of technical integration, which Lazarus (2008a) refers to as technical eclecticism, is the basis of multimodal therapy. Multimodal therapists bor- row from many other therapeutic models, using techniques that have been demon- strated to be effective in dealing with specific clinical problems. Whenever feasible, multimodal therapists employ empirically supported techniques.

In contrast, theoretical integration refers to a conceptual or theoretical cre- ation 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 the- ory alone. This approach emphasizes integrating the underlying theories of therapy along with techniques from each. Examples of this form of integration are dialectical

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behavior therapy (DBT) and acceptance and commitment therapy (ACT), both of which are described in Chapter 9.

Emotion-focused therapy (EFT), introduced in Chapter 7, is another form of theoretical integration. This approach is informed by the role of emotion in psy- chotherapeutic change. Greenberg (2011), a key figure in the development of EFT, conceptualizes the model as an empirically supported, integrative, experiential approach to treatment. Emotion-focused therapy is rooted in a person-centered philosophy, but it is integrative in that it synthesizes aspects of Gestalt therapy, experiential therapy, and existential therapy. Emotion-focused therapy blends the relational aspects of the person-centered approach with the active phenomenologi- cal awareness experiments of Gestalt therapy.

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 flexibility of a variety of interventions from multiple systems. An example of this form of integration is mindfulness-based cognitive therapy (MBCT), which integrates aspects of cognitive therapy and mindful- ness-based stress reduction procedures. As you may recall from Chapter 9, MBCT is a comprehensive integration of the principles and skills of mindfulness that has been applied to the treatment of depression (Segal, Williams, & Teasdale, 2013).

The common factors approach searches for common elements across differ- ent theoretical systems. Despite many differences among the theories, a recogniz- able core of counseling practice is composed of nonspecific variables common to all therapies. Lambert (2011) concludes that common factors can be a basis for psycho- therapy integration:

The common factors explanation for the general equivalence of diverse therapeu- tic interventions 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, support, warmth, developing a working alliance, opportunity for catharsis, practicing new behaviors, feedback, positive expectations of clients, working through one’s own conflicts, understanding interpersonal and intrapersonal dynamics, change that occurs outside of the therapy office, client factors, therapist effects, and learning to be self-reflective about one’s work (Norcross & Beutler, 2014; Prochaska & Norcross, 2014).These common factors are thought to be far more important in account- ing for therapeutic outcomes than the unique factors that differentiate one theory from another. Specific treatment techniques make relatively little difference in outcome when compared with the value of common factors, especially the human elements (Elkins, 2016). 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 received more attention and confirmation than a facilitative therapeutic relationship (Lambert, 2011). The importance of the therapeutic alliance is a well-established

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critical component of effective therapy. Research confirms that the client–therapist relationship is central to therapeutic change and is a significant predictor of both effectiveness and retention of therapy outcomes (Elkins, 2016; Miller, Hubble, & Seidel, 2015).

Advantages of Psychotherapy Integration An integrative approach provides a general framework that enables practi- tioners to make sense of the many aspects of the therapy process and provides a map giving direction to what practitioners do and say (Corey, 2015). One reason for the movement toward psychotherapy integration is the recognition that no single theory is comprehensive enough to account for the complexities of human behav- ior, especially when the range of client types and their specific 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 clinical practice requires a flexible and integrative perspective. Psychotherapy should be flexibly tailored to the unique needs and contexts of the individual client. Norcross 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 broad- ening their theoretical and practical bases and have become less restrictive in their focus. Many practitioners who claim allegiance to a particular system of therapy are expanding their theoretical outlook and developing a wider range of therapeu- tic techniques to fit 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, not theory, will be the integrative theme of the 21st century.

Practitioners who are open to an integrative perspective will find 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 definition, “different” from the oth- ers, practitioners have some basis to begin developing a theory that fits 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 theories is a more realistic goal. Developing an integrative perspective is a lifelong endeavor that is refined with clinical experience, reflection, reading, and discourse with colleagues.

The Challenge of Developing an Integrative Perspective A survey of approaches to counseling and psychotherapy reveals that no common philosophy unifies them. Many of the theories have different basic phi- losophies and views of human nature (Table 15.1). As the postmodern therapists

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TAbLe 15.1 The basic Philosophies

Psychoanalytic therapy

Human beings are basically determined by psychic energy and by early experiences. Unconscious motives and conflicts are central in present behavior. Early development is of critical importance because later personality problems have their roots in repressed childhood conflicts.

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, influence, and create events. Each person at an early age creates a unique style of life, which tends to remain relatively constant throughout life.

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

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 influences are related to present difficulties. 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, including mindfulness and acceptance approaches.

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.

Choice theory/ 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 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, flexible, 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.

Postmodern approaches

Based on the premise that there are multiple realities and multiple truths, postmodern therapies reject the idea that reality is external and can be grasped. People create meaning in their lives through conversations with others. The postmodern 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 therapy is on creating solutions in the present and the future.

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.

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remind us, our philosophical assumptions are important because they influence 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 counseling that is consistent with your own personality and belief system and that validates clients’ belief 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 pre- clude using techniques drawn from behavior therapy or from some of the cognitive 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 assumptions. Examine the key concepts of various theories as you begin to think about integra- tion (Table 15.2). By remaining theoretically consistent, but technically integrative, practitioners can spell out precisely the interventions they will employ with various clients, as well as the means by which they will select these procedures.

TAbLe 15.2 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 specific stage. Anxiety is a result of repression of basic conflicts. Unconscious processes are 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 finding goals to give life meaning. Other key concepts are striving for significance and superiority, developing a unique lifestyle, and understanding the family 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 firm 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, figure-formation process, awareness, unfinished business and avoidance, contact, and energy.

Behavior therapy

Focus is on overt behavior, precision in specifying goals of treatment, development of specific 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.

(continued)

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One of the challenges you will face as a counselor is to deliver therapeutic ser- vices in a brief, comprehensive, effective, and flexible way. Many of the theoretical 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. Short-term and very-short-term therapies are increasing (Norcross et al., 2013). Time-limited brief therapy refers to a variety of time-sensitive, goal-directed, efficiency-oriented methods. These methods can be incorporated in any theoretical approach (Hoyt, 2015). Lambert (2011) 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 with many client populations.

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, 2014). To develop this kind of integration, you 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 willing to continually test your hypotheses to determine how well they are working. Neukrug (2016) reminds us that “the ability to assimilate techniques from varying theoretical perspectives takes knowledge, time, and finesse” (p. 139).

Cognitive behavior therapy

Although psychological problems may be rooted in childhood, they are reinforced by present ways of thinking. A person’s belief system and thinking 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.

Choice theory/ 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 significant relationships. The approach rejects the medical model, the notion of transference, the unconscious, and dwelling on one’s past.

Feminist therapy

Core principles of feminist therapy are that the personal is 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 egalitarian, therapy focuses on strengths and a reformulated definition of psychological distress, and all types of oppression 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 problem. The emphasis is on externalizing the problem and 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 specific 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.

TAbLe 15.2 Key Concepts (continued)

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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 cli- ent populations. For some theories, this transition is easier than for others.

Clients can be harmed if they are expected to fit all the specifications 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 fit the dimensions of a single theory, practitioners need to tailor their theory and practice to fit the unique needs of the client. This calls for counselors to possess knowledge of various cultures, to be aware of their own cultural heritage, and to have skills to assist a wide spectrum of clients in dealing with the realities of their culture. Psychotherapy integration stresses tailoring interven- tions to the individual client rather than to an overarching theory, making this approach particularly well suited to considering cultural factors and the unique perspective of each client. Comas-Diaz (2014) believes that cultural competence enables counselors to work effectively in most clinical settings. Practitioners demonstrate their cultural com- petence by becoming aware of their own and their clients’ worldviews, and by being able to use culturally appropriate interventions to reflect their cultural beliefs, knowledge, and skills. This is a good time to review the discussion of the culturally skilled counselor in 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. The client’s ethnicity and culture and the concerns that bring this person to counseling challenge you to develop flexibility in utilizing an array of therapeutic strategies. Some clients will need more direction and guidance; others will be hesitant to talk about themselves in personal 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 conditioning 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 fit 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 find practical strategies for adapting the techniques you have developed to enable clients to exam- ine 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 reflecting on how your own culture influ- 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 beliefs and values are reflected in their behavior. Current interest in spiritual and religious beliefs has implications for how such beliefs might be incorporated in

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therapeutic relationships (Frame, 2003; Johnson, 2013; Young & Cashwell, 2011a). Survey data from members of both the American Psychological Association and the American Counseling Association indicate that spiritual and religious matters are therapeutically relevant, ethically appropriate, and potentially significant topics for the practice of counseling in secular settings (Delaney, Miller, & Bisono, 2007; Young, Wiggins-Frame, & Cashwell, 2007).

Worthington (2011) asserts that the increasing openness of therapists to cli- ents’ spiritual and religious concerns and interests has been fueled by the multicul- tural evolution. The emphasis on multiculturalism has empowered people to define themselves from a cultural perspective, which includes their spiritual, religious, and ethnic contexts. Johnson (2013) views spiritually informed therapy as a form of mul- ticultural therapy. The first step is for the therapist to be sincerely interested in the client’s spiritual beliefs and experiences and how he or she finds meaning in life. Johnson believes that a client-defined sense of spirituality can be a significant avenue for connecting with the client and can be an ally in the therapeutic change process. However, the emphasis is on what the client wants, not on the therapist’s spiritual experiences or agenda for the client.

Clients who are experiencing a crisis situation may find 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 find a purpose (or purposes) for living. Spiritual or religious beliefs can be a major sustaining power that supports clients when all else fails. Other clients 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 religion or spiritual- ity. Furthermore, counselors cannot ignore a client’s spiritual and religious perspec- tives if they want to practice in a culturally competent and ethical manner (Johnson, 2013; Young & Cashwell, 2011a, 2011b). It is essential for counselors to be aware of and understand their spiritual or religious attitudes, beliefs, values, and experiences if they expect to facilitate an exploration of these issues with clients.

Common Goals Spiritual values have a major part to play in human life and struggles. 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 influences include loving, caring, learning to listen with compassion, challenging clients’ basic life assumptions, accepting human imperfection, and going outside of self-oriented interests (social interest). Both a spiritual perspective and counseling can help people ponder questions of “Who am I?” and “What is the meaning of my life?” Pursuing these existential questions can foster healing.

Implications for Assessment and Treatment 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

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part of a client’s history, and thus it can be a part of the intake assessment 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 interventions. Young and Cashwell (2011a) maintain that counselors must assess whether clients’ spiritual or religious beliefs may be exacerbating or helping clients’ psychological problems.

Your Role as a Counselor It is critical that counselors not be judgmental when it comes to their clients’ beliefs and that counselors create an inviting and safe climate for clients to explore their values and beliefs. There are many paths toward fulfilling spiritual needs, and it is not your role as a counselor to prescribe any particular 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 finely 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. It is critical that you listen for how clients talk about existential concerns of meaning, values, mortality, and being in the world. Remain open to how your clients define, experience, and access whatever helps them stay connected to their core values and their inner wisdom (Johnson, 2013).

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 influence clients to embrace a spiritual perspective or to give up certain religious beliefs that you think are no longer func- tional for them. It is important to keep in mind that clients, not therapists, should determine the specific 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 Counseling: A Guide to Competent Practice (Cashwell & Young, 2011) and Spirituality in Counseling and Psychotherapy: An Integrative Approach That Empowers Clients (Johnson, 2013).

Issues Related to the Therapeutic Process Therapeutic Goals

The goals of counseling are almost as diverse as are the theoretical approaches (Table 15.3). Some possible goals include the following:

ŠŠ Restructuring the personality ŠŠ Uncovering the unconscious ŠŠ Creating social interest

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ŠŠ Finding meaning in life ŠŠ Curing an emotional disturbance ŠŠ Examining old decisions and making new ones ŠŠ Developing trust in oneself ŠŠ Becoming more self-actualizing

TAbLe 15.3 Goals of Therapy

Psychoanalytic therapy

To make the unconscious conscious. To reconstruct the basic personality. To assist clients in reliving earlier experiences and working through repressed conflicts. 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. To help clients recognize blocks to growth and 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 find 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.

Behavior therapy

To eliminate maladaptive behaviors and learn more effective behaviors. To identify factors that influence behavior and find 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. To assist clients in identifying their inner strengths, and to explore the kind of life they would like to have.

Choice theory/ Reality therapy

To help people become more effective in meeting all of their psychological needs. To enable clients to get reconnected with 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.

Postmodern approaches

To change the way clients view problems and what they can do about these concerns. To collaboratively establish specific, 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. To identify how a client’s problematic behavior may serve a function or purpose for the family. To understand how dysfunctional patterns can be handed down across generations. To recognize how family rules can affect each family member. To understand how past family of origin experiences continue to have an impact on individuals.

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ŠŠ Reducing maladaptive behavior and learning adaptive patterns ŠŠ Becoming grounded in the present moment ŠŠ Managing intense emotions such as anxiety ŠŠ Gaining more effective control of one’s life ŠŠ Reauthoring the story of one’s life

This diversity can be simplified by considering the degree of generality or speci- ficity of goals. Goals exist on a continuum from specific, 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 specifically they are defined.

Therapist’s Function and Role In working toward an integrative perspective, ask yourself these questions:

ŠŠ How do the counselor’s functions change depending on the stage of the counseling process?

ŠŠ Does the therapist maintain a basic role, or does this role vary in accor- dance with the characteristics of the client?

ŠŠ How does the counselor determine how active and directive to be? ŠŠ How is structuring handled as the course of therapy progresses? ŠŠ What is the optimum balance of responsibility in the client–therapist

relationship? ŠŠ What is the most effective way to monitor the therapeutic alliance? ŠŠ What, when, and how much counselor self-disclosure is therapeutic?

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 much looser and less defined structure. Solution-focused and narrative therapists view the client as the expert on his or her own life; they assist the client in reflection outside of the session that might result in self-directed change. Although they are active questioners, they are not prescriptive in their practice.

Structuring depends on the particular client and the specific circumstances he 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 provide a focus for the therapy process. As soon as possible, the client should be given a significant share of the responsibility for deciding on the con- tent 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.

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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 individu- als initiate therapy because they hope to cure a specific 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 conflicting feelings and reac- tions, may struggle with low self-esteem, or may have limited information and skills. Many seek to resolve conflicts 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, meaninglessness 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 pro- cess, selecting their own goals and working toward them, both in the sessions and in daily living. Some clients can benefit from recognizing and expressing pent-up feel- ings, others will need to examine their beliefs and thoughts, others will most need to begin behaving in different ways, and others will benefit from talking with you about their relationships with the significant 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 phases in the counseling process. Although some clients initially feel a need to be listened to and allowed to express deep feelings, they can profit later from examining the thought patterns that are contributing to their psychological pain. A some point in therapy, it is essential that clients translate what they are learning about themselves into con- crete action. The client’s given situation in the environment provides a framework for selecting interventions that are most appropriate.

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, cognitive therapy, and behavior therapy do not ignore the rela- tionship factor but place less emphasis on the relationship and more emphasis 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 spontane- ity are basic ingredients for successful outcomes. Therapists’ degree of caring, their interest and ability in helping their clients, and their genuineness influence the

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TAbLe 15.4 The Therapeutic Relationship

Psychoanalytic therapy

The classical analyst remains anonymous, and clients develop projections toward him or her. The 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 conflicts, 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 on equality. The focus is on identifying, exploring, and disclosing mistaken goals and faulty assumptions within the person’s lifestyle.

Existential therapy

The therapist’s main tasks are to accurately grasp 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 client and therapist can be changed by the encounter.

Person-centered therapy

The relationship is of primary importance. The qualities of the therapist, including genuineness, warmth, accurate empathy, respect, and being nonjudgmental—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 unfinished 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 sufficient to bring about change, it is considered essential for implementing behavioral procedures.

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. In strengths-based CBT, active incorporation of client strengths encourages full engagement in therapy and often provides avenues for change that otherwise would be missed.

Choice theory/ 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 of their relationships with respect to what they want and how effective they are in getting this. Therapists find 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.

Feminist therapy

The therapeutic relationship is based on empowerment and egalitarianism. Therapists actively break down the hierarchy of power and reduce artificial 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.

(continued)

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relationship. Therapists can become more effective by developing their personal qualities and their interpersonal abilities. Psychotherapy is primarily a human and relational endeavor that depends on the quality of the interpersonal connection between participants (Duncan, 2014; Elkins, 2016). Both client and therapist bring origins, culture, expectations, biases, defenses, and strengths to this relationship. How we create and nurture this powerful human relationship can be guided by the fruits of research (Norcross & Wampold, 2011a).

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 fit 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 prob- lems to be effective with them, it is critical that you be able to understand their world and respect them. Ask yourself how well prepared you are to counsel clients from a dif- ferent cultural background. To what degree do you think you can successfully estab- lish a therapeutic relationship with a client of a different race? Ethnic group? Gender? Age? Sexual orientation? Spiritual/religious orientation? Socioeconomic group? Do you see any potential barriers that would make it difficult for you to form a working relationship with certain clients? It is also important to consider the client’s diagnosis, resistance level, treatment preferences, and stage of change. Therapeutic techniques and styles should be selected to fit the client’s personal characteristics. Norcross and Beutler (2014) suggest that therapists create a new therapy for each client:

We believe that the purpose of integrative psychotherapy is not to create a single or unitary treatment. Rather, we select different treatment methods according to the patient and the context. The result is a more efficient and efficacious therapy— and one that fits both the client and the clinician. (p. 502)

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-affirming 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.

TAbLe 15.4 The Therapeutic Relationship (continued)

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The Place of Techniques and Evaluation in Counseling Drawing on Techniques From Various Approaches

Effective therapists incorporate a wide range of procedures in their thera- peutic 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 on therapeutic techniques and Table 15.6 on applications for

LO6

TAbLe 15.5 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 conflicts, 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 new possibilities.

Existential therapy

Few techniques flow from this approach because it stresses understanding first 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 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, reflection of feelings, clarification, “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 conflicting 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, flooding, eye movement and desensitization reprocessing, cognitive restructuring, social skills training, self-management programs, mindfulness and acceptance methods, behavioral rehearsal, and coaching. 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.

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.

(continued)

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TAbLe 15.6 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 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 sense of life, and finding 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.

Choice theory/ Reality therapy

This is an active, directive, and didactic therapy. Skillful questioning is a central technique used for the duration of the therapy process. Various techniques may be used to get 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 specific plan for change and make a commitment to follow through.

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 techniques frequently used include gender-role analysis 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, specific 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 finding 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. Some techniques include genograms, teaching, asking questions, joining the family, tracking sequences, 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.

TAbLe 15.5 Techniques of Therapy (continued)

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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 fields such as pediatrics, stress management, behavioral medicine, education, and geriatrics.

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 specific problems.

Choice theory/ 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.

Feminist therapy

Principles and techniques can be applied to a range of therapeutic modalities such as individual therapy, relationship counseling, family therapy, group counseling, and community intervention. The approach can be applied to both women and men with the goal of bringing about empowerment.

Postmodern approaches

Solution-focused therapy is well suited for people with adjustment disorders and for problems of anxiety and depression. Narrative therapy is now being used for a broad range of human difficulties 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.

each approach. 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 (Table 15.7) and limitations (Table 15.8) when applied to culturally diverse client populations. Although it is unwise to stereotype clients because of their cul- tural heritage, it is useful to assess the bearing cultural context has on their con- cerns. 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 proficiency 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 conflicts

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TAbLe 15.7 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, 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

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 conflicts.

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 conflicts 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 are likely to value the active and directive stance of the therapist.

Choice theory/ 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 satisfied. They can find 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 influence of expected cultural roles and explores client’s satisfaction with and knowledge of these roles.

Postmodern approaches

Focus is on the social and cultural context of behavior. Stories that are being authored in the therapy office need to be anchored in the social world in which the client lives. Therapists do not make assumptions about people and 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 cultural values and enables clients to become active agents of 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.

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TAbLe 15.8 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 conflict with cultural values that stress an interpersonal and environmental focus.

Adlerian therapy

This approach’s detailed interview about one’s family background can conflict 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 conflicts with the egalitarian, person-to- person spirit as a way to reduce social distance.

Existential therapy

Values of individuality, freedom, autonomy, and self-realization often conflict with cultural values of collectivism, respect for tradition, deference to authority, and interdependence. Some may be deterred by the absence of specific 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 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 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 choosing appropriate ways to solve problems.

Choice theory/ Reality therapy

This approach stresses taking charge of one’s own life, yet some clients are more interested in changing their external environment. Counselors need 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 significant 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.

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 difficult to explore conflicts openly.

and struggles, and to translate their insights into action programs by behaving in new ways in day-to-day living. Table 15.9 outlines the contributions of various approaches, and Table 15.10 describes some of the limitations of the various thera- peutic approaches. These tables will help you identify elements that you may want to incorporate in your own counseling perspective.

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TAbLe 15.9 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 first six 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 influence that Adlerian concepts have had on other systems and the integration of these concepts into various contemporary therapies. This is one of the first approaches to therapy that was humanistic, unified, 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.

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 modified. It is an open system. People without advanced training can benefit 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 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 conflicts. 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, thus providing a basis for accountable practice. Specific problems are identified, 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 therapeutic practice; numerous cognitive, emotive, and behavioral techniques; an openness to incorporating techniques from other approaches; and a methodology for challenging and changing faulty or negative 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. Strengths-based CBT is a form of positive psychology that addresses the resources within the client for change.

Choice theory/ 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 significant 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 unified 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 fit 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 stories in a positive direction. Clients are not blamed for 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 that invites clients to view themselves in new and more effective ways.

Family systems therapy

From a systemic perspective, neither the individual nor the family is blamed for a particular dysfunction. The family is empowered through the process of identifying 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 conflicts in systems outside of the family

TAbLe 15.10 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 specific 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 scientific methods. Tends to oversimplify some complex human problems and is based heavily on common sense.

Existential therapy

Many basic concepts are fuzzy and ill-defined, 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 reflection. 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.

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 unfinished and will not have a sense of integration of their learning. Clients who have difficulty using imagination may not profit from certain experiments.

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 conflicts, de-emphasizes the value of insight, and sometimes does not give enough weight to the client’s past. CBT might be too structured for some clients.

(continued)

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Evaluating the Effectiveness of Counseling and Therapy Mental health providers must be accountable and be able to demonstrate the efficacy of their services. In the era of managed care, it is essential for practi- tioners to demonstrate the degree to which their interventions are both clinically sound and cost-effective. Does therapy make a significant difference? Are people substantially better after therapy than they were without it? Can therapy actually be more harmful than helpful?

Evaluating how well psychotherapy works is far from simple. Therapeutic sys- tems 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 client’s social environ- ment 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.

How effective is psychotherapy? A meta-analysis of psychotherapy outcome lit- erature conducted by Smith, Glass, and Miller (1980) concluded that psychotherapy was highly effective and that all psychotherapeutic approaches worked about equally well. Prochaska and Norcross (2014) note that controlled outcome research consis- tently supports the effectiveness of psychotherapy. They point out that more than 5,000 individual studies and 500 meta-analyses have been conducted on the effec- tiveness 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. Psychotherapy is an efficacious approach to helping people who experience psychological distress improve their functioning (Miller et al., 2015).

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Choice theory/ 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, defining 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.

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 and narrative therapy 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 the system. Therapists’ self- knowledge and willingness 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 supervision, and be competent in assessing and treating individuals in a family context.

TAbLe 15.10 Limitations of the Approaches (continued)

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A summary of the research data shows little or no difference in outcome between specific therapeutic approaches (Miller et al., 2015). Lambert’s (2011) review of psy- chotherapy research makes it clear that the similarities rather than the differences among models account for the effectiveness of psychotherapy. Interpersonal, social, and affective factors common across therapeutic orientations are the primary deter- minants of effectiveness (Elkins, 2016).

Although it is clear that therapy works, there are no simple explanations of how it works. 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. Wampold (2010) concludes that “there is little evidence that the specific ingredients of any treatment are responsible for the benefits of therapy” (p. 71).

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; Bohart & Wade, 2013), and we can most productively direct our efforts toward ways of employing the client in the process of change.

Feedback-Informed Treatment Listening to client feedback about the therapy process is of the utmost impor- tance. Feedback-informed treatment (Fit) is designed to evaluate and to improve the quality and effectiveness of counseling services. FIT is an evidence-based practice that monitors client change and identifies modifications needed to enhance the therapeutic endeavor (Miller et al., 2015). FIT involves consistently obtaining feedback from clients regarding the therapeutic relationship and their clinical prog- ress, which is then used to tailor therapy to their unique needs. 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 (Miller et al., 2015).

Monitoring outcome and adjusting accordingly on the basis of feedback from the client must become routine practice. The client’s theory of change can be used as a basis for determining which approach, by whom, can be most effective for this per- son, with his or her specific problem, under this particular set of circumstances. This approach to practice requires continuous active client input, which is the most sig- nificant predictor of change in therapy (Hubble, Duncan, Miller, & Wampold, 2010).

Duncan (2014) believes that systematic client feedback should be integrated into all psychotherapeutic approaches because of its proven effectiveness in help- ing clients monitor and improve their therapy experience. Scott Miller and his associates at the International Center for Clinical Excellence (ICCE) developed two 4-item instruments to measure client progress and to rate the quality of the thera- peutic relationship. These rating instruments are brief, well-validated, client-rated scales. The Outcome rating scale (Ors) assesses the client’s therapeutic prog- ress through ratings of a client’s personal experience of well-being in his or her individual, interpersonal, and social functioning. The session rating scale (srs) measures a client’s perception of the quality of the therapeutic relationship, which includes the relational bond with the therapist, the perceived collaboration around specific tasks in therapy, and agreement on goals, methods, and client preferences (Miller et al., 2015).

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Feedback from clients regarding the therapeutic alliance and outcomes increases the effect of treatment, cuts dropout rates in half, and decreases the risk of deteriora- tion (Miller, 2011). Using client feedback, therapists can adjust and accommodate to maximize beneficial outcomes for clients. In essence, Duncan, Miller, and Sparks (2004) are arguing for practice-based evidence rather than evidence-based practice: “Becoming outcome informed not only amplifies the client’s voice but offers the most viable, research-tested method to improve clinical effectiveness” (p. 16). Cli- ent strengths and perceptions are the foundation of therapy work. Systematic and consistent assessment of the client’s perceptions of progress allows the therapist to customize the therapy to the individual needs and characteristics of each client. Ongoing client feedback provides practitioners with a simple, practical, and mean- ingful method for documenting the usefulness of treatment.

In this section, I describe how I would integrate con-cepts and techniques from the 11 theoretical per- spectives in counseling Stan on the levels of thinking, feeling, and doing. I indicate what aspects from the vari- ous theories I would draw on in working with Stan at the various stages of his therapy. As you read the Ques- tions for Reflection at the end of this section, think about how you would work with Stan from your own integrative perspective.

clarifying the therapeutic relationship In establishing the therapeutic relationship, I am in- fluenced by the person-centered, existential, Gestalt, feminist, postmodern, and Adlerian approaches. I ask myself these questions: “To what degree am I able to listen to and hear Stan in a nonjudgmental way? Am I able to respect and care for him? Do I have the ca- pacity to enter his subjective world without losing my own identity? Am I able to share with him my own thoughts and reactions as they pertain to our relation- ship?” I invite Stan’s questions about this therapeutic relationship. One goal is to demystify the therapy pro- cess; another is to get some focus for the direction of our sessions by developing clear goals for the therapy.

clarifying the goals of therapy With respect to setting goals, precision and clarity are essential. Once we have identified some 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 modifications in our therapeutic alliance.

Throughout our time together, 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 helping him meet his goals. It is important that Stan provide the direction in which he wants to travel on his journey. Once I have a clear sense of the specific 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 in the therapy sessions and on his own away from our sessions.

Working With stan’s Past, Present, and Future Dealing With the Past In my integrative approach, I tend 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 significant experiences in our childhood. I favor the Gestalt approach of asking Stan to bring into the here and now those people in his life with whom he feels unfinished. A variety of role-playing techniques in which Stan addresses significant others through symbolic work in our sessions will bring Stan’s past intensely to life in the present moment of our sessions.

An Integrative Approach Applied to the Case of Stan

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Dealing With the Present 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 significant clues about what is unfinished 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.

Dealing With the Future If Stan 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 five years hence. Connecting present behavior with future plans is an excellent way to help Stan formulate a concrete plan of action, which can give him a way to create his future.

identifying and exploring Feelings The authenticity of my relationship with Stan encour- ages him to begin to identify and share with me a range of feelings. Our open and trusting relationship is not sufficient to change Stan’s personality and behavior, however, and I continue to use my knowledge, skills, and experiences to help Stan clarify his own thoughts. Stan is the best expert on his own life, and I assist him in coming to value the ways in which he is the expert in the therapeutic endeavor as well.

I draw heavily on Gestalt experiments to help Stan express and explore his feelings. Eventually, I ask him to avoid merely talking about situations and about feelings. Rather, I encourage him to bring whatever reactions he is having into the present. For instance, if I notice tears in his eyes, I may direct him to “be his tears now.” By putting words to his tears, he avoids ab- stract intellectualization about all the reasons he is sad or tense. Before he can change his feelings, Stan must allow himself to fully experience them. The experiential therapies provide valuable tools for guiding him to the expression of his feelings.

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 decisions he made. I get him to think about the reason he made certain early deci- sions. Finally, I challenge Stan to look at these deci- sions about life, about himself, and about others and to make necessary revisions that can lead him to creat- ing a life of his own choosing.

The cognitive behavioral therapies have a range of cognitive techniques that can help Stan recognize con- nections between his cognitions and his behaviors. Over a number of sessions we work on specific beliefs. My role is to promote corrective experiences that will lead to changes in his thinking. 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. 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. This provides a basis for change in his behavior.

Doing: another essential component of therapy Feeling 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 situ- ations in various action programs. 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. Homework assignments (preferably ones that Stan gives himself) 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. Thus, each week we discuss his progress toward meeting his goals, and we review how well he is completing his assignments, as well as how his action plan is working.

Moving toward termination of therapy 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

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and attitudes to daily social situations without profes- sional 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 ac- tion plan and talking about how he can best maintain his new learning.

In a behavioral spirit, evaluating the process and outcomes of therapy seems essential. This evaluation can take the form of devoting some time to discuss- ing Stan’s specific changes in therapy. A few questions for focus are: “What stands out the most for you, Stan? What did you learn that you consider the most valuable? 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 potential difficulties 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 cope constructively with future prob- lems. By addressing potential problems and stum- bling 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 cannot return for a visit or session when he considers it appropriate.

commentary on the thinking, Feeling, and Doing Perspective Although the steps I described with Stan may appear relatively structured and even simple, actually work- ing with clients is more complex and less predictable. If you are practicing from an integrative perspec- tive, it would be a mistake to assume that it is best to always begin working with what clients are think- ing (or feeling or doing). Effective counseling begins where the client is, not where a theory indicates a cli- ent 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. If Stan can change his thoughts, I believe he is likely to change some of his behaviors and his feelings. If he changes his feel- ings, 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 human 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. As counselors, a mistake we can make is getting too far ahead of our clients by thinking, “What should I do next?” By staying 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 reactions 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.

Questions for Reflection ŠŠ What themes in Stan’s life do you find most sig-

nificant, and how might you draw on these themes during the initial phase of counseling?

ŠŠ What specific concepts from the various theoreti- cal orientations would you be most inclined to utilize in your work with Stan?

ŠŠ Identify some key techniques from the various therapies that you are most likely to employ in your therapy with Stan.

ŠŠ How would you develop experiments for Stan to carry out both inside and outside the therapy sessions?

ŠŠ 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?

Visit CengageBrain.com or watch the DVD for the video program on Theory and Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes, session 13 (an integrative approach), for a dem- onstration of my approach to counseling stan from this perspective. This session deals with termination and takes an integrative view of stan’s work.

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T here are multiple pathways to health and well-being, and I believe Gwen can benefit from a va- riety of counseling theories and holistic practices. The integrative approach embraces an attitude that affirms the intrinsic value of each individual. It is a unifying approach that attends to the person at the affective, behavioral, cognitive, and physiological levels of func- tioning. It also addresses the spiritual dimension of a client’s life.

As an integrative therapist and a woman of color, I am willing to share my experiences with Gwen when it is therapeutically appropriate. I want Gwen to know that I respect her life experiences, struggles, strengths, unique qualities, and personal reality. I see Gwen as an intelligent African American woman with great depth and wisdom. Utilizing an integrative approach with Gwen allows me to take into account the many views of the change process that are available to assist her at this time in her life.

In my initial interview with Gwen, I let her know that I am not a purist in my approach to therapy and that I will draw from different counseling theories to cre- ate a treatment approach that is tailored to her needs. I begin establishing a therapeutic alliance with Gwen by drawing heavily from a client-centered orientation It is important for me to extend unconditional positive re- gard in the midst of acknowledging the suffering and anxiety Gwen is experiencing in her day-to-day life. I want Gwen to know that she is the expert on her life and that she is in charge of our work together. I will intro- duce ideas and techniques, and I let Gwen know that she is free to say what does not work for her in our sessions.

When Gwen and I began our therapeutic journey together, I was very interested in learning about her family history. I encouraged Gwen to create a geno- gram that depicted three generations and indicated educational levels, health issues, relationship patterns, and religious orientation. This approach was borrowed from family therapy and assisted us in seeing family patterns that have given her strength and support (her spirituality), as well as patterns that have caused chal- lenges for her (taking on family members’ problems).

Through exploring her family history, Gwen begins to slowly recognize she has taken on characteristics that don’t necessarily belong to her. Generational trans- mission—passing down traits, habits, and values from one generation to the next—has predisposed Gwen to be a rescuer like many of her female relatives. She ex- plores some of the old automatic negative thoughts that were passed on from other generations that keep her feeling overwhelmed. One of Gwen’s faulty beliefs is that “If I don’t do it, no one else will.” This particular cognitive distortion keeps her is a spiral of doing ev- erything without reaching out to others for assistance or support. Her belief that no one else can assist her has caused fatigue and frustration. Through cognitive behavior therapy, Gwen becomes more aware of the thoughts she is thinking and how they affect how she feels about herself.

Using an integrative format allows me to incorpo- rate everything Gwen brings to therapy as a route to her own healing process. Gwen shared with me early in our sessions that her relationship with God was a source of great strength in her life. I acknowledge and respect Gwen’s spiritual values, and I pay attention to how her spirituality can be a significant part of her treatment and healing. Spirituality became a central part of our therapy sessions because Gwen made it clear that her spiritual beliefs were a vital resource for her.

I asked Gwen to talk about what was most helpful about the way she worshiped. Gwen replied, “I enjoy reading the scriptures. It helps me to see that I am not alone and that my problems are not new. There are messages that I can reflect on in scripture. Reading the Bible gives me comfort in my spirit.” We explore the existential questions around the meaning in life and talk about suffering, anxiety, and death. Gwen strug- gles with fears for her son’s life, and she feels great sad- ness as her mother’s health declines. Gwen’s spiritual- ity is becoming her anchor and support as she wrestles with these realities of life.

Bringing in the dimension of spirituality recon- nects Gwen to a daily practice of reading scripture in the morning and listening to praise music on the way

An Integrative Approach Applied to the Case of Gwen*

*Dr. Kellie Kirksey writes about her ways of thinking and practicing from an integrative perspective and applying this model to Gwen.

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to the office. Gwen notices that her mood is not as negative when she engages in her daily spiritual prac- tice. She hadn’t realized that she had stopped engag- ing in activities that kept her focused and uplifted. The stress of taking care of her mother and juggling work and family life created an imbalance that perpetuated faulty cognitions and behaviors.

In our early sessions Gwen engaged in automatic negative thinking and made statements such as “I am never going to feel healthy again.” “My children never want to spend time with me.” “I will always feel iso- lated.” Examining Gwen’s cognitive distortions and assisting her in noticing and challenging them helped her to become increasingly aware of how these thought patterns cause her distress.

I introduced Gwen to a simple 5-minute medita- tion practice aimed at both calming her mind of anxious thoughts and increasing her ability to focus. I suggested to Gwen that during these brief meditations she could notice her thoughts without judgment. This simple mindfulness practice is likely to have a cumulative im- pact on her ability to relax and gain more inner resil- ience. With continued practice, Gwen discovers that she is not simply her thoughts, that she can be the observer of those thoughts, and that she can watch them flow by rather than letting them control her behavior and mood.

I typically begin and end each session with a brief assessment by Gwen about the session. I depend on regular feedback to make the process truly collabora- tive and to ensure that Gwen’s therapeutic needs are being met. My first question for Gwen is always: “How would you like to best use the time we have together?” My job is to be fully present so that I can effectively integrate therapeutic approaches that will assist Gwen on her journey of transformation as she returns to a state of optimal functioning and balance.

I make no assumptions and ask Gwen if she is will- ing to work with what naturally arises as the therapy progresses. If she does not give an affirmative answer, then our direction of therapy needs to be modified. I explain that my techniques are aimed at meeting Gw- en’s goals and healing her needs. This statement seems to increase Gwen’s comfort level, and she is more will- ing to try new ways of being in a session.

To decrease Gwen’s symptoms of depression and anxiety, I introduce her to a process I call “transfor- mative movement and reflection.” I teach Gwen a vari- ety of techniques, range from subtle to dynamic, that come from global healing practices such as yoga, tai chi, drumming, and yogic pranayama, to mention a few. These activities increase mindfulness and present moment awareness and help Gwen release tension and stress from her body and mind. The movement prac- tices also assist in healthy emotional expression. Gwen is not very interested in drumming, but listening to music and moving is relaxing for her while in session and at home. Gwen begins to see that she has resourc- es and tools that she can use in moments of stress in her daily life. My goal is to introduce Gwen to multiple tools to heal on the levels of mind, body, and spirit. I am sensitive to Gwen’s personal goals from the mo- ment she walks into my office, and I remain open to the possibilities that lie ahead of us until the very end.

Questions for Reflection ŠŠ What ideas and techniques shared in this piece

belong to each theoretical approach? ŠŠ How comfortable are you in introducing nontradi-

tional therapeutic techniques? ŠŠ Based on who you are, what theories seem to be the

most natural for you to utilize from an integrative theoretical approach when working with Gwen?

Summary 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 about the behavioral dimension? Most of the 11 therapeutic orientations

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discussed here focus primarily 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-depth knowledge of the various theories. Without such knowledge, you cannot formulate a true synthesis. Simply put, you cannot integrate what you do not know (Nor- cross & Beutler, 2014). A central message of this book has been to remain open to each theory, to do further reading, and to reflect on how the key concepts of each approach fit your personality. Building your personalized orientation to counseling, which is based on what you consider to be the best features of several theories, is a long-term venture.

In addition to considering your own personality, think about what concepts and techniques work best with a range of clients. It requires knowledge, skill, art, and experience 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 therapeu- tic intervention. Although reflecting on your personal preferences is important, I hope that you balance your preferences with evidence from the research studies. Developing a personal approach to counseling practice does not imply that any- thing goes. Indeed, in this era of managed care and evidence-based practice, your personal preferences will not likely be the sole determinant of your psychotherapy practice. In counseling clients with certain clinical problems (such as depression and generalized anxiety), specific techniques have demonstrated their effective- ness. For instance, behavior therapy, cognitive behavior therapy, cognitive 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 theoretical constructs. Ethical practice implies that you employ efficacious procedures in dealing with clients and their problems, and that you are able to provide a theoretical 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 pro- cedures. 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 designed to assist you in conceptualizing your view of the counseling process.

Concluding Comments 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 see the differences among them?” 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

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an introductory survey course will not turn you into accomplished counselors, it generally provides the basis for selecting from among the many models to which you 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 can use from each of the approaches described. You will not be in a position to conceptual- ize a completely developed integrative perspective after your first course in coun- seling theory, but you now have the tools to begin the process of integration. With additional study and practical experience, you will be able to expand and refine your emerging personal philosophy of counseling.

Finally, the book will have been put to good use if it has stimulated you to think 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 and to the impact you can have on those who estab- lish a relationship with you personally and professionally. This book and your course may have raised questions for you regarding your decision to become a counselor. Seek out at least one of your professors and explore any questions you may have.

Self-Reflection and Discussion Questions 1. What are the four major approaches to psychotherapy integration?

How can these routes to integration be useful for you in designing your perspective on counseling?

2. In feedback-informed treatment, clients provide reactions to their expe- rience of the session and to the therapist. How open do you imagine you would be to hearing honest feedback from your clients about you as a therapist and about the interventions you are making? Do you see yourself as being able to engage in a discussion with your clients regarding both their positive and negative reactions to a session?

3. In developing your integrative approach to counseling, what factors would you most consider?

4. What importance do you place on research that seeks to identify what makes psychotherapy work?

5. If you had to select one theory that would serve as your primary theory, which theory would you select and why?

Where to Go From Here 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 drawing on techniques from various theoretical models. I demonstrate how the foundation of my integrative approach rests on existential therapy. In this session I am drawing heavily from principles of the action-oriented therapies.

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AN INTEgRATIVE PERsPECTIVE 459

Other Resources The International Center for Clinical Excellence (ICCE) is a worldwide web-based community of practitioners, health care managers, administrators, educators, poli- cymakers, and researchers dedicated to promoting excellence in behavioral health care services. This online community facilitates sharing best practices and innova- tive ideas specifically designed to improve behavioral health care practice and enable practitioners and managers to achieve their personal best as helping professionals. The ORS and the SRS rating scales described in the text can be downloaded for free at the website.

The ICCE manuals on feedback-informed treatment (FIT) consist of a series of six guides covering the most important information for practitioners and agencies implementing FIT as a part of routine care. The manuals cover the following con- tent areas:

Manual 1. What Works in Therapy: A Primer

Manual 2. Feedback-Informed Clinical Work: The Basics

Manual 3. Feedback-Informed Supervision

Manual 4. Documenting Change: A Primer on Measurement, Analysis, and Reporting

Manual 5. Feedback-Informed Clinical Work: Specific Populations and Service Settings

Manual 6. Implementing Feedback-Informed Work in Agencies and Sys- tems of Care

The goal for the series is to provide practitioners with a thorough grounding in the knowledge and skills associated with outstanding clinical performance. These manuals are a useful resource for clinicians who want to learn to practice FIT. For more information about ICCE and the resources available, contact:

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 www.scottdmiller.com

Recommended Supplementary Readings Psychotherapy Integration (Stricker, 2010) is a concise presentation that deals with the theory, therapeu- tic process, evaluation, and future developments of integrative approaches.

The Human Element of Psychotherapy: A Nonmedi- cal Model of Emotional Healing (Elkins, 2016) devel- ops the thesis that psychotherapy is decidedly a

relational, not a medical, endeavor. This book sum- marizes research supporting the notion that the quality of the interpersonal connection between cli- ent and therapist is what determines effectiveness, not the therapist’s theory or techniques.

Handbook of Psychotherapy Integration (Norcross & Goldfried, 2005) is an excellent resource for

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460 CHAPTER FIFTEEN

conceptual and historical perspectives on therapy integration. This edited volume gives a comprehen- sive overview of the major current approaches, such as theoretical integration and technical eclecticism.

The Sage Encyclopedia of Theory in Counseling and Psychotherapy (Neukrug, 2015) is an comprehen- sive collection of short articles on the spectrum of approaches and techniques for counseling.

The Art of Integrative Counseling (Corey, 2013a) is designed to assist students in developing their own integrative approach to counseling. This book is complemented by the DVD for Integrative Counseling: The Case of Ruth and Lecturettes (Corey, 2013c).

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 final chapter. This book also is designed to fit well with the DVD for Inte- grative Counseling: The Case of Ruth and Lecturettes (Corey, 2013c).

Integrating Spirituality and Religion into Counseling: A Guide to Competent Practice (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.

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Part 1 Basic Issues in Counseling Practice American Counseling Association. (2014). ACA code of ethics. Alexandria, VA: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. American Psychological Association. (2010). Ethical principles of psychologists and code of conduct (2002, Amended June 1, 2010). Retrieved from http://www.apa .org/ethics/code/index.aspx. *American Psychological Association Presidential Task Force on Evidence- Based Practice. (2006). Evidence- based practice in psychology. American Psychologist, 61, 271–285. Arredondo, P., Toporek, R., Brown, S., Jones, J., Locke, D., Sanchez, J., & Stadler, H. (1996). Operationalization of multicultural counseling competencies. Journal of Multicultural Counseling and Development, 24(1), 42–78. *Barnett, J. E., & Johnson, W. B. (2008). Ethics desk reference for psychologists. Washington, DC: American Psychological Association. *Barnett, J. E., & Johnson, W. B. (2015). Ethics desk reference for counselors (2nd ed.). Alexandria, VA: American Counseling Association. *Chung, R. C-Y., & Bemak, F. (2012). Social justice counseling: The next step beyond multiculturalism. Thousand Oaks, CA: Sage. Codes of Ethics for the Helping Professions (5th ed.). (2015). Boston, MA: Cengage Learning. *Corey, G. (2010). Creating your professional path: Lessons from my journey. Alexandria, VA: American Counseling Association. *Corey, G. (2013a). The art of integrative counseling (3rd ed.). Belmont, CA: Brooks/ Cole, Cengage Learning. *Corey, G. (2013b). Case approach to counseling and psychotherapy (8th ed.). Belmont, CA: Brooks/Cole, Cengage Learning. *Corey, G. (2013c). DVD for Theory and Practice of Counseling and Psychotherapy: The case of Stan and lecturettes. Belmont, CA: Brooks/Cole, Cengage Learning.

*Corey, G. (2017). Student manual for theory and practice of counseling and psychotherapy (10th ed.). Boston, MA: Cengage Learning. *Corey, G., & Corey, M. (2014). I never knew I had a choice (10th ed.). Belmont, CA: Cengage Learning. *Corey, G., Corey, M., Corey, C., & Callanan, P. (2015). Issues and ethics in the helping professions (9th ed.). Boston, MA: Cengage Learning. *Corey, G., Corey, M., & Haynes, R. (2015). Ethics in action: DVD and workbook (3rd ed.). Boston, MA: Cengage Learning. *Corey, G., & Haynes, R. (2013). DVD for integrative counseling: The case of Ruth and lecturettes. Belmont, CA: Cengage Learning. *Corey, M., & Corey, G. (2016). Becoming a helper (7th ed.). Boston, MA: Cengage Learning. Cukrowicz, K. C., White, B. A., Reitzel, L. R., Burns, A. B., Driscoll, K. A., Kemper, T. S., & Joiner, T. E. (2005). Improved treatment outcome associated with the shift to empirically supported treatments in a graduate training clinic. Professional Psychology: Research and Practice, 36(3), 330–337. *Dailey, S. F., Gill, C. S., Karl, S. L., & Minton, C. A. B. (2014). DSM-5 learning companion for counselors. Alexandria, VA: American Counseling Association. Deegear, J., & Lawson, D. M. (2003). The utility of empirically supported treatments. Professional Psychology: Research and Practice, 34(3), 271–277. *Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (Eds.). (2010). The heart and soul of change: Delivering what works in therapy (2nd ed.). Washington, DC: American Psychological Association. Edwards, J. A., Dattilio, F. M., & Bromley, D. B. (2004). Developing evidence-based practice: The role of case-based research. Professional Psychology: Research and Practice, 35(6), 589–597. *Elkins, D. N. (2009). Humanistic psychology: A clinical manifesto. Colorado Springs, CO: University of the Rockies Press. *Elkins, D. N. (2016). The human elements of psychotherapy: A nonmedical model of emotional healing. Washington, DC: American Psychological Association.

*Geller, J. D., Norcross, J. C., & Orlinsky, D. E. (Eds.). (2005a). The psychotherapist's own psychotherapy: Patient and clinician perspectives. New York: Oxford University Press. *Geller, J. D., Norcross, J. C., & Orlinsky, D. E. (2005b). The question of personal therapy: Introduction and prospectus. In J. D. Geller, J. C. Norcross, & D. E. Orlinsky (Eds.), The psychotherapist's own psychotherapy: Patient and clinician perspectives (pp. 3–11). New York: Oxford University Press. Gold, S. H., & Hilsenroth, M. J. (2009). Effects of graduate clinicians' personal therapy on therapeutic alliance. Clinical Psychology and Psychotherapy, 16(3), 159–171. Gutheil, T. G., & Brodsky, A. (2008). Preventing boundary violations in clinical practice. New York: Guilford Press. *Herlihy, B., & Corey, G. (2015a). ACA ethical standards casebook (7th ed.). Alexandria, VA: American Counseling Association. *Herlihy, B., & Corey, G. (2015b). Boundary issues in counseling: Multiple roles and responsibilities (3rd ed.). Alexandria, VA: American Counseling Association. Herlihy, B., & Corey, G. (2015c). Confidentiality. In B. Herlihy & G. Corey, ACA ethical standards casebook (7th ed., pp. 169–182). Alexandria, VA: American Counseling Association. Herlihy, B., & Corey, G. (2015d). Managing value conflicts. In B. Herlihy & G. Corey, ACA ethical standards casebook (7th ed., pp. 193–204). Alexandria, VA: American Counseling Association. Herlihy, B., Hermann, M. A., & Greden, L. R. (2014). Legal and ethical implications of using religious beliefs as the basis for refusing to counsel certain clients. Journal of Counseling & Development 92(2), 148–153. Jencius, M. (2015). Technology, social media, and online counseling. In B. Herlihy & G. Corey (Eds.), ACA ethical standards casebook (7th ed., pp. 245–258). Alexandria, VA: American Counseling Association.

References and Suggested Readings

461

*Books and articles marked with an asterisk are suggested for further study.

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Kaplan, D. M. (2014). Ethical implications of a critical legal case for the counseling profession: Ward v. Wilbanks. Journal of Counseling & Development 92(2), 142–146. Kaplan, D. M. (2016). Raising the bar: New concepts in the 2014 ACA code of ethics. In I. Marini & M. A. Stebnicki (Eds.), The Professional Counselor's Desk Reference (2nd ed., pp. 37–42). New York: Springer. Kocet, M. M., & Herlihy, B. J. (2014). Addressing value-based conflicts within the counseling relationship: A decision- making model. Journal of Counseling & Development, 92(2), 180–186. *Kottler, J. A., Englar-Carlson, M., & Carlson, J. (Eds.). (2013). Helping beyond the 50-minute hour: Therapists involved in meaningful social action. New York: Routledge (Taylor & Francis). *Knapp, S. J., & VandeCreek, L. (2006). Practical ethics for psychologists: A positive approach. Washington, DC: American Psychological Association. Lambert, M. J. (2011). Psychotherapy research and its achievements. In J. C. Norcross, G. R. Vandenbos, & D. K. Freedheim (Eds.), History of psychotherapy (2nd ed., pp. 299–332). Washington, DC: American Psychological Association. Lazarus, A. A., & Zur, O. (2002). Dual relationships and psychotherapy. New York: Springer. *Lee, C. C. (Ed.). (2013). Multicultural issues in counseling: New approaches to diversity (4th ed.). Alexandria, VA: American Counseling Association. Lee, C. C. (2015). Social justice and counseling across cultures. In B. Helihy & G. Corey, ACA ethical standards casebook (7th ed., pp. 155–168). Alexandria, VA: American Counseling Association. Lee, C. C., & Park, D. (2013). A conceptual framework for counseling across cultures. In C. C. Lee (Ed.), Multicultural issues in counseling: New approaches to diversity (4th ed., pp. 3–12). Alexandria, VA: American Counseling Association. *Nagy, T. F. (2011). Essential ethics for psychologists: A primer for understanding and mastering core issues. Washington, DC: American Psychological Association. *Norcross, J. C. (2005). The psychotherapist's own psychotherapy: Educating and developing psychologists. American Psychologist, 60(8), 840–850. *Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work: Evidence-based

responsiveness (2nd ed.). New York: Oxford University Press. Norcross, J. C., Beutler, L. E., & Levant, R. F. (2006). Evidence-based practices in mental health: Debate and dialogue on the fundamental questions. Washington, DC: American Psychological Association. *Norcross, J. C., & Guy, J. D. (2007). Leaving it at the office: A guide to psychotherapist self-care. New York: Guilford Press. *Norcross, J. C., Hogan, T. P., & Koocher, G. P. (2008). Clinician's guide to evidence-based practices. New York: Oxford University Press. Norcross, J. C., & Lambert, M. J. (2011). Evidence-based therapy relationships. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed., pp. 3–21). New York: Oxford University Press. Norcross, J. C., & Wampold, B. E. (2011). Evidence-based therapy relationships: Research conclusions and clinical practices. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed., pp. 423–430). New York: Oxford University Press. Orlinsky, D. E., Norcross, J. C., Ronnestad, M. H., & Wiseman, H. (2005). Outcomes and impacts of the psychotherapists' own psychotherapy. In J. D. Geller, J. C. Norcross, & D. E. Orlinsky (Eds.), The psychotherapist's own psychotherapy: Patient and clinician perspectives (pp. 214–230). New York: Oxford University Press. Ratts, M. J., & Pedersen, P. B. (2014). Counseling for multiculturalism and social justice: Integration, theory, and application. Alexandria, VA: American Counseling Association. *Remley, T. P., & Herlihy, B. (2016). Ethical, legal, and professional issues in counseling (5th ed.). Upper Saddle River, NJ: Merrill/Prentice-Hall. *Schank, J. A., & Skovholt, T. M. (2006). Ethical practice in small communities: Challenges and rewards for psychologists. Washington, DC: American Psychological Association. *Skovholt, T. M., & Jennings, L. (2004). Master therapists: Exploring expertise in therapy and counseling. Boston: Pearson Education. *Sperry, L., & Carlson, J. (2011). How master therapists work: Exploring change from the first through the last session and beyond. New York: Routledge (Taylor & Francis).

Spotts-De Lazzer, A. (2012). Facebook for therapists: Friend or unfriend? The Therapist, 24(5), 19–23. *Stebnicki, M. A. (2008). Empathy fatigue: Healing the mind, body, and spirit of professional counselors. New York: Springer. Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards. A call to the profession. Journal of Counseling and Development, 70(4), 477–486. *Sue, D. W., & Sue, D. (2013). Counseling the culturally diverse: Theory and practice (6th ed.). New York: Wiley. Van Brunt, B. (2015). Harm to others: The assessment and treatment of dangerousness. Alexandria, VA: American Counseling Association. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Hillsdale, NJ: Erlbaum. *Wheeler, N., & Bertram, B. (2015). The counselor and the law: A guide to legal and ethical practice (7th ed.). Alexandria, VA: American Counseling Association. *Yalom, I. D. (1997). Lying on the couch: A novel. New York: Perennial. *Yalom, I. D. (2003). The gift of therapy: An open letter to a new generation of therapists and their patients. New York: HarperCollins (Perennial). *Zur, O. (2007). Boundaries in psychotherapy: Ethical and clinical explorations. Washington, DC: American Psychological Association.

Chapter 4 Psychoanalytic Therapy Barber, J. P., Muran, J. C., McCarthy, K. S., & Keefe, J. R. (2013). Research on dynamic therapies. In M. J. Lambert (Ed.), Bergin and Garfield's handbook of psychotherapy and behavior change (6th ed., pp. 443–494). Hoboken, NJ: Wiley. Clarkin, J., Yeomans, F., & Kernberg, O. (2006). Psychotherapy for borderline personality: Focusing on object relations. Washington DC: Psychiatric Press. *Corey, G. (2013). Case approach to counseling and psychotherapy (8th ed.). Belmont, CA: Brooks/Cole, Cengage Learning. Corey, G. (2016). Theory and practice of group counseling (9th ed.). Boston, MA: Cengage Learning. *Curtis, R. C., & Hirsch, I. (2011). Relational psychoanalytic psychotherapy. In S. B. Messer & A. S. Gurman (Eds.), Essential psychotherapies: Theory and practice (3rd ed., pp. 72–104). New York: Guilford Press.

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Enns, C. Z. (1993). Twenty years of feminist counseling and therapy: From naming biases to implementing multifaceted practice. The Counseling Psychologist, 21(1), 3–87. *Erikson, E. H. (1963). Childhood and society (2nd ed.). New York: Norton. Freud, S. (1949). An outline of psychoanalysis. New York: Norton. *Freud, S. (1955). The interpretation of dreams. London: Hogarth Press. *Gabbard, G. (2005). Psychodynamic psychiatry in clinical practice (4th ed.). Washington, DC: American Psychiatric Press. *Harris, A. S. (1996). Living with paradox: An introduction to Jungian psychology. Belmont, CA: Brooks/Cole, Cengage Learning. Hayes, J. A. (2004). Therapist know thyself: Recent research on counter- transference. Psychotherapy Bulletin, 39(4), 6–12. Hayes, J. A., Gelso, C. J., & Hummel, A. M. (2011). Management of countertransference. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed., pp. 239–258). New York: Oxford University Press. *Hedges, L. E. (1983). Listening perspectives in psychotherapy. New York: Aronson. *Jung, C. G. (1961). Memories, dreams, reflections. New York: Vintage. Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. New York: Aronson. Kernberg, O. F. (1976). Object-relations theory and clinical psychoanalysis. New York: Aronson. Kernberg, O. F. (1997). Convergences and divergences in contemporary psychoanalytic technique and psychoanalytic psychotherapy. In J. K. Zeig (Ed.), The evolution of psychotherapy: The third conference (pp. 3–22). New York: Brunner/Mazel. Kernberg, O. F., Yeomans, F. E., Clarkin, J. F., & Levy, K. N. (2008). Transference focused psychotherapy: Overview and update. International Journal of Psychoanalysis, 89, 601–620. Klein, M. (1975). The psychoanalysis of children. New York: Dell. Kohut, H. (1971). The analysis of self. New York: International Universities Press. Kohut, H. (1977). Restoration of the self. New York: International Universities Press.

Kohut, H. (1984). How does psychoanalysis cure? Chicago: University of Chicago Press. Levenson, H. (2010). Brief dynamic therapy. Washington, DC: American Psychological Association. Linehan, M. M. (1993a). Cognitive- behavioral treatment of borderline personality disorder. New York: Guilford Press. Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder. New York: Guilford Press. Linehan, M. M. (2015). DBT skills training manual (2nd ed.). New York: Guilford Press. *Luborsky, E. B., O'Reilly-Landry, M., & Arlow, J. A. (2011). Psychoanalysis. In R. J. Corsini & D. Wedding (Eds.), Current psychotherapies (9th ed., pp. 15–66). Belmont, CA: Brooks/Cole, Cengage Learning. Mahler, M. S. (1968). On human symbiosis or the vicissitudes of individuation. New York: International Universities Press. Masterson, J. F. (1976). Psychotherapy of the borderline adult: A developmental approach. New York: Brunner/Mazel. *McWilliams, N. (2014). Psychodynamic therapy. In L. S. Greenberg, N. McWilliams, & A. Wenzel, Exploring three approaches to psychotherapy (pp. 71–127). Washington, DC: American Psychological Association. McWilliams, N. (2016). Psychoanalysis. In I. Marini & M. A. Stebnicki (Eds.), The professional counselor's desk reference (2nd ed., pp. 183–190). New York: Springer. Messer, S. B., & Gurman, A. S. (2011). Essential psychotherapies: Theory and practice (3rd ed.). New York: Guilford Press. Messer, S. B., & Warren, C. S. (2001). Brief psychodynamic therapy. In R. J. Corsini (Ed.), Handbook of innovative therapies (2nd ed., pp. 67–85). New York: Wiley. Mitchell, S. A. (1988). Relational concepts in psychoanalysis: An integration. Cambridge, MA: Harvard University Press. *Mitchell, S. A. (2000). Relationality: From attachment to intersubjectivity. Hillsdale, NJ: Analytic Press. Mitchell, S. A., & Black, M. J. (1995). Freud and beyond: A history of modern psychoanalytic thought. New York: Basic Books. Prochaska, J. O., & Norcross, J. C. (2014). Systems of psychotherapy: A transtheoretical analysis (8th ed.). San Francisco, CA: Cengage Learning. *Rutan, J. S., Stone, W. N., & Shay, J. J. (2014). Psychodynamic group psychotherapy (5th ed.). New York: Guilford Press.

*Safran, J. D., & Kriss, A. (2014). Psychoanalytic psychotherapies. In D. Wedding & R. J. Corsini (Eds.), Current psychotherapies (10th ed., pp. 19–54). Belmont, CA: Brooks/Cole, Cengage Learning. Schore, A. N. (2012). The science of the art of psychotherapy. New York: Norton. Schore, A. N. (2014). The right brain is dominant in psychotherapy. Psychotherapy, 51, 388–397. *Schultz, D. P., & Schultz, S. E. (2013). Theories of personality (10th ed.). San Francisco, CA: Wadsworth, Cengage Learning. Sharf, R. S. (2016). Theories of psychotherapy and counseling: Concepts and cases (6th ed.). Boston, MA: Cengage Learning. *St. Clair, M. (with Wigren, J.). (2004). Object relations and self psychology: An introduction (4th ed.). Belmont, CA: Brooks/Cole, Cengage Learning. Stern, D. N. (1985). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. New York: Basic Books. Strupp, H. H. (1992). The future of psychodynamic psychotherapy. Psychotherapy, 29(l), 21–27. Wolitzky, D. L. (2011a). Contemporary Freudian psychoanalytic psychotherapy. In S. B. Messer & A. S. Gurman (Eds.), Essential psychotherapies: Theory and practice (3rd ed., pp. 33–71). New York: Guilford Press. Wolitzky, D. L. (2011b). Psychoanalytic theories in psychotherapy. In J. C. Norcross, G. R. Vandenbos, & D. K. Freedheim (Eds.), History of psychotherapy (2nd ed., pp. 65–100). Washington, DC: American Psychological Association. Yalom, I. D. (2003). The gift of therapy: An open letter to a new generation of therapists and their patients. New York: HarperCollins (Perennial).

Chapter 5 Adlerian Therapy Adler, A. (1958). What life should mean to you. New York: Capricorn. (Original work published 1931) Adler, A. (1959). Understanding human nature. New York: Premier Books. (Original work published 1927) Adler, A. (1964). Social interest. A challenge to mankind. New York: Capricorn. (Original work published 1938)

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Chapter 8 Gestalt Therapy *Barber, P. (2006). Becoming a practitioner researcher: A Gestalt approach to holistic inquiry. London: Middlesex University Press. Beisser, A. R. (1970). The paradoxical theory of change. In J. Fagan & I. L. Shepherd (Eds.), Gestalt therapy now (pp. 77–80). New York: Harper & Row (Colophon). *Bowman, C. (2005). The history and development of Gestalt therapy. In A. Woldt & S. Toman (Eds.), Gestalt therapy: History, theory, and practice (pp. 3–20). Thousand Oaks, CA: Sage. Breshgold, E. (1989). Resistance in Gestalt therapy: An historical theoretical perspective. The Gestalt Journal, 12(2), 73–102. *Brown, J. R. (2007). Gestalt therapy. In A. B. Rochlen (Ed.), Applying counseling theories: An online case-based approach (pp. 127–141). Upper Saddle River, NJ: Pearson Prentice-Hall. *Brownell, P. (2008). Handbook for theory, research and practice in Gestalt therapy. Newcastle, UK: Cambridge Scholar Publishing. Brownell, P. (2016). Gestalt therapy. In I. Marini & M. A. Stebnicki (Eds.), The professional counselor's desk reference (2nd ed., pp. 241–245). New York: Springer. Clarkson, P., & Mackewn, J. (1993). Fritz Perls. Newbury Park, CA: Sage. Conyne, R. K. (2015). Gestalt group therapy. In E. Neukrug (Ed.), The Sage encyclopedia of theory in counseling and

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*Latner, J. (1986). The Gestalt therapy book. Highland, NY: Center for Gestalt Development. Levitsky, A., & Perls, F. (1970). The rules and games of Gestalt therapy. In J. Fagan & I. Shepherd (Eds.), Gestalt therapy now (pp. 140–149). New York: Harper & Row (Colophon). Maurer, R. (2005). Gestalt approaches with organizations and large systems. In A. Woldt & S. Toman (Eds.), Gestalt therapy: History, theory, and practice. (pp. 237–256). Thousand Oaks, CA: Sage. Melnick, J., & Nevis, S. (2005). Gestalt therapy methodology. In A. Woldt & S. Toman (Eds.), Gestalt therapy: History, theory, and practice. (pp. 101–116). Thousand Oaks, CA: Sage. Passons, W. R. (1975). Gestalt approaches in counseling. New York: Holt, Rinehart & Winston. *Perls, F. (1969a). Gestalt therapy verbatim. Moab, UT: Real People Press. Perls, F. (1969b). In and out of the garbage pail. Moab, UT: Real People Press. Perls, F., Hefferline, R., & Goodman, R. (1951). Gestalt therapy: Excitement and growth in the human personality. New York: Dell. Perls, L. (1976). Comments on new directions. In E. W. L. Smith (Ed.), The growing edge of Gestalt therapy (pp. 221– 226). New York: Brunner/Mazel. Polster, E. (1987a). Escape from the present: Transition and storyline. In J. K. Zeig (Ed.), The evolution of psychotherapy (pp. 326–340). New York: Brunner/Mazel. *Polster, E. (1987b). Every person's life is worth a novel: How to cut through emotional pain and discover the fascinating core of life. New York: Norton. *Polster, E. (1995). A population of selves: A therapeutic exploration of personality diversity. San Francisco: Jossey-Bass. Polster, E. (2006). Uncommon ground. Phoenix, AZ: Zeig, Tucker, and Theissen. *Polster, E., & Polster, M. (1973). Gestalt therapy integrated: Contours of theory and practice. New York: Brunner/Mazel. Polster, E., & Polster, M. (1976). Therapy without resistance: Gestalt therapy. In A. Burton (Ed.), What makes behavior change possible? (pp. 259–277). New York: Brunner/Mazel. *Polster, E., & Polster, M. (1999). From the radical center: The heart of Gestalt therapy. Cambridge, MA: Gestalt Institute of Cleveland Press.

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on the same team? Los Angeles, CA: Pacific Gestalt Institute. Zahm, S. (1998). Therapist self-disclosure in the practice of Gestalt therapy. The Gestalt Journal, 21, 21–52. *Zinker, J. (1978). Creative process in Gestalt therapy. New York: Random House (Vintage).

Chapter 9 Behavior Therapy *Alberti, R. E., & Emmons, M. L. (2008). Your perfect right: A guide to assertive behavior (9th ed.). Atascadero, CA: Impact. Antony, M. M. (2014). Behavior therapy. In D. Wedding & R. J. Corsini (Eds.), Current psychotherapies (10th ed., pp. 193– 229). Belmont, CA: Brooks/Cole, Cengage Learning. *Antony, M. M., & Roemer, L. (2011a). Behavior therapy. Washington, DC: American Psychological Association. Antony, M. M., & Roemer, L. (2011b). Behavior therapy: Traditional approaches. In S. B. Messer & A. S. Gurman (Eds.), Essential psychotherapies: Theory and practice (3rd ed., pp. 107–142). New York: Guilford Press. Bandura, A. (1969). Principles of behavior modification. New York: Holt, Rinehart & Winston. Bandura, A. (Ed.). (1971a). Psychological modeling: Conflicting theories. Chicago: Aldine-Atherton. Bandura, A. (1971b). Psychotherapy based upon modeling principles. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change. New York: Wiley. Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall. Bandura, A. (1982). Self-efficacy mechanisms in human agency. American Psychologist, 37, 122–147. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall. *Bandura, A. (1997). Self-efficacy: The exercise of self-control. New York: Freeman. Bandura, A., & Walters, R. H. (1963). Social learning and personality development. New York: Holt, Rinehart & Winston. Batten, S. V., & Ciarrochi, J. V. (2015). Acceptance and commitment therapy. In E. Neukrug (Ed.), The Sage encyclopedia of theory in counseling and psychotherapy, (Vol. 1, pp. 7–10). Thousand Oaks, CA: Sage.

*Beck, A. T. (1976). Cognitive therapy and emotional disorders. New York: New American Library. *Beck, A. T., & Weishaar, M. E. (2014). Cognitive therapy. In D. Wedding & R. J. Corsini (Eds.), Current psychotherapies (10th ed., pp. 231–264). Belmont, CA: Brooks/ Cole, Cengage Learning. *Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). New York: Guilford Press. *Corey, G. (2013). Case approach to counseling and psychotherapy (8th ed.). Belmont, CA: Brooks/Cole, Cengage Learning. *Corey, G. (2016). Theory and practice of group counseling (9th ed.). Boston, MA: Cengage Learning. *Corey, G. (2017). Student manual for theory and practice of counseling and psychotherapy (10th ed.). Boston, MA: Cengage Learning. *Cormier, S., Nurius, P. S., & Osborn, C. (2013). Interviewing and change strategies for helpers (7th ed.). Belmont, CA: Brooks/ Cole, Cengage Learning. Dimidjian, S., & Linehan, M. M. (2008). Mindfulness practice. In W. O'Donohue & J. E. Fisher (Eds.), Cognitive behavior therapy: Applying empirically supported techniques in your practice (2nd ed., pp. 327– 336). Hoboken, NJ: Wiley. Dobson, K. S. (2012). Cognitive therapy. Washington, DC: American Psychological Association. Ferguson, K. E., & Sgambati, R. E. (2008). Relaxation. In W. O'Donohue & J. E. Fisher (Eds.), Cognitive behavior therapy: Applying empirically supported techniques in your practice (2nd ed., pp. 434–444). Hoboken, NJ: Wiley. *Fishman, D. B., Rego, S. A., & Muller, K. L. (2011). Behavioral theories in psychotherapy. In J. C. Norcross, G. R. Vandenbos, & D. K. Freedheim (Eds.), History of psychotherapy (2nd ed., pp. 101–140). Washington, DC: American Psychological Association. Follette, W. C., & Callaghan, G. M. (2011). Behavior therapy: Functional- contextual approaches. In S. B. Messer & A. S. Gurman, (Eds.), Essential psychotherapies: Theory and practice (3rd ed., pp.184–220). New York: Guilford Press. Germer, C. K. (2012). Cultivating compassion in psychotherapy. In C. K. Germer & R. D. Siegel (Eds.), Wisdom and compassion in psychotherapy: Deepening mindfulness in clinical practice (pp. 93–110). New York: Guilford Press.

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*Leahy, R. L. (Ed.). (2006b). Roadblocks in cognitive-behavioral therapy. New York: Guilford Press. *Ledley, D. R., Marx, B. P., & Heimberg, R. G. (2010). Making cognitive-behavioral therapy work: Clinical processes for new practitioners (2nd ed.). New York: Guilford Press. Lopez, S. J., & Snyder, C. R. (Eds.). (2011). The Oxford handbook of positive psychology. New York: Oxford University Press. Marlatt, G., & Donovan, D. M. (Eds.). (2005). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors (2nd ed.). New York: Guilford Press. *Meichenbaum, D. (1977). Cognitive behavior modification: An integrative approach. New York: Plenum Press. *Meichenbaum, D. (1985). Stress inoculation training. New York: Pergamon Press. Meichenbaum, D. (1986). Cognitive behavior modification. In F. H. Kanfer & A. P. Goldstein (Eds.), Helping people change: A textbook of methods (pp. 346–380). New York: Pergamon Press. Meichenbaum, D. (1993). Stress inoculation training: A 20 year update. In P. M. Lehrer & R. L. Woolfolk (Eds.), Principles and practice of stress management (2nd ed., pp. 373–406). New York: Guilford Press. Meichenbaum, D. (1994a). A clinical handbook/practical therapist manual: For assessing and treating adults with post- traumatic stress disorder (PTSD). Waterloo, Ontario, Canada: Institute Press. Meichenbaum, D. (1994b). Treating adults with PTSD. Clearwater, FL: Institute Press. Meichenbaum, D. (1997). The evolution of a cognitive-behavior therapist. In J. K. Zeig (Ed.), The evolution of psychotherapy: The third conference (pp. 96–104). New York: Brunner/Mazel. Meichenbaum, D. (2002). Treatment of individuals with anger-control problems and aggressive behaviors: A clinical handbook. Clearwater, FL: Institute Press. Meichenbaum, D. (2007). Stress inoculation training: A preventive and treatment approach. In P. M. Lehrer, R. L. Woolfolk, & W. Sime (Eds.), Principles and practices of stress management (3rd ed., pp. 497–518). New York: Guilford Press. *Meichenbaum, D. (2008). Stress inoculation training. In W. O'Donohue & J. E. Fisher (Eds.), Cognitive behavior therapy:

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Chapter 11 Choice Theory/Reality Therapy American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. *Corey, G. (2013). Case approach to counseling and psychotherapy (8th ed.). Belmont, CA: Brooks/Cole, Cengage Learning. Corey, G. (2016). Theory and practice of group counseling (9th ed.). Boston, MA: Cengage Learning. Gerdes, P., Wubbolding, S., & Wubbolding, R. (2012). Expanding the practical use of the perceptual system. International Journal of Choice Theory and Reality Therapy, 32(1), 16–19. Glasser, W. (1965). Reality therapy: A new approach to psychiatry. New York: Harper & Row. Glasser, W. (1968). Schools without failure. New York: Harper & Row. Glasser, W. (1992). Reality therapy. New York State Journal for Counseling and Development, 7(l), 5–13.

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language of change (pp. 324–344). New York: Guilford Press. *Anderson, H., & Goolishian, H. (1992). The client is the expert: A not- knowing approach to therapy. In S. McNamee & K. J. Gergen (Eds.), Therapy as social construction (pp. 25–39). Newbury Park, CA: Sage. Bateson, G. (1972). Steps to an ecology of mind. New York: Ballantine. Berg, I. K. (1994). Family based services: A solution-focused approach. New York: Norton. Berg, I. K., & Miller, S. D. (1992). Working with the problem drinker: A solution- focused approach. New York: Norton. *Bertolino, B., & O'Hanlon, B. (2002). Collaborative, competency-based counseling and therapy. Boston: Allyn & Bacon. *Brown, L. S. (2010). Feminist therapy. Washington, DC: American Psychological Association. Bubenzer, D. L., & West, J. D. (1993). William Hudson O'Hanlon: On seeking possibilities and solutions in therapy. The Family Journal: Counseling and Therapy for Couples and Families, 1(4), 365–379. Corey, G. (2013). Case approach to counseling and psychotherapy (8th ed.). Belmont, CA: Brooks/Cole, Cengage Learning. Corey, G. (2016). Theory and practice of group counseling (9th ed.). Boston, MA: Cengage Learning. *De Jong, P., & Berg, I. K. (2013). Interviewing for solutions (4th ed.). Belmont, CA: Brooks/Cole, Cengage Learning. *De Shazer, S. (1985). Keys to solutions in brief therapy. New York: Norton. *De Shazer, S. (1988). Clues: Investigating solutions in brief therapy. New York: Norton. *De Shazer, S. (1991). Putting difference to work. New York: Norton. *De Shazer, S. (1994). Words were originally magic. New York: Norton. De Shazer, S., & Berg, I. (1988). Doing therapy: A post-structural revision. Journal of Marital and Family Therapy, 18, 71–81. *De Shazer, S., & Dolan, Y. M. (with Korman, H., Trepper, T., McCullom, E., & Berg, I. K.). (2007). More than miracles: The state of the art of solution-focused brief therapy. New York: Haworth Press. Drewery, W., & Winslade, J. (1997). The theoretical story of narrative therapy. In G. Monk, J. Winslade, K. Crocket, & D. Epston (Eds.), Narrative therapy in practice:

The archaeology of hope (pp. 32–52). San Francisco: Jossey-Bass. Epston, D., & White, M. (1992). Consulting your consultants: The documentation of alternative knowledges. In Experience, contradiction, narrative and imagination: Selected papers of David Epston and Michael White, 1989–1991 (pp. 11–26). Adelaide, South Australia: Dulwich Centre. Franklin, C., Trepper, T. S., Gingerich, W. J., & McCollum, E. E. (Eds.). (2012). Solution-focused brief therapy: Research, practice, and training. New York: Oxford University Press. *Freedman, J., & Combs, G. (1996). Narrative therapy: The social construction of preferred realities. New York: Norton. Freedman, J., Epston, D., & Lobovits, D. (1997). Playful approaches to serious problems: Narrative therapy with children and their families. New York: Norton. George, E., Iveson, C., & Ratner, H. (2015). Solution-focused brief therapy. In E. Neukrug (Ed.), The Sage encyclopedia of theory in counseling and psychotherapy, (Vol. 2, pp. 946–950). Thousand Oaks, CA: Sage. Gergen, K. (1985). The social constructionist movement in modern psychology. American Psychologist, 40, 266–275. Gergen, K. (1991). The saturated self. New York: Basic Books. Gergen, K. (1999). An invitation to social construction. Thousand Oaks, CA: Sage. *Gingerich, W. J., & Peterson, L. T. (2013). Effectiveness of solution-focused brief therapy: A systematic qualitative review of controlled outcome studies. Research on Social Work Practice, 23(3), 266–283. *Guterman, J. T. (2013). Mastering the art of solution-focused counseling (2nd ed.). Alexandria, VA: American Counseling Association. Hoyt, M. F. (2009). Brief psychotherapies: Principles and practices. Phoenix, AZ: Zeig, Tucker & Theisen, Inc. Hoyt, M. F. (2011). Brief psychotherapies. In S. B. Messer & A. S. Gurman (Eds.), Essential psychotherapies: Theory and practice (3rd ed., pp. 387–425). New York: Guilford Press. Hoyt, M. F. (2015). Brief therapy. In E. Neukrug (Ed.), The Sage encyclopedia of theory in counseling and psychotherapy, (Vol. 1, pp. 144–147). Thousand Oaks, CA: Sage.

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Chapter 14 Family Systems Theory Adler, A. (1927). Understanding human nature (W. B. Wolfe, Trans.). New York: Fawcett. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Andersen, T. (1987). The reflecting team: Dialogue and metadialogue in clinical work. Family Process, 26(4), 415–428. *Andersen, T. (1991). The reflecting team: Dialogues and dialogues about the dialogues. New York: Norton. Anderson, H. (1993). On a roller coaster: A collaborative language system approach to therapy. In S. Friedman (Ed.), The new language of change (pp. 324–344). New York: Guilford Press. *Anderson, H., & Goolishian, H. (1992). The client is the expert: A not- knowing approach to therapy. In S. McNamee & K. J. Gergen (Eds.), Therapy as social construction (pp. 25–39). Newbury Park, CA: Sage. *Becvar, D. S., & Becvar, R. J. (2012). Family therapy: A systemic integration (8th ed.). Boston, MA: Allyn & Bacon (Pearson). Bitter, J. R. (2009). The mistaken notions of adults with children. Journal of Individual Psychology, 65(4), 135–155. *Bitter, J. R. (2014). Theory and practice of family therapy and counseling (2nd ed.). Belmont, CA: Brooks/Cole, Cengage Learning. Bitter, J. R., Roberts, A., & Sonstegard, M. A. (2002). Adlerian family therapy. In J. Carlson & D. Kjos (Eds.), Theories and strategies of family therapy (pp. 41–79). Boston: Allyn & Bacon. *Bowen, M. (1978). Family therapy in clinical practice. New York: Jason Aronson. *Breunlin, D. C., Schwartz, R. C., & Mackune-Karrer, B. (1997). Metaframeworks: Transcending the models of family therapy (Rev. ed.). San Francisco: Jossey-Bass.

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AN INTEGRATIVE PERSPECTIVE 481 Name Index

Adams, M., 137, 140, 145–146, 148 Adler, A., 6, 78, 96, 98, 101–103, 271, 406 Al-Rashidi, B., 328–329 American Counseling Association (ACA),

23, 49 American Counseling Association Code

of Ethics, 42, 49, 52 American Psychiatric Association, 46,

102, 405 American Psychological Association,

340 Andersen, T., 410 Anderson, C., 407, 416 Anderson, H., 369–370, 376, 410 Ansbacher, H., 98–103, 114, 125 Ansbacher, R., 99–103, 114 Antony, M., 233–234, 239, 248, 251 APA Presidential Task Force on

Evidence-Based Practice, 48 Arciniega, G., 119–120 Arkowitz, H., 182 Arlow, J., 67–70, 91–92 Arnkoff, D., 431 Arredondo, P., 26 Asnaani, A., 281, 287, 305 Austin, S., 174 Axelsson, L., 199–200, 210–211

Baldwin, M., 411 Bandura, A., 7, 232–235 Banmen, J., 408 Barber, J., 69 Barber, P., 225 Barnett, J., 44, 46 Bateson, G., 377, 386 Batten, S., 256 Beck, A., 7, 270, 280–282, 284–288 Beck, J., 7, 270, 280–281, 286–287 Becvar, D., 404 Becvar, R., 404 Beisser, A., 201 Bell, A., 428 Bemak, F., 44–45 Berg, I., 7, 369–370, 374, 377–379, 397 Bertram, B., 42–43 Bertolino, B., 369, 387, 391, 397 Beutler, L., 48, 428–430, 434, 442 Binswanger, L., 135 Bisono, A., 436 Bitter, J., 97, 100, 102, 108–109, 112,

114–116, 118–119, 125–126, 346, 348, 406, 408–410, 414, 423

Black, M., 82 Blau, S., 272

Blau, W., 73 Bohart, A., 165, 171, 173, 176–177,

185, 451 Borden, A., 381 Boscolo, L., 424 Boss, M., 135 Bowen, M., 7, 407 Bowman, C., 214 Bozarth, J., 165–167, 171, 177–178 Brabeck, K., 346, 348, 362 Brabeck, M., 346, 348, 362 Bracke, P., 158 Breshgold, E., 213, 224 Breunlin, D., 409, 415 Brickell, J., 322, 324, 328–329, 333 Brodsky, A., 52 Bromley, D., 48 Brooks, J., 185 Brown, J., 199, 201, 210 Brown, L., 7, 339, 341, 344, 348–349,

363, 369 Brown, S., 26 Brownell, P., 211–212, 225 Bubenzer, D., 375, 409 Buber, M., 135, 149 Bugental, J., 133–134, 136–137, 147, 149,

151, 158 Burns, A., 48 Butler, A., 286 Byars-Winston, A., 340, 345

Cain, D., 164–165, 169, 173–177, 185–186, 190–191

Cairrochi, J., 256 Callaghan, G., 236, 264 Callanan, P., 38, 40, 42–43 Cannon, K., 343 Carlson, J.D., 19–20, 96–97, 100–103,

106, 109, 114, 116, 119, 121, 125–126, 409

Carlson, J.M., 121 Carmichael, A., 405 Carter, B., 407 Cashwell, C., 436–437 Castaldo, J., 287 Cavasos, L., 185 Cecchin, F., 424 Chambless, D., 287 Chang, R., 258–259 Christensen, O., 108–109, 112, 406 Chung, R., 44–45 Clark, A., 102, 106, 111–112, 175 Clark, D., 288 Clarkin, J., 82

Clayton, X., 287 Clemmer, F., 102 Cole, E., 338–339 Cole, L., 126, 346 Comas-Diaz, L., 435 Combs, G., 382, 384, 386, 397 Comstock, D., 343 Conyne, R., 205, 214, 218–219 Cooper, M., 137, 159 Corbett, G., 182–183 Corey, C., 38, 40, 42–43 Corey, G., 13, 24, 34, 38–40, 42–43, 47,

49–50, 73, 77, 113, 119, 146, 150, 153, 177, 180, 211, 220, 239, 243, 250, 258, 275–276, 279, 289, 327, 346, 362, 380–381, 389, 429, 431

Corey, M., 38–40, 42–43, 146, 219 Cormier, S., 238, 243, 245, 250 Craske, M., 245–246 Crawford, T., 276 Crethar, H., 340, 354 Crocket, K., 382, 385 Cukrowicz, K., 48 Cummins, A., 287 Curtis, R., 69, 71, 73–75

Dailey, S., 47 Dattilio, F., 48, 158, 232, 235, 285–289,

307 Dean, L., 182 Deegear, J., 48 DeJong, P., 369–370, 374, 377–379, 397 Delaney, H., 436 de Shazer, S., 7, 369, 371–374, 376–378,

397 Deurzen, E., van, 133, 137, 140, 144–146,

148–153, 158–159 Dienes, K., 270, 286 DiGiuseppe, R., 263–264, 285, 304 Dimidjian, S., 253 Dinkmeyer, D., 100, 108, 116 DiPietro, R., 106, 111, 125 Disque, J., 116 Donovan, D., 296 Doolin, E., 175 Dreeben, S., 253–254 Dreikurs, R., 6, 98, 103, 105, 108–109,

118, 406, 414–415 Drewery, W., 386 Driscoll, K., 48 Dudley, R., 290 Duffey, T., 353 Duncan, B., 18, 178, 192, 397, 430, 442,

451–452

481

63727_Name Index_rev01.indd 481 21/09/15 3:52 PM

482 NAmE INdEx

Edwards, J., 48 Eldridge, N., 343 Elkins, D., 18–19, 149, 157, 164–167,

171, 190, 192, 430–431, 442, 451 Elliott, R., 176 Ellis, A., 7, 270–279, 304, 306 Ellis, D., 271–279, 304, 306–307 Emery, G., 282 Englar-Carlson, M., 106, 114, 119,

126, 353 Enns, C.Z., 7, 92, 338–341, 344–345,

348–349, 351, 353–354, 362 Epp, L., 153 Epstein, N., 287 Epston, D., 7, 369, 372, 381–382, 384,

387–389, 410 Eriksen, K., 348, 353 Erikson, E., 59, 64–66 Espin, O., 7, 338–339 Evans, K., 340, 344–346, 348–350,

352–353 Evans, M., 353 Evans, T., 114

Fang, A., 281, 287, 305 Farber, B., 175 Farha, B., 143 Fassinger, R., 339–340, 352 Feder, B., 220 Ferguson, K., 243 Fernbacher, S., 220 Fishman, D., 252 Fishman, H., 424 Fitzpatrick, S., 252–253 Follette, V., 250, 256 Follette, W., 236, 264 Forman, E., 250–251, 256 Frame, M., 436–437 Frankl, V., 6, 130, 140, 144 Franklin, C., 371 Freedman, J., 381–382, 384, 386, 397 Freeman, A., 270, 281, 285–287,

303–304, 307 Freeman, S., 303–304 Freiberg, H., 167 Freud, S., 6, 58–61, 64–66, 77–78 Frew, J., 202–203, 210–211, 213–214, 220 Fulton, P., 251, 256

Gamori, M., 408 Garcia-Preto, N., 407 Gavey, N., 348 Gelder, M., 288 Geller, J., 21–22 Gelso, C., 71–72 George, E., 375–376, 379 Gerber, J., 408 Gerdes, P., 322

Gergen, K., 368 Germer, C., 251, 254–256 Gerson, R., 407 Gill, C., 47 Gilligan, C., 339, 341–342 Gingerich, W., 371 Gladding, S., 409–410 Glass, C., 431 Glass, G., 450 Glasser, W., 7, 312–314, 317–318,

321, 333 Gold, S., 22 Goldenberg, H., 405, 423 Goldenberg, I., 405, 423 Goldfried, M., 428, 431 Goldman, R., 169, 171, 190, 206, 225 Goodman, R., 206 Goolishian, H., 369–370, 376, 410 Gottman, J., 411 Gould, W., 135 Granvold, D., 287 Greden, L., 23 Greenberg, L., 167–169, 171, 176, 190,

206, 430 Greenberger, D., 284, 286, 288–289 Griffith, J., 110 Gross, A., 244–245 Guterman, J., 373, 376, 378–379 Gutheil, T., 52 Guy, J., 34

Haberstroh, S., 353 Hackmann, A., 288 Haigh, E., 282, 284, 288 Haley, J., 424 Hammer, T., 343 Hanna, M., 286 Hanna, S., 409 Hardy, K., 416 Harper, R., 272–273 Harris, A., 79 Hawes, C., 108–109, 112 Hayes, J., 71–72 Hayes, S., 250–251, 255–256 Hays, D., 112 Hays, P., 298–299 Hazlett-Stevens, 245–246 Head, L., 244–245 Headley, J., 344, 348, 351 Healey, A., 126, 346 Hedges, L., 80–82 Hefferline, R., 206 Heidegger, M., 134–135 Heimberg, R., 263, 277, 279 Henry, J., 248–249, 256–257 Herbert, 250–251, 256 Herlihy, B., 23–24, 39, 42–43, 46, 49–50,

352–353, 362

Hermann, M., 23 Higginbotham, H., 258–259 Hilsenroth, M., 22 Hirsch, I., 69, 71, 73–75 Hoffman, E., 96 Hoffmann, S., 281, 287, 305 Hogan, T., 48–49, 192 Hollon, S., 263–264, 284–285, 287,

304 Horney, K., 271 Houts, A., 251, 255 Hoyt, M., 125, 372–374, 397, 434 Hubble, M., 18, 178, 192, 397, 430–431,

450–451 Hummel, A., 71–72

Imhof, L., 328–329 Ingram, R., 305 Iveson, C., 375–376, 379

Jacobs, L., 199, 206, 210, 214, 219, 224, 226

Jacobs, N., 277 Jacobson, E., 242 Jencius, M., 42, 52 Jennings, L., 19–20 Johnson, J., 100–103, 116, 126, 153 Johnson, R., 436–437 Johnson, W., 44, 46 Joiner, T., 48 Jones, J., 26 Jordan, J., 338, 343 Josselson, R., 138, 144, 146, 148–149,

152 Jung, C., 59, 77–79

Kabat-Zinn, J., 251, 253–254, 262 Kaplan, A., 338, 343 Karl, S., 47 Karpiak, C., 429 Kaschak, E., 342 Kazantzis, N., 287 Keefe, J., 69 Kefir, N., 102 Kemper, T., 48 Kendall, P., 287 Kernberg, O., 81–82 Kerr, M., 407 Kersh, B., 185 Kierkegaard, S., 134 Kim, R., 328–329 Kincade, E., 346, 349, 352–353 King, A., 339 Kirksey, K., 13, 87, 122, 156, 187, 223,

260, 302, 331, 357, 394, 455 Kirschenbaum, H., 164–165, 191 Klein, M., 81, 174 Knapp, S., 38

63727_Name Index_rev01.indd 482 21/09/15 3:52 PM

NAmE INdEx 483

Kocet, M., 23 Kohut, H., 80, 82 Kolden, G., 174 Koocher, G., 48–49, 192 Kress, V., 248–249, 256–257, 348, 353 Kriss, A., 75 Krug, O., 137, 139, 147, 153, 158, 169 Kuo, J., 252–253 Kuyken, W., 290

Lambert, M., 18, 430, 434, 451 Lambert, S., 405 Latner, J., 202 Lawson, D., 48 Lazarus, A., 250, 429 Lazarus, C., 250 Leahy, R., 287, 305 Ledley, D., 263, 277, 279 Lee, C., 44 Lee, M., 397 Leszez, M., 152 Levant, R., 48 Levensky, E., 185 Levenson, H., 83–84 Levitsky, A., 214 Levy, K., 82 Lewis, J., 409 Lichtanski, K., 139–140, 145 Linehan, M., 92, 250–253, 256 Lipchik, E., 398 Lisiecki, J., 116 Lister, K., 429 Lobovits, D., 381 Locke, D., 26 Lojk, L.,328–329 Lopez, S., 290 Luborsky, E., 67–70, 91–92 Ludgate, J., 288 Luepnitz, D., 410

Mackune-Karrer, B., 409, 415 Madigan, S., 386, 389, 391 Mahler, M., 81 Maisel, R., 381 Maniacci, M., 96, 105–106, 109, 116, 119,

125–126 Marbley, A., 346 Marecek, J., 348 Marlatt, G., 296 Martell, C., 237 Marx, B., 263, 277, 279 Maslow, A., 169, 171 Masterson, J., 82 Maurer, R., 213 May, R., 6, 131, 135, 142, 146, 148 McCarthy, K., 69 McCollum, E., 371 McCollum, V., 352–353

McDavis, R., 26 McDonald, A., 168 McElwain, B., 159 McGoldrick, M., 407, 416 McKenzie, W., 382, 387–390, 398 McWilliams, N., 59, 64, 67, 69, 71, 75,

79–80, 84, 91 Meichenbaum, D., 7, 270, 292–297, 305,

307 Melnick, J., 210–211 Messer, S., 83 Metcalf, L., 372, 380 Miller, J.B., 7, 338, 341, 343 Miller, M., 340, 344–345, 348–350, 352 Miller, S., 18, 178, 192, 397, 430–431,

450–452 Miller, T., 450 Miller, W., 182–183, 240, 436 Milliren, A., 102, 114 Miltenberger, R., 233, 239, 241–242 Minton, C., 47 Minuchin, S., 408, 424 Mitchell, S., 80, 82 Mooney, K., 289–291, 305, 307 Monk, G., 382–385–390, 397–398 Morgan, S., 254–255 Morgan, W., 254–255 Mosak, H., 105–106, 110–111, 125–126 Mozdzierz, G., 116 Muller, K., 252 Muran, J., 69 Murphy, J., 371–372, 375–377, 379–381,

398

Nagy, T., 42–43, 51 Nash, S., 340, 354 Neff, K., 254 Neukrug, E., 369, 371, 429, 434 Nevis, S., 210–211 Newbauer, J., 14 Newlon, B., 119–120 Newman, C., 287 Nichols, M., 409, 423 Nicoll, W., 108–109, 112, 114–115, 125 Nietzsche, F., 134 Niles, B., 251 Norcross, J., 18–22, 34, 48–49, 83, 176,

184, 192, 247, 264, 375, 428–431, 434, 442, 450

Nurius, P., 238, 243, 245, 250 Nutt, R., 338 Nylund, D., 390

O’Hanlon, W., 369 372, 375, 378, 383, 386–387, 391, 397

O’Reilly–Landry, M., 67–70, 91–92 Orlinsky, D., 21–22 Osborn, C., 238, 243, 245, 250

Pachankis, J., 428 Padesky, C., 7, 270, 280–281, 284,

286–291, 305, 307 Parsons, J., 343 Paul, G., 237 Peller, J., 373, 397 Peluso, P., 116 Perls, F., 7, 200, 206, 214, 217 Perls, L., 7, 210 Peterman, M., 287 Petry, S., 407 Pew, W., 98 Pfund, R., 429, 434 Pietrefesa, A., 251 Plummer, D., 220 Polster, E., 7, 198, 202, 204–205, 208–210,

212–213 Polster, M., 7, 198, 202, 204–205, 209–210,

212–213 Potter, C., 251 Powers, R., 110 Prata, G., 424 Pretzer, J., 287 Prochaska, J., 83, 184, 247, 264, 375,

429–430, 434, 450 Psychotherapy Networker, 429 Pusateri, C., 344, 348, 351

Raskin, N., 166 Ratner, H., 375–376, 379 Rego, S., 252 Reinecke, M., 270, 286–287 Reitzel, L., 48 Remer, P., 341, 344–351, 353–355, 363 Remley, T., 42–43, 46 Resnick, R., 199, 210, 214, 224 Rice, J., 338 Rice, R., 382, 385 Riskind, J., 287 Roberts, A., 406 Robertson, P., 126, 346 Robins, C., 252–253 Roemer, L., 233, 248, 251 Rogers, C., 7, 164–167, 170–171, 173,

175, 179–181, 185, 410 Rogers, N., 7, 164, 178–181, 191, 339 Rollnick, S., 182–183, 240 Ronnestad, M. 21 Rosenthal, M., 252–253 Rothblum, E., 338–339 Ruben, S., 139–140, 145 Rush, A., 282 Russell, D., 164–165 Russell, J., 136, 139–140, 147, 150, 159 Rutan, J., 70–71, 76–77, 79

Sackett-Maniacci, L., 105, 126 Safran, J., 75

63727_Name Index_rev01.indd 483 21/09/15 3:52 PM

484 NAmE INdEx

Salazar, G., 343 Salkovskis, P., 288 Salmon, P., 253–254 Sanchez, J., 26 Sartre, J., 136, 139 Satir, V., 7, 407–408, 410–411, 414 Sauer, A., 270, 286 Sawyer, A., 281, 287, 305 Scher, C., 305 Schmertz, S., 251 Schneider, K., 137, 139, 147, 149, 151,

153–154, 158, 169 Schore, A., 69 Schultz, D., 77–78, 99 Schultz, S., 77–78, 99 Schulz, F., 200–202, 209, 211–214 Schwartz, R., 409, 415 Sebold, J., 397 Seem, S., 346, 349, 352–353 Seeman, J., 165 Segal, Z., 251, 254–255, 305, 430 Segrin, C., 248 Seidel, J., 431, 450–451 Selvini Palazzolli, M., 424 Sephton, S., 253–254 Sgambati, R., 243 Shapiro, F., 247 Sharf, R., 84, 159 Sharp, J., 133–134, 151 Shaw, B., 282 Shay, J., 70–71, 76–77, 79 Sherman, R., 100 Shulman, B., 110 Siegel, R., 251, 256 Sinacore, A., 341 Skinner, B.F., 7, 232 Sklare, G., 381 Skovholt, T., 19–20 Smith, M., 450 Snyder, C., 290 Solomon, R., 247 Sonstegard, M., 97, 118–119, 406 Sparks, J., 452 Sperry, L., 19–20, 108, 116, 409 Spieglar, M., 233–234, 239, 241, 243,

245–247, 251, 256, 259, 264–265 Spotts-De Lazzer, A., 52 Stadler, H., 26

St. Clair, M., 79–81 Stebnicki, M., 34 Stern, D., 81 Stewart, M., 284, 287 Stiver, I., 338, 343 Stone, W., 70–71, 76–77, 79 Strentzsch, J., 343 Stricker, G., 429 Strosahl, K., 251, 255 Strumpfel, U., 225 Strunk, D., 284, 287 Strupp, H., 82 Sue, D., 26 Sue, D.W., 26 Surrey, J., 338, 343 Sweeney, T., 106

Tallman, K., 165, 173, 451 Tanaka-Matsumi, J., 258–259 Tausch, R., 165–167, 171, 177–178 Teasdale, J., 251, 254–255, 430 Terner, J., 98 Tharp, R., 249 Thomas, J., 390 Tillich, P., 131, 142 Tompkins, M., 285–286 Toporek, R., 26 Torres-Harding, S., 270, 286 Torres Rivera, E., 340, 354 Trepal, H., 343 Trepper, T., 371 Turner, L., 339

Uken, A., 397

Vaihinger, H., 100 VandeCreek, L., 38 Vonk, I., 281, 287, 305 Vontress, C., 141, 144, 149, 153, 159 Vujanovic, A., 251

Wade, A., 173, 451 Walker, L., 363 Walker, M., 343 Walsh, F., 407, 416 Walsh, R., 159 Walter, J., 373, 397 Walters, R., 232, 235

Wampold, B., 18–19, 178, 192, 430–431, 442, 451

Wang, C., 174 Warren, C., 83 Watson, D., 249 Watson, J., 171, 173, 176–177, 185,

190, 206 Watts, R., 96, 100, 105–106, 108–109,

111, 114–116, 119, 125–126 Weiner-Davis, M., 369, 372, 375,

378, 397 Weishaar, M., 270, 280, 282, 285–287,

307, 368 Wells, A., 288 Werner-Wilson, R., 339 West, J., 375, 409 Westra, H., 182 Wheeler, G., 199–200, 210–211 Wheeler, N., 42–43 White, B., 48 White, J., 281 White, M., 7, 369, 372, 381–382, 384,

386–389, 410, 414 Wiggins-Frame, M., 436 Williams, E., 339–340, 352, 354 Williams, J., 251, 254–255, 430 Williams, L., 405 Wilson, G., 233 Wilson, K., 251, 255 Winslade, J., 382–386, 389–390, 397 Wiseman, H., 21 Wolitzky, D., 59, 66–69, 71, 75–76, 82 Wolpe, J., 237 Worell, J., 341, 344–349, 353–354, 363 Worthington, E., 251, 436 Wubbolding, R., 7, 312–329, 334

Yalom, I., 6, 91, 131, 133, 138, 144, 146, 148–149, 152

Yeomans, F., 82 Yontef, G., 199–202, 206, 209–214, 219,

224, 226 Young, J., 436–437

Zahm, S., 224 Zimring, F., 165–167, 171, 177–178 Zinker, J., 202, 206, 212, 226 Zur, O., 50

63727_Name Index_rev01.indd 484 21/09/15 3:52 PM

AN INTEGRATIVE PERSPECTIVE 485 Subject Index

A-B-C framework, 273 ABC model, 238 Acceptance, 175, 251 Acceptance and commitment therapy,

255–256 Acceptance-based approaches, 250–256 Accommodation, 209 Accurate empathic understanding, 170,

175–176 Action plan, 288 Action, planning and, 324–326 Action stage, 184 Actualizing tendency, 170 Adlerian brief therapy, 108 Adlerian therapy, 95–128

application, 108–119 applied to the case of Gwen, 122–124 applied to the case of Stan, 121–122 client’s experience, 106–107 contributions, 125–126 key concepts, 98–104 limitations and criticisms, 126 multicultural perspective, 119–121 relationship between therapist and

client, 107–108 shortcomings, 120–121 strengths, 119–120 therapeutic goals, 104–105 therapeutic process, 104–108 therapeutic techniques and

procedures, 108–119 therapist’s function and role, 105–106

Adolescence, 65 Advice, 32 Aloneness, 142 Ambiguity, 30–31 Anal stage, 63, 65 Analytic framework, maintaining the, 73 Analytical psychology, 77 Anima, 78 Animus, 78 Antecedent event, 238 Anxiety, 28, 61, 144–145 Anxiety, existential, 144 Anxiety, neurotic, 145 Anxiety, normal, 145 Application to group counseling

Adlerian therapy, 118–119 behavior therapy, 256–258 choice theory/reality therapy, 326–327 existential therapy, 151–153 feminist therapy, 352 Gestalt therapy, 218–220

integrative approach, 444–445 narrative therapy, 390 person-centered therapy, 179–180 postmodern approaches, psychoanalytic therapy, 76–77 rational emotive behavior therapy, 279 solution-focused brief therapy,

380–381 Approaches, theoretical

Adlerian therapy, 95–128 behavior therapy, 231–268 choice theory/reality therapy,

311–336 cognitive behavior therapy, 269–310 existential therapy, 129–162 family systems therapy, 403–425 feminist therapy, 337–366 Gestalt therapy, 197–229 integrative perspective, 427–460 person-centered therapy, 163–195 postmodern approaches, 367–401 psychoanalytic therapy, 57–93 social constructionism, 368–370 solution-focused brief therapy,

371–381 Arbitrary inferences, 283 Archetypes, 78 Aspirational ethics, 38 Assertiveness training, 351–352 Assessment, 45, 177–178, 237, 348,

411–414 Assessment, functional, 237 Assimilation, 209 Assimilative integration, 430 Authenticity, 140 Automatic thoughts, 288 Autonomy versus shame and doubt, 65 Awareness, 206 Awareness, resistance to, 213

Basic philosophies, 432 Behavior therapy, 231–268

application, 240–258 applied to the case of Gwen, 260–262 applied to the case of Stan, 259–260 areas of development, 234–236 basic characteristics and assumptions,

236–237 client’s experience, 239–240 contributions, 263–264 historical background, 233–234 key concepts, 236–237 limitations and criticisms, 264–265

multicultural perspective, 258–259 relationship between therapist and

client, 240 shortcomings, 259 strengths, 258–259 therapeutic goals, 238 therapeutic process, 238–240 therapeutic techniques and

procedures, 240–258 therapist’s function and role, 238–239

Behavioral analysis, 238 Behavioral assessment interview, 238 Beliefs and attitudes, 26 Belonging, 102 Belonging power, love and, 314 Bibliotherapy, 276–277, 351 Birth order, 103 Blank-screen approach, 67 Blocks to energy, 205 Borderline personality disorder, 82 Boundary crossing, 51 Boundary violation, 52 Brief psychodynamic therapy, 83

Change, 115, 184, 321–322, 415 Characteristics, of effective counselors,

19–20 Choice theory/reality therapy, 311–336

application, 320–327 applied to the case of Gwen, 331–332 applied to the case of Stan, 329–330 client’s experience, 319 contributions, 332–333 key concepts, 314–318 limitations and criticisms, 333–334 multicultural perspective, 327–329 relationship between therapist and

client, 319–320 shortcomings, 329 strengths, 327–328 therapeutic goals, 318 therapeutic process, 318–320 therapeutic techniques and

procedures, 320–327 therapist’s function and role, 318–320

Classical conditioning, 235 Classical psychoanalysis, 64, 68 Client-centered therapy, 166 Codes, ethics, 39–40 Cognitive behavior modification,

293–298 contributions, 305–306 limitations and criticisms, 307

485

63727_Subject Index_rev02.indd 485 30/09/15 9:38 AM

486 SubjECT INdEx

Cognitive behavior therapy, 236, 269–310

applied to the case of Gwen, 302–303 applied to the case of Stan, 300–301 cognitive therapy, 281–288 contributions, 304–306 limitations and criticisms, 306–307 multicultural perspective, 298–299 rational emotive behavior therapy,

270–280 shortcomings, 298–299 strengths, 298 strengths-based cognitive behavior

therapy, 289–292 Cognitive homework, 276 Cognitive methods, 276–277 Cognitive model, generic, 282 Cognitive narrative approach, 297–298 Cognitive therapy, 280–288

applications, 287–288 basic principles, 284–285 client-therapist relationship, 286–287 contributions, 304–305 generic cognitive model, 282–284 limitations and criticisms, 306–307

Cognitive triad, negative, 282 Collaborative empiricism, 285 Collective unconscious, 78 Commitment, 140 Commitment, lack of, 30 Common factors approach, 430 Community feeling, 101–102 Compensation, 63 Concern-based ethics, 38 Confidentiality, 42–43 Confluence, 203 Confrontation, 214 Congruence, 170, 174–175 Consciousness, 60–61 Consequences, 238 Contact, 202–203 Contact, resistances to, 202–203, 213 Contemplation stage, 184 Contemporary psychoanalysis, 64 Contemporary relational Gestalt

therapy, 200 Contextual factors, 19 Counseling environment, 321 Countertransference, 31, 71 Courage, 142 Crisis, 64 Crisis intervention, 178–179 Culture, 25, 27–28 Cycle of counseling, 320

Death, 145–146 Death instincts, 59 Decision making, ethical, 39–41

Deconstruction, 386–388 Deflection, 203 Demands, 30 Denial, 62 Despair, integrity versus, 66 Development, stages of, 80–82 Diagnosis, 45, 348 Dialectical behavior therapy, 251–253 Dialogue, 209 Dichotomous thinking, 284 Direction and doing, 323 Displacement, 62 Disputing irrational beliefs, 276 Doing, direction and, 323 Dream analysis, 74 Dream work, 74, 217–218 Dual relationships, 49–52

Early childhood, 65 Early recollections, 106, 111–112 Egalitarian relationship, 344 Ego, 60 Ego-defense mechanism, 61–62 Ego psychology, 64, 79 Emotion-focused therapy, 167–168 Emotional disturbance, view of, 272–273 Emotive techniques, 277–278 Empathy, 175 Empowerment, 349 Empty-chair technique, 215 Encouragement, 114 Energy, 205 Energy, blocks to, 205 Engendered lives, 342 Ethical decision making, 39–41 Ethical decisions, 38 Ethical issues, 37–56 Ethical issues, assessment process, 45–47 Ethical issues, multicultural perspective,

43–45 Ethical obligation, 25 Ethics codes, 39–40 Evidence-based practice, 48–49 Exaggeration exercise, 217 Exception questions, 377–378 Exceptions, 377 Exercises, 211 Existential analysis, 135 Existential anxiety, 144 Existential guilt, 140 Existential neurosis, 144 Existential therapy, 129–162

application, 149–153 applied to the case of Gwen, 156–157 applied to the case of Stan, 155 client’s experience, 147–148 contributions, 158–159 key concepts, 137–146

key figures, 136–137 limitations and criticisms, 159 multicultural perspective, 153–154 relationship between therapist and

client, 148–149 shortcomings, 154 strengths, 153–154 therapeutic goals, 146–147 therapeutic process, 146–149 therapeutic techniques and

procedures, 149–153 therapist’s function and role, 147

Existential tradition, 137–138 Existential vacuum, 144 Existentialism, 168–169 Experiments, 211 Exposure therapies, 245 Expressive arts therapy, 180–182 Externalization, 386–388 Externalizing conversations, 387 Externally motivated, 314 Extinction, 241 Eye movement desensitization and

reprocessing (EMDR), 247

Family constellation, 106, 110–111 Family systems perspective, 404–405 Family systems therapy, 403–425

applied to the case of Gwen, 420–422 applied to the case of Stan, 417–420 basic assumption, 422 contributions, 423 development of, 406–407 focus, 422 goals and values, 422 human validation process model, 407 limitations and criticisms, 423–424 multicultural perspective, 415–417 multigenerational, 407 multilayered process, 409–415 postmodern perspectives, 409 shortcomings, 416–417 strengths, 415–416 structural-strategic, 408 techniques, 423 therapeutic relationship, 410

Faulty assumptions, 104 Fear-based ethics, 38 Feedback, therapist, 379 Feedback-informed treatment, 451 Feeling, staying with, 217 Feelings, 176 Feminist counseling, 339 Feminist perspective, 339 Feminist psychotherapy, 339 Feminist therapy, 337–366

application, 348–353 applied to the case of Gwen, 357–360

63727_Subject Index_rev02.indd 486 30/09/15 9:38 AM

SubjECT INdEx 487

applied to the case of Stan, 355–357 client’s experience, 347 contributions, 361–363 history and development, 340–341 key concepts, 341–345 limitations and criticisms, 363 multicultural and social justice

perspective, 354–355 principles of, 343–345 relationship between therapist and

client, 347 shortcomings, 355 strengths, 354 techniques and strategies, 349–354 therapeutic goals, 345–346 therapeutic process, 345–347 therapeutic techniques and

procedures, 348–353 therapist’s function and role,

346–347 Fictional finalism, 100 Field, 199 Field theory, 201 Figure, 201 Figure-formation process, 201–202, 212 Flexible-multicultural perspective, 341 Flooding, 245–246 Formula first session task, 378 Free association, 68, 73 Freedom, 139–141, 314 Friendship, 102 Fun, 314 Functional assessment, 238 Future projection technique, 215–216

Gender-fair approaches, 341 Gender-role, 350 Gender-role intervention, 350–351 Generativity versus stagnation, 66 Generic cognitive model, 282 Genital stage, 65–66 Genuineness, 174–175 Gestalt therapy, 197–229

application, 211–220 applied to the case of Gwen, 223–224 applied to the case of Stan, 221–222 client’s experience, 209–210 contributions, 225 interventions, 214–218 key concepts, 200–205 limitations and criticisms, 226 multicultural perspective, 220–221 relationship between therapist and

client, 210–211 shortcomings, 221 strengths, 220–221 therapeutic goals, 206 therapeutic process, 206–211

therapeutic techniques and procedures, 211–220

therapist’s function and role, 206–209 Goals, 438

Adlerian therapy, 104–105 behavior therapy, 238 choice theory/reality therapy, 318 existential therapy, 146–147 family systems therapy, 422 feminist therapy, 345–346 Gestalt therapy, 206 integrative perspective, 437–439 narrative therapy, 384 person-centered therapy, 171 psychoanalytic therapy, 66–67 rational emotive behavior therapy,

273–274 solution-focused brief therapy, 375

Ground, 201 Group work, 352–353 Guilt, initiative versus, 65 Gwen, case of

Adlerian therapy, 122–124 behavior therapy, 260–262 choice theory/reality therapy, 331–332 cognitive behavior therapy, 302–303 existential therapy, 156–157 family systems therapy, 420–422 feminist therapy, 357–360 Gestalt therapy, 223–224 integrative approach, 455–456 person-centered therapy, 187–189 postmodern approaches, 394–396 psychoanalytic therapy, 87–88

Here-and-now, 137 Hierarchy of needs, 170 Holism, 201 Holistic concept, 100 Homework, cognitive, 276 Human nature, view of

Adlerian therapy, 98–99 choice theory/reality therapy, 314–315 existential therapy, 137–138 Gestalt therapy, 200–201 person-centered therapy, 170–171 psychoanalytic therapy, 59

Human personality, 99–101 Human validation process model, 407 Humanism, 168–169 Humanistic philosophy, 170 Humanistic psychology, 169–170 Humor, 31–32, 278 Hypothesizing, 414–415

Id, 60 Id psychology, 64 Identification, 63

Identity, 141–143 Identity versus role confusion, 65 Immediacy, 177 Impasse, 205 Inauthenticity, 139 Individual psychology, 99 Individuation, 78 Industry versus inferiority, 65 Infancy, 65 Inferiority feelings, 99 Inferiority, industry versus, 65 Informed consent, 41–42 Initiative versus guilt, 65 Insight, 113 Instincts, death, 59 Instincts, life, 59 Integration, 113 Integrative perspective, 427–460

advantages of psychotherapy integration, 431

applied to the case of Gwen, 455–456 applied to the case of Stan, 452–455 challenge of developing, 431–433 client’s experience, 440 integration of multicultural issues,

435 integration of spirituality and religion,

435–437 movement toward psychotherapy

integration, 428–437 relationship between therapist and

client, 440–442 techniques and evaluation, 443–452 therapeutic goals, 437–439 therapeutic process, 437–442 therapist’s function and role, 439

Integrity versus despair, 66 Interactionist, 341 Internal dialogue, 294 Internal dialogue exercise, 215 Interpretation, 74, 113 Intimacy versus isolation, 66 Introjection, 63, 202 In vivo exposure, 245–246 In vivo flooding, 246 Isolation, intimacy versus, 66

Key concepts, 433–434 Adlerian therapy, 98–104 behavior therapy, 236–237 choice theory/reality therapy,

314–318 existential therapy, 137–146 family systems therapy, 410–415 feminist therapy, 341–345 Gestalt therapy, 200–205 narrative therapy, 382–383 person-centered therapy, 170–171

63727_Subject Index_rev02.indd 487 30/09/15 9:38 AM

488 SubjECT INdEx

Key concepts (continued ) psychoanalytic therapy, 59–66 rational emotive behavior therapy,

272–273 solution-focused brief therapy, 371–374

Kindness, 254

Labeling, 283 Language, 207, 277, 370 Latency stage, 65 Latent content, 74 Later life, 66 Libido, 59 Life-changing psychotherapy, 136 Life instincts, 59 Life-span perspective, 341 Lifestyle, 101 Lifestyle assessment, 106 Life tasks, 102–103 Listening, 382 Logotherapy, 144 Love and belonging power, 314

Magnification, 283 Maintaining the analytic framework, 73 Maintenance stage, 184 Making the rounds, 216 Mandatory ethics, 38 Manifest content, 74 Meaning, search for, 143–144 Meaning, sharing, 414–415 Meaninglessness, 144 Middle age, 66 Middle child, 104 Mindfulness, 250–256 Mindfulness-based cognitive therapy,

254–255, 430 Mindfulness-based stress reduction,

253–254 Minimization, 283 Minor psychotherapy, 108 Miracle question, 378 Mislabeling, 283 Mistaken goals, 104 Mistrust, trust versus, 65 Moral anxiety, 61 Motivational Interviewing, 182–184 Multicultural counseling, 25–28 Multigenerational family therapy, 407 Multimodal therapy, 250 Multiple relationships, 49–52

Narrative therapy, 382–390 application, 386–390 focus of, 382 key concepts, 382–383 therapeutic process, 383–384 therapeutic relationship, 385

therapeutic techniques and procedures, 386–390

therapist’s function and role, 384–385

therapy goals, 384 Narcissistic personality, 81 Needs, hierarchy of, 170 Negative cognitive triad, 282 Negative reinforcement, 241 Neurotic anxiety, 61, 145 Nonbeing, 145–146 Nondirective counseling, 166 Nonprofessional relationships, 49 Normal anxiety, 145 Normal infantile autism, 81 Not-knowing position, 370, 376, 396 Now, the, 204

Objective interview, 110 Object-relations theory, 79–84 Oldest child, 103 Only child, 104 Operant conditioning, 235 Operant conditioning techniques,

241–242 Oral stage, 63, 65 Organismic self-regulation, 202 Outcome rating scale, 451 Overgeneralization, 283

Paradoxical theory of change, 201 Perfectionism, 29 Person-centered approach, 167 Person-centered therapy, 163–195

application, 176–180 applied to the case of Gwen, 187–189 applied to the case of Stan, 186–187 client’s experience, 172–173 contributions, 190–191 development of the approach, 166–167 key concepts, 170–171 limitations and criticisms, 192–193 multicultural perspective, 184–186 relationship between therapist and

client, 173–176 shortcomings, 185–186 strengths, 184–185 therapeutic goals, 171 therapeutic process, 171–176 therapeutic techniques and

procedures, 176–180 therapist’s function and role, 171–172

Persona, 78 Personal characteristics, of effective

counselors, 19–20 Personal therapy, 20–22 Personality, development of, 63–66,

77–79

Personality, structure of, 59–61 Personalization, 283 Phallic stage, 63, 65 Phenomenological, 99 Phenomenological inquiry, 204 Picture album, 315 Planning and action, 324–326 Pleasure principle, 60 Positive ethics, 38 Positive orientation, 372 Positive psychology, 169, 372 Positive reinforcement, 241 Postmodern approaches, 367–410

applied to the case of Gwen, 394–396 applied to the case of Stan, 392–394 contributions, 397–398 limitations and criticisms, 398 multicultural perspective, 390–391 narrative therapy, 382–390 shortcomings, 391–392 social constructionism, 368–370 solution-focused brief therapy,

371–381 strengths, 390–391

Power analysis, 351 Precontemplation stage, 184 Preparation stage, 184 Preschool age, 65 Presence, 177 Present, 317 Pretherapy change, 377 Private logic, 106 Privileged communication, 42 Professional burnout, 34 Professional role, 33–34 Progressive muscle relaxation, 242–243 Projection, 62, 203 Psychoanalytic therapy, 57–93

application, 72–77 application to group counseling,

76–77 applied to the case of Gwen, 87–88 applied to the case of Stan, 85–87 client’s experience, 68–69 contributions, 89–91 counseling implications, 64 key concepts, 59–66 limitations and criticisms, 91–92 multicultural perspective, 84–85 relationship between therapist and

client, 69–72 shortcomings, 85 strengths, 84–85 therapeutic goals, 66–67 therapeutic process, 66–72 therapeutic techniques and

procedures, 72–77 therapist’s function and role, 67–68

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SubjECT INdEx 489

Psychodynamic therapy, 68 Psychoeducational methods, 277 Psychological investigation, 104 Psychosexual stages, 63, 65–66 Psychosocial stages, 64–66 Psychotherapy integration, 429 Punishment, 242 Punishment, negative, 242 Punishment, positive, 242

Quality world, 315 Question, miracle, 378 Questions, 386 Questions, exception, 377–378 Questions, scaling, 378

Rational emotive behavior therapy (REBT), 270–279

application, 275–279 behavioral techniques, 279 client’s experience, 274–275 cognitive methods, 276–277 contributions, 304 emotive techniques, 277–278 key concepts, 272–273 limitations and criticisms, 306 relationship between therapist and

client, 275 therapeutic goals, 273–274 therapeutic process, 273–275 therapeutic techniques and

procedures, 275–279 therapist’s function and role, 274 view of emotional disturbance,

272–273 Rational emotive imagery, 277–278 Rationalization, 62 Reaction formation, 62 Reality, 99 Reality anxiety, 61 Reality therapy/choice theory, 311–336

client, 319–320 shortcomings, 329 strengths, 327–328 therapeutic goals, 318 therapeutic process, 318–320 therapeutic techniques and

procedures, 320–327 therapist’s function and role, 318–320

Reeducation, 113–117 Reframing, 352 Regression, 63 Rehearsal exercise, 216–217 Reinforcement, negative, 241 Reinforcement, positive, 241 Relabeling, 352 Relapse prevention, 296 Relatedness, 142–143 Relational-cultural theory, 342–343 Relational model, 80 Relational psychoanalysis, 79–84 Relationship, 410–411 Reorientation, 113–117 Repression, 62 Research, 191 Resistance, 75, 136, 213 Resistances to contact, 202–203 Responsibility, 32, 139–141, 316–317 Restricted existence, 147 Retroflection, 203 Reversal exercise, 216 Role confusion, identity versus, 65 Role of stories, 382 Role playing, 278

Scaling questions, 378 Schema, 288 School age, 65 Second child, 103–104 Selective abstraction, 283 Self-awareness, 138–139 Self-care, 34 Self-compassion, 254 Self-directed behavior, 248–250 Self-disclosure, 28–29, 349–350 Self-efficacy, 235 Self-evaluation, 322–323 Self-instructional training, 293 Self-management programs, 248–250 Self-observation, 294 Self psychology, 79–84 Self-understanding, 113 Self-worth, 102 Separation–individuation, 81 Session rating scale, 451 Shadow, 78 Shame and doubt, autonomy versus, 65 Shame attacking exercises, 278 Sibling relationships, 103–104 Significance, 100–101 Silence, 30 Skills and intervention strategies,

26–27 Social action, 352 Social constructionism, 368–370 Social identity analysis, 350 Social interest, 101–102

Social learning approach, 235 Social media, 52 Social skills training, 248 Solution-focused brief therapy, 371–381

application, 377–381 basic assumptions, 373 characteristics, 373–374 key concepts, 371–374 therapeutic goals, 375 therapeutic process, 374–375 therapeutic relationship, 376–377 therapeutic techniques and

procedures, 377–381 therapist feedback, 379 therapist’s function and role, 375–376 unique focus, 371–372

Stages of development, 80–82 Stagnation, generativity versus, 66 Stan, case of

Adlerian therapy, 121–122 behavior therapy, 259–260 choice theory/reality therapy,

329–330 cognitive behavior therapy, 300–301 existential therapy, 155 family systems therapy, 417–420 feminist therapy, 355–357 Gestalt therapy, 221–222 integrative approach, 452–455 person-centered therapy, 186–187 postmodern approaches, 392–394 psychoanalytic therapy, 85–87

Stories, role of, 382 Strengths-based cognitive behavioral

therapy, 289–292 applications, 291–292 basic principles, 290 client-therapist relationship, 291 contributions, 305 limitations and criticisms, 307

Stress inoculation training, 294–297 Structural family therapy, 408 Structural-strategic approaches, 408 Student-centered teaching, 167 Subjective interview, 109 Sublimation, 63 Suggesting tasks, 379 Summary, 113 Superego, 60 Superiority, 100–101 Survival, 314 Symbiosis, 81 Syncretism, 428–429 Systematic desensitization, 243–245

Technical integration, 429 Techniques, therapeutic, 33 Terminating, 379–380

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490 SubjECT INdEx

Theoretical approaches Adlerian therapy, 95–128 behavior therapy, 231–268 choice theory/reality therapy, 311–336 cognitive behavior therapy, 269–310 existential therapy, 129–162 family systems therapy, 403–425 feminist therapy, 337–366 Gestalt therapy, 197–229 integrative perspective, 427–460 narrative therapy, 382–390 person-centered therapy, 163–195 postmodern approaches, 367–401 psychoanalytic therapy, 57–93

social constructionism, 368–370 solution-focused brief therapy, 371–381

Theoretical integration, 429 Therapeutic core conditions, 173 Therapeutic techniques, 33 Therapist feedback, 379 Therapy methods, 19 Therapy, personal, 20–22 Therapy relationship, 19 Thought records, 288 Total behavior, 315 Transference, 70, 75–76, 317 Transference relationship, 67 Trust versus mistrust, 65

Unconditional positive regard, 170, 175

Unconscious, 60–61 Unfinished business, 205

Value imposition, 23 Values, 22–24

Wants, 322–323 WDEP system, 322–326 Working-through process, 70

Young adulthood, 66 Youngest child, 104

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