Psychology Homeworks

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Here is an example of a helper’s challenge to a client who is not making the best use of her strengths: “For several weeks now you’ve made detailed plans to reach out to a friend. You say that when you do reach out to people they usually like you, and you have no reason to fear that this friend will reject you. Yet you have not made contact with her, and you have many reasons for not doing so. Let’s explore what is keeping you from contacting her.”

To make the issue of challenging more concrete, we present examples of other styles of challenging. The first statement illustrates an ineffective challenge; this is followed by an effective challenge alternative. • “You’re always so cold and aloof, and you make me feel distant from you.”

A more effective statement is: “I feel a distance between us, and I am interested in exploring this. This relationship between us is important to me. Sometimes in our sessions I feel you disconnect, and I wonder if you get this feedback in the outside world too?”

• “You’re always smiling, and that’s not real.” A more effective statement is: “Often when you say you’re angry, you’re smiling. I have a hard time knowing whether you are angry or happy. Are you aware of this?”

• “If I were your husband, I’d leave you. You’re full of hostility, and you’ll destroy any relationship.” A more effective statement is: “Anger is a perfectly normal human emotion, but it can result in destructive or harmful behavior. I feel startled by the intensity of your anger, and occasionally I even feel fear because of your angry behaviors. Many of the things you say are hurtful and create distance between us. Is this something you are aware of and would like to change?”

In the ineffective statements, the people being addressed are being told how they are, and in some way are being discounted. In the effective statements, the helper doing the talking is revealing his or her perceptions and feelings about the client and is reporting how the person’s behavior is affecting him or her.

If you want to learn more about challenging clients, we recommend The Skilled Helper (Egan & Reese, 2019); Intentional Interviewing and Counseling: Facilitating Client Development in a Multicultural Society (Ivey et al., 2018); and Interviewing and Change Strategies for Helpers (Cormier et al., 2017).

Using helper self-disclosure appropriately. Appropriately and timely disclosing aspects of yourself can be a powerful intervention in working with clients and facilitating a process of their self-exploration. It is a mistake to think of self-disclosure in terms of “all” or “none”; it can best be viewed on a continuum. There is a distinction between a helper’s self-disclosing statements (disclosing personal information about oneself) and self-involving statements (revealing personal thoughts, feelings, and reactions to the client in the context of here-and-now aspects of the helping relationship). Therapist self-disclosure refers to therapist statements that reveal something personal about the therapist’s life or person outside of therapy (Hill, Knox, & Pinto-Coelho, 2019). Self-involving statements, referred to as immediacy, lead to a discussion of the therapeutic relationship by both therapist and client in the here-and-now, as well as processing client–therapist interactions (Hill et al., 2019).

Letting our clients know how we are affected by what they are saying and doing is frequently more useful to them than revealing aspects of our personal life.

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If you are having a difficult time listening to a client, for example, it could be useful to let the person know this by saying: “I’ve noticed at times that it’s difficult for me to stay connected to what you’re telling me. I’m able to follow you when you talk about yourself and your own feelings, but I find myself losing interest when you go into great detail about all the things your daughter is doing or not doing.” In this statement, the client is not being labeled or judged, but the helper is giving his reactions about what he hears when his client tells stories about others. An example of an unhelpful response would be “You’re boring me!” This response is a judgment of the client, and the helper assumes no responsibility for his own lack of interest.

It can be therapeutic to talk about ourselves if doing so is for a client’s benefit, but it is not necessary to reveal detailed stories of our past to form a trusting relationship with others. Inappropriate self-disclosure of our personal problems to our clients can easily distract them from productive self-exploration. Examine the impact your disclosures have on others. If your self-disclosing behavior prevents clients from exploring their issues, it may be time to consider your own therapy or supervision.

Some helpers use self-disclosure inappropriately as a way of unburdening themselves. They take the focus away from clients and direct it to their own concerns. If our feelings are very much in the foreground and inhibit us from fully attending to a client, it may be helpful to let the client know we are distracted and it is our problem, not the client’s. Depending on our relationship with the client, we might share some aspects about our own situation, or we might simply reveal that what the client is struggling with touches us personally, without going into too much detail.

Identifying and assessing action strategies. Insight without action is of little value. Self-understanding and seeing a range of possible alternatives can be significant in the change process, but clients also need to identify specific actions they can take and are willing to carry out in everyday living. Clients often do not accomplish their goals because they devise strategies that are unrealistic. One function of helping at this stage is to assist clients in thinking of many possibilities to achieve their goals. Together, helpers and clients come up with a range of alternatives for coping with problems, assess how practical these strategies are, and decide on the best plans for action. Helpers have the task of guiding clients to recognize the skills they need to put goals into action.

The process of creating and carrying out plans enables people to begin to gain effective control over their lives. This is clearly the teaching phase of the helping process, which is best directed toward providing clients with new information and assisting them in the discovery of more effective ways of getting what they want and need. Throughout this planning phase, the helper continually urges clients to assume responsibility for their own choices and actions.

Wubbolding (2000, 2011, 2017) writes about the central place of planning and commitment in any change process, emphasizing that when clients make plans and follow through they are taking charge of their lives by redirecting their energy and making action choices. According to Wubbolding (2017), effective plans have several characteristics that can be summarized in the acronym SAMIC3.

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A results-centered plan is not complicated; it is simple. To achieve the desired result, the plan must be attainable and realistically doable. It is measurable, answering the question, “precisely when will I follow through on my plan?” “I” stands for immediate. It is important to implement the plan as soon as possible. The most effective plan is one controlled by the planner and not dependent on other individuals or outside circumstances. Ideally, the counselor, choosing a self- care behavior, makes a firm commitment to implement the plan. A consistent plan, repeated regularly, is required to achieve desired goals. Other specific guidelines for effective plans are listed below: • The plan should be within the limits of the motivation and capacities of

each client. Plans should be realistic and attainable. Helpers do well to caution clients about plans that are too ambitious or unrealistic. A realistic action plan for the first week working with a client with agoraphobia is that the client chooses to practice the progressive muscle relaxation learned in session every day and agrees to journaling for 10 minutes daily. It would be unrealistic to plan that the client will leave the house to go to the bank this week.

• Good plans are simple and easy to understand. Although plans need to be concrete and measurable, they should be flexible and open to modification as clients gain a deeper understanding of the specific behaviors that they want to change. An initial action plan for a client struggling with methamphetamine addiction might include abstaining from all substances; attending three Narcotics Anonymous meetings per week (Mondays, Thursdays, and Saturdays at 7:00 p.m.); calling a sponsor daily; avoiding all people, places, and things associated with previous methamphetamine use; actively working the 12 steps beginning with the first step; practicing deep breathing and meditation daily; and attending counseling sessions weekly.

• The plan should involve positive action and should be stated in terms of what the client will do. A client working to improve her self-esteem agrees to the following: “Each day this week I will say out loud the affirmation ‘I am lovable and worthy of great joy.’ I will also use the thought-stopping technique of picturing the stop sign every time I am aware of my negative self-talk statements, such as ‘I am not good enough.’ Then I will replace that negative self-defeating thought with my affirmation.”

• It is useful to encourage clients to develop plans that they can carry out independently. Plans that are contingent on what others will do lead clients to sense that they are not steering their own ship but are at the mercy of others. A client with depression symptoms commits to walking 30 minutes per day at 5:00 p.m. The client does not include her husband in the plan because she would then need to rely on her husband, which would limit her independent ability to carry out the plan.

• Good plans are specific and concrete. Clients can develop specificity when helpers raise questions such as “what?” “where?” “with whom?” “when?” and “how often?” A client whose goal is weight loss suggests a general plan to exercise more often. By asking narrowing questions, the client’s plan can become specific and measurable: walk on the treadmill at his local gym for 45 minutes every weekday before work, and meet with his personal trainer every Saturday morning at 9:00 a.m.

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• Effective plans are repetitive and ideally are performed daily. For people to overcome symptoms of depression, anxiety, negative thinking, or psychosomatic complaints, it is essential to replace these symptoms with new patterns of thinking and behaving. Each day, clients might choose a course that will lead to a sense of being in charge of their life.

• Plans should be done as soon as possible. Helpers can ask questions such as “What are you willing to do today to begin to change your life?” “You say you’d like to stop depressing yourself. What are you going to do now to attain this goal?”

• Effective planning involves process-centered activities. For example, clients may state that they will do any of the following: apply for a job, write a letter to a friend, take a yoga class, substitute nutritious food for unhealthy food, devote 2 hours a week to volunteer work, or take a vacation they have been wanting.

• Before clients carry out their plan, it is a good idea for them to evaluate it to determine if it is realistic, attainable, and reflective of what they need and want. After the plan has been carried out in real life, it is useful to evaluate it again. Helpers can raise the question with the client, “Is your plan helpful?” If the plan does not work, it can be reevaluated and alternatives can be considered.

• For clients to commit themselves to their plan, it is useful for them to firm it up in writing.

• Part of developing a plan for action involves a discussion of the main costs and benefits of each strategy as well as a discussion of the possible risks involved and the chances for success. It is the helper’s task to work with clients in constructively dealing with any hesitations they might have to formulating plans or carrying them out. Resolutions and plans are meaningless unless there is a decision to carry

them out. It is crucial that clients commit themselves to a definite plan that they can realistically accomplish. The ultimate responsibility for making plans and following through on them rests with the client. It is up to each client to determine ways of carrying these plans outside the helping relationship and into the everyday world. Effective helping can be the catalyst that leads to self-directed, satisfying, and responsible living.

Carrying out an action program. Clients are encouraged to see the value in actively trying new behavior rather than being passive and leaving action to chance. One way of fostering an active stance by clients is to formulate clear contracts. In this way clients are continually reminded about what they want and what they are willing to do. Contracts are also a useful frame of reference for evaluating the outcomes of helping. Discussion can be centered on how well the contract is being met and what modifications of it might be in order.

If certain plans do not work out well, this is a topic for exploration in a subsequent session. For example, if a mother does not follow through with her plan to deal with her son who is getting in trouble in school, the counselor can explore with her what stopped her from carrying it out. Contingency plans are also developed. The counselor might role-play different ways the mother could deal with setbacks or with her son’s lack of cooperation. In this way clients learn how to deal with reverses and how to predict possible obstacles to their progress.

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Relapse prevention is an integral part of the final phase of therapy. At times, it is inevitable that clients will revert to old patterns and experience self-defeating thoughts and behaviors. It is a good practice to explore possible stumbling blocks and ways to cope with them. The point is not that clients never experience setbacks but that they become aware of when they slip into old familiar patterns that no longer work for them. Clients can think about difficulties they might face in sticking with their plans and ways to address any lapses. The goal of relapse prevention is to help clients maintain the gains they have made by using what they learned in counseling when they need it in the future (Dobson & Dobson, 2017).

Stage 5: Termination Termination, the fifth stage, assists clients in maximizing the benefits from the helping relationship and deciding how they can continue the change process. During this stage, clients consolidate their learning and make long-range plans. A helper’s role at this time is to prepare clients for termination, to encourage them to express any feelings or thoughts about ending the relationship, to review what they have accomplished, and to identify and discuss future plans.

Just as the initial session sets the tone for the helping relationship, the ending phase enables clients to maximize the benefits from the relationship and decide how they can continue the change process. As a helper, our goal is to work with clients in such a way that they can terminate the professional relationship with us as soon as possible and continue to make changes on their own. As mentioned earlier, in settings where brief therapy is the standard, it is especially important that termination and issues pertaining to restrictions on time be addressed at the initial session. If an agency policy specifies that clients can be seen for only six sessions, for example, clients have a right to know this from the outset.

Working in a short-term context, the final phase of the helping process should always be in the background. With brief interventions, the goal is to teach clients, as quickly and efficiently as possible, the coping skills they need to live in self-directed ways. Our overriding goal is to increase the chances that our clients will not continue to need us. It is critical to remember that if we are effective helpers we will eventually “put ourselves out of business”—at least with our current clients. We need to keep in mind that our role is to get clients working effectively on their own, not to keep them dependent on us for help. If we can teach our clients ways of finding their own solutions to problems, they can use what they have learned dealing with their present concerns when any future problems occur.

Preparing clients for termination. In cases of structured, time- limited counseling, clients need to be informed from the beginning about the approximate number of sessions available. Although clients may cognitively know there are a limited number of sessions, emotionally they may deny this restriction of their counseling experience. Termination should be discussed at the first session and be explored as necessary throughout the course of the helping relationship. In this way, termination does not come as a surprise to the client.

The limitation of time can help clients establish short-term, realistic goals for the helping process. Toward the end of each session, we can ask clients the

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degree to which they see themselves reaching the goals they have established. By reviewing the course of treatment, clients are in a position to identify what is and is not working for them in the helping process. Each session can be assessed in light of having a specific number of sessions devoted to accomplishing preset goals.

Ideally, termination is the result of a mutual decision by the client and the helper that the goals of the helping process have been accomplished. Effective termination provides clients with closure to their experience as well as a clear sense of what they need to do to continue this momentum in daily life.

Terminating when clients are not benefiting. Ethical standards state that it is improper to continue a professional relationship if it is clear that a client is not benefiting. Assessing whether the client is really being helped can be difficult. Consider this example: You have been seeing a client for some time who typically reports that she has nothing to talk about in the sessions. You have talked to her about her unwillingness to disclose much of herself in the counseling sessions. The client agrees yet continues her behavior. Finally, you suggest termination because, in your opinion, she is not benefiting from the counseling relationship. The client is reluctant to terminate despite her lack of involvement in the sessions. What would you do if you were confronted with this situation?

When a client who is not making progress does not wish to terminate, Younggren and Gottlieb (2008) suggest an open, collaborative stance on the part of the therapist. When a client does not seem to be benefiting from treatment, it is critical that the therapist explore with the client the reasons for the lack of progress. However, ultimately it is the therapist’s responsibility to determine whether further progress is likely to occur or if termination is in order.

Helpers need to be careful not to jump to the conclusion too quickly that the client is not making progress. During the early stages of the training process, it is common for some helpers to want “immediate success” with their clients. A novice helper dealing with his or her own self-doubt and insecurities could prematurely suggest that a client is not making progress. This could be upsetting and even damaging to the client’s self-esteem. Before determining that a client is not making adequate progress, it is wise for the novice helper to discuss this in supervision.

Taking steps to avoid fostering dependency. Helpers can foster clients’ dependent attitudes and behaviors in many subtle ways. Sometimes helpers actually prevent clients from ending a professional relationship. Instead of helping clients find their own direction, helpers may do too much for them, which results in clients assuming too little responsibility for action and change. Although our clients may temporarily become dependent on us, clinical and ethical issues arise if we foster their dependency and prevent their progress. Ask yourself these questions as a way of determining the degree to which you could encourage either dependent or independent behavior: • Do I have a hard time terminating a case? Do I have trouble “losing” a client?

Am I concerned about a reduction in my income? • Do I encourage clients to think about termination of the professional

relationship, and do I assist them in preparing for termination?

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• Might I need some clients more than they need me? Do I have a need to be needed? Am I flattered when clients express dependency on me?

• Do I challenge clients to do for themselves what they are able to do? How do I respond to clients when they press me for answers?

• To what degree do I encourage clients to look within themselves for potential resources to find their own answers? Some helpers may foster dependence in their clients as a way of feeling

important. When clients become passive and ask for answers, these helpers respond too quickly with problem-solving solutions. Such actions may not be helpful in the long run because clients are being reinforced to depend on you. Our main task as helpers is to encourage clients to rely on their own resources. By reinforcing the dependency of our clients, we are telling them that we do not trust that they can help themselves or that they can function independently of us.

Skills for ending the helping relationship. Basically, the interventions for endings pertain to assisting clients in consolidating their learning and determining how they can proceed once they stop coming in for treatment. Here are some considerations for effectively accomplishing these tasks: • We remind clients of the approaching ending of the sessions. This should be

done a couple of sessions before the final one. We might ask clients to think about any unfinished business they have and what they would most like to talk about in the final two meetings with us. We frequently can ask at a session prior to the last one, “If this were our last meeting, what would you want to talk about?”

• If we are not limited to a specified number of sessions, one option is to space out the final few sessions. Instead of meeting weekly, our client might come in every 3 weeks. This schedule allows more opportunity to practice and to prepare for termination.

• We review the course of treatment with clients. What lessons did clients learn, how did they learn them, and what do they intend to do with what they have learned? What did they find most helpful in the sessions? What was less helpful in the course of treatment? What were their greatest struggles, and what did they do to work through those challenges? What did they think about their own participation in this process?

• It is good practice to encourage clients to talk about their feelings of separation. Just as they may have had fears about seeking help, they may have different fears about ending the work with us.

• Examine your own feelings about endings. Helpers are often ambivalent about letting go of clients. It is possible to hold back clients because of our own reluctance to terminate with a client, for whatever reason. It is essential that we reflect on the degree to which we may need our clients more than they need us.

• It is a good idea to have an open-door policy, meaning that clients might be encouraged to return at a later time should they feel a need for further learning. Although professional helping is best viewed as a terminal process, at a later period of development clients may be ready to deal with a new set of problems or concerns in ways they were not willing to do when they initially began counseling. Clients may need only a few sessions to get refocused.

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• Those who have participated in counseling have acquired some needed skills and resources for continuing the process of personal growth. Assisting clients to translate their learning into action programs is one of the most important functions during the action phase and the ending phase of helping. If clients have been successful, the ending stage is a commencement; they now have some new directions to follow in dealing with problems as they arise. For this reason, discussing available programs and making referrals are especially timely toward the end of our work with clients. In this way, the end leads to new beginnings.

By Way of Review • Skills and knowledge are important in becoming an effective professional,

but personal qualities are equally important in determining our success as helpers. Our own life experiences play a vital role in our ability to be present and to be effective in working with clients.

• Your view of the helping process is largely a function of your beliefs about human nature and about how people change. It is essential that you clarify your beliefs about what brings about change.

• It is natural and expected for clients to experience a certain degree of ambivalence about change. Motivational interviewing is one approach that may help clients progress through the stages of change.

• Brief interventions are widely used today. They emphasize time-limited, solution-focused, structured, effective strategies that empower clients to make specific behavioral changes they desire.

• Effective helpers hold positive beliefs about people; have a healthy self- concept; ground their interventions in values; and possess empathy, congruence, warmth, compassion, genuineness, and unconditional positive regard.

• Generalizations that helpers make about clients tend to foster a self-fulfilling prophecy within clients. If helpers view clients as being highly dependent and unable to find their own way, they will most likely live up to this expectation.

• Mandated or involuntary clients may exhibit resistance toward entering the counseling relationship. If we expect these clients to be difficult and resistant, we are likely to see more of these behaviors. If we have positive expectations about their ability for change and growth, we are more likely to find ways to encourage these clients to benefit from the therapeutic relationship.

• There are five stages in the helping process. Stage 1 is the time for creating rapport and establishing the therapeutic alliance. Stage 2 consists of helping clients identify and clarify their problems. In Stage 3 the client and the helper collaboratively create goals. Stage 4 involves encouraging clients to engage in deeper self-exploration and develop an action plan aimed at change. This is a time to take action and to assist clients in translating what they have learned in counseling to everyday life situations. Stage 5 deals with termination and the consolidation of learning. Specific helper strategies are required at each of these stages. Developing these skills takes time and supervised practice.

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What Will You Do Now? 1. Identify a few of your key beliefs and assumptions that stand out after you

have read this chapter. To examine how you acquired these beliefs and assumptions, talk with someone you know who tends to hold similar beliefs. Then seek out somebody with a different perspective. With both of these people, discuss how you developed your beliefs.

2. Consider the skills needed for effective helping, and select what you consider to be your one major asset and your one major limitation, and write them down. How do you see your main asset enabling you to be an effective helper? How might your main limitation get in the way of working successfully with others? What can you do to work on the area that limits you? You might ask people you know well to review your statements about yourself. Do they see you as you see yourself?

3. As part of a class assignment, write a one-page essay that describes your personal view of what helping is about. How would you approach writing this essay if the reader is a layperson who knows little about the helping process? How would your essay be modified if the reader is a potential employer or clinical supervisor?

4. After reflecting on your beliefs about people and about the helping process, write some key ideas in your journal pertaining to the role that your beliefs play in the manner in which you might intervene in the lives of clients. How do your beliefs influence the suggestions you make to clients? How are your beliefs the groundwork for the strategies from which you will draw in dealing with client populations?

5. As you review the stages of the helping process, ask yourself what you consider to be your most important tasks at each of the different stages. Write in your journal about some of the challenges you expect to face when working with people at each of these stages. For example, might termination be a difficult process for you? Would you have difficulty appropriately sharing your life experiences with your clients? Might you have difficulty challenging clients? What can you do to develop the personal characteristics and skills you will need to effectively intervene at each of the stages of helping?

6. For the full bibliographic entry for each of these sources, consult the References at the back of the book. For comprehensive overviews of stages in the helping process, descriptions of systematic skill development, and intervention strategies, see Cormier (2016), Cormier, Nurius, and Osborn (2017), DeJong and Berg (2013), Egan and Reese (2019), Ivey, Ivey, and Zalaquett (2018), James and Gilliland (2017), Teyber and Teyber (2017), and Young (2013).

CHAPTER 7 Theory Applied to Practice

Learning Objectives 1. Provide a general framework for theory applied to practice. 2. Explain how a thinking, feeling, and behaving model can serve as an

integrative approach to counseling practice. 3. Describe the key concepts and techniques of psychoanalytic approaches. 4. Describe the key concepts and techniques of experiential and relationship-

oriented approaches. 5. Describe the key concepts and techniques of cognitive behavioral

approaches. 6. Discuss the major categories that are a part of mindfulness approaches to

therapy. 7. Describe the key concepts and techniques of postmodern approaches. 8. Explain the unique ways family systems approaches differ from individual

counseling. 9. Explain practical ways to develop an integrative approach to counseling

practice. 10. Describe how evidence-based practice fits into the future of integrative

psychotherapy.

Focus Questions 1. Why is theory relevant to practice? 2. The psychodynamic approaches emphasize understanding how childhood

experiences influence the person you are today. Do you value understanding the past as a key to the present? How might you work with a client from the perspective of the past? the present? the future?

3. The experiential approaches stress the value of a client’s direct experience rather than being taught by the counselor. How much do you trust a client’s ability to lead the way in a helping relationship?

4. In the experiential approaches, the client–counselor relationship is the most important determinant for therapeutic outcomes. What specific things can a helper do to form a collaborative working relationship with a client?

5. The cognitive behavioral approaches give primary attention to how thinking influences the way we feel and act. To what extent do you value focusing on a client’s thinking processes?

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6. The postmodern approaches de-emphasize the therapist-as-expert and view the client as the expert. What do you think of this position?

7. Family systems approaches consider the functioning of the whole family rather than that of a single individual. What unique value do you see in working with a client’s issues based on his or her family of origin? How much emphasis would you give to family-of-origin work when meeting with clients?

8. What are the advantages and disadvantages of brief models of therapy? How do brief, solution-focused intervention strategies fit the requirements of managed care programs?

9. How do you determine whether an intervention you are planning to use is suitable for the client?

10. What do you understand by developing your own integrative perspective on the helping process? What do you think it would take to be able to effectively integrate some basic concepts and techniques from various theoretical orientations?

Aim of the Chapter The purpose of this chapter is to provide you with a brief overview of some of the major theories of counseling that have applicability to a variety of helping relationships. We consider the role of theory as a guiding factor for practicing effectively. You will be introduced to the following five general theoretical orientations: psychodynamic models, experiential and relationship-oriented approaches, cognitive behavioral therapies, the postmodern approaches, and the family systems perspective. We also present our own integrative approach, emphasizing the role of thinking, feeling, and acting in human behavior, which is based on selected ideas from most of the theories presented in this chapter.

Your theoretical orientation provides a map for making interventions, and developing this perspective takes considerable time and experience. A theory provides a structure for organizing information you get about a client, designing appropriate interventions, and evaluating the outcomes. We stress the importance of developing a personal stance toward counseling that fits the person you are and is flexible enough to meet the unique needs of the client population with which you work. The main objective of this chapter is to stimulate your thinking about how to design a framework for practice.

Theory as a Roadmap There are many theoretical approaches to understanding what makes the helping process work. Different practitioners might work in a variety of ways with the same client, largely based on their theory of choice. Their theory will provide them with a framework for making sense of the multitude of interactions that occur within the therapeutic relationship. Some helpers focus on feelings, believing that what clients need most is to identify and express feelings that have been repressed. Other helpers emphasize gaining insight and explore the reasons for actions and interpret clients’ behavior. Some are not much concerned about having clients develop insight or express their feelings. Their focus is on

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behavior and assisting clients to develop specific action plans to change what they are doing. Other practitioners encourage clients to focus on examining their beliefs about themselves and about their world; they believe change will result if clients can eliminate faulty thinking and replace it with constructive thoughts and self-talk.

Helpers may focus on the past, the present, or the future. It is important to consider whether you see the past, present, or future as being the most productive avenue of exploration. This is more than just a theoretical notion. If you believe your clients’ past is a crucial aspect to explore, many of your interventions are likely to be designed to assist them in understanding their past. If you think your clients’ goals and strivings are important, your interventions are likely to focus on the future. If you are oriented toward the present, many of your interventions will emphasize what your clients are thinking, feeling, and doing in the moment.

Each of these choices represents a particular theoretical orientation. Attempting to practice without having an explicit theoretical rationale is like flying a plane without a flight plan. If you operate in a theoretical vacuum and are unable to draw on theory to support your interventions, you may flounder in your attempts to help people change.

Theory is not a rigid set of structures that prescribes, step by step, what and how you should function as a helper. Rather, we see theory as a general framework that enables you to make sense of the many facets of the helping process, providing you with a map that gives direction to what you do and say. Your theory needs to be appropriate for your client population, setting, and the type of counseling you provide. A theory is not something divorced from you as a person. At best, a theory becomes an integral part of the person you are and an expression of your uniqueness.

Our Theoretical Orientation Neither of us subscribes to any single theory in its totality. Rather, we function within an integrative framework that we continue to develop and modify as we practice. We draw on concepts and techniques from most of the contemporary counseling models and adapt them to our own unique personalities. Our theoretical orientations and styles of practice are primarily a function of the individuals we are. Our conceptual framework takes into account the thinking, feeling, and behaving dimensions of human experience.

We value approaches that emphasize the thinking dimension. We typically challenge clients to think about the decisions they have made about themselves. Some of these decisions may have been necessary for their psychological survival as children but now may not be functional. We want clients to be able to make necessary revisions that enable them to be more fully themselves. One way we do this is by asking clients to pay attention to their “self-talk.” Here are some questions we encourage clients to ask themselves: How are my problems caused or exacerbated by the assumptions I make about myself, about others, and about life? How do I contribute to or intensify my problems by the thoughts and beliefs I hold? How can I begin to free myself by critically evaluating the sentences I repeat to myself? Many of the techniques we use are designed to tap clients’ thinking processes, to help them

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think about events in their lives and how they have interpreted these events, and to work on a cognitive level to change certain belief systems.

Thinking is only one dimension that we pay attention to in our work with clients. The feeling dimension is also extremely important. We emphasize this facet of human experience by encouraging clients to identify and express their feelings. Clients are often emotionally frozen due to unexpressed and unresolved emotional concerns. If they allow themselves to experience the range of their feelings and talk about how certain events have affected them, their healing process is facilitated. If individuals feel listened to and understood, they are more likely to express more of the feelings that they have kept to themselves.

Thinking and feeling are vital components in the helping process, but eventually clients must express themselves in the behaving or doing dimension. Clients can spend many hours gaining insights and expressing pent-up feelings, but at some point they need to get involved in an action-oriented program of change. Their feelings and thoughts can then be applied to real-life situations. Examining current behavior is the heart of the helping process. We tend to ask questions such as these: What are you doing? What do you see for yourself now and in the future? Does your present behavior have a reasonable chance of getting you what you want, and will it take you in the direction you want to go? If the emphasis of the helping process is on what people are doing, there is a greater chance that they will also be able to change their thinking and feeling.

In addition to highlighting the thinking, feeling, and behaving dimensions, we help clients consolidate what they are learning and apply these new behaviors to situations they encounter every day. Some strategies we use are contracts, homework assignments, action programs, self-monitoring techniques, support systems, relapse prevention tools, and self-directed programs of change. These approaches all stress the role of commitment on the clients’ part to practice new behaviors, to follow through with a realistic plan for change, and to develop practical methods for carrying out this plan in everyday life.

The existential approach is the foundation of our integrative approach to counseling, and it underlies our integrated focus on thinking, feeling, and behaving. We both operate on the assumption that counseling is a life-changing process and that we each can be the architects of our own lives. We invite people to look at the choices they do have, however limited they may be, and to accept responsibility for choosing for themselves. We help clients discover their inner resources and learn how to use them in resolving their difficulties. If clients don’t like the design of their present existence, they can take steps to revise the blueprints. We do not provide answers for clients, but we facilitate a process that leads clients toward greater awareness of the knowledge and skills they can draw on to solve both their present and future problems. We believe counseling is a journey in which the therapist is a guide who facilitates client exploration.

We realize that choices available to people are oftentimes limited, and their freedom may be restricted by external factors. The unfortunate reality is that many clients have had to contend with oppressive conditions such as racism, discrimination, sexism, and poverty; it is important for helpers to do more than assume that clients are capable of changing their internal world. Helpers also have a role to play in bringing about change in the external environment when societal or community conditions are directly contributing to a client’s problems.

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Individuals cannot be understood without considering the various systems that affect them—family, social groups, community, church, and other cultural forces. For the helping process to be effective, it is critical to understand how individuals influence and are influenced by their social world. Effective helpers need to acquire a holistic approach that encompasses all facets of human experience.

As we work with an individual, we are not consciously thinking about what theory we are using. We adapt the techniques we use to fit the needs of the individual rather than attempting to fit the client to our techniques. In deciding on techniques to introduce, we take into account an array of factors about the client population. We consider the client’s readiness to confront an issue, the client’s cultural background, the client’s value system, and the client’s trust in us as helpers. A general goal that guides our practice is helping clients identify and experience whatever they are feeling, identifying ways in which their assumptions influence how they feel and behave, and experimenting with alternative modes of behaving. We have a rationale for using the techniques we employ, and our interventions generally flow from some aspects of the theories that we describe in the remainder of this chapter.

One way to understand how the various major theoretical orientations apply to the counseling process is to consider five categories under which most contemporary systems fall. These are (1) the psychodynamic approaches, which stress insight in therapy (psychoanalytic and Adlerian therapy); (2) the experiential and relationship-oriented approaches, which stress feelings and subjective experiencing (existential, person-centered, and Gestalt therapy); (3) the cognitive behavioral approaches, which stress the role of thinking and doing and tend to be action-oriented (behavior therapy, rational emotive behavior therapy, cognitive therapy, and reality therapy); (4) the postmodern approaches, which stress a collaborative and consultative stance on the therapist’s part (solution-focused brief therapy, motivational interviewing, narrative therapy, feminist therapy); and (5) family systems approaches, which stress understanding the individual within the entire system of which he or she is a part.

Although we have separated the theories into five general groups, this categorization is somewhat arbitrary. Overlapping concepts and themes make it difficult to neatly compartmentalize these theoretical orientations. Most training programs at the graduate level require students to take a semester-long theory course that describes each theory in great depth. Our purpose here is to provide an overview of the focus of each of these approaches by outlining their basic assumptions, key concepts, therapeutic goals, therapeutic relationship, techniques, multicultural applications, and main contributions to the helping process.

Psychodynamic Approaches Psychodynamic approaches provide the foundation from which many diverse theoretical orientations have sprung. Although most helpers will not have the training to practice psychoanalytically, this point of view is useful in gaining an understanding of client dynamics and how therapy can assist clients in working through some deeply engrained personality problems. Psychoanalytic therapy

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has progressed far beyond Freud; many contemporary forms of relational psychoanalysis can be adapted to brief therapeutic approaches.

Along with Freud, Alfred Adler was a major contributor to the development of the psychodynamic approach to therapy. Although influenced by many of Freud’s ideas, Adler developed a very different approach to therapy. Adlerians put the focus on reeducating individuals and reshaping society. Adler was the forerunner of a subjective approach to psychology that focuses on internal determinants of behavior such as values, beliefs, attitudes, goals, interests, and the individual perception of reality. He was a pioneer of an approach that is holistic, social, goal oriented, systemic, and humanistic. As you will see, many of Adler’s key concepts are found in other theories that emerged later in time.

Psychoanalytic Approach Overview and basic assumptions. The psychoanalytic approach rests on the assumption that normal personality development is based on dealing effectively with successive psychosexual and psychosocial stages of development. Faulty personality development is the result of inadequately resolving a specific developmental conflict. Practitioners with a psychoanalytic orientation are interested in the client’s early history as a way of understanding how past situations contribute to a client’s present problems.

Key concepts. The psychoanalytic approach is an in-depth and generally longer-term exploration of personality. Some of the key concepts that form this theory include consciousness and unconsciousness, dealing with anxiety, the functioning of ego-defense mechanisms, and the developmental stages throughout the life span.

Therapeutic goals. A primary goal is to make the unconscious conscious. Restructuring personality rather than solving immediate problems is the main goal. Childhood experiences are reconstructed in therapy, and these experiences are explored, interpreted, and analyzed. Successful outcomes of psychoanalytic therapy result in significant modification of an individual’s personality and character structure.

Therapeutic relationship. Psychoanalytically oriented therapists try to relate objectively with warm detachment. Both transference and countertransference are central aspects in the relationship. The focus is on resistances that occur in the therapeutic process, on interpretation of these resistances, and on working through transference feelings. Through this process, clients explore the parallels between their past and present experience and gain new understanding that can be the basis for personality change.

Techniques. All techniques are designed to help the client gain insight and bring repressed material to the surface so that it can be attended to in a conscious way. Major techniques include maintaining the analytic framework, free association, interpretation, dream analysis, analysis of resistance, and analysis of transference. These techniques are geared to increasing awareness, acquiring insight, and beginning a working-through process that will lead to a reorganization of the personality.

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Multicultural applications. The psychosocial approach that emphasizes turning points at various stages of life has relevance for understanding diverse client populations. Therapists can assist clients in identifying and dealing with the influence of environmental situations on their personality development. The goals of brief psychodynamic therapy are to provide a new understanding for current problems. With this briefer form of psychoanalytically oriented therapy, clients can relinquish old patterns and establish new patterns in their present behavior.

Contributions. The theory provides a comprehensive and detailed system of personality. It emphasizes the legitimate place of the unconscious as a determinant of behavior, highlights the significant effect of early childhood development, and provides techniques for tapping the unconscious. Several factors can be applied by practitioners who are not psychoanalytically oriented, such as understanding how resistance is manifested and can be therapeutically explored, how early trauma can be worked through successfully, and understanding the manifestations of transference and countertransference in the therapy relationship. Many other theoretical models have developed as reactions against the psychoanalytic approach.

Suggestions for further reading. A useful book for an overview of this approach is Brief Dynamic Therapy (Levenson, 2017).

The Adlerian Approach Overview and basic assumptions. According to the Adlerian approach, people are primarily social beings, influenced and motivated by societal forces. Adlerian therapy rests on a central belief that our happiness is largely related to social connectedness. Because we are embedded in a society, we cannot be understood in isolation from that social context. We are primarily motivated by a desire to belong. Human nature is viewed as creative, active, and decisional. The approach focuses on the unity of the person and on understanding the individual’s subjective perspective. The subjective decisions each person makes regarding the specific direction of this striving form the basis of the individual’s lifestyle (or personality style). The lifestyle consists of our beliefs and assumptions about others, the world, and ourselves; these views lead to distinctive behaviors that we adopt in pursuit of our life goals. We can shape our own future by taking risks and making decisions in the face of unknown consequences. People who seek counseling are not viewed as being “sick”; rather, they are seen as being discouraged and functioning on the basis of self-defeating and self-limiting assumptions. Clients require encouragement to correct mistaken perceptions of self and others and to learn to initiate new behavioral interaction patterns.

Key concepts. Consciousness, not the unconscious, is the center of personality. The Adlerian approach is based on a growth model and stresses the individual’s positive capacities to live fully in society. Adler saw humans as creative beings who possess strengths and abilities to effectively meet the problems of living. The theory is characterized by seeing unity in the personality,

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understanding a person’s world from a subjective vantage point, and stressing life goals that give direction to behavior. Social interest, the heart of this theory, involves a sense of identification with humanity, a feeling of belonging, and a concern with bettering society. Inferiority feelings often serve as the wellspring of creativity, motivating people to strive for mastery, superiority, and perfection. People attempt to compensate for both imagined and real inferiorities, which helps them overcome handicaps.

Therapeutic goals. Counseling is a collaborative effort, with client and therapist working on mutually accepted goals. Change is aimed at both the cognitive and behavioral levels. Adlerians are mainly concerned with challenging clients’ mistaken notions and faulty assumptions. Working cooperatively with clients, therapists try to provide encouragement so that clients can develop socially useful goals. Some specific goals include fostering social interest, helping clients overcome feelings of discouragement, changing faulty motivation, restructuring mistaken assumptions, and assisting clients to feel a sense of equality with others.

Therapeutic relationship. The client–therapist relationship is based on mutual respect, and both client and counselor are active parties in a relationship between equals. Through this collaborative partnership, clients recognize that they are responsible for their behavior. The emphasis is on examining the client’s lifestyle, which is expressed in everything the client does. Therapists frequently interpret this lifestyle by demonstrating connections between the past, the present, and the client’s future strivings.

The therapeutic process involves placing emphasis on the individual’s lifestyle—the cognitive framework or schema from which the individual attempts to understand life and to make behavior choices. More specifically, the therapist seeks to ascertain the faulty, self-defeating perceptions and assumptions about self, others, and life that maintain the problematic behavioral patterns the client brings to therapy.

Techniques. Adlerian therapists have developed a variety of cognitive, behavioral, and experiential techniques that can be applied to a diverse range of clients in a variety of settings and formats. Adlerians are not bound to follow a specific set of procedures, which gives them a great deal of freedom in working with clients in ways that are uniquely suited to their own therapeutic style. Some specific techniques they often employ are attending, encouragement, confrontation, summarizing, interpreting experiences within the family, early recollections, acting as if, catching oneself, suggestion, and homework assignments.

Multicultural applications. The interpersonal emphasis of the Adlerian approach is most appropriate for counseling people from diverse backgrounds. The approach offers a range of cognitive and action-oriented techniques to help people explore their concerns in a cultural context. Adlerian practitioners are flexible in adapting their interventions to each client’s unique life situation and are guided by what is in the best interests of the client. Adlerian therapy is an encouragement-focused counseling approach that has a psychoeducational focus,

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a present and future orientation, and is a brief, time-limited horizon. These characteristics make the Adlerian approach suitable for working with a wide range of client problems.

Contributions. One of Adler’s most important contributions is his influence on other therapy systems. There are significant linkages between Adlerian theory and most of the present-day theories. Indeed, Adler’s ideas are a part of many other psychological schools, such as family systems approaches, Gestalt therapy, reality therapy, rational emotive behavior therapy, cognitive therapy, person- centered therapy, solution-focused brief therapy, and existential therapy. These approaches are all based on a similar concept of the person as purposive and self-determining and as striving for growth and meaning in life.

Suggestions for further reading. An excellent resource on this approach is Adlerian Therapy (Carlson & Englar-Carlson, 2017). For further discussions of Adlerian therapy, see Corey (2021, chap. 5), Neukrug (2018, chap. 4), Prochaska and Norcross (2018, chap. 3), Watts (2019), and Wedding and Corsini (2019, chap. 3).

Experiential and Relationship-Oriented Approaches Therapy is often viewed as a journey taken by counselor and client, a journey that delves deeply into the world as perceived and experienced by the client. This journey is influenced by the quality of the person-to-person encounter in the therapeutic situation. The value of the therapeutic relationship is a common denominator among all therapeutic orientations, yet some approaches place more emphasis than others do on the role of the relationship as a healing factor. This is especially true of the existential, person-centered, and Gestalt approaches. These relationship-oriented approaches (sometimes known as experiential approaches) are all based on the premise that the quality of the client–counselor relationship is primary, with techniques being secondary. The experiential approaches are grounded on the premise that the therapeutic relationship fosters a creative spirit of inventing techniques aimed at increasing awareness, which enables clients to change some of their patterns of thinking, feeling, and behaving.

Some of the key concepts common to all experiential approaches that are believed to be related to effective therapeutic outcomes include the following: • The quality of the person-to-person encounter in the therapeutic situation is

the catalyst for positive change. • The counselor’s main role is to be present with clients during the therapeutic

hour. This implies that the counselor has good contact with the client and is centered.

• Clients can best be invited to grow by a counselor modeling authentic behavior.

• A therapist’s attitudes and values are at least as critical as his or her knowledge, theory, or techniques.

• Counselors who are not sensitively tuned in to their own reactions to a client run the risk of becoming technicians rather than artists.

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• The I-Thou relationship enables clients to experience the safety necessary for risk-taking behavior.

• Awareness emerges within the context of a genuine meeting between the counselor and the client, or within the context of I-Thou relating.

• The basic work of therapy is done by the client. The counselor’s job is to create a climate in which the client is likely to try out new ways of being. These somewhat overlapping notions give a sense of the paramount

importance of the therapeutic relationship. Counselors who operate in the framework of the relationship-oriented therapies are much less anxious about using the “right technique.” Their techniques are most likely designed to enhance some aspect of the client’s experiencing rather than being used to stimulate clients to think, feel, or act in a certain manner.

The Existential Approach Overview and basic assumptions. The existential perspective holds that we define ourselves by our choices. Although outside factors restrict the range of our choices, we have some freedom because we control our attitudes and behavior. Because we have the capacity for awareness, we have freedom, yet with this freedom comes responsibility for the choices we make. People seeking therapy often have led a restricted existence, functioning with a limited degree of self-awareness. The therapist’s job is to assist clients in becoming aware of how they are living so they can consider changes they may want to make. As an outgrowth of the therapeutic venture, clients are able to recognize patterns of living that are no longer useful for them, and they begin to accept responsibility for changing their future.

Key concepts. There are six key propositions of existential therapy: (1) We have the capacity for self-awareness. (2) Because we are basically free beings, we must accept the responsibility that accompanies our freedom. (3) We have a concern to preserve our uniqueness and identity; we come to know ourselves in relation to knowing and interacting with others. (4) The significance of our existence and the meaning of our life are never fixed once and for all; instead, we re-create ourselves through our projects. (5) Anxiety is part of the human condition. (6) Death is also a basic human condition, and awareness of it gives significance to living.

Therapeutic goals. The principal goal is to work with clients in recognizing their role in creating the kind of life they presently have. The existential approach places primary emphasis on understanding clients’ current experience, not on using therapeutic techniques. Existential therapists believe that we are capable of self-awareness, which is the distinctive capacity that allows us to reflect and to decide. With this awareness, we become free beings who are responsible for choosing the way we live, and thus we create our own destiny. The notions of freedom and responsibility challenge us to redesign our lives and to accept responsibility for choosing for ourselves. However, making choices gives rise to existential anxiety, another basic human characteristic, which is heightened when we reflect on the reality of death. Facing the inevitable prospect of eventual death gives the present moment significance as we become aware that we do not

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have forever to accomplish our goals. The reality of death is a catalyst that can challenge us to create a life that has meaning and purpose.

Therapeutic relationship. The client–therapist relationship is of paramount importance because the quality of the I-Thou encounter offers a context for change. Instead of prizing therapeutic objectivity and professional distance, existential therapists value being fully present, and they strive to create caring relationships with clients. Therapy is a collaborative relationship in which both client and therapist are involved in a journey into self-discovery.

Existential therapy and person-centered therapy place central prominence on the person-to-person relationship. Both of these approaches emphasize striving to maintain an equal-power relationship and an attitude of unconditional positive regard. Client growth occurs through a genuine encounter. A key factor influencing the outcome of therapy is the quality of the therapeutic relationship.

Techniques. Existential therapy reacts against the tendency to view therapy as a system of well-defined techniques; it affirms looking at those unique characteristics that make us human and building therapy upon them. Primary emphasis is on understanding the client’s current experience. Existential therapists are free to adapt their interventions to their own personality and style, as well as paying attention to what each client requires. Therapists are not bound by any prescribed procedures and can use techniques from other therapeutic models. Interventions are used in the service of broadening the ways in which clients live in their world. Techniques are tools to help clients become aware of their choices and their potential for action.

Multicultural applications. Because the existential approach is based on universal human themes, and because it does not dictate a particular way of viewing reality, it is highly applicable when working in a multicultural context. In working with cultural diversity, it is essential to recognize the commonalities and similarities among clients. Themes such as relationships, finding meaning, anxiety, suffering, and death are concerns that transcend the boundaries that separate cultures. Clients in existential therapy are encouraged to examine the ways their present existence is being influenced by social and cultural factors. From a social justice perspective, the freedom to choose needs to be viewed within the context of environmental realities such as discrimination and oppression.

Contributions. The person-to-person therapeutic relationship lessens the chances of dehumanizing therapy. The approach has something to offer counselors regardless of their theoretical orientation. The basic ideas of this approach can be incorporated into practice regardless of the counselor’s particular theory. It provides a perspective for understanding the value of anxiety and guilt, the role and meaning of death, and the creative aspects of being alone and choosing for oneself.

Suggestions for further reading. An excellent resource on the existential approach is Existential-Humanistic Therapy (Schneider & Krug, 2017). For further discussions of existential therapy, see Corey (2021, chap. 6), Deurzen (2010, 2012), Elkins (2009, 2016), Neukrug (2018, chap. 5), Prochaska and Norcross (2018, chap. 4), and Wedding and Corsini (2019, chap. 8).

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The Person-Centered Approach Overview and basic assumptions. Person-centered therapy was originally developed by Carl Rogers in the 1940s as a reaction against psychoanalytic therapy. Based on a subjective view of human experience, the person-centered approach emphasizes the client’s resources for becoming self- aware and for resolving blocks to personal growth. It puts the client, not the therapist, at the center of the therapeutic process. It is the client who primarily brings about change. Rogers did not present his approach as being a final model, and he expected the theory and practice to evolve over time. By participating in the therapeutic relationship, clients actualize their potential for growth, wholeness, spontaneity, and inner-directedness.

Key concepts. A key concept is that clients have the capacity for resolving life’s problems effectively without interpretation and direction from an expert therapist. Clients are able to change without a high degree of structure and direction from the therapist. This approach emphasizes fully experiencing the present moment, learning to accept oneself, and deciding on ways to change.

Therapeutic goals. A major goal is to provide a climate of safety and trust in the therapeutic setting so that the client, by using the therapeutic relationship for self-exploration, can become aware of obstacles to growth. The client tends to move toward more openness, greater self-trust, and more willingness to evolve as opposed to being a static entity. The client learns to live by internal standards as opposed to taking external cues for what he or she should become. The aim of therapy is not merely to solve problems but to assist a client’s growth process to enable him or her to better cope with present and future problems.

Therapeutic relationship. The person-centered approach emphasizes the attitudes and personal characteristics of the therapist and the quality of the client–therapist relationship as the prime determinants of the outcomes of therapy. The qualities of the therapist that determine the relationship include genuineness, nonpossessive warmth, accurate empathy, unconditional acceptance of and respect for the client, permissiveness, caring, and the ability to communicate those attitudes to the client. Effective therapy is based on the quality of the relationship between therapist and client. The client is able to translate his or her learning in therapy to outside relationships with others.

Techniques. Because this approach stresses the client–therapist relationship as a necessary and sufficient condition leading to change, it specifies few techniques. Techniques are always secondary to the therapist’s attitudes. The approach minimizes directive techniques, interpretation, questioning, diagnosis, and collecting history. It maximizes active listening and hearing, expressing empathy, reflection of feelings, and clarification.

Multicultural applications. The emphasis on universal, core conditions provides the person-centered approach with a framework for understanding diverse worldviews. Empathy, being present, and respecting the values of clients are essential attitudes and skills in counseling culturally diverse clients. Person- centered counselors convey a deep respect for all forms of diversity and value understanding the client’s subjective world in an accepting and open way.

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Contributions. One of the first therapeutic orientations to break from traditional psychoanalysis, the person-centered approach stresses the active role and responsibility of the client. It is a positive and optimistic view and calls attention to the need to account for a person’s inner and subjective experiences. Emphasizing the crucial role of the therapist’s attitude, this approach makes the therapeutic process relationship-centered rather than technique-centered.

Suggestions for further reading. A useful book for an overview of this approach is Person-Centered Psychotherapies (Cain, 2010).

Gestalt Therapy Overview and basic assumptions. Gestalt therapy is an experiential and existential approach based on the assumption that individuals and their behavior must be understood in the context of their present environment. The therapist’s task is to facilitate clients’ exploration of their present experience. Awareness, choice, and responsibility are cornerstones of practice. Clients carry on their own therapy as much as possible by doing experiments designed to heighten awareness and to engage in contact. Change occurs naturally as awareness of “what is” increases. Heightened awareness can also lead to a more thorough integration of parts of the client that were fragmented or unknown. Gestalt therapy pays attention to process as well as content. This approach is phenomenological because it focuses on the client’s perceptions of reality and is existential because it is grounded in the notion that people are always in the process of becoming, remaking, and rediscovering themselves.

Key concepts. This approach focuses on the here-and-now, direct experiencing, awareness, bringing unfinished business from the past into the present, and dealing with unfinished business. Other concepts include energy and blocks to energy, contact and resistance to contact, and paying attention to nonverbal cues. Clients identify their own unfinished business from the past that is interfering with their present functioning by reexperiencing past situations as though they were happening in the present moment.

Therapeutic goals. The goal is attaining awareness and greater choice. Awareness includes knowing the environment and knowing oneself, accepting oneself, and being able to make contact. Clients are helped to note their own awareness process so that they can be responsible and can selectively and discriminatingly make choices. With awareness the client is able to recognize denied aspects of the self and proceed toward reintegration of all its parts.

Therapeutic relationship. This approach stresses the I-Thou relationship. The focus is not on the techniques employed by the therapist but on who the therapist is as a person and the quality of the relationship. Factors emphasized include the therapist’s presence, authentic dialogue, gentleness, direct self- expression, and a greater trust in the client’s experiencing. There is a creative spirit of suggesting, inventing, and carrying out experiments aimed at increasing awareness. The counselor assists clients in experiencing all feelings more fully and letting them make their own interpretations. Technical expertise

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is important, but the therapeutic engagement is paramount. Rather than interpreting the meaning of experience for clients, the therapist focuses on the “what” and “how” of their behavior.

Techniques. Although the therapist functions as a guide and a catalyst, presents experiments, and shares observations, the basic work of therapy is done by the client. Therapists do not force change on clients; rather, they create experiments within a context of the I-Thou dialogue in a here-and-now framework. These experiments are the cornerstone of experiential learning. Although the therapist suggests the experiments, this is a collaborative process with full participation by the client. Gestalt experiments take many forms: setting up a symbolic dialogue between a client and a significant person in his or her life; assuming the identity of a key figure through role playing; reliving a painful event; exaggerating a gesture, posture, or some nonverbal mannerism; or carrying on a dialogue between two conflicting aspects within an individual.

Multicultural applications. Gestalt therapy can be used creatively and sensitively with culturally diverse populations if interventions are used flexibly and in a timely manner. Gestalt practitioners focus on understanding the person and not on the use of techniques. Experiments are done with the collaboration of the client and with an attempt to understand the background of the client’s culture.

Contributions. Gestalt therapy recognizes the value of working with the past from the perspective of the here-and-now. This orientation emphasizes doing and experiencing as opposed to merely talking about problems in a detached way. Gestalt therapy gives attention to nonverbal and body messages, which broaden the field of material to be explored in a helping relationship. It provides a perspective on growth and enhancement, not merely a treatment of disorders. The method of working with dreams is a creative pathway to increased awareness of key existential messages in life.

Suggestions for further reading. A useful and current resource on this approach is Gestalt Therapy (Wheeler & Axelsson, 2015). For further discussion of Gestalt therapy, see Corey (2021, chap. 8), Neukrug (2018, chap. 6), Prochaska and Norcross (2018, chap. 6), and Wedding and Corsini (2019, chap 9).

Cognitive Behavioral Approaches This section describes some of the main cognitive behavioral approaches, which include behavior therapy, rational emotive behavior therapy, cognitive therapy, and reality therapy. It also includes an introduction to the third wave of behavior therapy approaches known as mindfulness and acceptance therapies. Although the cognitive behavioral approaches are quite diverse, they do share these attributes: (1) a collaborative relationship between client and therapist, (2) the premise that psychological distress is largely a function of disturbances in cognitive processes, (3) an emphasis on changing cognitions to produce desired changes in affect and behavior, and (4) a time-limited and educational treatment focusing on specific target problems. The cognitive behavioral approaches are

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based on a structured, psychoeducational model, and they tend to emphasize the role of homework, place responsibility on the client to assume an active role both during and outside of therapy sessions, and draw from a variety of cognitive and behavioral techniques to facilitate change. Cognitive behavioral practitioners are concerned with teaching clients how to be their own therapist. Typically, a therapist will educate clients about the nature and course of their problem, about the process of cognitive therapy, and how thoughts influence emotions and behaviors. The educative process includes providing clients with information both about their presenting problems and about relapse prevention, which consists of ways to deal with the inevitable setbacks clients are likely to experience as they apply what they are learning to daily life. Of all the therapeutic models, the cognitive behavioral therapies have gained most in popularity and are increasingly being used as the basis for practice with a wide variety of client populations, with a multitude of problems, and in many different settings.

Behavior Therapy Overview and basic assumptions. Behavioral approaches assume that people are basically shaped by both learning and the sociocultural environment. Due to the diversity of views and strategies, it is more accurate to think of behavioral therapies rather than a unified approach. The central characteristics that unite the diversity of views of the field of behavior therapy are a focus on observable behavior, current determinants of behavior, learning experiences to promote change, and rigorous assessment and evaluation. A basic assumption of the behavioral perspective is that most problematic cognitions, emotions, and behaviors have been learned and that new learning can modify them. Although this modification process is often called “therapy,” it is more properly an educational experience in which individuals are involved in a teaching/ learning process.

Key concepts. Behavior therapy emphasizes current behavior as opposed to historical antecedents, precise treatment goals, diverse therapeutic strategies tailored to these goals, and objective evaluation of therapeutic outcomes. Therapy focuses on behavior change in the present and on action programs. Concepts and procedures are stated explicitly, tested empirically, and revised continually. There is an emphasis on measuring a specific behavior before and after an intervention to determine if, and to what degree, behaviors change as a result of a procedure.

Therapeutic goals. A hallmark of behavior therapy is the identification of specific goals at the outset of the therapeutic process. The general goals are to increase personal choice and to create new conditions for learning. An aim is to eliminate maladaptive behaviors and to replace them with more constructive patterns. Generally, client and therapist collaboratively specify treatment goals in concrete, measurable, and objective terms. In helping clients achieve their goals, behavior therapists typically assume an active and directive role. Although the client generally determines what behavior will be changed, the therapist typically determines how this behavior can best be modified.

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Therapeutic relationship. Although the approach does not place primary emphasis on the client–therapist relationship, a good working relationship is an essential precondition for effective therapy. The skilled therapist can conceptualize problems behaviorally and make use of the therapeutic relationship in bringing about change. The assumption is that clients make progress primarily because of the specific behavioral techniques used rather than by the relationship with the therapist. The therapist’s role is to teach concrete skills through the provision of instructions, modeling, and performance feedback. Therapists tend to be active and directive and to function as consultants and problem solvers. Clients must also be actively involved in the therapeutic process from beginning to end, and they are expected to cooperate in carrying out therapeutic activities, both in the sessions and outside of therapy.

Techniques. Behavior therapy differs from other therapies in that it is brief, active, directive, collaborative, and focused on factors maintaining problem behaviors rather than on factors that may have triggered a problem initially. Assessment and diagnosis are done at the outset to determine a treatment plan. Behavioral treatment interventions are individually tailored to specific problems experienced by clients. Any technique that can be demonstrated to change behavior may be incorporated in a treatment plan. A strength of the approach lies in the many and varied techniques aimed at producing behavior change, a few of which are relaxation methods, systematic desensitization, in vivo desensitization, flooding, assertion training, and self-management programs.

Multicultural applications. Behavioral approaches can be appropriately integrated into counseling with culturally diverse client populations when culture-specific procedures are developed. The approach emphasizes teaching clients about the therapeutic process and stresses changing specific behaviors. By developing their problem-solving skills, clients learn concrete methods for dealing with practical problems within their cultural framework.

Contributions. Behavior therapy is usually a short-term approach, and it has wide applicability. It emphasizes research into and assessment of the techniques used, thus providing accountability. Specific problems are identified and explored, and clients are kept informed about the therapeutic process and about the gains being made. The approach has demonstrated effectiveness in many areas of human functioning, and the concepts and procedures are easily grasped. The therapist is an explicit reinforcer, consultant, model, teacher, and expert in behavioral change.

Suggestions for further reading. For further discussion of behavior therapy, see Corey (2021, chap. 9), Craske (2017), Dobson and Dobson (2017), Kazantzis, Dattilio, and Dobson (2017), Ledley, Marx, and Heimberg (2018), and Wedding and Corsini (2019, chap. 6).

Rational Emotive Behavior Therapy Overview and basic assumptions. Albert Ellis is considered the father of rational emotive behavior therapy (REBT) and the grandfather of cognitive behavior therapy. Rational emotive behavior therapy rests on the premise that thinking, evaluating, analyzing, questioning, doing, practicing, and redeciding

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are the basics of behavior change. The cognitive behavioral approaches are based on the assumption that a reorganization of one’s self-statements will result in a corresponding reorganization of one’s behavior.

Key concepts. REBT holds that although emotional disturbance is rooted in childhood, people keep repeating irrational and illogical beliefs. Emotional problems are the result of one’s beliefs, not events, and these beliefs need to be challenged. Clients are taught that the events of life themselves do not disturb us; rather, our interpretation of events is what is critical.

Therapeutic goals. The goal of REBT is to eliminate a self-defeating outlook on life, to reduce unhealthy emotional responses, and to acquire a more rational and tolerant philosophy. Two main goals of REBT are to assist clients in the process of achieving unconditional self-acceptance and to learn unconditional acceptance of others. To accomplish these goals, REBT offers clients practical ways to identify their underlying faulty beliefs, to critically evaluate these beliefs, and to replace them with constructive beliefs.

Therapeutic relationship. Therapy is a process of reeducation, and the therapist functions largely as a teacher in active and directive ways. As clients begin to understand how they continue to contribute to their problems, they need to actively practice changing their self-defeating behavior and converting it to rational behavior.

Techniques. REBT utilizes a wide range of cognitive, emotive, and behavioral methods with most clients. This approach blends techniques to change clients’ patterns of thinking, feeling, and acting. Techniques are designed to induce clients to critically examine their present beliefs and behavior. REBT focuses on specific techniques for changing a client’s self-defeating thoughts in concrete situations. In addition to modifying beliefs, REBT helps clients see how their beliefs influence what they feel and what they do. From a cognitive perspective, REBT demonstrates to clients that their beliefs and self-talk keep them disturbed. Although this approach does not give priority to feelings, as clients explore what they are thinking and how they are acting, feelings often surface. When feelings do emerge, they can be addressed.

Multicultural applications. Some factors that make REBT effective in working with diverse client populations include tailoring treatment to each individual, addressing the role of the external environment, the active and directive role of the therapist, the emphasis on education, relying on empirical evidence, the focus on present behavior, and the brevity of the approach. REBT practitioners function as teachers; clients acquire a wide range of skills they can use in dealing with the problems of living. This educational focus appeals to many clients who are interested in learning practical and effective methods of bringing about change.

Contributions. REBT is a comprehensive, integrative approach to therapy aimed at changing disturbances in thinking, feeling, and behaving. REBT has taught us how people can change their emotions by changing the content of their thinking. Counseling is brief and places value on active practice in experimenting with new behavior so that insight is carried into doing.

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Suggestions for further reading. A useful book for an overview of this approach is Rational Emotive Behavior Therapy (Ellis & Ellis, 2011).

Cognitive Therapy Overview and basic assumptions. Aaron Beck is a pioneer of cognitive therapy who made important contributions in understanding and treating disorders such as depression and anxiety. Cognitive therapy (CT) rests on the premise that cognitions are the major determinants of how we feel and act. CT assumes that the internal dialogue of clients plays a major role in their behavior. The ways in which individuals monitor and instruct themselves and interpret events shed light on the dynamics of disorders such as depression and anxiety.

Key concepts. According to CT, psychological problems stem from commonplace processes such as faulty thinking, making incorrect inferences on the basis of inadequate or incorrect information, and failing to distinguish between fantasy and reality. Cognitive therapy consists of changing dysfunctional emotions and behaviors by modifying inaccurate and dysfunctional thinking.

Therapeutic goals. The goal of CT is to change the way clients think by using their automatic thoughts to reach the core schemata and begin to introduce the idea of schema restructuring. Changes in beliefs and thought processes tend to result in changes in the way people feel and how they behave. Clients in CT are encouraged to gather and weigh the evidence in support of their beliefs. Through the collaborative therapeutic effort, they learn to discriminate between their own thoughts and the events that occur in reality.

Therapeutic relationship. CT emphasizes a collaborative effort by both therapist and client to frame the client’s conclusions in the form of a testable hypothesis. Cognitive therapists are continuously active and deliberately interactive with the client; they also strive to engage the client’s active participation and collaboration throughout all phases of therapy.

Techniques. CT emphasizes a Socratic dialogue to help clients discover their misconceptions for themselves. Through a process of guided discovery, the therapist functions as a catalyst and guide who helps clients understand the connection between their thinking and the ways they feel and act. Cognitive therapists teach clients how to be their own therapist. This includes educating clients about the nature and course of their problems, about how CT works, and how their thinking influences their emotions and behaviors. Techniques in CT are designed to identify and test the client’s misconceptions and faulty assumptions. Homework is often used, which is tailored to the client’s specific problems and arises out of the collaborative therapeutic relationship. Homework is generally presented as an experiment, and clients are encouraged to create their own self- help assignments as a way to keep working on issues addressed in their therapy sessions.

Multicultural applications. CT is culturally sensitive in that it uses the individual’s belief system, or worldview, as part of the method of self-change.

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The collaborative nature of CT offers clients the structure many clients want, yet the therapist still strives to enlist clients’ active participation in the therapeutic process. Because of the way CT is practiced, with emphasis on enlisting the full participation of clients, it is ideally suited to working with clients from diverse backgrounds.

Contributions. CT has been demonstrated to be effective in the treatment of anxiety, phobias, and depression. This approach has received a great deal of attention by clinical researchers. Many specific cognitive techniques have been supported by empirical evidence as being useful in teaching clients ways to change their belief systems.

Suggestions for further reading. If you are interested in further reading on integrating cognitive therapy into a comprehensive approach, consult J. Beck (2005, 2011), Dobson and Dobson (2017), Ellis and Ellis (2011), Kazantzis, Dattilio, and Dobson (2017), Meichenbaum (2012, 2017), Sperry and Sperry (2018), and Vernon and Doyle (2018). For a general treatment of cognitive perspectives, see Beck and Weishaar (2019, chap. 7) and Corey (2021, chap. 10).

Choice Theory/Reality Therapy Overview and basic assumptions. Choice theory rests on the assumption that humans are internally motivated and behave to control the world around them according to some purpose within them. Choice theory, which is the underlying philosophy of the practice of reality therapy, provides a framework that explains the why and how of human behavior. Founded and developed by William Glasser in the 1960s, reality therapy posits that people are responsible for what they do. Based on existential principles, reality therapy holds that we choose our own destiny. Reality therapy is based on the assumption that human beings are motivated to change (1) when they determine that their current behavior is not getting them what they want and (2) when they believe they can choose other behaviors that will get them closer to what they want. Clients are expected to make an assessment of their current behavior to determine specific ways they may want to change.

Key concepts. The core concept of this approach is that behavior is our best attempt to control our perceptions of the external world so they fit our internal world. Total behavior includes four inseparable but distinct components—acting, thinking, feeling, and the physiology that accompanies our actions. A key concept of reality therapy and choice theory is that no matter how dire our circumstances may be, we always have a choice. The key to changing a total behavior is through acting and thinking, for these aspects of total behavior are easier to change than are the feeling and physiology components. An emphasis of reality therapy is on assuming personal responsibility and on dealing with the present.

Therapeutic goals. The overall goal of this approach is to help people find better ways to meet their needs for survival, love and belonging, power, freedom, and fun. Changes in behavior should result in the satisfaction of basic needs. Clients are expected to make a self-evaluation of what they are doing, thinking, and feeling to assess whether this is getting them what they want and to assist them in finding a better way to function.

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Therapeutic relationship. The therapist initiates the therapeutic process by becoming involved with the client and creating a supportive and challenging relationship. Practitioners teach clients how to make significant connections with others. Throughout therapy the counselor avoids criticism, refuses to accept clients’ excuses for not following through with agreed-upon plans, and does not easily give up on clients. Instead, counselors continue to ask clients to evaluate the effectiveness of what they are choosing to determine if better choices may be possible.

Techniques. The practice of reality therapy can best be conceptualized as the cycle of counseling, which consists of two major components: (1) the counseling environment and (2) specific procedures that lead to change in behavior. Reality therapy is active, directive, and didactic. Skillful questioning and various behavioral techniques are employed to help clients make a comprehensive self-evaluation.

Some of the specific procedures in the practice of reality therapy have been developed by Robert Wubbolding (2011, 2017). These procedures are summarized in the WDEP model, which refers to the following clusters of strategies:

W = wants: exploring wants, needs, and perceptions D = direction and doing: focusing on what clients are doing and the

direction that this is taking them E = evaluation: challenging clients to make an evaluation of their total

behavior P = planning and commitment: assisting clients in formulating realistic

plans and making a commitment to carry them out

Multicultural applications. Reality therapists demonstrate their respect for the cultural values of their clients by helping them explore how satisfying their current behavior is both to themselves and to others. After clients make this self-assessment, they identify those areas of living that are not working for them. Clients are then in a position to formulate specific and realistic plans that are consistent with their cultural values.

Contributions. As a short-term approach, reality therapy can be applied to a wide range of clients. Reality therapy consists of simple, clear concepts that are easily understood by many in the human services field, and the principles can be used by parents, teachers, and clergy. As a positive and action-oriented approach, it appeals to a variety of clients who are typically viewed as difficult to treat. This approach teaches clients to focus on what they are able and willing to do in the present to change their behavior.

Suggestions for further reading. The most current book on reality therapy is Reality Therapy and Self-Evaluation: The Key to Client Change (Wubbolding, 2017). For further discussion of reality therapy and choice theory, see Corey (2021, chap. 11), Glasser (1998, 2001), Neukrug (2018, chap. 11), and Wubbolding (2011, 2013, 2016, 2017).

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Mindfulness and Acceptance Therapies Mindfulness and acceptance are cutting-edge therapeutic approaches often referred to as the third wave of behavior therapy. These third-generation behavior therapies center around four core themes: (1) an expanded view of psychological health, (2) a broad view of acceptable therapeutic outcomes, (3) mindfulness and acceptance, and (4) designing a life worth living. The mindfulness and acceptance therapies are expected to increase in popularity in the future (Prochaska & Norcross, 2018). Mindfulness-based therapies are effective treatments for stress disorders and may be even more effective when combined with therapeutic lifestyle changes such as exercise, time in nature, diet and nutrition, recreation, providing service to others, relationships, relaxation, and spiritual involvement (Walsh & Vaughan, 2019).

Contemporary developments in the cognitive behavioral tradition include four major approaches: (1) dialectical behavior therapy (DBT), which has become a recognized treatment for borderline personality disorder; (2) mindfulness- based stress reduction (MBSR), which applies mindfulness techniques to coping with stress and promoting physical and psychological health; (3) mindfulness- based cognitive therapy (MBCT), aimed primarily at treating depression; and (4) acceptance and commitment therapy (ACT), which encourages clients to accept unpleasant sensations rather than attempting to control or change them. All of these mindfulness-based approaches have been subjected to empirical scrutiny, which is a hallmark of the behavioral tradition.

For an in-depth discussion of the role of mindfulness in psychotherapeutic practice, see Acceptance and Mindfulness in Cognitive Behavior Therapy: Understanding and Applying the New Therapies (Herbert & Forman, 2011); Mindfulness and Psychotherapy (Germer, Siegel, & Fulton, 2013); Wisdom and Compassion in Psychotherapy: Deepening Mindfulness in Clinical Practice (Germer & Siegel, 2012), and The Mindfulness Solution: Everyday Practices for Everyday Problems (Siegel, 2010).

Dialectical behavior therapy. Dialectical behavior therapy (DBT) was developed by Marsha Linehan (1993a, 1993b), who wanted to alleviate emotional suffering for those who were considering suicide. Now DBT is considered a key approach for treating individuals diagnosed with borderline personality disorder. DBT has been proven effective in treating a wide range of disorders, including anxiety disorders, depression, substance use disorder, posttraumatic stress disorder, eating disorders, and nonsuicidal self-injury (Linehan, 2015).

Dialectical behavior therapists emphasize a strong therapeutic alliance, which occurs by establishing a structured, predictable therapeutic environment. A general goal of DBT is to decrease ineffective coping behaviors and increase effective behaviors through skills training and generalizing these skills to daily life. When clients begin DBT, they are asked to identify some specific goals in life that would make life worth living (Kelly & Robinson, 2018).

Mindfulness, the unfolding of experience moment by moment, is a fundamental skill in DBT that enables individuals to be aware of and accept

This section is adapted from The Art of Integrative Counseling (Corey, 2019, chap. 8) and Theory and Practice of Counseling and Psychotherapy (Corey, 2021, chap. 9).