A Paragraph

Read: Tan: Chapters 1 – 4

Chapters 1

Overview of Counseling and Psychotherapy

Theory, Research, and Practice

Sigmund Freud (1856–1939), the founder of psychoanalysis, is often credited with the birth of psychotherapy, or the “talking cure.” However, the deep roots of counseling and psychotherapy go back many centuries before Freud. Today the field of counseling and psychotherapy is large and diverse. There has been a proliferation of major therapies in the past fifty years: from thirty-six systems of psychotherapy identified by R. A. Harper in 1959 to over five hundred today (Prochaska & Norcross 2018, 1), with some authors even estimating over a thousand current approaches to counseling and psychotherapy (J. Sommers-Flanagan & Sommers-Flanagan, 2018, 391). Even the definitions of counseling and psychotherapy differ from author to author and from textbook to textbook. Most people think of counseling and psychotherapy as involving a professional counselor or therapist helping clients to deal with their problems in living. Let us take a closer look at some definitions of counseling and psychotherapy in this introductory overview chapter.

Definitions of Counseling and Psychotherapy

There are many different definitions of psychotherapy, none of which is precise (Corsini & Wedding 2008). James Prochaska and John Norcross (2018) have chosen to use the following working definition of psychotherapy (from Norcross 1990, 218): “Psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable” (2).

Similarly, there are also several possible definitions of counseling. Christian psychologist Gary Collins has defined counseling as “a relationship between two or more persons in which one person (the counselor) seeks to advise, encourage and/or assist another person or persons (the counselee[s]) to deal more effectively with the problems of life” (1972, 13). He further states: “Unlike psychotherapy, counseling rarely aims to radically alter or remold personality” (14). Some authors therefore try to differentiate counseling and psychotherapy on a continuum, with psychotherapy dealing with deeper problems and seeking to significantly change personality. However, most authors in the mental health field today do not differentiate between counseling and psychotherapy (see, e.g., Corey 2021; Day 2004; Fall, Holden, & Marquis 2017; Parrott 2003; J. Sommers-Flanagan & Sommers-Flanagan 2018), agreeing with Charles Truax and Robert Carkhuff (1967), who, years ago, already used the two terms interchangeably. In fact, C. H. Patterson emphatically asserts that no essential differences exist between counseling and psychotherapy (1973, xiv). This is the view I take in this textbook on counseling and psychotherapy from a Christian perspective.

John Sommers-Flanagan and Rita Sommers-Flanagan also use counseling or psychotherapy interchangeably and define it as

(a) a process that involves (b) a trained professional who abides by (c) ethical guidelines and has (d) competencies for working with (e) diverse individuals who are in distress or have life problems that led them to (f) seek help (possibly at the insistence of others), or they may be (g) seeking personal growth, but either way, these parties (h) establish an explicit agreement (informed consent) to (i) work together (more or less collaboratively) toward (j) mutually acceptable goals (k) using theoretically based or evidence-based procedures that, in the broadest sense, have been shown to (l) facilitate human learning or human development or reduce disturbing symptoms. (2018, 7, emphasis in original)

Psychotherapy and Psychological Treatments

David Barlow (2004, 2005, 2006) has attempted to differentiate psychotherapy from psychological treatments, which may add more confusion rather than clarity to the already diverse definitions available for counseling and psychotherapy. He suggests that “psychological treatments” should refer to those dealing primarily with pathology, while “psychotherapy” should refer to treatments that address adjustment or growth (2006, 216). Psychological treatments are therefore those that are clearly compatible with the objectives of health-care systems that address pathology. He further stresses that the two activities of psychological treatment (which is more specific) and psychotherapy (which is more generic) would not be distinguished based on theory, technique, or evidence, but only on the problems they deal with. He is aware that these are controversial recommendations. However, I believe Barlow’s (2006) recommendation is not only controversial but also potentially confusing and may not really help to clarify the definition of terms. Examples of psychological treatments provided by Barlow include “assertive community treatment, cognitive-behavioral therapy, community reinforcement approaches, dialectical behavior therapy, family focused therapy, motivational interviewing, multisystemic interpersonal therapy, parent training (for externalizing disorders in children), personal therapy for schizophrenia, and stress and pain management procedures” (2004, 873, emphasis in original). We can see that many of these examples of psychological treatments are already part and parcel of counseling and psychotherapy.

Overview of Counseling and Psychotherapy: Theory

Although over five hundred varieties of counseling and psychotherapy presently exist, most of them can be subsumed under the major schools of counseling and psychotherapy that are usually covered in textbooks in this field of people-helping. There are usually eleven to fifteen major ones, depending on the author and the text. In this book the following thirteen major theoretical approaches to counseling and psychotherapy will be covered in some detail (in chaps. 4–16), based on the theories and techniques developed by their founders and practitioners: psychoanalytic therapy, Adlerian therapy, Jungian therapy, existential therapy, person-centered therapy, Gestalt therapy, reality therapy, behavior therapy, cognitive behavior therapy and rational emotive behavior therapy, mindfulness and acceptance-based cognitive-behavioral therapies, constructivist therapies, integrative therapies and positive psychotherapy, and marital and family therapy.

Psychoanalytic Therapy. The key figure within the field of psychoanalysis and psychoanalytic therapy is Sigmund Freud. He originated a theory of personality development focused on experiences in the first six years of life that determine the subsequent development of personality. Freudian or psychoanalytic theory emphasizes unconscious factors, especially sexual and aggressive drives motivating human behavior. Psychoanalytic therapy employs techniques such as free association (allowing the client to say whatever comes to mind without censorship); dream analysis (interpreting the latent or hidden meaning of the dream mainly through the use of symbols that have consistent significance for almost every person); and analysis of transference (when the client responds to the analyst or therapist as a significant person of authority in their life, thereby revealing childhood conflicts the client has experienced). The goal of psychoanalytic therapy is to help make the unconscious to be conscious and strengthen the ego. Contemporary versions of psychoanalytic therapy, such as object-relations theory, focus more on attachment and human relationship needs rather than on sexual and aggressive drives. Attachment theory and therapies are therefore covered in more detail, as are supportive therapy, brief psychodynamic therapy, and the recently developed mentalization-based therapy.

Adlerian Therapy. Alfred Adler founded Adlerian therapy, originally called individual psychology. Another major figure in this approach is Rudolph Dreikurs, who was responsible for making it better known in the United States. Adlerian therapy is based on a growth model of the human person. It emphasizes the need for the client to take responsibility in making choices that help determine their own destiny and that provide meaning and direction for their life. Adlerian therapy uses techniques, such as investigating the client’s lifestyle or basic orientation toward life, by exploring birth order, early recollections from childhood years, and dreams; encouragement; acting “as if” (trying a behavior or action the client is afraid of failing in, acting as if it will succeed); and paradoxical intention (encouraging clients to do or exaggerate the very behaviors they are attempting to avoid).

Jungian Therapy. The key figure of Jungian therapy, or analytical psychology, is Carl Jung. Jung’s interest in mystical traditions led him to conclude that human beings have a significant and mysterious potential within their unconscious. He described both a personal unconscious as well as a collective unconscious. Jungian therapy encourages clients to connect the conscious and unconscious aspects of their mind in constant dialogue, with the goal of individuation or becoming one’s own person. Jungian therapy techniques include the extensive use of dream analysis and the interpretation of symbols to help clients recognize their archetypes (ordering or organizing patterns in the unconscious). Examples of archetypal images include major ones such as the persona, the shadow, the anima and animus, and the Self, as well as others such as the earth mother, the hero, and the wise old man.

Existential Therapy. The key figures of existential therapy include Viktor Frankl, the founder of logotherapy; Rollo May; Ludwig Binswanger; Medard Boss; James Bugental; and Irvin Yalom. It focuses on helping clients experience their existence in an authentic, meaningful, and responsible way, encouraging them to freely choose or decide, so that they can create meaning in their lives. Existential therapy therefore emphasizes more the relationship and encounter between therapist and client rather than therapeutic techniques. Core life issues often dealt with in existential therapy include death, freedom, meaninglessness, isolation, and the need to be authentic and real in responsibly choosing one’s values and approach to life. Existential therapists can be optimistic or pessimistic to the point of being nihilistic, and they include those who are religious as well as those who are antireligious. Although techniques are not stressed in existential therapy, Frankl developed several techniques in logotherapy, a specific approach to existential therapy. Some examples are dereflection (encouraging the client to ignore the problem and focus attention on something more pleasant or positive); paradoxical intention (asking the client to do or exaggerate the very behavior the client fears doing); and modifying the client’s attitudes or thinking (especially about the past, which cannot be changed, so that more meaningful or hopeful ways of looking at things become the focus).

Person-Centered Therapy. Carl Rogers founded person-centered therapy, which was previously called nondirective counseling or client-centered therapy. Person-centered therapy assumes that each person has a deep capacity for significant and positive growth when provided with the right environment and relationships. The client is trusted to lead in therapy and is free to discuss whatever they wish. Person-centered therapy is therefore not focused on problem solving but aims instead to help clients know who they are authentically and to become what Rogers calls “fully functioning” persons. According to Rogers, three therapeutic conditions are essential for facilitating client change and growth; these are the major person-centered therapy “relationship techniques”: congruence or genuineness; unconditional positive regard (valuing the client with respect); and accurate empathy (empathic understanding of the client’s perspective or internal frame of reference). Motivational interviewing is a more contemporary therapy that has Rogerian or person-centered foundations, especially empathy, but goes beyond that to using problem-solving and specific interventions for therapeutic change.

Gestalt Therapy. Frederick (Fritz) Perls and Laura Perls founded Gestalt therapy, an experiential therapy that emphasizes increasing the client’s awareness, especially of the here and now, and integration of body and mind. The Gestalt therapist assumes a quite active role in helping clients become more aware so that they can solve their problems in their own way and time. Examples of Gestalt therapy techniques that focus on doing include dream work, which is experiential; converting questions to statements; using personal nouns; assuming responsibility; the empty chair; exaggeration; and confrontation.

Reality Therapy. William Glasser founded reality therapy, which focuses on the present and emphasizes the client’s strengths. It is based on choice theory as developed by Glasser, which asserts that people are responsible for choosing their own thinking and actions, which then directly influence their emotional and physiological functioning. Choice theory also posits five basic needs of all human beings: survival, love and belonging, power, freedom, and fun. Reality therapy helps clients to become more responsible and realistic and therefore more successful in achieving their goals. Examples of reality therapy techniques include structuring; confrontation; contracts; instruction; role-playing; support; skillful questioning (e.g., “Does your present behavior enable you to get what you want now? Will it take you in the direction you want to go?”); and emphasizing choice (e.g., by changing nouns and adjectives into verbs).

Behavior Therapy. The key figures of behavior therapy include Joseph Wolpe, Hans Eysenck, Arnold Lazarus, Albert Bandura, B. F. Skinner, and Donald Meichenbaum. Behavior therapy applies not only the principles of learning but also experimental findings from scientific psychology to the treatment of specific behavioral disorders. It is therefore an empirically based approach to therapy that is broadly social learning oriented in theory. Behavior therapists view human beings as products of their environments and learning histories. The behavior therapist plays an active and directive role in therapy. Behavior therapy has developed many techniques that continue to be refined through systematic empirical research. Examples of therapeutic techniques used in behavior therapy include positive reinforcement (reward for desirable behavior); assertiveness training (role-playing with clients to help them learn to express their thoughts and feelings more freely); systematic desensitization (pairing of a neutral or pleasant stimulus with one that has been conditioned to elicit fear or anxiety); and flooding (exposing the client to stimuli that elicit maximal anxiety for the purpose of eventually extinguishing the anxiety).

Cognitive Behavior Therapy and Rational Emotive Behavior Therapy. The key figures of cognitive behavior therapy (CBT) and rational emotive behavior therapy (REBT) are Aaron Beck, the founder of cognitive therapy (CT), and Albert Ellis, the founder of REBT. Donald Meichenbaum, mentioned in the preceding discussion of behavior therapy, is also often noted as an important figure in CBT because he developed cognitive behavior modification (CBM) and stress inoculation training (SIT), which are incorporated into CBT. Beck’s CT approach focuses on how maladaptive and dysfunctional thinking affects feelings and behavior. It attempts to help clients overcome emotional problems such as depression, anxiety, and anger by teaching them to identify, challenge, and modify errors in thinking or cognitive distortions. Similarly, Ellis developed REBT as an active and directive approach to therapy that focuses on changing clients’ irrational beliefs, which are viewed as the root of emotional problems. CBT and REBT assume that clients have the capacity to change their maladaptive thinking and hence to change problem feelings and behaviors. CBT and REBT employ a wide range of therapeutic techniques, many of which have been empirically supported by documented results or systematic research. Examples of CBT techniques include coping skills training (helping clients use cognitive and behavioral skills to cope more effectively with stressful situations); cognitive restructuring (helping clients change or modify maladaptive, dysfunctional thoughts); and problem solving (helping clients explore options and implement suitable solutions to specific problems and challenges). Examples of REBT techniques include use of the A-B-C theory of REBT (A refers to Activating Events, B to Irrational Beliefs, and C to Consequences—emotional and/or behavioral—of such beliefs) and more specifically keeping an A-B-C diary of daily experiences; disputation (of irrational beliefs); and action homework.

Mindfulness and Acceptance-Based Cognitive-Behavioral Therapies: DBT, MBSR, MBCT, and ACT. Mindfulness and acceptance-based CBT approaches in the third wave of behavior therapy have sprung into prominence, especially in the last couple of decades. Mindfulness refers to focusing attention on one’s immediate experience in the here and now, the present moment; acceptance means having an open, receptive, and curious mindset without censure and a judgmental attitude. The four major approaches are as follows:

Dialectical behavior therapy (DBT) was originally developed by Marsha Linehan for helping people with borderline personality disorder and has four major components: regulating affect, tolerating distress, improving interpersonal relationships, and training in mindfulness.

Mindfulness-based stress reduction (MBSR) was developed by Jon Kabat-Zinn, originally using a group intervention to teach clients sitting meditation, mindful yoga, and a body-scan meditation for observing and experiencing all their body sensations, with daily practice of mindful meditation for forty-five minutes.

Mindfulness-based cognitive therapy (MBCT) was developed by Zindel Segal, J. Mark Williams, and John Teasdale; it is a combination of MBSR (mindfulness training) and CBT, originally conducted in an eight-week group treatment for clients who experienced recurrent depression.

Acceptance and commitment therapy (ACT) was developed by Steven C. Hayes and his colleagues to help clients embrace and accept painful experiences rather than try to control or avoid them, and to live with committed action according to one’s values. ACT has six major components: acceptance, cognitive defusion (flexibility instead of rigidity), being present, self as context with a transcendent sense of self, values, and committed action (according to one’s values).

Constructivist therapies are based on social constructionist theory that emphasizes the client as expert instead of the therapist as expert, so that the therapist assumes a not-knowing stance in affirming and with curiosity supporting the creative ways that clients develop to solve their problems themselves, often by restorying their lives from fresh perspectives. Constructivist approaches are therefore postmodern in orientation and include two major therapies: solution-focused brief therapy (SFBT), usually brief, was developed by Steve de Shazer and Insoo Kim Berg in the context of family therapy but is also applicable to individual and couple therapy; and narrative therapy, developed by Michael Kingsley White and David Epston for therapy with families and couples, but also with individuals, groups, and even communities. SFBT emphasizes solutions and what works for the client, for example, by asking key questions such as the miracle question: “Suppose that one night while you were asleep, there was a miracle and this problem was solved. How would you know? What would be different?” Narrative therapy helps clients to re-author their lives in less oppressive and more constructive ways, with more options, often using a process called externalization, in which they see their problems as being outside of themselves.

Integrative Therapies and Positive Psychotherapy. Integrative therapies represent several approaches to counseling and psychotherapy that are based on integration of different theories and techniques to treat certain clients with specific problems in a flexible and responsive way, following outcome research. The four major models or pathways of integrative therapies are (1) theoretical integration (e.g., integrative psychodynamic-behavior therapy, developed by Paul Wachtel); (2) technical eclecticism (e.g., multimodal therapy, developed by Arnold Lazarus; transtheoretical psychotherapy, developed by James Prochaska and Carlo DiClemente originally with ten change processes and six stages of readiness to change; and prescriptive psychotherapy or systematic treatment selection, developed by Larry Beutler and John Norcross); (3) common-factors approaches (e.g., common-factors integrative therapy developed by Sol Garfield, and a contextual model for psychotherapy developed by Bruce Wampold that emphasizes therapist empathy, congruence, and positive regard, plus goal collaboration between client and therapist); and (4) assimilative integration (e.g., psychodynamically based integrative therapy developed by George Stricker and Jerry Gold that is essentially psychodynamic therapy integrated with some techniques from Gestalt therapy or experiential therapy, and more recently from ACT). Positive psychotherapy is not a new school or genre of psychotherapy but a more recent approach to counseling and therapy that can be considered an integration of more traditional therapy focusing on fixing what’s wrong with a positive psychology perspective emphasizing building what’s strong, including character strengths and virtues of the client. Based on positive psychology, positive psychotherapy helps clients to grow in flourishing with positive emotions, positive relationships, good work, and a deep sense of personal meaning and purpose, and not just to alleviate negative symptoms. Key figures in the development of positive psychotherapy are Tayyab Rashid and Martin Seligman. Seligman helped found the positive psychology movement at the turn of this millennium.

Marital and Family Therapy. Marital and family therapy is an umbrella term referring to over twenty systemic therapies. The important figures in this approach include Salvador Minuchin, the founder of the structural approach; Jay Haley and the Milan Group, who developed the strategic approach; Murray Bowen, who developed family systems theory and transgenerational (multigenerational) family therapy; and Virginia Satir, who developed conjoint family therapy. More recently, Susan Johnson and Leslie Greenberg have become well known for their development of emotionally focused therapy for couples. Other key figures include Nathan Ackerman, Carl Whittaker, Ivan Boszormenyi-Nagy, Steve de Shazer, Michael White, Neil Jacobsen, John Gottman, Alan Gurman, and Richard Schwartz. Marital and family therapy approaches assume that the crucial factor in helping individuals to change is to understand and work with the interpersonal systems within which they live and function. In other words, the couple and the family must be considered in effective or efficacious therapy for individual problems as well as marital and family issues. Examples of marital and family therapy techniques that seek to modify dysfunctional patterns of interaction in couples and families and effect therapeutic change include reframing (seeing problems in a more constructive or positive way); boundary setting (either to establish firmer limits or lines of separation or to build more flexible boundaries for deeper connection); communication skills training; family sculpting (asking a couple or family members to physically put themselves in specific positions to reflect their family relationships); and constructing a genogram (a three-generation family tree or history).

A more detailed discussion, including biblical perspectives and critiques, appears in the chapter devoted to each of these thirteen major theoretical approaches to counseling and psychotherapy. Counseling theory is important. It provides a framework of understanding and practice that guides the counselor and psychotherapist in their attempts to help clients (see Truscott 2010). Each of us has our own implicit, if not explicit, theory of counseling. We may or may not be aware of our basic assumptions and views of how to best help people with their problems in living. Kevin Fall, Janice Holden, and Andre Marquis have provided the following questions for clarifying and articulating one’s theory of counseling; you may find them useful in formulating your own theory, no matter how basic it may be:

Human Nature. Are people essentially good, evil, or neutral? How much of personality is inborn or determined by biological and/or other innate factors? Are there inborn drives, motives, tendencies, or other psychological or behavioral characteristics that all human beings have in common? How much of a person’s individuality is determined by heredity or other innate factors? What behavioral or psychological characteristics (e.g., inborn drives, tendencies, motives), if any, do all people have in common?

Role of the Environment in Personality Development. How influential is a person’s physical and/or social environment in personality development? How does the environment affect personality development? How does the influence of the environment vary across the life span?

Model of Functionality. What constitutes functionality/mental health or dysfunctionality/mental unhealth in an individual? How do innate and environmental factors interact in influencing a person’s functioning, be it relatively healthy or unhealthy?

Personality Change. How does a personality change after it is to some extent developed? What conditions are necessary but not alone sufficient for personality change to occur, and what conditions are both necessary and sufficient? What role do thoughts, feelings, and/or actions play in the change process? Is change best produced by attending to one’s past, present, and/or future? How much does insight and/or action contribute to change? How much responsibility does one have for changing oneself? (adapted from Fall, Holden, & Marquis 2017, 9–1)

These are the kinds of questions we need to ask ourselves in reflecting on our own theory of counseling. We will also ask such questions of the thirteen major theoretical approaches to counseling and psychotherapy that will be covered in more depth and detail later in this book (chaps. 4–16). A. W. Combs (1989) has noted that many counseling theorists value a theory of counseling that is complete, clear, consistent, concrete, current, creative, and conscious, that is, that has the seven Cs (see Fall, Holden, & Marquis 2017, 10–11).

Overview of Counseling and Psychotherapy: Research

Theory plays a significant role in guiding the counselor or therapist in helping clients. However, every theory must be subjected to research to determine its truth or validity, as well as the efficacy and effectiveness of its application in actual practice. Research is therefore another crucial dimension in the field of counseling and psychotherapy. Scientific and systematic research on the processes and outcomes of counseling and psychotherapy began only in the 1940s, when Carl Rogers started recording his therapy sessions so that they could be studied and evaluated. Since then, research in this field has mushroomed, although some controversies and issues still remain. See the appendix for a review of research in the field of counseling and psychotherapy, focusing on the question “Is psychotherapy effective?” More specific empirical or research findings on the effectiveness of each of the major approaches to counseling and psychotherapy covered in this book are provided in the chapters on these approaches.

Overview of Counseling and Psychotherapy: Practice

In this final section of the overview of counseling and psychotherapy, we will briefly cover the following topics: primary theoretical orientations of counselors and psychotherapists in practice in the United States, major types of therapists or mental health practitioners and the settings in which they practice, several contemporary developments in the practice of counseling and psychotherapy, and examples of major professional organizations and their websites for counselors and psychotherapists.

Primary Theoretical Orientations of Counselors and Psychotherapists

Prochaska and Norcross have summarized the major findings from several surveys or studies of the self-identified primary theoretical orientations of clinical psychologists, counseling psychologists, social workers, and counselors in the United States (2018, 3). The most popular theoretical orientation self-reported by counseling psychologists and social workers is eclectic/integrative therapy (using theories and techniques from various approaches): 31 percent of counseling psychologists and 26 percent of social workers. However, cognitive therapy is now self-reported as the primary theoretical orientation by 31 percent of clinical psychologists and 29 percent of counselors (the highest percentage for both groups). Only 23 percent of counselors selected eclectic/integrative therapy as their primary theoretical orientation. Judith Todd and Arthur Bohart (2006) note that while eclecticism is the most popular approach among practicing psychotherapists, cognitive therapies and theories are now the dominant therapeutic orientation in many professional contexts, including university clinical psychology programs.

Prochaska and Norcross (2018, 442–443) have also summarized the main findings of a Delphi Poll they conducted with seventy expert panelists; its composite ratings indicate what will happen in the field of psychotherapy over the next ten years. In terms of primary theoretical orientations of the future, mindfulness therapies were ranked first for the greatest increase over the next decade, followed closely by cognitive behavior therapy, integrative therapy, multicultural therapies, motivational interviewing, and dialectical behavior therapy. Therapies expected to decrease the most included transactional analysis, Adlerian therapy, Jungian therapy, and classical psychoanalysis. It was also predicted that short-term therapy, psychoeducational groups, crisis intervention, couples/marital therapy, and group therapy will increase in the future, with no change for individual therapy and conjoint family therapy and a decrease in long-term therapy.

Major Types of Mental Health Practitioners and Practice Settings

There are several major types of mental health practitioners in the United States who may provide counseling and psychotherapy. Les Parrott lists the following (see 2003, 14–16):

Psychiatrists are medical doctors who have specialized training in the diagnosis and treatment of mental disorders. They are qualified to prescribe psychotropic medications and can practice counseling and psychotherapy. Some psychiatrists have also been trained in psychoanalysis.

Psychoanalysts have received advanced training of at least three years in Freudian psychoanalysis or some other more contemporary version of psychoanalysis at institutes of psychoanalytic training. Such training institutes often require their psychoanalytic trainees to be licensed psychologists or psychiatrists.

Clinical psychologists are educated at the doctoral level (PhD, PsyD, or EdD), including internship training in psychological assessment and psychotherapy. They must be licensed in the state in which they practice.

Counseling psychologists are usually educated at the doctoral level, with internship training in helping people deal more effectively with their problems in living. Counseling psychologists also must be licensed to be in independent practice. They function very much like clinical psychologists do, except that counseling psychologists tend to see clients with less severe psychopathology, although this is less often the case today than in the past.

School psychologists are usually educated at the doctoral level to closely work with educators and others to facilitate the holistic development of children in school. They often assess and counsel children with diverse types of problems, as well as consult with teachers, parents, and other school staff.

Industrial/organizational psychologists are educated at the doctoral level. They are involved in enhancing the effectiveness of organizations and helping to improve productivity and the well-being of employees as well as management staff.

Marriage and family therapists are trained at the master’s or doctoral level in marital and family therapy. In most states they must be licensed to practice as marriage, family, and child counselors or marital and family therapists.

Social workers usually have a master’s degree in social work. They also must be licensed in many states as clinical social workers in order to do individual as well as family counseling and therapy.

Psychiatric nurses have an associate or baccalaureate degree, specializing in psychiatric services. A psychiatric nurse with a master’s degree in nursing and psychiatric/mental health certification can also do private practice.

Pastoral counselors are ministers, usually with master’s degrees in theology or divinity, who also have had special training and experience in counseling from a spiritual perspective. Many of them have received training from a clinical pastoral education center in the United States, which has over 350 such centers.

Vocational counselors have a master’s degree that prepares them to counsel people to help them in their vocational choices and professional development.

Occupational counselors have a bachelor’s or master’s degree and internship experience that prepares them to help people with physical challenges to make the best use of their resources.

School counselors have an advanced degree in counseling psychology and are involved in helping people with career and educational issues.

Substance-abuse counselors have bachelor’s or master’s degrees and counsel people with alcohol and/or drug addictions or substance-abuse problems.

Paraprofessional or lay counselors have limited training in counseling but do not have advanced degrees in counseling and are not licensed mental health professionals. They usually do their counseling work under the supervision of a licensed mental health professional.

Another group of mental health practitioners not mentioned by Parrott (2003) is the category of professional counselors or licensed professional counselors with master’s degrees in counseling who have also been licensed in the state in which they practice. Also, in some countries, Australia being one example, family physicians or medical doctors often do frontline counseling and psychotherapy with patients.

There are several major practice settings in which mental health professionals do counseling and related work, including private practice, community mental health centers, hospitals, human service agencies, schools, and workplaces (see Parrott 2003, 16).

Some Contemporary Developments in Counseling and Psychotherapy

Several significant contemporary developments in counseling and psychotherapy have occurred in recent years. Not surprisingly, given the computer and internet revolution in this information age, and the use of smartphones with many different apps, one such development has been in the area of technological applications. Examples include the use of computer technology in virtual therapy, used as a therapeutic intervention for the treatment of anxiety disorders. Psychotherapy can also be provided by telephone and especially smartphones, videoconferencing, and videotelephone, in what has been called telepsychotherapy. Such therapies, of course, raise serious ethical and logistical issues, but such technological innovations in psychotherapy are here to stay and will proliferate (see Prochaska & Norcross 2018, 447–448). Telepsychotherapy and more generally telehealth (for delivering health care by distance) became crucial and essential services during the COVID-19 pandemic in 2020 due to lockdowns and stay-at-home orders in the US as well as around the world.

Another contemporary development in clinical practice is the integration of religion or spirituality and psychotherapy (see Tan 1996c, 2001b, 2013a). Since Allen E. Bergin (1980) published his seminal article on psychotherapy and religious values over four decades ago (see also S. L. Jones 1994), religiously or spiritually oriented psychotherapy has become an important part of the current practice of counseling and psychotherapy (for more recent examples, see Aten & Leach 2009; Aten, McMinn, & Worthington 2011; Gill & Freund 2018; R. S. Jones 2019; Pargament 2007; Pargament, Exline, & Jones 2013; Pargament, Mahoney, & Shafranske 2013; Plante 2009; Richards & Bergin 2004, 2005, 2014; Sears & Niblick 2014; Sperry 2011; Sperry & Shafranske 2005). More specifically, Christian approaches to therapy have further developed in recent years (see, e.g., N. T. Anderson, Zuehlke, & Zuehlke 2000; Appleby & Ohlschlager 2013; Clinton & Ohlschlager 2002; Clinton, Hart, & Ohlschlager 2005; Collins 2007; Greggo & Sisemore 2012; Hawkins & Clinton 2015; E. L. Johnson 2017; Knabb, Johnson, Bates, & Sisemore 2019; Malony & Augsburger 2007; McMinn & Campbell 2007; J. C. Thomas 2018; J. C. Thomas & Sosin 2011; Worthington et al. 2013; see also S. L. Jones & Butman 2011; Tan 2011a; Yarhouse & Sells 2017), and research findings have provided empirical support for the efficacy of Christian therapy (see Worthington et al. 2011) and its effectiveness in actual clinical settings (see Wade, Worthington, & Vogel 2007; see also T. B. Smith, Bartz, & Richards 2007), as well as of religious and spiritual therapies in general (see Captari et al. 2018; see also Hook et al. 2019).

Contemporary clinical practice has also been significantly impacted by multicultural perspectives, including dealing with subtle microaggressions as well as more overt racism and other types of discrimination (see D. W. Sue et al. 2019; but see also Lilienfeld 2017, 2020; Lui & Quezada 2019; M. T. Williams 2020a, 2020b); feminist therapy (L. Brown 2018); and postmodern approaches such as narrative therapy, solution-focused brief therapy, and social constructionism (see Corey 2021).

As a final example of another significant contemporary development in therapeutic practice, let us turn to a major movement in psychology today called positive psychology. Martin Seligman and Mihaly Csikszentmihalyi (2000) introduced the emerging science of positive psychology over two decades ago, referring to the study of positive emotion, positive character, and positive institutions and how to nurture them. This movement has really taken off, with a mushrooming body of literature as well as recent empirical attempts to validate or support positive psychology interventions (M. E. P. Seligman et al. 2005; see also Tan 2006a for a review with a biblical perspective and critique of applied positive psychology; Hackney 2021; and McMinn 2017). Martin Seligman, Tayyab Rashid, and A. C. Parks (2006) reported findings from two research studies that provided empirical support for the effectiveness of positive psychotherapy (based on positive psychology), employing exercises or interventions explicitly aimed at increasing positive emotion, engagement, and meaning in treating depression. Since then, positive psychotherapy has been further developed, with more empirical support for its efficacy (see Rashid & Seligman 2018a, 2018b, 2019; and chap. 15 of this book). A meta-analysis of 51 positive psychology interventions with a total of 6,018 participants (Sin & Lyubomirsky 2009) showed significant enhancement of well-being (effect size = .29) and significant alleviation of depressive symptoms (effect size = .32). Positive psychology (including positive psychotherapy) focuses more on identifying the character strengths and virtues of clients and less on specifying their psychopathologies or psychological deficits (see Joseph 2015; C. Peterson & Seligman 2004; Rashid & Seligman 2018a, 2018b, 2019).

Examples of Major Professional Organizations for Counselors and Psychotherapists

The following list includes examples of major professional organizations and their websites that are relevant to counselors and psychotherapists in clinical practice:

American Counseling Association (ACA), www.counseling.org

American Psychological Association (APA), www.apa.org

American Association for Marriage and Family Therapy (AAMFT), www.aamft.org/index_nm.asp

National Association of Social Workers (NASW), www.naswdc.org

Two examples of specifically Christian professional organizations and their websites:

Christian Association for Psychological Studies (CAPS), www.CAPS.net

American Association of Christian Counselors (AACC), www.AACC.net

Recommended Readings

Castonguay, L. G., Constantino, M. J., & Beutler, L. E. (Eds.). (2019). Principles of change: How psychotherapists implement research in practice. New York: Oxford University Press.

Corey, G. (2021). Theory and practice of counseling and psychotherapy (Updated 10th ed.). Boston: Cengage.

Joseph, S. (Ed.). (2015). Positive psychology in practice (2nd ed.). Hoboken, NJ: Wiley & Sons.

Lambert, M. J. (Ed.). (2013). Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed.). Hoboken, NJ: Wiley and Sons.

Nathan, P. E., & Gorman, J. M. (Eds.). (2015). A guide to treatments that work (4th ed.). New York: Oxford University Press.

Norcross, J. C., & Lambert, M. J. (Eds.). (2019). Psychotherapy relationships that work. Vol. 1: Evidence-based therapist contributions (3rd ed.). New York: Oxford University Press.

Norcross, J. C., & Wampold, B. E. (Eds.). (2019). Psychotherapy relationships that work. Vol. 2: Evidence-based therapist responsiveness (3rd ed.). New York: Oxford University Press.

Prochaska, J. O., & Norcross, J. C. (2018). Systems of psychotherapy: A transtheoretical analysis (9th ed.). New York: Oxford University Press.

Chapters 2

The Person of the Counselor

Chapter 1 provided an overview of the field of counseling and psychotherapy, focusing on theory, research, and practice areas. While a good deal of time will be spent in coming chapters discussing technique and major therapeutic interventions, establishing a connection is important to forming a productive therapeutic relationship. Research findings have shown that, in general, therapeutic change in clients results from client and therapist factors more than from techniques (M. J. Lambert & Barley 2002; see also Baldwin & Imel 2013; Duncan et al. 2010; M. J. Lambert 2013). The person of the counselor or therapist is therefore crucial in effective therapy. Although knowledge and skills are important in conducting effective counseling, the person of the counselor is one of the most important determinants and instruments of effective therapeutic work (Corey 2021). Who you are as a person and a professional in the counseling field is therefore the focus of this chapter. In practice, the person and the professional are actually integrated or intertwined entities that cannot be separated (Corey 2021). However, we will consider the counselor in these two intimately connected categories: (1) the counselor as a professional and (2) the counselor as a person.

The Counselor as a Professional: Personal Characteristics of Effective Counselors

The counselor as a professional, a therapeutic person, is usually described as someone with specific helpful characteristics. Gerald Corey has provided a list of personal characteristics of effective counselors (emphasizing that the crucial quality involves the counselor’s willingness to struggle to become a more therapeutic person), including the following: “Effective therapists have an identity; respect and appreciate themselves; are open to change; make choices that are life oriented; are authentic, sincere, and honest; have a sense of humor; make mistakes and are willing to admit them; generally live in the present; appreciate the influence of culture; have a sincere interest in the welfare of others; possess effective interpersonal skills; become deeply involved in their work and derive meaning from it; are passionate; and are able to maintain healthy boundaries” (2021, 19–20). No one counselor or therapist possesses all these desirable characteristics of an effective counselor. However, every counselor should be willing to develop these traits (see also Kottler & Carlson 2014; Norcross & Lambert 2019; Norcross & Wampold 2019; Skovholt & Jennings 2004; Sperry & Carlson 2011).

Based on a review of the research literature available on this topic, other personal qualities of effective counselors include psychological health, genuine interest in others, empathic abilities, personal warmth, self-awareness, tolerance of ambiguity, and awareness of values (see Parrott 2003, 24–35). Gary Collins (2007) added three other important counselor traits: integrity, courage, and genuine ability to care. While such personal qualities of effective counselors apply to both Christian and secular therapists, some unique characteristics of distinctively Christian counselors warrant further description.

Unique Characteristics of Christian Counselors

Christian counseling can be simply defined as counseling or psychotherapy that is Christ centered, biblically based, and Spirit filled (see Tan 2001b, 24). Christian counseling also primarily concerns character, including the personal godliness of the counselor or therapist. This emphasis is consistent with this chapter’s focus on the person of the counselor and James Guy’s (1987) classic book on the personal life of the psychotherapist.

Personal or intrapersonal integration, referring to a person’s own appropriation of faith and integration of psychological and spiritual experience, is therefore foundational in all integration work (i.e., integration of Christian faith and psychology or counseling) that includes principled (theory and research), professional (practice), and personal integration (Tan 2001b). As I have previously noted:

Carter and Narramore (1979) have suggested several essential attitudes and attributes relevant to intrapersonal or personal integration, which cover both psychological and spiritual aspects, including the following: humility and an awareness of finite limitations, tolerance for ambiguity, balanced expression of one’s intellect and emotions, openness instead of defensiveness due to personal anxieties and insecurities, and an eternal perspective on our work as part of humanity’s God-ordained task of reconciling human beings to God, themselves, and others. Crabb (1977) . . . has emphasized the need for Christian psychologists to do the following: spend as much time in the regular and systematic study of the Bible as in the study of psychology; have both a general grasp of the structure and overall content of Scripture as well as working knowledge of Bible doctrine; and be involved in the fellowship of a Bible-believing church. (Tan 1987b, 35)

The spirituality or spiritual growth of the Christian counselor is therefore a unique and distinctive aspect of the person of the Christian counselor. In this context, the use of spiritual disciplines in a grace-filled way, empowered by the Holy Spirit, is crucial in facilitating personal and spiritual growth into deeper Christlikeness in both the Christian counselor and the client (Tan 1998; see also Eck 2002). Spiritual disciplines include practices such as solitude and silence, listening and guidance, prayer and intercession, Bible study and meditation, repentance and confession, yielding and submission, fasting, worship, fellowship, simplicity, service, and witness (Tan & Gregg 1997). They should be practiced not in a legalistic way but in dependence on the power and presence of the Holy Spirit and God’s grace. They are therefore “disciplines of the Holy Spirit” (Tan & Gregg 1997).

The uniqueness of the Christian counselor can be characterized by at least four distinctives of Christian counseling:

unique assumptions that are based on the Bible, including beliefs about God’s attributes (e.g., God is compassionate and sovereign), the nature of human persons, the reality of sin, the authority of the Bible, the forgiveness of sins and salvation through Jesus Christ, and hope for the future

unique goals that include not only alleviating symptoms or reducing psychological and emotional suffering but also facilitating spiritual growth when appropriate, based on Christian or biblical values

unique methods that go beyond standard counseling skills and techniques, for example, avoiding immoral or unbiblical methods such as encouraging extramarital or premarital sex, and using spiritual interventions such as prayer and Scripture ethically and appropriately in counseling sessions

unique giftedness from God in the work of counseling or people-helping (including having spiritual gifts from the Holy Spirit, such as encouragement or exhortation) (see Collins 2007, 18–21)

A Christian counselor therefore practices in a Christ-centered, biblically based, and Spirit-filled way. Additional elements of such a distinctive approach to counseling from a Christian and biblical perspective will be provided in the latter part of this book (part 3).

Issues and Potential Pitfalls Facing Beginning Counselors

Novice counselors or therapists face certain issues and potential pitfalls as they begin their counseling work. It can be helpful for beginning counselors to be aware of these issues and possible pitfalls early, so that unnecessary anxiety or pain can be avoided. Here I briefly review two helpful lists of these issues and pitfalls.

Corey has listed and briefly described the following issues that novice counselors usually face as they begin seeing clients in clinical practice:

dealing with personal anxieties and self-doubts, by talking them over with a supervisor and other beginning counselors

being themselves and disclosing their experiences, while maintaining a proper balance between hiding behind a professional facade and sharing too much about themselves and burdening clients as a result

avoiding perfectionism, trying to be a perfect counselor, which is impossible; instead, being open to making mistakes and learning from them, especially in supervision

being honest about their own limitations, so that they learn which clients and problems they can or cannot effectively counsel—after sufficient exposure to diverse clients, problems, and settings—and make appropriate referrals when needed

understanding silence so that they explore its meaning with their clients and are not afraid of silence or react anxiously to it

dealing with demands from clients, especially if they are unrealistic or unreasonable demands; setting clear expectations and boundaries in the first session with clients can be helpful

dealing with clients who lack commitment, especially involuntary clients, such as those who have been mandated by a court order to have therapy; it may help to prepare such clients for the process of counseling

tolerating ambiguity, for example, when clients do not seem to be improving at all; sometimes clients get worse before they get better, so counselors need to be patient with such ambiguity for a while

becoming aware of their countertransference or projections that affect their reactions to clients, for example, when they are emotionally reactive or defensive toward their clients or are unable to be present with clients because their own issues are getting in the way; counselors need to engage in their own self-exploration with a supervisor, peer, or even their own therapist

developing a sense of humor that is appropriate, so that they do not take themselves and their work too seriously yet do not underrate the pain and suffering of their clients

sharing responsibility with the client, so that ultimately clients are empowered to make their own decisions, with the counselor’s help and support

declining to give advice all the time to clients who need to grow in making their own decisions; counselors need to learn to provide guidance and make suggestions only judiciously, with proper respect for the client’s decision-making process and responsibility (unless there is a crisis situation when the client is unable to function or make decisions)

defining their role as a counselor; this may change over time and include a variety of roles; however, counselors will focus on giving warmth and support as well as challenging clients in a caring way to take the steps needed toward therapeutic change

maintaining vitality as a person and as a professional to avoid professional burnout; self-care strategies are crucial, and they include the following therapeutic lifestyle changes for enhancing wellness as described by R. Walsh (2011): physical activity, exercise, diet and nutrition, being in nature, relationships, recreation, religious or spiritual involvement, and service to others (see Corey 2021, 28–35)

In a similar vein, Les Parrott has listed and briefly described the following common pitfalls that beginning counselors may face: premature problem solving, setting limits, fear of silence, interrogating (asking too many questions of clients), impatience, moralizing, and reluctance to refer (see 2003, 35–39).

Novice counselors will benefit from reviewing these two lists and preparing themselves to deal with such potential or common pitfalls before they actually encounter them.

The Counselor as a Person

The counselor as a person, with human strengths and weaknesses, faces several other areas of potential concern. Collins (2007) has listed a few, including the following: the counselor’s motivation, the counselor’s mistakes, the counselor’s vulnerability, the counselor’s burnout, and the counselor’s counselors (21–32).

With regard to the counselor’s motivation, the counselor may have several personal needs that are potentially harmful to the client and the counseling process. Examples of such needs include the need to control or rescue; the need for relationships; the need for information based mostly on unhealthy curiosity; the need for affirmation, acceptance, and approval; and the need for assistance with the counselor’s own personal problems (see Collins 2007, 31–32).

With regard to the counselor’s mistakes, it is helpful to bear in mind that all counselors make mistakes. However, the following common mistakes should be avoided as far as possible: engaging in casual conversations with the client instead of counseling; attempting to solve problems prematurely; asking too many questions too quickly; showing a disrespectful or judgmental attitude; being too emotionally involved; being distant or superficial; being defensive when feeling threatened or challenged (see Collins 2007, 32).

With regard to the counselor’s vulnerability, counselors need to be alert to and deal appropriately with manipulation by clients; overinvolvement emotionally with clients, including countertransference; client resistance; and feelings of sexual attraction to clients or from clients (see Collins 2007, 32).

With regard to the counselor’s burnout, counseling can be emotionally draining work and thus entails a high risk of burnout. Burnout symptoms include exhaustion, a feeling of detachment from clients, and the tendency to withdraw. To prevent or recover from burnout, counselors need spiritual strength, social support from other people, freedom from the drive to achieve, awareness that they cannot do everything, periods of time to be away from people, continued development of their counseling skills, and other people with whom they can share their burdens (see Collins 2007, 32). Strategies for self-care, including preventing burnout, will be covered in more detail later in this chapter.

Finally, with regard to the counselor’s counselors, counselors are encouraged to have other counselor friends who can provide support and perspective and can point them to Jesus Christ, the ultimate Counselor, who gives us hope, strength, and direction through the Holy Spirit (see Collins 2007, 32). Christian counselors can cast their cares and clients upon the Lord Jesus through prayer in their own individual lives and walk with God.

In the last section of this chapter, we will examine in more detail the crucial topic of self-care for the counselor.

Self-Care for the Counselor

Self-care is essential for the well-being of the counselor, as well as for the efficient, effective, and ethical practice of counseling and the ultimate benefit of the client (see Norcross & VandenBos 2018; see also Hays 2014). Some people may misunderstand the term “self-care” to mean “selfish care” or “self-centered care” for oneself. Self-care for the counselor, however, refers to healthy and wise strategies for taking good care of oneself as a counselor in order to manage stress well and prevent burnout (see Morse et al. 2012). The eventual effect of good self-care, which is an ethical imperative throughout a counselor’s professional life, is the ability to function well and effectively as a counselor and therefore to better help clients (Barnett, Baker, et al. 2007). It is thus loving and wise to engage in proper self-care that eventually leads to the helping and healing of others. However, there is still a lack of systematic training in self-care in professional psychology training programs, and therefore self-care needs to be viewed as a competency to be taught and practiced so that more systematic training in self-care can be provided (Maranzan et al. 2018). John Norcross and Gary VandenBos (2018) describe thirteen helpful self-care strategies for counselors and psychotherapists (see sidebar 2.1).

The Resilient Practitioner: Burnout Prevention and Self-Care Strategies for Counselors and Others

Thomas Skovholt (2001) wrote a helpful and practical book that comprehensively covers burnout prevention and self-care strategies for counselors, therapists, teachers, and health professionals (see also Skovholt & Trotter-Mathison 2016). Such self-care strategies can help a counselor become a resilient practitioner who has learned to prevent burnout and to grow in balanced wellness in physical, spiritual, emotional/social, and intellectual areas of health. Skovholt emphasizes the counselor’s need to take care of the self just as the opera singer must take care of the voice, the baseball pitcher the arm, the carpenter the tools, the professor the mind, the photographer the eyes, and the ballerina the legs (2001, ix). Before we more closely examine the specific self-care strategies for producing the resilient practitioner, it is helpful to first consider the poor self-care deadly dozen that Skovholt has listed. These pitfalls should be avoided as far as possible by counselors who want to prevent burnout and grow in balanced wellness:

Toxic supervisor and colleague support

Little fun in life or work

Unclear understanding of one’s own needs

Lack of a professional development process that helps transform experience into greater competence and reduced anxiety

Absence of energy-giving personal life

Inability to turn down unreasonable requests

Accumulated effects of vicarious traumatization

Mainly one-way personal relationships, with self as giver or provider of caring

Perfectionism in tasks at work

Ambiguous professional losses that remain unresolved

A strong need to be needed

Professional success defined only in terms of client’s positive change or appreciation (see Skovholt 2001, 210)

Skovholt (2001) also lists ten activities for self-care (see sidebar 2.2).

Self-Care Strategies: Sustaining the Professional Self

The following are strategies for nurturing and sustaining the professional self of the counselor: avoiding the impulse toward grandiosity; thinking long-term; putting together and actively applying an individual development method or plan; cultivating professional self-understanding; creating a professional greenhouse (environment for growth) at work; having leadership that facilitates balance between self-care and caring for others; drawing on professional social support from peers; getting support from bosses, supervisors, and mentors; being nurtured from work as managers, supervisors, and mentors; learning how to be both playful and professional; releasing emotions of distress through professional venting; learning to be a “good-enough practitioner”; understanding the reality of early professional anxiety, which is pervasive; reinventing oneself to increase excitement and reduce boredom; dealing with ambiguous professional loss by minimizing it; and learning to refuse unreasonable requests (see Skovholt 2001, 206–207, 130–144).

Self-Care Strategies: Sustaining the Personal Self

In the area of nurturing and sustaining the personal self of the counselor, Skovholt focuses on self-care activities to nurture the emotional self, the financial self, the humorous self, the loving self, the nutritious self, the physical self, the playful self, the priority-setting self, the recreational self, the relaxation and stress-reduction self, the solitary self, and the spiritual or religious self (2001, 208–209, 148–162).

Another study, focusing on gender and work-setting differences in career-sustaining behaviors and burnout among professional psychologists, found that the following six strategies were highly important for all 595 psychologists surveyed: maintaining a sense of humor; maintaining self-awareness/self-monitoring; maintaining balance between personal and professional lives; maintaining professional identity/values; engaging in hobbies; and spending time with spouse, partner, or family (Rupert & Kent 2007). Those working in solo or group independent practice reported a greater sense of personal accomplishment, more sources of satisfaction, fewer sources of stress, and more control at work than those working in agency settings. Women working in independent practice reported less emotional exhaustion than women working in agency settings.

Another example of research on burnout and coping in human service practitioners is a study done in Spain of 211 professionals, either child-protection workers or in-home caregivers, who completed an inventory on coping and an inventory on burnout (Jenaro, Flores, & Arias 2007). Burnout was conceptualized as consisting of emotional exhaustion, depersonalization, and a reduction of personal accomplishment. Coping strategies were classified as problem focused (e.g., planning and active coping, focus on efforts to solve the problem or situation, social support, personal growth, and positive reinterpretation) and emotion focused (e.g., religion, humor, alcohol/drug intake, disengagement, identifying emotions and venting them, acceptance, denial, and restraint coping). This study found that coping strategies by themselves may help prevent worker turnover but do not preclude burnout. It also reported that high job and salary satisfaction, together with active coping strategies, play an important role in enhancing personal accomplishment, whereas low job and salary satisfaction together with passive or emotional coping strategies predict higher emotional exhaustion.

Self-Care: Some Reflective Questions and Further Suggestions

In bringing this chapter on the person of the counselor to a close, I briefly review the helpful insights provided by Michael J. Mahoney, a well-known psychologist who developed constructive psychotherapy (2003). In an earlier significant book on human change processes and the scientific foundations of psychotherapy, he lists twenty-three reflective questions for counselors to ask themselves in order to engage in better and healthier self-care (1991, 370). Some examples of these helpful reflective questions for self-care are “How happy are you most of the time? How do you feel about yourself? Do you seek and accept help or comfort from others? Is your rest usually adequate and satisfying? What are your fears? What gives meaning or purpose to your life? What are your hopes? What could you do to be more self-caring? With whom can you talk about your inner life? Do you laugh and cry? What forms of music and movement do you enjoy? What are your spiritual needs and comforts? If you could change three things in your life, what would they be?” (370). Mahoney emphasizes the importance for the counselor to be vigilantly sensitive to their own physical, emotional, and psychospiritual needs, all of which are interdependent.

More recently, Mahoney has made several helpful recommendations for counselor or therapist self-care in the context of doing constructive psychotherapy (which integrates ideas from constructivist and narrative therapy with insights from cognitive-behavioral, humanistic, systems-based, psychodynamic, and other therapeutic approaches):

Be gentle with yourself; honor your own process.

Get adequate rest.

Make yourself comfortable.

Move your body often.

Develop a ritual of transition for leaving work at the office.

Receive regular professional massages.

Cherish your friendship and intimacy with family.

Cultivate your commitment to helping; honor the privilege of our profession.

Ask for and accept comfort, help, and counsel (including personal therapy).

Create a support network among your colleagues.

Enjoy yourself.

Follow your heart and embrace your spiritual seeking. (2003, 260–261)

From a more distinctively Christian perspective, the regular practice of the spiritual disciplines mentioned earlier in this chapter (see Tan & Gregg 1997) can be very helpful in preventing burnout by facilitating spiritual growth and centering in Christ, with the power and presence of the Holy Spirit. Specific means of God’s grace enabling the Christian counselor to enter more into God’s rest or to experience God’s peace in a restless world include Shepherd-centeredness in Christ, Spirit-filled surrender to God, solitude and silence, simplicity, Sabbath-keeping (one day a week ceasing from gainful employment: resting and worshiping God), sleep, spiritual community, servanthood, and stress management from a biblical perspective that emphasizes values such as love, faithfulness, and humility, rather than success, competitiveness, and perfectionism (see Tan 2003d; Tan 2006b). Learning to rest in Christ (Matt. 11:28–30; see also Mark 6:31; Luke 10:38–42) in these ways will help a Christian counselor to better manage stress and prevent burnout (see also Hart 1995, 1999). Self-care for the Christian counselor, like self-care for any counselor, is therefore an essential and biblically sound aspect of the person and experience of the counselor or psychotherapist. This is so because appropriate and healthy counselor self-care eventually leads to more effective and ethical helping and healing of clients (see Norcross & VandenBos 2018).

However, a biblical or Christian perspective on self-care for the Christian counselor will also appropriately critique self-care as a concept and emphasize the need to go beyond self-care to “God-care” for us and “we-care” for each other in a loving spiritual community or the church, as Siang-Yang Tan and Melissa Castillo (2014) have pointed out. They concluded: “Beyond ‘self care’—or beyond our abilities to care for ourselves—is God’s desire to care for us through friendship with Christ and through friendships with others in Christian community. Beyond self-care is ‘God-care’ for us, and ‘we-care’ or ‘community-care’ in the body of Christ for one another, where healing relationships, role-models, accountability, bearing one another’s burdens, and other interdependent maturing aspects of spiritual formation promote health, growth, and resilience” (Tan & Castillo 2014, 93).

Sally Canning (2011) has similarly critiqued self-care as tending to overemphasize the need to maintain “balance” in one’s life and lifestyle. She hesitates teaching and practicing such “self-care” because as Christians we need to go beyond balanced self-care and embrace stewardship and even sanctified suffering in seasons of our lives that may sometimes significantly stretch us and knock us out of balance. We therefore need to trust more in “God-care” for us and in his sovereign provision and grace for us, even in our struggles and sanctified sufferings (as well as joys) that are crucial for our Christian spiritual formation into deeper Christlikeness (see Tan 2019a).

Recommended Readings

Guy, J. D. (1987). The personal life of the psychotherapist. New York: Wiley & Sons.

Hays, P. A. (2014). Creating well-being: Four steps to a happier, healthier life. Washington, DC: American Psychological Association.

Mahoney, M. J. (2003). Constructive psychotherapy: A practical guide. New York: Guilford.

Norcross, J. C., & VandenBos, G. R. (2018). Leaving it at the office: A guide to psychotherapist self-care (2nd ed.). New York: Guilford.

Skovholt, T. M. (2001). The resilient practitioner: Burnout prevention and self-care strategies for counselors, therapists, teachers, and health professionals. Needham Heights, MA: Allyn & Bacon.

Skovholt, T. M., & Trotter-Mathison, M. (2016). The resilient practitioner: Burnout prevention and self-care strategies for the helping professions (3rd ed.). New York: Routledge.

Tan, S. Y. (2003). Rest: Experiencing God’s peace in a restless world. Vancouver, BC: Regent College Publishing.

Chapters 3

Legal and Ethical Issues in Counseling and Psychotherapy

Counseling or psychotherapy is a unique kind of work that places the welfare and well-being of the client above and beyond the needs of the counselor or therapist. However, there are potential pitfalls and dangers in doing such therapeutic work, with the ever-present possibility of harming the client. The therapist therefore must be aware of the major legal and ethical issues involved in conducting therapy in order to avoid certain pitfalls and prevent possible harm to the client.

Legal issues involve the laws of a specific country, state, or province that govern the practice of counseling or psychotherapy in that geographical area or political entity. Legal issues facing therapists are therefore those that relate to “state and federal laws and regulations, binding case law, administrative rules, or court orders” (S. Knapp, Gottlieb, et al. 2007, 54). Ethical issues are broader and encompass professional standards of right and wrong that guide the work of counselors and therapists, helping them to enhance the well-being and welfare of their clients and avoid harming them. Professional counselors and organizations of counselors and therapists have similar ethical codes governing their practice, such as the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct, or APA Ethics Code (American Psychological Association [APA] 2002) for psychologists. More often than not, the laws that regulate the practice of counselors and therapists are consistent with the ethical principles that govern and guide such counselors in their professional work. For example, Samuel Knapp and his colleagues note that most ethical therapists or practicing psychologists would agree with the following standards: sex with clients is prohibited; information about clients must be kept confidential (with few exceptions); therapists should be competent in the services they provide; and therapists must refrain from insurance fraud (S. Knapp, Gottlieb, et al. 2007, 54). However, there are times when laws and ethics may collide or conflict with each other in certain situations with specific clients. At such times, the therapist may choose to follow the law even while struggling with ethical dilemmas, or the therapist may decide that the most ethical position would be conscientious objection to a specific law. Knapp and his colleagues provide a helpful review of these difficult situations and issues and make suggestions for a constructive decision-making process at times when laws and ethics may collide (S. Knapp, Gottlieb, et al. 2007; see also S. Knapp, VandeCreek, & Fingerhut 2017). Usually, however, ethical therapists will follow the laws regulating their practice as well as the ethical codes of their professional organizations. Although what is legal may sometimes not be ethical, and what is ethical may not be legal, most often the ethical choice is the legal one, and the legal one is ethical.

Legal Issues in Counseling and Psychotherapy

In their practice counselors and therapists are affected by the law in various ways. Judith Todd and Arthur Bohart (2006, 440–444) observe that legislation passed in the United States regarding privacy and security issues can directly or indirectly impact the professional practice of therapists; an example is the Health Insurance Portability and Accountability Act (HIPAA) passed by Congress in 1996. Another example is licensing laws that directly govern the professional practice of therapists or counselors, who must possess the requisite educational degrees and hours of supervised clinical experience and pass specific licensing examinations in a state before they are legally qualified to be in independent practice in that state. Some other laws apply to health care in general yet affect the professional practice of counselors and therapists.

Todd and Bohart (2006) also emphasize another area of law that impacts therapists: litigation or lawsuits filed against counselors and therapists for malpractice or negligence. Court decisions made in such lawsuits become legal precedents that subsequently directly affect professional therapeutic practice. For example, having a sexual relationship with a current client is not only unethical but also illegal in many states in the United States. Mandatory reporting of child, elder, and dependent adult abuse and of clients considered a danger to self or to others has also become law in most states. Counselors and therapists engaged in professional practice must therefore be aware of such legal issues that directly or indirectly affect them (see, e.g., Levicoff 1991; Ohlschlager & Mosgofian 1992; Remley & Herlihy 2020; A. Wheeler & Bertram 2019).

Ethical Issues in Counseling and Psychotherapy

The APA Ethics Code, revised and published in 2002, “is intended to provide specific standards to cover most situations encountered by psychologists. It has as its goals the welfare and protection of the individuals and groups with whom psychologists work and the education of members, students, and the public regarding ethical standards of the discipline” (APA 2002, 1062). This code was updated in 2010 with a few amendments (to Introduction and Applicability and Standards 1.02 and 1.03) and again in 2016 (effective January 1, 2017) with one amendment (to Standard 3.04) (see APA 2017). The APA Ethics Code can also be used, with some adaptation, by other counselors and therapists who may not be professional psychologists. Other professional organizations in the mental health field, of course, also have their own ethics codes (e.g., American Counseling Association [ACA], American Association of Marriage and Family Therapy [AAMFT], and the National Association of Social Workers [NASW]), and they should also be consulted (e.g., see ACA, 2014). The APA Ethics Code begins with a section on five aspirational general principles meant to reflect the very highest ethical ideals of psychologists; the code then delineates specific ethical standards representing the definite obligations of proper professional conduct. The general principles are as follows:

Principle A: Beneficence and Nonmaleficence

Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons, and the welfare of animal subjects of research. . . . Psychologists strive to be aware of the possible effect of their own physical and mental health on their ability to help those with whom they work.

Principle B: Fidelity and Responsibility

Psychologists establish relationships of trust with those with whom they work. They are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists uphold professional standards of conduct, clarify their professional roles and obligations, accept appropriate responsibility for their behavior, and seek to manage conflicts of interest that could lead to exploitation or harm. . . .

Principle C: Integrity

Psychologists seek to promote accuracy, honesty, and truthfulness in the science, teaching, and practice of psychology. In these activities psychologists do not steal, cheat, or engage in fraud, subterfuge, or intentional misrepresentation of fact. . . .

Principle D: Justice

Psychologists recognize that fairness and justice entitle all persons to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures, and services being conducted by psychologists. . . .

Ethics therefore are the moral principles and standards that guide a group or a person regarding right behavior. Gerald Corey, Marianne Corey, and Patrick Callanan (2007) differentiate between principle ethics and virtue ethics in the context of counseling and therapy (see also Corey, Corey, & Corey 2019, 13–15). Principle ethics are the specific rules for right behavior in specific situations. Virtue ethics are the highest ethical ideals to which counselors or therapists aspire and thus focus more on the character of the counselor or therapist than on specific behavior. The five general principles of the APA Ethics Code can be viewed as virtue ethics; the more specific ethical standards can be understood as mainly principle ethics (see also Barnett & Johnson 2008).

Confidentiality, Competence, and Choice

Major ethical issues in counseling and psychotherapy can also be summarized in three major categories, as W. W. Becker (1987) has done (in his application of ethical and legal issues more specifically to the area of paraprofessional or lay counseling): confidentiality, competence, and choice, aimed eventually at maintaining trust in the counseling relationship since trust is the essence of such a relationship.

In the category of confidentiality, ethical counselors will keep confidential anything a client reveals or discloses to them in the process of counseling. There are exceptions, however. By law, many states now require that professional counselors report situations involving child, elder, or dependent adult abuse or those in which clients may potentially harm themselves or others.

In the category of competence, professional counselors must receive the requisite academic or educational degrees, supervised clinical training and experience, and licensing (after passing licensing board examinations in certain states) in order to be in independent practice, charging fees for their services (with some pro bono or free work at times). They should also practice within the limits of their professional expertise or competence and refer clients to other, better qualified, or trained professional counselors when such clients present clinical problems beyond their own professional competence to treat. However, clinical competence for practicing psychologists or counselors is not as easy to define as it may seem, and its definition should be viewed more as “a work in progress” (Barnett, Doll, et al. 2007, 510; see also N. J. Kaslow et al. 2007). Nevertheless, graduate student educators and clinical supervisors, as gatekeepers of the profession of counseling and psychotherapy, need to be ethically responsible and adequately deal with professional competence problems in trainees or supervisees (W. B. Johnson et al. 2008), including those in Christian practitioner training programs (Palmer, White, & Chung 2008; see also W. B. Johnson 2007b; M. L. Nelson et al. 2008).

Finally, in the category of choice, the client’s freedom to decide whether to participate in counseling must be protected. Informed consent must be obtained from clients before therapy is started. However, the exact parameters of what a counselor or therapist should share with a client in obtaining that informed consent before starting therapy are not always clear-cut. Moreover, obtaining informed consent should also apply to other roles that psychologists or counselors may have such as conducting clinical assessment, research, or clinical supervision (see Barnett, Wise, et al. 2007). J. E. Barnett has pointed out that for informed consent to be legally valid, the following three conditions must be fulfilled (see Gross 2001): the information presented must be understood by the client, the client must provide the consent voluntarily, and the client must have the competence needed to provide the consent (Barnett 2007a, 181). He also cites from the APA Ethics Code that each informed consent agreement in the therapy context should include information about “the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality” (APA 2002, 1072) and include “reasonable alternatives available, their relative risks and benefits, and the right to refuse or withdraw from treatment” (Barnett 2007a, 180). Barnett has emphasized that informed consent should not be viewed as a onetime event that takes place just before therapy is started. Instead, it should be seen as an ongoing process because significant changes in the therapy provided may be proposed in the course of treatment, in which case further informed consent may be needed.

The APA Ethics Code covers many other ethical principles and standards; it should be read and consulted for more detailed information that will be helpful in ethical decision making (see APA 2002, 2017). However, no ethical code is sufficient in and of itself to provide concrete answers to all ethical dilemmas that counselors may face. Counselors and therapists therefore need to learn the steps necessary to engage in a constructive process of ethical decision making.

The Process of Ethical Decision Making

Corey, Corey, and Callanan (2007) have provided a helpful integrated model consisting of the following step to help a counselor carefully reflect on potential ethical problems in the process of ethical decision making:

identify the ethical issue or problem and clarify whether it is primarily moral, legal, ethical, clinical, or professional in nature

identify the various aspects of the ethical dilemma, including the rights, responsibilities, and welfare of every person involved in it

consult appropriate ethics codes for any guidance that may be helpful and relevant to the ethical issue being faced

be aware of laws and regulations relevant to the ethical problem

consult various sources, including other professionals, in order to receive different perspectives on the ethical issue at hand

explore all possible options for action, including further discussion of various options with other professionals as well as with the client if appropriate

consider the consequences of each of the options available for action, and especially how it would affect the client

choose what seems to be the most appropriate ethical option for action and then execute it, with follow-up evaluation of the results to see if any further action may be needed

Different counselors may sometimes offer different solutions for complex and difficult ethical dilemmas (S. Knapp, Gottlieb, et al. 2007; see also Pope & Vasquez 2016), including situations where there may be value conflicts in diverse cultures (S. Knapp & VandeCreek 2007). The crucial task before a counselor is to engage in a process of constructive and mature ethical decision making, always keeping in mind the welfare and well-being of the client, and to do no harm to the client. One ethical issue that often comes up for discussion among counselors and therapists concerns boundary issues and dual or multiple relationships with clients, which we will now examine.

Boundary Issues and Dual and Multiple Relationships: A Crucial Ethical Issue in Counseling

Boundaries and multiple relationships (including dual relationships) are among the most commonly discussed and debated ethical issues in the context of clinical practice (see Pope & Wedding 2008). Some authors and counselors will advocate avoiding all dual and multiple relationships with clients as an ethical boundary in order to prevent any possible exploitation of or harm to the client. Others have advised engaging in dual and multiple relationships with clients only when necessary and in clinically helpful situations, such as practicing in certain rural or military situations and culturally diverse contexts (see Barnett, Lazarus, et al. 2007).

The APA Ethics Code states the following as part of Standard 3.05 on “Multiple Relationships”:

A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.

A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.

Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical. (APA 2002, 1065)

It is clear from the last sentence quoted that not all multiple and dual relationships with clients are unethical, because such relationships do not automatically or always cause impairment or risk exploitation or harm to the client. The APA Ethics Code therefore does not prohibit all dual or multiple relationships. Boundary crossings into clinically helpful multiple relationships with clients can therefore be appropriate and ethical, and such crossings should be differentiated from boundary violations that cause impairment and harm to clients. An example of a boundary crossing is to touch a client on the shoulder or forearm as an expression of comfort when that client is experiencing deep grief over the loss of a loved one. An example of a boundary violation is to touch a client in a sexually explicit way (see Barnett 2007b). The APA Ethics Code is very clear that psychologists should not get involved in exploitative multiple relationships, such as engaging in sexual intimacies with clients they are still treating (APA 2002, Standard 10.05) or with relatives or significant others of such clients (Standard 7.07). Psychologists also should not provide therapy to former sexual partners (Standard 10.07).

On the other hand, there are other kinds of multiple relationships that do not involve boundary violations and are therefore not unethical (A. A. Lazarus & Zur 2002; see also Zur 2007). Arnold Lazarus emphasizes the need to strongly challenge restrictive draconian views such as prohibiting all multiple or dual relationships in clinical practice:

One of the most contentious issues has revolved around deep concerns in several quarters about dual or multiple relationships. Thus, when I argued that therapeutic benefits accrued when I selectively transcended strict professional boundaries and “partied and socialized with some clients, played tennis with others, took long walks with some, graciously accepted small gifts, and gave presents (usually books) to a fair number” (Lazarus 1994, 257), I was assailed by eight critics, who saw me as a dangerous, iconoclastic maverick. . . .

It must be clearly understood that the foregoing boundary crossings were not carried out in a rash or capricious manner without careful consideration. Dual relationships are rarely advisable with borderline, histrionic, violent, antisocial, or other seriously disturbed clients. As was underscored by Lazarus and Zur (2002), “before entering into a dual relationship take into consideration the welfare of the client, . . . avoidance of harm, exploitation and conflict of interest, and the risk of impairment of clinical judgment” (p. 474). The raison d’être behind any boundary crossing is the psychotherapist’s confidence that it is likely to prove beneficial to the client. (A. A. Lazarus 2007, 405)

Therefore, it is necessary to clarify which dual or multiple relationships should be avoided and which ones are acceptable or even necessary (Barnett 2007b). For example, in certain rural areas with small populations, the counselor or therapist may need to treat someone in the community whom the counselor knows quite well, such as the church pastor or the local banker, in a necessary and potentially helpful dual or multiple relationship with the client.

W. B. Johnson emphasizes the need for virtue ethics that focus not only on the ethical guidelines and principles for dealing with boundaries and dual and multiple relationships with clients but also on the person, character, of the psychologist or therapist and “clear moral virtues such as prudence, integrity, and compassion” (2007a, 410). Counselors and therapists therefore need to personally grow in the process of becoming ethical helping professionals (R. Sommers-Flanagan & Sommers-Flanagan 2007) and pursue not just mandatory ethics at the minimum level, but aspirational ethics for the best interests of clients and positive ethics in doing their best for clients: they should focus on concern-based ethics and not fear-based ethics (see Corey 2021, 38). Biblical perspectives on ethics that emphasize agape love and virtue ethics and ethical practice by Christian counselors or therapists are also crucial (see Browning 2006; Ohlschlager & Clinton 2002; R. K. Sanders 2013; Tjeltveit 1992, 1999). There are distinctively Christian codes of ethics governing the practice of Christian counselors and therapists (see, e.g., American Association of Christian Counselors 2014 for the AACC Y-2014 Code of Ethics). These perspectives and codes will be covered in the last chapter of this book, which focuses on legal and ethical issues in Christian counseling and psychotherapy.

Recommended Readings

American Counseling Association (2014). ACA code of ethics. Alexandria, VA: American Counseling Association.

American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060–1073.

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct. Retrieved from http://www.apa.org/ethics/code/ethics-code-2017.pdf.

Barnett, J. E., & Johnson, W. B. (2008). Ethics desk reference for psychologists. Washington, DC: American Psychological Association.

Barnett, J. E., & Johnson, W. B. (2015). Ethics desk reference for counselors (2nd ed.). Alexandria, VA: American Counseling Association.

Corey, G., Corey, M., & Corey, C. (2019). Issues and ethics in the helping professions (10th ed.). Boston, MA: Cengage.

Pope, K. S., & Vasquez, M. J. T. (2016). Ethics in psychotherapy and counseling: A practical guide (5th ed.). San Francisco: Jossey-Bass.

Wheeler, A. M., & Bertram, B. (2019). The counselor and the law: A guide to legal and ethical practice (8th ed.). Alexandria, VA: American Counseling Association.

Chapters 4

Psychoanalytic Therapy

Sigmund Freud (1856–1939), the founder of psychoanalysis, is still a towering figure in the field of counseling and psychotherapy. Some authors and textbooks have erroneously credited him for being the founder of psychotherapy, but other important figures, such as Paul Dubois (1848–1918) and Pierre Janet (1859–1947), were also influential in the history of modern psychotherapy (see Corsini & Wedding 2008, 11–12). In fact, therapeutic work in the care of souls preceded Freud by many centuries. However, the theories and therapeutic techniques developed by Freud in psychoanalysis are still unique and substantial. Although the Freudian psychoanalytic approach is no longer as popular or widespread today, it is still influential in the development of more recent psychoanalytic or more broadly psychodynamic approaches to therapy that have gone beyond some of Freud’s original ideas. Examples of such contemporary psychoanalytic therapies include ego psychology, object relations psychology, self psychology, and relational psychoanalysis, which will be briefly described later in this chapter. Of course, other schools of therapy have been developed in reaction to Freud’s psychoanalytic views and even in outright rejection of many of his ideas and techniques.

Biographical Sketch of Sigmund Freud

Sigmund Freud was born to Jewish parents in Freiburg, Moravia (formerly in Austria, now in the Czech Republic), on May 6, 1856, the eldest of eight children (five daughters and three sons). The Freud family moved to Vienna when Sigmund was four years old so that his father, who was a wool merchant, would have better business prospects. In their crowded apartment, Sigmund had his own study and bedroom. His mother favored him and had high expectations for him to excel academically and professionally. His father was very authoritarian, like many fathers in that era and culture (E. Jones 1953).

Freud excelled in his academic work and graduated summa cum laude from secondary school. He was fluent in several languages, including the classical languages Greek, Latin, and Hebrew, as well as English, Italian, French, and Spanish (Ellenberger 1970). Eventually Freud decided on a career in medicine and obtained his medical degree from the University of Vienna in 1881, when he was twenty-five years old. He married Martha Bernays in 1886, and they had six children. Their youngest child, Anna Freud, eventually became a well-known psychoanalyst herself, focusing on the treatment of children and on the development of the ego, that system of personality in Freudian theory that interacts with the reality-based external world.

Freud had been exposed to the work of Josef Breuer on hysterical illness during the six years he worked with Ernst Brucke, a well-known physiologist, while still in medical school. Due to financial reasons, Freud left Brucke and began a residency in surgery. In 1883 he trained in neurology and psychiatry at the Viennese General Hospital. He also spent four months in 1885 in Paris with Jean Charcot, a renowned neurologist who used hypnosis to treat hysterical symptoms. This experience enabled Freud to recognize the significance of the unconscious mind, although he later questioned the usefulness of hypnosis as a therapeutic technique. He also discussed with Josef Breuer how Breuer helped his patient Anna O., who had exhibited hysterical symptoms, by mentioning emotional material while she was under hypnosis. Freud began using this technique with his own patients, and he and Breuer published Studies on Hysteria in 1895.

Freud’s father died in 1896; around this time his collaboration with Breuer also began to deteriorate. Freud’s radical views on how traumatic sexual experiences in childhood can cause hysteria did not sit well with others, including Breuer. In 1897, in his early forties, Freud began a painful three-year process of psychoanalysis on himself, including analyzing his dreams and exploring his own childhood memories. He suffered from significant emotional problems at this time, such as serious worries about his finances and phobias of death and heart disease. Through his self-analysis, Freud came to realize that he had strong feelings of hostility toward his father and sexual feelings as a child toward his mother. From his own self-observations and reflections, as well as his treatment of patients, Freud continued to develop his unique psychoanalytic theory and psychoanalysis as a major therapeutic approach. After this intensive three-year period of self-analysis, he published his best-known work, The Interpretation of Dreams, in 1900.

In 1902 Freud formed the Wednesday Psychological Society, which met initially at his home to discuss his psychoanalytic ideas. In 1908 this group became the Vienna Psychoanalytic Society, numbering among its members prominent and brilliant colleagues of Freud, such as Alfred Adler, Carl Jung, and Otto Rank. However, many of Freud’s colleagues were alienated by his inability to tolerate dissenting views and his insistence on having absolute control of what constituted psychoanalysis, as its founder. As a result, key figures such as Adler and Jung eventually left the Vienna Psychoanalytic Society. Adler went on to establish his own school of psychotherapy, called individual psychology; Jung likewise founded another school of psychotherapy, called analytical psychology.

Freud thus spent the later part of his professional life in relative isolation, working more on his own while, ironically, becoming more renowned and successful. He continued to keep a grueling schedule, working eighteen-hour days, seeing patients and writing. Freud habitually smoked twenty cigars almost daily, and in 1923 he was diagnosed with bone cancer of his jaw and mouth. He eventually underwent thirty-three operations, but despite his painful struggle with bone cancer for most of the final two decades of his life, he continued to work long hours and produced many significant writings. Freud reluctantly left Vienna for London in 1938, just before World War II. A year later, in September 1939, he died, probably from physician-assisted suicide, using a lethal dose of morphine (Gay 1988). Freud left behind what many still consider to be the most comprehensive and substantial theory of personality, psychopathology, and psychotherapy in his unique approach of psychoanalysis. His published collected works ultimately included twenty-four volumes (see Standard Edition of the Complete Works of Sigmund Freud, published by Hogarth Press, London, 1953–1974).

Freud’s life and work have been described in more detail by several authors. For further information and details of Freud’s life and professional career, see Ernest Jones (1953, 1955, 1957, also 1961), who gives the most complete account, as well as Henri Ellenberger (1970), Peter Gay (1988), Paul Roazen (2001), and Amy Demorest (2005), as recommended by Richard Sharf (2016, 33).

Major Theoretical Ideas of Freudian Psychoanalysis

Perspective on Human Nature

Freud’s view of human nature was mainly pessimistic and at best somewhat neutral. It was also a deterministic view, in which human actions or behaviors are understood as caused by irrational forces, mainly unconscious, called drives or instincts. These innate instincts evolve through several stages of psychosexual development in a person’s childhood so that their personality is essentially formed by the age of six.

Freud divided such human drives or instincts into two major types: the life instincts (Eros) and libido, originally referring to sexual energy but eventually broadened to include all life energy that seeks to experience pleasure and avoid pain; and the death instincts (Thanatos), which are associated with death and aggression. Both of these sexual and aggressive drives, life-and-death instincts, are crucial motivators of human action according to Freud.

The Unconscious and Levels of Consciousness

Freud’s concepts of the unconscious and of the different levels of consciousness that exist in a person are often viewed as his most significant contributions to the mental health field. He described three levels of consciousness: the conscious, the preconscious, and the unconscious. The conscious, what one is aware of experiencing at a particular moment—such as holding a pen in one’s hand or feeling painful sensations—is actually only a small part of a person’s mental life. The preconscious includes memories that can be easily recalled, such as remembering what one ate for lunch yesterday or details from a movie seen last weekend. The largest level of consciousness, however, is the unconscious, which contains memories and experiences that have been repressed or pushed out of consciousness because they are too threatening, such as feelings of hostility toward a parent or painful childhood memories of sexual abuse. The unconscious also refers to everything that one is unaware of, including hidden needs and motivations. Freud viewed the conscious level as only a small part of the mind, like the proverbial tip of the iceberg. The unconscious, which exists below the level of awareness, is the largest part of the mind and influences or controls most psychological functioning. It cannot be directly observed but can be inferred from phenomena such as dreams, forgetting a well-known fact or name, and slips of the tongue (e.g., saying “nipple” instead of “ripple”). The major goal of psychoanalysis is therefore to make the unconscious conscious so that a person can have more freedom to choose.

Personality Structure

Freud’s psychoanalytic theory postulates three major systems in the personality structure of each person: the id, the ego, and the superego. These psychological systems should not be understood literally as referring to three physically separate parts of a person. However, the three systems are seen as consisting of psychic energy that is limited in its availability. The id can be conceptualized as the biological system, the ego as the psychological system, and the superego as the social system of personality, broadly speaking (Corey 2021), but all three systems function together as a whole. In a nutshell, the id refers to powerful biological forces, the superego to the conscience, and the ego to the rational system of one’s personality that interacts with external reality and mediates between the id and the superego.

The Id. The id (or “it”) is the original, unconscious system of personality. A person is born with an id, and one might say that an infant is all id. The id is full of psychic or instinctual energy waiting to be discharged so that homeostasis can be maintained. It is driven by the pleasure principle, seeking always to avoid pain and to experience pleasure and satisfaction of its intrinsic needs. The id remains so throughout a person’s life, wishing and acting to fulfill desires without rational thinking. The id therefore is characterized by primary process thinking that is irrational and primitive, that seeks self-gratification, with no concern for others. The two basic instincts operating in the id are the life (or sexual) and death (or aggressive) instincts or drives. The newborn infant therefore invests emotional energy, or cathects, in objects that will immediately meet or fulfill its demanding needs. The object may be a nipple or a blanket that serves to reduce the infant’s needs.

The Ego. The ego (the “I”) is the system of personality that interacts with the real world “out there.” It can be likened to an executive who provides control and regulation of one’s personality. It begins functioning around age six to eight months to help the id fulfill its demanding needs and impulses in a more appropriate and acceptable way in the real world. The ego therefore acts to control consciousness and regulate the primitive drives or instincts of the id. The ego follows the reality principle, using rational and realistic thinking, or secondary process thinking, which results in action plans for meeting needs that do not impulsively follow the pleasure principle but instead suspend or control it. It therefore censors and restrains the id, a function described as anticathexis. The ego, in this context, helps an infant or young child not to act out angrily or cry when personal wishes are not fulfilled.

The Superego. The superego is the social or judicial system of personality that contains the social and parental values and standards to which a person has been exposed. It follows the morality principle and guides a person in deciding whether a specific behavior is right or wrong, good or bad. The superego therefore provides a moral code by introjection (the process of incorporating into oneself the values and standards of parents and society). The id impulses are controlled or restrained by the superego, but the ego is also influenced by the superego to aim for perfection and moralistic ideals rather than more realistic and reasonable goals. The superego therefore strives for perfection, not pleasure, and can push a person into an extreme or legalistic submission to perfectionistic and pathological standards that cannot be attained. When this happens, when the superego is functioning against both the id and the ego, neuroses or psychological disorders can develop. Anxiety is often experienced by a person when the id, the ego, and the superego are in such conflict.

Anxiety

Anxiety is a central concept in psychoanalytic therapy. It refers to a feeling of dread and tension resulting from previously repressed factors coming to awareness, such as feelings, experiences, and memories. Anxiety functions as a warning of potential danger and also motivates people to act in certain ways (see Corey 2021, 61).

Freud conceptualized anxiety as consisting of three major types: reality, neurotic, and moral. Reality anxiety is the fear of an external situation that is appropriate to the degree of real danger present, such as fear of a nearby poisonous snake about to strike. Neurotic anxiety is the fear of being overwhelmed by one’s instincts or drives (id) so that one ends up doing something that will be punished. Moral anxiety is the fear of violating one’s own conscience or internalized parental and societal standards (superego). Neurotic and moral anxieties are therefore related to conflicts or threats within the person. When an individual experiences anxiety, the ego copes or responds by using defense mechanisms.

Defense Mechanisms

The ego employs defense mechanisms or ego-defense mechanisms (Corey 2021, 61) to deal with the pain of anxiety by distorting or even denying reality. Defense mechanisms operate at the level of the unconscious. When the ego uses them infrequently and appropriately, they can serve a constructive purpose by reducing stress or anxiety and enabling the person to cope more effectively. However, if they are used too often to avoid the pain of anxiety by denying or blocking out reality, they can become destructive and pathological, resulting in more severe psychological disorders. Common defense mechanisms include repression, denial, displacement, sublimation, reaction formation, projection, rationalization, regression, intellectualization, and identification.

Repression. Freud considered repression the most fundamental or important defense mechanism, one on which his psychoanalytic theory was founded. Repression is the unconscious attempt of the ego to block out of consciousness (i.e., repress) negative experiences that are too painful or threatening for a person to acknowledge. Especially painful experiences or memories of the first five to six years of a person’s childhood are repressed, so that they are stored in the unconscious. However, they still affect and motivate the thoughts, feelings, and behaviors of the person later in life. An example of repression would be a man who has feelings of hostility and hatred toward his father, but these feelings are entirely repressed or blocked from conscious awareness because they are too overwhelming for the person to acknowledge. Such repressed feelings are not under the voluntary control of an individual because repression operates at the unconscious level.

Denial. Denial is a defense mechanism that usually functions at more preconscious and even conscious levels, whereby an individual refuses to accept the reality of a given situation or event that is negative, painful, or anxiety provoking. This mechanism therefore denies reality. For example, an individual refuses to accept the news of having cancer and continues to live as if not having cancer, without getting much-needed medical treatment. In another example, some fanatical fans of Elvis Presley still deny that he is dead!

Displacement. Displacement is a defense mechanism whereby an individual copes with anxiety by shifting the discharge of their impulses from a threatening object or person to a much safer substitute. For example, a very mild-mannered man who has received a strong reprimand from his supervisor at work comes home and kicks his dog (out of frustration and anger toward his supervisor but now redirected to his dog).

Rationalization. Rationalization is an individual’s attempt to explain away painful experiences with reasons or excuses that are not accurate or true. For example, a man who does not get a much anticipated and desired job promotion believes that he really did not want the promotion because of all the extra stresses and responsibilities that come with it, including much international travel.

Regression. When the ego is threatened, an individual may use the defense mechanism of regression, thereby returning to an earlier stage of development that was less stressful but also uses less mature or less appropriate behaviors to cope with the current anxiety. An example can be found in a first grader who is failing academically and then resorts to infantile behaviors such as crying for mother and thumb-sucking.

Intellectualization. Intellectualization is a defense mechanism whereby a person detaches from a painful emotional experience by focusing only on their own thoughts and the minute details involved in trying to analyze and explain the negative emotional experience. For example, a mother who just received news that her two-year-old son was killed by a drunk driver might begin a long discussion of the meaning of life and death and how it is all fated and beyond anyone’s control instead of dealing with her feelings of shock, grief, loss, and anger at the drunk driver.

Identification. Identification is a defense mechanism whereby an individual who is threatened by anxiety or other negative feelings assumes the characteristics of others who may be more successful, thereby associating or identifying with them. An example would be an adolescent who struggles with deep feelings of failure and inferiority who identifies with a famous rock band by dressing like the band members and mimicking their speech.

Personality Development: Freud’s Psychosexual Stages of Development

Freud was radical in his time when he described the psychoanalytic theory of psychosexual stages of development that every person goes through. He believed that the personality development of an individual is basically completed by around age five or six. His theory is biologically based, focusing on the flow of sexual energy through the following psychosexual stages of normal human development: oral, anal, phallic, latency, and genital. The oral, anal, and phallic stages of psychosexual development occur by age five or six, after which comes the relatively calm latency stage, which lasts for about six years. Then the genital stage in adolescence occurs around the onset of puberty. Gratification of the sexual drive is central to Freud’s theory, but this is experienced in various parts of the body as a person matures, eventually culminating in the genital area. If a person experiences certain traumatic events in early childhood in any of these psychosexual stages of development, fixation may then occur at a specific stage, with such abnormal development resulting in an individual being more vulnerable to stress and crisis later in life.

Oral Stage. The oral stage takes place in the first eighteen months of life. It focuses mainly on the mouth for experiencing gratification of the infant’s needs and drives, which are virtually all id-driven at this first and earliest stage. The infant initially is unable to differentiate between self and others or the environment. Dependence on the mother for gratification of the infant’s needs through sucking and eating is crucial; therefore, the mother-infant relationship is central in the oral stage. The mouth is also involved in other activities such as biting, spitting, holding on to, and closing, plus eating and sucking. The specific experiences of the infant or child in the oral stage will affect the person’s adulthood. For example, if the child depends too much on the mother and she overindulges the child, the child may experience fixation at this oral stage and later become an overdependent adult. However, if the mother underindulges the child and provides irregular or inattentive feeding, the child may become insecure and have trouble trusting others or forming intimate relationships with others as an adult.

Anal Stage. The anal stage occurs between the ages of eighteen months and three years, when the focus of gratification and pleasure is the anal area, involving the holding or releasing of feces or the defecation processes, as well as urination. During this anal stage, the ego begins to differentiate from the id. Children are also learning to have more control over their own bodily processes as well as control over others (e.g., by often saying, “No”). Toilet training is a central developmental task in the anal stage. Depending on how strict parents are in toilet training their children, the child may later develop an obsession with cleanliness and orderliness, with a fixation on this stage described as being anal-retentive; or the child may become disorderly and even destructive, that is, anal-expulsive.

Phallic Stage. The phallic stage occurs around the age of three to five or six years, when the gratification of sexual needs moves from the anal area to the genital area. Self-stimulation of the penis for boys and the clitoris for girls (masturbation) leads to pleasurable experiences. The realization that boys have penises but girls do not is a crucial part of the phallic stage, leading to what Freud called penis envy (or wishing to have a penis of one’s own) in girls and castration anxiety (or the fear of losing one’s own penis) in boys.

Boys also have an unconscious sexual desire for their mothers and wish to get rid of the father as a rival. They resolve this Oedipus complex by identifying with the father and channeling their sexual wishes into more acceptable outlets. Girls, in a somewhat different way, have an unconscious desire for their fathers (who have their desired object, a penis) and a hatred for their mothers; Carl Jung and others have labeled this the Electra complex, a term that Freud himself was reluctant to use. Girls also need to resolve this complex by identifying with their mothers so that they can vicariously have the desired object. This aspect of Freudian psychoanalytic theory has received strong criticism from other theorists and feminists. Problems leading to fixation at this phallic stage may result in sexual identity difficulties in adulthood and possible difficulties in relationships with the opposite sex or with the same sex.

Latency Stage. The latency stage occurs from around the age of six to twelve years or puberty. It is a period of relative calm, with sexual drives being more repressed. Children at this latency stage spend more of their energy focusing on school and friends and developing important social and technical skills to prepare them to function well as adults in society. Their personalities have already been formed in the previous stages of psychosexual development, by age five or six, after which Freud believed that significant personality change is almost impossible.

Genital Stage. At puberty, around age twelve, an individual enters the genital stage, when pleasure is experienced more directly through genital stimulation in the context of heterosexual relationships. The focus now is on others rather than on the self, in the experience of genital sexual satisfaction. If a person has gone through the other earlier stages of psychosexual development without significant fixations or traumas, then there is sufficient libidinal energy available for the youth to live a relatively normal life. Such a life means having the ability to love and to work, the ideals of personal maturity that psychoanalysts try to help their patients achieve in successful psychoanalysis.

Freud’s theory of psychosexual stages of development has been strongly challenged and criticized by other psychoanalytic theorists. Erik Erikson (1902–1994), for example, emphasized much more the psychosocial stages of development, focusing not only on child development but also on the entire adult span of human development until death. Briefly, Erikson (1950) delineated and described the following stages of psychosocial development:

infancy (first year of life), focusing on developing trust versus mistrust

early childhood (ages one to three), focusing on developing autonomy versus shame and doubt

preschool age (three to six), focusing on developing initiative versus guilt

school age (ages six to twelve), focusing on developing industry versus inferiority

adolescence (ages twelve to eighteen), focusing on developing identity versus role confusion

young adulthood (ages eighteen to thirty-five), focusing on intimacy versus isolation

middle age (ages thirty-five to sixty), focusing on developing generativity versus stagnation

later life (ages sixty plus), focusing on developing integrity versus despair

Joan Erikson, Erikson’s wife for sixty-four years, more recently included another stage that she termed “disgust versus wisdom” (ages in the eighties and nineties), focusing on developing gerotranscendence (Sharf 2016). This ninth stage of psychosocial development involves moving from a rational and materialistic perspective to a deeper focus on spirituality and experiencing peace of mind (Erikson 1997).

Other challenges and modifications to traditional psychoanalytic theory as originally described by Freud have come from more contemporary approaches to psychoanalytic therapy and, in particular, the four major schools: ego psychology, object relations psychology, self psychology, and relational psychoanalysis.

Ego Psychology

Ego psychology focuses more on the ego and its conscious and adaptive functions rather than on the id and unconscious drives, which seemed to preoccupy Freud. Anna Freud (1895–1982), Sigmund Freud’s daughter, made significant contributions to ego psychology by emphasizing the ego in child development in her description of developmental lines, an example of which is the gradual evolving of more other-centered behaviors rather than self-centered behaviors as a child matures (A. Freud 1965). She also expanded the notion of defense mechanisms to include normal and constructive ones that enable an individual to deal more effectively with the world (A. Freud 1936). As already mentioned, Erik Erikson is another major theorist in ego psychology, noted especially for his description of the psychosocial stages of human development over the entire life span of an individual. Other well-known figures in ego psychology, sometimes labeled as “the American school,” include Heinz Hartmann (1958) and David Rapaport (1951).

Object Relations Psychology

The object relations perspective focuses more specifically on how past childhood relationships between a child and the child’s significant others, especially the mother or other love objects in the child’s life, affect personality development and later adult life. It also emphasizes past internalized relationships or object relations rather than internal sexual or aggressive drives in the determination of one’s present and future behavioral patterns. A specific process described by object relations theorists as individuation refers to how an individual can separate from their mother and develop into an independent person. Well-known theorists in object relations psychology, sometimes described as “the British school,” include Donald Winnicott (1966), W. R. D. Fairbairn (1954), Melanie Klein (1957, 1975), Margaret Mahler (1968, 1979a, 1979b), and Otto Kernberg (1975, 1976). More detailed descriptions of object relations approaches can be found in St. Clair and Wigren (2004).

Self Psychology

The self psychology school is based on the major contributions of Heinz Kohut (1913–1981), who wrote several significant books (1971, 1977, 1984) that define and describe his theoretical concept of the self (see also St. Clair & Wigren 2004). He emphasized how relationships with other people, especially parental figures in childhood experiences, have a profound influence on the development of the sense of self in an individual. If such childhood experiences have been nurturing and healthy, a stable sense of self will result so that one is able to develop mature relationships with others as an adult. However, if early childhood experiences have been more negative and emotionally depriving, then a less healthy sense of self will result, and the person’s ability to relate to others well will be significantly limited. Kohut especially focused on the treatment of narcissistic and borderline disorders that involve a person’s sense of a damaged or inadequate self.

Relational Psychoanalysis

A more recent development in psychoanalytic theory and therapy has been the significant work of Stephen A. Mitchell (1988, 2000) and his colleagues (see J. R. Greenberg 2001; J. R. Greenberg & Mitchell 1983) on relational psychoanalysis. This approach emphasizes the mutuality of the therapeutic relationship between the analyst and the client. In other words, both the analyst and the client influence each other on the conscious and unconscious levels such that the analytic or therapeutic relationship cannot be viewed as neutral, with the analyst objectively observing and analyzing the client in a unilateral way. This relational perspective has been described as intersubjective (see Orange, Atwood, & Stolorow 1997; Stolorow, Atwood, & Brandchaft 1994; Stolorow, Brandchaft, & Atwood 1987), interpersonal, or relational (see Wachtel 2008; also Bland & Strawn 2014a; M. T. Hoffman, 2011). Mitchell alsoalso focused on how culture affects both the analyst and the client, thus critiquing and moving beyond Freud’s original idea of unconscious biological drives that affect every individual because they are supposed to be universal in nature.

These four major schools of contemporary psychoanalytic approaches have critiqued and modified traditional Freudian psychoanalysis. Psychoanalytic therapy today is more diverse and less authoritarian, especially regarding how the analytic relationship is viewed and experienced. Examples of the newer approaches to psychoanalytic theory and practice are a greater emphasis on the conscious and adaptive functions of the ego (and less on the unconscious drive of the id), on object relations or internalized relationships with significant others or love objects, on the development of the self, and on a more mutual and reciprocal analytic relationship between the analyst and the client.

Another significant development in recent years has been the ascendency of attachment theory, based on the pioneering work of John Bowlby (1969, 1977, 1988) and Mary Ainsworth (Ainsworth et al. 1978), not only in developmental psychology (Dixon 2003) but also in psychotherapy and, more specifically, psychoanalytic therapy and psychodynamic therapy. This has resulted in several attachment-theory-based, or attachment-based, child and family interventions, as well as several attachment-based adult therapies (see K. N. Levy & Johnson 2019; see also Cassidy & Shaver 2016; Mikulincer & Shaver 2016).

Attachment Theory and Attachment-Based Therapies

Bowlby (1969, 1977) was the originator of attachment theory, which emphasizes that the affectional bond between an infant and the caregiver, developed from their early interactions, leads to one’s “internal working models” of self and the other (Bowlby 1977). Secure attachment between an infant and the caregiver results from a caregiver who sensitively and consistently gives love, comfort, food, and warmth to the infant. The infant experiences such a caregiver as a safe haven to turn to when facing distress or other needs, and also as a secure base who will watch over the infant venturing out to explore the environment. However, if the infant’s needs are not reliably and lovingly met by the caretaker (usually the mother), insecure attachment occurs, which can lead to vulnerability and psychopathology and even specific problems or disorders (see K. N. Levy & Johnson 2019, 179). Ainsworth further developed attachment theory with more empirical work (Ainsworth et al. 1978). Based on observational studies of mother-infant interactions in the “strange situation” involving experiences of separation and reunification, three major classifications of attachment were identified: secure attachment, anxious-avoidant attachment, and anxious-ambivalent (or anxious-resistant) attachment. Disorganized attachment was a later fourth classification that was added. Bowlby’s attachment theory was initially rejected by mainstream psychoanalysis but more recently has become a major theoretical framework for clinical work (e.g., see Obegi & Berant 2009) with emerging attachment-based psychoanalytic therapies (see T. W. Hall & Maltby 2014; see also Eagle 2013; Fonagy 2001; K. N. Levy & Johnson 2019; Wallin 2007).

Mary Main, who studied with Ainsworth, developed the semi-structured adult attachment interview with her students Nancy Kaplan and Carol George (Main, Kaplan, & Cassidy 1985; George, Kaplan, & Main 1985), which led to further significant developments in attachment theory. They identified three major adult attachment patterns: secure, dismissing, and enmeshed/preoccupied, with two later additional categories of unresolved and “cannot classify” (see K. N. Levy & Johnson 2019, 179). A self-report measure of adult attachment style has also been developed by Cindy Hazan and Phillip Shaver (1987), with three major scales: secure, anxious, or avoidant, following the earlier infant-strange-situation classifications. A fourth category of fearful attachment was added by other researchers (Bartholomew & Horowitz 1991).

Kenneth Levy and Benjamin Johnson (2019), in their comprehensive and empirically based review of attachment and psychotherapy, noted that several attachment-based parent-child interventions and psychotherapies were developed in the 1980s and 1990s; since then, even more have emerged. They briefly list and describe twenty-one of these child and family interventions, some of which have received empirical support for their effectiveness (180–183). They also list seven attachment-based adult interventions, focusing on three major therapies that are explicitly based on attachment theory and have received some empirical support for their effectiveness in treating several psychological disorders (183–186).

The first major attachment-based adult therapy is interpersonal psychotherapy or IPT (Klerman et al. 1984; see also E. Frank & Levenson 2010; Verdeli & Weissman 2019; Weissman, Markowitz, & Klerman 2017). It is based on psychodynamic neo-Freudian theory that is more interpersonally oriented (e.g., the work of Karen Horney, Harry Stack Sullivan, Erich Fromm, Clara Thompson and Frieda Fromm-Reichman, as well as Franz Alexander and Thomas French, who emphasized the corrective emotional experience between the therapist and client, and especially the work of Sullivan and Bowlby). It is a structured and time-limited therapy that focuses on the therapist interpersonally providing a secure base and safe haven in therapy for the client to experience attachment security with a warm, empathic, collaborative, and active therapist who is not too directive. It also uses psycho-education and homework assignments. IPT has been found to be as effective as cognitive-behavioral therapy (CBT) for major depressive disorder but has also been further developed to treat other problems such as eating disorders and addictions (see Carroll, Rounsaville, & Gawin 1991). A quite similar therapy to IPT, attachment-based family therapy (ABFT), has shown effective results for adolescents suffering from family conflict, internalizing and externalizing behaviors, anxiety, depression, suicidality, and hopelessness (G. S. Diamond, Wintersteen, et al. 2010). In fact, numerous randomized clinical or controlled trials have been conducted, and the results from the meta-analyses (Cuijpers et al. 2011, Cuijpers, Donker, et al. 2016) support the efficacy of IPT for mood disorders, some anxiety disorders, and bulimia nervosa, but not for anorexia nervosa or substance abuse (see Prochaska & Norcross 2018, 169–171; see also Verdeli & Weissman 2019).

The second major attachment-based adult therapy is emotion focused or emotionally focused therapy (EFT) for couples, but more recently it has been used also for individuals and families. Susan Johnson (2019), the primary developer of EFT, recently provided an update of EFT and the empirical evidence that has accumulated for its efficacy as an attachment-based therapy and now as an empirically supported treatment. She also summarized ten core principles of attachment theory and science that are foundational to EFT (2019, 6–9). While EFT is attachment based, emotion centered, and relational, with some connection to relational psychodynamic therapies, it is not strongly psychoanalytic in orientation.

Levy and Johnson (2019) mentioned three steps that EFT implements to help couples, using an attachment injury resolution model (see Makinen & Johnson 2006): First the therapist guides the couple to view their troubling emotions from an attachment perspective (e.g., in discussions of fears related to closeness or loss). Second, the therapist encourages the couple to communicate more openly about their needs and interpersonal risk-taking in order to deepen an attachment bond between the couple. Third, as the couple develops more attachment security, other secondary issues (such as drinking problems) can be better dealt with in their relationship, which now has a strong love connection or attachment bond (see K. N. Levy & Johnson 2019, 183, 185). There is some empirical evidence to support the effectiveness of this EFT intervention (Makinen & Johnson 2006) and the stability of the improvements over a three-year period (Halchuk, Makinen, & Johnson 2010).

Susan Johnson (2019) has written about EFT as an attachment-based therapy that focuses on love or developing strong attachment bonds in couples and between people. She has described it as a “hold-me-tight” approach (S. M. Johnson 2008) with love sense, which emphasizes love as key and crucial to human relationships and a civilized society (S. M. Johnson 2013). She has also coauthored a hold-me-tight guide from a spiritual perspective for Christian couples called Created for Connection (S. M. Johnson & Sanderfer 2016). Further descriptions of EFT can also be found in chapter 16 on marital and family therapy (below; see also L. S. Greenberg 2017; L. S. Greenberg & Goldman 2019).

The third major attachment-based adult therapy is mentalization based treatment (MBT), developed by Peter Fonagy and Anthony Bateman, initially in the treatment of borderline personality disorder (Bateman & Fonagy 1999, 2009, 2012, 2016; Fonagy & Bateman 2006). MBT combines philosophy or theory of mind, Kleinian theory, ego psychology, and attachment theory (K. N. Levy & Johnson 2019, 185). Mentalization refers to the social-cognitive-affective capacity to think about mental states (e.g., wishes, desires, and intentions) in oneself and in others. MBT therefore focuses on reflective function as a core aspect of therapy in helping clients develop their mentalizing capacity to be more aware of one’s own thinking and internal states as well as others’ thinking and internal states, including the therapist’s, and be better able to process them. The therapeutic relationship between the therapist and client is crucial in MBT, which is a relational psychoanalytic therapy that is also attachment-based. Growing empirical evidence for the efficacy of MBT, especially for borderline personality disorder and maintenance of treatment gains compared to treatment-as-usual, has been found in two large-scale randomized controlled trials involving eighteen months of MBT in outpatient treatment as well as in a day hospital program (Bateman & Fonagy 1999, 2009). MBT is now also being used in the treatment of mood disorders and somatoform conditions, and of youth and family problems (Bateman & Fonagy 2012).

Levy and Johnson (2019) noted that in addition to these three major explicitly attachment-based therapies, there are two other examples of therapies indirectly or implicitly based on attachment theory in emphasizing the therapeutic alliance between the therapist and client and the exploration of past and present relational experiences so that more adaptive views of self and other may occur. These two therapies are supportive psychodynamic psychotherapy (SDT), which is an object relations and psychoanalytically oriented treatment for borderline personality disorder (Appelbaum 2005), and transference-focused psychotherapy (TFP), which is a psychoanalytically oriented therapy with some integration of attachment theory in its focus on reflective function (Clarkin, Yeomans, & Kernberg 2006), based on the object relations work of Kernberg (1968). SDT has received some empirical support for its effectiveness in treating personality disorders (e.g., Clarkin et al. 2007); TFP has also been found to be effective for the treatment of personality disorders such as borderline personality disorder and narcissistic personality disorder (Clarkin et al. 2007; D. Diamond et al. 2013).

Attachment theory across the life span and in many areas of psychology and other disciplines has exploded in its growth in recent decades, with over thirty thousand entries in a literature search from 1975 to 2016 (Cassidy & Shaver 2016, x). Mikulincer and Shaver (2016) found the huge literature published on attachment theory “daunting” in 2007 but observed that it had become “gargantuan” by 2016 (ix). Attachment theory has also achieved a more significant and central place in psychoanalytic therapy and psychodynamic therapy. Hall and Maltby thus concluded: “An attachment-based psychoanalytic modality believes that the patient’s attachment to the therapist is primary in the change process. The common interventions . . . focus on the patient-therapist relationship and include attunement/empathic interventions, relational interventions, reflective interventions, appropriate use of interpretation and effective self-disclosure” (2014, 214).

In recent years more work has also been done on the integration of psychoanalytic and psychodynamic therapies, especially relationally based and attachment-based approaches with Christianity or spirituality (e.g., see Bland & Strawn 2014a; M. T. Hoffman 2011; Rizzuto & Shafranske 2013; Sorenson 2004).

The therapeutic process and relationship as well as the major therapy techniques and interventions of more traditional psychoanalytic therapy will now be discussed.

Therapeutic Process and Relationship

Traditional Freudian psychoanalysis (with the analyst seeing the client usually four times a week, sitting behind the client, who lies on a couch) and psychoanalytic therapy (with the analyst seeing the client one to three times a week, usually face-to-face) have two main goals of therapy: to help bring the unconscious to conscious awareness and to strengthen the ego so that an individual is less influenced by instinctual drives (sexual and aggressive) of the id or demanding perfectionist standards of the superego, and freer to act in more realistic ways. Psychoanalysis therefore aims at restructuring one’s personality and not simply attenuating symptoms or solving problems. Insight or understanding of childhood experiences is achieved by analyzing them through using several major psychoanalytic methods of therapy. Such insight is seen as a key curative factor in successful psychoanalysis. However, it is not merely intellectual insight or understanding; it is also insight based on working through or experiencing specific memories and feelings, especially from childhood.

The therapist’s role in traditional psychoanalysis is passive, aimed at maintaining neutrality or anonymity, with almost no self-disclosure at all. The analyst therefore behaves like a “blank screen” to facilitate the development of a transference relationship in which the client will project or transfer unconsciously onto the analyst some feelings and experiences that originally were associated with past parental figures, especially in early childhood. The analyst puts forth a best effort to achieve a good working alliance or therapeutic relationship with the client. Most of the time, the analyst is simply listening to the client, occasionally asking key questions, murmuring the proverbial Freudian “Um-hmm,” and judiciously and infrequently interpreting the client’s unconscious material as well as resistances.

Psychoanalysis and psychoanalytic therapy are therefore very intensive forms of psychotherapy, requiring a client to commit to a long-term therapeutic relationship, which can last for several years. The client must be willing to follow the “fundamental rule” of free association—that is, saying whatever comes to mind without any evaluation or censorship—in order to reveal unconscious material for the analyst and the client to explore. This is hard work, and the client’s motivation or readiness to change is crucial for psychoanalysis and psychoanalytic therapy to be successful. Psychoanalytic therapy is usually considered modestly successful if it has effectively helped the client to be able to love and work in life.

Major Therapeutic Techniques and Interventions

Several major therapeutic techniques or interventions in traditional psychoanalytic therapy have been somewhat modified in more contemporary approaches to such therapy (see McWilliams 2004; Summers & Barber 2010). However, the primary methods of traditional psychoanalytic therapy are still foundational. At least six of them are basic to psychoanalytic therapy: “maintaining the analytic framework, free association, interpretation, dream analysis, analysis and interpretation of resistance, and analysis and interpretation of transference” (Corey 2021, 73–76).

Maintaining the Analytic Framework

The analyst listens intently to the client’s free associations, paying special attention to disruptions or blockages in free association, which may indicate the presence of repressed anxiety-provoking material that is beginning to emerge into consciousness. The analyst listens especially for hidden meanings in the client’s free associations and notices slips of the tongue, or Freudian slips, that may be due to unconscious conflicts. Therefore, the analyst does not take whatever the client expresses at face value. In using the technique of free association, the analyst ultimately identifies and interprets unconscious material and conflicts that may emerge, so that the client can gain deeper insight and understanding.

Interpretation

Interpretation is the psychoanalytic technique whereby the analyst clarifies and explains to the client the meaning of certain unconscious material emerging in the client through dreams, free association, experiences in the therapeutic relationship between the analyst and the client, and resistances or blockages. Through interpretation, the analyst enables the client to gain insight into unconscious material that is surfacing and to help the client’s ego deal with such material more effectively and realistically.

Interpretation must be well timed and based on sufficient unconscious material to substantiate the accuracy of that interpretation. Otherwise, “wild analysis,” wild interpretation that is off target, can occur, to the possible detriment of the therapeutic process and the relationship with the client. The readiness of the client to accept a specific interpretation is also a crucial factor. Interpretations are most helpful if they involve material that is preconscious or beginning to become conscious and if they begin with more surface material and proceed to deeper levels of meaning, yet only as far as the client is ready to go.

Dream Analysis

Freud considered dreams “the royal road to the unconscious.” Dreams are the raw material of the unconscious. Dream analysis is therefore another crucial technique in psychoanalytic therapy. The analyst encourages the client to record and report their dreams and free associate to them, saying whatever comes to mind while describing the dreams. The analyst then discusses and interprets the client’s dreams and free associations to the dreams or parts of them that can be viewed on two levels: the manifest content of a dream, referring to the surface material or details of the dream; and the latent content of a dream, referring to its unconscious or hidden meaning. The analyst is especially involved in pointing out and interpreting the latent content and meaning of a dream.

Freud described several dreamed symbols often reported by clients, figures that seem to have consistent meanings for almost every client. Examples are tree trunks and candles representing the penis, and steps and ladders symbolizing sexual intercourse. However, there is a danger of overgeneralizing such symbolic meanings in dreams, so dreams should still be interpreted in the proper context of a specific client’s life.

Analysis and Interpretation of Resistance

Resistance is a basic psychoanalytic concept that refers to a client’s blocking or defending against bringing unconscious and repressed material into conscious awareness, mainly because it is emotionally painful and provokes anxiety to do so. Resistance therefore is a major barrier to therapeutic progress in psychoanalytic therapy. A client can show resistance in various ways, such as being consistently late for appointments, not producing much by way of free associations, talking incessantly about superficial topics like the traffic or sports, and especially by abruptly terminating psychoanalytic therapy early in the therapeutic process.

The analyst will analyze and interpret the client’s resistances so that the client can overcome them and become more aware of unconscious issues and repressed feelings, memories, or experiences. It is crucial, however, for the analyst to first interpret resistances that are clear or obvious to the client so that the client will be more accepting of the interpretation rather than further resist the analyst’s interpretation. The analysis and interpretation of resistance must be conducted in a deeply empathic and clinically sensitive way so that the client’s defenses are not too quickly or harshly confronted. Otherwise, further resistance may result.

Analysis and Interpretation of Transference

Another important technique of psychoanalytic therapy is the analysis and interpretation of transference. Transference occurs when the client unconsciously relates to the analyst as if the analyst were a parental figure from the client’s earlier life, usually childhood. Both positive (e.g., admiration) and negative (e.g., anger) experiences and feelings can occur in transference to the analyst or therapist. The analyst allows the transference to develop and then interprets its meaning to the client. This analysis of the transference helps the client to achieve deeper insight into their past experiences and how they may still be affecting and influencing present relationships and experiences.

The traditional Freudian view is that the analysis of transference is an essential part of psychoanalytic therapy. The analyst also needs to be careful of their own unconscious responses to the client that reflect unresolved issues with significant figures from the analyst’s own past relationships, especially in childhood, a phenomenon known as countertransference. Analysts are therefore required to have their own personal or training analysis and further consultation or supervision, when this is determined to be necessary, in order to become more aware of and minimize countertransference to their clients. More contemporary approaches to psychoanalytic therapy, however, also focus on how to constructively use countertransference for better understanding the client, rather than always viewing countertransference as an inappropriate or unhealthy phenomenon requiring constant vigilance and control by the analyst.

Critique of Psychoanalytic Therapy: Strengths and Weaknesses

Traditional psychoanalysis and psychoanalytic therapy are based on Freud’s theories, which many still consider to be the most comprehensive view of personality, psychopathology, and psychotherapy. Several psychoanalytic concepts such as the unconscious, defense mechanisms, resistance, and transference and countertransference in the therapeutic relationship are still helpful notions being used not only by psychoanalysts and psychoanalytic therapists but also by other psychotherapists. Some therapists have found the psychoanalytic approach to be the richest and deepest in theory and practice among the many psychotherapies available today.

However, Freudian psychoanalytic therapy has several significant weaknesses and limitations. First, although Freud’s psychoanalytic theory is comprehensive, some of his ideas are not easily translated into testable hypotheses that can be verified by empirical research, for example, the id, the ego, and the superego, or Eros (life instinct) and Thanatos (death instinct).

Second, his theory narrowly focuses on sexual and aggressive drives and emphasizes his conviction that biology is destiny. However, there are other motivational forces or drives not considered by Freud that may be equally or even more important than sexual and aggressive instincts in influencing human behavior. Other theorists and therapeutic approaches have emphasized other drives or motivations (e.g., social or spiritual), which will be discussed in later chapters of this book.

Third, some of Freud’s original ideas have been viewed as sexist, especially by women and feminist therapists. For example, penis envy, the Oedipus complex, and the tendency to blame the mother in poor parent-child relationships that supposedly lead to adult psychological disorders—these have all been criticized for denigrating women and viewing them as inferior to men.

Fourth, traditional psychoanalysis or psychoanalytic therapy is an intensive, long-term, and hence expensive form of psychotherapy, which only the relatively wealthy can afford. It is therefore not as suitable for managed care, which emphasizes and covers shorter-term and brief therapies. It also focuses on intrapsychic or personal conflicts and dynamics, often without paying sufficient attention to other real-life concerns such as employment, poverty, and social issues that may be more important and relevant to people from more diverse socioeconomic and cultural backgrounds. From a multicultural perspective, psychoanalysis and psychoanalytic therapy may therefore not be as meaningful or appropriate for some clients from certain ethnic and cultural groups, who may prefer a more direct, problem-solving approach to therapy.

Fifth, the neutral and anonymous therapeutic stance of the analyst in traditional psychoanalysis may be difficult for some clients to tolerate. It may also be experienced by certain clients in a potentially harmful or anti-therapeutic way. The traditional analytic approach also requires a minimal level of ego strength on the part of the client, enabling participation in and benefit from such an intensive and demanding form of therapy. Some contemporary approaches to psychoanalytic therapy, such as relational psychoanalysis, have therefore modified the analytic relationship into one that is more mutual and reciprocal between analyst and client.

Finally, the empirical or research support for the efficacy of traditional psychoanalysis is limited and based on naturalistic studies, not on randomized controlled trials or controlled outcome studies; therefore, no definitive conclusions can be made at this time (see Safran, Kriss, & Foley 2019). For example, Rolf Sandell and colleagues in Sweden conducted a large naturalistic outcome study of over four hundred patients, but with no control groups, and found that both psychoanalysis and psychoanalytic therapy were effective treatments (Sandell 2001, 2012; Sandell et al. 2000, 2002). However, there is now more empirical evidence supporting the efficacy of both long-term and short-term psychoanalytic therapy or psychodynamic therapy, including several randomized controlled trials for a range of psychological disorders (e.g., see Abbass et al. 2014; Driessen et al. 2015; Eagle 2013; Keefe et al. 2014; Leichsenring & Rabung 2011; Leichsenring, Luyten, et al. 2015; R. A. Levy, Ablon, & Kächele 2012; Shedler 2010; Steinert et al. 2017; Town, Abbass, & Hardy 2011; Town et al. 2012). More details are included in the section on “Research” later in this chapter.

A Biblical Perspective on Psychoanalytic Therapy

Freud’s view of human nature was somewhat negative and pessimistic: a person must struggle with the basic aggressive and sexual instincts of the id as well as the perfectionistic standards and demands of the superego, with the ego mediating these extreme forces into realistic compromises so that the person can learn to love and work satisfactorily in life. The biblical view of human nature as sinful and fallen (Rom. 3:23) is somewhat consistent with Freud’s description of the human psyche. However, this is only half the story. The Bible also teaches that we are created in the image of God (Gen. 1:26–27) and therefore have the potential to be somewhat like God in our character, especially if we are in Christ, who makes us part of the new creation (2 Cor. 5:17; cf. RSV) and capable, by the power of the Holy Spirit, to be transformed into deeper Christlikeness (Rom. 8:29). The potential for change through Christ is therefore greater than a purely Freudian view would allow, especially in its deterministic notion that one’s personality is already formed by age five or six (see S. L. Jones & Butman 2011).

Second, Freud emphasizes the unconscious and the need to gain insight that is not only intellectual but also experiential in making the unconscious conscious and resolving intrapsychic conflict; this emphasis points to the need for wisdom and awareness of the darker side of human nature, a view that can be recognized as consistent with biblical teaching (Jer. 17:9). However, his narrow focus on aggressive and sexual instincts in the motivation of human behavior is unbalanced. There are other human motivations such as spiritual longings for God, including agape love for God and for neighbor or the other (cf. Mark 12:30–31), that are real and not pathological obsessional neurosis as Sigmund Freud (1927) claimed in his antireligious views emphasizing that we created God in our own image in wish fulfillment of a longing for a father, rather than that God created us in his image.

Third, the traditional therapeutic stance of the analyst or therapist in staying as neutral and anonymous as possible, with a clinical aloofness that is assumed to facilitate transference, which can then be interpreted by the analyst—such a stance can be viewed as problematic from a biblical perspective that emphasizes the centrality of agape love in all human relationships (1 Cor. 13), including therapeutic relationships (see Browning & Cooper 2004). Contemporary approaches to psychoanalytic therapy such as relational psychoanalysis, however, have modified this traditional analytic stance so that a more mutual and reciprocal relationship between the analyst and the client can be achieved. A Christian approach to relational psychoanalysis will be based more on agape love (see M. T. Hoffman 2007, 2011; see also Bland & Strawn 2014a; Sorenson 2004). Several Christian approaches to contemporary psychoanalytic therapy were described in a special issue of the Journal of Psychology and Theology (35, no. 1, 2007) devoted to psychoanalytic psychotherapy and religion, using a case-study approach, edited by Brad D. Strawn (2007). It was published in honor of the late Christian psychologist and contemporary psychoanalyst Randall Lehman Sorenson and his major work, Minding Spirituality (2004), which focused on the integration of spirituality or religion and psychoanalysis. Some Christian psychoanalysts maintain that the traditional psychoanalytic stance of the analyst is actually a manifestation of deep agape love and empathy for the client.

Research: Empirical Status of Psychoanalysis and Psychoanalytic Therapy

Over the last several decades or so, most outcome evaluations of the effectiveness of psychoanalysis and psychoanalytic therapy have involved uncontrolled case studies and clinical surveys (see Galatzer-Levy et al. 2000; Sandell 2001, 2012; Sandell et al. 2000, 2002; Wallerstein 1986, 1996, 2001, 2009). The best-known and widely published study reported by Robert S. Wallerstein, the Menninger project, was conducted at the Menninger Clinic in Topeka, Kansas; it extended over thirty years and involved extensive assessment and follow-up of forty-two patients, half of whom were seen in traditional psychoanalysis and the other half in psychoanalytic therapy. Wallerstein (1986, 1996, 2001, 2009) concluded that traditional psychoanalysis was less successful than expected, whereas supportive psychoanalytic therapy was more successful than expected, but both were relatively beneficial. He also noted that therapeutic change is not contingent on inner conflict resolution, and interior structural change cannot be clearly differentiated from external behavior change. A larger and more recent naturalistic outcome study of over four hundred patients, yet also with no control groups, was conducted by Sandell and colleagues in Sweden, called the Stockholm Outcome of Psychoanalysis and Psychotherapy Project. They concluded that both psychoanalysis and psychoanalytic therapy were effective treatments (Sandell 2001, 2012; Sandell et al. 2000, 2002). Empirical support for the efficacy of traditional psychoanalysis is therefore limited to naturalistic studies and not based on randomized controlled trials or controlled outcome studies (with random assignment of patients and appropriate control groups); therefore, no definitive conclusions about the efficacy of traditional psychoanalysis can be made at this present time (Safran, Kriss, & Foley 2019; see also Fisher & Greenberg 1996). However, this can no longer be said of the efficacy of psychoanalytic therapy and more broadly psychodynamic therapy, which have received more substantial empirical support in recent years, including a growing number of randomized controlled trials, for both long-term and short-term psychoanalytic and psychodynamic therapies (e.g., see Abbass et al. 2014; Driessen et al. 2015; Eagle 2013; Keefe et al. 2014; Leichsenring & Rabung 2011; Leichsenring, Luyten, et al. 2015; R. Levy, Ablon, & Kächele 2012; Shedler 2010; Steinert et al. 2017; Town, Abbass, & Hardy 2011; Town et al. 2012).

Jonathan Shedler (2010) reviewed the outcome research on psychodynamic or psychoanalytic therapy, whether short-term or long-term, and concluded that the empirical evidence strongly supported the efficacy of psychodynamic therapy. Effect sizes for psychodynamic therapy are as large as those found for other empirically supported, evidence-based, treatments. Psychodynamic therapy was also found to have more robust long-term effects, with increasing therapeutic gains over time in follow-up evaluations (see also Driessen et al. 2015). However, a more recent longitudinal meta-analysis examined the long-term effects of psychodynamic therapies versus non-dynamic therapies and found no significant differences at all after treatment (Kivlighan et al. 2015). Psychodynamic and nondynamic therapies therefore showed equivalent enduring effects, contrary to what Shedler (2010) reported earlier. Shedler’s review and conclusions were also methodologically criticized, with rebuttals (e.g., see Anestis, Anestis, & Lilienfeld 2011; D. McKay 2011), focusing on the weaknesses of the studies and meta-analyses that he reviewed (e.g., pooling the effects of poorly designed studies with small samples, use of inadequate outcome measures). Nevertheless, some of his conclusions have received more empirical support in the last decade or so (see studies and reviews cited earlier).

Falk Leichsenring, Frank Leweke, Susanne Klein, and Christiane Steinert (2015)—in a more recent wide-ranging meta-analysis of thirty-nine randomized controlled trials evaluating the efficacy of psychodynamic therapy, using stricter criteria for empirically supported therapies that are “efficacious” or “possibly efficacious”—found that psychodynamic therapy is efficacious for major depressive disorder, social anxiety disorder, somatoform pain disorder, borderline and heterogeneous personality disorders, and anorexia nervosa; they are also possibly efficacious for dysthymia, complicated grief, panic disorder, generalized anxiety disorder, and substance abuse/dependence. There was insufficient evidence for obsessive-compulsive, posttraumatic stress, bipolar, and schizophrenia spectrum disorders. Psychodynamic therapy was also reported to be as effective as other forms of treatment in most comparisons. They therefore concluded that there is strong empirical evidence for the efficacy of psychodynamic or psychoanalytic therapy for a wide range of disorders (see also Leichsenring, Luyten, et al. 2015 for a review of sixty-four randomized controlled trials supporting the efficacy of psychodynamic therapy).

There is now some emerging empirical evidence for the possible relative greater efficacy of long-term psychodynamic and psychoanalytic therapy over short-term psychodynamic therapy (e.g., Leichsenring, Abbass, et al. 2013; see also Huber et al. 2013, Lindfors et al. 2014), but this is not a definitive finding. Both long-term and short-term psychoanalytic therapy have been found to be effective treatments for a variety of disorders. As mentioned earlier, there is also empirical evidence supporting the efficacy of several attachment-based therapies such as IPT, EFT, MBT, SDT, and TFP (see K. Levy & B. Johnson 2019).

More specifically, psychodynamic or psychoanalytic therapy has been found to be as effective as other active treatments in comparative studies, for depression (Driessen et al. 2015; see also Cuijpers 2017) as well as for anxiety disorders (Keefe et al. 2014). A common previous claim of the superiority of cognitive behavior therapy over psychodynamic therapy in the treatment of depression and anxiety disorders is no longer valid and has been challenged and mainly discredited by these recent findings.

The empirical evidence supporting the efficacy or effectiveness of psychoanalytic therapy or psychodynamic therapy, both short-term and long-term, is therefore now rather substantial, but this is still not the case for traditional psychoanalysis that has not been subjected to randomized controlled trials or better-controlled outcome studies instead of just naturalistic studies and surveys. Psychodynamic therapy or psychoanalytic therapy, however, can be regarded as an empirically supported or evidence-based treatment for a range of psychological disorders.

Future Directions

Future Directions

Many authors and counselors have predicted the demise of psychoanalysis and psychoanalytic therapy in the last few decades, but it has not happened. In fact, interest in psychoanalysis and psychoanalytic therapy continues to be strong, even among Christian therapists (see Strawn 2007; also Bland & Strawn 2014a; M. T. Hoffman 2011). However, the percentage of psychotherapists in the United States who endorse psychoanalytic therapy as their primary theoretical orientation is still small, about 3 percent of clinical psychologists, 1 percent of counseling psychologists, 5 percent of social workers, and 2 percent of counselors (Prochaska & Norcross 2018, 3). More of them endorsed broad-based psychodynamic therapy as their primary theoretical orientation: about 15 percent of clinical psychologists, 9 percent of counseling psychologists, 9 percent of social workers, and 5 percent of counselors (Prochaska & Norcross 2018, 3). Psychoanalytic therapy or psychodynamic therapy has also received more substantial empirical support for its efficacy for a range of psychological disorders and can be considered an empirically supported treatment (e.g., see Leichsenring, Leweke, et al. 2015). Further empirical research on psychoanalytic and psychodynamic therapy will be conducted in the years to come.

Several crucial modifications to traditional Freudian theory have been made in recent years. As noted earlier, the therapeutic relationship in psychoanalytic therapy is now more often viewed as mutual and interpersonal. There is also more openness to and integration of other psychotherapy approaches, such as humanistic and cognitive therapies, as well as the integration of neuroscience and psychoanalysis, called neuropsychoanalysis (Prochaska & Norcross 2018; see also E. B. Luborsky, O’Reilly-Landry, & Arlow 2008). Relational theory has been further developed and refined so that relational psychoanalytic concepts can be integrated with other psychotherapeutic approaches, including cognitive-behavioral therapies (Wachtel 2008). More recently, the core competencies of relational psychoanalysis have been described in a guide to practice, study, and research (Barsness 2018).

Traditional or classical psychoanalysis is being provided to less than 1 percent of all clients receiving counseling or psychotherapy today. It has become less important as relatively shorter-term versions of relational psychoanalysis and time-limited psychoanalytic therapy (e.g., see Levenson 2017; McWilliams 2004, 2011; Summers & Barber 2010) are now more widespread and popular (Prochaska & Norcross 2018). A specific development in this context is the use of treatment manuals that provide detailed instruction for conducting time-limited psychoanalytic or more broad-based psychodynamic therapy (Sharf 2016). For example, the Core Conflictual Relationship Theme method developed by Lester Luborsky and his colleagues has been described in detail in treatment manuals (Book 1998; L. Luborsky 1984; L. Luborsky & Crits-Christoph 1998). This method is a sixteen-session model for conducting brief psychodynamic or psychoanalytic therapy. The therapist focuses on relationships that the client brings up, clarifying the client’s wish, a response from the other, and a response from the client. The therapist makes carefully timed interpretations of client transference, reflecting the client’s attitudes and behaviors from past, early relationships that still influence current relationships with others, including the relationship with the therapist (see Sharf 2016, 64–65). Attachment theory has also become an important part of contemporary psychoanalysis and psychoanalytic therapy (e.g., see Eagle 2013; Fonagy 2001; Wallin 2007). Several attachment-based therapies that have received some empirical support for their efficacy include interpersonal psychotherapy, emotionally focused therapy, mentalization-based treatment, supportive psychodynamic therapy, and transference focused therapy (see K. N. Levy & Johnson 2019).

Despite these current changes and future directions of psychoanalysis and psychoanalytic therapy, several important concepts from Freud are still valued today, based on substantial empirical and clinical support. They include the importance of the unconscious; the crucial role of childhood traumas and experiences in the development of behavioral problems; the pervasiveness of inner conflict in the lives of human beings, who must then devise compromise solutions; and the powerful impact that mental representations of self, others, and relationships have on the current functioning of individuals (Westen 1998).

Formal training to be a psychoanalyst usually requires a minimum of four years of coursework, after one obtains a doctoral degree (PhD or PsyD) in clinical psychology or completes a psychiatry residency and is admitted into a psychoanalytic institute of training. Some institutes also admit social workers in clinical practice. The formal training includes the personal analysis of the candidate in training by a senior psychoanalyst, as well as supervised treatment of analysands or clients seen by the candidate three to five times a week for a few years. The American Psychoanalytic Association (www.apsa.org), founded in 1911 and part of the International Psychoanalytical Association, is the largest psychoanalytic society in the United States. Division 39, the Division of Psychoanalysis of the American Psychological Association, had a list of ninety-two training programs in psychoanalysis. Many psychoanalytic journals are also being published, including the International Journal of Psychoanalysis and the American Journal of Psychoanalysis (E. B. Luborsky, O’Reilly-Landry, & Arlow 2008, 28–29). Psychoanalysis and especially psychoanalytic therapy (that is more relational and attachment-based) will therefore continue to be a significant part of contemporary counseling and psychotherapy, with some even stating that psychoanalysis is actually flourishing and thriving (e.g., see Sharf 2016, 66).

Recommended Readings

In addition to Freud’s own works (a total of twenty-four volumes of the Standard Edition published by Hogarth Press in London), the following books are recommended for further reading:

Bland, E. A., & Strawn, B. D. (Eds.). (2014). Christianity and psychoanalysis: A new conversation. Downers Grove, IL: IVP Academic.

Brenner, C. (1974). An elementary textbook of psychoanalysis (Rev. ed.). Garden City, NY: Doubleday.

Eagle, M. N. (2013). Attachment and psychoanalysis: Theory, research and clinical applications. New York: Guilford.

Gabbard, G. O. (2010). Long-term psychodynamic psychotherapy: A basic text. Washington, DC: American Psychiatric Association.

Gabbard, G. O., Litowitz, B. E., & Williams, P. (2012). Textbook of psychoanalysis (2nd ed.). Washington, DC: American Psychiatric Association.

Hall, C. S. (1999). A primer of Freudian psychology. New York: Meridian.

Jones, E. (1961). The life and work of Sigmund Freud (Abridged ed.). New York: Basic Books.

Levenson, H. (2017). Brief dynamic therapy (2nd ed.). Washington DC: American Psychological Association.

McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner’s guide. New York: Guilford.

Mitchell, S. A. (2000). Relationality: From attachment to intersubjectivity. Hillsdale, NJ: Analytic Press.

St. Clair, M., & Wigren, J. (2004). Object relations and self psychology: An introduction (4th ed.). Belmont, CA: Brooks/Cole.

Summers, R. F., & Barber, J. P. (2010). Psychodynamic therapy: A guide to evidence-based practice. New York: Guilford.

Wallin, D. J. (2007). Attachment in psychotherapy. New York: Guilford.

Read: Seligman, Kress & Reichenberg: Chapters 1 – 2

Chapter 1

Foundations of Effective Counseling

Learning Outcomes

When you have finished this chapter, you should be able to:

• Explain the development and commonalities of Counseling Theories.

• Identify the characteristics of successful clients and of successful counselors.

• Describe why clients’ developmental levels are important in the context of counseling and counseling theory selection.

• Describe how culture/diversity issues and legal/ethics issues are important in the context of counseling theories.

• Explain the value of a strengths-based perspective in counseling.

Before considering specific theories of counseling and psychotherapy, it is important to pave the way by providing some information on the history and development of these approaches. This chapter focuses on some of the foundational elements that relate to effective counseling (e.g., the counseling relationship) and considerations that influence the counseling theories used (e.g., the counseling setting, a client’s developmental level). The chapter addresses the following topics:

· Characteristics of clients who benefit from counseling

· The therapeutic alliance

· Helpful personal and professional characteristics of the counselor

· Client developmental considerations

· Culturally competent counseling

· The importance of a strengths-based perspective

· Counseling settings and how this relates to counseling theories used

· Ethical and legal guidelines and standards that relate to counseling theories.

Later in this chapter, the Diaz family—Roberto, Edie, and Ava—make their first appearance. The Skill Development section focuses on a review of effective questioning and interviewing techniques that lead to productive intake assessments. The Reflect and Respond section includes activities that reinforce those skills. The use of minimal encouragers and the Reflect and Respond section center on questioning and interviewing for a productive intake/initial assessment.

Development of Counseling Theories

Prior to the late 19th century, people understood little about mental and emotional difficulties and approaches that could be used to help individuals change. Many people with severe mental health symptoms were forcibly confined in institutions and exposed to largely ineffective therapies, while those with mild or moderate difficulties typically received no professional help.

The development of psychodynamic approaches to psychotherapy, spearheaded by the work of Sigmund Freud, led to the emergence of what has been called the first force of psychotherapy. Viewing past experiences as the source of people’s present emotional difficulties and emphasizing unconscious processes and long-term therapy, psychodynamic approaches provided a solid foundation for the field of psychotherapy, but that approach had clear limitations.

The research and practice of B. F. Skinner, as well as more modern theorists such as Albert Ellis, Aaron Beck, William Glasser, and Donald Meichenbaum, led to the emergence of the second force of psychotherapy: behavioral and cognitive theories and interventions. Behavioral approaches, which originated in the 1950s, have been integrated with cognitive approaches, developed primarily in the 1980s, leading to the cognitive behavioral approaches that received considerable attention and empirical support in the 1990s. Cognitive and behavioral approaches emphasize the interaction between thoughts, feelings, and behaviors. They use interventions that generally focus on the present and seek to minimize dysfunctional cognitions and behaviors while replacing them with more helpful and positive thoughts and actions.

Carl Rogers’ innovative work emerged in the 1960s and led to the development of the third force of psychotherapy: existential-humanistic psychotherapy. The work of Fritz Perls, Viktor Frankl, and others contributed to this force, which emphasizes the importance of emotions and sensations and of people taking charge of and creating meaning in their own lives. These approaches also drew attention to the importance of the therapeutic alliance.

During the later part of the 20th century and the front end of the 21st century, therapists have entered the era of the fourth force of psychotherapy: therapies that focus on Contextual/Systemic approaches (e.g., feminist, family systems, postmodern, multicultural). Contextual/Systemic therapists concentrate on individual identity (e.g., gender, culture, age, race, and sexual orientation) and consider context and culture as they impact clients’ experiences and their change processes. Becoming culturally competent, being an ally with clients, and remaining open to their multiple perspectives of themselves and their world are essential for today’s therapists. Networking and collaboration with other mental health professionals, providers of community resources, and important people in clients’ lives are now viewed as integral to successful counseling. Theories of counseling and psychotherapy, as well as their implementation, have changed in response to the fourth force.

More than 400 counseling theories have been identified and described in the literature (Zarbo, Tasca, Cattafi, & Compare, 2015). Of course, all these theories cannot be reviewed in this text. Therefore, the following criteria were used to select the theories covered in this text:

1. The theories are clear, coherent, and easily communicated.

2. They are compatible with or can be adapted to include the therapeutic commonalities.

3. They encompass a concept of positive emotional development and health that can be used in setting goals and assessing progress.

4. They help therapists organize and make sense of information.

5. They are comprehensive, explaining and addressing a broad range of concerns and disorders.

6. They give therapists direction, steps, and guidelines for facilitating positive change.

7. They encompass strategies and interventions that grow out of and are consistent with the underlying theory.

8. They provide therapists with a common language that facilitates counseling and collaboration.

9. They are widely used in practice and generate research. Even if these approaches have not been conclusively validated by empirical research, the research is promising and their widespread use or growing popularity suggests that therapists find these approaches beneficial to their clients.

10. They focus on individual counseling and psychotherapy. (This book primarily addresses counseling with individuals, with the exception of one chapter that summarizes the major family therapy theories.)

Whether therapists describe themselves as integrative or eclectic (incorporating a variety of themes and techniques into their work), or affiliated with a particular theoretical model, counseling theories all shed light on people’s challenges and change processes and provide skills that promote emotional health. It is difficult to determine the most popular theoretical orientations of various mental health providers. Little research on this topic exists, and when practitioners are asked about their theory preferences, only a small number of theories are presented to them as options, thus limiting the findings. With that said, Table 1.1 presents an overview of the theoretical orientation of choice of U.S. counselors, clinical psychologists, counseling psychologists, and social workers.

Source: Data from Bechtoldt, H., Norcross, J. C., Wyckoff, L., Pokrywa, M. L., & Campbell, L. F. (2001). Theoretical orientations and employment settings of clinical and counseling psychologists: A comparative study. The Clinical Psychologist, 54(1), 3–6; Bike, D. H., Norcross, J. C., & Schatz, D. M. (2009). Processes and outcomes of psychotherapists’ personal therapy: Replication and extension 20 years later. Psychotherapy, 46(1), 19–31; Goodyear, R. Lichtenberg, J., Hutman, H., Overland, E., Bedi, R., Christiani, K., . . . Young, C. (2016). A global portrait of counselling psychologists’ characteristics, perspectives, and professional behaviors. Counselling Psychology Quarterly, 29, 115–138. doi: 10.1080/09515070.2015.1128396; Norcross, J. C., & Karpiak, C. P. (2012). Clinical psychologists in the 2010s: Fifty years of the APA Division of Clinical Psychology. Clinical Psychology: Science and Practice, 19, 1–12.

Understanding Counseling Theories

Counseling, at its most basic level, is about helping people grow and change. When clients present for counseling, it can be difficult to know what information needs to be gathered and how to proceed in best helping clients make the changes they seek. Therapists use theories to organize and simplify the vast amount of information that clients present. Therapists’ theories serve as the roadmap for determining the best way to help clients change. Theories assist counselors in organizing information about clients and in determining how to use such information to support clients.

Available resources on various techniques and interventions to facilitate client change are abundant. A quick Internet search reveals millions of counseling techniques and interventions. As an example, the Jongsma (e.g., Jongsma, Peterson, & Bruce, 2014) series includes numerous treatment planning books, which provide examples of short-term objectives, long-term goals, and therapeutic interventions for helping clients achieve their goals. There has also been a recent trend toward the use of computer software systems that generate predetermined counseling goals, objectives, and interventions based on clients’ presenting concerns.

These resources can be very helpful tools, but counselors must pull on a counseling theory that can guide their conceptualization of their clients’ situations and help them identify what interventions might be most useful (Kress & Paylo, 2019). Counselors who rely on a hodgepodge of techniques or interventions that are not thoughtfully linked to theory run the risk of harming their clients. Clients deserve to have counselors who thoughtfully conceptualize their situations and select counseling techniques grounded in both theory and science (Kress & Paylo, 2019). Anyone can apply counseling interventions and techniques, but skilled therapists will apply a theory and use this theory to guide and focus counseling and to determine when and how to apply specific interventions; the application of theory is what makes us unique and what separates us from the proverbial “armchair psychologists” of the world.

At the most basic level, theories are important because they help counselors to do the following:

· Weed through a vast amount of presenting information and understand and recognize what client information needs to be identified, gathered, and organized

· Conceptualize clients’ situations and identify what is supporting their problems in living

· Identify ways of approaching clients that can help them make changes.

Theories of counseling and psychotherapy have been referred to as counseling or therapy approaches, treatment systems, treatment approaches, and theories of change, along with other terms. In this text, the terms therapy and counseling will primarily be used to refer to an integrated set of concepts that provides explanations for and descriptions of the following:

· Stages, patterns, and important factors in people’s emotional development

· Healthy emotional development, as well as problematic or abnormal emotional development

· How to help people develop in positive ways and reduce symptoms that are distressing and/or cause impairment in functioning

· The role of therapists and how that role contributes to counseling

· Strategies for putting the theory into practice (e.g., identifying and modifying cognitive distortions, reflecting feelings, developing a clear plan for behavioral change)

· Specific skills or interventions that can enhance implementation of the counseling approach (e.g., use of earliest recollections, analysis of dreams, diaphragmatic breathing)

· Information on people who are likely to benefit from this counseling approach; this information might include people’s age, cultural background, strengths, presenting issues, counseling settings, and other factors.

An effective theory is easily understood and comprehensive, provides explanations for a wide variety of presenting issues, and generates research. Effective counseling theories are also encouraging and instills in clients the confidence required to make positive changes; therefore, effective counseling theories integrate encouragement to some extent (Wong, 2015). Effective theories are grounded in an understanding of human development. They offer a framework for gathering and organizing information and exploring personality. They present a theory of development and change that helps us understand people and their concerns. They supply steps and interventions that encourage learning and growth and that allow for evaluation of progress and modification of treatment/counseling plans if needed. They provide reassurance and direction. They lend themselves to development of testable hypotheses that can be investigated to determine the validity and usefulness of the approach, and they promote further study and improvement of the counseling process. Counseling approaches that have proven their value over time are also reasonably well validated.

Readers of this text come from diverse backgrounds, including professional counseling, psychology, marriage and family therapy, social work, art therapy, and other professions. A number of terms can be used to describe those who help people make changes. People’s professional background, the setting in which they work, and their formal job title are just a few of the factors that determine whether they refer to themselves as clinical mental health counselors, school counselors, psychologists, therapists, psychotherapists, and so on. To accommodate the broad array of backgrounds of readers, in this text, the generic terms counselor and therapist will generally be used to describe those who help people change.

Counseling is Effective

Before proceeding, it is important to ask ourselves if counseling and therapy are effective. In fact, research consistently suggests the effectiveness of counseling (Leichsenring, 2009; Levy, Ablon, & Kachele, 2012). Approximately 75% to 80% of clients benefit significantly from counseling (Clement, 2013). This improvement rate is comparable to the improvements perceived by those receiving various medical procedures (Maltzman, 2016). Counseling outcomes do not differ based on the education or on the degree or license of the person providing services (Norcross & Lambert, 2011). The positive effect of counseling and therapy is achieved in the first 10 to 20 sessions. Studies also indicate that positive effects of therapy last long after counseling has ended (Bolier et al., 2013).

What makes therapy effective? Common factors—that is, factors common to all therapeutic approaches—such as the therapeutic alliance, counselors’ demonstration of empathy, clients’ and counselors’ expectations for change, and the hope that clients experience improvement secondary to meeting with a counselor, may be what makes counseling effective (Ardito & Rabellino, 2011; Wampold, 2015). We should feel good about the fact that what we do as counselors matters and that our efforts are effective.

Although differences in outcome among various forms of therapy are not strong, this does not detract from the importance of effectively using various approaches and strategies and tailoring them to the individual’s unique needs. Therapists and researchers no longer ask whether counseling is effective; that has been conclusively demonstrated. Nor do they ask which counseling modality works best. Now we know that most therapies work.

Even though we know counseling is effective, many important questions need to be asked: What are the key ingredients of a successful therapeutic relationship? When is counseling most likely to be effective? What characteristics set apart the successful therapist? What client traits, attitudes, and behaviors enhance counseling, and how can these features be fostered? What counseling approaches and strategies are most effective for specific problems? Which theories can be integrated to produce even greater effectiveness? What are some common factors inherent in all counseling approaches? These are only a few of the important questions that today’s therapists are asking and that will be addressed in this text.

Current research suggests that specific counseling approaches and interventions are just one factor in producing change. Research indicates that clients attribute 40% of the change they experience in counseling to extratherapeutic factors (including the internal resources and events that occur in their lives), 30% to the therapist–client relationship, 15% to particular techniques and interventions, and 15% to their hope and expectation of positive change (Duncan, Miller, Wampold, & Hubble, 2010).

Several important points emerge from this finding. First, therapists may not be as powerful as they might think; in fact, clients’ life experiences and circumstances and their inner resources seem to be the most powerful factor in change. Consequently, therapists must take the time to know and understand their clients, to grasp their perspectives on the world, to hear their stories, and to learn about their lives so that therapists can help their clients to make the most of those extratherapeutic factors. Second, the therapeutic alliance is of great importance. Promoting a positive relationship characterized by conditions and interactions that encourage desired changes can make a significant difference in the success of counseling. Observing that interventions represent only 15% of the factors contributing to change, readers may be tempted to ask, “Why, then, pay so much attention to learning specific counseling theories?” In reality, 60% or more of client change can be attributed to the theories used, because in addition to the techniques and interventions used (15%), the skills and strategies of the therapist are largely responsible for the development of the therapeutic alliance (30% of the source of change) and for engendering hope and positive expectations in clients (15% of the source of change). Furthermore, counseling can also make a difference in people’s ability to make positive use of extratherapeutic factors such as support systems, community resources, and educational programs. Thus, techniques and interventions associated with various theoretical approaches are important not only for their direct impact on symptoms and problems, but also for their indirect impact on the therapeutic alliance as well as on client attitudes and behaviors associated with successful counseling.

Common Factors

Common factors, or a common set of variables, are at play in the different forms of therapy, and these common factors make all therapies effective. What follows is a summary of what we believe makes therapy effective:

· A therapeutic relationship characterized by collaboration, trust, mutual investment in the therapy process, shared respect, genuineness, and positive emotional feelings

· A safe, supportive, and healing context

· Goals and a sense of direction as to where counseling is headed

· A shared understanding between therapists and clients about the nature of the problems and concerns to be addressed in treatment and the change processes that will be used to resolve problems

· A credible approach to addressing the client’s presenting problems

· Therapeutic learning, which typically includes feedback and corrective experiences

· The encouragement of client self-efficacy and problem-solving abilities

· Improvement in clients’ ability to identify, express constructively, and modify their emotions

· Improvement in clients’ ability to identify, assess the validity of, and modify their thoughts

· Improvement in clients’ ability to assess and change dysfunctional behaviors as well as acquire new and more effective behaviors that promote coping, impulse control, sound relationships, and good emotional and physical health.

Later in this chapter, the therapeutic relationship, the working alliance, and the ingredients that contribute to successful counseling will be discussed in greater depth.

Characteristics of Successful Clients

Both the personal qualities and the backgrounds of clients help determine the success of counseling (Bohart & Tallman, 2010). Therapists can maximize the positive influence of client characteristics by adopting a strength-based perspective (Duncan et al., 2010; discussed later in this chapter); by believing that clients are motivated and capable of change and using that belief to instill hope and optimism during the counseling process; and by promoting an environment where clients feel safe discussing their struggles and trying out new ways of being.

Both pretherapy characteristics—or characteristics that clients bring to counseling—and those qualities that clients manifest in counseling can have an impact on therapy outcome. For example, some research has found that client intelligence, education, and socioeconomic level all play a role in positive counseling outcomes (Leibert & Dunne-Bryant, 2015). The following behaviors and attitudes that clients demonstrate during counseling play an important part in the counseling process.

Client Motivation

The term motivation is a broad one that therapists use to describe a range of client behaviors associated with readiness for change and an ability to engage productively in that process. Particularly important aspects of client motivation include engagement in and cooperation with counseling and a willingness to self-disclose, confront problems, put forth effort to change, and, if necessary, experience some temporary anxiety and discomfort in the hope of eventual benefit. Other signs of strong client motivation include low levels of defensiveness and a belief that counseling is necessary and important. Not surprisingly, self-referred clients are less likely to terminate counseling prematurely than are clients referred by others.

Clients often struggle to make behavior changes; part of them wants to change, but part of them does not want to change. It may be that change is frightening, or that the behaviors to be changed may be working for clients in some way, or it may be that clients feel, in some ways, comfortable with things the way they are. Motivational interviewing (Miller & Rollnick, 2012), discussed later in this text, can encourage a client’s readiness for change. Motivational interviewing is a directive, client-centered counseling approach that is focused on encouraging clients’ behavior change by helping them to explore and resolve their ambivalence toward making changes. Motivational interviewing techniques can be particularly helpful with clients who have substance use disorders, eating disorders, and other behavior problems, as they help these clients prepare for, and make the most of, counseling.

Client Expectations

Hope or optimism is another essential element of counseling. Therapy is hard work for both clients and therapists. For people to persist in that process and tolerate the increased anxiety it often causes, as well as the commitment of time and resources, they must believe that counseling has something positive to offer and that, at the end of the process, they will be better off than they were before counseling.

People who have a clear and accurate understanding of counseling and its strengths and limitations are more likely to have successful therapy outcomes. Pretherapy preparation of clients via role induction can make a considerable difference in people’s expectations for counseling and correspondingly in their commitment to counseling, willingness to self-disclose, and alliance with the therapist (Shaw & Murray, 2014; Patterson, Anderson, & Wei, 2014). Similarly, effective engagement of the client in the very first session has been shown to make a positive contribution to successful therapy (Shaw & Murray, 2014).

In general, clients who are informed of what to expect—or understand their role as a client—have a better grasp of counseling and their role in the process, seem more optimistic about making positive changes, and demonstrate greater willingness to self-disclose and talk about their concerns. Role induction is the process of orienting clients to counseling so they are more likely to become successful clients who comprehend and can make good use of the therapeutic process. Role induction can help both the client and the therapist engage productively in a common endeavor and can contribute greatly to the efficiency and success of therapy.

Role induction occurs during the first counseling session as part of the intake and assessment process.

Role induction typically entails discussing the following topics with clients early in the therapeutic relationship and ensuring that clients understand and are comfortable with the information that has been discussed:

· The nature of the counseling process

· How counseling promotes positive change

· The kinds of issues and concerns that usually respond well to counseling

· The collaborative nature of the client–counselor relationship

· The roles and responsibilities of the counselor

· The roles and responsibilities of the client

· How clients can get the most out of counseling

· The importance of honesty and self-disclosure on the part of the client

· The kinds of changes people can realistically expect from counseling.

Client Engagement

Counseling is not something that is done to clients; rather, clients and their families are active participants in the counseling process (Kress & Paylo, 2019). Clients who succeed in counseling freely present their concerns, collaborate with the therapist in a mutual endeavor, and take steps to improve their lives. They develop a problem-solving attitude and maintain positive expectations of change (Patterson et al., 2014). They recognize that at least some of their difficulties come from within themselves and believe they have the power to improve their situation. They view the need for personal change as significant and can identify a specific problem they want to address. Clients who do better in counseling and maintain gains believe that the changes made in therapy were primarily a result of their own efforts (Scholl, Ray, & Brady-Amoon, 2014). These people probably feel empowered as a result of their counseling successes and are optimistic that they can continue to make positive changes and choices, even after counseling has ended.