PERSONAL COUNSELING THEORY

Read: Seligman, Kress & Reichenberg: Chapter 15

Seligman, L., Kress, V. & Reichenberg, L. (2021). Theories of Counseling and Psychotherapy: Systems, Strategies (5th ed.). Hoboken, NJ: Pearson. ISBN: 9780134460864.

Chapter 15

Learning Outcomes 

      

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

      

      • Identify your preferred theoretical orientation. 

      • Identify the benefits and challenges associated with eclectic and integrated therapies. 

      • Describe the nature and characteristics associated with eclectic and integrated therapies. 

      • Describe the various types of theoretical eclecticism. 

      • Identify examples of integrative therapies and give descriptions of each. 

      • Identify the factors that should be considered in selecting and developing a theoretical orientation. 

      • Identify the current trends that are likely to impact the future of counseling and psychotherapy. 

      • Compare and contrast the counseling theories discussed in this text. 

      

       

     Finally! You have reached the concluding chapter in this book and probably the end of your course. Your mind is swimming with all things theories. While you may be eager to apply what you have learned, you may also feel overwhelmed by all this information; that is a normal reaction. This chapter will discuss how you might proceed in developing your approach to counseling. 

     Because most practitioners identify as integrative/eclectic (Prochaska & Norcross, 2018), this chapter will begin with a discussion of theory integration, along with several examples of integrative therapies so that you might develop an understanding of what such theories can look like. Also provided is a brief review of common factors found in counseling theories. Next, the chapter focuses on the factors you should consider in selecting and developing your theoretical orientation. An overview of all the theories discussed in this text will also be presented in an organized, table format. Anticipating changes in the field can help you meet your professional goals, provide effective counseling, and contribute to your profession. As such, a section on future directions in counseling and psychotherapy brings this chapter and this book to a close.

Integrative Therapies 

    

   Many mental health professionals prefer an integrated or eclectic approach to counseling. In fact, nearly 34% of counseling psychologists, 26% of social workers, and 23% of counselors describe their primary theoretical orientation as eclectic or integrative, with most others indicating they pull on at least several approaches (Prochaska & Norcross, 2018). These percentages have 468increased over the years, and the integration trend seems likely to continue. Even therapists who adhere to one theoretical orientation commonly incorporate interventions from other counseling approaches. However, it should be stressed that before therapists can integrate approaches, they must first be grounded in and able to apply at least one theory. 

   Most therapists would probably benefit from having a framework or theory to guide them in organizing and applying a diverse array of counseling strategies, so that they can successfully address a broad range of clients and concerns. Not only is this desirable from a therapeutic point of view, but also a systematic approach to eclecticism may facilitate therapists’ efforts to demonstrate accountability to third parties. 

   Knowledge of an array of theoretical approaches is necessary so that therapists can determine which approach is best for each of their clients; this also affords therapists a range of useful interventions. Most therapists draw on a variety of theories and interventions in developing a counseling plan that seems likely to help a given person.

The Growth of Eclectic and Integrated Approaches 

     

    Many factors account for the trend toward integrative and eclectic approaches to counseling. Most importantly is the fact that no single theory has yet been found that can clearly capture the entire range of human experiences across the lifespan. In light of the diversity of people seeking counseling—who vary according to many dimensions, including culture, ethnicity, gender, sexual orientation, intelligence, abilities, interpersonal skills, life experiences, self-awareness, support systems, and symptoms—strictly adhering to one specific model of counseling or psychotherapy may greatly reduce therapeutic options. At the same time, evidence increasingly indicates that matching clients who have a preferred counseling approach or type of therapist with that preference reduces the dropout rate and is more likely to result in improvements in therapeutic outcomes (Swift, Callahan, & Vollmer, 2011). 

    As therapists’ years of experience increase, they are less likely to strictly follow just one theoretical approach (Miller, Duncan, & Hubble, 2002). Perhaps this happens because finding and combining the best research-based practices that match specific client needs has been shown to require therapeutic expertise (APA Presidential Task Force on Evidence-Based Practice, 2006). 

    In addition, no one theoretical model has proven itself superior to the rest despite efforts to identify such a theory. According to Hansen (2002), “ . . . meta-analysis of counseling outcome studies clearly shows that no one approach has emerged as the correct or most helpful . . . it seems that all well-established approaches promote healing” (p. 315). 

    At the same time, research has demonstrated that some approaches are more effective than others with particular client problems, when addressing different mental illnesses with which clients struggle, and when working with different types of people. For example, cognitive therapy and interpersonal psychotherapy are especially powerful when working with those who have major depressive disorder (Nathan & Gorman, 2002), whereas reality therapy has been widely used when working with youth who have conduct disorder. In addition, research suggests that counseling is an essential ingredient when counseling those who struggle with various mental disorders, and medication alone is not enough (Kress & Paylo, 2019). 

    The following factors have combined during the past 30 years to move therapists in the direction of preferring integrative and eclectic approaches over adherence to one specific theory (Prochaska & Norcross, 2018):

     

     The large and growing number of approaches to counseling, with more than 500 counseling theories having been identified 

     The increasing diversity and complexity of clients and their concerns 

     The inability of any one approach to successfully address all clients’ needs and all problems469 

     The growing importance of solution-focused brief approaches that encourage therapists to draw on and combine interventions from various systems of therapy to find the most effective and efficient strategy for each situation 

     The availability of training opportunities, as well as case studies and other informative literature, that give therapists the opportunity to study, observe, and gain experience in a wide variety of approaches 

     The requirement of most state and national credentialing bodies that therapists obtain postgraduate continuing education units, which encourages continued professional growth and development of new skills and ideas 

     Increasing pressure from managed care organizations, governmental agencies, consumers, and others for therapists to determine the most effective and efficient approach for each client, to plan and document their work, and to maintain accountability 

     The growing body of compelling research demonstrating which approaches are most likely to be successful in helping particular people, those with certain disorders or problems (Kress & Paylo, 2019) 

     The increasing availability of manuals, providing detailed and empirically validated treatment plans for use in helping people who have specific mental disorders or presenting problems (e.g., anger management difficulties). 

     The development of organizations such as the Society for the Exploration of Psychotherapy Integration that focus on studying and promoting theoretical integration 

     The emergence of models providing blueprints or guidelines for logical and therapeutically sound integration of approaches 

     Therapists’ increasing awareness that common factors among counseling approaches, such as the nature of the therapeutic alliance, are at least as important in determining counseling success as are specific strategies. 

     

    This array of factors nudges many therapists toward an eclectic or integrative model as their preferred orientation toward counseling. 

     

     The Challenges of Eclectic and Integrated Approaches 

     

    Choosing to adopt an eclectic or integrated theoretical orientation is challenging and probably demands more of therapists than does adherence to one specific theory. If therapists decide, for example, to specialize in cognitive therapy, they should develop expertise in that approach and know when it is and is not likely to be helpful so that they can refer out those clients unlikely to benefit from cognitive therapy. Because they have limited the scope of their work, these therapists do not have to develop expertise in other approaches, although they should be familiar with them. 

    However, therapists who view their primary theoretical orientation as eclectic or integrated need expertise in a range of counseling approaches so they can draw on them in creating effective counseling experiences. Of course, therapists who have an eclectic or integrated orientation also set limits on the scope of their practice; no therapist could have sufficient knowledge and expertise in the entire range of therapeutic approaches required to address all clients and all problems. Therapists should define the scope of their practice according to the nature of their clientele, the client problems they address, and the strategies they employ. Nevertheless, therapists who prefer eclectic or integrated approaches still have a more comprehensive and challenging professional role than that of therapists with a specific theoretical orientation. 

    In addition, therapists advocating for an eclectic or integrated approach must carefully consider their approach to working with each client to ensure that the disparate parts of counseling constitute a seamless whole in which each intervention is chosen deliberately to accomplish a purpose. Counseling must not just be an amalgam of “tricks of the trade” but, rather, should reflect coherence, relevance, and planning and be solidly grounded in both theory and empirical research. “The danger of creating a ‘hodge-podge’ of apples and oranges can be avoided if the theories are compatible, carefully integrated, and if they reflect the basic characteristics of mental health counseling” (Schwartz & Waldo, 2003; pp. 101–102).

The Benefits of Eclectic and Integrated Approaches 

    

   Integrated and eclectic theoretical approaches have benefits as well as challenges. They bring flexibility to the counseling process, enabling therapists to tailor their work to specific clients and concerns in an effort to find a good fit between the counseling approach and clients. 

   This is especially important when therapists work with people from diverse cultural backgrounds who may respond better to modified or integrated approaches than to standardized ones. For example, some people from Asian backgrounds may respond best to approaches that are structured in nature but that also recognize the importance of the family and society. Therapists can demonstrate multicultural competence by creating an integrated approach to counseling that reflect sensitivity to clients’ culture and context. 

   Because they have greater flexibility in their work, therapists espousing an integrated or eclectic approach probably can work with a broader range of people and problems than those who affiliate themselves with a single counseling theory. Of course, all therapists must practice within their areas of expertise or obtain supervision or training to expand their skills. 

   In addition, integrated and eclectic approaches allow therapists to adapt standard counseling approaches to their own beliefs about human growth and development as well as to their natural style and personality. 

   Finally, integrated and eclectic approaches facilitate therapists’ efforts to assume a scientist-practitioner role and to combine theoretical information, empirical research, and practical experience. Basing their work on counseling approaches that have demonstrated their value through research, therapists can expand on that foundation by incorporating into their work ideas that have face validity as well as strategies they have used successfully with other clients. 

   

   The Nature of Eclectic and Integrated Approaches 

    

   When therapists first began to describe their theoretical orientations as eclectic, the term lacked a clear meaning; it simply suggested that therapists drew on more than one approach to counseling. Although some therapists who characterized their work as eclectic were gifted therapists and astute theoreticians with a clear rationale for combining interventions in their work, others lacked a thoughtful and systematic approach to therapy. Eysenck (1970) denounced what he referred to as “lazy eclecticism” (p. 140), the use of a grab bag of interventions combined without an overriding logic. Without a logic or structure, eclecticism can lead to counseling that is haphazard and inconsistent, lacking in direction and coherence. Such an approach reflects a lack of knowledge and professionalism and is incompatible with current emphases on accountability in counseling and psychotherapy. 

   

 Examples of Eclectic and Integrated Approaches

Different strategies can be used to practice from an integrated or eclectic perspective. Four types of eclecticism are commonly identified: 

    

    Atheoretical eclecticism is characterized by combining interventions without an overriding theory of change or development. Unless an intuitive or underlying logic prevails, therapists whose work reflects atheoretical eclecticism run the risk of syncretism—providing counseling that is without direction, including elements that are disparate and perhaps incompatible. Such an approach probably will be confusing to clients, may lead them to question the therapist’s competence (as well as their own), can interfere with client cooperation and motivation, and may well lead to counseling failure. 

    Common factors eclecticism hypothesizes that certain elements of counseling, notably a therapeutic alliance that communicates support, empathy, and unconditional positive regard, are primarily responsible for promoting client growth and change (Norcross & Wampold, 2011). Specific interventions are linked to these common factors rather than to a specific theory. In Chapter 1 you learned about commonalities in successful counseling. 

    Technical eclecticism provides a framework for combining interventions from different approaches without necessarily subscribing to the theories or philosophies associated with those interventions. In general, therapists who practice technical eclecticism seek out the most effective techniques available for their clients’ specific problems. Technical eclecticism can be thought of as an organized collection of interventions, rather than an integration of ideas. The selection of interventions should have an empirical basis, reflecting research on the effectiveness of various interventions in successfully addressing clients’ concerns. However, technical eclecticism lacks a coherent model for human development and growth. Lazarus’ multimodal therapy exemplifies this type of eclecticism. 

    Theoretical integration offers conceptual guidelines for combining two or more counseling approaches to provide a clearer understanding of clients and more effective ways to help them. A theoretical integration usually provides therapists with a framework for understanding how people grow and change and guidelines for developing counseling plans that reflect that understanding. Integrated counseling approaches often include a multistage, systematic approach to therapy as well as information on assessing client strengths and difficulties and matching theories to clients. Therapists have guidelines to help them answer the seminal question “What treatment, by whom, is the most effective for this individual with that specific problem, and under what set of circumstances?” (Paul, 1967, p. 109). In a true theoretical integration, the whole is greater than the sum of its parts. The combination of approaches blends well and forms a new theory or approach that builds on and improves each of the individual approaches to form a better product. Counseling is theory focused rather than technique driven.

Characteristics of Sound Eclectic and Integrated Approaches 

    

   Certain hallmarks distinguish conceptually sound integrated and eclectic approaches from eclecticism that is haphazard and ill conceived. Sound eclecticism has the following characteristics: 

    

     Evidence of building on the strengths of existing theories 

     A coherent combination of theories that creates a unified whole 

     An underlying theory of human behavior and development 

     A philosophy or theory of change 

     Logic, guidelines, and procedures for adapting the approach to a particular person or problem 

     Strategies and interventions, related to the underlying theories, that facilitate change 

     Inclusion of the commonalities of effective counseling, such as support, positive regard, empathy, and client–therapist collaboration.

Formulating an Integrative Theory 

    

   When therapists formulate an integrative counseling theory, they must address many questions, including the following: 

    

    What model of human development underlies the theory? 

    How does this theory suggest that change is best facilitated? 

    What information should be obtained in an intake interview? 

    What conception does this approach have of the influence of the past on the present, and how should past experiences and difficulties be addressed in counseling? 

    How important is insight in promoting change, and how much attention should be paid in counseling to improving insight? 

    How important is exploration of emotions in promoting change, and how much attention should be paid to helping people identify, express, and modify their emotions? 

    How important is identification and modification of dysfunctional cognitions in promoting change, and how much attention should be paid in counseling to helping people alter their cognitions? 

    How important is identification and modification of self-destructive and unhelpful behaviors in promoting change, and how much attention should be paid in counseling to helping people alter their behaviors? 

    What sorts of people and problems are likely to respond well to this approach? 

    In what counseling settings and contexts is this approach likely to succeed? 

    How well does this approach address issues of diversity, and what is the appropriate use of this approach with people from multicultural backgrounds? 

    What is the place of diagnosis and treatment planning in this approach? 

    What are the overall goals of counseling? 

    What types of therapeutic alliances and client–therapist interactions are most likely to be productive? 

    What counseling skills are especially important for those who adopt this approach? 

    What interventions and strategies are compatible with this theory? 

    How should this approach be adapted for use with individuals? Families? Groups? 

    How long is counseling likely to last? 

    How is effectiveness measured, and what determines when counseling is finished? 

    Has this theory been adequately substantiated by empirical research? If not, what information is needed to support the value of this approach? 

    

   The therapist can overcome some of the shortcomings of eclectic and integrated approaches by adopting a sound and systematic rationale for how counseling is focused. Procedures should not be selected haphazardly; instead, their selection should depend on a logical decisional process that takes into account the client, the setting, the problem, and the nature of the therapist’s skills (Lazarus & Beutler, 1993).

Examples of Integrative Theories 

    

   Although most therapists do not adhere to a systematic approach to theoretical integration, they probably have formulated their own logic for combining compatible theories. The most common combinations of theories, in descending order of frequency, include (1) cognitive and behavioral approaches, (2) humanistic and cognitive approaches, and (3) psychoanalytic and cognitive approaches (Prochaska & Norcross, 2018). The presence of cognitive therapy in all three combinations 473is noteworthy, suggesting the flexibility of that approach and its importance in counseling. A brief overview of three integrative therapies will be provided in this section. 

    

     Cyclical Psychodynamic Therapy 

     

    The first person to truly integrate two separate theoretical orientations was Paul Wachtel (1977), who combined psychodynamic therapy with behavior therapy to create cyclical psychodynamic–behavior therapy. As its name implies, this approach integrates the insight achieved through psychodynamic therapy with applied behavioral interventions, with the goal of providing a more powerful intervention than with either modality alone. 

    Wachtel’s groundbreaking work is considered an example of technical eclecticism (Sharf, 2016). It broadened the field by providing a primary and secondary approach to therapy while also emphasizing the need to adapt counseling to the client’s worldview, to consider both social and psychological dimensions, and to empower the client (Wachtel, 2008; Wachtel, Kruk, & McKinney, 2005). 

    Wachtel’s theory has been called “the most comprehensive and influential integrative theory of personality” (Stricker & Gold, 2011, p. 343). Wachtel and others found much support for the theory of a cyclical nature of personality dynamics. The term “vicious cycles” comes to mind, in which people continue to repeat patterns of behavior, or even make reality consistent with their expectations of what will happen. Research has shown that people induce in others the behavior they expect from them (Gilbert & Jones, 1986). Such self-fulfilling prophesies, also known as fundamental attribution errors or expectancy biases, can keep people stuck in a continuing pattern despite their greatest efforts to overcome that pattern. 

    Wachtel suggests that early experiences trigger cycles or patterns of behavior that are maintained by present attitudes or inclinations. He believes that an integration of psychodynamic and behavioral approaches provides a dynamic approach in which insight leads to behavioral change and behavioral change leads to insight into a cyclical pattern.

   The opposite is also true. For example, individuals who lean toward depression may actually elicit and contribute to relationships that maintain that negativity. Even while protesting that they want to change, these individuals may actually surround themselves with people who reinforce negative behaviors and increase the sense of victimization. A similar dynamic occurs when individuals solicit an opinion from a friend or colleague—they are seeking out the person who will give them the answer they want to hear. Alternatively, they avoid people who do not act in accordance with their needs (Wachtel, 1997). Cyclical psychodynamic–behavior therapy emphasizes the contextual nature of psychological processes and circular causation—how people mutually shape each other’s experience (Stricker & Gold, 2011). 

    When assessing clients, therapists who use cyclical psychodynamic–behavior therapy look at areas such as conflict, character, resistance, and object representations. After initial assessments, ongoing evaluations and adjustments occur throughout the counseling process to integrate behavioral or psychodynamic interventions, as the need arises.

For example, Mark, a 35-year old government employee, came for therapy because he had an affair. He noted in the first session that he did not know why he did it, but recalled “doing stupid things” when he was a teenager and thinks that might somehow be related to his current behavior. During the session he reveals that sometimes he also participates in self-defeating behaviors (smokes pot, drinks alcohol), but he doesn’t know why he does this either. He recognizes the potential risks involved (job loss, relationship loss, arrest) but also is feeling “stuck” in his job and he has a sense of insecurity that he is not good enough for promotion.

Using Wachtel’s cyclical dynamics and an interpersonal perspective, the therapist first focused on Mark’s externalization of his feelings, to help him become aware of, and recognize, the anger and resentment that he suppressed and then tried to avoid by reaching for drugs, alcohol, or sex. Encouraging both insight and action gradually exposes people to their frightening images and fantasies so that they can learn to cope with them more effectively. Mark was able to identify a pattern of behavior that had been with him since childhood, of not wanting to recognize or express difficult feelings that made him uncomfortable. Over the years, Mark had externalized his feelings, and would turn to drugs or sex to make himself feel better and reaffirm his self-worth. He recognized the cyclical nature of the pattern, and the fact that it was self-defeating, but he felt helpless to do anything about it. Consider the following excerpt from a therapy session with Mark: 

      

        T herapist: 

       So, you said a woman approached you in a bar, made overtures, and you went home with her, but you don’t know why. 

       

        M ark: 

         Yes, exactly. She came on to me. She was beautiful.

      T herapist: 

      How did you feel about that? 

       

      M ark: 

       I feel stupid now. I told my girlfriend about it and she wants to break up with me. 

       

 T herapist: 

        But what did you feel back in the bar, when this was happening? 

       

      M ark: 

       I guess I thought here’s this great opportunity that doesn’t come around very often. 

       

       T herapist: 

      Mmmm. How do you feel right now, talking to me about this? 

       

      M ark: 

     What do you mean? 

       

      T herapist: 

        What do you feel here, telling me this? What are your feelings? 

       

      M ark: 

       I don’t know. It was difficult to come here today. 

       

      T herapist: 

        Okay, so you don’t know how you are feeling . . . you are struggling to identify your feelings. 

       

      M ark: 

      Right. 

       

        T herapist: 

       

       

       What would you like to do about that? 

       

      

        M ark: 

       

       

       About what? 

       

      

        T herapist: 

       

       

       About struggling to recognize your feelings. 

       

      

        M ark: 

       

       

       Ummm. That’s why I’m here. I don’t seem to know what I’m feeling or even that I’m feeling something, I just want to go off and do something else, and . . . 

       

      

        T herapist: 

       

       

       And avoid the uncomfortable feelings? 

       

      

        M ark: 

       

       

       Exactly. I just want to put the feelings out of my mind and go have fun. Why do I do that? 

       

      

        T herapist: 

       

       

       Mark, I’d like to help you, and part of that is getting to know you better, staying connected and being honest, and exploring in the session how this feels—how this interaction between us feels to you as you try to explore your feelings more deeply. 

       

      

        M ark: 

       

       

       Does it matter? 

       

      

        T herapist: 

       

       

       It matters a great deal. If you are willing to do that, to be more open with me and to try to express what you’re going through as feelings come up, I will understand you better, and feel more connected to you. 

       

      

        M ark: 

       

       

       But it’s hard for me. I get frustrated when I can’t put it in words. 

       

      

        T herapist: 

       

       

       Let’s see if we can slow it down a bit. I wonder if this is similar to what happens in your relationships. You feel something, and those feelings quickly 475become overwhelming and all jumbled together, and then you become frustrated or angry and start to feel overwhelmed and . . . 

       

      

        M ark: 

       

       

       Exactly! And then I just want to DO something to make those feelings go away. Can you help me? 

       

      

        T herapist: 

       

       

       I think you’ve taken a good first step. You said that you have problems recognizing feelings, and why you act on them. I’m here to help you figure that out. I think if you can slow down, try to explain what you feel in the moment, and when you get overwhelmed or frustrated just sit with those feelings for a moment. There’s no need to escape or act on the feelings. You can also start trying to do this with other relationships in your life. With your girlfriend. You can try to feel what you feel, and ask her to help out. That’s how we connect with each other, right? Do you think you can try that this week? 

       

       M ark: 

       This isn’t something I usually do so it will be weird, but I’ll try.

In a departure from the traditional stance of psychoanalytic therapy, the therapist is active and affirming, working from a relational psychodynamic perspective. The therapist helped Mark to identify that his feelings become overwhelming and he acts out to escape from the discomfort. By providing an opportunity in the session for Mark to try to express his feelings, the therapist is helping Mark to recognize the pattern of disengagement that seems to be causing him problems in relationships, and to substitute another, more effective behavior of attempting to express himself to others. Practicing this new type of behavior will raise more feelings, and at times Mark may feel overwhelmed and be tempted to disengage. Prior to this session the therapist had helped Mark to identify alternative, healthy behaviors he enjoys, such as exercise, playing music, and reading, which he can substitute for the self-defeating behaviors (substance use, sex) when he starts to feel overwhelmed. 

    As we can see from this short vignette, the cyclical psychodynamic–behavior therapist is supportive and directive and provides a safe environment within the session for Mark to explore his feelings and attempt to change his interactional patterns. With continued practice, Mark’s goal will be to recognize his feelings and share them in the moment, reduce his anxiety, and eliminate the behaviors that continue to cause problems in his life. 

    Integrative therapies that are client centered or interpersonal tend to focus on empathy, unconditional positive regard, and re-creating the client’s problems in the therapy session with the therapist. The relationship becomes the “vehicle of change” (Stricker & Gold, 2011, p. 442). Most cognitive behavioral therapy (CBT)–focused integrative therapies do not dismiss the importance of the therapeutic alliance but view the alliance as only one of many factors in the change process.

       Wachtel’s cyclical psychodynamic therapy is just one of many forms of integrative therapy that provide a dynamic source of behavioral change. Now, we turn to a discussion of multimodal therapy. 

    

   Multimodal Therapy 

     

    Multimodal therapy is one of the best known of the technical eclectic approaches (Harwood, Beutler, & Charvat, 2010). Multimodal therapy was developed by Arnold Lazarus, a pioneer in technical eclecticism. Lazarus was trained in behavior therapy, although he soon recognized the limitations of that approach and began to incorporate cognitive and other strategies into his work. Suggesting that therapists take a broad view of people and ways to help, Lazarus advocates technical eclecticism, which draws on many theories and strategies to match an approach to a client and problem. 

    Multimodal therapy is firmly grounded in behavior therapy, emphasizes outcomes, and draws from social learning and cognitive theories, while pulling on interventions from a number 476of theories. In addition, multimodal therapy has a humanistic component and values the uniqueness and self-determination of each individual. This approach also pays attention to context, looking at the individual as well as the individual’s culture, society, politics, and environment (Lazarus, 1996). 

    Multimodal therapists look at the client holistically; consequently, counseling needs to be flexible and versatile, drawing on a variety of approaches. For Lazarus, technical eclecticism, in which therapists select procedures from different modalities based on what works best for the client’s needs, but without necessarily subscribing to the overall theories, is the ideal way to plan such an approach (Lazarus, 1989). The ability to address client concerns from multiple vantage points simultaneously gives multimodal therapists considerable power and leverage, and results in more effective outcomes. 

    Counseling that reflects technical eclecticism, as described by Lazarus, has the following characteristics. It is:

Grounded in a theory of the therapist’s choice 

     Enhanced by interventions associated with compatible approaches to counseling 

     Focused on interventions that have had their value substantiated by research. 

     

    Selection of specific counseling strategies is guided by a systematic framework for matching intervention to client, problem, and situation (Lazarus, 2006). 

    In multimodal therapy, a careful assessment of clients and their concerns is an essential precursor to planning counseling. One of Lazarus’ most important contributions to the growing movement toward integrative counseling was the development of an assessment model that delineates seven basic categories of client functioning, represented by the acronym BASIC I.D.: 

     

      

      Behavior: observable actions, responses, and habits 

      Affect: moods and emotions 

      Sensations: physical concerns, sensory experiences (touch, taste, smell, sight, hearing) 

      Images: fantasies, dreams, memories, mental pictures, and people’s views of themselves, their lives, and their futures 

      Cognitions: thoughts, beliefs, philosophies, values, plans, opinions, insights, self-talk 

      Interpersonal relations: friendships and intimate relationships, interactions with others 

      Drugs, biology: broadly defined as biological functioning, including overall health, nutrition, exercise, self-care. 

      

     

    Therapy via multimodal therapy typically begins with a comprehensive assessment of these seven areas, using questions and scales to identify both strengths and problem areas. This helps therapists identify interventions that might be helpful in the specific area of concern. For example, let’s create a BASIC I.D. for Edie. Imagine that Edie came in for the first session. Our initial goal is to assess her functioning in each area of the BASIC I.D. During the intake interview, we elicit information from Edie about her history, her family life, and her relationships with Roberto and with her daughter Ava. Based on Edie’s responses, we develop the following chart: 

     

      B: Behavior: 

       Edie is arguing with Roberto more than usual. She is having trouble sleeping, and her relationship with her daughter is tense. 

       

       

       A: Affect: 

       She feels taken for granted and angry.477 

       

       

       S: Sensations: 

       She is starting to get headaches. 

       

       

       I: Images: 

       Edie imagines that all of the stress she is under is causing her cancer to come back. She visualizes the cancer cells growing inside her. 

       

       

       C: Cognitions: 

       Normally very compassionate with herself, she has started to criticize herself and engage in negative self-talk that she is a poor wife and mother. 

       

       

       I: Interpersonal relations: 

       Edie has distanced herself from her friends and from her mother. 

       

       

       D: Drugs: 

       Edie denies any problems with substance abuse. 

       

      

     

    Now that we have elicited this information from Edie, the question becomes one of where to begin and how to use the information to create an effective approach to counseling that takes the client’s needs into account. Lazarus (2006) found that each person favors some BASIC I.D. modalities over others. For example, a person might be characterized as a sensory reactor, an affective reactor, or an imagery reactor, depending on which modality is preferred. 

    The Structural Profile Inventory helps identify a person’s preferred modalities. This form asks people to indicate on a scale of 1 to 7 how important each of the seven areas of functioning is in their lives. Listing the seven areas in descending order of a person’s ratings yields a structural profile for that person. Constructing a diagram or bar graph of the relative strengths of a person’s seven areas of functioning is useful in clarifying patterns (Lazarus, 1976). 

    As an example, we asked Edie to rank order the list of seven modalities. Following are her results: 

     

     Interpersonal relations: 7 

     Affect: 6 

     Cognitions: 5 

     Behavior: 4 

     Sensations: 3 

     Images: 2 

     Drugs, biology: 1.

      Completing this profile helped Edie realize that she sometimes lets her strong emotions and need for approval and closeness cloud her judgment so that her feelings control her decisions. Changes she saw as desirable included moderating these two areas and improving her self-care and health habits. 

    Another way to use the BASIC I.D. is to look at a person’s modality firing order. Lazarus suggests that each person has a characteristic sequence of reactions to stressors and that this sequence usually mirrors that person’s structural profile. For example, when Edie was under stress, she usually first felt rejected and unloved (interpersonal relations), while becoming angry and scared (affect). Then she began a dialogue with herself, focused on how unlovable she felt and how many mistakes she had made in her relationships. This often caused her difficulty because she would erroneously accuse others of not caring about her, would overreact with anger and fear, and would then blame herself for the conflict. None of these reactions afforded her a way to discuss and dispel conflict with others. Consciously making some changes—in particular, moderating her emotions, considering new cognitions, and developing behaviors that promoted dialogue and resolution—helped Edie handle stress more effectively. 

    478An individual seems to respond best to interventions that target preferred modalities. For example, a person who emphasizes imagery is likely to benefit from visualization, whereas a person who focuses on thinking and analyzing probably will respond well to interventions that help identify and modify cognitive distortions. The resulting chart can then be discussed with the client, along with recommended counseling approaches that have shown effectiveness for the client’s specific problems.

The Transtheoretical Model of Change 

    

   The transtheoretical model of change, developed by Prochaska and others (Prochaska & DiClemente, 1986; Prochaska & Norcross, 2018), provides a theory of behavior change that incorporates elements from many different theoretical perspectives (hence the name, transtheoretical). Inherent in the theory is recognition of the uniqueness and diversity of other models, as well as their commonalities. Also known as the stages-of-change model, the transtheoretical model reflects the scientist-practitioner approach to developing theories and is based on both empirical research and practice. 

   The transtheoretical model can be applied to mental health and behavioral health problems and has been used successfully to reduce smoking, stress, violence, and bullying behaviors. It is a stage model that links interventions (processes of change) and the target of change efforts (levels of change) to the person’s stage of change. Assessment and matching are essential ingredients in this approach, as they are in many eclectic and integrated theories. 

   The transtheoretical model provides an organized and methodical approach to planning and integrating counseling strategies based on the following: 

    

    Five stages of change: Clients go through predictable stages as they engage in counseling, and that theory must be matched to clients’ level of readiness for change. Although progression through these phases may be direct and linear, it is more likely to reflect a spiral, with relapses and other factors causing people to cycle back through previous phases in the change process. The five stages include (Petrocelli, 2002):

Precontemplation: People in this stage see no need to change. They may be involuntary clients, seeking help because of a court order or family pressure. 

      Contemplation: People in this stage recognize that they have difficulties but have not made a commitment to take action needed for change. 

      Preparation: At this stage, people have decided to change and have even taken some small steps toward change. 

      Action: Now people are motivated and committed to making changes. They exert effort over time to accomplish those changes. 

      Maintenance: People act in ways that are likely to maintain and continue their positive changes and avoid relapse. 

       

    Ten processes of change: Determining a person’s stage of change is used to identify strategies and interventions likely to be successful and to help that person progress to the next stage of change. The developers of the model identified 10 change processes that demonstrated their value in both research and practice: consciousness raising, catharsis/dramatic relief, self-reevaluation, environmental reevaluation, self-liberation, social liberation, counterconditioning, stimulus control, contingency management, and helping relationships (Prochaska & Norcross, 2018). Strategies that promote awareness, such as consciousness raising and evaluation of self and environment, are particularly helpful and well received during the early precontemplation and contemplation stages, whereas action-oriented interventions, such as contingency management and conditioning, are more useful in the later action and maintenance stages.479 

    Five levels of change: The transtheoretical model considers a hierarchical organization of five levels of psychological problems that are likely to be addressed in psychotherapy (Prochaska & Norcross, 2018). The five levels include: 

      

      Symptom/situational problems 

      Maladaptive cognitions 

      Current interpersonal conflicts 

      Family/systems conflicts 

      Intrapersonal conflicts. 

       

    

   The transtheoretical model recognizes the importance of the therapeutic alliance, which is viewed as the most robust common factor in therapy. They also see the value of a healing setting and a confiding relationship. The therapist is viewed as an expert on change who has the task of tailoring the therapeutic relationship, as well as tailoring counseling, to each client’s stage of change.

   The transtheoretical model shows considerable promise. It provides a conceptual scheme to explain how people change and how to facilitate that change. It generalizes to a broad range of problems, it encourages innovation, and advocates both empirical research and experience to determine the value of this approach. Overall, 25 years of controlled research on the transtheoretical model indicate that the model is an evidence-based self-help approach for addressing addictions and habits that need to be changed and shows promise as a psychotherapy for depression and other disorders, but more research is needed (Prochaska & Norcross, 2018). Even so, behavioral health programs that have tailored interventions to match the client’s stage of change and the processes of change have shown greater efficacy. Specific programs have increased abstinence rates for smokers, improved stress management in an at-risk population, and reduced bullying and violence among high school and middle school students at 25 selected schools in the United States (Prochaska & Norcross, 2018). These aforementioned programs and the transtheoretical model program for stress reduction, have both achieved evidence-based status from the Substance Abuse and Mental Health Services Administration. Additional controlled research trials are on-going. 

   Opposition, rejection of therapists’ suggestions, and not following through on counseling interventions are all typical of highly resistant clients. When clients are more resistant, therapists might consider less directive counseling approaches, at least until trust is established. Conversely, clients who are highly motivated are more likely to do well with approaches that require a higher level of involvement (e.g., cognitive behavioral therapy), as these approaches require clients to complete homework assignments and practice identified behaviors (Norcross & Beutler, 2019). 

   Motivational interviewing (discussed in the person-centered therapy chapter) and the transtheoretical model are often linked and connected in the literature (Miller & Rollnick, 2013). However, motivational interviewing is not based on the transtheoretical model (Miller & Rollnick, 2013). Miller and Rollnick describe motivational interviewing and the transtheoretical model as ‘kissing cousins who never married’ (2013, p. 35). The transtheoretical model, on the one hand, provides an understanding of what initiates behavior change and how change may occur (Prochaska & DiClemente, 2002). Motivational interviewing, on the other hand, is a specific counseling approach that encourages, promotes, and optimizes the client’s drive for change. The transtheoretical model is often used in motivational interviewing to help assess clients’ current level of readiness for behavior change. The main focus in motivational interviewing is, however, on helping people through conversations that support and initiate behavior change (Miller & Rollnick, 2013). 

   Not all theories are strategically integrated, nor do they all fit into a specific theories category. Textbox 15.1 and Textbox 15.2 describe two examples of such theories.

Textbox 15.1 Interpersonal Psychotherapy 

     

    Interpersonal psychotherapy is based on a psychobiological approach to mental illness and informed by the interpersonal work of the ego psychologist Harry Stack Sullivan (1953, 1970). While it has a focus on interpersonal relationships, it is not really a psychodynamic approach, nor is it a humanistic approach. Some would argue that its lack of underlying theory of personality and development indicates that it is not a full-fledged approach at all. But without doubt, this time-limited approach is effective and growing in popularity worldwide, especially in places where it offers an alternative to costly medication when working with people who have psychological disorders. 

    Interpersonal psychotherapy was initially developed by Gerald Klerman and colleagues in the 1970s in New Haven, Connecticut, as part of a collaborative research program on depression (Verdeli & Weissman, 2011). Interpersonal psychotherapy emphasizes social and interpersonal experiences. It recognizes the importance of the unconscious and of early childhood interactions but gives more attention to current relationships and patterns, social roles, and coping skills. 

    According to interpersonal psychotherapy, the loss of a parent, or any other disruption in the relationship between a child and the child’s primary caregiver, can increase vulnerability to depression as an adult. Once the vulnerability to depression has been established, stressful interpersonal experiences in adulthood can lead to the onset or recurrence of depression. Interpersonal psychotherapy postulates that strong social bonds reduce the likelihood of depression. 

    Interpersonal psychotherapy is a focused, time-limited approach in which client and therapist typically meet for 14 to 18 weekly sessions. Therapy is focused on (1) interpersonal deficits (social roles and interactions among people), (2) role expectations and disputes, and (3) role transitions, or (4) grief (Weissman, Markowitz, & Klerman, 2007). Therapy seeks to identify a focal concern, alleviate symptoms, and improve interpersonal functions. 

    Counseling via IPT includes three phases: 

     

     Initial sessions. Counseling objectives of phase 1 include assessment of symptoms and identification of one or two focal concerns linked to the symptoms, such as grief, interpersonal conflicts, role transitions, or interpersonal deficits. In addition, therapists explain IPT and help clients recognize that their symptoms represent a disorder that can be ameliorated through counseling. 

     Intermediate phase. This phase focuses on the problem or interpersonal difficulty identified in phase 1. Goals are established, and strategies are used to achieve those goals. IPT encourages use of a variety of strategies, including support, questions to elicit emotion and content, interpretation, identification of patterns, advice giving, education, clarification, feedback on communication, teaching of decision-making skills, behavior change techniques, role playing, and use of the therapeutic relationship. Although therapists play an active role, clients are encouraged to take as much responsibility as possible for their therapy. 

     Termination phase. Termination is planned and carefully processed, beginning at least two to four sessions before the conclusion of therapy. Clients’ feelings of anger, sadness, loss, and grief are accepted and discussed. Therapists give clients the message that they are now capable of handling these feelings and moving ahead in their lives. 

     

    Research has given considerable support to IPT, which was originally designed to address depression but has since found value in addressing a number of other conditions, including bipolar disorder in conjunction with medication management (Frank, 2005), specific types of depression (peripartum, in conjunction with medical illnesses, with older adults, in the Hispanic population), bulimia and other eating disorders, posttraumatic stress disorder (PTSD), social anxiety disorder, and conflicts in interpersonal relationships (Kriston, Wolff, Westphal, Holzel, & Harter, 2014; Mann, McGrath, & Roose, 2013; Markowitz & Weissman, 2012; Mufson, Dorta, Moreau, & Weissman, 2011; Rafaeli & Markowitz, 2011). 

    Interpersonal psychotherapy provides a time-limited, manualized counseling approach for working with people of all ages, from adolescents to older adults, and in a variety of settings (Weissman et al., 2007). Many professionals appreciate this approach because it recognizes the role of relationships in people’s lives and provides a prescribed course of therapy that is concise and easy to follow.

Textbox 15.2 Eye Movement Desensitization Reprocessing (EMDR) 

     

    Eye movement desensitization and reprocessing (EMDR) includes elements of behavior therapy (e.g., exposure therapy), CBT (e.g., a focus on changing cognitions), and neuroscience (i.e., bilateral stimulation facilitated by eye movements, alternating sounds, and/or tapping). EMDR was discovered in 1987 by Francine Shapiro (2018), a senior research fellow at the Mental Research Institute in Palo Alto, California. EMDR requires the client to visualize an important memory followed by the physical sensations it invites. The client follows the therapist’s finger as it moves rapidly back and forth; this is repeated again and again until the client’s anxiety is reduced. The client then moves to reprocessing other memories that come up after previous memories are reprocessed. Essentially, the EMDR approach involves integrating a behavioral assessment, exposure such as imaginal flooding (i.e., evoking the memory of a traumatic event), cognition (i.e., recognizing and replacing negative thoughts), relaxation (i.e., intentional breathing exercises), and guided eye movements to help the individual learn to access, process, and resolve traumatic memories. 

    EMDR has eight phases. The first phase involves taking a client history to assess the client’s readiness for undergoing EMDR. The second phase is psychoeducational, in which the therapist teaches the client about what EMDR is and what reactions may occur from the process. The third phase occurs when the therapist gathers baseline data from the client. In this phase, the client selects a memory and uses subjective units of distress (SUDS) to label the distress level. These first three phases are the introduction to behavioral assessment phases. The fourth phase is the desensitization phase, which is the longest phase. The client focuses on the memory that was selected and experiences the emotions that arise as the therapist conducts the bilateral stimulation. This could include moving the hand back and forth 12 inches from the client’s face, using hand taps, or repeating verbal cues. After the bilateral set, which usually consists of 15 to 30 eye movements, the client takes a deep breath and reflects on what the experience was like, including thoughts, feelings, and sensations. The fifth phase is the installation phase, which involves linking the positive thought to the original memory through the use of eye movements. During the sixth phase, the client does a body scan to gain awareness of any tension, which would then be decreased through eye movements. The seventh and eighth phases are the emotional equilibrium phases. The client is also asked to keep a journal containing distressing thoughts, dreams, and images throughout the week. The client is taught to use relaxation techniques to reduce the distressing thoughts. EMDR typically takes four to six sessions that are 1.5 to 2 hours long. 

    Eye movement desensitization and reprocessing originally focused on people who had suffered trauma, including rape, molestation, and war experiences, by helping them to reduce negative images and emotions related to those images and modify self-destructive cognitions. EMDR is particularly helpful for treating clients who have experienced trauma (Chen et al., 2012). It also shows promise for anxiety, depression, eating disorders, and obsessive-compulsive disorder (OCD; Balbo, Zaccagnino, Cussino, & Civilotti, 2017; Chen et al., 2012; Marsden, Lovell, Blore, Ali, & Delgadillo, 2018). In a meta-analysis, trauma-focused CBT and EMDR were shown to be more effective in addressing PTSD as compared to other therapies (Bisson et al., 2007). Some argue that its effectiveness lies in the exposure therapy aspects of the approach, which overlap with the 482previously mentioned interventions (Schubert & Lee, 2009). Nevertheless, given the prevalence of EMDR as an approach for addressing PTSD, it is important for therapists to understand this approach and its value in helping those who have PTSD. 

    Eye movement desensitization and reprocessing with children has not yet proved as effective as EMDR with adults. Existing studies have so far suggested that positive results of EMDR with children are due to the cognitive component of this approach rather than the eye movements or bilateral stimulation (Greyber, Dulmus, & Cristalli, 2012).

Finding Your Counseling Theory 

    

   Readers who are relatively new to counseling and psychotherapy may view it as presumptuous or unrealistic to consider which counseling theory is best for them. However, choosing and emulating a style is a good way to learn almost any skill. Even Picasso, generally regarded as one of the most creative and innovative artists of the 20th century, began his career as a representational artist, painting in the traditional styles of the masters and only moving on to seek his own style after he had developed skill in established approaches to painting. 

   On the one hand, having studied many counseling theories, you may already have a preferred approach in mind. On the other hand, you may feel overwhelmed by the vast array of appealing choices. 

   Personal experiences can inform and influence the theories you value. Responding to the following questions can help you consider how your past experiences may impact your theory selection: 

    

     

     What theoretical approaches have been emphasized in your training and modeled by your professors? What are your reactions to these theories? What do you value and not value about these models? 

     If you have been employed as a therapist, what counseling approaches were advocated at your place(s) of employment? Which ones seemed most effective and compatible with your personal style? 

     If you received counseling or psychotherapy yourself, what approaches did your therapist emphasize? How successful were those approaches in helping you? What elements of your therapist’s approach did you value and not value? 

     

    

   Chapter 1 discussed common factors. Because of the importance of common factors in understanding what helps clients change in counseling, it is worth reviewing their importance as you find your preferred counseling approach. Research and experience increasingly confirm the existence of common factors in counseling and psychotherapy, overriding characteristics associated with successful counseling, regardless of a therapist’s theoretical orientation. Therapists have clues indicating what kind of therapeutic contexts, relationships, and processes are most likely to lead to positive therapy outcomes, and these cut across all counseling theories. Now that you know about a broad range of counseling theories, you probably have realized that beneficial commonalities in counseling approaches also play an important part in determining counseling outcome. In fact, as much as 70% of the outcome variance between different types of therapy can be attributed to common factors shared by all successful therapies (Wampold, 2010). The factors most commonly found across all therapeutic types and orientations are as follows: 

    

     

     A positive therapeutic alliance that is collaborative 

     A credible approach that addresses the client’s problems 

     Factors related to the client, such as self-efficacy, problem solving, motivation for change, and hopefulness that therapy will work (Norcross & Lambert, 2011). 

     

    The research on common factors accounting for client improvement can be divided into three broad categories (Lambert, 1992; Lambert & Bergin, 1994):

Support factors, including a positive, reassuring, and trusting therapeutic alliance and a therapist who communicates warmth, respect, empathy, genuineness, and acceptance 

     Learning factors, including changes in clients’ thinking and perceptions, receiving advice, acquisition of insight, corrective emotional experiences, and increased self-acceptance and expectations for personal effectiveness 

     Action factors, including an expectation for positive change, improved behavioral regulation, reality testing, modeling, practicing, completing homework tasks, receiving suggestions, confronting fears and problems, processing, working through, and having success experiences. 

     

    Does this mean that your theoretical orientation is not important? Absolutely not! Counseling factors account for between 8% and 15% of the variance. However, this research does suggest that whatever theory you select, counseling is likely to be effective, and this is reassuring. Counseling needs to be tailored to the needs of the specific client, and regardless of which modality is used, therapists must also attend to the relationship between client and therapist (Norcross & Lambert, 2011).

    

   Clients’ diagnoses—if applicable—are one example of an important variable to consider when selecting and applying a theory (Norcross & Beutler, 2019). For better or worse, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association, 2013), is the classification system on which all U.S. mental health professionals rely when diagnosing. Diagnoses can help suggest what theories or approaches may be most useful with clients. For example, if a client is experiencing severe, debilitating depression, the research suggests the client might benefit from behavior activation therapy. Therefore, clients’ diagnoses might impact what theory or interventions are used in counseling. Therapists are increasingly called upon to be dynamic in their understanding and application of various counseling approaches (Kress & Paylo, 2019). 

   Many suggest that it may be most helpful for new therapists to become competent in applying one theory. Once newer therapists have a solid understanding of a theory’s strengths, limitations, and applications, they are better able to integrate other theories. In counseling and psychotherapy, acquiring expertise in counseling theories that have established their value can provide a solid foundation for eventually developing a personal eclectic or integrated approach or deciding to specialize in one or two established theories. 

    

     

     Determinants of Theoretical Orientation 

     

    Many determinants, including the factors that follow, contribute to therapists’ choice of theoretical orientation: 

     

     Therapists who are encouraged, through course work and professional experiences, to adopt a particular approach to counseling are more likely to embrace a specific theory than an integrated or eclectic approach (Robertson, 1979). This is especially true if they are exposed to a charismatic proponent of that theory. 

     Beginning therapists are more likely to embrace one, specific theoretical approach. They have not yet determined which theory best fits them and their clients, nor have most beginning therapists acquired enough understanding of the entire spectrum of counseling approaches to allow thoughtful integration of a variety of approaches. In addition, adherence to a single theory can provide new therapists with reassuring structure and guidelines. 

     Similarly, length of therapy experience bears a positive relationship to the likelihood that therapists will have adopted an integrated or eclectic orientation (Prochaska & Norcross, 2018). 484Exposure to a diverse and complex array of clients and concerns, as well as to therapists who practice a range of counseling approaches, leads many therapists and psychologists to conclude that any one theory is too limited to meet their needs. Even theories that seem comprehensive and well supported in the literature may have gaps and shortcomings in practice. 

     Therapists’ perceptions of their work are another relevant factor. Therapists who view their work as a reflection of their philosophy of life are more likely to assume an integrated or eclectic stance than are therapists who view their work in practical terms, seeing it primarily as a way to earn a living (Robertson, 1979). 

     Therapists’ personalities and worldviews are other important factors. Finding a theoretical approach that is compatible with who they are and how they conceive of the process of helping people seems likely to enhance therapists’ effectiveness as well as their enjoyment of their work.

     

    For many therapists, their early years in the profession give them the opportunity to experiment with many approaches; determine what is and is not successful for them; and find a counseling system that is compatible with their professional roles, their self-images, their personalities, and their worldviews. For example, among counseling students, several factors contributed to their counseling theory choice (Petko, Kendrick, & Young, 2016). Personal values play a role in how therapists select their counseling theory. When people’s values match with the counseling theory, people are more likely to use that theory. Other contributors to theory selection include the theory making sense logically and the techniques being well liked. Most therapists find that their professional interests and ideas evolve with experience, enabling them to refine their counseling approaches as they hone their skills. Later in their careers, therapists who are self-employed and who are able to practice a theoretical orientation that is congruent with their personalities report greater job satisfaction (Topolinski & Hertel, 2007). 

    

    

          Counseling Theory and Therapist Personality 

     

    Whether or not you have honed in on your current theory of choice, be sure to pay attention to the influence your personality has on the theories you are drawn to. Therapists tend to prefer approaches that are compatible with their personality styles. For example, therapists’ preferred theoretical orientations and their personality types as reflected on the Myers-Briggs Type Indicator (MBTI) may predict what theories therapists are most interested in (Ciorbea & Nedelcea, 2012). Thinking types (Ts) may be more likely to choose predominantly cognitive and behavioral techniques (e.g., behavioral, rational emotive, and reality therapy). Specifically, ENTJs (i.e., those who are Extraverted, iNtuitive, Thinking, Judging) may be more likely to choose cognitive and behavioral therapies. Feeling types (Fs) may be more likely to choose predominantly humanistic and experiential therapies. Specifically, ESFJs (i.e., those who are Extroverted, Sensing, Feeling, Judging) and ISFPs (i.e., those who are Introverted, Sensing, Feeling, Judging) may be more likely to choose humanistic and experiential therapies. Those who score higher on the perceiving preference on the MBTI are more likely to choose a humanistic or existential theoretical orientation, and those who score higher on the judging type are more likely to choose a cognitive or behavior therapy. 

    Using your self-knowledge, feedback you have received from others, and the results of the MBTI or any personality inventories you might have taken, think about your personality and the counseling theories that seem most compatible with who you are and what you value. Again, further reading about and exposure to those approaches might help you choose a theoretical approach that is best for you at this point in your career. Keep in mind that you are not making an irrevocable commitment, but merely choosing a starting point that will help you continue the development of your counseling skills in a comfortable and focused way. With experience, you will become increasingly clear about the best approach for you and your clients, and you will find your theoretical approach changing, evolving, and improving. 

    

 Theoretical Orientation Reflection Questions

     

    It is important to remember that your theoretical orientation will evolve as you begin to work with clients. The theory you apply will also be influenced by the setting in which you work and the populations you work with. It is also unlikely that your theory will be black and white; you will likely draw on many aspects of various theoretical orientations as you determine what theories best fit the needs of individual clients. It is also necessary to tailor your therapeutic approach to meet the needs of all your clients, and you must consider their culture, as this inevitably impacts the therapeutic relationship and progress. While most therapists assimilate techniques and methods from diverse theoretical perspectives, it takes many years of practice and experience to cultivate the ability to integrate; both art and science are required for integrating approaches, and the development of such skills can truly be learned only in the trenches, with experience. Remember, the therapeutic relationship is at the core of each theoretical orientation no matter what approach you choose. It is important to keep an open mind as you grow in your theoretical orientation(s) and understand that the best way to develop your theoretical orientation is through your real-life experiences as a therapist. The following questions can help your reflect on what theoretical orientation you may be drawn to: 

     

      

      What is the core of human nature? Are human beings good, neutral, bad, or a mix? 

      Do you think that only one reality exists, or do you think that multiple realities can exist? 

      What causes human behavior (i.e., biology, learning, social relationships/influence of others)? In other words, what do you believe motivates human behavior? 

      When working with a client, would you consider the target to be the whole person or a specific aspect of the person/problem? 

      What are the principal concepts that explain human experience? 

      What are your beliefs about the development of problems in living? Is it necessary to understand the current problem or do you need to focus only on the current behavior? 

      What foundations or ingredients make up a healthy person? What approach fits best with your ideas around what a healthy person is (i.e., someone who has rational thoughts, someone who reaches self-actualization, someone who has a healthy family)? 

      What do you believe should be the target of therapy (e.g., clients’ thoughts, behavior, or feelings)? What do you believe most facilitates clients’ change processes? 

      What is the impact of social relationships on people’s mental health? How important are social relationships in influencing and supporting mental health? 

      What style do you think is most effective in encouraging clients’ change processes (i.e., active, directive, laid back, problem solving)? Who has the most responsibility for change (i.e., the client, the therapist, both)?

Overview of Counseling Theories 

    

   In this section of the chapter, an overview of the theories discussed in this text will be provided. I hope that in reviewing the theories in a cohesive way, you will be able to more clearly identify the theory or theories that most resonate with you. 

    

     

     Basic Philosophy/Key Concepts 

     

    Each counseling theory has basic theoretical foundations that are critical in guiding therapist practice. That said, there should be room in therapists’ practice to thoughtfully select interventions associated with other theories, as needed. For example, consider a client who is struggling with supervisor 486problems at work. Using a feminist therapy theory, a therapist will aim to empower the client to assert herself and ask to have her needs met. Yet the client may not have the skills to know how to do this secondary to a lifetime of subverting her voice because of societal expectations of women. As such, a feminist theorist might integrate behavior therapy interventions to help teach her the skills she requires to be successful in meeting her goals. In this situation, the therapist did not lose sight of the overarching philosophy of feminist therapy (e.g., client empowerment, breaking down limiting societal barriers that hold women/girls down) when selecting this intervention commonly associated with a different theoretical approach. What is important is that therapists are faithful to their underlying philosophies yet have the capacity to be technically integrative. As another example, it would not make sense for a therapist to tell a client she worked from a person-centered and cognitive behavioral perspective. The underlying philosophies of these two approaches are very different: CBT holds that learning cognitive and behavioral skills is the key to change, while a person-centered perspective is founded on the idea that the counseling relationship and enhanced awareness are foundational to change. At times a CBT therapist might pull on techniques associated with a person-centered approach, and vice versa, but the basic philosophy and theory should guide therapists’ thinking and approach. Table 15.1 provides an overview of basic philosophies that guide major theories and Table 15.2 provides an overview of key concepts that guide the major theories discussed in this text. 

     

      

      Table 15.1 Basic Philosophies of Counseling Theories

Table 15.2 Key Concepts of Counseling Theories

             Therapy Goals 

    

   In Table 15.3 an overview of the counseling goals associated with each theory is provided. As can be seen, counseling goals in particular have tremendous diversity. In many ways, this dimension—the goals of counseling—is what most readily distinguishes one theory from another. All of the theories hold the relationship as important to some extent, but when you begin to consider the focus and goals of counseling, the theories begin to stand apart. For example, existential theory has as its goal finding 490491meaning in one’s life, while person-centered theory has as its focus becoming more self-actualized. Even though these theories both value the therapeutic relationship and have humanistic foundations, they have different goals. 

    

      Table 15.3 Goals of Counseling

The theories also differ in terms of how specific they are; some theories’ goals are easier to pin down and drill in on (e.g., CBT, behavior therapy), while others are less well defined (e.g., person-centered or postmodern approaches). Along these lines, these same theories’ goals can be more short term focused (e.g., traditional CBT approaches), while others are more focused on a person’s long-term growth and development (e.g., contemporary CBT approaches). 

   

   Relationship Between Therapist and Client 

    

   Boiled down to its essence, therapy is founded on the idea that a human connection is valuable. As such, all of the theories discussed in this text consider the therapeutic relationship to be important, with some (e.g., person-centered, Gestalt, existential theories) believing it is more important than others (e.g., CBT, behavior therapy). Because therapists bring their personal characteristics to the counseling relationship, it is vital for them to be self-aware of their personality, values, cultural experiences and cultural limitations, and expectations of themselves and their clients, along with many other factors. Personal therapy is a great way for therapists to enhance their self-awareness so that they can be prepared to promote and encourage healthy relationships with their clients. On a related note, it is important that therapists have an awareness of the types of clients with whom they may struggle to develop a therapeutic relationship. For example, some counselors may have a difficult time building a relationship with certain populations (e.g., sex offenders, clients who abuse substances, children). An awareness of limitations is important, and addressing these issues will help deter problems from developing in the long run. Table 15.4 presents an overview of the therapeutic relationship in each theory. 

    

           Table 15.4 The Therapeutic Relationship

Counseling Techniques and Applications

Clients have unique counseling needs, and not all clients will respond to certain techniques in the same way. It would be short sighted and potentially harmful to clients if the same techniques were used with everyone. As previously discussed, clients’ personal characteristics (e.g., motivation to make changes) and their presenting problems/diagnoses (e.g., anxiety) are just some of the considerations that may impact the counseling techniques used. Ideally, the counseling techniques chosen will be the ones most beneficial to the client. Knowing when clients need what techniques, though, is complicated. As a start, it is helpful for therapists to be well versed in a variety of techniques; in other words, good therapists have many tools in their toolbox.

In Chapter 1, the setting in which a therapist works was discussed as important when considering what counseling theory or techniques to use. Level of care was also examined as a major consideration that will significantly determine a therapist’s methods. The setting and the level of care, then, will influence which counseling theories a therapist uses. As an example, a school counselor who is helping a student with a peer conflict may use counseling techniques that differ from those used by a mental health therapist working with a psychotic patient on a psychiatric ward who is experiencing a conflict with another patient. 

   When selecting counseling techniques, therapists should consider evidence-based practices. However, they must also take into account the approaches they are trained to use, clients’ counseling preferences, the confines of the setting in which they work, and a myriad of additional considerations (Kress & Paylo, 2019). The use of evidence-based approaches is more or less important, depending on the clients’ needs. To use an extreme example, if the therapist is counseling a 5-year-old who has endured significant trauma secondary to child sex trafficking, it would be irresponsible and unethical to not pull on the wide array of research that points to counseling approaches that may help the child resolve trauma and thus its long-term effects. At the other extreme, if a therapist is counseling a 494college student dealing with roommate conflicts, the therapist will have more freedom and flexibility in terms of the interventions used, as the stakes are not as high and the client is likely not as complex.

Therapists should consider what is already known in the research literature (e.g., peer-reviewed journals and federal registries) with regard to effective counseling techniques. Some helpful guidelines that may assist therapists in evaluating whether a theory, approach, or intervention should be deemed evidenced based and used in practice are (SAMHSA, 2009): 

    

    Guideline 1: Approaches and interventions need to be based on some documented, clear conceptual model of change. 

    Guideline 2: Approaches and interventions must be similar to, or found in, federal registries and/or the peer-reviewed literature. 

    Guideline 3: The approaches and interventions should be supported by the documentation of multiple scientific inquiries that seem credible, and rigorous, and by evidence consistent with positive effects. 

    Guideline 4: The approaches and interventions should have been reviewed and deemed credible by informed experts in the identified area. 

    

   Additionally, when determining what interventions and techniques to use and when and how to use them, the following might also apply: 

    

    Therapists should ensure that they have developed a strong therapeutic alliance with the client. 

    Therapists should consider the client’s issue or concern and what the client wants to get out of counseling. 

    Therapists should consider how the client’s preferences may intersect with the techniques being selected. 

    Therapists should consider their history with using the techniques and ensure that they have the competency to use such techniques. 

    

   Adhering to these considerations enables therapists to select interventions that are consistent with clients’ preferences and that adhere to therapists’ individual competencies. Table 15.5 provides an overview of the techniques associated with different theories, and Table 15.6 presents an overview of the populations that each theory works well with. 

    

     

Table 15.5 Counseling Techniques

Table 15.6 Counseling Applications

          Multicultural Counseling 

    

   Therapists must be sensitive to cultural issues if they are to best meet clients’ needs. Every theory presented in this text is founded on assumptions that are more or less compatible with different cultures’ ways of being. Therapists are all challenged to consider the cultural strengths and limitations of each theory and how that theory can be modified for use with those from diverse backgrounds. Some theories are easier to modify than others, depending on the population. In Chapter 1, culture and diversity considerations related to theories were discussed, and this topic was reviewed in each subsequent chapter. In Tables 15.7 and 15.8, multicultural strengths and limitations of the theories are presented. 

    

      Table 15.7 Multicultural Strengths 

     

Table 15.8 Multicultural Limitations 

Closely related to cultural considerations are spirituality and religious considerations in counseling. Spirituality is a part of clients’ worldview and culture; thus, therapists must assess the role clients’ religion and spirituality might play—or not play—when selecting and applying various theories and techniques. Therapists should never ignore clients’ religion or spirituality, and they should always make sure to assess the role this plays in their clients’ lives, if any. Spirituality and religious considerations are very important to many clients, and, in fact, for many clients they may be the most important factor influencing their existence, with it defining their beliefs about themselves and their world (Cashwell & Young, 2011). Since many clients’ religious and spiritual beliefs provide their foundation, these beliefs can be harnessed, supported, and mobilized to help clients reach their goals. For many clients, their religion or spirituality can offer a great source of comfort during difficult times; it can guide clients when they do not know which direction to head; and it can help clients identify their life’s meaning and purpose. It is important for therapists to understand their own thoughts, values, and attitudes concerning spirituality and religion so they can better understand how they might influence or respond to clients who have different ideas (Cashwell & Young, 2011).

     

Strengths and Limitations of Theories 

    

   Every theory has strengths and limitations; there is no theory that is a best theory for all therapists or all clients. Tables 15.9 and 15.10 present the limitations and the contributions of each theory. 

    

     

Table 15.9 Limitations of the Theory 

Table 15.10 Contributions of the Theory

One important consideration related to theory selection is the amount of time required to effect change (Hoyt, 2017; Norcross, Hogan, & Koocher, 2008). Therapists, school counselors/psychologists, and all who work with those seeking mental health services are increasingly required to help their clients as quickly as possible. Pressure to be brief comes not only from third-party payers and employers (e.g., schools) but also from clients, as most clients want their problems resolved in as little time as possible. Brief therapy methods can be applied to all of the theories discussed in this text, some more readily than others, of course (Hoyt, 2017). 

   Providers are also increasingly called upon to demonstrate effectiveness of their methods. Again, some of the theories discussed in this text lend themselves to measurement and evaluation, whereas the effectiveness of some other theories may be more difficult to determine. For example, behavior therapy has as its focus behavioral change that can readily be measured, whereas postmodern approaches have as their focus subjective client perceptions of change. Both outcomes are meaningful; it is just that one outcome is easier to objectively determine than the other.

     

Future Directions in Counseling and Psychotherapy 

    

   The following trends and issues are likely to impact the direction of systems and strategies of counseling and psychotherapy in the 21st century (Kress & Paylo, 2019; Prochaska & Norcross, 2018): 

    

    Cultural competence will become the norm as therapists attend to their own, as well as their clients’, worldviews. Background, culture, religion and philosophy, ability, age, and gender are important aspects of people’s social location and must be integrated into any efforts to tailor therapy to meet the needs of individuals. 

    As research methods evolve, providers will develop a better sense of what theories or interventions may be most effective in addressing different presenting issues. In other words, counselors will get better at answering the critical question: “What treatment, by whom, is most effective for this individual with that specific problem under which set of circumstances?” (Paul, 1967, p. 111). 

    Attention to the contributions of biology and neurophysiology to emotional health and development will increase. Assessments such as magnetic resonance imaging (MRI) and functional MRI (fMRI) will find more frequent application in diagnosis. Researchers may better identify when and how psychotropic medications may be useful. 

    The use of telemental health counseling will continue to develop and expand. Legal and ethical guidelines will evolve to regulate the use of technology in the counseling profession. Therapists who use online counseling, Skype, virtual reality, e-mail, text messaging, and social media will need to stay current with federal, state, and local laws regarding insurance reimbursement, confidentiality, and privacy requirements. 

    Recognition of childhood antecedents to adult mental disorders will lead to the development of earlier prevention programs. Counselors all play a role in the advocacy of such programs, as they prevent the development of future problems. 

    Managed care will continue to focus on accountability. Many federal, state, and military funding agencies already require the use of empirically supported treatments as a prerequisite of reimbursement for services. For better or worse, the medical model will continue, and therapists will be expected to use evidence-based practices if they want to be eligible for third-party reimbursement. 

    In the future, an increasing number of therapists will elect not to participate in insurance plans, as managed care systems continue to exert influence over therapeutic decision making, require manualized care, set therapy guidelines, and track therapist effectiveness. 

    Research will continue to focus on and clarify the common elements across counseling approaches that are linked to counseling success. 

    Not only will a positive and collaborative therapeutic alliance continue to be one of the most important elements of successful therapy, but also research into the specific factors that foster an effective and collaborative alliance will increase. 

    New models of psychotherapy will be proposed, theoretical integration will expand, and many existing theories will be further refined. 

    With increasing recognition of the negative lifelong effects of childhood trauma, neglect, and abuse, attachment-related and trauma-based therapies will grow in importance and use. 

    Postmodern and other nonlinear approaches will continue to influence conceptions of counseling and psychotherapy and are increasingly likely to be integrated into other counseling approaches. 

    Spirituality and religion will be integrated into the assessment, conceptualization, and practice of all different types of counseling, as clients seek to find holistic therapies that focus on mind, body, and spirit.506 

    Eastern-influenced philosophies and the tools of mindfulness meditation, acceptance, and compassion (loving kindness) will be integrated into counseling approaches as a way to reduce stress and provide a holistic approach to counseling. 

    Collaborations between school counselors and mental health therapists will increase in an effort to address problems of school violence, suicide, and crisis management.

    Counseling and psychotherapy will continue to be important in helping people cope with problems and emotional difficulties, in part because the value of mental health counseling has been so well established and in part because research and holistic thinking will extend the breadth of its reach.

Summary 

    

   This chapter addressed integration of theories and provided several examples of integrated theories. A majority of therapists report that their primary theoretical orientation is an integrative or eclectic approach. Integrated approaches are grounded in theory and seek to combine and blend multiple counseling strategies into a unique whole that is more than the sum of its parts. Eclecticism, in contrast, lacks a unifying theory but is practical, providing a prototype or structure for selecting and applying interventions drawn from many approaches to counseling and psychotherapy. An increase in research on the common factors that exist in therapies across all theoretical orientations has provided additional support for the development of systems that allow therapists to create tailored experiences for clients that address the seminal question of what works best for whom, in the here and now of the therapy session. 

   As Lazarus predicted decades ago, technical integration of different modes of therapy is becoming the new worldview in psychotherapy. We expect to see the development of even newer integrated approaches in the areas of religion and spirituality, multicultural psychotherapy, and common factors approaches to counseling in the not too distant future. 

   In this chapter, information about a broad range of approaches to counseling and psychotherapy was also synthesized and summarized. The questions posed in this chapter can help therapists identify their preferred approaches to counseling, as can the exercises designed to facilitate professional growth. This chapter also reviewed trends expected to have an impact on counseling and psychotherapy in the future. 

   Counseling is an exciting profession. Helping others can be quite rewarding and fulfilling. As a therapist, you are never finished growing—there are perpetual opportunities to grow and learn more. I hope that this text has helped you to learn more about the important counseling theories, skills, and strategies you can use to help others. However, like any book on counseling theories, it can give you only an introduction to these approaches. The counseling field is constantly changing, and I strongly encourage you to continue to study and practice these counseling approaches through additional reading, continuing education, supervised experience, peer feedback, and research on your own practice. 

   Therapists do very important work, work that can make a great difference in the lives of individuals, groups, families, and even societies. I hope you will treasure and honor the trust that people put in you and will do your best to use your skills to do good for others. I also hope this book will help you to keep the energy and spirit of the mental health professions alive in your work. 

   

   

    

    Recommended Readings 

    

    

    Hill, C. E. (2014). Helping skills: Facilitating exploration, insight, and action (4th ed.). Washington, DC: American Psychological Association.

Lazarus, A. A. (2006). Brief but comprehensive psychotherapy: The multimodal way. New York, NY: Springer. 

    Lazarus, A. A. (2008). Technical eclecticism and multimodal therapy. In J. L. Lebow (Ed.), Twenty-first century psychotherapies: Contemporary approaches to theory and practice (pp. 424–452). Hoboken, NJ: John Wiley & Sons.508 

    Schneider, K. (2008). Existential-integrative psychotherapy: Guideposts to the core of practice. New York, NY: Routledge. 

    Teyber, E., & McClure, F. H. (2011). Interpersonal process in therapy: An integrative model (6th ed.). Belmont, CA: Thomson/Brooks Cole. 

    Wachtel, P. L. (2011). Inside the session: What really happens in psychotherapy. Washington, DC: American Psychological Association. 

    Also recommended is the Journal of Psychotherapy Integration.