Behavior Therapy

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SE/Corey, Theory and Practice of Counseling and Psychotherapy, 11th Edition ISBN -978-0-357-76442-8 ©20XX Designer: XXX Text & Cover printer: Sheridan Versailles Binding: PB Trim: 8” x 10” CMYK

Gerald Corey

Eleventh Edition

Theory and Practice of Counseling and Psychotherapy

Eleventh Edition

Corey Theory and Practice of Counseling and Psychotherapy

Theories at-a-Glance The tables in this book compare theories over a range of topics, thereby providing you with the ability to easily compare, contrast, and grasp the practical aspects of each theory. These tables also serve as invaluable resources that can be used to review the key concepts, philoso- phies, limitations, contributions to multicultural counseling, applications, techniques, and goals of all theories in this text.

The following chart provides a convenient guide to the tables in this text.

Pages

6–7 Table 1.1 Overview of Contemporary Counseling Models

71–72 Table 4.1 Ego-Defense Mechanisms

74–75 Table 4.2 Comparison of Freud’s Psychosexual Stages and Erikson’s Psychosocial Stages

537 Table 15.1 The Basic Philosophies

538–539 Table 15.2 Key Concepts

543 Table 15.3 Goals of Therapy

546–547 Table 15.4 The Therapeutic Relationship

548–549 Table 15.5 Techniques of Therapy

549–550 Table 15.6 Applications of the Approaches

551 Table 15.7 Contributions to Multicultural Counseling

552 Table 15.8 Limitations in Multicultural Counseling

553–554 Table 15.9 Contributions of the Approaches

554–555 Table 15.10 Limitations of the Approaches

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Overview of Focus Questions for the Theories For the chapters dealing with the different theories, you will have a basic understand- ing of this book if you can answer the following questions as they apply to each of the eleven theories:

Who are the key figures (founder or founders) associated with the approach?

What are some of the basic assumptions underlying this approach?

What are a few of the key concepts that are essential to this theory?

What do you consider to be the most important goals of this therapy?

What is the role the therapeutic relationship plays in terms of therapy outcomes?

What are a few of the techniques from this therapy model that you would want to incorporate into your counseling practice?

What are some of the ways that this theory is applied to client populations, settings, and treat- ment of problems?

What do you see as the major strength of this theory from a diversity perspective?

What do you see as the major shortcoming of this theory from a diversity perspective?

What do you consider to be the most significant contribution of this approach?

What do you consider to be the most significant limitation of this approach?

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The following chart provides a convenient guide to the tables in this text.

Pages

6–7 Table 1.1 Overview of Contemporary Counseling Models

71–72 Table 4.1 Ego-Defense Mechanisms

74–75 Table 4.2 Comparison of Freud’s Psychosexual Stages and Erikson’s Psychosocial Stages

537 Table 15.1 The Basic Philosophies

538–539 Table 15.2 Key Concepts

543 Table 15.3 Goals of Therapy

546–547 Table 15.4 The Therapeutic Relationship

548–549 Table 15.5 Techniques of Therapy

549–550 Table 15.6 Applications of the Approaches

551 Table 15.7 Contributions to Multicultural Counseling

552 Table 15.8 Limitations in Multicultural Counseling

553–554 Table 15.9 Contributions of the Approaches

554–555 Table 15.10 Limitations of the Approaches

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Gerald Corey Professor Emeritus of Human Services and Counseling

at California State University, Fullerton

Distinguished Visiting Professor of Counseling at University of Holy Cross, New Orleans

Theory and Practice of Counseling and

Psychotherapy Eleventh Edition

Australia ● Brazil ● Canada ● Mexico ● Singapore ● United Kingdom ● United States

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Theory and Practice of Counseling and Psychotherapy, Eleventh Edition Gerald Corey

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Dedication

To the future generation of counselors:

Pursue your dreams.

You are here to change the world for the better.

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About the Author

Gerald “Jerry” Corey, EdD, ABPP, is professor emeritus of human services and counseling at California State University at Fullerton and is distinguished visiting professor of counseling at the University of Holy Cross in New Orleans, where each semester he teaches intensive courses in counseling theories, group counseling, and ethics. He received his doctorate in counseling from the University of Southern Cali- fornia in 1967. He was awarded an honorary doctorate in Humane Letters in 1992 from National Louis University. He is a Diplomate in Counseling Psychology, Ameri- can Board of Professional Psychology; a licensed psychologist; and a National Certi- fied Counselor. He is a Fellow of the American Psychological Association (Division 17, Counseling Psychology; and Division 49, Group Psychotherapy); a Fellow of the American Counseling Association; and a Fellow of the Association for Specialists in Group Work. Both Jerry and his wife, Marianne Corey, received the Lifetime Achieve- ment Award from the American Mental Health Counselors Association in 2011, and both of them received the Eminent Career Award from ASGW in 2001. Jerry was the recipient of the Outstanding Professor of the Year Award from California State Uni- versity at Fullerton in 1991. He received the Thomas Hohenshil National Publica- tions Award, which was presented at the American Counseling Association’s Virtual Conference in 2021. He is the author or coauthor of 16 textbooks in counseling cur- rently in print, along with more than 70 journal articles and book chapters. Several of his books have been translated into other languages. Theory and Practice of Counsel- ing and Psychotherapy has been translated into Arabic, Indonesian, Portuguese, Turk- ish, Korean, and Chinese. Theory and Practice of Group Counseling has been translated into Korean, Chinese, Spanish, and Russian. Issues and Ethics in the Helping Professions has been translated into Korean, Japanese, and Chinese.

With his colleagues, Jerry has conducted workshops in the United States, Germany, Ireland, Belgium, Scotland, Mexico, Canada, China, and Korea with a spe- cial focus on training in group counseling. In his leisure time, Jerry likes to hike and bicycle in the mountains and the desert and drive his 1931 Model A Ford with his grandchildren. Jerry and Marianne have been married since 1964. They have two adult daughters (Heidi and Cindy), two granddaughters, and one grandson.

In addition to Theory and Practice of Counseling and Psychotherapy, Eleventh Edition (and Student Manual) (2024), other publications by Gerald Corey, all with Cengage Learning, include:

◆ Issues and Ethics in the Helping Professions, Eleventh Edition (2024, with Marianne Schneider Corey and Cindy Corey)

◆ Theory and Practice of Group Counseling, Tenth Edition (and Student Manual) (2023)

◆ Becoming a Helper, Eighth Edition (2021, with Marianne Schneider Corey)

◆ Groups: Process and Practice, Tenth Edition (2018, with Marianne Schneider Corey and Cindy Corey)

◆ I Never Knew I Had a Choice, Eleventh Edition (2018, with Marianne Schneider Corey and Michelle Muratori)

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◆ Group Techniques, Fourth Edition (2015, with Marianne Schneider Corey, Patrick Callanan, and J. Michael Russell)

◆ Case Approach to Counseling and Psychotherapy, Eighth Edition (2013)

The following seven books are published by the American Counseling Association:

◆ Clinical Supervision in the Helping Professions: A Practical Guide, Third Edition (2021, with Robert Haynes, Patrice Moulton, and Michelle Muratori)

◆ Personal Reflections on Counseling (2020) ◆ The Art of Integrative Counseling, Fourth Edition (2019) ◆ Counselor Self-Care (2018, with Michelle Muratori, Jude T. Austin, and

Julius A. Austin II) ◆ ACA Ethical Standards Casebook, Seventh Edition (2015, with Barbara

Herlihy) ◆ Boundary Issues in Counseling: Multiple Roles and Relationships, Third

Edition (2015, with Barbara Herlihy) ◆ Creating Your Professional Path: Lessons From My Journey (2010)

Jerry has also made several educational video programs on various aspects of counseling practice: (1) Counseling with the Case of Gwen (2019); (2) Group Theories in Action (2019); (3) Ethics in Action (2015, with Marianne Schneider Corey and Robert Haynes); (4) Groups in Action: Evolution and Challenges (2014, with Marianne Schneider Corey and Robert Haynes); (5) Counseling with the Case of Stan and Lecturettes (2013); (6) Integrative Counseling: The Case of Ruth and Lecturettes (2013, with Robert Haynes); and (7) Lecturettes for Theory and Practice of Group Counseling (2012). All of these programs are available through Cengage Learning, and most of them are part of the MindTap programs.

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Preface xvii

Par t 1

Basic Issues in Counseling Practice

1 Introduction and Overview 1 Introduction 2 Where I Stand 3 Suggestions for Using the Book 5 Overview of the Theory Chapters 6 Introduction to the Case of Stan 9 Intake Interview With Stan 10 Overview of Some Key Themes in Stan’s Life 12

Introduction to the Case of Gwen 13 Meet Dr. Kellie Kirksey 13 Background on the Case of Gwen 13 Intake Session 14

Video on Counseling Sessions With Gwen 15 Overview of Video MindTap Program for The Case of Gwen 15 Chapter 1 Intake Session 15 Chapter 2 Multicultural Perspectives 15 Chapter 3 Informed Consent Session 15 Chapter 4 Psychoanalytic (Psychodynamic) Therapy 15 Chapter 5 Adlerian Therapy 15 Chapter 6 Existential Therapy 16 Chapter 7 Person-Centered Therapy 16 Chapter 8 Gestalt Therapy 16 Chapter 9 Behavior Therapy 16 Chapter 10 Cognitive Behavior Therapy 16 Chapter 11 Choice Theory/Reality Therapy 16 Chapter 12 Feminist Therapy/Social Justice 16 Chapter 13 Postmodern Approaches: Solution- Focused Brief Therapy 17 Chapter 14 Family Systems Therapy 17 Chapter 15 Integrative Approaches 17

2 The Counselor: Person and Professional 18

Introduction 19 The Counselor as a Therapeutic Person 19 Personal Characteristics of Effective Counselors 20

Personal Therapy for the Counselor 22 The Counselor’s Values and the Therapeutic Process 24 The Role of Values in Counseling 24 Can Counselors Who Self-Identify as Religious Provide Value-Free Counseling to LGBTQ1 Clients? 25 Addressing Religious and Spiritual Values in Counseling 26 The Role of Values in Developing Therapeutic Goals 28

Becoming an Effective Multicultural Counselor 28 Acquiring Competencies in Multicultural Counseling 29 Incorporating Culture in Counseling Practice 31

Issues Faced by Beginning Therapists 32 Dealing With Anxiety 32 Being Yourself and Self-Disclosure 33 Avoiding Perfectionism 33 Being Honest About Your Limitations 34 Understanding Silence 34 Dealing With Demands From Clients 34 Dealing With Clients Who Lack Commitment 34 Tolerating Ambiguity 35 Becoming Aware of Your Countertransference 35 Developing a Sense of Humor 36 Sharing Responsibility With the Client 36 Declining to Give Advice 36 Defining Your Role as a Counselor 37

Maintaining Your Vitality as a Person and as a Professional 37

Contents

vii

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viii Contents

Summary 40 Self-Reflection and Discussion Questions 40 Recommended Supplementary Readings for Chapter 2 41 References 41

3 Ethical Issues in Counseling Practice 44

Introduction 45 Putting Clients’ Needs Before Your Own 45 Ethical Decision Making 46 The Role of Ethics Codes as a Catalyst for Improving Practice 46 Some Steps in Making Ethical Decisions 47

The Right of Informed Consent 48 Dimensions of Confidentiality 49 Ethical Concerns With the Use of Technology 49 Exceptions to Confidentiality and Privileged Communication 50

Ethical Issues From a Multicultural Perspective 50 Are Current Theories Adequate in Working With Culturally Diverse Populations? 51 Is Counseling Culture-Bound? 51 Focusing on Both Individual and Environmental Factors 52

Ethical Issues in the Assessment Process 52 The Role of Assessment and Diagnosis in Counseling 52

Ethical Aspects of Evidence-Based Practice 55 Managing Multiple Relationships in Counseling Practice 56 Perspectives on Multiple Relationships 58

Becoming an Ethical Counselor 61 Summary 61 Self-Reflection and Discussion Questions 62 Where to Go From Here 62 Recommended Supplementary Readings for Chapter 3 64 References 64

Par t 2

Theories and Techniques of Counseling

4 Psychoanalytic Therapy 66 Introduction 67 Key Concepts 68 View of Human Nature 68 Structure of Personality 68 Consciousness and the Unconscious 70 Anxiety 70 Ego-Defense Mechanisms 71 Development of Personality 72

The Therapeutic Process 75 Therapeutic Goals 75 Therapist’s Function and Role 75 Client’s Experience in Therapy 76 Relationship Between Therapist and Client 78

Application: Therapeutic Techniques and Procedures 81 Maintaining the Analytic Framework 81 Free Association 82 Interpretation 82 Dream Analysis 83 Analysis and Interpretation of Resistance 83 Analysis and Interpretation of Transference 84 Application to Group Counseling 85 Applying the Psychoanalytic Approach to School Counseling 86

Jung’s Perspective on the Development of Personality 87 Contemporary Trends: Object-Relations Theory, Self Psychology, and Relational Psychoanalysis 89 Summary of Stages of Development 90 Some Directions of Contemporary Psychodynamic Therapy 92

An Expert’s Perspective on Psychoanalytic Therapy 94 Discussion Questions Related to Dr. Blau’s Psychoanalytic Perspective 97

Psychoanalytic Therapy From a Multicultural Perspective 98 Strengths From a Diversity Perspective 98

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Contents ix

Shortcomings From a Diversity Perspective 98

Psychoanalytic Therapy Applied to the Case of Stan 99 Psychoanalytic Therapy Applied to the Case of Gwen 100 Summary and Evaluation 102 Summary 102 Contributions of the Classical Psychoanalytic Approach 103 Contributions of Contemporary Psychoanalytic Approaches 103 Limitations and Criticisms of Psychoanalytic Approaches 105

Self-Reflection and Discussion Questions 106 Where to Go From Here 106 Recommended Supplementary Readings for Chapter 4 107 References 107

5 Adlerian Therapy 109 Introduction 113 Key Concepts 113 View of Human Nature 113 Goal-Directed Movement 114 Goal-Orientation and the Unity of the Personality 115 Community Feeling and Social Interest 117 Private Logic 118 Life Tasks 120 Influences on Individual Development 120 Birth Order and Sibling Relationships 122 Culture, Race, and Ethnicity: Systemic Holism 123

The Therapeutic Process 124 Therapeutic Goals 124 Therapist’s Function and Role 125 Client’s Experience in Therapy 125 Relationship Between Therapist and Client 127

Application: Therapeutic Techniques and Procedures 127 Phase 1: Establishing the Relationship 128 Phase 2: Assessing the Individual’s Psychological Dynamics 128 Phase 3: Encourage Self-Understanding and Insight 132 Phase 4: Adaptive Reorientation and Reeducation 133

Application for Individual Psychology 137 Application for Family Counseling 138 Application for Group Counseling 138 Applying the Adlerian Approach to School Counseling 139

An Expert’s Perspective on Adlerian Therapy 141 Discussion Questions Related to Dr. Bitter’s Adlerian Perspective 145

Adlerian Therapy From a Multicultural Perspective 146 Strengths From a Diversity Perspective 146 Shortcomings From a Diversity Perspective 147

Adlerian Therapy Applied to the Case of Stan 148 Adlerian Therapy Applied to the Case of Gwen 149 Summary and Evaluation 151 Summary 151 Contributions of the Adlerian Approach 152 Limitations and Criticisms of the Adlerian Approach 153

Self-Reflection and Discussion Questions 153 Where to Go From Here 154 Free Podcasts for ACA Members 154 Other Resources 154

Recommended Supplementary Readings for Chapter 5 155 References 155

6 Existential Therapy 158 Introduction 161 Historical Background in Philosophy and Existentialism 162 Key Figures in Contemporary Existential Psychotherapy 165

Key Concepts 166 View of Human Nature 166 Proposition 1: The Capacity for Self-Awareness 167 Proposition 2: Freedom and Responsibility 168 Proposition 3: Striving for Identity and Relationship to Others 170 Proposition 4: The Search for Meaning 172 Proposition 5: Anxiety as a Condition of Living 174 Proposition 6: Awareness of Death and Nonbeing 175

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x Contents

The Therapeutic Process 175 Therapeutic Goals 175 Therapist’s Function and Role 176 Client’s Experience in Therapy 177 Relationship Between Therapist and Client 177

Application: Therapeutic Techniques and Procedures 179 Phases of Existential Counseling 180 Clients Appropriate for Existential Counseling 180 Application to Brief Therapy 181 Application to Group Counseling 181 Applications of Existential Approach to School Counseling 182

An Expert’s Perspective on Existential Therapy 183 Discussion Questions Related to Dr. Deurzen’s Existential Perspective 186

Existential Therapy From a Multicultural Perspective 186 Strengths From a Diversity Perspective 186 Shortcomings From a Diversity Perspective 187

Existential Therapy Applied to the Case of Stan 188 Existential Therapy Applied to the Case of Gwen 189 Summary and Evaluation 191 Summary 191 Contributions of the Existential Approach 191 Limitations and Criticisms of the Existential Approach 193

Self-Reflection and Discussion Questions 193 Where to Go From Here 194 Free Podcasts for ACA Members 194 Other Resources 194

Recommended Supplementary Readings for Chapter 6 196 References 196

7 Person-Centered Therapy 198 Introduction 200 Four Periods of Development of the Approach 201 Emotion-Focused Therapy 202 Existentialism and Humanism 203 Abraham Maslow’s Contributions to Humanistic Psychology 204

Key Concepts 206 View of Human Nature 206

The Therapeutic Process 207 Therapeutic Goals 207 Therapist’s Function and Role 207 Client’s Experience in Therapy 208 Relationship Between Therapist and Client 209

Application: Therapeutic Techniques and Procedures 212 Early Emphasis on Reflection of Feelings 212 Evolution of Person-Centered Methods 212 The Role of Assessment 214 Application of the Philosophy of the Person-Centered Approach 214 Application to Crisis Intervention 215 Application to Group Counseling 215 Application of the Person-Centered Approach With Children and Adolescents in School Counseling 216

Person-Centered Expressive Arts Therapy 217 Principles of Expressive Arts Therapy 217 Creativity and Offering Stimulating Experiences 218

An Expert’s Perspective on Person-Centered Expressive Arts 219 Discussion Questions Related to the Person-Centered Expressive Arts Perspective 221

Person-Centered Therapy From a Multicultural Perspective 222 Strengths From a Diversity Perspective 222 Shortcomings From a Diversity Perspective 222

Person-Centered Therapy Applied to the Case of Stan 224 Person-Centered Therapy Applied to the Case of Gwen 225 Summary and Evaluation 227 Summary 227 Contributions of the Person-Centered Approach 228 Limitations and Criticisms of the Person-Centered Approach 229

Self-Reflection and Discussion Questions 230 Where to Go From Here 231 Free Podcasts for ACA Members 231 Other Resources 231

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Contents xi

Recommended Supplementary Readings for Chapter 7 232 References 232

8 Gestalt Therapy 235 Introduction 237 Key Concepts 238 View of Human Nature 238 Some Principles of Gestalt Therapy Theory 239 Contact and Resistances to Contact 240 The Now 242 Unfinished Business 243 Energy and Blocks to Energy 244

The Therapeutic Process 244 Therapeutic Goals 244 Therapist’s Function and Role 245 Client’s Experience in Therapy 247 Relationship Between Therapist and Client 248

Application: Therapeutic Techniques and Procedures 249 The Experiment in Gestalt Therapy 249 Preparing Clients for Gestalt Experiments 251 The Role of Confrontation 252 Gestalt Therapy Interventions 253 Application to Group Counseling 257 Application of the Gestalt Approach to School Counseling 258

An Expert’s Perspective on Gestalt Therapy 260 Discussion Questions Related to the Gestalt Therapy Perspective 262

Gestalt Therapy From a Multicultural Perspective 263 Strengths From a Diversity Perspective 263 Shortcomings From a Diversity Perspective 263

Gestalt Therapy Applied to the Case of Stan 264 Gestalt Therapy Applied to the Case of Gwen 266 Summary and Evaluation 267 Summary 267 Contributions of Gestalt Therapy 267 Limitations and Criticisms of Gestalt Therapy 268

Self-Reflection and Discussion Questions 270

Where to Go From Here 270 Other Resources 270 Training Programs and Associations 270

Recommended Supplementary Readings for Chapter 8 271 References 271

9 Behavior Therapy 273 Introduction 276 Historical Background 276 Four Areas of Development 277

Key Concepts 279 Current Trend in Behavior Therapy 279 Basic Characteristics and Assumptions 279

The Therapeutic Process 280 Therapeutic Goals 280 Therapist’s Function and Role 281 Client’s Experience in Therapy 282 Relationship Between Therapist and Client 283

Application: Therapeutic Techniques and Procedures 283 Applied Behavioral Analysis: Operant Conditioning Techniques 284 Progressive Muscle Relaxation 285 Systematic Desensitization 286 In Vivo Exposure and Flooding 288 Eye Movement Desensitization and Reprocessing 290 Social Skills Training 292 Self-Management Programs and Self-Directed Behavior 292 Multimodal Therapy: Clinical Behavior Therapy 294 Mindfulness and Acceptance-Based Approaches 295 Application to Group Counseling 304 Applying the Behavioral Approach to School Counseling 306

An Expert’s Perspective on Behavior Therapy 307 Discussion Questions Related to the Behavior Therapy Perspective 309

Behavior Therapy From a Multicultural Perspective 309 Strengths From a Diversity Perspective 309

Shortcomings From a Diversity Perspective 311

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xii Contents

Behavior Therapy Applied to the Case of Stan 311 Behavior Therapy Applied to the Case of Gwen 313 Summary and Evaluation 314 Summary 314 Contributions of Behavior Therapy 315 Limitations and Criticisms of Behavior Therapy 316

Self-Reflection and Discussion Questions 318 Where to Go From Here 318 Other Resources 318 Mindfulness and Acceptance-Based Approaches 319

Recommended Supplementary Readings for Chapter 9 319 References 320

10 Cognitive Behavior Therapy 323 Introduction 324 Albert Ellis’s Rational Emotive Behavior Therapy 324 Introduction 324

Key Concepts 326 View of Emotional Disturbance 326 ABC Framework 327

The Therapeutic Process 328 Therapeutic Goals 328 Therapist’s Function and Role 328 Client’s Experience in Therapy 329 Relationship Between Therapist and Client 330

Application: Therapeutic Techniques and Procedures 330 The Practice of Rational Emotive Behavior Therapy 330 Applications of REBT as a Brief Therapy 334 Application of REBT to Group Counseling 334 Application of REBT to School Counseling 335

An Expert’s Perspective on Rational Emotive Behavior Therapy 336 Discussion Questions Related to the REBT Perspective 338

Aaron Beck’s Cognitive Therapy 340 Introduction 340 A Generic Cognitive Model 341 Basic Principles of Cognitive Therapy 343 The Client–Therapist Relationship 345

Applications of Cognitive Therapy 346 Applying Cognitive-Behavioral Counseling With Adolescents in Schools 348

Christine Padesky and Kathleen Mooney’s Strengths-Based Cognitive Behavior Therapy 350 Introduction 350 Basic Principles of Strengths-Based CBT 350 The Client–Therapist Relationship 351 Applications of Strengths-Based CBT 351

An Expert’s Perspective on Cognitive Behavior Therapy 353 Discussion Questions Related to Dr. Christine Padesky’s Cognitive Behavior Perspective 355

Donald Meichenbaum’s Cognitive Behavior Modification 356 Introduction 356 How Behavior Changes 357 Stress Inoculation Training 358 A Cognitive Narrative Approach to Cognitive Behavior Therapy 360

Cognitive Behavior Therapy From a Multicultural Perspective 361 Strengths From a Diversity Perspective 361 Shortcomings From a Diversity Perspective 362

Cognitive Behavior Therapy Applied to the Case of Stan 364 Cognitive Behavior Therapy Applied to the Case of Gwen 366 Summary and Evaluation 367 Summary 367 Contributions of the Cognitive-Behavioral Approaches 368 Limitations and Criticisms of the Cognitive- Behavioral Approaches 370

Self-Reflection and Discussion Questions 372 Where to Go From Here 372 Recommended Supplementary Readings for Chapter 10 374 References 374

11 Choice Theory/Reality Therapy 377 Introduction 379 Key Concepts 380 View of Human Nature 380

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Contents xiii

Choice Theory Explanation of Behavior 382 Characteristics of Reality Therapy 382

The Therapeutic Process 384 Therapeutic Goals 384 Therapist’s Function and Role 385 Client’s Experience in Therapy 385 Relationship Between Therapist and Client 386

Application: Therapeutic Techniques and Procedures 386 The Practice of Reality Therapy 386 The Counseling Environment 387 Procedures That Lead to Change 387 The “WDEP” System 388 Application to Group Counseling 393 Application of Reality Therapy to School Counseling 394

An Expert’s Perspective on Choice Theory/ Reality Therapy 395 Discussion Questions Related to the Choice Theory/ Reality Therapy Perspective 397

Choice Theory/Reality Therapy From a Multicultural Perspective 397 Strengths From a Diversity Perspective 397 Shortcomings From a Diversity Perspective 399

Reality Therapy Applied to the Case of Stan 400 Reality Therapy Applied to the Case of Gwen 401 Summary and Evaluation 403 Summary 403 Contributions of Choice Theory/Reality Therapy 403 Limitations and Criticisms of Choice Theory/Reality Therapy 404

Self-Reflection and Discussion Questions 405 Where to Go From Here 405 Free Podcasts for ACA Members 405 Other Resources 406

Recommended Supplementary Readings for Chapter 11 407 References 407

12 Feminist Therapy 408 Introduction 410 History and Development 412

Key Concepts 413 Constructs of Feminist Theory 413 Feminist Perspective on Personality Development 413 Recent Trends in Feminist Therapy 414 Principles of Feminist Therapy 415

The Therapeutic Process 417 Therapeutic Goals 417 Therapist’s Function and Role 418 Client’s Experience in Therapy 419 Relationship Between Therapist and Client 420

Application: Therapeutic Techniques and Procedures 420 The Role of Assessment and Diagnosis 420 Techniques and Strategies 421 The Role of Men in Feminist Therapy 425 Application of the Feminist Approach to Group Work 426 Feminist Social Justice Principles Applied to School Counseling 426

An Expert’s Perspective on Feminist Therapy 428 Discussion Questions Related to the Feminist Therapy Perspective 432

Feminist Therapy From a Multicultural and Social Justice Perspective 432 Strengths From a Diversity Perspective 432 Shortcomings From a Diversity Perspective 434

Feminist Therapy Applied to the Case of Stan 434 Feminist Therapy Applied to the Case of Gwen 436 Summary and Evaluation 439 Summary 439 Contributions of Feminist Therapy and Multicultural and Social Justice Perspectives 441 Limitations and Criticisms of Feminist Counseling 442

Self-Reflection and Discussion Questions 443 Where to Go From Here 444 Other Resources 444

Recommended Supplementary Readings for Chapter 12 445 References 445

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xiv Contents

13 Postmodern Approaches 448 Some Contemporary Founders of Postmodern Therapies 449 Introduction to Social Constructionism 449 Historical Glimpse of Social Constructionism 450 The Collaborative Language Systems Approach 451

Solution-Focused Brief Therapy 452 Introduction 452 Key Concepts 453 The Therapeutic Process 455 Applying SFBT to Group Counseling 462 Application of Solution-Focused Counseling to School Counseling 463

An Expert’s Perspective on Solution-Focused Brief Therapy 464 Discussion Questions Related to the Solution- Focused Brief Therapy Perspective 467

Motivational Interviewing 468 The MI Spirit 468 Common Ground With Person-Centered Therapy 468 The Basic Principles of Motivational Interviewing 469 The Stages of Change 470 Common Ground With Solution-Focused Brief Therapy 471 Application of Motivational Interviewing to School Counseling 472

Narrative Therapy 474 Introduction 474 Key Concepts 474 The Therapeutic Process 475 Application: Therapeutic Techniques and Procedures 478 Application of Narrative Therapy to Group Counseling 482

An Expert’s Perspective on Narrative Therapy 483 Discussion Questions Related to the Narrative Therapy Perspective 487

Postmodern Approaches From a Multicultural Perspective 487 Strengths From a Diversity Perspective 487 Shortcomings From a Diversity Perspective 488

Postmodern Approaches Applied to the Case of Stan 489

Postmodern Approaches Applied to the Case of Gwen 491 Summary and Evaluation 493 Summary 493 Contributions of Postmodern Approaches 494 Limitation and Criticisms of Postmodern Approaches 496

Self-Reflection and Discussion Questions 496 Where to Go From Here 497 Free Podcasts for ACA Members 497 Other Resources 497 Training in Solution-Focused Therapy Approaches 498 Training in Narrative Therapy 498

Recommended Supplementary Readings for Chapter 13 498 References 499

14 Family Systems Therapy 502 Introduction 503 The Family Systems Perspective 503 Differences Between Systemic and Individual Approaches 504

Development of Family Systems Therapy 505 Structural-Strategic Family Therapy 507 Recent Innovations in Family Therapy 508

A Multilayered Process of Family Therapy 509 Forming a Relationship 509 Conducting an Assessment 510 Hypothesizing and Sharing Meaning 513 Facilitating Change 514 Application of Family Systems Approaches to School Counseling 515

An Expert’s Perspective on Family Systems Therapy 516 Discussion Questions Related to the Family Systems Therapy Perspective 520

Family Systems Therapy From a Multicultural Perspective 520 Strengths From a Diversity Perspective 520 Shortcomings From a Diversity Perspective 521

Family Therapy Applied to the Case of Stan 522 Family Therapy Applied to the Case of Gwen 525

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Contents xv

Summary and Evaluation 527 Summary 527 Contributions of Family Systems Approaches 528 Limitations and Criticisms of Family Systems Approaches 529

Self-Reflection and Discussion Questions 529 Where to Go From Here 529 Recommended Supplementary Readings for Chapter 14 530 References 530

Par t 3

Integration and Application

15 An Integrative Perspective 532 Introduction 533 The Movement Toward Psychotherapy Integration 533 Pathways Toward Psychotherapy Integration 534 Advantages of Psychotherapy Integration 536 The Challenge of Developing an Integrative Perspective 536 Integration of Multicultural Issues in Counseling 539 Integration of Spirituality and Religion in Counseling 540

The Therapeutic Process 542

Therapeutic Goals 542 Therapist’s Function and Role 544 Client’s Experience in Therapy 544 Relationship Between Therapist and Client 545

The Place of Techniques and Evaluation in Counseling 547 Drawing on Techniques From Various Approaches 547 Evaluating the Effectiveness of Counseling and Therapy 555 Feedback-Informed Treatment 556

An Integrative Approach Applied to the Case of Stan 557 An Integrative Approach Applied to the Case of Gwen 560 Summary 562 Concluding Comments 563 Self-Reflection and Discussion Questions 564 Where to Go From Here 564 Other Resources 564

Recommended Supplementary Readings for Chapter 15 565 References 565

Name Index 567

Subject Index 573

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This book is intended for counseling courses for undergraduate and graduate students in psychology, counselor education, human services, and the mental

health professions. It surveys the major concepts and practices of the contemporary therapeutic systems and addresses some ethical and professional issues in counsel- ing practice. The book aims to teach students to select wisely from various theories and techniques and to begin to develop a personal style of counseling.

I have found that students appreciate an overview of the divergent contempo- rary approaches to counseling and psychotherapy. They also consistently say that the first course in counseling means more to them when it deals with them person- ally. Therefore, I stress the practical applications of the material and encourage per- sonal reflection. Using this book can be both a personal and an academic learning experience.

In this updated eleventh edition, every effort has been made to retain the major qualities that students and professors have found useful in previous editions: the succinct overview of the key concepts of each theory and their implications for prac- tice, the straightforward and personal style, and the book’s comprehensive scope. Care has been taken to present the theories in an accurate and fair way. I have attempted to be simple, clear, and concise. Because many students want suggestions for further readings, I have included both recommended supplementary readings and a reference list at the end of each chapter.

Overview of the Book and What’s New in the Eleventh Edition This edition includes updated material and refines selected existing discussions. Part 1 deals with issues that are basic to the practice of counseling and psycho- therapy. Chapter 1 puts the book into perspective and introduces readers to the cases of Stan and Gwen. An overview of the videos illustrating counseling sessions with Gwen conducted by nine different therapists is incorporated in this chapter. In Chapter 2, students are introduced to the counselor—as a person and a professional. There is an updated and expanded discussion of becoming an effective multicul- tural counselor. There is some new material on wellness, counselor self-care, and therapeutic lifestyle changes. Chapter 3 introduces students to a range of key ethical issues in counseling practice.

Part 2 is devoted to a consideration of 11 theories of counseling. All of the theo- ries have been revised and expanded to reflect recent trends and developments in the practice of that theoretical approach, and references have been updated for each theory chapter. In addition, Adlerian therapy, traditional behavior therapy, third- wave behavioral approaches, cognitive behavior therapy, feminist therapy, and the postmodern approaches (solution-focused brief therapy, motivational interviewing,

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Preface to Eleventh Edition

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xviii Preface to Eleventh Edit ion

and narrative therapy) all have undergone major revisions, which highlight signifi- cant developments of these theories. As has been true of earlier editions, each of the theory chapters follows a common organizational pattern, and students can easily compare and contrast the various models. This pattern includes core topics such as key concepts, the therapeutic process, therapeutic techniques and procedures, multicultural perspectives, and the theory applied to the case of Stan and the case of Gwen.

Students will have a basic understanding of the 11 theories if they can answer the following questions about each theory introduced in Part 2:

◆ Who are the key figures or founders associated with each theory? ◆ What are some of the basic assumptions underlying each theory? ◆ What are a few key concepts of each theory? ◆ What are the primary goals of each theory? ◆ What role does the therapeutic relationship play in each theory? ◆ What techniques from each theory could be incorporated in an

integrated perspective? ◆ What are some of the major strengths of the theory from a diversity

perspective? ◆ What are some of the major shortcomings of the theory from a

diversity perspective? ◆ What are some of the key contributions of the theory? ◆ What are some of the key limitations of the theory?

The summary and evaluation at the end of each chapter describes the contribu- tions, strengths, limitations, and applications of the theory. Special attention is given to the strengths and shortcomings of the theory in working with diverse client populations. Students are given recommendations regarding where to look for further training in the “Where To Go From Here” sections at the end of each chapter.

A new feature in the theory chapters of Part 2 is a section on how each theory can be applied to school counseling. The application of the various theories to coun- seling in school settings is a perspective that was requested by students and faculty. These sections were contributed by individuals who have expertise both in the the- ory being discussed and in school counseling.

Another new feature of Part 2 is a section in which an expert in each theory addresses six specific questions about the theory. The expert perspectives are pro- vided by diverse contributors who are steeped in the theory, which enables students to see similarities and differences among the theories.

Part 3 presents an integrative perspective. I believe that an integrative approach to counseling practice is the best way to meet the needs of diverse cli- ent populations in many different settings. Numerous tables and other material help students compare and contrast the 11 theoretical orientations and illus- trates ways these approaches might be integrated. Important discussions explain the psychotherapy integration movement, how to integrate religion/spiritual- ity in counseling, research demonstrating the central role of the therapeutic

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Preface to Eleventh Edit ion xix

alliance, and some conclusions from the research literature on the effectiveness of psychotherapy. I also encourage students to develop a framework that leads to their own synthesis.

Supplemental Resources Student and Instructor Resources

In this eleventh edition, I have made every effort to incorporate those aspects that have worked best in the courses on counseling theory and practice that I teach. To help readers apply theory to practice, a Student Manual is available on the Companion Website. The Student Manual for Theory and Practice of Counseling and Psychotherapy is designed for experiential work and contains open-ended ques- tions, cases for exploration and discussion, structured exercises, self-inventories, and a variety of activities that can be done both in class and out of class. The Student Manual has a glossary for each of the theories, activities and exercises, case examples, and chapter quizzes for assessing the level of mastery of basic concepts of each theory.

Also available online is a revised and updated Instructor’s Resource Manual, which includes suggestions for teaching the course, class activities to stimulate interest. This instructor’s manual is now geared for the following learning pack- age: Theory and Practice of Counseling and Psychotherapy; Student Manual for Theory and Practice of Counseling and Psychotherapy; and Case Approach to Counseling and Psychotherapy.

Additional instructor assets include an Educator’s Guide, PowerPoint® slides, and a test bank powered by Cognero®. Sign up or sign in at www.cengage.com to search for and access this product and its online resources.

MindTap for Theory and Practice of Counseling and Psychotherapy Today’s leading online learning platform, MindTap for Theory and Practice of Counsel- ing and Psychotherapy, 11th edition, gives you complete control of your course to craft a personalized, engaging learning experience that challenges students, builds confi- dence, and elevates performance.

MindTap introduces students to core concepts from the beginning of your course using a simplified learning path that progresses from understanding to application and delivers access to eTextbooks, study tools, interactive media, auto- graded assessments, and performance analytics.

Use MindTap for Theory and Practice of Counseling and Psychotherapy, 11th edition, as-is, or personalize it to meet your specific course needs. You can also easily inte- grate MindTap into your Learning Management System (LMS).

The MindTap for Theory and Practice of Counseling and Psychotherapy, 11th edition, contains Video Quizzes related to the Case of Stan and the Case of Gwen. There are also two online-only chapters: Chapter 16, “Case Illustration: An Integrative Approach in Working With Stan,” and Chapter 17, “Transactional Analysis”.

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xx Preface to Eleventh Edit ion

Alignment With CACREP Standards* CACREP Core Curriculum Standards for various areas of counseling are reflected throughout this eleventh edition of Theory and Practice of Counseling and Psychotherapy. Chapter numbers relevant to the CACREP standards appear in parentheses follow- ing the standards listed here.

Professional Counseling Orientation and Ethical Practice 1. The role and process of the professional counselor advocating on behalf

of the profession (Chapter 3) 2. Advocacy processes needed to address institutional and social barriers that

impede access, equity, and success for clients (Chapter 3) 3. Professional counseling organizations, including membership benefits,

activities, services to members, and current issues (Chapter 3) 4. Ethical standards of professional counseling organizations and credential-

ing bodies, and applications of ethical and legal considerations in profes- sional counseling (Chapter 3)

5. Self-care strategies appropriate to the counselor role (Chapter 2)

Social and Cultural Diversity 1. Theories and models of multicultural counseling, cultural identity develop-

ment, and social justice and advocacy (Chapters 2–14) 2. Multicultural counseling competencies (Chapters 2–3) 3. Help-seeking behaviors of diverse clients (Chapters 2–14) 4. The impact of spiritual beliefs on clients’ and counselors’ worldviews

(Chapter 2) 5. Strategies for identifying and eliminating barriers, prejudices, and processes of

intentional and unintentional oppression and discrimination (Chapter 3)

Counseling and Helping Relationships 1. Theories and models of counseling (Chapters 2–15) 2. A systems approach to conceptualizing clients (Chapter 14) 3. The impact of technology on the counseling process (Chapter 3) 4. Counselor characteristics and behaviors that influence the counseling

process (Chapter 2) 5. Essential interviewing, counseling, and case conceptualization skills

(Chapter 1) 6. Developmentally relevant counseling treatment or intervention plans

(Chapter 4) 7. Development of measurable outcomes for clients (Chapter 15) 8. Evidence-based counseling strategies and techniques for prevention and

intervention (Chapter 3)

*Council for Accreditation of Counseling Related Educational Programs. (2016). CACREP Standards.

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Preface to Eleventh Edit ion xxi

9. Processes for aiding students in developing a personal model of counseling (Chapter 15)

Group Counseling and Group Work 1. Theoretical foundations of group counseling and group work

(Chapters 4–13) 2. Therapeutic factors and how they contribute to group effectiveness

(Chapters 4–13) 3. Characteristics and functions of effective group leaders (Chapter 2) 4. Ethical and culturally relevant strategies for designing and facilitating

groups (Chapters 4–13)

Acknowledgments Thank you to these professors who use this book and who reviewed new and revised material for the theory chapters:

◆ Jake Morris, PhD, professor of counseling at Lipscomb University ◆ Bryan Farha, EdD, professor and director of applied behavioral studies

and counseling at Oklahoma City College ◆ Alex Becnel, PhD, assistant professor in the Department of

Special Education, Counseling, and Student Affairs, at Kansas State University

Kellie Kirksey, PhD, reviewed the strengths and shortcomings of the theories from a multicultural/diversity perspective. Her insights and commentary enhanced the discussion of these sections for all theory chapters.

Various experts reviewed selected chapters and in some cases provided new lit- erature and examples for the chapters. These individuals are:

◆ Paul Rasmussen, PhD, Chapter 5, Adlerian Therapy ◆ Jon Sperry, PhD, Chapter 5, Adlerian Therapy ◆ Len Sperry, PhD, MD, Chapter 5, Adlerian Therapy ◆ Caroline Bailey, PhD, Chapter 9, Behavior Therapy ◆ Sherry Cormier, PhD, Chapter 9, Behavior Therapy ◆ Debbie Joffe Ellis, MDAM, Chapter 10, Cognitive Behavior Therapy

(REBT) ◆ Christine Padesky, PhD, Chapter 10, Cognitive Behavior Therapy ◆ Robert Wubbolding, EdD, Chapter 11, Choice Theory/Reality

Therapy ◆ Carolyn Zerbe Enns, PhD, Chapter 12, Feminist Therapy ◆ John Murphy, PhD, Chapter 13, Postmodern Therapy:

Solution-Focused Brief Therapy ◆ Gerald Monk, PhD, Chapter 13, Postmodern Therapy:

Narrative Therapy

Many thanks go to all those who contributed to the school counseling sec- tions: Sheri Bauman, PhD (Psychoanalytic therapy, Existential therapy, and Choice

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xxii Preface to Eleventh Edit ion

theory/Reality therapy); Hideko Sera, PsyD (Adlerian therapy); Sam Steen, PhD (Person-Centered therapy); Margaret Hindman, PhD, and Kristi Perryman, PhD (Gestalt therapy); Kellie Kirksey, PhD (Behavior therapy); Debbie Joffe Ellis, MDAM (Rational emotive behavior therapy); Alex Becnel, PhD (Cognitive behavioral coun- seling); Carolyn Zerbe Enns, PhD (Feminist social justice therapy); John Murphy, PhD (Solution-focused counseling); Gerald Monk, PhD (Narrative therapy); Jenni- fer Melfie, Med (Motivational interviewing); and James Robert Bitter, EdD (Family systems therapy).

Appreciation also goes to the individuals who provided an expert’s perspec- tive on each theory: Psychoanalytic Therapy, William Blau; Adlerian Therapy, James Robert Bitter; Existential Therapy, Emmy van Deurzen; Person-Centered Expres- sive Arts, Natalie Rogers; Gestalt Therapy, Jon Frew; Behavior Therapy, Sherry Cormier; Rational Emotive Behavior Therapy, Debbie Joffe Ellis; Cognitive Behav- ior Therapy, Christine A. Padesky; Choice Theory/Reality Therapy, Robert E. Wub- bolding; Feminist Therapy, Carolyn Zerbe Enns; Solution-Focused Brief Therapy, John J. Murphy; Narrative Therapy, John Winslade; and Family Systems Therapy, James Robert Bitter.

Many of the ideas in this eleventh edition are the result of my interaction and discussions with graduate students, teaching assistants, and guest present- ers beginning in 2020 in my Counseling Theories classes at the University of Holy Cross in New Orleans. These Counseling Theories courses were weekend intensives presented via Zoom. The questions and comments from students in these classes were helpful to me in rethinking many of the concepts and techniques for the vari- ous theory chapters.

Marianne Schneider Corey (life partner of almost 60 years) has been greatly instrumental in the development of my integrative approach to counseling. Since the first edition of this book in 1977, Marianne and I have been involved in teaching and presenting workshops. We have had frequent conversations about the contri- butions of the diverse theoretical perspectives. Her influence is largely responsible for significant shifts in my thinking regarding the practical applications of the counseling theories in this textbook.

Special recognition goes to Kay Mikel, the manuscript editor of this edition, whose exceptional editorial talents continue to keep this book reader friendly.

Gerald Corey

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1Introduction and Overview

1. Explain the author’s philosophical stance.

2. Identify suggested ways to use this book.

3. Differentiate between each contemporary counseling model discussed in this book.

4. Identify key issues presented in the case of Stan.

5. Identify key issues presented in the case of Gwen.

6. Describe the key themes of the video counseling sessions with Gwen.

Learning Objectives

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2 Chapter One

Introduction Counseling students can begin to acquire a counseling style tailored to their own personality by familiarizing themselves with the major approaches to therapeu- tic practice. This book surveys 11 approaches to counseling and psychotherapy, presenting the key concepts of each approach and discussing features such as the therapeutic process (including goals), the client–therapist relationship, and spe- cific procedures used in the practice of counseling. This information will help you develop a balanced view of the major ideas of each of the theories and acquaint you with the practical techniques commonly employed by counselors who adhere to each approach. I encourage you to keep an open mind and to seriously consider both the unique contributions and the particular limitations of each therapeutic system presented in Part 2.

You cannot gain the knowledge and experience you need to synthesize various approaches by merely completing an introductory course in counseling theory. This process will take many years of study, training, and practical counseling experience. Nevertheless, I recommend a personal integration as a framework for the profes- sional education of counselors. When students are presented with a single theory and are expected to subscribe to it alone, their effectiveness will be limited when working with a diverse range of clients in the future.

An undisciplined mixture of approaches, however, can be an excuse for failing to develop a sound rationale for systematically adhering to certain concepts and to the techniques that are extensions of them. It is easy to pick and choose fragments from the various therapies because they support our biases and preconceptions. By studying the theories presented in this book, you will have a better sense of how to integrate concepts and techniques from different approaches when defining your own personal synthesis and framework for counseling.

Each therapeutic approach has useful dimensions for understanding human behavior. No theory is either “right” or “wrong”; each theory offers a unique con- tribution to understanding human behavior and has implications for counseling practice. Accepting the validity of one theory does not necessarily imply rejecting other approaches. There is a clear place for theoretical pluralism, especially in a soci- ety that is becoming increasingly diverse.

Although I suggest that you remain open to incorporating diverse approaches into your own personal synthesis—or integrative approach to counseling—you can quickly become overwhelmed and confused if you attempt to learn everything at once, especially if this is your introductory course in counseling theories. A case can be made for initially getting an overview of the major theoretical orientations, and then learning a particular approach by becoming steeped in that approach for some time rather than superficially grasping many theoretical approaches. An inte- grative perspective is not developed in a random fashion; it is an ongoing process that is well thought out. Successfully integrating concepts and techniques from diverse approaches requires years of reflective practice, gaining practical experience in counseling, and a great deal of reading about the various theories. In Chapter 15, I discuss in more depth some ways to begin designing your integrative approach to counseling practice.

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Introduct ion and Over v iew 3

Where I Stand My philosophical orientation is strongly influenced by the existential approach. Because this approach does not prescribe a set of techniques and procedures, I draw techniques from various therapy approaches presented in this book. I particularly like to use role-playing techniques. When people reenact scenes from their lives, they tend to become more psychologically engaged than when they merely report anecdotes about themselves. I also incorporate many techniques derived from cog- nitive behavior therapy.

The psychoanalytic emphasis on early psychosexual and psychosocial develop- ment is useful. Our past plays a crucial role in shaping our current personality and behavior. I challenge the deterministic notion that humans are the product of their early conditioning and, thus, are victims of their past. But I believe that an explora- tion of the past is often useful, particularly to the degree that the past continues to influence present-day emotional or behavioral difficulties.

I value the cognitive behavioral focus on how our thinking affects the way we feel and behave. These therapies also emphasize current behavior. Thinking and feeling are important dimensions, but it can be a mistake to overemphasize them and not explore how clients are behaving. What people are doing often provides a good clue to what they really want. I also like the emphasis on specific goals and on encouraging clients to formulate concrete aims for their own therapy sessions and in life.

More approaches have been developing methods that involve collaboration between therapist and client, making the therapeutic venture a shared responsibility. This collaborative relationship, coupled with teaching clients ways to use what they learn in therapy in their everyday lives, empowers clients to take an active stance in their world. It is imperative that clients be active, not only in their counseling sessions but in daily life as well. Homework, collaboratively designed by clients and therapists, can be a vehicle for assisting clients in putting into action what they are learning in therapy.

A related assumption of mine is that we can exercise increasing freedom to cre- ate our own future. Accepting personal responsibility does not imply that we can be anything we want to be. Social, environmental, cultural, and biological realities oftentimes limit our freedom of choice. Being able to choose must be considered in the sociopolitical contexts that exert pressure or create constraints; oppression is a reality that can restrict our ability to choose our future. We are also influenced by our social environment, and much of our behavior is a product of learning and conditioning. That being said, I believe an increased awareness of these contextual forces enables us to address these realities. It is crucial to learn how to cope with the external and internal forces that influence our decisions and behavior.

Feminist therapy has contributed an awareness of how environmental and social conditions contribute to the problems of women and men and how gender-role

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Refer to the MindTap for this book to interact with video quizzes and various video programs to expand your knowledge on topics relevant to Chapter 1.

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4 Chapter One

socialization leads to a lack of gender equality. Family therapy teaches us that it is not possible to understand the individual apart from the context of the family system. Both family therapy and feminist therapy are based on the premise that to understand the individual it is essential to take into consideration the interpersonal dimensions and the sociocultural context rather than focusing primarily on the intrapsychic domain. This comprehensive approach to counseling goes beyond understanding our internal dynamics and addresses the environmental and systemic realities that surround us.

My philosophy of counseling challenges the assumption that therapy is exclu- sively aimed at “curing” psychological “ailments.” Such a focus on the medical model restricts therapeutic practice because it stresses deficits rather than strengths. Instead, I agree with the postmodern approaches (see Chapter 13), which are grounded on the assumption that people have both internal and external resources to draw upon when constructing solutions to their problems. Therapists will view these individuals quite differently if they acknowledge that their clients possess competencies rather than pathologies. I view each individual as having resources and competencies that can be discovered and built upon in therapy.

Psychotherapy is a process of engagement between two people, both of whom are bound to change through the therapeutic venture. At its best, this is a collabora- tive process that involves both the therapist and the client in co-constructing solu- tions regarding life’s tasks. Most of the theories described in this book emphasize the collaborative nature of the practice of psychotherapy.

Therapists are not in business to change clients, to give them quick advice, or to solve their problems for them. Instead, counselors facilitate healing through a pro- cess of genuine dialogue with their clients. The kind of person a therapist is remains the most critical factor affecting the client and promoting change. If practitioners possess wide knowledge, both theoretical and practical, yet lack human qualities of compassion, caring, good faith, honesty, presence, realness, and sensitivity, they are more like technicians. I believe that those who function exclusively as technicians do not make a significant difference in the lives of their clients. It is essential that coun- selors explore their own values, attitudes, and beliefs in depth and work to increase their own awareness. Throughout the book I encourage you to find ways to apply what you are reading to your personal life. Doing so will take you beyond a mere academic understanding of these theories.

With respect to mastering the techniques of counseling and applying them appropriately and effectively, it is my belief that you are your own best technique. Your engagement with clients is useful in moving the therapeutic process along. It is impossible to separate the techniques you use from your personality and the rela- tionship you have with your clients.

Administering techniques to clients without regard for the relationship vari- ables is ineffective. Techniques cannot substitute for the hard work it takes to develop a constructive client–therapist relationship. Although you can learn atti- tudes and skills and acquire certain knowledge about personality dynamics and the therapeutic process, much of effective therapy is the product of artistry. Counseling entails far more than becoming a skilled technician. It implies that you are able to establish and maintain a good working relationship with your clients, that you can draw on your own experiences and reactions, and that you can identify techniques suited to the needs of your clients.

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Introduct ion and Over v iew 5

As a counselor, you need to remain open to your own personal development and to address any significant personal problems. The most powerful ways for you to teach your clients is by the behavior you model and by the ways you connect with them. I suggest that you experience a wide variety of techniques yourself as a client. Reading about a technique in a book is one thing; actually experiencing it from the vantage point of a client is quite another. If you have practiced mindfulness exer- cises, for example, you will have a much better foundation for guiding clients in the practice of becoming increasingly mindful in daily life. If you have carried out real- life homework assignments as part of your own self-change program, you will have increased empathy for clients and their potential problems. Your own anxiety over self-disclosing and addressing personal concerns can be a most useful anchoring point as you work with the anxieties of your clients. The courage you display in your personal therapy will help you appreciate how essential courage is for your clients.

Your personal characteristics are of primary importance in becoming a coun- selor, but it is not sufficient to be merely a good person with good intentions. To be effective, you also must have supervised experiences in counseling and sound knowledge of counseling theory and techniques. Furthermore, it is essential to be well grounded in the various theories of personality and to learn how they are related to theories of counseling. Your conception of the person and the individual character- istics of your client affect the interventions you will make. Differences between you and your client may require modification of certain aspects of the theories. Some practitioners make the mistake of relying on one type of intervention (supportive, confrontational, information giving) for most clients with whom they work. In real- ity, different clients may respond better to one type of intervention than to another. Even during the course of an individual’s therapy, different interventions may be needed at various times. Practitioners should acquire a broad base of counseling techniques that are suitable for individual clients rather than forcing clients to fit into a single approach to counseling.

Suggestions for Using the Book Here are some specific recommendations on how to get the fullest value from this book. The personal tone of the book invites you to relate what you are reading to your own experiences. As you read Chapter 2, “The Counselor: Person and Profes- sional,” begin the process of reflecting on your needs, motivations, values, and life experiences. Consider how you are likely to bring the person you are becoming into your professional work. You will assimilate much more knowledge about the vari- ous therapies if you make a conscious attempt to apply the key concepts and tech- niques of these theories to your own life. Chapter 2 helps you think about how to use yourself as your single most important therapeutic instrument, and it addresses a number of significant ethical issues in counseling practice.

Before you study each of the theory chapters, I suggest that you at least briefly read Chapter 15, which provides a comprehensive review of the key concepts from all 11 theories presented in this textbook. I try to show how an integration of these perspectives can form the basis for creating your own personal synthesis for coun- seling. In developing an integrative perspective, it is essential to think holistically. To understand human functioning, it is imperative to account for the physical,

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6 Chapter One

emotional, mental, social, cultural, political, and spiritual dimensions. If any one of these facets of human experience is neglected, a theory is limited in explaining how we think, feel, and act.

To provide you with a consistent framework for comparing and contrasting the various therapies, the 11 theory chapters share a common format. This format includes a few notes on the personal history of the founder or another key figure; a brief historical sketch showing how and why each theory developed at the time it did; a discussion of the approach’s key concepts; an overview of the therapeutic pro- cess, including the therapist’s role and the client’s work; therapeutic techniques and procedures; applications of the theory from a multicultural perspective; application of the theory to the cases of Stan and Gwen; a summary and evaluation that focuses on the contributions and limitations of the theory; self-reflection and discussion questions; suggestions of how to continue your learning about each approach; and recommendations for further reading.

The Preface includes a complete description of other resources that fit as a pack- age and complement this textbook. In the MindTap Video Quizzes related to The Case of Stan, I demonstrate my way of counseling Stan from the various theoretical approaches in 13 sessions and present my perspective on the key concepts of each theory in a brief lecture, with emphasis on the practical application of the theory. A more recent video, The Case of Gwen, shows nine therapists working with Gwen using their own approaches.

Overview of the Theory Chapters I have selected 11 therapeutic approaches for this book. Table 1.1 presents an over- view of these approaches, which are explored in depth in Chapters 4 through 14. I have grouped these approaches into four general categories.

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Table 1.1 Overview of Contemporary Counseling Models

Psychodynamic Approaches

Psychoanalytic therapy Founder: Sigmund Freud. A theory of personality development, a philosophy of human nature, and a method of psychotherapy that focuses on unconscious factors that motivate behavior. Attention is given to the events of the first six years of life as determinants of the later development of personality.

Adlerian therapy Founder: Alfred Adler. Key Figure: Rudolf Dreikurs. Following Adler, Dreikurs is credited with popularizing this approach in the United States. This is a growth model that stresses assuming responsibility, creating one’s own destiny, and finding meaning and goals to create a purposeful life. Key concepts are used in most other current therapies.

Experiential and Relationship-Oriented Therapies

Existential therapy Key Figures: Viktor Frankl, Rollo May, and Irvin Yalom. Reacting against the tendency to view therapy as a system of well-defined techniques, this model stresses building therapy on the basic conditions of human existence, such as choice, the freedom and responsibility to shape one’s life, and self-determination. It focuses on the quality of the person-to-person therapeutic relationship.

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Introduct ion and Over v iew 7

Person-centered therapy Founder: Carl Rogers. Key Figure: Natalie Rogers. This approach was developed during the 1940s as a nondirective reaction against psychoanalysis. Based on a subjective view of human experiencing, it places faith in and gives responsibility to the client in dealing with problems and concerns.

Gestalt therapy Founders: Fritz and Laura Perls. Key Figures: Miriam and Erving Polster. An experiential therapy stressing awareness and integration; it grew as a reaction against analytic therapy. It integrates the functioning of body and mind and places emphasis on the therapeutic relationship.

Cognitive Behavioral Approaches

Behavior therapy Key figures: B. F. Skinner, Albert Bandura, and Marsha Linehan. This approach applies the principles of learning to the resolution of specific behavioral problems. Results are subject to continual experimentation. The methods of this approach are always in the process of refinement. The mindfulness and acceptance-based approaches are rapidly gaining popularity.

Cognitive behavior therapy Founders: Albert Ellis and A. T. Beck. Ellis founded rational emotive behavior therapy, a highly didactic, cognitive, action-oriented model of therapy. Beck founded cognitive therapy, which gives a primary role to thinking as it influences behavior. Judith Beck continues to develop cognitive behavior therapy (CBT); Christine Padesky has developed strengths-based CBT. Donald Meichenbaum, who helped develop cognitive behavior therapy, has made significant contributions to resilience as a factor in coping with trauma.

Choice theory/Reality therapy Founder: William Glasser. Key Figure: Robert Wubbolding. This short-term approach is based on choice theory and focuses on the client assuming responsibility in the present. Through the therapeutic process, clients are able to learn more effective ways of meeting their needs.

Systems and Postmodern Approaches

Feminist therapy This approach grew out of the efforts of many women, a few of whom are Jean Baker Miller, Carolyn Zerbe Enns, Lillian Comas-Diaz, Thelma Bryant-Davis, and Laura Brown. A central concept is the concern for the psychological oppression of women. Focusing on the constraints imposed by the sociopolitical status to which women have been relegated, this approach explores women’s identity development, self-concept, goals and aspirations, and emotional well-being.

Postmodern approaches A number of key figures are associated with the development of these various approaches to therapy. Steve de Shazer and Insoo Kim Berg are the cofounders of solution-focused brief therapy. Michael White and David Epston are the major figures associated with narrative therapy. Social constructionism, solution-focused brief therapy, narrative therapy, and motivational interviewing all assume that there is no single truth; rather, it is believed that reality is socially constructed through human interaction. These approaches maintain that clients are the experts in their own life.

Family systems therapy A number of significant figures have been pioneers of the family systems approach, two of whom are Murray Bowen and Virginia Satir. This systemic approach is based on the assumption that the key to changing the individual is understanding and working with the family.

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8 Chapter One

First are the psychodynamic approaches. Psychoanalytic therapy is based largely on insight, unconscious motivation, and reconstruction of the personality. The psycho- analytic model appears first because it has had a major influence on all of the formal systems of psychotherapy. Some of the therapeutic models are extensions of psycho- analysis, others are modifications of analytic concepts and procedures, and still others emerged as a reaction against psychoanalysis. Many theories of psychotherapy have borrowed and integrated principles and techniques from psychoanalytic approaches.

Adlerian therapy differs from psychoanalytic theory in many respects, but it can broadly be considered an analytic perspective. Adlerians focus on meaning, goals, purposeful behavior, conscious action, belonging, and social interest. Although Adlerian theory accounts for present behavior by studying childhood experiences, it does not focus on unconscious dynamics.

The second category comprises the experiential and relationship-oriented therapies: the existential approach, the person-centered approach, and Gestalt therapy. The existential approach stresses a concern for what it means to be fully human. It suggests certain themes that are part of the human condition, such as freedom and respon- sibility, anxiety, guilt, awareness of being finite, creating meaning in the world, and shaping one’s future by making active choices. This approach is not a unified school of therapy with a clear theory and a systematic set of techniques. Rather, it is a philos- ophy of counseling that stresses the divergent methods of understanding the subjec- tive world of the person. The person-centered approach, which is rooted in a humanistic philosophy, places emphasis on the basic attitudes of the therapist. It maintains that the quality of the client–therapist relationship is the prime determinant of the outcomes of the therapeutic process. Philosophically, this approach assumes that clients have the capacity for self-direction without active intervention and direction on the therapist’s part. Another experiential approach is Gestalt therapy, which offers a range of experiments to help clients gain awareness of what they are experiencing in the here and now—that is, the present. In contrast to person-centered therapists, Gestalt therapists tend to take an active role as they follow the leads provided by their clients. These approaches tend to emphasize emotion as a route to bringing about change, and in a sense, they can be considered emotion-focused therapies.

Third are the cognitive behavioral approaches, sometimes known as the action- oriented therapies because they all emphasize translating insights into behavioral action. These approaches include choice theory/reality therapy, behavior therapy, rational emotive behavior therapy, and cognitive therapy. Reality therapy focuses on clients’ current behavior and stresses developing clear plans for new behaviors. Like reality therapy, behavior therapy puts a premium on doing and on taking steps to make concrete changes. A current trend in behavior therapy is toward paying increased attention to cognitive factors as an important determinant of behavior. Rational emo- tive behavior therapy and cognitive therapy highlight the necessity of learning how to challenge inaccurate beliefs and automatic thoughts that lead to behavioral prob- lems. These cognitive behavioral approaches are used to help people modify their inaccurate and self-defeating assumptions and to develop new patterns of acting.

The fourth general approach encompasses the systems and postmodern perspec- tives. Feminist therapy and family therapy are systems approaches, but they also share postmodern notions. The systems orientation stresses the importance of understanding individuals in the context of the surroundings that influence their

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Introduct ion and Over v iew 9

development. To bring about individual change, it is essential to pay attention to how the individual’s personality has been affected by gender-role socialization, cul- ture, family, and other systems.

The postmodern approaches include social constructionism, solution-focused brief therapy, narrative therapy, and motivational interviewing. These newer approaches challenge the basic assumptions of traditional approaches by assuming that there is no single truth and that reality is socially constructed through human interaction. Both postmodern and systemic theories focus on how people produce their own lives in the context of systems, interactions, social conditioning, and discourse.

In my view, practitioners need to pay attention to what their clients are thinking, feeling, and doing, and a complete therapy system must address all three of these fac- ets. Some of the therapies included here highlight the role that cognitive factors play in counseling. Others place emphasis on the experiential aspects of counseling and the role of feelings. Still others emphasize putting plans into action and learning by doing. Combining all of these dimensions provides the basis for a comprehensive therapy framework.

Introduction to the Case of Stan You will learn a great deal by seeing a theory in action, preferably in a live demonstra- tion or as part of experiential activities in which you function in the alternating roles of client and counselor. An online program demonstrates one or two techniques from each of the theories. As Stan’s counselor, I show how I would apply some of the principles of each of the theories you are studying to Stan. Many of my students find this case history of the hypothetical client (Stan) helpful in understanding how vari- ous techniques are applied to the same person. Stan’s case, which describes his life and struggles, is presented here to give you significant background material to draw from as you study the applications of the theories. Each of the 11 theory chapters in Part 2 includes a discussion of how a therapist with the orientation under discussion is likely to proceed with Stan. We examine the answers to questions such as follows:

◆ What themes in Stan’s life merit special attention in therapy? ◆ What concepts would be useful to you in working with Stan on his

problems? ◆ What are the general goals of Stan’s therapy? ◆ What possible techniques and methods would best meet these goals? ◆ What are some characteristics of the relationship between Stan and his

therapist? ◆ How might the therapist proceed? ◆ How might the therapist evaluate the process and treatment outcomes

of therapy?

In Chapter 15, (which I recommend you read early) I explain how I would work with Stan, suggesting concepts and techniques I would draw on from many of the theo- ries (forming an integrative approach).

A single case illustrates both contrasts and parallels among the approaches. It also will help you understand the practical applications of the 11 theories and pro- vide a basis for integrating them. A summary of the intake interview with Stan and

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10 Chapter One

some key themes in his life are presented next to provide a context for making sense of the way therapists with various theoretical orientations might work with Stan. Try to find attributes of each approach that you can incorporate into a personalized style of counseling.

Intake Interview With Stan The setting is a community mental health agency where both individual and group counseling are available. Stan comes to counseling because of his drinking. He was convicted of driving under the influence, and the judge determined that he needed professional help. Stan recognizes that he does have problems, but he is not con- vinced that he is addicted to alcohol. Stan arrives for an intake interview and pro- vides the counselor with this information:

At the present time I work in construction. I like building houses but probably won’t stay in construction for the rest of my life. When it comes to my personal life, I’ve always had difficulty getting along with people. I could be called a “loner.” I like people in my life, but I don’t seem to know how to stay close to people. It probably has a lot to do with why I drink. I’m not very good at making friends or getting close to people. Probably the reason I sometimes drink a bit too much is because I’m so scared when it comes to socializing. Even though I hate to admit it, when I drink, things are not quite so overwhelming. When I look at others, they seem to know the right things to say. Next to them I feel dumb. I’m afraid that people don’t find me very interesting. I’d like to turn my life around, but I just don’t know where to begin. That’s why I went back to school. I’m a part-time col- lege student majoring in psychology. I want to better myself. In one of my classes, Psychology of Personal Adjustment, we talked about ourselves and how people change. We also had to write an autobiographical paper.

That is the essence of Stan’s introduction. The counselor says that she would like to read his autobiography. Stan hopes it will give her a better understanding of where he has been and where he would like to go. He brings her the autobiography, which reads as follows:

Where am I currently in my life? At 35 I feel that I’ve wasted most of my life. I should be finished with college and into a career by now, but instead I’m only a junior. I can’t afford to really commit myself to pursuing college full time because I need to work to support myself. Even though construction work is hard, I like the satisfaction I get when I look at what I have done.

I want to get into a profession where I could work with people. Someday, I’m hoping to get a master’s degree in counseling or in social work and eventually work as a counselor with kids who are in trouble. I know I was helped by someone who cared about me, and I would like to do the same for someone else.

I have few friends and feel scared around most people. I feel good with kids. But I wonder if I’m smart enough to get through all the classes I’ll need to become a counselor. One of my problems is that I frequently get drunk. This happens when I feel alone and when I’m scared of the intensity of my feelings. At first drinking seemed to help, but later on I felt awful. I have abused drugs in the past also.

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Introduct ion and Over v iew 11

I feel overwhelmed and intimidated when I’m around attractive women. I feel cold, sweaty, and terribly nervous. I think they may be judging me and see me as not much of a man. I’m afraid I just don’t measure up to being a real man. When I am sexually intimate with a woman, I am anxious and preoccupied with what she is thinking about me.

I feel anxiety much of the time. I often feel as if I’m dying inside. I think about committing suicide, and I wonder who would care. I can see my family coming to my funeral and feeling sorry for me. I feel guilty that I haven’t worked up to my potential, that I’ve been a failure, that I’ve wasted much of my time, and that I let people down a lot. I get down on myself and wallow in guilt and feel very depressed. At times like this I feel hopeless and think I’d be better off dead. For all of these reasons, I find it difficult to get close to anyone.

There are a few bright spots. I did put a lot of my shady past behind me, and I did get into college. I like this determination in me—I want to change. I’m tired of feeling the way I do. I know that nobody is going to change my life for me. It’s up to me to get what I want. Even though I feel scared at times, I like that I’m willing to take risks.

What was my past like? A major turning point for me was the confidence my supervisor had in me at the youth camp where I worked the past few summers. He helped me get my job, and he also encouraged me to go to college. He said he saw a lot of potential in me for being able to work well with young people. That was hard for me to believe, but his faith inspired me to begin to believe in myself. Another turning point was my marriage and divorce. This marriage didn’t last long. It made me wonder about what kind of man I was! Joyce was a strong and dominant woman who kept repeating how worthless I was and how she did not want to be around me. We had sex only a few times, and most of the time I was not very good at it. That was hard to take. It made me afraid to get close to a woman. My parents should have divorced. They fought most of the time. My mother (Angie) constantly criticized my father (Frank Sr.). I saw him as weak and passive. He would never stand up to her. There were four of us kids. My parents compared me unfavorably with my older sister (Judy) and older brother (Frank Jr.). They were “perfect” children, successful honors’ students. My younger brother (Karl) and I fought a lot. They spoiled him. It was all very hard for me.

In high school I started using drugs. I was thrown into a youth rehabilitation facility for stealing. Later I was expelled from regular school for fighting, and I landed in a continuation high school. I went to school in the mornings and had afternoons for on-the-job training. I got into auto mechanics, was fairly success- ful, and even managed to keep myself employed for three years as a mechanic.

I can still remember my father asking me: “Why can’t you be like your sister and brother? Why can’t you do anything right?” And my mother treated me much the way she treated my father. She would say: “Why do you do so many things to hurt me? Why can’t you grow up and be a man? Things are so much better around here when you’re gone.” I recall crying myself to sleep many nights, feeling terribly alone. There was no talk of religion in my house, nor was there any talk of sex. In fact, I find it hard to imagine my folks ever having sex.

Where would I like to be five years from now? What kind of person do I want to become? Most of all, I would like to start feeling better about myself. I would like to be able to stop drinking altogether and still feel good. I want to like myself

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12 Chapter One

much more than I do now. I hope I can learn to love at least a few other people, most of all, a woman. I want to lose my fear of women. I would like to feel equal with others and not always have to feel apologetic for my existence. I want to let go of my anxiety and guilt. I want to become a good counselor for kids. I’m not certain how I’ll change or even what all the changes are that I hope to make. I do know that I want to be free of my self-destructive tendencies and learn how to trust people more. Perhaps when I begin to like myself more, I’ll be able to trust that others will find something about me to like.

Effective therapists, regardless of their theoretical orientation, would pay atten- tion to suicidal thoughts. In his autobiography Stan says, “I think about commit- ting suicide.” At times he doubts that he will ever change and wonders if he’d be “better off dead.” Before embarking on the therapeutic journey, the therapist would need to make an assessment of Stan’s current ego strength (his ability to manage life realistically), which would include a discussion of his suicidal thoughts.

Overview of Some Key Themes in Stan’s Life A number of themes appear to represent core struggles in Stan’s life. Here are some of the statements we can assume that he may make at various points in his therapy and themes that will be addressed from the theoretical perspectives in Chapters 4 through 15:

◆ Although I’d like to have people in my life, I just don’t seem to know how to go about making friends or getting close to people.

◆ I’d like to turn my life around, but I have no sense of direction. ◆ I want to make a difference. ◆ I am afraid of failure. ◆ I know when I feel alone, scared, and overwhelmed, I drink heavily to

feel better. ◆ I am afraid of women. ◆ Sometimes at night I feel a terrible anxiety and feel as if I’m dying. ◆ I often feel guilty that I’ve wasted my life, that I’ve failed, and that I’ve

let people down. At times like this, I get depressed. ◆ I like it that I have determination and that I really want to change. ◆ I’ve never really felt loved or wanted by my parents. ◆ I’d like to get rid of my self-destructive tendencies and learn to trust

people more. ◆ I put myself down a lot, but I’d like to feel better about myself.

In the chapters in Part 2, I write about how I would apply selected concepts and techniques of the particular theory in counseling Stan. In addition, in these chapters you are asked to think about how you would continue counseling Stan from each of these different perspectives. In doing so, refer to the introductory material given here. To make the case of Stan come alive for each theory, I highly recommend that you interact with The Case of Stan sessions in this book’s MindTap through the Case of Stan Video Quizzes. In this video program, I counsel Stan from each of the various theories and provide brief lectures that highlight each theory.

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Introduct ion and Over v iew 13

Background on the Case of Gwen Gwen is a 56-year-old, married, African American woman presenting with fibromy- algia, difficulty sleeping, and a history of anxiety and depression. She reports feeling stress and isolation on her job and is having a difficult time managing her multiple roles. Gwen is the oldest of five children, and after her parents’ divorce, she took on the responsibility of caring for her younger siblings. Gwen has been married to Ron for 31 years and states they have ups and downs but basically their relationship is supportive. Ron is employed as a high school teacher and has always made the fam- ily a priority. They have three adult children: Brittany age 29, Lisa age 26, and Kevin age 23. Gwen has a master’s degree in accounting and is employed at a large firm as a CPA. She reports being the only woman of color at her job. Because she is the only one speaking up for issues of diversity and racial equality at her workplace, she often feels isolated and tired. She does not have enough time to spend with friends or to do the things she once enjoyed because of her long work hours. Gwen also helps her adult children with their bills when needed and is the primary caretaker of her mother, who resides with her and is in the advanced stages of dementia.

This is Gwen’s first time in formal counseling. She reports having gone to her pastor when she was feeling “down” in the past. Gwen also reports times of being sexually molested by an older cousin. She seeks counseling because she is having dif- ficulty staying focused at work and is generally feeling sad and overwhelmed. Gwen also reports experiencing a great deal of anxiety. She states she is not suicidal but is “sick and tired of feeling sick and tired.” Gwen summarizes her current situation by saying, “I realized the other day that I am tired of just existing and surviving. So here I am.” Gwen was referred to Dr. Kirksey by the pastor of her church. Despite the many challenges in her life, Gwen says that her faith in God is strong and church has always been her place of refuge.

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I invited Dr. Kellie Kirksey to create a case (“Gwen”) based on a composite of her clients over her many years of prac- tice. Gwen’s concerns are dis- cussed as they relate to the theory featured in each chap- ter, and Dr. Kirksey demon- strates how she would work with Gwen using techniques that illustrate key concepts from the theory.

Kellie N. Kirksey, PhD, received her doctorate in Counselor Education and Psychology at The Ohio State University. She is a licensed clinical counselor, a certi- fied rehabilitation counselor, and an approved clinical supervisor. She has practiced and taught in the coun- seling field for more than 25 years and has focused her work in the area of multicultural counseling, social jus- tice, integrative counseling, and wellness.

Dr. Kirksey enjoys exploring how wellness is achieved in other cultures and has given numerous workshops and presentations on wellness and self-care in North America, South Africa, Botswana, Hawaii, and Italy.

Kellie N. Kirksey

Ke lli

e Ki

rk se

Introduction to the Case of Gwen Meet Dr. Kellie Kirksey

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14 Chapter One

Intake Session Gwen begins by saying she is ready to unload the stressors she has been holding inside. She states that she has held everything together for everyone far too long. During this initial session, I also address the relevant aspects of informed consent and begin an ongoing process of educating Gwen on how the therapeutic process works.

Gwen says she feels a heaviness in her heart, which is associated with all that is expected of her at work and with her family, what she has not accomplished, and where she is heading. I acknowledge this heaviness and ask her to start wherever she wants. Gwen states that she has not felt carefree since she was a young child before her parents’ divorce. Her parents moved to the North from Georgia for work when she was eight years old. Both of her parents were teachers and valued education. Her neighborhood and school were predominantly African American, and the commu- nity was close. In high school she was bussed across town to a predominately White school, and Gwen states she began to encounter what she felt were racist attitudes at this school.

I felt different and excluded, and this was reinforced by occasional name calling and subtle slights. That was one of the first times I remember feeling like I had to work twice as hard to get ahead and to be accepted in life. Throughout college I worked hard to be successful by pushing myself to achieve what people said I couldn’t, but it seems that all my hard work has just worn me down.

A number of life concerns bring Gwen into counseling. A few of her concerns relate to her work. She experiences mounting tension on the job, and when she asserts her opinions, she is labeled as emotional and angry. The more tension she experiences at work, the less she engages at home. An additional concern is that her mother is slowly fading into another world due to dementia. Gwen states that she is feeling terrible about herself and does not even want to be around people anymore. Everything irritates her and she prefers to spend time by herself. Gwen reports the following:

I feel like a shell of a person. I am not depressed where I am wanting to kill myself. I just feel numb. There is no real point to doing this daily routine of waking, suf- fering through the day, and going to bed just to get up and do it all over again. My life is like a flat note with little joy. I don’t go out; I don’t have sex; and I am too tired to do anything. Nothing I do is good enough. I start projects, and then it’s like they disappear. Nothing ever gets finished, and then I feel worse about myself. Sometimes I feel like I want to go into a cave and never come out. I feel like I will lose everything if I don’t make some changes in my life. Everything looks good on the outside, but inside of me, I am on edge and need to do something different. My pastor and mentor tell me I am sabotaging myself. Usually, I get defensive and withdrawn, but this time I want to get better, and I am ready to do what it takes. I am done with feeling tired all the time and hiding from people. My goal is to live a more balanced life and to learn how to reduce my stress level.

The first step of our journey is to build a working alliance based on mutual respect. I let Gwen know that this is her time to use as she pleases, and that it is a safe and confidential space.

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Introduct ion and Over v iew 15

Video on Counseling Sessions with Gwen Overview of Video MindTap Program for The Case of Gwen

A feature of this edition of the book is video sessions that illustrate counseling Gwen for all of the chapters. These videos bring the case of Gwen to life, and Gwen is now included in each theory chapter. Kellie Kirksey is featured in each chapter of the book as Gwen’s therapist. In this video, Kirksey reverses roles and “becomes the cli- ent Gwen” for all 15 sessions as nine therapists show how they would counsel Gwen from various theoretical perspectives. These therapists are diverse in age, race, cul- ture, ethnicity, professional identity and experience, and gender. They demonstrate selected techniques, and each therapist focuses on a particular aspect of the case presented in the book. Each of these sessions is about 20 minutes in length. The highlights from these sessions are presented next for each of the theory chapters.

Chapter 1 Intake Session Lupe-Alle Corliss, MSW, LCSW, conducts an intake interview with Gwen. The ses- sion focuses on major stressors in Gwen’s life, selected aspects of her history, her presenting problems, and establishing a working alliance. This session provides the foundation for all of the therapy sessions with Gwen.

Chapter 2 Multicultural Perspectives Galo Arboleda, MSW, LCSW, invites Gwen to share what it is like for her to meet with a Latino social worker. The theme of this session includes cultural aspects and how Gwen’s cultural values and background, and her life experiences, are basic to understanding her present life situation.

Chapter 3 Informed Consent Session Casey Huynh, MFT, MA in Counseling, demonstrates selected aspects of the informed consent process. The therapist asks Gwen to talk about their differ- ences in culture and race: Gwen is African American and the therapist is Chinese, Vietnamese. They explore how their differences might affect their work together. Gwen asks the therapist about confidentiality.

Chapter 4 Psychoanalytic (Psychodynamic) Therapy Damian Fowler, MA in Counseling, demonstrates how Gwen’s early history has a present-day influence on her problems and concerns. The therapist explains the concept of transference, and they discuss the potential for a transference reaction on Gwen’s part because the therapist reminds Gwen of her son.

Chapter 5 Adlerian Therapy Kristi Kanel, PhD, MFT, conducts an Adlerian lifestyle assessment about Gwen’s family constellation, her early recollections, her siblings, and some basic mistakes that Gwen feels are influencing her today.

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16 Chapter One

Chapter 6 Existential Therapy Naomi Tapia, graduate student in a counseling program, deals with existential themes of anxiety and death awareness. They explore some of Gwen’s personal sto- ries of racism and injustice and her search for meaning. The therapist is a student interning in counseling, and she invites Gwen to share her reactions to working with a student intern.

Chapter 7 Person-Centered Therapy Melissa Rivera-Flores, graduate student and an intern in a social work program, begins by informing Gwen of her position of being a student. This session demon- strates how therapist empathy and compassion enable Gwen to explore her feeling of being overwhelmed more deeply. This session emphasizes how therapy is a col- laborative journey driven by what the client brings to the session.

Chapter 8 Gestalt Therapy Leah Brew, PhD, LPCC, CCMHC, NCC, focuses on the mind–body connection. Gwen brings unfinished business into the here and now, especially her relationship with her husband. The theme of staying with her body in the present moment is illustrated as a foundational principle.

Chapter 9 Behavior Therapy Kristi Kanel, PhD, MFT, gives Gwen instructions in relaxation training, which she can use to cope with anxiety and her feeling of being overwhelmed. Part of Gwen’s therapy involves social skills training, and she learns interpersonal skills and how to communicate effectively.

Chapter 10 Cognitive Behavior Therapy Randy Alle-Corliss, MSW, LCSW, uses rational emotive behavior therapy tech- niques to help Gwen identify and challenge negative self-talk and faulty thinking. The therapist teaches Gwen the ABC framework to change how her thoughts influ- ence her emotions and behaviors. The therapist demonstrates role reversal and cogni- tive disputation. The session shows how homework can be collaboratively designed.

Chapter 11 Choice Theory/Reality Therapy Galo Arboleda, MSW, LCSW, assists Gwen in creating an action plan designed to help her achieve her personal goals. She has already begun taking a yoga class and is seeing results. The therapist helps Gwen identify additional key changes she most wants to make in her life. The specific steps in creating an action plan are demonstrated.

Chapter 12 Feminist Therapy/Social Justice Leah Brew, PhD, LPCC, CCMHC, NCC, is most concerned about validating Gwen’s experiences with discrimination and oppression. Gwen says that as a woman of color she often experiences being unheard. The therapist explores with Gwen what she

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Introduct ion and Over v iew 17

learned growing up about the value of her voice. This session looks at how issues of gender and race are central to understanding Gwen’s current struggles. The thera- pist encourages Gwen to take steps toward social action to change her life situation.

Chapter 13 Postmodern Approaches: Solution-Focused Brief Therapy Damian Fowler, MA in Counseling, applies several solution-focused brief therapy (SFBT) techniques to identify Gwen’s resources. Using an SFBT scaling technique, the therapist asks Gwen to rate the pressure she feels on a scale of to 10. The thera- pist asks her to think about some time when the stress was not overwhelming and what she was doing to better manage her stress (exception questions).

Chapter 14 Family Systems Therapy Lupe-Alle Corliss, MSW, LCSW, explores with Gwen what it was like for her in her family of origin. In a previous session, the therapist encouraged Gwen to create a family genogram that depicted three generations. She is asked to talk about her family genogram. After talking about her family of origin briefly, she is asked about any parallels with her present family. She identifies some of the changes she would like in her family, and she asks about inviting her husband to join her for a couples session.

Chapter 15 Integrative Approaches Randy Alle-Corliss, MSW, LCSW, introduces Gwen to multiple tools to heal on the levels of mind, body, and spirit. The session shows how an integrative perspective focuses on the interaction among the cognitive, emotive, and behavioral domains. The therapist inquires how Gwen feels about working with an older White man.

Session 16 is an interview conducted by Gerald Corey who asks Dr. Kirksey to talk about what it was like for her to assume the role of the client Gwen with the different therapists and different modalities. Gwen steps out of her role as a client and shares some of who she is as Kellie Kirksey, PhD, LPCC-S, CRC, holistic psychotherapist. She shares how it was for her to become Gwen’s therapist in the book and how it felt for her to reverse roles and become the client in the video.

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2 The Counselor: Person and Professional

1. Identify the characteristics of the counselor as a therapeutic person.

2. Describe the benefits of seeking personal counseling as a counselor.

3. Explain the concept of bracketing and what is involved in managing a counselor’s personal values.

4. Explain how values relate to identifying goals in counseling.

5. Discuss the role of diversity issues in the therapeutic relationship.

6. Describe what is involved in acquiring competency as a multicultural counselor.

7. Identify issues faced by beginning therapists.

8. Describe the main therapeutic lifestyle changes that are key to self-care.

Learning Objectives

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The Counselor : Per son and Profess ional 19

Introduction One of the most important instruments you have to work with as a counselor is yourself as a person. In preparing for counseling, you will acquire knowledge about the theories of personality and psychotherapy, learn assessment and intervention techniques, and discover the dynamics of human behavior. Such knowledge and skills are essential, but by themselves they are not sufficient for establishing and maintaining effective therapeutic relationships. To every therapy session we bring our human qualities and the experiences that have influenced us. In my judgment, this human dimension is one of the most powerful influences on the therapeutic process. Ample research supports the conclusion that psychotherapy is an irreduc- ibly human encounter (Norcross & Lambert, 2019c).

A good way to begin your study of contemporary counseling theories is by reflecting on the personal issues raised in this chapter. By remaining open to self- evaluation, you not only expand your awareness of self but also build the foundation for developing your abilities and skills as a professional. The theme of this chapter is that the person and the professional are intertwined facets that cannot be separated in reality. We know, clinically and scientifically, that the person of the therapist and the therapeutic relationship contribute to therapy outcome at least as much as the particular treatment method used (Duncan et al., 2010; Elkins, 2016; Norcross & Lambert, 2019a, 2019c; Norcross & Wampold, 2019).

Refer to the MindTap for this book to interact with video quizzes and various video programs to expand your knowledge on topics relevant to Chapter 2.

The Counselor as a Therapeutic Person Counseling is an intimate form of learning, and it demands a practitioner who is willing to be an authentic person in the therapeutic relationship. It is within the context of the person-to-person connection that the client experiences growth. If we hide behind the safety of our professional role, our clients are likely to keep them- selves hidden from us. If we strive for technical expertise alone, and leave our own reactions and self out of our work, we are likely to be ineffective counselors. Our own genuineness can have a significant effect on our relationship with our clients. If we are willing to look at our lives and make the changes we want, we can model that process by the way we reveal ourselves and respond to our clients. If we are inauthentic, we will have difficulty establishing a working alliance with our clients. If we model authenticity by engaging in appropriate self-disclosure, our clients will tend to be honest with us as well.

I believe that who the counselor is directly relates to establishing and maintain- ing effective therapy relationships with clients. But what does the research reveal about the role of the counselor as a person and the therapeutic relationship on psy- chotherapy outcome? Abundant research indicates the centrality of the person of

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the therapist as a primary factor in successful therapy. The person of the psycho- therapist is inextricably intertwined with the outcome of psychotherapy (see Elkins, 2016). Clients place more value on the personality and character of the therapist than on the specific techniques used. Indeed, evidence-based psychotherapy rela- tionships are critical to the psychotherapy endeavor (Norcross & Lambert, 2019a; Norcross & Wampold, 2019).

Techniques themselves have limited importance in the therapeutic process. Wampold (2001) conducted a meta-analysis of many research studies on therapeu- tic effectiveness and found that the personal and interpersonal components are essential to effective psychotherapy, whereas techniques have relatively little effect on therapeutic outcome. The contextual factors—the alliance, the relationship, the per- sonal and interpersonal skills of the therapist, client agency, and extra-therapeutic factors—are the primary determinants of therapeutic outcome. This research sup- ports what humanistic psychologists have maintained for years: “It is not theories and techniques that heal the suffering client but the human dimension of therapy and the ‘meetings’ that occur between therapist and client as they work together” (Elkins, 2009, p. 82). The therapy relationship accounts for client improvement as much as, and perhaps more than, the specific treatment methods used (Norcross & Lambert, 2019c). In short, both the therapy relationship and the therapy methods used influence the outcomes of treatment. It is essential that the methods used sup- port the therapeutic relationship being established with the client. Norcross and Lambert (2019a) capture the essence of what constitutes an effective therapist: “The research shows than an effective psychotherapist is one who employs specific methods, who offers strong relationships, and who customizes both treatment methods and relationship stances to the individual person and condition” (p. 19). Norcross and Cooper (2021) state: “Privileging the client’s cultures, values, and pref- erences is what matters” (p. 41). They maintain that it is the ethical duty of thera- pists to honor strong preferences of clients.

Personal Characteristics of Effective Counselors Particular personal qualities and characteristics of counselors are significant in creat- ing a therapeutic alliance with clients. My views regarding these personal characteris- tics are supported by research on this topic (Norcross & Lambert, 2019a, 2019b, 2019c; Norcross & Wampold, 2019; Skovholt & Jennings, 2004; Sperry & Carlson, 2011). I do not expect any therapist to exemplify in detail all the traits described in the list that follows. Rather, the willingness to struggle to become a more therapeutic person is the crucial variable. This list is intended to stimulate you to examine your own ideas about what kind of person can make a significant difference in the lives of others.

◆ Effective therapists have an identity. They know who they are, what they are capable of becoming, what they want out of life, and what is essential.

◆ Effective therapists respect and appreciate themselves. They can give and receive help and love out of their own sense of self-worth and strength. They feel adequate with others and allow others to feel powerful with them.

◆ Effective therapists are open to change. They exhibit a willingness and courage to leave the security of the known if they are not satisfied

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with the way they are. They make decisions about how they would like to change, and they work toward becoming the person they want to become.

◆ Effective therapists make choices that are life oriented. They are aware of early decisions they made about themselves, others, and the world. They are not the victims of these early decisions, and they are willing to revise them if necessary. They are committed to living fully rather than settling for mere existence.

◆ Effective therapists are authentic, sincere, and honest. They do not hide behind rigid roles or facades. Who they are in their personal life and in their professional work is congruent.

◆ Effective therapists have a sense of humor. They are able to put the events of life in perspective. They have not forgotten how to laugh, especially at their own foibles and contradictions.

◆ Effective therapists may make mistakes and are willing to admit them. They do not dismiss their errors lightly, yet they do not choose to dwell on misery.

◆ Effective therapists generally live in the present. They are not riveted to the past, nor are they fixated on the future. They are able to experi- ence and be present with others in the “now.”

◆ Effective therapists appreciate the influence of culture. They are aware of the ways in which their own culture affects them, and they respect the diversity of values espoused by other cultures. They are sen- sitive to the unique differences arising out of social class, race, sexual orientation, and gender.

◆ Effective therapists have a sincere interest in the welfare of others. This concern is based on respect, care, trust, and a real valuing of others.

◆ Effective therapists possess good interpersonal skills. They are capable of entering the world of others without getting lost in this world, and they strive to create collaborative relationships with oth- ers. They readily entertain another person’s perspective and can work together toward consensual goals.

◆ Effective therapists become deeply involved in their work and derive meaning from it. They can accept the rewards flowing from their work, yet they are not slaves to their work.

◆ Effective therapists are passionate. They have the courage to pursue their dreams and passions, and they radiate a sense of energy.

◆ Effective therapists are able to maintain healthy boundaries. Although they strive to be fully present for their clients, they don’t carry the problems of their clients around with them during leisure hours. They know how to say no, which enables them to maintain balance in their lives.

This picture of the characteristics of effective therapists might appear unreal- istic. Who could be all those things? Certainly I do not fit this bill! Do not think of these personal characteristics from an all-or-nothing perspective; rather, con- sider them on a continuum. A given trait may be highly characteristic of you, at one extreme, or it may be very uncharacteristic of you, at the other extreme. I have

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presented this picture of the therapeutic person with the hope that you will examine it and develop your own concept of what personality traits you think are essential to strive for to promote your own personal growth. For a more detailed discussion of the person of the counselor and the role of the therapeutic relationship in outcomes of treatments, see Psychotherapy Relationships That Work, Volume 1 (Norcross & Lambert, 2019b), Psychotherapy Relationships That Work, Volume 2 (Norcross & Wampold, 2019), How Master Therapists Work: Exploring Change From the First Through the Last Session and Beyond (Sperry & Carlson, 2011), and Master Therapists: Exploring Expertise in Therapy and Counseling (Skovholt & Jennings, 2004).

Personal Therapy for the Counselor Discussion of the counselor as a therapeutic person raises another issue debated in counselor education: Should people be required to participate in counseling or therapy before they become practitioners? My view is that counselors can benefit greatly from the experience of being clients at some time, a view that is supported by research (Norcross, 2005; Orlinsky et al., 2005). This experience can be obtained before your training, during it, or both, but I strongly support some form of self- exploration as vital preparation in learning to counsel others.

The vast majority of mental health professionals have experienced personal therapy, typically on several occasions (Geller et al., 2005b). Ronnestad, Orlinsky, and Wiseman (2016) state that the benefits of psychotherapy for therapists as people include “positive increments in self-awareness, self-knowledge, self-understanding, self-care, and self-acceptance as well as reduction in symptoms and improved rela- tionships and personal growth generally” (p. 230). Orlinsky, Norcross, Ronnestad, and Wiseman (2005) suggest that personal therapy contributes to the therapist’s professional work in three ways: (1) as part of the therapist’s training, personal therapy offers a model of therapeutic practice in which the trainee observes a more experienced therapist at work and learns experientially what is helpful or not help- ful; (2) a beneficial experience in personal therapy can further enhance a therapist’s interpersonal skills, which are essential to skillfully practicing therapy; and (3) suc- cessful personal therapy can contribute to a therapist’s ability to deal with the ongo- ing stresses associated with clinical work.

In his research on personal therapy for mental health professionals, Norcross (2005) states that lasting lessons practitioners learn from their personal therapy experiences pertain to interpersonal relationships and the dynamics of psychother- apy. Some of these lessons learned are the centrality of warmth, empathy, and the personal relationship; having a sense of what it is like to be a therapy client; valuing patience and tolerance; and appreciating the importance of learning how to deal with transference and countertransference. By participating in personal therapy, counselors can prevent their potential future countertransference from harming clients.

Through our work as therapists, we can expect to confront our own unexplored personal blocks such as loneliness, power, death, and intimate relationships. This does not mean that we need to be free of conflicts before we can counsel others, but we need to be aware of what these conflicts are and how they are likely to affect us

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as persons and as counselors. For example, if we have great difficulty dealing with anger or conflict, we may not be able to assist clients who are dealing with anger or with conflictual relationships.

When I began counseling others, old wounds were opened and feelings I had not explored in depth came to the surface. It was difficult for me to encounter a client’s depression because I had failed to come to terms with the way I had escaped from my own depression. I did my best to cheer up depressed clients by talking them out of what they were feeling, mainly because of my own inability to deal with such feel- ings. In the early years of my work as a counselor in a university counseling center, I wondered what I could do for my clients. I often had no idea what, if anything, my clients were getting from our sessions. I couldn’t tell if they were getting better, staying the same, or getting worse. It was important to me to note progress and to see change in my clients. If I did not see immediate results, I had many doubts about whether I could become an effective counselor. What I did not understand at the time was that my clients needed to struggle to find their own answers. To see my clients feel better quickly was my need, not theirs. It never occurred to me that people often feel worse for a time as they give up their defenses and open themselves to their pain. My early experiences as a counselor showed me that I could benefit by participating in personal therapy to better understand how my personal problems were affecting my professional work. I realized that periodic therapy, especially early in one’s career, can be most useful.

Personal therapy can be instrumental in healing the healer. If student counsel- ors are not actively involved in the pursuit of their own healing and growth, they will probably have considerable difficulty entering the world of a client. As counselors, we cannot take our clients any farther than we have gone ourselves. If we are not committed personally to the value of examining our own life, how can we inspire clients to examine their lives? By experiencing our own psychotherapy, we gain an experiential frame of reference with which to view ourselves. This provides a basis for understanding and having compassion for our clients, and we can draw on our own memories of reaching impasses in our therapy, of both wanting to go farther and at the same time resisting change.

Our own therapy can help us develop patience with our patients! We learn what it feels like to deal with anxieties that are aroused by self-disclosure and self-exploration and how to creatively facilitate deeper levels of self-exploration in clients. As we increase our self-awareness through our own therapy, we gain increased appreciation for the courage our clients display in their therapeutic jour- ney. Gold and Hilsenroth (2009) studied graduate clinicians and found that those who had personal therapy felt more confident and were more in agreement with their clients on the goals and tasks of treatment than were those who had not expe- rienced personal therapy. They also found that graduate clinicians who had experi- enced personal therapy were able to develop strong agreement with their clients on the goals and tasks of treatment. Participating in a process of self-exploration can reduce the chances of assuming an attitude of arrogance or of being convinced that we are totally healed. Wise and Barnett (2016) suggest that personal psychotherapy on a periodic basis is an ideal self-care strategy. Personal therapy is one of the ways to enhance our well-being and competence throughout our career. We can learn a great deal from our experience as a client that we can use professionally.

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For a comprehensive discussion of personal therapy for counselors, see The Psychotherapist’s Own Psychotherapy: Patient and Clinician Perspectives (Geller et al., 2005a).

The Counselor’s Values and the Therapeutic Process The importance of self-exploration for counselors carries over to the values and beliefs we hold. My experience in teaching and supervising students of counseling shows me how crucial it is that students be aware of their values, of where and how they acquired them, and of how their values can influence their interventions with clients.

The Role of Values in Counseling Our values are core beliefs that influence how we act, in both our personal and our professional lives. Personal values influence how we view counseling and the man- ner in which we interact with clients, including the way we conduct client assess- ments, our views of the goals of counseling, the interventions we choose, the topics we select for discussion in a counseling session, how we evaluate progress, and how we interpret clients’ life situations.

Although total objectivity cannot be achieved, we can strive to avoid being encapsulated by our own worldview. We need to guard against the tendency to use our power to influence clients to accept our values; persuading clients to accept or adopt our value system is not a legitimate outcome of counseling. From my perspec- tive, the counselor’s role is to create a climate in which clients can examine their thoughts, feelings, and actions and to empower them to arrive at their own solu- tions to problems they face. The counselor’s task is to assist individuals in finding answers that are most congruent with their own values. It is not beneficial to give clients your answers to their questions about life.

You may not agree with certain of your clients’ values, but you need to respect their right to hold divergent values from yours. This is especially true when counsel- ing clients who have a different cultural background and perhaps do not share your own core cultural values. Your role is to provide a safe, accepting, and inviting envi- ronment in which clients can explore the congruence between their values and their behavior. If clients acknowledge that what they are doing is not getting them what they want, it is appropriate to assist them in developing new ways of thinking and behaving to help them move closer to their goals. This is done with full respect for their right to decide which values they will use as a framework for living. Individuals seeking counseling need to clarify their own values and goals, make informed deci- sions, choose a course of action, and assume responsibility and accountability for the decisions they make.

Managing your personal values so they do not contaminate the counseling pro- cess is referred to as bracketing. Counselors are expected to set aside (or bracket) their personal beliefs and values when working with a wide range of clients (Kocet & Herlihy, 2014). Your core values may differ in many ways from the core values of your clients, and they will bring you a host of problems framed by their own worldview. Some clients may have felt rejected by others or have suffered from discrimination,

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and they should not be exposed to further discrimination by counselors who refuse to render services to them because of differing values (Herlihy et al., 2014).

Counselors must have the ability to work with a range of clients with diverse worldviews and values. Counselors may impose their values either directly or indi- rectly, or intentionally or without awareness. Value imposition refers to counselors directly attempting to define a client’s values, attitudes, beliefs, and behaviors. The American Counseling Association (ACA, 2014) has taken a clear position on this, stating that the counselor’s personal values should neither interfere with the coun- seling process nor be imposed on a client. Although this ethical mandate is clear, counselors often experience difficulty in successfully navigating value conflicts in a way that preserves client autonomy and the counseling relationship (Kocet & Herlihy, 2014). The ACA Code of Ethics (ACA, 2014) is explicit regarding this matter:

Personal Values. Counselors are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors. Counselors respect the diversity of clients, train- ees, and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are incon- sistent with the client’s goals or are discriminatory in nature. (Standard A.4.b.)

Value exploration is at the heart of why many counselor education programs encourage or require personal therapy for counselors in training. Your personal therapy sessions provide an opportunity for you to examine your beliefs and values and to explore your motivations for wanting to share your belief system.

Clients are in a vulnerable position and require understanding and support from a counselor rather than judgment. It can be burdensome for clients to be sad- dled with your disclosure of not being able to get beyond value differences. Clients may interpret this as a personal rejection and suffer harm as a result. Counseling is about working with clients within the framework of their value system. As a profes- sional counselor, you are expected to have basic competencies across race, ethnicity, gender, sexual orientation, and all other characteristics listed in the nondiscrimina- tion statement of the ACA Code of Ethics (ACA, 2014). If you experience difficulties over conflicting personal values with clients, the ethical course of action is to seek supervision or consultation and learn ways to effectively manage these differences. Merely disagreeing with a client’s value system is not ethical grounds for a referral. It is unethical for a counselor to refer a client based on a lack of agreement on values. Consider a referral only when you clearly lack the necessary knowledge and skills to deal with the issues presented by the client. The counseling process is not about your personal values; it is about the values and needs of your clients. Your task is to help clients explore and clarify their beliefs and apply their values to solving their problems (Herlihy & Corey, 2015).

Can Counselors Who Self-Identify as Religious Provide Value-Free Counseling to LGBTQ1 Clients?

The concept of human diversity encompasses all forms of oppression, discrimina- tion, and prejudice, including those directed toward people on the basis of their age, gender, socioeconomic status, religious affiliation, disability, or sexual orientation. Working with lesbian, gay, bisexual, and transgender (LGBTQ1) individuals often

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presents a challenge to mental health practitioners who hold traditional values. Counselors or counselors-in-training must begin by challenging their own personal prejudices, biases, fears, attitudes, assumptions, and stereotypes regarding sexual orientation if they expect to understand the ways in which prejudice, discrimina- tion, and multiple forms of oppression are manifested in society toward LGBTQ1 people. Some religiously conservative counselors view same-sex relationships as immoral, and this attitude can harm LGBTQ1 clients who have the right to expect that they can discuss their intimate relationship concerns in therapy without fear that their counselor will be judgmental (Herlihy et al., 2014).

In a phenomenological study, Bayne, Harness, Kane, and Warfield (2021) interviewed 12 counselors who identified as religious and stated that they believed they could provide competent ethical counseling to lesbian and gay cli- ents. The participants in this study demonstrated varying degrees of comfort in incorporating sexual orientation into counseling, and they differed in their view of whether value conflicts should be accommodated within counseling practice. Seven of the participants stated that they were able to remain true to themselves and their values by committing to the idea that God is loving and accepting. Nine of the participants said they addressed these value conflicts by focusing on client autonomy and supporting the client’s own values by prioritizing whatever would be most beneficial to the needs of the client. Although the participants in this study acknowledged challenges in navigating value conflicts, many pointed to professional ethics and standards of care to delineate the scope of their role as a counselor. They stressed the counselor’s responsibility to bracket values as the core of competent and ethical practice.

Most of the participants believed that they could maintain their personal reli- gious beliefs and provide counseling services within the framework of the ACA Code of Ethics (ACA, 2014). Bayne et al. (2021) contend that counselors and counselor edu- cators should view value conflicts as a developmental process that can be difficult and can progress beyond training in graduate school. This study demonstrates the importance of providing a safe climate in educational programs to enable coun- selors-in-training to engage in open discussion of conflicts between their personal values and working toward compliance with professional mandates. By being proac- tive, counselors-in-training can guard against unintentionally imposing their values on clients.

Counselors and counselor trainees have an ethical responsibility to acquire and use professional knowledge and skills in serving the diverse range of clients that they are likely to encounter in their practice. Counselors must be invested in the process of a client’s decision making rather than in directing the client toward outcomes the counselor judges to be appropriate.

For a more comprehensive discussion of working effectively with the concerns of LGBTQ1 individuals, I recommend Affirmative Counseling with LGBTQ1 People (Ginicola et al., 2017).

Addressing Religious and Spiritual Values in Counseling The American Psychological Association (APA, 2017) affirms that religion is a key consideration within diversity (Principle E), and states that attending to a client’s

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religious and spiritual values and beliefs can positively influence outcomes of the therapy process. Asking questions about a client’s religious or spiritual back- ground at the beginning of therapy demonstrates to the client that religious and spiritual values can be an asset in therapy. If counselors do not inquire about a client’s spiritual or religious values and concerns during assessment, the cli- ent may be hesitant to bring up these topics in counseling sessions. Religious and spiritual values can foster increased social belonging, connection, and sup- port. Counselors can use this important cultural lens in case conceptualization, developing treatment goals, and selecting appropriate interventions (Captari et al., 2018; Hook et al., 2019).

Captari et al. (2018) and Hook et al. (2019) presented the results of meta-analyses examining the effectiveness of religious and spiritual accommodation in the prac- tice of psychotherapy. They found that incorporating religious and spiritual values when clients wanted to include this as a part of the therapy process significantly improve treatment outcomes. However, they caution therapists to avoid making assumptions based on religious identification and to recognize that considerable variation exists in the needs, wants, and expectations of clients. Captari et al. (2018) and Hook et al. (2019) suggest a variety of questions that could be asked of clients regarding their religious and spiritual values: What do these values mean to the cli- ent? What role do these values play in their day-to-day life? How is this a source of strength? Have they been the target of oppression or abuse due to their religious or spiritual values? The authors also present the following recommendations for clini- cal practice:

◆ Consider religion and spirituality as a potentially significant aspect of the client’s identity. Explore the client’s history, values, and commit- ment to religion and spirituality as part of the intake session and the informed consent process.

◆ Incorporate the client’s religious and spiritual values and worldview in psychotherapy as requested and when clinically indicated. Follow the client’s lead when incorporating these beliefs and practices.

◆ When a client’s treatment goals include not only symptoms remission but also spiritual development, integrating the client’s religious and spiritual values in therapy is a treatment of choice.

◆ Customize treatment when working with clients whose religious and spiritual values are an influential force in their daily life. It is important to assess clients’ preferences and accommodate treatment accordingly.

◆ Practice respect and cultural humility when discussing clients’ religious worldviews and practices.

Therapists must exercise care and avoid imposing their agenda on clients. For many clients, spirituality or religion are core aspects of their sense of self, world- view, and value system. Religious or spiritual concerns may be relevant to the rea- sons some clients seek therapy, either as areas of conflict for them or as sources of strength and support that can enhance the therapy process (Barnett & Johnson, 2011). If clients do not see religion and spirituality as being relevant factors in their life, it is not appropriate for counselors to take the lead and bring these matters into the therapy process.

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For an in-depth treatment of the use of religious and spiritual values in the counseling process, see Integrating Spirituality and Religion Into Counseling (Cashwell & Young, 2020).

The Role of Values in Developing Therapeutic Goals Who should establish the goals of counseling? Almost all theories are in agreement that it is largely the client’s responsibility to decide upon goals, collaborating with the therapist as therapy proceeds. Counselors have general goals, which are reflected in their behavior during the therapy session, in their observations of the client’s behavior, and in the interventions they make. The general goals of counselors must be congruent with the personal goals of the client.

Setting goals is inextricably related to values. The client and the counselor need to explore what they hope to obtain from the counseling relationship, whether they can work with each other, and whether their goals are compatible. Even more important, it is essential that the counselor be able to understand, respect, and work within the framework of the client’s world rather than forcing the client to fit into the therapist’s scheme of values.

In my view, therapy ought to begin with an exploration of the client’s expec- tations and goals. Clients initially tend to have vague ideas of what they expect from therapy. They may be seeking solutions to problems, they may want to stop hurting, they may want to change others so they can live with less anxiety, or they may seek to be different so significant people in their life will be more accepting of them. In some cases, clients have no goals; they are in the therapist’s office simply because they were sent for counseling by their parents, probation officer, or teacher.

So where can a counselor begin? The initial interview can be used most pro- ductively to focus on the client’s goals or lack of them. The therapist may begin by asking any of these questions: “What do you expect from counseling? Why are you here? What do you want? What do you hope to leave with? How is what you are cur- rently doing working for you? What aspects of yourself or your life situation would you most like to change?”

When a person seeks a counseling relationship with you, it is important to coop- eratively discover what this person is expecting from the relationship. If you try to figure out in advance how to proceed with your clients, you may be depriving them of the opportunity to become active partners in their own therapy. It is important to keep this focus in mind so the client’s agenda is addressed rather than an agenda of your own.

Becoming an Effective Multicultural Counselor Therapists must be able to actively engage and effectively work with diverse client populations. Becoming a diversity-competent counselor is not a destination to be reached; rather, it is a lifelong learning process that includes formal training, self-reflection, and questioning what is occurring in cross-cultural therapeutic part- nerships. Counselors entering cross-cultural helping relationships need to develop a variety of techniques and skills consistent with the life experiences and cultural values of their clients (Lee, 2019b). Effective counselors are continually developing

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attitudes and beliefs that enable them to work more effectively with diverse client populations. They realize that they can never say they have achieved an ultimate level of competency (Corey et al., 2024).

Becoming a competent multicultural practitioner involves cultural awareness, cultural knowledge, and cultural skills (Sue et al., 2022). Soto et al. (2018) address the importance of considering the cultural experiences and background of clients as part of multicultural competence. In their meta-analytic review, they note that clients are more likely to engage in treatment, remain in therapy, and experience positive outcomes when treatments are tailored to match the characteristics of their clients. It is essential for therapists to solicit client feedback regarding cultural con- siderations to bridge the gap between the perceptions of the client and the therapist about the effectiveness of cultural adaptations in the therapy process.

Part of the process of becoming an effective multicultural counselor involves learning how to recognize diversity issues and shape your counseling practice to fit the client’s worldview. Counselors have an ethical obligation to understand these cultural differences and to assist clients in making decisions that are congruent with their worldview, not to live by the therapist’s values. When therapists neglect how their worldviews and cultural values influence the ways they practice, or when they fail to understand the role that culture plays in their clients’ lives, Pope et al. (2021) contend that therapists are limiting their ability to make appropriate and useful interventions: “The road toward cultural competence, or the ability to develop inter- ventions that are culturally responsive, begins by looking inward toward the self and outward toward others” (p. 81).

The standards established by the Council for Accreditation of Counseling and Related Educational Programs (CACREP, 2016) require training programs to pro- vide curricular and experiential offerings in multicultural and pluralistic trends, including characteristics within and among diverse groups nationally and interna- tionally. CACREP standards call for supervised practicum experiences that include clients from the environments in which trainees are preparing to work. It is expected that trainees will study ethnic groups, subcultures, the changing roles of women, sexism, urban and rural societies, cultural mores, and spiritual practices.

Acquiring Competencies in Multicultural Counseling Diversity-competent practitioners understand their own cultural conditioning, the cultural values of their clients, and the sociopolitical system of which they are a part. Acquiring this understanding begins with counselors’ awareness of the cul- tural origins of any values, biases, and attitudes they may hold. Counselors from all cultural groups must examine their expectations, attitudes, biases, and assump- tions about the counseling process and about people from diverse groups. Recog- nizing our biases and prejudices takes courage because most of us do not want to acknowledge that we have cultural biases. Everyone has biases, but being unaware of the biased attitudes we hold is an obstacle to client care. It takes a concerted effort and vigilance to monitor our biases, attitudes, and values so that they do not inter- fere with establishing and maintaining successful counseling relationships.

A major part of becoming a diversity-competent counselor involves challeng- ing the idea that the values we hold are automatically true for others. Counselors

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must determine whether their values and the assumptions they have made about the nature and functioning of therapy are appropriate for culturally diverse clients.

Sue, Arredondo, and McDavis (1992) and Arredondo and her colleagues (1996) developed a conceptual framework for competencies and standards in multicultural counseling that address three areas: (1) beliefs and attitudes, (2) knowledge, and (3) skills. For an in-depth treatment of multicultural counseling and therapy com- petence, refer to Counseling the Culturally Diverse: Theory and Practice (Sue et al., 2022; also see Lee 2019a, 2019b, 2019c).

Beliefs and Attitudes First, diversity-competent practitioners have moved from being culturally unaware to ensuring that their personal biases, values, or problems will not interfere with their ability to work with clients who are culturally different from them. They believe cultural self-awareness and sensitivity to one’s own cultural heritage are essential for any form of helping. Counselors are aware of their positive and negative emotional reactions toward people from other racial and ethnic groups that may prove detrimental to establishing collaborative helping relationships. They seek to examine and understand the world from the vantage point of their clients. They respect clients’ religious and spiritual beliefs and values. They are comfortable with differences between themselves and others in terms of race, ethnicity, culture, and beliefs. Rather than maintaining that their cultural heritage is superior, they are able to accept and value cultural diversity. They realize that traditional theories and techniques may not be appropriate for all clients or for all problems. Culturally skilled counselors monitor their functioning through consultation, supervision, and further training or education.

Knowledge Second, diversity-competent practitioners actively attempt to understand the worldview of their clients. They know their own racial and cultural heritage and understand how it affects them personally and professionally. They understand the dynamics of oppression, racism, discrimination, and stereotyping and are in a position to detect their own racist attitudes, beliefs, and feelings. They understand the worldview of their clients, and they learn about their clients’ cultural background. They do not impose their values and expectations on their clients from differing cultural backgrounds and avoid stereotyping clients. Diversity-competent practitioners understand that external sociopolitical forces influence all groups, and they know how these forces operate with respect to the treatment of minorities. These practitioners are aware of the institutional barriers that prevent minorities from utilizing the mental health services available in their communities. They possess knowledge about the historical background, traditions, and values of the client populations with whom they work including minority family structures, hierarchies, values, and beliefs. Furthermore, they are knowledgeable about community characteristics and resources and can help clients make use of indigenous support systems. In areas where they are lacking in knowledge, they seek resources to assist them. The greater their depth and breadth of knowledge of culturally diverse groups, the more likely they are to be effective practitioners.

Skills and Intervention Strategies Third, diversity-competent practitioners have acquired skills in working with culturally diverse populations. Counselors take

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responsibility for educating their clients about the therapeutic process, including matters such as setting goals, appropriate expectations, legal rights, and the counselor’s orientation. Multicultural counseling is enhanced when practitioners use methods and strategies and define goals consistent with the life experiences and cultural values of their clients. Such practitioners modify and adapt their interventions to accommodate cultural differences. They do not force their clients to fit within one counseling approach, and they recognize that counseling techniques may be culture-bound. They are able to send and receive both verbal and nonverbal messages accurately and appropriately. They become actively involved with clients outside the office (community events, celebrations, and neighborhood groups) if doing so is culturally appropriate. They are willing to seek out educational, consultative, and training experiences to enhance their ability to work with culturally diverse client populations. They consult regularly with other professionals who possess expertise in multicultural counseling regarding issues of culture to determine whether referral may be necessary.

Incorporating Culture in Counseling Practice It is unrealistic to expect a counselor to know everything about the cultural back- ground of a client, but some understanding of the client’s cultural and ethnic back- ground is necessary. It is a good idea for counselors to ask clients to provide them with the information they will need to work effectively. Incorporating culture into the therapeutic process is not limited to working with clients from a certain racial, ethnic, or cultural background. For counseling to be effective, therapists must take into account the worldview and background of every client. Failing to do this seri- ously restricts the potential impact of the therapeutic endeavor.

Counseling is by its very nature diverse in a multicultural society, so it is easy to see that there are no ideal therapeutic approaches. Instead, different theories have distinct features that have appeal for different cultural groups. Some theoretical approaches have limitations when applied to certain populations. Effective multi- cultural practice demands an open stance on the part of the practitioner, flexibility, and a willingness to modify strategies to fit the needs and the situation of the indi- vidual client. Practitioners who truly respect their clients will be aware of clients’ hesitations and will not be too quick to misinterpret this behavior. Instead, they will patiently attempt to enter the world of their clients as much as they can. Although practitioners may not have had the same experiences as their clients, the empathy shown by counselors for the feelings and struggles of their clients is fundamental to good therapeutic outcomes. We are more often challenged by our differences than by our similarities to look at what we are doing.

Practical Guidelines in Addressing Culture If the counseling process is to be effective, cultural concerns must be addressed with all clients. Here are some guidelines that may increase your effectiveness when working with clients from diverse backgrounds:

◆ Learn more about how your own cultural background has influenced your thinking and behaving. Take steps to increase your understanding of other cultures.

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◆ Identify your basic assumptions, especially as they apply to diversity in culture, ethnicity, race, gender, class, age, spirituality, religion, and sexual orientation. Think about how your assumptions are likely to affect your professional practice.

◆ Examine where you obtained your knowledge about culture. ◆ Remain open to ongoing learning of how the various dimensions of

culture may affect therapeutic work. Realize that this skill does not develop quickly or without effort.

◆ Be willing to identify and examine your own personal worldview and any prejudices you may hold about other racial/ethnic groups.

◆ Learn to pay attention to the common ground that exists among peo- ple of diverse backgrounds.

◆ Be flexible in applying the methods you use with clients. Don’t be wedded to a specific technique if it is not appropriate for a given client.

◆ Remember that practicing from a multicultural perspective can make your job easier and can be rewarding for both you and your clients.

It takes time, study, and experience to become a diversity-competent practitio- ner. Multicultural competence cannot be reduced simply to cultural awareness and sensitivity, to a body of knowledge, or to a specific set of skills. Instead, it requires a combination of all of these factors. Norcross and Wampold (2019) found that expressing cultural humility and tracking clients’ satisfaction with cultural respon- siveness markedly improves client engagement, retention, and treatment outcome. They also note that adapting therapy to the entire person results in more success and reduces dropouts.

Issues Faced by Beginning Therapists When you complete formal coursework and begin helping clients, you will be chal- lenged to integrate and to apply what you have learned. At that point, you are likely to have some real concerns about your adequacy as a person and as a professional. Beginning therapists typically face a number of common issues as they learn how to help others. Here are some useful guidelines to assist you in your reflection on what it takes to become an effective counselor. For my answers to questions on a range of topics that are of interest to beginning counselors, see Personal Reflections on Counseling (Corey, 2020).

Dealing With Anxiety Most beginning counselors have ambivalent feelings when meeting their first cli- ents. A certain level of anxiety demonstrates that you are aware of the uncertainties of the future with your clients and of your abilities to really be there for them. A willingness to recognize and deal with these anxieties, as opposed to denying them, is a positive sign. That we have self-doubts is normal; it is how we deal with them that matters. One way is to openly discuss our self-doubts with a supervisor and peers. The possibilities are rich for meaningful exchanges and for gaining support from fellow interns who probably have many of the same concerns and anxieties.

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Being Yourself and Self-Disclosure If you feel self-conscious and anxious when you begin counseling, you may have a tendency to be overly concerned with what the books say and with the mechanics of how to proceed. Inexperienced therapists too often fail to appreciate the values inherent in simply being themselves. If we are able to be ourselves in our thera- peutic work, and appropriately disclose our reactions in counseling sessions, we increase the chances of being authentic. It is this level of genuineness and presence that enables us to connect with our clients and to establish an effective therapeutic relationship with them.

It is possible to err by going to extremes in two different directions. At one end are counselors who lose themselves in their fixed role and hide behind a professional facade. These counselors are so caught up in maintaining stereotyped role expecta- tions that little of their personal self shows through. Counselors who adopt this behavior will likely remain anonymous to clients, and clients may perceive them as hiding behind a professional role.

At the other end of the spectrum is engaging in too much self-disclosure. Some counselors make the mistake of inappropriately burdening their clients with their spontaneous impressions about their clients. Judging the appropriate amount of self-disclosure can be a problem even for seasoned counselors, and it is often especially worrisome for new counselors. In determining the appropriateness of self- disclosure, consider what to reveal, when to reveal, and how much to reveal. It may be useful to mention something about ourselves from time to time, but we must be aware of our motivations for making ourselves known in this way. Assess the readi- ness of a client to hear these disclosures as well as the impact doing so might have on the client. Remain observant during any self-disclosure to get a sense of how the client is being affected by it.

The most productive form of self-disclosure is related to what is going on between the counselor and the client within the counseling session. The skill of immediacy involves revealing what we are thinking or feeling in the here and now with the cli- ent, but be careful to avoid pronouncing judgments about the client. When done in a timely way, sharing persistent reactions can facilitate therapeutic progress and improve the quality of our relationship with the client. Even when we are talking about reactions based on the therapeutic relationship, caution is necessary, and dis- cretion and sensitivity are required in deciding what reactions we might share.

Avoiding Perfectionism Perhaps one of the most common self-defeating beliefs with which we burden our- selves is that we must never make a mistake. Although we may well know intellectu- ally that humans are not perfect, emotionally we often feel that there is little room for error. To be sure, you will make mistakes, whether you are a beginning or a seasoned therapist. If our energies are tied up presenting an image of perfection, this will affect our ability to be present for our clients. I tell students to question the notion that they should know everything and be perfectly skilled. I encourage them to share their mistakes or what they perceive as errors during their supervision meet- ings. Students willing to risk making mistakes in supervised learning situations and willing to reveal their self-doubts will find a direction that leads to growth.

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Being Honest About Your Limitations You cannot realistically expect to succeed with every client. It takes honesty to admit that you cannot work successfully with every client. It is important to learn when and how to make a referral for clients when your limitations prevent you from help- ing them. However, there is a delicate balance between learning your realistic limits and challenging what you sometimes think of as being “limits.” Before deciding that you do not have the life experiences or the personal qualities to work with a given population, try working in a setting with a population you do not intend to specialize in. This can be done through diversified field placements or visits to agencies.

Understanding Silence Silent moments during a therapeutic session may seem like silent hours to a begin- ning therapist, yet this silence can have many meanings. The client may be quietly thinking about some things that were discussed earlier or evaluating some insight just acquired. The client may be waiting for the therapist to take the lead and decide what to say next, or the therapist may be waiting for the client to do this. Either the client or the therapist may be distracted or preoccupied, or neither may have any- thing to say for the moment. The client and the therapist may be communicating without words. The silence may be refreshing, or the silence may be overwhelming. Perhaps the interaction has been on a surface level, and both people have some fear or hesitancy about getting to a deeper level. When silence occurs, acknowledge and explore with your client the meaning of the silence.

Dealing With Demands From Clients A major issue that puzzles many beginning counselors is how to deal with clients who seem to make constant demands. Because therapists feel they should extend themselves in being helpful, they often burden themselves with the unrealistic idea that they should give unselfishly, regardless of how great clients’ demands may be. These demands may manifest themselves in a variety of ways. Clients may want to see you more often or for a longer period than you can provide. They may want to see you socially. Some clients may expect you to continually demonstrate how much you care or demand that you tell them what to do and how to solve a problem. One way of heading off these demands is to make your expectations and boundaries clear during the initial counseling sessions or in the disclosure statement.

Dealing With Clients Who Lack Commitment Involuntary clients may be required by a court order to obtain therapy, and you may be challenged in your attempt to establish a working relationship with them. It is possible to do effective work with mandated clients, but practitioners must begin by openly discussing the nature of the relationship. Counselors who omit preparation and do not address clients’ thoughts and feelings about coming to counseling are likely to encounter resistance. It is critical that therapists not

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promise what they cannot or will not deliver. It is good practice to make clear the limits of confidentiality as well as any other factors that may affect the course of therapy. In working with involuntary clients, it is especially important to prepare them for the process; doing so can go a long way toward increasing their coopera- tion and involvement.

Tolerating Ambiguity Many beginning therapists experience the anxiety of not seeing immediate results. They ask themselves: “Am I really doing my client any good? Is the client perhaps getting worse?” I hope you will learn to tolerate the ambiguity of not knowing for sure whether your client is improving, at least during the initial sessions. Realize that oftentimes clients may seemingly “get worse” before they show therapeutic gains. Also, realize that the fruitful effects of the joint efforts of the therapist and the client may manifest themselves after the conclusion of therapy.

Becoming Aware of Your Countertransference Working with clients can affect you in personal ways, and your own vulnerabilities and countertransference are bound to surface. If you are unaware of your personal dynamics, you are in danger of being overwhelmed by a client’s emotional expe- riences. Beginning counselors need to learn how to “let clients go” and not carry around their problems until the next session. The most therapeutic thing is to be as fully present as we are able to be during the therapy hour, but to let clients assume the responsibility of their living and choosing outside of the session. If we become lost in clients’ struggles and confusion, we cease being effective agents in helping them find solutions to their problems. If we accept responsibility for our clients’ decisions, we are blocking rather than fostering their growth.

Countertransference, defined broadly, includes any of our projections that influence the way we perceive and react to a client. This phenomenon occurs when we are triggered into emotional reactivity, when we respond defensively, or when we lose our ability to be present in a relationship because our own issues become involved. Recognizing the manifestations of our countertransference reactions is an essential step in becoming competent counselors. Unless we are aware of our own conflicts, needs, assets, and liabilities, we can use the therapy hour more for our own purposes than for being available to our clients. Because it is not appropriate for us to use clients’ time to work through our reactions to them, it is all the more impor- tant that we be willing to work on ourselves in our own sessions with another thera- pist, supervisor, or colleague. If we do not engage in this kind of self-exploration, we increase the danger of losing ourselves in our clients and using them to meet our unfulfilled needs.

The emotionally intense relationships we develop with clients can be expected to tap into our own unresolved problem areas. Our clients’ stories and pain are bound to have an impact on us. We will be affected by their stories and can express compassion and empathy. However, we have to realize that it is their pain and not carry it for them lest we become overwhelmed by their life stories and thus render ourselves ineffective in working with them. Although we cannot completely free ourselves from any traces of countertransference or ever fully resolve all personal

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conflicts from the past, we can become aware of ways these realities influence our professional work. Our personal therapy can be instrumental in enabling us to rec- ognize and manage our countertransference reactions. (This topic is explored in more depth in Chapter 4.)

Developing a Sense of Humor Therapy is a responsible endeavor, but it need not be deadly serious. Both clients and counselors can enrich a relationship through humor. What a welcome relief when we can admit that pain is not our exclusive domain. It is important to recognize that laughter or humor does not mean that work is not being accom- plished. There are times, of course, when laughter is used to cover up anxiety or to escape from the experience of facing threatening material. The therapist needs to distinguish between humor that distracts and humor that enhances the situation.

Sharing Responsibility With the Client You might struggle with finding the optimum balance in sharing responsibility with your clients. One mistake is to assume full responsibility for the direction and outcomes of therapy. This will lead to taking from your clients their rightful respon- sibility of making their own decisions. It could also increase the likelihood of your early burnout. Another mistake is for you to refuse to accept the responsibility for making accurate assessments and designing appropriate treatment plans for your clients. How responsibility will be shared should be addressed early in the course of counseling. It is your responsibility to discuss specific matters such as length and overall duration of the sessions, confidentiality, general goals, and methods used to achieve goals. (Informed consent is discussed in Chapter 3.)

It is important to be alert to your clients’ efforts to get you to assume responsi- bility for directing their lives. Many clients seek a “magic answer” as a way of escaping the anxiety of making their own decisions. It is not your role to assume responsibil- ity for directing your clients’ lives. Collaboratively designing contracts and home- work assignments with your clients can be instrumental in your clients’ increasingly finding direction within themselves. Perhaps the best measure of our effectiveness as counselors is the degree to which clients are able to say to us, “I appreciate what you have been to me, and because of your faith in me, and what you have taught me, I am confident that I can go it alone.” Eventually, if we are effective, we will be out of business!

Declining to Give Advice Quite often clients who are suffering come to a therapy session seeking and even demanding advice. They want more than direction; they want a wise counselor to make a decision or resolve a problem for them. However, counseling should not be confused with dispensing information. Therapists help clients discover their own solutions and recognize their own freedom to act. Even if we, as therapists, were able to resolve clients’ struggles for them, we would be fostering their dependence on us. They would continually need to seek our counsel for every new twist in their

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difficulties. Our task is to help clients make independent choices and accept the consequences of their choices. The habitual practice of giving advice does not work toward this end.

Defining Your Role as a Counselor One of your challenges as a counselor will be to define and clarify your pro- fessional role. As you read about the various theoretical orientations, you will discover the many different roles of counselors that are related to the various theories. As a counselor, you will likely be expected to function with a diverse range of roles.

From my perspective, the central function of counseling is to help clients recognize their own strengths, discover what is preventing them from using their resources, and clarify what kind of life they want to live. Counseling is a pro- cess by which clients are invited to look honestly at their behavior and make cer- tain decisions about how they want to modify the quality of their life. In this framework counselors provide support and warmth, yet care enough to challenge clients so that they will be able to take the actions necessary to bring about sig- nificant change.

Maintaining Your Vitality as a Person and as a Professional

Ultimately, your single most important instrument is the person you are, and a pow- erful intervention is your ability to model aliveness and realness. It is of paramount importance that we take care of ourselves, for how can we take care of others if we are not taking care of ourselves? We need to work at dealing with those factors that threaten to drain life from us and render us helpless. I encourage you to consider how you can apply the theories you will be studying to enhance your life from both a personal and a professional standpoint.

Learn to look within yourself to determine what choices you are making (and not making) to keep yourself vital. If you are aware of the factors that sap your vitality as a person, you are in a better position to prevent the condition known as professional burnout. You have considerable control over whether you become burned out or not. You cannot always control stressful events, but you do have a great deal of control over how you interpret and react to these events. It is important to realize that you cannot continue to give, while getting little in return. There is a price to pay for always being available and for assuming responsibility over the lives and destinies of others. Become attuned to the subtle signs of burnout rather than waiting for a full-blown condition of emotional and physical exhaustion to set in. You would be wise to develop your own strategy for keeping yourself alive personally and professionally.

Self-monitoring is a crucial first step in self-care. If you make an honest inven- tory of how well you are taking care of yourself in specific domains, you will have a framework for deciding what you may want to change. By making periodic assess- ments of the direction of your own life, you can determine whether you are living

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the way you want to live. If not, decide what you are willing to actually do to make changes occur. By being in tune with yourself, by having the experience of centered- ness and solidness, and by feeling a sense of personal power, you have the founda- tion for integrating your life experiences with your professional experiences. Such an awareness can provide the basis for retaining your physical and psychological vitality and for being an effective professional.

As counseling professionals, we tend to be caring people who are good at tak- ing care of others, but often we do not treat ourselves with the same level of care. Skovholt and Trotter-Mathison (2016) note that those in the helping professions are experts at one-way caring in their professional work, and they ask us to exam- ine the number of one-way caring relationships in our personal life. Counselors are encouraged to find a balance in their personal life that offsets the many one- way caring relationships in their professional life. We must be willing to take steps to protect our own vitality if we are to provide our clients with the competent ser- vices they deserve. If we neglect to care for ourselves, our clients will not be getting the best of us. If we are physically drained and psychologically depleted, we will not have much to give to those with whom we work. We cannot provide nourish- ment to our clients if we are not nourishing ourselves. To be able to commit to making a difference in the lives of clients, we must work to maintain our vitality. Discovering ways to consistently practice self-care is best viewed as an ongoing preventive activity.

Mental health professionals often comment that they do not have time to take care of themselves. My question to them is this: “Can you afford not to take care of yourself?” To successfully meet the demands of our professional work, we must take care of ourselves physically, psychologically, intellectually, socially, and spiritually. Ideally, our self-care should mirror the care we provide for others. Self-care is not a luxury; it is an ethical mandate. If we hope to have the vitality and stamina required to stay focused on our professional goals, we need to incorporate a wellness perspec- tive into our daily living. Wellness is not a one-time decision; rather, it is a process of making a series of decisions that lead to zest, peace, vitality, and happiness in our whole being (Corey et al., 2018).

In a classic article, Walsh (2011) provides a comprehensive review of therapeutic lifestyle changes (TLCs) that promote wellness for individuals: physical activity and exercise, nutrition and diet, time in nature, relationships, recreation, religious or spiritual involvement, and service to others. Walsh contends that TLCs offer signifi- cant therapeutic advantages such as enhancing health and well-being, and research and clinical evidence support the value of this practice. Some suggestions based on Walsh’s list of therapeutic lifestyle changes follow for you to consider as specific ways to take care of yourself.

◆ Physical activity. One key practice to promote general wellness is to establish physical activity and regular exercise as a part of your daily life. There is no single path to developing an exercise program; take your time and design a plan that is right for you. Find something suit- able for your age, physical condition, and life circumstances and some- thing that you want to make a consistent part of your life. If you choose

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a form of exercise that you enjoy, you will find it easier to commit to this practice on a regular basis.

◆ Diet and nutrition. By learning how to eat wisely and well, how to manage your weight, and how to become physically fit, you will begin a lifelong process toward wellness. By establishing healthy eating habits, you increase your ability to maintain the vitality that is necessary to provide quality care to your clients (Corey et al., 2018).

◆ Being in nature. Immersing yourself in nature provides numerous benefits as a path toward enhancing both physical and mental health. Walsh (2011) asserts that nature calms the body and mind, reduces stress, removes mental trivia, offers the gift of silence, and calls to mind what matters most in life. The Dalai Lama (2001) suggests that wellness and happiness are enhanced and supported when we spend at least 30 minutes a day in nature.

◆ Relationships. Abundant research shows that good relationships are central to both physical and psychological well-being (Corey et al., 2018; Walsh, 2011). The individuals you choose to have in your life will have an impact on your worldview and on your professional work. Establishing relationships that are fulfilling and supportive can posi- tively influence your level of well-being.

◆ Recreation. Recreation involves creating new interests that become your path to vitality. Most of us find it challenging to balance work, family, and leisure pursuits. We need to pause long enough to savor and enjoy experiences that rejuvenate us. With some imagination, you can identify activities that not only provide a time out from work but also enhance your relationships with others (Corey et al., 2018).

◆ Religious/spiritual involvement. Walsh (2011) identifies religious and spiritual involvement as a significant aspect of lifestyle that can apply to both your personal and professional life. Walsh notes that religious and spiritual involvement is most beneficial in therapy when it centers on themes such as love, acceptance, and forgiveness. Despite our differences, we can strive to make our world a better place by treat- ing others with compassion and kindness. The Dalai Lama (2001) talks about core spiritual values such as goodness, love, compassion, toler- ance, patience, contentment, forgiveness, human warmth, caring, and kindness toward oneself. Reflecting on these ideas can help you deter- mine how you can incorporate these actions as a part of your care of self and care of others.

◆ Providing service to others. Providing service to others is a thera- peutic lifestyle change that can enhance the quality of your life, both personally and professionally (Walsh, 2011). As part of your self- care, reflect on the service to others and the positive changes you can make in your own way. You will likely find meaning in giving back to others and in knowing that you are making a difference (Corey et al., 2018).

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Wellness and self-care are being given increased attention in professional jour- nals and at professional conferences. When reading about self-care and wellness, reflect on what you can do to put what you know into action. At this point, take some time to consider what basic changes, if any, you want to make to promote your well-being. What kind of action plan can you create for maintaining your vitality as a person and as a professional? In designing your personal action plan, you might find selected readings useful in stimulating ideas.

If you are interested in learning more about therapist self-care, I recommend Leaving It at the Office: A Guide to Psychotherapist Self-Care (Norcross & VandenBos, 2018) and Counselor Self-Care (Corey et al., 2018).

Summary One of the basic issues in the counseling profession concerns the significance of the counselor as a person in the therapeutic relationship. In your professional work, you are asking people to take an honest look at their lives and to make choices concerning how they want to change, so it is critical that you do this in your own life. Ask yourself questions such as “What do I personally have to offer others who are struggling to find their way?” and “Am I doing in my own life what I may be urging others to do?”

You can acquire an extensive theoretical and practical knowledge and can make that knowledge available to your clients. But to every therapeutic session you also bring yourself as a person. If you are to promote change in your clients, you need to be open to change in your own life. This willingness to attempt to live in accordance with what you teach and thus to be a positive model for your clients is what makes you a “therapeutic person.”

Self-Reflection and Discussion Questions 1. From your perspective, what are three of the main personal characteris-

tics of an effective counselor? As you review the list in the chapter, how would you assess yourself in each area?

2. The role of values in counseling is given considerable attention in this chapter. What challenges might you encounter in managing your val- ues and dealing ethically with differences in values between you and your clients?

3. What are your thoughts about what is involved in becoming a diversity- competent practitioner?

4. Issues faced by beginning counselors are addressed in this chapter. What are some of the challenges that you expect to encounter as a new professional? What can you do now to begin working on these concerns?

5. Self-care is an ethical mandate. How would you assess your present level of self-care from a holistic perspective? What are some of your strengths in taking care of yourself? What is one area of self-care that you would like to improve? What steps are you willing to take to make the changes you desire?

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Leaving It at the Office: A Guide to Psychotherapist Self-Care (Norcross & VandenBos, 2018) addresses 12 self-care strategies that are supported by empiri- cal evidence. The authors develop the position that self-care is personally essential and professionally ethical. This is one of the most useful books on ther- apist self-care and on prevention of burnout.

Counselor Self-Care (Corey, Muratori, Austin, & Austin, 2018) offers diverse, realistic perspectives on how to achieve work–life balance and personal wellness from graduate school through retirement. In addition to the authors’ perspectives as profes- sionals at different stages of their careers, more than 50 guest contributors share their experiences and thoughts about self-care, including what challenges them most. This book is aimed at helping read- ers create their own practical self-care action plan through self-reflection.

Psychotherapy Relationships That Work, Volume 1: Evidence-Based Therapist Contributions (Norcross & Lambert, 2019b) and Psychotherapy Relationships That Work, Volume 2: Evidence-Based Responsiveness (Norcross & Wampold, 2019) are both compre- hensive treatments of the effective elements of the therapy relationship. Many different contributors address ways of tailoring the therapy relationship to individual clients. Implications from research for effective clinical practice are presented.

Becoming a Helper (M. Corey & Corey, 2021) expands on issues dealing with the personal and professional lives of helpers and ethical issues in counseling practice.

Student Manual for Theory and Practice of Counseling and Psychotherapy (Corey, 2024) is designed to help you integrate theory with practice and to make the concepts covered in this book come alive. It con- sists of self-inventories, overview summaries of the theories, a glossary of key concepts, study ques- tions, issues and questions for personal applica- tion, activities and exercises, comprehension checks and quizzes, and case examples. The manual is fully coordinated with the textbook to make it a personal study guide.

The Art of Integrative Counseling (Corey, 2019) pres- ents concepts and techniques from the various theories of counseling and provides guidelines for readers in developing their own approach to coun- seling practice.

Case Approach to Counseling and Psychotherapy (Corey, 2013) provides case applications of how each of the theories presented in this book works in action. A hypothetical client, Ruth, experiences counseling from all of the therapeutic models.

Personal Reflections on Counseling (Corey, 2020) is a personal book that addresses an array of questions often asked by students. Some topical question themes include creating your professional path, mentoring and being a mentee, surviving graduate school, ben efiting from personal therapy, focusing on self-care and wellness, becoming an ethical coun- selor, managing value con flicts in counseling, using self-disclosure therapeutically, deal ing with difficult clients, getting the most out of supervision, and becoming a writer.

Recommended Supplementary Readings for Chapter 2

References American Counseling Association. (2014). ACA code of ethics. https://www. counseling.org/resources/aca-code-of -ethics.pdf American Psychological Association. (2017). Ethical principles of psychologists and code of conduct. http://www.apa.org /ethics/code/ethics-code-2017.pdf Arredondo, P., Toporek, R., Brown, S., Jones, J., Locke, D., Sanchez, J., & Stadler, H. (1996). Operationalization of

multicultural counseling competencies. Journal of Multicultural Counseling and Development, 24(1), 42–78. Barnett, J. E., & Johnson, W. B. (2011). Integrating spirituality and religion into psychotherapy: Persistent dilemmas, ethical issues, and a proposed decision- making process. Ethics and Behavior, 21(2), 147–164. Bayne, H. B., Harness, L., Kane, B., & Warfield, M. (2021) Christian

counselors and affirmative counseling of lesbian and gay clients. Journal of Counseling and Development, 99, 60–71. Captari, I. E., Hook, J. N., Hoyt, W., Davis, D. E., McElroy-Heltzel. S. L., & Worthington Jr., E. L. (2018). Integrating clients’ religion and spirituality within psychotherapy: A comprehensive meta-analysis. Jour- nal of Clinical Psychology, 74(11), 1938–1951.

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Cashwell, C. S., & Young, J. S. (Eds.). (2020). Integrating spirituality and religion into counseling: A guide to competent practice (3rd ed.). American Counseling Association. Corey, G. (2013). Case approach to counseling and psychotherapy (8th ed.). Brooks/Cole, Cengage Learning. Corey, G. (2019). The art of integrative counseling (4th ed.). American Counseling Association. Corey, G. (2020). Personal reflections on counseling. American Counseling Association. Corey, G. (2024). Student manual for theory and practice of counseling and psychotherapy (11th ed.). Cengage Learning. Corey, G., Corey, M., & Corey, C. (2024). Issues and ethics in the helping professions (11th ed.). Cengage Learning. Corey, G., Muratori, M., Austin, J., & Austin, J. (2018). Counselor self-care. American Counseling Association. Corey, M., & Corey, G. (2021). Becoming a helper (8th ed.). Cengage Learning. Council for Accreditation of Counseling Related Educational Programs. (2016). CACREP standards. http://www.cacrep.org/wp-content /uploads/2017/08/2016-Standards -with-citations.pdf Dalai Lama. (2001). An open heart: Practicing compassion in everyday life. Little Brown. Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (Eds.). (2010). The heart and soul of change: Delivering what works in therapy (2nd ed.). American Psychological Association. Elkins, D. N. (2009). Humanistic psychology: A clinical manifesto. University of the Rockies Press. Elkins, D. N. (2016). The human elements of psychotherapy: A nonmedical model of emotional healing. American Psychological Association. Geller, J. D., Norcross, J. C., & Orlinsky, D. E. (Eds.). (2005a). The psychotherapist’s own psychotherapy: Patient and clinician perspectives. Oxford University Press. Geller, J. D., Norcross, J. C., & Orlinsky, D. E. (2005b). The question of personal therapy: Introduction and prospectus. In J. D. Geller, J. C. Norcross, & D. E. Orlinsky (Eds.), The psychotherapist’s own psychotherapy: Patient and clinician perspectives (pp. 3–11). Oxford University Press.

Ginicola, M. M., Smith, C., & Filmore, J. M. (Eds.). Affirmative counseling with LGBTQ+ people. American Counseling Association. Gold, S. H., & Hilsenroth, M. J. (2009). Effects of graduate clinicians’ personal therapy on therapeutic alliance. Clinical Psychology and Psychotherapy, 16(3), 159–171. Herlihy, B., & Corey, G. (2015). Managing value conflicts. In ACA ethical standards casebook (7th ed., pp. 193–204). American Counseling Association. Herlihy, B., Hermann, M. A., & Greden, L. R. (2014). Legal and ethical implications of using religious beliefs as the basis for refusing to counsel certain clients. Journal of Counseling & Development 92(2), 148–153. Hook, J. N., Captari, L. E., Hoyt, W., Davis, D. E., McElroy, S. E., & Worthington, E. L. (2019). Religion and spirituality. In J. C. Norcross & B. E. Wampold (Eds.), Psychotherapy relationships that work, Volume 2: Evidence- based therapist responsiveness (3rd ed., pp. 212–263). Oxford University Press. Kocet, M. M., & Herlihy, B. J. (2014). Addressing value-based conflicts within the counseling relationship: A decision- making model. Journal of Counseling & Development, 92(2), 180–186. Lee, C. C. (2019a). The cross-cultural encounter: Meeting the challenge of culturally competent counseling. In C. C. Lee (Ed.), Multicultural issues in counseling: New approaches to diversity (5th ed., pp. 15–21). American Counseling Association. Lee, C. C. (2019b). Multicultural competency: A conceptual framework for counseling across cultures. In C. C. Lee (Ed.), Multicultural issues in counseling: New approaches to diversity (5th ed., pp. 3–13). American Counseling Association. Lee, C. C. (Ed.). (2019c). Multicultural issues in counseling: New approaches to diversity (5th ed.). American Counseling Association. Norcross, J. C. (2005). The psychotherapist’s own psychotherapy: Educating and developing psychologists. American Psychologist, 60(8), 840–850. Norcross, J. C., & Cooper, M. (2021). Personalizing psychotherapy: Assessing and accommodating patient preferences. American Psychological Association.

Norcross, J. C., & Lambert, M. J. (2019a). Evidence-based psychotherapy relationships: The third task force. In J. C. Norcross & M. J. Lambert (Eds.), Psychotherapy relationships that work, Volume 1: Evidence-based therapist contributions (3rd ed., pp. 1–23). Oxford University Press. Norcross, J. C., & Lambert, M. J. (Eds.). (2019b). Psychotherapy relationships that work, Volume 1: Evidence-based therapist contributions (3rd ed.). Oxford University Press. Norcross, J. C., & Lambert, M. J. (2019c). What works in the psychotherapy relationship: Results, conclusions, and practices. In J. C. Norcross & M. J. Lambert (Eds.), Psychotherapy relationships that work, Volume 1: Evidence-based therapist contributions (3rd ed., pp. 631–646). Oxford University Press. Norcross, J. C., & VandenBos, G. R. (2018). Leaving it at the office: A guide to psychotherapist self-care (2nd ed.). Guilford Press. Norcross, J. C., & Wampold, B. E. (Eds.). (2019). Psychotherapy relationships that work, Volume 2: Evidence-based responsiveness (3rd ed.). Oxford University Press. Orlinsky, D. E., Norcross, J. C., Ronnestad, M. H., & Wiseman, H. (2005). Outcomes and impacts of the psychotherapists’ own psychotherapy. In J. D. Geller, J. C. Norcross, & D. E. Orlinsky (Eds.), The psychotherapist’s own psychotherapy: Patient and clinician perspectives (pp. 214–230). Oxford University Press. Pope, K. S., Vasquez, M. J. T., Chavez- Duenas, N. Y., & Adames, H. Y. (2021). Ethics in psychotherapy and counseling: A practical guide (6th ed.). Wiley. Ronnestad, M. H., Orlinsky, D. E., & Wiseman, H. (2016). Professional development and personal therapy. In J. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), APA handbook of clinical psychology (vol. 5, pp. 223–235). American Psychological Association. Skovholt, T. M., & Jennings, L. (2004). Master therapists: Exploring expertise in therapy and counseling. Pearson Education. Skovholt, T. M., & Trotter-Mathison, M. (2016). The resilient practitioner Burnout prevention and self-care strategies for the helping professions (3rd ed.). Routledge, Taylor & Francis.

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Soto, A., Smith, T. B., Griner, D., Domenech Rodriguez, M., & Bernal, G. (2018). Cultural adaptations and therapist multicultural competence: Two meta-analytic reviews. Journal of Clinical Psychology, 74(11), 1907–1903. Sperry, L., & Carlson, J. (2011). How master therapists work: Exploring change from the first through the last session and beyond. Routledge, Taylor & Francis.

Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards. A call to the profession. Journal of Counseling & Development, 70(4), 477–486. Sue, D. W., Sue, D., Neville, H. A., & Smith, L. (2022). Counseling the culturally diverse: Theory and practice (9th ed.). Wiley. Walsh, R. (2011). Lifestyle and mental health. American Psychologist, 66, 579–592.

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Erlbaum. Wise, E. H., & Barnett, J. E. (2016). Self- care for psychologists. In J. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), APA handbook of clinical psychology (vol. 5, pp. 209–222). American Psychological Association.

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Ethical Issues in Counseling Practice

1. Describe mandatory, aspirational, and positive ethics.

2. Identify characteristics and procedural steps of ethical decision making.

3. Explain the right of informed consent.

4. Articulate the dimensions of confidentiality (privacy, privileged communications, and exceptions).

5. Recognize the ethical and legal aspects of using technology.

6. Identify the major exceptions to confidentiality.

7. Discuss ethical issues from a multicultural perspective.

8. Recognize when it is necessary to modify techniques with diverse clients.

9. Identify some key ethical issues in assessment and diagnosis.

10. Explain how ethnic and cultural factors can influence assessment and diagnosis.

11. Compare arguments for and against evidence-based practice.

12. Describe ethical issues related to multiple relationships in counseling practice.

13. Discuss various perspectives on multiple relationships.

14. Explain the differences between a boundary crossing and a boundary violation.

15. Explain how to manage boundaries and risks associated with using social media.

16. Explain what is involved in becoming an ethical counselor.

Learning Objectives

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Introduction This chapter introduces some of the ethical principles and issues that will be a basic part of your professional practice. I hope to stimulate your thinking about the importance of ethical practice so you will have a sound foundation for making ethical decisions. Topics addressed include balancing clients’ needs against your own needs, ways of making good ethical decisions, educating clients about their rights, parameters of confidentiality, ethical concerns in counseling diverse client populations, and ethical issues involving diagnosis, evidence-based practice, and dealing with multiple relationships and managing boundaries.

Students sometimes think of ethics merely as a list of rules and prohibitions that result in sanctions and malpractice actions if practitioners do not follow them. You will learn that becoming an ethical practitioner is far more complex than a set of rules. Mandatory ethics involves a level of ethical functioning at the minimum level of professional practice. In contrast, aspirational ethics focuses on doing what is in the best interests of clients. Functioning at the aspirational level involves the high- est standards of thinking and conduct. Aspirational practice requires counselors to do more than simply meet the letter of the ethics code. It entails understanding the spirit of the code and the principles on which the code is based. Fear-based ethics does not constitute sound ethical practice. Ethics is more than a list of things to avoid for fear of punishment. Strive to work toward concern-based ethics, and think about how you can become the best practitioner possible (Corey et al., 2024). Positive ethics is an approach taken by practitioners who want to do their best for clients rather than simply meet minimum ethical and legal standards to stay out of trouble (Knapp & VandeCreek, 2012).

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Refer to the MindTap for this book to interact with video quizzes and various video programs to expand your knowledge on topics relevant to Chapter 3.

Putting Clients’ Needs Before Your Own As counselors we cannot always keep our personal needs completely separate from our relationships with clients. Ethically, it is essential that we become aware of our own needs, areas of unfinished business, potential personal problems, and espe- cially our sources of countertransference. We need to realize how such factors could interfere with effectively and ethically serving our clients.

Our professional relationships with our clients exist for their benefit. A use- ful question to frequently ask yourself is this: “Whose needs are being met in this relationship, my client’s or my own?” It takes considerable professional maturity to make an honest appraisal of how your behavior affects your clients. It is not unethi- cal for us to meet our personal needs through our professional work, but it is essen- tial that these needs be kept in perspective. An ethical problem exists when we meet our needs, in either obvious or subtle ways, at the expense of our clients’ needs. It is crucial that we avoid exploiting or harming clients.

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We all have certain blind spots and distortions of reality. As helping profes- sionals, we must actively work toward expanding our self-awareness and learn to recognize our areas of prejudice and vulnerability. If we are aware of our personal problems and are willing to work through them, there is less chance that we will project them onto clients. If certain problem areas surface and old conflicts become reactivated, we have an ethical obligation to do whatever it takes to avoid harming our clients.

We must also examine other less obviously harmful personal needs that can get in the way of creating growth-producing relationships, such as the need for con- trol and power; the inordinate need to be nurturing; the need to change others in the direction of our own values; the need for feeling adequate, particularly when it becomes overly important that the client confirm our competence; and the need to be respected and appreciated. It is crucial that we do not meet our needs at the expense of our clients. For an expanded discussion of this topic, see Becoming a Helper (M. Corey & Corey, 2021, chap. 1).

Ethical Decision Making The ready-made answers to ethical dilemmas provided by professional organizations typically contain only broad guidelines for responsible practice. In practice, you will have to apply the ethics codes of your profession to the many practical problems you face. Professionals are expected to exercise prudent judgment when it comes to interpreting and applying ethical principles to specific situations. Although you are responsible for making ethical decisions, you do not have to do so alone. Learn about the resources available to you. Consult with colleagues, keep yourself informed about laws affecting your practice, keep up to date in your specialty field, stay abreast of developments in ethical practice, reflect on the impact your values have on your practice, and be willing to engage in honest self-examination. You should also be aware of the consequences of practicing in ways that are not sanctioned by organiza- tions of which you are a member or the state in which you are licensed to practice.

The Role of Ethics Codes as a Catalyst for Improving Practice Professional codes of ethics serve a number of purposes. They educate counseling practitioners and the general public about the responsibilities of the profession. They provide a basis for accountability, and they protect clients from unethical practices. Perhaps most important, ethics codes provide a basis for reflecting on and improving your professional practice. Self-monitoring is a better route for pro- fessionals to take than being policed by an outside agency (Herlihy & Corey, 2015a).

From my perspective, an unfortunate recent trend is for ethics codes to increas- ingly take on legalistic, rule-based dimensions. Being an ethical practitioner involves far more than following a list of rules. Practitioners anxious to avoid any litigation may gear their practices mainly toward fulfilling legal minimums. If we are too concerned with being sued, it is unlikely that we will be very creative or effective in our work. It makes sense to be aware of the legal aspects of practice and to know and practice risk-management strategies, but we should not lose sight of what is best for our clients. One of the best ways to prevent being sued for malpractice is to

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Ethical Issues in Counsel ing Pract ice 47

demonstrate respect for clients, keep client welfare as a central concern, and practice within the framework of professional codes.

No code of ethics can delineate the appropriate or best course of action in each problematic situation a professional will face. In my view, ethics codes are best used as guidelines to formulate sound reasoning and serve practitioners in making the best judgments possible. A number of professional organizations and their websites are listed near the end of the chapter; each has its own code of ethics, which you can access through its website. Compare your professional organization’s code of ethics to several others to understand their similarities and differences.

Some Steps in Making Ethical Decisions Most models for ethical decision making focus on the application of principles to ethical dilemmas. My colleagues and I have identified a series of procedural steps to help you think through ethical problems when using these principles (Corey et al., 2024):

◆ Identify the problem or dilemma. Gather information that will shed light on the nature of the problem. This will help you decide whether the problem is mainly ethical, legal, professional, clinical, or moral.

◆ Identify the potential issues. Evaluate the rights, responsibilities, and welfare of all those who are involved in the situation.

◆ Look at the relevant ethics codes for general guidance on the matter. Consider whether your own values and ethics are consistent with or in conflict with the relevant guidelines.

◆ Consider the applicable laws and regulations, and determine how they may have a bearing on an ethical dilemma.

◆ Seek consultation from more than one source to obtain various per- spectives on the dilemma, and document in the client’s record the sug- gestions you received from this consultation.

◆ Brainstorm various possible courses of action. Continue discussing options with other professionals. Include the client in this process of considering options for action. Again, document the nature of this discussion with your client.

◆ Enumerate the consequences of various decisions, and reflect on the implications of each course of action for your client.

◆ Decide on what appears to be the best possible course of action. Once the course of action has been implemented, follow up to evaluate the outcomes and to determine whether further action is necessary. Docu- ment the reason for the actions you took as well as your evaluation measures.

In reasoning through any ethical dilemma, there is rarely just one course of action to follow, and practitioners may make different decisions. The more subtle the ethical dilemma, the more complex and demanding the decision-making pro- cess. Professional maturity implies that you are open to questioning and discussing your quandaries with colleagues. In seeking consultation, it is generally possible to protect the identity of your client and still get useful input that is critical to making

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sound ethical decisions. Because ethics codes do not make decisions for you, it is a good practice to demonstrate a willingness to explore various aspects of a prob- lem, raise questions, discuss ethical concerns with others, and continually clarify your values and examine your motivations. To the degree that it is possible, include the client in all phases of the ethical decision-making process. Again, it is essential to document how you included your client as well as the steps you took to ensure ethical practice.

The Right of Informed Consent Regardless of your theoretical framework, informed consent is an ethical and legal requirement that is an integral part of the therapeutic process. It also establishes a basic foundation for creating a working alliance and a collaborative partnership between the client and the therapist. Informed consent involves the right of clients to be informed about their therapy and to make autonomous decisions pertaining to it. Providing clients with information they need to make informed choices tends to promote the active cooperation of clients in their counseling plan. By educating your clients about their rights and responsibilities, you are both empowering them and building a trusting relationship with them. Seen in this light, informed con- sent is something far broader than simply making sure clients sign the appropriate forms. It is a positive approach that helps clients become active partners and true collaborators in their therapy.

Some aspects of the informed consent process include the general goals of coun- seling, the responsibilities of the counselor toward the client, the responsibilities of clients, limitations of and exceptions to confidentiality, legal and ethical parameters that could define the relationship, the qualifications and background of the prac- titioner, the fees involved, the services the client can expect, and the approximate length of the therapeutic process. Other areas might include the benefits of counsel- ing, the risks involved, and the possibility that the client’s case will be discussed with the therapist’s colleagues or supervisors.

There are a host of ways to violate a client’s privacy through the inappropri- ate use of various forms of modern-day technology. Most of us have become accus- tomed to relying on technology, and we need to give careful thought to the subtle ways client privacy can be compromised. As a part of the informed consent process, it is wise to discuss the potential privacy problems of using a wide range of technol- ogy and to take preventive measures to protect both you and your clients. For exam- ple, clients and counselors should carefully consider privacy issues before agreeing to send email or text messages to clients’ workplace or home. A good policy is to limit exchanges to basic information such as appointment times.

Educating the client begins with the initial counseling session, and this process will continue for the duration of counseling. The challenge of fulfilling the spirit of informed consent is to strike a balance between giving clients too much information and giving them too little. For example, it is too late to tell minors that you intend to consult with their parents after they have disclosed that they are considering an abortion. Young clients have a right to know about the limitations of confidential- ity before they make such highly personal disclosures. Clients can be overwhelmed,

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Ethical Issues in Counsel ing Pract ice 49

however, if counselors go into too much detail initially about the interventions they are likely to make. It takes both intuition and skill for practitioners to strike a balance.

Informed consent in counseling can be provided in written form, orally, or some combination of both. If it is done orally, therapists must make an entry in the cli- ent’s clinical record documenting the nature and extent of informed consent. It is a good idea to provide basic information about the therapy process in writing, as well as to discuss with clients topics that will enable them to get the maximum ben- efit from their counseling experience. Written information protects both clients and therapists and enables clients to think about the information and bring up ques- tions at the following session.

For a more complete discussion of informed consent and client rights, see Issues and Ethics in the Helping Professions (Corey et al., 2024, chap. 5), The Counselor and the Law: A Guide to Legal and Ethical Practice (Wheeler & Bertram, 2019, chap. 3), and Ethical, Legal, and Professional Issues in Counseling (Remley & Herlihy, 2020, chap. 4).

Dimensions of Confidentiality Confidentiality and privileged communication are two related but somewhat dif- ferent concepts. Both of these concepts are rooted in a client’s right to privacy. Confidentiality is an ethical concept, and in most states it is the legal duty of thera- pists not to disclose information about a client. Privileged communication is a legal concept that protects clients from having their confidential communications revealed in court without their permission (Herlihy & Corey, 2015a). All states have enacted into law some form of psychotherapist–client privilege, but the specifics of this privilege vary from state to state. These laws ensure that disclosures clients make in therapy will be protected from exposure by therapists in legal proceedings. Generally speaking, the legal concept of privileged communication does not apply to group counseling, couples counseling, family therapy, child and adolescent ther- apy, or whenever there are more than two people in the room.

Confidentiality is central to developing a trusting and productive client– therapist relationship. Because no genuine therapy can occur unless clients trust in the privacy of their revelations to their therapists, professionals have the responsibil- ity to define the degree of confidentiality that can be promised. Counselors have an ethical and legal responsibility to discuss the nature and purpose of confidentiality with their clients early in the counseling process. In addition, clients have a right to know that their therapist may be discussing certain details of the relationship with a supervisor or a colleague.

Ethical Concerns With the Use of Technology Issues pertaining to confidentiality and privacy can become more complicated when technology is involved. Section H of the ACA Code of Ethics (American Counsel- ing Association [ACA], 2014) contains the standards with regard to the use of tech- nology, relationships established through computer-mediated communication, and social media as a delivery platform. Major subsections address competency to

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50 Chapter Three

provide services and the laws associated with distance counseling, components of informed consent and security (confidentiality and its limitations), client verifica- tion, the distance counseling relationship (access, accessibility, and professional boundaries), maintenance of records, accessibility of websites, and the use of social media (Jencius, 2015).

Exceptions to Confidentiality and Privileged Communication Although most counselors agree on the essential value of confidentiality, they real- ize that other obligations may override this pledge. There are times when con- fidential information must be divulged, and there are many instances in which keeping or breaking confidentiality becomes a cloudy issue. In determining when to breach confidentiality, therapists must consider the requirements of the law, the institution in which they work, and the clientele they serve. Because these cir- cumstances are frequently not clearly defined by accepted ethics codes, counselors must exercise professional judgment.

Whenever counselors are not clear about their obligations regarding confiden- tiality or privileged communication, it is critical to seek consultation and to docu- ment these discussions. Remley and Herlihy (2020) identify various exceptions to confidentiality and privileged communication. There is a legal requirement to break confidentiality in cases involving child abuse, abuse of the elderly, abuse of depen- dent adults, and danger to self or others. All mental health practitioners and interns need to be aware of their duty to report in these situations and to know the limita- tions of confidentiality. Here are some other circumstances in which information must legally be reported by counselors:

◆ When the therapist believes a client under the age of 16 is the victim of incest, rape, child abuse, or some other crime

◆ When the therapist determines that the client needs hospitalization ◆ When information is made an issue in a court action ◆ When clients request that their records be released to them or to a third

party

In general, the counselor’s primary obligation is to protect client disclosures as a vital part of the therapeutic relationship. Informing clients about the limits of con- fidentiality does not necessarily inhibit successful counseling.

For a more complete discussion of confidentiality, see Issues and Ethics in the Help- ing Professions (Corey et al., 2024, chap. 6), The Counselor and the Law: A Guide to Legal and Ethical Practice (Wheeler & Bertram, 2019, chap. 5), and Ethical, Legal, and Profes- sional Issues in Counseling (Remley & Herlihy, 2020, chap. 5).

Ethical Issues From a Multicultural Perspective Ethical practice requires that we take the client’s cultural context into account in counseling practice. There is abundant evidence that supports the need to consider the culture of our clients and our cultural competence in our professional work, and not doing so can harm clients (Pope et al., 2021). In this section, we look at how

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Ethical Issues in Counsel ing Pract ice 51

it is possible for practitioners to practice unethically if they do not address cultural differences in counseling practice.

Are Current Theories Adequate in Working With Culturally Diverse Populations?

I believe current theories can be, and need to be, expanded to include a multicul- tural perspective. Assumptions made about mental health, optimum human devel- opment, the nature of psychopathology, and the nature of effective treatment may have little relevance for some clients. For traditional theories to be relevant in a multicultural and diverse society, they must incorporate an interactive person-in- the-environment focus. That is, individuals are best understood by taking into consideration salient cultural and environmental variables. It is important for ther- apists to create therapeutic strategies that are congruent with the range of values and behaviors that are characteristic of a pluralistic society.

Is Counseling Culture-Bound? Historically, therapists have relied on Western therapeutic models to guide their practice and to conceptualize problems that clients present in mental health set- tings. Western models of counseling have some limitations when applied to spe- cial populations and cultural groups such as Asian and Pacific Islanders, Latinx, Native Americans, and African Americans. Some multicultural writers have asserted that theories of counseling and psychotherapy represent different worldviews, each with its own values, biases, and assumptions about human behavior. Some of these approaches may not be applicable to clients from different racial, ethnic, and cul- tural backgrounds. Methods often need to be modified when working with clients from diverse cultural backgrounds (Sue et al., 2022).

Contemporary therapy approaches are grounded on a core set of values, which are neither value-neutral nor applicable to all cultures. For example, the values of individual choice and autonomy are not universal. In some cultures, the key values are collectivist, and primary consideration is given to what is good for the group. Regardless of the therapist’s orientation, it is crucial to listen to clients and deter- mine why they are seeking help and how best to deliver the help that is appropriate for them. Competent therapists understand themselves as social and cultural beings and possess at least a minimum level of knowledge and skill that they can bring to bear on any counseling situation. These practitioners understand what their clients need and avoid forcing clients into a preconceived mold.

Cultural diversity is a fact of life in our world. To the extent that counselors are focused on the values of the dominant culture and insensitive to variations among groups and individuals, they are at risk for practicing unethically (Barnett & Johnson, 2015). Counselors need to understand and accept clients who have a different set of assumptions about life, and they need to be alert to the possibility of imposing their own worldview. In working with clients from different cultural backgrounds and life experiences, it is important that counselors resist making value judgments for them. It is essential to be mindful of diversity and social justice issues if we are to practice ethically and effectively (Chung & Bemak, 2012; Lee, 2015, 2018, 2019).

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Focusing on Both Individual and Environmental Factors A theoretical orientation provides practitioners with a map to guide them in a pro- ductive direction with their clients. It is hoped that the theory orients them but does not control what they attend to in the therapeutic venture. Counselors who operate from a multicultural framework also have certain assumptions and a focus that guides their practice. They view individuals in the context of the family and the culture, and their aim is to facilitate social action that will lead to change within the client’s community rather than merely increasing the individual’s insight. Both multicultural practitioners and feminist therapists maintain that therapeutic prac- tice will be effective only to the extent that interventions are tailored toward social action aimed at changing those factors that are creating the problems of clients rather than blaming them for their condition (Chung & Bemak, 2012). These topics are developed in more detail in later chapters.

An adequate theory of counseling does deal with the social and cultural fac- tors of an individual’s problems. However, there is something to be said for help- ing clients deal with their response to environmental realities. Counselors may well be at a loss in trying to bring about social change when they are sitting with a cli- ent who is in pain because of social injustice. Using techniques from many of the traditional therapies, counselors can help clients increase their awareness of their options in dealing with barriers and struggles. However, it is necessary to focus on both individual and social factors if change is to occur, as the feminist, post- modern, and family systems approaches to therapy teach us. Indeed, the person-in- the-environment perspective acknowledges this interactive reality. For a more detailed treatment of the ethical issues in multicultural counseling, see Chung and Bemak (2012); Corey, Corey, and Corey (2024, chap. 4); and Lee (2019).

Ethical Issues in the Assessment Process Both clinical and ethical issues are associated with the use of assessment and diag- nostic procedures. As you will see when you study the various theories of counsel- ing, some approaches place heavy emphasis on the role of assessment as a prelude to the treatment process; other approaches find assessment less useful in this regard.

The Role of Assessment and Diagnosis in Counseling Assessment and diagnosis are integrally related to the practice of counseling and psychotherapy, and both are often viewed as a prerequisite for planning treatment. For some approaches, a comprehensive assessment of the client is the initial step in the therapeutic process. The rationale is that specific counseling goals cannot be formulated and appropriate treatment strategies cannot be designed until a client’s past and present functioning is understood. Regardless of their theoretical orienta- tion, therapists need to engage in assessment, which is generally an ongoing part of the therapeutic process. This assessment may be subject to revision as the clinician gathers additional data during therapy sessions. Some practitioners consider assess- ment as a part of the process that leads to a formal diagnosis.

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Assessment consists of evaluating the relevant factors in a client’s life to iden- tify themes for further exploration in the counseling process. Diagnosis, which is sometimes part of the assessment process, consists of identifying a specific mental disorder based on a pattern of symptoms. Both assessment and diagnosis can be understood as providing direction for the treatment process.

Diagnosis may include an explanation of the causes of the client’s difficulties, an account of how these problems developed over time, a classification of any dis- orders, a specification of preferred treatment procedure, and an estimate of the chances for a successful resolution. The purpose of diagnosis in counseling and psy- chotherapy is to identify disruptions in a client’s present behavior and lifestyle. Once problem areas are clearly identified, counselor and client are able to collaboratively establish the goals of the therapy process, and then a treatment plan can be tailored to the unique needs of the client. A diagnosis provides a working hypothesis that guides the practitioner in understanding the client. The therapy sessions provide useful clues about the nature of the client’s problems. Thus, diagnosis begins with the intake interview and continues throughout the duration of therapy.

Practitioners who favor the use of diagnostic procedures argue that these proce- dures enable the therapist to identify a particular emotional or behavioral disorder, which helps in designing an appropriate treatment plan. Diagnosis stems from the medical model of mental health, which holds that underlying causal factors, some of which are biological, produce different types of disorders.

A diagnosis is a label with no capacity to describe the totality of a human being. Therefore, it is important to learn how the specific diagnosis is expressed in a par- ticular client. Once formulated, a diagnosis may follow an individual even if the assigned diagnosis no longer fits the person.

Some clinicians view diagnosis as central to the counseling process, but oth- ers view it as unnecessary, as a detriment, or as discriminatory against people of color. As you will see when you study the therapeutic models in this book, some approaches do not use diagnosis as a precursor to treatment.

Considering Ethnic and Cultural Factors in Assessment and Diagnosis A danger of the diagnostic approach is the possible failure of counselors to consider ethnic and cultural factors in certain patterns of behavior. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) emphasizes the importance of being aware of unintentional bias and keeping an open mind to the presence of distinctive ethnic and cultural patterns that could influence the diagnostic process (American Psychiatric Association, 2013). It is crucial that clinicians consider cultural factors and how these may influence the client’s current behaviors, feelings, thoughts, and symptom presentation. Unless cultural variables are considered, some clients may be subjected to erroneous diagnoses. Certain behaviors and personality styles may be labeled neurotic or deviant simply because they are not characteristic of the dominant culture. Counselors who work with diverse client populations may erroneously conclude that a client is repressed, inhibited, passive, or unmotivated when in reality certain personality characteristics may be considered quite normal for a particular population.

The DSM-5 deals with a variety of disorders pertaining to developmental stages, learning and cognition, trauma, personality, substance abuse, moods, anxiety, sex

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and gender identity, eating, sleep, impulse control, and adjustment. The DSM-5 is based on a medical model of mental illness that defines problems as residing with the individual rather than in society. Critics argue that DSM diagnoses do not ade- quately consider contextual, social, and cultural factors, which may play a signifi- cant role in the problems of clients. The DSM system tends to pathologize clients, perpetuating the oppression of clients from diverse groups (Remley & Herlihy, 2020). Counselors need to think carefully before rendering a diagnosis and take into consideration the realities of discrimination, oppression, and racism in society and in the mental health disciplines.

Assessment and Diagnosis From Various Theoretical Perspectives The theory from which you operate will influence your thinking about the use of a diagnostic framework in your therapeutic practice. Many practitioners who use the cognitive behavioral approaches and the medical model place heavy emphasis on the role of assessment as a prelude to the treatment process. The rationale is that specific therapy goals cannot be designed until a clear picture emerges of the client’s past and present functioning. In addition, progress, change, improvement, or success may be difficult to evaluate without an initial assessment. Counselors who base their practice on the relationship-oriented approaches tend to view the process of assessment and diagnosis as external to the immediacy of the client–counselor relationship and believe it may impede their understanding of the subjective world of the client. As you will see in Chapter 12, feminist therapists contend that traditional diagnostic practices are often oppressive and that such practices are based on a White, male-centered, Western notion of mental health and mental illness. Both the feminist perspective and the postmodern approaches (see Chapter 13) charge that these diagnoses ignore societal contexts. Therapists with a feminist, social constructionist, solution-focused, or narrative therapy orientation challenge many DSM-5 diagnoses. However, these practitioners do make assessments and draw conclusions about client problems and strengths.

Regardless of your theoretical orientation, you will most likely be expected to work within the DSM framework if you are practicing in a community mental health agency or in any other agency in which insurance companies pay for psychological services. These organizations will require client assessment and diagnosis, so you need to become familiar with the diagnostic categories and the structure of the DSM-5. In short, you will need to develop competence in utilizing diagnostic proce- dures to function effectively in most mental health agencies.

A Commentary on Assessment and Diagnosis Most practitioners and many writers in the field consider assessment and diagnosis to be a continuing process that focuses on understanding the client. The collaborative perspective that involves the client as an active participant in the therapy process implies that both the therapist and the client are engaged in a search-and-discovery process from the first session to the last. Even though some practitioners may avoid formal diagnostic procedures and terminology, making tentative hypotheses and sharing them with clients throughout the process is a form of ongoing assessment and diagnosis. This perspective on assessment and diagnosis is consistent with the principles of feminist therapy, an approach that is critical of traditional diagnostic procedures.

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Ethical dilemmas may be created when diagnosis is done strictly for insurance purposes, which often entails arbitrarily assigning a client to a diagnostic classifica- tion. However, it is a clinical, legal, and ethical obligation of therapists to screen cli- ents for life-threatening problems such as organic disorders, schizophrenia, bipolar disorder, and suicidal types of depression. Students need to learn the clinical skills necessary to do this type of screening, which is a form of diagnostic thinking.

It is useful to assess the whole person, which includes assessing dimensions of mind, body, and spirit. Therapists need to take biological processes into account as possible underlying factors of psychological symptoms and work closely with phy- sicians when necessary. However, clients’ values can be instrumental resources in the search for solutions to their problems, and spiritual and religious values often illuminate client concerns.

For a more detailed discussion of assessment and diagnosis in counseling prac- tice as it is applied to a single case, consult Case Approach to Counseling and Psychotherapy (Corey, 2013), in which theorists from 12 different theoretical orientations share their diagnostic perspectives on the case of Ruth. For a comprehensive review of the changes in the DSM-5, see DSM-5 Learning Companion for Counselors (Dailey et al., 2014).

Ethical Aspects of Evidence-Based Practice Mental health practitioners are faced with the task of choosing the best interven- tions with a particular client. For many practitioners, this choice is based on their theoretical orientation. In recent years, however, a shift has occurred toward promot- ing the use of specific interventions for particular problems or diagnoses based on empirically supported treatments (APA Presidential Task Force on Evidence-Based Practice, 2006; Cukrowicz et al., 2005; Deegear & Lawson, 2003; Edwards et al., 2004).

This trend toward specific, empirically supported treatment is referred to as evidence-based practice (EBP): “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (APA Presidential Task Force on Evidence-Based Practice, 2006, p. 273). Increasingly, those practitioners who work in a behavioral health care system must cope with the challenges associated with evidence-based practice. Norcross, Hogan, Koocher, and Maggio (2017) advocate for inclusive evidence-based practices that incorporate the three pillars of EBP: (1) looking for the best available research, (2) relying on clinical expertise, and (3) taking into consideration the client’s characteristics, culture, and preferences. Evidence-based practices tend to emphasize only one of these aspects— interventions based on the best available research.

Abundant psychotherapy research consistently reveals that the client, the therapist, their relationship, the therapist’s personality and therapeutic style, the treatment method, and the context all contribute to treatment success or failure (Norcross & Lambert, 2019a). The central aim of evidence-based practice is to require psychotherapists to base their practice on techniques that have empirical evidence to support their efficacy. Research studies empirically analyze the most effective and efficient treatments, which then can be widely implemented in clini- cal practice (Norcross et al., 2006). Although evidence-based treatment methods are given prominence in current practice, these treatment methods do not overshadow

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the central role of the therapeutic relationship. Norcross and Lambert (2019b) note: “Efforts to promulgate best practices and evidence-based treatments without including the relationship and responsiveness are seriously incomplete and poten- tially misleading” (p. 631). Norcross and Lambert conclude that the psychotherapy relationship makes substantial and consistent contributions to therapy outcomes independent of the specific type of psychological treatment. They emphasize that the best outcomes in psychotherapy depend on concurrently using both evidence- based treatments and evidence-based relationships.

In many mental health settings, clinicians are pressured to use interventions that are both brief and standardized. In such settings, treatments are operational- ized by reliance on a treatment manual that identifies what is to be done in each therapy session and how many sessions will be required (Edwards et al., 2004). Many practitioners believe this approach is mechanistic and does not take into full consid- eration the relational dimensions of the psychotherapy process and individual vari- ability. Indeed, relying exclusively on standardized treatments for specific problems may raise another set of ethical concerns because the reliability and validity of these empirically based techniques is questionable.

Human change is complex and difficult to measure beyond such a simplis- tic level that the change may be meaningless. Furthermore, not all clients come to therapy with clearly defined psychological disorders. Many clients have existential concerns that do not fit with any diagnostic category and do not lend themselves to clearly specified symptom-based outcomes. EBP may have something to offer mental health professionals who work with individuals with specific emotional, cognitive, and behavioral disorders, but it does not have a great deal to offer practitioners work- ing with individuals who want to pursue more meaning and fulfillment in their lives.

Norcross, Hogan, Koocher, and Maggio (2017) contend that the call for account- ability in mental health care is here to stay and that all mental health professionals are challenged by the mandate to demonstrate the efficiency, efficacy, and safety of the services they provide. They emphasize that the overarching goal of EBP is to enhance the effectiveness of client services and to improve public health, and they warn that mental health professionals need to take a proactive stance to make sure this goal is kept in focus. They realize there is potential for misuse and abuse by third-party payers who could selectively use research findings as cost-containment measures rather than ways of improving the quality of services delivered.

For further reading on the topic of evidence-based practice, I recommend Clini- cian’s Guide to Evidence-Based Practices: Behavioral Health and Addictions (Norcross et al., 2017). For an excellent book that demonstrates the ethics of assessing and accommo- dating client preferences, see Personalizing Psychotherapy (Norcross & Cooper, 2021).

Managing Multiple Relationships in Counseling Practice Dual or multiple relationships, either sexual or nonsexual, occur when counselors assume two (or more) roles simultaneously or sequentially with a client. This may involve assuming more than one professional role or combining professional and nonprofessional roles. The term multiple relationship is more often used than the term dual relationship because of the complexities involved in these relationships, but both

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terms appear in various professional codes of ethics, and the ACA (2014) uses the term nonprofessional relationships. In this section, I use the broader term of multiple rela- tionships to encompass both dual relationships and nonprofessional relationships.

When clinicians blend their professional relationship with another kind of relationship with a client, ethical concerns must be considered. Many forms of nonprofessional interactions or nonsexual multiple relationships pose a challenge to practitioners. Some examples of nonsexual dual or multiple relationships are combining the roles of teacher and therapist or of supervisor and therapist; bartering for goods or therapeutic services; borrowing money from a client; providing therapy to a friend, an employee, or a relative; engaging in a social relationship with a cli- ent; accepting an expensive gift from a client; or going into a business venture with a client.

Some multiple relationships are clearly exploitative and do serious harm both to the client and to the professional. For example, becoming emotionally or sexually involved with a current client is clearly unethical, unprofessional, and in many states it is illegal. Sexual involvement with a former client is unwise, can be exploitative, and is generally considered unethical. The argument can be made that a lifelong prohi- bition of sexual relations with ex-clients is warranted because of the ongoing power differential and the transference/countertransference dynamics between the par- ties, and the psychological damage that is possible long after treatment has ended (Levine & Courtois, 2021).

The subject of sexual boundary violations in psychotherapy is addressed from many perspectives by Steinberg, Alpert, and Courtois (2021) in their book devoted to therapist indiscretions, transgressions, and misconduct. These authors main- tain that sexual contact between a therapist and a client is regarded as unethical and morally and ethically wrong by all major mental health and medical profes- sions. However, they caution that despite these ethical and legal prohibitions, sexual boundary violations are still taking place, and they may have increased. The harm of sexual boundary violations extends beyond the victims to family members, col- leagues, institutions, and to the profession at large (Gomez et al., 2021).

Although sexual relationships in psychotherapy are never justified and are clearly harmful, nonsexual multiple relationships are complex and multidimen- sional, which makes simple and absolute solutions unrealistic. It is not always pos- sible to play a single role in your work as a counselor, nor is it always desirable. You may have to deal with managing multiple roles, regardless of the setting in which you work or the client population you serve. It is wise to give careful thought to the complexities of multiple roles and relationships before embroiling yourself in an ethically questionable situation.

Ethical reasoning and judgment come into play when ethics codes are applied to specific situations. The ACA Code of Ethics (ACA, 2014) makes it clear that counsel- ing professionals must learn how to manage multiple roles and responsibilities in an ethical way. This entails dealing effectively with the power differential that is inherent in counseling relationships and training relationships, balancing boundary issues, addressing nonprofessional relationships, and striving to avoid using power in ways that might cause harm to clients, students, or supervisees (Herlihy & Corey, 2015b).

Although multiple relationships do carry inherent risks, it is a mistake to con- clude that these relationships are always unethical and necessarily lead to harm

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and exploitation. Some of these relationships can be beneficial to clients if they are implemented thoughtfully and with integrity (Zur, 2007, 2017).

Perspectives on Multiple Relationships What makes multiple relationships so problematic? Herlihy and Corey (2015b) con- tend that some of the problematic aspects of engaging in multiple relationships are that they are pervasive; they can be difficult to recognize; they are unavoidable at times; they are potentially harmful, but not necessarily always harmful; they can be beneficial; and they are the subject of conflicting advice from various experts. A review of the literature reveals that dual and multiple relationships are hotly debated. Except for sexual intimacy with current clients, which is unequivocally unethical, there is not much consensus regarding the appropriate way to deal with multiple relationships.

Some of the codes of the professional organizations advise against forming multiple relationships, mainly because of the potential for misusing power, exploit- ing the client, and impairing objectivity. When multiple relationships exploit clients, or have significant potential to harm clients, they are unethical. The ethics codes do not mandate avoidance of all such relationships, however; nor do the codes imply that nonsexual multiple relationships are unethical. The current focus of ethics codes is to remain alert to the possibilities of harm to clients and to develop safe- guards to protect clients. Although codes can provide some general guidelines, good judgment, the willingness to reflect on one’s practices, and being aware of one’s motivations are critical dimensions of an ethical practitioner. It bears repeating that multiple relationship issues cannot be resolved with ethics codes alone; counselors must think through all of the ethical and clinical dimensions involved in a wide range of boundary concerns.

A consensus of many writers is that multiple relationships are inevitable and unavoidable in some situations and that a global prohibition is not a realistic answer. Because interpersonal boundaries are not static but undergo redefinition over time, the challenge for practitioners is to learn how to manage boundary fluctuations and to deal effectively with overlapping roles (Herlihy & Corey, 2015b). One key to learning how to manage multiple relationships is to think of ways to minimize the risks involved.

Ways of Minimizing Risk In determining whether to proceed with a multiple relationship, it is critical to consider whether the potential benefit to the client of such a relationship outweighs its potential harm. Some relationships may have more potential benefits to clients than potential risks. It is your responsibility to develop safeguards aimed at reducing the potential for negative consequences. Herlihy and Corey (2015b) identify the following guidelines:

◆ Set healthy boundaries early in the therapeutic relationship. Informed consent is essential from the beginning and throughout the therapy process.

◆ Involve clients in ongoing discussions and in the decision-making process, and document your discussions. Discuss with your clients what you expect of them and what they can expect of you.

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◆ Consult with fellow professionals as a way to maintain objectivity and identify unanticipated difficulties. Realize that you don’t need to make a decision alone.

◆ When multiple relationships are potentially problematic, or when the risk for harm is high, it is always wise to work under supervision. Document the nature of this supervision and any actions you take in your records.

◆ Self-monitoring is critical throughout the process. Ask yourself whose needs are being met and examine your motivations for considering becoming involved in a dual or multiple relationship.

In working through a multiple relationship concern, it is best to begin by ascer- taining whether such a relationship can be avoided. Zur (2017) notes that multiple relationships cannot always be avoided, especially in small towns. Nor should every multiple relationship be considered unethical. However, when a therapist’s objectiv- ity and competence are compromised, the therapist may find that personal needs surface and diminish the quality of the therapist’s professional work. Sometimes multiple relationships are avoidable and your involvement would put the client needlessly at risk. In other cases, such relationships are unavoidable. One way of dealing with any potential problems is to adopt a policy of completely avoiding any kind of nonprofessional interaction. As a general guideline, it is probably best to avoid multiple relationships to the extent this is possible. Therapists should docu- ment precautions taken to protect clients when such relationships are unavoidable. Another alternative is to deal with each dilemma as it develops, making full use of informed consent and at the same time seeking consultation and supervision in dealing with the situation. This second alternative includes a professional require- ment for self-monitoring. It is one of the hallmarks of professionalism to be willing to grapple with these ethical complexities of day-to-day practice.

Two excellent resources on the ethical and clinical dimensions of multiple rela- tionships are Boundaries in Psychotherapy: Ethical and Clinical Explorations (Zur, 2007) and Multiple Relationships in Psychotherapy and Counseling: Unavoidable, Common, and Mandatory Dual Relations in Therapy (Zur, 2017).

Establishing Personal and Professional Boundaries Establishing and main- taining consistent yet flexible boundaries is necessary if you are to effectively counsel clients. If you have difficulty establishing and maintaining boundaries in your personal life, you are likely to find that you will have difficulty when it comes to managing boundaries in your professional life. If you are successful in establishing boundaries in various aspects of your personal life, you have a good foundation for creating sound boundaries with clients. Developing appropriate and effective boundaries in your counseling practice is the first step to learning how to manage multiple relationships.

One important aspect of maintaining appropriate professional boundaries is to recognize boundary crossings and prevent them from becoming boundary vio- lations. A boundary crossing is a departure from a commonly accepted practice that could potentially benefit a client. For example, attending the wedding of a client may be extending a boundary, but it could be beneficial for the client. In contrast, a

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boundary violation is a serious breach that harms the client and is therefore uneth- ical. A boundary violation is a boundary crossing that takes the practitioner out of the professional role, generally involves exploitation, and results in harm to a client (Gutheil & Brodsky, 2008). Flexible boundaries can be useful in the counseling pro- cess when applied ethically. Some boundary crossings pose no ethical problems and may enhance the counseling relationship. Other boundary crossings may lead to a pattern of blurred professional roles and become problematic.

Social Media and Boundaries Kolmes (2017) writes that multiple roles and relationships between clients and therapists are becoming increasingly common online. These multiple relationships include social, professional, and business relationships, and all of them present new challenges for a therapist. From an ethical perspective, it is critical to understand the nature of these multiple relationships, when they may become problematic, and when they are a part of the therapeutic process. Kolmes asserts that multiple relationships via social media and the Internet potentially have both positive and negative impacts: “Some multiple relationships may be beneficial to the therapeutic relationship if they are well managed by a sensitive and thoughtful clinician. They can even offer opportunities to enhance the clinical relationship. Other multiple roles may erode the therapy relationship in a variety of ways” (pp. 186–187). The challenge is for practitioners who participate in social media with clients to develop a social media policy. Kolmes claims that a policy statement can reduce confusion and provide clients with guidelines pertaining to social media. “Simply thinking through your policies to create such a document offers the opportunity to review your ethics code and explore your own thinking on what you want your approach to be” (p. 192).

Spotts-De Lazzer (2012) believes practitioners will have to translate and maintain traditional ethics when it comes to social media and offers these recommendations:

◆ Include clear and thorough social networking policies as part of the informed consent process.

◆ Limit what is shared online. ◆ Regularly update protective settings because social media providers

often change their privacy rules.

To avoid inappropriate multiple relationships, Reamer (2021) recommends that practitioners create separate personal and professional social media and web- sites that establish clear boundaries. Increasingly, clients or former clients want to become friends with their counselor via the Internet. Reamer states that it is not unusual for a mental health professional to receive a “friend request” from a client or former client. As a way to minimize becoming embroiled in boundary violations in the use of technology, Reamer suggests that clinicians develop a social media pol- icy and review it with their clients. A typical social media policy informs clients that their therapist cannot become their “friend” on social networking sites, explaining that it is of the utmost importance to maintain clear professional boundaries.

The advent of digital technology has introduced unprecedented ethical and risk-management challenges involving multiple relationships and boundaries. Reamer (2021) states that the use of digital technology poses a host of ethical issues related to the blending of boundaries in both clients’ and therapists’ personal and

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professional lives. Counselors are advised to seriously consider these changes in the complex intersection between privacy and boundaries. The digital age has brought novel boundary-related risks and perils, as well as many potential advantages to con- sumers of behavioral health services. Reamer agrees that digital technology in the mental health field is here to stay, and he asserts that “clinicians must make delib- erate ethical decisions about how to use technology in ways that maintain clear, ethical, professional client boundaries” (p. 187).

As social media use continues to spread, the ACA Code of Ethics (ACA, 2014) emphasizes the need for counselors to develop a social media policy and to include that in their informed consent discussions. The virtual relationship between coun- selor and client and how counselors can safely maintain a virtual presence are emphasized in ACA’s revised code (Jencius, 2015).

Becoming an Ethical Counselor Knowing and following your profession’s code of ethics is part of being an ethi- cal practitioner, but these codes do not make decisions for you. As you become involved in counseling, you will find that interpreting the ethical guidelines of your professional organization and applying them to particular situations demand the utmost ethical sensitivity. Even responsible practitioners differ over how to apply established ethical principles to specific situations. In your professional work, you will deal with questions that do not always have obvious answers. You will have to assume responsibility for deciding how to act in ways that will further the best interests of your clients.

Throughout your professional life, you will need to reexamine the ethical ques- tions raised in this chapter. You can benefit from both formal and informal oppor- tunities to discuss ethical dilemmas during your training program. Even if you resolve some ethical matters while completing a graduate program, there is no guar- antee that these matters have been settled once and for all. These topics are bound to take on new dimensions as you gain more experience. Oftentimes students burden themselves unnecessarily with the expectation that they should resolve all potential ethical problem areas before they begin to practice. Throughout your professional life, seek consultation from trusted colleagues and supervisors whenever you face an ethical dilemma. Ethical decision making is an evolutionary process that requires you to be continually open and self-reflective. Becoming an ethical practitioner is not a final destination but a journey that will continue throughout your career.

Summary It is essential that you learn a process for thinking about and dealing with ethical dilemmas, keeping in mind that most ethical issues are complex and defy simple solutions. A sign of good faith is your willingness to share your struggles with col- leagues. Such consultation can be helpful in clarifying issues by giving you another perspective on a situation. New issues are constantly surfacing, and positive eth- ics demands periodic reflection and an openness to change on the part of the practitioner.

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If one fundamental question can tie together all of the issues discussed in this chapter, it is this: “Who has the right to counsel another person?” This question can be the focal point of your reflection on ethical and professional issues. It also can be the basis of your self-examination each day that you meet with clients. Continue to ask yourself: “What makes me think I have a right to counsel others?” “What do I have to offer the people I’m counseling?” “Am I doing in my own life what I’m encouraging my clients to do?” At times, you may feel that you have no ethical right to counsel others, perhaps because your own life isn’t always the model you would like it to be for your clients. More important than resolving all of life’s issues is knowing what kinds of questions to ask and remaining open to reflection.

This chapter has introduced you to a number of ethical issues that you are bound to face at some point in your counseling practice. I hope your interest has been piqued and that you will want to learn more. For additional information on this important topic, I recommend Issues and Ethics in the Helping Professions (Corey et al., 2024) and Ethics in Psychotherapy and Counseling: A Practical Guide (Pope et al., 2021).

Self-Reflection and Discussion Questions 1. If you are facing an ethical dilemma, what steps would you take to

resolve this dilemma? 2. Informed consent is both a legal and an ethical requirement that is an inte-

gral part of the therapeutic process. What specific aspects of informed con- sent would you want to address with your clients at the initial session?

3. Ethical practice involves taking the client’s cultural context into con- sideration regardless of your theoretical orientation. How would you incorporate cultural factors into your counseling practice?

4. What challenges might you encounter in conducting an assessment and rendering a diagnosis with clients?

5. Multiple relationships are not necessarily unethical and at times may be beneficial to a client. What guidelines would you consider in determining whether to proceed with a multiple relationship or avoid the relationship?

Where to Go From Here The following professional organizations provide helpful information about what each group has to offer, including the code of ethics for the organization.

3. Commission on Rehabilitation Counselor Certification (CRCC): Code of Professional Ethics for Rehabilitation Counselors, © 2017 Visit www.crccertification.com for more information on this organization.

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17. British Association for Counselling and Psychotherapy (BACP): Ethical Framework for Good Practice in Counselling and Psychotherapy, © 2013 Visit www.bacp.co.uk for more information on this organization.

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Recommended Supplementary Readings for Chapter 3 The Counselor and the Law: A Guide to Legal and Ethical Practice (Wheeler & Bertram, 2019) offers a comprehensive overview of the law as it pertains to counseling practice. It highlights ethical and legal responsibilities of counselors and identifies risk- management strategies.

Ethics in Psychotherapy and Counseling: A Practical Guide (Pope, Vasquez, Chavez-Duenas, & Adames, 2021) presents in clear fashion a wide range of top- ics in professional ethics, including ethics in real life, pitfalls in ethical judgment, therapists in a virtual world, creating a professional will, sexual attraction to clients, nonsexual multiple relationships, and using strategies for self-care.

Ethics Desk Reference for Counselors (Barnett & Johnson, 2015) is a practical guide to understanding and applying the ACA Code of Ethics. This reference book is easy to read, interesting, and has appeal for both students and practitioners.

ACA Ethical Standards Casebook (Herlihy & Corey, 2015a) contains a variety of useful cases and essays that are geared to the ACA Code of Ethics. The exam- ples illustrate and clarify the meaning and intent of the ethical standards.

Boundary Issues in Counseling: Multiple Roles and Responsibilities (Herlihy & Corey, 2015b) puts the multiple relationship controversy into perspective. The book focuses on dual relationships in a variety of work settings.

Multiple Relationships in Psychotherapy and Counsel- ing: Unavoidable, Common, and Mandatory Dual Rela- tions in Therapy (Zur, 2017) presents the thoughts of 26 contributors on various dimensions of multiple relationships, including mandatory multiple rela- tionships in military, police, and forensic settings; unavoidable contacts in rural practice; multiple relationships in faith communities; multiple rela- tionships in educational settings; digital and social media multiple relationships; risk management challenges in a digital world; and multiple relation- ships in clinical supervision.

Issues and Ethics in the Helping Professions (Corey, Corey, & Corey, 2024) is devoted entirely to the issues introduced briefly in this chapter. Designed to involve readers in a personal and active way, open- ended cases are presented that ask readers to formu- late their own thoughts on a wide range of ethical issues.

References American Counseling Association. (2014). ACA code of ethics. https://www .counseling.org/resources/aca-code-of -ethics.pdf American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books .9780890425596 American Psychological Association Presidential Task Force on Evidence- Based Practice. (2006). Evidence- based practice in psychology. American Psychologist, 61, 271–285. Barnett, J. E., & Johnson, W. B. (2015). Ethics desk reference for counselors (2nd ed.). American Counseling Association. Chung, R. C-Y., & Bemak, F. (2012). Social justice counseling: The next step beyond multiculturalism. SAGE.

Corey, G. (2013). Case approach to counseling and psychotherapy (8th ed.). Brooks/Cole, Cengage Learning. Corey, G., Corey, M., & Corey, C. (2024). Issues and ethics in the helping professions (11th ed.). Cengage Learning. Corey, M., & Corey, G. (2021). Becoming a helper (8th ed.). Cengage Learning. Cukrowicz, K. C., White, B. A., Reitzel, L. R., Burns, A. B., Driscoll, K. A., Kemper, T. S., & Joiner, T. E. (2005). Improved treatment outcome associated with the shift to empirically supported treatments in a graduate training clinic. Professional Psychology: Research and Practice, 36(3), 330–337. Dailey, S. F., Gill, C. S., Karl, S. L., & Minton, C. A. B. (2014). DSM-5 learning companion for counselors. American Counseling Association.

Deegear, J., & Lawson, D. M. (2003). The utility of empirically supported treatments. Professional Psychology: Research and Practice, 34(3), 271–277. Edwards, J. A., Dattilio, F. M., & Bromley, D. B. (2004). Developing evidence-based practice: The role of case- based research. Professional Psychology: Research and Practice, 35(6), 589–597. Gomez, J. M., Noll, L. R., Adams-Clark, A. A., & Courtois, C. A. (2021). When colleagues betray. In A. Steinberg, J. L. Alpert, & C. A. Courtois (Eds.), Sexual boundary violations in psychotherapy: Facing therapist indiscretions, transgressions, and misconduct (pp. 297–315). American Psychological Association. Gutheil, T. G., & Brodsky, A. (2008). Preventing boundary violations in clinical practice. Guilford Press.

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Herlihy, B., & Corey, G. (2015a). ACA ethical standards casebook (7th ed.). American Counseling Association. Herlihy, B., & Corey, G. (2015b). Boundary issues in counseling: Multiple roles and responsibilities (3rd ed.). American Counseling Association. Jencius, M. (2015). Technology, social media, and online counseling. In B. Herlihy & G. Corey (Eds.), ACA ethical standards casebook (7th ed., pp. 245–258). American Counseling Association. Kolmes, K. (2017). Digital and social media multiple relationships on the Internet. In O. Zur (Ed.), Multiple relationships in psychotherapy and counseling: Unavoidable, common, and mandatory dual relations in therapy (pp. 185–195). Routledge, Taylor & Francis. Knapp, S. J., & VandeCreek, L. (2012). Practical ethics for psychologists: A positive approach (2nd ed.). American Psychological Association. Lee, C. C. (2015). Social justice and counseling across cultures. In B. Herlihy & G. Corey, ACA ethical standards casebook (7th ed., pp. 155–168). American Counseling Association. Lee, C. C. (Ed.). (2018). Counseling for social justice (3rd ed.). American Counseling Association Foundation. Lee, C. C. (Ed.). (2019). Multicultural issues in counseling: New approaches to diversity (5th ed.). American Counseling Association. Levine, S. B., & Courtois, C. A. (2021). Boundaries and ethics of professional

conduct. In A. Steinberg, J. L. Alpert, & C. A. Courtois (Eds.), Sexual boundary violations in psychotherapy: Facing therapist indiscretions, transgressions, and misconduct (pp. 45–65). American Psychological Association. Norcross, J. C., Beutler, L. E., & Levant, R. F. (2006). Evidence-based practices in mental health: Debate and dialogue on the fundamental questions. American Psychological Association. Norcross, J. C., & Cooper, M. (2021). Personalizing psychotherapy: Assessing and accommodating patient preferences. American Psychological Association. Norcross, J. C., Hogan, T. P., Koocher, G. P., & Maggio, L. A. (2017). Clinician’s guide to evidence-based practices: Behavioral health and addictions (2nd ed.). Oxford University Press. Norcross, J. C., & Lambert, M. J. (2019a). Evidence-based psychotherapy relationships: The third task force. In J. C. Norcross & M. J. Lambert (Eds.), Psychotherapy relationships that work, Volume 1: Evidence-based therapist contributions (3rd ed., pp. 1–23). Oxford University Press. Norcross, J. C., & Lambert, M. J. (2019b). What works in the psychotherapy relationship: Results, conclusions, and practices. In J. C. Norcross & M. J. Lambert (Eds.), Psychotherapy relationships that work, Volume 1: Evidence-based therapist contributions (3rd ed., pp. 631–646). Oxford University Press. Pope, K. S., Vasquez, M. J. T., Chavez- Duenas, N. Y., & Adames, H. Y. (2021).

Ethics in psychotherapy and counseling: A practical guide (6th ed.). Wiley. Reamer, F. G. (2021). Sexual boundary violations in the digital age: New frontiers and emerging challenges. In A. Steinberg, J. L. Alpert, & C. A. Courtois (Eds.), Sexual boundary violations in psychotherapy: Facing therapist indiscretions, transgressions, and misconduct (pp. 185–201). American Psychological Association. Remley, T. P., & Herlihy, B. (2020). Ethical, legal, and professional issues in counseling (6th ed.). Pearson. Spotts-De Lazzer, A. (2012). Facebook for therapists: Friend or unfriend? The Therapist, 24(5), 19–23. Steinberg, A., Alpert, J. L., & Courtois, C. A. (Eds.). (2021). Sexual boundary violations in psychotherapy: Facing therapist indiscretions, transgressions, and misconduct. American Psychological Association. Sue, D. W., Sue, D., Neville, H. A., & Smith, L. (2022). Counseling the culturally diverse: Theory and practice (9th ed.). Wiley. Wheeler, A. M., & Bertram, B. (2019). The counselor and the law: A guide to legal and ethical practice (8th ed.). American Counseling Association. Zur, O. (2007). Boundaries in psychotherapy: Ethical and clinical explorations. American Psychological Association. Zur, O. (Ed.). (2017). Multiple relationships in psychotherapy and counseling: Unavoidable, common, and mandatory dual relations in therapy. Routledge, Taylor & Francis.

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4 Psychoanalytic Therapy

1. Explain the Freudian deterministic view of human nature.

2. Identify the differences between the id, ego, and superego.

3. Explain how ego-defense mechanisms help individuals cope with anxiety.

4. Discuss the influence of early childhood development on an individual’s present problems.

5. Identify the main differences between classical psychoanalysts and ego psychology theorists.

6. Explain the rationale for the analyst maintaining an anonymous role in classical psychoanalysis.

7. Identify what is expected of clients who participate in traditional (classical) psychoanalysis.

8. Explain the role of transference and countertransference in the therapy process.

9. Define these techniques commonly used in psychoanalytic practice: maintaining the analytic framework,

free association, interpretation, dream analysis, and analysis and interpretation of resistance and transference.

10. Explain the application of psychodynamic concepts to group therapy.

11. Discuss the application of the psychoanalytic approach to school counseling.

12. Describe unique characteristics of the Jungian perspective on personality development.

13. Describe these contemporary trends in psychoanalytically oriented therapy: object-relations theory, self psychology, and relational psychoanalysis.

14. Identify some of the strengths and the shortcomings of psychoanalysis from a multicultural perspective.

15. Describe some of the main contributions and limitations of psychodynamic therapy.

Learning Objectives

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Introduction Freud’s views continue to influence contemporary practice. Many of his basic con- cepts are still part of the foundation on which other theorists build and develop their ideas. Indeed, most of the theories of counseling and psychotherapy discussed in this book have been influenced by psychoanalytic principles and techniques. Some of these therapeutic approaches extended the psychoanalytic model, others modified its concepts and procedures, and others emerged as a reaction against it.

Freud’s psychoanalytic system is a model of personality development and an approach to psychotherapy. He gave psychotherapy a new look and new horizons, calling attention to psychodynamic factors that motivate behavior, focusing on the role of the unconscious, and developing the first therapeutic procedures for under- standing and modifying the structure of one’s basic character. Freud’s theory is a benchmark against which many other theories are measured.

I begin with discussion of the basic psychoanalytic concepts and practices that originated with Freud, then provide a glimpse of a few of the diverse approaches that fall well within his legacy. We are in an era of theoretical pluralism in psy- choanalytic theory today and can no longer speak of the psychoanalytic theory of treatment (Wolitzky, 2011). Both psychoanalysis and its more flexible variant,

Sigmund Freud (1856–1939) was the firstborn in a Viennese family of three boys and five girls. His father, like many oth- ers of his time and place, was very authoritarian. Freud’s family background is a factor to consider in understand- ing the development of his theory.

Even though Freud’s family had limited finances and was forced to live in a crowded

apartment, his parents made every effort to foster his obvious intellectual capacities. Freud had many inter- ests, but his career choices were restricted because of his Jewish heritage. He finally settled on medicine. Only four years after earning his medical degree from the University of Vienna at the age of 26, he attained a prestigious position there as a lecturer.

Freud devoted most of his life to formulating and extending his theory of psychoanalysis, and the most creative phase of his life corresponded to a period when he was experiencing severe emotional problems of his own. During his early 40s, Freud had numerous psychosomatic disorders, as well as exaggerated fears of dying and other phobias, and was involved in the difficult task of self-analysis. By exploring the meaning

of his own dreams, he gained insights into the dynam- ics of personality development. He first examined his childhood memories and came to realize the intense hostility he had felt for his father. He also recalled his childhood sexual feelings for his mother, who was attractive, loving, and protective. He then clinically for- mulated his theory as he observed his patients work through their own problems in analysis.

Freud had very little tolerance for colleagues who diverged from his psychoanalytic doctrines. He attempted to keep control over the movement by expel- ling those who dared to disagree. Carl Jung and Alfred Adler, for example, worked closely with Freud, but each founded his own therapeutic school after repeated dis- agreements with Freud on theoretical and clinical issues.

Freud was highly creative and productive, fre- quently putting in 18-hour days. His collected works fill 24 volumes. Freud’s productivity remained at this pro- lific level until late in his life when he contracted cancer of the jaw. During his last two decades, he underwent 33 operations and was in almost constant pain. He died in London in 1939.

As the originator of psychoanalysis, Freud dis- tinguished himself as an intellectual giant. He pio- neered new techniques for understanding human behavior, and his efforts resulted in the most com- prehensive theory of personality and psychotherapy ever developed.

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68 Chapter Four

psychoanalytically oriented psychotherapy, are discussed in this chapter. In addi- tion, I summarize Erik Erikson’s theory of psychosocial development, which extends Freudian theory in several ways, and give brief attention to Carl Jung’s approach. Finally, I look at contemporary psychoanalytic approaches: object-rela- tions theory, self psychology, and the relational model of psychoanalysis. These contemporary theories are variations on psychoanalytic theory that entail modifi- cation or abandonment of Freud’s drive theory but take Freud’s theories as their point of departure (Wolitzky, 2011). Although deviating significantly from tradi- tional Freudian psychoanalysis, these approaches retain the emphasis on uncon- scious processes, the role of transference and countertransference, the existence of ego defenses and internal conflicts, and the importance of early life experiences (McWilliams, 2016).

Refer to the MindTap for this book to interact with video quizzes and various video programs to expand your knowledge on topics relevant to Chapter 4.

Key Concepts

View of Human Nature The Freudian view of human nature is basically deterministic. According to Freud, our behavior is determined by irrational forces, unconscious motivations, and bio- logical and instinctual drives as these evolve through key psychosexual stages in the first six years of life.

Instincts are central to the Freudian approach. Although he originally used the term libido to refer to sexual energy, he later broadened it to include the energy of all the life instincts. These instincts serve the purpose of the survival of the individ- ual and the human race; they are oriented toward growth, development, and creativ- ity. Libido, then, should be understood as a source of motivation that encompasses sexual energy but goes beyond it. Freud includes all pleasurable acts in his concept of the life instincts; he sees the goal of much of life as gaining pleasure and avoiding pain.

Freud also postulates death instincts, which account for the aggressive drive. At times, people manifest through their behavior an unconscious wish to die or to hurt themselves or others. Managing this aggressive drive is a major challenge to the human race. In Freud’s view, both sexual and aggressive drives are powerful determi- nants of why people act as they do.

Structure of Personality According to the Freudian psychoanalytic view, the personality consists of three sys- tems: the id, the ego, and the superego. These are names for psychological structures and should not be thought of as manikins that separately operate the personality;

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one’s personality functions as a whole rather than as three discrete segments. The id is roughly all the untamed drives or impulses that might be likened to the biologi- cal component. The ego attempts to organize and mediate between the id and the reality of dangers posed by the id’s impulses. One way to protect ourselves from the dangers of our own drives is to establish a superego, which is the internalized social component, largely rooted in what the person imagines to be the expectations of parental figures. Because the point of taking in these imagined expectations is to protect ourselves from our own impulses, the superego may be more punitive and demanding than the person’s parents really were. Actions of the ego may or may not be conscious. For example, defenses typically are not conscious. Because ego and consciousness are not the same, the slogan for psychoanalysis has shifted from “making the unconscious conscious” to “where there was id, let there be ego.”

From the orthodox Freudian perspective, humans are viewed as energy systems. The dynamics of personality consist of the ways in which psychic energy is distrib- uted to the id, ego, and superego. Because the amount of energy is limited, one sys- tem gains control over the available energy at the expense of the other two systems. Behavior is determined by this psychic energy.

The ID The id is the original system of personality; at birth a person is all id. The id is the primary source of psychic energy and the seat of the instincts. It lacks organization and is blind, demanding, and insistent. A cauldron of seething excitement, the id cannot tolerate tension, and it functions to discharge tension immediately. Ruled by the pleasure principle, which is aimed at reducing tension, avoiding pain, and gaining pleasure, the id is illogical, amoral, and driven to satisfy instinctual needs. The id never matures, remaining the spoiled brat of personality. It does not think but only wishes or acts. The id is largely unconscious, or out of awareness.

The Ego The ego has contact with the external world of reality. It is the “executive” that governs, controls, and regulates the personality. As a “traffic cop,” it mediates between the instincts and the surrounding environment. The ego controls consciousness and exercises censorship. Ruled by the reality principle, the ego does realistic and logical thinking and formulates plans of action for satisfying needs. The ego, as the seat of intelligence and rationality, checks and controls the blind impulses of the id. Whereas the id knows only subjective reality, the ego distinguishes between mental images and things in the external world.

The Superego The superego is the judicial branch of personality. It includes a person’s moral code, the main concern being whether an action is good or bad, right or wrong. It represents the ideal rather than the real and strives not for pleasure but for perfection. The superego represents the traditional values and ideals of society as they are handed down from parents to children. It functions to inhibit the id impulses, to persuade the ego to substitute moralistic goals for realistic ones, and to strive for perfection. As the internalization of the standards of parents and society, the superego is related to psychological rewards and punishments. The rewards are feelings of pride and self-love; the punishments are feelings of guilt and inferiority.

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70 Chapter Four

Consciousness and the Unconscious Perhaps Freud’s greatest contributions are his concepts of the unconscious and of the levels of consciousness, which are the keys to understanding behavior and the problems of personality. The unconscious cannot be studied directly but is inferred from behavior. Clinical evidence for postulating the unconscious includes the fol- lowing: (1) dreams, which are symbolic representations of unconscious needs, wishes, and conflicts; (2) slips of the tongue and forgetting, for example, a famil- iar name; (3) posthypnotic suggestions; (4) material derived from free-association techniques; (5) material derived from projective techniques; and (6) the symbolic content of psychotic symptoms.

For Freud, consciousness is a thin slice of the total mind. Like the greater part of the iceberg that lies below the surface of the water, the larger part of the mind exists below the surface of awareness. The unconscious stores all experiences, memories, and repressed material. Needs and motivations that are inaccessible—that is, out of awareness—are also outside the sphere of conscious control. Most psychological functioning exists in the out-of-awareness realm. The aim of psychoanalytic therapy is to make the unconscious motives conscious, for only then can an individual exer- cise choice. Understanding the role of the unconscious is central to grasping the essence of the psychoanalytic model of behavior.

Unconscious processes are at the root of all forms of neurotic symptoms and behaviors. From this perspective, a “cure” is based on uncovering the meaning of symptoms, the causes of behavior, and the repressed materials that interfere with healthy functioning. It is to be noted, however, that intellectual insight alone does not resolve the symptom. The client’s need to cling to old patterns (repetition) must be confronted by working through transference distortions, a process discussed later in this chapter.

Anxiety Also essential to the psychoanalytic approach is its concept of anxiety. Anxiety is a feeling of dread that results from repressed feelings, memories, desires, and expe- riences that emerge to the surface of awareness. It can be considered as a state of tension that motivates us to do something. It develops out of a conflict among the id, ego, and superego over control of the available psychic energy. The function of anxiety is to warn of impending danger.

There are three kinds of anxiety: reality, neurotic, and moral. Reality anxiety is the fear of danger from the external world, and the level of such anxiety is pro- portionate to the degree of real threat. Neurotic and moral anxieties are evoked by threats to the “balance of power” within the person. They signal to the ego that unless appropriate measures are taken the danger may increase until the ego is over- thrown. Neurotic anxiety is the fear that the instincts will get out of hand and cause the person to do something for which she or he will be punished. Moral anxiety is the fear of one’s own conscience. People with a well-developed conscience tend to feel guilty when they do something contrary to their moral code. When the ego cannot control anxiety by rational and direct methods, it relies on indirect ones— namely, ego-defense behavior.

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Ego-Defense Mechanisms Ego-defense mechanisms help the individual cope with anxiety and prevent the ego from being overwhelmed. Rather than being pathological, ego defenses are normal behaviors that can have adaptive value provided they do not become a style of life that enables the individual to avoid facing reality. The defenses employed depend on the indi- vidual’s level of development and degree of anxiety. Defense mechanisms have two char- acteristics in common: (1) they either deny or distort reality, and (2) they operate on an unconscious level. Table 4.1 provides brief descriptions of some common ego defenses.

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Table 4.1 Ego-Defense Mechanisms

Defense Uses for Behavior

Repression Threatening or painful thoughts and feelings are excluded from awareness.

One of the most important Freudian processes, it is the basis of many other ego defenses and of neurotic disorders. Freud explained repression as an involuntary removal of something from consciousness. It is assumed that most of the painful events of the first five or six years of life are buried, yet these events do influence later behavior.

Denial “Closing one’s eyes” to the existence of a threatening aspect of reality.

Denial of reality is perhaps the simplest of all self-defense mechanisms. It is a way of distorting what the individual thinks, feels, or perceives in a traumatic situation. This mechanism is similar to repression, but it generally operates at preconscious and conscious levels.

Reaction formation

Actively expressing the opposite impulse when confronted with a threatening impulse.

By developing conscious attitudes and behaviors that are diametrically opposed to disturbing desires, people do not have to face the anxiety that would result if they were to recognize these dimensions of themselves. Individuals may conceal hate with a facade of love, be extremely nice when they harbor negative reactions, or mask cruelty with excessive kindness.

Projection Attributing to others one’s own unacceptable desires and impulses.

This is a mechanism of self-deception. Lustful, aggressive, or other impulses are seen as being possessed by “those people out there, but not by me.”

Displacement Directing energy toward another object or person when the original object or person is inaccessible.

Displacement is a way of coping with anxiety that involves discharging impulses by shifting from a threatening object to a “safer target.” For example, the meek man who feels intimidated by his boss comes home and unloads inappropriate hostility onto his children.

Rationalization Manufacturing “good” reasons to explain away a bruised ego.

Rationalization helps justify specific behaviors, and it aids in softening the blow connected with disappointments. When people do not get positions they have applied for in their work, they think of logical reasons they did not succeed, and they sometimes attempt to convince themselves that they really did not want the position anyway.

Sublimation Diverting sexual or aggressive energy into other channels.

Energy is usually diverted into socially acceptable and sometimes even admirable channels. For example, aggressive impulses can be channeled into athletic activities, so that the person finds a way of expressing aggressive feelings and, as an added bonus, is often praised.

Regression Going back to an earlier phase of development when there were fewer demands.

In the face of severe stress or extreme challenge, individuals may attempt to cope with their anxiety by clinging to immature and inappropriate behaviors. For example, children who are frightened in school may indulge in infantile behavior such as weeping, excessive dependence, thumb-sucking, hiding, or clinging to the teacher.

(continued)

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72 Chapter Four

Development of Personality

Importance of Early Development A significant contribution of the psycho analytic model is delineation of the stages of psychosexual and psychosocial development from birth through adulthood. The psychosexual stages refer to the Freudian chronological phases of development, beginning in infancy.

Freud postulated three early stages of development that often bring people to counseling when not appropriately resolved. First is the oral stage, which deals with the inability to trust oneself and others, resulting in the fear of loving and forming close relationships and low selfesteem. Next is the anal stage, which deals with the inability to recognize and express anger, leading to the denial of one’s own power as a person and the lack of a sense of autonomy. Third, is the phallic stage, which deals with the inability to fully accept one’s sexuality and sexual feelings, and also to dif ficulty in accepting oneself as a man or a woman. According to the Freudian psycho analytic view, these three areas of personal and social development—love and trust, dealing with negative feelings, and developing a positive acceptance of sexuality—are all grounded in the first six years of life. This period is the foundation on which later personality development is built. When a child’s needs are not adequately met dur ing these stages of development, an individual may become fixated at that stage and behave in psychologically immature ways later on in life.

Erikson’s Psychosocial Perspective The developmental stages postulated by Freud have been expanded by other theorists. Erik Erikson’s (1963) psychosocial perspective on personality development is especially significant. Erikson built on Freud’s ideas and extended his theory by stressing the psychosocial aspects of development beyond early childhood. The psychosocial stages refer to Erikson’s basic psychological and social tasks, which individuals need to master at intervals from infancy through old age. This stage perspective provides the counselor with the conceptual tools for understanding key developmental tasks characteristic of

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Defense Uses for Behavior

Introjection Taking in and “swallowing” the values and standards of others.

Positive forms of introjection include incorporation of parental values or the attributes and values of the therapist (assuming that these are not merely uncritically accepted). One negative example is that in concentration camps some of the prisoners dealt with overwhelming anxiety by accepting the values of the enemy through identification with the aggressor.

Identification Identifying with successful causes, organizations, or people in the hope that you will be perceived as worthwhile.

Identification can enhance self-worth and protect one from a sense of being a failure. This is part of the developmental process by which children learn gender-role behaviors, but it can also be a defensive reaction when used by people who feel basically inferior.

Compensation Masking perceived weaknesses or developing certain positive traits to make up for limitations.

This mechanism can have direct adjustive value, and it can also be an attempt by the person to say “Don’t see the ways in which I am inferior, but see me in my accomplishments.”

Table 4.1 Ego-Defense Mechanisms (continued)

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the various stages of life. Erikson’s theory of development holds that psychosexual growth and psychosocial growth take place together, and that at each stage of life we face the task of establishing equilibrium between ourselves and our social world. He describes development in terms of the entire life span, divided by specific crises to be resolved. According to Erikson, a crisis is equivalent to a turning point in life when we have the potential to move forward or to regress. At these turning points, we can either resolve our conflicts or fail to master the developmental task. To a large extent, our life is the result of the choices we make at each of these stages.

Erikson is often credited with bringing an emphasis on social factors to contem- porary psychoanalysis. Classical psychoanalysis is grounded on id psychology, and it holds that instincts and intrapsychic conflicts are the basic factors shap- ing personality development (both normal and abnormal). Contemporary psychoanalysis tends to be based on ego psychology, which does not deny the role of intrapsychic conflicts but emphasizes the striving of the ego for mastery and competence throughout the human life span. Ego psychology therapists assist clients in gaining awareness of their defenses and help them develop better ways of coping with these defenses (McWilliams, 2016). Ego psychology deals with both the early and the later developmental stages, for the assumption is that current problems cannot simply be reduced to repetitions of unconscious conflicts from early childhood. The stages of adolescence, mid-adulthood, and later adulthood all involve particular crises that must be addressed. As one’s past has meaning in terms of the future, there is continuity in development, reflected by stages of growth; each stage is related to the other stages.

Viewing an individual’s development from a combined perspective that includes both psychosexual and psychosocial factors is useful. Erikson believed Freud did not go far enough in explaining the ego’s place in development and did not give enough attention to social influences throughout the life span. A compari- son of Freud’s psychosexual view and Erikson’s psychosocial view of the stages of development is presented in Table 4.2.

Counseling Implications By taking a combined psychosexual and psychosocial perspective, counselors have a helpful conceptual framework for understanding developmental issues as they appear in therapy. The key needs and developmental tasks, along with the challenges inherent at each stage of life, provide a model for understanding some of the core conflicts clients explore in their therapy sessions. Questions such as these can give direction to the therapeutic process:

◆ What are some major developmental tasks at each stage in life, and how are these tasks related to counseling?

◆ What themes give continuity to this individual’s life? ◆ What are some universal concerns of people at various points in life? How

can people be challenged to make life-affirming choices at these points? ◆ What is the relationship between an individual’s current problems and

significant events from earlier years? ◆ What choices were made at critical periods, and how did the person

deal with these various crises? ◆ What are the sociocultural factors influencing development that need

to be understood if therapy is to be comprehensive?

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Table 4.2 Comparison of Freud’s Psychosexual Stages and Erikson’s Psychosocial Stages

Period of Life Freud Erikson

First year of life Oral stage Sucking at mother’s breasts satisfies need for food and pleasure. Infant needs to get basic nurturing, or later feelings of greediness and acquisitiveness may develop. Oral fixations result from deprivation of oral gratification in infancy. Later personality problems can include mistrust of others, rejecting others; love, and fear of or inability to form intimate relationships.

Infancy: Trust versus mistrust If significant others provide for basic physical and emotional needs, infant develops a sense of trust. If basic needs are not met, an attitude of mistrust toward the world, especially toward interpersonal relationships, is the result.

Ages 1–3 Anal stage Anal zone becomes of major significance in the formation of personality. Main developmental tasks include learning independence, accepting personal power, and learning to express negative feelings such as rage and aggression. Parental discipline patterns and attitudes have significant consequences for the child’s later personality development.

Early childhood: Autonomy versus shame and doubt A time for developing autonomy. Basic struggle is between a sense of self-reliance and a sense of self-doubt. Child needs to explore and experiment, to make mistakes, and to test limits. If parents promote dependency, child’s autonomy is inhibited and capacity to deal with the world successfully is hampered.

Ages 3–6 Phallic stage Basic conflict centers on unconscious incestuous desires that child develops for parent of opposite sex and that, because of their threatening nature, are repressed. Male phallic stage, known as Oedipus complex, involves mother as love object for boy. Female phallic stage, known as Electra complex, involves girl’s striving for father’s love and approval. How parents respond, verbally and nonverbally, to child’s emerging sexuality has an impact on sexual attitudes and feelings that child develops.

Preschool age: Initiative versus guilt Basic task is to achieve a sense of competence and initiative. If children are given freedom to select personally meaningful activities, they tend to develop a positive view of self and follow through with their projects. If they are not allowed to make their own decisions, they tend to develop guilt over taking initiative. They then refrain from taking an active stance and allow others to choose for them.

Ages 6–12 Latency stage After the torment of sexual impulses of the preceding years, this period is relatively quiescent. Sexual interests are replaced by interests in school, playmates, sports, and a range of new activities. This is a time of socialization as child turns outward and forms relationships with others.

School age: Industry versus inferiority Child needs to expand understanding of the world, continue to develop appropriate gender- role identity, and learn the basic skills required for school success. Basic task is to achieve a sense of industry, which refers to setting and attaining personal goals. Failure to do so results in a sense of inadequacy.

Ages 12–18 Genital stage Old themes of the phallic stage are revived. This stage begins with puberty and lasts until senility sets in. Even though there are societal restrictions and taboos, adolescents can deal with sexual energy by investing it in various socially acceptable activities such as forming friendships, engaging in art or in sports, and preparing for a career.

Adolescence: Identity versus role confusion A time of transition between childhood and adulthood. A time for testing limits, for breaking dependent ties, and for establishing a new identity. Major conflicts center on clarification of self-identity, life goals, and life’s meaning. Failure to achieve a sense of identity results in role confusion.

Ages 18–35 Genital stage continues Core characteristic of mature adult is the freedom “to love and to work.” This move toward adulthood involves freedom from parental influence and the capacity to care for others.

Young adulthood: Intimacy versus isolation Developmental task at this time is to form intimate relationships. Failure to achieve intimacy can lead to alienation and isolation.

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Psychosocial theory gives special weight to childhood and adolescent factors that are significant in later stages of development while recognizing that the later stages also have their significant crises. Themes and threads can be found running throughout clients’ lives.

The Therapeutic Process Therapeutic Goals

A primary aim of the psychodynamic approach is fostering clients’ capacities to cope with and solve their own problems (McWilliams, 2014). The ultimate goal of psychoanalytic treatment is to increase adaptive functioning, which involves the reduction of symptoms and the resolution of conflicts (Wolitzky, 2020). Two goals of Freudian psychoanalytic therapy are to make the unconscious conscious and to strengthen the ego so that behavior is based more on reality and less on instinctual cravings or irrational guilt. Successful analysis is believed to result in significant modification of the individual’s personality and character structure. Therapeutic methods are used to bring out unconscious material. Then childhood experiences are reconstructed, discussed, interpreted, and analyzed. It is clear that the process is not limited to solving problems and learning new behaviors. Rather, there is a deeper probing into the past to develop the level of self-understanding that is assumed to be necessary for a change in character. Psychoanalytic therapy is oriented toward achieving insight, but not just an intellectual understanding; it is essential that the feelings and memories associated with this self-understanding be experienced.

Therapist’s Function and Role In classical psychoanalysis, analysts typically assume an anonymous nonjudgmen- tal stance, which is sometimes called the blank screen approach. They avoid self- disclosure and maintain a sense of neutrality to foster a transference relationship, in which their clients will make projections onto them. This transference relation- ship is a cornerstone of psychoanalysis and “refers to the client’s tendency to view

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Ages 35–60 Genital stage continues Middle age: Generativity versus stagnation There is a need to go beyond self and family and be involved in helping the next generation. This is a time of adjusting to the discrepancy between one’s dream and one’s actual accomplishments. Failure to achieve a sense of productivity often leads to psychological stagnation.

Ages 60+ Genital stage continues Later life: Integrity versus despair If one looks back on life with few regrets and feels personally worthwhile, ego integrity results. Failure to achieve ego integrity can lead to feelings of despair, hopelessness, guilt, resentment, and self-rejection.

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the therapist in terms that are shaped by his or her experiences with important care- givers and other significant figures who played important roles during the develop- mental process” (Safran et al., 2019, pp. 38–39). These projections of clients, which have their origins in unfinished and repressed situations, are considered “grist for the mill,” and their analysis is viewed as the essence of therapeutic work. Unlike the classical psychoanalytic perspective, the current relational perspective rejects the possibility of analytic neutrality and anonymity (McWilliams, 2014).

One of the central functions of analysis is to help clients acquire the freedom to love, work, and play. Other functions include assisting clients in achieving self- awareness, honesty, and more effective personal relationships; in dealing with anxi- ety in a realistic way; and in gaining control over impulsive and irrational behavior. Establishing a therapeutic alliance is a key treatment goal, and repairing any dam- aged alliance is essential if therapy is to progress (McWilliams, 2014). The empathic attunement to the client facilitates the analyst’s appreciation of the client’s intrapsy- chic world. The therapist strives to enter the client’s experiential world by imagin- ing, both cognitively and affectively, the individual’s subjective experience (Wolitzky, 2020). Particular attention is given to the client’s resistances. The analyst listens in a respectful, open-minded, openhearted way and decides when to make appro- priate interpretations; tact and timing are essential for effective interpretations (McWilliams, 2014). A major function of interpretation is to accelerate the process of uncovering unconscious material. The psychoanalytic therapist pays attention to both what is spoken and what is unspoken, listens for gaps and inconsistencies in the client’s story, infers the meaning of reported dreams and free associations, and remains sensitive to clues concerning the client’s feelings toward the therapist.

Organizing these therapeutic processes within the context of understanding personality structure and psychodynamics enables the analyst to formulate the nature of the client’s problems. One of the central functions of the analyst is to teach clients the meaning of these processes (through interpretation) so that they are able to achieve insight into their problems, increase their awareness of ways to change, and thus gain more control over their life. A primary aim of psychodynamic approaches is to foster the capacity of clients to solve their own problems.

The process of psychoanalytic therapy is somewhat like putting the pieces of a puzzle together. Whether clients change depends considerably more on their readi- ness to change than on the accuracy of the therapist’s interpretations. If the thera- pist pushes the client too rapidly or offers ill-timed interpretations, therapy will not be effective. Change occurs through the process of reworking old patterns so clients might become freer to act in new ways (Luborsky et al., 2011).

Client’s Experience in Therapy Clients interested in classical psychoanalysis must be willing to commit themselves to an intensive, long-term therapy process. After some face-to-face sessions with the analyst, clients lie on a couch and engage in free association; that is, they try to say whatever comes to mind without self-censorship. This process of free association is known as the “fundamental rule.” Clients report their feelings, experiences, associa- tions, memories, and fantasies to the analyst. Lying on the couch encourages deep, uncensored reflections and reduces the stimuli that might interfere with getting in

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touch with internal conflicts and productions. It also reduces the ability of clients to “read” their analyst’s face for reactions, which fosters the projections character- istic of a transference.

The client in psychoanalysis experiences a unique relationship with the analyst. The client is free to express any idea or feeling, no matter how irresponsible, scandal- ous, politically incorrect, selfish, or infantile. The analyst remains nonjudgmental, listening carefully and asking questions and making interpretations as the analy- sis progresses. This structure encourages the client to loosen defense mechanisms and “regress,” experiencing a less rigid level of adjustment that allows for positive therapeutic growth but also involves some vulnerability. It is a responsibility of the therapist to keep the analytic situation safe for the client. The analyst is not free to engage in spontaneous self-expression, and every intervention by the therapist is made to further the client’s progress. In classical analysis, therapeutic neutral- ity and anonymity are valued by the analyst, and holding a consistent setting or “frame” plays a large part in this analytic technique. Therapeutic change requires an extended period of “working through” old patterns in the safety of the therapeutic relationship.

Psychodynamic psychotherapy has been used to refer to “forms of treatment that are based on psychoanalytic theory but lack some of the defining characteris- tics of psychoanalysis” (Safran et al., 2019, p. 37). It emerged as a way of shorten- ing and simplifying the lengthy process of classical psychoanalysis (Luborsky et al., 2011). Many psychoanalytically oriented practitioners, or psychodynamic therapists (as distinct from analysts), do not use all the techniques associated with classical analysis. However, most psychodynamic therapists remain alert to transference manifestations, explore the meaning of clients’ dreams, explore both the past and the present, offer interpretations for defenses and resistance, and are concerned with unconscious material. According to McWilliams (2014), the essence of psychody- namic therapy does not hinge on a specific population or technique: “rather, it is whether there is attention to unconscious processes, especially as they are manifested and potentially influenced in the relationship with the therapist” (p. 82).

Clients in psychoanalytic therapy make a commitment with the therapist to stick with the procedures of an intensive therapeutic process. They agree to talk because their verbal productions are the heart of psychoanalytic therapy. They are typically asked not to make any radical changes in their lifestyle during the period of analysis, such as getting a divorce or quitting their job. The reason for avoiding mak- ing such changes pertains to the therapeutic process that oftentimes is unsettling and also associated with loosening of defenses. These restrictions are less relevant to psychoanalytic psychotherapy than to classical psychoanalysis. Psychoanalytic psy- chotherapy typically involves fewer sessions per week, the sessions are usually face to face, and the therapist is supportive; hence, there is less therapeutic “regression.”

Psychoanalytic clients are ready to terminate their sessions when they and their analyst mutually agree that they have resolved those symptoms and core conflicts that were amenable to resolution, have accomplished the main goals of therapy, have clarified and accepted their remaining emotional problems, have understood the historical roots of their difficulties, have mastery of core themes, have insight into how their environment affects them and how they affect the environment, have achieved reduced defensiveness, and can integrate their awareness of past problems

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with their present relationships. Curtis (2020) suggests that termination tends to bring up intense feelings of attachment, separation, and loss. Thus a termination date is set well enough in advance to talk about these feelings and about what the client learned in psychotherapy. Therapists assist clients in clarifying what they have done to bring about changes.

Relationship Between Therapist and Client There are some differences between how the therapeutic relationship is conceptual- ized by classical analysis and contemporary relational analysis. The classical ana- lyst stands outside the relationship, comments on it, and offers insight-producing interpretations. In contemporary relational psychoanalysis, the therapist does not strive for an objective stance. Contemporary psychodynamic therapists focus as much on here-and-now transference as on earlier reenactments from the past. By bringing the past into the present relationship, a new understanding of the past can unfold (Wolitzky, 2020). Contemporary psychodynamic therapists view their emotional communication with clients as a useful way to gain information and cre- ate connection. Analytic therapy focuses on feelings, perceptions, and actions that are happening in the moment in the therapy sessions (McWilliams, 2014). Safran, Kriss, and Foley (2019) assert that “because transference involves a type of reliving of clients’ early relationships in the present, the therapist’s observation and feed- back can help them see, understand, and appreciate their own contribution to the situation” (p. 39).

Transference and countertransference are central to understanding psychody- namic therapy. A significant aspect of the therapeutic relationship is manifested through transference reactions, which involve the unconscious repetition of the past in the present. Transference is the client’s unconscious shifting to the analyst of feelings, attitudes, and fantasies (both positive and negative) that are reactions to significant figures who played important roles during the developmental process. Early experiences establish templates that shape the perceptions of individuals in the present (Safran et al., 2019). A client often has a mixture of positive and nega- tive feelings and reactions to a therapist. When these feelings become conscious and are transferred to the therapist, clients can understand and resolve past “unfinished business.” As therapy progresses, childhood feelings and conflicts begin to surface from the depths of the unconscious, and clients regress emotionally. Transference takes place when clients resurrect these early intense conflicts relating to love, sexu- ality, hostility, anxiety, and resentment; bring them into the present; reexperience them; and attach them to the therapist. For example, clients may transfer unre- solved feelings toward a stern and unloving father to the therapist, who, in their eyes, becomes stern and unloving. Angry feelings are the product of negative transference, but clients also may develop a positive transference and, for example, fall in love with the therapist, wish to be adopted, or in many other ways seek the love, acceptance, and approval of an all-powerful therapist. In short, the therapist becomes a current substitute for significant others.

If therapy is to produce change, the transference relationship must be worked through. The working-through process consists of repetitive and elaborate explo- rations of unconscious material and defenses, most of which originated in early

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childhood. Clients learn to accept their defensive structures and recognize how they may have served a purpose in the past (Rutan et al., 2014). This results in a reso- lution of old patterns and enables clients to make new choices. Effective therapy requires that the client develop a relationship with the therapist in the present that is a corrective and integrative experience.

Clients have many opportunities to see the variety of ways in which their core conflicts and core defenses are manifested in their daily life. For clients to become psychologically independent, it is assumed that they must not only become aware of this unconscious material but also achieve some level of free- dom from behavior motivated by infantile strivings, such as the need for total love and acceptance from parental figures. If this demanding phase of the thera- peutic relationship is not properly worked through, clients simply transfer their infantile wishes for universal love and acceptance to other figures. It is precisely in the client–therapist relationship that the manifestation of these childhood motivations becomes apparent.

Regardless of the length of psychoanalytic therapy, traces of our childhood needs and traumas will never be completely erased. Infantile conflicts may not be fully resolved, even though many aspects of transference are worked through with a therapist. We may need to struggle at times throughout our life with feelings that we project onto others as well as with unrealistic demands that we expect others to fulfill. In this sense, we experience transference with many people, and our past is always a vital part of the person we are presently becoming.

It is a mistake to assume that all feelings clients have toward their therapists are manifestations of transference. Many of these reactions may have a reality base, and clients’ feelings may well be directed to the here-and-now style the therapist exhibits. Not every positive response (such as liking the therapist) should be labeled “positive transference.” Conversely, a client’s anger toward the therapist may be a function of the therapist’s behavior; it is a mistake to label all negative reactions as signs of “negative transference.”

The notion of never becoming completely free of past experiences has sig- nificant implications for therapists who become intimately involved in the unresolved conflicts of their clients. Even if the conflicts of therapists have sur- faced to awareness, and even if therapists have dealt with these personal issues in their own intensive therapy, they may still project distortions onto clients. Therapists’ countertransference reactions are inevitable because all thera- pists have unresolved conflicts and personal vulnerabilities that are activated through their professional work. From a traditional psychoanalytic perspec- tive, countertransference is viewed as a phenomenon that occurs when there is inappropriate affect, when therapists respond in irrational ways, or when they lose their objectivity in a relationship because their own conflicts are triggered. Countertransference consists of a therapist’s unconscious emotional responses to a client based on the therapist’s own past, resulting in a distorted perception of the client’s behavior (Rutan et al., 2014). Over the years this traditional view of countertransference has broadened to include all of the therapist’s total reac- tions, not only to the client’s transference but to all aspects of the client’s per- sonality and behavior. In this broader perspective, countertransference involves the therapist’s total emotional response to a client and may include withdrawal,

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anger, love, annoyance, powerlessness, avoidance, overidentification, control, or sadness. In today’s psychoanalytic practice, countertransference is manifested in the form of subtle nonverbal, tonal, and attitudinal actions that inevitably affect clients, either consciously or unconsciously (Curtis, 2020; Safran et al., 2019; Wolitzky, 2011).

To avoid misunderstanding and overidentification with clients, the ana- lytic approach requires therapists to undergo their own analytic psychotherapy. McWilliams (2014) emphasizes how important it is for therapists to access and understand their unconscious and suggests that a key outcome of therapy is humil- ity, which provides a good foundation for creating authentic, egalitarian, and heal- ing connections with clients. Personal therapy and clinical supervision for therapists can be helpful in better understanding how internal reactions influence the therapy process and how to use these countertransference reactions to benefit the work of therapy (Hayes et al., 2019; McWilliams, 2014).

Not all countertransference reactions are detrimental to therapeutic progress. Indeed, countertransference reactions are often the strongest source of data for understanding the world of the client and for self-understanding on the therapist’s part. For example, a therapist who notes a countertransference mood of irritabil- ity may learn something about a client’s pattern of being demanding, which can be explored in therapy. Viewed in this more positive way, countertransference can become a key avenue for helping the client gain self-understanding. Most research on countertransference has dealt with its deleterious effects, but Hayes (2004) sug- gests it would be useful to undertake systematic study of the potential therapeutic benefits of countertransference.

Psychoanalytic therapists vary in the manner in which they use their observa- tions of countertransference. In some instances, the feelings may be shared with the client, but traditional analytic therapists strive to minimize their expression of countertransference while silently learning from its inevitable occurrence. The abil- ity of therapists to gain self-understanding and to establish appropriate boundaries with clients is critical in managing and effectively using their countertransference reactions (Hayes et al., 2019).

It is of paramount importance that therapists develop some level of objec- tivity and not react defensively and subjectively in the face of anger, love, adulation, criticism, and other intense feelings expressed by their clients. If psy- chotherapists become aware of a strong aversion to certain types of clients, a strong attraction to other types of clients, psychosomatic reactions that occur at definite times in therapeutic relationships, and the like, it is imperative for them to seek professional consultation, clinical supervision, or enter their own therapy for a time to work out these personal issues that stand in the way of them being effective therapists.

Through the client–therapist relationship, clients acquire insights into the workings of their unconscious processes. Awareness of and insights into repressed material are the bases of the analytic growth process. Clients come to understand the association between their past experiences and their current behavior. The psychoanalytic approach assumes that without this dynamic self- understanding there can be no substantial personality change or resolution of present conflicts.

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Application: Therapeutic Techniques and Procedures This section deals with the techniques most commonly used by psychoanalytically oriented therapists. Also included are sections on the application of the psycho- analytic approach to group counseling and to school counseling. Psychoanalytic or psychodynamic therapy differs from traditional psychoanalysis in these ways:

◆ The therapy has more limited objectives than restructuring one’s personality.

◆ The therapist is less likely to use the couch. ◆ There are fewer sessions each week. ◆ There is more frequent use of supportive interventions such as reassur-

ance, expressions of empathy and support, and suggestions. ◆ There is more emphasis on the here-and-now relationship between

therapist and client. ◆ There is more latitude for therapist self-disclosure without “polluting

the transference.” ◆ Less emphasis is given to the therapist’s neutrality. ◆ There is a focus on mutual transference and countertransference

enactments. ◆ The focus is more on pressing practical concerns than on working with

fantasy material.

The techniques of psychoanalytic therapy are aimed at increasing awareness, fostering insights into the client’s behavior, and understanding the meanings of symptoms. The therapy proceeds from the client’s talk to catharsis (or expression of emotion), to insight, to working through unconscious material. This work is done to attain the goals of intellectual and emotional understanding and reeducation, which, it is hoped, will lead to personality change. The six basic techniques of psy- choanalytic therapy are (1) maintaining the analytic framework, (2) free association, (3) interpretation, (4) dream analysis, (5) analysis of resistance, and (6) analysis of transference.

The text Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 2) pro- vides an illustration by Dr. William Blau, a psychoanalytically oriented therapist, of some treatment techniques in The Case of Ruth.

Maintaining the Analytic Framework The psychoanalytic process stresses maintaining a particular framework aimed at accomplishing the goals of this type of therapy. Maintaining the analytic frame refers to a whole range of procedural and stylistic factors, such as the analyst’s rela- tive anonymity, maintaining neutrality and objectivity, the regularity and consis- tency of meetings, starting and ending the sessions on time, clarity on fees, and basic boundary issues such as the avoidance of advice giving or imposition of the therapist’s values (Curtis, 2020). One of the most powerful features of psychoana- lytically oriented therapy is that the consistent framework is itself a therapeutic fac- tor, comparable on an emotional level to the regular feeding of an infant. Analysts attempt to minimize departures from this consistent pattern (such as vacations,

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changes in fees, or changes in the meeting environment). Where departures are unavoidable, these will often be the focus of interpretations.

Free Association Free association is a central technique in psychoanalytic therapy, and it plays a key role in the process of maintaining the analytic frame. In free association, clients are encouraged to say whatever comes to mind, regardless of how painful, silly, trivial, illogical, or irrelevant it may seem. In essence, clients try to flow with any feelings or thoughts by reporting them immediately without censorship. As the analytic work progresses, most clients will occasionally depart from this basic rule, and these resistances will be interpreted by the therapist when it is timely to do so.

Free association is one of the basic tools used to open the doors to unconscious wishes, fantasies, conflicts, and motivations. This technique often leads to some recollection of past experiences and, at times, a catharsis or release of intense feel- ings that have been blocked. This release is not seen as crucial in itself, however. During the free-association process, the therapist’s task is to identify the repressed material that is locked in the unconscious. The sequence of associations guides the therapist in understanding the connections clients make among events. Blockings or disruptions in associations serve as cues to anxiety-arousing material. The thera- pist interprets the material to clients, guiding them toward increased insight into the underlying dynamics.

As analytic therapists listen to their clients’ free associations, they hear not only the surface content but also the hidden meaning. Nothing the client says is taken at face value. Areas that clients do not talk about are as significant as the areas they choose to discuss. Psychodynamic therapists invite their clients to speak about themselves as openly as possible and to note instances when doing so is difficult (McWilliams, 2014).

Interpretation Interpretation consists of the analyst pointing out, explaining, and even teaching the client the meanings of behavior that is manifested in dreams, free association, resistances, defenses, and the therapeutic relationship itself. The functions of inter- pretations are to enable the ego to assimilate new material and to speed up the process of uncovering further unconscious material. Interpretation is grounded in the therapist’s assessment of the client’s personality and of the factors in the cli- ent’s past that contributed to current difficulties. Under contemporary definitions, interpretation includes identifying, clarifying, and translating the client’s material. Relational psychoanalytic therapists tend to discuss their observations in the spirit of mutual discovery with the client. They present possible meanings associated with a client’s thoughts, feelings, or events as a hypothesis rather than as pronounce- ments about a client’s inner world (Curtis, 2020). Interpretations are provided in a collaborative manner to help clients make sense of their lives and to expand their consciousness.

The therapist uses the client’s reactions as a gauge in determining a client’s read- iness to make an interpretation. It is important that interpretations be appropriately

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timed because the client will reject therapist interpretations that are poorly timed. A general rule is that interpretation should be presented when the phenomenon to be interpreted is close to conscious awareness. In other words, the therapist should interpret material that the client has not yet seen but is capable of tolerating and incorporating. Another general rule is that interpretation should start from the sur- face and go only as deep as the client is able to go.

Dream Analysis Dream analysis is an important procedure for uncovering unconscious material and giving the client insight into some areas of unresolved problems. During sleep, defenses are lowered and repressed feelings surface. Freud sees dreams as the “royal road to the unconscious,” for in them one’s unconscious wishes, needs, and fears are expressed. Some motivations are so unacceptable to the person that they are expressed in disguised or symbolic form rather than being revealed directly.

Dreams have two levels of content: latent content and manifest content. Latent content consists of hidden, symbolic, and unconscious motives, wishes, and fears. Because they are so painful and threatening, the unconscious sexual and aggressive impulses that make up latent content are transformed into the more acceptable manifest content, which is the dream as it appears to the dreamer. The process by which the latent content of a dream is transformed into the less threatening manifest content is called dream work. The therapist’s task is to uncover disguised meanings by studying the symbols in the manifest con- tent of the dream.

During the session, therapists may ask clients to free associate to some aspect of the manifest content of a dream for the purpose of uncovering the latent meanings. Therapists participate in the process by exploring clients’ associations with them. Interpreting the meanings of the dream elements helps clients unlock the repression that has kept the material from consciousness and relate the new insight to their present struggles. Dreams may serve as a pathway to repressed material, but dreams also provide an understanding of clients’ current functioning. Relational psycho- analytic therapists are particularly interested in the connection of dreams to clients’ lives. The dream is viewed as a significant message to clients to examine something that could be problematic if left unexamined (Curtis, 2020).

Analysis and Interpretation of Resistance Resistance, a concept fundamental to the practice of psychoanalysis, is anything that works against the progress of therapy and prevents the client from produc- ing previously unconscious material. Specifically, resistance is the client’s reluc- tance to bring to the surface of awareness unconscious material that has been repressed. Resistance refers to any idea, attitude, feeling, or action (conscious or unconscious) that fosters the status quo and gets in the way of change. During free association or association to dreams, the client may evidence an unwilling- ness to relate certain thoughts, feelings, and experiences. Freud viewed resistance as an unconscious dynamic that people use to defend against the intolerable anxiety and pain that would arise if they were to become aware of their repressed impulses and feelings.

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As a defense against anxiety, resistance operates specifically in psychoanalytic therapy to prevent clients and therapists from succeeding in their joint effort to gain insights into the dynamics of the unconscious. An assumption of analytic treatment is that clients wish both to change and to remain embedded in their old world. Clients tend to cling to their familiar patterns, regardless of how painful they may be. Therapists need to create a safe climate so clients can recognize resistance and explore it in therapy (Curtis, 2020; McWilliams, 2014; Wolitzky, 2020). Because resistance blocks threatening material from entering awareness, analytic therapists point it out, but Safran, Kriss, and Foley (2019) caution therapists to avoid framing resistance in a way that implies that the client is not cooperating with the treat- ment. Therapists’ interpretations help clients become aware of the reasons for the resistance so they can deal with them. As a general rule, therapists point out and interpret the most obvious resistances to lessen the possibility of clients’ rejecting the interpretation and to increase the chance that they will begin to look at their resistive behavior.

Resistances are not just something to be overcome. Because they are representa- tive of usual defensive approaches in daily life, they need to be recognized as devices that defend against anxiety but that interfere with the ability to accept change that could lead to experiencing a more gratifying life. It is crucial that therapists respect the resistances of clients and assist them in working therapeutically with their defenses. When handled properly, exploring resistance can be an extremely valuable tool in understanding the client.

Analysis and Interpretation of Transference As was mentioned earlier, transference manifests itself in the therapeutic process when earlier relationships contribute to clients distorting the present with the therapist. The transference situation is considered valuable because its manifes- tations provide clients with the opportunity to reexperience a variety of feelings that would otherwise be inaccessible. Through the relationship with the therapist, clients express feelings, beliefs, and desires that they have buried in their uncon- scious. Interpreting transference is a route to elucidating the client’s intrapsychic life. Through this interpretation, clients can recognize how they are repeating the same dynamic patterns in their relationships with the therapist, with significant figures from the past, and in present relationships with significant others. Through appropriate interpretations and working through of these current expressions of early feelings, clients are able to become aware of and to gradually change some of their long-standing patterns of behavior. Analytically oriented therapists consider the process of exploring and interpreting transference feelings as the core of the therapeutic process because it is aimed at achieving increased awareness and per- sonality change.

The analysis of transference is a central technique in both classical psycho- analysis and psychoanalytically oriented therapy because it allows clients to achieve here-and-now insight into the influence of the past on their present functioning. Interpretation of the transference relationship enables clients to work through old conflicts that are keeping them fixated and retarding their emotional growth. In essence, the effects of early relationships are counteracted

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by working through a similar emotional conflict in the current therapeutic relationship. An example of utilizing transference is given in a later section on The Case of Stan.

Application to Group Counseling The psychodynamic model offers a conceptual framework for understanding the history of the members of a group and a way of thinking about how their past is affecting them now in the group and in their everyday lives. Group leaders can think psychoanalytically, even if they do not use many psychoanalytic techniques. Regard- less of their theoretical orientation, it is well for group therapists to understand such psychoanalytic phenomena as transference, countertransference, resistance, and the use of ego-defense mechanisms as reactions to anxiety.

Transference and countertransference have significant implications for the practice of group counseling and therapy. Group work may re-create early life situa- tions that continue to affect the client. In most groups, individuals elicit a range of feelings such as attraction, anger, competition, and avoidance. These transference feelings may resemble those that members experienced toward significant people in their past. Members will most likely find symbolic mothers, fathers, siblings, and lovers in their group. Group participants frequently compete for the attention of the leader—a situation reminiscent of earlier times when they had to vie for their parents’ attention with their brothers and sisters. This rivalry can be explored in a group as a way of gaining increased awareness of how the participants dealt with competition as children and how their past success or lack of it affects their present interactions with others. A basic tenet of psychodynamic therapy groups is the notion that group participants, through their interactions within the group, re-create their social situ- ation, implying that the group becomes a microcosm of their everyday lives (Rutan et al., 2014). Groups can provide a dynamic understanding of how people function in out-of-group situations. Projections onto the leader and onto other members are valuable clues to unresolved conflicts within the person that can be identified, explored, and worked through in the group.

The group therapist also has reactions to members and is affected by members’ reactions. Countertransference can be a useful tool for the group therapist to under- stand the dynamics that might be operating in a group. However, group leaders need to be alert to signs of unresolved internal conflicts that could interfere with effective group functioning and create a situation in which members are used to satisfy the leaders’ own unfulfilled needs. If, for example, a group therapist has an extreme need to be liked and approved of, the therapist might behave in ways to get members’ approval and confirmation, resulting in behaviors primarily designed to please the group members and ensure their continued support.

Group therapists need to exercise vigilance lest they misuse their power by turning the group into a forum for pushing clients to adjust by conforming to the dominant cultural values at the expense of losing their own worldview and cultural identity. Group practitioners also need to be aware of their own potential biases. The concept of countertransference can be expanded to include unacknowledged bias and prejudices that may be conveyed unintentionally through the techniques used by group therapists.

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For a more extensive discussion of the psychoanalytic approach to group coun- seling, refer to Theory and Practice of Group Counseling (Corey, 2023, chap. 6). Psychody- namic Group Psychotherapy (Rutan et al., 2014) also provides an excellent discussion of this subject. In addition, Gerald Corey facilitates a group session from a psycho- analytic perspective in the Group Theories in Action videos in the MindTap program.

Applying the Psychoanalytic Approach to School Counseling

This section was provided by Sheri Bauman, PhD, a former school counselor and a professor emerita of counseling at the University of Arizona. Her research focuses on bullying and cyberbullying.

Although it may seem to school counselors that psychoanalytic theory is primarily of historical interest, they owe much to psychoanalytic thinkers whose pioneering work has applications for their practice. Several concepts from psychoanalytic the- ory are relevant for contemporary school counselors: the importance of early child- hood, the development of play therapy, defense mechanisms, and transference and countertransference. School counselors do not have to be trained in psychoanalysis to incorporate these concepts into their own framework, and these concepts are compatible with other theoretical approaches.

Freud emphasized infancy and early childhood as critical developmental periods that set the stage for later development and functioning. With the recent recognition that adverse childhood experiences unfortunately are not rare, school counselors have been encouraged to adopt a trauma-informed approach. School counselors are often the best coordinators for schoolwide trainings and practices, and consultation with teachers and parents about specific children can be conducted from a trauma- informed perspective. School counselors can help teachers understand that behav- iors of concern may be symptoms of trauma that respond well to specific classroom environments and teacher interactions. When I had an opportunity to meet with parents as a school counselor, I made a point of getting a history with an emphasis on early childhood. This information provided insights into factors that may have contributed to current concerns and increased our understanding of the student.

An early extension of psychoanalytic practice was the use of play therapy with children. Although school counselors do not use play therapy in the manner of these early play therapists, having toys and expressive materials available is essential for enrichment. Play is the language of the child and the way they most readily express themselves. I acquired a reasonable collection of toys by visiting garage sales and through other inexpensive sources. One high school student would casually pick up a teddy bear and keep it next to him whenever we met. Upon meeting me for the first time, a middle school student used two of the teddy bears to reenact a fight. Soon after, she talked about how her older brother was mean to her. A fourth grader I worked with insisted that I play with her, and her directive bossy behavior helped me understand her difficulty with friendships. In all of these experiences, the toys acted as a therapeutic vessel, enabling the students to more fully express themselves.

Defense mechanisms are ways in which we manage anxiety. What looks like deliberate misbehavior may in fact be the child’s use of a defense mechanism. School counselors help students become aware of when they are using defenses and help

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them decide if these defenses are helpful or have undesirable consequences. In their capacity as educators, school counselors teach students alternative strategies for managing stressful emotions and difficult situations. School counselors also help teachers and parents recognize that what appears to be problematic behavior may be an attempt by the child to cope with difficult feelings.

Children also express their feelings and worries with significant adults by uncon- sciously transferring them to the other adults in their life. The school counselor or teacher may represent authority or a parental figure to the student; the behavior toward the counselor may reflect struggles the student is experiencing at home. The source of a student’s angry reaction out of proportion to the situation may well be an instance of transference. The counselor has an opportunity to bring these pro- cesses into the student’s awareness, which may lead to a fruitful exploration of these important relationships. Similarly, school counselors need to recognize when coun- tertransference may be affecting their reactions and responses to a student, and they have an ethical obligation to manage their potential countertransference.

Jung’s Perspective on the Development of Personality At one time Freud referred to Carl Jung as his spiritual heir, but Jung eventually developed a theory of personality that was markedly different from Freudian psy- choanalysis. Jung’s analytical psychology is an elaborate explanation of human nature that combines ideas from history, mythology, anthropology, and religion (Schultz & Schultz, 2013). Jung made monumental contributions to our deep understanding of the human personality and personal development, particularly during middle age.

Jung’s pioneering work places central importance on the psychological changes that are associated with midlife. He maintained that at midlife we need to let go of many of the values and behaviors that guided the first half of our life and confront our unconscious. We can best do this by paying attention to the messages of our dreams and by engaging in creative activities such as writing or painting. The task facing us during the midlife period is to be less influenced by rational thought and to instead give expression to these unconscious forces and integrate them into our conscious life (Schultz & Schultz, 2013).

Jung learned a great deal from his own midlife crisis. At age 81 he wrote about his recollections in his autobiography, Memories, Dreams, Reflections (Jung, 1961), in which he also identified some of his major contributions. Jung made a choice to focus on the unconscious realm in his personal life, which influenced the development of his theory of personality. However, he had a very different conception of the unconscious than did Freud. Jung was a colleague of Freud’s and valued many of his contribu- tions, but Jung eventually came to the point of not being able to support some of Freud’s basic concepts, especially his theory of sexuality. Jung (1961) recalled Freud’s words to him: “My dear Jung, promise me never to abandon the sexual theory. This is the most essential thing of all. You see, we must make a dogma of it, an unshak- able bulwark” (p. 150). Jung became convinced that he could no longer collaborate with Freud because he believed Freud placed his own authority over truth. Freud had little tolerance for theoreticians such as Jung and Adler who dared to challenge his theories. Although Jung had a lot to lose professionally by withdrawing from Freud,

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he saw no other choice. He subsequently developed a spiritual approach that places great emphasis on being impelled to find meaning in life in contrast to being driven by the psychological and biological forces described by Freud.

Jung maintained that we are not merely shaped by past events (Freudian deter- minism), but that we are influenced by our future as well as our past. Part of the nature of humans is to be constantly developing, growing, and moving toward a balanced and complete level of development. For Jung, our present personality is shaped both by who and what we have been and also by what we aspire to be in the future. His theory is based on the assumption that people tend to move toward the fulfillment or realization of all of their capabilities. Achieving individuation—the harmonious integration of the conscious and unconscious aspects of personality—is an innate and primary goal. For Jung, we have both con- structive and destructive forces, and to become integrated, it is essential to accept our dark side, or shadow, with its primitive impulses such as selfishness and greed. Acceptance of our shadow does not imply being dominated by this dimension of our being but simply recognizing that this is a part of our nature.

Jung taught that many dreams contain messages from the deepest layer of the unconscious, which he described as the source of creativity. Jung referred to the collective unconscious as “the deepest and least accessible level of the psyche,” which contains the accumulation of inherited experiences of human and prehuman species (as cited in Schultz & Schultz, 2013, p. 95). Jung saw a connection between each person’s personality and the past, not only childhood events but also the history of the species. This means that some dreams may deal with an individual’s relationship to a larger whole such as the family, universal humanity, or generations over time. The images of universal experiences contained in the collective uncon- scious are called archetypes. Among the most important archetypes are the persona, the anima and animus, and the shadow. The persona is a mask, or public face, that we wear to protect ourselves. The animus and the anima represent both the biological and psychological aspects of masculinity and femininity, which are thought to coexist in both sexes. The shadow has the deepest roots and is the most dangerous and powerful of the archetypes. It represents our dark side—the thoughts, feelings, and actions that we tend to disown by projecting them outward. In a dream, all of these parts can be considered manifestations of who and what we are.

Jung agreed with Freud that dreams provide a pathway into the unconscious, but he differed from Freud on their functions. Jung wrote that dreams have two purposes. They are prospective, that is, they help people prepare themselves for the experiences and events they anticipate in the near future. But they also serve a com- pensatory function, working to bring about a balance between opposites within the person. They compensate for the overdevelopment of one facet of the individual’s personality (Schultz & Schultz, 2013).

Jung viewed dreams more as an attempt to express than as an attempt to repress and disguise. Dreams are a creative effort of the dreamer who is struggling with contradiction, complexity, and confusion. The aim of the dream is resolution and integration. According to Jung, each part of the dream can be understood as some projected quality of the dreamer. His method of interpretation draws on a series of dreams obtained from a person, during the course of which the meaning gradually unfolds.

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For further reading on this topic, I suggest Memories, Dreams, Reflections (Jung, 1961) and Living With Paradox: An Introduction to Jungian Psychology (Harris, 1996).

Contemporary Trends: Object-Relations Theory, Self Psychology, and Relational Psychoanalysis

Psychoanalytic theory continues to evolve. Freud emphasized intrapsychic conflicts pertaining to the gratification of basic needs. Writers in the neo-Freudian school moved away from this orthodox position and contributed to the growth and expan- sion of the psychoanalytic movement by incorporating the cultural and social influ- ences on personality. Ego psychology is part of classical psychoanalysis with the emphasis placed on the vocabulary of id, ego, and superego, and on Anna Freud’s identification of defense mechanisms. She spent most of her professional life adapt- ing psychoanalysis to children and adolescents. Erikson (1963) expanded this per- spective by emphasizing psychosocial development throughout the life span.

Psychoanalytic theory has evolved, undergoing a number of reformulations over the years (McWilliams, 2016). Today psychoanalytic theory is comprised of a variety of schools, including the classical perspective, ego psychology, object-relations and inter- personal psychoanalysis, self psychology, and relational psychoanalysis. Rutan, Stone, and Shay (2014) note some commonalities between these psychoanalytic perspectives: “All presuppose a supportive, warm, but neutral and fairly unobtrusive therapist who strives to create a safe, supportive, and therapeutic relationship” (p. 73).

Object-relations theory encompasses the work of a number of rather differ- ent psychoanalytic theorists who are especially concerned with investigating attach- ment and separation. They emphasize how our relationships with other people are affected by the way we have internalized our experiences of others and set up repre- sentations of others within ourselves. Object relations are interpersonal relation- ships as these are represented intrapsychically, and they influence our interactions with the people around us. The term object was used by Freud to refer to that which satisfies a need, or to the significant person or thing that is the object, or target, of one’s feelings or drives. It is used interchangeably with the term other to refer to an important person to whom the child, and later the adult, becomes attached. Rather than being individuals with separate identities, others are perceived by an infant as objects for gratifying needs. Object-relations theories have diverged from ortho- dox psychoanalysis. However, some theorists, most notably Otto Kernberg, attempt to integrate the increasingly varied ideas that characterize this school of thought within a classical psychoanalytic framework (St. Clair, 2004).

Traditional psychoanalysis assumes that the analyst can discover and name the intrapersonal “truth” about individual clients. As psychoanalytic theory has evolved, the approach has more fully considered the unconscious influence of other people. Self psychology, which grew out of the work of Heinz Kohut (1971), emphasizes how we use interpersonal relationships (self objects) to develop our own sense of self. Kohut emphasized nonjudgmental acceptance, empathy, and authenticity. Kohut and other self psychologists put empathy in the forefront of psychoanalytic healing and choose interventions based on them being genuinely empathically attuned to clients (McWilliams, 2016).

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The contemporary relational psychodynamic model is based on the assump- tion that therapy is an interactive process between client and therapist. What occurs between individuals in the therapeutic dyad is of central importance, and the thera- peutic relationship is considered essential to bringing about change (Curtis, 2020). Wolitzky (2020) states that self psychologists, object-relations therapists, and other contemporary Freudian therapists regard the therapeutic relationship as directly healing in its own right. Whether called intersubjective, interpersonal, or relational, a number of contemporary psychoanalytic approaches are based on the exploration of the complex conscious and unconscious dynamics at play with respect to both therapist and client. The relational movement ushered in a new emphasis on a more egalitarian therapeutic style (McWilliams, 2016). Relational analysts put value on not knowing, and they approach clients with genuine curiosity. Therapists expect to participate in mutual enactments, or repetition of themes from the client’s life that evoke themes of their own.

From the time of Freud to the late 20th century, the power between analyst and patient was unequal. Contemporary relational theorists have challenged what they consider to be the authoritarian nature of the traditional psychoanalytic relation- ship and replaced it with a more egalitarian model. The task of relational analysis is to explore each client’s life in a creative way, customized to the therapist and client working together in a particular culture at a particular moment in time.

Mitchell (1988, 2000) has written extensively about these new conceptualiza- tions of the analytic relationship. He integrates developmental theory, attachment theory, systems theory, and interpersonal theory to demonstrate the profound ways in which we seek attachments with others, especially early caregivers. Interpersonal analysts believe that countertransference provides an important source of informa- tion about the client’s character and dynamics. Mitchell adds to this object-relations position a cultural dimension, noting that the caregiver’s qualities reflect the par- ticular culture in which the person lives. We are all deeply embedded within our cultures. Different cultures maintain different values, so there can be no objective psychic truths. Our internal (unconscious) structures are all relational and relative. This is in stark contrast to the Freudian notion of universal biological drives that could be said to function in every human.

Summary of Stages of Development Most contemporary psychoanalytic theories center on predictable developmental sequences in which the early experiences of the self shift in relation to an expand- ing awareness of others. Once self–other patterns are established, it is assumed they influence later interpersonal relationships. Specifically, people search for relation- ships that match the patterns established by their earlier experiences. People who are either overly dependent or overly detached, for example, can be repeating patterns of relating they established with their mother when they were toddlers (Hedges, 1983). These newer theories provide insight into how an individual’s inner world can cause difficulties in living in the everyday world of people and relationships (St. Clair, 2004).

Margaret Mahler (1968) had a central influence on contemporary object-rela- tions theory. A pediatrician who emphasized the observation of children, she viewed

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the resolution of the Oedipus complex during Freud’s proposed phallic stage as less critical than the child’s progression from a symbiotic relationship with a maternal figure toward separation and individuation. Her studies focus on the interactions between the child and the mother in the first three years of life. Mahler conceptual- izes the development of the self somewhat differently from the traditional Freudian psychosexual stages. Her belief is that the individual begins in a state of psychologi- cal fusion with the mother and progresses gradually to separation. The unfinished crises and residues of the earlier state of fusion, as well as the process of separating and individuating, have a profound influence on later relationships. Object rela- tions of later life build on the child’s search for a reconnection with the mother (St. Clair, 2004). Psychological development can be thought of as the evolution of the way in which individuals separate and differentiate themselves from others.

Mahler (1968) calls the first three or four weeks of life normal infantile autism. Here the infant is presumed to be responding more to states of physiological tension than to psychological processes. Mahler believes the infant is unable to differenti- ate itself from its mother in many respects at this age. According to Melanie Klein (1975), another major contributor to the object-relations perspective, the infant perceives parts—breasts, face, hands, and mouth—rather than a unified self. In this undifferentiated state there is no whole self, and there are no whole objects. When adults show the most extreme lack of psychological organization and sense of self, they may be thought of as returning to this most primitive infantile stage. Subse- quent infant research by Daniel Stern (1985) has challenged this aspect of Mahler’s theory, maintaining that infants are interested in others practically from birth.

Mahler’s (1968) next phase, called symbiosis, is recognizable by the 3rd month and extends roughly through the 8th month. At this age the infant has a pronounced dependency on the mother. She (or the primary caregiver) is clearly a partner and not just an interchangeable part. The infant seems to expect a very high degree of emotional attunement with its mother.

The separation–individuation process begins in the 4th or 5th month. During this time the child moves away from symbiotic forms of relating. The child experiences separation from significant others yet still turns to them for a sense of confirma- tion and comfort. The child may demonstrate ambivalence, being torn between enjoying separate states of independence and dependence. The toddler who proudly steps away from the parents and then runs back to be swept up in approving arms illustrates some of the main issues of this period (Hedges, 1983, p. 109). Others are looked to as approving mirrors for the child’s developing sense of self; optimally, these relationships can provide a healthy self-esteem.

Children who do not experience the opportunity to differentiate, and those who lack the opportunity to idealize others while also taking pride in themselves, may later suffer from narcissistic character disorders and problems of self-esteem. The narcissistic personality is characterized by a grandiose and exaggerated sense of self-importance and an exploitive attitude toward others, which serve the function of masking a frail self-concept. Such individuals seek attention and admiration from others. They unrealistically exaggerate their accomplishments, and they have a ten- dency toward extreme self-absorption. Kernberg (1975) characterizes narcissistic peo- ple as focusing on themselves in their interactions with others, having a great need to be admired, possessing shallow affect, and being exploitive and, at times, parasitic in

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their relationships with others. Kohut (1971) characterizes such people as perceiving threats to their self-esteem and as having feelings of emptiness and deadness.

“Borderline” conditions are also rooted in the period of separation– individuation. People with a borderline personality disorder have moved into the separation process but have been thwarted by parental rejection of their individu- ation. In other words, a crisis ensues when the child does develop beyond the stage of symbiosis, but the parents are unable to tolerate this beginning individuation and withdraw emotional support. Borderline people are characterized by instabil- ity, irritability, self-destructive acts, impulsive anger, and extreme mood shifts. They typically experience extended periods of disillusionment, punctuated by occasional euphoria. Kernberg (1975) describes the syndrome as including a lack of clear iden- tity, a lack of deep understanding of other people, poor impulse control, and the inability to tolerate anxiety.

Mahler’s (1968) final subphase in the separation–individuation process involves a move toward constancy of self and object. This development is typically pronounced by the 36th month (Hedges, 1983). By now others are more fully seen as separate from the self. Ideally, children can begin to relate without being overwhelmed with fears of losing their sense of individuality, and they may enter into the later psycho- sexual and psychosocial stages with a firm foundation of selfhood. Borderline and narcissistic disorders seem to be rooted in traumas and developmental disturbances during the separation–individuation phase. However, the full manifestations of the personality and behavioral symptoms tend to develop in early adulthood.

This chapter permits only a glimpse of the newer formulations in psychoana- lytic theory. If you would like to pursue this emerging approach, good overviews can be found in Mitchell (1988, 2000), Mitchell and Black (1995), and Wolitzky (2011).

Treating Borderline and Narcissistic Disorders Some of the most powerful tools for understanding borderline and narcissistic personality disorders have emerged from the psychoanalytic models. Among the most significant theorists in this area are Kernberg (1975, 1976, 1997; Kernberg et al., 2008), Kohut (1971, 1977, 1984), and Masterson (1976). A great deal of psychoanalytic writing deals with the nature and treatment of borderline and narcissistic personality disorders and sheds new light on the understanding of these disorders. Kohut (1984) maintains that people are their healthiest and best when they can feel both independence and attachment, taking joy in themselves and also being able to idealize others. Mature adults feel a basic security grounded in a sense of freedom, self-sufficiency, and self-esteem; they are not compulsively dependent on others but also do not have to fear closeness.

If you are interested in learning more about treating individuals with borderline personality disorders from an object-relations perspective, see Psychotherapy for Bor- derline Personality (Clarkin et al., 2006).

Some Directions of Contemporary Psychodynamic Therapy Strupp (1992) maintains that the various contemporary modifications of psycho- analysis have infused psychodynamic psychotherapy with renewed vitality and vigor. Although long-term analytic therapy will remain a luxury for most people in our society, there has been a growing trend toward short-term treatments for

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specific disorders, limited goals, and containment of costs. Strupp’s comments on the directions in psychodynamic theory and practice, which are listed below, are as relevant today as they were in the early 1990s.

◆ Increased attention is being given to disturbances during childhood and adolescence.

◆ The emphasis on treatment has shifted to dealing therapeutically with chronic personality disorders, borderline conditions, and narcissistic personality disorders. There is also a movement toward devising spe- cific treatments for specific disorders.

◆ Increased attention is being paid to establishing a good therapeutic alliance early in therapy. A collaborative working relationship is now viewed as a key factor in a positive therapeutic outcome with psychody- namic approaches.

◆ There is a renewed interest in the development of briefer forms of psy- chodynamic therapy, largely due to societal pressures for accountability and cost-effectiveness.

Strupp’s assessment of the current scene and his predictions for the future have been quite accurate.

The Trend Toward Brief, Time-Limited Psychodynamic Therapy Many psycho- analytically oriented therapists are adapting their work to a time-limited framework while retaining their original focus on depth and the inner life. These therapists support the use of briefer therapy when this is indicated by the client’s needs rather than by arbitrary limits set by a managed care system. Although there are different approaches to brief psychodynamic therapy, Prochaska and Norcross (2018) believe they all share these common characteristics:

◆ Work within the framework of time-limited therapy. ◆ Target a specific interpersonal problem and goals during initial sessions. ◆ Assume a less neutral therapeutic stance than is true of traditional ana-

lytic approaches. ◆ Establish a rapid and strong working alliance early in the therapy. ◆ Use interpretation relatively early in the therapy relationship. ◆ Emphasize the process of terminating therapy.

Brief psychodynamic therapy (BPT) has proven to be a promising approach. Empirical literature demonstrates that brief therapy works. This adaptation applies the principles of psychodynamic theory and therapy to treating selective disorders within a preestablished time limit of anywhere from 8 to 25 sessions (Levenson, 2017). BPT uses key psychodynamic concepts such as the enduring impact of psy- chosexual, psychosocial, and object-relational stages of development; the existence of unconscious processes and resistance; the usefulness of interpretation; the impor- tance of the working alliance; and reenactment of the client’s past emotional issues in relation to the therapist.

Most forms of the time-limited dynamic approach call upon the therapist to assume an active and directive role in quickly formulating a therapeutic focus, such as a central theme or problem area that guides the work (Levenson, 2017). Some

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possible goals of this approach might include conflict resolution, greater access to feelings, increasing choice possibilities, improving interpersonal relationships, and symptom remission. Levenson emphasizes that the aim of time-limited dynamic therapy is not to bring about a cure but to foster changes in behavior, thinking, and feeling. Levenson states: “In brief therapy, we are not looking for therapeutic perfec- tionism” (p. 93). The goals of BPT are accomplished by using the client–therapist relationship as a way to understand how the person interacts in the world. It is assumed that clients interact with the therapist in the same dysfunctional ways they interact with significant others.

McWilliams (2014, 2016) acknowledges the pressures psychoanalytic practitio- ners face in creating short-term treatments that focus on unconscious processes, especially as they are manifested and influenced in the therapeutic relationship. Brief psychodynamic therapy tends to emphasize a client’s strengths, competencies, and resources in dealing with real-life issues. Levenson (2017) notes that a major modification of the psychoanalytic technique is the emphasis on the here and now of the client’s life rather than exploring the there and then of childhood.

BPT provides an opportunity to begin the process of change, which continues long after therapy is terminated. Short-term treatments are based on conceptual approaches similar to those of long-term therapy, but the techniques used are dif- ferent. Levenson (2017) acknowledges that the interactive, directive, focused, and self-disclosing strategies of brief psychodynamic therapy are not suited for all clients or all therapists. This approach is generally not suitable for individuals with severe characterological disorders or for those with severe depression. Clients who are suit- able for psychodynamic therapy generally are curious, are at least minimally self- reflective, and are not overly fearful of attachments (McWilliams, 2014).

By the end of brief therapy, clients tend to have acquired a richer range of inter- actions with others, and they continue to have opportunities to practice functional behaviors in daily life. At some future time, clients may have a need for additional therapy sessions to address different concerns. Instead of thinking of time-limited dynamic psychotherapy as a definitive intervention, it is best to view this approach as offering multiple, brief therapy experiences over an individual’s life span.

If you want to learn more about time-limited dynamic therapy, I recommend Brief Dynamic Therapy (Levenson, 2017).

An Expert’s Perspective on Psychoanalytic Therapy In this section, William Blau, PhD, a licensed psychologist in private prac- tice and an adjunct instructor at Copper Mountain College in Joshua Tree, California, provides answers to the following questions. Although his theo- retical orientation is psychoanalytic, he often uses techniques from other approaches.

1. What is the most important contribution of the psychoanalytic approach for the practice of individual therapy?

I believe the essential contribution of psychoanalysis is the conceptu- alization of psychotherapy as the interactive exploration of a client’s mental life through nonjudgmental questioning and listening. This

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dialectical approach to alleviating mental suffering is rooted in the Socratic belief that the essential truth underlying the client’s problems is to be found in the client’s mind, even if the client is initially unaware of its nature. Healing dialogue was developed in the context of psycho- analysis but has been adopted, at least in part, by many other psycho- therapeutic schools. Within psychoanalysis, the therapeutic dialogue ranges from the free-association/interpretation of classic Freudian analysis to the open interchanges of relational therapists.

2. What two or three key concepts of psychoanalytic therapy are especially applicable to the practice of individual counseling or therapy?

The unconscious. Freud challenged the idea that most human choices are rational responses to realistic alternatives and conscious desires. The mind, from the perspective of psychoanalysis, is largely uncon- scious, and unconscious processes are major determinants of our behavior. Psychotherapy clients seek relief from mental distress, and they typically recognize that they play some role in maintaining their suffering. Nevertheless, it is rarely helpful to simply tell a client what the client is doing wrong. Therapy involves helping clients understand how embedded beliefs and habitual reactions contribute to their dis- tress. The psychoanalytic understanding of unconscious processes provides a framework for understanding how, and sometimes why, one sabotages one’s own quest for happiness.

The importance of early development. Psychoanalysis emphasizes the dynamic relationship between instinctual programming and social learning within each individual. At all stages, many of an individual’s beliefs about the world are learned from observation rather than from formal instruction. Early preverbal experiences make lasting impres- sions. All clients engage in therapy with some fixed beliefs that they accept simply as part of who they are. Some of these are the cognitive “schema” addressed by many therapies, but some relics of the earliest learning are experienced not as logical beliefs but as inherent parts of the self, or as self-evident truths. Psychoanalytic therapy attempts to expose the origin of these patterns, making the unconscious conscious, and freeing the client from the tyranny of the past.

Transference and countertransference. The therapeutic dialogue can be conceptualized as a psychodrama having a cast of many more than two characters. Transference is the client’s projection of attributes of another person onto the therapist. For example, my client may speak to me “as-if” I had attributes of the client’s father or another significant person. My reaction to the client’s words may be distorted by my coun- tertransference—my own projections onto the client—and may influ- ence what I say to the client. Hence, the therapeutic dialogue has the potential for complex mutual distortions. I believe this transference- countertransference dance occurs in all psychotherapy, and therapists of all theoretical orientations should benefit from recognizing it.

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3. What two or three techniques from the psychoanalytic approach have practical value for practitioners of individual therapy?

Silence. In the free-association technique of classical analysis, the therapist simply listens without comment as the client attempts to share whatever thoughts arise. In contrast, like most contemporary therapists, I typically engage actively in the therapeutic dialogue. Nevertheless, I consistently rely on the discipline of simply listen- ing to the client, and becoming attuned to the client’s experiential world, before commenting on that world. I find that silence, the willingness to “shut up and listen,” is essential to development of the therapeutic relationship, which is critical to positive therapeutic outcomes.

Nonjudgmental interpretation. As a psychoanalytic therapist, I am aware that a client’s symptoms are maintained as defenses against threats to the self. Any therapeutic attempt to loosen the hold of the symptoms on the client must be done in such a way as to pro- mote the client’s insight without invalidating the client’s present adjustment. Hence, my interpretation of a client’s symptom often emphasizes that the symptom was a useful, necessary response to a situation in the past. Having established the symptom’s former value, it may be possible for the client to both understand its persistence and to recognize that it is no longer helpful but has, in fact, become harmful. I frame my interpretations as hunches rather than pro- nouncements of truth.

Monitoring countertransference. I find the practice of monitoring my countertransference reactions to be essential. Although transfer- ence interpretations are sometimes useful, I believe monitoring my spontaneous reactions to a client is always necessary.

4. How does the psychoanalytic approach address diversity, mul- ticultural, and social justice issues for the practice of individual counseling? Psychoanalytic theory has played a part in cross-cultural studies since Freud’s early work on psychoanalytic anthropology. Psychoanalytic theorists and researchers have consistently demonstrated the deleteri- ous effects of discrimination, providing strong support for opposing racism and supporting social justice. The psychoanalytic conceptual- ization of ego-defense mechanisms—particularly projection, displace- ment, denial, and reaction formation—provides an understanding of the mechanisms underlying intolerance and prejudice. Psychoanalytic therapy can be seen as confronting ghosts of the past in order to defeat the demons of the present; the “demons” of intolerance and hatred can be addressed in therapy by exposing distortions learned in early child- hood and internalized uncritically into the client’s superego. Thera- peutic work with diverse clients requires vigilant countertransference

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monitoring lest the “ghosts” in the therapist’s past distort the thera- pist’s understanding of the client.

5. In what ways can psychoanalytically oriented psychotherapy be applied to brief therapy (or time-limited counseling)?

Although intended to be of shorter duration than classical psycho- analysis, psychoanalytically oriented psychotherapy is typically a long-term approach. Some analytic therapists do brief therapy, but I consider this to be a specialized practice. In general, the duration of analytic treatment needs to be based on the time needed to develop a therapeutic relationship and address the client’s problems success- fully. Nevertheless, it is possible to conceptualize a client’s problems from a psychoanalytic perspective and within a nonjudgmental ther- apeutic frame, while also using short-term techniques such as stress management, anger management, and teaching emotional self-regu- lation skills. I have also found mindfulness practice and biofeedback to be very useful.

6. From your perspective, what is the current status and the future of the psychoanalytic approach?

I believe the current and future status of the psychoanalytic approach to be excellent, at least in comparison to past periods when it was either enthroned as a rigid dogma or ridiculed as unscientific nonsense. Psy- choanalytic therapy has always been based on the relationship between therapist and client, and studies on “evidence-based treatment” have consistently found the therapeutic relationship to be of primary impor- tance. Moreover, there is a hopeful trend toward integrating different therapeutic approaches, and I believe analytic therapy can “play well” with such emerging therapies as mindfulness, radical acceptance, and dialectical behavior therapy, as well as with existential therapy and some forms of cognitive therapy.

Discussion Questions Related to Dr. Blau’s Psychoanalytic Perspective

1. “I believe this transference-countertransference dance occurs in all psy- chotherapy, and therapists of all theoretical orientations should benefit from recognizing it.” How would recognizing transference help you treat your clients?

2. “Psychoanalytic therapy can be seen as confronting ghosts of the past in order to defeat the demons of the present.” How does this idea fit with your view of the purpose and goals of therapy?

3. The willingness to “shut up and listen” is essential to the develop- ment of a therapeutic relationship. How effective do you think silence and listening are to discovering the inner world of the client?

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Psychoanalytic Therapy From a Multicultural Perspective Strengths From a Diversity Perspective

Psychoanalytically oriented therapy can be appropriate for culturally diverse popula- tions if techniques are modified to fit the settings in which a therapist practices. All of us have a background of childhood experiences and have addressed developmental cri- ses throughout our lives. Erikson’s psychosocial approach, with its emphasis on criti- cal issues in stages of development, has particular application to clients from diverse cultures. Erikson has made significant contributions to how social and cultural fac- tors affect people in many cultures over the life span. Therapists can help their clients review environmental situations at the various critical turning points in their lives to determine how certain events have affected them either positively or negatively.

Psychotherapists need to recognize and confront their own potential sources of bias and how countertransference could be conveyed unintentionally through their interventions. To the credit of the psychoanalytic approach, it stresses the value of intensive psychotherapy as part of the training of therapists. This helps therapists become aware of their own sources of countertransference, including their biases, prejudices, and racial or ethnic stereotypes.

Shortcomings From a Diversity Perspective Psychoanalytic therapy is generally more concerned with long-term personality recon- struction than with short-term problems of living. In addition, traditional psychoana- lytic approaches are costly, and psychoanalytic therapy is generally perceived as being based on upper- and middle-class Western values. All clients do not share these values, and for many the cost of treatment is prohibitive. Another shortcoming pertains to the ambiguity inherent in most psychoanalytic approaches. This can be problematic for clients from cultures who expect the therapist to be more active and provide more structure than is typical in psychoanalytic treatment (Wolitzky, 2020). The therapist should not assume, however, that Asian American clients prefer a more structured, directive, problem-oriented approach to counseling and may not continue therapy if a nondirective or unstructured approach is employed. It is wise to discuss expecta- tions and perceptions of therapy with clients within the first few sessions. Therapists must inquire and treat each client as an individual and not rely on a group stereotype. Furthermore, intrapsychic analysis may be in direct conflict with some clients’ social framework and environmental perspective (Sue et al., 2022).

Many writers on social justice counseling emphasize how important it is to con- sider possible external sources of clients’ problems, especially if clients have experienced an oppressive environment. The psychoanalytic approach can be criticized for failing to adequately address the social, cultural, and political factors that result in an individual’s problems. If there is not a balance between the external and internal perspectives, clients may feel responsible for their condition. However, the nonjudgmental stance that is a cor- nerstone of the psychoanalytic tradition may ameliorate any tendency to blame the client.

Applying a psychoanalytic approach with low-income clients of any cultural, racial, or ethnic background may be unhelpful. These clients often seek profes- sional help in dealing with a crisis situation and need to find solutions to con- crete problems, or at least some direction in addressing survival needs pertaining to

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housing, employment, and child care. This does not imply that low-income clients are unable to profit from analytic therapy; rather, this particular orientation could be more beneficial after more pressing issues and concerns have been resolved.

Psychoanalytic Therapy Applied to the Case of Stan In each of the theory chapters, the case of Stan is used to demonstrate the practical applications of the the- ory in question. Refer to the last section of Chapter 1, where Stan’s biography is given, to refresh your mem- ory of his central concerns.

The psychoanalytic approach focuses on the uncon- scious psychodynamics of Stan’s behavior. Considerable attention is given to material that he has repressed. At the extreme, Stan demonstrated a self-destructive tendency, which is a way of inflicting punishment on himself. Instead of directing his hostility toward his parents and siblings, he turned it inward. Stan’s preoccupation with drinking could be hypothesized as evidence of an oral fixation. Because he never received love and acceptance during his early childhood, he is still suffering from this depri- vation and continues to desperately search for approval and acceptance from others. Stan’s gender-role identifica- tion was fraught with difficulties. He learned the basis of female–male relationships through his early experiences with his parents. What he saw was fighting, bickering, and discounting. His father was the weak one who always lost, and his mother was the strong, domineering force who could and did hurt men. Stan generalized his fear of his mother to all women. It also could be hypothesized that the woman he married was similar to his mother, both of whom reinforced his feelings of impotence.

The opportunity to develop a transference relation- ship and work through it with the therapist is the core of the therapy process. Stan will eventually relate to me as he did to his father, and this process will be a valuable means of gaining insight into the origin of Stan’s difficul- ties in relating to others. The analytic process stresses an intensive exploration of Stan’s past. Stan devotes much therapy time to reliving and exploring his early past. As he talks, he gains increased understanding of the dy- namics of his behavior. He begins to see connections between his present problems and early experiences in his childhood. Stan explores memories of relationships with his siblings and with his mother and father and also

explores how he has generalized his view of women and men from his view of these family members. It is expect- ed that Stan will reexperience old feelings and uncover buried feelings related to traumatic events. From another perspective, apart from whatever conscious insight Stan may acquire, the goal is for him to have a more integrat- ed self, where feelings split off as foreign (the id) become more a part of what he is comfortable with (the ego). In Stan’s relationship with me, his old feelings can have dif- ferent outcomes from his past experiences with signifi- cant others and can result in deep personality growth.

I am likely to explore some of these questions with Stan: “What did you do when you felt unloved?” “As a child, what did you do with your negative feelings?” “As a child, could you express your anger, hurt, and fears?” “What effects did your relationship with your mother and father have on you?” “What did this teach you about women and about men?” Brought into the here and now of the transference relationship, I might ask, “When have you felt anything like you felt with your parents?”

The analytic process focuses on key influences in Stan’s developmental years, sometimes explicitly, sometimes in terms of how those earlier events are being relived in the present analytic relationship. As he comes to understand how he has been shaped by these past experiences, Stan is increasingly able to ex- ert control over his present functioning. Many of Stan’s fears become conscious, and then his energy does not have to remain fixed on defending himself from unconscious feelings. Instead, he can make new deci- sions about his current life. He can do this only if he works through the transference relationship, however, for the depth of his endeavors in therapy largely deter- mine the depth and extent of his personality changes.

If I am operating from a contemporary object-rela- tions psychoanalytic orientation, my focus may well be on Stan’s developmental sequences. Particular atten- tion is paid to understanding his current behavior in the world as largely a repetition of one of his earlier devel-

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opmental phases. Because of his dependency, it is useful in understanding his behavior to see that he is now re- peating patterns that he formed with his mother during his infancy. Viewed from this perspective, Stan has not accomplished the task of separation and individuation. He is still “stuck” in the symbiotic phase on some levels. He is unable to obtain confirmation of his worth from himself, and he has not resolved the dependence–in- dependence struggle. Looking at his behavior from the viewpoint of self psychology can shed light on his dif- ficulties in forming intimate relationships.

Follow-Up: You Continue as Stan’s Therapist With each of the 11 theoretical orientations, you will be encouraged to try your hand at applying the principles and techniques you have just studied in the chapter to working with Stan from that particular perspective. The information presented about Stan from each of these theory chapters will provide you with some ideas of how you might continue working with him if he were referred to you. Do your best to stay within the general spirit of each theory by identifying specific concepts you would draw from and techniques that you might use in helping Stan explore the struggles he identifies.

Questions for Reflection ◆ How much interest would you have in Stan’s early

childhood? What are some ways you’d help him

see patterns between his childhood issues and his current problems?

◆ Consider the transference relationship that is likely to be established between you and Stan. How might you react to his making you into a signifi- cant person in his life?

◆ In working with Stan, what countertransference issues might arise for you?

◆ What resistances and defenses might you predict in your work with Stan? From a psychoanalytic perspective, how would you interpret and work with this resistance?

◆ Which of the various forms of psychoanalytic therapy—classical, relational, or object relations— would you be most inclined to apply in working with Stan?

Refer to the MindTap for The Case of Stan Video Quiz for Chapter 1, Session 1 (an initial session with Stan) and The Case of Stan Video Quiz for Chapter 4, Session 2 (on psychoanalytic ther- apy), for a demonstration of my approach to counseling Stan from this perspective. The first session consists of the intake and assessment process. The second session focuses on Stan’s resistance and dealing with transference.

Psychoanalytic Therapy Applied to the Case of Gwen* In each of the theory chapters, the case of Gwen is used to demonstrate the practical applications of that theoretical approach. Refer to the last section of Chapter 1, where Gwen’s background information and intake session are presented, to refresh your memory of her central concerns.

Gwen show’s up late for her appointment and states that she is feeling frustrated with a work project she is behind on.

Gwen: I feel like I am on the edge of falling apart, like nothing is going right and everyone is looking at me like I’m a failure. I am just sad and unable to put the pieces together. I am behind on every- thing . . . and I am scared I will lose it all.

I listen to Gwen with the goal of allowing her to con- nect to what lies beneath the surface of her strong emotions. As a psychoanalytic therapist, I believe the

*Dr. Kellie Kirksey writes about her ways of thinking and practicing from a psychoanalytic perspective and applies this model to Gwen.

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genesis of psychological problems is rooted in the unconscious mind. Issues brought into session often stem from unresolved childhood conflicts and trauma. Childhood pain and suffering is not necessarily rooted in an extreme or horrific event; children may repress memories of any negative emotional event.

My initial goal is to help Gwen see how her early his- tory is affecting her current habits, feelings, and behav- iors. Once Gwen is able to bring the unconscious mate- rial to a conscious level, she can better understand her triggers and recurrent emotional conflicts. In making unconscious material conscious, Gwen can recognize the origins of her behavior, explore some of these pat- terns, work through early experiences, release dys- functional behaviors, and begin relating to life from a position of greater clarity and strength.

Gwen continues discussing her frustrations with work and begins to cry. I help Gwen achieve a more re- laxed state so she can bypass the conscious mind and find out what is happening at an unconscious level. My intervention is not the typical free association of tra- ditional psychoanalysis but rather guided association based on familiar emotions.

Therapist: Sit back and relax for a moment. Go back to one of the very first times in life when you felt this same or a similar feeling of frustration. Let yourself go back in time, back to when you were a little girl and you had the sense that nothing was going right and that things were falling apart.

[I prompt Gwen.]

You feel yourself getting younger and younger. When you are there, tell me how old you are, who is there with you, and describe the situation.

I watch as Gwen’s facial expression begins to change. After a few minutes she begins to speak.

Gwen: I am five years old, and I am sitting at the kitchen table crying. I have on a pink dress, and the front of my dress is dirty. My mother had told me to wait for her in the car. Instead of waiting in the car, I started playing in the backyard and got dirty. She hit my legs, and I just cried and cried. She yelled and told me that I always mess everything up. All I wanted to do was to play. I never got to play, I just wanted to kick the ball around and have some fun.

Gwen continues to cry as she tells me about her- self as a little girl. I ask her to go to another time in her childhood when she had that same feeling of frustration.

Gwen: I am 12 years old, and I am upstairs in my parent’s room. My little sister had set the bed on fire, and my parents are blaming me because I was supposed to be watching her. I tell them that I was watching her. I keep telling them that it is not my fault, but they don’t listen to me. They put me on punishment for two months, and I overhear them say that I never do anything right.

Therapist: What did that little girl need in those situ- ations?

Gwen: I needed understanding, and someone to tell me it was going to be OK. I needed love, even though I was not the perfect little girl.

I ask Gwen to reflect on what decision she made at that time as a little girl. Gwen pauses and then replies.

Gwen: I decided I had to be perfect in order to be loved.

I ask Gwen to reflect on how often this early decision af- fects her life now. She sits quietly for a while and then comments that she often feels like that little girl. Gwen is surprised by the feelings and insights that have surfaced.

Gwen: I had not thought about those early times in ages. I can’t believe those situations still bother me. I had not realized that.

In that moment Gwen recognizes the power of the un- conscious and how bringing the unconscious material to the surface can serve as a healing force in her life. I tell Gwen that as an adult she is now able to give that little girl aspects of herself: love, acceptance, and attention.

Gwen tells me that loving the little girl aspects of her sounds a bit strange, but she is open to being gen- tler with herself—just as she wanted her parents to be easier on her and love her as she was.

Gwen: I never imagined that those spankings and getting yelled at stuck with me all these years. So now I see that everything seems to be connected,

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and all that I have ever experienced is still affect- ing me today. Wow! I have to go home and sit with all of this.

As Gwen leaves my office, I tell her to pay attention to her dreams and keep a dream journal for the next week so we can continue to explore the unconscious mate- rial through the symbols in her dreams. Gwen smiles and says she had no idea therapy would be like this. I remind her that psychoanalytically oriented therapy is a long journey and that she is not alone.

It is important for me to be aware of transference (Gwen’s unconscious reactions to me). My awareness of transference can facilitate Gwen’s deepening connec- tion to her past. It is also important for me to be aware of countertransference (my unconscious reactions to Gwen). As Gwen spoke of getting spanked as a child, I could relate to her pain and felt her sadness. I could have told countless stories of pain inflicted upon me

during my childhood, but it is not my session. However, I can use my countertransference in a productive way by deepening my therapeutic relationship with Gwen and showing empathy for the hurt child that she was. I examine the feelings and sensations that came up for me in the session, and I challenge myself to seek supervision or peer consultation when necessary to avoid engaging in behavior that is not therapeutically beneficial.

Questions for Reflection ◆ What interventions did the therapist make to help

Gwen begin to see how her early experiences have an impact on her present behavior?

◆ What therapeutic value do you see in facilitating Gwen’s exploration of early childhood pain?

◆ If you were counseling Gwen, what potential countertransference issues might surface for you?

Summary and Evaluation Summary

Some major concepts of psychoanalytic theory include the dynamics of the uncon- scious and its influence on behavior, the role of anxiety, an understanding of trans- ference and countertransference, and the development of personality at various stages in the life cycle.

Erikson broadened Freud’s developmental perspective by including psychoso- cial trends. In his model, each of the eight stages of human development is charac- terized by a crisis, or turning point. We can either master the developmental task or fail to resolve the core struggle. (Table 4.2 compares Freud’s and Erikson’s views on the developmental stages.)

Psychoanalytic therapy consists largely of using methods to bring out uncon- scious material that can be worked through. It focuses primarily on childhood experiences, which are discussed, reconstructed, interpreted, and analyzed. The assumption is that this exploration of the past, which is typically accomplished by working through the transference relationship with the therapist, is necessary for character change. The most important techniques typically employed in psychoana- lytic practice are maintaining the analytic framework, free association, interpreta- tion, dream analysis, analysis of resistance, and analysis of transference.

Unlike Freudian theory, Jungian theory is not reductionist. Jung viewed humans positively and focused on individuation, the capacity of humans to move toward wholeness and self-realization. To become what they are capable of becoming, indi- viduals must explore the unconscious aspects of their personality, both the per- sonal unconscious and the collective unconscious. In Jungian analytical therapy, the

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therapist assists clients in tapping into their inner wisdom. The goal of therapy is not merely the resolution of immediate problems but the transformation of personality.

The contemporary trends in psychoanalytic theory are reflected in these general areas: ego psychology, object-relations interpersonal approaches, self psychology, and relational approaches. Ego psychology does not deny the role of intrapsy- chic conflicts but emphasizes the striving of the ego for mastery and competence throughout the human life span. The object-relations approaches are based on the notion that at birth there is no differentiation between others and self and that oth- ers represent objects of need gratification for infants. Separation–individuation is achieved over time. When this process is successful, others are perceived as both separate and related. Self psychology focuses on the nature of the therapeutic rela- tionship, using empathy as a main tool. The relational approaches emphasize what evolves through the client–therapist relationship.

Contributions of the Classical Psychoanalytic Approach I believe therapists can broaden their understanding of clients’ struggles by appre- ciating Freud’s many significant contributions. It must be emphasized that compe- tent use of psychoanalytic techniques requires training beyond what most therapists are given in their training program. The psychoanalytic approach provides practi- tioners with a conceptual framework for looking at behavior and for understand- ing the origins and functions of symptoms. Applying the psychoanalytic point of view to therapy practice is particularly useful in (1) understanding resistances that take the form of canceling appointments, fleeing from therapy prematurely, and refusing to look at oneself; (2) understanding that unfinished business can be worked through, so that clients can provide a new ending to some of the events that have restricted them emotionally; (3) understanding the value and role of transfer- ence; and (4) understanding how the overuse of ego defenses, both in the counseling relationship and in daily life, can keep clients from functioning effectively.

Although there is little to be gained from blaming the past for the way a person is now or from dwelling on the past, considering the early history of a client is often useful in understanding and working with a client’s current situation. The client can use this awareness in making significant changes in the present and in future direc- tions. Even though you may not agree with all of the premises of the classical psycho- analytic position, many of the psychoanalytic concepts provide a useful framework for understanding clients and helping them achieve a deeper understanding of the roots of their conflicts.

Contributions of Contemporary Psychoanalytic Approaches If the psychoanalytic (or psychodynamic) approach is considered in a broader con- text than is true of classical psychoanalysis, it becomes a more powerful and useful model for understanding human behavior. Although I find Freud’s psychosexual concepts of value, adding Erikson’s emphasis on psychosocial factors gives a more complete picture of the critical turning points at each stage of development. Inte- grating these two perspectives is, in my view, most useful for understanding key themes in the development of personality. Erikson’s developmental schema does not avoid the psychosexual issues and stages postulated by Freud; rather, Erikson

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extends the stages of psychosexual development throughout the life span. His per- spective integrates psychosexual and psychosocial concepts without diminishing the importance of either.

Therapists who work from a developmental perspective are able to see conti- nuity in life and to see certain directions their clients have taken. This perspective provides a broad picture of an individual’s struggle, and clients are able to discover some significant connections among the various life stages.

The contemporary trends in psychoanalytic thinking contribute to the under- standing of how our current behavior in the world is largely a repetition of patterns set during one of the early phases of development. Object-relations theory helps us see the ways in which clients interacted with significant others in the past and how they are superimposing these early experiences on present relationships. For the many clients in therapy who are struggling with issues such as separation and individuation, intimacy, dependence versus independence, and identity, these newer formulations can provide a framework for understanding how and where aspects of development have been fixated. They have significant implications for many areas of human interaction including intimate relationships, the family and child rearing, and the therapeutic relationship.

In my opinion, it is possible to use key concepts of a psychodynamic framework to provide structure and direction to a counseling practice and at the same time to draw on other therapeutic techniques. I find value in the contributions of those writers who have built on the basic ideas of Freud and have added an emphasis on the social and cultural dimensions affecting personality development. In contem- porary psychoanalytic practice, more latitude is given to the therapist in using tech- niques. The newer psychoanalytic theorists have enhanced, extended, and refocused classical analytic techniques. They are concentrating on the development of the ego, are paying attention to the social and cultural factors that influence the differen- tiation of an individual from others, and are giving new meaning to the relational dimensions of therapy.

Several meta-analyses have found that the quality of the therapeutic relation- ship and the therapeutic alliance are critical to the outcomes of analytic therapy, and research attests to the overall helpfulness of psychoanalytic treatments. McWilliams (2014) admits that psychoanalytic therapies are difficult to investigate through randomized controlled trials because they are more complex, individualized, and unstructured than many other therapy approaches. However, the professional com- munity needs to appreciate the value of process research, qualitative research, case studies, and accumulated clinical wisdom. McWilliams cites some literature on evidence-based psychodynamic therapy and adds that literature is emerging that supports the efficacy of psychodynamic therapies. There is also extensive empirical literature on attachment, emotion, defenses, personality, and other areas that sup- port the theoretical models and clinical experiences of psychoanalytic therapists.

Although contemporary psychodynamic approaches diverge considerably in many respects from the original Freudian emphasis on drives, the basic Freudian concepts of unconscious motivation, the influence of early development, transfer- ence, countertransference, and resistance are still central to the newer psychody- namic approaches. These concepts are of major importance in therapy and can be incorporated into therapeutic practices based on various theoretical approaches.

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Limitations and Criticisms of Psychoanalytic Approaches There are a number of practical limitations of psychoanalytic therapy. Considering factors such as time, expense, and availability of trained psychoanalytic therapists, the practical applications of many psychoanalytic techniques are limited. This is especially true of methods such as free association on the couch, dream analysis, and extensive analysis of the transference relationship. A factor limiting the practi- cal application of classical psychoanalysis is that many severely disturbed clients lack the level of ego strength needed for this treatment.

A major limitation of traditional psychoanalytic therapy is the relatively long time commitment required to accomplish analytic goals. Contemporary psychoanalytically oriented therapists are interested in their clients’ past, but they intertwine that under- standing with the present and with future goals. The emergence of brief, time-limited psychodynamic therapy is a partial response to the criticism of lengthy therapy. Psy- chodynamic psychotherapy evolved from traditional analysis to address the need for treatment that was not so lengthy and involved (Levenson, 2017).

A potential limitation of the psychoanalytic approach is the anonymous role assumed by some therapists. This stance can be justified on theoretical grounds, but in therapy situations other than classical psychoanalysis this stance is unduly restric- tive. The newer formulations of psychoanalytic practice place considerable emphasis on the interaction between therapist and client in the here and now, and therapists can decide when and what to disclose to clients. Yalom (2003) suggests that appro- priate therapist self-disclosure tends to enhance therapy outcomes. Rather than adopting a blank screen, he believes it is more productive to strive to understand the past as a way of shedding light on the dynamics of the present therapist–client rela- tionship. This is in keeping with the spirit of the relational analytic approach, which emphasizes the here-and-now interaction between therapist and client.

From a feminist perspective there are distinct limitations to a number of Freudian concepts, especially the Oedipus and Electra complexes. In her review of feminist coun- seling and therapy, Enns (1993) also notes that the object-relations approach has been criticized for its emphasis on the role of the mother–child relationship in determining later interpersonal functioning. The approach gives great responsibility to mothers for deficiencies and distortions in development. Fathers are conspicuously absent from the hypothesis about patterns of early development; only mothers are blamed for inad- equate parenting. Linehan’s (1993a, 1993b, 2015) dialectical behavior therapy (DBT), addressed in some detail in Chapter 9, is an eclectic approach that avoids mother bash- ing while accepting the notion that the borderline client experienced a childhood envi- ronment that was “invalidating” (Linehan, 1993a, pp. 49–52).

Luborsky, O’Reilly-Landry, and Arlow (2011) note that psychoanalytic therapies have been criticized for being irrelevant to contemporary culture and being appro- priate only to an elite, highly educated clientele. To this criticism, they counter with the following statement: “Psychoanalysis is a continually evolving field that has been revised and altered by psychoanalytic theorists and clinicians ever since its origin. This evolution began with Freud himself, who often rethought and substantially revised his own ideas” (p. 27).

In a special issue of Psychoanalytic Psychology in 2021, 20 analysts from the United States, Latin America, and Europe contributed articles on how the coronavirus

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pandemic necessitated major shifts in the way they practiced psychoanalysis. Vorus and Ellman (2021) provide an overview of key takeaways from these analysts that include remote therapy by telephone or videoconferencing replacing in-person ther- apy; analysts reporting shared traumatic experiences along with their clients; and the challenges of working with complex traumatic factors. The ever-present danger of the pandemic was only one of several disturbing events in 2020. Protests against police killing people of color, social unrest due to social and political changes, and the challenges to democracy also increased anxiety for many people. Applying psy- choanalysis to meet the pressing needs of clients in times of crisis may be beneficial in the future as remote sessions make this therapy more available in underserved areas.

Self-Reflection and Discussion Questions 1. What are a few key concepts of the relational psychoanalytic approach

that you would be most likely integrate into your counseling practice?

2. Psychoanalytic therapists pay particular attention to early childhood experiences and the past as crucial determinants of present behavior. What are your thoughts about this emphasis? How does this concept apply to your life?

3. Transference can allow clients to explore the parallels between their past and present experience and to acquire a new understanding of their dynamics. What value would you place on exploring transference with a client?

4. What are some aspects of the psychoanalytic approach that you think could be applied to brief therapy or time-limited therapy?

5. What is one topic area that has the potential to trigger countertransfer- ence for you? How can you identify your countertransference reactions? How can you best manage your countertransference as a therapist?

Where to Go From Here DVDs from the American Psychological Association’s Systems of Psychotherapy Video Series that address the psychoanalytic approaches discussed in this chapter include the following:

McWilliams, N. (2007). Psychoanalytic Therapy

Safran, J. (2008). Relational Psychotherapy

Safran, J. (2010). Psychoanalytic Therapy Over Time

Wachtel, P. (2008). Integrative Relational Psychotherapy

Levenson, H. (2009). Brief Dynamic Therapy Over Time

Psychotherapy.net (www.Psychotherapy.net) is a comprehensive resource for students and professionals, offering videos and interviews with renowned

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psychoanalysts such as Otto Kernberg and Nancy McWilliams. New articles, inter- views, blogs, and videos are published monthly. Two from 2011 by Otto Kernberg are Otto Kernberg: Live Case Consultation and Psychoanalytic Psychotherapy for Personality Disorders: An Interview with Otto Kernberg, MD.

Various colleges and universities offer special workshops or short courses through continuing education on topics such as therapeutic considerations in working with borderline and narcissistic personalities. These workshops could give you a new per- spective on the range of applications of contemporary psychoanalytic therapy.

For further information about training programs, workshops, and graduate programs in various states, contact the American Psychoanalytic Association (www .apsa.org).

Recommended Supplementary Readings for Chapter 4 Psychodynamic Group Psychotherapy (Rutan et al., 2014) presents a comprehensive discussion of vari- ous facets of psychodynamic group therapy. Among the topics addressed are the stages of group devel- opment, the role of the group therapist, therapeutic factors accounting for change, working with diffi- cult groups and difficult group members, and time- limited psychodynamic groups.

Brief Dynamic Therapy (Levenson, 2017) describes a model of psychodynamic therapy that fits the real- ity of time-limited therapy and outlines the steps toward clinical work that is both focused and deep. This excellent book deals with how psychoanalytic concepts and techniques can be modified to suit the needs of many clients who cannot participate in long-term therapy.

Psychoanalytic Psychotherapy: A Practitioner’s Guide (McWilliams, 2004) is a fine primer on psycho- analytically oriented treatment designed for begin- ning therapists. The author provides guidelines for addressing common clinical challenges and offers excellent points on therapist self-care, professional development, and personal therapy for practitioners.

Psychoanalysis and Psychoanalytic Therapies (Safran, 2012) describes the major turning points in the development of psychoanalytic theory and practice over time. Key theoretical concepts are discussed and interventions are described.

Psychodynamic Psychiatry in Clinical Practice (Gabbard, 2005) offers an excellent account of vari- ous psychoanalytic perspectives on borderline and narcissistic disorders.

References Clarkin, J., Yeomans, F., & Kernberg, O. (2006). Psychotherapy for borderline personality: Focusing on object relations. Psychiatric Press. Corey, G. (2013). Case approach to counseling and psychotherapy (8th ed.). Brooks/Cole, Cengage Learning. Corey, G. (2023). Theory and practice of group counseling (10th ed.). Cengage Learning. Curtis, R. C. (2020). Relational psychoanalytic/psychodynamic psycho- therapy. In S. B. Messer & N. J. Kaslow

(Eds.), Essential psychotherapies: Theory and practice (4th ed., pp. 71–108). Guilford Press. Enns, C. Z. (1993). Twenty years of feminist counseling and therapy: From naming biases to implementing multifaceted practice. The Counseling Psychologist, 21(1), 3–87. Erikson, E. H. (1963). Childhood and society (2nd ed.). Norton. Gabbard, G. (2005). Psychodynamic psychiatry in clinical practice (4th ed.). American Psychiatric Press.

Harris, A. S. (1996). Living with paradox: An introduction to Jungian psychology. Brooks/Cole, Cengage Learning. Hayes, J. A. (2004). Therapist know thyself: Recent research on countertransference. Psychotherapy Bulletin, 39(4), 6–12. Hayes, J. A., Gelso, C. J., Kivlighan, M., & Goldberg, S. B. (2019). Managing countertransference. In J. C. Norcross & M. J. Lambert (Eds.), Psychotherapy relationships that work: Evidence-based therapist contributions (3rd ed., vol. 1, pp. 522–548). Oxford University Press.

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Hedges, L. E. (1983). Listening perspectives in psychotherapy. Aronson. Jung, C. G. (1961). Memories, dreams, reflections. Vintage. Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. Aronson. Kernberg, O. F. (1976). Object-relations theory and clinical psychoanalysis. Aronson. Kernberg, O. F. (1997). Convergences and divergences in contemporary psychoanalytic technique and psycho- analytic psychotherapy. In J. K. Zeig (Ed.), The evolution of psychotherapy: The third conference (pp. 3–22). Brunner/Mazel. Kernberg, O. F., Yeomans, F. E., Clarkin, J. F., & Levy, K. N. (2008). Transference focused psychotherapy: Overview and update. International Journal of Psychoanalysis, 89, 601–620. Klein, M. (1975). The psychoanalysis of children. Dell. Kohut, H. (1971). The analysis of self. International Universities Press. Kohut, H. (1977). Restoration of the self. International Universities Press. Kohut, H. (1984). How does psychoanalysis cure? University of Chicago Press. Levenson, H. (2017). Brief dynamic therapy (2nd ed.). American Psychological Association. Linehan, M. M. (1993a). Cognitive- behavioral treatment of borderline personality disorder. New York: Guilford Press. Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder. Guilford Press. Linehan, M. M. (2015). DBT skills training manual (2nd ed.). Guilford Press.

Luborsky, E. B., O’Reilly-Landry, M., & Arlow, J. A. (2011). Psychoanalysis. In R. J. Corsini & D. Wedding (Eds.), Current psychotherapies (9th ed., pp. 15–66). Brooks/Cole, Cengage Learning. Mahler, M. S. (1968). On human symbiosis or the vicissitudes of individuation. International Universities Press. Masterson, J. F. (1976). Psychotherapy of the borderline adult: A developmental approach. Brunner/Mazel. McWilliams, N. (2004). Psychodynamic therapy: A practitioner’s guide. Guilford Press. McWilliams, N. (2014). Psychodynamic therapy. In L. S. Greenberg, N. McWilliams, & A. Wenzel, Exploring three approaches to psychotherapy (pp. 71–127). American Psychological Association. McWilliams, N. (2016). Psychoanalysis. In I. Marini & M. A. Stebnicki (Eds.), The professional counselor’s desk reference (2nd ed., pp. 183–190). Springer. Mitchell, S. A. (1988). Relational concepts in psychoanalysis: An integration. Harvard University Press. Mitchell, S. A. (2000). Relationality: From attachment to intersubjectivity. Analytic Press. Mitchell, S. A., & Black, M. J. (1995). Freud and beyond: A history of modern psychoanalytic thought. Basic Books. Prochaska, J. O., & Norcross, J. C. (2018). Systems of psychotherapy: A transtheoretical analysis (9th ed.). Oxford University Press. Rutan, J. S., Stone, W. N., & Shay, J. J. (2014). Psychodynamic group psychotherapy (5th ed.). Guilford Press. Safran, J. D. (2012). Psychoanalysis and psychoanalytic therapies. American Psycho- logical Association.

Safran, J. D., Kriss, A., & Foley, V. K. (2019). Psychodynamic psychotherapies. In D. Wedding & R. J. Corsini (Eds.), Current psychotherapies (11th ed., pp. 21–57). Cengage Learning. Schultz, D. P., & Schultz, S. E. (2013). Theories of personality (10th ed.). Wadsworth, Cengage Learning. St. Clair, M. (with Wigren, J.). (2004). Object relations and self psychology: An introduction (4th ed.). Brooks/Cole, Cengage Learning. Stern, D. N. (1985). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. Basic Books. Strupp, H. H. (1992). The future of psychodynamic psychotherapy. Psycho- therapy, 29(l), 21–27. Sue, D. W., Sue, D., Neville, H. A., & Smith, L. (2022). Counseling the culturally diverse: Theory and practice (9th ed.). Wiley. Vorus, N., & Ellman, S. J. (2021). Notes from a pandemic: A year of COVID- 19. Psychoanalytic Psychology, 38(2), 97–98. https://doi. org/10.1037/pap0000364 Wolitzky, D. L. (2011). Psychoanalytic theories in psychotherapy. In J. C. Norcross, G. R. Vandenbos, & D. K. Freedheim (Eds.), History of psychotherapy (2nd ed., pp. 65–100). American Psychological Association. Wolitzky, D. L. (2020). Contemporary Freudian psychoanalytic psychotherapy. In S. B. Messer & N. J. Kaslow (Eds.), Essential psychotherapies: Theory and practice (4th ed., pp. 35–70). Guilford Press. Yalom, I. D. (2003). The gift of therapy: An open letter to a new generation of therapists and their patients. HarperCollins, Perennial.

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Adlerian Therapy

1. Describe these key concepts of the Adlerian approach: goal-directed movement, goal orientation, and the unity of personality and lifestyle.

2. Explain the meaning of social interest and how this is a foundational concept of the Adlerian approach.

3. Define the life tasks and explain the implications for therapy practice.

4. Describe how Adlerians view birth order and the implications of sibling relationships.

5. Discuss the role of the family constellation and early recollections in a lifestyle assessment.

6. Explain how the relationship between therapist and client is viewed from the Adlerian perspective.

7. Describe the four phases of the Adlerian therapeutic process.

8. Identify what is involved in a thorough assessment of an individual.

9. Explain how Adlerians view the role of interpretation in the therapy process.

10. Describe what is involved in the reorientation and reeducation process.

11. Describe areas in which the Adlerian approach can be applied.

12. Discuss the application of the Adlerian approach to school counseling.

13. Identify the strengths and limitations of Adlerian therapy from a diversity perspective.

14. Discuss the unique contributions of this approach to the development of other counseling approaches.

15. Identify at least one criticism of the Adlerian approach.

Learning Objectives

5 Coauthored by James Robert Bitter and Gerald Corey

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Alfred Adler (1870–1937) grew up in a Vienna family of six boys and two girls. His younger brother died at a very young age while in bed next to Alfred. Adler’s early child- hood was not a happy time; he was sickly and very much aware of death. At age 4, he nearly died of pneumo- nia, and he overheard the

doctor tell his father “Alfred is lost.” Adler associated this time with his decision to become a physician. Because he was ill so much dur- ing the first few years of his life, Adler’s mother pam- pered him. He developed a trusting relationship with his father but did not feel very close to his mother. He was extremely jealous of his older brother, Sigmund, which led to a strained relationship between the two during childhood and adolescence. When we consider Adler’s strained relationship with Sigmund Freud, we cannot help but suspect that patterns from his early family constellation were repeated in this relationship.

Adler’s early childhood experiences had an impact on the formation of his theory. He shaped his own life rather than leaving it to fate. Adler was always con- sidered bright, but he did just enough to get by in school until one day he realized that a math teacher did not know the answer to a question he had posed. Adler waited until the best students had given it a try, and then he raised his hand and stood up. Peo- ple laughed at him, but he came up with the right answer. After that he began to apply himself, and he rose to the top of his class. He went on to study medicine at the University of Vienna, entering private practice as an ophthalmologist, and then shifted to general medicine. He eventually specialized in neu- rology and psychiatry, and he had a keen interest in incurable childhood diseases.

Adler was Jewish and experienced anti-Semitism as well as the horrors of World War I. Those experiences,

and the sociopolitical context of the time, contributed to his emphasis on humanism and the need for people to work together. He was acutely aware of the impact of context and culture on the human personality, and his theory emanated from this awareness.

Adler had a passionate concern for the common person and was outspoken about child-rearing practices, school reforms, and prejudices that re- sulted in conflict. He spoke and wrote in simple, nontechnical language and advocated for children at risk, the democratic education of children and adult education, women’s rights, the equality of the sexes, family counseling, and community mental health (Watts, 2012). Adler’s (1927/1959) Under- standing Human Nature was the first major psychol- ogy book to sell hundreds of thousands of copies in the United States. After serving in World War I as a medical officer, Adler created 32 child guidance clinics in the Vienna public schools and began train- ing teachers, social workers, physicians, and other professionals. He pioneered the practice of teach- ing professionals through live demonstrations with parents and children before large audiences, now called “open-forum” family counseling. The clinics he founded grew in number and in popularity, and he was indefatigable in lecturing and demonstrat- ing his work.

Although Adler had an overcrowded work schedule most of his professional life, he still took some time to sing, enjoy music, and be with friends. In the mid- 1920s he began lecturing in the United States, and he later made frequent visits and tours. He ignored the warning of his friends to slow down, and on May 28, 1937, while taking a walk before a scheduled lecture in Aberdeen, Scotland, Adler collapsed and died of heart failure.

If you have an interest in learning more about Adler’s life, see Edward Hoffman’s (1996) excellent bi- ography, The Drive for Self. For more on Adler’s writings and their meaning in modern society, see Jon Carlson and Michael Maniacci’s (2012) edited book, Alfred Adler Revisited.

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James Robert Bitter (b. 1947), coauthor of this chapter, is one of the leading contemporary figures in Adlerian therapy. He grew up in Wenatchee, Washington, the oldest of two children, both adopted. While still in high school, Manford Sonstegard, a student and colleague of Rudolf Dreikurs,

started a family education center in his town. Sonstegard would later become Bitter’s men- tor, teaching him how to be an effective counselor.

Bitter’s mother died of cancer when he was 14 years old, and he felt he was largely on his own in high school and college. An underachiever in everything, after his sophomore year in college, a friend challenged him to approach learning seriously and take charge of his life. Bitter began to achieve in both academic work and ex- tracurricular activities.

Introduced to Adlerian family counseling in the 1970s by Professor Tom Edgar, Bitter and other students at Idaho State University opened the first family educa- tion center in Idaho. Bitter received a master’s degree and a doctorate at Idaho State University, then took a job at the West Virginia College of Graduate Studies in a counseling program chaired by Manford Sonstegard. Over the next 13 years, together they taught courses, ran workshops and conferences, wrote papers and ed- ited a journal, and developed an Adlerian model for group counseling (Sonstegard & Bitter, 2004).

After a month-long training session led by Virgina Satir in 1979, Bitter became part of Satir’s AVANTA Net- work. For the next nine years, Bitter helped lead some of Satir’s training sessions. In 1987, Satir came to California State University at Fullerton to help Bitter initiate a new era in the counseling program there. At Fullerton, Bitter met Jerry Corey, who encouraged Bitter to contribute to this book as well as to write his own books, one of which is Theory and Practice of Couples and Family Counsel- ing (Bitter, 2021). This collaboration and friendship with Corey has continued for more than a quarter of a century. Bitter served as president of the North American Society of Adlerian Psychology (NASAP) in 2016 and 2017, and he received the Lifetime Achievement Award for Contribu- tions to Adlerian Psychology from NASAP in 2022.

Bitter is an Adlerian integrationist, like his friend the late Jon Carlson. He integrates ideas gathered from other people, but his foundation remains in the systemic thera- peutic practice of Adlerian psychology. Bitter believes Adler’s emphasis on the importance of community feeling and acting with social interest are what guarantees mental health and helps people overcome inferiority feelings and know that they have a place in the world. Bitter brings his philosophy and practical experience to the discussion of Adlerian theory and practice in this chapter.

Although this chapter draws from many Adlerian sources, it is primarily informed by two current and prominent Adlerian models: Paul Rasmussen’s (2010, 2021; Rasmussen & Schuyler, 2020) adaptive reorien- tation therapy and Len Sperry and Jon Sperry’s (2020) pattern-focused/case conceptualization model.

Paul R. Rasmussen (b. 1959) is the founder and director of the Emotional Health Initiative (EHI). He conducts workshops and coordinates and trains the EHI team who also offer workshops and follow-up consulta- tions. He obtained his PhD in clinical psychology at the University of Georgia. He is

an adjunct professor at the University of South Carolina and at Columbia College (Columbia, SC). He taught for 20 years at Furman University (Greenville, SC) before join- ing the core faculty at Adler University in Chicago where he served as director of the Adler Child-Guidance Center. He now works with U. S. military veterans in postmilitary readjustment.

Rasmussen is a diplomate in Adlerian Psychol- ogy, a licensed clinical psychologist, and the author of Personality-Guided Cognitive-Behavior Therapy (2005), The Quest to Feel Good (2010), and more than

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Len Sperry (b. 1943) is a pro- fessor of mental health coun- seling and director of clinical training at Florida Atlantic University and is a clinical pro- fessor of psychiatry and be- havioral medicine at the Medical College of Wisconsin. He has taught, practiced, re- searched, and written about mental health counseling,

particularly Adlerian therapy, for five decades. In 1972, he completed the postdoctoral certificate in psycho- therapy at the Adler Institute of Chicago (now Adler University) where he was mentored by Rudolf Dreikurs.

Sperry is board certified in psychiatry, preventive medicine, clinical psychology, and Adlerian psychol- ogy. He is also a fellow of the American Psychologi- cal Association, the American Psychiatric Association, the American College of Preventive Medicine, and the American Counseling Association. In addition, he is the coeditor of the Journal of Individual Psychology, the editor-in-chief of the American Journal of Family Therapy, and is on the editorial board of 10 other journals.

Among his 1,100+ professional publications and 100+ professional books is an edited volume titled Psychopathology and Psychotherapy: DSM-5 Diagnosis, Case Conceptualization, and Treatment (Sperry et al., 2014). His research and scholarly interests include case conceptualization, family therapy, integrated spiri- tual psychotherapy, integrative behavioral health, and pattern-focused therapy.

His unique contribution to Adlerian psychology is articulating an integrative approach to Adlerian case conceptualization and developing an evidence-based psychotherapy called pattern-focused Adlerian therapy.

This approach is described and illustrated in Learning and Practicing Adlerian Therapy (Sperry & Binensztok, 2019).

Jonathan Sperry (b. 1983) is an associate professor in the clinical mental health counseling program at Lynn University. He obtained his PhD in counseling at Florida Atlantic University in 2011 and has been a professional counselor in counseling and psychological services there since 2009. Sperry’s area of expertise is case con- ceptualization in counseling practice. He is a diplomate in Adlerian psychology and has been active with various Adlerian psychology organizations since 2008. He was president of the North American Society of Adlerian Psy- chology in 2018-2019, and he was appointed coeditor of the Journal of Individual Psychology in 2017. He has also been a faculty member at the International Committee on Adlerian Summer Schools and Institutes since 2015.

Sperry has coauthored six books, five book chapters, and various professional articles, including Psychopa- thology and Psychotherapy: DSM-5 Diagnosis, Case Con- ceptualization, and Treatment (Sperry, Carlson, et al., 2014); Case Conceptualization: Mastering This Compe- tency With Ease and Confidence (Sperry & Sperry, 2012, 2020), with Arabic, Korean, and Turkish translations; Cognitive Behavior Therapy of the DSM-5 Personality Disorders (Sperry & Sperry, 2015); Cognitive Behavioral Therapy in Counseling Practice (Sperry & Sperry, 2017); and The 15-Minute Case Conceptualization (Sperry & Sperry, 2021).

Sperry has given workshops and lectures through- out the United States and in 22 countries around the globe, including Bulgaria, the Bahamas, Brazil, Canada, China, France, Germany, Ireland, Japan, Mexico, Morocco, the Netherlands, Romania, Russia, Slovakia, Singapore, South Korea, Taiwan, Turkey, the United Kingdom, Ukraine, and Uruguay.

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40 professional articles. Rasmussen teaches through- out the United States, Europe, and Asia on topics related to emotional heath and clinical treatment. His model of Adlerian therapy, adaptive reorientation therapy, is one

of the newest and most progressive Adlerian approach- es to counseling and psychotherapy—and it is current- ly the model of choice in his Veterans Administration clinical setting.

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Adler ian Therapy 113

Introduction Along with Freud and Jung, Alfred Adler was a major contributor to the initial development of the psychodynamic approach to therapy. After a decade of collabo- ration, Freud and Adler parted company, with Freud declaring that Adler was a her- etic who had deserted him. Adler resigned as president of the Vienna Psychoanalytic Society in 1911 and founded the Society for Individual Psychology in 1912. Freud then asserted that it was not possible to support Adlerian concepts and still remain in good standing as a psychoanalyst.

Later, a number of other psychoanalysts deviated from Freud’s orthodox posi- tion. These Freudian revisionists—including Karen Horney, Erich Fromm, and Harry Stack Sullivan—agreed that relational, social, and cultural factors were of great sig- nificance in shaping personality. Even though these three therapists are typically called neo-Freudians, it would be more appropriate, as Heinz Ansbacher (1979) has suggested, to refer to them as neo-Adlerians because they moved away from Freud’s biological and deterministic point of view and toward Adler’s social-psychological and teleological (or goal-oriented) view of human nature.

Adler stressed the unity of personality, contending that people can only be understood as integrated and complete beings. This view also espoused the pur- poseful nature of behavior, emphasizing that where we have come from is not as important as where we are striving to go. Adler believed that we create ourselves rather than merely being shaped by our childhood experiences.

After Adler’s death in 1937, Rudolf Dreikurs was the most significant figure in bringing Adlerian psychology to the United States, especially as its principles applied to education, parenting, individual and group therapy, and family coun- seling. Dreikurs is credited with giving impetus to the idea of child guidance cen- ters and to training professionals to work with a wide range of clients (Terner & Pew, 1978).

Refer to the MindTap for this book to interact with video quizzes and various video programs to expand your knowledge on topics relevant to Chapter 5.

Key Concepts View of Human Nature

Adler abandoned Freud’s basic theories because he believed Freud was exces- sively narrow in his emphasis on biological and instinctual determination. Adler believed that the individual begins to form an approach to life somewhere in the first six years of living. He focused on the person’s past as perceived in the pres- ent and how an individual’s interpretation of early events continued to influence that person’s present behavior. According to Adler, humans are motivated primarily by social relatedness rather than by sexual urges; behavior is purposeful and goal- directed; and consciousness, more than the unconscious, is the focus of therapy. Adler stressed choice and responsibility, meaning in life, and striving for success,

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completion, and perfection. Adler and Freud created very different theories, even though both men grew up in the same city in the same era and were educated as physicians at the same university. Their individual and distinct childhood experi- ences, their personal struggles, and the populations with whom they worked were key factors in the development of their particular views of human nature (Schultz & Schultz, 2013).

Goal-Directed Movement Adler did not believe that people had a personality; to be sure, humans had person- ality traits and character, and all of these parts and ways of being were, for him, directed toward and pursuant to a final life goal. In short, everything in human life is goal-directed movement. From birth to death, we are engaged in striving, in overcoming and compensating, in moving from an experienced, perceived, and felt minus to a similarly felt and imagined plus (Adler, 1929/1969). It is that imag- ined plus position that gives individual movement its direction and motivation; we become oriented toward fulfillment in our imagined future.

As the child grows, the goal continues to evolve, never really changing its rudi- mentary vision but expanding and refining it, so that movement is adapted to the demands of life. Although each individual’s law of movement is unique, it is possible to gain an initial sense of individual movement by considering it from one or more of four perspectives: movement toward, movement against, movement away from, and ambivalent movement (what Adlerians sometimes call hesitant movement; Sperry & Sperry, 2020). A subcategory of movement against self occurs when individuals work against their own self-interest, even to the point of being self-destructive.

The movements of infancy and very early childhood are almost always move- ments toward because survival depends on attachment and connection. The child reaches for the secure attachment to the parent, often to the mother, and in that attachment both are nurtured. Mutuality turns out be true at almost every possible human level, including spirituality and meaning, emotions, and even physical well- ness. Breastfeeding, for example, improves the immune systems of both the child and the mother. Being rocked in a parent’s arms can calm both beings at once. Adler (1931/1958) called such attachments the child’s first experience of cooperation. It is then the job of the primary caregiver to redirect the child’s first connection: first to the other parent if there is one, then to siblings, and later to friends, neighbors, school, and the community.

As the child gets older, movements toward another begin to take on many forms, some of which are useful, such as constructive attention-getting (Dreikurs, 1948), and others that are less useful. Disruptive attention-getting, dependency, clutching, shyness, separation anxiety, pleasing to secure safety or to be valued may all be mis- taken forms of moving toward. Such mistaken forms are often the result of parental pampering and overprotection (Adler, 1931/1958).

Pampering and overprotection can also lead to ambivalent movement. When things are regularly done for children that they can do for themselves, they lose a sense of being capable; they lose courage and may become discouraged; they hesi- tate, feel anxious, and may even freeze in the face of life’s challenges. Such movement may be characterized by displays of inadequacy (Dreikurs, 1948), in giving up when

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faced with life tasks and challenges, and with both anxiety and depression becoming everyday life experiences.

At the other end of pampering and overprotection are children who have been hated, abused, or neglected. Such children often feel that their survival is threat- ened, and they become skilled at withdrawal or movement away; this movement is a safeguard or protection against loss and hurt. Some children, however, develop a movement against others, reacting with anger and the assertion of power and even seeking revenge (Dreikurs, 1948). In such cases, the movement against is seen as the child’s best hope for survival.

Not all of these movements are survival-based. When children can develop a secure attachment with one or more adults, movement is often in the service of con- nection and the feeling of belonging. The various movements aim at helping us to count, to feel capable, and to handle life’s challenges. When life’s challenges and burdens become too much for the individual, however, these four movements can be seen in both clinical and personality disorders.

So what do the four general movements look like in relation to mental discour- agement? We know that the movements will be determined by a personal goal of overcoming, and in mental illness that goal involves the desire for safety and secu- rity. We know it is not the problems in the person’s life but rather the individual’s evaluation of self, others, and life that drives movement. And when this evaluation turns stress into distress, the feelings that result communicate both the internal assessment of self and the world and a relational demand that others protect them or take care of them. These movements are most easily seen in what are called per sonality disorders (American Psychiatric Association, 2013), but they are also present in clinical disorders.

Some of the feelings, behaviors, and disorders described in Table 5.1 can easily reflect more than one movement or be individualized into a combination of move- ments. Although we may find that a single movement is involved—for example, anger as a movement against—we do not yet know the particular use of anger in the individual’s style of living. We merely know that the person feels under threat and feels compelled to fight back and to win at any cost.

Mosak and Rasmussen (2002) use dance as a metaphor for the therapeutic encounter. Clients enter the dance of therapy in a multitude of ways, from the bold, assertive, never hesitant posture of the straightforward dancer to the wallflowers who never take the floor and distance themselves. Some dancers appear to go in one direction, but shift, sometimes constantly, to a different destination. Some dancers are passive or hesitate, and others show off. Dancers may ignore the music until it goes away, and others simply demonstrate that they are the worst dancers in the world. Each of these dance partners enters therapy with a style of movement, and they engage the process with what they have commonly relied on in life. It is the counselor who encourages the client “to alter the music [heard] and to dance a new dance” (p. 120).

Goal-Orientation and the Unity of the Personality What others might consider an individual personality, Adlerians understand to be the person’s style of living, and each person’s style includes a life aim or goal, a

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personal law of movement, and the individual’s opinion, assessment, and evalua- tion of self and the problems or tasks of life that must be faced. When Adlerians speak of lifestyle or, more specifically of lifestyle assessment, it is the person’s style of movement through life that is being addressed. Adler (1927/1959) believed that the individual’s goal emerged early in childhood, perhaps as early as 4 or 5 years of age, at least as a prototype; the goal is an early formulation of what the child would be like if fully successful, whole or complete: It is the child envisioning perfection. At this young age, it is highly likely that mistakes will be made—errors in judgment, thinking, and perceiving—and these errors may lead to further mistakes in feeling and behaving.

Once the life goal is formed, it unifies the personality: With some occasional deviations in pattern, every thought, conviction, belief, feeling or emotion, and certainly our behaviors become directed toward—and oriented to—that final goal.

Table 5.1 General Movements by Individuals

Movement Emotions, Behaviors, and Possible Disorders

Movement toward Emotions: Some forms of shyness; embarrassment; humiliation; shame; envy; lust; guilt.

Behaviors: Attention getting; dependency; pleasing and placating; putting others first to the exclusion of self.

Disorders: Some uses of separation anxiety; disinhibited social engagement disorder; histrionic personality disorder; dependent personality disorder; some uses of borderline personality disorder.

Movement against Emotions: Frustration; disappointment in others; anger; disgust; resentment; contempt. Behaviors: Anger outbursts, rage, and some uses of impulsive behavior; excessive criticism; some forms of stonewalling.

Disorders: Selective mutism; conduct disorder and antisocial personality disorder; narcissistic personality disorder; some uses of borderline personality disorder; paranoid personality disorder.

Movement against self (subcategory of movement against)

Emotions: Personal disappointment; (a subcategory) self-contempt. Behaviors: Cutting and other forms of self-harm; suicide. Disorders: Anorexia, bulimia; body dysmorphic disorder; trichotillomania; excoriation.

Movement away from Emotions: Sadness; sorrow and grief; hurt; dread; depression. Behaviors: Depersonalization; insomnia. Disorders: Some forms of attention-deficit/hyperactivity disorder (ADHD); some uses of separation anxiety; reactive attachment disorder; avoidant personality disorder; selective phobias; social anxiety disorder; schizophrenia; schizoid personality disorder; schizotypal personality disorder; schizoaffective disorder; acute stress disorder; and post-traumatic stress disorder (PTSD).

Ambivalent movement Emotions: Fear; feeling stuck; anxiety, panic; anguish. Behaviors: Hesitation; some forms of stonewalling; panic attacks; hoarding; insomnia; dissociation or depersonalization. Disorders: Panic disorder; generalized anxiety disorder; dissociative identity disorder; dissociative amnesia; passive aggressive personality disorder; obsessive compulsive personality disorder.

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Because we will never reach a goal of perfection, the goal is, of course, fictional, a guiding ideal that serves as a final endpoint off in the distance. This is what Adler (1932) means by the concept of a fictional finalism. Literally, the power of the goal comes from the quality of it being beyond us, more than we are now or ever will be, but envisioned, at least early in life, as possible.

Community Feeling and Social Interest As Paul Rasmussen (2010) suggests, we are all doing the same thing: We are all moving through space, advancing time, and changing circumstances with the goal that our lives will go well. We all want feel good, happy, satisfied, and complete. The problem, of course, is that we keep running into roadblocks, chal- lenges, and events for which we are not prepared. If we can’t feel good, we at least want to feel better, and “better is always better, but better is not always good” (p. 7). It is when we are confronted with life’s challenges that our style of living will be most clearly expressed and revealed. And like everything else internal to the person, feelings communicate the individual’s goals, law of movement, and perceptions of self.

It is not the movement, however, that determines the happiness and functional- ity of the individual. It is the degree to which the person’s movement is imbued with community feeling (Adler’s term was Gemeinschaftsgefühl) and enacted with social interest. Community feeling, so central to Adlerian thought, is also one of the least developed concepts in the model. Within Adler’s (1929, 1932, 1938) system, the con- cept grew and developed over time.

Community feeling is what connects the individual to all of humankind. Adler’s (1938) community is more than where one lives or the culture within which one is raised. It is the feeling of belonging to the ongoing history of humanity, of being called to make a contribution to the whole. It is the human community beyond time and space. It is the feeling of being at home in the world, of feeling that one matters at least as much as others in the world. It is not so much the feeling of being God- like as it is the feeling of being more fully human, of being good enough, of having something to offer and ultimately leave behind. In this sense, the meaning of life is exactly the contributions to humankind and to life that we make while we are here on earth. Adler’s community feeling is both systemic and relational; personal mental health is derived from the feeling of connection, from being more concerned about others than we are about ourselves. Personal happiness derives from aiding others in the pursuit of their happiness.

When we apply this perspective to the individual’s law of movement, it becomes much easier to differentiate useful from useless movements. Let’s take the move- ment against through this differentiation. What does a movement against look like when it is useful? Positive movement against might include taking a stand in social justice movements, speaking up for someone in need, or acts of nonviolent civil dis- obedience for a cause or for people who have been marginalized or experienced dis- crimination. Notice how large the scale of these movements against are. For example, Sam wears a T-shirt that proclaims his war against cars, and he steadfastly refuses

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to own one. It is one of his many contributions to climate change, to the hope that there will be a planet for humans to inhabit in 100 years.

Similarly, movement away from with the spirit of a community feeling can sometimes be seen as withdrawing from a fight or simply choosing to stay calm when being provoked. It may be experienced by giving over leadership that one has had to others who can advance the group. Mahatma Gandhi did this when England left India to be governed by its own people. Some former presidents of the United States do this when they leave office. People who have a community-based social interest are often good leaders, but they can also be good followers.

Even ambivalent movement can be useful. All people feel stuck at one time or another. It is not being stuck that counts; rather, it is what is done with the expe- rience. People with a community feeling do not panic. They do not descend into anxiety. What separates them from others is their ability to stay present; to let the experience be what it is; to consider options in stillness; not to move until they are ready. It is possible to freeze and stand still in fear, a law of movement that seeks safety; it is also possible to stand still in peace and contemplation. The Dalai Lama (1998/2009) provides multiple examples of this.

The opposite of community feeling is found in Adler’s (1935/1996a, 1935/1996b) descriptions of neurosis. It is here that Adler emphasizes the impact of exaggerated feelings of inferiority and the lack of preparation for living that leads to a retreat from the demands and challenges of life—and specifically, from the tasks of friend- ship, work, and love. It is the inferiority feeling that leads to withdrawal and isola- tion, exaggerated forms of safeguarding, and in cases of depression, the experience of self-absorption. These forms of movement characterize mental illness.

Life without problems—life without stress—is impossible. At times. we expe- rience problems, challenges, and burdens that we cannot ignore. Stress, itself, does not lead to dysfunction. Distress is the experience of being overwhelmed, believing that one is not up to facing the challenge or feeling incapable of han- dling a situation. Such an inferiority feeling leads to emotional reactivity: per- haps anger, almost always anxiety, and sometimes depression. The eminent Canadian researcher Hans Selye (1974) echoed Adler’s call to social interest. Selye suggested that people should try to live each day in a manner that would earn the love of others.

Private Logic For Adler, those who are unable to connect with their fellow human beings develop a private intelligence, a private logic. It is thinking about self, others, and life as if the only thing that matters is the individual. Private logic often leads to withdrawal and isolation, to self-absorption and maladaptive responses. Everyone is biased toward self, of course, but those with a community feeling can move beyond the conscious and sometime unconscious self-orientation that permeates the private thinking associated with self-survival.

Private logic includes all the mistaken beliefs, faulty assumptions and convic- tions, and incomplete knowledge that individuals develop to preserve their sense of worth, and most of these biases are intuitive rather than conscious. The results of such private orientations to life are experienced in maladaptive patterns,

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interpersonal conflicts, and emotional distress. When stress becomes distress, private logic kicks in along with feelings of inferiority and being overwhelmed. These feelings in turn stimulate other feelings (fear, anxiety, anger, depression), and each of these negative feelings compels action and activities that seek one of those positive feelings that all of us want. These highly desired feelings are what Rasmussen (2010) calls “the Z factor,” the individual’s experience of feeling good (p. 11). There is no Z factor without an overarching life goal of success, achieve- ment, or fulfillment. Both Z-factor positive emotions and the negative compel- ling emotions are markers along the road of life, feedback within one’s style of living, letting the person and others know how the journey is going. Between any- thing an individual experiences (X) and the resulting feeling (Y or Z) is the person’s thoughts and interpretations (T). If the resulting feeling is positive and makes us happy, that is the desired outcome—the Z factor, the validating emotion. If the resulting feeling is negative, it is a compelling emotion (Y) directly related to our private logic or how we think (T) and demanding that we act (A) in an effort to achieve a more desirable outcome (Figure 5.1).

Emotions serve the purpose of providing immediate existential feedback as well as communicating to others what the individual wants or needs. Anger, for example, flows from the belief that “I am entitled to a certain outcome.” It communicates that “I will attack; I must win at any cost; I seek victory.” There is an outward ori- entation to anger that suggests the person has strength and will use it to the fullest extent, but that outward strength masks an equally strong feeling of weakness.

Now let’s consider anxiety, what does it suggest? Anxiety is a hypervigilance emotion, the feeling that one is at loose ends. Indeed, it informs us of loose ends that need to be tied up. Anxiety calls on the individual to be alert, to pay attention, to get on top of things: “Life is dangerous, and I need someone to bail me out of this danger!” Depression, however, flows from the experience of hopelessness. It is an emotional waving of the white flag, a throwing in of the towel: “It is hopeless, but please bother to reach out: I need someone to take care of me.” Dozens of emotional responses signal stress, and when stress is interpreted as being overwhelming, it becomes distress. Each emotional response reflects the individual’s self-assessment, communicates desired outcomes to others, and compels behaviors that the indi- vidual hopes will restore happiness and well-being.

Rasmussen (2010) notes that some feelings can be an end in themselves: the Z factor, the outcome we seek. These feelings include joy, happiness, contentment, love, and pride. They reflect achievement of desired states; nothing else needs to happen. These are feelings that result from common sense when we approach life tasks with a community feeling and social interest.

X Stimulating

Event

T Private Logic

A Behavioral

Action

Y Compelling

Emotion

Z Validating

Feeling (The Desired State)

Figure 5.1 The Z Factor

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Life Tasks Adler (1964) contends that we must successfully master at least three universal life tasks. All people need to address these life tasks, regardless of age, gender, time in history, culture, or nationality. These tasks are building friendships (social task), establishing intimacy (love/marriage task), and contributing to society (work task). These life tasks are so fundamental to human living that dysfunction in any one of them is often an indicator of a psychological disorder. Each of these tasks requires the development of psychological capacities for friendship and belonging, for con- tribution and self-worth, and for cooperation.

For Adler (1927/1959), the meaning of life is contribution. In this sense, our occu- pation is more than the work we do; it is also the recognition that we have a limited amount of time on this earth, and occupation is about how we choose to use the time we have been given. Have we just taken care of ourselves, or have we made a contribu- tion to others—and in a larger sense, to the ongoing development of humankind?

Influences on Individual Development We are born with a set of givens, including temperament, inherited genetics, a bio- logical structure and biological predispositions, mental capacities or limitations, and a social and cultural environment poised to shape us into the person that those who love us hope we will become. But none of these building bricks determine how life will go. Rather, it is the manner in which the person experiences them, inter- prets them, and uses them that makes individuals who they are. It is each person’s attitude toward life that fixes one’s relationship to life and to the outside world and results in a style of living (Adler, 1935). Still, there can be no denying that some influences have a very strong impact on personal development.

Family Constellation and Family Values Adler was the first systemic therapist and the first to actually practice family counseling—often in front of a live audience (Bitter, 2021). Family constellation was his term for what we now call the family system. During Adler’s lifetime, ideal families were headed by heterosexual couples in which mothers, for the most part, raised the children, and fathers were providers and available to guide their children as often as possible. It was the mother’s job to form the first bond with the newborn, giving the child an experience of safe connection and the child’s first cooperative relationship. As the child grew, the mother’s task was to turn the baby toward the father, then siblings, and finally toward the larger world. Within the family, the ideal parental team treated each other with mutual respect, kindness, and caring, setting a model for how men and women could get along with one another.

When both parents share common values, have similar beliefs and convictions, and approach the tasks of life in the same manner, they set a model for the children in everyday life. These shared ways of being become family values, orientations to life that are experienced as givens: They are what our family does; it is who we are. Children almost always accept these values early in life. Later, they may rebel against them or, conversely, promote them, but the values themselves are strong enough that they cannot be ignored.

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Family Atmosphere Before the first child is even born, the atmosphere into which the child will enter is being set in motion. The child may be welcomed into the world by a single parent, perhaps completely alone, but often with a support system that may include extended family members, friends, or even people hired to provide child care and family support. When two parents head the family, the relationship between the coupled partners sets the tone and the atmosphere for the family. It does not matter whether the couple is heterosexual, same-sex, trans, gender neutral, or gender fluid. These couples are the leadership teams of their families, and their attitudes and feelings for each other provide the child with the first experiences of life and security.

The child is constantly watching, observing, and interpreting: What do these parent-people do together? Are they in competition or do they cooperate? How do they talk to one another and to me, the child? Do they stick together or can they be wedged apart? Are they attentive or distracted? Are they present or gone? Do they respond to my needs, and if so, how do they do it? And what do I need to do to gain their attention and support? How do they make decisions? Do they fight and, if so, what about? How do their arguments affect me? Are there things they both agree on or that they always do as if these beliefs and actions were set in concrete, automatic, and not to be questioned?

The family atmosphere set by the parents and sometimes the extended family can be nurturing or abusive; it can be like a playground, or it can be a jungle; it can be peaceful or tense, cooperative or competitive, safe or frightening. Parents set the tone in how they respond to each other and to each of the children.

Gender Guiding Lines and Gender Identities The families with whom Adler worked were mostly headed by two heterosexual parents. In the early part of the 20th century, only two gender identities were recognized, and one’s gender was assigned at birth based on a doctor’s assessment of anatomy. Parents seldom disagreed with the assignment. In these families, parents served as gender guiding lines for their children; that is, little boys looked at their fathers for a model of what men were like, and little girls did the same with their mothers. In this sense, a child would look at the parent of the same gender and almost always decide that it was inevitable: When the child became an adult, that child would be just like the parent with whom he or she identified. Other adults in the family might offer alternative models for the child to consider, but the parental model held the most power.

In heterosexual families of the 21st century, much the same thing happens for children who are cisgendered. In single parent families, children of the same sex as the single parent will also see that parent as a powerful guide for how they will be when they mature. But what about a child raised with two same-sex parents? Even a child who is the same gender as the same-sex parents will be presented with multiple models. In the end, parents are powerful models for how adults are in the world, but when the child experiences same-sex models, interpretation is everything. That child experiences choice differently than a child with a single parent or heterosexual parents. This is also true in children for whom the same-gendered parent is absent or missing and for children who are misassigned at birth or whose gender identity is neutral or fluid. These children are literally co-constructing their identities within the contexts of their lives, and their subjective interpretation of self is what counts.

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Birth Order and Sibling Relationships The Adlerian approach is unique in giving special attention to the relationships between siblings and the psychological birth position in one’s family. Adler identi- fied five psychological positions, or vantage points, from which children tend to view life: oldest, second of only two, middle, youngest, and only. Birth order does not determine who a person will be, but it does increase an individual’s probability of having a certain set of experiences. In the end, however, it is the interpretation that one assigns to these experiences that creates the meaning of birth order in the indi- vidual’s life.

Adler (1931/1958) observed that many people wonder why children in the same family often differ so widely, and he pointed out that it is a fallacy to assume that children of the same family are formed in the same environment. Although siblings share aspects in common in the family constellation, the psychological situation of each child is different from that of the others due to birth order. The following description of the influence of birth order is based on Ansbacher and Ansbacher (1964), Dreikurs (1953), and Adler (1931/1958).

1. The oldest child generally receives a good deal of attention and focused energy; for a time, the oldest child is an only child, and all the benefits of emotional connection and attunement accrue. When a new sibling arrives on the scene, however, oldest children find themselves ousted from this favored position: They are dethroned, no longer unique or special. Oldest children may readily believe that the newcomer (or intruder) will rob them of the love to which they are accustomed. Most often, the oldest adopts the position of a model child, bossing younger children and exhibiting a high achievement drive. These oldest children tend to be dependable and hard working, building on their advantage of being first and striving to keep ahead.

2. The second child of only two is in a different position. From the moment of birth, second children share the attention of adults with another child. The typical second child behaves as if in a race and is generally under full steam at all times. It is as though this second child were in training to surpass the older child. This competitive struggle between the first two children influences the later course of their lives. The younger child develops a knack for finding out the elder child’s weak spots and proceeds to win praise from both parents and teachers by achieving successes where the older sibling has failed. If one is talented in a given area, the other strives for recognition by developing other abilities. The second-born is often opposite to the firstborn.

3. The middle child often feels squeezed out. This child may become convinced of the unfairness of life and feel cheated. This person may assume a “poor me” attitude and can become a problem child. How- ever, especially in families characterized by conflict, the middle child may become the switchboard and the peacemaker, the person who holds things together. If there are four children in a family, the second child will often feel like a middle child and the third will be more easy- going, more social, and may align with the firstborn.

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4. The youngest child is always the baby of the family and tends to be the most pampered one. Because of being pampered or spoiled, young- est children may develop helplessness into an art form and become experts at putting others in their service. Youngest children tend to go their own way, often developing in ways no others in the family have attempted; in the end, they may outshine everyone.

5. The only child has another kind of problem. Although sharing some of the characteristics of the oldest child (for example, a high achievement drive), the only child will never be dethroned and may not learn to share or cooperate with other children. What only children do learn is how to deal with adults, because they make up the child’s whole world. Often, the only child is pampered by parents and may become depend- ently tied to one or both of them. Only children often learn more adult language earlier in life, may want to have center stage all of the time, and if their position is challenged, they will feel it is unfair.

Birth position is an interpretation, and each of these descriptions may be totally incorrect for any given person. However, birth order and the interpretation of one’s position in the family has a great deal to do with how adults interact in the world. Individuals acquire a certain style of relating to others in childhood and form a defi- nite picture of themselves that they carry into their adult interactions. In Adlerian therapy, working with family dynamics, especially relationships among siblings, assumes a key role. It is important to avoid stereotyping individuals, but certain per- sonality trends that began in childhood because of sibling relationships can influ- ence individuals throughout life.

Culture, Race, and Ethnicity: Systemic Holism Like birth order, culture is a vantage point from which individuals view life. If you are born at a specific location on the planet and are raised for 10 years in the culture that dominates and permeates that location, it is highly likely that you will embrace the worldview, values, and social orientations of that culture. Culture is to families within it as families are to family members. There will be individual differences, but the general way of being is a very strong influence. Culture expresses itself in community values, beliefs, and convictions; it is celebrated and reinforced in ritu- als; and it is structured through laws and religion. We can leave our culture, travel the world—indeed, we can become citizens of the world—but nothing feels quite the same as home until we return to where we started life.

Some cultures are built around race and ethnicity, especially when one’s race or ethnicity has experienced oppression and marginalization. When any group feels that their members are under attack or challenged or dismissed, banding together is the first line of defense. Groups who have banded together will develop distinct cultures of their own over time.

Every part of the world has a dominant culture. In the United States, the dominant culture is male, White, rich, heterosexual, abled, right-handed, relatively young, and Christian. Those who perfectly match the dominant culture experience unearned privilege throughout their lives. To be sure, the dominant culture has real power, and to the extent that one is not part of the dominant culture, there is

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oppression. The intent of a dominant culture is to reinforce itself and marginalize alternative positions. In the end, it is not the race, ethnicity, gender, socioeconomic level, religion, or culture that determines who a person is; rather, it is the interpre- tation that the individual attaches to these profound influences and to the experi- ences they have. It is impossible to fully understand the individual outside of the full, systemic, social embeddedness of the person’s life.

The Therapeutic Process Therapeutic Goals

Adlerian counseling and therapy rests on a collaborative arrangement between the client and the counselor. In general, the therapeutic process includes forming a rela- tionship based on mutual respect; a holistic psychological investigation or lifestyle assessment; and disclosing mistaken goals and faulty assumptions within the per- son’s style of living. This is followed by a reeducation or reorientation of the client toward the useful side of life, and replacement of a maladaptive pattern with an adap- tive one. The main aim of therapy is to develop the client’s sense of belonging and to assist in the adoption of behaviors characterized by community feeling and social interest. The emphasis is on health, well-being, and prevention of problems rather than on remediation. Adlerians favor the growth model of personality and empha- size strengths and resources (Carlson & Englar-Carlson, 2013, 2017; Sweeney, 2019).

A key goal is to assist clients in addressing the tasks of life. Adlerians recognize the need to assist clients with first-order change, addressing and managing severe symptoms, but the real aim of therapy is to help people live more adaptive lives, replacing maladaptive patterns of coping and living with more socially useful pat- terns. More adaptive lives are characterized by the development of what Adlerians call psychological muscle (Rasmussen & Schuyler, 2020). Psychological muscle is the exercise of responsibility, cooperation, respect for self and others, and courage in the daily approach to the life tasks.

Encouragement is the most powerful method available for changing a person’s beliefs; it helps clients build self-confidence and stimulates courage. Courage is the willingness to act even when fearful in ways that are consistent with social interest. Fear and courage go hand in hand; without fear, there would be no need for courage. The loss of courage, or discouragement, results in mistaken beliefs and dysfunc- tional behavior. Discouraged people tend to act only in line with their perceived self-interest, which often is associated with a lack of social interest.

Maniacci and Sackett-Maniacci (2019) suggest working toward these goals dur- ing the educational process of therapy:

◆ Foster social interest and community feeling ◆ Help clients overcome feelings of discouragement and inferiority ◆ Modify clients’ lifestyle in the direction of becoming more adaptive,

flexible, and social ◆ Change faulty motivation ◆ Encourage equality and acceptance of self and others ◆ Help individuals become contributing members of the world

community

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Therapist’s Function and Role The Adlerian therapist’s role is to help clients become aware of their faulty world- view and to provide clients with a new “cognitive map” that enables them to change their feelings and behavior (Carlson & Englar-Carlson, 2017). All clients come to counseling and therapy hoping to feel good, and if they cannot feel good, they at least want to feel better and find a way to manage those events that lead them to feel badly (Rasmussen, 2010). Adlerians operate on the assumption that clients will feel and behave better once they discover and correct their basic mistakes. They tend to look for major mistakes in thinking and evaluating such as mistrust, selfish- ness, unrealistic ambitions, and lack of confidence. In addition to examining basic mistakes, Adlerian therapists often help clients identify and explore their core fears, such as being imperfect, being vulnerable, being disapproved of, or suffering from past regrets (Carlson & Englar-Carlson, 2017).

It is precisely these mistakes in the client’s internal assessments that lead to symptomatic presentations. Such symptoms are most often expressed in emotional disturbance, and to be sure, Adlerian counselors will help clients manage their symptoms when they are severe. Addressing emotional disturbance and correcting mistakes, even replacing maladaptive patterns with more adaptive ones, however, is a means to an end, not the end in and of itself.

The ultimate role of the therapist is to facilitate the development of a preferred style of living, a coping style in which the life tasks become opportunities for the development of psychological muscle—and a life in which a community feeling and social interest are manifest in the contributions that people make to others. In sup- porting the achievement of this larger goal of therapy, the initial symptoms with which clients present themselves often disappear—simply because they are no longer needed.

Client’s Experience in Therapy How do clients maintain their lifestyle, and why do they resist changing it? A per- son’s style of living serves the individual by staying stable and constant. In other words, it is predictable. It is, however, also resistant to change throughout most of one’s life. Generally, people fail to change because they do not recognize the errors in their thinking or the purposes of their behaviors; they do not know what to do differently and are fearful of leaving old patterns for new and unpredictable out- comes. Thus, even though their ways of thinking and behaving are not successful, they tend to cling to familiar patterns (Sweeney, 2019). Clients in Adlerian counsel- ing focus their work on desired outcomes and a resilient lifestyle that can provide a new blueprint for their actions.

Clients come to therapy when their unhappiness, often presented as emotional disturbance, is greater than they can stand. Few clients ever start with a concern about their thinking or behaving. Most of the time, clients are unhappy, and they want the counselor to help them feel good—if not good, the client would at least like to feel better.

Negative emotions have a purpose. They signal to the individual that some- thing in life is wrong and needs attention. They signal to others that the person is in

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distress and needs help—often in the form of a desired outcome. And they suggest a way of thinking and approaching life that is maladaptive.

Let’s consider a few of the more common emotions with which people present for therapy. Anxiety, for example, is a battle emotion. The person is worried about potential outcomes, but the client is still in the fight, still hoping for “things” to work out. The emotion tells the person to be vigilant, to be on alert, that there is a threat to one’s well-being or integrity. It says to others, “Hey, join the battle with me. We may be in danger. I need your help and support.”

Perhaps the emotional presentation is anger. Anger signals that the person feels in danger of losing or not getting what the person wants. It comes from the belief that the person is entitled to a certain outcome. It says to others, “I will not accept what you are saying or doing, and if I have to, I will attack: I am willing to remove you as an obstacle; I am not against seeking revenge.”

And then there is depression. Depression comes from a sense of impending defeat or failure. In some cultures, it is recognition of an impending loss of face. It is a retreat from life’s tasks, a withdrawal from the playing field. It says to others, “I need to find hope, help, or relief.”

The linking of emotional (symptomatic) presentation to cognitive orientations is essential to understanding the maladaptive pattern of the client. These three emo- tions provide examples, but similar patterns emerge around the feelings of frus- tration, dread, fear, panic, sadness, sorrow, shame, resentment, disgust, contempt, jealousy, greed, and guilt, to name a few others. Think about what these emotions might mean to the individual’s internal sense of self and what the person might be communicating to others.

Every presentation in therapy has a precipitating event that is supported by social, familial, and biological predispositions and perpetuated by reinforcers in the person’s environment (Sperry & Sperry, 2020). Precipitating events tell you what pushed the client to seek help, what compelled the person to act. Reinforcers are all the social triggers that keep the maladaptive pattern going. And predispositions are largely revealed through what Adlerians call lifestyle assessment.

Lifestyle assessment is a more formal investigation of the individual’s approach to life, including the orientation the person adopted in their family constellation, what the person came to expect in the family’s atmosphere, and the thinking, values, and convictions with which the person was raised. Lifestyle assessment also inves- tigates the experiences and interpretations the individual has in relation to the life tasks of work, friendship, and love. Finally, early recollections are used to verify how the client sees self, others, and life—and to identify patterns that have been with the person for a very long time.

To provide a concrete example, think of a chronically depressed middle-aged man who begins therapy. After a lifestyle assessment is completed, these basic mis- takes are identified:

◆ He has convinced himself that nobody could really care about him. ◆ He rejects people before they have a chance to reject him. ◆ He is harshly critical of himself, expecting perfection. ◆ He has expectations that things will rarely work out well. ◆ He burdens himself with guilt because he is convinced he is letting

everyone down.

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Even though this man may have developed these mistaken beliefs about himself and life when he was young, he is still clinging to them as rules for living. His expec- tations, most of which are pessimistic, tend to be fulfilled because, on some level, he is seeking to validate his beliefs. Indeed, his depression will eventually serve the purpose of helping him avoid contact with others, a life task at which he expects to fail. In therapy, this man will learn how to challenge the structure of his private logic. In his case the syllogism goes as follows:

◆ “I am basically unlovable.” ◆ “The world is filled with people who are likely to reject me.” ◆ “Therefore, I must keep to myself so I won’t be hurt.”

It is easy to see how depression might follow from this thinking, but Adlerians also know that the depression serves as an excuse for this man’s retreat from life. It is important for the therapist to listen for the underlying purposes of this cli- ent’s behavior. He has isolated himself from any community feeling, so his social interest is low. Through the therapeutic process, clients will discover that they have resources and options to draw on in dealing with significant life issues and life tasks.

Relationship Between Therapist and Client Adlerians consider a good client–therapist relationship to be one between equals that is based on cooperation, mutual trust and respect, confidence, collaboration, and alignment of goals. They place special value on the counselor’s modeling of communi- cation and acting in good faith. From the beginning of therapy, the relationship is col- laborative, characterized by two people working equally toward specific, agreed-upon goals. Adlerian therapists strive to establish and maintain an egalitarian therapeutic alliance, a person-to-person relationship with their clients that is facilitated by empa- thy and support. Developing a strong therapeutic relationship is essential to success- ful outcomes. It is a foundation for both a subjective and an objective psychological investigation, and it provides support for personal transformation and change. In the end, the Adlerian therapist helps the client substitute an adaptive pattern for a mal- adaptive pattern (Sperry & Binensztok, 2019; Sperry & Sperry, 2020).

Application: Therapeutic Techniques and Procedures Adlerian counseling is structured around four central objectives that correspond to the four phases of the therapeutic process (Dreikurs, 1967).

1. Establish the proper therapeutic relationship. 2. Explore the psychological dynamics operating in the client (an

assessment). 3. Encourage the development of self-understanding (insight translated

into action). 4. Help the client make new choices (reorientation and reeducation).

These phases are not linear and do not progress in rigid steps; rather, they can best be understood as a weaving that leads to a tapestry. Dreikurs (1997) incorporated these phases into what he called minor psychotherapy in the context and service of holistic medicine. This way of working is discussed in the following sections.

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Phase 1: Establishing the Relationship The Adlerian practitioner works in a collaborative way with clients, and this relationship is based on a sense of interest that grows into caring, involvement, and friendship. Therapeutic progress is possible only when there is an alignment of clearly defined goals between therapist and client. To be effective, the counsel- ing process must deal with the personal issues the client recognizes as significant and is willing to explore and change. The therapeutic efficacy in the later phases of Adlerian therapy is predicated on the development and continuation of a solid therapeutic relationship during this first phase of therapy (Watts, 2015).

Adlerian therapists focus on making person-to-person contact with clients rather than starting with “the problem.” Clients’ concerns may surface rather quickly in therapy, but the initial focus should be on the person, not the problem. One way to create effective contact is for counselors to help clients become aware of their assets and strengths rather than dealing continually with their deficits and liabilities. During the initial phase, a positive relationship is created by listening, empathizing, and responding—by demonstrating a respect for clients’ capacities to understand the purpose and seek change and by exhibiting hope and caring. When clients enter therapy, they typically have a diminished sense of self-worth and self- respect. They lack faith in their ability to cope with the tasks of life, and they often feel discouraged. Therapists provide support, which is an antidote to despair and discouragement. For some people, therapy may be one of the few times in which they have truly experienced a caring human relationship.

Adlerians pay more attention to the subjective experiences of the client than they do to using techniques. During the initial phase of counseling, the therapist works to understand the client’s identity and experience of the world—and to understand the patterns, both adaptive and maladaptive, with which the individual meets the challenges of life. Adlerians note a distinction between a therapeutic relationship and a therapeutic alliance. The former refers to the bond between the counselor and the client: “To form a bond with the therapist, the client should feel understood, comfortable, and hopeful about the course of therapy” (Sperry & Binensztok, 2019, p. 41). A therapeutic alliance includes such a bond coupled with a mutual agreement on counseling goals and the methods that will be used to reach those goals.

Techniques are fitted to the needs of each client and may include attending and listening with empathy, following the subjective experience of the client as closely as possible, identifying and clarifying goals, and suggesting initial hunches about purpose in client’s symptoms, actions, and interactions. Adlerians attempt to grasp both the verbal and nonverbal messages of the client; they want to access the core patterns in the client’s life. If clients feel deeply understood and accepted, they are likely to focus on what they want from therapy and thus establish goals.

Phase 2: Assessing the Individual’s Psychological Dynamics Psychotherapy may be a foreign concept to individuals in certain cultures. For exam- ple, Asian American clients may expect the counselor to be active in structuring the sessions and to focus on solving problems. It is important that Adlerian therapists explain the assessment and treatment process and the necessity for obtaining per- sonal information, especially about family structure (Sue et al., 2022).

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A strong therapeutic alliance is a foundation for conducting a thorough assess- ment of the client’s approach to living—even though the development of a thera- peutic alliance and an assessment often happen at the same time. This assessment phase proceeds from two interview forms: the subjective interview and the objective interview (Dreikurs, 1997). In the subjective interview, the counselor helps clients tell their life story as completely as possible. This process is facilitated by a gen- erous use of empathic listening and responding. Active listening, however, is not enough. The subjective interview must flow from a sense of wonder, fascination, and interest. What the client says will spark an interest in the counselor and lead, naturally, to the next most significant question or inquiry about the life story of the client. Indeed, the best subjective interviews treat clients as experts in their own lives, allowing clients to feel completely heard. Throughout the subjective interview, the Adlerian counselor is listening for clues to the purposive aspects of the client’s cop- ing and approaches to life. “The subjective interview should extract patterns in the person’s life, develop hypotheses about what works for the person, and determine what accounts for the various concerns in the client’s life” (Bitter et al., 1998, p. 98). Toward the end of this part of the interview, Adlerian therapists ask, “Is there any- thing else you think I should know to understand you and your concerns?”

An initial assessment of the purpose that symptoms, actions, or difficulties serve in a person’s life can be gained from Dreikurs’s (1997) revision of The Question. Adlerians often end a subjective interview by asking, “How would your life be different, and what would you be doing differently, if you did not have this symptom or prob- lem?” Adlerians use this question to help with a differential diagnosis. More often, the symptoms or problems experienced by the client help the client avoid something that is perceived as necessary but from which the person wishes to retreat, usually a life task: “If it weren’t for my depression, I would get out more and see my friends.” Such a statement betrays the client’s concern about the possibility of being a good friend or being welcomed by these friends. “I need to get married, but how can I with these panic attacks?” indicates the person’s worry about being a partner in a marriage. Depression can serve as the client’s solution when faced with problems in relationships or work. If a client reports that nothing would be different, especially with physical symptoms, Adlerians suspect that the problem may be organic and require medical intervention.

The objective interview seeks to discover information about (a) how problems in the client’s life began; (b) any precipitating events; (c) a medical history, including current and past medications; (d) a social history; (e) the reasons the client chose therapy at this time; (f) the person’s coping with life tasks; and (g) a lifestyle assess- ment. Based on interview approaches developed by Adler and Dreikurs, the lifestyle assessment begins with an investigation of the person’s family constellation and early childhood history (Powers & Griffith, 2012; Shulman & Mosak, 1988). Coun- selors also interpret clients’ early memories, seeking to understand the meaning that they have attached to life experiences. Adlerians operate on the assumption that it is the interpretations people develop about themselves, others, the world, and life that govern what they do. All people are in movement throughout life; the unique man- ner in which someone moves through life is called the style of living. Lifestyle assess- ment seeks to develop a holistic narrative of the person’s life, to make sense of the way the person copes with life tasks, and to uncover the private interpretations and logic involved in that coping.

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For example, if Jenny has lived most of her life in a critical environment, and now she believes she must be perfect to avoid even the appearance of failure, the assessment process will highlight the restricted living that flows from this perspec- tive. Another example is Ramon who grew up as a child of undocumented immi- grants. He lived most of his life in fear of his environment, and he tried to remain invisible and was wary of trusting others. Now he struggles to connect with peers and to maintain a committed relationship. The assessment process explores how his lifestyle is inconsistent with his stated goals of wanting connection.

The Family Constellation Adler considered the family of origin as having a central impact on an individual’s personality. Adler suggested that it was through the family constellation that we form our unique view of self, others, and life. Factors such as cultural and familial values, gender-role expectations, and the nature of interpersonal relationships are all influenced by a child’s observation of the interactional patterns within the family. Adlerian assessment relies heavily on an exploration of the client’s family constellation, including the client’s evaluation of conditions that prevailed in the family when the person was a young child (family atmosphere), birth order, parental relationship and family values, and extended family and culture. Some of these questions are almost always explored:

◆ Who was the favorite child? ◆ What was your father’s relationship with the children? Your mother’s? ◆ Which child was most like your father? Your mother? In what respects? ◆ Who among the siblings was most different from you? In what ways? ◆ Who among the siblings was most like you? In what ways? ◆ What were you like as a child? ◆ How did your parents get along? In what did they both agree? How did

they handle disagreements? How did they discipline the children?

An investigation of the family constellation is far more comprehensive than these few questions, but these questions provide an idea of the type of information the counselor is seeking. The questions are tailored to the individual client with the goal of eliciting the client’s perceptions of self and others, of development, and of the experiences that have affected that development.

Early Recollections The counselor also uses early recollections as an assessment procedure. Early recollections (ERs) are defined as “stories of events that a person says occurred [one time] before he or she was 10 years of age” (Mosak & Di Pietro, 2006, p. 1). ERs are specific incidents that clients recall, along with the feelings and thoughts that accompanied these childhood incidents. ERs are not about the past; they do not even need to be accurate representations of the past. Memories are important for their use in the present. They remind clients of their perspectives on self, others, and life, and they suggest the stance that clients should take in the present. The interpretation of ERs provides a point of departure for the therapeutic venture. An interpretation of ERs can provide an understanding of what clients do and how they think in both adaptive and maladaptive ways (Mosak & Di Pietro, 2006).

Early recollections are a series of small mysteries that can be woven together into a tapestry that leads to an understanding of how we view ourselves, how we see the

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world, what our life goals are, what motivates us, what we value and believe in, and what we anticipate for our future (Clark, 2002; Mosak & Di Pietro, 2006). Out of the thousands of early memories we might have, Adler reasoned that we select those special memories that project the essential convictions and even the basic mistakes of our lives. To a large extent, what we selectively attend to from the past is reflective of what we believe, how we behave in the present, and our anticipation of the future (Watts, 2015).

Early memories cast light on the “story of our life” because they represent meta- phors for our current views. Most people can recall 6 to 12 memories. By under- standing why we retain these specific memories and what they tell us about how we see ourselves, others, and life in the present, it is possible to get a clear sense of our mistaken notions, present attitudes, social interests, and possible future behavior. Exploring early recollections involves discovering how mistaken notions based on faulty goals and values continue to create problems in a client’s life. Early recollec- tions serve an organizing function in understanding the purposefulness of behav- ior, the style of life, striving for superiority, holism, and birth order (Clark, 2012).

To elicit such recollections, the counselor might proceed as follows: “I would like to hear about your early memories. Think back to when you were very young, as early as you can remember (before the age of 10), and tell me something that hap- pened one time. Be sure to recall something you remember, not something you were told about by others.” After receiving each memory, the counselor might also ask: “What part stands out to you? What was the most vivid part of your early memory? If you played the whole memory like a movie and stopped it at one frame, what would be happening? Putting yourself in that moment, what are you feeling? What’s your reaction?” Three memories are usually considered a minimum to assess a pat- tern, and some counselors ask for as many as a dozen.

Adlerian therapists use early recollections as a projective technique (Clark, 2002; Hays, 2013) and to (a) assess the client’s convictions about self, others, life, and eth- ics; (b) assess the client’s stance in relation to the counseling session and the coun- seling relationship; (c) verify the client’s coping patterns; and (d) assess individual strengths, assets, and interfering ideas (Bitter et al., 1998, p. 99). In interpreting these early recollections, Adlerians may consider questions such as these:

◆ What part does the client take in the memory? Is the client an observer or a participant?

◆ Who else is in the memory? What position do others take in relation to the client?

◆ What are the dominant themes and overall patterns of the memories? ◆ What feelings are expressed in the memories? ◆ Why does the client choose to remember this event? What is the client

trying to convey?

Let’s try this out. Here are three memory stories and some guesses about what these memories might mean.

Memory 1: “I was 4 years old. We were staying at grandma and grandpa’s house. I got to sleep in the attic, and it had a neat hole from which I could spy on the adults below. I could see and hear them, but they could not see me. I love being sneaky.”

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Interpretation: I like to (a) be on top of things; (b) know what’s going on— even if it’s none of my business; and (c) I like to be an observer.

Memory 2: “I am 8 years old. It is summer. My father wants to take me with him to a baseball game, but I am not around. I am off playing where I should not be, and my mom can’t find me. I miss out on going with my dad. I cry when I am told, and I am sad.”

Interpretation: If I do things I am not supposed to do, even if I am having fun, I might miss out on something even more fun.

Memory 3: “I am in the second or third grade, maybe 8 or 9. I am asked to come to the blackboard and work out a problem. I remember how to do it mostly. I get almost to the end, but I cannot complete it. Someone else has to come up and complete it, and I miss out on getting to the right answer. I am watching Gary Snitley complete the problem, and I am disappointed that I didn’t remember it.”

Interpretation: There is always someone out there who is smarter than me. If I am going to do something and get credit for it, I better do it all and do it right the first time; there is no room for error.

Can you match these tentative interpretations with the details offered in each memory story?

Integration and Summary Once material has been gathered from both subjective and objective interviews with the client, integrated summaries of the data are developed. Different summaries are prepared for different clients, but common ones are a narrative summary of the person’s subjective experience and life story; a summary of family constellation and developmental data; a summary of early recollections, personal strengths or assets, and interfering ideas; and a summary of coping strategies. The summaries are presented to the client and discussed in the session, with the client and the counselor together refining specific points. This information provides the client with the chance to discuss specific topics and to raise questions.

The Student Manual that accompanies this textbook includes a concrete exam- ple of the lifestyle assessment as it is applied to the case of Stan. In Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 3), Drs. Jim Bitter and Bill Nicoll present a lifestyle assessment of another hypothetical client, Ruth.

Phase 3: Encourage Self-Understanding and Insight During this third phase, Adlerian therapists interpret the findings of the assess- ment as an avenue for promoting self-understanding and insight. When Adlerians speak of insight, they are referring to an understanding of the motivations and patterns that operate in a client’s life. Self-understanding is only possible when hid- den purposes and goals of behavior are made conscious. Adlerians consider insight as a special form of awareness that facilitates a meaningful understanding within the therapeutic relationship and acts as a foundation for change. Insight without action, however, is not enough. Insight is a means to an end, but not an end in itself. People can make rapid and significant changes without much insight.

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Disclosure and well-timed interpretations are techniques that facilitate the pro- cess of gaining insight. Interpretation deals with clients’ underlying motives for behaving the way they do in the here and now. Adlerian disclosures and interpreta- tions are concerned with creating awareness of one’s direction in life, one’s goals and purposes, one’s private logic and how it works, and one’s current behavior.

Adlerian interpretations are suggestions presented tentatively in the form of open-ended questions that can be explored in the sessions. They are hunches or guesses, and they often begin with phrases such as “I could be wrong, but I am wondering if . . . ,” “Could it be that . . . ,” or “Is it possible that . . .” Because inter- pretations are presented in this manner, clients do not often need to defend them- selves, and they feel free to discuss and even argue with the counselor’s hunches and impressions. Through this process, both counselor and client eventually come to understand the client’s motivations, the ways in which these motivations are now contributing to the maintenance of the problem, and what the client can do to cor- rect the situation. During this phase of therapy, the counselor helps clients under- stand the limitations of the style of life they have chosen, and how they can make changes in their approach to life to live more fully by their chosen goals.

Phase 4: Adaptive Reorientation and Reeducation The final stage of the therapeutic process is known as reorientation and reeduca- tion. The goal of therapy is not merely a reduction of symptoms (first-order change), although such change is often a necessary first step. Nor is it the emergence of a more adaptive orientation to life (second-order change). Rather, it is the development of a preferred life and the styles of living and patterns that support it—third-order change. “Third order change should be the ultimate therapeutic goal as it allows the client to effectively respond to life stressors in an adaptive way without the need for continu- ing therapy” (Sperry & Binensztok, 2019, p. 44). At the heart of third-order change is the development of psychological muscle (Rasmussen, 2021; Rasmussen & Schuyler, 2020). Psychological muscle includes the traits and capacities required for meeting the challenges posed by the life tasks, and like any physical muscle, these traits and capaci- ties must be exercised, practiced, and used in order to build psychological strength.

Rasmussen and Schuyler (2020) relate the tasks of life to the character traits of psychological muscle and to what Bettner and Lew (1989/2005) call the Crucial C’s, that is, those capacities necessary for people to attain self-esteem, self-respect, and a personal identity (Table 5.2). Clients are both encouraged and challenged to develop the courage to take risks and make changes in their life. During this phase, clients figure out how to reorient their current style of living to the useful side of life, increasing their community feeling and social interest. The useful side involves a sense of belonging and being valued, having an interest in others and their welfare, courage, the acceptance of imperfection, confidence, a sense of humor, a willingness to contribute, and an outgoing friendliness. The useless side of life is characterized by self-absorption, withdrawal from life tasks, self-protection, or acts against one’s fellow human beings. People acting on the useless side of life become less functional and are more susceptible to psychopathology. Adlerian therapy stands in opposition to self-depreciation, isolation, and retreat, and it seeks to help clients gain courage and to connect to strengths within themselves, to others, and to life.

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The Encouragement Process Encouragement is the most distinctive Adlerian procedure, and it is central to all phases of counseling and therapy. It is especially important as people consider changes in their lives. Encouragement literally means “to build courage.” Encouragement is a process of increasing the courage needed for a person to face difficulties in life (Carlson & Englar-Carlson, 2017). Courage develops when people become aware of their strengths, when they feel they belong and are not alone, and when they have a sense of hope and can see new possibilities for themselves and their daily living. Therapists help clients focus on their resources and strengths and to have faith that they can make life changes, even though life can be difficult. Milliren, Evans, and Newbauer (2007) consider encouragement key in promoting and activating social interest. They add that encouragement is the universal therapeutic intervention for Adlerian counselors, that it is a fundamental attitude, or way of being, rather than a technique. Because clients often do not recognize or accept their positive qualities, strengths, or internal resources, one of the counselor’s main tasks is to help them do so.

Adlerians believe discouragement is the basic condition that prevents people from functioning, and they see encouragement as the antidote. Encouragement begins with acknowledging that life is difficult at times. Therapists instill faith in clients that they have the ability to make life changes (Carlson & Englar-Carlson, 2017). As a part of the encouragement process, Adlerians use a variety of relational, cognitive, behavioral, emotional, and experiential techniques to help clients identify and challenge self-defeating cognitions.

Encouragement takes many forms, depending on the phase of the counseling process. In the relationship phase, encouragement results from the mutual respect the counselor seeks to engender. Here is an opening intervention focusing on encouragement:

Client: I almost didn’t come . . .

Counselor: . . . but you did.

Client: Yes, but I just don’t know. Maybe it would have been better just to end it all, not even bother.

Table 5.2 Life Tasks, Psychological Muscle, and the Crucial C’s

Life Task Area of Challenge

Psychological Muscle The Essential Trait

Crucial C The Outcome

Work: long-term self-sustenance and resource management

Responsibility Doing what needs to be done, even if unpleasant

Feeling Capable

Social/Friendship: forming affiliations and relationships; getting along with others

Cooperation Getting along with others and contributing to group success

Feeling Connected

Love/Sex: controlling impulses and forming intimacies

Respect (self and others) Acting in the best interests of others and the self

Feeling that one Counts

Imperfection: managing the inevitability of being imperfect

Courage Being willing to risk failure and to face discomforts

Having Courage

Sources: Adapted from Rasmussen, 2021, p. 80; and Rasmussen & Schuyler, 2020, p. 312.

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Counselor: So, you are in a lot of pain, even thinking about ending it all, but still you came. That took a lot of courage, How did you manage to summon that courage and then act on it?

In the assessment phase, which is partially designed to illuminate personal strengths, clients are encouraged to recognize that they are in charge of their own lives and can make different choices based on new understandings.

During reorientation, encouragement comes when new possibilities are gener- ated and when clients are acknowledged and affirmed for taking positive steps to change their lives for the better. This later intervention focused on encouragement has a triumphant tone:

Counselor: Let me see if I understand this. You were in a familiar family setting. Your father was berating you about a minor difference of opinion, really trying to push your buttons, and you managed not only to stay calm but also offered to help him sort some materials in his office. You must feel so proud of yourself, triumphant even. What a transformation of your normal interactions.

Client: Yes, and I even walked away feeling I had made a difference in his life. I did not lose my temper. I did not strike back. I actually just heard him in a different way, knew he needed to feel right and important, and when I let that happen, everything changed between us.

Counselor: You even know the steps that got you there.

Client: Yes, I do.

Counselor: Achieving a change in long-held family patterns is one of the hardest things to attain. You have a right to feel delighted.

Change and the Search for New Possibilities During the reorientation phase of counseling, clients make decisions and modify their goals. They are encouraged to act as if they were the people they want to be, which can serve to challenge self-limiting assumptions. Clients are asked to catch themselves in the process of repeating old patterns that have led to ineffective behavior (Watts, 2015). Commitment is an essential part of reorientation. If clients hope to change, they must be willing to set tasks for themselves in everyday life and do something specific about their problems. In this way, clients translate their new insights into concrete actions. Bitter and Nicoll (2004) emphasize that real change happens between sessions, and not in therapy itself. They state that arriving at a strategy for change is an important first step, but they stress that it takes courage and encouragement for clients to apply what they have learned in therapy to daily living.

This action-oriented phase is a time for solving problems and making deci- sions. The counselor and the client consider possible alternatives and their conse- quences, evaluate how these alternatives will meet the client’s goals, and decide on a specific course of action. The best alternatives and new possibilities are those gener- ated by the client, and the counselor must offer the client a great deal of support and encouragement during this stage of the process.

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Making a Difference Adlerian therapists seek to make a difference in the lives of their clients. That difference may be manifested by a change in behavior or attitude or perception. Adlerians use many different techniques to promote change, some of which have become common interventions in other therapeutic models. Techniques that go by the names of immediacy, advice, humor, silence, paradoxical intention, acting as if, catching oneself, the push-button technique, externalization, reauthoring, avoiding the traps, confrontation, use of stories and fables, early recollection analysis, lifestyle assessment, encouragement, Metta meditation, task setting and commitment, homework, and terminating and summarizing have all been used (Carlson & Englar-Carlson, 2017; Carlson & Johnson, 2016; Dinkmeyer & Sperry, 2000; Disque & Bitter, 1998; Mozdzierz et al., 2009). Contemporary Adlerian practitioners are diverse in their styles of counseling, and they can creatively employ a wide range of other techniques that are philosophically consistent with the basic theoretical premises of Adlerian psychology. Adlerians are pragmatic when it comes to using techniques that are appropriate for a given client. In general, however, Adlerian practitioners focus on motivation modification more than behavior change and encourage clients to make holistic changes on the useful side of living.

All therapy is a cooperative effort, and making a difference depends on the thera- pist’s ability to win the client’s cooperation. In Adlerian pattern-focused therapy, case conceptualization is used to both identify maladaptive patterns and formulate imme- diate and long-term treatment plans (Sperry & Binensztok, 2019; Sperry & Sperry, 2020). Initially, clients present themselves for therapy because of emotional/behavioral symptoms or conflicts that feel overwhelming to them. These symptoms are usually triggered by some precipitant that reflects the client’s orientation and pattern of coping and living. Biological, social, and cultural histories reveal predispositions to both precipi- tants and patterns just as current perpetuants or external reinforcers keep the problem going. Even though second- and third-order change are the ultimate goal, literally the adoption of an adaptive orientation to living, it is not uncommon to start with inter- ventions designed to interrupt the maladaptive pattern. Let’s focus on one technique traditionally associated with Adlerian counseling to see what it looks like in action.

Harold Mosak, an Adlerian therapist, used the push-button technique with clients who know they are depressed but feel that the depression controls them and that nothing can be done. The goal of this technique is to help clients become aware of their role in contributing to their unpleasant feelings. Typically, clients are asked to re-create an unpleasant memory, which is then followed by recalling a pleasant memory (Watts, 2015).

Counselor: I am sure we can end your depression rather easily. Let’s start with what you really need to do with your life [the set up].

Client: Wait a minute. If you can get rid of my depression easily, let’s do it.

Counselor: Well, OK. You will have to close your eyes. I want you to think about the worst, most awful thing that has happened to you recently. When you have it in mind, I want you to raise your right hand. [The client pauses for a few moments and then raises his hand.] Now, I would like you to add the feeling you feel when you think about this horrible part of your life.

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[Taking the client’s right hand, the counselor presses the index finger onto the client’s leg.] We will call this your depression button. Now, I want you to think about the best thing that has happened to you or could happen to you or you would love to have happen to you. Raise your left hand when you know what that is.

Client: I can’t really think of anything.

Counselor: You may have to go back to an earlier time to remember a really good time that you would like to have in your life now, but I know you can do it. [A minute later the man raises his left hand.] Now, add the feeling you have thinking about that happy time. [Taking the client’s left hand, the counselor presses the index finger onto the client’s other leg.] So you have a depression button on your right leg, and you can push it and think about everything horrible, awful, or worse, and feel depressed. Or you can push the happy button on the other leg, think about wonderful things or events or people, and feel happy. If you come in next week and tell me you have felt depressed, I will simply ask you why you decided to push the depression button rather than the happy button.

The push-button technique recognizes that “control” is a major theme in depression, and this intervention is designed to help the client regain a sense of con- trol over the negative feelings that seem overwhelming. An effective way of using this technique may be to give the client, especially a child or an adolescent, an actual push-button to carry in their pocket as a physical reminder.

A reduction in a negative emotion (i.e., depression) is not the end goal of therapy. More important to therapy is a reorientation to life that leaves the individual less vulnerable to emotional distress. Through consideration of the individual’s lifestyle development, therapist and client can work together to identify mistaken beliefs and find new, more optimal strategies for deriving a positive state. This will require that individuals adjust their orientation to life with an emphasis on social realities and the development of psychological muscle and social interest (Rasmussen, 2021, p. 94). When this latter reorientation occurs, symptoms tend to disappear on their own without the need for direct or even ongoing interventions.

Application for Individual Psychology Adler anticipated the future direction of the helping professions by calling upon therapists to become social activists and by addressing the prevention and reme- diation of social conditions that were contrary to social interest and resulted in human problems. Adler’s own experiences of discrimination and the influence of social inequality are well represented in his writings. Adler’s pioneering efforts on prevention services in mental health led him to increasingly advocate for the role of Individual Psychology in schools and families. Because Individual Psychology is based on a growth model, not a medical model, it is applicable to such varied spheres of life as child guidance; parent–child counseling; couples counseling;

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family counseling and therapy; group counseling and therapy; individual coun- seling with children, adolescents, and adults; cultural conflicts; correctional and rehabilitation counseling; and mental health institutions. Adler’s basic ideas have been incorporated into the practices of school psychology, school counseling, the community mental health movement, and parent education. Adlerian principles have been widely applied to substance abuse programs, social problems to combat poverty and crime, problems of the aged, school systems, religion, and business. Adlerian ideas also have had widespread international application and acceptance (see Fall and Winter 2012 special issues of the Journal of Individual Psychology for international perspectives on Individual Psychology).

Application for Family Counseling With its emphasis on the family constellation, holism, and the freedom of the therapist to improvise, Adler’s approach contributed to the foundation of the fam- ily therapy perspective. Adlerians working with families focus on the family atmo- sphere, the family constellation, and the interactive goals of each member (Bitter, 2021). The therapeutic process seeks to increase awareness of the purposeful inter- actions of the individuals within the family system. Those who practice Adlerian family therapy strive to understand the goals, beliefs, and behaviors of each family member and the family as an entity in its own right.

Adlerians pioneered open-forum family counseling (Bitter & Byrd, 2017b). Starting with Adler’s child guidance centers in the 1920s, Adlerians learned to inter- view families in front of a community of their peers, focusing on mistaken goals in children (Dreikurs, 1948) and equally mistaken notions in adults (Bitter, 2009). Similar to group counseling, open forum family counseling is a process that cannot guarantee confidentiality—and initially, the model met with some resistance from professional psychiatrists and psychologists. What is lost in terms of confidentiality, however, is gained back in accountability and the development of an encouraging therapeutic community.

Both in private and open forums, Adlerian family counselors help families dis- engage from repetitive, nonproductive interactions, replacing them with cooperative ones (Armerding, 2021). They help family members become aware of the purposes of mistaken behaviors, and replace punishment and other forms of negative disci- pline with encouragement and natural and logical consequences (see Nelson, 2006).

Adlerian open-forum family counseling is addressed by Christensen (2004). For more on the Adlerian approach to family counseling, refer to Theory and Practice of Couples and Family Counseling (Bitter, 2021, chap. 6) and Bitter and Byrd (2017a, 2017b).

Application for Group Counseling Adler and his coworkers used a group approach in their child guidance centers in Vienna as early as 1921 (Dreikurs, 1969). Dreikurs extended and popularized Adler’s work with groups and used group psychotherapy in his private practice for more than 40 years. Although Dreikurs introduced group therapy into his psychiatric practice as a way to save time, he quickly discovered some unique characteristics of

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groups that made them an effective way of helping people change. Inferiority feel- ings can be challenged and counteracted effectively in groups, and the mistaken concepts and values that are at the root of social and emotional problems can be deeply influenced because the group is a value-forming agent (Sonstegard & Bitter, 2004).

The rationale for Adlerian group counseling is based on the premise that our problems are mainly of a social nature. The group provides the social context in which members can develop a sense of belonging, social connectedness, and community. Sonstegard and Bitter (2004) write that group participants come to see that many of their problems are interpersonal in nature, that their behavior has social meaning, and that their goals can best be understood in the frame- work of social purposes. Group counseling is particularly helpful in promoting social interest. The process of developing group cohesion parallels social interest (promoting the social welfare, in this case of the group) and community feeling (feeling connected and closer to the group itself), which are primary goals of Adlerian therapy. For example, in a men’s group, one of the core goals is often helping discouraged and isolated men feel useful to others (building altruism) and connected to fellow men. While this group process is building, group mem- bers are also building their social interest by feeling connected to something bigger than themselves.

The use of early recollections is a unique feature of Adlerian group counseling. As mentioned earlier, from a series of early memories, individuals can get a clear sense of their mistaken notions, current attitudes, social interests, and possible future behavior. Through the mutual sharing of these early recollections, members develop a sense of connection with one another, and group cohesion is increased. The group becomes an agent of change because of the improved interpersonal rela- tionships among members and the emergence of hope.

Especially valuable is the way Adlerian group counselors implement action strat- egies at each of the group sessions, particularly during the reorientation stage when new decisions are made and goals are modified. To challenge self-limiting assump- tions, members are encouraged to act as if they were the person they want to be. They are asked to “catch themselves” in the process of repeating old patterns that have led to ineffective or self-defeating behavior. If they hope to change, members come to appreciate that they need to set tasks for themselves, apply group lessons to daily life, and take steps in finding solutions to their problems.

Adlerian group therapy is addressed by Sonstegard, Bitter, Pelonis-Peneros, and Nicoll (2001). For more on the Adlerian approach to group counseling, refer to Theory and Practice of Group Counseling (Corey, 2023, chap. 7) and Sonstegard and Bitter (2004). In addition, Gerald Corey facilitates a group session from an Adlerian perspective in the Group Theories in Action videos in the MindTap program.

Applying the Adlerian Approach to School Counseling

This section was provided by Hideko Sera, PsyD, director of Equity, Inclusion and Belonging at Morehouse College, whose 20+ year career has focused on education, training, and advocacy for Black, Indigenous, and people of color.

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Alfred Adler was well ahead of his time. His theory is practical yet philosophical and hopeful in the sense that we are the creators of our own choices. Even in the most challenging circumstances, we have an option to frame these situations. Hav- ing been taught and trained by one of the giants of Adlerian psychology, the late Harold Mosak, I have a solid foundation for appreciating the timeless relevancy of Adler’s theoretical framework in school settings.

Schools offer meaning-making opportunities. Educators and students learn to navigate expectations and rules that differ from what transpires at home. Our fami- lies are the first gateway to learning about basic rules and expectations about rela- tionships/units, relational structures, and our positionality within these structures and relationships. In contrast, schools offer a more expanded community-based sys- tem in which many different and sometimes contradictory expectations of values, meanings, solutions, and goals must be navigated. Students also develop self-image and self-worth in various educational spaces.

Adler’s main theoretical concepts have applications specific to individuals who work within school settings. Teachers, school administrators, school counselors, and others who contribute to student learning and success may find the following reminders helpful.

◆ Understand students in their totality. Students are not simply a sum of their grades or test scores. In the United States, schools often praise high performers, but some students’ strengths are hard to measure by a set of biased performance tests. Each student is a unique being whose purposefulness in behaving and learning suggests meaningful inqui- ries: Who are they as individuals and, more important, who are they becoming? We must remember that interventions and approaches for one student may not work for others, and what once worked for a stu- dent may not work again, given contextual changes and impacts. Adler did not use a cookie-cutter approach.

◆ Think about behavior teleologically. Children and adolescents are not who they are because of heredity or environment; these are merely the circumstance of their lives. It is what they make of these building blocks of life that matters. When schoolchildren misbehave, ask “What was the purpose of that behavior?” rather than a befud- dled “What were you thinking?” or “Why?” School-aged children’s goals almost always have something to do with wanting to count, wanting to belong, wanting to connect, or feeling a lack of courage in the face of a challenge.

◆ Provide appropriate encouragement to students. Be cautious in promoting what success looks like in education. Adler’s exceptional student Rudolph Dreikurs was a prominent child specialist, and he believed that encouragement was a critical factor for nurturing a person’s potentials and capabilities. During their development pro- cess, students must receive plenty of encouragement from those who believe in their abilities. At the same time, Dreikurs cautioned against encouragement used to seek perfection. Dreikurs believed in having the

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courage to be imperfect; that is, we should not chase after the mirage of the unattainable notion of perfection.

◆ Foster empathic students. Being able to put yourself in another per- son’s predicament is essential for leaders and change agents today. Literature in business has recently begun focusing on empathy as one of the core components of effective leaders. As Adler noted, our well- being is deeply connected to what we do for others—not simply what we are doing for ourselves, our success, happiness, and enlightenment. For Adler, us was as important or more important than me. In addi- tion, genderized empathy is a mainstream value in the United States today. We must be mindful of our own biases, what Adler called private logic. For example, when praising female students’ empathic abili- ties, are you using terms such as sensitive and kind but characterizing the same empathic qualities in male students as weak and not assertive enough?

As early as 1930, Adler wrote and spoke to teachers and parents about the impor- tance of a democratic education of children. In the United States, Dreikurs (1957/1968) and associates (Dreikurs et al., 1998/2013) continued to develop an Adlerian model of education and school counseling that was comprehensive and encouraging.

An Expert’s Perspective on Adlerian Therapy In this section, James Robert Bitter, EdD, a professor of counseling in the Department of Counseling and Human Services at East Tennessee State Univer- sity, provides answers to the following questions.

1. What is the most important contribution of the Adlerian approach for the practice of individual therapy? I believe that the concept of holism and the unity of the personality go a long way toward working in useful ways with clients. Adler called his approach Individual Psychology to emphasize that each person is best understood as a whole being, complete and indivisible, in movement toward self-selected goals of wholeness, completion, actualization, and even perfection. Early in life, people create a fictional sense of completeness or perfection, a goal toward which they continue to strive throughout life. Once this life goal is set, it unifies the personality such that every thought, conviction, value, belief, feeling, and action aims at that goal. Because these fictional final goals begin to form so early in life, mistakes are made. Some- times there are mistaken goals that guide a person’s life; sometimes there are merely mistaken ideas about or approaches toward otherwise accept- able goals. Each person adopts a style of movement toward the life goal, a style of living that encompasses everything the person has learned and will still learn. In this sense, an Adlerian understanding of individual clients is always systemic, taking into account how the person sees self, others, life,

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and the world; taking into account the person’s family background, cul- ture, gender, and place in history; and seeking to understand the particular meaning or interpretation that the individual attaches to a life story. If we understand the whole of the individual’s style of living, the individual’s movement toward a goal of wholeness, then we can identify and correct mistakes, reassess and reorient the movement in useful ways, and celebrate corrections to faulty values and beliefs.

2. What two or three key concepts of the Adlerian approach are especially applicable to the practice of individual counseling or therapy?

Understanding life tasks. Adler noted that three life tasks were universal to all people. These tasks cannot be avoided, and they have to be resolved socially. We are communal beings (we formed into herds to survive as a species), and getting along with others (friendship) and cooperation are essential to a full and productive life. Because we cannot all do the same thing, dividing the labor and making a contribution to the whole is also essential. Indeed, the contributions we make to others, and the usefulness of our time on earth, directly relate to meaning and value in our life. And finally, human beings come in many genders and sexes. A certain number of two sexes must cooperate enough to procreate the species and keep us going. Whether we procreate or not, however, we all need inti- macy in our lives. We all need to get along with sexes other than our own; we all live better if we treat each other with mutual respect and an appreciation of difference.

Psychology of use. One of the most important differences between Adler’s conceptualization of client experience and modern psychiatry is that Adlerians look at the use a problem or disorder has in the cli- ent’s life. In contrast to psychiatric meaning, Adlerians avoid looking at a disorder as something a person has or is; the verbs “to have” and “to be” are eschewed in favor of looking at the purpose that is served by maintaining the disorder. In 1927, Adler introduced “The Question,” which solution-focused therapists later rediscovered and call “The Miracle Question.” It is phrased thusly: “What would you be doing if you woke up tomorrow and your problem had disappeared?” Solution- focused therapists use the answer to help the person start building that life, often running into resistance. Adler recognized that the disorder is being maintained so the person will not have to live life without the problem. Perhaps a person might say, “If I were not depressed, I would be more productive at work, and I would get a promotion, maybe even become a supervisor or a boss.” Adlerians understand that the person does not really feel up to that level of productive work and accomplish- ment; the depression acts as a reason for not trying and possibly failing. Adlerians pay special attention to which of the three life tasks a disor- der is related to—social, work, or intimacy—and how that disorder is used to avoid perceived failure in the task.

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3. What two or three techniques from Adlerian therapy have practi- cal value for practitioners of individual therapy?

Presence. Presence is the therapist’s ability to bring all of their atten- tion to the person in the session. It is using one’s eyes and ears (and, to a lesser extent, touch and smell) to fully take someone in. It is paying attention to language, how it is used, and what it expresses. Presence involves not being distracted by other matters. This is what Carl Rogers called psychological contact. It requires empathy, interest, and in some cases fascination, curiosity, and inquisitiveness. It is making clients feel that they are the therapist’s whole world for the time that both are together.

Pattern-focused therapy. At the heart of Adlerian therapy is the goal of understanding the movement of the individual through life, to become acquainted with how the person perceives self, others, life, and the world, and to understand the person’s methods of coping and what purpose individual strategies have. Most often, individuals present for therapy with some sort of emotional disturbance. Emo- tions alert the individual to existential threats in their life (anxiety) or to challenges to which they feel entitled to a certain outcome (anger) or serve as a call for help (depression). In addition, there is almost always a precipitating event that triggers the emotional disturbance in such a profound way that counseling is sought. Between the pre- cipitating event and the presentation, there is a pattern of thinking, coping, and behaving that is maladaptive. Patterns of thinking and coping are almost always grounded in bio-psycho-social predisposi- tions, hereditary and environmental experiences that serve as a foun- dation for the present day. All of this is supported by reinforcers in everyday life—by people and events that perpetuate maladaptive pat- terns. Adlerians learn to listen for maladaptive thinking, coping, and behaving and seek to replace these with adaptive patterns based in a community feeling and social interest.

Assessment of early recollections/early memories. Early recollec- tions are a projective technique, and understanding them allows the therapist to enter into the meaning and interpretations that govern the client’s life movement. We have more than a million life experiences (depending on what you count as an experience) between birth and 10 years of age. However, if you press most people, they have a difficult time coming up with more than 12 actual early memories that they can visualize and almost reexperience. The important question is not what do you remember but why do you remember these early recollections. Adler’s answer was that we remember those experiences that say some- thing about who we are; how we see others, life, and the world; how we would like or hate the world to be; and what convictions or ethical stances we have because of these views. An Adlerian counselor starts by asking a client to think back before the age of 10: “Tell me something that happened one time.” In listening to the memory, the counselor

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asks what stands out and what the person’s feeling or reaction is at that moment. This allows the counselor to guess about the meaning of an individual’s early recollection.

4. How does the Adlerian approach address diversity, multicul- tural, and social justice issues for the practice of individual counseling? Because Adlerians address individuals holistically and bring a systemic orientation to clinical work, no individual is completely understood unless the person is known from the perspective of family, culture, and the issues or challenges that the individual has had to face. To know “Jim,” it is not enough to know what he thinks or how he feels. I must also know how Jim was raised and in what socioeconomic condition, within what culture, religion, or part of the country or world, as a member of what race or ethnicity, and having experienced life from the perspective of a given gender or sexual orientation. Was Jim part of the privileged class in relation to these possibilities, or did he experience the challenges associated with minority races, marginalized cultures, gender discrimination, poverty, disability, or heterosexism. What did Jim learn from and about his life experiences, and if parts of his life are still being negatively affected by bigotry or discrimination, what can be done by Jim with support or by the counselor, personally, to address these inequities? Adler was one of the first to address gender and socio- economic inequality; today Adlerians take social justice very seriously and look for ways to change conditions that harm people as a whole as well as individually.

5. In what ways can Adlerian therapy be applied to brief therapy (or time-limited counseling)? For a while, my colleague Bill Nicoll and I were big proponents of Adlerian brief therapy. It was an easy position to take because a full lifestyle assessment can be done in one or two sessions, and the com- pleteness with which a therapist can know a client is truly remarkable. By addressing the mistakes in thinking, behaving, and movement, change can be supported and encouraged; clients can cogenerate new options for themselves; and support for practicing new behaviors and engaging new experiences can be offered.

The problem with brief therapy for me is that it is too easily absorbed into managed care with a focus on solving or eliminating psy- chiatric symptoms. Clients who need a serious amount of help are often expected to improve within a few months, having no more than about 10 days in residential treatment even after a suicide attempt. Indeed, some clients with severe problems related to trauma and abuse are not even covered in these medical systems unless depression or anxiety can also be diagnosed—and then the emphasis is on getting over the depres- sion, not addressing the trauma or abuse.

I came into the counseling profession when the emphasis was on relationship and how to build an effective alliance with clients.

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There were state-run, state-supported community mental health centers and state residential care facilities for the seriously ill, and it was not uncommon to see clients for years and to support indi- viduals through long stretches of their lives. I have seen that many clients need an extended period of time to feel safe enough to reveal the real pain in their lives. This is especially true of those who have been traumatized or abused. I am lucky: I work at a university and get paid a salary that allows me to see people, when necessary, for a long time, and I have come to value this in my work more and more.

6. From your perspective, what is the current status and the future of the Adlerian approach? Everyone who goes into a counseling program wants to learn how to be present and engaged. That is, perhaps, why almost every program emphasizes person-centered therapy and Rogers’s use of reflection, reflection of feeling, empathic understanding, and unconditional positive regard. Adler would not disagree with the importance of this. However, as students become clinicians, they often find them- selves wanting to go beyond mere presence. Next to declaring one- self eclectic, practicing clinicians tend to name Adlerian therapy as the most influential part of their work. This is in part because of Adler’s emphasis on social interest as a foundation for mental health. It is in part because the holistic approach helps counselors understand what the person wants and where the person is going in life. It helps the client choose a preferred life as opposed to merely ending an uncomfortable, undesirable symptom. Many of the newer approaches grew out of an Adlerian understanding of people and human nature. Many current Adlerians have easily incorporated the best from new approaches into the extremely comprehensive and broad model that Adler developed.

There is a substantial annual convention related to Adlerian psychology in the United States and Canada as well as smaller ones throughout the year. There is a growing international Adlerian associa- tion as well as practitioners in every country of Europe, and in Japan, China, Korea, and Hong Kong. Adler once thought his approach would be the basis for all of what we now call humanistic psychology. That will probably not be the case, but it is not going away anytime soon either. Adlerian therapy will remain one of the most useful approaches for helping individuals face their problems and enrich their lives.

Discussion Questions Related to Dr. Bitter’s Adlerian Perspective

1. Early in life, people create a fictional sense of completeness or perfec- tion, a goal toward which they continue to strive throughout life. Does this concept have any personal meaning to you, and if so in what way?

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2. Presence involves not being distracted by other matters. It requires empathy, interest, and in some cases fascination, curiosity, and inquisi- tiveness. To what extent do you think presence is related to building a therapeutic alliance?

3. “Early recollections are a projective technique, and understanding them allows the therapist to enter into the meaning and interpre- tations that govern the client’s life movement.” How important do you think early recollections are to understanding your clients’ issues?

Adlerian Therapy From a Multicultural Perspective Strengths From a Diversity Perspective

Carlson and Englar-Carlson (2017) believe that Adlerian theory is well suited to counseling diverse populations and doing social justice work. They state that Adle- rian therapy not only focuses acutely on multicultural and social justice issues but is “alive, well, and poised to address the concerns of a contemporary global society” (p. 24). It is critical to hear the stories of our clients and to understand their level of acculturation into the dominant society. We never want to work with clients based on what we heard or read about that particular group. In our work as therapists, listening to the lived experiences and family stories are indispensable.

Although the Adlerian approach is called Individual Psychology, its focus is on the person in a social context. Clients are encouraged to define themselves within their social environments and to understand how those environments influence their lifestyle and health. Adlerians allow broad concepts of age, ethnicity, lifestyle, sexual/affectional orientations, and gender differences to emerge in therapy, and these issues are addressed in the therapeutic process (Carlson & Englar-Carlson, 2017). It is important that assessment goes beyond the individual perspective to include family, community, and societal influences (Sue et al., 2022). Arciniega and Newlon (2003) believe that Adlerian theory holds a great deal of promise for addressing diversity issues because it emphasizes understanding the individual in a familial and sociocultural context; pays attention to the role of social interest and contributing to others; and focuses on belonging and the collective spirit. In a 1967 address to the American Society of Adlerian Psychology, Kenneth B. Clark (2021) made a similar declaration, noting that Adlerian psychology was both the founda- tion and the underpinning of Brown vs. The Board of Education. Bluvshtein et al. (2021) further noted the impact of Clark’s address and Adlerian psychology in general on their understanding of prejudice and the drive toward social justice.

Adlerian therapists tend to focus on cooperation and socially oriented val- ues as opposed to competitive and individualistic values, which is well-suited for our increasingly multicultural and pluralistic society. Native American clients, for example, tend to value cooperation over competition. One such client told a story about a group of boys who were in a race. When one boy got ahead of the others, he would slow down and allow the others to catch up, and they all made it to the fin- ish line at the same time. Although the coach tried to explain that the point of the

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race was for an individual to finish first, these boys were socialized to work together cooperatively as a group. Adlerian therapy is easily adaptable to cultural values that emphasize community.

Adlerians are conscious of the value of adapting their techniques to each client’s situation, but most of them do conduct a lifestyle assessment that is heavily focused on the structure and dynamics within the client’s family. Clients have been condi- tioned to respect their family heritage and to appreciate the impact of their family on their own personal development. It is essential that counselors be sensitive to the conflicting feelings and struggles of their clients. If counselors demonstrate an understanding of these cultural values, it is likely that these clients will be receptive to an exploration of their lifestyle. Such an exploration will involve a detailed discus- sion of their own place within their family.

It should be noted that Adlerians investigate culture in much the same way that they approach birth order and family atmosphere. Culture is a vantage point from which life is experienced and interpreted; it is also a background of values, history, convictions, beliefs, customs, and expectations that must be addressed by the individual. Culture provides a way of grasping the subjective and expe- riential perspective of an individual. Although culture influences each person, it is expressed within each individual differently, according to the perception, evaluation, and interpretation of culture that the person holds. Adlerians find opportunities for viewing the self, others, and the world in multidimensional ways during therapy.

Shortcomings From a Diversity Perspective Adlerian theory has some potential drawbacks for clients who are not interested in exploring past childhood experiences, early memories, family experiences, and dreams. This approach also has limited effectiveness with clients who do not under- stand the purpose of exploring the details of a lifestyle analysis when dealing with life’s current problems (Arciniega & Newlon, 2003). In addition, some clients may view the counselor as the “expert” and expect the counselor to provide solutions to their problems. These clients may have difficulty understanding the role of the Adlerian therapist because Adlerian therapists are not experts in solving other peo- ple’s problems. Therapists can accept their role as experts in providing therapy, but clients are the experts regarding their own life (Sue et al., 2022). Adlerian therapists work collaboratively with clients to introduce alternative methods of coping with life concerns.

Many clients who have pressing problems are hesitant to discuss areas of their lives that they may not see as connected to the struggles that bring them into therapy. In some cultures, individuals believe that it is inappropriate to reveal family information, and it is critical that therapists remain sensitive and understanding of a client’s culturally constructed beliefs about disclosing fam- ily information. Therapists who are able to self-disclose about their own family traditions from a cultural perspective could serve as a model for their clients. If therapists are able to demonstrate an understanding of a client’s cultural values and share their own experiences, it is likely that the client will be more open to the assessment and treatment process.

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Adlerian Therapy Applied to the Case of Stan The basic aims of an Adlerian therapist working with Stan are fourfold and correspond to the four stages of counseling: (1) establishing and maintaining a good working relationship with Stan, (2) exploring Stan’s dynamics, (3) encouraging Stan to develop insight and understanding, and (4) helping Stan see new alterna- tives and make new choices.

To develop mutual trust and respect, I pay close at- tention to Stan’s subjective experience and attempt to get a sense of how he has reacted to the turning points in his life. During the initial session, Stan reacts to me as the expert who has the answers. He is convinced that when he makes decisions he generally ends up regretting the results. Stan approaches me out of des- peration. Because I view counseling as a relationship between equals, I initially focus on his feeling of being unequal to most other people. A good place to begin is exploring his feelings of inferiority, which he says he feels in most situations. The goals of counseling are de- veloped mutually, and I avoid deciding for Stan what his goals should be. I also resist giving Stan the simple formula he is requesting.

I prepare a lifestyle assessment based on a question- naire that taps information about Stan’s early years, es- pecially his experiences in his family. (See the Student Manual for Theory and Practice of Counseling and Psy- chotherapy [Corey, 2024] for a complete description of this lifestyle assessment form as it is applied to Stan.) This assessment includes a determination of whether Stan poses a danger to himself because Stan did men- tion suicidal ideation. During the assessment phase, which might take a few sessions, I explore with Stan his social relationships, his relationships with members of his family, his work responsibilities, his role as a man, and his feelings about himself. I place considerable emphasis on Stan’s goals in life and his priorities. I do not pay a great deal of attention to his past, except to show him the consistency between his past and pres- ent as he moves toward the future.

As an Adlerian counselor, I place value on explor- ing early recollections as a source of understanding his goals, motivations, and values. I ask Stan to report his earliest memories.

Stan: I was about 6, I went to school, and I was scared of the other kids and the teacher. When I came home, I cried and told my mother I didn’t want to go back to school. She yelled at me and called me a baby. After that I felt horrible and even more scared.

Another of Stan’s early recollections was at age 8:

Stan: My family was visiting my grandparents. I was playing outside, and some neighborhood kid hit me for no reason. We started fighting, and my mother came out and scolded me for being such a rough kid. She wouldn’t believe me when I told her he started the fight. I felt angry and hurt that she didn’t believe me.

Based on these early recollections, I suggest that Stan sees life as frightening and unpredictably hostile and that he feels he cannot count on women; they are like- ly to be harsh, unbelieving, and uncaring.

Having gathered the data based on the lifestyle as- sessment about his family constellation and his early recollections, I assist Stan in the process of summariz- ing and interpreting this information. I pay particu- lar attention to identifying basic mistakes, which are faulty conclusions about life and self-defeating per- ceptions. Here are some of the mistaken conclusions Stan has reached:

◆ “I must not get close to people, because they will surely hurt me.”

◆ “Because my own parents didn’t want me and didn’t love me, I’ll never be desired or loved by anybody.”

◆ “If only I could become perfect, maybe people would acknowledge and accept me.”

◆ “Being a man means not showing emotions.”

The information I summarize and interpret leads to insight and increased self-understanding on Stan’s part. He gains increased awareness of his need to control his world so that he can keep painful feel- ings in check. He sees more clearly some of the ways he tries to gain control over his pain: through the use of alcohol, avoiding interpersonal situations that are

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threatening, and being unwilling to count on others for psychological support. Through continued empha- sis on his beliefs, goals, and intentions, Stan comes to see how his private logic is inaccurate. In his case, a syllogism for his style of life can be explained in this way: (1) “I am unloved, insignificant, and do not count”; (2) “The world is a threatening place to be, and life is unfair”; and (3) “Therefore, I must find ways to protect myself and be safe.” During this phase of the process, I make interpretations centering on his lifestyle, his current direction, his goals and purposes, and how his private logic works. Of course, Stan is expected to carry out homework assignments that assist him in translat- ing his insights into new behavior. In this way he is an active participant in his therapy.

In the reorientation phase of therapy, Stan and I work together to consider alternative attitudes, be- liefs, and actions. By now, Stan sees that he does not have to be locked into old patterns. He feels encour- aged and realizes that he has the power to change his life. He accepts that he will not change merely by gain- ing insights and knows that he will have to make use of these insights by carrying out an action-oriented plan. Stan begins to feel that he can create a new life for himself and not remain the victim of circumstances.

Questions for Reflection ◆ What are some ways you would attempt to

establish a relationship with Stan based on

trust and mutual respect? Can you imagine any difficulties in developing this relationship with him?

◆ What aspects of Stan’s lifestyle particularly inter- est you? In counseling him, how would these be explored?

◆ The Adlerian therapist identified four of Stan’s mistaken conclusions. Can you identify with any of these basic mistakes? If so, do you think this would help or hinder your therapeutic effective- ness with him?

◆ How might Stan’s cultural identity and context be assessed, and what might be the relationship to his presenting concerns?

◆ How might you assist Stan in discovering his social interest and going beyond a preoccupation with his own problems?

◆ What strengths and resources in Stan might you draw on to support his determination and com- mitment to change?

Refer to the MindTap for The Case of Stan Video Quiz for Chapter 5 (Session 3 on Adlerian therapy) for a demonstration of my approach to counseling Stan by focusing on his early recollections.

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

Adlerian Therapy Applied to the Case of Gwen* As the eldest child, Gwen learned early on that she was responsible not only for herself but for all those in need around her as well. She often sacrificed her own desires in an effort to please others. She knows how to stand up for herself, but too often she takes on the role of helper and loses her sense of personal meaning and identity.

Gwen: I have played by everyone’s rules for so long, and now I am just tired. I just can’t seem to win.

Therapist: If I were facing everything you are facing, I too would be tired and sad . . . and sometimes irritated.

I want to normalize Gwen’s experience because I understand that being an African American woman

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juggling multiple roles carries with it additional stresses and burdens.

Therapist: Is it safe to say that your life feels out of control?

Gwen: Yes. I can’t remember the last time I felt I was really in the driver’s seat.

Therapist: So, let’s see. You take care of your spouse, your mother, and check in on your siblings—which, by the way, you have been doing since you were a child. Even though your children are gone, you still listen to their needs on a regular basis and help out in any way that you can. You seldom if ever see your friends (there’s no time), and you cannot seem to concentrate on your work enough to feel produc- tive. Did I understand you correctly?

Gwen: Yes. You got it all.

Therapist: I am not even sure I am close to getting it all, because all of that is enough to overload anyone.

Gwen: Yes, I am totally overloaded. I have to handle all of this, get things done, and get life back to normal. But I just can’t get focused.

Therapist: Yes. There is so much. You get distracted; you start running without knowing where you are going; you worry; and the cycle continues.

Gwen: I just have so many problems.

Therapist: What would you be doing with your life if you did not have all of these problems in your life? How would your life be different? [Asking “The Question.”]

Gwen: That’s just it: I don’t know anymore. Well, I wouldn’t feel so depressed anymore. I would hope for a better life with my husband and friends, but I don’t even know if that is possible.

Gwen comes to the next session looking somewhat more relaxed than at our first session. I ask her what accounts for this improvement, and she says that really

everything is about the same, but she felt understood at the last session, so she has some hope. I thank her for telling me and congratulate her on the courage she has shown in coming to therapy.

Therapist: Gwen, I would like to get to know you a little better, to have a sense of what you have learned from life. Would it be OK if I ask you about some important parts of your life so far?

Gwen: Yes, of course.

During this session, I begin to ask Gwen about the story of her life, using the tools Adlerians include in a lifestyle assessment. I ask about her family constella- tion, including descriptions of and the relationship be- tween her parents. I ask which of her siblings was most different from her and in what way? Which one was like her and in what way? And what was she like as a child? In each of these descriptions, Gwen tells me about the early meaning she attached to her family life. During this discussion she tells me about being molested as a child by an older cousin and her determination to pro- tect her siblings from a similar fate.

In the next session, Gwen tells me about her devel- opmental history, addressing each one of Adler’s three tasks of life. She has always been a person who had just a few close friends, and she tends to take charge. “I guess some of my friends think I am a bit bossy. I know my sister does for sure, and she is still my best friend.” Gwen has always worked, first in the home, and then increasingly out in the world. She had her first real job when she was 14, having lied about her age, so she could work at a neighborhood restaurant. She has al- ways taken care of other people, even while going to college—and now she continues to do so even though she has heavy demands at work. Her husband is a com- munity activist. Ron is the only man with whom she has ever been in love. She feels they are growing apart, but they handle it by both staying busy. It is easy to hear in her stories how responsible for others she feels, how exhausted she must be, and how much of herself gets lost in the daily struggles.

Therapist: The struggles you mention are hard enough by themselves. But you also mentioned dealing

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with experiences of racism and sexism. Can you tell me about some of the particular challenges you have had to face as an African American woman?

I, too, am an African American woman, but I cannot assume that my own experiences are similar to hers. I have to hear what meaning she personally associates with race and gender, which are additional tasks of life she must address every day of her existence. I want to know what her biggest challenge is as a member of her culture as well as her greatest strength and points of cultural pride.

Toward the end of the session, I ask Gwen to prepare a list of early recollections for our next session. I ask her to remember six or more stories that happened before she was 8 years old. I want her to think of the event like a moving picture and stop it at a single frame: What is happening in that frame, and what is she feeling? What is her reaction to what happened? If this were a newspaper story, what would be the headline? These memories will most likely confirm what I am already learning about Gwen, and they will help me identify the convictions and beliefs, some of which may be faulty, that guide her life.

Lifestyle assessment is a way of investigating the cli- ent’s unique approach to the life tasks of love, friend- ship, and work. It is filled with meaning and identity and convictions and beliefs. It also contains the traits

that make up the individual’s internal resources, the motivations for both feelings and behaviors, and the foundation for where life might develop from here. The golden rule of Individual Psychology is that “ev- erything can be different.” What difference does Gwen want to make in her life now?

Questions for Reflection ◆ What are your thoughts about asking Gwen to

identify some of her early recollections? Is this kind of ancient history really important in how an indi- vidual develops a lifestyle? Why do we remember these things?

◆ Gwen wants more suggestions from her therapist. If you were her therapist, how would you inter- vene with her when she wants more direction from you?

◆ Encouragement is a foundational technique of Adlerian therapy. Can you identify any encourag- ing behaviors by the therapist? What value do you place on encouragement? What is the difference between encouragement and praise?

◆ How interested would you be in getting informa- tion from Gwen about issues of race and culture?

◆ What additional Adlerian technique would you use if you were counseling Gwen? What would your aim be in making this intervention?

Summary and Evaluation Summary

Adler was far ahead of his time, and most contemporary therapies have incorpo- rated at least some of his ideas. Individual Psychology assumes that people are moti- vated by social factors; are responsible for their own thoughts, feelings, and actions; are the creators of their own lives, as opposed to being helpless victims; and are impelled by purposes and goals, looking more toward the future than back to the past.

The basic goal of the Adlerian approach is to help clients identify and change their mistaken beliefs about, self, others, and life, accept the social realities of daily living, and participate more fully in a social world. Clients are not viewed as psychologically impaired but as discouraged. The therapeutic process helps individuals become aware of their patterns and make some basic changes in their style of living, which lead to changes in the way they feel and behave. The role of the family in the development of the individual is emphasized. Therapy is a cooperative venture that challenges clients

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to translate their insights into action in the real world. Contemporary Adlerian theory is an integrative approach, combining cognitive, constructivist, existential, psychody- namic, relational, and systems perspectives. Some of these common characteristics include an emphasis on establishing a respectful client–therapist relationship, an emphasis on clients’ strengths and resources, and an optimistic and future orientation.

Contributions of the Adlerian Approach A strength of the Adlerian approach is its flexibility and its integrative nature. Adlerian therapists are resourceful and flexible in drawing on many methods, which can be applied to a diverse range of clients in a variety of settings and formats. They tend to be theoretically consistent and technically eclectic (Watts, 2015). Therapists are mainly concerned with doing what is in the best interests of clients rather than squeezing clients into one theoretical framework (Carlson et al., 2006).

Another contribution of the Adlerian approach is that it is suited to brief, time- limited therapy. Adler was a proponent of time-limited therapy, and the techniques used by many contemporary brief therapeutic approaches are very similar to inter- ventions created by—or commonly used by—Adlerian practitioners (Carlson et al., 2006). Adlerian therapy and contemporary brief therapy share a number of charac- teristics, including quickly establishing a strong therapeutic alliance, a clear prob- lem focus and goal alignment, rapid assessment and application to treatment, an emphasis on active and directive intervention, a psychoeducational focus, a pres- ent and future orientation, a focus on clients’ strengths and abilities and an opti- mistic expectation of change, and a time sensitivity that tailors treatment to the unique needs of the client (Carlson & Englar-Carlson, 2017; Hoyt, 2015). Mosak and Di Pietro (2006) state that early recollections are a significant assessment interven- tion in brief therapy. These early recollections are often useful in minimizing the number of therapy sessions. This procedure takes little time to administer and inter- pret and provides a direction for therapists to pursue.

It is difficult to overestimate the contributions of Adler to contemporary thera- peutic practice. In many ways, we believe Adler’s influence on current practice is greater than that of Freud. Many of Adler’s ideas were revolutionary and far ahead of his time. His influence went beyond counseling individuals and extended into the community mental health movement (Ansbacher, 1974). Abraham Maslow, Viktor Frankl, Rollo May, Paul Watzlawick, Karen Horney, Erich Fromm, Carl Rogers, Virginia Satir, William Glasser, Aaron T. Beck, and Albert Ellis have all acknowl- edged their debt to Alfred Adler (Carlson & Englar-Carlson, 2017). Both Frankl and May see him as a forerunner of the existential movement because of his position that human beings are free to choose and are entirely responsible for what they make of themselves. This view also makes Adler a pioneer of the subjective approach to psychology, which focuses on the internal determinants of behavior: values, beliefs, attitudes, goals, interests, personal meanings, subjective perceptions of reality, and strivings toward self-realization.

One of Adler’s most important contributions was his influence on other ther- apy systems, and Bitter (2008; Bitter et al., 2009) has drawn attention to the link between Adlerian thinking and feminist therapy approaches. Adler is considered by many to be the grandfather of modern psychotherapy. Many of his basic ideas have

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found their way into most of the other psychological schools, a few of which include existential therapy, cognitive behavior therapy, rational emotive behavior therapy, reality therapy, solution-focused brief therapy, feminist therapy, and family therapy.

In many respects, Adler seems to have paved the way for current developments in both the cognitive and constructivist therapies (Watts, 2012, 2015). Adlerians’ basic premise is that if clients can change their thinking then they can change their feelings and behavior. A study of contemporary counseling theories reveals that many of Adler’s notions have reappeared in these modern approaches with dif- ferent nomenclature, and often without giving Adler the credit he is due (Watts, 2015). One example of this is found in the emergence of the positive psychology movement, which calls for an increased study of hope, courage, contentment, hap- piness, well-being, perseverance, resilience, tolerance, and personal resources. Adler clearly addressed major themes associated with positive psychology long before this approach appeared on the therapeutic scene (Watts, 2012).

Carlson and Englar-Carlson (2013) assert that Adlerians face the challenge of continuing to develop their approach to meet the needs of a contemporary global society: “Whereas Adlerian ideas are alive in other theoretical approaches, there is a question about whether Adlerian theory as a stand-alone approach is viable in the long term” (p. 124). With so many Adlerian concepts co-opted by other models, these authors believe that for the Adlerian model to survive and thrive it will be nec- essary to find ways to strive for significance.

Limitations and Criticisms of the Adlerian Approach Adler had to choose between devoting his time to formalizing his theory and teach- ing others the basic concepts of Individual Psychology. He placed practicing therapy and teaching before organizing and presenting a well-defined and systematic the- ory. Many of Adler’s ideas are vague and general, which makes it difficult to conduct research on some concepts (Carlson & Johnson, 2016). His written presentations are often more poetic than scientific, and many of them are transcripts of lectures he gave. Adler’s global reach was unprecedented, but he did not attend to the way his work was translated. Although he was brilliant in many ways, he was not scholarly in the modern sense of that term (Maniacci, 2012).

Self-Reflection and Discussion Questions 1. What are some of your earliest memories? Identify one specific early

memory and reflect on the significance this early recollection has for you. What value do you see in the Adlerian technique of having indi- viduals recall their earliest memories?

2. Adlerians contend that each of us has a unique lifestyle, or personality, that starts to develop in early childhood to compensate for and over- come some perceived inferiority. How does this key concept apply to you? In what ways have you felt inferior in the past, and how have you dealt with it? Do you see any potential connection between your strug- gle with basic inferiority feelings and your accomplishments?

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3. From an Adlerian perspective, individuals are best understood by looking at their future strivings. How are your goals influencing what you are doing now? How do you think your past has influenced your future goals? In what ways can you apply this purposive, goal-oriented approach in your work as a therapist?

4. Adlerians emphasize the family constellation. Reflect on what it was like for you to grow up in your family. How would you characterize your relationship with each of your siblings? What did you learn about yourself and others through your early family experiences?

5. Social interest is a central concept in the Adlerian approach. What value do you place on social interest in your own life? In what ways do you think you could assist your clients in developing their social interest?

Where to Go From Here Free Podcasts for ACA Members

You can download ACA Podcasts (prerecorded interviews) by going to www .counseling.org and clicking on the Resource button, and then the Podcast Series. For Chapter 5, look for Podcast 11, Adlerian Therapy, by Dr. Jon Carlson.

Other Resources Videos from Psychotherapy.net demonstrate Adlerian therapy with adults, families, and children and are available to students and professionals (www.Psychotherapy .net). New articles, interviews, blogs, therapy cartoons, and videos are published monthly. For this chapter, see the following:

Carlson, J. (1997). Adlerian Therapy (Psychotherapy with the Experts Series)

Carlson, J. (2001). Adlerian Parent Consultation (Child Therapy with the Experts Series)

Kottman, T. (2001). Adlerian Play Therapy (Child Therapy with the Experts Series)

Two other videos that depict Adlerian therapy with a real client are available from the American Psychological Association (www.apa.org/pubs/videos/index.aspx). One shows an example of brief Adlerian therapy, and the other shows six sessions working with the same client over time:

Carlson, J. D. (2005). Adlerian Therapy (Systems of Psychotherapy series)

Carlson, J. D. (2006). Psychotherapy Over Time (Psychotherapy in Six Sessions video series)

If your thinking is allied with the Adlerian approach, consider seeking train- ing in Individual Psychology or becoming a member of the North American Society of Adlerian Psychology (NASAP). Students can join NASAP for free the first year.

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To obtain information and a list of Adlerian organizations and institutes, contact the North American Society of Adlerian Psychology (www.alfredadler.org).

The society publishes a newsletter and a quarterly journal and maintains a list of institutes, training programs, and workshops in Adlerian psychology. The Journal of Individual Psychology presents current scholarly and professional research. Columns on counseling, education, and parent and family education are regular features. Information about subscriptions is available by contacting the society.

If you are interested in pursuing training, postgraduate study, continuing edu- cation, or a degree, contact NASAP for a list of Adlerian organizations and insti- tutes. A few training institutes are listed here:

Adler School of Professional Psychology (www.adler.edu)

Adlerian Training Institute, Inc. (www.adleriantraining.com)

International Committee of Adlerian Summer Schools and Institutes (www.icassi.net)

Recommended Supplementary Readings for Chapter 5 Adlerian Psychotherapy (Carlson & Englar-Carlson, 2017) is a comprehensive and concise overview of key concepts of Adlerian theory. This is a clearly written book and a useful resource for learning about the the- ory, process, and practice of the Adlerian approach.

Adlerian Counseling and Psychotherapy: A Practitioner’s Wellness Approach (Sweeney, 2019) is one of the most comprehensive books written on the wide range of Adlerian applications to therapy and wellness.

The Quest to Feel Good (Rasmussen, 2010) explores the uses of emotions in psychotherapy and how emotions can be adaptive or maladaptive responses to the tasks and demands of life. A model for adap- tive reorientation within the Adlerian model is pre- sented and demonstrated.

Learning and Practicing Adlerian Therapy (Sperry & Binensztok, 2019) is a complete manual on how to conduct Adlerian pattern-focused therapy. Using the case of Jennifer, the authors explore the principles of Adlerian psychology and take the reader through multiple sessions from beginning to termination.

The Key to Psychotherapy: Understanding the Self- Created Individual (Powers & Griffith, 2012) is a useful source of information for doing a lifestyle assessment. Separate chapters deal with inter- view techniques, lifestyle assessment, early recol- lections, the family constellation, and methods of summarizing and interpreting information.

Adler, A. (1929). The science of living. George Allen & Unwin. Adler, A. (1932). What life should mean to you. George Allen and Unwin. Adler, A. (1935). The fundamental views of individual psychology. International Journal of Individual Psychology, 1(1), 5–8. Adler, A. (1938). Social interest: A challenge to mankind. Faber & Faber.

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

Adler, A. (1969). The practice and theory of Individual Psychology. Littlefield, Adams. (2nd rev. ed. published 1929) Adler, A. (1996a). The structure of neurosis. Individual Psychology, 52(4), 351– 362. (Original work published 1935) Adler, A. (1996b). What is neurosis? Individual Psychology, 52(4), 318–333. (Original work published 1935)

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Sperry, L., & Sperry, J. (2015). Cognitive behavior therapy of DSM5 personality disorders: Assessment, case conceptualization, and treatment. Routledge. Sperry, L., & Sperry, J. (2017). Cognitive behavior therapy in counseling practice. Routledge. Sperry, L., & Sperry, J. (2020). Case con ceptualization: Mastering the competency with ease and confidence (2nd ed.). Routledge. Sperry, L., & Sperry, J. (2021). The fifteen minute case conceptualization: Mastering the patternfocused approach. Routledge. Sue, D. W., Sue, D., Neville, H. A., & Smith, L. (2022). Counseling the culturally diverse: Theory and practice (9th ed.). Wiley. Sweeney, T. J. (2019). Adlerian counseling and psychotherapy: A practitioner’s wellness approach (6th ed.). Routledge. Terner, J., & Pew, W. L. (1978). The courage to be imperfect: The life and work of Rudolf Dreikurs. Hawthorn. Watts, R. E. (2012). On the origin of the striving for superiority and of social interest. In J. Carlson & M. P. Maniacci (Eds.), Alfred Adler revisited (pp. 41–47). Routledge, Taylor & Francis. Watts, R. E. (2015). Adlerian therapy. In E. Neukrug (Ed.), The SAGE encyclopedia of theory in counseling and psychotherapy (vol. 1, pp. 30–35). SAGE.

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Existential Therapy6

1. Identify the major themes that characterize existential philosophy and therapy.

2. Compare the unique contributions of some prominent existential thinkers and therapists.

3. Examine the key concepts and basic assumptions underlying this approach, including self- awareness, freedom and responsibility, intimacy and isolation, meaning in life, death anxiety, and authenticity.

4. Identify the therapeutic goals of existential therapy.

5. Discuss the unique emphasis placed on the therapeutic relationship.

6. Describe the three phases of existential counseling.

7. Describe the applications of this approach to brief therapy.

8. Identify the applications of this approach to group counseling.

9. Discuss the applications of this approach to school counseling.

10. Describe ways in which the existential approach is and is not well suited to multicultural counseling.

11. Evaluate the contributions and limitations of the existential approach.

Learning Objectives

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Viktor Frankl (1905–1997) was born and educated in Vienna. He founded the Youth Advisement Centers there in 1928 and directed them un- til 1938. From 1942 to 1945 Frankl was a prisoner in the Nazi concentration camps at Auschwitz and Dachau, where his parents, brother, wife, and children died. He vividly re-

membered his horrible experi- ences in these camps, but he did not allow them to dampen his love and enthusiasm for life. He traveled all around the world, giving lectures in Europe, Latin America, Southeast Asia, and the United States.

Frankl received his MD in 1930 and his PhD in phi- losophy in 1949, both from the University of Vienna. He became an associate professor at the University of Vienna and later was a distinguished speaker at the United States International University in San Diego. He was a visiting professor at Harvard, Stanford, and Southern Methodist universities. Frankl’s works have been translated into more than 20 languages, and his ideas continue to have a major impact on the devel- opment of existential therapy. His compelling book Man’s Search for Meaning (1963) has been a best-seller around the world.

Although Frankl had begun to develop an exis- tential approach to clinical practice before his grim years in the Nazi death camps, his experiences there confirmed his views. Frankl (1963) observed and per- sonally experienced the truths expressed by existen- tial philosophers and writers who hold that we have choices in every situation. Even in terrible circum- stances, he believed, we could preserve a vestige of spiritual freedom and independence of mind. He learned experientially that everything could be taken from a person except one thing: “the last of human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way” (p. 104). Frankl believed that the essence of being human lies

in searching for meaning and purpose. We can dis- cover this meaning through our actions and deeds, by experiencing a value (such as love or achievements), and by suffering.

Frankl was deeply influenced by Freud, but he dis- agreed with the rigidity of Freud’s psychoanalytic sys- tem and became a student of Alfred Adler. Reacting against most of Freud’s deterministic notions, Frankl developed his own theory and practice of psycho- therapy, which emphasized the concepts of freedom, responsibility, meaning, and the search for values. He established his international reputation as the founder of what has been called “The Third School of Viennese Psychoanalysis,” the other two being Sigmund Freud’s psychoanalysis and Alfred Adler’s In- dividual Psychology.

Frankl was a central figure in developing existen- tial therapy in Europe and in bringing it to the United States. He was fond of quoting Nietzsche: “He who has a why to live for can bear with almost any how” (as cited in Frankl, 1963, pp. 121, 164). Frankl contended that those words could be the motto for all psychothera- peutic practice. Another quotation from Nietzsche seems to capture the essence of Frankl’s own experi- ence and writings: “That which does not kill me, makes me stronger” (as cited in Frankl, 1963, p. 130).

Frankl developed logotherapy, which means “therapy through meaning.” Frankl’s philosophical model sheds light on what it means to be fully alive. The central themes running through his works are life has meaning under all circumstances; the central mo- tivation for living is the will to meaning; we have the freedom to find meaning in all that we think; and we must integrate body, mind, and spirit to be fully alive. Frankl’s writings reflect the theme that the modern person has the means to live but often has no mean- ing to live for.

I have selected Frankl as one of the key figures of the existential approach because of the dramatic way in which his theories were tested by the tragedies of his life. His life was an illustration of his theory, for he lived what his theory espouses.

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Rollo May (1909–1994) first lived in Ohio and then moved to Michigan as a young child along with his five brothers and a sister. He remembered his home life as being unhappy, a situation that contributed to his interest in psychology and counseling. In his personal life, May struggled with his own existential concerns and the failure of two marriages.

May graduated from Oberlin College in 1930 and then went to Greece as a teacher. During his summers in Greece, he traveled to Vienna to study with Alfred Adler. After receiving a degree in theology from Union Theological Seminary, May decided that the best way to reach out and help people was through psychology instead of theology. He completed his doctorate in clinical psychology at Columbia University and started a private practice in New York; he also became a super- visory training analyst for the William Alanson Institute.

While May was pursuing his doctoral program, he came down with tuberculosis, which resulted in a two- year stay in a sanitarium. During his recovery period, May spent much time learning firsthand about the nature of anxiety. He also spent time reading, and he studied the works of Søren Kierkegaard, which was the catalyst for May recognizing the existential dimensions of anxiety and resulted in him writing The Meaning of Anxiety (1950). His popular book Love and Will (1969) re- flects his own personal struggles with love and intimate

relationships and mirrors Western society’s questioning of its values pertaining to sex and marriage.

The greatest personal influence on Rollo May was the existential theologian Paul Tillich (author of The Cour- age to Be, 1952), who became his mentor and a personal friend. The two spent much time together discussing philosophical, religious, and psychological topics. May was deeply influenced by the existential philosophers, by the concepts of Freudian psychology, and by many aspects of Alfred Adler’s Individual Psychology. Most of May’s writings reflect a concern with the nature of human experience, such as recognizing and dealing with power, accepting freedom and responsibility, and discovering one’s identity. He draws from his rich knowledge based on the classics and his existential perspective.

May’s writings have had a significant impact on existentially oriented practitioners, and his writings helped translate key existential concepts into psy- chotherapeutic practice in the United States and Europe. May believed psychotherapy should be aimed at helping people discover the meaning of their lives and should be concerned with the problems of being rather than with problem solving. It takes courage to “be,” and our choices determine the kind of person we become. Questions of being include learning to deal with issues such as sex and intimacy, growing old, fac- ing death, and taking action in the world. According to May, the real challenge is for people to be able to live in a world where they are alone and where they will eventually have to face death. It is the task of therapists to help individuals find ways to contribute to the bet- terment of the society in which they live.

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Irvin Yalom (b. 1931) was born of parents who immi- grated from Russia shortly af- ter World War I. During his ear- ly childhood, Yalom lived in the inner city of Washington, D.C., in a poor neighborhood. Life on the streets was peril- ous, and Yalom took refuge indoors reading novels and

other works. Twice a week he made the hazardous bi- cycle trek to the library to stock up on reading supplies. He found an alternative and satisfying world in reading fiction, which was a source of inspiration and wisdom to him. Early in his life he decided that writing a novel was the very finest thing a person could do, and subse- quently he has written several teaching novels.

Irvin Yalom is Professor Emeritus of Psychiatry at the Stanford University School of Medicine. A psychiatrist and author, Yalom has been a major figure in the field Irvin Yalom

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of group psychotherapy since publication in 1970 of his influential book The Theory and Practice of Group Psychotherapy (Yalom & Leszcz, 1970/2020), which has been translated into 12 languages and is currently in its sixth edition. His pioneering work, Existential Psycho- therapy (1980), is a classic and authoritative textbook on existential therapy. A contemporary existential therapist in the United States, Yalom acknowledges the contributions of both European and American psy- chologists and psychiatrists to the development of ex- istential thinking and practice. Drawing on his clinical experience and on empirical research, philosophy, and literature, Yalom developed an existential approach to psychotherapy that addresses four “givens of existence,” or ultimate human concerns: freedom and responsibil- ity, existential isolation, meaninglessness, and death. These existential themes deal with the client’s exis- tence, or being-in-the-world. Yalom believes the vast majority of experienced therapists, regardless of their theoretical orientation, address these core existen- tial themes. How we address these existential themes greatly influences the design and quality of our lives.

Psychotherapy has been endlessly intriguing for Yalom, who has approached all of his patients with a sense of wonderment at the stories they reveal. He believes that a different therapy must be designed

for each client because each has a unique story. He advocates using the here and now of the therapeutic relationship to explore the client’s interpersonal world, and he believes therapists must be transparent, espe- cially regarding their experience of the client. His basic philosophy is existential and interpersonal, which he applies to both individual and group therapy.

Irvin Yalom has authored many stories and novels related to psychotherapy, including Love’s Executioner (1987), When Nietzsche Wept (1992), Lying on the Couch (1997), Momma and the Meaning of Life (2000), and The Schopenhauer Cure (2005). His 2008 nonfiction book, Staring at the Sun: Overcoming the Terror of Death, is a treatise on the role of death anxiety in psychotherapy, illustrating how death and the meaning of life are foundational themes associated with in-depth thera- peutic work. In their 2021 book, A Matter of Death and Life, Irvin and Marilyn Yalom describe their experience during the last months of her life after she was diag- nosed with cancer. The Yaloms share how they dealt with profound new struggles: Marilyn to die a good death, and Irv to live on without her. This is a moving account of dealing with death, loss, anxiety, and grief that illustrates existential themes in life. Yalom’s works, translated into more than 20 languages, have been widely read by therapists and laypeople alike.

Introduction Existential therapy is a way of thinking, or an attitude about psychotherapy, more than it is a particular style of practicing psychotherapy. It is not a separate school of therapy, nor is it a clearly defined model with specific techniques. A wide range of beliefs and practices characterize the field of existential psychotherapy, making it more appropriate to refer to existential therapies rather than to a single existential approach (Craig et al., 2016).

Existential therapy focuses on exploring themes such as mortality, meaning, freedom, responsibility, anxiety, and aloneness as these relate to a person’s current struggle. The goal of existential therapy is to assist clients in their exploration of the existential “givens of life,” how these are sometimes ignored or denied, and how addressing them can ultimately lead to a deeper, more reflective and meaningful existence. Clients are invited to reflect on life, to recognize their range of alterna- tives, and to decide among them. Existential therapy is grounded on the assumption that we are free and therefore responsible for our choices and actions. We are the

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authors of our lives, and we design the pathways we follow. This chapter addresses some of the existential concepts and themes, such as the “givens of life,” that have significant implications for the existentially oriented practitioner.

A basic existential premise is that we are not victims of circumstance because, to a large extent, we are what we choose to be. Once clients begin the process of recognizing the ways in which they have passively accepted circumstances and sur- rendered control, they can start down a path of consciously shaping their own lives. The first step in the therapeutic journey is for clients to accept responsibility. As Yalom (2003) puts it, “Once individuals recognize their role in creating their own life predicament, they also realize that they, and only they, have the power to change that situation” (p. 141). The aim of existential therapy is to invite clients to explore their values and beliefs and to take action that grows out of this honest appraisal of their life’s purpose.

Refer to the MindTap for this book to interact with video quizzes and various video programs to expand your knowledge on topics relevant to Chapter 6.

Historical Background in Philosophy and Existentialism Many streams of thought contributed to the existential therapy movement in the 1940s and 1950s, and it arose spontaneously in different parts of Europe and among different schools of psychology and psychiatry. Many Europeans found that their lives had been devastated by World War II, and they struggled with existential issues including feelings of isolation, alienation, and meaningless- ness. Early writers focused on the individual’s experience of being alone in the world and facing the anxiety of this situation. The European existential perspec- tive focused on human limitations and the tragic dimensions of life (Sharp & Bugental, 2001).

The thinking of existential psychologists and psychiatrists was influenced by a number of philosophers and writers during the 19th century. To understand the philosophical underpinnings of modern existential psychotherapy, one must have some awareness of the cultural, philosophical, and religious writings of Søren Kierkegaard, Friedrich Nietzsche, Martin Heidegger, Jean-Paul Sartre, and Martin Buber. These major figures of existentialism and existential phenomenology pro- vided the basis for the formation of existential therapy. Ludwig Binswanger and Medard Boss were also early existential psychoanalysts who contributed key ideas to existential psychotherapy. Acknowledging the influence of these early philoso- phers, Yalom found that each contributed significant themes that guided his own thinking:

◆ From Kierkegaard: creative anxiety, despair, fear and dread, guilt, and nothingness

◆ From Nietzsche: death, suicide, and will ◆ From Heidegger: authentic being, caring, death, guilt, individual

responsibility, and isolation

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◆ From Sartre: meaninglessness, responsibility, and choice ◆ From Buber: interpersonal relationships, I/Thou perspective in therapy,

and self-transcendence

Søren Kierkegaard (1813–1855) A Danish philosopher and Christian theologian, Kierkegaard was particularly concerned with angst—a Danish and German word whose meaning lies between the English words dread and anxiety— and he addressed the role of anxiety and uncertainty in life. Existential anxiety is associated with making basic decisions about how we want to live, and it is not pathological. Kierkegaard believed that anxiety is the school in which we are educated to be a self. Without the experience of angst, we may go through life as sleepwalkers. But many of us, especially in adolescence, are awakened into real life by a terrible uneasiness. Life is one contingency after another, with no guarantees beyond the certainty of death. This is by no means a comfortable state, but it is necessary to our becoming human. Kierkegaard believed that “the sickness unto death” arises when we are not true to ourselves. What is needed is the willingness to risk a leap of faith in making choices. Becoming human is a project, and our task is not so much to discover who we are as to create ourselves.

Friedrich Nietzsche (1844–1900) The German philosopher Nietzsche is the iconoclastic counterpart to Kierkegaard, expressing a revolutionary approach to the self, to ethics, and to society. Like Kierkegaard, he emphasized the importance of subjectivity. Nietzsche set out to prove that the ancient definition of humans as rational was entirely misleading. We are far more creatures of will than we are impersonal intellects. But where Kierkegaard emphasized the “subjective truth” of an intense concern with God, Nietzsche located values within the individual’s “will to power.” We give up an honest acknowledgment of this source of value when society invites us to rationalize powerlessness by advocating other worldly concerns. If, like sheep, we acquiesce in “herd morality,” we will be nothing but mediocrities. But if we release ourselves by giving free rein to our will to power, we will tap our potentiality for creativity and originality. Kierkegaard and Nietzsche, with their pioneering analyses of anxiety, depression, subjectivity, and the authentic self, together are generally considered to be the originators of the existential perspective (Sharp & Bugental, 2001).

Martin Heidegger (1889–1976) Heidegger’s phenomenological existentialism reminds us that we exist “in the world” and should not try to think of ourselves as beings apart from the world into which we are thrown. The way we fill our everyday life with superficial conversation and routine shows that we often assume we are going to live forever and can afford to waste day after day. Our moods and feelings (including anxiety about death) are a way of understanding whether we are living authentically or whether we are inauthentically constructing our life around the expectations of others. When we translate this wisdom from vague feeling to explicit awareness, we may develop a more positive resolve about how we want to be. Phenomenological existentialism, as presented by Heidegger, provides a view of human history that does not focus on past events but motivates individuals to look forward to “authentic experiences” that are yet to come.

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Martin Buber (1878–1965) Leaving Germany to live in the new state of Israel, Buber took a less individualistic stand than most of the other existentialists. He said that we humans live in a kind of betweenness; that is, there is never just an I, but always an other. The I, the person who is the agent, changes depending on whether the other is an it or a Thou. But sometimes we make the serious mistake of reducing another person to the status of a mere object, in which case the relationship becomes I/it. Although Buber recognizes that of necessity we must have many I/it interactions (in everyday life), we are seriously limited if we live only in the world of the I/it. Buber stresses the importance of presence, which has three functions: (1) it enables true I/Thou relationships; (2) it allows for meaning to exist in a situation; and (3) it enables an individual to be responsible in the here and now (Gould, 1993). In a famous dialogue with Carl Rogers, Buber argued that the therapist and the client could never be on the same footing because the latter comes to the former for help. When the relationship is fully mutual, we have become “dialogic,” a fully human condition.

Ludwig Binswanger (1881–1966) An existential analyst, Binswanger proposed a holistic model of self that addresses the relationship between the person and his or her environment. He used a phenomenological approach to explore significant features of the self, including choice, freedom, and caring. He based his existential approach largely on the ideas of Heidegger and accepted Heidegger’s notion that we are “thrown into the world.” However, this “thrown-ness” does not release us from the responsibility of our choices and for planning for the future (Gould, 1993). Existential analysis (Daseinanalysis) emphasizes the subjective and spiritual dimensions of human existence. Binswanger (1975) contended that crises in therapy were typically major choice points for the client. Although he originally looked to psychoanalytic theory to shed light on psychosis, he moved toward an existential view of his patients. This perspective enabled him to understand the worldview and immediate experience of his patients, as well as the meaning of their behavior, as opposed to superimposing his view as a therapist on their experience and behavior.

Medard Boss (1903–1990) Both Binswanger and Boss were early existential psychoanalysts and significant figures in the development of existential psychotherapy. They talked of dasein, or being-in-the-world, which pertains to our ability to reflect on life events and attribute meaning to these events. They believed the therapist must enter the client’s subjective world without presuppositions that would get in the way of this experiential understanding. Both Binswanger and Boss were significantly influenced by Heidegger’s seminal work Being and Time (1962), which provided a broad basis for understanding the individual (May, 1958). Boss was deeply influenced by Freudian psychoanalysis, but even more so by Heidegger. Boss’s major professional interest was applying Heidegger’s philosophical notions to therapeutic practice, and he was especially concerned with integrating Freud’s methods with Heidegger’s concepts, as described in his book Daseinanalysis and Psychoanalysis (1963).

Jean-Paul Sartre (1905–1980) A philosopher and novelist, Sartre was convinced, in part by his years in the French Resistance in World War II, that humans are

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even more free than earlier existentialists had believed. The existence of a space— nothingness—between the whole of our past and the now frees us to choose what we will. Our values are what we choose. The failure to acknowledge our freedom and choices results in emotional problems. This freedom is hard to face, so we tend to invent an excuse by saying, “I can’t change now because of my past conditioning.” Sartre called excuses “bad faith.” No matter what we have been, we can make choices now and become something quite different. We are condemned to be free. To choose is to become committed; this is the responsibility that is the other side of freedom. Sartre’s view was that at every moment, by our actions, we are choosing who we are being. Our existence is never fixed or finished. Every one of our actions represents a fresh choice. When we attempt to pin down who we are, we engage in self-deception (Russell, 2007).

Key Figures in Contemporary Existential Psychotherapy Viktor Frankl, Rollo May, and Irvin Yalom (featured at the beginning of the chap- ter) created their existential approaches to psychotherapy from their strong back- grounds in both existential and humanistic psychology. James Bugental has also made major contributions to the development of existential therapy in the United States, and Emmy van Deurzen continues to influence the practice of existential therapy in Great Britain.

James Bugental (1915–2008) James Bugental (1987) wrote about life-changing psychotherapy, which is the effort to help clients examine how they have answered life’s existential questions and to invite them to revise their answers so they can live more authentically. Bugental coined the term “existential-humanistic” psychotherapy, and he was a leading spokesperson for this approach. His philosophical and therapeutic approach included a curiosity and focus that moved him away from the traditional therapeutic milieu of labeling and diagnosing clients. His work emphasized the cultivation of both client and therapist presence. The therapist’s primary task involves helping clients make new discoveries about themselves in the living moment, as opposed to merely talking about themselves.

Central to Bugental’s approach is his view of resistance, which from an existential-humanistic perspective is not resistance to therapy per se but rather to being fully present both during the therapy hour and in life. Resistance is seen as part of the self-and-world construct—how we understand out being and relationship to the world at large. Forms of resistance include intellectualizing, being argumentative, always seeking to please, and any other life-limiting pattern. As resistance emerges in the therapy sessions, the therapist repeatedly notes, or “tags,” the resistance so clients increase their awareness and ultimately have an increased range of choices.

Bugental’s theory and practice emphasized the distinction between therapeu- tic process and content. He became known for being a masterful teacher and psy- chotherapist, primarily because he lived his work. He was an existentialist at heart, which made him a great model and mentor, not only for clients but also for students and professionals. In his workshops, he developed many exercises to help thera- pists refine and practice their skills. He frequently brought his interventions to life with live demonstrations, which emphasized therapeutic work taking place in the

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moment, impromptu here-and-now dialogue, and exploring in the context of self as client or therapist. Bugental’s (1987) classic text, The Art of the Psychotherapist, is widely recognized for deconstructing the therapy process and moving beyond theory and generalizations to show what actually occurs moment-to-moment in the therapeu- tic encounter. Psychotherapy Isn’t What You Think (Bugental, 1999) is the last book he wrote before he died in 2008, at the age of 93.

British Contribution to Existential Therapy Emmy van Deurzen, a key con- tributor to British existential psychology, is a philosopher, psychotherapist, and counseling psychologist. Deurzen has earned a worldwide reputation in existential psychotherapy through her many books and her role in teaching and training. Deurzen (2012) states that existential therapy is not designed to “cure” people of illness in the tradition of the medical model because people are not sick but are “sick of life or clumsy at living” (p. 30). Deurzen’s (2014) psychotherapy practice has taught her that individuals have incredible resilience and intelligence in overcoming their problems once they commit themselves to a self-searching process. Her therapy clients find meaning in their past hardships rather than experiencing these difficulties as defining them in old patterns. Her clients are able to recognize the contradictions and paradoxes of life and to face their troubles and solve dilemmas. They also discover what is most important in life.

Deurzen is the cofounder of the New School of Psychotherapy and Counselling, which is developing academic and training programs. The existential approach has spread rapidly in Britain in recent decades and is now an alternative to traditional methods (Deurzen, 2002, 2012). For a description of the historical context and devel- opment of existential therapy in Britain, see Deurzen (2002), Deurzen and Adams (2011), and Cooper (2017); for an excellent overview of the theory and practice of existential therapy, see Deurzen (2012) and Schneider and Krug (2017; 2020). Later in this chapter Deurzen provides an expert’s perspective on the existential approach in which she addresses six key questions about the approach. For information on the New School in Britain, see the Other Resources section at the end of this chapter.

Key Concepts View of Human Nature

The crucial significance of the existential movement is that it reacts against the ten- dency to identify therapy with a set of techniques. Instead, it bases therapeutic prac- tice on an understanding of what it means to be human. The existential movement stands for respect for the person, for exploring new aspects of human behavior, and for divergent methods of understanding people. It uses numerous approaches to therapy based on its assumptions about human nature.

The existential tradition seeks a balance between recognizing the limits and tragic dimensions of human existence on one hand and the possibilities and oppor- tunities of human life on the other hand. It grew out of a desire to help people engage the dilemmas of contemporary life, such as isolation, alienation, and meaningless- ness. The current focus of the existential approach is on the individual’s experience

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of being in the world alone and facing the anxiety of this isolation. “No relationship can eliminate existential isolation, but aloneness can be shared in such a way that love compensates for its pain” (Yalom & Josselson, 2019, p. 291).

The existential view of human nature is captured, in part, by the notion that the significance of our existence is never fixed once and for all; rather, we continu- ally re-create ourselves through our projects. Humans are in a constant state of transition, emerging, evolving, and becoming in response to the tensions, contra- dictions, and conflicts in our lives. Being a person implies that we are discovering and making sense of our existence. We continually question ourselves, others, and the world. Although the specific questions we raise vary in accordance with our developmental stage in life, the fundamental themes do not vary. We pose the same questions philosophers have pondered throughout Western history: “Who am I?” “What can I know?” “What ought I to do?” “What can I hope for?” “Where am I going?”

The basic dimensions of the human condition, according to the existential approach, include (1) the capacity for self-awareness; (2) freedom and responsibility; (3) creating one’s identity and establishing meaningful relationships with others; (4) the search for meaning, purpose, values, and goals; (5) anxiety as a condition of living; and (6) awareness of death and nonbeing. I develop these propositions in the following sections by summarizing themes that emerge in the writings of existential philosophers and psychotherapists, and I also discuss the implications for counsel- ing practice of each of these propositions.

Proposition 1: The Capacity for Self-Awareness Freedom, choice, and responsibility constitute the foundation of self-awareness. The greater our awareness, the greater our possibilities for freedom (see Proposition 2). We increase our capacity to live fully as we expand our awareness in the following areas:

◆ We are finite and do not have unlimited time to do what we want in life.

◆ We have the potential to take action or not to act; inaction is a decision. ◆ We choose our actions, and therefore we can partially create our own

destiny. ◆ Meaning is the product of discovering how we are “thrown” or situated

in the world and then, through commitment, living creatively. ◆ As we increase our awareness of the choices available to us, we also

increase our sense of responsibility for the consequences of these choices.

◆ We are subject to loneliness, meaninglessness, emptiness, guilt, and isolation.

◆ We are basically alone, yet we have an opportunity to relate to other beings.

We can choose either to expand or to restrict our consciousness. Because self- awareness is at the root of most other human capacities, the decision to expand it is fundamental to human growth. Here are some areas of emerging awareness that individuals may experience in the counseling process:

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◆ They see how they are trading the security of dependence for the anxiet- ies that accompany choosing for themselves.

◆ They begin to see that their identity is anchored in someone else’s defi- nition of them; that is, they are seeking approval and confirmation of their being in others instead of looking to themselves for affirmation.

◆ They learn that in many ways they are keeping themselves prisoner by some of their past decisions, and they realize that they can make new decisions.

◆ They learn that although they cannot change certain events in their lives they can change the way they view and react to these events.

◆ They learn that they are not condemned to a future similar to the past, for they can learn from their past and thereby reshape their future.

◆ They realize that they are so preoccupied with suffering, death, and dying that they are not appreciating living.

◆ They are able to accept their limitations yet still feel worthwhile, for they understand that they do not need to be perfect to feel worthy.

◆ They come to realize that they are failing to live in the present moment because of preoccupation with the past, planning for the future, or try- ing to do too many things at once.

Increasing self-awareness—which includes awareness of alternatives, motiva- tions, factors influencing the person, and personal goals—is an aim of all counsel- ing. People engaged in therapy need to learn that a price must be paid for increased awareness. As we become more aware, it is more difficult to “go home again.” Igno- rance of our condition may have brought contentment along with a feeling of par- tial deadness, but as we open the doors in our world, we can expect more turmoil as well as the potential for more fulfillment.

Proposition 2: Freedom and Responsibility A characteristic existential theme is that people are free to choose among alterna- tives and therefore play a large role in shaping their own destiny. Schneider and Krug (2017) write that existential therapy embraces three values: (1) the freedom to become within the context of natural and self-imposed limitations; (2) the capacity to reflect on the meaning of our choices; and (3) the capacity to act on the choices we make. Although we do not choose the circumstances into which we are born, we create our own destiny by the choices we make. Sartre claims we are constantly confronted with the choice of what kind of person we are becoming, and to exist is never to be finished with this kind of choosing. Living an authentic existence requires that we assume responsibility for our choices (Rubin & Lichtanski, 2015).

A central existential concept is that although we long for freedom we often try to escape from our freedom by defining ourselves as a fixed or static entity (Russell, 2007). Jean-Paul Sartre (1971) refers to this as the inauthenticity of not accepting personal responsibility. We can then avoid choosing and instead make excuses such as these: “Since that’s the way I’m made, I couldn’t help what I did” or “Naturally I’m this way, because I grew up in a dysfunctional family.” An inauthentic mode of existence consists of lacking awareness of personal responsibility for our lives and passively assuming that our existence is largely controlled by external forces.

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Freedom implies that we are responsible for our lives, for our actions, and for our failures to take action. From Sartre’s perspective, people are condemned to free- dom. He calls for a commitment to choosing for ourselves. Existential guilt is being aware of having evaded a commitment, or having chosen not to choose. This guilt is a condition that grows out of a sense of incompleteness, or a realization that we are not what we might have become. Guilt may be a sign that we have failed to rise to the challenge of our anxiety and that we have tried to evade it by not doing what we know is possible for us to do (Deurzen, 2012). This condition is not viewed as neurotic, nor is it seen as a symptom that needs to be cured. Existential guilt can be a powerful source of motivation toward transformation and living authentically (Rubin & Lichtanski, 2015). The existential therapist explores this guilt to see what clients can learn about the ways in which they are living their life. This guilt also results from allowing others to define us or to make our choices for us. Sartre said, “We are our choices.” Authenticity implies that we are living by being true to our own evaluation of what is a valuable existence for ourselves; it is the courage to be who we are. One of the aims of existential therapy is to help people face up to the difficulties of life with courage rather than avoiding life’s struggles (Deurzen & Adams, 2011).

For existentialists, then, being free and being human are identical. Freedom and responsibility go hand in hand. We are the authors of our lives in the sense that we create our destiny, our life situation, and our problems (Russell, 1978). Assuming responsibility is a basic condition for change. Clients who refuse to accept responsi- bility by persistently blaming others for their problems are not likely to profit from therapy.

Frankl (1978) also links freedom with responsibility. He suggested that the Statue of Liberty on the East Coast should be balanced with a Statue of Responsibil- ity on the West Coast. His basic premise is that freedom is bound by certain limita- tions. We are not free from conditions, but we are free to take a stand against these restrictions. Ultimately, these conditions are subject to our decisions, which means we are responsible.

The therapist assists clients in discovering how they are avoiding freedom and encourages them to learn to risk using it. Not to do so is to cripple clients and make them dependent on the therapist. Therapists have the task of teaching clients that they can explicitly accept that they have choices, even though they may have devoted most of their life to evading them. Those who are in therapy often have mixed feel- ings when it comes to choice. As Russell (2007) puts it, “We resent it when we don’t have choices, but we get anxious when we do! Existentialism is all about broadening the vision of our choices” (p. 111).

People often seek psychotherapy because they feel that they have lost control of how they are living. They may look to the counselor to direct them, give them advice, or produce magical cures. They may also need to be heard and understood. Two central tasks of the therapist are inviting clients to recognize how they have allowed others to decide for them and encouraging them to take steps toward choosing for themselves. In inviting clients to explore other ways of being that are more fulfilling than their present restricted existence, some existential counselors ask, “Although you have lived in a certain pattern, now that you recognize the price of some of your ways, are you willing to consider creating new patterns?” Others may have a vested

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interest in keeping the client in an old pattern, so the initiative for changing this pattern will have to come from the client.

Cultural factors need to be taken into account in assisting clients in the process of examining their choices. A person who is struggling with feeling limited by her family situation can be invited to look at her part in this process and values that are a part of her culture. For example, Meta, a Norwegian American, is working to attain a professional identity as a social worker, but her family thinks she is being selfish and neglecting her primary duties. The family is likely to exert pressure on her to give up her personal interests in favor of what they feel is best for the welfare of the entire family. Meta may feel trapped in the situation and see no way out unless she rejects what her family wants. In cases such as this, it is useful to explore the client’s underlying values and to help her determine whether her values are working for her and for her family. Clients such as Meta have the challenge of weighing values and balancing behaviors between two cultures. Ultimately, Meta must decide in what ways she might change her situation, and she needs to assess values based on her culture. The existential therapist will invite Meta to begin to explore what she can do and to realize that she can be authentic in spite of pressures put on her by her situ- ation. According to Vontress (2013), we can be authentic in any society, whether we are a part of an individualistic or a collectivistic society.

It is essential to respect the purpose that people have in mind when they initiate therapy. If we pay careful attention to what our clients tell us about what they want, we can operate within an existential framework. We can encourage individuals to weigh the alternatives and to explore the consequences of what they are doing with their lives. Although oppressive forces may be severely limiting the quality of their lives, we can help clients see that they are not solely the victims of circumstances beyond their control. Even though we sometimes cannot control things that happen to us, we have complete control over how we choose to perceive and handle them. Although our freedom to act is limited by external reality, our freedom to be relates to our internal reality. At the same time that people are learning how to change their external environment, they can be challenged to look within themselves to recognize their own contributions to their problems. They can explore their own resources and discover new courses of action that will lead to a change in their situation.

Proposition 3: Striving for Identity and Relationship to Others People are concerned about preserving their uniqueness and centeredness, yet at the same time they have an interest in going outside of themselves to relate to other beings and to nature. Each of us would like to discover a self or, to put it more authen- tically, to create our personal identity. This is not an automatic process, and creating an identity takes courage. As relational beings, we also strive for connectedness with others. Many existential writers discuss loneliness, uprootedness, and alienation, which can be seen as the failure to develop ties with others and with nature.

The trouble with so many of us is that we have sought directions, answers, val- ues, and beliefs from the important people in our world. Rather than trusting our- selves to search within and find our own answers to the conflicts in our life, we sell out by becoming what others expect of us. Our being becomes rooted in their expec- tations, and we become strangers to ourselves.

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The Courage to Be Paul Tillich (1886–1965), a leading Protestant theologian of the 20th century, believed awareness of our finite nature gives us an appreciation of ultimate concerns. It takes courage to discover the true “ground of our being” and to use its power to transcend those aspects of nonbeing that would destroy us (Tillich, 1952). Courage entails the will to move forward in spite of anxiety- producing situations, such as facing our death (May, 1975). We struggle to discover, to create, and to maintain the core deep within our being. One of the greatest fears of clients is that they will discover that there is no core, no self, no substance, and that they are merely reflections of everyone’s expectations of them. A client may say, “My fear is that I’ll discover I’m nobody, that there really is nothing to me. I’ll find out that I’m an empty shell, hollow inside, and nothing will exist if I shed my masks.” If clients demonstrate the courage to confront these fears, they might well leave therapy with an increased tolerance for the uncertainty of life. By assisting clients in facing the fear that their lives or selves are empty and meaningless, therapists can help clients to create a self that has meaning and substance that they have chosen.

Existential therapists may begin by asking their clients to allow themselves to intensify the feeling that they are nothing more than the sum of others’ expectations and that they are merely the introjects of parents and parent substitutes. How do they feel now? Are they condemned to stay this way forever? Is there a way out? Can they create a self if they find that they are without one? Where can they begin? Once clients have demonstrated the courage to recognize this fear, to put it into words and share it, it does not seem so overwhelming. I find that it is best to begin work by inviting clients to accept the ways in which they have lived outside themselves and to explore ways in which they are out of contact with themselves.

The Experience of Aloneness The existentialists postulate that part of the human condition is the experience of aloneness. But they add that we can derive strength from the experience of looking to ourselves and sensing our separation. The sense of isolation comes when we recognize that we cannot depend on anyone else for our own confirmation; that is, we alone must give a sense of meaning to life, and we alone must decide how we will live. If we are unable to tolerate ourselves when we are alone, how can we expect anyone else to be enriched by our company? Before we can have any solid relationship with another, we must have a relationship with ourselves. We are challenged to learn to listen to ourselves. We have to be able to stand alone before we can truly stand beside another.

The Experience of Relatedness We humans depend on relationships with others. We want to be significant in another’s world, and we want to feel that another’s presence is important in our world. When we are able to stand alone and tap into our own strength, our relationships with others are based on our fulfillment, not our deprivation. If we feel personally deprived, however, we can expect little but a clinging and symbiotic relationship with someone else.

Perhaps one of the functions of therapy is to help clients distinguish between a neurotically dependent attachment to another and a life-affirming relationship in which both people are enhanced. The therapist can challenge clients to exam- ine what they get from their relationships, how they avoid intimate contact, how

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they prevent themselves from having equal relationships, and how they might create therapeutic, healthy, and mature human relationships. Existential therapists speak of intersubjectivity, which is the fact of our interrelatedness with others and the need for us to struggle with this in a creative way.

Struggling With Our Identity Because of our fear of dealing with our aloneness, Farha (1994) points out that some of us get caught up in ritualistic behavior patterns that cement us to an image or identity we acquired in early childhood. We become trapped in a doing mode to avoid the experience of being. Part of the therapeutic journey consists of the therapist challenging clients to begin to examine the ways in which they have lost touch with their identity, especially by letting others design their life for them. The therapy process itself is often frightening for clients when they realize that they have surrendered their freedom to others and that in the therapy relationship they will have to assume their freedom again. By refusing to give easy solutions or answers, existential therapists confront clients with the reality that they alone must find their own answers.

Proposition 4: The Search for Meaning A distinctly human characteristic is the struggle for a sense of significance and purpose in life. In my experience the underlying conflicts that bring people into counseling and therapy are centered in these existential questions: “Why am I here?” “What do I want from life?” “What gives my life purpose?” “Where is the source of meaning for me in life?”

Existential therapy can provide the conceptual framework for helping clients challenge the meaning in their lives. Questions that the therapist might ask are, “Do you like the direction of your life?” “Are you pleased with what you now are and what you are becoming?” “If you are confused about who you are and what you want for yourself, what are you doing to get some clarity?”

The Problem of Discarding Old Values One of the problems in therapy is that clients may discard traditional (and imposed) values without creating other, suitable ones to replace them. What does the therapist do when clients no longer cling to values that they never really challenged or internalized and now experience a vacuum? Clients may report that they feel like a boat without a rudder. They seek new guidelines and values that are appropriate for the newly discovered facets of themselves, and yet for a time they are without them. One of the tasks of the therapeutic process is to help clients create a value system based on a way of living that is consistent with their way of being.

The therapist’s job is to trust in the capacity of clients to eventually create an internally derived value system that provides the foundation for a meaningful life. They will no doubt flounder for a time and experience anxiety as a result of the absence of clear-cut values. The therapist’s trust is important in encouraging clients to trust their own capacity to create a new source of values.

Meaninglessness According to Frankl (1963), the central human concern is to discover meaning that will give one’s life direction. Frankl’s life experiences and his

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clinical work led him to the conclusion that a lack of meaning is the major source of existential stress and anxiety in modern times. He views existential neurosis as the experience of meaninglessness. When the world we live in seems meaningless, we may wonder whether it is worth it to continue struggling or even living. Faced with the prospect of our mortality, we might ask, “Is there any point to what I do now, since I will eventually die? Will what I do be forgotten when I am gone? Given the fact of mortality, why should I busy myself with anything?” A man in one of my groups captured precisely the idea of personal significance when he said, “I feel like another page in a book that has been turned quickly, and nobody bothered to read the page.”

Meaninglessness in life can lead to emptiness and hollowness, or a condition that Frankl calls the existential vacuum. This condition is often experienced when people do not busy themselves with routine or with work. Because there is no preor- dained design for living, people are faced with the task of creating their own meaning. At times people who feel trapped by the emptiness of life withdraw from the struggle of creating a life with purpose. Experiencing meaninglessness and establishing values that are part of a meaningful life are issues that become the heart of counseling.

Creating New Meaning Logotherapy is designed to help clients find meaning in life. Logotherapists do not tell clients what their meaning in life should be. Instead, existential therapists facilitate an exploration of past, present, and future meanings to help clients identify and connect or reconnect with potential sources of meaning in their lives (Craig et al., 2016). Therapists suggest that human suffering (the tragic and negative aspects of life) can be turned into human achievement by the stand clients take when faced with it. Frankl (1978) contends that people who confront pain, guilt, despair, and death can effectively deal with their despair and thus triumph.

Meaning is not something that we can directly search for and obtain. Paradoxi- cally, the more rationally we seek it, the more likely we are to miss it. Meaning is created out of an individual’s engagement with what is valued, and this commit- ment provides the purpose that makes life worthwhile (Deurzen, 2012). I like the way Vontress (2013) captures the idea that meaning in life is an ongoing process we struggle with throughout our life: “What provides meaning one day may not pro- vide meaning the next, and what has been meaningful to a person throughout life may be meaningless when a person is on his or her deathbed” (p. 147).

In Meaning in Life: A Therapist’s Guide, Clara Hill (2018) provides a model for working with meaning in life in psychotherapy. Hill’s work focuses on existential psychotherapy, but she believes that therapists from all theoretical orientations need to address the role of meaning in life as an integral part of the therapeutic process. Meaning in life is a universal concern that often underlies presenting problems that individuals bring to therapy (such as depression, anxiety, isolation, physical illness, aging, and death anxiety). A key role of therapists is to assist clients in deciding whether they want to achieve more meaning in life, and if so, what actions they can take to bring about such changes. Therapists offer support and at the same time challenge their clients to question the degree to which they are lead- ing a meaningful life.

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Proposition 5: Anxiety as a Condition of Living Anxiety arises from one’s personal strivings to survive and to maintain and assert one’s being, and the feelings anxiety generates are an inevitable aspect of the human condition. Existential anxiety is the unavoidable result of being confronted with the givens of existence—death, freedom, choice, isolation, and meaninglessness (Vontress, 2013; Yalom, 1980; Yalom & Josselson, 2019). Existential anxiety arises as we recognize the realities of our mortality, our confrontation with pain and suf- fering, our need to struggle for survival, and our basic fallibility. We experience this anxiety as we become increasingly aware of our freedom and the consequences of accepting or rejecting that freedom. In fact, when we make a decision that involves reconstruction of our life, the accompanying anxiety can be a signal that we are ready for personal change and can be a stimulus for growth. If we learn to listen to the subtle messages of anxiety, we can dare to take the steps necessary to change the direction of our lives.

Existential therapists differentiate between normal and neurotic anxiety, and they see anxiety as a potential source of growth. Normal anxiety is an appropri- ate response to an event being faced. Accepting freedom and the responsibility for making decisions and life choices, searching for meaning, and facing mortality can be frightening. This kind of anxiety does not have to be repressed, and it can be a powerful motivational force toward change and growth (Rubin & Lichtanski, 2015). From the existential viewpoint, normal anxiety is an invitation to freedom. “Anxiety is a teacher, not an obstacle or something to be removed or avoided” (Deurzen & Adams, 2011, p. 24).

Failure to move through anxiety results in neurotic anxiety, which is anxiety about concrete things that is out of proportion to the situation. Neurotic anxiety is typically out of awareness, and it tends to immobilize the person. Being psy- chologically healthy entails living with as little neurotic anxiety as possible, while accepting and struggling with the unavoidable existential anxiety that is a part of living.

Many people who seek counseling want solutions that will enable them to elimi- nate anxiety. Creating the illusion that there is security in life may help us cope with the unknown, yet we know on some level that we are deceiving ourselves. Deurzen (2012) believes that existential anxiety is part of living with awareness and being fully alive. In fact, the courage to live fully entails accepting the reality of death and the anxiety associated with uncertainty. Facing existential anxiety involves viewing life as an adventure rather than hiding behind imagined securities that seem to offer protection. Opening up to new life means opening up to anxiety. We pay a steep price when we short-circuit anxiety.

The existential therapist can help clients recognize that learning how to tolerate ambiguity and uncertainty and how to live without props can be a necessary phase in the journey from dependence to autonomy. The therapist and client can explore the possibility that, although breaking away from crippling patterns and building new ways of living will be fraught with anxiety for a while, anxiety will diminish as the client experiences more satisfaction with newer ways of being. When a client becomes more self-confident, the anxiety that results from an expectation of catas- trophe is likely to decrease.

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Proposition 6: Awareness of Death and Nonbeing The existentialist does not view death negatively but holds that awareness of death as a basic human condition gives significance to living. A distinguishing human characteristic is the ability to grasp the reality of the future and the inevitability of death. It is necessary to think about death if we are to think significantly about life. Death should not be considered a threat; death provides the motivation for us to take advantage of appreciating the present moment. Instead of being frozen by the fear of death, reflecting on the reality of death can teach us how to live fully. Deurzen and Adams (2011) write: “Life is a taskmaster, while death is a master teacher” (p. 105). If we defend ourselves against the reality of our eventual death, life becomes insipid and meaningless. But if we realize that we are mortal, we know that we do not have an eternity to complete our projects and that the present is crucial. Our awareness of death is the source of zest for life and creativity. Death and life are interdependent: although physical death destroys us, the idea of death saves us (Yalom, 1980, 2003).

Yalom (2008) recommends that therapists talk directly to clients about the reality of death. He believes the fear of death percolates beneath the surface and haunts us throughout life. Death is a visitor in the therapeutic process, and Yalom believes that ignoring its presence sends the message that death is too overwhelming to explore. Confronting this fear can be the factor that helps us transform an inauthentic mode of living into a more authentic one. Accepting the reality of our personal death can result in a major shift in the way we live in the world (Yalom & Josselson, 2019). We can turn our fear of death into a positive force when we accept the reality of our mortality. In Staring at the Sun: Overcoming the Terror of Death, Yalom (2008) develops the idea that confronting death enables us to live in a more compassionate way. Frank (2022) contends that death anxi- ety can cause us to connect as well as cause feelings of isolation and despair: “A confrontation with death can lead to rebirth of a more aware, alive, honest, and authentic being” (p. 123).

One focus in existential therapy is on exploring the degree to which clients are doing the things they value. Without being morbidly preoccupied by the ever-pres- ent threat of nonbeing, people can develop a healthy awareness of death as a way to evaluate how well they are living and what changes they want to make in their lives. Those who fear death also fear life. When we emotionally accept the reality of our eventual death, we realize more clearly that our actions do count, that we do have choices, and that we must accept the ultimate responsibility for how well we are liv- ing (Corey et al., 2018).

The Therapeutic Process Therapeutic Goals

Existential therapy is best considered as an invitation to clients to recognize the ways in which they are not living fully authentic lives and to make choices that will lead to their becoming what they are capable of being. An aim of therapy is to assist clients in moving toward authenticity and learning to recognize when

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they are deceiving themselves (Deurzen, 2012). The existential orientation holds that there is no escape from freedom as we will always be held responsible. We can relinquish our freedom, however, which is the ultimate inauthenticity. Existential therapy aims at helping clients face anxiety and engage in action that is based on the authentic purpose of creating a worthy existence. Authenticity involves claim- ing authorship—taking responsibility for our actions and the way we are living (Deurzen & Adams, 2011).

May (1981) contends that people come to therapy with the self-serving illusion that they are inwardly enslaved and that someone else (the therapist) can free them. Existential therapists are mainly concerned about helping people to reclaim and reown their lives. The task of existential therapy is to teach clients to listen to what they already know about themselves, even though they may not be attending to what they know. Schneider and Krug (2020) identify four essential aims of existential- humanistic therapy: (1) to help clients become more present to both themselves and others; (2) to assist clients in identifying ways they block themselves from fuller pres- ence; (3) to challenge clients to assume responsibility for designing their present lives; and (4) to encourage clients to choose more expanded ways of being in their daily lives.

Increased awareness is the central goal of existential therapy, which allows clients to discover that alternative possibilities exist where none were recognized before. Clients come to realize that they are able to make changes in their way of being in the world.

Therapist’s Function and Role Existential therapists are primarily concerned with understanding the subjective world of clients to help them come to new understandings and options. Existen- tial therapists are especially concerned about clients avoiding responsibility; they consistently invite clients to accept personal responsibility. When clients complain about the predicaments they are in and blame others, the therapist is likely to ask them how they contributed to their situation.

Therapists with an existential orientation usually deal with people who have what could be called a restricted existence. These clients have a limited aware- ness of themselves and are often vague about the nature of their problems. They may see few, if any, options for dealing with life situations, and they tend to feel trapped, helpless, and stuck. One of the therapist’s functions is to assist clients in seeing the ways in which they constrict their awareness and the cost of such constrictions (Bugental, 1997). The therapist may hold up a mirror, so to speak, so that clients can gradually engage in self-confrontation. In this way, clients can see how they became the way they are and how they might enlarge the way they live. Once clients are aware of factors in their past and of stifling modes of their present existence, they can begin to accept responsibility for changing their future.

Existential practitioners may make use of techniques that originate from diverse theoretical orientations, yet no set of techniques is considered essential. The thera- peutic journey is creative and uncertain and different for each client. Russell (2007) captures this notion well: “There is no one right way to do therapy, and certainly no

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rigid doctrine for existentially rooted techniques. What is crucial is that you create your own authentic way of being attuned to your clients” (p. 123). Existential thera- pists encourage experimentation not only within the therapy office but also outside of the therapy setting, based on the belief that life outside therapy is what counts. Practitioners often ask clients to reflect on or write about problematic events they encounter in daily life (Schneider, 2011).

Client’s Experience in Therapy Clients in existential therapy are clearly encouraged to assume responsibility for how they are currently choosing to be in their world. Effective therapy does not stop with this awareness itself, for the therapist encourages clients to take action on the basis of the insights they develop through the therapeutic process. Experi- mentation with new ways of behaving in the outside world is necessary if clients are to change. Furthermore, clients must be active in the therapeutic process, for during the sessions they must decide what fears, guilt feelings, and anxieties they will explore.

Merely deciding to enter psychotherapy is itself a frightening prospect for most people. The experience of opening the doors to oneself can be frightening, excit- ing, joyful, depressing, or a combination of all of these. As clients wedge open the closed doors, they also begin to loosen the deterministic shackles that have kept them psychologically bound. Gradually, they become aware of what they have been and who they are now, and they are better able to decide what kind of future they want. Through the process of their therapy, individuals can explore alternatives for making their visions real.

When clients plead helplessness and attempt to convince themselves that they are powerless, May (1981) reminds them that their journey toward freedom began by putting one foot in front of the other to get to his office. As narrow as their range of freedom may be, individuals can begin building and augmenting that range by taking small steps.

Another aspect of the experience of being a client in existential therapy is con- fronting ultimate concerns rather than coping with immediate problems. Rather than focusing on solving problems, existential therapy is aimed toward removing roadblocks to meaningful living and helping clients assume responsibility for their actions (Yalom & Josselson, 2019). Existential therapists assist people in facing life with courage, hope, and a willingness to find meaning in life. Deurzen and Adams (2011) maintain that a therapist must resonate with the client’s experience and struggle to face life honestly. This capacity for resonance must be honed constantly, and it requires the therapist to be fully present with the client and take part in the therapeutic encounter in a fully engaged manner.

Relationship Between Therapist and Client The therapeutic relationship is central in creating a climate conducive for clients to engage in an honest exploration of the way they are living. The therapeutic rela- tionship is at the heart of existential practice (Craig et al., 2016) because the quality of this person-to-person encounter is the stimulus for positive change. Attention

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is given to the client’s immediate, ongoing experience, especially what is going on in the interaction between therapist and client. Therapy is viewed as a social microcosm in the sense that the interpersonal and existential problems of the cli- ent will become apparent in the here and now of the therapy relationship (Yalom & Josselson, 2019).

Therapists with an existential orientation believe their basic attitudes toward the client and their own personal characteristics of honesty, integrity, and cour- age are what they have to offer. Therapy is a journey taken by therapist and cli- ent that delves deeply into the world as perceived and experienced by the client. But this type of quest demands that therapists also be in contact with their own phenomenological world. Existential therapy is a voyage into self-discovery and a journey of life-discovery for both client and therapist (Deurzen, 2010; Yalom & Josselson, 2019).

Buber’s (1970) conception of the I/Thou relationship has significant implica- tions here. His understanding of the self is based on two fundamental relationships: the I/it and the I/Thou. The I/it is the relation to time and space, which is a necessary starting place for the self. The I/Thou is the relationship essential for connecting the self to the spirit and, in so doing, to achieve true dialogue. This form of relation- ship is the paradigm of the fully human self, the achievement of which is the goal of Buber’s existential philosophy. Relating in an I/Thou fashion means that there is direct, mutual, and present interaction. Rather than prizing therapeutic objectivity and professional distance, existential therapists strive to create caring and intimate relationships with their clients.

The core of the therapeutic relationship is respect, which implies faith in clients’ potential to cope authentically with their troubles and in their ability to discover alternative ways of being. Existential therapists share their reactions to clients with genuine concern and empathy as one way of deepening the therapeutic relationship. Therapists invite clients to grow by modeling authentic behavior. If therapists keep themselves hidden during the therapeutic session or if they engage in inauthentic behavior, clients will also remain guarded and persist in their inau- thentic ways.

Bugental (1987) emphasizes the crucial role the presence of the therapist plays in the therapeutic relationship. In his view, many therapists overlook its funda- mental importance. He contends that therapists are too often so concerned with the content of what is being said that they are not aware of the distance between themselves and their clients. Therapists need to be genuinely interested in the well- being of clients. Clients value therapists who demonstrate presence and authentic- ity and who meet them as a person, not as someone caught up in a professional role (Craig et al., 2016).

Existential therapists believe therapeutic presence is necessary for establish- ing trust and safety in the therapeutic relationship. Michael Alcee (2022) writes: “Therapeutic presence is a sublime communion that allows us to temporarily escape our isolation and become a part of the world again instead of merely feeling apart” (p. 123). Alcee states that therapeutic presence is difficult because it requires us to tolerate not knowing. Presence is not an absolute or perfect way of being, but it does offer “a secure enough base from which to have a personal and meaningful connec- tion” (p. 121).

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Application: Therapeutic Techniques and Procedures The existential approach is unlike most other therapies in that it is not technique- oriented. Existentially oriented therapists may incorporate many techniques from other models or create their own techniques, but these interventions are made within the context of striving to understand the subjective world of the client. Exis- tential therapists have a set of assumptions and attitudes that guide their inter- ventions with clients, and one of my colleagues, Bryan Farha, created an existential technique that helped his clients ponder the meaning and purpose of their lives. He asked clients to sit outside at night and look at the stars for about an hour. While doing this, his clients began to think about deep existential issues such as “Where did I come from?” “Where am I going?” and “How vast is the universe?” Farha is convinced that therapists can successfully create their own existential interventions.

The interventions existential practitioners employ are based on philosophi- cal views about the nature of human existence. These practitioners prefer descrip- tion, understanding, and exploration of the client’s subjective reality, as opposed to diagnosis, treatment, and prognosis (Deurzen, 2002). “Existential therapists prefer to be thought of as philosophical companions, not as people who repair psyches” (Vontress, 2013, p. 150). Yalom and Josselson (2019) describe existential therapists as “fellow travelers” who are willing to make themselves known through appropri- ate self-disclosure. It is not theories and techniques that heal but the encounter that occurs between client and therapist as they work together (Elkins, 2007, 2016). Elkins (2016) cites the findings of meta-analyses of hundreds of studies that identi- fied the factors related to therapeutic effectiveness. “Remarkably, the findings showed that techniques had little to do with effectiveness and that common factors were the real agents of change” (p. 4). Elkins has become convinced that the human elements of psychotherapy are the primary factors in emotional healing.

A primary ground rule of existential work is the openness to the individual creativity of the therapist and the client. Existential therapists need to adapt their interventions to their own personality and style, as well as being sensitive to what each client requires. The main guideline is that the existential practitioner’s inter- ventions are responsive to the uniqueness of each client (Deurzen, 2010). See Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 4) for an illustration of how Dr. J. Michael Russell works in an existential way with some key themes in the case of Ruth.

Deurzen (2012) believes that the starting point for existential work is for practi- tioners to clarify their views on life and living. She stresses the importance of thera- pists reaching sufficient depth and openness in their own lives to venture into clients’ murky waters without getting lost. The nature of existential work is assisting people in the process of living with greater expertise and ease. Deurzen (2010) identifies how therapists make a difference with clients: “We help them to get better at reflect- ing on their situation, deal with their dilemma, face their predicament and think for themselves” (p. 236). Deurzen reminds us that existential therapy is a collaborative adventure in which both client and therapist will be transformed if they allow them- selves to be touched by life. When the deepest self of the therapist meets the deepest part of the client, the counseling process is at its best. Therapy is a creative, evolving process of discovery that can be conceptualized in three general phases.

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Phases of Existential Counseling During the initial phase of counseling, therapists assist clients in identifying and clarifying their assumptions about the world. Clients are invited to define and ques- tion the ways in which they perceive and make sense of their existence. They examine their values, beliefs, and assumptions to determine their validity. This is a difficult task for many clients because they may initially present their problems as resulting almost entirely from external causes. They may focus on what other people “make them feel” or on how others are largely responsible for their actions or inaction. The therapist teaches them how to reflect on their own existence and to examine their role in creating their problems in living.

During the middle phase of existential counseling, clients are assisted in more fully examining the source and authority of their present value system. This process of self-exploration typically leads to new insights and some restructuring of values and attitudes. Individuals get a better idea of what kind of life they consider worthy to live and develop a clearer sense of their internal valuing process.

The final phase of existential counseling focuses on helping people take what they are learning about themselves and putting it into action. Transformation is not limited to what takes place during the therapy hour. The therapeutic hour is a small contribution to a person’s renewed engagement with life, or a rehearsal for life (Deurzen, 2002). The aim of therapy is to enable clients to discover ways of imple- menting their examined and internalized values in a concrete way between sessions and after therapy has terminated. Clients typically discover their strengths and find ways to put them to the service of living a purposeful existence.

Clients Appropriate for Existential Counseling Existential practice has been applied in a variety of settings and with a diverse population of clients, including those with substance abuse issues, individuals from various ethnic and racial groups, gay and lesbian clients, and psychiatric inpatients (Schneider, 2011). A strength of the perspective is its focus on available choices and pathways toward personal growth. For people who are coping with developmental crises, experiencing grief and loss, confronting death, or facing a major life decision, existential therapy is especially appropriate. Critical turning points that mark passages from one stage of life into another include the struggle for identity in adolescence, cop- ing with possible disappointments in middle age, adjusting to children leaving home, coping with failures in marriage and work, and dealing with increased physical limita- tions as one ages. These developmental challenges involve both dangers and opportu- nities. Uncertainty, anxiety, and struggling with decisions are all part of this process.

Deurzen (2002) suggests that this form of therapy is most appropriate for clients who are committed to dealing with their problems about living, for people who feel alienated from the current expectations of society, or for those who are searching for meaning in their lives. It tends to work well with people who are at a crossroads and who question the state of affairs in the world and are willing to challenge the status quo. It can be useful for people who are on the edge of existence, such as those who are dying or contemplating suicide, who are working through a developmental or situational crisis, who feel that they no longer belong in their surroundings, or who are starting a new phase of life.

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Application to Brief Therapy The existential approach can focus clients on significant areas such as assuming per- sonal responsibility, making a commitment to deciding and acting, and expanding their awareness of their current situation. It is possible for a time-limited approach to serve as a catalyst for clients to become actively and fully involved in each of their therapy sessions. Clients can be encouraged to view each session as their last one and be challenged with this question: “If this were the last opportunity you had for chang- ing your life, what is most salient for you?” Sharp and Bugental (2001) maintain that short-term applications of the existential approach require more structuring and clearly defined and less ambitious goals. At the termination of short-term therapy, it is important for individuals to evaluate what they have accomplished and what issues may need to be addressed later. It is essential that both therapist and client determine that short-term work is appropriate and that beneficial outcomes are likely.

Application to Group Counseling An existential group can be described as people making a commitment to a lifelong journey of self-exploration with these goals: (1) enabling members to become hon- est with themselves, (2) widening their perspectives on themselves and the world around them, and (3) clarifying what gives meaning to their present and future life (Deurzen, 2002). An open attitude toward life is essential, as is the willingness to explore unknown territory. Recurring universal themes evolve in many groups, challenging members to seriously explore existential concerns such as the ability to choose a path in life, freedom and anxiety, how to live a meaningful life in the face of the reality of death, and how to establish authentic and mutual relation- ships (Leszcz, 2015). The heart of the work in an existential group is overcoming avoidance of universal existential concerns because not addressing these themes diminishes one’s engagement with life. The group leader is generally more of a participant-observer who engages as an informed fellow traveler rather than as an aloof sage. Leszcz (2015) notes that the leader engages in appropriate self-disclosure and transparency, gives feedback, and shares personal reactions within the group. Leader disclosures center on the members’ interests rather than on the leader’s needs or interests.

The existential group provides the optimal conditions for therapeutic work on responsibility. The members are responsible for the way they behave in the group, and this provides a mirror for how they are likely to act in the world. A group rep- resents a microcosm of the world in which participants live and function. A group can be instrumental in helping members see how some of the self-constricting pat- terns they manifest in the group parallel patterns in their everyday life. Over time the interpersonal and existential problems of the participants become evident in the here-and-now interactions within the group (Yalom & Josselson, 2019). Through feedback, members learn to view themselves through others’ eyes, and they learn the ways in which their behavior affects others. Building on what members learn about their interpersonal functioning in the group, they can take increased responsibility for making changes in everyday life. The group experience provides opportunities to relate to others in meaningful ways, to learn to be themselves in the company of other people, and to establish rewarding, nourishing relationships.

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In existential group counseling, members come to terms with the paradoxes of existence: that life can be undone by death, that success is precarious, that we are determined to be free, that we are responsible for a world we did not choose, and that we must make choices in the face of doubt and uncertainty. Members experience anxiety when they recognize the realities of the human condition, including pain and suffering, the need to struggle for survival, and their basic fallibility. Clients learn that there are no ultimate answers for ultimate concerns. Through the support that is within a group, participants are able to tap the strength needed to create an internally derived value system that is consistent with their way of being.

A group provides a powerful context to look at oneself and to consider what choices might be more authentically one’s own. Members can openly share their fears related to living in unfulfilling ways and come to recognize how they have com- promised their integrity. Members can gradually discover ways in which they have lost their direction and can begin to be truer to themselves. The group becomes a place where people can be together in deeply meaningful ways. Members learn that it is not in others that they find the answers to questions about significance and purpose in life. Existential group leaders help members live in authentic ways and refrain from prescribing simple solutions. For a more detailed discussion of the exis- tential approach to group counseling, see Corey (2023, chap. 9).

Applications of Existential Approach to School Counseling

This section was provided by Sheri Bauman, PhD, a former school counselor and a professor emerita of counseling at the University of Arizona. Her research focuses on bullying and cyberbullying.

At first glance, existential theory may seem too philosophical, especially for use with children and adolescents. School counselors need proven techniques rather than abstract ideas to be able to help students. A closer look, however, reveals that existential theory is relevant for school counselors because it can increase students’ self-awareness and address developmental concerns common to the human condition. I urge school counselors not to shy away from broaching these vital topics with students.

Existential theorists stress the importance of the counselor–client relationship, and this is key for school counselors. Students need to perceive the counselor as warm, trustworthy, genuinely interested in them, and reliable. As a school counselor, I tried to get to know as many students as possible. When they came to me for coun- seling, we had already established a relationship, even if casually. I made a point of being noticeable and approachable wherever students gathered—the lunchroom, the school grounds, the hallways, and classrooms. Occasionally I even played basketball (badly) with a group of boys during lunch. I know this visibility helped students see me as someone familiar whom they might approach if they had a problem to solve.

The existential focus on the four “givens” of the human condition—awareness of death, freedom and responsibility, meaning in life, and aloneness—are topics as important for children and adolescents as they are for adults. Many adults, includ- ing school counselors, seem to be afraid to talk about these topics, either because they believe the child cannot understand them or that talking about these matters

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will cause distress. I believe that not talking about these topics contributes to gener- alized (or existential) anxiety.

Death is not something from which children can be protected. Even young children may experience the death of a pet, grandparent, parent, even a classmate, and adults can help them process these events. Sometimes children think they shouldn’t talk about death because adults in their lives avoid it, which leads to more confusion and anxiety in the child. When a classmate died, a younger child ask me, “Am I going to die too?” and adolescents struggled to acknowledge their own mortality. Within an authentic counseling relationship, it is critical to ask students how they are handling the loss and to respond to questions honestly and age-appropriately. School counselors can assist individual students and offer grief groups when needed.

Existential theory recognizes that people are free to make choices in life, from trivial to important. For adolescents, who often resist authority and reject the status quo, the notion that they have freedom to choose is appealing. Even when decisions are made by others, students can learn that they have a choice in how to think about the situation. In addition, the freedom to make choices comes with responsibility for the consequences, so it is helpful for students to anticipate possible outcomes and accept responsibility for their choices. School counselors discuss important and minor student choices with this in mind.

Adolescents are in the process of developing an identity, which includes finding purpose or meaning in their life. The career exploration and counseling provided by school counselors entails more than finding a job. School counselors introduce possibilities and support students’ quest for what to do and who to be. This is con- sistent with existential theory.

Finally, existential theory recognizes that although we are ultimately alone we also have a need to be in relationship with others. The drive for connection motivates much of the behavior of young people. School counselors recognize the importance of belonging and relationships and help students navigate the challenges they encounter with others in their lives. Encouraging students to spend time alone and appreciate their own company is worthwhile; however, I confess that I was not very successful in this endeavor. Solitude is frightening for many students; their phones and friends are central to their world. I hope I planted a seed that will prove helpful in time and that you can see how existential theory is relevant in the work of the school counselor.

An Expert’s Perspective on Existential Therapy In this section, Emmy van Deurzen, PhD, provides answers to a series of ques- tions about existential therapy. She has written more than a dozen books on existential therapy and is a world authority on this approach. She established exis- tential psychotherapy in the United Kingdom by founding the Society for Existen- tial Analysis, the School at Regent’s College and the New School of Psychotherapy and Counselling, which she directs, as well as having a private practice.

1. What is the most important contribution of the existential approach for the practice of individual therapy?

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The philosophical emphasis of existential therapy is its greatest strength and its greatest contribution to individual therapy. In working with people existentially, we assist them to ask the big questions that free them from their daily problems by getting a broader perspective and greater clarity. We look at the ways in which clients’ cultural, social, political, and ideo- logical contexts affect them. This approach helps clients get back in touch with what matters most to them and what they feel passionately about, so that they become inspired to take new action and fully engage with life.

2. What two or three key concepts of existential psychotherapy are especially applicable to the practice of individual counseling or therapy?

Anxiety. Angst, or existential anxiety, was likened by Kierkegaard to a dizziness of freedom. He thought that experiencing angst was the sine qua non of assuming responsibility for your life. Anxiety is the basic ingre- dient of vitality. It provides the energy we need to tackle challenges. Learning to be anxious in the right way—not too much nor too little—is the key to living a reflective, meaningful life.

Freedom. Discovering that we are ultimately free to change things in our lives and that we can start anew or make a difference in the world goes hand in hand with assuming responsibility for what we make of our lives. Freedom and responsibility are always set within the limits of human existence. We have to learn about our own limitations as well as about our possibilities.

Values and meaning. In deciding how to make changes in the way we live, we become aware of the values that guide us. Values are paradoxi- cal: we can only appreciate life when confronting our mortality or truly appreciate love when we have contended with loss. Many people avoid the negatives, and it becomes difficult for them to detect values or find life meaningful. This is not a form of pathology but part of the dis- covery of what life is all about. Suffering is one way in which we learn about meaning. Creativity and enjoyment are other ways of finding meaning.

3. What two or three techniques from the existential approach have practical value for practitioners of individual therapy? Existential therapists use phenomenological methods. One aspect of this is the discipline of staying with description rather than jumping to interpretation or explanation. The emphasis is on what things mean to the client rather than on interpretations based on attributions derived from theory.

Similarly, existential therapy focuses on the biases of individuals, which are rooted in their worldview and colors all of their experience. Existential therapists have specific ways of eliciting, clarifying, and challenging people’s assumptions, values, and beliefs.

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Existential work makes explicit what was previously implicit and unsaid. It looks at everything in its wider context and explores subtext in depth. In doing so, it often discovers paradoxes, conflicts, and dilemmas that have to be recognized for their contradictions and tensions before they can be overcome and transcended in a dialectical manner. This is accom- plished within the context of a collaborative therapeutic relationship, which is conducted through dialogue. Dialogue is a way for two or more people to look at issues carefully from different angles.

4. How does existential therapy address diversity, multicultural, and social justice issues for the practice of individual counseling? Because of its philosophical nature, existential work questions cultural assumptions and is committed to making sense of the human condition with an open attitude of wonder. There are many different ways of doing existential therapy, and in different parts of the world the method has been applied in combination with different ideologies. The creativity of the ther- apist in adjusting the work to the local conditions, and indeed to each new client, is paramount.

5. In what ways can the existential approach be applied to brief therapy (or time-limited counseling)? Existential philosophy is highly aware of the importance of space and time. It accepts that death and the end of life are as important as our beginnings and that everything is relative and inexorably limited and changeable. Limits help us to make the most of the time that is avail- able, and in many ways all forms of brief therapy introduce an existential element by using the urgency that the limited availability of time cre- ates. The time frame of brief existential therapy can therefore be used to good advantage in helping people think seriously about how they want to take charge of their life.

6. From your perspective, what is the current status and the future of existential psychotherapy? Philosophy was created several millennia ago as a way to harness human wisdom and develop better ways of understanding and living our lives. In this sense, existential therapy has been around for a very long time. As a contemporary therapy, it has a history of close to a hundred years, but it remained a highly specialized approach until the end of the 20th century. Existential therapists have jealously guarded their very personal way of working, and they have long resisted formulations of existential techniques or skills, preferring to remain spontaneous and flexible. In recent decades, existential therapy has become more well-known and written about. It has rapidly gained respect as people have become tired of formulaic methods and have found the philosophical freedom of existential work refreshing. Existential therapy is becoming increas- ingly popular across the world. The First World Congress for Existential Therapy, bringing together therapists from all continents, took place in London in 2015.

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Discussion Questions Related to Dr. Deurzen’s Existential Perspective 1. What key concepts of this approach do you find the most personally

relevant? 2. Dr. Deurzen stated that “learning to be anxious in the right way—not

too much nor too little—is the key to living a reflective, meaningful life.” Do you think understanding anxiety in this way can help your work with clients?

3. What is your reaction to the statement that we can only appreciate life when we are confronted with our mortality?

Existential Therapy From a Multicultural Perspective Strengths From a Diversity Perspective

Because the existential approach does not dictate a particular way of viewing or relating to reality, and because of its broad perspective, this approach is highly relevant in working in a multicultural context (Deurzen, 2012). Vontress and colleagues (1999) write about the existential foundation of cross-cultural coun- seling: “Existential counseling is probably the most useful approach to helping clients of all cultures find meaning and harmony in their lives, because it focuses on the sober issues each of us must inevitably face: love, anxiety, suffering, and death” (p. 32). These are the human experiences that transcend the boundaries that separate cultures.

Existential therapy emphasizes presence, the I/Thou relationship, and courage. As such, it can be effectively applied with diverse client populations with a range of specific problems and in a wide array of settings (Schneider, 2008, 2011; Schneider & Krug, 2017, 2020). Schneider’s (2008) “existential-integrative” model of practice coordinates a variety of therapeutic modes within an overarching existential or expe- riential framework. Vontress (2013) believes existential therapy is especially useful in working with culturally diverse populations because of its focus on universality, or the similarities we all share. He encourages counselors-in-training to focus on the universal commonalities of clients first and secondarily on areas of differences. In working with cultural diversity, it is essential to recognize how we are both alike and different.

The existential focus on subjective experience, or phenomenology, is a strength from a multicultural perspective. Another strength is the emphasis on shared deci- sion making in the counseling process. Client choices and preferences pertaining to their therapy are honored, and therapists strive to accommodate to client prefer- ences. There is recognition that clients are the experts when it comes to the values they choose to live by and are the experts in knowing how they want to fashion their existence. Therapists acknowledge the client as the expert, and they use their professional expertise to create a collaborative partnership with the client (Norcross & Cooper, 2021). Being able to drop assumptions about what you think you know about a client’s culture and be fully present is of the utmost importance. Counselor humility opens the door for communication with clients.

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There is wide-ranging international interest in the existential approach, and in several Scandinavian societies, an East European society (encompassing Estonia, Latvia, Lithuania, Russia, Ukraine, and Belarus), and Mexican and South American societies this therapy is thriving. In addition, an Internet course, SEPTIMUS, is taught in Ireland, Iceland, Sweden, Poland, Czech Republic, Romania, Italy, Portugal, Austria, France, Belgium, the United Kingdom, Israel, and Australia. The First Inter- national East-West Existential Psychology Conference was held in Nanjing, China, with representatives from the United States, Korea, and Japan. The International Collaborative of Existential Counsellors and Psychotherapists (ICECAP) meets online and hosts international conferences as well. The existential movement in the United Kingdom is thriving, and several doctoral programs are offered. These inter- national developments confirm that existential therapy has wide appeal for diverse populations in many parts of the world.

Shortcomings From a Diversity Perspective For those who hold a systemic perspective, the existentialists can be criticized on the grounds that they are excessively individualistic and ignore the social factors that cause human problems. However, with the advent of the “existential-integrative” model of practice (Schneider, 2008), this situation is beginning to change. Accord- ing to Schneider (2011), existential practitioners are not only concerned with facilitating individual change but with promoting an in-depth inquiry that has implications for social change: “One cannot simply heal individuals to the neglect of the social context within which they are thrust. To be a responsible practitioner, one must develop a vision of responsible social change alongside and in coordina- tion with one’s vision of individual transformation” (p. 281).

Some individuals who seek counseling may operate on the assumption that they have very little choice because environmental circumstances severely restrict their ability to influence the direction of their lives. Even if they change internally, they see little hope that the external realities of racism, discrimination, and oppres- sion will change. They are likely to experience a deep sense of frustration and feel- ings of powerlessness when it comes to making changes outside of themselves. As you will see in Chapter 12, feminist therapists maintain that therapeutic practice will be effective only to the extent that therapists intervene with some form of social action to change those factors that are creating clients’ problems. Existential ther- apists can incorporate practices of teaching clients a range of advocacy skills and assisting them in taking some steps toward actively coping with their life circum- stances. In working with people of color who come from challenging environments, it is important to explore the lived skills of resilience, tenacity, and ingenuity that have been developed as a result of being a part of their neighborhood. If a counselor too quickly puts across the message to these clients that they have a choice in mak- ing their lives better, they may feel patronized and misunderstood. Counselors can listen deeply to how clients overcame certain environmental issues and point these skills out to clients as a strength. Resiliency can provide a good focus for counseling when the therapist is willing to explore and lean into clients’ life stories with them.

Existential theory is highly focused on the philosophical assumption of self- determination, which may not take into account the complex factors that many

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people who have been oppressed must deal with. In many cultures, it is not possible to talk about the self and self-determination apart from the context of their social network and environmental conditions. However, a case can be made for the exis- tential approach being instrumental in enabling clients to make conscious choices when it comes to the values they live by. Existential therapists do not push auton- omy apart from a client’s culture. They do assist clients in critically evaluating the source of their values and making a choice rather than uncritically accepting the val- ues of their culture and family. Often creating a safe space for clients to share their journeys supports them in seeing themselves both within the family context and also as an individual. A colleague counseled a Hindu client who had been a vegetar- ian for 25 years because her parents were, and they explored how most of her lifestyle was modeled by that of her parents. This kept her from knowing what her personal values were. She began to think more critically about where else in her life she had left herself out of the equation.

Many clients expect a structured and problem-oriented approach to counseling that is not found in the conventional existential approach. Although clients may feel better if they have an opportunity to talk and to be understood, they are likely to expect the counselor to take some action to bring about a change in their life situ- ation. A major task for the counselor who practices from an existential perspective is to provide enough concrete direction for these clients without taking the respon- sibility away from them. Counselors would do well to expand the space for their clients to speak out and be heard.

Existential Therapy Applied to the Case of Stan As an existentially oriented therapist, I counsel Stan with the assumption that he has the capacity to in- crease his self-awareness and decide for himself the future direction of his life. I want him to realize more than anything else that he does not have to be the victim of his past conditioning but can be the archi- tect in redesigning his future. He can free himself of his deterministic shackles and accept the respon- sibility that comes with directing his own life. This approach emphasizes the importance of my under- standing of Stan’s world, primarily by establishing an authentic relationship as a means to a fuller degree of self-understanding.

Stan is demonstrating what Sartre would call “bad faith” by not accepting personal responsibility. I con- front Stan with the ways in which he is attempting to escape from his freedom through alcohol and drugs. Eventually, I challenge Stan’s passivity. I reaffirm that

he is now entirely responsible for his life, for his actions, and for his failure to take action. I do this in a support- ive yet firm manner.

I do not see Stan’s anxiety as something negative, but as a vital part of living with uncertainty and free- dom. Because there are no guarantees and because the individual is ultimately alone, Stan can expect to experience some degree of healthy anxiety, aloneness, guilt, and even despair. These conditions are not neu- rotic in themselves, but the way in which Stan orients himself and copes with these conditions is critical.

Stan sometimes talks about his suicidal feelings. Certainly, I investigate further to determine if he poses an immediate threat to himself. In addition to this as- sessment to determine lethality, I view his thoughts of “being better off dead” as symbolic. Could it be that Stan feels he is dying as a person? Is Stan using his hu- man potential? Is he choosing a way of merely existing

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instead of affirming life? Is Stan mainly trying to elicit sympathy from his family? I invite Stan to explore the meaning and purpose in his life. Is there any reason for him to want to continue living? What are some of the projects that enrich his life? What can he do to find a sense of purpose that will make him feel more signifi- cant and alive?

Stan needs to accept the reality that he may at times feel alone. Choosing for oneself and living from one’s own center accentuates the experience of aloneness. He is not, however, condemned to a life of isolation, alienation from others, and loneliness. I hope to help Stan discover his own centeredness and live by the values he chooses and creates for himself. By doing so, Stan can become a more substantial person and come to appreciate himself more. When he does, the chances are lessened that he will have a need to secure approv- al from others, particularly his parents and parental substitutes. Instead of forming a dependent relation- ship, Stan could choose to relate to others out of his strength. Only then would there be the possibility of overcoming his feelings of separateness and isolation.

Questions for Reflection ◆ If Stan resisted your attempts to help him see that

he is responsible for the direction of his life, how might you intervene?

◆ Stan experiences a great deal of anxiety. From an existential perspective, how do you view his anxiety? How might you work with his anxiety in helpful ways?

◆ If Stan talks with you about suicide as a response to despair and a life without meaning, how would you respond?

Refer to the MindTap for The Case of Stan Video Quiz for Chapter 6, Session 4 (existential ther- apy), for a demonstration of my approach to counseling Stan from this perspective. This ses- sion focuses on the themes of death and the meaning of life.

Existential Therapy Applied to the Case of Gwen* In working with Gwen from an existential approach, I want to be a witness to her subjective experience of the world and assist her in exploring powerful life themes such as meaning making, the inevitability of death, freedom, choice, and responsibility. It is impor- tant for me to hear and understand the concerns Gwen brings to this session. As Gwen walks into my office, I observe her rounded shoulders and feel the heaviness of her emotions.

Therapist: Tell me what you are experiencing [phenomenological inquiry].

Gwen: I feel overwhelmed, shut down, sad, and exhausted.

Therapist: The feelings you describe sound similar to your feelings when you first began counseling: numbness, feeling like your life is a flat note with little joy.

Gwen: Yes! I am tired of the violence. I am tired of young Black men that look like my son losing their lives. This has got to stop. Something has to change in our country, and I don’t mean

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

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on the surface. Something has really got to change.

Therapist: I hear you.

Gwen: I can’t even sleep at night. I am trying not to watch the news because young people dying seems like an everyday occurrence. It’s not fair. Life cut short by ignorance and injustice. When I haven’t heard from my children in a while, I get a hole in the pit of my stomach. I am just sick thinking I will lose my child.

I am focused on being present for Gwen as she grap- ples with these challenging existential themes in her life. I listen to Gwen’s personal stories of racism and injustice and her search for meaning. She describes her anxiety as being like a fog that is always there and that no one can do anything about. Her sense of helplessness and fear of death for her son is real. I as- sist Gwen in seeing that she has options in how she confronts experiences of injustice and unfairness as they occur in her life. As Gwen explores and expresses her anxieties and fears, she begins to realize she has the power and freedom to create meaning from the circumstances that arise in her life. Even those events and experiences that bring her pain can assist her in taking more control of her circumstances and living in a more vital manner.

Gwen: Worrying keeps me up much of the night. I end up feeling scared and depressed, and then I get into this whole spiral where everything feels wrong. Life is so fragile and can be cut short in a blink.

Therapist: It seems as though you have come to the realization that we are finite and that time is limited, and that’s frightening and anxiety producing.

Gwen: I feel helpless. I fear for my son’s life and feel like there is nothing I can do to protect him.

Therapist: With these intense feelings of helplessness, fear, and anxiety, how do you even get through your day?

Gwen: I have been through a lot and I have survived. Even though I have my fears, I surprise myself and bounce back eventually. At the end of the day, it’s my faith and the knowledge that I am making a dif- ference in the world by passing my faith on to my children that helps me move forward.

As an existential practitioner, I share with Gwen that anxiety is a natural part of life and that death aware- ness is a powerful force that can assist us in living a full- er existence. In our awareness of our own mortality, we can decide to take charge of our life and make choices that enhance our existence. Gwen begins to see that her experience of anxiety may be a key to informing her of exactly how she might begin to do things differ- ently in her life.

As our session comes to a close, I remind Gwen of the powerful themes that surfaced in her session and her ability to identify as a strong, spiritual, resilient woman. I support her decision to journal more of her thoughts and feelings about what gives meaning and joy to her life and how she can make a difference in these challenging times.

Questions for Reflection ◆ What existential question is Gwen facing in her life? ◆ How would you experience being in the room with

Gwen during this session? What may surface for you as you sit with her?

◆ How can awareness of the fragility of life be a cata- lyst for making decisions about how to live more fully? Have you ever lost someone close to you? What decisions did you make?

◆ Gwen has talked about her loneliness and isola- tion, which are part of the human condition. How do you think an existential approach can help Gwen deal with this issue?

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Summary and Evaluation Summary

Existential therapists believe we all are capable of self-awareness, which is the distinc- tive capacity that allows us to reflect and to decide. With this awareness we become free beings who are responsible for choosing the way we live, and we influence our own destiny. This awareness of freedom and responsibility gives rise to existential anxiety, which is another basic human characteristic. Whether we like it or not, we are free, even though we may seek to avoid reflecting on this freedom. The knowl- edge that we must choose, even though the outcome is not certain, leads to anxiety. This anxiety is heightened when we reflect on the reality that we are mortal. Facing the inevitable prospect of eventual death gives the present moment significance, for we become aware that we do not have forever to accomplish our projects. Humans are unique in their striving toward fashioning purposes and values that give mean- ing to living. Whatever meaning our life has is developed through freedom and a commitment to make choices in the face of uncertainty.

Existential therapy places central prominence on the person-to-person relation- ship. It assumes that client growth occurs through this genuine encounter. It is not the techniques a therapist uses that make a therapeutic difference; rather, it is the quality of the client–therapist relationship that heals (Elkins, 2016). It is essential that thera- pists reach sufficient depth and openness in their own lives to allow them to venture into their clients’ subjective world without losing their own sense of identity. Presence is both a condition for therapy to occur and a goal of therapy. Existential therapists strive to be authentic and self-disclosing in their therapy work. Because this approach focuses on the goals of therapy, basic conditions of being human, and therapy as a shared journey, practitioners are not bound by specific techniques. Although existen- tial therapists may apply techniques from other orientations, their interventions are guided by a philosophical framework about what it means to be human.

Contributions of the Existential Approach The existential approach has helped bring the person back into central focus. It concentrates on the central facts of human existence: self-consciousness and our consequent freedom. To the existentialist goes the credit for providing a new view of death as a positive force, not a morbid prospect to fear, for death gives life meaning. Existentialists have contributed a new dimension to the understanding of anxiety, guilt, loneliness, and alienation.

I particularly appreciate the way Deurzen (2012) views the existential practitioner as a mentor and fellow traveler who encourages people to reflect upon the problems they encounter in living. What clients need is “some assistance in surveying the terrain and in deciding on the right route so that they can again find their way” (p. 30). The existential approach encourages people to live life by their own standards and values.

One of the major contributions of the existential approach is its emphasis on the human quality of the therapeutic relationship. This aspect lessens the chances of dehumanizing psychotherapy by making it a mechanical process. Existential coun- selors reject the notions of therapeutic objectivity and professional distance, viewing them as being unhelpful.

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I very much value the existential emphasis on freedom and responsibility and our capacity to redesign our life by choosing with awareness. This perspective pro- vides a sound philosophical base on which to build a personal and unique therapeu- tic style because it addresses the core struggles of the contemporary person.

The existential themes explored in this chapter came into sharp focus early in 2020 with the arrival of the COVID-19 pandemic. An increasing number of people sought mental health services, feeling isolated from others, experiencing anxiety over becoming ill and being hospitalized, losing family members and friends, and even facing their own possible death. The pandemic brought to light the relation- ship between freedom and responsibility and of making choices with no guaranteed outcomes. Americans were faced with making choices about getting vaccinated or not, of wearing masks or not, of staying away from people, and of coping with high levels of stress as we remained isolated. We heard the refrain of many who opposed mandatory vaccination policies and the requirement of wearing masks because it restricted their freedom. Existential ideas of freedom and accepting the conse- quences of these choices were dramatically illustrated. As new variants appeared, fear of not being out of the woods continued and anxiety intensified. Clients need- ing the opportunity to talk about their fears and the choices facing them each day embraced the existential approach. For an in-depth treatment of the pandemic and its implications for the counseling profession, I recommend Counseling Practice During Phases of a Pandemic Virus (Stebnicki, 2021).

Contributions to the Integration of Psychotherapies From my perspective, the key concepts of the existential approach can be integrated into most therapeutic schools. Regardless of a therapist’s orientation, the foundation for practice can be based on existential themes (Corey, 2019). A key contribution is the possibility of a creative integration of the conceptual propositions of existential therapy with many other therapeutic orientations (Bugental & Bracke, 1992; Schneider, 2008, 2011; Schneider & Krug, 2017, 2020). One example of such a creative integration is provided by Dattilio (2002), who integrates cognitive behavioral techniques with the themes of an existential approach. As a cognitive behavior therapist and author, Dattilio maintains that he directs much of his efforts to “helping clients make a deep existential shift—to a new understanding of the world” (p. 75). He uses techniques such as restructuring of belief systems, relaxation methods, and a variety of cognitive and behavioral strategies, but he does so within an existential framework that can begin the process of real-life transformation. Many of his clients suffer from panic attacks or depression, and Dattilio often explores existential themes of meaning, guilt, hopelessness, and anxiety with them—and at the same time he provides them with cognitive behavioral tools to cope with the problems of daily living. In short, he grounds symptomatic treatment in an existential approach.

Some people have argued that the trend toward positive psychology is similar to the existential approach. It is true that existential therapy invites clients to recog- nize their strengths, to change their attitudes toward life events, and to realize their capacity for resilience. Although existential therapists favor intensity and passion- ate experience, including that of happiness, it is important to note that they equally value the darker side of human nature and would encourage clients to learn to value both sides of their experience (Deurzen, 2009).

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Limitations and Criticisms of the Existential Approach A major criticism often aimed at this approach is that it lacks a systematic state- ment of the principles and practices of psychotherapy. Some practitioners have trouble with what they perceive as its mystical language and concepts. Some thera- pists who claim adherence to an existential orientation describe their therapeutic style in vague and global terms such as self-actualization, dialogic encounter, authentic- ity, and being-in-the-world. This particular use of language causes confusion at times and makes it difficult to conduct research on the process or outcomes of existential therapy.

Both beginning and advanced practitioners who are not of a philosophical turn of mind tend to find many of the existential concepts lofty and elusive. As we have seen, this approach places primary emphasis on a subjective understanding of the world of clients. It is assumed that techniques follow understanding. The fact that few techniques are generated by this approach makes it essential for practitioners to develop their own innovative procedures or to borrow from other schools of therapy. For counselors who believe they need a specific set of techniques to counsel effec- tively, this approach has limitations (Vontress, 2013).

Practitioners who prefer a counseling practice based on research contend that concepts should be empirically sound, that definitions should be operational, that hypotheses should be testable, and that therapeutic practice should be based on the results of research into both the process and outcomes of counseling. Certainly, the notions of manualized therapy and evidence-based practice are not part of the existential perspective because every psychotherapy experience is unique (Walsh & McElwain, 2002). According to Cooper (2017), existential practitioners reject the idea that the therapeutic process can be measured and evaluated in quantitative and empirical ways. Although existential practices are generally upheld in research on therapeutic effectiveness (see Elkins, 2009), few studies directly evaluate and exam- ine the existential approach.

According to Deurzen (2002), the main limitation of this approach is that of the level of maturity, life experience, and intensive training required of practitioners. Existential therapists need to be wise and capable of profound and wide-ranging understanding of what it means to be human. Authenticity is a cardinal character- istic of a competent existential practitioner, which is certainly more involved than mastering a body of knowledge and acquiring technical skills. Russell (2007) puts this notion nicely: “Authenticity means being able to sign your own name on your work and your life. It means you will want to take responsibility for creating your own way of being a therapist” (p. 123).

Self-Reflection and Discussion Questions 1. Identify at least one turning point in your life. What decision did you

make at this time, and how has this influenced the person you are today?

2. What does existential anxiety mean to you? How do you deal with this kind of anxiety in your life?

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3. Existential therapy provides a philosophy and a framework for psycho- therapy, but few techniques. How can you have an existential orienta- tion and at the same time incorporate techniques from other therapy models?

4. Existential themes have relevance for working with a range of clients with a variety of problems in various settings. What one existential theme do you believe is a key issue for many people today?

5. How would you work with a client who has little interest in exploring existential themes and asks for advice on how to deal with some con- crete problem?

Where to Go From Here Free Podcasts for ACA Members

You can download ACA Podcasts (prerecorded interviews) at www.counseling.org; click on the Resource button and then the Podcast Series. For Chapter 6, Existential Therapy, look for Podcast 14 by Dr. Gerald Corey.

Other Resources The American Psychological Association offers a DVD by K. J. Schneider (2009) titled Existential-Humanistic Therapy in their Systems of Psychotherapy Video Series.

Psychotherapy.net is a comprehensive resource for students and profession- als that offers videos and interviews on existential therapy featuring Irvin Yalom, James Bugental, and Rollo May. New video and editorial content is made available monthly. DVDs relevant to this chapter are available at www.psychotherapy.net and include the following:

Bugental, J. F. T. (1995). Existential-Humanistic Psychotherapy in Action

Bugental, J. (1997). Existential-Humanistic Psychotherapy (Psychotherapy with the Experts Series)

Bugental, J. (2008). James Bugental: Live Case Consultation

May, R. (2007). Rollo May on Existential Psychotherapy

Yalom, I. (2002). The Gift of Therapy: A Conversation with Irvin Yalom, MD

Yalom, I. (2006). Irvin Yalom: Live Case Consultation

Yalom, I. (2011). Confronting Death and Other Existential Issues in Psychotherapy

If you are interested in further information on Irvin Yalom, check out his website (www.yalom.com).

The Existential-Humanistic Institute’s (EHI) primary focus is training; the institute offers courses and, in conjunction with Saybrook University, a new

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certificate program in existential-humanistic therapy and theory. A second- ary focus is community building. EHI was formed as a nonprofit organization under the auspices of the Pacific Institute in 1997 and provides a home for those mental health professionals, scholars, and students who seek in-depth training in existential-humanistic theory and practice. EHI’s year-long certificate program offers graduate and postgraduate students an opportunity to gain a basic foun- dation in the theory and practice of existential-humanistic therapy. EHI offers courses on the principles of existential-humanistic practice and case seminars in existential-humanistic theory and practice. Most of EHI’s instructors have stud- ied extensively with such masters as James Bugental, Irvin Yalom, and Rollo May, and are, like Kirk Schneider and Orah Krug, acknowledged leaders of the exis- tential-humanistic movement today. For more information, go to the Existential- Humanistic Institute (www.ehinstitute.org).

The Society for Existential Analysis is a professional organization devoted to exploring issues pertaining to an existential/phenomenological approach to counseling and therapy. Membership is open to anyone interested in this approach and includes students, trainees, psychotherapists, philosophers, psy- chiatrists, counselors, and psychologists. Members receive a regular newsletter and an annual copy of the Journal of the Society for Existential Analysis. The soci- ety provides a list of existentially oriented psychotherapists for referral purposes. The School of Psychotherapy and Counselling at Regent’s University in London offers an advanced diploma in existential psychotherapy as well as short courses in the field. Additional Information is available at www.dilemmas.org. For more information, go to the Society for Existential Analysis (www.existentialanalysis .co.uk/).

The International Society for Existential Psychotherapy and Counselling was created in London in July 2006 and was renamed International Collaborative of Existential Counselors and Psychotherapists soon after (www.icecap.org.uk). It brings together the existing national societies as well as providing a forum for the development and accreditation of the approach. For more information, go to the International Society for Existential Psychotherapy and Counselling (www.existen- tialpsychotherapy.net).

SEPTIMUS is an Internet-based course taught in Ireland, Iceland, Sweden, Poland, Czech Republic, Romania, Italy, Portugal, Austria, Belgium, France, Israel, Australia, and the United Kingdom. Additional Information is available at www .psychotherapytraining.net and at the Psychotherapy Training on the Net: SEPTI- MUS (www.septimus.info).

The New School of Psychotherapy and Counselling (NSPC) now offers two doc- toral programs: one in existential psychotherapy and one in existential counselling psychology. NSPC offers intensive courses for distance learners (worldwide student body) including e-learning. For more information, go to the New School of Psycho- therapy and Counselling (www.nspc.org.uk).

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Recommended Supplementary Readings for Chapter 6 Everyday Mysteries: A Handbook of Existential Psycho- therapy (Deurzen, 2010) provides a framework for practicing counseling from an existential perspec- tive. The author puts into clear perspective topics such as anxiety, authentic living, clarifying one’s worldview, determining values, discovering mean- ing, and coming to terms with life.

Existential Counselling and Psychotherapy in Practice (Deurzen, 2012) offers an excellent presentation of the theory and practice of existential therapy based on the European tradition. The author provides a framework for addressing problems in living rather than techniques for working with clients.

Skills in Existential Counselling and Psychotherapy (Deurzen & Adams, 2011) is a clearly written book that explains the existential attitude, highlights the importance of the person of the therapist, and describes the process of existential therapy. This is a superb resource that provides a basis for under- standing how to apply existential notions to thera- peutic practice.

Existential Therapies (Cooper, 2017) provides a useful and clear introduction to the existential

therapies. There are separate chapters on logo- therapy, the British school of existential analysis, the American existential-humanistic approach, dimensions of existential therapeutic practice, and brief existential therapies.

Existential Psychotherapy (Yalom, 1980) is a superb treatment of the ultimate human concerns of death, freedom, isolation, and meaninglessness as these issues relate to therapy. This book has depth and clarity, and it is rich with clinical examples that illus- trate existential themes.

Existential-Humanistic Therapy (Schneider & Krug, 2017) is a clear presentation of the theory and practice of existential-humanistic therapy. This approach incorporates techniques from other con- temporary therapeutic approaches.

I Never Knew I Had a Choice (Corey et al., 2018) is a self-help book written from an existential per- spective. Topics include our struggle to achieve autonomy; the meaning of loneliness, death, and loss; and how we choose our values and philoso- phy of life.

References Alcee, M. (2022). Therapeutic improvisation: How to stop winging it and own it as a therapist. Norton. Binswanger, L. (1975). Being-in-the-world: Selected papers of Ludwig Binswanger. Souvenir Press. Boss, M. (1963). Daseinanalysis and psychoanalysis. Basic Books. Buber, M. (1970). I and thou (W. Kaufmann, Trans.). Scribner’s. Bugental, J. F. T. (1987). The art of the psychotherapist. Norton. Bugental, J. F. T. (1997). There is a fundamental division in how psychotherapy is conceived. In J. K. Zeig (Ed.), The evolution of psychotherapy: The third conference (pp. 185–196). Brunner/Mazel. Bugental, J. F. T. (1999). Psychotherapy isn’t what you think: Bringing the psychotherapeutic engagement into the living moment. Zeig, Tucker.

Bugental, J. F. T., & Bracke, P. E. (1992). The future of existential-humanistic psychotherapy. Psychotherapy, 29(1), 28–33. Cooper, M. (2017). Existential therapies (2nd ed.). SAGE. Corey, G. (2013). Case approach to counseling and psychotherapy (8th ed.). Brooks/Cole, Cengage Learning. Corey, G. (2019). The art of integrative counseling (4th ed.). American Counseling Association. Corey, G. (2023). Theory and practice of group counseling (10th ed.). Cengage Learning. Corey, G., Corey, M., & Muratori, M. (2018). I never knew I had a choice (11th ed.). Cengage Learning. Craig, M., Vos, J., Cooper, M., & Correia, E. A. (2016). Existential psychotherapies. In D. J. Cain, K. Keenan, & S. Rubin (Eds.), Humanistic psychotherapies: Handbook of

research and practice (2nd ed., pp. 283–317). American Psychological Association. Dattilio, F. M. (2002, January–February). Cognitive-behaviorism comes of age: Grounding symptomatic treatment in an existential approach. The Psychotherapy Networker, 26(1), 75–78. Deurzen, E. van. (2002). Existential therapy. In W. Dryden (Ed.), Handbook of individual therapy (4th ed., pp. 179–208). SAGE. Deurzen, E. van. (2009). Psychotherapy and the quest for happiness. SAGE. Deurzen, E. van. (2010). Everyday mysteries: A handbook of existential psychotherapy (2nd ed.). Routledge. Deurzen, E. van. (2012). Existential counselling and psychotherapy in practice (3rd ed.). SAGE. Deurzen, E. van. (2014). Becoming an existential therapist. Existential Analysis:

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Journal of the Society for Existential Analysis, 25(1), 6–16. Deurzen, E. van, & Adams, M. (2011). Skills in existential counselling and psychotherapy. SAGE. Elkins, D. N. (2007). Empirically supported treatments: The deconstruction of a myth. Journal of Humanistic Psychology, 47, 474–500. Elkins, D. N. (2009). Humanistic psychology: A clinical manifesto. University of the Rockies Press. Elkins, D. N. (2016). The human elements of psychotherapy: A nonmedical model of emotional healing. American Psychological Association. Farha, B. (1994). Ontological awareness: An existential/cosmological epistemology. The Person-Centered Periodical, 1(1), 15–29. Frank, M. L. B. (2022). Existential therapy. In D. Capuzzi & M. D. Stauffer (Eds.), Counseling and psychotherapy: Theories and interventions. (7th ed., pp. 117–138). American Counseling Association. Frankl, V. (1963). Man’s search for meaning. Beacon. Frankl, V. (1978). The unheard cry for meaning. Simon & Schuster, Touchstone. Gould, W. B. (1993). Viktor E. Frankl: Life with meaning. Brooks/Cole. Heidegger, M. (1962). Being and time. Harper & Row. Hill, C. E. (2018). Meaning in life: A therapist’s guide. American Psychological Association. Leszcz, M. (2015). Existential group psychotherapy. In E. Neukrug (Ed.), SAGE encyclopedia of theory in counseling and psychotherapy (vol. 1, pp. 365–368). SAGE. May, R. (1950). The meaning of anxiety. Ronald Press. May, R. (1958). The origins and significance of the existential movement in psychology. In R. May, E. Angel, & H. R. Ellenberger (Eds.), Existence: A new dimension in psychiatry and psychology. Basic Books.

May, R. (1975). The courage to create. Norton. May, R. (1981). Freedom and destiny. Norton. Norcross, J. C., & Cooper, M. (2021). Personalizing psychotherapy: Assessing and accommodating patient preferences. American Psychological Association. Rubin, S., & Lichtanski, K. (2015). Existential therapy. In E. Neukrug (Ed.), SAGE encyclopedia of theory in counseling and psychotherapy (vol. 1, pp. 368–373). SAGE. Russell, J. M. (1978). Sartre, therapy, and expanding the concept of responsibility. American Journal of Psychoanalysis, 38, 259–269. Russell, J. M. (2007). Existential psychotherapy. In A. B. Rochlen (Ed.), Applying counseling theories: An online case- based approach (pp. 107–125). Pearson Prentice-Hall. Sartre, J. P. (1971). Being and nothingness. Bantam Books. Schneider, K. J. (Ed.). (2008). Existential- integrative psychotherapy: Guideposts to the core of practice. Routledge. Schneider, K. J. (2011). Existential- humanistic psychotherapies. In S. B. Messer & A. S. Gurman, (Eds.), Essential psychotherapies: Theory and practice (3rd ed., pp. 261–294). Guilford Press. Schneider, K. J., & Krug, O. T. (2017). Existential-humanistic therapy (2nd ed.) American Psychological Association. Schneider, K. J., & Krug, O. T. (2020). Existential-humanistic psychotherapies. In S. B. Messer & N. J. Kaslow (Eds.), Essential psychotherapies: Theory and practice (4th ed., pp. 257–293). Guilford Press. Sharp, J. G., & Bugental, J. F. T. (2001). Existential-humanistic psychotherapy. In R. J. Corsini (Ed.), Handbook of innovative therapies (2nd ed., pp. 206–217). Wiley. Stebnicki, M. A. (2021). Counseling practice during phases of a pandemic virus. American Counseling Association. Tillich, P. (1952). The courage to be. Yale University Press.

Vontress, C. E. (2013). Existential therapy. In J. Frew & M. D. Spiegler (Eds.), Contemporary psychotherapies for a diverse world (pp. 131–164). Routledge, Taylor & Francis. Vontress, C. E., Johnson, J. A., & Epp, L. R. (1999). Cross-cultural counseling: A casebook. American Counseling Association. Walsh, R. A., & McElwain, B. (2002). Existential psychotherapies. In D. J. Cain & J. Seeman (Eds.), Humanistic psychotherapies: Handbook of research and practice (pp. 253–278). American Psychological Association. Yalom, I. D. (1980). Existential psychotherapy. Basic Books. Yalom, I. D. (1987). Love’s executioner: And other tales of psychotherapy. Harper Perennial. Yalom, I. D. (1992). When Nietzche wept. Basic Books. Yalom, I. D. (1997). Lying on the couch: A novel. Harper Perennial. Yalom, I. D. (2000). Momma and the meaning of life: Tales of psychotherapy. Harper Perennial. Yalom, I. D. (2003). The gift of therapy: An open letter to a new generation of therapists and their patients. HarperCollins, Perennial. Yalom, I. D. (2005). The Schopenhauer cure: A novel. HarperCollins. Yalom, I. D. (2008). Staring at the sun: Overcoming the terror of death. Jossey-Bass. Yalom, I. D., & Josselson, R. (2019). Existential psychotherapy. In D. Wedding & R. Corsini (Eds.), Current psychotherapies (11th ed., pp. 273–308). Cengage Learning. Yalom, I. D., & Leszcz, M. (2020). The theory and practice of group psychotherapy (6th ed.). Basic Books. (Original work published 1970) Yalom, I. D., & Yalom, M. (2021). A matter of death and life. Redwood Press.

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7 Person-Centered Therapy

1. Examine the evolution of person- centered therapy over time.

2. Describe the main thrust of emotion-focused therapy.

3. Differentiate the contributions of Carl Rogers and Abraham Maslow to humanistic psychology.

4. Explain the role of the therapist’s attitudes in the therapy process.

5. Describe the ways that empathy, unconditional positive regard, and genuineness are fundamental to the process and outcome of therapy.

6. Identify the personal characteristics of therapists that are essential for clients’ progress.

7. Examine the application of the person-centered approach to crisis intervention.

8. Discuss the application of the person-centered approach for group counseling.

9. Discuss the application of the person-centered approach for school counseling.

10. Describe the unique characteristics of person- centered expressive arts and how it is based on person-centered philosophy.

11. Explain the contributions and shortcomings of the person-centered approach to understanding and working with clients from diverse cultures.

12. Identify the contributions and limitations of the person-centered approach.

Learning Objectives

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Carl Rogers (1902–1987), a major spokesperson for hu- manistic psychology, led a life that reflected the ideas he developed for half a cen- tury. He showed a question- ing stance, a deep openness to change, and the courage to forge into unknown ter- ritory both as a person and as a professional. In writing

about his early years, Rogers (1961) recalled his fam- ily atmosphere as characterized by close and warm relationships but also by strict religious standards. Play was discouraged, and the virtues of the Protes- tant ethic were extolled. His boyhood was somewhat lonely, and he pursued scholarly interests instead of social ones. Rogers was an introverted person, and he spent a lot of time reading and engaging in imagina- tive activity and reflection. During his college years his interests and academic major changed from agri- culture to history, then to religion, and finally to clini- cal psychology.

Rogers held academic positions in various fields, including education, social work, counseling, psycho- therapy, group therapy, peace, and interpersonal rela- tions, and he earned recognition around the world for originating and developing the humanistic movement in psychotherapy. His foundational ideas, especially the central role of the client–therapist relationship as a means to growth and change, have been incorporated in many other theoretical approaches. Rogers’s ideas

continue to have far-reaching effects on the field of psychotherapy (Cain, 2010).

It is difficult to overestimate the significance of Rogers’s contributions to clinical and counseling psychology. He was a courageous pioneer who “was about 50 years ahead of his time and has been waiting for us to catch up” (Elkins, 2009, p. 20). Often called the “father of psychotherapy research,” Rogers was the first to study the counseling process in depth by analyzing the transcripts of actual therapy sessions, and he was the first clinician to conduct major studies on psychotherapy using quantitative methods. He was the first to formulate a comprehensive theory of personality and psychother- apy grounded in empirical research, and he contributed to developing a theory of psychotherapy that focused on the strengths and resources of individuals. He was not afraid to take a strong position and challenged the status quo throughout his professional career.

During the last 15 years of his life, Rogers applied the person-centered approach to world peace by training policymakers, leaders, and groups in conflict. Perhaps his greatest passion was directed toward the reduction of interracial tensions and the effort to achieve world peace, for which he was nominated for the Nobel Peace Prize in 1987.

For a detailed video presentation of the life and works of Carl Rogers, see Carl Rogers: A Daughter’s Tribute (N. Rogers, 2002), which is described in the Other Resources section at the end of this chapter. For an in-depth look at this remarkable man and his work, see Carl Rogers: The Quiet Revolutionary (Rogers & Russell, 2002) and The Life and Work of Carl Rogers (Kirschenbaum, 2009).

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Natalie Rogers (1928–2015) was a pioneer in expressive arts therapy. Building on her father’s work, she devel- oped a multimodal, person- centered expressive arts process that she named the “Creative Connection.” Per- son-centered expressive arts therapy employs a variety of

forms—movement, painting, sculpting, music, writing, and improvisation—in a supportive setting to facilitate growth and healing. It extends person-centered theory by helping individuals access their feelings through creative expressions. As N. Rogers developed the con- cept of the Creative Connection, she invited the client or group member to try to access inner feelings through an uninterrupted sequence of movement, sound, vi- sual art, and journal writing. As clients move through this process, hidden or unconscious aspects of self are Natalie Rogers

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discovered, and clients share their insights with the therapist.

N. Rogers’s work evolved from what she felt was lacking in her father’s theory. As a woman growing up in an era when females were meant to be accom- modating to men, she eventually discovered her un- derlying anger at being a second-class citizen. Her art was one vehicle to express and gain insight into this injustice. She also expressed her anger at her father because he was unknowingly a part of the patriarchal system. He was surprised but open to learning. After

hearing about the role he and other men played in holding women back, he changed many of his ways of being and writing.

N. Rogers facilitated groups and workshops, trained therapists, and lectured in the United States, England, Hong Kong, Latin America, Russia, and South Korea un- til her death in 2015. She was an adjunct professor at the California Institute of Integral Studies and the In- stitute for Imaginal Studies. Natalie Rogers’s main goal was to facilitate individual and planetary healing by in- corporating the expressive arts in cross-cultural work.

Introduction Of all the pioneers who have founded a therapeutic approach, for me Carl Rogers stands out as one of the most influential figures in revolutionizing the direction of counseling theory and practice. Rogers has become known as a “quiet revolution- ary” who both contributed to theory development and whose influence continues to shape counseling practice today (see Cain, 2010; Kirschenbaum, 2009; Rogers & Russell, 2002).

The person-centered approach shares many concepts and values with the exis- tential perspective presented in Chapter 6. Rogers’s basic assumptions are that peo- ple are essentially trustworthy, that they have a vast potential for understanding themselves and resolving their own problems without direct intervention on the therapist’s part, and that they are capable of self-directed growth if they are involved in a specific kind of therapeutic relationship. From the beginning, Rogers empha- sized the attitudes and personal characteristics of the therapist and the quality of the client–therapist relationship as the prime determinants of the outcome of the thera- peutic process. He consistently relegated to a secondary position matters such as the therapist’s knowledge of theory and techniques. This belief in the client’s capacity for self-healing is in contrast with many theories that view the therapist’s techniques as the most powerful agents that lead to change (Bohart & Tallman, 2010). Clearly, Rogers revolutionized the field of psychotherapy by proposing a theory that cen- tered on the client as the primary agent for constructive self-change (Elkins, 2016).

Contemporary person-centered therapy is the result of an evolutionary process that continues to remain open to change and refinement (see Cain, 2010; Cain et al., 2016). Rogers did not present the person-centered theory as a fixed and completed approach to therapy. He hoped that others would view his theory as a set of tenta- tive principles relating to how the therapy process develops, not as dogma. Rogers expected his model to evolve and was open and receptive to change.

Refer to the MindTap for this book to interact with video quizzes and various video programs to expand your knowledge on topics relevant to Chapter 7.

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Four Periods of Development of the Approach In tracing the major turning points in Rogers’s approach, Zimring and Raskin (1992) and Bozarth, Zimring, and Tausch (2002) have identified four periods of develop- ment. In the first period, during the 1940s, Rogers developed what was known as nondirective counseling, which provided a powerful and revolutionary alternative to the directive and interpretive approaches to therapy then being practiced. While he was a professor at Ohio State University, Rogers (1942) published Counseling and Psychotherapy: Newer Concepts in Practice, which described the philosophy and practice of nondirective counseling. Rogers’s theory emphasized the counselor’s creation of a permissive and nondirective climate. When he challenged the basic assumption that “the counselor knows best,” he realized this radical idea would affect the power dynamics and politics of the counseling profession, and indeed it caused a great furor (Elkins, 2009, 2016).

Rogers also challenged the validity of commonly accepted therapeutic proce- dures such as advice, suggestion, direction, persuasion, teaching, diagnosis, and interpretation. Based on his conviction that diagnostic concepts and procedures were inadequate, prejudicial, and often misused, Rogers omitted them from his approach. Nondirective counselors avoided sharing a great deal about themselves with clients and instead focused mainly on reflecting and clarifying the clients’ ver- bal communications and intended meanings.

In the second period, during the 1950s, Rogers (1951) renamed his approach client-centered therapy, which reflected his emphasis on the client rather than on non- directive methods. In addition, he started the Counseling Center at the University of Chicago. This period was characterized by a shift from clarification of feelings to a focus on the phenomenological world of the client. Rogers assumed that the best vantage point for understanding how people behave was from their own internal frame of reference. He focused more explicitly on the actualizing tendency as the basic motivational force that leads to client change.

The third period, which began in the late 1950s and extended into the 1970s, addressed the necessary and sufficient conditions of therapy. Rogers (1957) set forth a hypothesis that resulted in three decades of research. A significant publication was On Becoming a Person (Rogers, 1961), which addressed the nature of “becoming the self that one truly is,” an idea he borrowed from Kierkegaard. Rogers published this work during the time that he held joint appointments in the departments of psychology and psychiatry at the University of Wisconsin. In this book he described the process of “becoming one’s experience,” which is characterized by an openness to experience, a trust in one’s experience, an internal locus of evaluation, and the willingness to be in process. During the 1950s and 1960s, Rogers and his associates continued to test the underlying hypotheses of the client-centered approach by con- ducting extensive research on both the process and the outcomes of psychotherapy. He was interested in how people best progress in psychotherapy, and he studied the qualities of the client–therapist relationship as a catalyst leading to personality change.

Rogers and his associates at the University of Chicago conducted research to identify the ingredients in psychotherapy that account for therapeutic change. The client-centered approach emphasized the role of the therapist as a facilitator of

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growth and honored the inherent power of the client. Research findings consistently supported this approach, confirming that therapeutic change is due to personal and interpersonal factors rather than to specific techniques for curing specific disorders (Elkins, 2016). On the basis of this research, the approach was further refined and expanded (Rogers, 1961). For example, client-centered philosophy was applied to education and was called student-centered teaching (Rogers & Freiberg, 1994). The approach was also applied to encounter groups (Rogers, 1970).

The fourth phase, during the 1980s and the 1990s, was marked by considerable expansion to education, couples and families, industry, groups, conflict resolution, politics, and the search for world peace. Because of Rogers’s ever-widening scope of influence, including his interest in how people obtain, possess, share, or surren- der power and control over others and themselves, his theory became known as the person-centered approach. This shift in terms reflected the broadening application of the approach. Although the person-centered approach has been applied mainly to individual and group counseling, important areas of further application include education, family life, leadership and administration, organizational development, health care, cross-cultural and interracial activity, and international relations. Dur- ing the 1980s Rogers directed his efforts toward applying the person-centered approach to politics, especially to efforts related to the achievement of world peace.

In a comprehensive review of the research on person-centered therapy over a period of 60 years, Bozarth, Zimring, and Tausch (2002) concluded the following:

◆ In the earliest years of the approach, the client rather than the therapist determined the direction and goals of therapy, and the therapist’s role was to help the client clarify feelings. This style of nondirective therapy was associated with increased understanding, greater self-exploration, and improved self-concepts.

◆ Later a shift from clarification of feelings to a focus on the client’s lived experiences took place.

◆ As person-centered therapy developed further, research centered on the core conditions assumed to be both necessary and sufficient for successful therapy. The attitude of the therapist—an empathic under- standing of the client’s world and the ability to communicate a non- judgmental stance to the client—along with the therapist’s genuineness were found to be basic to a successful therapy outcome.

◆ The main source of successful psychotherapy is the client. The thera- pist’s attention to the client’s frame of reference fosters the client’s uti- lization of inner and outer resources.

Emotion-Focused Therapy Emotion-focused therapy (EFT) is an experiential approach to therapy that is empir- ically supported and research-informed (Goldman et al., 2021; Greenberg & Goldman, 2019). EFT emerged as a person-centered approach informed by understanding the role of emotion in human functioning and psychotherapeutic change (Greenberg, 2017). The essence of EFT is an integration of person-centered relational principles, Gestalt therapy methods, and contemporary emotion theory (Goldman et al., 2021).

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Leslie Greenberg, a prominent figure in the development of this integrative approach, states that EFT is designed to help clients increase their awareness of their emotions and make productive use of them. EFT recognizes the importance of the growth that occurs through the client–therapist relationship (Goldman, 2016). Once the therapeutic alliance is created, however, the EFT practitioner actively works with emotions using a range of experiential techniques to strengthen the self, regulate affect, and create new meaning.

EFT strategies focus on two major tasks: (1) help clients with too little emo- tion access their emotions, and (2) help clients who experience too much emotion contain their emotions (Greenberg, 2017). Many traditional therapies emphasize conscious understanding and cognitive and behavioral change, but they often neglect the foundational role of emotional change. A main goal of EFT is to help individuals access and process emotions to construct new ways of being. Through experiential techniques, new narratives can be created that disrupt maladaptive past emotional schemas, which provides opportunities for positive emotional experienc- ing (McDonald, 2015). This approach has a good deal to offer with respect to teach- ing us about the role of emotion in personal change and how emotional change can be a primary pathway to cognitive and behavioral change (Greenberg, 2017). Both psychoanalytic and cognitive behavioral approaches are increasingly focusing on emotions.

EFT emphasizes the importance of awareness, acceptance, and understanding the visceral experience of emotion. Greenberg (2017) believes that our emotions can- not be changed merely by talking about them, understanding their origins, or by modifying our beliefs. Clients are encouraged to identify, experience, accept, express, explore, transform, and manage their emotions. EFT skills are designed to aid in the exploration, deepening, regulation, and transformation of negative problematic emotions (Goldman et al., 2021). EFT is an integrative approach to therapy because it synthesizes aspects of person-centered therapy, existential therapy, and Gestalt therapy. McDonald (2015) reports that a strength of EFT is that it is an empiri- cally validated brief therapeutic approach with demonstrated effectiveness in treat- ing anxiety, intimate partner violence, eating disorders, and trauma. Over the past 30 years, research studies have demonstrated the efficacy of EFT, established the relationship between clients’ changes in emotion during therapy and a positive out- come, and established the effectiveness of EFT as an evidence-based treatment for specific disorders (Goldman, 2016). EFT is being applied to counseling individuals, groups, couples, families, and in working in diverse cultural contexts.

The theory and practice of EFT are only briefly discussed in this chapter. For an in-depth discussion of the principles and techniques involved in the practice of EFT, see Greenberg (2017), Emotion-Focused Therapy. See also Goldman (2016), “Emotion- Focused Therapy,” and Goldman, Vaz, and Rousmaniere (2021), Deliberate Practice in Emotion-Focused Therapy.

Existentialism and Humanism In the 1960s and 1970s there was a growing interest among counselors in a third force in therapy as an alternative to the psychoanalytic and behavioral approaches. Under this heading fall existential therapy (Chapter 6), person-centered therapy

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(Chapter 7), Gestalt therapy (Chapter 8), and certain other experiential and rela- tionship-oriented approaches.

The connections between the terms existentialism and humanism have tended to be confusing for students and theorists alike. The two viewpoints have much in common, yet there also are significant philosophical differences between them. They share a respect for the client’s subjective experience, the uniqueness and individual- ity of each client, and a trust in the capacity of the client to make positive and con- structive conscious choices. They have in common an emphasis on concepts such as freedom, choice, values, personal responsibility, autonomy, purpose, and meaning. Both approaches place little value on the role of techniques in the therapeutic pro- cess and emphasize instead the importance of genuine encounter.

They differ in that existentialists take the position that we are faced with the anxiety of choosing to create an identity in a world that lacks intrinsic meaning. Existentialists tend to acknowledge the stark realities of human experience, and their writings often focus on death, anxiety, meaninglessness, and isolation. The humanists, in contrast, take the somewhat less anxiety-evoking and more optimistic view that each of us has a natural potential that we can actualize and through which we can find meaning. Many contemporary existential therapists refer to themselves as existential-humanistic practitioners, indicating that their roots are in existential phi- losophy but that they have incorporated many aspects of North American humanis- tic psychotherapies (Schneider & Krug, 2017).

As will become evident in this chapter, the existential and person-centered approaches have parallel concepts with regard to the client–therapist relationship being at the core of therapy. The phenomenological emphasis that is basic to the exis- tentialist approach is also fundamental to person-centered theory. Both approaches focus on the client’s perceptions and call for the therapist to be fully present with the client so that it is possible to understand the client’s subjective world, and they both emphasize the client’s capacity for self-awareness and self-healing. The thera- pist aims to provide the client with a safe, responsive, and caring relationship to facilitate self-exploration, growth, and healing (Watson et al., 2011).

Abraham Maslow’s Contributions to Humanistic Psychology Abraham Maslow (1970) was a pioneer in the development of humanistic psychology and was influential in furthering the understanding of self-actualizing individuals. Many of Carl Rogers’s ideas, especially on the positive aspects of being human and the fully functioning person, are influenced by Maslow’s basic philoso- phy. Maslow criticized Freudian psychology for what he saw as its preoccupation with the sick and dark side of human nature. Maslow believed too much research was being conducted on anxiety, hostility, and neuroses and too little into joy, cre- ativity, and self-fulfillment. Self-actualization was the central theme of the work of Abraham Maslow (1968, 1970, 1971).

Maslow studied what he called “self-actualizing people” and found that they dif- fered in important ways from so-called normal individuals. The core characteristics of self-actualizing people are self-awareness, freedom, basic honesty and caring, and trust and autonomy. Other characteristics of self-actualizing individuals include a capacity to welcome uncertainty in their lives, acceptance of themselves and others,

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spontaneity and creativity, a need for privacy and solitude, autonomy, a capacity for deep and intense interpersonal relationships, a genuine caring for others, an inner- directedness (as opposed to the tendency to live by others’ expectations), the absence of artificial dichotomies within themselves (such as work/play, love/hate, and weak/ strong), and a sense of humor (Maslow, 1970). All of these personal characteristics are compatible with the person-centered philosophy.

Maslow postulated a hierarchy of needs as a source of motivation, with the most basic needs being physiological needs. If we are hungry and thirsty, our attention is riveted on meeting these basic needs. Next are the safety needs, which include a sense of security and stability. Once our physical and safety needs are fulfilled, we become concerned with meeting our needs for belonging and love, followed by our need for esteem, both from self and others. We are able to strive toward self-actualization only after these four basic needs are met. Koltko-Rivera (2006) reports that Maslow amended his model, adding self-transcendence as a motivational step beyond self-actualization. Recognizing self-transcendence as part of Maslow’s hierarchy has several key impli- cations for theory and research: it provides (a) a more comprehensive understanding of worldviews regarding the meaning of life; (b) a broader understanding of the moti- vational roots of altruism, social progress, and wisdom; (c) a basis for the integration of spirituality into the mainstream of psychology; and (d) a more integrated mul- ticultural approach to psychological theory. At the self-actualization level, people strive to realize their potential. However, in striving for self-transcendence, people seek meaning, purpose, and communion beyond the self.

The Vision of Humanistic Philosophy The underlying vision of humanistic phi- losophy is captured by the metaphor of how an acorn, if provided with the appropriate conditions, will “automatically” grow in positive ways, pushed naturally toward its actualization as an oak. In contrast, for many existentialists there is nothing that we “are,” no internal “nature” we can count on. We are faced at every moment with a choice about what to make of this condition. Maslow’s emphasis on the healthy side of being human and the emphasis on joy, creativity, and self-fulfillment are part of the person-centered philosophy. The humanistic philosophy on which the person-centered approach rests is expressed in attitudes and behaviors that create a growth-producing climate. According to Rogers (1986), when this philosophy is lived, it helps people develop their capacities and stimulates constructive change in others. Individuals are empowered, and they are able to use this power for personal and social transformation.

Humanistic psychology emphasizes the constructive and positive side of human experience. The positive psychology movement that has come into prominence shares many concepts on the healthy side of human existence with the humanistic approach. Historically, psychologists have given more attention to negative emo- tions than to positive emotions, and there has been a focus on studying pathology, weaknesses, and suffering. The advocates of positive psychology call for increased study of hope, courage, contentment, authentic happiness, well-being, perseverance, resilience, grit, tolerance, and personal resources. Positive psychologists are moti- vated to help people thrive, not just to survive. Martin Seligman (2011), the founder of positive psychology, has focused his efforts on an initiative to increase global well- being. Positive psychology is following in the footsteps of humanistic psychology.

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The humanistic emphasis on optimism, growth, and health laid the foundation for the development of the positive psychology movement. Positive psychotherapy is a therapeutic approach within the broader field of positive psychology that aims at expanding the scope of traditional psychotherapy. This therapy approach builds on positive resources that result in wellness and should get as much attention as the amelioration of symptoms (Rashid & Seligman, 2019).

Key Concepts View of Human Nature

A common theme originating in Rogers’s early writing and continuing to per- meate all of his works is a basic sense of trust in the client’s ability to move for- ward in a constructive manner if conditions fostering growth are present. If one is able to get to the core of an individual, Rogers’s professional experience taught him that one finds a trustworthy, positive center. In keeping with the philosophy of humanistic psychology, Rogers firmly maintained that people are trustwor- thy, resourceful, capable of self-understanding and self-direction, able to make constructive changes, and able to live effective and productive lives. When thera- pists are able to experience and communicate their realness, support, caring, and nonjudgmental understanding, significant changes in the client are most likely to occur.

Rogers maintained that three therapist attributes create a growth-promoting climate in which individuals can move forward and become what they are capable of becoming: (1) congruence (genuineness, or realness), (2) unconditional positive regard (acceptance and caring), and (3) accurate empathic understanding (an abil- ity to deeply grasp the subjective world of another person). According to Rogers, if therapists communicate these attitudes, those being helped will become less defen- sive and more open to themselves and their world, and they will behave in prosocial and constructive ways.

The actualizing tendency is a directional process of striving toward realization, fulfillment, autonomy, and self-determination. This natural inclination of humans is based on Maslow’s (1970) studies of self-actualizing people, and it has significant implications for the practice of therapy. Because of the belief that the individual has an inherent capacity to move away from maladjustment and toward psycho- logical health and growth, the therapist places the primary responsibility on the cli- ent. The person-centered approach rejects the role of the therapist as the authority who knows best and of the passive client who depends on the therapist’s expertise. Therapy is rooted in the client’s capacity for awareness and self-directed change in attitudes and behavior.

The person-centered approach emphasizes clients’ abilities to engage their own resources to act in their world with others. Clients can move forward in constructive directions and successfully deal with obstacles (both from within themselves and outside of themselves) that are blocking their growth. By promoting self-awareness and self-reflection, clients learn to exercise choice. Humanistic therapists emphasize a discovery-oriented approach in which clients are the experts on their own inner experience (Watson et al., 2011), and they encourage clients to make changes that

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will lead to living fully and authentically, with the realization that this kind of exis- tence demands a continuing struggle.

The Therapeutic Process Therapeutic Goals

Rogers did not believe the goal of therapy was merely to solve problems. Rather, the goal is to assist clients in achieving a greater degree of independence and inte- gration so they can better cope with problems as they identify them. Before clients are able to work toward that goal, they must first get behind the masks they wear, which they develop through the process of socialization. Clients come to recog- nize that they have lost contact with themselves by using facades. In a climate of safety in the therapeutic session, they also come to realize that there are more authentic ways of being. The therapist does not choose specific goals for the client. The cornerstone of person-centered theory is the view that clients in a relationship with a facilitating therapist have the capacity to define and clarify their own goals. Person-centered therapists are in agreement on the matter of not setting goals for what clients need to change, yet they differ on the matter of how to best help clients achieve their own goals and to find their own answers (Bohart & Watson, 2020).

Therapist’s Function and Role The role of person-centered therapists is rooted in their ways of being and attitudes, not in techniques designed to get the client to “do something.” Research on person- centered therapy indicates that the attitude of therapists, rather than their knowl- edge, theories, or techniques, facilitate personality change in clients (Rogers, 1961). Basically, therapists use themselves as an instrument of change by encountering clients on a person-to-person level. In examining the human elements of psycho- therapy, Elkins (2016) concludes that the human dimensions are more powerful determinants of therapeutic effectiveness than theories or techniques. It is the thera- pist’s attitude and belief in the inner resources of the client that creates the thera- peutic climate for growth.

Person-centered theory holds that the therapist’s function is to be present and accessible to clients and to focus on their immediate experience. First and foremost, the therapist must be willing to be real in the relationship with clients. By being con- gruent, accepting, and empathic, the therapist is a catalyst for change. Instead of viewing clients in preconceived diagnostic categories, the therapist meets them on a moment-to-moment experiential basis and enters their world. Through the therapist’s attitude of genuine caring, respect, acceptance, support, and understanding, clients are able to loosen their defenses and rigid perceptions and move to a higher level of personal functioning. When these therapist attitudes are present, clients then have the necessary freedom to explore areas of their life that were either denied to awareness or distorted. Schneider and Krug (2020) put these attitudes into perspective with this statement: “The therapist’s goal is to be a companion on the client’s journey of self- discovery. By being warm, empathic, accepting, and genuine, the therapist provides an atmosphere in which the client’s own thrust towards growth can operate” (p. 233).

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Client’s Experience in Therapy Therapeutic change depends on clients’ perceptions both of their own experience in therapy and of the counselor’s basic attitudes. If the counselor creates a climate conducive to self-exploration, clients have the opportunity to explore the full range of their experience, which includes their feelings, beliefs, behavior, and worldview. What follows is a general sketch of clients’ experiences in therapy.

Clients come to the counselor in a state of incongruence; that is, a discrepancy exists between their self-perception and their experience in reality. For example, Leon, a college student, may see himself as a future physician, yet his below-average grades could exclude him from medical school. The discrepancy between how Leon sees himself (self-concept) or how he would like to view himself (ideal self-concept) and the reality of his poor academic performance may result in anxiety and personal vul- nerability, which can provide the necessary motivation to enter therapy. Leon must perceive that a problem exists or, at least, that he is uncomfortable enough with his present psychological adjustment to want to explore possibilities for change.

One reason clients seek therapy is a feeling of basic helplessness, powerlessness, and an inability to make decisions or effectively direct their own lives. They may hope to find “the way” through the guidance of the therapist. Within the person- centered framework, however, clients soon learn that they can be responsible for themselves in the relationship and that they can learn to be more free by using the relationship to gain greater self-understanding.

As counseling progresses, clients are able to explore a wider range of beliefs and feelings. They can express their fears, anxiety, guilt, shame, hatred, anger, and other emotions that they had deemed too negative to accept and incorporate into their self-structure. With therapy, people distort less and move to a greater acceptance and integration of conflicting and confusing feelings. They increasingly discover aspects within themselves that had been kept hidden. As clients feel understood and accepted, they become less defensive and become more open to their experience. Because they feel safer and are less vulnerable, they become more realistic, perceive others with greater accuracy, and become better able to understand and accept others. Individu- als in therapy come to appreciate themselves more as they are, and their behavior shows more flexibility and creativity. They become less concerned about meeting oth- ers’ expectations, and thus begin to behave in ways that are truer to themselves. These individuals direct their own lives instead of looking outside of themselves for answers. In short, their experience in therapy is like throwing off the self-imposed shackles that had kept them in a psychological prison. With increased freedom, they tend to become more mature psychologically and move toward increased self-actualization.

Person-centered therapy rests on the assumption that clients can create their own self-growth and are active self-healers. The therapy relationship provides a sup- portive structure within which clients’ self-healing capacities are activated (Bohart & Wade, 2013). It is clients who do the majority of the work in therapy sessions. When clients are active, open, and involved participants, they are likely to make progress. Client openness and nondefensiveness are among the best predictors of a favorable outcome. The level of active involvement and participation by clients increases as they experience a therapist’s presence, empathy, positive regard, relational depth, and authenticity (Cain, 2016).

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Relationship Between Therapist and Client Rogers (1957) based his hypothesis of the “necessary and sufficient conditions for therapeutic personality change” on the quality of the relationship: “If I can provide a certain type of relationship, the other person will discover within himself or herself the capacity to use that relationship for growth and change, and personal develop- ment will occur” (Rogers, 1961, p. 33). Rogers (1967) hypothesized further that “sig- nificant positive personality change does not occur except in a relationship” (p. 73). Rogers’s hypothesis was formulated on the basis of many years of his professional experience, and it remains basically unchanged to this day.

1. Two persons are in psychological contact. 2. The first, whom we shall term the client, is in a state of incongruence,

being vulnerable or anxious. 3. The second person, whom we term the therapist, is congruent (real

or genuine) in the relationship, and this congruence is perceived by the client.

4. The therapist experiences unconditional positive regard for the client.

5. The therapist experiences an empathic understanding of the client’s internal frame of reference and endeavors to communicate this experi- ence to the client.

6. The communication to the client of the therapist’s empathic under- standing and unconditional positive regard is to a minimal degree achieved. (as cited in Cain 2002, p. 20)

Rogers hypothesized that no other conditions were necessary. If the therapeutic core conditions exist over some period of time, constructive personality change will occur. The core conditions do not vary according to client type. Furthermore, they are both necessary and sufficient for therapeutic change to occur.

The process of change depends to a large degree on the quality of the therapeu- tic relationship between client and therapist. The therapist alone does not establish the therapeutic alliance; the client and therapist together co-create the working alli- ance (Keenan & Rubin, 2016). When therapists work collaboratively with clients to co-create an optimally individualized therapy, the probability of a good outcome increases (Cain, 2016). As clients experience the realness of the therapist, clients drop many of their pretenses and become real with both themselves and the therapist.

This humanistic approach is perhaps best characterized as a way of being and as a shared journey in which therapist and client reveal their humanness and participate in a growth experience. Therapists can be a relational guide on this journey because they are usually more psychologically experienced in this role than the client. Thera- pists are invested in broadening their own life experiences and are willing to do what it takes to deepen their self-knowledge.

Rogers admitted that his theory was strikingly provocative and radical. His for- mulation has generated considerable controversy, for he maintained that many con- ditions other therapists commonly regard as necessary for effective psychotherapy were nonessential. The core therapist conditions of congruence, unconditional posi- tive regard, and accurate empathic understanding have subsequently been embraced

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by many therapeutic schools as essential in facilitating therapeutic change. These core qualities of therapists, along with the therapist’s presence, work holistically to create a safe environment for learning (Cain, 2010). Regardless of theoretical orien- tation, most therapists strive to listen fully and empathically to clients, especially during the initial stages of therapy. We now turn to a detailed discussion of how these core conditions are an integral part of the therapeutic relationship.

Congruence, or Genuineness Congruence implies that therapists are real; that is, they are genuine, integrated, and authentic during the therapy hour. They are without a false front, their inner experience and outer expression of that experience match, and they can openly express feelings, thoughts, reactions, and attitudes that are present in the relationship with the client. This communication is done with careful reflection and considered judgment on the therapist’s part (Kolden et al., 2019).

Through authenticity the therapist serves as a model of a human being strug- gling toward greater realness. Being congruent might necessitate expressing a range of feelings including anger, frustration, liking, concern, and annoyance. This does not mean that therapists should impulsively share all of their reactions, for self- disclosure must be appropriate, well timed, and have a constructive therapeutic intent. Counselors can try too hard to be genuine; sharing because they think it will be good for the client, without being genuinely moved to express something regarded as personal, can be incongruent. Person-centered therapy stresses that counseling will be inhibited if the counselor feels one way about the client but acts in a different way. For example, if the practitioner dislikes or disapproves of the cli- ent, but feigns acceptance, therapy will be impaired. Cain (2010) stresses that thera- pists need to be attuned to the emerging needs of the client and to respond in ways that are in the best interests of the individual. If therapists keep this in mind, they are likely to make sound therapeutic decisions most of the time.

Rogers’s concept of congruence does not imply that only a fully self-actualized therapist can be effective in counseling. Because therapists are human, they cannot be expected to be fully authentic. Congruence exists on a continuum from highly congruent to very incongruent. This is true of all three characteristics. Neither unconditional positive regard nor empathy can operate unless the therapist is perceived as being genuine. Congruence lends credibility to empathy and positive regard, and it occupies a central position in the person-centered conceptualization (Kolden et al., 2019).

Unconditional Positive Regard and Acceptance The second attitude thera- pists need to communicate is deep and genuine caring for the client as a person. Unconditional positive regard can best be achieved through empathic identification with the client. The caring is nonpossessive and is not contaminated by evaluation or judgment of the client’s feelings, thoughts, and behavior as good or bad. Therapists warmly accept clients without placing stipulations on their acceptance. It is not an attitude of “I’ll accept you when . . .”; rather, it is one of “I’ll accept you as you are.” When counselors display a positive, nonjudgmental, respectful, caring, and accepting attitude toward their clients, therapeutic change is more likely (Farber et al., 2019).

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According to Rogers’s (1977) research, the greater the degree of caring, prizing, accepting, and valuing of the client in a nonpossessive way, the greater the chance that therapy will be successful. He also makes it clear that it is not possible for thera- pists to genuinely feel acceptance and unconditional caring at all times. However, if therapists have little respect for their clients, or an active dislike or disgust, it is not likely that the therapeutic work will be fruitful. If therapists’ caring stems from their own need to be liked and appreciated, constructive change in the client is inhibited. This notion of positive regard has implications for all therapists, regardless of their theoretical orientation (Farber et al., 2019).

Accurate Empathic Understanding One of the main tasks of the therapist is to understand clients’ experience and feelings sensitively and accurately as they are revealed in the moment-to-moment interaction during the therapy session. The therapist strives to sense clients’ subjective experience, particularly in the here and now. The aim is to encourage clients to get closer to themselves, to feel more deeply and intensely, and to recognize and resolve the incongruity that exists within them.

Empathy is a deep and subjective understanding of the client with the client. Empathy is not sympathy, or feeling sorry for a client. Therapists are able to share the client’s subjective world by drawing from their own experiences that may be similar to the client’s feelings. Yet therapists must not lose their own separateness. Rogers (1961) defined empathy as the capacity to see the world of another by assuming the internal frame of reference of that person: “To sense the client’s private world as if it were your own but without ever losing the ‘as if ’ quality—this is empathy, and it seems essential to therapy” (p. 284). Rogers regarded empathy as one of the most potent factors in bringing about learning and self-directed change, thus locating power in the person and not in the expert. Rogers asserts that when therapists can grasp the client’s private world as the client sees and feels it—without losing the separateness of their own identity—constructive change is likely to occur. Cain (2016) states that consistent empathic attunement is the foundation of all therapeutic approaches and contends that therapist empathy is basic to establishing a therapeutic alliance with clients. When clients feel listened to without evaluation, they feel free to disclose deeply personal aspects of themselves. There is consistent and robust evidence that clients’ perceptions of feeling understood by their therapist is a key factor in positive outcomes. Years of research have consistently demonstrated that empathy is one of the most powerful determinants of client progress in therapy (Elliott et al., 2019).

Clark (2022) describes an integral model of empathy in the counseling and psy- chotherapy process that is based on three ways of knowing: (1) subjective empathy enables practitioners to experience what it is like to be the client; this kind of empa- thy evokes a practitioner’s internal capacities that are often neglected as experien- tial resources for understanding and making empathic connections with a client; (2) interpersonal empathy pertains to understanding a client’s internal frame of refer- ence; it conveys a sense of a client’s phenomenological experiencing and facilitates a broad range of empathy-based therapeutic skills; and (3) objective empathy relies on knowledge sources outside of a client’s frame of reference; it draws upon theoretical knowledge and accrued therapy experience in the service of empathically knowing a client. By using a multiple-perspective integral model of empathy, counselors have a broader way to understand clients.

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Accurate empathy is the cornerstone of the person-centered approach, and it is a necessary ingredient of any effective therapy (Cain, 2010). Accurate empathic understanding implies that the therapist will sense clients’ feelings as if they were their own without becoming lost in those feelings. It is a way for therapists to hear the meanings expressed by their clients that often lie at the edge of their awareness. A key way of determining whether an individual experiences a therapist’s empathy is to secure feedback from the client. It is a therapist’s responsibility to monitor the quality of the therapeutic relationship, the progress of clients, and identify any strains in the relationship (Cain, 2016). Clients’ perceptions of feeling understood by their therapists relate favorably to outcome. Empathic therapists strive to dis- cover the meaning of the client’s experience, understand the overall goals of the cli- ent, and tailor their responses to the particular client. Effective empathy is grounded in authentic caring for the client (Elliott et al., 2019).

Miller and Moyers (2021) maintain that a central aspect of accurate empathy is striving to understand the client’s own experience and perspective. Effective thera- pists exhibit a sense of curiosity and an interest in grasping another’s experience. Therapists high on the skill of accurate empathy demonstrate a deep understanding of a client’s meaning and have the ability to convey this understanding to the cli- ent. Miller and Moyers report that meta-analyses indicate that empathy is associated with greater client self-exploration and positive therapy outcomes.

According to Watson (2016), full empathy entails understanding the meaning and feeling of a client’s experiencing. It is like grasping “what it is like to be you.” Empathy is an active ingredient of change that facilitates clients’ cognitive processes and emotional self-regulation. More than 70 years of research has consistently dem- onstrated that therapist empathy is the most potent predictor of client progress in therapy. Empathy is an essential aspect of successful therapy in every therapeutic modality (Cain, 2016; Elliott et al., 2019; Watson, 2016).

Application: Therapeutic Techniques and Procedures Early Emphasis on Reflection of Feelings

Rogers’s original emphasis was on grasping the world of the client and reflecting this understanding. As his view of psychotherapy developed, however, he empha- sized the therapist’s relationship with the client. Rogers and other contributors to the development of the person-centered approach have been critical of the stereo- typic view that this approach is basically a simple restatement of what the client just said.

Evolution of Person-Centered Methods Contemporary person-centered therapy is the result of an evolutionary process of more than 70 years, and it continues to remain open to change and refinement. One of Rogers’s main contributions to the counseling field is the notion that the qual- ity of the therapeutic relationship, as opposed to administering techniques, is the primary agent of growth in the client. The therapist’s ability to establish a strong connection with clients is the critical factor determining successful counseling

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outcomes. Effective therapy requires therapists to be fully present and engaged with their clients. When therapists are fully present, they bring a sustained, focused, and mindful attention to their clients (Cain, 2016).

Techniques may be suggested to some clients, but they are not basic to the prac- tice of person-centered therapy. “Being with” clients and entering imaginatively into their world of perceptions and feelings is sufficient for facilitating a process of change. When person-centered therapists suggest a technique, the way the sug- gestion is made is crucial. Some clients do better with more direction, and others do better in a nondirective climate (Cain, 2010). Person-centered therapists who adopt an integrative approach may be more flexible in how they help clients achieve their therapeutic goals. These therapists use concepts, methods, and relational styles from other approaches, enabling them to individualize therapy to better fit with their clients’ needs (Murphy & Joseph, 2016).

What is essential for clients’ progress is the therapist’s presence. Qualities and skills such as listening, accepting, respecting, understanding, and responding must be honest expressions by the therapist. Techniques may be suggested when doing so fosters the process of client and therapist being together in an empathic way. Tech- niques are not attempts at “doing anything” to a client (Bohart & Watson, 2020).

Rogers expected person-centered therapy to continue to evolve and supported others in breaking new ground. One of the main ways in which person-centered therapy has evolved is the diversity, innovation, and individualization in practice. There is no longer one way of practicing person-centered therapy (Cain, 2010), and there has been increased latitude for therapists to share their reactions, to confront clients in a caring way, and to participate more actively and fully in the therapeutic process (Bozarth et al., 2002). Immediacy, or addressing what is going on between client and therapist, is highly valued in this approach. This development encourages the use of a wider variety of methods and allows for considerable diversity in per- sonal style among person-centered therapists. The shift toward genuineness enables person-centered therapists both to practice in more flexible and integrative ways that suit their personalities and to have greater flexibility in tailoring the counseling relationship to suit different clients (Bohart & Watson, 2020). Cain (2010, 2013) believes it is necessary for therapists to adapt their therapeutic style to accommodate the unique needs of each client. In applying person-centered therapy to clients, it is good to heed the advice of Norcross and Cooper (2021) who claim that therapists should adapt to clients rather than expecting clients to adapt to therapists. The per- son-centered approach allows for assessing and accommodating client preferences and for tailoring the relational stance and methods to what clients want and need. Norcross and Cooper consistently remind therapists that adapting care to client preferences is effective in strengthening the therapeutic relationship, reducing pre- mature termination, and improving therapy outcomes.

Person-centered therapists have the freedom to use a variety of responses and methods to assist their clients; a guiding question therapists need to ask is, “Does it fit?” Cain (2013) contends that, ideally, therapists will continually monitor whether what they are doing fits, especially whether their therapeutic style is compatible with their clients’ way of viewing and understanding their problems. For an illustration of how Dr. David Cain works with the case of Ruth in a person-centered style, see Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 5).

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Today, those who practice a person-centered approach work in diverse ways that reflect both advances in theory and practice and a plethora of personal styles. This is appropriate and fortunate, for none of us can emulate the style of Carl Rogers and still be true to ourselves. If we strive to model our style after Rogers, and if that style does not fit for us, we are not being ourselves and we are not being fully congruent.

The Role of Assessment Assessment is frequently viewed as a prerequisite to the treatment process. Many mental health agencies use a variety of assessment procedures, including diagnos- tic screening, identification of clients’ strengths and liabilities, and various tests. Person-centered therapists generally do not find traditional assessment and diagno- sis to be useful because these procedures encourage an external and expert perspec- tive on the client (Bohart & Watson, 2020). What matters is not how the counselor assesses the client but the client’s self-assessment. From a person-centered perspec- tive, the best source of knowledge about the client is the individual client. Rogers saw therapy as co-assessment, whereby the therapist and the client engage in a con- tinuous process of self-understanding.

Assessment seems to be gaining in importance in short-term treatments in most counseling agencies, and it is imperative that clients be involved in a collaborative process in making decisions that are central to their therapy. Today it may not be a question of whether to incorporate assessment into therapeutic practice but of how to involve clients as fully as possible in their assessment and treatment process.

Application of the Philosophy of the Person-Centered Approach The person-centered approach has been applied to working with individuals, groups, and families. Bozrath, Zimring, and Tausch (2002) cite studies done through the 1990s that revealed the effectiveness of person-centered therapy with a wide range of client problems including anxiety disorders, alcoholism, psychosomatic prob- lems, agoraphobia, interpersonal difficulties, depression, cancer, and personality disorders. Person-centered therapy has been shown to be as viable as the more goal- oriented therapies. Furthermore, outcome research conducted in the 1990s revealed that effective therapy is based on the client–therapist relationship in combination with the inner and external resources of the client (Duncan et al., 2010).

The person-centered approach has been applied extensively in training both professionals and paraprofessionals who work with people in a variety of settings. This approach emphasizes staying with clients as opposed to getting ahead of them with interpretations. People without advanced psychological education are able to benefit by translating the therapeutic conditions of genuineness, empathic under- standing, and unconditional positive regard into both their personal and profes- sional lives. Learning to listen to oneself with acceptance is a valuable life skill that enables individuals to be their own therapists. The basic concepts are straightfor- ward and easy to comprehend, and they encourage locating power in the person rather than fostering an authoritarian structure in which control and power are denied to the person. These core skills also provide an essential foundation for vir- tually all of the other therapy systems covered in this book. If counselors are lacking

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in these relationship and communication skills, they will not be effective in carrying out a treatment program for their clients.

The person-centered approach demands a great deal of the therapist. An effec- tive person-centered therapist must be an astute listener who is grounded, centered, genuine, respectful, caring, present, focused, patient, and accepting in a way that involves maturity. Without a person-centered way of being, mere application of skills is likely to be hollow. Natalie Rogers (2011) points out that the person-centered approach is a way of being that is easy to understand intellectually but is very dif- ficult to put into practice. She believes that the core conditions of genuineness, posi- tive regard, and empathy are most important in developing trust, safety, and growth in a group.

Application to Crisis Intervention The person-centered approach is especially applicable in crisis intervention such as an unwanted pregnancy, an illness, a disastrous event, or the loss of a loved one. People in the helping professions (nursing, medicine, education, the ministry) are often first on the scene in a variety of crises, and they can do much if the basic atti- tudes described in this chapter are present. When people are in crisis, one of the first steps is to give them an opportunity to fully express themselves. Sensitive listening, hearing, and understanding are essential at this point. Being heard and understood helps ground people in crises, helps to calm them in the midst of turmoil, and enables them to think more clearly and make better decisions. Although a person’s crisis is not likely to be resolved by one or two contacts with a helper, such contacts can pave the way for being open to receiving help later. If people in crisis do not feel understood and accepted, they may lose hope of “returning to normal” and may not seek help in the future. Genuine support, caring, and nonpossessive warmth can go a long way in building bridges that can motivate people to do something to work through and resolve a crisis. Communicating a deep sense of understanding should always precede other more problem-solving interventions.

In crisis situations, person-centered therapists may need to provide more struc- ture and direction than would be the case for clients who are not experiencing a cri- sis. Suggestions, guidance, and even direction may be called for if clients are not able to function effectively. For example, it may be necessary to take action to hospitalize a suicidal client to protect this person from self-harm.

Application to Group Counseling The person-centered approach emphasizes the unique role of the group counselor as a facilitator rather than a leader. The primary function of the facilitator is to create a safe and healing climate—a place where the group members can interact in honest and meaningful ways. In this climate members become more appreciative and trust- ing of themselves as they are and are able to move toward self-direction and empow- erment. The facilitator’s way of being can create a productive climate within a group:

Facilitators cannot make participants trust the group process. Facilitators earn trust by being respectful, caring, and even loving. Being an effective group

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facilitator has much to do with one’s “way of being.” No method or technique can evoke trust unless the facilitator has a capacity to be fully present, considerate, caring, authentic, and responsive. This includes the ability to challenge people constructively. (N. Rogers, 2011, p. 57)

With the presence of the facilitator and the support of other members, participants realize that they do not have to experience the struggles of change alone and that groups as collective entities have their own source of transformation.

Carl Rogers (1970) clearly believed that groups tend to move forward if the facilitator exhibits a deep sense of trust in the members and refrains from using techniques or exercises to get a group moving. Facilitators should avoid making interpretive comments or group process observations because such comments are apt to make the group self-conscious and slow the process down. Group process observations should come from members, a view that is consistent with Rogers’s philosophy of placing the responsibility for the direction of the group on the mem- bers. Instead of leading the members toward specific goals, the group facilitator assists members in developing attitudes and behaviors of genuineness, acceptance, and empathy, which enables the members to interact with each other in therapeu- tic ways to find their own sense of direction as a group.

Regardless of a group leader’s theoretical orientation, the core conditions that have been described here are highly applicable to any leader’s style of group facilitation. Only when the leader is able to create a person-centered climate will movement take place within a group. All of the theories discussed in this book depend on the quality of the therapeutic relationship as a foundation. As you will see, the cognitive behavioral approaches to group work also emphasize cre- ating a working alliance and collaborative relationships. Indeed, most effective approaches to group work share key elements of a person-centered philosophy. For a more detailed treatment of person-centered group counseling, see Corey (2023, chap. 10).

Application of the Person-Centered Approach With Children and Adolescents in School Counseling

This section was provided by Sam Steen, PhD, an associate professor, licensed professional school counselor, and director of the Diversity Research Action Con- sortium at George Mason University. He specializes in school counseling, group work, and cultivating Black students’ academic identity development.

I use a person-centered approach as a counseling lens in all of my profes- sional interactions, especially when working with children and families in school settings. Pause and think about your own relationships. How “genuine,” “non- judgmental,” and truly “open” are you within these relationships? How long did it take to get to that level of connection? Now imagine that you are a student engaging in this relationship with an adult stranger. Now imagine you are the school counselor offering this opportunity to connect and explore whatever is being discussed. Imagine that the topic is a difficult one that involves other peers or other adults in the school or extended family members or caretakers outside of school.

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As I work with students, families, and staff in an individual setting, I remem- ber that establishing solid relationships take time. Sometimes in schools you may have only one session, which means that a therapeutic alliance needs to be created quickly. I don’t wait until a student is in my office or my group to build this relation- ship. I walk the halls, conduct bus duty, peruse the cafeteria, visit classrooms, and attend extracurricular activities, and these efforts often pay off. When the student needs support, I continue building on this relationship. But I also work to com- municate that the time I am spending with the student is private (within the limits of confidentiality), safe, honest, without judgment. I offer students a platform to explore everything that might be bringing us together.

I use considerable nonverbal communication, such as facial gestures, and a good deal of body language in attempting to communicate. I do my best to demon- strate active listening, focus on the present, and express kindness and compassion. I respect and aim to acknowledge obvious aspects of the intersections of identity between the student and me. I speak softly and slowly at times to increase under- standing for young students and English language learners alike. Other skills that I use include reflection of feelings and content. I state these reflections in an open way, and students are free to accept or reject these reflections. Offering my reflec- tions and stating observations comes from a place of curiosity, and I invite feedback from students. It is not important for me to be correct but rather that I be a sound- ing board. I use open-ended questions, silence, and even humor when appropriate.

The person-centered spirit enables students to decide what it is they want as they move forward. I believe that students have everything they need to be success- ful. Students have answers within themselves, and it is not my role to provide them with answers. My role is to help them tease out their own answers. The more I strive to incorporate a person-centered approach in working with children, the more I learn about myself and others. It is imperative that my main focus be on the needs of the students, as they are the experts in their journey of life.

Person-Centered Expressive Arts Therapy* Natalie Rogers (1993, 2011) expanded on her father’s (C. Rogers, 1961) theory of creativity using the expressive arts to enhance personal growth for individuals and groups. N. Rogers’s approach, known as expressive arts therapy, extends the person-centered approach to spontaneous creative expression, which symbolizes deep and sometimes inaccessible feelings and emotional states. Counselors trained in person-centered expressive arts offer their clients the opportunity to create move- ment, visual art, journal writing, sound, and music to express their feelings and gain insight from these activities.

Principles of Expressive Arts Therapy Expressive arts therapy uses various artistic forms—movement, drawing, painting, sculpting, music, writing, and improvisation—toward the end of growth, healing,

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*Much of the material in this section is based on key ideas that are more fully developed in The Creative Connection: Expressive Arts as Healing (N. Rogers, 1993) and The Creative Connection for Groups: Person-Centered Expressive Arts for Healing and Social Change (N. Rogers, 2011). This section was written in close collaboration with Natalie Rogers.

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and self-discovery. This is a multimodal approach integrating mind, body, emo- tions, and inner spiritual resources. Methods of expressive arts therapy are based on humanistic principles but give fuller form to Carl Rogers’s notions of creativity. These principles include the following (N. Rogers, 1993):

◆ All people have an innate ability to be creative. ◆ The creative process is transformative and healing. The healing aspects

involve activities such as meditation, movement, art, music, and jour- nal writing.

◆ Personal growth and higher states of consciousness are achieved through self-awareness, self-understanding, and insight.

◆ Self-awareness, understanding, and insight are achieved by delving into our feelings of grief, anger, pain, fear, joy, and ecstasy.

◆ Our feelings and emotions are an energy source that can be channeled into the expressive arts to be released and transformed.

◆ The expressive arts lead us into the unconscious, thereby enabling us to express previously unknown facets of ourselves and bring to light new information and awareness.

◆ One art form stimulates and nurtures the other, bringing us to an inner core or essence that is our life energy.

◆ A connection exists between our life force—our inner core, or soul—and the essence of all beings.

◆ As we journey inward to discover our essence or wholeness, we discover our relatedness to the outer world, and the inner and outer become one.

The various art modes interrelate in what Natalie Rogers calls the “creative connec- tion.” When we move, it affects how we write or paint. When we write or paint, it affects how we feel and think.

Natalie Rogers’s approach is based on a person-centered theory of individual and group process. The same conditions that Carl Rogers and his colleagues found basic to fostering a facilitative client–counselor relationship also help support creativity. Personal growth takes place in a safe, supportive environment created by counselors or facilitators who are genuine, warm, empathic, open, honest, congruent, and caring—qualities that are best learned by first being expe- rienced. Taking time to reflect on and evaluate these experiences allows for per- sonal integration at many levels—intellectual, emotional, physical, and spiritual.

Creativity and Offering Stimulating Experiences Natalie Rogers states that this deep faith in the individual’s innate drive to become fully oneself is basic to the work in person-centered expressive arts. Individu- als have a tremendous capacity for self-healing through creativity when given the proper environment. When one feels appreciated, trusted, and given support to use individuality to develop a plan, create a project, write a paper, or to be authentic, the challenge is exciting, stimulating, and enables a sense of personal expansion. N. Rogers believes the tendency to actualize and become one’s full potential, includ- ing innate creativity, is undervalued, discounted, and frequently squashed in our

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society. Traditional educational institutions tend to promote conformity rather than original thinking and the creative process.

Person-centered expressive arts therapy utilizes the arts for spontaneous creative expression that symbolizes deep and sometimes inaccessible feelings and emotional states. The conditions that foster creativity require acceptance of the individual, a nonjudgmental setting, empathy, psychological freedom, and availability of stim- ulating and challenging experiences. With this type of environment in place, the facilitative internal conditions of the client are encouraged and inspired. The client experiences a nondefensive openness and an internal locus of evaluation. N. Rogers (1993) believes that we cheat ourselves out of a fulfilling and joyous source of cre- ativity if we cling to the idea that an artist is the only one who can enter the realm of creativity. Art is not only for the few who develop a talent or master a medium. We all can use various art forms to facilitate self-expression and personal growth. For a more extensive coverage of expressive arts, see The Creative Connection for Groups: Person-Centered Expressive Arts for Healing and Social Change (N. Rogers, 2011).

An Expert’s Perspective on Person-Centered Expressive Arts Natalie Rogers, PhD, is the founder of the person-centered expressive arts approach, has written two books on the subject, and has conducted workshops in many parts of the world on person-centered expressive arts for healing and social change. In this section, she provides answers to the following questions.

1. What is the most important contribution of the person-centered expressive arts approach for the practice of individual therapy? I believe the most important contribution we have made to the practice of individual therapy is bringing the expressive arts into the session as a means of helping the client find nonverbal ways of communicating with self and with the therapist. Person-centered expressive arts (PCEA) provides a pathway to colors, form, and symbols that emerge from the unconscious and have special meaning for the individual. This offers a new language to discover and experience unknown aspects of oneself. When my clients share their experi- ence through images and symbols, I can quickly absorb the world from their viewpoint. My clients have told me that expressive arts helped them visualize change and identify constructive actions that led to a healing process.

2. What two or three key concepts of the person-centered expressive arts approach are especially applicable to the practice of individual counseling or therapy?

The Creative Connection® The Creative Connection is a process I have developed that integrates movement, sound, art, and journal writing in a sequence. Moving with the intention of discovering feelings, for example, opens us to profound awareness that can then be expressed in color, line, and form. Following this with visual art—color, clay, collage—brings the individual to the deep wellspring of creativity, often revealing unconscious material. This process needs the safe, nonjudgmental, nurturing environ- ment offered by the person-centered approach.

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Integrating Carl Rogers’s person-centered values and methods with the expressive arts. The foundation of my work is the belief and deep faith that each person has the inner capacity to discover their full potential. Carl Rogers’s extensive research demonstrated that personal growth takes place in a safe, nonjudgmental, permissive environment. This environment is carefully defined, and the three conditions that foster a person-centered relationship include unconditional positive regard, empathy, and congruence. These qualities are defined in depth (and are not easy to achieve) in both Carl’s and my writing.

3. What two or three techniques from person-centered expressive arts have practical value for practitioners of individual therapy? The most important process is to follow the client’s lead. When a client is discussing something that has deep meaning, but the client seems to be “talking about something” (story form), such as anger at a boss, I might say, “Would you like to try using the colors to express how you feel about this situation? Use your nondominant hand to select colors, and just let any- thing happen on the paper.” The client might scribble black and red all over the paper. This visual expression brings deeper awareness on the part of the client and a more profound communication between client and therapist.

In more general terms, when I work with a client, I often offer a brief meditation to start the session. During this meditation, I may ask her to be in touch with any feelings or body sensations she is experiencing. Depend- ing on our rapport, I may offer a Creative Connection sequence to help her access more information about those feelings or body sensations. I may suggest authentic movement followed by visual arts and journal writing to help her go on her inner journey. I view myself as a partner and companion on the journey of self-discovery, and there is no one right way to proceed. I encourage my clients to access their feelings and intuition. In my experi- ence, expressive arts therapy provides a holistic way to access and integrate the wisdom that emerges from the mind, the body, and the spirit.

4. How does person-centered expressive art therapy address diversity, multicultural, and social justice issues for the practice of individual counseling? My personal mission has been to work cross-culturally and to facilitate under- standing within and between international groups. Working with expressive arts removes masks and language barriers because the nonverbal, symbolic, and mythic expressions that arise are understood across cultures. In a multi- cultural group, our participants frequently comment that the expressive arts process serves as a common language and a bridge to understanding. The importance of creating the safe, nonjudgmental, person-centered environ- ment is crucial in allowing multicultural individuals or groups to reveal their true attitudes and feelings. My colleagues and I have worked all over the world, including in Europe, Mexico, Japan, Russia, South America, South Korea, and the United States, building cross-cultural bridges with expressive arts. Using person-centered expressive arts to address diversity, multicultural, and social justice issues helps us understand that we are all humans with hopes and aspirations, suffering, anger, and love. As I worked around the world, I realized that developing our personal creativity promotes peace and understanding.

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5. In what ways can person-centered expressive arts therapy be applied to brief therapy (or time-limited counseling)? One of the most important aspects of person-centered therapy is to under- stand the world as the client experiences it. Developing a trusting relation- ship with the client is fundamental for all therapists. It is my belief that being empathic, congruent, and caring are essential elements of all counsel- ing processes, whether it is brief therapy or longer-term therapy. Person- centered expressive arts is used in a wide variety of situations including education, hospitals, hospice, social service, therapy, and in the workplace. Dissertation research indicates that person-centered expressive arts has also been used in educational settings, for decision making, and in the workplace.

6. From your perspective, what is the current status and the future of the person-centered expressive arts approach to individual counseling? It is exciting to report the current status of person-centered expressive arts (PCEA). We have now become a recognized specialty in the ever-evolving field of expressive arts. After 30 years of offering a 400-hour training program in the United States, Japan, South Korea, Argentina, and Hong Kong, with hundreds of PCEA practitioners around the world, we are a community with strong values and deep bonds. We are developing our own biannual sympo- sium, a website and social media communications, and we continue our cer- tificate program through Sofia University in California.

We understand the deep need to integrate the mind, body, emotions, and spirit. Although verbal therapy will always be essential, part of the ther- apeutic process is to awaken the creative life force energy. Person-centered expressive arts is an international and cross-cultural network of human- istic expressive artists, consultants, educators, and therapists. We provide education, research, resources, and mentorship to foster creativity, growth, and transformation. We envision a world in which people use their creative capacity to achieve deep interpersonal and global connections.

Discussion Questions Related to the Person-Centered Expressive Arts Perspective

1. What do you imagine it would be like for you to participate in expres- sive arts therapy?

2. N. Rogers states: “In a multicultural group, our participants frequently com- ment that the expressive arts process serves as a common language and a bridge to understanding. The importance of creating the safe, nonjudgmen- tal, person-centered environment is crucial in allowing multicultural individ- uals or groups to reveal their true attitudes and feelings.” If the arts provide a common language for all people, what benefits could incorporating expres- sive arts in therapy sessions bring to your multicultural clients?

3. N. Rogers states: “Developing a trusting relationship with the client is fundamental for all therapists. It is my belief that being empathic, con- gruent, and caring are essential elements of all counseling processes, whether it is brief therapy or longer-term therapy.” How would you begin to develop a trusting relationship with your clients?

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Person-Centered Therapy From a Multicultural Perspective Strengths From a Diversity Perspective

One of the strengths of the person-centered approach is its impact on the field of human relations with diverse cultural groups. Person-centered philosophy and prac- tice can now be studied in several European countries, South America, and Japan. Here are some examples of ways in which this approach has been incorporated in various countries and cultures:

◆ In several European countries person-centered concepts have had a sig- nificant impact on the practice of counseling as well as on education, cross-cultural communication, and reduction of racial and political tensions.

◆ In the 1970s Rogers and his associates began conducting workshops promoting cross-cultural communication. Well into the 1980s he led large workshops in many parts of the world. International encounter groups have provided participants with multicultural experiences.

◆ Japan, Australia, South America, Mexico, and the United Kingdom have all been receptive to person-centered concepts and have adapted these practices to fit their cultures.

◆ Shortly before his death, Carl Rogers conducted intensive workshops with professionals in the former Soviet Union.

There is no doubt that Carl Rogers has had a global impact. His work has reached more than 30 countries, and his writings have been translated into 12 languages. The emphasis on core conditions makes the person-centered approach useful in understanding diverse worldviews. The underlying philosophy of person-centered therapy is grounded on the importance of hearing the deeper messages of a client. Empathy, being present, and respecting the values of clients are basic attitudes and skills in counseling culturally diverse clients. Although person-centered therapists are aware of diversity factors, they do not make initial assumptions about individu- als (Cain, 2010, 2013). Therapists realize that each client’s journey is unique and take steps to tailor their methods to fit the individual.

Many practitioners believe person-centered therapy is ideally suited to clients in a diverse world. Bohart and Watson (2020) claim that the person-centered philosophy is particularly appropriate for working with diverse client populations because the counselor does not assume the role of expert who is going to impose a “right way of being” on the client. Instead, the therapist is a “fellow explorer” who attempts to understand the client’s phenomenological world in an interested, accepting, and open way and checks with the client to confirm that the therapist’s perceptions are accurate.

Shortcomings From a Diversity Perspective Although the person-centered approach has made significant contributions to counseling people from diverse social, political, and cultural backgrounds, there are some shortcomings to practicing exclusively within this framework. Many cli- ents who come to community mental health clinics or who are involved in out- patient treatment want more structure than this approach provides. Some clients

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seek professional help to deal with a crisis, to alleviate emotional problems, or to learn coping skills in dealing with everyday problems. These clients often expect counselors to provide guidance or give advice and can be put off by this unstruc- tured approach. Sue and his colleagues (2022) maintain that many Asian American clients expect the counselor to take an active role in structuring the therapy session and identifying for clients’ expectations of how they can best participate in their therapy. Sue and colleagues add that for many Asian American clients it is appropri- ate that therapy be time limited, that the focus be on concrete problem solving, and that therapy should focus on the present or immediate future.

A second shortcoming of the person-centered approach is that it is difficult to translate the core therapeutic conditions into actual practice in certain cultures. Communication of these core conditions must be consistent with the client’s cul- tural framework. Consider, for example, the expression of therapist congruence and empathy. Clients accustomed to indirect communication may not be comfortable with direct expressions of empathy or self-disclosure on the therapist’s part.

A third shortcoming in applying the person-centered approach with clients from diverse cultures pertains to the fact that this approach extols the value of an internal locus of evaluation. The humanistic foundation of person-centered therapy emphasizes dimensions such as self-awareness, freedom, autonomy, self-acceptance, inner-directedness, and self-actualization. Cain (2010) points out that “persons from collectivistic cultures are oriented less toward self-actualization and more toward intimacy, connection, and harmony with others and toward what is best for the community and the common good” (p. 143). For clients from collectivistic cul- tures, Sue and colleagues (2022) contend that the individualistic perspective will likely need to be modified to take into consideration the family and how the deci- sions clients make can affect their family. The emphasis on development of indi- vidual autonomy and personal growth may be viewed as being selfish in a culture that stresses the common good.

Consider Lupe, a Latina client who values the interests of her family over her self-interests. From a person-centered perspective, she could be viewed as being in danger of “losing her own identity” by being primarily concerned with her role in taking care of others in the family. Rather than pushing her to make her personal wants a priority, the counselor will explore Lupe’s cultural values and her level of commitment to these values in working with her. It would be inappropriate for the counselor to communicate a vision of the kind of woman she should be.

Despite these shortcomings, the person-centered approach offers many oppor- tunities for working with clients from diverse cultures. There is great diversity among any group of people, and there is room for a variety of therapeutic styles. Counseling a culturally diverse client may require more activity and structuring than is usu- ally the case in a person-centered framework, but the potential positive impact of a counselor who responds empathically to a client’s cultural context cannot be over- estimated. Every human interaction is an interaction between diverse individuals because none of us are the same. Two sisters growing up in the same home, in the same neighborhood, with the same parents will have diverse views and experiences between them. Therapists must strive to become aware of their cultural assumptions and blind spots in order to show up with an openness to be authentically present with clients.

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Person-Centered Therapy Applied to the Case of Stan Stan’s autobiography indicates that he has a sense of what he wants for his life. As a person-centered therapist, I rely on his self-report of the way he views himself rather than on a formal assessment and di- agnosis. My concern is with understanding him from his internal frame of reference. Stan has stated goals that are meaningful for him. He is motivated to change and seems to have sufficient anxiety to work toward these desired changes. I have faith in Stan’s ability to find his own way, and I trust that he has the necessary resources for reaching his therapy goals. I encourage Stan to speak freely about the discrepancy between the person he sees himself as being and the person he would like to become; about his feelings of being a failure, being inadequate; about his fears and uncer- tainties; and about his hopelessness at times. I attempt to create an atmosphere of freedom and security that will encourage Stan to explore the threatening aspects of his self-concept.

Stan has a low evaluation of his self-worth. Al- though he finds it difficult to believe that others really like him, he wants to feel loved. He says, “I hope I can learn to love at least a few people, most of all, women.” He wants to feel equal to others and not have to apol- ogize for his existence, yet most of the time he feels inferior. By creating a supportive, trusting, and encour- aging atmosphere, I can help Stan learn to be more accepting of himself, with both his strengths and limi- tations. He has the opportunity to openly express his fears of women, of not being able to work with people, and of feeling inadequate and stupid. He can explore how he feels judged by his parents and by authorities. He has an opportunity to express his guilt—that is, his feelings that he has not lived up to his parents’ expec- tations and that he has let them and himself down. He can also relate his feelings of hurt over not having ever felt loved and wanted. He can express the loneliness and isolation that he so often feels, as well as the need to numb these feelings with alcohol or drugs.

Stan is no longer totally alone, for he is taking the risk of letting me into his private world of feelings.

Stan gradually gets a sharper focus on his experienc- ing and is able to clarify his own feelings and attitudes. He sees that he has the capacity to make his own deci- sions. In short, our therapeutic relationship frees him from his self-defeating ways. Because of the caring and faith he experiences from me in our relationship, Stan is able to increase his own faith and confidence in himself.

My empathy assists Stan in hearing himself and accessing himself at a deeper level. Stan gradually becomes more sensitive to his own internal mes- sages and less dependent on confirmation from oth- ers around him. As a result of the therapeutic venture, Stan discovers that there is someone in his life whom he can depend on—himself.

Questions for Reflection ◆ How would you respond to Stan’s deep feelings

of self-doubt? Could you enter his frame of refer- ence and respond in an empathic manner that lets Stan know you hear his pain and struggle without needing to give advice or suggestions?

◆ How would you describe Stan’s deeper struggles? What sense do you have of his world?

◆ To what extent do you think that the relation- ship you would develop with Stan would help him move forward in a positive direction? What, if anything, might get in your way—either with him or in yourself—in establishing a therapeutic relationship?

Refer to the MindTap for The Case of Stan Video Quiz for Chapter 7, Session 5 (person-centered therapy), for a demonstration of my approach to counseling Stan from this perspective. This session focuses on exploring the immediacy of our relationship and assisting Stan in finding his own way.

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Person-Centered Therapy Applied to the Case of Gwen* Gwen arrives for this session moving quite slowly. She reports having been in pain for the past few days. I asked her to describe the pain in her body, and she ex- plains that it is a full body achiness.

Gwen: I can’t sleep through the night, and I feel tired all day long. I try to push through the achiness, but sometimes I just want to sit down and not get up.

Therapist: Tell me more about this feeling.

Gwen: I don’t mean sit down and die, I mean sit down and take a break from life for a while. I have just been feeling down and stressed.

To gain a better understanding of how Gwen’s pain has affected her week, I administer a brief rating scale at the beginning of this session. The Outcome Rating Scale (ORS) is a short questionnaire developed by Scott D. Miller that assesses how well a person has been do- ing (individually, interpersonally, socially, and overall well-being) during the last week. I explain that the ORS will give us a quick look at her current level of func- tioning and feeling. The ORS can also help Gwen see which particular areas of her life hold the most stress for her. Gwen marks the form quickly, and the results indicate that personal well-being and interpersonal re- lationships are her most significant areas of challenge. This assessment provides a starting point for discuss- ing how our therapeutic relationship is contributing to her overall well-being.

Therapist: Gwen, I hope that information is helpful for you. Where would you like to start today?

Gwen: I need to work on the personal well-being is- sues. I just want to unwind and relax a little before I go back into my busy day. I get so tired of running around so much. I seem to live in an “overwhelm” mode. I am ready to retire that way of living. I could use some balance in my life. I know that’s why I

have been feeling so achy. It’s the stress I have been carrying. I can feel the tension.

Therapist: Would you like to say more about the sense of “overwhelm” you mentioned?

Gwen: I am always juggling between getting my own house in order and putting out fires with my mom’s health team or insurance. I work hard at my job, and then I come home and need to get my own house in order. I am stretched in too many directions, and at the end of the day I still feel like I am on call and can’t turn my mind off. I lay down at night and feel all my responsibilities whirling around in my mind. Sometimes I just cover my head and hope that ev- erything will go away and I can at least have some peace at night. I know nothing will disappear from my list until I take it off and that I have to make an effort to find space for relaxation in my life.

Therapist: Hearing you explain what “overwhelm mode” looks like for you gets my heart rate up [immediacy]. Although you know that many of your responsibilities will not diminish, you would like to find some way of dealing with them and find more peace in your life.

Gwen: Yes, but I don’t know where to begin. I can’t seem to find time for relaxation.

Therapist: It sounds like you feel unsure about where to start and whether you’ll find time for yourself at all. I am wondering when you feel somewhat relaxed.

Gwen: I feel best when I’m caught up with all my proj- ects at work and have some time for myself. I like it when I have crossed some things off my list of things to do. I used to reward myself with a spa day when I finished a big project. I haven’t done that in ages.

*Dr. Kellie Kirksey writes about her ways of thinking and practicing from a person-centered perspective and applying this model to Gwen.

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Therapist: As you talk about this time, I can see how excited you are about crossing things off your list and having time for yourself. That’s when you really feel good about yourself—when you’re accom- plishing things yet you realize you need to take care of yourself too.

Gwen: Before I became the caregiver for my mom, I used to get to the gym about three days a week. I loved doing dancing and yoga! It really made a difference in my stress level. Working out just fell by the wayside as my life got busier.

Therapist: That must be exhausting; you take care of your mom, husband, grown kids, colleagues, and everyone else. Yet I hear that you are not taking care of yourself. How satisfied are you about meet- ing your own needs right now?

Gwen: Not at all. I have totally abandoned myself. I am feeling worn down.

Therapist: Tell me more about being worn down.

Gwen: I guess saying I am worn down is a bit extreme [Gwen is smiling]. My body is definitely telling me to slow down and focus on me for a change.

Therapist: So one side is telling you that you can’t keep up this pace and you need to take care of yourself, and the other side is saying, “Gwen, you need to handle everything that’s being thrown at you.”

Gwen: That sounds right. It’s been a while since I actu- ally paid attention to myself. I feel sad saying that out loud. I know I want to do something different. Even if it’s a small something!

Therapist: You are disappointed in yourself for not rec- ognizing that you need a break, and yet you seem determined to make some small change now. Can you identify what you might begin to do differently?

Gwen: I want to make myself a priority. I can start tak- ing my breaks at work again and use that time to

take care of me. I used to do some stretching at my desk and walk around the building. It was actually fun: we would do a pedometer challenge at work. It was good. I don’t know why I let all of that go. I just started putting everyone and everything in front of me. We even have a lunch time dance class I could go to. I forgot how happy doing those little things used to make me feel.

Therapist: It sounds like you regret that some of those activities aren’t in you life. What would it look like to make yourself a priority in some small way?

Gwen: I guess I could find 15 minutes to do something for myself. I could even go get my hair done. Maybe a break in my regular routine would be helpful. It’s been forever since I treated myself.

Therapist: With you changing your lifestyle, I want to make sure you do it safely. I suggest you ask your primary care physician about a physical examina- tion to determine any possible reasons for the pain and physical symptoms you are experiencing.

Gwen: That is a good idea, and I will follow up on that suggestion.

Therapist: Before you leave, I want to give you the Ses- sion Rating Scale (SRS). All you have to do is rate to- day’s session based on four items: our relationship, goals and topics, therapeutic approach, and overall view of our time today. It’s similar to the form you filled out at the beginning of session.

Gwen takes a moment to fill out the form and pass- es it back with marks reflecting that she felt heard and that we talked about what she wanted to discuss. She also marked that there was something missing from the session, which gave us an opportunity to identify what might be missing for her. Using the ORS and the SRS is a good way to get Gwen’s feedback on her own progress and her perception of the value of the thera- py session. As a therapist, I invite this feedback and see it as a useful way of understanding Gwen’s perspec- tive. In collaboration with Gwen, I strive to make ad- justments in my work with her based on her feedback. Gwen then says a few words about how she is feeling.

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Gwen: I am definitely not as tense as I was when I first came in. I needed to get some things off of my chest. I would have liked more suggestions from you on what I need to do next. I know you don’t have the magic answer, but sometimes that’s just what I want.

Therapist: Thanks for your honest feedback. The goal is for you to be the director of this session and of your life. As you lead the way, your own answers will surface to assist you in resolving some of your challenges. In today’s session you clearly identi- fied areas of stress, and then you reconnected with activities that brought you peace and relaxation in the past. You were able to find your answers within yourself.

Person-centered therapy is a collaborative journey driven by what the client brings into the session. I fol- lowed the lead provided by Gwen of what was trou- bling her and attempted to work within the framework

of what she said she wanted. At each step along the way, I show empathy and compassion for her challeng- es as she works to rebuild self-trust and reconnect to her own sense of personal power and value.

Questions for Reflection ◆ What are your thoughts about soliciting client

feedback using rating scales such as the ORS and the SRS?

◆ Gwen wants more suggestions from her therapist. If you were her therapist, how would you intervene with her when she wants more direction from you?

◆ How does person-centered therapy fit with who you are as a person? Would you be comfortable in mostly identifying the client’s underlying mes- sages as the therapist did in this session?

◆ Frequently person-centered therapists identify con- flicts or the competing sides of an issue. Where did the therapist do this in her dialogue with Gwen?

Summary and Evaluation Summary

Person-centered therapy is based on a philosophy of human nature that postulates an innate striving for self-actualization. Carl Rogers’s view of human nature is phe- nomenological; that is, we structure ourselves according to our perceptions of real- ity. We are motivated to actualize ourselves in the reality that we perceive.

Rogers’s theory rests on the assumption that clients can understand the factors in their lives that are causing them to be distressed. They also have the capacity for self-direction and constructive personal change. Change will occur if a congruent therapist makes psychological contact with a client in a state of anxiety or incongru- ence. It is essential for the therapist to establish a relationship the client perceives as genuine, accepting, and understanding. Therapeutic counseling is based on an I/ Thou, or person-to-person, relationship in the safety and acceptance of which cli- ents drop their defenses and come to accept and integrate aspects that they have denied or distorted. The person-centered approach emphasizes this personal rela- tionship between client and therapist; the therapist’s attitudes are more critical than are knowledge, theory, or techniques employed. In the context of this relationship, clients unleash their growth potential and become more of the person they are capa- ble of becoming. An abundance of research supports the notion that the human elements of psychotherapy (client factors, therapist effects, and the therapeutic

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alliance) are far more important than models and techniques in the effectiveness and outcomes of therapy (Elkins, 2016).

This approach places primary responsibility for the direction of therapy on the client. In the therapeutic context, individuals have the opportunity to decide for themselves and come to terms with their own personal power. The underlying assumption is that no one knows the client better than the client; in short, clients are viewed as the expert on their own life (Cain, 2010). The general goals of therapy are becoming more open to experience, achieving self-trust, developing an inter- nal source of evaluation, and being willing to continue growing. Specific goals are not suggested for clients; rather, clients choose their own values and goals. Current applications of the theory emphasize more active participation by the therapist than was the case earlier. Counselors are now encouraged to be fully involved as persons in the therapeutic relationship. More latitude is allowed for therapists to express their reactions and feelings as they are appropriate to what is occurring in therapy. Person-centered practitioners are willing to be transparent about persistent feelings that exist in their relationships with clients (Watson et al., 2011). It is the therapist’s job to adapt and accommodate in a manner that works best for each client, which means being flexible in the application of methods in the counseling process. The application of the person-centered approach must be tailored to the unique needs and preferences of each client (Cain, 2010; Norcross & Cooper, 2021; Norcross & Wampold, 2018, 2019).

Contributions of the Person-Centered Approach When Carl Rogers founded nondirective counseling more than 70 years ago, there were very few other therapeutic models. The longevity of this approach is certainly a factor to consider in assessing its influence. Rogers had, and his theory continues to have, a major impact on the field of counseling and psychotherapy. When he introduced his revolutionary ideas in the 1940s, he provided a powerful and radical alternative to psychoanalysis and to the directive approaches then practiced. Rogers was a pioneer in shifting the therapeutic focus from an emphasis on technique and reliance on therapist authority to that of the power of the therapeutic relationship. Today counselors will find that Rogers’s basic ideas are deeply ingrained in virtually every modern theory of counseling (Hazler, 2022).

As we have seen, Natalie Rogers has made a significant contribution to the appli- cation of the person-centered approach by incorporating the expressive arts as a medium to facilitate healing and social change, primarily in a group setting. She has been instrumental in the evolution of the person-centered approach using nonverbal methods to enable individuals to heal and to develop. Many individuals who have difficulty expressing themselves verbally can find new possibilities for self-expression through nonverbal channels and through the expressive arts (N. Rogers, 2011).

Kirschenbaum (2009) points out that the scope and influence of Rogers’s work has continued well beyond his death; the person-centered approach is alive, well, and expanding. Today there is not one version of person-centered therapy but a number of continuously evolving person-centered psychotherapies (Cain, 2010). Increasingly, person-centered therapists have begun to integrate concepts and methods from other theoretical orientations to the benefit of their clients

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(Cain, 2016). Although few psychotherapists claim to have an exclusive person- centered theoretical orientation, the philosophy and principles of this approach permeate the practice of most therapists. Most schools of therapy are increasingly recognizing the centrality of the therapeutic relationship as an essential component for therapeutic change.

Emphasis on Research One of Carl Rogers’s contributions to the field of psy- chotherapy was his willingness to state his concepts as testable hypotheses and to submit them to research. He literally opened the field to research. He was truly a pioneer in his insistence on subjecting the transcripts of therapy sessions to critical examination and applying research technology to counselor–client dialogues. According to Cain (2010), an enormous body of research, conducted over a period of 70 years, supports the effectiveness of the person-centered approach. This research is ongoing in many parts of the world and continues to expand and refine our understanding of what constitutes effective psychotherapy. Murphy and Joseph (2016) predict, “For the future, we envisage a person-centered experiential therapy that offers a flexible, effective, and evidence-based therapy that is widely available” (p. 210).

Even his critics give Rogers credit for having conducted and inspired others to conduct extensive studies of counseling process and outcome. Rogers presented a challenge to psychology to design new models of scientific investigation capable of dealing with the inner, subjective experiences of the person. His theories of therapy and personality change have had a tremendous heuristic effect. Although much controversy surrounds this approach, his work has challenged practitioners and theoreticians to examine their own therapeutic styles and beliefs.

Limitations and Criticisms of the Person-Centered Approach Although I applaud person-centered therapists for their willingness to subject their hypotheses and procedures to empirical scrutiny, researchers have been critical of the methodological errors contained in some of these studies. Accusations of scien- tific shortcomings involve using control subjects who are not candidates for ther- apy, failing to use an untreated control group, failing to account for placebo effects, reliance on self-reports as a major way to assess the outcomes of therapy, and using inappropriate statistical procedures. In all fairness, these accusations apply to the research on many other therapeutic approaches as well.

There is a similar limitation shared by both the person-centered and existential (experiential) approaches. Neither of these therapeutic modalities emphasizes the role of techniques aimed at bringing about change in clients’ behavior. Proponents of psychotherapy manuals, or manualized treatment methods for specific disorders, find serious limitations in the experiential approaches due to their lack of attention to proven techniques and strategies. Those who call for accountability as defined by evidence-based practices within the field of mental health also are quite critical of the experiential approaches.

I do not believe manualized treatment methods can be considered the gold stan- dard in psychotherapy, however. There is good research demonstrating that tech- niques account for only 15% of client outcome (see Duncan et al., 2010), whereas

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contextual factors have powerful effects on what happens in therapy (Elkins, 2009, 2012, 2016). Research points to relational and client factors as the main predictors of effective therapy. Furthermore, the evaluation of evidence-based practices has been broadened to include best available research; the expertise of the clinician; and client characteristics, culture, and preferences (see Norcross et al., 2017; Norcross & Wampold, 2019).

A potential limitation of the person-centered approach is that some students- in-training and practitioners with this orientation may have a tendency to be very supportive of clients without being challenging. Out of their misunderstanding of the basic concepts of the approach, some have limited the range of their responses and counseling styles mainly to reflections and empathic listening. Although there is value in accurately and deeply hearing a client and in reflecting and communicat- ing understanding, counseling entails more than this. I believe that the therapeutic core conditions are necessary for therapy to succeed, yet I do not see them as being sufficient conditions for change for all clients at all times. From my perspective, these basic attitudes are the foundation on which counselors must then build the skills of therapeutic intervention.

A related challenge for counselors using this approach is to truly support clients in finding their own way. Counselors sometimes experience difficulty in allowing clients to decide their own specific goals in therapy. It is easy to give lip service to the concept of clients’ finding their own way, but it takes considerable respect for clients and faith on the therapist’s part to encourage clients to listen to themselves and fol- low their own directions, particularly when they make choices that are not what the therapist hoped for.

More than any other quality, the therapist’s genuineness determines the power of the therapeutic relationship (Kolden et al., 2019). If therapists submerge their unique identity and style in a passive and nondirective manner, they are not likely to affect clients in powerful ways. Therapist authenticity and congruence are so vital to this approach that those who practice within this framework must find a way to express their own reactions to clients.

Self-Reflection and Discussion Questions 1. To what degree do you believe clients have the ability to understand

and resolve their own problems without a great deal of advice or sug- gestions from a therapist?

2. This therapy approach places considerable importance on congruence (realness or genuineness) on the part of the therapist. How confident are you that you will be able to be genuine in your interaction with your clients?

3. The therapeutic relationship is given prominence in this theory. What kind of relationship do you hope to create with your clients? Identify the characteristics you deem most important.

4. Empathy is a core ingredient in person-centered therapy. What do you think you can do to increase your ability to develop empathy toward a client who you perceive of as being difficult?

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5. How would it be for you to practice by relying on a minimum of techniques and instead staying tuned into a client’s moment-by- moment experience?

Where to Go From Here Free Podcasts for ACA Members

You can download ACA Podcasts (prerecorded interviews) by going to www.coun- seling.org; click on the Resource button and then select the Podcast Series. For Chapter 7, Carl Rogers and the Person-Centered Approach, look for Podcast 7 by Dr. Howard Kirschenbaum.

Other Resources The American Psychological Association offers the following DVDs in their Psycho- therapy Video Series:

Greenberg, L. S. (2010). Emotion-Focused Therapy Over Time

Cain, D. J. (2010). Person-Centered Therapy Over Time

Psychotherapy.net is a comprehensive resource for students and professionals that offers videos and interviews featuring Natalie Rogers, Rollo May, and more. New articles, interviews, blogs, therapy cartoons, and videos are published monthly. DVDs relevant to this chapter are available at www.psychotherapy.net and include the following:

Rogers, N. (1997). Person-Centered Expressive Arts Therapy

May, R. (2007). Rollo May on Existential Psychotherapy

The Association for the Development of the Person-Centered Approach (ADPCA) is an interdisciplinary and international organization that consists of a network of individuals who support the development and application of the person- centered approach. Membership includes a subscription to the Person-Centered Journal, the association’s newsletter, a membership directory, and information about the annual meeting. ADPCA also provides information about continuing education and supervision and training in the person-centered approach. For information about the Person-Centered Journal, contact the editor (Jon Rose). For more information regarding the Association for the Development of the Person-Centered Approach, visit their website (www.adpca.org).

The Association for Humanistic Psychology is devoted to promoting personal integrity, creative learning, and active responsibility in embracing the challenges of being human in these times. Information about the Journal of Humanistic Psychology is available at the publisher’s website. For more information regarding the Association for Humanistic Psychology, visit their website (www.ahpweb.org).

Division 32 of APA, Society for Humanistic Psychology, represents a constella- tion of “humanistic psychologies” that includes the earlier Rogerian, transpersonal,

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and existential orientations as well as recently developing perspectives. Division 32 seeks to contribute to psychotherapy, education, theory, research, epistemological diversity, cultural diversity, organization, management, social responsibility, and change. The division has been at the forefront in the development of qualitative research methodologies. The Society for Humanistic Psychology offers journal access to The Humanistic Psychologist. Information about membership, conferences, and journals is available from the website of Division 32. For more informa- tion regarding the Society for Humanistic Psychology, visit their website (www .societyforhumanisticpsychology.com/).

Recommended Supplementary Readings for Chapter 7 On Becoming a Person (Rogers, 1961) is one of the best primary sources for further reading on person- centered therapy. This classic book is a collection of Carl Rogers’s articles on the process of psychother- apy, its outcomes, the therapeutic relationship, edu- cation, family life, communication, and the nature of the healthy person.

A Way of Being (Rogers, 1980) contains a series of writings on Carl Rogers’s personal experiences and perspectives, as well as chapters on the foundations and applications of the person-centered approach.

The Creative Connection: Expressive Arts as Healing (N. Rogers, 1993) is a practical, spirited book lavishly illustrated with color and action photos and filled with fresh ideas to stimulate creativity, self-expression, heal- ing, and transformation. Natalie Rogers combines the philosophy of her father with the expressive arts to enhance communication between client and therapist.

The Life and Work of Carl Rogers (Kirschenbaum, 2009) is a definitive biography of Carl Rogers that follows his life from his early childhood through his death. This book illustrates the legacy of Carl Rogers and shows his enormous influence on the field of counseling and psychotherapy.

Person-Centered Psychotherapies (Cain, 2010) contains a clear discussion of person-centered theory, the therapeutic process, evaluation of the approach, and future developments.

Humanistic Psychology: A Clinical Manifesto (Elkins, 2009) offers an insightful critique of the medical model of psychotherapy and the myth of empiri- cally supported treatments. The author calls for a relationship-based approach to psychother- apy that can provide both individual and social transformation.

References Bohart, A. C., & Tallman, K. (2010). Clients: The neglected common factor in psychotherapy. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed., pp. 83–111). American Psychological Association. Bohart, A. C., & Wade, A. G. (2013). The client in psychotherapy. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed., pp. 219–257). Wiley.

Bohart, A. C., & Watson, J. C. (2020). Person-centered and emotion-focused psychotherapies. In S. B. Messer & N. J. Kaslow (Eds.), Essential psychotherapies: Theory and practice (4th ed., pp. 221–256). Guilford Press. Bozarth, J. D., Zimring, F. M., & Tausch, R. (2002). Client-centered therapy: The evolution of a revolution. In D. J. Cain & J. Seeman (Eds.), Humanistic psychotherapies: Handbook of research and practice (pp. 147–188). American Psychological Association.

Cain, D. J. (2002). Defining characteristics, history, and evolution of humanistic psychotherapies. In D. J. Cain & J. Seeman (Eds.), Humanistic psychotherapies: Handbook of research and practice (pp. 3–54). American Psychological Association. Cain, D. J. (2010). Person-centered psychotherapies. American Psychological Association. Cain, D. J. (2013). Person-centered therapy. In J. Frew & M. D. Spiegler (Eds.), Contemporary psychotherapies for a diverse world (pp. 165–213). Routledge, Taylor & Francis.

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Cain, D. J. (2016). Toward a research- based integration of optimal practices of humanistic psychotherapies. In D. J. Cain, K. Keenan, & S. Rubin (Eds.), Humanistic psychotherapies: Handbook of research and practice (2nd ed., pp. 485–535). American Psychological Association. Cain, D. J., Keenan, K., & Rubin, S. (Eds.). (2016). Humanistic psychotherapies: Handbook of research and practice (2nd ed.). American Psychological Association. Clark, A. J. (2022). Empathy and mental health: An integral model for developing therapeutic skills in counseling and psychotherapy. Routledge. Corey, G. (2013). Case approach to counseling and psychotherapy (8th ed.). Brooks/Cole, Cengage Learning. Corey, G. (2023). Theory and practice of group counseling (10th ed.). Cengage Learning. Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (Eds.). (2010). The heart and soul of change (2nd ed.). American Psychological Association. Elkins, D. N. (2009). Humanistic psychology: A clinical manifesto. University of the Rockies Press. Elkins, D. N. (2012). Toward a common focus in psychotherapy research. Psychotherapy, 49(4), 450–454. Elkins, D. N. (2016). The human elements of psychotherapy: A nonmedical model of emotional healing. American Psychological Association. Elliott, R., Bohart, A. C., Watson, J. C., & Murphy, D. (2019). Empathy. In J. C. Norcross & M. J. Lambert (Eds.), Psychotherapy relationships that work: Evidence-based therapist contributions (vol. 1, 3rd ed., pp. 245–287). Oxford University Press. Farber, B. A., Suziki, J. Y., & Lynch, D. A. (2019). Positive regard and affirmation. In J. C. Norcross & M. J. Lambert (Eds.), Psychotherapy relationships that work: Evidence-based therapist contributions (vol. 1, 3rd ed., pp. 288–322). Oxford University Press. Goldman, R. N. (2016). Emotion-focused therapy. In D. J. Cain, K. Keenan, & S. Rubin (Eds.), Humanistic psychotherapies: Handbook of research and practice (2nd ed., pp. 319–350). American Psychological Association. Goldman, R. N., Vaz, A., & Rousmaniere, T. (2021). Deliberate

practice in emotion-focused therapy. American Psychological Association. Greenberg, L. S. (2017). Emotion-focused therapy (Rev. ed.). American Psychological Association. Greenberg, L. S., & Goldman, R. N. (Eds.). (2019). Clinical handbook of emotion- focused therapy. American Psychological Association. Hazler, R. J. (2022). Person-centered theory. In D. Capuzzi & M. D. Stauffer (Eds.), Counseling and psychotherapy: Theories and interventions. (7th ed., pp. 139–163). American Counseling Association. Keenan, K., & Rubin, S. (2016). The good therapist: Evidence regarding the therapist’s contribution to psychotherapy. In D. J. Cain, K. Keenan, & S. Rubin (Eds.), Humanistic psychotherapies: Handbook of research and practice (2nd ed., pp. 421–454). American Psychological Association. Kirschenbaum, H. (2009). The life and work of Carl Rogers. American Counseling Association. Kolden, G. G., Wang, C., Austin, S. B., Chang, Y., & Klein, M. H. (2019). Congruence/genuineness. In J. C. Norcross & M. J. Lambert (Eds.), Psychotherapy relationships that work: Evidence-based therapist contributions (vol. 1, 3rd ed., pp. 323–350). Oxford University Press. Koltko-Rivera, M. E. (2006). Rediscovering the later version of Maslow’s hierarchy of needs: Self- transcendence and opportunities for theory, research, and unification. Review of General Psychology, 10(4), 302–317. Maslow, A. (1968). Toward a psychology of being. Van Nostrand Reinhold. Maslow, A. (1970). Motivation and personality (2nd ed.). Harper & Row. Maslow, A. (1971). The farther reaches of human nature. Viking. McDonald, A. R. (2015). Emotion- focused therapy. In E. Neukrug (Ed.), Sage encyclopedia of theory in counseling and psychotherapy, (vol. 1, pp. 341–344). Sage. Miller, W. R., & Moyers, T. B. (2021). Effective psychotherapists: Clinical skills that improve client outcomes. Guilford Press. Murphy, D., & Joseph, S. (2016). Person- centered therapy: Past, present, and future orientations. In D. J. Cain, K. Keenan, & S. Rubin (Eds.), Humanistic psychotherapies: Handbook of research and practice (2nd ed.,

pp. 185–218). American Psychological Association. Norcross, J. C., & Cooper, M. (2021). Personalizing psychotherapy: Assessing and accommodating patient preferences. American Psychological Association. Norcross, J. C., Hogan, T. P., Koocher, G. P., & Maggio, L. A. (2017). Clinician’s guide to evidence-based practices: Behavioral health and addictions (2nd ed.). Oxford University Press. Norcross, J. C., & Wampold, B. E. (2018). A new therapy for each patient: Evidence- based relationships and responsiveness. Journal of Clinical Psychology, 74(11), 1889–1906. Norcross, J. C., & Wampold, B. E. (Eds.). (2019). Psychotherapy relationships that work, Volume 2: Evidence-based responsiveness (3rd ed.). Oxford University Press. Rashid, T., & Seligman, M. (2019). Positive psychotherapy. In D. Wedding & R. J. Corsini (Eds.), Current psychotherapies (11th ed., pp. 481–526). Cengage Learning. Rogers, C. (1942). Counseling and psychotherapy: Newer concepts in practice. Houghton Mifflin. Rogers, C. (1951). Client-centered therapy. Houghton Mifflin. Rogers, C. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95–103. Rogers, C. (1961). On becoming a person. Houghton Mifflin. Rogers, C. (1967). The conditions of change from a client-centered viewpoint. In B. Berenson & R. Carkhuff (Eds.), Sources of gain in counseling and psychotherapy. Holt, Rinehart & Winston. Rogers, C. (1970). Carl Rogers on encounter groups. Harper & Row. Rogers, C. (1977). Carl Rogers on personal power: Inner strength and its revolutionary impact. Delacorte Press. Rogers, C. (1980). A way of being. Houghton Mifflin. Rogers, C. (1986). Client-centered therapy. In I. L. Kutash & A. Wolf (Eds.), Psychotherapists casebook (pp. 197–208). Jossey-Bass. Rogers, C. R., & Freiberg, H. J. (1994). Freedom to learn (3rd ed.). Prentice Hall. Rogers, C. R., & Russell, D. E. (2002). Carl Rogers: The quiet revolutionary. Penmarin Books.

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Rogers, N. (1993). The creative connection: Expressive arts as healing. Science & Behavior Books. Rogers, N. (2002). Carl Rogers: A Daughter’s Tribute (CD ROM). Mingarden Media, Inc. www.nrogers.com Rogers, N. (2011). The creative connection for groups: Person-centered expressive arts for healing and social change. Science and Behavior Books. Schneider, K. J., & Krug, O. T. (2017). Existential-humanistic therapy (2nd ed.). American Psychological Association. Schneider, K. J., & Krug, O. T. (2020). Existential-humanistic psychotherapies.

In S. B. Messer & N. J. Kaslow (Eds.), Essential psychotherapies: Theory and practice (4th ed., pp. 257–293). Guilford Press. Seligman, M. E. P. (2011). Flourish: A visionary new understanding of happiness and well-being. Free Press. Sue, D. W., Sue, D., Neville, H. A., & Smith, L. (2022). Counseling the culturally diverse: Theory and practice (9th ed.). Wiley. Watson, J. C. (2016). The role of empathy in psychotherapy: Theory, research, and practice. In D. J. Cain, K. Keenan, & S. Rubin (Eds.), Humanistic psychotherapies: Handbook of research and practice (2nd ed.,

pp. 115–145). American Psychological Association. Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2011). Humanistic and experiential theories in psychotherapy. In J. C. Norcross, G. R. Vandenbos, & D. K. Freedheim (Eds.), History of psychotherapy (2nd ed., pp. 141–172). American Psychological Association. Zimring, F. M., & Raskin, N. J. (1992). Carl Rogers and client/person-centered therapy. In D. K. Freedheim (Ed.), History of psychotherapy: A century of change (pp. 629–656). American Psychological Association.

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8Gestalt Therapy

1. Discuss the evolution of this approach from the pioneering work of Fritz Perls to contemporary relational approaches.

2. Define the philosophy and basic assumptions underlying Gestalt theory and therapy.

3. Identify these key concepts of the approach: holism, field theory, the figure-formation process, and organismic self-regulation.

4. Describe how the trusting relationship is central to the use of experiments in the therapy process.

5. Discuss the role of confrontation in contemporary relational Gestalt therapy.

6. Explain these standard Gestalt therapy interventions: internal dialogue exercise, empty-chair technique, future projection, making the rounds, reversal exercise, rehearsal exercise, exaggeration exercise, staying with the feeling, and the Gestalt approach to dream work.

7. Describe the application of Gestalt therapy to group counseling.

8. Discuss the application of the Gestalt approach in working with school counseling.

9. Describe the practice of Gestalt therapy from a multicultural perspective.

10. Evaluate the contributions, strengths, and limitations of the Gestalt approach.

Learning Objectives

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Erving Polster (b. 1922) is still professionally active and gives presentations, therapy demon- strations, and workshops. He is regularly featured at the Evolu- tion of Psychotherapy confer- ence and the Brief Therapy con- ference. Erving Polster writes the following about his con- nection with Gestalt Therapy:*

I first became aware of Gestalt Therapy in 1953 when I attended a workshop in Cleveland with Frederick Perls. He was masterful in the therapy ses- sions he conducted with those of us who attended the workshop. Two aspects of the experience stand out for me. One was the combination of simplicity and power in both his concepts and his therapeutic work. The second was the surprising public nature of the personal explorations. This openness was revelatory in a process that had been steeped in privacy. Yet this freedom seemed both natural and daring, an enchanting exemplification of the drama of living.

These explorations led to the formation of the Gestalt Institute of Cleveland, where I was faculty chairman from 1956 to 1973. The courses I created there composed a point of view that became the foundation of Gestalt Therapy Integrated: Contours

of Theory and Practice (1973), a book coauthored with my wife, Miriam. We moved to San Diego in 1973 and opened the Gestalt Training Center. Peo- ple came there for 25 years from all over the world for extensive training work with us. Those were ex- citing and productive days, and Miriam and I had the pleasure of our partnership in developing our ideas and our training programs.

Some years later, I wrote Every Person’s Life Is Worth a Novel (1987b) and A Population of Selves: A Therapeutic Exploration of Personality Diversity (1995) and coauthored an anthology of Miriam’s and my writings titled From the Radical Center: The Heart of Gestalt Therapy (1999). Miriam died in 2001, at which point we had both been retired for two years. After she died, I came out of retirement and began to explore a new theme, advocating the ad- vancement of psychotherapy principles from a pri- vate office procedure into a communal application. I have written three books about this: Uncommon Ground (Polster, 2006), Beyond Therapy: Igniting Life Focus Community Movements (Polster, 2015), and Enchantment and Gestalt Therapy: Partners in Ex- ploring Life (Polster, 2021).

*I invited Erving Polster to write his biography and his wife Miriam’s biography, which he kindly accepted. My gratitude to Erv Polster for providing these sketches of the Polsters’ contributions to the development of Gestalt therapy.

Miriam Polster (1924–2001) earned her undergraduate de- gree in music. She was trained as a classical vocalist and a performer of operatic music. Her artistic gifts remained with her throughout her personal and professional life. M. Polster led workshops in which music served as a framework for as- sisting clients in exploring per- sonal experiences.

She was a strong advocate of the relational di- mension of Gestalt therapy, a counterpoint to the

skewed stereotype of it as confrontational and tech- nically narrow. The freshness of her perspectives, the clarity of her language, and the excitement evoked by her radiance all served to raise the charismatic potential of the therapist who entered into the realm of simple fascination with the way people lived their lives. The long arc of her influence was drawn by a feminine candor and conversational mutuality that achieved its strength through presence and intelli- gence more than through forcefulness; of relation- ship more than through manipulation; of optimism more than metallic rationalism; and, at last, of a wis- dom-based tension that created a natural progres- sion of experience.

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Introduction Gestalt therapy is an existential, phenomenological, and process-based approach created on the premise that individuals must be understood in the context of their ongoing relationship with the environment. Awareness, choice, and responsibility are cornerstones of practice. The initial goal is for clients to expand their awareness of what they are experiencing in the present moment. Through this awareness, change automatically occurs. The approach is phenomenological because it focuses on the client’s perceptions of reality and existential because it is grounded in the notion that people are always in the process of becoming, remaking, and rediscover- ing themselves. As an existential approach, Gestalt therapy gives special attention to existence as individuals experience it and affirms the human capacity for growth and healing through interpersonal contact and insight (Yontef, 1995). In a nutshell, this approach focuses on the here and now, the what and how of experiencing, the authenticity of the therapist, active dialogic inquiry and exploration, a dialogical relationship, and the I/Thou of relating (Brownell, 2016; Resnick, 2015; Wheeler & Axelsson, 2015; Yontef et al., 2019).

Fritz Perls was the main originator and developer of Gestalt therapy. Although Perls was influenced by psychoanalytic concepts, he took issue with Freud’s theory on a number of grounds. Although Freud’s view of human beings is basically mecha- nistic, Perls stressed a holistic approach to personality. Freud focused on repressed intrapsychic conflicts from early childhood, whereas Perls valued examining the present situation. The Gestalt approach focuses much more on process than on con- tent. This process involves Gestalt therapists putting themselves as fully as possible into the experience of the client without judgment, analyzing, or interpreting, while concurrently holding a sense of one’s individual, independent presence. Therapists devise experiments designed to increase clients’ awareness of what they are doing and how they are doing it moment to moment. Perls asserted that how individuals behave in the present moment is far more crucial to self-understanding than why they behave as they do. Awareness usually involves insight and sometimes intro- spection, but Gestalt therapists consider it to be much more than either. A defining

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Gestalt Therapy Integrated: Contours of Theory and Practice (1973), coauthored with her husband, Erving Polster, is considered a classic and a benchmark in the evolution of Gestalt therapy. In Eve’s Daughters: The Forbidden Heroism of Women (1992), M. Polster paint- ed an eye-opening picture of the contributions and the character of women in our society. She spelled out the historical role of women and their special heroic contributions to social progress. However, she went further than their overlooked heroism by also postulating a picture of heroism itself. She bright-

ened the concept by reminding us of the heroism that is a part of everyday living. This interweaving of women’s heroism with the heroism of everyday life ac- cented the value of women’s potential for effecting new social norms. Women’s heroism had been taken for granted and was relegated to the background of social importance. M. Polster tied this social expan- sion of feminine heroism, often part of their ministra- tions in the world of everyday living, to an enlivened understanding of the subtle role of ordinary heroism of people at large.

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characteristic of awareness is paying attention to the flow of your experience and being in contact with what you are doing when you are doing it (Resnick, 2015).

Self-acceptance, knowledge of the environment, responsibility for choices, and the ability to make contact with their field (a dynamic system of interrelationships) and the people in it are important awareness processes and goals, all of which are based on a here-and-now experiencing that is always changing. Clients are expected to do their own seeing, feeling, sensing, and interpreting, as opposed to waiting pas- sively for the therapist to provide them with insights and answers.

Contemporary relational Gestalt therapy stresses dialogue and the I/Thou relationship between client and therapist. Therapists emphasize the therapeutic relationship and work collaboratively with clients in a search for understanding (Brownell, 2016; Wheeler & Axelsson, 2015). Following the lead of Laura Perls and the “Cleveland school” when Erving and Miriam Polster and Joseph Zinker were on the faculty in the 1960s and 1970s, this model includes more support and increased sensitivity and compassion in therapy than the confrontational and dramatic style of Fritz Perls (Yontef, 1999). The majority of today’s Gestalt therapists emphasize support, acceptance, empathy, respect, and dialogue as well as caring confrontation.

Gestalt therapy is lively and promotes direct experiencing rather than the abstractness of talking about situations. Gestalt therapy is an experiential approach in that clients come to grips with what and how they are thinking, feeling, and doing as they interact with the therapist. Gestalt practitioners value being fully present during the therapeutic encounter with the belief that growth occurs out of genuine contact between client and therapist.

Refer to the MindTap for this book to interact with video quizzes and various video programs to expand your knowledge on topics relevant to Chapter 8.

Key Concepts View of Human Nature

The Gestalt view of human nature is rooted in existential philosophy, phenomenol- ogy, and field theory. Genuine knowledge is the product of what is immediately evident in the experience of the perceiver. Therapy aims at awareness and contact with the environment, which consists of both the external and internal worlds. The quality of contact with aspects of the external world (for example, other people) and the internal world (for example, parts of the self that are disowned) are monitored. The process of “reowning” parts of oneself that have been disowned and the unifica- tion process proceed step by step until clients can carry on with their own personal growth. By becoming aware, clients become able to make informed choices and thus to live a more meaningful existence.

Due to this view of human nature, Fritz Perls (1969) practiced Gestalt therapy paternalistically. Clients have to grow up, stand on their own two feet, and “deal with their life problems themselves” (p. 225). Perls’s style of doing therapy involved

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two personal agendas: moving the client from environmental support to self- support and reintegrating the disowned parts of one’s personality. His conception of human nature and these two agendas set the stage for a variety of techniques and for his confrontational style of conducting therapy. He was a master at intentionally frustrating clients to enhance their awareness.

A basic assumption of Gestalt therapy is that individuals have the capacity to self-regulate when they are aware of what is happening in and around them. Peo- ple are context sensitive and motivated to solve problems. The therapist is atten- tive to the client’s present experience and trusts in the process, thereby assisting the client in moving toward increased awareness, contact, and integration (Yontef et al., 2019).

The Gestalt theory of change posits that the more we work at becoming who or what we are not, the more we remain the same. Fritz’s good friend and psychiatrist colleague Arnie Beisser (1970) suggested that authentic change occurs more from being who we are than from trying to be who we are not. Beisser called this simple tenet the paradoxical theory of change. We are constantly moving between who we “should be” and who we “are.” Gestalt therapists ask clients to invest themselves fully in their current condition rather than striving to become who they should be. Knowing and accepting the truth of our situation builds wholeness and supports growth (Yontef et al., 2019).

Some Principles of Gestalt Therapy Theory Several basic principles underlying the theory of Gestalt therapy are briefly described in this section: holism, field theory, the figure-formation process, and organismic self-regulation. Other key concepts of Gestalt therapy are developed in more detail in the sections that follow.

Holism Gestalt is a German word meaning a whole or completion, or a form that cannot be separated into parts without losing its essence. All of nature is seen as a unified and coherent whole, and the whole is different from the sum of its parts. Because Gestalt therapists are interested in the whole person, they place no superior value on a particular aspect of the individual. Gestalt practice attends to a client’s thoughts, feelings, behaviors, body, memories, and dreams.

Field Theory Gestalt therapy is based on field theory, which, simply put, asserts that the organism must be seen in its environment, or in its context, as part of the constantly changing field. Gestalt therapists pay attention to and explore what is occurring at the boundary between the person and the environment. Emphasis may be on a figure (those aspects of the individual’s experience that are most salient at any moment) or the ground (those aspects of the client’s presentation that are often out of his or her awareness). Cues to this background can be found on the surface through physical gestures, tone of voice, demeanor, and other nonverbal content. This is often referred to by Gestalt therapists as “attending to the obvious,” while paying attention to how the parts fit together, how the individual makes contact with the environment, and integration.

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The Figure-Formation Process Derived from the study of visual perception by a group of Gestalt psychologists, the figure-formation process tracks how the individual organizes experience from moment to moment as some aspect of the environmental field emerges from the background and becomes the focal point of the individual’s attention and interest. For example, imagine seeing a woman on a hill in the distance. You do not see her clearly but receive an overall impression of this figure: a Gestalt. As you move closer, you gain more awareness of this figure and she becomes increasingly clear and more detailed: you see her face and the way she buttons her blouse. In the figure-formation process, contemporary Gestalt therapists facilitate the client’s movement toward and away from this figure of interest. The dominant needs of the individual at a given moment influence this process (Frew, 1997).

Organismic Self-Regulation The figure-formation process is intertwined with the principle of organismic self-regulation, a process by which equilibrium is “disturbed” by the emergence of a need, a sensation, or an interest. Organisms will do their best to regulate themselves, given their own capabilities and the resources of their environment (Latner, 1986). Individuals can take actions and make contacts to restore equilibrium or to contribute to growth and change. What emerges in therapeutic work is what is of interest to the client or what the client needs to gain equilibrium or to change. Gestalt therapists direct the client’s awareness to the figures that emerge from the background during a therapy session and use the figure-formation process as a guide for the focus of therapeutic work.

Contact and Resistances to Contact In Gestalt therapy contact is necessary if change and growth are to occur. Contact is made by seeing, hearing, smelling, touching, and moving. Effective contact means interacting with nature and with other people without losing one’s sense of individu- ality. Prerequisites for good contact are clear awareness, full energy, and the ability to express oneself. Contact between therapist and client are key to Gestalt therapy prac- tice. Miriam Polster (1987) claimed that contact is the lifeblood of growth. It is the continually renewed creative adjustment of individuals to their environment. It entails zest, imagination, and creativity. There are only moments of this type of contact, so it is most accurate to think of levels of contact rather than a final state to achieve. After a contact experience, there is typically a withdrawal to integrate what has been learned. Gestalt therapists talk about the two functions of boundaries: to connect and to sepa- rate. Both contact and withdrawal are necessary and important to healthy functioning.

Gestalt therapists focus on interruptions, disturbances, and resistances to con- tact, which were developed as coping processes but often end up preventing us from experiencing the present in a full and real way. Resistances are typically adopted out of our awareness and, when they function in a chronic way, can contribute to dysfunctional behavior. Polster (2021) makes the point that traditionally resistance implies that people are not doing what they “should” be doing. Resistance can be understood as behavior that keeps us from exploring personal conflicts or painful feelings. It is our attempt to protect ourselves from anxiety and defend ourselves from pain, and thus it serves a function.

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Therapists can understand clients’ reluctance as an outdated coping strategy that at one time served an adaptive function but is no longer useful. By honoring clients’ resistance, therapists are able to understand that a particular coping strat- egy was the best possible response to a difficult situation. Polster (2021) speaks of “creative resistance,” which implies that resistive behavior can be a desirable charac- teristic. Because resistances are developed as a means of coping with life situations, they possess positive qualities as well as problematic ones, and many contemporary Gestalt therapists refer to them as “contact boundary disturbances” (Polster, 2021). Polster and Polster (1973) describe five different kinds of contact boundary distur- bances: introjection, projection, retroflection, deflection, and confluence.

Introjection is the tendency to uncritically accept others’ beliefs and standards without assimilating them to make them congruent with who we are. These introj- ects remain alien to us because we have not analyzed and restructured them. When we introject, we passively incorporate what the environment provides rather than clearly identifying what we want or need. If we remain in this stage, our energy is bound up in taking things as we find them and believing that authorities know what is best for us rather than working for things ourselves.

Projection is the reverse of introjection. In projection we disown certain aspects of ourselves by assigning them to the environment. Those attributes of our person- ality that are inconsistent with our self-image are disowned and put onto, assigned to, and seen in other people; thus, blaming others for lots of our problems. By seeing in others the very qualities that we refuse to acknowledge in ourselves, we avoid tak- ing responsibility for our own feelings and the person who we are, and this keeps us powerless to initiate change. People who use projection as a pattern tend to feel that they are victims of circumstances, and they believe that people have hidden mean- ings behind what they say.

Retroflection consists of turning back onto ourselves what we would like to do to someone else or doing to ourselves what we would like someone else to do to or for us. This process is principally an interruption of the action phase in the cycle of experience and typically involves a fair amount of anxiety. People who rely on retroflection tend to inhibit themselves from taking action out of fear of embar- rassment, guilt, and resentment. People who self-mutilate or who injure themselves, for example, are often directing aggression inward out of fear of directing it toward others. Depression and psychosomatic complaints are often created by retroflecting. Typically, these maladaptive styles of functioning are adopted outside of our aware- ness; part of the process of Gestalt therapy is to help us discover a self-regulatory system so that we can deal realistically with the world.

Deflection is the process of distraction or veering off, so that it is difficult to maintain a sustained sense of contact. We attempt to diffuse or defuse contact through the overuse of humor, abstract generalizations, and questions rather than statements (Frew, 1986). When we deflect, we speak through and for others, beat- ing around the bush rather than being direct and engaging the environment in an inconsistent and inconsequential basis, which results in emotional depletion.

Confluence involves blurring the differentiation between the self and the environment. As we strive to blend in and get along with everyone, there is no clear demarcation between internal experience and outer reality. Confluence in rela- tionships involves the absence of conflicts, slowness to anger, and a belief that all

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parties experience the same feelings and thoughts we do. This style of contact is characteristic of clients who have a high need to be accepted and liked, thus finding enmeshment comfortable. This condition makes genuine contact extremely diffi- cult. A therapist might assist clients who use this channel of resistance by asking questions such as these: “What are you doing now?” “What are you experiencing at this moment?” “What do you want right now?”

Terms such as interruptions in contact or boundary disturbance refer to the charac- teristic styles people employ in their attempts to control their environment through one of these channels of resistance. The premise in Gestalt therapy is that contact is both normal and healthy, and clients are encouraged to become increasingly aware of their dominant style of blocking contact and their use of resistance. Today’s Gestalt therapists readily attend to how clients interrupt contact, approaching the interrup- tive styles with respect and taking each style seriously, knowing that it has served an important function in the past. It is important to explore what the resistance does for clients: what it protects them from, and what it keeps them from experiencing.

The Now One of the main contributions of the Gestalt approach is its emphasis on learning to appreciate and fully experience the present moment. A key principle of Gestalt therapy is that whatever is happening at the moment is center stage (Polster, 2021). Focusing on the past and the future can be a way to avoid coming to terms with the present. Polster and Polster (1973) developed the thesis that “power is in the present.” Some Gestalt therapists claim that clients have a tendency to invest their energies in bemoaning their past mistakes and ruminating about how life could and should have been different or engaging in endless resolutions and plans for the future. As clients direct their energy toward what was or what might have been or live in fantasy about the future, the power of the present diminishes.

Phenomenological inquiry involves paying attention to what is occurring now. Most people can stay in the present for only a short time and are inclined to find ways of interrupting the flow of the present. Instead of experiencing their feel- ings in the here and now, clients often talk about their feelings, almost as if their feelings were detached from their present experiencing. One of the aims of Gestalt therapy is to help clients to become increasingly aware of their present experience.

To help the client make contact with the present moment, Gestalt therapists ask “what” and “how” questions, but rarely ask “why” questions. To promote “now” awareness, the therapist encourages a dialogue in the present tense by asking ques- tions like these: “What is happening now?” “What is going on now?” “What are you experiencing as you sit there and attempt to talk?” “What is your awareness at this moment?” “How are you experiencing your fear?” “How are you attempting to with- draw at this moment?” “How is it for you to be with me in this room now?” Phenom- enological inquiry also involves suspending any preconceived ideas, assumptions, or interpretations concerning the meaning of a client’s experience.

For example, if Josephine begins to talk about sadness, pain, or confusion, the Gestalt therapist invites her to experience her sadness, pain, or confusion now. As she attends to the present experience, the therapist gauges how much anxiety or discomfort is present and chooses further interventions accordingly. The therapist

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might choose not to comment as Josephine moves away from the present moment, only to extend another invitation several minutes later. If a feeling emerges, the ther- apist might suggest an experiment that would help Josephine increase her aware- ness of the feeling, such as exploring where and how she experiences it. Likewise, if a thought or idea emerges, introducing an experiment can help her delve into the thought, explore it more fully, and consider its effects and possible ramifications.

Although the focus of Gestalt therapy is clearly on what is happening in the present, there are disadvantages of this exclusive focus if the past and the future are discounted. E. Polster (2021) claims that too tight of a focus on the here and now will foreclose on much that matters, such as the continuity of past and present. Gestalt therapists recognize that the past will make regular appearances in the pres- ent moment, usually because of some lack of completion of that past experience. When the past seems to have a significant bearing on clients’ present attitudes or behavior, it is dealt with by bringing it into the present as much as possible. When clients speak about their past, the therapist may ask them to reenact it as though they were living it now. The therapist directs clients to “bring the fantasy here” or “tell me the dream as though you were having it now,” striving to help them relive what they experienced earlier. For example, rather than talking about a past child- hood trauma with her father, a client becomes the hurt child and talks directly to her father in fantasy, or by imagining him being present in the room in an empty chair.

Unfinished Business When figures emerge from the background but are not completed and resolved, individuals are left with unfinished business, which can be manifested in unex- pressed feelings such as resentment, worry, rage, hatred, pain, anxiety, grief, guilt, and abandonment. Unacknowledged feelings create unnecessary emotional debris that clutters present-centered awareness. Because the feelings are not fully experi- enced in awareness, they linger in the background and are carried into present life in ways that interfere with effective contact with oneself and others: “These incomplete directions do seek completion and when they get powerful enough, the individual is beset with preoccupation, compulsive behavior, wariness, oppressive energy and much self-defeating behavior” (Polster & Polster, 1973, p. 36). Unfinished business often relates to feelings that have been left over from interpersonal relationships and persists until the individual faces and deals with the unexpressed feelings. The effects of unfinished business often show up in some blockage within the body, and the therapist’s task is to assist clients in exploring these bodily expressions. Gestalt therapists emphasize paying attention to the bodily experience on the assumption that if feelings are unexpressed they tend to result in some physical sensations or problems.

The impasse, or stuck point, occurs when external support is not available or the customary way of being does not work. The therapist’s task is to accompany clients in experiencing the impasse without rescuing or frustrating them. The coun- selor assists clients by providing situations that encourage them to fully experience their condition of being stuck. By completely experiencing the impasse, they are able to get into contact with their frustrations and accept whatever is rather than

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wishing they were different. Gestalt therapy is based on the notion that individuals have a striving toward actualization and growth and that if they accept all aspects of themselves without judging these dimensions they can begin to think, feel, and act differently.

Energy and Blocks to Energy When energy is blocked, in often results in unfinished business. In Gestalt therapy special attention is given to where energy is located, how it is used, and how it can be blocked. Blocked energy is another form of defensive behavior. It can be mani- fested by tension in some part of the body, by posture, by keeping one’s body tight and closed, by not breathing deeply, by looking away from people when speaking to avoid contact, by choking off sensations, by numbing feelings, and by speaking with a restricted voice, to mention only a few.

Clients may not be aware of their energy or where it is located, and they may experience it in a negative way. One of the tasks of the therapist is to help clients find the focus of interrupted energy, identify the ways in which they are blocking energy, and transform this blocked energy into more adaptive behaviors. Clients can be encouraged to recognize how their resistance is being expressed in their body. Rather than trying to rid themselves of certain bodily symptoms, clients can be encouraged to delve fully into tension states and bodily symptoms. For example, by allowing themselves to exaggerate their tight mouth and shaking legs, they can discover for themselves how they are diverting energy and keeping themselves from a full expression of aliveness.

The Therapeutic Process Therapeutic Goals

Gestalt therapy does not ascribe to a “goal-oriented” methodology per se, but ther- apists clearly attend to a basic goal—namely, assisting the client to attain greater awareness, and with it, greater choice. Awareness includes knowing the environ- ment, knowing oneself, accepting oneself, and being able to make contact. Increased and enriched awareness, by itself, is seen as curative. Without awareness, clients do not possess the tools for personality change. With awareness, they have the capac- ity to face, accept, and integrate denied parts as well as to fully experience their subjectivity. Through becoming aware of these denied parts and working toward owning their experience, clients can become integrated, or whole. When clients stay with their awareness, important unfinished business will emerge and can be dealt with in therapy. The Gestalt approach helps clients note their own awareness pro- cess so that they can be responsible and can selectively and discriminatingly make choices. Awareness emerges within the context of a genuine meeting (contact) between client and therapist.

The existential view is that we are continually engaged in a process of remaking and discovering ourselves (see Chapter 6). We do not have a static identity but dis- cover new facets of our being as we face new challenges. Through a creative involve- ment in Gestalt process, Zinker (1978) expects clients will do the following:

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◆ Move toward increased awareness of themselves ◆ Gradually assume ownership of their experience (as opposed to making

others responsible for what they are thinking, feeling, and doing) ◆ Develop skills and acquire values that will enable them to satisfy their

needs without violating the rights of others ◆ Become more aware of all of their senses ◆ Learn to accept responsibility for what they do, including accepting the

consequences of their actions ◆ Be able to ask for and get help from others and be able to give to others

Therapist’s Function and Role The Gestalt therapist’s job is to invite clients into an active partnership where they can learn about themselves by adopting an experimental attitude toward life. Gestalt therapists use active methods and personal engagement with clients to increase their awareness, freedom, and self-direction rather than directing them toward preset goals. Therapists set aside their biases and suspend assumptions and expectations in order to pay attention to what is emerging in their presence (Brownell, 2016).

Contemporary Gestalt practitioners view clients as the experts on their own experience and encourage them to attend to their sensory awareness in the pres- ent moment. Gestalt therapists value self-discovery and assume that clients can discover for themselves the ways in which they block or interrupt their awareness and experience. Although the therapist functions as a guide and a catalyst, presents experiments, and shares observations, Yontef (1993) stresses that the basic work of therapy is done by the client. Yontef maintains that the therapist’s task is to create a climate in which clients are likely to try out new ways of being and behaving. Gestalt therapists do not force change on clients through confrontation. Instead, they work within a context of I/Thou dialogue in a here-and-now framework.

An important function of Gestalt therapists is paying attention to clients’ body language. These nonverbal cues provide rich information as they often represent feelings of which the client is unaware. The therapist needs to be alert for gaps in attention and awareness and for incongruities between verbalizations and what cli- ents are doing with their bodies. Therapists might direct clients to speak for and become their gestures or body parts by asking, “What do your eyes say?” “If your hands could speak at this moment, what would they say?” “Can you carry on a con- versation between your right and left hands?” Clients may verbally express anger and at the same time smile. Or they may say they are in pain and at the same time laugh. Therapists can ask clients to become aware of what their laughter might mean. Laughter may mask feelings of anger or pain, and therapists can facilitate clients’ work in discovering what it could mean for them.

In addition to calling attention to clients’ nonverbal language, the Gestalt thera- pist places emphasis on the relationship between language patterns and personal- ity. Clients’ speech patterns are often an expression of their feelings, thoughts, and attitudes. The Gestalt approach focuses on overt speaking habits as a way to increase clients’ awareness of themselves, especially by asking them to notice whether their words are congruent with what they are experiencing or instead are distancing them from their emotions.

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Language can both describe and conceal. By focusing on language, clients are able to increase their awareness of what they are experiencing in the present moment and of how they are avoiding coming into contact with this here-and-now experi- ence. Here are some examples of the aspects of language that Gestalt therapists might focus on:

◆ “It” talk. When clients say “it” instead of “I,” they are using depersonal- izing language. The counselor may ask them to substitute personal pro- nouns for impersonal ones so that they will assume an increased sense of responsibility. For example, if a client says, “It is difficult to make friends,” he could be asked to restate this by making an “I” statement: “I have trouble making friends.”

◆ “You” talk. Global and impersonal language tends to keep the person hidden. The therapist often points out generalized uses of “you” and invites the client to experiment with substituting “I” when this is what is meant.

◆ Questions. Questions have a tendency to keep the questioner hidden, safe, and unknown. Gestalt therapists often ask clients to experiment with changing their questions into statements. In making personal statements, clients begin to assume responsibility for what they say. They may become aware of how they are keeping themselves mysteri- ous through a barrage of questions and how this serves to prevent them from making declarations that express themselves.

◆ Language that denies power. Some clients have a tendency to deny their personal power by adding qualifiers or disclaimers to their statements. The therapist may also point out to clients how certain qualifiers sub- tract from their effectiveness. Experimenting with omitting qualifiers such as “maybe,” “perhaps,” “sort of,” “I guess,” “possibly,” and “I sup- pose” can help clients change ambivalent messages into clear and direct statements. Likewise, when clients say “I can’t,” they are really implying “I won’t.” Encouraging clients to substitute “won’t” for “can’t” often assists them in owning and accepting their power by taking responsi- bility for their decisions. The therapist must be careful in intervening so that clients do not feel that everything they say is subject to scru- tiny. The therapist hopes to foster awareness of what is really being expressed through words, not to scrutinize behavior.

◆ Listening to clients’ metaphors. In his workshops, Erv Polster (1995) emphasizes the importance of a therapist learning how to listen to the metaphors of clients. By tuning into metaphors, the therapist gets rich clues to clients’ internal struggles. Examples of metaphors that can be amplified include client statements such as “It’s hard for me to spill my guts in here.” “At times I feel that I don’t have a leg to stand on.” “I feel like I have a hole in my soul.” “I need to be prepared in case some- one blasts me.” “I felt ripped to shreds after you confronted me last week.” “After this session, I feel as though I’ve been put through a meat grinder.” Beneath the metaphor may lie a suppressed internal dialogue that represents critical unfinished business or reactions to a present

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interaction. For example, to the client who says she feels that she has been put through a meat grinder, the therapist could ask: “What is your experience of being ground meat?” or “Who is doing the grinding?” It is essential to encourage this client to say more about what she is experi- encing. The art of therapy consists of assisting clients in translating the meaning of their metaphors so that they can be dealt with in therapy.

◆ Listening for language that uncovers a story. Polster (1995) also teaches the value of what he calls “fleshing out a flash.” He reports that clients often use language that is elusive yet gives significant clues to a story that illus- trates their life struggles. Effective therapists learn to pick out a small part of what someone says and then to focus on and develop this element. Clients are likely to slide over pregnant phrases, but the alert therapist can ask questions that will help them flesh out their story line. It is essential for therapists to pay attention to what is fascinating about the person who is sitting before them and get that person to tell a story.

In a workshop, I observed Erv Polster’s magnificent style in challenging a person (Joe) who had volunteered for a demonstration of an individual session. Although Joe had a fascinating story to reveal about a particular facet of his life, he was present- ing himself in a lifeless manner, and the energy was going flat. Eventually, Polster asked him, “Are you keeping my interest right now? Does it matter to you whether I am engaged with you?” Joe looked shocked, but he soon got the point. He accepted Polster’s challenge to make sure that he not only kept the therapist interested but also presented himself in a way to keep those in the audience interested. It was clear that Polster was directing Joe’s attention to a process of how he was expressing his feelings and life experiences rather than being concerned with what he was talking about.

Polster believes storytelling is not always a form of resistance. Instead, it can be the heart of the therapeutic process. He maintains that people are storytelling beings. The therapist’s task is to assist clients in telling their story in a lively way. Polster (1987b) believes many people come to therapy to change the titles of their stories rather than to transform their life stories.

Client’s Experience in Therapy The general orientation of Gestalt therapy is toward dialogue, an engagement between people who each bring their unique experiences to that meeting (Yontef et al., 2019). Traditional Gestalt therapists assumed that clients must be confronted about how they avoid accepting responsibility, but the dialogic attitude that charac- terizes contemporary Gestalt therapy creates the ground for a meeting place between client and therapist. Other issues that can become the focal point of therapy include the client–therapist relationship and the similarities in the ways clients relate to the therapist and to others in their environment.

Gestalt therapists do not make interpretations that explain the dynamics of an individual’s behavior or tell clients why they are acting in a certain way because they are not the experts on the client’s experience. Clients in Gestalt therapy are active par- ticipants who make their own interpretations and meanings. It is they who increase awareness and decide what they will or will not do with their personal meaning.

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Miriam Polster (1987) described a three-stage integration sequence that charac- terizes client growth in therapy. The first part of this sequence consists of discovery. Clients are likely to reach a new realization about themselves or to acquire a novel view of an old situation, or they may take a new look at some significant person in their life. Such discoveries often come as a surprise to them.

The second stage of the integration sequence is accommodation, which involves clients’ recognizing that they have a choice. Clients begin by trying out new behav- iors in the supportive environment of the therapy office, and then they expand their awareness of the world. Making new choices is often done awkwardly, but with ther- apeutic support clients can gain skill in coping with difficult situations. Clients are likely to participate in out-of-office experiments, which can be discussed in the next therapy session.

The third stage of the integration sequence is assimilation, which involves clients’ learning how to influence their environment. At this phase clients feel capable of dealing with the surprises they encounter in everyday living. They are now begin- ning to do more than passively accept the environment. Behavior at this stage may include taking a stand on a critical issue. Eventually, clients develop confidence in their ability to improve and improvise. Improvisation is the confidence that comes from knowledge and skills. Clients are able to make choices that will result in getting what they want. The therapist points out that something has been accomplished and acknowledges the changes that have taken place within the client. At this phase clients have learned what they can do to maximize their chances of getting what is needed from their environment.

Relationship Between Therapist and Client As an existential brand of therapy, Gestalt practice involves a person-to-person rela- tionship between therapist and client. Therapists are responsible for the quality of their presence, for knowing themselves and the client, and for remaining open to the client. They are also responsible for establishing and maintaining a therapeutic atmosphere that will foster a spirit of work on the client’s part. It is important that therapists allow themselves to be affected by their clients and that they actively share their own present perceptions and experiences as they encounter clients in the here and now. Gestalt therapists are encouraged to be appropriately self-disclosing. They model the process of useful interactions by disclosing their own awareness and experience (Yontef et al., 2019). However, therapists need to be thoughtful about what and when they share.

Gestalt therapists not only allow their clients to be who they are but also remain themselves and do not get lost in a role. Therapists must be grounded and in tune with themselves as well as being present for their clients. Therapists are expected to encounter clients with honest and immediate reactions, and therapists share their personal experience and stories in relevant and appropriate ways. Furthermore, they give feedback that enables clients to develop an awareness of what they are actually doing.

A number of writers have given central importance to the I/Thou relationship and the quality of the therapist’s presence, as opposed to emphasizing technical skills. They warn of the dangers of becoming technique-bound and losing sight of

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their own being as they engage with the client. Contemporary relational Gestalt therapy has moved beyond earlier (traditional) therapeutic practices. Creating a relationship (or alliance) is not a prelude to therapy; it is at the heart of Gestalt ther- apy. The therapist’s attitudes and behavior and the relationship that is established are what really count (Frew, 2013; Resnick, 2015; Wheeler & Axelsson, 2015; Yontef et al., 2019). It is through presence and mindfulness that the therapist is able to pay attention to the unfolding subjective experience of the client (Brownell, 2016).

Many contemporary Gestalt therapists place increasing emphasis on factors such as presence, authentic dialogue, gentleness, more direct self-expression by the therapist, decreased use of stereotypic exercises, and greater trust in the client’s experiencing. Laura Perls (1976) stressed the notion that the person of the thera- pist is more important than using techniques. She says, “There are as many styles as there are therapists and clients who discover themselves and each other and together invent their relationship” (p. 223). A current trend in Gestalt practice is toward greater emphasis on the client–therapist relationship, and therapists who operate from this orientation are able to establish a present-centered, nonjudgmen- tal dialogue that allows clients to deepen their awareness and to make contact with another person (Wheeler & Axelsson, 2015).

Polster and Polster (1973) emphasize the importance of therapists knowing themselves and being therapeutic instruments. Like artists who need to be in touch with what they are painting, therapists are artistic participants in the creation of new life. The Polsters implore therapists to use their own experiences as essential ingre- dients in the therapy process. According to them, therapists are more than mere responders or catalysts. If they are to make effective contact with clients, therapists must be in tune with both their clients and themselves. Therapy is a two-way engage- ment that changes both the client and the therapist. If therapists are not sensitively tuned to their own qualities of tenderness, toughness, and compassion and to their reactions to the client, they become technicians. Experiments should be aimed at awareness, not at simple solutions to a client’s problem.

Application: Therapeutic Techniques and Procedures The Experiment in Gestalt Therapy

Although the Gestalt approach is concerned with the obvious, its simplicity should not be taken to mean that the therapist’s job is easy. Developing a variety of inter- ventions is simple, but employing these methods in a mechanical fashion allows clients to continue inauthentic living. If clients are to become authentic, they need contact with an authentic therapist. Gestalt therapy methodology is tailored to the needs of clients, and experiments are typically presented in an invitational manner. Dr. Jon Frew, a Gestalt therapist, demonstrates Gestalt interventions applied to the case of Ruth in Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 6).

Before discussing the variety of Gestalt methods you could include in your rep- ertoire of counseling procedures, it is helpful to differentiate between exercises (or techniques) and experiments. Exercises are ready-made techniques that are some- times used to make something happen in a therapy session or to achieve a goal. They can be catalysts for individual work or for promoting interaction among members

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of a therapy group. Experiments, in contrast, grow out of the interaction between client and therapist, and they emerge within this dialogic process and provide clients with an opportunity to increase their awareness and try out new ways of thinking and behaving. They can be considered the very cornerstone of experiential learning. Frew (2013) defines the experiment “as a method that shifts the focus of counsel- ing from talking about a topic to an activity that will heighten the client’s aware- ness and understanding through experience” (p. 238). According to Melnick and Nevis (2005), experiments have been confused with techniques: “A technique is a performed experiment with specific learning goals. . . . An experiment, on the other hand, flows directly from psychotherapy theory and is crafted to fit the individual as he or she exists in the here and now” (p. 108).

In Gestalt therapy, an experiment is an intervention and an active technique that facilitates the collaborative exploration of a client’s experience (Brownell, 2016). Experiments give people a chance to be systematic in learning by doing and are best thought of as ways of exploring a client’s experiential world. Clients explore their awareness process and discover how their thinking, feeling, and behaving either works for them or does not. “The goal [of an experiment] is always learning—slowing down and deepening experience in the service of new understanding and new pos- sibilities for more flexible and effective response” (Wheeler & Axelsson, 2015, p. 40). Experiments are a key part of the ongoing dialogue between client and therapist, not a method to fix the client or to make the therapy process more exciting (Yontef & Schulz, 2013).

The experiment is fundamental to Gestalt therapy. These dramatic enactments are designed to increase the client’s awareness and learning (Brownell, 2016). The focus of this work is on discovery, so what is learned is a surprise to both client and therapist. Experiments in Gestalt therapy are novel creations arising from the flow between client and therapist (Brownell, 2016). Gestalt experiments are a creative adventure and a way in which clients can express themselves behaviorally. Experi- ments are spontaneous, one-of-a-kind, and relevant to a particular moment and a particular development of a figure-formation process. They are not designed to achieve a particular goal but occur in the context of a moment-to-moment contact- ing process between therapist and client. Polster (1995) indicates that experiments are designed by the therapist and evolve from the theme already being developed through therapeutic engagement, such as the client’s report of needs, dreams, fan- tasies, and body awareness. Experimentation is an attitude inherent in all Gestalt therapy; it is a collaborative process with full participation of the client. Experiments must be a phenomenological part of the therapeutic process, and clients test an experiment to determine how therapeutically helpful it is.

Miriam Polster (1987) says that an experiment is a way to bring out some kind of internal conflict by making this struggle an actual process. It is aimed at facilitat- ing a client’s ability to work through the stuck points of his or her life. Experiments encourage spontaneity and inventiveness by bringing the possibilities for action directly into the therapy session. By dramatizing or playing out problem situations or relationships in the relative safety of the therapy context, clients increase their range of flexibility of behavior. According to M. Polster, Gestalt experiments can take many forms: imagining a threatening future encounter; setting up a dialogue between a client and some significant person in his or her life; dramatizing the

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memory of a painful event; reliving a particularly profound early experience in the present; assuming the identity of one’s mother or father through role playing; focus- ing on gestures, posture, and other nonverbal signs of inner expression; or carrying on a dialogue between two conflicting aspects within the person. Clients may expe- rience the feelings associated with their conflicts as experiments bring struggles to life by inviting clients to enact them in the present. It is crucial that experiments be tailored to each individual and used in a timely and appropriate manner; they also need to be carried out in a context that offers a balance between support and risk. Sensitivity and careful attention on the therapist’s part are essential so that clients are “neither blasted into experiences that are too threatening nor allowed to stay in safe but infertile territory” (M. Polster & Polster, 1990, p. 104).

If students-in-training limit their understanding of Gestalt therapy to simply reading about the approach, Gestalt methods are likely to seem abstract and the notion of experiments may seem strange. Asking clients to “become” an object in one of their dreams, for instance, may seem silly and pointless. It is important for counselors to personally experience the power of Gestalt experiments and to feel com- fortable suggesting them to clients. In this regard, it can be most useful for trainees to personally experience Gestalt methods as a client.

Preparing Clients for Gestalt Experiments It is essential that counselors establish a relationship with their clients, so that the clients will feel trusting enough to participate in the learning that can result from Gestalt experiments. Clients will get more from Gestalt experiments if they are ori- ented and prepared for them. Through a trusting relationship with the therapist, clients are likely to recognize any hesitation on their part and allow themselves to participate in these experiments.

If clients are to cooperate, counselors must avoid directing them in a command- ing fashion to carry out an experiment. Typically, I ask clients if they are willing to try out an experiment to see what they might learn from it. I also tell clients that they can stop whenever they choose to, so the power is with them. Clients at times say that they feel silly or self-conscious or that the task feels artificial or unreal. At such times, I am likely to respond by asking, “Are you willing to give it a try and see what happens?” The way in which clients resist doing an experiment reveals a great deal about their personality and their way of being in the world. Gestalt therapists expect and respect the emergence of reluctance and meet clients wherever they are. Gestalt experiments work best when the therapist is respectful of the client’s cultural back- ground and has a solid working alliance with the person. Clients with a long history of containing their feelings may be reluctant to participate in experiments that are likely to bring their emotions to the surface.

Contemporary Gestalt therapy places much less emphasis on resistance than the early version of Gestalt therapy. Although it is possible to look at “resistance to awareness” and “resistance to contact,” the idea of resistance is viewed as unneces- sary by some Gestalt therapists. Frew (2013) argues that the notion of resistance is completely foreign to the theory and practice of Gestalt therapy and suggests that resistance is a term frequently used for clients who are not doing what the therapist wants them to do. Polster and Polster (1976) suggest that it is best for therapists to

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observe what is actually and presently happening rather than trying to make some- thing happen. This gets away from the notion that clients are resisting and thus behaving wrongly. According to the Polsters, change occurs through contact and awareness—one does not have to try to change. Maurer (2005) writes about “appre- ciating resistance” as a creative adjustment to a situation rather than something to overcome. Maurer claims that we need to respect resistance, take it seriously, and view it as “the energy” and not “the enemy.”

It is well to remember that Gestalt experiments are designed to expand clients’ awareness and to help them try out new modes of behavior. Within the safety of the therapeutic situation, clients are given opportunities and encouraged to “try on” a new behavior. An experimental attitude in the therapeutic process involves the client’s input and allows what emerges between client and therapist to guide the direction of the therapy (Yontef & Schulz, 2013). This heightens the awareness of a particular aspect of functioning, which leads to increased self-understanding (Yontef, 1995). Experiments are only means to the end of helping people become more aware and making changes they most desire.

The Role of Confrontation Students are sometimes put off by their perception that a Gestalt counselor’s style is direct and confrontational. I tell my students that it is a mistake to equate the prac- tice of any theory with its founder. In the workshops that Fritz Perls gave, people often found him harshly confrontational and saw him as meeting his own needs through showmanship. Yontef (1993) refers to the traditional Perlsian style as a “boom-boom-boom therapy” characterized by theatrics, abrasive confrontation, and intense catharsis. Yontef (1993, 1999) is critical of the anti-intellectual, individ- ualistic, dramatic, and confrontational flavor that characterized traditional Gestalt therapy in the “anything goes environment” of the 1960s and 1970s.

The contemporary practice of Gestalt therapy has progressed beyond this style. According to Yontef (1999), contemporary relational Gestalt therapy has evolved to include more support and increased kindness and compassion in therapy. This approach “combines sustained empathic inquiry with crisp, clear, and relevant awareness focusing” (p. 10). Perls practiced a highly confrontational approach as a way to deal with avoidance, but this technique-focused style of working has given way to a more dialogue-centered methodology today (Frew, 2013; Yontef et al., 2019).

In contemporary Gestalt therapy, confrontation is set up in a way that invites clients to examine their behaviors, attitudes, and thoughts. Therapists can encour- age clients to look at certain incongruities, especially gaps between their verbal and nonverbal expression. Furthermore, confrontation does not have to be aimed at weaknesses or negative traits; clients can be challenged to recognize how they are blocking their strengths.

Therapists who care enough to make demands on their clients are telling them, in effect, that they could be in fuller contact with themselves and others. Ultimately, however, clients must decide for themselves if they want to accept this invitation to learn more about themselves. This caveat needs to be kept in mind with all of the experiments that are described here.

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Gestalt Therapy Interventions Exercises are preplanned activities that can be used to elicit emotion, produce action, or achieve a specific goal. Experiments, in contrast, are spontaneously cre- ated to fit what is happening in the therapeutic process and can be useful tools to help clients gain fuller awareness, experience internal conflicts, resolve incon- sistencies and dichotomies, and work through impasses that prevent completion of unfinished business (Conyne, 2015). Some therapists operate on the erroneous assumption that the practice of Gestalt therapy consists of a bag of techniques that define the therapy, but as Resnick (2015) states, techniques and exercises are the least important part of Gestalt therapy.

The techniques described here neither define Gestalt therapy nor are they a nec- essary part of Gestalt practice. When used at their best, these interventions fit the therapeutic situation and highlight whatever the client is experiencing. The follow- ing material is based on Levitsky and Perls (1970), with my own suggestions added for implementing these methods.

The Internal Dialogue Exercise One goal of Gestalt therapy is to bring about integrated functioning and acceptance of aspects of one’s personality that have been disowned and denied. Gestalt therapists pay close attention to splits in personality function. A main division is between the “top dog” and the “underdog,” and therapy often focuses on the war between the two.

The top dog is righteous, authoritarian, moralistic, demanding, bossy, and manipulative. This is the “critical parent” that badgers with “shoulds” and “oughts” and manipulates with threats of catastrophe. The underdog manipulates by playing the role of victim: by being defensive, apologetic, helpless, and weak and by feigning powerlessness. This is the passive side, the one without responsibility, and the one that finds excuses.

The top dog and the underdog are engaged in a constant struggle for control. The struggle helps explain why one’s resolutions and promises often go unfulfilled and why one’s procrastination persists. The tyrannical top dog demands that one be thus-and-so, whereas the underdog defiantly plays the role of disobedient child. As a result of this struggle for control, the individual becomes fragmented into control- ler and controlled. The civil war between the two sides continues, with both sides fighting for their existence.

The conflict between the two opposing poles in the personality is rooted in the mechanism of introjection, which involves incorporating aspects of others, usu- ally parents, into one’s personality. It is essential that clients become aware of their introjects, especially the toxic introjects that poison the person and prevent person- ality integration.

The Empty-Chair Technique Jacob Moreno, the founder of psychodrama, origi- nated the empty-chair technique, which was later incorporated into Gestalt therapy by Perls. The empty chair is a vehicle for the technique of role reversal, which is useful in bringing into consciousness the fantasies of what the “other” might be thinking or feeling. Essentially, this is a role-playing technique in which all the parts are played by the client. In this way the introjects can surface, and

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the client can experience the conflict more fully. There are many applications for this technique. One of the more important uses is to explore what another person in one’s social network might be feeling, and what that person’s more realistic predicament might be.

Using two chairs, the therapist asks the client to sit in one chair and be fully the top dog and then shift to the other chair and become the underdog. The dialogue can continue between both sides of the client. The conflict can be resolved by the client’s acceptance and integration of both sides. This exercise helps clients get in touch with a feeling or a side of themselves that they may be denying; rather than merely talking about a conflicted feeling, they intensify the feeling and experience it fully. Furthermore, by helping clients realize that the feeling is a very real part of themselves, the intervention discourages clients from disassociating the feeling. The goal of this exercise is to promote a higher level of integration between the polarities and conflicts that exist in everyone. The aim is not to rid oneself of certain traits but to learn to accept and live with the polarities.

Future Projection Technique In future projection, an anticipated event is bro- ught into the present moment and acted out. This technique, often associated with psychodrama, is designed to help clients express and clarify concerns they have about the future. These concerns may include wishes and hopes, dreaded fears of tomorrow, or goals that provide some direction to life. A client creates a future time and place with selected people, brings this event into the present, and gets a new perspective on a problem. Clients may act out either a version of the way they hope a given situation will ideally unfold or their version of a feared outcome. Once clients clarify their hopes for a particular outcome, they are in a better position to take specific steps that will enable them to achieve the future they desire.

Making the Rounds Making the rounds is a Gestalt exercise that involves asking a person in a group to go up to others in the group and either speak to or do something with each person. The purpose is to confront, to risk, to disclose the self, to experiment with new behavior, and to grow and change. I have experimented with “making the rounds” when I sensed that a participant needed to face each person in the group with some theme. For example, a group member might say: “I’ve been sitting here for a long time wanting to participate but holding back because I’m afraid of trusting people in here. And besides, I don’t think I’m worth the time of the group anyway.” I might counter with “Are you willing to do something right now to get yourself more invested and to begin to work on gaining trust and self- confidence?” If the person answers affirmatively, my suggestion could well be, “Go around to each person and finish this sentence: ‘I don’t trust you because . . .’ ” Any number of exercises could be invented to help individuals involve themselves and choose to work on the things that keep them frozen in fear.

Some other related illustrations and examples that I find appropriate for the making-the-rounds intervention are reflected in clients’ comments such as these: “I would like to reach out to people more often.” “Nobody in here seems to care very much.” “I’d like to make contact with you, but I’m afraid of being rejected [or accepted].” “It’s hard for me to accept compliments; I always discount good things people say to me.”

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The Reversal Exercise Certain symptoms and behaviors often represent reversals of underlying or latent impulses. Thus, the therapist could ask a person who claims to suffer from severe inhibitions and excessive timidity to play the role of an exhibitionist. I remember a client in one of our therapy groups who had difficulty being anything but sugary sweet. I asked her to reverse her typical style and be as negative as she could be. The reversal worked well; soon she was playing her part with real gusto, and later she was able to recognize and accept her “negative side” as well as her “positive side.”

The theory underlying the reversal technique is that clients take the plunge into the very thing that is fraught with anxiety and make contact with those parts of themselves that have been submerged and denied. This technique can help clients begin to accept certain personal attributes that they have tried to deny.

The Rehearsal Exercise Oftentimes we get stuck rehearsing silently to ourselves so that we will gain acceptance. When it comes to the performance, we experience stage fright, or anxiety because we fear that we will not play our role well. Internal rehearsal consumes much energy and frequently inhibits our spontaneity and willingness to experiment with new behavior. When clients share their rehearsals out loud with a therapist, they become more aware of the many preparatory means they use in bolstering their social roles. They also become increasingly aware of how they try to meet the expectations of others, of the degree to which they want to be approved, accepted, and liked, and of the extent to which they go to attain acceptance.

The Exaggeration Exercise One aim of Gestalt therapy is for clients to become more aware of the subtle signals and cues they are sending through body language. Movements, postures, and gestures may communicate significant meanings, yet the cues may be incomplete. In this exercise the person is asked to exaggerate the movement or gesture repeatedly, which usually intensifies the feeling attached to the behavior and makes the inner meaning clearer. Some examples of behaviors that lend themselves to the exaggeration technique are trembling (shaking hands, legs), slouched posture and bent shoulders, clenched fists, tight frowning, facial grimacing, crossed arms, and so forth. If a client reports that his or her legs are shaking, the therapist may ask the client to stand up and exaggerate the shaking. Then the therapist may ask the client to put words to the shaking limbs.

Staying With the Feeling Most people want to escape from fearful stimuli and avoid unpleasant feelings. At key moments when clients refer to a feeling or a mood that is unpleasant and from which they have a great desire to flee, the therapist may urge clients to stay with their feeling and encourage them to go deeper into the feeling or behavior they wish to avoid. Facing and experiencing feelings not only takes courage but also is a mark of a willingness to endure the pain necessary for unblocking and making way for newer levels of growth. A strong therapeutic relationship built on trust and nonjudgmental acceptance fosters the safety needed for clients to stay with these unpleasant feelings.

The Gestalt Approach to Dream Work In psychoanalysis dreams are inter- preted, intellectual insight is stressed, and free association is used to explore the unconscious meanings of dreams. The Gestalt approach to dream work does not

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interpret and analyze dreams. Instead, the intent is to bring dreams back to life and relive them as though they were happening now. The dream is acted out in the present, and the dreamer becomes a part of his or her dream. The suggested format for working with dreams includes making a list of all the details of the dream; remembering each person, event, and mood in it; and then becoming each of these parts by transforming oneself, acting as fully as possible and inventing dialogue. Each part of the dream is assumed to be a projection of the self, and the client creates scripts for encounters between the various characters or parts. All of the different parts of a dream are expressions of the client’s own contradictory and inconsistent sides. By engaging in a dialogue between these opposing sides, the client gradually becomes more aware of the range of his or her own feelings.

Perls’s concept of projection is central in his theory of dream formation; every person and every object in the dream represents a projected aspect of the dreamer. Perls (1969) suggested that “we start with the impossible assumption that whatever we believe we see in another person or in the world is nothing but a projection” (p. 67). Recognizing the senses and understanding projections go hand in hand. Clients do not think about or analyze the dream but use it as a script and experi- ment with the dialogue among the various parts of the dream. Because clients can act out a fight between opposing sides, eventually they can appreciate and accept their inner differences and integrate the opposing forces. Freud called the dream the royal road to the unconscious, but to Perls dreams are the “royal road to inte- gration” (p. 66).

According to Perls, the dream is the most spontaneous expression of the exis- tence of the human being. It represents an unfinished situation, but every dream also contains an existential message regarding oneself and one’s current struggle. Everything can be found in dreams if all the parts are understood and assimilated; dreams serve as an excellent way to discover personality voids by revealing missing parts and clients’ methods of avoidance. Perls asserts that if dreams are properly worked with, the existential message becomes clearer. If people do not remember dreams, they may be refusing to face what is wrong with their life. At the very least, the Gestalt counselor asks clients to talk to their missing dreams. For example, as directed by her therapist, a client reported the following dream in the present tense, as though she were still dreaming:

I have three monkeys in a cage. One big monkey and two little ones! I feel very attached to these monkeys, although they are creating a lot of chaos in a cage that is divided into three separate spaces. They are fighting with one another—the big monkey is fighting with the little monkey. They are getting out of the cage, and they are clinging onto me. I feel like pushing them away from me. I feel totally overwhelmed by the chaos that they are creating around me. I turn to my mother and tell her that I need help, that I can no longer handle these monkeys because they are driving me crazy. I feel very sad and very tired, and I feel discouraged. I am walking away from the cage, thinking that I really love these monkeys, yet I have to get rid of them. I am telling myself that I am like everybody else. I get pets, and then when things get rough, I want to get rid of them. I am trying very hard to find a solution to keeping these monkeys and not allowing them to have such a terrible effect on me. Before I wake up from my dream, I am making the decision to put each monkey in a separate cage, and maybe that is the way to keep them.

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The therapist then asked his client, Brenda, to “become” different parts of her dream. She became the cage, and she became and had a dialogue with each monkey, and then she became her mother, and so forth. One of the most powerful aspects of this technique was Brenda’s reporting her dream as though it were still happen- ing. She quickly perceived that her dream expressed a struggle she was having with her husband and her two children. From her dialogue work, Brenda discovered that she both appreciated and resented her family. She learned that she needed to let them know about her feelings and that together they might work on improving an intensely difficult lifestyle. She did not need an interpretation from her therapist to understand the clear message of her dream.

Application to Group Counseling As a therapeutic orientation based on field theory, Gestalt therapy is well suited for a group context. A main goal of the Gestalt group is to heighten awareness and self-regulation through interactions with one another and the group itself (Conyne, 2015). Gestalt therapy encourages direct experience and actions as opposed to merely talking about conflicts, problems, and feelings. If members have anxieties per- taining to some future event, they can enact these future concerns in the present. This here-and-now focus enlivens the group and assists members in vividly explor- ing their concerns. Moving from talking about to action is often done by the use of experiments in a group. Gestalt therapy employs a rich variety of interventions designed to intensify what group members are directly experiencing in the present moment for the purpose of leading to increased awareness. Gestalt group therapists attend to matters such as verbal and nonverbal language, postures, voice, interper- sonal interactions, and group processes (Conyne, 2015).

When one member is the focus of work, other members can enhance an indi- vidual’s work. Through the skill of linking, the group leader can bring a num- ber of members into the exploration of a problem. I prefer an interactive style of Gestalt group work and find that bringing in an interpersonal dimension maximizes the therapeutic potency within the group. I do not like to introduce a technique to promote something happening within a group; rather, I tend to invite members to try out different behavioral styles as a way to heighten what a given member might be experiencing at the moment. A group format provides a context for a great deal of creativity in using interventions and designing experi- ments. These experiments need to be tailored to each group member and used in a timely manner; they also need to be carried out in a context that offers a balance between support and risk. Experiments, at their best, evolve from what is going on within individual members and what is happening in the group at the moment.

Although Gestalt group leaders encourage members to heighten their aware- ness and attend to their interpersonal style of relating, leaders tend to take an active role in creating experiments to help members tap into their resources. Gestalt group leaders are actively engaged with the members, and leaders frequently engage in self- disclosure as a way to enhance relationships and create a sense of mutuality within the group. Gestalt group practitioners are especially concerned with awareness, con- tact, and experimentation (Yontef et al., 2019).

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If members experience the group as being a safe place, they will be inclined to move into the unknown and challenge themselves. To increase the chances that members will benefit from Gestalt methods, group leaders need to communicate the general purpose of these interventions and create an experimental climate. Group facilitators are not trying to push an agenda; rather, members are free to try something new and determine for themselves the outcomes of an experiment.

In training workshops in group counseling that Marianne Schneider Corey and I conducted in Korea, the Gestalt approach was well accepted. Group mem- bers were very open and willing to share themselves emotionally once a climate of safety was created. Adopting the stance of phenomenological inquiry, we strive to avoid making assumptions about the members of a group, and we are careful not to impose our worldviews or values on them. Instead, we approach clients with respect, interest, compassion, and presence. We work collaboratively with our clients to discover how to best help them resolve the difficulties they experi- ence internally, interpersonally, and in the context of their social environment. Although it is unrealistic to think you need to know everything about different cultures, it is essential to bring an attitude of respect and appreciation for dif- ferences to your work in diverse cultural environments around the world. With these attitudes we found that we were able to use many Gestalt interventions with Korean people in a group training context. In some ways this is not surprising because in Korea there is an emphasis on collectivistic values, and group work fits well into the Korean culture.

For a more detailed account of Gestalt therapy in groups, see Feder and Frew (2008), Feder (2006), and Corey (2023, chap. 11).

Application of the Gestalt Approach to School Counseling

This section was provided by two counselor educators. Margaret L. Hindman, PhD, is an assistant professor of counselor education at St. Bonaventure Univer- sity. She is a licensed professional counselor in Arkansas, a registered play thera- pist, and has supervised experience in expressive arts. Kristi Perryman, PhD, is an associate professor of counseling at the University of Arkansas. She is also the founder of the Missouri State University Institute for Play Therapy and the Uni- versity of Arkansas Office of Play Therapy Research and Training.

Gestalt therapy has long been used by school counselors and offers a develop- mentally appropriate way of working with students. Because the focus is more on playful activities and less on verbal expression, it is a perfect fit for school- aged students. Frequent sessions with students are not always possible due to high student-to-counselor ratios and the numerous responsibilities of the school counselor. In our experience, the Gestalt approach offers a timely way of process- ing and helping students learn how to emotionally regulate and how to be more successful in the classroom.

Both of us have benefited greatly from the work of Violet Oaklander, a pioneer in the field of Gestalt play therapy. In Windows to Our Children: A Gestalt Therapy Approach to Children and Adolescents, Oaklander (1988) describes various creative activities she uses that are aimed at helping children experience their feelings,

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understand their relationship with people in their environment, and help children develop a sense of responsibility for their actions. These activities work well with direct services provided by the school counselor such as small groups, individual counseling, and classroom lessons. Oaklander (2006) claims that what is directly perceived, felt, and experienced is more relevant than a counselor’s explanations and interpretations. She sees value in projection through art and storytelling as ways of increasing a child’s self-awareness. A major focus is to help children become aware of what they are doing, how they are doing it, and how they can change themselves.

Art and play are natural ways to communicate across cultures, and the Gestalt approach can be a powerful way to counsel diverse and underserved student popula- tions. These students frequently have contact boundary disturbances related to the trauma they and their families have experienced from systemic racism, microaggres- sions, and fear rooted in seeing people who look like them being harmed and even killed. These experiences are often stored in the brain as implicit memory, with no words to describe the feelings. Gestalt techniques, such as imaginative play, can offer a way to access these feelings and bring wholeness in a safe and developmentally appropriate way. Resolving these implicit memories can lead to more regulation and a stronger sense of self.

A fifth-grade boy (Luis) who had moved to the United States from Puerto Rico was referred to me (Margaret) because he was kicking another boy in the classroom, having difficulty relating to peers, and struggling academically. During the first two sessions, Luis said he needed a translator. I soon realized that he could speak and understand English and that his request was a way to protect himself. Through a translator, Luis shared his deep feelings of sadness related to a family death while they were transitioning to the United States. I then asked him to draw a picture of himself and his family in Puerto Rico, and later to draw his family and himself in America. After the drawing, he stopped speaking through the translator and seemed to forget the translator was there. Luis talked directly to me about missing his fam- ily who were left in Puerto Rico. In a later session, he drew a picture of his dreams of who he hopes to become when he is an adult: someone who cares for others, who is respected, and who is successful.

During one of our final sessions, Luis expressed feeling peaceful about our counseling ending, as did I. We both knew he was ready and could seek counseling again if he needed it. I invited Luis to create a memory from our time together that he could take with him. He wrote on a rock, “Kindness is magic.” Then he went through all the forms of communication and connection we had practiced in our time together. He used sand tray, art, puppets, and role play to process the end of our time together and to say good-bye. When it was time to go, he used a puppet to block the door. He did not want to go. Then he said he was ready and that he would always remember our time together, and I knew I would too.

I (Margaret) worked with another counselor to form a group that consisted of Marshallese and Latinx elementary boys struggling primarily with impulse control behaviors. We developed a curriculum that incorporated a comic book about a new young Spider-Man, who was also a person of color. Each session the students were guided a step further in developing their projection through creativity, imaginative play, experimentation, and sensation awareness with prompts (create something to

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symbolize a superhero, create your own comic strip on a superhero with that power) to ultimately becoming their own superhero (decorating a cape, using power poses and movement). In a group setting, we observed them as they practiced making con- tact with one another, learned more about their role, and engaged in experiments in order to change their role.

The eight-week group involved a trip to a local museum to view a superhero exhibit for a culminating experience in which the students practiced skills they learned in group. Few of these students had ever been out of their neighborhood and none had been to a museum, so the field trip offered some challenges and many opportunities to practice their new skills. They had to use inside voices to express themselves, stay with the group even if they wanted to go somewhere else, and respect others’ personal space in a setting where people are constantly moving. Some of the paintings in the museum were about social justice issues, and the students practiced asking questions, sharing their opinions, and applying the artist’s message to their own struggles with inequality. Through Gestalt counseling, this group of students engaged in experiences that helped develop personal awareness, process their emo- tions, and develop a stronger sense of self.

In our experience, counseling is about being, not just doing. It is about being pres- ent and open to what is shared. Being with is where the meaning is and the place where change can begin. Children are taught what to do all day at school; this is helpful only when partnered with being present and in contact with self, the envi- ronment, and the person before you. Being a counselor in schools is magical because we can accept and connect with children in the here and now.

For more on how to apply Gestalt therapy and experiential approaches with children and adolescents in schools, we highly recommend Oaklander’s works (1988, 1997, 1999, 2001, 2006). Violet Oaklander also offers virtual training through Oaklandertraining.org.

An Expert’s Perspective on Gestalt Therapy In this section, Jon Frew, PhD, ABPP, professor of psychology at Pacific Univer- sity’s School of Professional Psychology and in private practice in Vancouver, Washington, provides answers to the following questions.

1. What is the most important contribution of Gestalt therapy for the practice of individual therapy? One of the major contributions is that Gestalt therapists encourage their clients to understand the importance of both the content and the process of their lives. The subject matter of most psychotherapy approaches is pri- marily content. Clients talk about their distant and near past experiences. Logic is applied, causes and effects are sought, and behaviors are explained and interpreted. In contrast, Gestalt therapists attend to how content and process can be blended for a complete picture. The richness of the here-and- now processes that exist in the present moment are incorporated into the therapeutic approach. Examples of those processes are eye contact, tone of voice, gestures, and facial expressions.

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2. What two or three key concepts of the Gestalt approach are especially applicable to the practice of individual counseling or therapy?

Phenomenological inquiry. This is both a stance and a method of engaging our clients. We bracket off, as much as possible, our precon- ceptions and biases and explore the client’s subjective experience. We ask pertinent questions, make observations, and teach our clients how to describe, rather than explain, their experience.

Holism. A client is composed of many parts including thoughts, feel- ings, physical sensations, spirituality, and behaviors. Gestalt therapists have no favorite part they seek out. Therapy is most lively and useful to the client when the therapist attends to what the client sees as the most salient at any moment, for example, a dream, a disturbing thought, or a powerful feeling.

Environmental support. Gestalt therapists believe that clients will regain health if they are able to be aware of current “field conditions” and make contact with the environment in ways in which current needs will be addressed. Through the ongoing therapeutic relation- ship, the Gestalt therapist provides support for awareness and for contact functions to be restored.

3. What two or three techniques from Gestalt therapy have practical value for practitioners of individual therapy? Many Gestalt therapists do not employ techniques, but two basic methods are central to the approach. The first is derived from the concept of “dia- logue” as put forward by Martin Buber. Gestalt therapists are aware of the healing power of certain rare moments in human contact that Buber called I/Thou moments. To create the conditions in the therapeutic relationship in which these moments are possible, Gestalt therapists practice inclusion. Inclu- sion occurs when the client understands at a very genuine level that the thera- pist “gets it.” The therapist is able to convey by words and nonverbally that he or she truly gets what it is like for the client to be in his or her immediate experience. The client feels apprehended, understood, and confirmed by the therapist. There is no sense of being judged. No matter what your therapeutic approach, practicing inclusion is a valuable intervention method.

The second method is the use of the experiment. There are countless types of experiments, and each fits unique moments in the therapy session. One way to think about the experiment is as a way to move from “talking about” a topic or subject during the session to trying out an activity that will create energy, action, and the potential for clients to gain an awareness or attempt a kind of contact with the environment that is not part of their typical pattern of behaviors. In a recent therapy session, one of my clients expressed discomfort with what she termed the intensity of my eye contact. We experimented by having her alternate looking at me, away from me, and shutting her eyes—all for short periods of time. The experiment can also be used as a homework project. The therapist suggests the client try some- thing out, such as going to a restaurant alone. In the next session, the client

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discusses “how it went” or perhaps admits that he or she did not complete the experiment. There is no such thing as a failed experiment. In the case of homework, the therapist explores what came up for the client in the restau- rant or what came up that prevented completion of the suggested activity.

4. How does the Gestalt approach address diversity, multicultural, and social justice issues for the practice of individual counseling? Contemporary Gestalt therapy can be a useful and effective approach with clients from diverse backgrounds because it takes the clients’ context into account, including the value systems of clients. Western values about what is normal or expected are not imposed on our clients. Gestalt therapy is not, therefore, an adjustment therapy or a tool to encourage assimilation to majority values or ways of living. Our clients are adjusting creatively to the demands of their past and present environments. Clients require our support to make sense out of this process of creative adjustment, especially clients who are diverse or who are experiencing discrimination or microag- gressions. Because we practice from a phenomenological stance, we attempt to see every client without preconceptions, stereotypes, or agendas to change them to meet goals that are not their goals or reason to be in therapy.

5. In what ways can the Gestalt approach be applied to brief therapy (or time-limited counseling)? Gestalt therapy has been applied to longer- and short-term counseling situ- ations. Many of the key concepts of Gestalt therapy can be adapted to a brief therapy approach.

6. From your perspective, what is the current status and the future of the Gestalt approach? Gestalt therapy was one of the top five counseling approaches during the 1970s. There was a period of transition during which this orientation worked to define itself without being misidentified as equivalent to how Fritz Perls demonstrated Gestalt therapy in the 1960s. There was a period of transition during which this orientation worked to differentiate itself from how it was presented by Fritz Perls in the 1960s. Currently, Gestalt therapy is enjoying a surge of popularity and recognition, particularly outside the United States. It is well represented and respected in Brazil, Japan, Russia, Australia, New Zealand, Turkey, the United Kingdom, and many other countries. In the United States and beyond, the vast majority of Gestalt training occurs in institute settings, not in academia. Many in the Gestalt therapy community recognize that we must conduct more research to continue to have credibility among academics and insurance companies. That research will need to fit the approach and will be qualitative and process focused.

Discussion Questions Related to the Gestalt Therapy Perspective 1. What do you understand about the difference between content and

process? “Gestalt therapists attend to how content and process can be blended for a complete picture.”

2. What aspects of Gestalt therapy most interest you and why? 3. In what way are experiments an attempt to move toward action and

away from “talking about”?

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Gestalt Therapy From a Multicultural Perspective Strengths From a Diversity Perspective

There are opportunities to creatively use Gestalt methods with culturally diverse populations if interventions are timed appropriately and used flexibly. One of the advantages of drawing on Gestalt experiments is that they can be tailored to fit the unique way in which clients perceive and interpret their culture. Although most therapists have preconceptions, Gestalt therapists strive to approach each client in an open way. By bracketing their own values, Gestalt therapists remaining receptive to how clients’ realities differ from their own. They do this by checking out their biases and views in dialogue with the client. This is particularly important in work- ing with individuals from diverse cultures.

Gestalt therapy is particularly effective in helping people integrate the polari- ties within themselves. Many bicultural clients experience an ongoing struggle to reconcile what appears to be diverse aspects of the two cultures in which they live. In one of my weeklong groups, a dynamic piece of work was done by a woman with European roots. Her struggle consisted of integrating her American side with her experiences in Germany as a child. I suggested that she “bring her family into this group” by talking to selected members in the group as though they were members of her family. I invited her to imagine that she was 8 years old and that she could now say to her parents and siblings things that she had never expressed. She was asked to speak in German (because this was her primary language as a child). The combined factors of her trust in the group, her willingness to re-create an early scene by reliving it in the present moment, and her symbolic work with fantasy helped her achieve a significant breakthrough. She was able to put a new ending to an old and unfinished situation through her participation in this Gestalt experiment.

There are many opportunities to apply Gestalt experiments in creative ways with diverse client populations. In cultures where indirect speech is the norm, non- verbal behaviors may emphasize the unspoken content of verbal communication. These clients may express themselves nonverbally more expressively than they do with words. Gestalt therapists typically ask clients to focus on their gestures, facial expressions, and what they are experiencing within their own body. They attempt to fully understand the background of their clients’ culture. They are concerned about which aspects of this background become central or figural for their clients and what meaning clients place on these figures.

Shortcomings From a Diversity Perspective To a greater extent than is true of most other approaches, there are some potential problems in too quickly utilizing Gestalt experiments with some clients. Gestalt methods can lead to a high level of intense feelings. This focus on affect has clear limitations with those clients who have been culturally socialized to be emotionally reserved and to avoid openly expressing feelings. As mentioned earlier, some indi- viduals believe expressing feelings openly is a sign of weakness and a display of one’s vulnerability. Intense emotional displays may be associated with shame and can be considered as signs of immaturity or a lack of self-control. Thus, it is often more

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appropriate to focus on behavior more than emotions (Sue et al., 2022). Therapists who operate on the assumption that catharsis is necessary for any change to occur are likely to find certain clients becoming increasingly reluctant to participate in experiments, and such clients may prematurely terminate counseling. Other indi- viduals have strong cultural injunctions prohibiting them from directly express- ing their emotions to their parents (such as “Never show your parents that you are angry at them” or “Strive for peace and harmony, and avoid conflicts”). I recall a client from India who was asked by his counselor to “bring your father into the room.” The client was very reluctant to even symbolically tell his father of his disap- pointment with their relationship. In his culture, the accepted way to deal with his father was to use his uncle as a go-between, and it was considered highly inappropri- ate to express any negative feelings toward his father. The client later said that he would have felt very guilty if he had symbolically told his father what he sometimes thought and felt.

Gestalt therapists who have truly integrated their approach are sensitive enough to practice in a flexible way. They consider the client’s cultural framework and are able to adapt methods that are likely to be well received. They strive to help clients experience themselves as far as possible in the present, yet they are not rigidly bound by dictates, nor do they routinely intervene whenever clients stray from the present. Sensitively staying in contact with a client’s flow of experiencing entails the ability to focus on the person and not on the mechanical use of techniques for a certain effect. The therapist can engage in simple experiments that involve noticing body language. A colleague reported noticing the tense shoulders of an African American woman. The therapist asked her to tell the story of her tense shoulders. This led to an intense conversation about acts of racism she had experienced and subsequent hypervigilance in her life. Gestalt therapists have the distinct opportunity to demon- strate the art of truly seeing clients and validating their existence.

Gestalt Therapy Applied to the Case of Stan Gestalt-oriented therapy focuses on the unfinished business Stan has with his parents, siblings, and ex- wife. It appears that this unfinished business consists mainly of feelings of resentment, and Stan turns this resentment on himself. His present life situation is spotlighted, but he may also need to reexperience past feelings that could be interfering with his present attempts to develop intimacy with others.

Although the focus is on Stan’s present behavior, I guide him toward becoming aware of how he is car- rying old baggage around and how it interferes with his life today. My task is to assist him in re-creating the context in which he made creative adjustments during his childhood years that are no longer serving him well.

One of his cardinal introjections was, “I’m stupid, and it would be better if I did not exist.”

Stan has been influenced by cultural messages that he has accepted. I am interested in exploring his cultural background, including his values and the values characteristic of his culture. With this focus, I assist Stan in identifying some of the following cul- tural introjections: “Don’t talk about your family with strangers, and don’t hang your dirty linen in public.” “Don’t confront your parents because they deserve respect.” “Don’t be too concerned about yourself.” “Don’t show your vulnerabilities; hide your feel- ings and weaknesses.” I invite Stan to examine those introjections to assess their utility in his present cir- cumstances. Although he can decide to retain those

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aspects of his culture that he prizes, he is in a posi- tion to modify or reject other cultural expectations. Of course, this will be done when these issues emerge in the foreground of his work.

I ask Stan to attend to what he becomes aware of as the session begins: “What are you experiencing as we are getting started today?” As I encourage Stan to tune in to his present experience and selectively make observations, a number of figures will emerge. The goal is to focus on a figure of interest, one that seems to hold the most energy or relevance for Stan. When a figure is identified, my task is to deepen Stan’s aware- ness of this thought, feeling, body sensation, or insight through related experiments.

In typical Gestalt fashion, Stan deals with his pres- ent struggles within the context of our relationship and through experimentation. One possible experi- ment would involve Stan becoming some of those individuals who told him how to think, feel, and behave as a child. He can then become the child that he was and respond to them from the place where he feels the most confusion or pain. He experiences in new ways the feelings that accompany his beliefs about himself, and he comes to a deeper appreciation of how his feelings and thoughts influence what he is doing today.

Stan has learned to hide his emotions rather than to reveal them. Understanding this about him, we explore his objections and concerns about “getting into feelings.” The figure of interest now is his hesita- tion to experience or express emotion. Although I have no agenda to get Stan to experience his feelings at this point, it is important for him to increase his awareness of his reluctance and to explore the meaning it holds for him.

If Stan decides that he wants to experience his emo- tions rather than deny them, I ask: “What are you aware of now having said what you did?” Stan says that he can’t get his ex-wife out of his mind. He tells me about the pain he feels over that relationship and how he is frightened of getting involved again lest he be hurt again. I continue to ask him to focus inward and get a sense of what stands out for him at this very moment. Stan replies: “I’m hurt and angry over all the pain that I’ve allowed her to inflict on me.” I ask him to imagine himself in earlier scenes with his ex-wife, as though the painful situation were occurring in the here and now. He symbolically relives and reexperiences the

situation by talking “directly” to his wife. By expressing his resentments and hurts directly, Stan can begin to complete some unfinished business that is interfering with his current functioning. By participating in this experiment, Stan is attaining more awareness of what he is now doing and how he keeps himself locked into his past.

Questions for Reflection ◆ How might you begin a session with Stan? Would

you suggest a direction he should pursue? Would you wait for him to initiate work? Would you ask him to continue from where he left off in the previ- ous session? Would you attend to whatever theme or issue becomes figural to him?

◆ What unfinished business can you identify in Stan’s case? Does any of his experience of being stuck remind you of yourself? How might you work with Stan if he did bring up your own unfinished business?

◆ What kind of an experiment might you propose to assist Stan in learning more about his hesita- tion and reluctance to access and express his feelings?

◆ Stan participated in an experiment to deal with pain, resentment, and hurt over situations with his ex-wife. How might you have worked with the material Stan brought up? What kind of experi- ment might you design? How would you decide what kind of experiment to create?

◆ How might you work with Stan’s cultural mes- sages? Would you be able to respect his cultural values and still encourage him to make an assess- ment of some of the ways in which his culture is affecting him today?

Refer to the MindTap for The Case of Stan Video Quiz for Chapter 8, Session 6 (Gestalt therapy), for a demonstration of my approach to coun- seling Stan from this perspective. This session consists of Stan exploring one of his dreams in Gestalt fashion.

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Gestalt Therapy Applied to the Case of Gwen* From a Gestalt perspective, I am interested in assisting Gwen in becoming more aware of herself as a whole person in the here and now. My job is to hold a mirror up and help her see herself with greater clarity. I notice that Gwen has a slight limp as she walks into my office. I ask about her limp, and Gwen tells me she has had a great deal of pain in her left hip for the past week. She explains that she has had trouble with her hip before and that an MRI revealed negative results. She goes on to say that it may be due to their old mattress.

Therapist: Describe exactly where the pain is and what the sensations feel like.

Gwen: Well, it feels uncomfortable in the crease of my hip, and it’s a dull sore feeling.

Therapist: Describe the texture and color of the feel- ing in your hip [asking her to make contact with her bodily sensations].

Gwen: The pain is prickly, gray, and heavy [she begins to connect with her body in the moment].

Therapist: What is that hip saying to you?

Gwen: This seems a bit strange, and I must admit I am uncomfortable in giving my hip a voice.

Therapist: Although it may seem strange, I hope you will give it a try to see what you might learn from doing this. You can always stop when you think that doing this is not helpful.

Gwen: OK, this is uncomfortable, but I will give it a try [she has trust in our relationship]. This hip is moan- ing and groaning!

Therapist: [An experiment may increase this connec- tion.] This may feel a little weird, but try to become your hip and exaggerate how your hip is feeling.

Gwen: [Begins to groan and whimper and tears come to her eyes] I am so tired of the mountain of things

I have to do and never getting anywhere. I feel like a fallen tree in the forest. I have fallen and no one knows I am there, and it is up to me to get up and get going again.

In her daily life Gwen typically holds back her true feel- ings. She is used to suppressing her irritations and even her triumphs. Because she was frequently ignored as a child, she feels that her thoughts and emotions don’t really matter. Her role at work is to solve problems, and at home she is the caretaker of everyone. She rarely allows herself to be vulnerable or fully human. Gwen sees herself as “in charge” and seldom gives herself a moment to pause or catch her breath.

Gwen: I know that basically I have a good life, I just rush past the good stuff and forget to stop and re- ally appreciate all the blessings. I can get so caught up in what I have not done or what feels wrong, but I can’t really complain. I know this hip is telling me to slow down and enjoy more of my life. I don’t have to be that fallen tree, I just need to ask for the support I really need [her body has shifted and she seems more relaxed in her chair].

Therapist: Bring your attention back to your hip. What does it feel like now?

Gwen: It feels better now. It might be OK to slow down. It might even be OK to take myself off of some of these committees I am on. [Laughing] May- be my hip just needs to sit on a beach somewhere or at least slow down enough to have some fun.

Therapist: It is important for you to stop for a moment and check in with your body. We hold our emo- tions in our bodies. It’s important to take time out to listen to what the sensations in our body may be telling us.

As Gwen’s awareness increases, she is beginning to realize some of her past ways of functioning are no longer serving her and she can begin to do something differently. It is my hope that Gwen can now see the

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

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Summary and Evaluation Summary

Gestalt therapy is an experiential approach that stresses present awareness and the quality of contact between the individual and the environment. The major focus is on assisting the client to become aware of how behaviors that were once part of creatively adjusting to past environments may be interfering with effective functioning and liv- ing in the present. The goal of the approach is, first and foremost, to gain awareness.

Another therapeutic aim is to assist clients in exploring how they make contact with elements of their environment. Change occurs through the heightened awareness of “what is.” Because the Gestalt therapist has no agenda beyond assisting clients to increase their awareness, there is no need to label a client’s behavior as “resistance.” Instead, the therapist simply follows this new process as it emerges. The therapist has faith that self-regulation is a naturally unfolding process. Awareness is a key require- ment for the restoration of self-regulation within the person’s environment (Resnick, 2015). With expanded awareness, clients are able to reconcile polarities and dichotomies within themselves and proceed toward the reintegration of all aspects of themselves.

The therapist works with the client to identify the figures—the most salient aspects of the individual–environmental field—as they emerge from the background. The Gestalt therapist believes each client is capable of self-regulating if those figures are engaged and resolved so others can replace them. The role of the Gestalt therapist is to help clients identify the most pressing issues, needs, and interests and to design experiments that sharpen those figures or that explore resistances to contact and awareness. Gestalt therapists are encouraged to be appropriately self-disclosing, both about their here-and-now reactions in the therapy hour and about their personal experiences, when doing so will facilitate the therapeutic process (Yontef et al., 2019).

Contributions of Gestalt Therapy One contribution of Gestalt therapy is the exciting way in which the past is dealt with in a lively manner by bringing relevant aspects into the present. Therapists challenge clients in creative ways to become aware of and work with issues that are

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connection between her unexpressed emotions and the discomfort in her physical body. Gestalt therapy gives Gwen the opportunity to focus on what is hap- pening in her mind and body in the present moment and on how an expression of emotions can lead to a release in her physical body. Gestalt therapy can assist Gwen in becoming more aware of herself as a whole person. She can begin to challenge unfinished busi- ness that has enabled her to experience success in her career but has also resulted in her feeling over- whelmed and filled with anxiety.

Questions for Reflection ◆ What is the importance of exploring bodily sensa-

tions and physical symptoms with Gwen? ◆ What therapeutic value do you see in asking Gwen

to “become her hip” and speak from it? ◆ What are your reactions to the way that the thera-

pist introduced the idea to Gwen of carrying out an experiment?

◆ How might you have experienced doing this experiment if you were in Gwen’s position?

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obstructing current functioning. Furthermore, paying attention to the obvious ver- bal and nonverbal leads provided by clients is a useful way to approach a counseling session. Through the skillful and sensitive use of Gestalt interventions, practitio- ners can assist clients in heightening their present-centered awareness of what they are thinking and feeling as well as what they are doing.

Gestalt methods bring conflicts and human struggles to life. Gestalt therapy is a creative approach that uses experiments to move clients from talk to action and experience. The creative and spontaneous use of active experiments is a pathway to experiential learning. The focus is on growth and enhancement rather than being a system of techniques to treat disorders, which reflects an early Gestalt motto, “You don’t have to be sick to get better.” Clients are provided with a wide range of tools— in the form of Gestalt experiments—for discovering new facets of themselves and making decisions about changing their course of living.

The Gestalt approach to working with dreams is a unique pathway for people to increase their awareness of key themes in their lives. By seeing each aspect of a dream as a projection of themselves, clients are able to bring the dream to life, to interpret its personal meaning, and to assume responsibility for it.

Gestalt therapy is a holistic approach that values each aspect of the individual’s experience equally. Therapists allow the figure-formation process to guide them. They do not approach clients with a preconceived set of biases or a set agenda. Instead, they place emphasis on what occurs at the boundary between the individual and the environment. Therapists do not try to move the client anywhere. The main goal is to increase the client’s awareness of “what is.” Instead of trying to make some- thing happen, the therapist’s role is assisting the client to increase awareness that will allow reidentification with the part of the self from which he or she is alienated.

A key strength of Gestalt therapy is the attempt to integrate theory, practice, and research. Although Gestalt therapy was light on empirical research during its early years, some research has been done. Strumpfel and Goldman (2002) note that both process and outcome studies have advanced the theory and practice of Gestalt ther- apy, and they summarize a number of significant findings based on outcome research:

◆ Outcome studies have demonstrated Gestalt therapy to be equal to or greater than other therapies for various disorders.

◆ More recent studies have shown that Gestalt therapy has a beneficial impact with personality disturbances, psychosomatic problems, and substance addictions.

◆ The effects of Gestalt therapy tend to be stable in follow-up studies one to three years after termination of treatment.

◆ Gestalt therapy has demonstrated effectiveness in treating a variety of psychological disorders.

Limitations and Criticisms of Gestalt Therapy Most of my criticisms of Gestalt therapy pertain to the traditional version, or the style of Fritz Perls, which emphasized confrontation and de-emphasized the cog- nitive factors of personality. The traditional style of Gestalt therapy placed more attention on using techniques to confront clients and getting them to experience

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their feelings. Contemporary Gestalt therapy has come a long way, and more atten- tion is being given to theoretical instruction and cognitive factors in general.

In Gestalt therapy clients clarify their thinking, explore beliefs, and put meaning to experiences they are reliving in therapy. Clients assume an active role in partici- pating in experiments, and they learn experientially. The emphasis is on facilitating the clients’ own process of self-discovery and learning. This experiential and self- directed learning process is based on the fundamental belief in organismic self-reg- ulation, which implies that clients arrive at their own truths through awareness and improved contact with the environment. It seems to me, however, that clients can engage in self-discovery and at the same time benefit from appropriate teaching by the therapist. In addition to the benefits of experiential learning, clients can profit from timely and useful information, and a psychoeducational focus can enhance the learning process.

Contemporary Gestalt practice places a high value on the contact and dialogue between therapist and client. For Gestalt therapy to be effective, the therapist must have a high level of personal development. Being aware of one’s own needs and see- ing that they do not interfere with the client’s process, being present in the moment, and being willing to be nondefensive and self-revealing demands a lot from the ther- apist, and Gestalt therapists must be well-trained.

Gestalt therapists pay attention to energy and the body. When clients are experi- encing intense emotions, a gentle nonsexual touch can be a source of support if clients are open to touch. Rodriguez (2021) writes that understanding the power dynamics between client and therapist is essential when using touch in Gestalt therapy. In her training in Gestalt therapy, Rodriguez learned that only well-trained and experienced clinicians should make use of touch in therapy. The unethical use of touch can result in a boundary violation, but Rodriguez has found little to no published literature on sexual boundary violations in Gestalt therapy. Rodriguez believes Gestalt therapists need to address the ethical use of body awareness in their training, and they must maintain a healthy contact boundary in the therapeutic relationship.

Some Cautions Typically, Gestalt therapists are highly active and exhibit sensi- tivity, timing, inventiveness, empathy, and respect for the client (Zinker, 1978). If therapists lack these qualities, their experiments can easily boomerang. Some therapists employ Gestalt techniques without having a sound theoretical rationale. Inept therapists may use powerful techniques to stir up feelings and open up problems clients have kept from full awareness only to abandon the clients once they have managed to have a dramatic catharsis. Such a failure to stay with clients and help them work through what they have experienced and bring some closure to the experience can be detrimental and could be considered as unethical practice.

Effective practitioners of Gestalt therapy require a strong general clinical back- ground and training, not only in the theory and practice of Gestalt therapy but also in personality theory, psychopathology, and knowledge of psychodynamics (Yontef et al., 2019). Competent practitioners need to have engaged in their own personal therapy and to have had advanced clinical training and supervised experience. Such therapists have learned to blend a phenomenological and dialogic approach, which is inherently respectful to the client, with well-timed experiments.

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Self-Reflection and Discussion Questions 1. What are some advantages you can see in asking clients to bring any

problems or concerns they are experiencing into the here and now? 2. The ability of a therapist to be present during the therapy session is

central in Gestalt therapy practice. Can you think of some challenges you are likely to face in being fully present for your clients? How can you deal with these challenges?

3. What do you understand as the difference between an experiment and an exercise or technique in Gestalt therapy?

4. Energy and blocks to energy are given prominence in Gestalt therapy. What are some ideas you have for working with a client’s energy with- out making interpretations for the client?

5. Imagine yourself as a client with a Gestalt therapist. What do you think this experience would be like for you?

Where to Go From Here Other Resources

Psychotherapy.net is a comprehensive resource for students and professionals that offers videos demonstrating Gestalt therapy with adults and children. New articles, interviews, blogs, therapy cartoons, and videos are published monthly. DVDs relevant to this chapter are available at www.psychotherapy.net and include the following:

Oaklander, V. (2001). Gestalt Therapy with Children (Child Therapy with the Experts Series)

Polster, E. (1997). Psychotherapy With the Unmotivated Patient

Training Programs and Associations If you are interested in furthering your knowledge and skill in the area of Gestalt therapy, you might consider pursuing Gestalt training, which would include attend- ing workshops, seeking out personal therapy from a Gestalt therapist, and enrolling in a Gestalt training program that would involve reading, practice, and supervision. A comprehensive list of these resources, along with their websites is available in the Appendixes of Woldt and Toman’s textbook (2005). Some of the most prominent training programs and associations are listed here.

Gestalt Institute of Cleveland, Inc. (www.gestaltcleveland.org)

Pacific Gestalt Institute (www.gestalttherapy.org)

Gestalt Center for Psychotherapy and Training (www.gestaltnyc.org)

Gestalt International Study Center (www.GISC.org)

Gestalt Therapy Training Center Northwest (www.gttcnw.org)

Gestalt Associates Training, Los Angeles (www.gatla.org)

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The most prominent professional associations for Gestalt therapy that hold international conferences follow.

Association for the Advancement of Gestalt Therapy (www.AAGT.org)

European Association for Gestalt Therapy (www.EAGT.org)

Gestalt Australia New Zealand (www.ganz.org.au)

Gestalt Review (www.gestaltreview.com)

British Gestalt Journal (www.britishgestaltjournal.com)

The Gestalt Directory includes information about Gestalt practitioners and training programs throughout the world and is available free of charge upon request to the Center for Gestalt Development, Inc. The center also has many books, audiotapes, and videotapes available that deal with Gestalt practice. More information on the Center for Gestalt Development can be found on their website (www.gestalt.org).

Recommended Supplementary Readings for Chapter 8 Gestalt Therapy Verbatim (Perls, 1969) provides a firsthand account of the way Fritz Perls worked. It contains many verbatim transcripts of workshop demonstrations.

Gestalt Therapy (Wheeler & Axelsson, 2015) offers an excellent introduction to the theory, evolution, research, and practice of Gestalt therapy. The book is based on principles that encourage an active, present-focused, relational stance on the thera- pist’s part.

Gestalt Therapy: History, Theory, and Practice (Woldt & Toman, 2005) introduces the histori- cal underpinnings and key concepts of Gestalt therapy and features applications of those con- cepts to therapeutic practice. This is a significant publication in the field of Gestalt therapy, and it contains pedagogical learning activities and experiments, review questions, and photographs for all contributors.

Gestalt Therapy Integrated: Contours of Theory and Prac- tice (E. Polster & Polster, 1973) is a classic in the field and an excellent source for those who want a more advanced and theoretical treatment of this model.

Enchantment and Gestalt Therapy: Partners in Explor- ing Life (Polster, 2021) brings to life many key themes in Gestalt therapy, a few of which include working in the here and now, life focus groups, understanding resistance, and fundamentals of contact boundaries. The author describes the phenomenon of enchant- ment in psychotherapy, and he describes his own experiences over his long career as a Gestalt therapist.

Beyond the Hot Seat Revisited: Gestalt Approaches to Group (Feder & Frew, 2008) is one of the few books exclusively devoted to Gestalt approaches to group work, and I highly recommend it. Separate chap- ters are devoted to Gestalt group process, family therapy, training groups, intensive workshops, and other clinical applications.

References Beisser, A. R. (1970). The paradoxical theory of change. In J. Fagan & I. L. Shepherd (Eds.), Gestalt therapy now (pp. 77–80). Harper & Row, Colophon.

Brownell, P. (2016). Contemporary Gestalt therapy. In D. J. Cain, K. Keenan, & S. Rubin (Eds.), Humanistic psychotherapies: Handbook of research and practice (2nd ed.

pp. 219–250). American Psychological Association. Conyne, R. K. (2015). Gestalt group therapy. In E. Neukrug (Ed.), SAGE

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encyclopedia of theory in counseling and psychotherapy (vol. 1, pp. 452–456). SAGE. Corey, G. (2013). Case approach to counseling and psychotherapy (8th ed.). Brooks/Cole, Cengage Learning. Corey, G. (2023). Theory and practice of group counseling (10th ed.). Cengage Learning. Feder. B. (2006). Gestalt group therapy: A practical guide. Gestalt Institute Press. Feder, B., & Frew, J. (Eds.). (2008). Beyond the hot seat revisited: Gestalt approaches to group.: Gestalt Institute Press. Frew, J. E. (1986). The functions and patterns of occurrence of individual contact styles during the development phase of the Gestalt group. The Gestalt Journal, 9(l), 55–70. Frew, J. E. (1997). A Gestalt therapy theory application to the practice of group leadership. Gestalt Review, 1(2), 131–149. Frew, J. (2013). Gestalt therapy. In J. Frew & M. D. Spiegler (Eds.), Contemporary psychotherapies for a diverse world (pp. 215–257). Routledge. Taylor & Francis. Latner, J. (1986). The Gestalt therapy book. Center for Gestalt Development. Levitsky, A., & Perls, F. (1970). The rules and games of Gestalt therapy. In J. Fagan & I. Shepherd (Eds.), Gestalt therapy now (pp. 140–149). Harper & Row, Colophon. Maurer, R. (2005). Gestalt approaches with organizations and large systems. In A. Woldt & S. Toman (Eds.), Gestalt therapy: History, theory, and practice. (pp. 237–256). SAGE. Melnick, J., & Nevis, S. (2005). Gestalt therapy methodology. In A. Woldt & S. Toman (Eds.), Gestalt therapy: History, theory, and practice (pp. 101–116). SAGE. Oaklander, V. (1988). Windows to our children: A Gestalt therapy approach to children and adolescents. Center for Gestalt Development. Oaklander, V. (1997). The rosebush. In H. Kaduson & C. Schafer (Eds.), 101 favorite play therapy techniques (pp. 11–13). Jason Aronson. Oaklander, V. (1999). Group play therapy from a Gestalt therapy perspective. In D.

S. Sweeney & L. F. Homeyer (Eds.), Group play therapy: How to do it, how it works, whom it’s best for (pp. 162–175). Jossey-Bass. Oaklander, V. (2001). Gestalt play therapy. International Journal of Play Therapy, 10(2), 45–55. doi:https://10.1037/ h0089479. Oaklander, V. (2006). Hidden treasure: A map to the child’s inner self. Karnac Books. Perls, F. (1969). Gestalt therapy verbatim. Real People Press. Perls, L. (1976). Comments on new directions. In E. W. L. Smith (Ed.), The growing edge of Gestalt therapy (pp. 221–226). Brunner/Mazel. Polster, E. (1987a). Escape from the present: Transition and storyline. In J. K. Zeig (Ed.), The evolution of psychotherapy (pp. 326–340). Brunner/Mazel. Polster, E. (1987b). Every person’s life is worth a novel: How to cut through emotional pain and discover the fascinating core of life. Norton. Polster, E. (1995). A population of selves: A therapeutic exploration of personality diversity. Jossey-Bass. Polster, E. (2006). Uncommon ground. Zeig, Tucker, and Theissen. Polster, E. (2015). Beyond therapy: Igniting life focus community movements. Transaction. Polster, E. (2021). Enchantment and Gestalt therapy: Partners in exploring life. Routledge. Polster, E., & Polster, M. (1973). Gestalt therapy integrated: Contours of theory and practice. Brunner/Mazel. Polster, E., & Polster, M. (1976). Therapy without resistance: Gestalt therapy. In A. Burton (Ed.), What makes behavior change possible? (pp. 259–277). Brunner/Mazel. Polster, E., & Polster, M. (1999). From the radical center: The heart of Gestalt therapy. Gestalt Institute of Cleveland Press. Polster, M. (1987). Gestalt therapy: Evolution and application. In J. K. Zeig (Ed.), The evolution of psychotherapy (pp. 312–325). Brunner/Mazel. Polster, M. (1992). Eve’s daughters: The forbidden heroism of women. Jossey-Bass. Polster, M., & Polster, E. (1990). Gestalt therapy. In J. K. Zeig & W. M. Munion

(Eds.), What is psychotherapy? Contemporary perspectives (pp. 103–107). Jossey-Bass. Resnick, R. W. (2015). Gestalt therapy. In E. Neukrug (Ed.), SAGE encyclopedia of theory in counseling and psychotherapy (vol. 1, pp. 456–461). SAGE. Rodriguez, M. N. (2021). Going beyond the contact boundary: A Gestalt therapy perspective. In A. Steinberg, J. L. Alpert, & C. A. Courtois, (Eds.), Sexual boundary violations in psychotherapy: Facing therapist indiscretions, transgressions, and misconduct (pp. 117–128). American Psychological Association. Strumpfel, U., & Goldman, R. (2002). Contacting Gestalt therapy. In D. J. Cain & J. Seeman (Eds.), Humanistic psychotherapies: Handbook of research and practice (pp. 189–219). American Psychological Association. Sue, D. W., Sue, D., Neville, H. A., & Smith, L. (2022). Counseling the culturally diverse: Theory and practice (9th ed.). Wiley. Wheeler, G., & Axelsson, L. S. (2015). Gestalt therapy. American Psychological Association. Woldt, A., & Toman, S. (Eds.). (2005). Gestalt therapy: History, theory, and practice. SAGE. Yontef, G. M. (1993). Awareness, dialogue and process: Essays on Gestalt therapy. Gestalt Journal Press. Yontef, G. (1995). Gestalt therapy. In A. S. Gurman & S. B. Messer (Eds.), Essential psychotherapies: Theory and practice (pp. 261– 303). Guilford Press. Yontef, G. (1999). Awareness, dialogue and process: Preface to the 1998 German edition. The Gestalt Journal, 22(1), 9–20. Yontef, G., Jacobs, L., & Bowman, C. (2019). Gestalt therapy. In D. Wedding & R. J. Corsini (Eds.), Current psychotherapies (11th ed., pp. 309–348). Cengage Learning. Yontef, G., & Schulz, F. (2013). Dialogic relationship and creative techniques: Are they on the same team? Pacific Gestalt Institute. Zinker, J. (1978). Creative process in Gestalt therapy. Random House, Vintage.

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9Behavior Therapy*

1. Identify the key figures associated with the development of behavior therapy.

2. Differentiate the four developmental areas of behavior therapy: classical conditioning, operant conditioning, social cognitive theory, and cognitive behavior therapy.

3. Evaluate the central characteristics and assumptions that unite the diverse field of behavior therapy.

4. Explain how the function and role of the therapist affects the therapy process.

5. Describe the role of the client– therapist relationship in the behavioral approaches.

6. Identify the diverse array of beha vioral techniques and procedures and how they fit within the evidencebased practice movement.

7. Describe the key concepts of EMDR, its main applications,

and the effectiveness of this approach.

8. Describe the basic elements of social skills training.

9. Explain the main steps involved in selfmanagement programs.

10. Identify the key concepts of the four major approaches of the mindfulness and acceptancebased behavior therapies.

11. Examine the application of behavioral principles and techniques to brief interventions and to group counseling.

12. Discuss the application of the behavior therapy approach to school counseling.

13. Describe the advantages and short comings of behavior therapy in working with culturally diverse clients.

14. Discuss the evaluation of contemporary behavior therapy.

Learning Objectives

*I want to express appreciation to Caroline Bailey, PhD, for substantial contributions strengthening and updating this chapter, and for her work in incorporating practical examples throughout the chapter. I also want to acknowledge Sherry Cormier, PhD, for her review of this chapter and her contribution of an expert’s perspective on behavior therapy.

Coauthored by Caroline Bailey and Sherry Cormier

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B. F. Skinner (1904–1990) re- ported that he was brought up in a warm, stable family environ- ment.* As he was growing up, Skinner was greatly interested in building all sorts of things, an interest that followed him throughout his professional life. He received his PhD in psychol- ogy from Harvard University in

1931 and eventually returned to Harvard after teaching in several universities. He had two daughters, one of whom is an educational psy- chologist and the other an artist.

Skinner was a prominent spokesperson for behav- iorism and can be considered the father of the behav- ioral approach to psychology. Skinner championed radical behaviorism, which places primary emphasis on the effects of environment on behavior. Skinner was also a determinist; he did not believe that humans had free choice. He acknowledged that feelings and thoughts exist, but he denied that they caused our ac- tions. Instead, he stressed the cause-and-effect links between objective, observable environmental condi- tions and behavior. Skinner maintained that too much

attention had been given to internal states of mind and motives, which cannot be observed and changed directly, and that too little focus had been given to en- vironmental factors that can be directly observed and changed. He was extremely interested in the concept of reinforcement, which he applied to his own life. For example, after working for many hours, he would go into his constructed cocoon (like a tent), put on head- phones, and listen to classical music (Frank Dattilio, personal communication, September 24, 2010).

Most of Skinner’s work was of an experimental nature in the laboratory, but others have applied his ideas to teaching, managing human problems, and social plan- ning. Science and Human Behavior (Skinner, 1953) best illustrates how Skinner thought behavioral concepts could be applied to every domain of human behavior. In Walden II (1948) Skinner describes a utopian commu- nity in which his ideas, derived from the laboratory, are applied to social issues. His 1971 book, Beyond Freedom and Dignity, addressed the need for drastic changes if our society was to survive. Skinner believed that science and technology held the promise for a better future.

*This biography is based largely on Nye’s (2000) discussion of B. F. Skinner’s radical behaviorism.

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Albert Bandura (1925–2021) was born in a small town in northern Alberta, Canada; he was the youngest of six children in a family of East- ern European descent.* Ban- dura spent his elementary and high school years in the one school in town, which was short of teachers and

resources. These meager edu- cational resources proved to be an asset rather than a liability as Bandura early on learned the skills of self- directedness, which would later become one of his re- search themes. He earned his PhD in clinical psychology from the University of Iowa in 1952, and a year later he

joined the faculty at Stanford University. Bandura and his colleagues did pioneering work in the area of social modeling and demonstrated that modeling is a power- ful process that explains diverse forms of learning (see Bandura 1971a, 1971b; Bandura & Walters, 1963). In his research programs at Stanford University, Bandura and his colleagues explored social learning theory and the prominent role of observational learning and social modeling in human motivation, thought, and action. By the mid-1980s Bandura had renamed his theoreti- cal approach social-cognitive theory, which shed light on how we function as self-organizing, proactive, self- reflective, and self-regulating beings (see Bandura, 1986). This notion that we are not simply reactive organisms shaped by environmental forces or driven by inner im- pulses represented a dramatic shift in the development

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of behavior therapy. Bandura broadened the scope of behavior therapy by exploring the inner cognitive- affective forces that motivate human behavior.

There are some existential qualities inherent in Bandura’s social-cognitive theory. Bandura has pro- duced a wealth of empirical evidence that demon- strates the life choices we have in all aspects of our lives. In Self-Efficacy: The Exercise of Control (Bandura, 1997), Bandura shows the comprehensive applications of his theory of self-efficacy to areas such as human de- velopment, psychology, psychiatry, education, medi- cine and health, athletics, business, social and political change, and international affairs.

Bandura has concentrated on four areas of research: (1) the power of psychological modeling in shaping thought, emotion, and action; (2) the mechanisms of human agency, or the ways people influence their own motivation and behavior through choice; (3) people’s perceptions of their efficacy to exercise influence over the events that affect their lives; and (4) how stress

reactions and depressions are caused. Bandura has created one of the few mega-theories that still thrive in the 21st century. He has shown that people need a sense of self-efficacy and resilience to create a success- ful life and to meet the inevitable obstacles and adver- sities they encounter.

Bandura has written nine books, many of which have been translated into various languages. In 2004 he received the Outstanding Lifetime Contribution to Psychology Award from the American Psychological Association. Bandura reshaped the contemporary un- derstanding of human behavior with his insights into such areas as how people interact and learn, how they develop and in some cases violate moral codes, and how the belief in one’s ability helps determine success. He died on July 26, 2021, at his home in Stanford, Cali- fornia at the age of 95.

*This biography is based largely on Panjares’s (2004) discussion of Bandura’s life and work.

Marsha M. Linehan (b. 1943) is professor emerita of psychology and director emerita of the Behavioral Research and Therapy Clinics at the University of Washington. She earned her PhD at Loyola University Chicago and is certified by the American Board of Pro- fessional Psychology. Linehan is the creator of dialecti- cal behavior therapy (DBT), a therapy model that com- bines behavioral science with concepts of acceptance and mindfulness. Linehan’s primary research interest is in the development and evaluation of evidence-based treatments for people at high suicide risk who are diffi- cult to treat and who exhibit characteristics of border- line personality disorder.

As is the case for many of the founders of a coun- seling theory, Linehan’s life experiences were the im- petus for the development of her theory. In Building a Life Worth Living, Marsha Linehan (2020) describes her life journey as a descent into hell. Shortly before Linehan was supposed to graduate from high school, she was admitted to the Institute for Living for an

extended period of time because of physical, psycho- logical, and behavioral problems, including suicidal behavior. She describes hell as being trapped in a small room with no way out. “When I reflect on my life, I often realize that there is no amount of happi- ness in the universe that could ever balance the sear- ing, excruciating, emotional pain I experienced those many years ago” (p. 23). She writes that her story is about never giving up, in spite of failure after failure, and in getting up and carrying on. It is a story about persistence and love. Linehan made a vow to God that she would get herself out of hell and that she would also find a way to get others out of hell. She put her professional energy into developing DBT, a popular approach that has solid research backing. As a part of her spiritual journey, Linehan spent a year in a Zen monastery and eventually became a Zen mas- ter. She brought Zen and mindfulness practices into psychotherapy and combined Eastern practices with behavior therapy.

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Introduction Behavior therapy practitioners focus on directly observable behavior, current deter- minants of behavior, learning experiences that promote change, tailoring treatment strategies to individual clients, and rigorous assessment and evaluation. Behavior therapy has been used to treat a wide range of psychological disorders with specific client populations. Anxiety disorders, depression, posttraumatic stress disorder, substance abuse, eating and weight disorders, sexual dysfunction, pain manage- ment, schizophrenia, and hypertension have all been successfully treated using this approach (Antony, 2019). With children and adolescents, behavioral approaches are also used to treat developmental disabilities such as autism spectrum disorder (Laugeson & Frankel, 2010) and externalizing behavior disorders such as opposi- tional defiant disorder (Bodiford et al., 2010; Kazdin, 2005). Behavioral procedures are used in the fields of developmental disabilities, mental illness, education and special education, community psychology, clinical psychology, rehabilitation, busi- ness, self-management, sports psychology, health-related behaviors, medicine, and gerontology (Miltenberger, 2016).

Historical Background The behavioral approach had its origin in the 1950s and early 1960s, and it was a radi- cal departure from the dominant psychoanalytic perspective. The behavior therapy movement differed from other therapeutic approaches in its application of principles of classical and operant conditioning to the treatment of a variety of problem behav- iors. Today, it is difficult to find a consensus on the definition of behavior therapy because the field has grown, become more complex, and is marked by a diversity of views. Contemporary behavior therapy is no longer limited to treatments based on traditional learning theory (Antony et al., 2020), and it increasingly overlaps with other theoretical approaches (Antony, 2019). Behavior therapists now use a variety of evidence-based techniques in their practices, including cognitive therapy, social skills training, relaxation training, and mindfulness strategies—all discussed in this chapter. The following historical sketch of behavior therapy is largely based on Spiegler (2016).

Traditional behavior therapy arose simultaneously in the United States, South Africa, and Great Britain in the 1950s. In spite of harsh criticism and resistance from psychoanalytic psychotherapists, the approach has survived. Its focus was on dem- onstrating that behavioral conditioning techniques were effective and were a viable alternative to psychoanalytic therapy.

In the 1960s, Albert Bandura developed social learning theory, which combined classical and operant conditioning with observational learning. Bandura made cog- nition a legitimate focus for behavior therapy. During the 1960s a number of cogni- tive behavioral approaches sprang up that focused on cognitive representations of the environment rather than on characteristics of the objective environment.

Contemporary behavior therapy emerged as a major force in psychology during the 1970s, and it had a significant impact on education, psychology, psychotherapy, psychiatry, and social work. Behavioral techniques were expanded to provide solu- tions for business, industry, and child-rearing problems as well. Behavior therapy techniques were viewed as the treatment of choice for many psychological problems.

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The 1980s were characterized by a search for new horizons in concepts and methods that went beyond traditional learning theory. Behavior therapists contin- ued to subject their methods to empirical scrutiny and to consider the impact of the practice of therapy on both their clients and the larger society. Increased attention was given to the role of emotions in therapeutic change, as well as to the role of biological factors in psychological disorders. Three of the most significant devel- opments in the field were (1) the continued emergence of cognitive behavior ther- apy as a major force, (2) the application of behavioral techniques to the prevention and treatment of health-related disorders, and (3) the emergence of the third-wave behavior therapies (mindfulness and acceptance-based approaches).

By the late 1990s the Association for Behavioral and Cognitive Therapies (ABCT) (formerly known as the Association for Advancement of Behavior Therapy) claimed a membership of about 4,500. Currently, ABCT includes approximately 6,000 men- tal health professionals and students who are interested in empirically based behav- ior therapy or cognitive behavior therapy. This name change and description reveals the current thinking of integrating behavioral and cognitive therapies.

By the early 2000s, the behavioral tradition had broadened considerably, which involved enlarging the scope of research and practice. This newest development, sometimes known as the “third generation” or “third wave” of behavior therapy, includes mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), dialectical behavior therapy (DBT), and acceptance and commit- ment therapy (ACT). Behavior therapies are among the most widely used treatment interventions for psychological and behavioral problems today. The evidence sup- porting behavioral and cognitive behavioral treatments for particular problems is better developed than for any other therapeutic approach (Antony, 2019).

Refer to the MindTap for this book to interact with video quizzes and various video programs to expand your knowledge on topics relevant to Chapter 9.

Four Areas of Development Contemporary behavior therapy can be understood by considering four major areas of development: (1) classical conditioning, (2) operant conditioning, (3) social- cognitive theory, and (4) cognitive behavior therapy.

Classical conditioning (respondent conditioning) refers to what happens prior to learning that creates a response through pairing. A key figure in this area is Ivan Pavlov who illustrated classical conditioning through experiments with dogs. Plac- ing food in a dog’s mouth leads to salivation, which is respondent behavior. When food is repeatedly presented with some originally neutral stimulus (something that does not elicit a particular response), such as the sound of a bell, the dog will eventu- ally salivate to the sound of the bell alone. However, if a bell is sounded repeatedly but not paired again with food, the salivation response will eventually diminish and become extinct. An example of a procedure that is based on the classical condition- ing model is Joseph Wolpe’s systematic desensitization, which is described later in

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this chapter. This technique illustrates how principles of learning derived from the experimental laboratory can be applied clinically. Desensitization can be applied to people who, through classical conditioning, developed an intense fear of flying after having a frightening experience while flying.

Technically one can develop an intense fear of flying without having a frighten- ing experience personally. For example, someone may see visual images of a plane crashing off the coast of Brazil and develop a fear of flying even though that person has never flown anywhere. Some researchers hold a different view and believe that fear of flying may be due primarily to claustrophobia (Frank Dattilio, personal com- munication, September 24, 2010).

Most of the significant responses we make in everyday life are examples of operant behaviors, such as reading, writing, driving a car, and eating with utensils. Operant conditioning involves a type of learning in which behaviors are influenced mainly by the consequences that follow them. If the environmental changes brought about by the behavior are reinforcing—that is, if they provide some reward to the organism or eliminate aversive stimuli—the chances are increased that the behavior will occur again. If the environmental changes produce no reinforcement or pro- duce aversive stimuli, the chances are lessened that the behavior will recur. Posi- tive and negative reinforcement, punishment, and extinction techniques, described later in this chapter, illustrate how operant conditioning in applied settings can be instrumental in developing prosocial and adaptive behaviors. Operant techniques are used by behavioral practitioners in parent education programs, such as parent management training (Kazdin, 2005), and with weight management programs.

The behaviorists of both the classical and operant conditioning models excluded any reference to mediational concepts, such as the role of thinking pro- cesses, attitudes, and values. This focus is perhaps due to a reaction against the insight-oriented psychodynamic approaches. The social learning approach (or the social-cognitive approach) developed by Albert Bandura and Richard Walters (1963) is interactional, interdisciplinary, and multimodal (Bandura, 1977, 1982). Social- cognitive theory involves a triadic reciprocal interaction among the environment, personal factors (beliefs, preferences, expectations, self-perceptions, and interpreta- tions), and individual behavior. In the social-cognitive approach, the environmental events on behavior are mainly determined by cognitive processes governing how environmental influences are perceived by an individual and how these events are interpreted. A basic assumption is that people are capable of self-directed behavior change and that the person is the agent of change. For Bandura (1982, 1997), self- efficacy is the individual’s belief or expectation that he or she can master a situa- tion and bring about desired change. An example of social learning is how people develop effective social skills after they are in contact with other people who effec- tively model interpersonal skills.

Cognitive behavior therapy (CBT) represents the mainstream of contempo- rary behavior therapy and is a popular theoretical orientation among psychologists. Cognitive behavioral therapy operates on the assumption that what people believe influences how they act and feel. Since the early 1970s, the behavioral movement has conceded a legitimate place to thinking, even to the extent of giving cognitive factors a central role in understanding and treating emotional and behavioral problems. By the mid-1970s, cognitive behavior therapy had replaced behavior therapy as the

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accepted designation, and the field began emphasizing the interaction among affec- tive, behavioral, and cognitive dimensions.

Contemporary behavior therapy has much in common with cognitive behavior therapy in which the mechanism of change is both cognitive (modifying thoughts to change behaviors) and behavioral (altering external factors that lead to behav- ior change). Social skills training, cognitive therapy, stress management training, mindfulness, and acceptance-based practices all represent the cognitive behavioral tradition. This chapter goes beyond the traditional behavioral perspective and deals mainly with applied aspects of this model. Chapter 10 is devoted to the cognitive behavioral approaches, which focus on changing clients’ cognitions (thoughts and beliefs) that maintain psychological problems.

Key Concepts Current Trend in Behavior Therapy

Contemporary behavior therapy is grounded on a scientific view of human behavior that accommodates a systematic and structured approach to counseling. The cur- rent trend in behavior therapy is toward developing procedures that give control to clients and thus increase their range of freedom. Behavior therapy aims to increase people’s skills so that they have more options for responding. By overcoming debili- tating behaviors that restrict choices, people are freer to select from possibilities that were not available to them earlier, which increases individual freedom.

Basic Characteristics and Assumptions Seven key characteristics define behavior therapy and its assumptions. One defining characteristic is that behavior therapy is based on the principles and procedures of the scientific method. Experimentally derived principles of learning are systemati- cally applied to help people change their maladaptive behaviors. The distinguishing characteristic of behavioral practitioners is their systematic adherence to precision and to empirical evaluation. Behavior therapists state treatment goals in concrete objective terms to make replication of their interventions possible. Treatment goals are agreed upon by the client and the therapist. Throughout the course of therapy, the therapist assesses problem behaviors and the conditions that are maintaining them. Evaluation methods are used to discern the effectiveness of both assessment and treatment procedures. Therapeutic techniques employed must have demon- strated effectiveness. In short, behavioral concepts and procedures are stated explic- itly, tested empirically within a conceptual framework, and revised continually.

Behavior is not limited to overt actions a person engages in that we can observe, however; behavior also includes internal processes such as cognitions, images, beliefs, and emotions. The key characteristic of a behavior is that it is something that can be operationally defined.

Behavior therapy deals with the client’s current problems and the factors influ- encing them today rather than analyzing possible historical determinants. Empha- sis is on specific factors that influence present functioning and what factors can be used to modify performance. Behavior therapists look to the current environmental

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events that maintain problem behaviors and help clients produce behavior change by changing environmental events, through a process called functional assessment, or what Wolpe (1990) referred to as a “behavioral analysis.” Behavior therapy recog- nizes the importance of the individual, the individual’s environment, and the inter- action between the person and the environment in facilitating change.

Clients involved in behavior therapy are expected to assume an active role by engaging in specific actions to deal with their problems. Rather than simply talking about their condition, clients are required to do something to bring about change. Clients monitor their behaviors both during and outside the therapy sessions, learn and practice coping skills, and role-play new behavior. Therapeutic tasks that clients carry out in daily life, or homework assignments, are a basic part of this approach. Behavior therapy is an action-oriented and an educational approach, and learning is viewed as being at the core of therapy. Clients learn new and adaptive behaviors to replace old and maladaptive behaviors.

This approach assumes that change can take place without insight into under- lying dynamics and without understanding the origins of a psychological problem. Behavior therapists operate on the premise that changes in behavior can occur prior to or simultaneously with understanding of oneself, and that behavioral changes may well lead to an increased level of self-understanding. Although it is true that insight and understanding about the contingencies that exacerbate one’s problems can supply motivation to change, knowing that one has a problem and knowing how to change it are two different things (Martell, 2007).

Assessment is an ongoing process of observation and self-monitoring that focuses on the current determinants of behavior, including identifying the prob- lem and evaluating the change. Assessment informs the treatment process and involves attending to the culture of clients as part of their social environments, including social support networks relating to target behaviors. Critical to behav- ioral approaches is the careful assessment and evaluation of the interventions used to determine whether the behavior change resulted from the procedure.

Behavioral treatment interventions are individually tailored to specific prob- lems experienced by the client. Several therapy techniques may be used to treat an individual client’s problems. An important question that serves as a guide for this choice is, “What treatment, by whom, is the most effective for this individual with that specific problem and under which set of circumstances?” (Paul, 1967, p. 111).

The Therapeutic Process Therapeutic Goals

Goals occupy a place of central importance in behavior therapy. The general goals of behavior therapy are to increase personal choice and to create new conditions for learning. The client, with the help of the therapist, defines specific treatment goals at the outset of the therapeutic process. Although assessment and treatment occur together, a formal assessment takes place prior to treatment to determine behaviors that are targets of change. Continual assessment throughout therapy determines the degree to which identified goals are being met. It is important to devise a way to measure progress toward goals based on empirical validation.

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Contemporary behavior therapy stresses clients’ active role in formulating spe- cific measurable goals. Goals must be clear, concrete, understood, and agreed on by the client and the counselor. Counselor and client discuss the behaviors associated with the goals, the circumstances required for change, the nature of subgoals, and a plan of action to work toward these goals. This process of determining therapeu- tic goals entails a negotiation between client and counselor that results in a con- tract that guides the course of therapy. Behavior therapists and clients alter goals throughout the therapeutic process as needed.

Therapist’s Function and Role Behavior therapists conduct a thorough functional assessment (or behavioral analysis) to identify the maintaining conditions by systematically gathering infor- mation about situational antecedents (A), the dimensions of the problem behavior (B), and the consequences (C) of the problem. This is known as the ABC model, and the goal of a functional assessment of a client’s behavior is to understand the ABC sequence. This model of behavior suggests that behavior (B) is influenced by some particular events that precede it, called antecedents (A), and by certain events that follow it, called consequences (C). Antecedent events cue or elicit a certain behavior. For example, with a client who has trouble going to sleep, listening to a relaxation tape may serve as a cue for sleep induction. Turning off the lights and removing the television from the bedroom may elicit sleep behaviors as well. Consequences are events that maintain a behavior in some way, either by increasing or decreasing it. For example, a client may be more likely to return to counseling after the counselor offers verbal praise or encouragement for having come in or for having completed some homework. A client may be less likely to return if the counselor is consistently late to sessions. In doing a behavioral assessment interview, the therapist’s task is to identify the particular antecedent and consequent events that influence, or are functionally related to, an individual’s behavior (Cormier et al., 2017).

Behaviorally oriented practitioners tend to be active and directive and to func- tion as consultants and problem solvers. They rely heavily on empirical evidence about the efficacy of the techniques they apply to particular problems. Behavioral practitioners must have skills in selecting and applying treatment methods. They pay close attention to the clues given by clients, and they are willing to follow their clini- cal hunches. Behavior therapists use some techniques common to other approaches, such as summarizing, reflection, clarification, and open-ended questioning. Behav- ior therapists are directive and often offer suggestions (Antony, 2019), but they may perform these other functions as well (Miltenberger, 2016; Speigler, 2016):

◆ The therapist strives to understand the function of client behaviors, includ- ing how certain behaviors originated and how they are sustained. With this understanding, the therapist formulates initial treatment goals and designs and implements a treatment plan to accomplish these goals.

◆ The behavioral clinician uses strategies that have research support for use with a particular kind of problem. These evidence-based strategies promote generalization and maintenance of behavior change. A num- ber of these strategies are described later in this chapter.

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◆ The clinician evaluates the success of the change plan by measuring progress toward the goals throughout the duration of treatment. Outcome measures are given to the client at the beginning of treat- ment (called a baseline) and collected again periodically during and after treatment to determine whether the strategy and treatment plan are working. If not, adjustments are made in the strategies being used.

◆ Follow-up assessments are conducted to evaluate whether the changes are durable over time. Clients learn how to identify and cope with potential setbacks and acquire behavioral and cognitive coping skills to maintain changes and to prevent relapses.

Let’s examine how a behavior therapist might perform these functions. A cli- ent comes to therapy to reduce her anxiety, which is preventing her from leaving the house. The therapist is likely to begin with a specific analysis of the nature of her anxiety. The therapist will ask how she experiences the anxiety of leaving her house, including what she actually does in these situations. Systematically, the thera- pist gathers information about this anxiety. When did the problem begin? In what situations does it arise? What does she do at these times? What are her feelings and thoughts in these situations? Who is present when she experiences anxiety? What does she do to reduce the anxiety? How do her present fears interfere with living effectively? After this assessment, specific behavioral goals are developed, and strate- gies such as relaxation training, systematic desensitization, and exposure therapy are designed to help the client reduce her anxiety to a manageable level. The therapist will get a commitment from the client to work toward the specified goals, and the two of them will evaluate the client’s progress toward meeting these goals through- out the duration of therapy.

For a description of applying a behavioral approach to the assessment and treat- ment of an individual client, see Dr. Sherry Cormier’s behavioral interventions with Ruth in Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 7).

Client’s Experience in Therapy One of the unique contributions of behavior therapy is that it provides the therapist with a well-defined system of procedures to employ. Both therapist and client have clearly defined roles, and the importance of client awareness and participation in the therapeutic process is stressed. Behavior therapy is characterized by an active role for both therapist and client. A large part of the therapist’s role is to teach concrete skills through the provision of instructions, modeling, and performance feedback. The client engages in behavioral rehearsal with feedback until skills are well learned and generally receives active homework assignments (such as self-monitoring of problem behaviors) to complete between therapy sessions. Behavior clinicians emphasize that changes clients make in therapy need to be translated into their daily lives.

It is important for clients to be motivated to change, and they are expected to engage in therapeutic activities, both during therapy sessions and in everyday life. If clients are not involved in this way, the chances are slim that therapy will be success- ful. Motivational interviewing (see Chapter 13), which honors the clients’ resistance

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in such a way that their motivation to change is increased over time, is a behavioral strategy that has considerable empirical support (Miller & Rollnick, 2013; Naar & Safren, 2017).

Clients are encouraged to experiment for the purpose of enlarging their reper- toire of adaptive behaviors. Counseling is not complete unless actions follow ver- balizations. Behavioral practitioners make the assumption that it is only when the transfer of changes is made from the sessions to everyday life that the effects of therapy can be considered successful. Clients are as aware as the therapist is regard- ing when the goals have been accomplished and when it is appropriate to termi- nate treatment. It is clear that clients are expected to do more than merely gather insights; they need to be willing to make changes and to continue implementing new behavior once formal treatment has ended.

Relationship Between Therapist and Client Behavioral practitioners have increasingly recognized the role of the therapeutic relationship and therapist behavior as critical factors related to the process and out- come of treatment. As you will recall, the experiential therapies (existential therapy, person-centered therapy, and Gestalt therapy) place primary emphasis on the nature of the engagement between counselor and client. Today, most behavioral practitio- ners stress the value of establishing a collaborative working relationship with clients but contend that warmth, empathy, authenticity, permissiveness, and acceptance are necessary, but not sufficient, for behavior change to occur. The client–therapist relationship is a foundation on which behavioral strategies are built to help clients change in the direction they wish (Kazantzis et al., 2017).

Application: Therapeutic Techniques and Procedures A strength of the behavioral approaches is the development of specific therapeutic procedures that must be shown to be effective through objective means. The results of behavioral interventions become clear because therapists receive continual direct feedback from their clients. A hallmark of the behavioral approaches is that the therapeutic techniques are empirically supported and evidence-based practice is highly valued. Behavior therapy has been shown to be effective with many different populations and for a wide array of disorders. Behavioral techniques can easily be incorporated in other approaches as well.

The therapeutic procedures used by behavior therapists are specifically designed for a particular client rather than being randomly selected from a “bag of tech- niques.” Therapists are often quite creative in their interventions. In the following sections, I describe a range of behavioral techniques available to the practitioner: applied behavioral analysis, relaxation training, systematic desensitization, expo- sure therapies, eye movement desensitization and reprocessing, social skills training, self-management programs, multimodal therapy, and mindfulness and acceptance- based approaches. These techniques do not encompass the full spectrum of behav- ioral procedures, but they do represent a sample of the approaches used in the practice of contemporary behavior therapy.

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Applied Behavioral Analysis: Operant Conditioning Techniques This section describes a few key principles of operant conditioning: positive rein- forcement, negative reinforcement, extinction, positive punishment, and negative punishment. For a detailed treatment of the wide range of operant conditioning methods that are part of contemporary behavior modification, I recommend Miltenberger (2016) and Speigler (2016).

The most important contribution of applied behavior analysis is that it offers a functional approach to understanding clients’ problems and addresses these prob- lems by changing antecedents and consequences (the ABC model). Behaviorists believe we respond in predictable ways because of the gains we experience (positive reinforcement) or because of the need to escape or avoid unpleasant consequences (negative reinforcement). Once clients’ goals have been assessed, specific behaviors are targeted. The goal of reinforcement, whether positive or negative, is to increase the target behavior. Positive reinforcement involves the addition of something of value to the individual (such as praise, attention, money, or food) as a consequence of certain behavior. The stimulus that follows the behavior is the positive reinforcer. For example, a child earns excellent grades and is praised for studying by her parents. If she values this praise, it is likely that she will have an investment in studying in the future. When the goal of a program is to decrease or eliminate undesirable behav- iors, positive reinforcement is often used to increase the frequency of more desirable behaviors, which replace undesirable behaviors. In the above example, the parental praise functions as the positive reinforcer and makes it more likely that the child will maintain or even increase the frequency of studying and earning good grades. Note that if a child did not value parental praise, this would not serve as a reinforcer. This is why behavior therapists typically perform a reinforcement inventory, a struc- tured assessment to identify what the client finds reinforcing before implementing a reinforcement system. The reinforcer is not defined by the form or substance that it takes but rather by the function it serves: namely, to maintain or increase the fre- quency of a desired behavior.

Negative reinforcement involves the escape from or the avoidance of aversive (unpleasant) stimuli. The individual is motivated to exhibit a desired behavior to avoid the unpleasant condition. For example, a friend of mine does not appreciate waking up to the shrill sound of an alarm clock. She has trained herself to wake up a few minutes before the alarm sounds to avoid the aversive stimulus of the alarm buzzer.

In a classroom setting, teachers often use behavior management systems that combine both positive reinforcement and negative reinforcement strategies to maintain classroom control. For example, a behavior thermometer can be posted at the front of the classroom with each student’s name posted on it. Students whose names are in the green zone are publicly praised for their good behavior, and those in the yellow or red are punished. The goal is for individual students to modify their behavior so that they stay in the green zone.

Another operant method of changing behavior is extinction, which refers to withholding reinforcement from a previously reinforced response. In applied set- tings, extinction can be used for behaviors that have been maintained by positive reinforcement or negative reinforcement. For example, in the case of children who

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display temper tantrums, parents often reinforce this behavior by the attention they give to it. An approach to dealing with problematic behavior is to eliminate the con- nection between a certain behavior (tantrums) and positive reinforcement (atten- tion). In this example, if the parent ignores the child’s tantrum-related behaviors, these behaviors will decrease or be eliminated through the extinction process. It should be noted that extinction might well have negative side effects, such as anger and aggression. Also note that during the extinction process unwanted behaviors may increase temporarily before they begin to decrease. Extinction can reduce or elimi- nate certain behaviors, but extinction does not replace those responses that have been extinguished.

Another way behavior is controlled is through punishment, sometimes referred to as aversive control, in which the consequences of a certain behavior result in a decrease of that behavior. The goal of reinforcement is to increase the target behavior, but the goal of punishment is to decrease the target behavior. Miltenberger (2016) describes two kinds of punishment that may occur as a con- sequence of behavior: positive punishment and negative punishment. In positive punishment, an aversive stimulus is added after the behavior to decrease the fre- quency of a behavior (such as a time-out procedure with a child who is displaying misbehavior).

In negative punishment, a reinforcing stimulus is removed following the behav- ior to decrease the frequency of a target behavior (such as deducting money from a worker’s salary for missing time at work, or taking television time away from a child for misbehavior). In both kinds of punishment, the behavior is less likely to occur in the future. These four operant procedures form the basis of behavior therapy pro- grams for parenting skills training and are used in the self-management procedures discussed later in this chapter.

Some behavioral practitioners are opposed to using aversive control or pun- ishment and recommend substituting positive reinforcement. The key principle in the applied behavior analysis approach is to use the least aversive means possible to change behavior, and positive reinforcement is known to be the most powerful change agent. It is essential that reinforcement be used as a way to develop appropri- ate behaviors that replace the behaviors that are suppressed.

In educational, community-based, and home-based settings, applied behav- ioral analysis (ABA) therapy is used for the treatment of autism spectrum disorder. ABA is a structured, systematic approach that uses behavioral principles of learn- ing to target specific behaviors for change and modification. For example, a teacher may use ABA strategies to help children on the autism spectrum learn to focus in the classroom by praising on-task behaviors and ignoring off-task behaviors and redirecting inappropriate behaviors such as leaving their seat or interrupting others.

Progressive Muscle Relaxation Progressive muscle relaxation has become increasingly popular as a method of teaching people to cope with the stresses produced by daily living. It is aimed at achieving muscle and mental relaxation and is easily learned. After clients learn the basics of relaxation procedures, it is essential that they practice these exercises daily to obtain maximum results.

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Jacobson (1938) is credited with initially developing the progressive muscle relaxation procedure. It has since been refined and modified, and relaxation pro- cedures are frequently used in combination with a number of other behavioral techniques. Progressive muscle relaxation involves several components. Clients are given a set of instructions that teaches them to relax. They assume a passive and relaxed position in a quiet environment while alternately contracting and relaxing muscles. This progressive muscle relaxation is explicitly taught to the client by the therapist. Deep and regular breathing also is associated with producing relaxation. At the same time, clients learn to mentally “let go,” perhaps by focusing on pleas- ant thoughts or images. Clients are instructed to actually feel and experience the tension building up, to notice their muscles getting tighter and study this tension, and to hold and fully experience the tension. It is useful for clients to experience the difference between a tense and a relaxed state. The client is then taught how to relax all the muscles while visualizing the various parts of the body, with emphasis on the facial muscles. The arm muscles are relaxed first, followed by the head, the neck and shoulders, the back, abdomen, and thorax, and then the lower limbs. Relaxation becomes a well-learned response, which can become a habitual pattern if practiced for about 25 minutes each day. Therapists often record relaxation instructions for clients to practice for homework. These recordings can be customized to meet the client’s unique needs and to be sensitive to any mobility impairments or pain the client may experience.

Relaxation procedures have been applied to a variety of clinical problems, either as a separate technique or in conjunction with related methods. The most common use has been with problems related to stress and anxiety, which are often manifested in psychosomatic symptoms. Relaxation training has benefits in areas such as pre- paring patients for surgery, teaching clients how to cope with chronic pain, help- ing people manage anxiety, and reducing the frequency of migraine attacks. Some other ailments for which progressive muscle relaxation is helpful include asthma, headache, hypertension, insomnia, irritable bowel syndrome, and panic disorder (Cormier et al., 2017).

For an exercise of the phases of the progressive muscle relaxation procedure that you can apply to yourself, see Student Manual for Theory and Practice of Counseling and Psychotherapy (Corey, 2024).

Systematic Desensitization Systematic desensitization, which is based on the principle of classical condition- ing, is a basic behavioral procedure developed by Joseph Wolpe, one of the pioneers of behavior therapy. Clients imagine successively more anxiety-arousing situations at the same time that they engage in a behavior that competes with anxiety. Grad- ually, or systematically, clients become less sensitive (desensitized) to the anxiety- arousing situation. This procedure can be considered a form of exposure therapy because clients are required to expose themselves to anxiety-arousing images as a way to reduce anxiety.

Systematic desensitization is an empirically researched behavior therapy pro- cedure that is time consuming, yet it is clearly effective and efficient in reducing maladaptive anxiety and treating anxiety-related disorders, particularly in the area

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of specific phobias (Cormier et al., 2017; Spiegler, 2016). Before implementing the desensitization procedure, the therapist conducts an initial interview to identify spe- cific information about the anxiety and to gather relevant background information about the client. This interview, which may last several sessions, gives the therapist a good understanding of who the client is. The therapist questions the client about the particular circumstances that elicit the conditioned fears. For instance, under what circumstances does the client feel anxious? If the client is anxious in social situ- ations, does the anxiety vary with the number of people present? Is the client more anxious with women or men? The client is asked to begin a self-monitoring process consisting of observing and recording situations during the week that elicit anxi- ety responses. Some therapists also administer a questionnaire to gather additional data about situations leading to anxiety.

If the decision is made to use the desensitization procedure, the therapist gives the client a rationale for the procedure and briefly describes what is involved. A three-step process is carried out in the desensitization process: (1) relaxation train- ing, (2) development of a graduated anxiety hierarchy, and (3) systematic desen- sitization through presentation of hierarchy items while the client is in a deeply relaxed state.

The first step is progressive muscle relaxation, which was described earlier. The therapist uses a quiet, soft, and pleasant voice to teach progressive muscular relax- ation. The client is asked to create imagery of previously relaxing situations, such as sitting by a lake or wandering through a beautiful field. It is important that the client reach a state of calm and peacefulness. The client is instructed to practice relaxation both as a part of the desensitization procedure and also outside the ses- sion on a daily basis.

The therapist then works with the client to develop an anxiety hierarchy for each of the identified areas. Stimuli that elicit anxiety in a particular area are analyzed, such as rejection, jealousy, criticism, disapproval, or any phobia. The therapist con- structs a ranked list of situations that elicit increasing degrees of anxiety or avoid- ance. The hierarchy is arranged in order from the most anxiety-provoking situation the client can imagine down to the situation that evokes the least anxiety. If it has been determined that the client has anxiety related to fear of rejection, for exam- ple, the highest anxiety-producing situation might be rejection by the spouse, next, rejection by a close friend, and then rejection by a coworker. The least disturbing situation might be a stranger’s indifference toward the client at a party.

Desensitization does not begin until several sessions after the initial interview has been completed. Enough time is allowed for clients to learn relaxation in therapy sessions, to practice it at home, and to construct their anxiety hierarchy. The desen- sitization process begins with the client reaching complete relaxation with eyes closed. A neutral scene is presented, and the client is asked to imagine it. If the cli- ent remains relaxed, he or she is asked to imagine the least anxiety-arousing scene on the hierarchy of situations that has been developed. Some clients may experi- ence initial anxiety when they imagine the scene; however, using relaxation tech- niques they are able to countercondition their anxious response to the stimulus and desensitize themselves to the feared object, situation, or setting. When clients are calm and relaxed, the therapist can move on to the next item on the hierarchy. The therapist moves progressively up the hierarchy until the client signals that he

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or she is experiencing anxiety, at which time the scene is terminated. Relaxation is then induced again, and the scene is reintroduced again until little anxiety is experi- enced to it. Treatment ends when the client is able to remain in a relaxed state while imagining the scene that was formerly the most disturbing and anxiety-producing. The core of systematic desensitization is repeated exposure in the imagination to anxiety-evoking situations without experiencing any negative consequences.

Homework and follow-up are essential components of successful desensiti- zation. Clients are encouraged to practice selected relaxation procedures daily, at which time they visualize scenes completed in the previous session. Gradually, they can expose themselves to daily-life situations as they manage their anxieties. Cli- ents tend to benefit the most when they have a variety of ways to cope with anxiety- arousing situations that they can continue to use once therapy has ended (Head & Gross, 2008).

Systematic desensitization is among the most empirically supported therapy methods available, especially for the treatment of anxiety. Not only does systematic desensitization have a good track record in dealing with fears, but it also has been used to treat a variety of conditions including anger, asthmatic attacks, insomnia, motion sickness, nightmares, and sleepwalking (Spiegler, 2016). Systematic desen- sitization is often acceptable to clients because they are gradually and symbolically exposed to anxiety-evoking situations. For a more detailed discussion of systematic desensitization, see Head and Gross (2008), Speigler (2016), and Cormier et al. (2017).

From a client’s perspective, systematic desensitization is appealing because it is collaborative, targeted, and time-limited. In many cases, clients can complete treat- ment for a simple phobia in 12 to 16 weeks (Goldfried & Davison, 1994). For clients who experience phobias that are life-limiting or work-interfering, systematic desen- sitization offers a relatively quick, empirically supported solution to a serious obsta- cle in their life. For example, imagine a child welfare social worker with a phobia of rats. Her job requires her to do home visits, and she often encounters conditions in which rats are present. Her response to rats is to run from them screaming and crying in fear, which is not acceptable behavior for a social worker visiting a client’s home. Undergoing treatment with systematic desensitization, this client was able to move from crying at the thought of imaging a rat to seeing a rat in a client’s home without anxiety—in just 14 sessions.

In Vivo Exposure and Flooding Exposure therapies are designed to treat fears and other negative emotional responses by introducing clients, under carefully controlled conditions, to the situ- ations that contributed to such problems. Exposure is a key process in treating a wide range of problems associated with fear and anxiety. Exposure therapy involves systematic confrontation with a feared stimulus, either through imagination or in vivo (live). Imaginal exposure can be used prior to implementing in vivo exposure when a client’s fears are so severe that the client is unable to participate in live expo- sure (Hazlett-Stevens & Craske, 2008). Whatever route is used, exposure involves contact by clients with what they find fearful. Desensitization is one type of expo- sure therapy, but there are others. Two variations of traditional systematic desensi- tization are in vivo exposure and flooding.

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In Vivo Exposure In vivo exposure involves client exposure to the actual anxiety- evoking events rather than simply imagining these situations. Live exposure has been a cornerstone of behavior therapy for decades. Hazlett-Stevens and Craske (2008) describe the key elements of the process of in vivo exposure. Typically, treatment begins with a functional analysis of objects or situations a person avoids or fears. Together, therapist and client generate a hierarchy of situations for the client to encounter in ascending order of difficulty. In vivo exposure involves repeated systematic exposure to fear items, beginning from the bottom of the hierarchy. Clients engage in a brief, graduated series of exposures to feared events. During the exposure to the feared stimulus or situation, the therapist is continually assessing the client’s anxiety using what is called a subjective units of distress scale (SUDS). The specific design of the scale may differ depending on the client’s age or unique needs, but SUDS requires the client to self-report the anxiety using a Likert scale (often from 1–100). Initially, the client’s anxiety is often significantly elevated when the stimulus is introduced. As is the case with systematic desensitization, clients learn responses incompatible with anxiety, such as responses involving muscle relaxation. Clients are encouraged eventually to experience their full fear response during exposure without engaging in avoidance. In doing this, the client learns that the negative consequences or outcomes that were feared did not occur. The client experiences negative reinforcement in the form of anxiety reduction and creates new associations with the formerly feared stimulus, situation, or setting. Between therapy sessions, clients carry out self-directed exposure exercises. Progress with home practice is reviewed, and the therapist provides feedback on how the client could deal with any difficulties encountered.

In some cases, the therapist may accompany clients as they encounter feared situations. For example, a therapist could go with clients in an elevator if they had phobias about using elevators. Of course, when this kind of out-of-office procedure is used, matters of safety and appropriate ethical boundaries are always considered. People who have extreme fears of certain animals could be exposed to these ani- mals in real life in a safe setting with a therapist. For example, a client with a fear of cockroaches could be exposed to a store bought cockroach during the course of a therapy session. Self-managed in vivo exposure—a procedure in which clients expose themselves to anxiety-evoking events on their own—is an alternative when it is not practical for a therapist to be with clients in real-life situations.

Role-playing exercises can be a powerful tool for in vivo exposure treatments. For example, a client who fears rejection from a potential romantic partner may avoid interacting with this person. Therapist and client could explore the basis of that fear, and then therapist and client could role play having a conversation with this person, exposing the client to those fears in a graded, structured manner.

Flooding Another form of exposure therapy is flooding, which refers to either in vivo or imaginal exposure to anxiety-evoking stimuli for a prolonged period of time. As is characteristic of all exposure therapies, even though the client experiences anxiety during the exposure, the feared consequences do not occur.

In vivo flooding consists of intense and prolonged exposure to the actual anx- iety-producing stimuli. Remaining exposed to feared stimuli for a prolonged period without engaging in any anxiety-reducing behaviors allows the anxiety to decrease

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on its own. Generally, highly fearful clients tend to curb their anxiety through the use of maladaptive behaviors. In flooding, clients are prevented from engaging in their usual maladaptive responses to anxiety-arousing situations. In vivo flooding tends to reduce anxiety rapidly.

Imaginal flooding is based on similar principles and follows the same proce- dures except the exposure occurs in the client’s imagination instead of in daily life. An advantage of using imaginal flooding over in vivo flooding is that there are no restrictions on the nature of the anxiety-arousing situations that can be treated. In vivo exposure to actual traumatic events (airplane crash, rape, fire, flood) is often not possible nor is it appropriate for both ethical and practical reasons. Imaginal flood- ing can re-create the circumstances of the trauma in a way that does not bring about adverse consequences to the client. Survivors of an airplane crash, for example, may suffer from a range of debilitating symptoms. They are likely to have nightmares and flashbacks to the disaster; they may avoid travel by air or have anxiety about travel by any means; and they probably have a variety of distressing symptoms such as guilt, anxiety, and depression. In vivo and imaginal exposure, as well as flooding, are frequently used in the behavioral treatment for anxiety-related disorders, specific phobia, social phobia, panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and agoraphobia (Hazlett-Stevens & Craske, 2008).

Because of the discomfort associated with prolonged and intense exposure, some clients may not elect these exposure treatments. It is important for the behav- ior therapist to work with the client to create motivation and readiness for exposure. From an ethical perspective, clients should have adequate information about pro- longed and intense exposure therapy before agreeing to participate. It is important that they understand that anxiety will be induced as a way to reduce it. Clients need to make informed decisions after considering the pros and cons of subjecting them- selves to temporarily stressful aspects of treatment. Clients should be informed that they can terminate exposure if they experience a high level of anxiety.

The repeated success of exposure therapy in treating various disorders has resulted in exposure being used as a part of most behavioral treatments for anxiety disorders. Spiegler (2016) notes that exposure therapies are among the most potent behavioral procedures available for anxiety-related disorders, and they can have long-lasting effects. However, he adds, using exposure as a single treatment proce- dure is not always sufficient. In cases involving severe and multifaceted disorders, more than one behavioral intervention is often required. This is especially true with posttraumatic stress disorders. Increasingly, imaginal and in vivo exposure are being used in combination, which fits with the trend in behavior therapy to use treatment packages as a way to enhance the effectiveness of therapy.

Eye Movement Desensitization and Reprocessing Eye movement desensitization and reprocessing (EMDR) is a form of exposure therapy that entails assessment and preparation, imaginal flooding, and cognitive restructuring in the treatment of individuals with traumatic memories. Accord- ing to Shapiro and Solomon (2015), “EMDR is an integrative psychotherapeutic approach that conceptualizes current mental health problems as emanating from past experiences that have been maladaptively stored neurophysiologically as

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unprocessed memories” (p. 303). The treatment involves the use of rapid, rhythmic eye movements and other bilateral stimulation to treat clients who have experienced traumatic stress. “EMDR comprises eight phases and a three-pronged methodology to identify and process (1) memories of past adverse life experiences that underlie present problems, (2) current situations that elicit disturbance, and (3) needed skills that will provide positive memory templates to guide the client’s future behavior” (p. 389). Developed by Francine Shapiro (2001), this therapeutic procedure draws from a wide range of behavioral interventions. Designed to assist clients in dealing with posttraumatic stress disorders, EMDR has been applied to a variety of popula- tions including children, couples, sexual abuse victims, combat veterans, victims of crime, rape survivors, accident victims, and individuals dealing with anxiety, panic, depression, grief, addictions, and phobias.

Shapiro (2001) emphasizes the importance of the safety and welfare of the cli- ent when using this approach. EMDR may appear simple to some, but the ethical use of the procedure demands training and clinical supervision, as is true of using exposure therapies in general. Because of the powerful reactions from clients, it is essential that practitioners know how to safely and effectively manage these occur- rences. Therapists should not use this procedure unless they receive proper training and supervision from an authorized EMDR instructor. A more complete discussion of this behavioral procedure can be found in Shapiro (2001, 2002a).

There is some controversy over whether the eye movements themselves create change or whether cognitive techniques paired with eye movements act as change agents. The role of lateral eye movements has yet to be clearly demonstrated, and some evidence indicates that the eye movement component may not be integral to the treatment (Prochaska & Norcross, 2018; Speigler, 2016). In a review of con- trolled studies of EMDR in the treatment of trauma, Shapiro (2002b) reports that EMDR clearly outperforms no treatment and achieves similar or superior results to other methods of treating trauma. Shapiro and Solomon (2015) state that extensive research has validated EMDR, and randomized trials have confirmed that EMDR is both effective and efficient. Twelve sessions with combat veterans resulted in the elimination of PTSD diagnosis in more than 77% of the cases. When it comes to the overall effectiveness of EMDR, Prochaska and Norcross (2018) note that “in its 30-year plus history, EMDR has been tested in more than 30 controlled outcome studies, probably garnering more controlled research than any other method used to treat trauma” (p. 191). In writing about the future of EMDR, Prochaska and Nor- cross make several predictions: increasing numbers of practitioners will receive train- ing in EMDR; outcome research will shed light on EMDR’s effectiveness compared to other current therapies for trauma; and further research and practice will provide a sense of its effectiveness with disorders beyond posttraumatic stress disorder.

From the client’s perspective, EMDR therapy can be less triggering than some of the exposure-based treatments for trauma because it does not require the client to describe the traumatic event in detail. Much of the work the client does is imag- ined exposure, with the assistance of the therapist and the light bar and pulsator tools, rather than the more intense discussion of the traumatic event customary in traditional talk therapy. For clients with average cognitive skills, but limited verbal output, or who simply prefer a more action-oriented or sensory-based approach in which less talking is required, EMDR is often appealing.

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Social Skills Training Social skills training is a broad category that deals with an individual’s ability to inter- act effectively with others in various social situations; it is used to help clients develop and achieve skills in interpersonal competence. Social skills involve being able to com- municate with others in a way that is both appropriate and effective. Individuals who experience psychosocial problems that are partly caused by interpersonal difficulties are good candidates for social skills training. Typically, social skills training involves various behavioral techniques such as psychoeducation, modeling, behavior rehearsal, and feedback. Social skills training is effective in treating psychosocial problems by increas- ing clients’ interpersonal skills (Kress & Henry, 2015; Segrin, 2008). Some of the desir- able aspects of social skills training are that it has a very broad base of applicability and that it can easily be tailored to suit the particular needs of individual clients.

Key elements of social skills training include assessment, direct instruction and coaching, modeling, role playing, and homework assignments (Segrin, 2008). Cli- ents learn information that they can apply to various interpersonal situations, and skills are modeled for them so they can actually see how skills can be used. A key step involves clients putting into action the information they are acquiring. Individu- als actively practice desired behaviors through role playing. Feedback and reinforce- ment assist clients in conceptualizing and using a new set of social skills that enables them to communicate more effectively. If clients are able to correct their problem- atic behaviors in practice situations, they can then apply these new skills in daily life (Kress & Henry, 2015). A follow-up phase is critical for clients in establishing a range of effective behaviors that can be applied to many social situations.

A few examples of evidence-based applications of social skills training include alcohol/substance abuse, attention-deficit/hyperactivity disorder, bullying, social anxiety, emotional and behavioral problems in children, behavioral treatment for couples, and depression (Antony et al., 2020; Segrin, 2008). A popular variation of social skills training is anger management training, which is designed for indi- viduals who have trouble with aggressive behavior.

The Program for the Evaluation and Enrichment of Relational Skills (PEERS) is a highly effective social skills training program for teens diagnosed with developmen- tal disorders and high functioning autism spectrum disorder (Laugeson & Frankel, 2010). Using behavior therapy techniques such as homework, modeling, in vivo practice, and psychoeducation in a group-based model, teens and their parents learn important friendship skills such as making phone calls and managing electronic com- munication as well as skills necessary to navigate the social environment and deal with teasing, hosting “get togethers,” and handling peer disagreements. Teens learn the skills in a group with the guidance of therapists and coaches, and parents learn how to support the skills at home and in the community in their own therapy group. This evidence-based, parent-assisted social skills training program has been adapted for use in school settings (Laugeson, 2014) and international settings (Yamada et al., 2020).

SelfManagement Programs and SelfDirected Behavior For some time there has been a trend toward “giving psychology away.” This involves psychologists being willing to share their knowledge so that “consumers” can

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increasingly learn to use self-directed behaviors and not be dependent on experts to deal with their problems. Psychologists who share this perspective are primarily concerned with teaching people the skills they will need to manage their own lives effectively. An advantage of self-management techniques is that treatment can be extended to consumers in ways that cannot be done with traditional approaches to therapy. Another advantage is that costs are minimal. Because clients have a direct role in their own treatment, techniques aimed at self-change tend to increase involvement and commitment to their treatment.

The basic idea of self-management assessments and interventions is that change can be brought about by teaching people to use coping skills in problematic situa- tions. Self-management strategies include teaching clients how to select realistic goals, how to translate these goals into target behaviors, how to create an action plan for change, and ways to self-monitor and evaluate their actions (Kress & Henry, 2015). Generalization and maintenance of the outcomes are enhanced by encourag- ing clients to accept the responsibility for carrying out these strategies in daily life.

In self-management programs, people make decisions concerning specific behaviors they want to control or change. People frequently discover that a major reason they do not attain their goals is the lack of certain skills or unrealistic expec- tations of change. Hope can be a therapeutic factor that leads to change, but unre- alistic hope can pave the way for a pattern of failures in a self-change program. A self-directed approach can provide the guidelines for change and a realistic plan that will lead to change.

If you want to succeed in such a program, a careful analysis of the context of the behavior pattern is essential, and you must be willing to follow some basic steps such as these provided by Watson and Tharp (2014):

1. Selecting goals. Goals should be established one at a time, and they should be measurable, attainable, positive, and significant for you. It is essential that expectations be realistic.

2. Translating goals into target behaviors. Identify behaviors targeted for change. Once targets for change are selected, anticipate obstacles and think of ways to negotiate them.

3. Self-monitoring. Deliberately and systematically observe your own behavior, and keep a behavioral diary in which you record your actions, thoughts, and feelings along with comments about the relevant ante- cedent cues and consequences. This diary can help you identify what you need to change.

4. Working out a plan for change. A good plan involves substituting new thoughts and behaviors for ineffective thoughts and behaviors. Devise an action program to bring about actual changes that are in line with your goals. Various plans for the same goal can be designed, each of which can be effective. Some type of self-reinforcement system is necessary in this plan because reinforcement is the cornerstone of modern behavior therapy. Discover and select reinforcers to use until the new behaviors have been implemented in everyday life. Practice the new behaviors you want to acquire or refine, and take steps to ensure that the gains made will be maintained.

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5. Evaluating an action plan. Evaluate the plan for change to determine whether goals are being achieved, and adjust and revise the plan as other ways to meet goals are learned. Be willing to adjust your plan as conditions change. Evaluation is an ongoing process rather than a one- time occurrence, and self-change is a lifelong practice.

Self-management strategies have been successfully applied to many populations and problems, a few of which include coping with panic attacks, reducing perfection- ism, helping children to cope with fear of the dark, increasing creative productiv- ity, managing anxiety in social situations, encouraging speaking in front of a class, increasing exercise, reducing conflict with coworkers, improving study habits, control of smoking, and dealing with depression (Watson & Tharp, 2014). Research on self- management has been conducted in a wide variety of health problems, a few of which include arthritis, asthma, cancer, cardiac disease, substance abuse, diabetes, headaches, vision loss, depression, nutrition, and self-health care (Cormier et al., 2017).

Multimodal Therapy: Clinical Behavior Therapy Multimodal therapy is a comprehensive, systematic, holistic approach to behavior therapy developed by the late Arnold Lazarus (1989,1997, 2005, 2008), a key pioneer in clinical behavior therapy. Multimodal therapy is grounded in social-cognitive learning theory. The assessment process is multimodal, butt the treatment is cogni- tive behavioral and draws upon empirically supported methods. It is an open system that encourages technical eclecticism in that it applies diverse behavioral techniques from a variety of theories to a wide range of problems. Whenever possible, multi- modal therapists strive to incorporate empirically supported and evidence-based treatments in their practice (Lazarus & Lazarus, 2015).

Multimodal therapists borrow techniques from many other therapy systems, but Lazarus and Lazarus (2015) point out that these techniques are never used in a shotgun manner: “a rag-tag combination of techniques without a sound rationale will likely result only in syncretistic confusion” (p. 682). Multimodal therapists take great pains to determine precisely what relationship and what treatment strategies will work best with each client and under which particular circumstances. Because individuals are troubled by a variety of specific problems, it is appropriate that a multitude of treatment strategies be used in bringing about change. Therapeutic flexibility and versatility, along with breadth over depth, are highly valued, and mul- timodal therapists are constantly adjusting their procedures to achieve the client’s goals. Multimodal therapists create a specific treatment plan for each client based on a comprehensive assessment of the client’s presenting concerns. This approach uses a wide variety of techniques drawn from various theoretical orientations, and these techniques are not anchored to the theories from which they are drawn (Kelley, 2018). The therapeutic relationship is the soil that enables techniques to take root, and multimodal therapists recognize that a good working alliance is a cornerstone in the foundation of effective therapeutic practice (Lazarus & Lazarus, 2015). Mul- timodal therapists tend to be very active during therapist sessions, functioning as trainers, educators, consultants, coaches, and role models. They provide informa- tion, instruction, and feedback as well as modeling assertive behaviors. They offer suggestions, positive reinforcements, and are appropriately self-disclosing.

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For an illustration of how Dr. Lazarus applies the BASIC I.D. assessment model to the case of Ruth, along with examples of various techniques he uses, see Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 7).

Mindfulness and AcceptanceBased Approaches The third generation (or “third wave”) of behavior therapy emphasizes consider- ations that were considered off limits for behavior therapists until recently, includ- ing mindfulness, acceptance, the therapeutic relationship, spirituality, values, meditation, being in the present moment, and emotional expression (Corey, 2019; Herbert & Forman, 2011). Third-generation behavior therapies center around five interrelated core themes: (1) an expanded view of psychological health, (2) a broad view of acceptable outcomes in therapy, (3) acceptance, (4) mindfulness, and (5) creating a life worth living.

Mindfulness is “the awareness that emerges through having attention on pur- pose, in the present moment, and nonjudgmentally, to the unfolding of experience moment by moment” (Kabat-Zinn, 2003, p. 145). In mindfulness practice, clients train themselves to intentionally focus on their “present experience with accep- tance” (Siegel, 2010, p. 27) and develop an attitude of curiosity and compassion toward present experience.

Mindfulness shows promise across a broad range of clinical problems, includ- ing the treatment of depression, anxiety disorders, relationship problems, substance abuse, and psychophysiological disorders (Germer et al., 2013). It is useful in treat- ing posttraumatic stress disorder among military veterans. Through mindfulness exercises, veterans may be better able to observe repetitive negative thinking and prevent extensive engagement with maladaptive ruminative processes. Movement away from the disease model of psychological disorders and toward wellness is a key dimension of mindfulness and acceptance therapies.

Acceptance is a process involving receiving one’s present experience without judgment or preference, but with curiosity and kindness, and striving for full aware- ness of the present moment (Germer, 2013). Acceptance is an alternative way of responding to our internal experience. It is not primarily viewed as a set of coping skills for dealing with problems; rather, it is considered as a way of being in the world, and a way of reducing suffering (Fruzzetti et al., 2019).

For an extensive discussion of mindfulness and acceptance, see Acceptance and Mindfulness in Cognitive Behavior Therapy: Understanding and Applying the New Therapies (Herbert & Forman, 2011).

Recent developments in the cognitive behavioral tradition include four major approaches: (1) mindfulness-based stress reduction, an eight-week group program that applies mindfulness techniques to coping with stress and promoting physical and psychological health (Kabat-Zinn, 1990, 2003; Lehrhaupt & Meibert, 2017); (2) mind- fulness-based cognitive therapy, aimed primarily at treating depression (Segal et al., 2013); (3) dialectical behavior therapy, which has become a recognized treatment for borderline personality disorder and for other clients who are difficult to treat (Linehan, 1993a, 1993b, 2015, 2020); and (4) acceptance and commitment therapy, which encourages cli- ents to accept unpleasant sensations rather than attempting to control or change them (Hayes et al., 2012; Hayes & Lillis. 2012). All four of these approaches use

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mindfulness strategies that have been subjected to empirical scrutiny, a hallmark of the behavioral tradition. The mindfulness-based approaches have a rich empirically based research tradition of positive outcomes (Pantaleno & Sisti, 2018).

Mindfulness-Based Stress Reduction (MBSR) Jon Kabat-Zinn, at the University of Massachusetts, developed mindfulness-based stress reduction (MBSR) in 1979 to see if it was possible to create a training program to relieve medical patients of stress, pain, illness, and other forms of suffering. The eight-week structured group program involves training people in mindfulness meditation. MBSR was originally designed to help people increase their responsibility for their own well-being and to actively develop inner resources for treating their physical health concerns (Kabat- Zinn, 2003). MBSR is not a form of psychotherapy per se, but it can be an adjunct to psychotherapy. MBSR is a journey of coming home to ourselves (Lehrhaupt & Meibert, 2017). Instructors of MBSR classes comprise a wide range of professionals including physicians, social workers, teachers, nurses, yoga teachers, coaches, and psychologists, to mention a few.

The essence of mindfulness-based stress reduction consists of the notion that much of our distress and suffering results from continually wanting things to be different from how they actually are. MBSR assists people in learning how to live more fully in the present rather than ruminating about the past or being overly con- cerned about the future. MBSR does not actively teach cognitive modification tech- niques, nor does it label certain cognitions as “dysfunctional.” This is not consistent with the nonjudgmental attitude one strives to cultivate in mindfulness practice.

The approach adopted in the MBSR program is to develop the capacity for sus- tained directed attention through formal and informal meditation practice. The eight-week MBSR program is structured with a theme (mindful self-care, mindful communication, or dealing with stress more effectively). There is a heavy emphasis on experiential learning and the process of client self-discovery. In formal practice, skills taught including sitting meditation, walking meditation, and mindful yoga, which are aimed at cultivating mindfulness. The sessions include a body scan medi- tation, which helps clients to observe all the sensations in their body. Clients are encouraged to bring mindfulness into all of their daily activities, and this informal practice includes being mindful when standing, walking, eating, and doing chores. Those who are involved in the program are encouraged to practice formal mindful- ness meditation for 45 minutes daily. Informal mindfulness practice generally raises three questions: Am I living this moment to its fullest? To what extent am I able to live in the present? Do I avoid living in the present moment by ruminating about the past or getting lost in the future?

In Mindfulness-Based Stress Reduction, Lehrhaupt and Meibert (2017) dedicate a chapter to each of the eight sessions in a MBSR course. The key themes for each ses- sion are briefly described here:

◆ The first week is devoted to orienting participants in the class to the basic concept of mindfulness, for people to get to know one another, and to establish ground rules. Participants are introduced to the body scan experience, and they learn about what mindfulness involves, both formally and informally.

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◆ The theme of the second week is how we perceive the world and ourselves.

◆ One focus of the third session is learning a series of gentle yoga exer- cises that can be practiced at home. This session addresses being at home with your body.

◆ The fourth week of the MBSR program begins with a guided sitting meditation. The theme entails exploring sources of stress and how to relate to difficult life situations more effectively.

◆ In the fifth session, participants learn how to view thoughts in a new way. There is an exploration of stress-increasing thoughts and consider- ation of ways to relate to difficult thoughts.

◆ The theme of the sixth session is exploring mindful communication styles. Participants learn how to communicate more effectively and practice these new skills at home and work.

◆ Week seven is devoted to mindful self-care practices. ◆ The last session begins with a body scan, as is the case with most ses-

sions, and a mindfulness exercise. Participants share their experience of the program and how it is affecting their daily life. The theme is how to continue this journey both formally and informally upon completion of the program.

The MBSR program is designed to teach participants to relate to external and internal sources of stress in constructive ways, and an ongoing commitment to cultivate and practice its principles in each moment is required. MBSR is not a problem-solving technique; rather, it involves acquiring a mindful way of being. It is more like an art form that individuals develop over time as they deepen their focus through disciplined practice. Kabat-Zinn (2003) makes it clear that mindfulness is not about getting anywhere or fixing anything: “It is an invitation to allow oneself to be where one already is and to know the inner and outer landscape of the direct experience in each moment” (p. 148). Lehrhaupt and Meibert (2017) emphasize three key themes in MBSR:

◆ Mindfulness takes place in the present moment. ◆ Mindfulness can be trained, strengthened, and can be cultivated. ◆ Mindfulness training gives us access to our own wisdom and

insight.

MBSR programs are offered in hospitals, clinics, schools, workplaces, corporate offices, law schools, prisons, and at inner city health centers (Kabat-Zinn, 2003). MBSR has many clinical applications, and it is expected that the approach will evolve to address a range of negative psychological states, such as anxiety, stress, and depression. This approach has many applications in the area of health and gen- eral well-being and in promoting healthy lifestyle changes. Lehrhaupt and Meibert (2017) report MBSR as being helpful in improving the quality of life for people of all age groups. They also state that research studies have shown than MBSR is help- ful in alleviating the symptoms of psychological distress for a range of conditions, including chronic pain, high blood pressure, sleep disorders, depression and anxiety, chronic diseases, cancer, common stress, and burnout. Numerous research reviews

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and meta-analyses indicate that mindfulness, acceptance, and compassion-based treatments are effective in promoting physical and psychological health (Germer, 2013). One of these studies suggests that MBSR training may lead to changes in the brain that result in people being able to better cope with negative emotional reac- tions under stress (as cited in Kabat-Zinn, 2003).

It is important for counselors or MBSR teachers to commit to developing a per- sonal mindfulness practice for themselves before they begin to introduce mindful- ness experiences to their clients (Pantaleno & Sisti, 2018). Counselors can gain a great deal by establishing even short periods of time for quiet reflection.

For a further discussion on mindfulness in clinical practices, see Mindfulness and Psychotherapy (Germer et al., 2013); Wisdom and Compassion in Psychotherapy: Deepening Mindfulness in Clinical Practice (Germer & Siegel, 2012); Mindfulness-Based Stress Reduc- tion (Lehrhaupt & Meibert, 2017); and Third-Wave Cognitive Behavioral Theories with Mindfulness-Based Interventions (Haddock, 2022).

Mindfulness-Based Cognitive Therapy (MBCT) This program is a compre- hensive integration of the principles and skills of mindfulness applied to the treatment of depression. Mindfulness-based cognitive therapy (MBCT) is also an eight-week group treatment program of two-hour weekly sessions, which was adapted from Kabat-Zinn’s (1990, 2003) mindfulness-based stress reduction program. The program integrates techniques from MBSR with teaching cognitive behavioral skills to clients. The primary aim is to change clients’ awareness of and relation to their negative thoughts. Participants are taught how to respond in skillful and intentional ways to their automatic negative thought patterns (Segal et al., 2013).

Segal, Williams, and Teasdale (2013) describe the essence of the eight sessions in the MBCT program:

◆ Therapy begins by identifying negative automatic thinking of people experiencing depression and by introducing some basic mindfulness practices.

◆ In the second session, participants learn about the reactions they have to life experiences and learn more about mindfulness practices. Clients learn the importance of kindness and self-compassion, both to self and to others.

◆ The third session is focused on gathering the scattered mind; partici- pants learn breathing techniques and focus their attention on their present experiencing. Clients learn how to anchor thoughts with a focus on the breath while allowing experience to unfold.

◆ In session four, the emphasis is on learning to experience the moment without becoming attached to outcomes; participants practice sitting meditation and mindful walking.

◆ The fifth session teaches participants how to accept their experiencing without holding on; participants learn the value of allowing and letting be.

◆ Session six is used to describe thoughts as “merely thoughts”; clients learn that they do not have to act on their thoughts. They can tell

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themselves, “I am not my thoughts” and “Thoughts are not facts.” A day of mindfulness practice is scheduled between the sixth and seventh session. During this retreat, the participants are together in silence. This silent retreat is aimed at quieting the mind and giving participants an opportunity to create a sense of inner peace.

◆ In session seven, participants learn how to take care of themselves and to develop an action plan to deal with the threat of relapse.

◆ Session eight focuses on maintaining and extending new learning; cli- ents learn how to generalize their mindfulness practices to daily life.

Segal, Williams, and Teasdale (2013) describe kindness and self-compas- sion as essential components of MBCT. Mindfulness is a way of developing self- compassion, which is a form of self-care when facing difficult situations. Mindful- ness practices focus on moment-to-moment experiencing and assist clients in devel- oping an attitude of open awareness and acceptance of what is rather than being self-critical. When we acknowledge our shortcomings without critical judgment, we can begin to treat ourselves with kindness. We can intentionally activate goodwill toward ourselves and others while experiencing emotions such as anger, anxiety, and depression. Research has shown that self-compassion is positively associated with emotional well-being and decreased levels of anxiety and depression (Morgan et al., 2013; Neff, 2012; Neff & Germer, 2018). Other research findings on the associa- tion between self-compassion and emotional well-being have been reported by Neff (2012):

◆ Self-compassionate people recognize when they are suffering, and they are kind toward themselves in these moments.

◆ Self-compassion is associated with greater wisdom and emotional intelligence.

◆ Self-compassion is associated with feelings of life satisfaction and con- nection to others.

◆ Self-compassionate individuals tend to experience increased happiness, optimism, curiosity, and positive emotions.

◆ Self-compassion engenders compassion toward others.

Morgan, Morgan, and Germer (2013) report that there is ample evidence that mindfulness meditation enhances the ability to pay attention in a concentrated and sustained manner. Being able to attend to present experiencing is a route to devel- oping compassion toward oneself and expressing compassion toward others. Mind- fulness is something that is caught more than something that is taught. The attitude and behavior of the instructor/facilitator of the MBCT group are critical in helping participants acquire an accepting way of being and discarding self-critical and judg- mental habits.

MBCT emphasizes experiential learning, in-session practice, learning from feed- back, completing homework assignments, and applying what is learned in the pro- gram to challenging situations encountered outside of the sessions. The brevity of MBCT makes this approach an efficient and cost-effective treatment. For a more detailed review of MBCT, see Mindfulness-Based Cognitive Therapy for Depression (Segal et al., 2013).

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Dialectical Behavior Therapy (DBT) Dialectical behavior therapy was originally developed to treat chronically suicidal individuals diagnosed with borderline personality disorder, and it is now recognized as a major psychological treatment for this population. Formulated by Marsha Linehan (1993a, 1993b, 2015), who was motivated to alleviate emotional suffering for those miserable enough to consider suicide, dialectical behavior therapy (DBT) is effective in helping highly suicidal people live a life worth living. With highly suicidal clients, the therapeutic relationship is what keeps them alive (Linehan, 2020). DBT has been proven effective in treating a wide range of disorders across different settings, including substance dependence, depression, posttraumatic stress disorder, eating disorders, suicidal behavior, and nonsuicidal self-injury (Fruzzetti et al., 2019; Linehan, 2015; Rizvi & King, 2019). Linehan originally designed DBT for people who are at high risk for suicide and self-harm, for severely dysfunctional people, and for individuals who are difficult to treat. However, the basic DBT skills can be useful for people who want to live more fulfilled and emotionally stable lives (Linehan, 2020). The ultimate goal of DBT is to build a life worth living. This takes place in steps that involve behavioral changes that result from replacing maladaptive behaviors with skillful behaviors (Swenson, 2016).

DBT is a comprehensive psychosocial treatment composed of cognitive, behav- ioral, and mindfulness-based strategies; however, at its core DBT is a behavioral approach (Rizvi & King, 2019). DBT is a promising blend of behavioral and psy- choanalytic techniques for treating borderline personality disorders. Like analytic therapy, DBT emphasizes the importance of the psychotherapeutic relationship, validation of the client, the etiologic importance of the client having experienced an “invalidating environment” as a child, and confrontation of resistance.

DBT treatment includes both acceptance-based strategies and change-oriented strategies. The treatment program is geared toward helping clients make changes in their behavior and environment while communicating acceptance of their cur- rent state. To help clients who have particular problems with emotional regulation, DBT teaches clients to recognize and accept the existence of simultaneous, oppos- ing forces. Dialectics is a key concept in DBT, which involves the tension, or synthesis, between opposites. This tension is between encouraging clients to embrace accep- tance while seeking change (Linehan, 2020). Rizvi and King (2019) contend that a key principle of DBT is for the therapist to dialectically balance acceptance with change. “Determining how much to emphasize acceptance and change is part of the ‘dance’ that DBT therapists engage in with their clients” (p. 306). By acknowledging this fundamental dialectic relationship—such as not wanting to engage in a certain behavior, yet knowing they have to engage in the behavior if they want to achieve a desired goal—clients can learn to integrate the opposing notions of acceptance and change. The therapist can teach clients how to regulate their emotions and behav- iors. Linehan (2020) captures the essence of DBT in these statements: “DBT is a very pragmatic therapy, helping people to be effective in all aspects of their lives. DBT is a very problem-solving, focused, action-oriented treatment” (p. 172).

DBT does not offer a cure for people whose lives are unbearable; it is a path to building a meaningful life. This approach helps client gain acceptance of their problems and also offers practical ways of solving their problems (Linehan, 2020). DBT skills training is not a “quick fix” approach. It generally involves a minimum

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of one year of treatment and includes both individual therapy and skills train- ing done in a group. DBT is an empirically supported intervention that employs behavioral and cognitive behavioral techniques, including a form of exposure therapy in which the client learns to tolerate painful emotions without enacting self-destructive behaviors.

DBT draws on Zen teachings and practices to integrate mindfulness and acceptance-based interventions in therapy. Some of the Zen Buddhist principles and practices include being aware of the present moment, seeing reality without distortion, accepting reality without judgment, letting go of attachments that result in suffering, developing a greater degree of acceptance of self and others, and enter- ing fully into present activities without separating oneself from ongoing events and interactions (Linehan, 2020; Rizvi & King, 2019; Swenson, 2016).

DBT promotes a structured, predictable therapeutic environment. The goals are tailored to each individual. When clients begin in DBT, the therapist asks them to identify some specific goals in life that would make life worth living. There are four categories of DBT skills: mindfulness skills, distress tolerance skills, emo- tional regulation skills, and interpersonal effectiveness skills (Linehan, 2020; Swenson, 2016). The first two DBT skills offer a path to acceptance of reality as it is; the last two are change skills that help people make changes that will lead to a meaningful existence.

Mindfulness is the act of focusing on the present moment, without judgment and without attachment. It is a fundamental skill in DBT that teaches individuals to be aware of and accept the world as it is and to respond to each moment effectively. Mindfulness permeates the whole of DBT. Through mindfulness, clients learn to embrace and tolerate the intense emotions they experience when facing distressing situations, which helps reduce pain and increase happiness.

Distress tolerance is aimed at helping individuals recognize emotions associated with negative situations without becoming overwhelmed by these situations. Cli- ents learn how to tolerate crisis situations effectively by finding solutions to sources of stress.

Emotional regulation includes identifying emotions, identifying obstacles to changing emotions, reducing vulnerability, and increasing positive emotions. Cli- ents learn the benefits of regulating emotions such as anger, depression, and anxiety.

Interpersonal effectiveness skills help people be effective in their relationships with others. Clients learn how to ask for what they need and how to say “no” while maintaining self-respect and relationships with others. This skill entails increasing the chances that a client’s goals will be met without damaging the relationship.

DBT helps individuals acquire and generalize the skills they learn in therapy to their life outside of therapy. Because DBT places heavy emphasis on didactic instruc- tion and teaching mindfulness skills, therapists must obtain training to become competent in applying these skills and be able to model specific strategies and atti- tudes for clients. Therapists who want to employ mindfulness strategies must also have personal understanding of these interventions to be able to effectively use them with clients. For many clients, participating in DBT is an intensive commitment to learning and growth that requires time, adjustment, and hard work as they undergo the change process. Empathic understanding and support, as well as appropriate boundary setting, are critical elements for successful treatment with DBT.

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For a more detailed review of DBT, see DBT Skills Training Manual (Linehan, 2015), which includes instructions for orienting clients to DBT and explains how to use many skills in DBT. For the life and work of Marsha Linehan, see Building a Life Worth Living (Linehan, 2020). For a comprehensive, clear, and personal account of DBT, see DBT Principles in Action: Acceptance, Change, and Dialectics (Swenson, 2016).

Acceptance and Commitment Therapy (ACT) Another mindfulness-based approach is acceptance and commitment therapy (Hayes et al., 2005, 2012). ACT is a unique empirically based psychological intervention that uses acceptance and mindfulness strategies, together with commitment and behavior change strategies, to increase psychological flexibility, which involves the ability to focus on and engage in what we are doing, opening up and making room for our thoughts and feelings, and taking action. ACT is a behavior therapy that uses values and mindfulness skills to help people create a meaningful life (Harris, 2019). What sets ACT apart from other Western psychotherapy approaches is that symptom reduction is not the primary goal. This approach eschews the assumption that given a normal environment, good social interactions, and a healthy lifestyle people will be satisfied and happy. Instead, ACT argues that human suffering is often the result of perfectly normal human psychological processes and is not reflective of symptomology or somehow “abnormal.” ACT seeks to help clients transform their relationships to their difficult experiences and free them from the habitual need to avoid unpleasant events. They expand their psychological flexibility and live in ways that are driven by values rather than by avoidance.

In ACT Made Simple, Harris (2019) addresses the six core therapeutic processes of ACT: contact with the present moment, cognitive defusion, acceptance, self-as- context, values, and committed action. The following description of these core prin- ciples and processes of ACT is an adaptation of concepts from Harris (2006, 2019).

Making contact with the present moment means flexibly paying attention to the world around us and to the psychological world within us. This involves bringing full awareness to our here-and-now experiences with openness, curiosity, interest, and flexibility, connecting with and engaging fully in our experience. Flexible atten- tion is essential for self-awareness and self-knowledge, and it plays a central role in the practice of ACT.

Cognitive defusion involves stepping back and separating or detaching from our thoughts, images, and memories. We watch our thinking rather than getting tan- gled in our thoughts, and we hold our thoughts lightly instead of clinging to them tightly. In contrast to the cognitive behavioral approaches, discussed in Chapter 10, in which dysfunctional thoughts are identified and challenged, in ACT there is little emphasis on changing the content of a client’s thoughts. Hayes (2004) has found that confronting maladaptive cognitions strengthens rather than reduces these cog- nitions. Instead, the emphasis is on our relationship with our thoughts. When we relate to our thinking as if our thoughts are literal truths or somehow real things to which we must attend, then our thinking can dominate our actions. The goal is for individuals to become aware of and examine their thoughts. Clients learn how to change their relationship to their thoughts by observing them dispassionately; they need to recognize that thoughts are transient experiences that are truly unavoidable. They learn how to accept and coexist with thoughts and feelings they may have been

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trying to deny or avoid. When people try to avoid or get rid of unwanted private experiences, they are likely to suffer psychologically in the long term. Harris (2019) writes that ACT usually changes our thinking significantly, but it does not do this by challenging, disputing, ignoring, or dismissing difficult or unhelpful thoughts. “It does this via (a) defusing from such thoughts, (b) accepting that they will keep recurring, and (c) at the same time, actively cultivating new, more flexible and effec- tive ways of thinking” (p. 313).

Acceptance is a core principle of ACT that involves fully accepting present expe- rience and mindfully letting go of obstacles. In this approach “acceptance is not merely tolerance—rather it is the active nonjudgmental embracing of experience in the here and now” (Hayes, 2004, p. 32). “Acceptance is the adoption of an intention- ally open, receptive, flexible, and nonjudgmental posture with respect to moment- to-moment experience” (Hayes & Lillis, 2012, p. 90). Acceptance involves opening up and making room for unwanted private experiences including thoughts, feel- ings, memories, sensations, and images. Instead of resisting or avoiding unpleasant private experiences, we allow them to flow through us. Acceptance is a stance from which to conduct therapy and from which a client can conduct life that provides an alternative to contemporary forms of cognitive behavioral therapy.

In ACT clients are taught to notice their self-as-context for all experience. Clients learn that their thoughts, feelings, images, and memories are not the essence of who they are. Clients come to understand that difficult experiences cannot be avoided, they do not define who we are, and in many ways they can be transcended through contact with the true nature of the self.

Values are a basic part of the therapeutic process, and the work of ACT depends on what an individual wants and values. Values work aims to enhance a sense of choice over the meaning and purpose of behavior in a way that promotes vitality and intrinsic motivation. The role of an ACT therapist is to help clients become more fully themselves and to live a more vital life that is consistent with their values (Hayes & Lillis, 2012). Client and therapist work together to identify personal values in areas such as work, relationships, spirituality, and well-being. ACT practitioners might ask clients, “What do you want your life to stand for?” “What kind of life do you want?” “What do you deeply care about, and are you willing to center your life around your passion?”

Hayes and Lillis (2012) note that the therapeutic relationship is central in ACT. The therapist needs to have a commitment to a path of openness, awareness, and engagement. Both therapist and client are “fellow travelers in the journey of life” (p. 66). ACT requires active participation from clients. “The client is being asked to show up physically and psychologically, and to engage in therapy as a relationship between two equal human beings” (p. 68). ACT therapy involves assisting clients to choose values they want to live by, designing specific goals, and taking steps to achieve their goals. This values clarification and identification sets the stage for cli- ents to use their chosen values as guiding principles rather than relying on their thinking or their sensations to guide them. Values are like a compass that gives us direction and guides us in our life’s journey.

A commitment to action is essential, and clients are asked to make mindful deci- sions about what they are willing to do to live a valued and meaningful life. It is only by putting their values into action that clients can experience a rich, full, and

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meaningful life. Clients need to do what it takes to live in accordance with their values. Are they willing to experience some discomfort to live by the values they have chosen? Hayes and Lillis (2012) state, “Success in ACT therapy is moving forward with values-based behavior in the face of barriers or challenges” (p. 95). Concrete homework and behavioral exercises are two ways clients can commit to action. Mindfulness exercises can be used in the sessions and as homework. When mindful- ness is carried into daily life, it can enhance the progress of therapy. Another form of homework asks clients to write down life goals or things they value in various aspects of their life. Clients learn to allow experience to come and go while they pur- sue a meaningful life.

When clients are focused on living values-driven and meaningful lives, they often find that their “symptoms” are reduced as a by-product of this pursuit. As clients become more psychologically flexible, their symptomology no longer constricts their universe of choices or the repertoire of responses available to them in any given cir- cumstance. Essentially, by focusing on important aspects of living and engaging in committed action, symptoms become less relevant and less distressing. Moreover, cli- ents learn effective ways of responding to their difficulties rather than trying to escape from these difficulties. This leads to less constriction and more openness to living.

ACT is an effective form of therapy that continues to influence the practice of behavior therapy. This approach emphasizes common processes across clinical dis- orders, which makes it easier to learn basic treatment skills. Practitioners can then implement basic principles in diverse and creative ways. ACT has been empirically shown to be effective in the treatment of a variety of disorders, including polysub- stance abuse, depression, generalized anxiety disorder, panic disorder, eating disor- ders, phobias, posttraumatic stress disorder, and chronic pain (Batten & Cairrochi, 2015; Hayes & Lillis, 2012; Podina & David, 2018). Hayes and Lillis (2012) conclude: “The ACT community is making a difference in the prevention and alleviation of human suffering and the promotion of human health and development” (p. 13).

Harris (2019) consistently encourages practitioners who are learning ACT to be themselves and to adapt any of the ACT techniques to their own style of counseling. He suggests being creative in the use of techniques and exercises. He reminds readers that ACT is a process-based model, not a technique-based approach, and that there is room for practitioners to develop a style that suits their personality. Harris recom- mends that therapists interested in learning ACT can best do so by applying ACT to themselves and being willing to practice these skills.

For more information about ACT, see Acceptance and Commitment Therapy (Hayes & Lillis, 2012), Acceptance and Commitment Therapy: The Process and Practice of Mindful Change (Hayes et al., 2012), and ACT Made Simple: An Easy-to-Read Primer on Acceptance and Commitment Therapy (Harris, 2019).

Application to Group Counseling Behavioral group therapy incorporates classical behavior therapy treatment prin- ciples rooted in classical conditioning, operant conditioning, and social learning theory. The focus of a behavioral group is on teaching, modeling, and applying scientific principles to target specific behaviors for change (Kress & Henry, 2015). Group-based behavioral approaches emphasize teaching members of a group

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self-management skills and a range of new coping behaviors, as well as how to restructure their thoughts. Clients can learn to use these techniques to control their lives, deal effectively with present and future problems, and function well after they complete their group experience. Many groups are designed primarily to increase the client’s degree of control and freedom in specific aspects of daily life.

Group leaders who function within a behavioral framework may develop tech- niques from various theoretical viewpoints. Behavioral practitioners make use of a brief, active, directive, structured, collaborative, psychoeducational model of therapy that relies on empirical validation of its concepts and techniques. The leader follows the progress of group members through the ongoing collection of data before, dur- ing, and after all interventions. Such an approach provides both the group leader and the members with continuous feedback about therapeutic progress. Today many groups in community agencies demand this kind of accountability.

Behavioral group therapy has some unique characteristics that set it apart from most of the other group approaches. A distinguishing characteristic of behavioral practitioners is their systematic adherence to specification and measurement. The specific unique characteristics of behavioral group therapy include (1) conducting a behavioral assessment, (2) precisely spelling out collaborative treatment goals, (3) formulating a specific treatment procedure appropriate to a particular problem, and (4) objectively evaluating the outcomes of therapy. Behavioral group practitio- ners tend to utilize short-term, time-limited interventions aimed at efficiently and effectively solving problems and assisting members in developing new skills.

Behavioral group leaders assume the role of teacher and encourage members to learn and practice skills in the group that they can apply to everyday living. Group leaders typically assume an active, directive, and supportive role in the group and apply their knowledge of behavioral principles and skills to the resolution of prob- lems. They model active participation and collaboration by their involvement with members in creating an agenda, designing homework, and teaching skills and new behaviors. Leaders carefully observe and assess behavior to determine the conditions that are related to certain problems and the conditions that will facilitate change. Members in behavioral groups identify specific skills that they lack or would like to enhance. Assertiveness and social skills training fit well into a group format. Relax- ation procedures, behavioral rehearsal, modeling, coaching, meditation, and mind- fulness techniques are often incorporated in behavioral groups. The experience of being mindful is expanded in the group setting where people meditate and are still in the presence of others. Most of the other techniques described earlier in this chap- ter can be applied to group work.

Most behavior therapy groups blend cognitive and behavioral concepts and techniques. There are many different types of groups with a behavioral twist, or groups that blend both behavioral and cognitive methods for specific populations. Structured groups, with a psychoeducational focus, are especially popular in vari- ous settings today. At least four general approaches can be applied to the practice of behavioral groups: (1) social skills training groups, (2) psychoeducational groups with specific themes, (3) stress management groups, and (4) mindfulness and accep- tance-based behavior therapy in groups.

For a more detailed discussion of cognitive behavioral approaches to groups, see Corey (2023, chap. 13).

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Applying the Behavioral Approach to School Counseling

This section was provided by Kellie Kirksey, PhD, a licensed clinical counselor, a certified rehabilitation counselor, and an approved clinical supervisor. She has practiced and taught in the counseling field for more than 25 years and has focused her work in the area of multicultural counseling, social justice, integrative counseling, and wellness.

My history with mindfulness began long before it became a common buzz word. As a fourth grader, I was introduced to what I would now consider mindfulness meditation. My teacher was a tall woman with a soft voice. At some time in each day, she would have us clear our desk, fold our arms, and put our heads down. “Relax and breathe,” she would say, as she played soft music. Cat Stevens was one of her favorites, “We shall never pass this way again,” he crooned. Basically, he was saying be in this moment now, and don’t miss it because it will never return. Bringing our mind to the moment helped us set aside our squabbles and poor test grades for a few minutes. Our teacher taught us to find peace and ease in the middle of our day. I learned the pause in our day was something that helped me feel rested. As an adult, I continue to take midday breaks to restore myself.

The classroom is the perfect place to teach mindfulness meditation and sim- ple breathing techniques to stimulate the relaxation response. Young people are exposed to multiple stressors daily. The pandemic has compounded these stressors, and teachers are in a great position to introduce students to simple skills to support themselves in responding to daily challenges in healthy ways. I feel fortunate to have been raised with a mother who encouraged slow, meandering nature walks. Looking at the trees, rocks, or flowers was a treat.

Focusing on the intricacies of any object is a mindful practice. Introducing stu- dents to a variety of ways to simply pay attention to the moment they are living in is invaluable. Paying close attention to what you are doing is mindfulness. Noticing the sensations in your body is mindfulness. Taking a careful look at your food, noticing the color, texture, and aroma is mindfulness. Awareness without judgment is the goal, which involves noticing and accepting what exists in the moment. Meditation is not about sitting still on a cushion and having a blank mind. Our minds are always engage in thinking, that is what the mind does. When we meditate, noticing the thoughts and not clinging to them is the goal. We can always circle back to those thoughts later.

Conscious breathing is a great meditation strategy. Have students inhale through the nose and exhale through the mouth. Ask students to pay attention to how the breath feels as it enters the nose and how the breath feel as it exits the mouth. Have students notice the rise and fall of their belly as they pay attention to their breath. Have students notice their shoulders, and prompt them to relax their neck and shoulders. The breath is one of the simplest pathways to stress relief because it activates the parasympathetic nervous system. Basically, it alerts the body that it is alright to rest and restore.

As a new university professor, I began every class with a guided meditation, stillness, or a mindful walk around the classroom. I was in the business of training counselors and felt that supporting counselors in practicing stress management techniques could be beneficial for them in the field. I was criticized by the chair of my

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department for having my students meditate too much, but I never stopped meditat- ing in class. I believe in the health and wellness benefits of meditation, and science is empirically proving why meditation has become a best practice. Before teaching any of these techniques to students, it is critical for school counselors or teachers to per- sonally practice and experience mindfulness. Sharing your personal practice is power- ful; students can see how these strategies have assisted you as a teacher or counselor and as a person dedicated to wellness and self-care. Mindfulness has been a lifelong practice for me, and it has made all the difference in the world.

An Expert’s Perspective on Behavior Therapy In this section, Sherry Cormier, PhD, professor emerita of counseling, rehabilita- tion counseling, and counseling psychology at West Virginia University, provides answers to the following questions. She is currently affiliated with Full Circle Healing Arts and the Wellness House in Annapolis, Maryland.

1. What is the most important contribution of behavior therapy for the practice of individual therapy? This is a challenging question because it is hard to narrow the multiple con- tributions of behavior therapy into a single or primary one. For me, the most important contribution of behavior therapy is the application of the principles of science to select and support the use of evidence-based interventions and techniques. These approaches help clients achieve specific goals and help clini- cians assess progress toward such outcomes during therapy. This concept dif- ferentiates behavior therapy from other approaches because it is supported by empirical research. Both clients and counselors collect data that measure prog- ress to determine if the intervention is helping the client make desired changes.

2. What two or three key concepts of behavior therapy are especially applicable to the practice of individual counseling or therapy? I believe two key concepts discussed in this chapter are especially applicable to the practice of individual counseling and therapy. One concept is the emphasis on the individual, the individual client’s environment, and the interaction between the person and the environment. The second key con- cept is the idea that the therapy process and interventions are selected and tailored specifically for each individual client. Treatment is based on the client’s presenting issues and level of distress, with the acute awareness that the same interventions might not work equally well for all clients. Behavior therapists conduct individual assessments with each client that involve a behavioral analysis of the client’s issues, as well as the client’s preferences and personal and cultural characteristics. The results of this assessment helps the counselor develop a treatment plan for each individual client.

3. What two or three techniques from the behavioral approach have practical value for practitioners of individual therapy? Three techniques that I especially like to use from behavior therapy are relaxation, self-management, and mindfulness strategies. These are very useful in individual counseling and can be quite easily learned even by less experienced helpers.

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Relaxation techniques are helpful with both anxious individuals and clients who are experiencing high levels of stress. There are several advantages when relaxation is used in individual counseling. First, relaxation usually helps clients feel somewhat better, almost imme- diately. Second, relaxation procedures can easily be utilized by clients outside of the therapy sessions. These procedures can even be accessed on smartphones. There are now a number of new digital apps available for clients to access relaxation skills.

Self-management strategies are useful because they help the client learn coping skills and methods of changing that can be applied in real life. I find self-management strategies to be particularly empowering to clients because these strategies allow clients to take charge of the changes they decide to make. Self-management helps clients develop proactive and adaptive habits and can facilitate tracking progress toward stated goals and intentions.

Mindfulness strategies are of great value because they can be used within sessions to promote positive mental health and also outside of sessions as homework via a plethora of digital apps. Mindfulness helps clients learn to deal with distractions, promotes concentration and attention, dismiss intrusive thoughts, and enhance compassion for self and others.

4. How does behavior therapy address diversity, multicultural, and social justice issues for the practice of individual counseling? Behavior therapy has relevance to diverse clients in many ways. Many clients prefer action-oriented, pragmatic approaches rather than emotive ones, and behavior therapy does not require emotional catharsis for change. This is an approach that focuses on pragmatic action and the development of cop- ing and problem-solving skills, a value that is quite compatible for a wide range of clients. Finally, behavior therapy can promote social justice by its focus on environmental conditions that create problematic situations such as discriminatory and oppressive behaviors and conditions. As a feminist, I find the focus on self-change to be especially empowering to clients. Cli- ents are encouraged to become their own best therapist and change agent by applying the skills they have learned in counseling sessions to problem- solve current and future issues. Self-regulation is a major goal of the behav- ioral approach. The knowledge and skills that clients acquire are used to increase a sense of personal power and self-efficacy.

5. In what ways can behavior therapy be applied to brief therapy (or time-limited counseling)? Behavior therapy is quite applicable to brief therapy, especially for adjust- ment issues and lifestyle change concerns. Behavior therapy can often be conducted in four to eight sessions for these kinds of problems, especially with motivated clients who have clear goals for change. The behavioral approach fits particularly well with briefer therapy models because the over- all goal is not to redo or fix a person but to enable clients to address specific

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concerns in a way that benefits them in real-life situations, and ultimately, without the assistance of the therapist. Behavior therapy by its nature is time-limited and is typically effective within 10 to 16 sessions. Therapists focus on helping clients resolve identifiable specific concerns rather than bring about personality or characterological change.

6. From your perspective, what is the current status and the future of the behavioral approach? The current status and future growth of behavior therapy appear strong! Today this approach has greater empirical support than any other theory. Currently, the more traditional behavior therapy approach is often merged with a cognitive or a cognitive behavioral therapy approach. The third-wave approaches continue to grow in both frequency of use and empirical sup- port. For example, dialectical behavior therapy (DBT) is a primary component of current addictions treatment programs. Mindfulness-based cognitive therapy (MBCT), which was developed originally for use with clients at risk for relapse from depression, is also now used by a multitude of counselors as a tool to promote positive mental health. Acceptance and commitment therapy (ACT), an approach that emphasizes both acceptance and mindfulness as adaptive responses to life’s challenges, is currently used not only in this way but also in the treatment of substance misuse, chronic pain, and eating disorders. With the growth of the Internet to address the access to services gap, exacerbated by the global COVID-19 pandemic, digital treatments are being developed rapidly, particularly mobile phone apps that teach behav- ior therapy and cognitive behavior therapy skills to consumers and clients.

Discussion Questions Related to the Behavior Therapy Perspective 1. Dr. Cormier states: “Many clients prefer action-oriented, pragmatic

approaches rather than emotive ones, and behavior therapy does not require emotional catharsis for change.” How can this orientation be a benefit for some clients?

2. What are some ways you might use behavioral interventions where brief approaches are necessary?

3. Are there any specific behavioral methods that you would like to incor- porate into your personal life?

Behavior Therapy From a Multicultural Perspective Strengths From a Diversity Perspective

Behavior therapy has some clear advantages over many other theories in counseling culturally diverse clients. Because of their cultural and ethnic backgrounds, some clients hold values that are contrary to the free expression of feelings and the shar- ing of personal concerns. An African American client once shared that her father often said that he would give her something to really cry about if she ever displayed sadness or cried. In her home, it was unacceptable to display emotions. This lack of

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emotional expression was a protective action. The message she heard was to never show vulnerability because it could get you killed.

Behavioral counseling does not generally emphasize expressing emotions or experiencing catharsis. Rather, it stresses changing specific behaviors and develop- ing problem-solving skills. Some potential strengths of the behavioral approaches in working with diverse client populations include its specificity, task orientation, focus on objectivity, focus on cognition and behavior, action orientation, dealing with the present more than the past, emphasis on brief interventions, teaching cop- ing strategies, and problem-solving orientation. The attention given to transfer of learning and the principles and strategies for maintaining new behavior in daily life are crucial. Clients who are looking for action plans and specific behavioral changes are likely to cooperate with this approach because they can see that it offers them concrete methods for dealing with their problems of living.

Behavior therapy focuses on environmental conditions that contribute to a cli- ent’s problems. Social and political influences can play a significant role in the lives of people of color through discriminatory practices and economic problems, and the behavioral approach takes into consideration the social and cultural dimensions of the client’s life. Behavior therapy is based on an experimental analysis of behav- ior in the client’s own social environment and gives special attention to a number of specific conditions: the client’s cultural conception of problem behaviors, estab- lishing specific therapeutic goals, and increasing the client’s expectation of success- ful therapeutic outcomes. The foundation of ethical practice involves a therapist’s familiarity with the client’s culture, as well as the competent application of this knowledge in formulating assessment, diagnostic, and treatment strategies.

The behavioral approach has moved beyond treating clients for a specific symp- tom or behavioral problem. Instead, it stresses a thorough assessment of the per- son’s life circumstances to ascertain not only what conditions give rise to the client’s problems but also whether the target behavior is amenable to change and whether such a change is likely to lead to a significant improvement in the client’s total life situation.

In designing a change program for clients from diverse backgrounds, effective behavioral practitioners conduct a functional analysis of the problem situation. This assessment includes the cultural context in which the problem behavior occurs, the consequences both to the client and to the client’s sociocultural environment, the resources within the environment that can promote change, and the impact that change is likely to have on others in the client’s social surroundings. Assessment methods should be chosen with the client’s cultural background in mind (Spiegler, 2016). Counselors must be knowledgeable as well as open and sensitive to issues such as these: What is considered normal and abnormal behavior in the client’s cul- ture? What are the clients’ culturally based conceptions of their problems? What is the potential role of spirituality or religion in the client’s life? What kind of infor- mation about the client is essential in making an accurate assessment? To engage clients at this level, therapists need to do their own work and feel comfortable with their own culture. Therapists need to embark on their journey as multilayered and multicultural individuals. It takes effort to explore our cultural background, yet it is a worthwhile endeavor. As the saying goes, “We can only take our clients as far as we have gone.”

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Shortcomings From a Diversity Perspective Although behavior therapy is sensitive to differences among clients in a broad sense, behavior therapists need to become more responsive to specific issues pertaining to all forms of diversity. Because race, gender, ethnicity, age, and sexual orientation are critical variables that influence the process and outcome of therapy, it is essential that behavior therapists pay careful attention to these factors and address social justice issues as they arise in a client’s therapy.

Some behavioral counselors may focus on using a variety of techniques in nar- rowly treating specific behavioral problems. Instead of viewing clients in the context of their sociocultural environment, these practitioners concentrate too much on problems within the individual. In doing so, they may overlook significant issues that are contributing to the problems that clients bring to therapy. Counselors must be courageous in calling out racial and cultural disparities. Conversations about sys- temic racism often need to be a part of the practice of counseling. Therapists must get comfortable with being uncomfortable and explore how they have benefited from a societal structure that intentionally disenfranchises entire groups of people.

The fact that behavioral interventions often work well raises an interesting issue in multicultural counseling. When clients make significant personal changes, it is very likely that others in their environment will react to them differently. Before deciding too quickly on goals for therapy, counselor and client need to discuss the complexity inherent in change. It is essential for therapists to conduct a thor- ough assessment of the interpersonal and cultural dimensions of the problem and acknowledge the potential problems that could arise within the family as a result of a client’s changes. Clients should be helped in assessing the possible consequences of some of their newly acquired social skills. Once goals are determined and ther- apy is underway, clients should have opportunities to talk about the problems they encounter as they bring new skills and behaviors into their home and work settings. All of this needs to be discussed at the beginning of therapy. The ripple effect of change and movement will shift the entire family dynamic. Knowing this clearly in the beginning stage of therapy, therapists can support clients in building strategies to cope with potential pushback from family and friends.

Behavior Therapy Applied to the Case of Stan In Stan’s case many specific and interrelated prob- lems can be identified through an assessment pro- cess. Behaviorally, he is defensive, avoids eye con- tact, speaks hesitantly, uses alcohol excessively, has a poor sleep pattern, and displays various avoidance behaviors in social and interpersonal situations. In the emotional area, Stan has a number of specific problems, some of which include anxiety, panic at-

tacks, depression, fear of criticism and rejection, feel- ing worthless and stupid, and feeling isolated and alienated. He experiences a range of physiological complaints such as dizziness, heart palpitations, and headaches. Cognitively, he worries about death and dying, has many self-defeating thoughts and beliefs, is governed by categorical imperatives (“shoulds,” “oughts,” “musts”), engages in fatalistic thinking, and

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compares himself negatively with others. In the inter- personal area, Stan is unassertive, has an unsatisfac- tory relationship with his parents, has few friends, is afraid of contact with women and fears intimacy, and feels socially inferior.

After completing this assessment, I focus on help- ing Stan define the specific areas where he would like to make changes. Before developing a treatment plan, I assist Stan in understanding the purposes of his behavior. I then educate Stan about how the ther- apy sessions (and his work outside of the sessions) can help him reach his goals. Early during treatment I help Stan translate some of his general goals into concrete and measurable ones. When Stan says, “I want to feel better about myself,” I help him define more specific goals. When he says, “I want to get rid of my inferiority complex,” I reply: “What exactly do you mean by this? What are some situations in which you feel inferior? What do you actually do that leads to feelings of inferiority?” Stan’s concrete aims include his desire to function without drugs or alcohol. I sug- gest that he keep a record of when he drinks and what events lead to drinking. My hope is that Stan will establish goals that are based on positive mark- ers, not negative goals. Instead of focusing on what Stan would like to get rid of, I am more interested in what he would like to acquire and develop.

Stan indicates that he does not want to feel apol- ogetic for his existence. I introduce behavioral skills training because he has trouble talking with his boss and coworkers. I demonstrate specific skills that he can use in approaching them more directly and con- fidently. This procedure includes modeling, role play- ing, and behavior rehearsal. He then tries more effec- tive behaviors with me as I play the role of the boss. I give him feedback on how strong or apologetic he seemed.

Imaginal exposure and systematic desensitiza- tion are appropriate in working with Stan’s fear of failing. Before using these procedures, I explain the procedure to Stan and get his informed consent. Stan first learns relaxation procedures during the ses- sions and then practices them daily at home. Next, he lists his specific fears relating to failure, and he

then generates a hierarchy of fear items. Stan identi- fies his greatest fear as fear of dating and interacting with women. The least fearful situation he identifies is being with a female student for whom he does not feel an attraction. I first do some systematic desen- sitization on Stan’s hierarchy. Stan begins repeated, systematic exposure to items that he finds frighten- ing, beginning at the bottom of the fear hierarchy. He continues with repeated exposure to the next fear hierarchy item when exposure to the previous item generates only mild fear. Part of the process involves exposure exercises for practice in various situations away from the therapy office.

The goal of therapy is to help Stan modify the be- havior that results in his feelings of guilt and anxiety. By learning more appropriate coping behaviors, elim- inating unrealistic anxiety and guilt, and acquiring more adaptive responses, Stan’s presenting symp- toms decrease, and he reports a greater degree of satisfaction.

Questions for Reflection ◆ How would you collaboratively work with Stan

in identifying specific behavioral goals to give a direction to your therapy?

◆ What behavioral techniques might be most appro- priate in helping Stan with his problems?

◆ Stan indicates that he does not want to feel apolo- getic for his existence. How might you help him translate this wish into a specific behavioral goal? What behavioral techniques might you draw on in helping him in this area?

◆ What homework assignments are you likely to sug- gest for Stan?

Refer to the MindTap for The Case of Stan Video Quiz for Chapter 9, Session 7 (“Behav- ior Therapy”), for a demonstration of my approach to counseling Stan from this perspec- tive. This session involves collaboratively work- ing on homework and behavior rehearsals to experiment with assertive behavior.

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Behavior Therapy Applied to the Case of Gwen* In daily life, Gwen has a tendency to try to get every- thing done without enlisting the support of others. In our previous session, she decided on a goal of asking for support from others both at home and at work. We engaged in behavioral rehearsals in which Gwen prac- ticed asking someone for support. Gwen found this dif- ficult, but she hesitantly said she was willing to try out these new behaviors. Her homework was to ask for help both at work and at home. Gwen is late for our session, and when she arrives she looks tired and defeated.

Gwen: Sorry I am late. I left work early to take my mother to the doctor, and the appointment ran longer than I expected.

Therapist: I am pleased you were able to make it, but our session will be shorter. Last week you talked about feeling disconnected from your husband. We agreed that asking him for assistance and sharing your daily life with him might help you commu- nicate with each other. What have you done this week to get support and share more at home?

Gwen: I expressed to colleagues that I needed help when completing some tasks at work, but I fell back into the same pattern of silence when at home with Ron.

Therapist: Tell me more about falling back into the same pattern of silence.

Gwen: I wanted to ask Ron to help with my mom, but ultimately I feel like she is my mom and my responsibility. He sees what I am doing and could offer to pitch in.

Therapist: You seemed eager to express your need for support to Ron, but then something stopped you. What do you think caused you to stop? [Using the ABC model]

Gwen: I hate to ask. It is my responsibility. I think I am the only one who can do it. I would feel like I was putting a burden on Ron’s shoulders if I asked for help.

Therapist: You must feel an overwhelming amount of pressure being solely responsible for so much.

Gwen: Yes, it is hard to make sense of it all.

Therapist: Let me see if I understand. It sounds as though taking care of your mom is your sole responsibility and not Ron’s [antecedent]. You do not want to feel like a burden to Ron, so you stop yourself from asking for support [behavior].

Gwen: Yes, when I get home I want to talk, but I do not want to become a burden on someone I love. So I just withdraw into myself [consequence].

Assessment is a large part of behavioral therapy, and reviewing homework assignments helps us to see if our approach is effective. Although Gwen was aware of her pattern of silence at home, she was not able to modify her behavior and express her feelings to her husband.

I decide to introduce Gwen to the concept of mindfulness to help her stop the automatic behaviors that have kept her feeling stressed and overwhelmed. Gwen has difficulty being in the present moment, and she could profit from slowing down and engag- ing in self-care activities. Mindfulness practice can bring increased peace and calm into her life and quiet the constant chatter in her mind. I want to give Gwen some simple tools she can use and practice at home.

Therapist: Gwen, take a moment to sit quietly. Let your thoughts flow away and concentrate your atten- tion on the present moment. How are you feeling? [She begins to notice bodily sensations] Gwen please bring your awareness to the top of your head and

*Dr. Kellie Kirksey writes about her ways of thinking and practicing from a behavior therapy perspective and how she would apply this model to Gwen.

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slowly begin to scan your entire body for any sensa- tions of tension or tightness. What are you noticing?

Gwen: I am aware of tightness in my chest. It feels like a ball of stress.

Therapist: Focus all of your attention on the sensation in your chest. As you consciously tell yourself to relax, simply notice the sensations without judging them. How are you feeling?

Gwen: It’s a little strange, but I feel more at ease than when I first walked in the door.

Therapist: Do you think you can practice this mind- fulness at home this week and focus on what you want to bring into your life?

Gwen: I do want to communicate better with my husband and be able to ask him for support. I feel much more relaxed here now, and I would like to try to feel that at home too. Calming myself and staying in the moment is a new experience for me.

Therapist: You have a good start on learning how mindfulness feels; let’s see how much progress you can make at home as you practice this week.

Gwen: OK, I feel less stressed when I slow down and try to relax in the moment. I am going to practice this every day during the week. [Goal-setting is an important part of behavior therapy]

I encourage Gwen to practice paying attention to her behaviors and to consider using mindfulness practice as a way of refocusing on what she wants to bring into her life. It is my hope that her mindfulness practice will lead to an overall reduction in stress and increased presence and connection in her life.

Questions for Reflection ◆ What could be the consequence(s) if Gwen does

not change her behavior? ◆ What kind of homework might you suggest to

Gwen? ◆ What kind of mindfulness practices would you like

to incorporate into your daily life?

Summary and Evaluation Summary

Behavior therapy is diverse with respect not only to basic concepts but also to tech- niques that can be applied in coping with specific problems with a wide range of clients. The behavioral movement includes four major areas of development: clas- sical conditioning, operant conditioning, social-cognitive theory, and increasing attention to the cognitive factors influencing behavior (see Chapter 10). Third- generation behavior therapies are recent developments in the field, and they include mindfulness and acceptance-based behavior therapies. These contemporary devel- opments rely on evidence-based procedures. A unique characteristic of all forms of behavior therapy is its strict reliance on the principles of the scientific method. Con- cepts and procedures are stated explicitly, tested empirically, and revised continu- ally. Treatment and assessment are interrelated and occur simultaneously. Research is considered to be a basic aspect of the approach, and therapeutic techniques are continually refined.

A cornerstone of behavior therapy is identifying specific goals at the outset of the therapeutic process. In helping clients achieve their goals, behavior therapists typi- cally assume an active and directive role. Although the client generally determines

LO14

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what behavior will be changed, the therapist typically determines how this behavior can best be modified. In designing a treatment plan, behavior therapists employ techniques and procedures from a wide variety of therapeutic systems and apply them to the unique needs of each client. Although behavior therapy is a structured approach, therapists must assess client preferences and accommodate the client’s culture, preferences, and personal characteristics.

Contemporary behavior therapy emphasizes the interplay between the individ- ual and the environment. Behavioral strategies can be used to attain both individual goals and societal goals. Because cognitive factors have a place in the practice of behavior therapy, techniques from this approach can be used to attain humanistic ends. It is clear that bridges can connect humanistic and behavioral therapies, espe- cially with the current focus of attention on self-management and the incorporation of mindfulness and acceptance-based approaches into behavioral practice. Mindful- ness practices rely on experiential learning and client discovery rather than on didac- tic instruction and require an ongoing effort to develop and refine. Self-compassion is a foundational part of the new wave of behavior therapies and is linked to an increased sense of well-being (Neff & Germer, 2018). These newer approaches repre- sent a blend of Eastern practices and Western methodology. Contemporary behavior therapy has broadened from a narrow focus on dealing with simple problems to addressing complex aspects of personal functioning.

Contributions of Behavior Therapy Behavior therapy challenges us to reconsider our global approach to counseling. Some may assume they know what a client means by the statement, “I feel unloved; life has no meaning.” A humanist might nod in acceptance to such a statement, but the behaviorist may respond with a more targeted question: “Who specifically do you feel is not loving you?” “What is going on in your life to make you think it has no meaning?” “What are some specific things you might be doing that contribute to the state you are in?” “What would you most like to change?” A key strength of behavior therapy is its precision in specifying goals, target behaviors, and proce- dures. The specificity of the behavioral approaches helps clients translate unclear goals into concrete plans of action, and it helps both the counselor and the cli- ent keep these plans clearly in focus. Ledley, Marx, and Heimberg (2018) state that therapists can help clients learn about the contingencies that maintain their prob- lematic thoughts and behaviors and then teach them ways to make the changes they want. Techniques such as role playing, relaxation procedures, behavioral rehearsal, coaching, guided practice, modeling, feedback, learning by successive approxima- tions, mindfulness skills, and homework assignments can be included in any thera- pist’s repertoire, regardless of theoretical orientation.

An advantage behavior therapists have is the wide variety of specific behavioral techniques at their disposal. Because behavior therapy stresses doing, as opposed to merely talking about problems and gathering insights, practitioners use many strategies to assist clients in formulating a plan of action for changing behavior. The basic therapeutic conditions stressed by person-centered therapists—active listening, accurate empathy, positive regard, genuineness, respect, acceptance, and immediacy—need to be integrated into a behavioral framework.

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A major contribution of behavior therapy is its emphasis on research into and assessment of treatment outcomes. It is up to practitioners to demonstrate that therapy is working. If progress is not being made, therapists look carefully at the original analysis and treatment plan. Of all the therapies presented in this book, this approach and its techniques have been subjected to the most empirical research. Behavioral practitioners are put to the test of identifying specific interventions that have been demonstrated to be effective.

Evidence-based therapies (EBT) are a hallmark of both behavior therapy and cognitive behavior therapy (Dobson & Dobson, 2017). To their credit, behavior therapists are willing to examine the effectiveness of their procedures in terms of the generalizability, meaningfulness, and durability of change. Most studies show that behavior therapy methods are more effective than no treatment. Moreover, a number of behavioral and cognitive behavioral procedures are currently the best treatment strategies available for depression, obsessive-compulsive disorder, panic disorder, social phobia, hypochondriasis, generalized anxiety disorder, posttrau- matic stress disorder, eating disorders, borderline personality disorder, bipolar dis- order, and childhood disorders (Hollon & DiGiuseppe, 2011).

The new generation of mindfulness and acceptance-based therapies has shifted behavior therapy from treating simple and discrete problems to a more complex and complete psychotherapy that is based in behavioral principles (Prochaska & Norcross, 2018). Prochaska and Norcross “confidently predict the ascension and expansion of the third-wave therapies in the next decade, as do our experts forecast- ing the future of psychotherapy” (p. 286).

A strength of the behavioral approaches is the emphasis on ethical accountabil- ity. Behavior therapy is ethically neutral; it does not dictate whose behavior or what behavior should be changed. At least in cases of voluntary counseling, the behavioral practitioner only specifies how to change those behaviors the client targets for change. Clients have a good deal of control and freedom in deciding what the goals of therapy will be. A collaborative therapist–client relationship is an essential aspect of behavior therapy. Because clients are active in selecting goals and procedures in the therapy process and are applying what they are learning in therapy to daily life, the chance that they will become the target of unethical behavior is decreased (Speigler, 2016).

Limitations and Criticisms of Behavior Therapy Behavior therapy has been criticized for a variety of reasons. Let’s examine four common criticisms and misconceptions people often have about behavior therapy, together with my reactions.

Behavior Therapy Changes Behaviors More so Than Feelings Some critics argue that feelings must change before behavior can change. Behavioral practitioners hold that empirical evidence has not shown that feelings must be changed first, and behavioral clinicians do in actual practice deal with feelings as an overall part of the treatment process. A general criticism of both the behavioral and the cognitive approaches is that clients are not encouraged to experience their emotions. In concentrating on how clients are behaving or thinking, some behavior therapists tend to play down the working through of emotional issues. Generally, I favor

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initially focusing on what clients are feeling and then working with the behavioral and cognitive dimensions. When clients’ feelings are engaged, this seems to me to be a good point of departure. I can still tie a discussion of what clients are feeling with how this is affecting their behavior, and I can later inquire about their cognitions.

Behavior Therapy Does Not Provide Insight If this assertion is indeed true, behavior therapists would probably respond that insight is not a necessary requisite for behavior change. It is possible for therapy to proceed without a client knowing how change is taking place. Although change may be taking place, clients often cannot explain precisely why. Furthermore, insights may result after clients make a change in behavior. Behavioral shifts often lead to a change in understanding or to insight, which may lead to emotional changes as well.

Behavior Therapy Treats Symptoms Rather Than Causes The psychoanalytic assumption is that early traumatic events are at the root of present dysfunction. Behavior therapists may acknowledge that deviant responses have historical origins, but they contend that history is less important in the maintenance of current problems than environmental events such as antecedents and consequences. Behavior therapists emphasize changing current environmental circumstances to change behavior.

Unless historical causes of present behavior are therapeutically explored, critics maintain that new symptoms will soon take the place of those that were “cured.” Behaviorists rebut this assertion on both theoretical and empirical grounds. They contend that behavior therapy directly changes the maintaining conditions of prob- lem behaviors (symptoms), thereby indirectly changing the problem behaviors. Fur- thermore, they assert that there is no empirical evidence that symptom substitution occurs after behavior therapy has successfully eliminated unwanted behavior because they have changed the conditions that give rise to those behaviors (Spiegler, 2016).

Behavior Therapy Involves Control and Social Influence by the Therapist All therapists have a power relationship with the client and thus therapy involves social influence; the ethical issue relates to the therapist’s degree of awareness of this influence and how it is addressed in therapy. Behavior therapy recognizes the importance of making the social influence process explicit, and it emphasizes client- oriented behavioral goals. Therapy progress is continually assessed and treatment is modified to ensure that the client’s goals are being met.

Behavior therapists address ethical issues by stating that therapy is basically a psychoeducational process. At the outset of behavior therapy, clients learn about the nature of counseling, the procedures that may be employed, and the benefits and risks. People who seek behavior therapy are given information about the specific therapy pro- cedures appropriate for their particular problems. To some extent, they also participate in the choice of techniques that will be used in dealing with their problems. With this information clients become informed, genuine partners in the therapeutic venture.

The literature in the field of behavior therapy is so extensive that it is not pos- sible in one brief survey chapter to present a comprehensive discussion of behavioral concepts and techniques. The suggested readings at the end of this chapter offer more in-depth knowledge regarding this complex approach.

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Self-Reflection and Discussion Questions 1. Behavior therapists use a brief, active, directive, collaborative, present-

focused, didactic, psychoeducational model of therapy that relies on empirical validation of its concepts and techniques. What do you see as the main strengths and limitations of this focus?

2. What are some unique characteristics common to all of the behavioral therapies? How do you see these therapies as being able to apply to a setting in which you might work?

3. The third- wave of behavioral approaches involve mindfulness and acceptance-based concepts. What aspects of these concepts would you most want to incorporate in your work with clients?

4. How can you apply mindfulness techniques in your daily life? What value do you place on becoming more mindful?

5. What are some of the behavioral interventions that you can see yourself applying to your personal life? What specific behavioral techniques do you most want to incorporate in your counseling practice?

Where to Go From Here Other Resources

DVDs offered by the American Psychological Association that are relevant to this chapter include the following:

Antony, M. M. (2009). Behavioral Therapy Over Time (APA Psychotherapy Video Series)

Hayes, S. C. (2011). Acceptance and Commitment Therapy (Systems of Psycho- therapy Video Series)

Psychotherapy.net is a comprehensive resource for students and professionals that offers videos and interviews on behavior therapy. New video and editorial con- tent is made available monthly. DVDs relevant to this chapter are available at www .psychotherapy.net and include the following:

Stuart, R. (1998). Behavioral Couples Therapy (Couples Therapy With the Experts Series)

If you have an interest in further training in behavior therapy, the Association for Behavioral and Cognitive Therapies (ABCT) is an excellent resource. ABCT is a membership organization of more than 4,500 mental health professionals and stu- dents who are interested in behavior therapy, cognitive behavior therapy, behavioral assessment, and applied behavioral analysis. Members receive discounts on all ABCT publications, including those listed here:

◆ Directory of Graduate Training in Behavior Therapy and Experimental-Clinical Psychology is an excellent source for students and job seekers who want information on programs with an emphasis on behavioral training.

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◆ Directory of Psychology Internships: Programs Offering Behavioral Training describes training programs having a behavioral component.

◆ Behavior Therapy is an international quarterly journal focusing on origi- nal experimental and clinical research, theory, and practice.

◆ Cognitive and Behavioral Practice is a quarterly journal that features clini- cally oriented articles.

Full and associate memberships are $199 and include one journal subscription (to either Behavior Therapy or Cognitive and Behavioral Practice) and a subscription to the Behavior Therapist (a newsletter with feature articles, training updates, and asso- ciation news). Membership also includes reduced registration and continuing edu- cation course fees for ABCT’s annual convention held in November, which features workshops, master clinician programs, symposia, and other educational presenta- tions. Student memberships are $49. For more information, visit the Association for Behavioral and Cognitive Therapies website (www.abct.org).

Mindfulness and Acceptance-Based Approaches If you are interested in finding out more about mindfulness and acceptance-based programs and resources for the newer therapies, explore some of these websites:

Institute for Meditation and Psychotherapy (www.meditationandpsycho- therapy.org)

Mindfulness-Based Stress Reduction (www.umassmed.edu/cfm)

Dialectical Behavior Therapy (www.behavioraltech.com)

Acceptance and Commitment Therapy (www.acceptanceandcommitment- therapy.com)

Self-Compassion Resources (www.self-compassion.org)

Recommended Supplementary Readings for Chapter 9 Contemporary Behavior Therapy (Spiegler, 2016) is a comprehensive discussion of basic principles and applications of the behavior therapies. It is an excellent text that is based on research.

Interviewing and Change Strategies for Helpers (Cormier et al., 2017) is a comprehensive and clearly written textbook dealing with training experiences and skill development. This book offers practitioners a wealth of material on a variety of topics, such as assessment procedures, selection of goals, development of

appropriate treatment programs, and methods of evaluating outcomes.

Mindfulness and Psychotherapy (Germer et al., 2013) is a practical introduction to mindfulness and its clinical applications. This edited work addresses the basics of mindfulness meditation, the centrality of the therapeutic relationship, and ways that cultivating mindfulness can enhance acceptance and empathy.

Wisdom and Compassion in Psychotherapy: Deepening Mindfulness in Clinical Practice (Germer & Siegel, 2012)

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is an edited book that expands on the message that we need to treat ourselves as we would want other to treat us. Excellent contributed chapters discuss the meaning of wisdom and demonstrate the clinical applications inherent in blending Western psychotherapy and Buddhist psychology.

Mindfulness-Based Cognitive Therapy for Depression (Segal et al., 2013) is an excellent resource for those who are interested in learning about the fundamentals and clinical applications of mindfulness-based cognitive therapy, especially in working with depression.

The Mindfulness Solution: Everyday Practices for Everyday Problems (Siegel, 2010) is an outstanding

practical guide in applying mindfulness practices to living a meaningful life, as well as a guide for practitioners who wish to teach clients how to use mindfulness in meeting life’s challenges. This is a well-written book that highlights applications to personal and professional areas.

Imagery in Cognitive-Behavioral Therapy (Stopa, 2021) is a practical book addressing ways to incorporate imagery into behavior therapy and CBT. Procedures are described for implementing imaginal exposure, imaginal reliving in trauma-focused treatments, imagery rescripting, working with self-images, and using positive imagery to improve well-being.

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1. Identify common attributes shared by all cognitive behavior approaches.

2. Describe how the ABC model is a way of understanding the interaction among feelings, thoughts, and behavior.

3. Explain how cognitive methods can be applied to change thinking and behavior.

4. Discuss how REBT can be applied to school counseling.

5. Explain the unique contributions of Aaron Beck to the development of cognitive therapy.

6. Identify the basic principles of cognitive therapy.

7. Discuss application of the cognitive behavior approach to school counseling.

8. Describe the basic principles of strengths-based CBT.

9. Describe Meichenbaum’s three- phase process of behavior change.

10. Describe the key concepts and phases of Meichenbaum’s stress inoculation training.

11. Identify the strengths and limitations of cognitive behavior therapy from a multicultural perspective.

12. Differentiate REBT from cognitive therapy with respect to how faulty beliefs are explored in therapy.

13. Explain the main differences of Ellis, Beck, Padesky, and Meichenbaum as applied to the practice of CBT.

Learning Objectives

*I would like to acknowledge Dr. Debbie Joffe Ellis for her review and additional input of REBT in bringing this section of the chapter up to date. Appreciation also goes to Christine Padesky, PhD, for updating the section on strengths-based CBT.

10Cognitive Behavior Therapy*

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Introduction Traditional behavior therapy has broadened and largely moved in the direction of cognitive behavior therapy (CBT). Several of the more prominent cognitive- behavioral approaches are featured in this chapter, including Albert Ellis’s ratio- nal emotive behavior therapy (REBT), Aaron T. Beck and Judith Beck’s cognitive behavior therapy (CBT), Christine Padesky’s strengths-based CBT (SB-CBT), and Donald Meichenbaum’s cognitive behavior therapy. These approaches all fall under the general umbrella of CBT.

All of the cognitive-behavioral approaches share the basic characteristics and assumptions of traditional behavior therapy (see Chapter 9). Although these approaches are quite diverse, they do share these attributes: (1) a collaborative rela- tionship between client and therapist, (2) the premise that psychological distress is often maintained by cognitive processes, (3) a focus on changing cognitions to produce desired changes in affect and behavior, (4) a present-centered, time-limited focus, (5) an active and directive stance by the therapist, and (6) an educational treat- ment focusing on specific and structured target problems (Beck & Weishaar, 2019). In addition, both cognitive therapy and the cognitive-behavioral therapies are based on a structured psychoeducational model, make use of homework, place respon- sibility on the client to assume an active role both during and outside therapy ses- sions, emphasize developing a strong therapeutic alliance, and draw from a variety of cognitive and behavioral strategies to bring about change. Therapists help clients examine how they understand themselves and their world and suggest ways clients can experiment with new ways of behaving (Dienes et al., 2011).

To a large degree, the various cognitive behavior therapy approaches are based on the assumption that beliefs, behaviors, emotions, and physical reactions are all reciprocally linked. Changes in one area lead to changes in the other areas. A change in beliefs is not the only target of therapy, but enduring changes usually require a change in beliefs. CBT therapists apply behavioral techniques such as operant con- ditioning, modeling, and behavioral rehearsal to the more subjective processes of thinking and internal dialogue. In addition, therapists teach clients to actively test their beliefs in therapy, on paper, and through behavioral experiments. The cogni- tive-behavioral approaches include a variety of behavioral strategies (discussed in Chapter 9) as well as cognitive strategies as a part of their integrative repertoire.

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Refer to the MindTap for this book to interact with video quizzes and various video programs to expand your knowledge on topics relevant to Chapter 10.

Albert Ellis’s Rational Emotive Behavior Therapy Introduction

Rational emotive behavior therapy (REBT) was the first of the cognitive behavior therapies, and today it continues to be a major cognitive-behavioral approach. REBT has a great deal in common with the therapies that are oriented toward cognition

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Albert Ellis (1913–2007) was born in Pittsburgh but escaped to the wilds of New York at the age of 4 and lived there for the rest of his life (except for a year in New Jersey). He was hospitalized nine times as a child, mainly with nephritis, and de- veloped renal glycosuria

at the age of 19 and diabetes at the age of 40. Despite his many physical challenges, he lived an unusually robust, active, and energetic life until his death at the age of 93. As he put it, “I am busy spreading the gospel according to St. Albert.”

Realizing that he could counsel people skillfully and that he greatly enjoyed doing so, Ellis decided to become a psychologist. He was taught at college that psycho- analysis was the deepest form of psychotherapy, and as part of his training Ellis was analyzed and supervised by a psychoanalyst. He then practiced psychoanalytically ori- ented psychotherapy, but eventually he became disillu- sioned with the slow progress of his clients. He observed that they improved more quickly once they changed their ways of thinking about themselves and their prob- lems. Early in 1955 he developed an approach to psycho- therapy he called rational therapy and later rational emo- tive therapy, and which is now known as rational emotive behavior therapy (REBT). Ellis has rightly been referred to as the grandfather of cognitive behavior therapy.

To some extent Ellis developed his approach as a method of dealing with his own problems during his

youth. At one point in his life, for example, he had ex- treme fears of speaking in public. During his adolescence he was extremely shy around young women. At age 19 he forced himself to talk to 100 different women in the Bronx Botanical Gardens over a period of one month. Al- though he never managed to get a date from these brief encounters, he does report that he desensitized himself to his fear of rejection by women. By applying rational and behavioral methods, he managed to conquer some of his strongest emotional blocks (Ellis, 1994, 1997).

People who heard Ellis lecture often commented on his abrasive, humorous, and flamboyant style. In his workshops it seemed that he took delight in expressing the colorful and performing aspect of his teaching per- sonality, such as peppering his speech with four-letter words, in order to shake attendees from any complacen- cy and to motivate them to think about their thinking. He greatly enjoyed his work and teaching REBT, which was his passion and primary commitment in life. He gave workshops wherever he went in his travels and had pro- claimed, “I wouldn’t go to the Taj Mahal unless they asked me to do a workshop there!”

Ellis married Australian psychologist Debbie Joffe in November 2004, whom he has called “the greatest love of my life” (Ellis, 2008). They shared the same life goals and ideals, and they worked as a team present- ing workshops. He entrusted her to continue his work, which she continues to do with passion and dedica- tion. If you are interested in learning more about the life and work of Albert Ellis, I recommend two of his books: Rational Emotive Behavior Therapy: It Works for Me—It Can Work for You (Ellis, 2004a) and All Out! An Autobiography (Ellis, 2010).

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and behavior as it also emphasizes thinking, assessing, deciding, analyzing, and doing. Contemporary REBT is imbued with compassion and emphasizes the impor- tance of creating and maintaining unconditional acceptance of one’s self, of oth- ers, and of life, along with the emphasis and reminder of the benefit of practicing daily gratitude. A basic assumption of REBT is that people contribute to their own psychological problems, as well as to specific symptoms, by the rigid and extreme beliefs they hold about events and situations. REBT is based on the assumption that cognitions, emotions, and behaviors interact significantly and have a reciprocal cause-and-effect relationship. REBT has consistently emphasized all three of these modalities and their interactions, thus qualifying it as a holistic and integrative approach (Ellis & Ellis, 2019a, 2019b; D. Ellis, 2014; Norcross et al., 2019).

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Although REBT is generally conceded to be the parent of today’s cognitive-behav- ioral approaches, it was influenced by some aspects of earlier schools of thought. Ellis gave credit to Alfred Adler as an influential precursor of REBT in some ways, and Karen Horney’s (1950) ideas on the “tyranny of the shoulds” are apparent in the conceptual framework of REBT. Ellis also acknowledged his debt to some of the Eastern philosophies and the ancient Greeks, especially the Stoic philosopher Epicte- tus, who said around 2,000 years ago: “People are disturbed not by events, but by the views which they take of them” (as cited in Ellis, 2001a, p. 16). Ellis’s reformulation of Epictetus’s dictum can be stated this way: “People disturb themselves as a result of the rigid and extreme beliefs they hold about events more than the events themselves.”

REBT’s basic hypothesis is that our emotions are mainly created from our beliefs, which influence the evaluations and interpretations we make and fuel the reactions we have to life situations. Through the therapeutic process, clients are taught skills that give them the tools to identify and dispute irrational beliefs that have been acquired and self-constructed and are now maintained by self-indoctrination. They learn how to replace such detrimental ways of thinking with effective and rational cognitions, and as a result they change their emotional experience and their reactions to situations. The therapeutic process allows clients to apply REBT prin- ciples for change not only to a particular presenting problem but also enables them to prevent or to cope better with many other problems in life, current or future, that they might encounter. A large part of the therapy is seen as an educational process. The therapist functions in many ways like teacher, collaborating with the client on homework assignments and introducing strategies for constructive thinking. The client is the learner who then practices these new skills in everyday life.

The father of positive psychology, Martin E Seligman, has acknowledged the influence of REBT on his early work, and so has Aaron T. Beck. The basic attitude and manner of REBT could be described as that of “realistic optimism,” identifying negatives in order to minimize, transform, and heal them, and in so doing focusing primarily on what is encouraging, positive, and healthy.

In continuation of her husband’s work, Debbie Joffe Ellis is emphasizing the importance of applying gratitude and unconditional acceptance as daily practices. REBT is adaptable and relevant for people from various cultures, races, religions, and gender identifications. REBT is humanistic, nonrigid, nondamning, and embraces the value of unconditionally accepting belief systems that may be very dif- ferent to those of the individuals applying it. REBT’s techniques and activities are based on efficacy, compassion, and common wisdom and are generally acceptable to a multitude of people of diverse backgrounds. It is also compatible with many other approaches and is often integrated within other psychotherapeutic modalities.

Key Concepts View of Emotional Disturbance

REBT is based on the premise that we learn irrational beliefs from significant others during childhood and then re-create these irrational beliefs throughout our lifetime. We actively reinforce our self-defeating beliefs through the processes of autosuggestion and self-repetition, and we then behave in ways that are consistent

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with these beliefs. Hence, it is largely our own repetition of early-indoctrinated irra- tional beliefs, rather than a parent’s repetition, that keeps dysfunctional attitudes alive and operative within us.

Ellis asserted that self-damning and self-blame can be at the core of many emo- tional disturbances. If we want to become psychologically healthy, we had better stop blaming ourselves and others and learn to fully and unconditionally accept ourselves despite our imperfections. Ellis and Ellis (2019a) hypothesize that we have strong tendencies to transform our desires and preferences into dogmatic “shoulds,” “musts,” “oughts” demands and commands. When we are feeling disturbed, it is a good idea to look to our hidden dogmatic “musts” and absolutist “shoulds.” Such demands create disruptive feelings and dysfunctional behaviors (Ellis, 2001a, 2004a).

Here are three basics musts (or irrational beliefs) we internalize that inevitably lead to self-defeat (Ellis &Ellis, 2019a):

1. “I must do well and be loved and approved by others.” 2. “Other people must treat me fairly, kindly, and well.” 3. “The world and my living conditions must be comfortable, gratifying,

and just, providing me with all that I want in life.”

We have a strong tendency to make and keep ourselves emotionally disturbed by internalizing and perpetuating self-defeating beliefs such as these, which is one rea- son it is a real challenge to achieve and maintain good psychological health (Ellis, 2001a, 2001b).

ABC Framework The ABC model of personality is central to REBT theory and practice. This model provides a useful tool for understanding the client’s feelings, thoughts, events, and behavior (Ellis & Ellis, 2019a). A is the existence of an activating event or adversity, or an inference about an event by an individual. C is the emotional and behavioral conse- quence or reaction of the individual; the reaction can be either healthy or unhealthy. A (the activating event) does not cause C (the emotional consequence). Instead, B, which is the person’s belief about A, largely creates C, the emotional reaction.

If a person experiences depression after a divorce, for example, it is likely that it is not the divorce itself that causes the depressive reaction, nor any inference that one has failed, but the person’s beliefs about the divorce or about the failure to maintain the marriage (D. Ellis, 2014). Ellis maintains that the beliefs about the rejection and failure (at point B) are what mainly cause the depression (at point C)—not the actual event of the divorce or the person’s inference of being a failure because the marriage did not last (at point A). Believing that human beings are largely responsible for cre- ating their own emotional reactions and disturbances, and showing people how they can change their irrational beliefs that directly “cause” their disturbed emotional consequences, is at the heart of REBT (Ellis & Ellis, 2019a).

After A, B, and C comes D (disputing). Essentially, D encompasses methods that help clients challenge their irrational beliefs. There are three components of this disputing process: detecting, debating, and discriminating. Clients learn to dis- criminate between irrational (self-defeating) beliefs and rational (self-helping) beliefs (Ellis & Ellis 2019a). Once they can detect irrational beliefs, particularly absolutistic

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“shoulds” and “musts,” “awfulizing,” and “self-downing,” clients dispute dysfunc- tional beliefs by logically, empirically, and pragmatically questioning them. Clients are asked to vigorously argue themselves out of believing and acting on irrational beliefs. Although REBT uses many other cognitive, emotive, and behavioral meth- ods to help clients minimize their irrational beliefs, it emphasizes the benefit of the process of vigorously disputing (D) such beliefs both during therapy sessions and in everyday life. Following that, clients are encouraged to develop E, a new effective philosophy (new rational beliefs), which also has a practical side. A new and effec- tive belief system consists of replacing unhealthy irrational thoughts with healthy rational ones. Homework that is collaboratively designed can enhance and maintain these therapeutic gains and personal insights.

The Therapeutic Process Therapeutic Goals

The many roads taken in rational emotive behavior therapy lead toward the des- tination of clients minimizing their emotional disturbances and self-defeating behaviors by acquiring a more realistic, workable, and compassionate philosophy of life. The therapeutic process of REBT involves a collaborative effort between therapist and client to choose realistic and life-enhancing therapeutic goals. One of the therapist’s tasks is to help clients differentiate between realistic and unre- alistic goals and also between self-defeating and life-enhancing goals. A basic aim is to teach clients how to change their dysfunctional emotions and behaviors into healthy ones.

According to Ellis and Ellis (2019a), another goal of REBT is to assist cli- ents in the process of achieving unconditional self-acceptance (USA), unconditional other-acceptance (UOA), and unconditional life-acceptance (ULA). As clients become more willing and able to accept themselves, they are more likely to uncondition- ally accept others and to accept life as it is—despite and including its challenges and difficulties. According to Fruzzetti, McLean, and Erikson (2019), Ellis had an influence on the introduction of acceptance in Western psychotherapy. REBT attends to thinking in a similar manner to mindfulness and acceptance approaches, emphasizing observing our thoughts and not being wedded to our thoughts.

The emphasis on acceptance in the practice of REBT demonstrates a similarity in this respect with the “third-wave” approaches discussed in Chapter 9. A famous say- ing of Ellis (Ellis & Ellis, 2019a) is: “Life has inevitable suffering as well as pleasure. By realistically thinking, feeling, and acting to enjoy what you can, and unangrily and unwhiningly accepting painful aspects that cannot be changed, you open your- self to much joy” (p. 55).

Therapist’s Function and Role The therapist has specific tasks, and the first step is to show clients how they have incorporated many irrational absolute “shoulds,” “oughts,” and “musts” into their thinking. The therapist disputes clients’ irrational beliefs and encourages clients to

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engage in activities that will counter their self-defeating beliefs by replacing their rigid “musts” with preferences.

A second step in the therapeutic process is to demonstrate how clients are keep- ing their emotional disturbances active by continuing to think illogically and unre- alistically. In other words, when clients keep reindoctrinating themselves, they create their own psychological problems. Ellis reminds us that we are responsible for our own emotional destiny (Ellis, 2004b, 2010).

To get beyond mere recognition of irrational thoughts, the therapist takes a third step—helping clients change their thinking and minimize their irrational ideas. Although we may not be able to entirely eliminate the tendency to think irrationally, we can make ongoing efforts to reduce the frequency of such think- ing. The therapist encourages clients to identify the irrational beliefs they have unquestioningly accepted, demonstrates how they are continuing to indoctrinate themselves with these beliefs, and reminds them that change is possible with per- sistent effort.

The fourth step in the therapeutic process is to strongly encourage clients to develop a rational philosophy of life so that in the future they can avoid hurting themselves again by believing other irrational beliefs. Tackling only specific prob- lems or symptoms can give no assurance that new disabling fears will not emerge. It is desirable, then, for the therapist to dispute the core irrational thinking and to teach clients how to substitute rational beliefs and healthy behaviors for irrational beliefs and self-defeating behaviors.

In addition to the psychoeducational and therapeutic elements of the role of the therapist, clinicians also do their best to model REBT principles, including that of unconditional other acceptance (UOA). REBT acknowledges the benefit of the therapist developing a good rapport with the client and recognizes that doing so can enhance the efficacy of the therapeutic process. REBT clinicians believe that acceptance of their clients is a crucial part of the therapy process and is necessary if clients are to feel safe enough to reveal their secret thoughts, emotions, and actions to therapists (DiGiuseppe & Doyle, 2019). However, REBT also encourages the ther- apist to be alert to any unhealthy dependency the client may have on the therapist, and to make an effort to discourage that and to focus on reinforcing the benefits of the client developing greater self-sufficiency.

A misconception that some people have harbored is that REBT is an active, direct, and assertive approach that lacks sensitivity. REBT is not a “one size fits all” therapeutic style. Effective REBT therapists tailor, modify, or enhance their tone and manner to create and maintain good rapport with clients; they pay attention to cli- ents’ emotions and situations and adjust their manner accordingly. For example, a different tone would be expressed when addressing grief issues than might be used for vigorously motivating a client to counter procrastination.

Client’s Experience in Therapy The therapeutic process largely focuses on clients’ experiences in the present. Like the person-centered and existential approaches to therapy, REBT emphasizes here- and-now experiences and clients’ present ability to change the patterns of thinking and emoting that they constructed earlier. The therapist may not devote much time

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to exploring clients’ early history and making connections between their past and present behavior unless doing so may aid the therapeutic process. REBT differs from many other therapeutic approaches in that it does not place much value on free asso- ciation, working with dreams, or dealing with transference phenomena. Ellis and Ellis (2019b) maintain that transference is not encouraged, and when it does occur, the therapist is likely to confront it because it is generally based on the client’s dire need to be liked and approved of by the therapist. Any unhealthy neediness that clients dis- play can be counterproductive and foster dependence on approval from the therapist.

Clients are encouraged to actively work outside therapy sessions. By carrying out cognitive, emotive, and behavioral homework assignments, clients become increasingly proficient at minimizing irrational thinking and disturbances in feeling and behaving. Homework is carefully designed and agreed upon and is aimed at getting clients to carry out productive actions that contribute to emotional and attitudinal change. The out- comes of these assignments are checked in later sessions, and clients continue to focus on learning effective ways to dispute irrational and self-defeating thinking. Toward the end of a term of therapy sessions, the therapist helps clients review their progress, make plans, and identify strategies to prevent, or cope with, any new challenges as they arise.

Relationship Between Therapist and Client Because REBT is a cognitive and directive behavioral process, a warm relation- ship between therapist and client is not required, but it may enhance the process for some. At the very least, a respectful relationship is recommended. As with the person-centered therapy of Rogers, REBT practitioners strive to unconditionally accept all clients and to teach them to unconditionally accept others and them- selves. The therapist takes the mystery out of the therapeutic process, teaching cli- ents about the cognitive hypotheses of disturbance and helping clients understand how they are continuing to sabotage themselves and what they can do to change. Insight alone does not typically lead to psychotherapeutic change, action is also required. Therapists frequently acknowledge and encourage progress clients have made. REBT practitioners make an ongoing effort to unconditionally accept their clients (and themselves!) as imperfect beings who can learn how to help themselves through applying a variety of techniques, including teaching, bibliotherapy, and behavior modification (Ellis & Ellis, 2019a, 2019b; D. Ellis, 2014).

Application: Therapeutic Techniques and Procedures The Practice of Rational Emotive Behavior Therapy

Rational emotive behavior therapists are multimodal and integrative. REBT practitio- ners use a number of different modalities (cognitive, emotive, behavioral, and interper- sonal) to dispel self-defeating cognitions and to teach people how to acquire a rational approach to living. Therapists are encouraged to be flexible and creative in their use of methods, making sure to tailor the techniques to the unique needs of each client (Ellis & Ellis 2019a; D. Ellis, 2014). REBT practitioners adopt many types of techniques, especially the active and directive strategies, from the various theoretical schools, and in that sense REBT is truly an integrative approach (Norcross et al., 2019).

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For a concrete illustration of how Dr. Ellis works with the client Ruth draw- ing from cognitive, emotive, and behavioral techniques, see Case Approach to Coun- seling and Psychotherapy (Corey, 2013, chap. 8). What follows is a brief summary of the major cognitive, emotive, and behavioral techniques Ellis describes (Ellis, 2004a; Ellis & Ellis, 2019a).

Cognitive Methods REBT practitioners usually incorporate a persuasive cognitive methodology in the therapeutic process. They demonstrate to clients, often in a quick and direct manner, what it is that they are continuing to tell themselves. Then they teach clients how to challenge these self-statements so that they no longer believe them, encouraging clients to acquire a philosophy based on facts. REBT relies heavily on thinking, disputing, debating, challenging, interpreting, explaining, and teaching. The most efficient way to bring about lasting emotional and behavioral change is for clients to change their way of thinking (Ellis & Ellis, 2019a, 2019b).

Here are some cognitive techniques available to the therapist.

◆ Disputing irrational beliefs. The most common cognitive method of REBT consists of the therapist actively disputing clients’ irrational beliefs and teaching them how to do this challenging on their own. Clients dispute a particular “must,” absolute “should,” or “ought” until they no longer hold that irrational belief, or at least until it is diminished in strength. Here are some examples of questions or statements clients learn to tell themselves when they dispute their irrational ideas: “Why must people treat me fairly?” “How do I become a total flop if I don’t succeed at important tasks I try?” “If I don’t get the job I want, it may be disap- pointing, but I can certainly stand it.” “If life doesn’t always go the way I would like it to, it isn’t awful, just inconvenient.”

◆ Doing cognitive homework. REBT clients are expected to make lists of their problems, look for their absolutist beliefs, and dispute these beliefs. Clients are encouraged to record and think about how their beliefs contribute to their personal problems and are asked to work hard at uprooting these self-defeating cognitions. Homework assignments are a way of tracking down and attending to the “shoulds” and “musts” that are part of their internalized self-messages. In this way, clients gradu- ally learn to lessen anxiety and to challenge basic irrational thinking. They often fill out the REBT Self-Help Form, which is reproduced in the Student Manual for Theory and Practice of Counseling and Psychotherapy (Corey, 2024). Their comments on this form can focus therapy sessions as they critically evaluate the disputation of their beliefs. Clients may be encouraged to put themselves in risk-taking situations that will allow them to challenge self-limiting beliefs. For example, a client with a tal- ent for acting who is afraid to act in front of an audience because of fear of failure may be asked to take a small part in a stage play. Work in the therapy session can be designed so that out-of-session tasks are feasible and the client has the skills to complete these tasks. Making changes tends to be hard work. Doing work outside sessions is of real value in revising clients’ thinking, feeling, and behaving.

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◆ Bibliotherapy. REBT and other CBT approaches may use bibliotherapy as an adjunctive form of treatment. The advantages of bibliotherapy include cost-effectiveness, widespread availability, and the potential of reaching a broad spectrum of populations. Bibliotherapeutic approaches have empirical support for a range of clinical problems, including the treatment of depression and many anxiety disorders (Jacobs, 2008). Because therapy is seen as an educational process, clients are encouraged to read REBT self-help books such as Rational Emotive Behavior Therapy: It Works for Me—It Can Work for You (Ellis, 2004a) and other books by Ellis (1999, 2000, 2001a, 2001b, 2005, 2010; Ellis & Ellis, 2019a).

◆ Changing one’s language. REBT rests on the premise that imprecise language is one of the causes of distorted thinking processes. Clients learn that “musts,” “oughts,” and absolute “shoulds” can be replaced with preferences. Instead of saying “It would be absolutely awful if . . .” they learn to say “It would be inconvenient if . . .” Clients who use language patterns that reflect helplessness and self-condemnation can learn to employ new self-statements that help them think and behave differently. As a consequence, they also begin to feel differently.

◆ Psychoeducational methods. REBT programs introduce clients to various educational materials such as books, videos, and articles. Therapists educate clients about the nature of their problems and how treatment is likely to proceed. They ask clients how particular concepts apply to them. Clients are more likely to cooperate with a treatment program if they understand how the therapy process works and if they understand why particular techniques are being used (Ledley et al., 2018).

Emotive Techniques REBT practitioners use a variety of emotive procedures, including unconditional acceptance, rational emotive role playing, modeling, rational emotive imagery, and shame-attacking exercises. These emotive techniques tend to be vivid and evocative in nature, and their purpose is to dispute clients’ irrational beliefs. These strategies are used both during the therapy sessions and as homework assignments in daily life. Their purpose is not simply to provide a cathartic experience but to help clients change some of their thoughts, emotions, and behaviors (Ellis, 2001b; Ellis & Ellis, 2019a). Let’s look at some of these evocative and emotive therapeutic techniques in more detail.

◆ Rational emotive imagery. This is a form of intense mental practice designed to establish new emotional patterns in place of disruptive ones by thinking in healthy ways (see Ellis, 2001a, 2001b). In rational emotive imagery (REI), clients are asked to vividly imagine one of the worst things that might happen to them and to describe their disturb- ing feelings. Clients are shown how to train themselves to develop healthy emotions, and as their feelings about adversities change, they stand a better chance of changing their behavior in the situation. This technique can be usefully applied to interpersonal and other situations that are problematic for the individual. Clients who practice rational

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emotive imagery several times a week for a few weeks may reach the point where they no longer feel upset over these negative events (Ellis, 2001a; Ellis & Ellis, 2019a; D. Ellis, 2014).

◆ Humor. Ellis contends that emotional disturbances often result from taking oneself too seriously. He wrote hundreds of “Rational Humor- ous Songs” (Ellis, 2005) and often led attendees at his workshops in singing them. One appealing aspect of REBT is that it fosters the devel- opment of a better sense of humor and helps put life into healthy per- spective (Ellis 2004a, 2010). Humor has both cognitive and emotional benefits in bringing about change. Humor shows the absurdity of certain ideas that clients steadfastly maintain, and it teaches clients to laugh—not at themselves but at their self-defeating ways of thinking.

◆ Role playing. Role playing has emotive, cognitive, and behavioral compo- nents. The therapist may interrupt to show clients what they are telling themselves to create their disturbances and what they can do to change unhealthy feelings to healthy ones. Clients can rehearse certain roles to bring out what they feel in a situation. For example, Dawson may put off applying to a graduate school because he is afraid he won’t be accepted. Just the thought of not being accepted to the school of his choice brings out intense feelings of shame for “being stupid.” The focus is on work- ing through underlying irrational beliefs related to his unpleasant feel- ings. Dawson role-plays an interview with the dean of graduate students, notes his anxiety and the specific beliefs leading to it, and challenges his conviction that he absolutely must be accepted and that not gaining such acceptance means that he is a stupid and incompetent person.

◆ Shame-attacking exercises. Ellis developed exercises to help people reduce shame and anxiety over behaving in certain ways. He asserts that we can stubbornly refuse to feel ashamed by telling ourselves that it is not cata- strophic if someone thinks we are foolish. Practicing shame-attacking exercises can reduce, minimize, and prevent feelings of shame, guilt, anxiety, and depression (Ellis, 1999, 2000, 2001a, 2001b, 2005, 2010; Ellis &Ellis, 2019a, 2019b). The exercises are aimed at increasing self- acceptance and mature responsibility, as well as helping clients see that much of what they think of as being shameful has to do with the way they define reality for themselves. Clients may take the risk of doing something that they are ordinarily afraid to do because of what others might think. It is critical that clients are open to carrying out these exercises rather than the therapist pushing an agenda. Through homework practice, clients eventually learn that they can choose not to let others’ reactions or possible disapproval stop them from doing the things they would like to do. For example, clients may wear “loud” clothes designed to attract attention, sing loudly, ask a silly question at a lecture, or ask for a left-handed monkey wrench in a grocery store. By carrying out such assignments, clients are likely to find out that other people are not really that interested in their behavior. Note that these exercises do not involve illegal activities or acts that will be harmful to oneself, to others, or that will unduly alarm other people!

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Behavioral Techniques REBT practitioners use many of the standard behavior therapy procedures, especially operant conditioning, self-management principles, systematic desensitization, relaxation techniques, and modeling. Behavioral homework assignments carried out in real-life situations are particularly important. These assignments are done systematically and can be recorded and analyzed. Homework activities give clients opportunities to practice new skills outside of the therapy session, which may be even more valuable for clients than work done during the therapy hour (Ledley et al., 2018). Doing homework may involve in vivo desensitization (Ellis & Ellis, 2019a) and live exposure in daily life situations. Clients actually do new and difficult things, and in this way they put their insights to use in the form of concrete action. Acting differently helps them incorporate functional beliefs.

Applications of REBT as a Brief Therapy Ellis originally developed REBT to try to make psychotherapy more efficient than other systems of therapy. He maintained that the best and most effective therapy quickly teaches clients how to tackle present as well as future problems. REBT is well suited as a brief form of therapy, whether it is applied to individuals, groups, couples, or families. Clients learn self-therapy/self-help techniques that they can continue to apply through their own ongoing work and practice (Ellis & Ellis, 2019a).

Application of REBT to Group Counseling Cognitive behavior therapy (CBT) groups are among the most popular treat- ments in clinics and community agency settings. One of the most common CBT group approaches is based on REBT principles and techniques. REBT practitio- ners employ an active role in encouraging group members to commit themselves to practicing what they are learning in the group sessions in everyday life. What goes on during the group is valuable, but therapists know that consistent work between group sessions and after a group ends is crucial. The group context pro- vides members with tools they can use to become self-reliant and to accept them- selves, and others, unconditionally as they encounter new problems in daily living.

In group therapy, members are taught how to apply REBT principles to one another as well as to themselves. Ellis recommends that some clients experience group therapy as well as individual therapy. Group members (1) learn how their beliefs influence what they feel and what they do, (2) explore ways to change self- defeating thoughts in various concrete situations, and (3) learn to minimize symp- toms through a profound change in their philosophy. Ellis and Ellis (2019a, 2019b) contend that group REBT is frequently the treatment of choice because it affords many opportunities to practice assertiveness skills, to take risks by practicing dif- ferent behaviors, to challenge self-defeating thinking, to learn from the experiences of others, and to interact therapeutically and socially with each other in after-group sessions. All of the cognitive, emotive, and behavioral techniques described earlier are applicable to group counseling as are the techniques covered in Chapter 9 on behavior therapy. Behavioral homework and skills training are just two useful meth- ods for a group format. For a more detailed discussion of REBT applied to group counseling, see Corey (2023, chap. 13).

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Application of REBT to School Counseling

REBT can be applied to students in all grade levels in both individual and group counseling contexts. When children and adolescents are taught the principles of REBT and are encouraged to apply them as a part of their daily lives, they are likely to handle challenging situations more successfully and to be less upset when bad things happen, including all-too-common bullying. The lessons taught, ideally in schools and in the home, provide the how-to’s of coping with difficulties as well as having the potential to prevent many emotional, mental, and behavioral problems.

Three main elements of REBT are particularly pertinent for children and can be highly beneficial when taught to children six years of age and older.

Unconditional self-acceptance: Children and adolescents are taught that they have intrinsic worth without having to earn it. REBT is a humanis- tic approach that promotes kindness and compassion and encourages thoughtful and good behavior. We are reminded to avoid rating ourselves, to rate our behavior only to learn from it, and to make desired changes.

High frustration tolerance: Many young people may want what they want when they want it, and they can benefit from learning that in life it is highly probable that they will not get everything they want when they want it. Children and adolescents can be encouraged to accept those reali- ties, to think about what can be done to increase their chances of getting what they want, and to remind themselves that there are still other good things in life to enjoy.

Unconditional acceptance of others: Although each person is fallible and capable of failing at tasks, children and adolescents are encouraged to accept that making mistakes does not make them a failure. Young people can be taught to differentiate a bad action another person performs from the total person. The person still has worth despite the bad behavior.

REBT teaches children and adolescents to think about their thinking, to adopt the daily practice of positive self-talk, to embrace a core set of healthy and ratio- nal beliefs, and to identify, dispute, and replace irrational beliefs with rational ones. Armed with these pragmatic, simple, and effective tools, children can create and embrace life-enhancing attitudes, emotions, and behaviors.

REBT can teach young people an emotional vocabulary and the differences between healthy and unhealthy negative emotions. Using the ABC framework can help young people understand the connection among thoughts, emotions, and behavior and can teach them to be responsible for how they feel rather than for what other people do. Creative activities such as drawing posters with positive self- statements can reinforce cognitive activities.

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This section provided by Dr. Debbie Joffe Ellis illustrates how drawing from the ABC framework can help children and adolescents understand their emotions, thoughts, and behaviors. She believes school counselors can effectively apply REBT concepts to an educational experience.

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An Expert’s Perspective on Rational Emotive Behavior Therapy Debbie Joffe Ellis, MDAM (medical doctor of alternative medicine), travels around the world presenting workshops on REBT. Born and raised in Melbourne, Australia, she is a licensed psychologist (Australia), a licensed mental health counselor (New York), a presenter and writer, and an adjunct professor at Columbia University in New York City where she teaches rational emotive behavior therapy and comparative psychotherapies. For years she worked with her husband, Albert Ellis, giving public presentations and professional trainings in rational emotive behavior therapy, and she collaborated with him on writing and research projects until his death in 2007.

1. What is the most important contribution of rational emotive behavior therapy for the practice of individual therapy? REBT heralded in the cognitive revolution in psychotherapy in the early 1950s. It has contributed many profound gifts through its theory, philosophy, and a multitude of techniques, but a most important contribution is that it is an empowering holistic approach. REBT is an evidence-based, scientific, active- directive approach, but it is also humanistic and imbued with compassion. REBT encourages the unconditional acceptance of self, others, and life. This approach reminds us of the inseparable interplay of our thinking, emotions, and behaviors—and how they can affect our physical health and well-being.

2. What two or three key concepts of REBT are especially applicable to the practice of individual counseling or therapy? REBT teaches that it is not a situation in itself but how we perceive a situ- ation and our beliefs about it that create our resultant emotions. When we choose to think in rational ways about challenging events, we create healthy emotions. When we think in irrational ways, we create unhealthy and often debilitating emotions.

REBT teaches us the difference between constituents of healthy ratio- nal thinking and those of irrational thinking. It also teaches the difference between healthy negative emotions (which include concern, grief, sadness, dis- appointment, healthy anger, and regret) and the unhealthy negative emotions (anxiety, panic, extreme fear, depression, hopelessness, despondency, rage, guilt, and shame). REBT encourages us to think about our thinking, catch any irrational beliefs, dispute them, and replace them with rational ones that we repeat to ourselves often. By doing this, we create life-enhancing emotions.

REBT reminds us that each individual has worth—simply because we exist—and that our worth is in no way determined by talents, success, mate- rial wealth, skills, appearances, failures, or mistakes. Even if we fail at some- thing, it does not make us a failure. Abysmal self-damning, other damning, and life-damning are areas that require attention in therapy because they lead to emotional disturbance. REBT’s emphasis on unconditional accep- tance and the how-to’s of attaining and maintaining it are foundational to clients’ healing and well-being processes.

3. What two or three techniques from REBT have practical value for practitioners of individual therapy? One of REBT’s most effective techniques, which other cognitive approaches have incorporated into their arsenal, is the ABCDE framework for identifying

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irrational beliefs, disputing them, and replacing them with rational ones. Cli- ents are taught to use it, and it is one of the homework activities that they are often encouraged do. By using this approach over time, clients are empowered with the knowledge and experience that changing their thinking creates healthy emotions and that they are not victims of outer events or circumstances.

REBT’s famous shame-attacking technique is particularly helpful for individuals who need the approval of others, for those who base their worth on the opinions of others, and for those who experience extreme shyness or social phobia. Clients are encouraged to do something (nondangerous!) that attracts the attention of others, such as wearing a strange hat or outfit or singing out loud in public, all the while using vigorous self-talk in which they remind themselves that the opinions of others do not have any bearing on their worth.

During the therapeutic session, it can be helpful for therapist and client to engage in role playing. The therapist plays the role of someone with issues similar to those of the client. The therapist speaks and expresses attitudes and beliefs that evoke the client’s unhelpful emotions, and the client is invited to dispute those beliefs and to come up with rational and life-enhancing ones.

4. How does REBT address diversity, multicultural, and social justice issues for the practice of individual counseling? REBT strongly emphasizes the importance of unconditionally accepting oth- ers, whether or not they embrace our beliefs, culture, or preferences. Research has demonstrated that REBT is effective in helping individuals of diverse cultures, gender identifications, and religions. REBT supports their life- enhancing choices and goals, while paying attention to and being sensitive to the mores and taboos they embrace within the context of their culture/iden- tification/religion. REBT is effective in helping clients who have been victims of prejudice and bullying. Some of the elements of REBT that are pertinent to clients in counseling include developing unconditional acceptance of self, oth- ers, and life; tolerance for that which can’t be changed; self-interest, and social- interest. Clients are taught that accepting the wrong-doers does not mean accepting or approving of their bad behavior. REBT encourages people to seek justice when it is possible, to accept that at times it may not be possible, and to acknowledge that life will at times be unfair. Despite incivility and injustice that clients may have endured, they can choose to focus on doing what they can do, accepting what they can’t do, and remembering daily the things that they can be grateful for including the tough stuff of their past or present.

5. In what ways can REBT be applied to brief therapy (or time-limited counseling)? REBT is highly effective as a short-term approach for many people due to its simplicity and precision in helping clients to identify the root causes of their problems and issues, and through providing a variety of techniques that aid the elimination and relapse prevention of such disturbances. REBT provides psychoeducation and authentic and enthusiastic encouragement to clients, and therapists remind clients that to create and maintain healthy change requires ongoing effort. A significant number of clients dealing with anxiety, depression, and the other disturbing negative emotions have found improve- ment in fewer than six sessions, and they are made aware that to maintain

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their gains they will need to continue to make effort in their daily lives. Clients working on more complicated issues, including those with dual diagnoses, those suffering from borderline personality disorder, obsessive-compulsive disorder, or addictive behaviors, may benefit from longer-term REBT therapy.

6. From your perspective, what is the current status and the future of the REBT approach? The current status of REBT seems to be that it is being marginalized and neglected. CBT appears to be practiced as a treatment of choice by many, and it is my wish, as it was the wish of Albert Ellis, that REBT’s distinc- tive contributions to CBT and to the entire field of psychotherapy not be neglected or lost. The existence of the enormous body of CBT research (which also supports the premises of REBT) is another reason that CBT is more prominent these days. It is my hope that REBT will be taught to more children in schools, that more research will be done that continues to dem- onstrate its profound efficacy, that more counseling students will consider REBT as a modality to study in detail, and that more therapists will use it either as their primary approach or to supplement and enhance any other modality that they practice. If this is done, then more people will have the opportunity to choose to apply the principles of REBT in their daily lives.

Discussion Questions Related to the REBT Perspective 1. How comfortable would you be in carrying out a shame-attacking

exercise as a client? How likely are you to use shame-attacking exercises with any clients for specific purposes?

2. From what you have read about REBT, how comfortable would you be as a client with an REBT therapist?

3. Dr. Debbie Joffe Ellis writes: “REBT encourages us to think about our thinking, catch any irrational beliefs, dispute them, and replace them with rational ones that we repeat to ourselves often. By doing this we create life-enhancing emotions.” When you think of one of your faulty beliefs, how might you dispute such a belief?

Aaron Temkin Beck (1921–2021) was born in Providence, Rhode Island. His childhood, although happy, was interrupted by a life-threatening illness when he was 8 years old. As a consequence, he expe- rienced blood injury fears, fear of suffocation, and anx- iety about his health. Beck

used his personal problems as a basis for understanding others and for developing his cognitive theory.

A graduate of Brown University and Yale School of Medicine, Beck initially was trained as a neurologist, but he switched to psychiatry during his residency. Beck at- tempted to validate Freud’s theory of depression, but the results of his research did not support Freud’s mo- tivational model and the explanation of depression as “anger turned inward.” Beck set out to develop a model for depression that fit with his empirical findings, and for many years Beck endured isolation from and rejec- tion by most of his colleagues in the psychiatric com- munity. Through his research, Beck developed a cog- nitive theory of depression, which represented a new and comprehensive conceptualization. He found the

Aaron T. Beck

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cognitions of depressed individuals were character- ized by errors in interpretation that he called cognitive distortions. For Beck, negative thoughts reflect un- derlying dysfunctional beliefs and assumptions. When these beliefs are triggered by situational events, a de- pressive pattern is put in motion. Beck believed clients can assume an active role in modifying their dysfunc- tional thinking and thereby gain relief from a range of psychiatric conditions. His continuous research in the areas of psychopathology and the utility of cognitive therapy eventually earned him a place of prominence in the scientific community in the United States. Beck was the founder of cognitive therapy (CT), one of the most influential and empirically validated approaches to psychotherapy. He won nearly every national and in- ternational prize for his scientific contributions to psy- chotherapy and suicide research and was even short- listed for the Nobel Prize in medicine.

Beck joined the Department of Psychiatry of the University of Pennsylvania in 1954, where he held the position of University Professor (Emeritus) of Psychiatry. Beck successfully applied cognitive therapy to depression, generalized anxiety and panic disorders,

social anxiety, obsessive-compulsive disorder, suicide, alcoholism and drug abuse, eating disorders, marital and relationship problems, psychotic disorders, and personality disorders. He developed assessment scales for depression, suicide risk, anxiety, self-concept, and personality.

He was the founder of the Beck Institute, which is a research and training center directed by one of his four children, Dr. Judith Beck. He was married for more than 60 years and had nine grandchildren and five great- grandchildren. To his credit, Aaron Beck focused on developing the cognitive therapy skills of tens of thou- sands of clinicians throughout the world. In turn, many of them have established their own cognitive therapy centers. Beck had a vision for the cognitive therapy community that was global, inclusive, collaborative, empowering, and benevolent. He continued to remain active in writing and research until the end of his life at the age of 100. He published 24 books and more than 600 articles and book chapters.

For more on the life of Aaron T. Beck, see Aaron T. Beck (Weishaar, 1993) or “Aaron T. Beck: Mind, Man and Mentor” (Padesky, 2004).

Judith S. Beck (b. 1954) was born in Philadelphia, the sec- ond of four children. Both of her parents were quite nota- ble in their fields: her father, as “the father of cognitive thera- py,” and her mother, as the first female judge on the appellate court of the Commonwealth of Pennsylvania. From an early age, Judith Beck wanted

to be an educator, and she began her professional career teaching children with learning disabilities. Her ability to break down complex subjects into easily understandable ideas, so critical in the education of children with learning differences, is characteristic of all her work.

Beck later returned to graduate school, studied edu- cation and psychology, and completed a postdoctoral

fellowship at the Center for Cognitive Behavior Therapy at the University of Pennsylvania. In 1994 she and her father opened the nonprofit Beck Institute for Cognitive Therapy in suburban Philadelphia, and she is currently president of the institute.

Beck travels extensively in the United States and abroad, teaching and disseminating cognitive be- havior therapy and assisting a wide variety of orga- nizations in developing or strengthening their CT programs. Beck is a clinical associate professor at the University of Pennsylvania and was instrumental in founding the Academy of Cognitive Therapy, the “home” organization for cognitive therapists world- wide. She has written nearly 100 articles and chapters on a variety of CT topics and authored several books on cognitive therapy, including Cognitive Behavior Therapy: Basics and Beyond (2021), Cognitive Therapy for Challenging Problems: What to Do When the Basics

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Aaron Beck’s Cognitive Therapy Introduction

Aaron T. Beck developed cognitive therapy (CT) about the same time that Ellis was developing REBT. They were not aware of each others’ work and created their approaches independently. Ellis developed REBT based on philosophical tenets, whereas Beck’s CT was based on empirical research (Padesky & Beck, 2003). Like REBT, CT emphasizes education and prevention but uses specific methods tailored to particular issues. The specificity of CT allows therapists to link assessment, con- ceptualization, and treatment strategies.

Beck (1963, 1967) set out to create an evidence-based therapy for depres- sion, and he tested each of his theoretical constructs with empirical studies and conducted controlled outcome studies to determine how CT’s outcomes compared with existing psychotherapy and pharmacotherapy treatments for depression. Beck’s careful empirical approach was eventually adopted by col- leagues around the world.

In the treatment of depression, cognitive therapy skills are some of the most established tools for therapeutic change (DeRubeis et al., 2019). Evidence- supported CT approaches were developed for many disorders including depression, panic disorder, social anxiety, phobias, posttraumatic stress disorder, schizophre- nia and other psychotic disorders, hypochondriasis, body dysmorphic disorder, eat- ing disorders, insomnia, anger issues, stress, chronic pain and fatigue, and distress due to general medical problems such as cancer (Hofmann et al., 2012; White & Freeman, 2000).

Beck’s original depression research revealed that depressed clients had a nega- tive bias in their interpretation of certain life events, which resulted from active pro- cesses of cognitive distortion (Beck, 1967). This led Beck to believe that a therapy that helped depressed clients become aware of and change their negative thinking could be helpful. Unlike Ellis, Beck did not assert that negative thoughts were the sole cause of depression. Beck’s research indicated that depression could result from negative thinking, but it could also be precipitated by genetic, neurobiological, or environmental changes. One of Beck’s early contributions was to recognize that regardless of the cause of depression, once people became depressed, their thinking reflected what Beck referred to as the negative cognitive triad: negative views of the self (self-criticism), the world (pessimism), and the future (hopelessness). Beck believed that this negative cognitive triad maintained depression, even when nega- tive thoughts were not the original cause of an episode of depression (Beck, 1967; Beck et al., 1979).

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Don’t Work (2005), and the Cognitive Therapy Worksheet Packet (2011), as well as trade books with a cognitive behavioral program for diet and maintenance.

Judith Beck has three adult children, one of whom is a social worker specializing in CT.

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Cognitive therapy (CT) has a number of similarities to both rational emotive behavior therapy and behavior therapy. All of these therapies are active, directive, time-limited, present-centered, problem-oriented, collaborative, structured, and empirical. They include homework assignments (or out-of-session practice) and require clients to explicitly identify problems and the situations in which they occur (Beck & Weishaar, 2019). Similar to REBT and unlike behavior therapy, CT is based on the theoretical rationale that the way people feel and behave is influenced by how they perceive and place meaning on their experience. Three theoretical assumptions of CT are (1) that people’s thought processes are accessible to introspection, (2) that people’s beliefs have highly personal meanings, and (3) that people can discover these meanings themselves rather than being taught or having them interpreted by the therapist (Weishaar, 1993).

From the beginning Beck developed specific treatment protocols for each problem, unlike Ellis who might teach similar philosophical principles to people with anxiety, depression, or anger. Despite these differences, therapists who prac- tice behavior therapy, REBT, and CT learn from each other, and considerable over- lap exists in methods used by all three schools of therapy in contemporary clinical practice. The highest standard of practice today is to offer the best “evidence-based practice” regardless of its origins, so a therapist might use behavioral methods to treat phobias and cognitive methods to treat panic disorder because research has demonstrated these methods to be most effective in treating these problems. Many therapists refer to themselves as offering cognitive-behavioral therapy regardless of whether their original training was primarily in behavior therapy, REBT or CT.

A Generic Cognitive Model Reflecting on 50 years of research and the various applications of cognitive therapy, Beck has proposed a generic cognitive model to describe principles that pertain to all CT applications from depression and anxiety treatments to therapies for a wide variety of other problems including psychosis and substance use (Beck & Haigh, 2014). By linking psychological difficulties with adaptive human responses, Beck believed the generic cognitive model “has the potential to be the only empirically supported general theory of psychopathology” (p. 21). The generic cognitive model provides a comprehensive framework for understanding psychological distress, and some of its major principles are described here. Beck encouraged others to design research to investigate the components of his model in an effort to reach the best understanding possible of human cognition, behavior, and emotion. Let’s look at some of the principles on which this model is based.

Psychological distress can be thought of as an exaggeration of normal adaptive human func- tioning. When people are functioning well, they experience many different emotions in response to life events and behave in ways that help them solve problems, achieve goals, and protect themselves from harm. It is normal to sometimes withdraw from relationships, avoid situations we don’t feel prepared to handle, or worry about problems in the search of a solution. A psychological disorder begins when these normal emotions and behaviors become disproportionate to life events in degree or frequency. For example, when a person begins to worry most of the time, even about

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situations that most people take in stride, that person is showing signs of general- ized anxiety disorder.

Faulty information processing is a prime cause of exaggerations in adaptive emotional and behavioral reactions. Our thinking is directly connected to our emotional reactions, behaviors, and motivations. When we think about things in erroneous or distorted ways, we experience exaggerated or distorted emotional and behavioral reactions as well. Beck identifies several common cognitive distortions:

◆ Arbitrary inferences are conclusions drawn without supporting evi- dence. This includes “catastrophizing,” or thinking of the absolute worst scenario and outcomes for most situations. You might begin your first job as a counselor with the conviction that you will not be liked or valued. You are convinced that you fooled your professors and some- how just managed to get your degree, but now people will certainly see through you!

◆ Selective abstraction consists of forming conclusions based on an isolated detail of an event while ignoring other information. The sig- nificance of the total context is missed. As a counselor, you might measure your worth by your errors and weaknesses rather than by your successes.

◆ Overgeneralization is a process of holding extreme beliefs on the basis of a single incident and applying them inappropriately to dissimilar events or settings. If you have difficulty working with one adolescent, for example, you might conclude that you will not be effective counsel- ing any adolescents. You might also conclude that you will not be effec- tive working with any clients!

◆ Magnification and minimization consist of perceiving a case or situ- ation in a greater or lesser light than it truly deserves. You might make this cognitive error by assuming that even minor mistakes in counsel- ing a client could easily create a crisis for the individual and might result in psychological damage.

◆ Personalization is a tendency for individuals to relate external events to themselves, even when there is no basis for making this connection. If a client does not return for a second counseling session, you might be absolutely convinced that this absence is due to your terrible per- formance during the initial session. You might tell yourself, “This situ- ation proves that I really let that client down, and now she may never seek help again.”

◆ Labeling and mislabeling involve portraying one’s identity on the basis of imperfections and mistakes made in the past and allowing them to define one’s true identity. If you are not able to live up to all of a client’s expectations, you might say to yourself, “I’m totally worthless and should turn my professional license in right away.”

◆ Dichotomous thinking involves categorizing experiences in either-or extremes. With such polarized thinking, you might view yourself as either being the perfectly competent counselor (you always succeed with all clients) or as a total flop if you are not fully competent (there is no room for any mistakes).

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Our beliefs play a major role in determining what type of psychological distress we will experience. Each emotional and behavioral disorder is accompanied by beliefs specific to that problem. Consider two students who apply to college and are not accepted to their first choice of school. One of the students becomes depressed, the other becomes anxious. Depression is accompanied by negative thoughts about oneself (“I’ve failed,” “Nothing will work out for me,” “I’ll never get into medical school”). Anxious thoughts reflect overestimations of threat or danger (“Everyone will think less of me when they find out I wasn’t admitted to that college”) and underestima- tions of one’s coping (“I won’t know what to say to people about it”) and under- estimation of resources (“These other colleges won’t prepare me well enough for medical school”).

Central to cognitive therapy is the empirically supported observation that “changes in beliefs lead to changes in behaviors and emotions” (Beck & Haigh, 2014, p. 14). If the students in the previous example can change the way they think about not being accepted to their first-choice school, their depression and anxiety are likely to be lessened. The first student will undoubtedly feel less depressed once a more balanced view of the rejection letter is adopted (“More good students apply than can be admitted. My rejection does not mean I failed. I’m sure many students from my second choice school go on to attend medical school.”). Similarly, the anxious student would ben- efit from new beliefs as well (“I can tell others that I am disappointed that I did not get into my first-choice college. Some people might think less of me, but those who really care about me will understand that not everyone gets their first choice and they will be supportive.”).

If beliefs are not modified, clinical conditions are likely to reoccur. Even without counsel- ing or a change in beliefs, people often recover from feelings of depression or anxiety and return to their usual healthy functioning. However, these feelings may return in times of future stress or disappointment if their basic beliefs have not changed. In studies of the long-term effects of treatments for depression and anxiety disorders, DeRubeis, Keefe, and Beck (2019) report that cognitive therapy and other types of CBT therapies have the lowest rates of relapse. “CT skills are arguably one of the most established tools for therapeutic change” (p. 240). Many believe this is because these therapies lead to enduring changes in beliefs.

Basic Principles of Cognitive Therapy Cognitive therapy (CT) perceives psychological problems as an exaggeration of adaptive responses resulting from commonplace cognitive distortions. Like REBT, CT is an insight-focused therapy with a strong psychoeducational component that emphasizes recognizing and changing unrealistic thoughts and maladaptive beliefs. The client works in partnership with the therapist, assuming the role of a learner in the therapy sessions and engaging in homework that is carried out in daily life (Kazantzis et al., 2017). The goal of CT is to help clients learn practical skills that they can use to make changes in their thoughts, behaviors, and emotions and how to sustain these changes over time. Because cognitive therapy is a skills- based approach, clients are able to employ the cognitive model and its methods in effectively dealing with difficult situations they are likely to encounter after formal therapy is terminated (DeRubeis et al., 2019).

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In cognitive therapy, clients learn how to identify their dysfunctional thinking. Once clients identify cognitive distortions, they are taught to examine and weigh the evidence for and against them. This process of critically examining thoughts involves empirically testing them by looking for evidence, actively engaging in a Socratic dialogue with the therapist, carrying out homework assignments, doing behavioral experiments, gathering data on assumptions made, and forming alterna- tive interpretations (Dattilio, 2000; DeRubeis et al., 2019; Tompkins, 2004, 2006). From the beginning of treatment, clients learn to employ specific problem-solving and coping skills. Through a process of guided discovery, clients acquire insight about the connection between their thinking and the ways they act and feel.

Cognitive therapy is focused on present problems, regardless of a client’s diag- nosis. The past may be brought into therapy when the therapist considers it essen- tial to understand how and when certain core dysfunctional beliefs originated and how these ideas have a current impact on the client’s difficulties (Dattilio, 2002). The goals of this brief therapy include providing symptom relief, assisting clients in resolving their most pressing problems, changing beliefs and behaviors that main- tain problems, and teaching clients skills that serve as relapse prevention strategies.

Some Differences Between CT and REBT In both CT and REBT, reality testing is highly organized. Clients come to realize on an experiential level that they have misconstrued situations. Yet there are some important differences between these two approaches, especially with respect to therapeutic methods and style.

REBT is often highly directive, persuasive, and confrontational, and the teach- ing role of the therapist is emphasized. The therapist models rational thinking and helps clients to identify and dispute irrational beliefs, logically and pragmatically. In contrast, CT mainly uses Socratic dialogue, posing open-ended questions to clients with the aim of getting clients to reflect on personal issues and arrive at their own conclusions. CT places more emphasis on helping clients identify misconceptions for themselves rather than being taught. Through this reflective questioning pro- cess, the cognitive therapist collaborates with clients in testing the validity of their cognitions (a process called collaborative empiricism). Therapeutic change is the result of clients reevaluating faulty beliefs based on contradictory evidence that they have gathered.

There are also differences in how Ellis and Beck view faulty thinking. Through a process of rational disputation, Ellis works to persuade clients that certain of their beliefs are irrational and nonfunctional. Beck views his clients’ distorted beliefs as being the result of cognitive errors rather than being driven solely by irrational beliefs. Beck asks his clients to conduct behavioral experiments to test the accuracy of their beliefs. Cognitive therapists view dysfunctional beliefs as being problematic when they are a distortion of the whole picture, or when they are too absolute, broad, and extreme (Beck & Weishaar, 2019). For Beck, people live by rules (underlying assump- tions); they get into trouble when they label, interpret, and evaluate by a set of rules that are unrealistic or when they use the rules inappropriately or excessively. If cli- ents decide they are living by rules that are likely to lead to misery, the therapist asks clients to consider and test out alternative rules. Although cognitive therapy operates within clients’ frame of reference, the therapist continually asks clients to examine evidence for and against their belief system.

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The Client–Therapist Relationship The therapeutic relationship is basic to the application of cognitive therapy. Through his writings, it is clear that Beck believes effective therapists must combine empathy and sensitivity with technical competence (Beck, 1987). The core thera- peutic conditions described by Rogers in his person-centered approach are viewed by cognitive therapists as being necessary, but not sufficient, to produce optimum therapeutic effect. A therapeutic alliance is a necessary first step in cognitive ther- apy, especially in counseling difficult-to-reach clients. Without a working alliance, techniques applied will not be effective (Kazantzis et al., 2017). The relationship is designed to be collaborative, in which therapist and client assume an equal share of responsibility for addressing the client’s problems (DeRubeis et al., 2019). Thera- pists must have a cognitive conceptualization of cases, be creative and active, be able to improvise, be able to engage clients through a process of Socratic questioning, and be knowledgeable and skilled in the use of cognitive and behavioral strategies aimed at guiding clients in significant self-discoveries that will lead to change (Beck & Weishaar, 2019).

Cognitive therapists are continuously active and deliberately interactive with clients, helping clients frame their conclusions in the form of testable hypotheses. The cognitive therapist functions as a catalyst and a guide who helps clients under- stand how their beliefs and attitudes influence the way they feel and act. Clients are expected to identify the distortions in their thinking, summarize important points in the session, and collaboratively devise homework assignments that they agree to carry out. Cognitive therapists emphasize the client’s role in self-discovery. The assumption is that lasting changes in the client’s thinking and behavior will be most likely to occur with the client’s initiative, understanding, awareness, and effort (Beck & Weishaar, 2019; J. Beck, 2021).

Cognitive therapists identify specific, measurable goals and move directly into the areas that are causing the most difficulty for clients. Typically, a therapist will educate clients about the nature and course of their problem, about the process of cognitive therapy, and how thoughts influence their emotions and behaviors. One way of educating clients is through bibliotherapy, in which clients complete read- ings that support and expand their understanding of cognitive therapy principles and skills. These readings are assigned as an adjunct to therapy and are designed to enhance the therapeutic process by providing an educational focus (Dattilio & Free- man, 2007; Jacobs, 2008). Self-help books such as Mind Over Mood (Greenberger & Padesky, 2016) also provide an educational focus.

Homework is often used as a part of cognitive therapy because practicing cog- nitive-behavioral skills in real life facilitates more rapid and enduring gains. The purpose of homework is not merely to teach clients new skills but also to enable them to test their beliefs and to try out different behaviors in daily-life situations. Homework is generally presented to clients as an experiment that serves to continue work on issues addressed in a therapy session. Cognitive therapists realize that cli- ents are more likely to complete homework if it is tailored to their needs, if they participate in designing the homework, if they begin the homework in the therapy session, and if they talk about potential problems in implementing the homework (J. Beck, 2021). There are clear advantages to the therapist and the client working

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in a collaborative manner in negotiating mutually agreeable homework tasks. One indicator of a good therapeutic alliance is whether homework is done and done well (Kazantzis et al., 2017).

Applications of Cognitive Therapy Cognitive therapy initially gained recognition as an approach to treating depres- sion, but extensive research has been devoted to the study and treatment of many other psychiatric disorders. The popularity of cognitive therapy is due in part to the “strong empirical support for its theoretical framework and to the large number of outcome studies with clinical populations” (Beck & Weishaar, 2019, p. 268). Hun- dreds of research studies have confirmed the theoretical underpinnings of CT, and hundreds of outcome trials have established its efficacy for a wide range of psychi- atric disorders, psychological problems, and medical conditions with psychological components (DeRubeis et al., 2019; Hofmann et al., 2012).

Cognitive therapy has been successfully used to treat depression, each of the anxiety disorders, cannabis dependence, hypochondriasis, body dysmorphic disor- der, eating disorders, anger, schizophrenia, insomnia, and chronic pain (Chambless & Peterman, 2006; Dattilio & Kendall, 2007; Hofmann et al., 2012; Riskind, 2006); suicidal behavior, borderline personality disorders, narcissistic personality disor- ders, and schizophrenic disorders (Dattilio & Freeman, 2007); personality disorders (Pretzer & Beck, 2006); substance abuse (Newman, 2006); medical illness (Dattilio & Castaldo, 2001); crisis intervention (Dattilio & Freeman, 2007); couples and families therapy (Dattilio, 1993, 1998, 2001, 2005, 2010; Dattilio & Padesky, 1990; Epstein, 2006); and child abusers, divorce counseling, skills training, and stress management (Dattilio, 1998; Granvold, 1994; Reinecke et al., 2002). With children and adoles- cents, CT has been shown to be effective in the treatment of depression and anxiety disorders and more effective than medications for these problems. Clearly, cogni- tive therapy programs have been designed for all ages and for a variety of client populations.

Moreover, the effects of CT for depression and anxiety disorders seem to be more enduring that the effects of other treatments, with the exception of behavior therapy, which sometimes matches CT in duration of positive outcome. People who get better using CT are less likely to relapse than those who improve with medica- tion or most other psychotherapy approaches (DeRubeis et al., 2019; Hollon et al., 2006).

Applying Cognitive Techniques Beck and Weishaar (2019) describe both cognitive and behavioral methods that are part of the overall strategies used by cognitive therapists. Cognitive methods focus on identifying and examining a client’s beliefs, exploring the origins of these beliefs, and modifying them if the evidence does not support these beliefs. Examples of behavioral techniques typically used by cognitive therapists include activity scheduling, behavioral experiments, behavioral activation, skills training, role playing, behavioral rehearsal, and exposure therapy. Regardless of the nature of the specific problem, the cognitive therapist is mainly interested in applying procedures that will assist individuals in making alternative

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interpretations of events in their daily living and behaving in ways that move them closer to their goals and values.

Treatment Approaches The length and course of cognitive therapy varies greatly and is determined by the therapy protocols used for specific diagnoses. For example, cognitive therapy for depression generally lasts 16 to 20 sessions and begins with behavioral activation. Activity has an antidepressant effect, especially when the client engages in a mix of pleasurable, accomplished, and anti-avoidance activities. Clients rate their moods in relation to the activities they do throughout the day, and these observations are used as guides to find activities that provide a mood boost in subsequent weeks. As depression begins to lift, the therapist introduces additional skills such as thought records, which help clients identify negative automatic thoughts and test them. When evidence does not support the automatic thought, clients learn to generate alternative explanations that are less depressing. When evidence does support the problematic thought, clients are helped to create an action plan to solve the problem rather than ruminating on it (Greenberger & Padesky, 2016). Before the end of treatment, underlying assumptions that put clients at risk for relapse are examined such as perfectionistic assumptions (“If I make a mistake, then I am worthless.”). These assumptions are tested with behavioral experiments. For example, a perfectionistic client may intentionally make a mistake doing a particular task and evaluate whether there is still some worth and value to the outcome.

In contrast, cognitive therapy for panic disorder generally lasts only 6 to 12 ses- sions and targets catastrophic beliefs about internal physical and mental sensations (Clark et al., 1999). Clients are helped to identify the sensations that trigger a panic attack and the catastrophic beliefs about these sensations. For example, a client may think, “My heart is racing (sensation). That means I am having a heart attack (cata- strophic belief).” The therapist helps the client generate an alternative hypothesis to explain these feared sensations. For example, “A racing heart is not dangerous. It can be caused by exercise, anxiety, caffeine, and many other things. The heart is a muscle, and doctors recommend that you regularly raise your heart rate in exercise to keep it healthy.” The therapist then guides the client to conduct a series of experiments in a session in which the client creates the sensation and weighs evidence in support of the catastrophic and alternative hypotheses. Once the client begins to believe the alternative hypotheses in these experiments, which later are also done outside of therapy, panic attacks are reduced or disappear.

Application to Family Therapy The cognitive-behavioral approach focuses on cognitions, emotions, and behavior as they exert a mutual influence on one another within family relationships to cause dysfunction. Cognitive theory emphasizes schema, elsewhere defined as core beliefs, as a key aspect of the therapeutic process (Beck, 1976; Beck & Haigh, 2014). Therapists help families restructure distorted beliefs (or schema) in order to change dysfunctional behaviors. Some CT therapists place a strong emphasis on examining cognitions among individual family members as well as on what may be termed the “family schemata” (Dattilio, 1993, 1998, 2001, 2010). These jointly held beliefs about the family have formed as a result of years of

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interaction among family members. These schemata are influenced by the parents’ family of origin and have a major impact on how each individual thinks, feels, and behaves in the family system (Dattilio, 2001, 2005, 2010).

For a concrete illustration of how Dr. Dattilio applies cognitive principles and works with family schemata, see his cognitive-behavioral approach with Ruth in Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 8). For a dis- cussion of myths and misconceptions of cognitive behavior family therapy, see Dattilio (2001); for a concise presentation on the cognitive-behavioral model of family therapy, see Dattilio (2010). Also, for an expanded treatment of applications of cognitive-behavioral approaches to working with couples and families, see Bitter (2021) and Dattilio (1998).

Applying Cognitive-Behavioral Counseling With Adolescents in Schools

Alex Becnel, PhD, is an assistant professor in the Department of Special Educa- tion, Counseling, and Student Affairs at Kansas State University. He has experience as both a school counselor and a clinical counselor specializing in the treatment of adolescents and their families.

Cognitive behavior therapy (CBT) is an effective and empowering approach for help- ing adolescent students in the school setting. At their stage of development, many adolescents are prone to impulsivity both in thought and action. CBT can assist adolescent students by slowing down their thought processes and providing oppor- tunities to assess their cognitions. Consider a student who comes to the counselor’s office after failing a test. The student might say, “Now, I’ll never get into college!” Through CBT’s collaborative empiricism, the school counselor can ask open-ended questions to test the legitimacy of the student’s statement. The school counselor can facilitate a conversation in which the student self-identifies the distorted belief and incorporates a more functional belief.

In addition to individual work, many school counselors also work with students through classroom-based activities and small groups. CBT can be readily adapted to fit these settings. In larger classroom settings, adolescent students can benefit from learning the basic principles of CBT. One activity that I used in high school classrooms was the “Reaction Game.” In this classroom activity, I would pose sce- narios to the class and ask students how they would react. For example, “How would you react if someone cut you off in traffic?” Often students would identify emo- tional reactions that were incongruent with the situation (i.e., “I would roll down my window and scream at them!”). We would then work together to connect those emotional reactions to a particular thought (“I was angry because they thought that their time is more important than mine.”) and discuss the personal consequences of that thought (“I started the day off so angry that I couldn’t focus in my first class of the day.”). Through this simple dialogue, students can see how automatic thoughts can have negative consequences, and they are encouraged to look for new ways of thinking that do not result in a negative emotional consequence (“Maybe that other person is driving erratically because there is an emergency.”).

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CBT can also be a useful approach in school-based group counseling. Adoles- cents place high value on feedback from peers, so these settings are ideal agents of change. Collaborative empiricism can include collaboration with several students simultaneously. For example, if one student is struggling to identify the dysfunc- tional belief hidden behind the expressed emotion, the group leader could ask others in the group for feedback. Hearing new viewpoints from peers can strongly influence adolescents and cause them to reevaluate faulty beliefs.

As a high school counselor, I used Beck’s CT approach rather than the REBT approach. One advantage of the CT model in the high school setting is the role of power in the counseling relationship. In schools, adolescents often wield little power. Adult members of the school community, such as faculty and staff, often act with authority to enforce rules and to ensure that students comply. The highly directive nature of REBT may portray the counselor as another authority figure to adolescent students rather than as an ally. This style may cause students to withdraw and place barriers between themselves and the school counselor. The collaborative nature of CT, in contrast, allows school counselors to empower adolescents and encourage them to reflect on their thought processes. Students are then able to preserve their power and participate more freely. I would advise caution when assigning cognitive homework with adolescents. Adolescent students are already expected to complete homework as part of their school life, so it may be wise to frame these activities as “experiments” rather than as more “homework.”

Christine A. Padesky (b. 1953) was born and raised in the Mid- west. As an undergraduate sci- ence major at Yale University, she took a psychology course and became fascinated with this field, which offered a link be- tween her scientific and social change interests. While a PhD student in clinical psychology at the University of California,

Los Angeles, Padesky and her graduate research adviser published an article on gender differences in depres- sion symptoms that caught the attention of Aaron Beck. Beck and Padesky met and became friends, and he was her mentor throughout her career (see Padesky, 2004). In the 1980s she and Beck taught more than 20 work- shops together in the United States and abroad.

At Beck’s invitation, in 1983 Padesky opened one of the first Centers for Cognitive Therapy in the

western United States (now located in Huntington Beach, California). She partnered in this venture with Kathleen Mooney, a creative CBT therapist dedicat- ed to innovation and therapist education. Together they trained and hired staff for their clinic, which became a leading international training center. Padesky and Mooney developed many innovations in the practice of cognitive therapy including the use of constructive questions, the importance of identi- fying client imagery and metaphors for change, and an emphasis on client strengths. These innovations eventually formed the foundation of their therapy approach, known as strengths-based CBT (SB-CBT).

In 1995, Greenberger and Padesky (2016) first published Mind Over Mood: Change How You Feel by Changing the Way You Think, which became a popular self-help sensation. With sales of more than 1 million copies worldwide in 23 languages, Padesky’s dream of teaching people skills to improve their own moods so they did not need to rely on experts was realized.

Christine A. Padesky

Ch ris

tin e

Pa de

sk y

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Padesky lectures and teaches workshops in the United States and abroad. She is a consultant to therapists and clinics worldwide and participates in a number of re- search programs evaluating strengths-based CBT. In addition to Mind Over Mood, she has written four pro- fessional books and numerous articles and book chap- ters on a variety of CBT topics. Her recent book, The Clinician’s Guide to CBT Using Mind Over Mood, Padesky

(2020) details her CBT practice vision and illustrates it with more than 100 pages of therapist and client dia- logues. She produces top-rated video demonstrations of CBT in action and has an extensive catalog of audio training programs for mental health professionals and graduate students in mental health fields. Padesky’s YouTube channel (YouTube.com/ChristinePadesky) of- fers brief clinical tips for therapists and free webinars.

Christine Padesky and Kathleen Mooney’s Strengths-Based Cognitive Behavior Therapy

Introduction Strengths-based cognitive behavior therapy (SB-CBT) is a variant of Aaron Beck’s cognitive therapy developed by Christine Padesky and her colleague Kathleen Mooney (Padesky & Mooney, 2012). All the principles and evidence-based treatments developed by Aaron Beck and his colleagues are incorporated in strengths-based CBT. As the name implies, one central addition of SB-CBT is an emphasis on iden- tification and integration of client strengths at each phase of therapy. The main idea of SB-CBT is that active incorporation of client strengths encourages clients to engage more fully in therapy and often provides avenues for change that otherwise would be missed.

Basic Principles of Strengths-Based CBT Like cognitive therapy, SB-CBT is empirically based. This means that (1) thera- pists should be knowledgeable about evidence-based approaches pertaining to client issues discussed in therapy, (2) clients are asked to make observations and describe the details of their life experiences so what is developed in therapy is based in the real data of clients’ lives, and (3) therapists and clients collaborate in testing beliefs and experimenting with new behaviors to see if they help achieve desired goals.

Strengths are integrated into each phase of treatment in SB-CBT beginning with the intake interview. After reasons for seeking therapy are described and explored, the SB-CBT therapist expresses an interest in positive aspects of the client’s life: “Thank you for telling me about the reasons you came to therapy. Even though this is a tough time for you, I wonder if there are some things that are going well in your life or that bring you happiness, even now. If you are willing to tell me about some of those things, it will help me know you more as a whole person.”

In Collaborative Case Conceptualization: Working Effectively With Clients in CBT, Kuyken, Padesky, and Dudley (2009) show how positive interests and strengths identified in early therapy sessions can provide a wealth of information to help ther- apist and client collaboratively integrate strengths into case conceptualization and

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treatment. For example, clients often discover that they use more resilient strategies when they encounter obstacles in areas of positive interest than they do in problem areas of their life. These strategies can be added to plans to deal positively with prob- lem areas. A depressed client learning to be more active to boost mood will have an easier time engaging in activities that are part of a hobby or positive pastime than participating in activities that hold little interest for the client.

SB-CBT therapists help clients develop and construct new positive ways of inter- acting in the world. The SB-CBT model for building and strengthening personal resilience can be used on its own or integrated with another evidenced-based CBT treatment for a diagnostic disorder (Padesky & Mooney, 2012). For clients with chronic difficulties that have proven resistant to change, SB-CBT proposes that it is often easier to construct an entirely new way of doing things than to problem solve or modify a chronic way of doing things. When clients do not respond to standard treatments, SB-CBT therapists help clients cocreate a “NEW Paradigm,” which is their vision of how they would like to be and how they would like the difficult area of their life to be.

The Client–Therapist Relationship As with Beck’s cognitive therapy, SB-CBT therapists are collaborative, active, here- and-now focused, and client-centered. SB-CBT therapists are encouraging allies of their clients and need to be genuine, caring, and willing to engage with clients as full human beings in both struggles and successes. SB-CBT therapists do not take an “expert” stance but instead serve as curious assistants or guides to their clients’ own discovery and growth.

SB-CBT practitioners ask clients for imagery and metaphors to describe their experiences, both positive and negative. More than words, imagery and metaphors capture and integrate the emotional, cognitive, physiological, and behavioral aspects of experience. In addition to deconstructing beliefs and problems, SB-CBT empha- sizes the constructive use of Socratic dialogue. The SB-CBT therapist asks con- structive questions such as, “How would you like to be? or “How would you like this part of your life or relationships to be?” When clients are stuck in recurring patterns, SB-CBT teaches them that we do things “for good reasons” and shows clients how even destructive behaviors (such as cutting oneself when distressed) are done for self-protective reasons and as attempts to cope (“If I cut myself, then I will feel some emotional relief.”).

Applications of Strengths-Based CBT Three current applications for SB-CBT are as (1) an add-on for classic CBT, (2) a four-step model to build resilience and other positive qualities, and (3) the NEW Paradigm for chronic difficulties and personality disorders. SB-CBT operates as an add-on to classic CBT when clients come to therapy with goals to reduce prob- lematic moods (depression, anxiety, anger), behaviors (eating disorders, substance misuse) or other difficulties (psychoses, hypochondriasis) for which there are well- established and effective CBT protocols. In those cases, SB-CBT therapists help cli- ents identify their strengths and rely on these whenever helpful to guide therapy choices.

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The four-step model to build resilience provides a template for building positive qualities (Padesky & Mooney, 2012). Their four steps are (1) search, (2) construct, (3) apply, and (4) practice. Padesky and Mooney point out that there are usually just a few common pathways to a psychological disorder, but there are thousands of pathways to resilience. Rather than teach clients particular ways to be resilient, Padesky and Mooney suggest that therapists inquire about activities in clients’ lives that are going well and that clients do on a regular basis. These everyday activities clients are motivated to do are areas of strength. This search for strengths is the first step in their model.

The second step is to discover what obstacles clients encounter while doing these activities and how they manage these obstacles. A central idea is that every- body encounters obstacles in any frequently practiced activity, but when we enjoy an activity, we manage obstacles without even realizing that is what we are doing. For example, Jamar loves to play video games. He uses a variety of strategies to manage obstacles as they occur within the game and from external causes (such as loss of power to his electronic device). Jamar’s strategies include problem solving, getting help from friends, music to keep up his energy, and reminding himself that “I’m a fighter. I always find a way through.” These strategies are written down as his per- sonal model of resilience (PMR).

The third step involves the therapist helping Jamar creatively consider how he can apply his PMR to remain resilient in a more problematic area of his life, such as dating. Jamar makes a plan for how to use these strategies to help him meet people he would like to date, ask them out, and solve various dating difficulties that have proved challenging for him in the past.

The fourth stage involves Jamar conducting a series of dating experiments while he practices maintaining a focus on resilience. A key to this stage of the therapy is that Jamar sets a goal to “be resilient in the face of challenges,” not to succeed at dat- ing. Because his goal is to “stay resilient,” he has a better chance of experiencing his dates in a positive way. Even if he and his date don’t get along, he can feel good about staying resilient. This can help Jamar feel motivated no matter what happens. Over time, his resilience will be expressed both in persistence (problem solving, getting help from friends) and in acceptance that not every date will turn out as he would like (but he can enjoy the music anyway).

The same principles can be used to build other positive qualities such as altru- ism, creativity, and courage. The key is to find everyday areas of the person’s life where these qualities are already in evidence. For example, even a self-centered per- son may be very kind and concerned for a pet or certain friends. From these everyday experiences, the person can be helped to build a “personal model of X” (for example, altruism) and then consider how to apply and practice this positive quality in other life settings.

The final application of SB-CBT is the NEW Paradigm for chronic issues and personality disorders. This approach is more comprehensive and requires clients to vividly construct new ways to feel, think, and behave in their life. The four steps of this model are (1) conceptualize the OLD system of operating and help clients understand they do things “for good reasons,” (2) construct NEW systems of how clients would like to be, (3) strengthen the NEW using behavioral experiments to try on NEW ways of being and edit them as needed, and (4) relapse management.

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Therapists need significant training to practice the NEW Paradigm because it is essential that the therapist stay alert to identify when the OLD system interferes with client learning. The therapist must be able to help the client learn from every experience and process this learning through the NEW system, not the OLD.

An Expert’s Perspective on Cognitive Behavior Therapy In this section, Christine A. Padesky, PhD, Distinguished Founding Fellow, Acad- emy of Cognitive Therapy, and the cofounder of the Center for Cognitive Therapy in Huntington Beach, California, provides answers to the following questions.

1. What is the most important contribution of cognitive behavior therapy for the practice of individual therapy? The most important contribution across the many forms of CBT is that these therapies offer a new way of understanding human struggles that link emotions, thoughts, behaviors, physical reactions, and the cultures/ environments in which we live. CBT conceptualizations are usually scien- tifically tested, and the therapies that flow from these conceptual models generally lead to effective and enduring treatment effects. As a result of this scientific approach, the CBT therapies were the first to propose that different types of treatment methods might be needed for different human problems. Tailoring therapy to the individual and using a scien- tific understanding of what maintains particular diagnostic issues have led to more effective treatments.

2. What two or three key concepts of CBT are especially applicable to the practice of individual counseling or therapy? A central tenet of CBT is that the meanings we put on events and situations affect our behavior in these situations and our emotional reactions to them. Individual counselors can help clients identify their thoughts and images in particular situations, which helps clients understand their reactions better and often opens up new pathways for change.

A second key idea is that all thoughts are not equal. Therapists help clients discover the most important themes to address. Central thoughts may be in the form of images rather than words. Individual counselors who study CBT learn which types of thoughts and images to target in the treatments for various problems. For example, depression is best helped by targeting self-critical, pessimistic, and hopeless automatic thoughts. Anxiety disorders are resolved most quickly when client and therapist identify and target underlying assumptions about danger and threat and also boost the client’s confidence in his or her ability to cope with feared events.

3. What two or three techniques from CBT have practical value for practitioners of individual therapy? First, therapy is a collaborative effort by client and therapist rather than treatment by an expert. Therapy is a learning endeavor that empowers the client. Ideally, clients learn how to be their own therapist. I want my clients to feel better today but also to learn skills that will last a lifetime. Active

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collaboration at each stage of therapy (making a conceptualization, choos- ing topics to discuss during session, treatment methods, or learning assign- ments) increases the likelihood that clients are actively learning how to be their own therapist in the future.

Second, therapy should have an empirical basis so therapist or client biases do not interfere with doing what is best for the client. Individual therapists can be empirical in three ways: (1) learn what research has shown are the most effective therapy approaches, (2) work with clients to gather specific information and record observations about their thoughts, moods, behaviors, and physical reactions and how these are linked to specific situa- tions, and (3) test clients’ beliefs, behavioral options, and so forth by exam- ining the evidence in their life and doing experiments to see what happens when they try out new thoughts and behaviors. Techniques that foster both collaboration and an empirical approach include Socratic dialogue, auto- matic thought records, and behavioral experiments.

4. How does CBT address diversity, multicultural, and social justice issues for the practice of individual counseling? CBT is interested in personal meanings, so most CBT therapists work within the cultural framework of the client. Competent CBT therapists inquire about the client’s culture and how this affects the issues for which a client is seeking therapy, adopt a client’s language, and learn about a cli- ent’s culture. Cross-cultural research generally shows that the same theo- retical CBT principles apply across widely different cultures even though the content of thoughts is often different cross-culturally. For example, a client who experiences a racing heart in New York may think “I’m hav- ing a heart attack” and have a panic attack. A client in rural China who experiences a racing heart may think “the spirit of my aborted baby girl is haunting me” and have a panic attack. Although the thought content is different, the cognitive theory that panic disorder results from cata- strophic interpretations of internal sensations applies to both cases. Simi- lar therapy methods would help both clients, although these may need to be delivered in culturally adapted ways.

In addition, CBT methods can be used to help people who struggle with oppression and discrimination by helping them to depersonalize attacks or social discrimination. In recent years, CBT therapists have paid increasing attention to the long-term costs of racial trauma, homopho- bia, and the damaging effects of all types of social discrimination on individuals and communities. Social and environmental change can be a goal in CBT. If people in a particular community (family, neighborhood, workplace, school, country) are causing harm to a client, a CBT therapist does not simply look at thoughts about the harm. We help clients who are traumatized to problem solve ways to protect themselves and also consider whether it is beneficial for clients to either leave that community or set a therapy goal to try to change it. In addition, CBT therapists can help peo- ple who oppress or harm others become more aware of the costs of their own prejudices and work with them to reduce their racism, homophobia, and other biased views of others.

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5. In what ways can CBT be applied to brief therapy (or time-limited counseling)? CBT is the most widely practiced form of brief therapy in most developed countries around the world. CBT is active, strives to be as brief as possible, and is often one of the most effective and enduring treatments. That said, the desired length of treatment depends on the problem being addressed. On average, depression treatment requires 12 to 20 sessions. If a client is restricted to fewer sessions, CBT therapists generally choose one or two antidepressant CBT skills that are likely to make the biggest difference and teach those skills in the time available. Many of the anxiety disorders can be treated in 3 to 12 sessions, so that is already a brief therapy. CBT has even been used in single session therapy to help clients understand their diffi- culties. In these cases, therapists may recommend a self-help book such as Mind Over Mood (Greenberger & Padesky, 2016) to help clients learn skills that can lead to improvement in moods and other aspects of their lives.

6. From your perspective, what is the current status and the future of the cognitive-behavioral approach? CBT has been riding a wave of popularity and support for several decades now. It is one of the most highly recommended therapies for a wide range of issues from depression, anxiety disorders, and other mood issues to substance misuse, eating disorders, and other behavior problems. Current research is discovering that CBT can be an effective therapy in the treatment of psychosis and other more serious mental health issues as well. Personally, I hope CBT theory and methods will be taught more broadly in the future outside of a therapy setting as part of public education and prevention efforts. Children enjoy learning CBT methods, and a CBT skill set could potentially help pre- vent many problems in adolescence and adulthood. In my own work, we are learning that strengths-based CBT can help people develop positive quali- ties such as resilience as they are being treated for psychological difficulties. Finally, I hope the central themes of CBT (such as collaboration, choice of evidence-based therapy methods, and an emphasis on teaching clients skills) will become part of what is meant by “good psychotherapy,” so that a school of CBT won’t be required because therapists will all use these effective ideas.

Discussion Questions Related to Dr. Christine Padesky’s Cognitive Behavior Perspective

1. Dr. Padesky states: “I want my clients to feel better today but also to learn skills that will last a lifetime.” What skills can you apply to ensure that your clients will do more than feel better today?

2. “CBT methods can be used to help people who struggle with oppres- sion and discrimination by helping them to depersonalize attacks or social discrimination.” What CBT methods might you use to help peo- ple who are subject to oppression or discrimination?

3. “Therapy is a collaborative effort by client and therapist rather than treatment by an expert.” If you accept this idea, what specifically could you do to foster a collaborative relationship with clients?

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Donald Meichenbaum (b. 1940) was born in New York City (the Bronx) and learned early to be “street smart” and to be on the lookout for high- risk situations. He attended City College of New York and received his PhD in clinical psychology from the Univer- sity of Illinois. At the Univer- sity of Waterloo in Ontario,

Canada, he conducted research on the development of cognitive behavior therapy (CBT). He is one of the founders of CBT, and in a survey of clinicians he was voted one of the most influential therapists in the 20th century. He is the recipient of a Lifetime Achievement Award from the Clinical Division of the American Psy- chological Association for his work on suicide preven- tion. In 1995 Meichenbaum retired from the University of Waterloo to become the research director of the Melissa Institute for Violence Prevention, which is de- signed to “give science away” in order to reduce vio- lence and to treat victims of violence.

Meichenbaum attributes the origin of CBT to his mother, who had a knack for telling stories about her daily activities that were peppered with her thoughts,

feelings, and a running commentary. This childhood experience contributed to Meichenbaum’s psycho- therapeutic approach of constructivist narrative therapy, in which clients tell their stories and de- scribe what they did to “survive and cope.” Meichen- baum’s recent work with returning service members using iPod technology to bolster resilience is mod- eled on this approach. When therapy is successful, Meichenbaum ensures that clients take credit for the changes they have achieved. As he observes, “I am at my therapeutic best when the clients I see are one step ahead of me offering the observations or suggestions that I would otherwise offer” (Donald Meichenbaum, personal communication, October 21, 2010).

Meichenbaum has published extensively, includ- ing Cognitive Behavior Modification: An Integrative Ap- proach (1977), Stress Inoculation Training (1985), Treat- ment of Individuals With Anger-Control Problems and Aggressive Behaviors: A Clinical Handbook (2002), and Roadmap to Resilience: A Guide for Military, Trauma Victims and Their Families (2012). He has lectured in every state and in all provinces in Canada as well as internationally. He was a featured presenter at the Evo- lution of Psychotherapy conference in 2013 and the Brief Therapy conference in 2014.

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Donald Meichenbaum’s Cognitive Behavior Modification Introduction

Donald Meichenbaum’s (2017) cognitive behavior modification (CBM) com- bines some of the best elements of behavior therapy and cognitive therapy. A basic premise of CBM is that clients must become aware of how they think, feel, and behave and the impact they have on others before change can occur. Clients need to be able to interrupt the scripted nature of their behavior so that they can evalu- ate their behavior in various situations (Meichenbaum, 1993, 2007). Meichenbaum (2017) believes the quality of the therapeutic relationship is critical to positive out- comes, and he suggests working in a collaborative fashion with clients to develop the skills necessary to achieve the treatment goals. Therapists do not view them- selves as experts; instead, they continually seek feedback from their clients, supervi- sors, and colleagues.

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This approach shares with REBT and Beck’s cognitive therapy the assumption that distressing emotions are often the result of maladaptive thoughts. REBT is more direct and confrontational in uncovering and disputing irrational thoughts, whereas Meichenbaum’s self-instructional training focuses more on helping clients become aware of their self-talk and the stories they tell about themselves. Both REBT and CT focus on changing thinking processes, but Meichenbaum suggests that it may be easier and more effective to change our behavior rather than our thinking. Furthermore, our emotions and thinking are two sides of the same coin: the way we feel can affect our way of thinking, just as how we think can influence how we feel. The therapeutic process consists of teaching clients to make self-statements and training clients to modify the instructions they give to themselves so that they can cope more effectively with the problems they encounter. Cognitive restructuring plays a central role in Meichenbaum’s (1977, 1993) self-instructional training. He describes cognitive structure as the organizing aspect of thinking, which moni- tors and directs the choice of thoughts through an “executive processor” that “holds the blueprints of thinking” that determines when to continue, interrupt, or change thinking. Together, therapist and client practice the self-instructions and the desir- able behaviors in role-play situations that simulate problem situations in the client’s daily life.

How Behavior Changes Meichenbaum (1977) proposes that “behavior change occurs through a sequence of mediating processes involving the interaction of inner speech, cognitive structures, and behaviors and their resultant outcomes” (p. 218). He describes a three-phase process of change in which those three aspects are interwoven and believes that focusing on only one aspect will probably prove insufficient.

Phase 1: Self-observation. Clients learning how to observe their own behavior. When clients begin therapy, their internal dialogue is characterized by neg- ative self-statements and imagery. A critical factor is their willingness and ability to listen to themselves. This process involves an increased sensitivity to their thoughts, feelings, actions, physiological reactions, and ways of reacting to others. If depressed clients hope to make constructive changes, for example, they must first realize that they are not “victims” of negative thoughts and feelings. Rather, they are actually contributing to their depres- sion through the things they tell themselves. Although self-observation is necessary if change is to occur, it is not sufficient for change.

Phase 2: Starting a new internal dialogue. As a result of the early client–therapist contacts, clients learn to notice their maladaptive behaviors, and they begin to see opportunities for adaptive behavioral alternatives. If clients hope to change what they are telling themselves, they must initiate a new behavioral chain, one that is incompatible with their maladaptive behav- iors. Clients learn that psychological distress is a function of the interde- pendence of cognitions, emotions, behaviors, and resultant consequences. In therapy, clients learn to change their internal dialogue, which serves as a guide to new behavior.

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Phase 3: Learning new skills. Clients learn to interrupt the downward spiral of thinking, feeling, and behaving, and the therapist teaches clients more adaptive ways of coping using the resources they bring to therapy. Clients learn more effective coping skills, which are practiced in real-life situa- tions. As they behave differently in situations, they typically get different reactions from others. The stability of what they learn is greatly influenced by what they say to themselves about their newly acquired behavior and its consequences.

Stress Inoculation Training A particular application of a coping skills program is teaching clients stress management techniques by way of a strategy known as stress inoculation training (SIT). Using cognitive techniques, Meichenbaum (1985, 2007, 2008) has developed stress inoculation procedures that are a psychological and behav- ioral analog to immunization on a biological level. Individuals are given oppor- tunities to deal with relatively mild stress stimuli in successful ways, and they gradually develop a tolerance for stronger stimuli. This training is based on the assumption that we can affect our ability to cope with stress by modifying our beliefs and self-statements about our performance in stressful situations. Meichenbaum’s stress inoculation training is concerned with more than merely teaching people specific coping skills. His program is designed to prepare clients for intervention and motivate them to change, and it deals with issues such as resistance and relapse.

Stress inoculation training is a combination of information giving, Socratic discovery-oriented inquiry, cognitive restructuring, problem solving, relaxation training, behavioral rehearsals, self-monitoring, self-instruction, self-reinforce- ment, and modifying environmental situations (Meichenbaum, 2008). Collab- orative goals are set that nurture hope, direct-action skills, and acceptance-based coping skills. These coping skills are designed to be applied to both present prob- lems and future difficulties. Clients are assisted in generalizing what they have learned so they can use these skills in daily living, and relapse prevention strategies are taught. Meichenbaum (2008) describes stress inoculation training as a com- plex, multifaceted, cognitive-behavioral intervention that is both a preventive and a treatment approach.

Clients can acquire more effective strategies in dealing with stressful situations by learning how to modify their cognitive “set,” or core beliefs. The following proce- dures are designed to teach these coping skills:

◆ Expose clients to anxiety-provoking situations by means of role playing and imagery

◆ Require clients to evaluate their anxiety level ◆ Teach clients to become aware of the anxiety-provoking cognitions they

experience in stressful situations ◆ Help clients examine these thoughts by reevaluating their

self-statements ◆ Have clients note the level of anxiety following this reevaluation

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The Phases of Stress Inoculation Training Meichenbaum (2007, 2008) has designed a three-stage model for stress inoculation training: (1) the conceptual- educational phase, (2) the skills acquisition and consolidation phase, and (3) the application and follow-through phase.

During the conceptual-educational phase, the primary focus is on creating a ther- apeutic alliance with clients. This is done by helping clients gain a better under- standing of the nature of stress and reconceptualizing it in social-interactive terms. Initially, clients are provided with a conceptual framework in simple terms designed to educate them about ways of responding to a variety of stressful situations. They learn about the role cognitions and emotions play in creating and maintaining stress through didactic presentations, by curious questioning, and by a process of guided self-discovery. A collaborative relationship is created during this early phase, and together they rethink the stress concerns clients bring to understand the nature of the problem.

Clients often begin treatment feeling that they are victims of external circum- stances, thoughts, feelings, and behaviors over which they have no control. As a way to understand the subjective world of clients, the therapist generally elicits stories that clients tell themselves. Training includes teaching clients to become aware of their own role in creating their stress and their life stories. They acquire this aware- ness by systematically observing the statements they make internally as well as by monitoring the maladaptive behaviors that flow from this inner dialogue. Such self- monitoring continues throughout all the phases. As is true in cognitive therapy, clients typically keep an open-ended diary in which they systematically monitor and record their specific thoughts, feelings, and behaviors. In teaching these coping skills, therapists strive to be flexible in their use of techniques and to be sensitive to the individual, cultural, and situational circumstances of their clients.

During the skills acquisition and consolidation phase, the focus is on giving clients a variety of behavioral and cognitive coping skills to apply to stressful situations. This phase involves direct actions, such as gathering information about their fears, learn- ing specifically what situations bring about stress, arranging for ways to lessen the stress by doing something different, and learning methods of physical and psycholog- ical relaxation. The training involves cognitive coping; clients are taught that adaptive and maladaptive behaviors are linked to their inner dialogue. Through this training, clients acquire and rehearse a new set of self-statements. Meichenbaum (1986) pro- vides some examples of coping statements that are rehearsed in this phase of SIT:

◆ “How can I prepare for a stressor?” (“What do I have to do? Can I develop a plan to deal with the stress?”)

◆ “How can I confront and deal with what is stressing me?” (“What are some ways I can handle a stressor? How can I meet this challenge?”)

◆ “How can I cope with feeling overwhelmed?” (“What can I do right now? How can I keep my fears in check?”)

◆ “How can I make reinforcing self-statements?” (“How can I give myself credit?”)

Clients also are exposed to various behavioral interventions, such as relaxation training, social skills training, time-management instruction, and self-instruc- tional training. They are helped to make lifestyle changes by reevaluating priorities,

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developing support systems, and taking direct action to alter stressful situations. Through teaching, demonstration, and guided practice, clients learn the skills of progressive relaxation and practice them regularly to decrease arousal due to stress.

During the application and follow-through phase, the focus is on carefully arranging for transfer and maintenance of change from the therapeutic situation to everyday life. Clients practice their new self-statements and apply their new skills to everyday life. To consolidate the lessons learned in the training sessions, clients participate in a variety of activities, including imagery and behavior rehearsal, role playing, model- ing, and graded in vivo exposure. Once clients have become proficient in cognitive and behavioral coping skills, they practice behavioral assignments, which become increasingly demanding. They are asked to write down the homework assignments they are willing to complete. The outcomes of these assignments are carefully checked at subsequent meetings, and if clients do not follow through with them, therapist and client collaboratively consider the reasons for the failure.

Relapse prevention, which consists of procedures for dealing with the inevi- table setbacks clients are likely to experience as they apply what they are learning to daily life, is taught at this stage (Marlatt & Donovan, 2007). Clients learn to view any lapses that occur as “learning opportunities” rather than as “catastrophic failures.” Clients explore a variety of possible high-risk, stressful situations that they may reex- perience. In a collaborative fashion with the therapist, and with other clients in a group, clients rehearse and practice applying the skills they have learned to maintain the gains they have made. Follow-up and booster sessions typically take place at 3-, 6-, and 12-month periods as an incentive for clients to continue practicing and refin- ing their coping skills. SIT can be considered part of an ongoing stress management program that extends the benefits of training into the future.

Stress inoculation training has potentially useful applications for a wide variety of problems and clients and for both remediation and prevention. Clinical appli- cations of SIT are individually tailored to specific target populations and include anger control, pain control, anxiety management, assertion training, improving creative thinking, treating depression, dealing with health problems, and preparing for surgery. Stress inoculation training has been employed with medical patients and with psychiatric patients. Meichenbaum (2007) contends that the flexibility of the SIT format has contributed to its robust effectiveness. SIT has been successfully used with children, adolescents, and adults who have anger problems, anxiety dis- orders, phobias, social incompetence, addictions, alcoholism, sexual dysfunctions, social withdrawal, or posttraumatic stress disorder (PTSD), including use with vet- erans who experience combat-related PTSD (Meichenbaum, 1993, 1994a, 1994b, 2007, 2008, 2012).

A Cognitive Narrative Approach to Cognitive Behavior Therapy Meichenbaum (2015) has embraced a cognitive narrative perspective, which focuses on the plots, characters, and themes in the stories people tell about them- selves and others regarding significant events in their lives. Therapists elicit stories from their clients that are explored in the therapy process. This approach begins with the assumption that there are multiple realities. One of the therapeutic tasks is to help clients appreciate how they construct their realities and how they author

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their own stories (see Chapter 13). Meichenbaum claims that we are all “story tell- ers” and that we should be aware of the stories we tell ourselves and others. For example, some clients might see themselves as “prisoners of the past” or as “stub- born victims.” These phrases are not idle metaphors; they are the organizing sche- mas that color the ways individuals view themselves, their world, and their future. Therapists help clients appreciate how they construct reality and examine the implications and conclusions clients draw from their stories. Telling the “rest of the story”—what they did to survive and cope—bolsters clients’ strengths and helps them develop resilient-engendering behaviors. In this way, clients can move from being “stubborn victims” to becoming “tenacious survivors” and perhaps “impres- sive thrivers.” Meichenbaum (2012) works in a collaborative fashion with clients to develop the coping skills necessary to achieve these treatment goals. He uses a Socratic discovery-oriented approach and the art of questioning to assist clients in reaching their goals.

Meichenbaum (1997) uses these questions to evaluate the outcomes of therapy:

◆ Are clients now able to tell a new story about themselves and the world?

◆ Do clients now use more positive metaphors to describe themselves? ◆ Are clients able to predict high-risk situations and employ coping skills

in dealing with emerging problems? ◆ Are clients able to take credit for the changes they have been able to

bring about?

In successful therapy clients develop their own voices, take pride in what they have accomplished, and take ownership of the changes they are bringing about. In short, clients become their own therapists and take the therapist’s voice with them.

Cognitive Behavior Therapy From a Multicultural Perspective

Strengths From a Diversity Perspective Cognitive-behavioral approaches have several strengths in working with individu- als from diverse cultural, ethnic, and racial backgrounds. Asking clients during the intake process to share the strengths and challenges of their cultural, racial, and ethnic identity is an effective way to begin the discovery process. It is critical that counselors are aware of their own values, beliefs, and biases and that they respect clients’ core cultural values and belief systems (Shaw & Green, 2022). If therapists understand the core values of their culturally diverse clients, they can help clients explore these values and gain a full awareness of their conflicting feelings. Then the client and the therapist can work together to modify selected beliefs and practices. Cognitive-behavioral approaches can be modified to incorporate a collectivistic rather than an individualistic perspective (Sue et al., 2022). Cognitive behavior ther- apy tends to be culturally sensitive because it uses the individual’s belief system, or worldview, as part of the method of self-exploration. We cannot ethically engage clients without understanding their worldview.

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Because counselors with a cognitive-behavioral orientation function as teach- ers, clients are actively involved in learning skills to deal with the problems of living. In speaking with colleagues who work with culturally diverse populations, I have learned that their clients tend to appreciate the emphasis on cognition and action, as well as the emphasis on relationship issues. The collaborative approach of CBT offers clients a structured therapy program, yet the therapist still makes every effort to enlist clients’ active cooperation and participation. Psychotherapy is essentially a psychoeducational process, and cognitive and behavioral methods can facilitate this learning. The psychoeducational focus of CBT is a clear strength that can be applied to many clinical problems and used effectively in many settings with diverse client populations. A strength of CBT is integrating assessment of client beliefs, emotional responses, and behavioral choices throughout therapy, which communicates respect for clients’ viewpoints regarding their progress. Often individuals from diverse cul- tures are erased in this society and made invisible. The counselor has an opportunity to validate their clients by hearing them, seeing them, and respecting their life story.

Hays (2009) asserts there is an “almost perfect fit” between cognitive behav- ior therapy and multicultural therapy because these perspectives share common assumptions that make integration possible. Aspects that contribute to an integra- tive framework include the following:

◆ Interventions are tailored to the unique needs and strengths of the individual.

◆ Clients are empowered by learning specific skills they can apply in daily life (CBT) and by the emphasis on cultural influences that contribute to clients’ uniqueness (multicultural therapy).

◆ Inner resources and strengths of clients are activated to bring about change.

◆ Clients make changes that minimize stressors, increase personal strengths and supports, and establish skills for dealing more effectively with their physical and social (cultural) environments.

Shortcomings From a Diversity Perspective Exploring values and core beliefs plays an important role in all of the cognitive- behavioral approaches, and it is crucial for therapists to have some understanding of the cultural background of clients and to be sensitive to their struggles. REBT therapists would do well to use caution in their choice of language and expression when confronting clients about their beliefs and behaviors. REBT suggests that the therapist’s job is to help clients critically examine long-standing cultural values that result in dysfunctional emotions or behaviors, but a potential limitation of REBT is its negative view of dependency. It would be useful for therapists to do their per- sonal homework and explore the research on interdependence and the importance of the collective in our global community. Many cultures view interdependence as necessary to good mental health. Clients with long-cherished cultural values

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pertaining to interdependence may not respond favorably to forceful methods of persuasion toward independence. Cultural beliefs must be respected even though the counselor may be unfamiliar with the practices and belief system of their cli- ents. Skillful REBT practitioners carefully monitor their manner, style, and choice of words and communicate whenever possible in language that is congruent with the client’s culture.

Hays (2009) suggests that therapists avoid challenging the core cultural beliefs of clients unless the client is clearly open to this. By emphasizing col- laboration over confrontation, as the cognitive-behavioral approaches do, the therapist can avoid seeming to be disrespectful. Hays recommends drawing on the client’s culturally related strengths in developing helpful ways of thinking to replace unhelpful cognitions. For example, consider an Asian American cli- ent, Sung, from a culture that traditionally stresses values such as doing one’s best, cooperation, interdependence, and working hard. Sung may feel that she is bringing shame to her family if she is going through a divorce, and she may feel guilt if she perceives that she is not living up to the expectations and standards set for her by her family and her community. Sung can be helped to consider how her cultural values of cooperation and interdependence may enable her family to support her during a difficult divorce. The rules for Sung are likely to be different from the rules for a male member of her culture. The counselor could assist Sung in understanding and exploring how both her gender and her culture are factors to consider in her situation. If Sung is confronted too quickly on living by the expectations or rules of others, the results are likely to be counterproductive. Sung might even leave counseling if she feels that she is not being understood or being asked to disregard her cultural identity in order to fit into a more Western view of health and wellness.

The emphasis of CBT on assertiveness, independence, verbal ability, rationality, cognition, and behavioral change may limit its use in cultures that value subtle com- munication over assertiveness, interdependence over personal independence, listen- ing and observing over talking, and acceptance over behavior change (Hays, 2009). In CBT the focus is on the present, which can result in the therapist failing to recog- nize the role of the past in a client’s development. Cognitive-behavioral assessments involve the investigation of a client’s personal history. If the therapist is unaware of a client’s cultural beliefs, which are rooted in the past, the therapist may have difficulty interpreting the client’s personal experiences accurately.

Another limitation of CBT from a multicultural perspective involves its indi- vidualistic orientation. For clients from certain cultures, a collectivistic orientation implies considering the family and community context when assessing and defining problems (Sue et al., 2022). An inexperienced therapist may overemphasize cognitive restructuring to the neglect of environmental interventions. Hays (2009) points out that these potential limitations do not preclude the integration of CBT and multi- cultural counseling. Instead, being aware of these limitations “presents opportuni- ties for rethinking, refining, adapting and increasing the relevance and effectiveness of psychotherapy” (p. 356).

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Cognitive Behavior Therapy Applied to the Case of Stan From a cognitive-behavioral perspective, I want Stan to critically evaluate and modify his self-defeating beliefs, which will likely result in Stan acquiring more effective behavior. As his therapist, I am both goal oriented and problem focused. From the initial ses- sion, I ask Stan to identify his problems and formulate specific goals and help him reconceptualize his prob- lems in a way that will increase his chances of finding solutions.

I follow a clear structure for every session. The ba- sic procedural sequence includes (1) preparing him by providing a cognitive rationale for treatment and de- mystifying treatment; (2) encouraging him to monitor the thoughts that accompany his distress; (3) imple- menting behavioral and cognitive techniques; (4) as- sisting him in identifying and examining some basic beliefs and ideas; (5) teaching him ways to examine his beliefs and assumptions by testing them in the real world; and (6) teaching him basic coping skills that will enable him to avoid relapsing into old patterns.

As a part of the structure of the therapy sessions, I ask Stan for a brief review of the week, elicit feedback from the previous session, review homework assign- ments, collaboratively create an agenda for the session, discuss topics on the agenda, and set new homework for the week. I encourage Stan to perform personal ex- periments and practice coping skills in daily life.

Stan tells me that he would like to work on his fear of women and would hope to feel far less intimidated by them. He reports that he feels threatened by most women, but especially by women he perceives as pow- erful. In working with Stan’s fears, I proceed with four steps: educate him about his self-talk; have him moni- tor and evaluate his faulty beliefs; use cognitive and behavioral interventions; and collaboratively design homework with Stan that will give him opportunities to practice new behaviors in daily life.

First, I educate him about the importance of ex- amining his automatic thoughts, his self-talk, and the many “shoulds,” “oughts,” and “musts” he has accepted without questioning. Working with Stan as a collab- orative partner in his therapy, I guide him in discover- ing some basic thoughts that influence what he tells

himself and how he feels and acts. Here are some of his beliefs:

◆ “I always have to be strong, tough, and perfect.” ◆ “I’m not a man if I show any signs of weakness.” ◆ “If everyone didn’t love me and approve of me,

things would be catastrophic.” ◆ “If a woman rejected me, I really would be reduced

to a ‘nothing.’ ” ◆ “If I fail, I am then a failure as a person.” ◆ “I’m apologetic for my existence because I don’t

feel equal to others.”

Second, I assist Stan in monitoring and evaluat- ing the ways in which he keeps telling himself these self-defeating ideas. I assist him in clarifying specific problems and learning how to critically evaluate his thinking.

Therapist: You’re not your father. I wonder why you continue telling yourself that you’re just like him. Where is the evidence that your parents were right in their assessment of you? What is the evidence they were not right in their assessment of you? You say you’re such a failure and that you feel inferior. Do your present activities support this? If you were not so hard on yourself, how might your life be different?

Third, once Stan more fully understands the nature of his cognitive distortions and his self-defeating be- liefs, I draw on a variety of cognitive and behavioral techniques to help Stan learn to identify, evaluate, and respond to his beliefs. I rely heavily on cognitive tech- niques such as Socratic questioning, guided discovery, and cognitive restructuring to assist Stan in examining the evidence that seems to support or contradict his core beliefs. I work with Stan so he will view his basic beliefs and automatic thinking as hypotheses to be tested. In a way, he will become a personal scientist by checking out the validity of many of the conclu- sions and basic assumptions that contribute to his personal difficulties. By the use of guided discovery, Stan learns to evaluate the validity and functionality of his beliefs and conclusions. Stan can also profit from cognitive restructuring, which would entail observing

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his own behavior in various situations. For example, during the week he can take a particular situation that is problematic for him and pay attention to his automatic thoughts and internal dialogue: What is he telling himself as he approaches a difficult situation? As he learns to attend to his thoughts and behaviors, he may begin to see that what he tells himself has as much impact as others’ statements about him. He also sees the connections between his thinking and his be- havior problems. With this awareness he is in an ideal place to begin to learn a new, more functional internal dialogue.

Fourth, I work collaboratively with him in creating specific homework assignments to help him deal with his fears. It is expected that Stan will learn new coping skills, which he can practice first in session and then in daily life situations. It is not enough for him to merely say new things to himself; Stan needs to apply his new cognitive and behavioral coping skills in various daily situations. At one point, for instance, I ask Stan to explore his fears of powerful women and his rea- sons for continuing to tell himself that “They expect me to be strong and perfect. If I’m not careful, they’ll dominate me.” His homework includes approaching a woman for a date. If he succeeds in getting the date, he can think about his catastrophic expectations of what might happen. What would be so terrible if she did not like him or if she refused the date? Stan tells himself over and over that he must be approved of and that if any woman rebuffs him the consequences are more than he can bear. With practice, he learns to label distortions and is able to automatically iden- tify his negative thoughts and monitor his cognitive patterns. Through a variety of cognitive and behav- ioral strategies, he is able to acquire new information, change his basic beliefs, and implement new and more effective behavior.

Questions for Reflection ◆ My therapeutic style is characterized as an integra-

tive form of cognitive behavior therapy. I borrow

concepts and techniques from the approaches of Ellis, Beck, and Meichenbaum. In your work with Stan, what specific concepts would you borrow from these approaches? What cognitive- behavioral techniques would you use? What pos- sible advantages do you see, if any, in applying an integrative cognitive-behavioral approach in your work with Stan? Would there be any ben- efits in adding ideas from Padesky and Mooney’s strengths-based CBT?

◆ What are some things you would most want to teach Stan about how cognitive behavior therapy works? How would you explain to him the thera- peutic alliance and the collaborative therapeutic relationship?

◆ What are some of Stan’s most prominent faulty beliefs that get in the way of his living fully? What cognitive and behavioral techniques might you use in helping him examine his beliefs?

◆ Stan lives by many “shoulds” and “oughts.” His auto- matic thoughts seem to impede him from getting what he wants. What techniques would you use to encourage guided discovery on his part?

◆ What are some homework assignments that would be useful for Stan to carry out? How would you collaboratively design homework with Stan? How would you encourage him to develop action plans to test the validity of his thinking and his conclusions?

Refer to the MindTap for The Case of Stan Video Quiz for Chapter 10, Session 8 (“Cognitive Behavior Therapy”), for a demonstration of my approach to counseling Stan from this perspec- tive. This session focuses on exploring some of Stan’s faulty beliefs through the use of role- reversal and cognitive restructuring techniques.

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Cognitive Behavior Therapy Applied to the Case of Gwen* Gwen comes in, takes a seat, and begins telling me about the upcoming office retreat that she has to at- tend. Gwen wants to be more accepted and connected but has gotten into a pattern of isolating herself and using excuses not to socialize with others.

Gwen: I am dreading spending eight hours out in the country with a bunch of people I don’t really care to spent time with in the office! I know it’s going to be horrible!

Therapist: Stop for a moment and pay attention to your thoughts around being with your colleagues. What evidence do you have to support your predic- tion about attending the retreat? [Sensing a cogni- tive distortion]

Gwen: I never interact with my coworkers, and I can’t imagine that the retreat will be interesting. I feel anxious when I am around my coworkers. I do not feel that I am a part of their group. I feel judged and scrutinized by them.

Gwen’s faulty assumptions and cognitive distor- tions fuel her anxiety. I want to help Gwen recognize these old irrational thoughts and learn that these thoughts have caused her anxiety. “Awfulizing” the upcoming social event leads to more anxiety and trig- gers her desire to isolate herself. If Gwen can become more self-aware, she will be able to actively dispute her faulty beliefs.

Therapist: You are telling yourself that you will have a horrible time at the retreat. You think your cowork- ers will judge you. What evidence do you have that they are judging you? Do you have any evidence that suggests one or several of your coworkers are not judging you? Imagine that you are holding a picture of the retreat and how you fit in at work. The frame is old and dusty. What would happen if you put a new frame on the picture? Can you reframe your thoughts about going to the retreat and inter- acting with your coworkers in a more positive way?

Gwen: Well, I don’t have to say it will be horrible. I guess that thought makes me dread it. I truthfully don’t know how it will go at all. Maybe I can tell my- self to show up without judgment for a change and just see what happens. I get caught up in negative thinking sometimes.

Therapist: When you hear negative words in your mind or say them, allow yourself to cancel those thoughts. Dispute the negative statement, and replace it with a statement that supports how you want to feel and think about yourself. Tell me some of the cognitive distortions that keep you stuck in anxiety or negative feelings.

Gwen: I say to myself that the people at work are wait- ing for me to make a mistake, that I am different, and that they don’t want to socialize with me. Actu- ally, I haven’t really tried to get to know them.

Therapist: What can you do differently in the work- place to foster relationships with your coworkers that might serve to reduce your anxiety?

Gwen: I guess I could say hello to my coworkers in- stead of walking through the office ignoring them. I really do want to create positive relationships in the office and not feel like an outsider.

Therapist: And how will you respond to those nagging thoughts that everyone is against you?

Gwen: I am beginning to realize that there is really no evidence to support feeling that I am being judged and scrutinized by my coworkers. Maybe I am quiet because I am afraid they will reject me, and so I reject them first.

Therapist: Let’s agree on some homework for this week. When you are feeling judged and scrutinized, see if you can counter the assumptions you are making by looking at the facts.

*Dr. Kellie Kirksey writes about her ways of thinking and practicing in a CBT framework and applying this model to Gwen.

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Gwen: Maybe I could make a list of my assumptions and some of the negative thoughts that result from them. Then I could try to list some facts that coun- ter those negative thoughts.

Therapist: I am glad you are willing to try to find some facts to work with. I think this will help you to be less anxious.

Gwen: And I will try to be more friendly at work.

Therapist: Isolating yourself doesn’t seem to be work- ing, so let’s see how you feel when you talk with your coworkers.

I give Gwen a journal to record her homework ex- periments and how doing a new behavior affects her anxiety level. I encourage her to develop awareness of the automatic thoughts that occur to her so she can

become more adept at catching and disputing them. In our next session, we discuss her homework and evaluate the response it has had on her level of anxiety in the workplace.

Questions for Reflection ◆ What role, if any, does Gwen play in her experi-

ences of isolation? ◆ How does the therapist intervene to assist Gwen in

looking for evidence for her negative thinking? ◆ How would you encourage Gwen to complete her

homework assignment? ◆ How would you respond if you knew that Gwen

was being subjected to racism and rejection in the office? How would CBT help her in that case?

◆ What additional CBT technique might you use if you were counseling Gwen?

Summary and Evaluation Summary

REBT has evolved into a comprehensive and integrative approach that emphasizes thinking, assessing, deciding, doing, and compassion. This approach is based on the premise of the interconnectedness of thinking, feeling, and behaving and is both scien- tific and humanistic at its core. Therapy can begin with clients’ problematic behaviors and emotions, and clients can learn to dispute the thoughts that directly create them. To transform any self-defeating beliefs that are reinforced by a process of self-indoctrina- tion, REBT therapists employ active and directive techniques such as teaching, sugges- tion, persuasion, and homework assignments, and they encourage clients to substitute a rational belief system for an irrational one. The main strategies of REBT involve chal- lenging and replacing dysfunctional beliefs with rational beliefs (DiGiuseppe & Doyle, 2019). Therapists demonstrate how and why dysfunctional beliefs lead to negative emo- tional and behavioral results. They teach clients how to dispute self-defeating beliefs and behaviors that might occur in the future. REBT emphasizes the benefit of taking action—doing something about the insights one gains in therapy. Change comes about mainly by practicing new behaviors that replace old and ineffective ones. Unconditional self-acceptance, unconditional other-acceptance, and unconditional life-acceptance, along with daily gratitude, are strongly encouraged. Rational emotive behavior thera- pists are typically eclectic in selecting therapeutic strategies. They have the latitude to develop their own personal style and to exercise creativity. They are not bound by fixed techniques for particular problems. REBT concepts and techniques can be integrated into other psychotherapeutic approaches.

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Cognitive therapists also practice from an integrative stance, using many meth- ods to help clients learn to identify links between thoughts, emotions, behaviors, physiology, and situations. Some defining characteristics of cognitive therapy are that the client is active and works as a partner with the therapist; the therapist is active and directive; the therapy is structured and psychoeducational; an agenda provides focus for each session; and therapy is time limited (Freeman & Freeman, 2016). The working alliance is given special importance in cognitive therapy as a way of forming a collaborative partnership. Although rapport in the client–therapist relationship is viewed as helpful by Beck, it is not considered sufficient for therapy success. In cognitive therapy, it is presumed that clients are helped by the skillful use of a range of cognitive and behavioral interventions and by therapists engaging clients’ willingness to perform homework assignments between sessions. Cognitive therapists are expected to be able to conceptualize client problems in ways that link personal client experiences to the evidence-based treatments that are most likely to be successful.

All of the cognitive-behavioral approaches stress the importance of links between cognitive processes, emotions, and behavior. It is assumed that how people feel and what they actually do is largely influenced by their subjective assessment and interpretation of situations. Because this appraisal of life situations is influenced by beliefs, attitudes, assumptions, and internal dialogue, such cognitions become a major focus of therapy.

Contributions of the Cognitive-Behavioral Approaches Most of the therapies discussed in this book can be considered “cognitive” in a general sense because they have the aim of changing clients’ subjective views of themselves and the world. The cognitive-behavioral approaches have developed sys- tematic and sophisticated forms of psychotherapy that focus on testing assump- tions and beliefs and teaching clients the coping skills needed to deal with their problems. A basic principle of CBT is that emotional and behavioral changes can be achieved by changing cognitions, just as cognitive change can be altered by actions and emotions (Freeman & Freeman, 2016).

Ellis’s REBT and Beck’s CT represent the most systematic applications of cog- nitive behavior therapy. Both REBT and CT are based on a wide range of cogni- tive-behavioral techniques and follow a defined plan of action; they can often be relatively brief and structured treatments in keeping with the spirit of maximiz- ing effectiveness and efficiency, cost effectiveness, and evidence-based practice (DiGiuseppe & Doyle, 2019). The psychoeducational aspect of CBT and REBT is a clear strength that can be applied to many clinical problems and used effectively in many settings with diverse client populations (Ellis & Ellis, 2019a). The evidence basis in support of CBT therapies often makes them the “gold standard” by which therapy effectiveness is judged. A body of research supports the efficacy of REBT (DiGiuseppe & Doyle, 2019).

Ellis’s REBT One of the strengths of REBT is the focus on teaching clients ways to carry on their own therapy without the direct intervention of a therapist. I particularly like the emphasis that REBT puts on supplementary and psychoeducational

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approaches such as listening to tapes, reading self-help books, keeping a record of what they are doing and thinking, and carrying out homework assignments. In this way clients can further the process of change in themselves without becoming excessively dependent on a therapist.

Beck’s Cognitive Therapy Beck’s key concepts share similarities with REBT but differ in being empirically rather than philosophically derived, the processes by which therapy proceeds, and the formulation and treatment for different disorders. Beck made pioneering efforts in the treatment of anxiety, phobias, and depression. Beck demonstrated that a structured therapy that is present centered and problem oriented can be very effective in treating depression and anxiety in a relatively short time. Today, empirically validated treatments for both anxiety and depression have revolutionized therapeutic practice; research has demonstrated the efficacy of cognitive therapy for a variety of problems (DeRubeis et al., 2019; Hofmann et al., 2012). Beck developed specific cognitive procedures to help depressive clients evaluate their assumptions and beliefs and to create a new cognitive perspective that can lead to optimism and changed behavior. Research demonstrates that the effects of cognitive therapy on depression and hopelessness are usually maintained for at least one year after treatment. Cognitive therapy has been applied to a wide range of clinical populations that Beck did not originally believe were appropriate for this model, including treatment for posttraumatic stress disorder, schizophrenia, delusional disorders, bipolar disorder, and various personality disorders (Hofmann et al., 2012). The credibility of the cognitive model grows out of the fact that many of its propositions have been empirically tested.

Padesky and Mooney’s Strengths-Based CBT Beck’s CT has been further expanded with Padesky and Mooney’s strengths-based CBT approach. In addition to incorporating strengths at each phase of treatment, SB-CBT has successfully incorporated a wide range of modalities including imagery, metaphor, stories, and kinesthetic body experiences into the broad repertoire of CBT interventions. SB-CBT also provides models that extend CBT from evidence-based treatment of client problems to evidence-based models for developing positive qualities and client strengths. Instead of focusing solely on testing existing beliefs, SB-CBT offers systematic methods for helping clients construct new beliefs and behaviors that help realize their goals of “how they would like to be.”

Meichenbaum’s Cognitive Behavior Modification Meichenbaum’s work in self- instruction and stress inoculation training has been applied successfully to a variety of client populations and specific problems. Of special note is his contribution to understanding how stress is largely self-induced through inner dialogue. Meichenbaum’s integration of the cognitive narrative perspective is a key strength of his therapy style. He is able to combine elements of the postmodern interest in stories clients tell with assisting clients in changing their cognitions, feelings, and behaviors by drawing on a cognitive-behavioral conceptual framework.

A contribution of all of the cognitive-behavioral approaches is the emphasis on put- ting newly acquired insights into action. Homework assignments, which are col- laboratively designed by therapist and client, are well suited to enabling clients to

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practice new behaviors and assisting them in the process of learning more effective coping skills. It is important that collaboratively created homework be a natural outgrowth of what is taking place in the therapy session. Ellis’s REBT, Beck’s cog- nitive therapy, Padesky and Mooney’s strengths-based CBT, and Meichenbaum’s stress inoculation training all place special emphasis on practicing new skills both in therapy and in daily life, and homework is a key part of the learning process. Cli- ents learn how to generalize coping skills to various problem situations and acquire relapse prevention strategies to ensure that their gains are consolidated.

A major contribution made by Ellis, the Becks, Padesky and Mooney, and Meich- enbaum is the demystification of the therapy process. The cognitive-behavioral approaches are based on an educational model that stresses a working alliance between therapist and client. The models encourage self-help, provide for continu- ous feedback from the client on how well treatment strategies are working, and pro- vide a structure and direction to the therapy process that allows for evaluation of outcomes. Clients are active, informed, and responsible for the direction of therapy because they are partners in the enterprise.

Limitations and Criticisms of the Cognitive-Behavioral Approaches

Some critics have charged that the cognitive-behavioral approaches focus only lim- ited attention on the role of emotions in treatment. These therapies were originally developed to help people already experiencing extreme emotional arousal, and this perception may be an artifact of that fact. When clients are severely depressed or highly anxious, it is beneficial to focus less directly on these emotions per se and more on the balancing roles of belief and behavior. When CBT therapists work with clients who keep emotion at arms’ length, they use imagery, role play, and emotional expression to elicit emotion and bring it into therapy. Although CBT therapists may not talk about emotion as frequently as some other therapies, CBT is almost always dealing directly with emotion and its consequences. Some potential limitations of the various CBT approaches follow.

Ellis’s REBT I question the REBT assumption that exploring the past is ineffective in helping clients change faulty thinking and behavior. From my perspective, exploring past childhood experiences can have a great deal of therapeutic power if the discussion is connected to present functioning. In fact, Albert Ellis would (and Debbie Joffe Ellis continues to) listen to past childhood experiences in the initial session, or during early sessions. These stories can be valuable as sources of irrational beliefs still held by the client in the here and now. Attention would then very quickly move to exploring, disputing, and replacing these beliefs.

Another potential limitation of ineffective or inexperienced REBT therapists involves the misuse of the therapist’s power by imposing ideas of what constitutes rational thinking. Due to the active and directive nature of this approach, it is partic- ularly important for practitioners to avoid imposing their own philosophy of life on their clients. The skillful REBT therapist clarifies the REBT definitions of rational versus irrational thoughts and healthy negative emotions versus unhealthy negative emotions (Ellis & Ellis, 2019a).

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Some clients may have trouble with a confrontational style of REBT, especially if a strong therapeutic alliance has not been established. It is well to underscore that REBT can be effective when practiced in a style different from the bold manner that Albert Ellis frequently displayed. Albert Ellis often expressed the notion that ther- apists do not need to emulate his style to effectively incorporate REBT into their own repertoire of interventions. Debbie Joffe Ellis, who continues to teach and write about the “Ellis” REBT approach, enthusiastically encourages therapists to adhere to REBT tenets and principles in their own authentic manner and style (D. Ellis, 2014).

Beck’s Cognitive Therapy Cognitive therapy has been criticized for focusing too much on the power of positive thinking; being too superficial and simplistic; denying the importance of the client’s past; being too technique oriented; failing to use the therapeutic relationship; working only on eliminating symptoms and failing to explore the underlying causes of difficulties; ignoring the role of unconscious factors; and neglecting the role of feelings (Freeman & Dattilio, 1992; Weishaar, 1993).

Although the cognitive therapist is straightforward and looks for simple rather than complex solutions, this does not imply that the practice of cognitive therapy is simple. Cognitive therapists do not pursue positive thinking but rather thinking based on actual experiences. Cognitive therapists do not believe the unconscious is difficult to access. With direct and guided questioning, clients can identify assump- tions and beliefs that exist below awareness and also link these beliefs to behavioral patterns and emotional reactions. They also recognize that clients’ current problems are often a product of earlier life experiences, and they may explore with clients the ways their past is presently influencing them.

Padesky and Mooney’s Strengths-Based CBT The biggest criticism of strengths-based CBT is that the evidence base supporting the approach is still in its infancy. Some CBT therapists question whether the addition of client strengths adds anything to CBT’s effectiveness. Studies currently underway in Europe and the United Kingdom are testing this hypothesis, especially to see whether a strengths and resilience focus increases the enduring effects of therapy. Additional research is necessary to examine whether construction of new beliefs and behaviors is more effective than examining current beliefs and behaviors in the treatment of chronic problems.

Meichenbaum’s Cognitive Behavior Modification Meichenbaum is very charismatic in his workshop presentations. Much of the success of his approach may be based on his level of caring and his creativity in implementing CBT interventions. Practitioners without his wit, energy, personal flair, and direct therapeutic style may not get the same results even though they follow his treatment protocol. This emphasizes the importance for therapists to develop their own unique therapeutic style.

A potential limitation of any of the cognitive-behavioral approaches is the therapist’s level of personal development, training, knowledge, skill, perceptiveness, and ability to establish a therapeutic alliance. Although this is true of all therapeutic approaches, it is especially true for CBT practitioners because they tend to be active, highly struc- tured, offer clients useful information, and teach life skills. Who the therapist is as a person is as important as knowledge and skills. Therapists teach their clients

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through what they model. Debbie Joffe Ellis (2014) encourages practitioners to strive to be mindful, to think about their thinking, and to do their best to practice what they preach. In so doing, they can be healthy models for their clients and others and experience greater authenticity and satisfaction in their own lives as well.

Self-Reflection and Discussion Questions

1. In most CBT models, the therapist functions in many ways as a teacher. How does a psychoeducational model fit with your way of practicing counseling?

2. Cognitive-behavioral practitioners use a brief, active, directive, collab- orative, present-focused, didactic, psychoeducational model of therapy that relies on empirical validation of its concepts and techniques. What potential advantages do you see of this focus? Any disadvantages?

3. Ellis, Beck, Padesky, and Meichenbaum are all in the cognitive-behavioral camp, yet they all have distinctive approaches to counseling. Which of these approaches are you most drawn to and why?

4. CBT provides for use of a wide range of techniques. What techniques might you apply to yourself? What techniques are you likely to incor- porate in your work with clients?

5. The cognitive-behavioral therapies are among the most popular with today’s practitioners. What do you think accounts for the increased interest in CBT?

Where to Go From Here DVDs relevant to this chapter offered by the American Psychological Association from their Systems of Psychotherapy Video Series include the following:

Beck, J. (2005). Cognitive Therapy

Ellis, D. J. (2014). Rational Emotive Behavior Therapy

Meichenbaum, D. (2007). Cognitive Behavioral Therapy With Donald Meichenbaum

Vernon, A. (2010). Rational Emotive Behavior Therapy Over Time

Dobson, K. S. (2010). Cognitive Therapy Over Time

Persons, J. (2006). Cognitive-Behavior Therapy

Dobson, K. S. (2008). Cognitive-Behavioral Therapy for Perfectionism Over Time

Dobson, K. S. (2011). Cognitive-Behavioral Therapy Strategies

Audio recordings of workshops and videos relevant to this chapter that illustrate CBT protocols and methods in practice are also offered by Padesky at www. padesky.com:

Padesky, C. A. (1993). Cognitive Therapy for Panic Disorder

Padesky, C. A. (1996). Guided Discovery Using Socratic Dialogue

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Padesky, C. A. (1996). Testing Automatic Thoughts With Thought Records

Padesky, C. A. (1997). Collaborative Case Conceptualization

Padesky, C. A. (2003). Constructing NEW Core Beliefs

Padesky, C. A. (2004). Constructing NEW Underlying Assumptions & Behavioral Experiments

Padesky, C. A. (2008). CBT for Social Anxiety

Padesky, C. A. (2015). A Four-Step Approach to Building Resilience

Psychotherapy.net is a comprehensive resource for students and professionals that offers videos and interviews on cognitive behavior therapy. New video and edi- torial content is made available monthly. DVDs relevant to this chapter are available at www.psychotherapy.net.

For information about the work of Albert Ellis, and current presentations and REBT trainings, contact Debbie Joffe Ellis (www.debbiejoffeellis.com). Additional websites of interest on REBT include www.ellisrebt.com and www.rebtnetwork.org.

The International Journal of Cognitive Therapy provides information on theory, prac- tice, and research in cognitive behavior therapy. For information about the journal, contact the International Journal of Cognitive Therapy (www.guilford.com).

Padesky and Mooney’s Center for Cognitive Therapy, Huntington Beach, California, has separate websites for mental health professionals and for the public. At the web- site for mental health professionals, you can download pdf files of many of Padesky and Mooney’s writings, visit Padesky’s blog, and find recommendations for cogni- tive therapy books for both professionals and the public, audio and video training programs, workshops, consultations, and other cognitive therapy resources and information. The website for the public offers information about finding a CBT therapist, CBT articles of interest to the public, and links to the publishers of Mind Over Mood in more than 24 languages:

www.padesky.com (for mental health professionals)

www.MindOverMood.com (for the public)

In addition, Padesky also offers brief clinical tip videos and free full length webinars on her YouTube channel (YouTube.com/ChristinePadesky).

For more information about CBT workshops, supervision, a CBT blog, and a newsletter, contact the Beck Institute for Cognitive Behavior Therapy (www. beckinstitute.org).

The “home” organization for cognitive therapists worldwide is the Academy of Cognitive Therapy, which Aaron T. Beck and Judith S. Beck were instrumental in founding. Links to certified cognitive therapists worldwide as well as links to research and professional books of interest to therapists are available at the website of the Academy of Cognitive Therapy (www.academyct.org).

Donald Meichenbaum is research director of the Melissa Institute for Violence Prevention, a nonprofit organization designed to “give science away” in order to reduce violence and to treat victims of violence. The institute is dedicated to the study and prevention of violence through education, community service, research support, and consultation. For more information visit the website of the Melissa Institute for Violence Prevention (www.melissainstitute.org).

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Recommended Supplementary Readings for Chapter 10 Rational Emotive Behavior Therapy (Ellis & Ellis, 2019a) is a concise basic primer on REBT and is an excellent resource for updated information about the approach.

Albert Ellis Revisited (Carlson & Knaus, 2014) con- tains some of Ellis’s most influential writings on a variety of subjects. This edited book includes com- mentaries by contributors for each of Ellis’s articles.

Cognitive Therapy: Basics and Beyond (J. Beck, 2021) is a main text in cognitive therapy that presents a com- prehensive overview of the approach. An earlier edi- tion of this book was translated into 20 languages.

Mind Over Mood: Change How You Feel by Changing the Way You Think (Greenberger & Padesky, 2016) provides step-by-step worksheets to identify moods, solve problems, and test thoughts related to depres- sion, anxiety, anger, guilt, and shame. This is a popular self-help workbook and a valuable tool for therapists and clients learning cognitive therapy skills.

The Clinician’s Guide to CBT Using Mind Over Mood (Padesky, 2020) shows therapists how to integrate Mind Over Mood in therapy and use cognitive ther- apy treatment protocols for specific diagnoses. This detailed overview of CBT has troubleshooting guides, reviews cultural issues, and offers guidelines for individual, couples, and group therapy. It also provides detailed guidance on the empirical basis and use of all 60 worksheets in Mind Over Mood.

This succinct overview of cognitive therapy has troubleshooting guides, reviews cultural issues, and offers guidelines for individual, couples, and group therapy.

The Therapeutic Relationship in Cognitive-Behavioral Therapy: A Clinician’s Guide (Kazantzis et al., 2017) explains how the therapeutic relationship is central to cognitive-behavioral interventions. Also included are chapters on homework in therapy, relapse pre- vention, and ethical aspects of the therapeutic relationship.

Making Cognitive-Behavioral Therapy Work: Clinical Pro- cesses for New Practitioners (Ledley et al., 2018) deals with the process of assessment, case conceptualiza- tion, treatment planning, terminating therapy, and examining common challenges for new clinicians.

Evidence-Based Practice of Cognitive-Behavioral Therapy (Dobson & Dobson, 2017) covers many aspects of intervention, including psychoeducation, behavioral interventions, cognitive work, and values-informed goal setting. The authors separate myths from facts about behavior therapy and CBT. Handbook of Cognitive-Behavioral Therapies (Dobson & Dozois, 2019) is an edited book that reviews major approaches including emotion-centered problem- solving therapy, REBT, cognitive therapy, schema therapy, mindfulness- and acceptance-based inter- ventions, dialectical behavior therapy, and integra- tive psychotherapy.

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Ellis, A. (2010). All out! An autobiography. Prometheus Books. Ellis, A., & Ellis, D. J. (2019a). Rational emotive behavior therapy (2nd ed.). American Psychological Association. Ellis, A., & Ellis, D. J. (2019b). Rational emotive behavior therapy. In D. Wedding & R. J. Corsini (Eds.), Current psychotherapies (11th ed., pp. 157–198). Cengage Learning. Ellis, D. J. (2014). Rational emotive behavior therapy [DVD]. American Psychological Association. Epstein, N. B. (2006). Cognitive- behavioral therapy with couples: Theoretical and empirical status. In R. L. Leahy (Ed.), Contemporary cognitive therapy: Theory, research, and practice (pp. 367–388). Guilford Press. Freeman, A., & Dattilio, R. M. (Eds.). (1992). Comprehensive casebook of cognitive therapy. Plenum Press. Freeman, A., & Freeman, S. E. M. (2016). Basics of cognitive behavior therapy. In I. Marini & M. A. Stebnicki (Eds.), The professional counselor’s desk reference (2nd ed., pp. 191–196). Springer. Fruzzetti, A. E., McLean, C., & Erikson, K. M. (2019). Mindfulness and acceptance interventions in cognitive-behavioral therapy. In K. S. Dobson & D. J. A. Dozois (Eds.), Handbook of cognitive-behavioral therapies (4th ed., pp. 271–296). Guilford Press. Granvold, D. K. (Ed.). (1994). Cognitive and behavioral treatment: Method and applications. Brooks/Cole. Greenberger, D., & Padesky, C. A. (2016). Mind over mood: Change how you feel by changing the way you think (2nd ed.). Guilford Press. Hays, P. A. (2009). Integrating evidence- based practice, cognitive-behavior therapy, and multicultural therapy: Ten steps for culturally competent practice. Professional Psychology: Research and Practice, 40(4), 354–360. Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36, 427–440. Hollon, S. D., Stewart, M. O., & Strunk, D. (2006). Enduring effects for cognitive behavior therapy in the treatment of depression and anxiety, Annual Review of Psychology, 57, 285–315.

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Horney, K. (1950). Neurosis and human growth. Norton. Jacobs, N. N. (2008). Bibliotherapy utilizing CBT. In W. O’Donohue & J. E. Fisher (Eds.), Cognitive behavior therapy: Applying empirically supported techniques in your practice (2nd ed., pp. 60–67). Wiley. Kazantzis, N., Dattilio, F. M., & Dobson, K. S. (2017). The therapeutic relationship in cognitive-behavioral therapy: A clinician’s guide. Guilford Press. Kuyken, W., Padesky, C. A., & Dudley, R. (2009). Collaborative case conceptualization: Working effectively with clients in CBT. Guilford Press. Ledley, D. R., Marx, B. P., & Heimberg, R. G. (2018). Making cognitive-behavioral therapy work: Clinical processes for new practitioners (3rd ed.). Guilford Press. Marlatt, G. A., & Donovan, D. M. (Eds.). (2007). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors (2nd ed.). Guilford Press. Meichenbaum, D. (1977). Cognitive behavior modification: An integrative approach. Plenum Press. Meichenbaum, D. (1985). Stress inoculation training. Pergamon Press. Meichenbaum, D. (1986). Cognitive behavior modification. In F. H. Kanfer & A. P. Goldstein (Eds.), Helping people change: A textbook of methods (pp. 346–380). Pergamon Press. Meichenbaum, D. (1993). Stress inoculation training: A 20 year update. In P. M. Lehrer & R. L. Woolfolk (Eds.), Principles and practice of stress management (2nd ed., pp. 373–406). Guilford Press. Meichenbaum, D. (1994a). A clinical handbook/practical therapist manual: For assessing and treating adults with post-traumatic stress disorder (PTSD). Institute Press. Meichenbaum, D. (1994b). Treating adults with PTSD. Institute Press. Meichenbaum, D. (1997). The evolution of a cognitive-behavior therapist. In J. K. Zeig (Ed.), The evolution of psychotherapy: The third conference (pp. 96–104). Brunner/ Mazel. Meichenbaum, D. (2002). Treatment of individuals with anger-control problems and

aggressive behaviors: A clinical handbook. Institute Press. Meichenbaum, D. (2007). Stress inoculation training: A preventive and treatment approach. In P. M. Lehrer, R. L. Woolfolk, & W. Sime (Eds.), Principles and practices of stress management (3rd ed., pp. 497–518). Guilford Press. Meichenbaum, D. (2008). Stress inoculation training. In W. O’Donohue & J. E. Fisher (Eds.), Cognitive behavior therapy: Applying empirically supported techniques in your practice (2nd ed., pp. 529–532). Wiley. Meichenbaum, D. (2012). Roadmap to resilience: A guide for military, trauma victims and their families. Institute Press. Meichenbaum, D. (2015). Donald Meichenbaum. In E. Neukrug (Ed.), Sage encyclopedia of theory in counseling and psychotherapy (vol. 2, pp. 641–642). Sage. Meichenbaum, D. (2017). The evolution of cognitive behavior therapy: A personal and professional journey with Don Meichenbaum. Taylor & Francis. Newman, C. (2006). Substance abuse. In R. L. Leahy (Ed.), Contemporary cognitive therapy: Theory, research, and practice (pp. 206–227). Guilford Press. Norcross, J. C., Beutler, L. E., & Goldried, M. R. (2019). Cognitive- behavioral therapy and psychotherapy integration. In K. S. Dobson & D. J. A. Dozois (Eds.), Handbook of cognitive- behavioral therapies (4th ed., pp. 318–345). Guilford Press. Padesky, C. A. (2004). Aaron T. Beck: Man, mind and mentor. In R. Leahy (Ed.), Contemporary cognitive therapy: Theory, research and practice (pp. 3–24). Guilford Press. Padesky, C. A. (2007, July). The next frontier: Building positive qualities with CBT. Invited keynote address at the World Congress of Behavioural and Cognitive Therapies, Barcelona, Spain. Padesky, C. A. (with Greenberger, D.). (2020). The clinician’s guide to CBT using mind over mood. Guilford Press. Padesky, C. A., & Beck, A. T. (2003). Science and philosophy: Comparison

of cognitive therapy (CT) and rational emotive behavior therapy (REBT). Journal of Cognitive Psychotherapy: An International Quarterly, 17, 211–224. Padesky, C. A., & Mooney, K. A. (2012). Strengths-based cognitive- behavioural therapy: A four-step model to build resilience. Clinical Psychology & Psychotherapy, 19(4), 283–290. Pretzer, J., & Beck, J. (2006). Cognitive therapy of personality disorders. In R. L. Leahy (Ed.), Contemporary cognitive therapy: Theory, research, and practice (pp. 299–318). Guilford Press. Reinecke, M., Dattilio, F. M., & Freeman, A. (Eds.). (2002). Casebook of cognitive behavior therapy with children and adolescents (2nd ed.). Guilford Press. Riskind, J. H. (2006). Cognitive theory and research on generalized anxiety disorder. In R. L. Leahy (Ed.), Contemporary cognitive therapy: Theory, research, and practice (pp. 62–85). Guilford Press. Shaw, S., & Green, J. W. (2022). Cognitive behavioral theories. In D. Capuzzi & M. D. Stauffer (Eds.), Counseling and psychotherapy: Theories and interventions. (7th ed., pp. 193–216). American Counseling Association. Sue, D. W., Sue, S., Neville, H. A., & Smith, L. (2022). Counseling the culturally diverse: Theory and practice (9th ed.). Wiley. Tompkins, M. A. (2004). Using homework in psychotherapy: Strategies, guidelines, and forms. Guilford Press. Tompkins, M. A. (2006). Effective homework. In R. L. Leahy (Ed.), Roadblocks in cognitive-behavioral therapy (pp. 49–66). Guilford Press. Weishaar, M. E. (1993). Aaron T. Beck. Sage. White, J. R., & Freeman, A. (Eds.). (2000). Cognitive-behavioral group therapy for specific problems and populations. American Psychological Association.

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11Choice Theory/ Reality Therapy*

1. Identify the key figures associated with reality therapy.

2. Describe how choice theory is the theoretical underpinning of reality therapy.

3. Explain the concept and clinical implications of total behavior.

4. Examine the basic assumptions, unique characteristics, and goals of reality therapy.

5. Describe the role of therapist involvement in creating a counseling environment that is conducive to success.

6. Explain how the WDEP model is applied to practice.

7. Describe the application of reality therapy to group counseling.

8. Discuss the application of reality therapy to school counseling.

9. Identify the strengths and short comings of reality therapy in a multicultural context.

10. Discuss the contributions and limitations of the reality therapy approach.

Learning Objectives

*I would like to acknowledge Robert Wubbolding and Sandie Wubbolding for their review and additional input in bringing this chapter up to date.

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William Glasser (1925– 2013) was educated at Case Western Reserve University in Cleveland, Ohio. Initially a chemical engineer, he turned to psychology (MA, Clinical Psychology, 1948) and then to psychiatry, at- tending medical school (MD, 1953) with the inten- tion of becoming a psy- chiatrist. By 1957 he had

completed his psychiatric training at the Veterans Administration and UCLA in Los Angeles and in 1961 was board certified in psychiatry. Glasser was married to Naomi for 47 years, and she was very involved with the William Glasser Institute until her death in 1992. In 1995 Glasser married Carleen, who is an instructor at the institute and coauthor of several of his books.

Very early Glasser rejected the Freudian model, partly due to his observation of psychoanalytically trained therapists who did not seem to be implement- ing Freudian principles. Rather, they tended to hold people responsible for their behavior. Early in his ca- reer, Glasser was a psychiatrist at the Ventura School, a prison and school for girls operated by the California Youth Authority. He became convinced that his psy- choanalytic training was of limited utility in counseling these young people. From these observations, Glasser thought it best to talk to the sane part of clients, not their disturbed side. Glasser was also influenced by G. L. Harrington, a psychiatrist and mentor. Harrington believed in getting his patients involved in projects in the real world, and by the end of his residency Glasser began to put together ideas that would later be known as reality therapy.

In 1962 Glasser began to present public lectures on “reality psychiatry,” but few psychiatrists were in the audience. Most of those attending were educators,

social workers, counselors, and correctional workers, so Glasser changed the name of his system to “reality therapy,” which became the title of his groundbreaking book published in 1965. Educators found the principles of reality therapy helpful, and he was asked to apply it to the classroom and the school as an organization. As a result of this experience, he wrote Schools Without Failure in 1968, which had a major impact on the ad- ministration of schools, the training of teachers, and the way learning is conducted in schools. Glasser took the position that schools needed to be structured in ways to help students achieve a success identity as opposed to a failure identity. He advocated for a curriculum geared to the lives of learners. Glasser made significant contri- butions through in-service workshops for teachers and administrators. Since the late 1960s, reality therapy has been further applied to education and to virtually all other human relationships, especially intimate relation- ships. Most recently, reality therapy has been applied to management and supervision, coaching, family thera- py, and parenting. It is now taught and embedded on every continent except Antarctica.

Glasser became convinced that it was of paramount importance that clients accept personal responsibility for their behavior. By the early 1980s, Glasser was look- ing for a theory that could explain all his work. Glasser learned about control theory from William Powers, and he believed this theory had great potential. He spent the next 10 years expanding, revising, and clarifying what he was initially taught. By 1996 Glasser had be- come convinced that these revisions had so changed the theory that it was misleading to continue to call it control theory, and he changed the name to choice theory to reflect all that he had developed. The essence of reality therapy, now taught all over the world, is that we are all responsible for what we choose to do. We are internally motivated by current needs and wants, and we have more control over our present behavioral choices than many of us believe.

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Robert E. Wubbolding (b. 1936), born and raised in Cincinnati, Ohio, is the youngest of six children. He received his doctorate in counseling from the Uni- versity of Cincinnati, is a member of several profes- sional organizations, and has licenses as a counselor and as a psychologist. He taught high school history, worked

as a high school and elementary school counselor, and served as a consultant to drug and alcohol abuse programs of the U.S. Army and Air Force. Wubbolding began a career in the Catholic priesthood but later “left the clergy freely and honorably.” He is married to Sandra Trifilio, a former French teacher, who shares his passion for his work and is administrator of the Center for Reality Therapy and editor of his writings.

Wubbolding is now the director of the Center for Reality Therapy in Cincinnati and former faculty as- sociate at Johns Hopkins University. He is also pro- fessor emeritus of Xavier University, where he taught counselor education for 32 years. He loved teach- ing and viewed his students as being highly moti- vated, eager to learn, and experienced. One of his most meaningful experiences was teaching gradu- ate students in the counseling department at Xavier University.

After completing his doctorate, Wubbolding attended training sessions representing a wide range of coun- seling approaches, and he found reality therapy to be best suited to his interests. He attended many intensive training workshops conducted by William Glasser in Los Angeles, and in 1988 Glasser appointed him director of training for the William Glasser Institute.

Wubbolding served as visiting professor at the Uni- versity of Southern California in their overseas programs in Japan, Korea, and Germany, thus fulfilling his life- long desire to travel and to live in other countries. He has become an internationally known teacher, author, and practitioner of reality therapy and has introduced choice theory and reality therapy in Europe, Asia, and the Middle East. Among his specialties is adapting choice theory and reality therapy to various cultures and ethnic groups. He received the Gratitude Award (2009) for Initiating Reality Therapy in the United Kingdom and the Certificate of Reality Therapy Psychotherapist by the European Association for Psychotherapy (2009).

Wubbolding extended the theory and practice of reality therapy with his conceptualization of the WDEP system. He has written 18 books and more than 160 articles, essays, and chapters in textbooks as well as preparing more than 20 videos, some of which are ref- erenced in this chapter. His religious commitment and his life of service to others are apparent in his work, and he continues his vocation of teacher, counselor, psychologist, and active member of his church along with his wife Sandie.

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Introduction Reality therapists believe the underlying problem for many clients is the same: they are either involved in a present unsatisfying relationship or lack what could even be called a relationship. Many client problems are caused by their inability to connect, to get close to others, or to have a satisfying or successful relationship with at least one significant person in their life. The therapist guides clients toward a satisfying relationship and teaches them more effective ways of behaving. As clients are able to connect with people, their mental health improves.

Few clients understand that their problem, which is unhappiness, results from the way they are choosing to behave. What they do know is that they feel a great deal of pain or that they are unhappy because they have been sent for counseling by someone with authority who is not satisfied with their behavior—typically a court

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official, a school administrator, an employer, a spouse, or a parent. Reality therapists recognize that many clients choose their behaviors as a way to deal with the frustra- tions caused by unsatisfying relationships.

Glasser (2003) maintained that clients should not be labeled with a diagno- sis except when it is necessary for insurance purposes. From Glasser’s perspective, diagnoses are descriptions of the behaviors people choose in their attempt to deal with the pain and frustration that is endemic to their unsatisfying present relation- ships. Labeling these ineffective behaviors as mental illness is inaccurate. Glasser limits the term mental illness to conditions such as Alzheimer’s disease, epilepsy, head trauma, and brain infections—conditions associated with tangible brain dam- age. Because these people are suffering from a brain abnormality, Glasser’s view is that they should be treated primarily by neurologists. Wubbolding tempers these principles, advising counselors to follow standard practice and the standard of care regarding diagnosis and use of psychiatric medications. He adds that reality ther- apy is completely congruent with use of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013).

Reality therapy is based on choice theory as it is explained in several of Glasser’s (1998, 2001, 2003, 2011) books. (In this chapter, the discussion of Glasser’s ideas pertains to these four books, unless otherwise specified.) Choice theory is the theo- retical basis for reality therapy; it explains why and how we function. Reality therapy provides a delivery system for helping individuals take more effective control of their lives. If choice theory is the train track, reality therapy is the train delivering the product (Wubbolding, 2011). Therapy consists mainly of helping and sometimes teaching clients to make more effective choices as they deal with the people they need in their lives. It is essential for the therapist to establish a satisfying relation- ship with clients as a prerequisite for effective therapy. Once this relationship is developed, the skill of the therapist as listener and teacher assumes a central role. Wubbolding teaches that the procedures are the means for establishing and nour- ishing the therapeutic alliance.

Reality therapy has been used in a variety of settings. The approach is applicable to counseling, social work, education, crisis intervention, corrections and rehabili- tation, institutional management, and community development. Reality therapy is popular in schools, state mental health hospitals, halfway houses, and alcohol and drug abuse centers. Many of the military clinics that treat substance abusers use reality therapy as their preferred therapeutic approach.

Refer to the MindTap for this book to interact with video quizzes and various video pro- grams to expand your knowledge on topics relevant to Chapter 11.

Key Concepts View of Human Nature

Choice theory posits that we are not born blank slates waiting to be externally motivated by forces in the world around us. Rather, we are born with five geneti- cally encoded needs that drive us all our lives: survival, or self-preservation;

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love and belonging; power, or inner control; freedom, or independence; and fun, or enjoyment. Each of us has all five needs, but they vary in strength. For example, we all have a need for love and belonging, but some of us need more love than others. Choice theory is based on the premise that because we are by nature social creatures we need to both receive and give love. Glasser (2001, 2005) believes the need to love and to belong is the primary need because we need people to satisfy the other needs. It is also the most difficult need to satisfy because we must have a cooperative person to help us meet it. This concept aligns with the emphasis on the therapeutic alliance in current counseling literature (Forrest, 2021). Wubbolding also teaches that a sixth need can be incorporated into choice theory and reality therapy as proposed by Viktor Frankl: purpose and meaning. Because all behavior has a purpose, it seems that human beings have a need for meaning and purpose. A practical way to begin counseling is to explore with clients their purpose in deciding to seek help and what it would mean to them if their problems were resolved.

Our brain functions as a control system. It continually monitors our feelings to determine how well we are doing in our lifelong effort to satisfy these needs. When- ever we feel bad, one or more of these five needs is unsatisfied. Although we may not be aware of our needs, we know that we want to feel better. Driven by pain, we try to figure out how to feel better. Reality therapists teach clients choice theory, some- times subtly and indirectly, so clients can identify unmet needs and try to satisfy them.

Choice theory teaches that we do not satisfy our needs directly. Beginning shortly after birth and continuing all our lives, we keep close track of anything we do that feels very good. We store information inside our mind and build a file of wants, called our quality world, which is at the core of our life. It is our personal Shangri-la—the world we would like to live in if we could. It is completely based on our wants and needs, but unlike the needs, which are general, it is very specific. The quality world consists of specific images of people, activities, events, beliefs, posses- sions, and situations that fulfill our needs (Wubbolding, 2000, 2011, 2017). In our quality world, we develop an inner picture album of specific wants as well as precise ways to satisfy these wants. We are attempting to behave in a way that gives us the most effective control over our lives. Some pictures may be blurred, and the thera- pist’s role is to help clients clarify them. Pictures exist in priority for most people, yet clients may have difficulty identifying their priorities. Part of the process of reality therapy is assisting clients in prioritizing their wants and uncovering what is most important to them (Wubbolding, 2011, 2017). This is especially true when counsel- ing clients with drug abuse issues.

People we are closest to and most enjoy being with are the most important component of our quality world, and we most want to connect with these peo- ple. Those who enter therapy may have no one in their quality world or, more often, may have someone in their quality world whom they are unable to relate in a satisfying way. For therapy to have a chance of success, a therapist must be the kind of person that clients would consider putting in their quality world. Getting into the clients’ quality world is the art of therapy. It is from this rela- tionship with the therapist that clients begin to learn how to get close to the people they need.

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Choice Theory Explanation of Behavior Choice theory explains that all we ever do from birth to death is behave, and with some exceptions everything we do is chosen or at least generated from within our- selves. Every total behavior is our best attempt to get what we want to satisfy our needs. Total behavior teaches that all behavior is made up of four inseparable but distinct components—acting, thinking, feeling, and physiology—that necessarily accom- pany all of our actions, thoughts, and feelings. Choice theory emphasizes think- ing and acting, which makes this a general form of cognitive behavior therapy. The primary emphasis is on what the client is doing and how the doing component influences the other aspects of total behavior. Behavior is purposeful because it is designed to close the gap between what we want and what we perceive we are get- ting. Specific behaviors are always generated from this discrepancy. Our behaviors come from the inside, and thus we choose our destiny.

From Glasser’s perspective, to speak of being depressed, having a headache, being angry, or being anxious implies passivity and a lack of personal responsibility, and it is inaccurate. It is more accurate to think of these as parts of total behaviors and to use the verb forms depressing, headaching, angering, and anxietying to describe them. It is more accurate to think of people depressing or angering themselves rather than having the behaviors thrust upon them from the outside world. When people choose misery by developing a range of paining behaviors, it is because these are the best behaviors they are able to devise at the time, and these behaviors often get them what they want.

When a reality therapist starts teaching choice theory, the client will often pro- test and say, “I’m suffering, don’t tell me I’m choosing to suffer like this.” As painful as depressing is, the therapist explains that people do not choose pain and suffering directly; rather, it is an unchosen part of their total behavior. The behavior of the person is the best effort, ineffective as it is, to satisfy needs.

Wubbolding (2017) has added a new idea to choice theory. He believes that behavior is a language and that we send messages by what we are doing. The pur- pose of behavior is to influence the world to get what we want. Therapists ask clients what messages they are sending to the world by way of their actions: “What message do you want others to get?” “What message are others getting whether or not you intended to send it?” By considering the messages clients send to others, counselors can help clients indirectly gain a greater appreciation of messages they unintention- ally send to others.

Characteristics of Reality Therapy The role of meaningful relationships in fostering emotional health is receiving increased attention in contemporary reality therapy, which quickly focuses on the unsatisfying relationship or the lack of a relationship. Clients may complain of not being able to keep a job, not doing well in school, or not having a meaningful rela- tionship. When clients complain about how other people are causing them pain, reality therapists ask clients to consider how effective their choices are, especially as these choices affect their relationships with significant people in their lives. Choice theory teaches that talking about what clients cannot control is of minimal value;

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the emphasis is on what clients can control in their relationships. The basic axiom of choice theory, which is crucial for clients to understand, is that “the only person you can control is yourself.”

Reality therapists spend little time listening to complaining, blaming, and criti- cizing, for these are the most ineffective behaviors in our behavioral repertoire. What do reality therapists focus on? Here are some underlying characteristics of reality therapy.

Emphasize Choice and Responsibility Reality therapists see clients as being responsible for their own choices as they have more control of their behavior than they often believe. This does not mean people should be blamed or punished, unless they break the law, but it does mean the therapist never loses sight of the fact that clients are responsible for what they do. Choice theory changes the focus of responsibility to choice and choosing.

Reality therapists deal with people “as if” they have choices. Therapists focus on those areas where clients have choice, for doing so gets them closer to the people they need. For example, being involved in meaningful activities, such as work, is a good way to gain the respect of other people, and work can help clients fulfill their need for power. It is very difficult for adults to feel good about themselves if they don’t engage in some form of meaningful activity. As clients begin to feel good about themselves, it is less necessary for them to continue to choose ineffective and self-destructive behaviors.

Reject Transference Reality therapists strive to be themselves in their professional work. By being themselves, therapists can use the relationship to teach clients how to relate to others in their lives. Glasser contends that transference is a way that both therapist and client avoid being who they are and owning what they are doing right now. It is unrealistic for therapists to go along with the idea that they are anyone but themselves. Assume the client claims, “I see you as my father or mother and this is why I’m behaving the way I am.” In this situation, Glasser is likely to clearly and firmly respond, “I am not your mother, father, or anyone but myself.” Wubbolding claims that not all reality therapists would accept Glasser’s perspective on transference (personal communication, August 25, 2021).

Keep the Therapy in the Present Some clients come to counseling convinced that they must revisit the past if they are to be helped. Many therapeutic models teach that to function well in the present people must understand and revisit their past. Glasser (2001) disagrees with this assumption and contends that whatever mistakes were made in the past are not pertinent now. An axiom of choice theory is that the past may have contributed to a current problem but that the past is never the problem. To function effectively, people need to live and plan in the present and take steps to create a better future. We can only satisfy our needs in the present.

The reality therapist does not totally reject the past. If the client wants to talk about past successes or good relationships in the past, the therapist will listen because these may be repeated in the present. Reality therapists will devote only enough time to past failures to assure clients that they are not rejecting them. Wub- bolding contends that “history is not destiny.” Although the past has propelled us

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to the present, it does not have to determine our future. The focus is on what clients are able and willing to do right now to change their behavior (Wubbolding, 2016, 2017). However, Wubbolding states that past behaviors should be unpacked and reevaluated. The American novelist William Faulkner famously said, “The past is never dead. In fact, it is not even past.”

Avoid Focusing on Symptoms In traditional therapy, a great deal of time is spent focusing on symptoms by asking clients how they feel and why they are obsessing. Focusing on the past “protects” clients from facing the reality of unsatisfying present relationships, and focusing on symptoms does the same thing. Whether people are depressing or paining, they tend to think that what they are experiencing is happening to them. They are reluctant to accept the reality that their suffering is due to the total behavior they generate from within themselves. Their symptoms can be viewed as the body’s way of warning them that the behavior they are generating is not satisfying their basic needs. The reality therapist spends as little time as possible on the symptoms because they will last only as long as they are needed to deal with an unsatisfying relationship or the frustration of basic needs. Glasser (2005) maintains that almost all symptoms are caused by a present unhappy relationship. By focusing on present problems, especially interpersonal concerns, therapy can generally be shortened considerably.

Challenge Traditional Views of Mental Illness Choice theory rejects the traditional notion that people with problematic physical and psychological symptoms are mentally ill. Wubbolding (personal communication, August 25, 2021) takes a firm stand on using the DSM-5 in creative ways and adhering to standard practice, which includes diagnosing mental disorders. Glasser (2003), however, has warned people to be cautious of psychiatry, which can be hazardous to both one’s physical and mental health. He criticizes the traditional psychiatric establishment for relying heavily on the DSM-5 (American Psychiatric Association, 2013) for both diagnosis and treatment. Glasser (2003) challenges the traditionally accepted views of mental illness and treatment by the use of medication, especially the widespread use of psychiatric drugs that often results in negative side effects both physically and psychologically. Wubbolding (2017) contends that reality therapy is a mental health system rather than a mental disorder system. He incorporates the Ericksonian principle that “people don’t have problems, they have solutions that have not worked.” By reframing diagnostic categories and negative behaviors, the counselor helps clients perceive their behaviors in a very different light, which facilitates the search for more effective solutions and choices.

The Therapeutic Process Therapeutic Goals

A primary goal of contemporary reality therapy is to help clients get connected or reconnected with the people they have chosen to put in their quality world. In addi- tion to fulfilling this need for love and belonging, a basic goal of reality therapy is to help clients learn better ways of fulfilling all of their needs, including achievement,

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power or inner control, freedom or independence, and fun. The basic human needs serve to focus treatment planning and setting both short- and long-term goals. Reality therapists assist clients in making more effective and responsible choices related to their wants and needs.

In many instances, clients come voluntarily for therapy, and these clients are the easiest to help. However, another goal entails working with an increasing number of involuntary clients who may actively resist the therapist and the therapy process. These individuals often engage in violent behavior, addictions, and other kinds of antisocial behaviors. It is essential for counselors to do whatever they can to connect with involuntary clients. If the counselor is unable to make a connection, there is no possibility of providing significant help. If the counselor can make a connection, the goal of teaching clients how to fulfill their needs can slowly begin.

Therapist’s Function and Role Therapy is often considered as a mentoring process in which the therapist is the teacher and the client is the student. Reality therapists teach clients how to engage in self-evaluation, which is done by raising the question, “Is what you are choosing to do getting you what you want and need?” Here are some other questions that therapists often ask clients:

◆ How would you most like to change your life? ◆ What do you want in your life that you are not getting? ◆ What would you have in your life if you were to change? ◆ What do you have to do now to make the changes happen? ◆ If none of your external circumstances change, what will you do

differently?

The role of the reality therapist is to challenge clients to examine what they are doing rather than making the evaluation for them. Reality therapists assist clients in evaluating their own behavioral direction, specific actions, wants, perceptions, level of commitment, possibilities for new directions, and action plans. Clients then decide what to change and formulate a plan to facilitate the desired changes. The outcome is better relationships, increased happiness, and a sense of inner control over their life (Wubbolding, 2016).

It is the job of therapists to convey the idea that no matter how difficult life maybe, that there is hope. If therapists are able to instill this sense of hope, clients feel that they are no longer alone and that change is possible. Together client and therapist creatively address a range of concerns and options.

Client’s Experience in Therapy Clients are not expected to backtrack into the past or get sidetracked into talking about symptoms. Neither will much time be spent talking about feelings separate from the acting and thinking that are part of the total behaviors over which clients have direct control. The emphasis is on actions. When clients change what they are doing, they often change how they are feeling and thinking.

Reality therapists will gently, but firmly, challenge clients. They often ask clients questions such as these: “Is what you are choosing to do bringing you closer to the

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people you want to be closer to right now?” “Is what you are doing getting you closer to a new person if you are presently disconnected from everyone?” “Is your current level of commitment to make better choices sufficient to achieve your goals? If not, to what degree are you willing to modify your commitment level?” (Wubbolding, 2021a). These questions are part of the self-evaluation process, which is the corner- stone of reality therapy.

Clients can expect to experience some urgency in therapy. Time is important, as each session may be the last. Clients should be able to say to themselves, “I can begin to use what we talked about today in my life. I am able to bring my present experi- ences to therapy as my problems are in the present, and my therapist will not let me escape from that fact.”

Relationship Between Therapist and Client Reality therapy emphasizes an understanding, supportive, and trusting relationship. This therapeutic alliance is the foundation for an effective outcome. Wubbolding (2017) emphasizes the necessity for the counselor to be present physically, emo- tionally, mentally, and behaviorally. Although the therapeutic relationship is para- mount, it is not an end in itself, and it is not automatically curative or healing. For involvement between the therapist and the client to occur, the counselor must have certain personal qualities, including warmth, sincerity, congruence, understanding, acceptance, concern, respect for the client, openness, and the willingness to be chal- lenged by others. (For other personal characteristics, see Chapter 2.) Wubbolding (2011, 2016, 2020, 2023) identifies specific ways for counselors to create a climate that leads to involvement with clients. Some of these ways entail using attending behavior, listening to clients, suspending judgment, doing the unexpected, using humor appropriately, being oneself as a counselor, engaging in facilitative self- disclosure, listening for metaphors in the client’s mode of self-expression, listening for themes, summarizing and focusing, allowing consequences, allowing silence, and being an ethical practitioner. For therapeutic interventions to work effectively, a fair, firm, friendly, and trusting environment is necessary. Once involvement has been established, the counselor assists clients in gaining a deeper understanding of the consequences of their current behavior.

Application: Therapeutic Techniques and Procedures The Practice of Reality Therapy

The practice of reality therapy can best be conceptualized as the cycle of counseling (Wubbolding, 2023), which consists of two major components: (1) creating the coun- seling environment, and (2) implementing specific procedures that lead to changes in behavior. The art of counseling is to weave these components together in ways that lead clients to evaluate their lives and decide to move in more effective directions.

The cycle of counseling begins with creating a working relationship with clients and proceeds through an exploration of clients’ wants, needs, and perceptions. Cli- ents explore their total behavior and make their own evaluation of how effective they are in getting what they want. If clients decide to try new behavior, they make plans

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that will lead to change, and they commit themselves to those plans. The cycle of counseling includes following up on how well clients are doing and offering further consultation as needed.

The concepts of reality therapy may seem simple as they are presented here, but being able to translate these principles into therapeutic practice takes considerable skill and creativity (Wubbolding, 2016, 2017). All certified reality therapy counsel- ors are grounded in the same principles, but the manner in which these principles are applied varies depending on the counselor’s style, personal characteristics, and knowledge. These principles are applied in a progressive manner, but they should not be thought of as discrete and rigid categories. The art of practicing reality therapy involves far more than following procedures in a step-by-step, cookbook fashion. With choice theory in the background of practice, the counselor tailors the counseling to what each client presents. Although the counselor is prepared to work in a way that is meaningful to the client, the move toward satisfying relationships remains in the foreground.

Wubbolding has played a major role in the development of reality therapy and has extended the practice of reality therapy through development of the WDEP sys- tem. I especially value Wubbolding’s contributions to teaching reality therapy and to conceptualizing therapeutic procedures. His ideas render choice theory practical and useable by counselors, and his system provides a basis for conceptualizing and applying the theory. The Student Manual for Theory and Practice of Counseling and Psycho- therapy that accompanies this textbook contains Wubbolding’s (2023) chart, which diagrams the WDEP model. It describes counseling, coaching, managing, supervis- ing, and parenting and highlights issues and tasks to be accomplished throughout the cycle of counseling. The following sections are based on material from various sources (Glasser, 1992, 1998, 2001; Wubbolding, 2011, 2013, 2016, 2017, 2023).

The Counseling Environment The practice of reality therapy rests on the assumption that a supportive and chal- lenging environment allows clients to begin making life changes. The therapeutic relationship is the foundation for effective practice; if this is lacking, there is little hope that the system can be successfully implemented. Counselors who hope to create a therapeutic alliance strive to avoid arguing, attacking, accusing, demean- ing, blaming, bossing, criticizing, demeaning, finding fault, coercing, encouraging excuses, holding grudges, instilling fear, or giving up easily (Wubbolding, 2011, 2016, 2023). In a short period of time, clients generally begin to appreciate the caring, accepting, noncoercive choice theory environment. It is from this mildly confrontive yet always caring environment that clients learn to create the satisfy- ing environment that leads to successful relationships. In this coercion-free atmo- sphere, clients feel free to be creative and to begin to try new behaviors.

Procedures That Lead to Change Reality therapists operate on the assumption that we are motivated to change (1) when we are convinced that our present behavior is not meeting our needs and (2) when we believe we can choose other behaviors that will get us closer to what we want. Reality therapists begin by asking clients what they want from therapy.

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Therapists take the mystery and uncertainty out of the therapeutic process. They also inquire about the choices clients are making in their relationships.

In the first session, a skilled therapist looks for and defines the wants of the client. The therapist also looks for a key unsatisfying present relationship—usually with a spouse, a child, a parent, or an employer. The therapist might ask, “Whose behavior can you control?” This question may need to be asked several times during the next few sessions to deal with clients’ resistance to looking at their own behavior. The emphasis is on encouraging clients to focus on what they can control.

When clients begin to realize that they can control only their own behavior, ther- apy is underway. The rest of therapy focuses on how clients can make better choices. There are more choices available than clients realize, and the therapist explores these possible choices. Clients may be stuck in misery, blaming, and the past, but they can choose to change—even if the other person in the relationship does not change. Wubbolding (2011) points out that clients can learn they are not at the mercy of oth- ers, are not victims, are capable of gaining a sense of inner control, and have a range of choices open to them. In short, clients in reality therapy often acquire a sense of hope for a better future. Wubbolding (2021b) has incorporated the contribution of Julian Rotter (1954) who suggests that clients discuss their perceived locus of control with the therapist. Do clients feel oppressed and diminished by other peo- ple, their external circumstances, or even by their history? Although clients may not believe they have complete control, clients learn that they have more control than they previously believed. Clients realize that they do, in fact, have choices.

Reality therapists explore the tenets of choice theory with clients, helping them identify basic needs, discovering their quality world, and, finally, helping clients understand that they are choosing the total behaviors that are their symptoms. In every instance when clients make a change, it is their choice. With the therapist’s help, clients learn to make better choices than they did when they were on their own. Through choice theory, clients can acquire and maintain successful relationships.

The “WDEP” System Wubbolding (2000, 2016, 2017, 2022, 2023) uses the acronym WDEP to describe key procedures in the practice of reality therapy. The WDEP system can be used to help clients explore their wants, possible things they can do, opportunities for self- evaluation, and design plans for improvement (Wubbolding, 2011, 2016, 2017). The WDEP formulation is not intended to be implemented in a mechanical fashion; rather, this system is based on using specific interventions at the appropriate time (Wubbolding, 2022). Grounded in choice theory, the WDEP system assists people in satisfying their basic needs. Each of the letters refers to a cluster of strategies: W 5 wants, needs, and perceptions; D 5 direction and doing; E 5 self-evaluation; and P 5 planning. These strategies are designed to promote change. Let’s look at each one in more detail.

Wants (Exploring Wants, Needs, and Perceptions) Reality therapists assist clients in discovering their wants and hopes. All wants are related to the five basic needs. The key question asked is, “What do you want?” Through the therapist’s skillful questioning, clients are assisted in defining what they want from the

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counseling process and from the world around them. It is useful for clients to define what they expect and want from the counselor and from themselves. Part of counseling consists of exploring the “picture album,” or quality world, of clients and how their behavior is aimed at moving their perception of the external world closer to their inner world of wants.

Clients are given the opportunity to explore every facet of their lives, including what they want from their family, friends, and work. Furthermore, this exploration of wants, needs, and perceptions should continue throughout the counseling pro- cess as clients’ pictures change.

Here are some useful questions to help clients pinpoint what they want:

◆ If you were the person that you wish you were, what kind of person would you be?

◆ What would your family be like if your wants and their wants matched? ◆ What would you be doing if you were living as you want to live? ◆ Do you really want to change your life? ◆ What is it you want that you don’t seem to be getting from life? ◆ What do you think stops you from making the changes you would

like?

Wubbolding and Brickell (2009) and Gerdes, Wubbolding, and Wubbolding (2012, p. 51) now include questions focused on perceptions:

◆ How do you look at the situation? ◆ Where do you see your control?

People have a great deal more control than they often perceive, and these ques- tions help clients move from a sense of external control to a sense of internal control. This line of questioning sets the stage for applying other procedures in reality ther- apy. It is an art for counselors to know what questions to ask, how to ask them, and when to ask them. Relevant questions help clients gain insights and arrive at plans and solutions. Although well-timed, open-ended questions can help clients identify their counseling goals, excessive questioning can result in resistance and defensive- ness. In this phase of counseling, clients begin to commit to making changes in their behavior.

Direction and Doing The focus on the present is characterized by the key question asked by the reality therapist: “What are you doing?” Even though problems may be rooted in the past, clients need to learn how to deal with them in the present by learning better ways of getting what they want. Problems must be solved either in the present or through a plan for the future. The therapist’s challenge is to help clients make more need-satisfying choices.

Early in counseling it is essential to discuss with clients the overall direction of their lives, including where they are going and where their behavior is taking them. This exploration is preliminary to the subsequent evaluation of whether it is a desirable direction. The therapist holds a mirror before the client and asks, “What do you see for yourself now and in the future?” It often takes some time for this reflection to become clearer to clients so they can verbally express their perceptions.

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Reality therapy focuses on gaining awareness of and changing current total behavior. To accomplish this, reality therapists focus on questions like these: “What are you doing now?” “What did you actually do yesterday?” “What did you want to do differently this past week?” “What stopped you from doing what you said you wanted to do?” and “What will you do tomorrow?”

Listening to clients talk about feelings can be productive, but only if it is linked to what they are doing. When an emergency light on the car dashboard lights up, the driver is alerted that something is wrong and that immediate action is necessary to remedy a problem. In a similar way, when clients talk about problematic feelings, most reality therapists affirm and acknowledge these feelings. Rather than focusing mainly on these feelings, however, reality therapists encourage clients to take action by changing what they are doing and thinking. It is easier to change what we are doing and thinking than to change our feelings. From a choice theory perspective, discussions centering on feelings, without strongly relating them to what people are doing and thinking, are counterproductive.

Self-Evaluation The cornerstone of reality therapy procedures is self-evaluation. “Conducting a searching and fearless self-evaluation is the royal road to behavioral change” (Wubbolding, 2015, p. 860). Clients are asked to make the following self- evaluation: “Does your present behavior have a reasonable chance of getting you what you want now, and will it take you in the direction you want to go?” This evaluation involves the client examining behavioral direction, specific actions, wants, perceptions, new directions, and plans (Wubbolding, 2016, 2017). Wubbolding believes that clients often present a problem with a significant relationship, which is at the root of much of their dissatisfaction. The counselor can help clients evaluate their behavior by asking this question: “Is your current behavior bringing you closer to people important to you or is it driving you further apart?” Through skillful questioning, the counselor helps clients determine if what they are doing is helping them.

Artful questioning assists clients in evaluating their present behavior and the direc- tion this is taking them. Wubbolding (2000, 2011, 2017) suggests questions like these:

◆ Is what you are doing helping or hurting you? ◆ Is what you are doing now what you want to be doing? ◆ Is your behavior working for you? ◆ Is there a healthy congruence between what you are doing and what you

believe? ◆ Is what you are doing against the rules? ◆ Is what you want realistic or attainable? ◆ Does it help you to look at it that way? ◆ Is it really true that you have no control over your situation? ◆ How committed are you to the therapeutic process and to changing

your life? ◆ After carefully examining what you want, does it appear to be in your

best interests and in the best interest of others?

Asking clients to evaluate each component of their total behavior is a major task in reality therapy. It is the counselor’s task to assist clients in evaluating the quality of their actions and to help them make responsible choices and devise effective plans.

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Individuals will not change until they first decide that a change would be more advantageous. Without an honest self-assessment, it is unlikely that clients will change. Reality therapists are relentless in their efforts to help clients con- duct explicit self-evaluations of each behavioral component. When therapists ask a depressing client if this behavior is helping in the long run, they introduce the idea of choice to the client. The process of evaluation of the doing, thinking, feeling, and physiological components of total behavior is within the scope of the client’s responsibility.

Reality therapists may be directive with certain clients at the beginning of treatment to help clients recognize that some behaviors are not effective. In working with clients who are in crisis, for example, it is sometimes necessary to suggest straightforwardly what will work and what will not. Other clients, such as alcoholics and children of alcoholics, need direction early in the course of treatment, for they often do not have the thinking behaviors in their control system to be able to make consistent evaluations of when their lives are seri- ously out of effective control. These clients are likely to have blurred pictures and, at times, to be unaware of what they want or whether their wants are real- istic. As they grow and continue to interact with the counselor, they learn to make evaluations with less and less help from the counselor (Wubbolding, 2011; Wubbolding & Brickell, 2005, 2015).

Planning and Action Much of the significant work of the counseling process involves helping clients identify specific ways to fulfill their wants and needs. Once clients determine what they want to change, they are generally ready to explore other possible behaviors and formulate an action plan. The key question is, “What is your plan?” The process of creating and carrying out plans enables people to begin to gain effective control over their lives. If the plan does not work, for whatever reason, counselor and client work together to devise a different plan. The plan gives clients a starting point, a toehold on life, but plans can be modified as needed. Throughout this planning phase, the counselor continually urges clients to be willing to accept the consequences of their own choices and actions. Not only are plans discussed in light of how they can help the client personally, but plans are also designed in terms of how they are likely to affect others in the client’s life.

Wubbolding (2011, 2016, 2017) discusses the central role of planning and commitment. The culmination of the cycle of counseling rests with a plan of action. Although planning is important, it is effective only if the client has made a self-evaluation and determined that he or she wants to change a behavior. Wubbolding uses the acronym SAMIC3 to capture the essence of a good plan: simple, attainable, measurable, immediate, involved, controlled by the plan- ner, committed to, and consistently done. Wubbolding contends that clients gain more effective control over their lives with plans that have the following characteristics:

◆ The plan is within the limits of the motivation and capacities of the client. Skillful counselors help clients identify plans that involve greater need-fulfilling payoffs. Clients may be asked, “What plans could you make now that would result in a more satisfying life?”

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◆ Good plans are simple and easy to understand. They are realistically doable, positive rather than negative, dependent on the planner, spe- cific, immediate, and repetitive. Although they need to be specific, con- crete, and measurable, plans should be flexible and open to revision as clients gain a deeper understanding of the specific behaviors they want to change.

◆ The plan involves a positive course of action, and it is stated in terms of what the client is willing to do. Even small plans can help clients take significant steps toward their desired changes.

◆ Counselors encourage clients to develop plans that they can carry out independently of what others do. Plans that are contingent on others lead clients to sense that they are not steering their own ship but are at the mercy of the ocean.

◆ Effective plans are repetitive and, ideally, are performed daily. ◆ Plans are carried out as soon as possible. Counselors can ask the ques-

tion, “What are you willing to do today to begin to change your life?” ◆ Plans involve process-centered activities. For example, clients may plan

to do any of the following: apply for a job, write a letter to a friend, take a yoga class, substitute nutritious food for junk food, devote two hours a week to volunteer work, or take a vacation that they have been wanting.

◆ Before clients carry out their plan, it is a good idea for them to evaluate it with their therapist to determine whether it is realistic and attainable and whether it relates to what they need and want. After the plan has been carried out in real life, it is useful to evaluate it again and make any revisions that may be necessary.

◆ To help clients commit themselves to their plan, it is useful for them to firm it up in writing.

Resolutions and plans are empty unless there is a commitment to carry them out. It is up to clients to determine how to take their plans outside the restricted world of therapy and into the everyday world. Effective therapy can be the catalyst that leads to self-directed, responsible living.

Asking clients to determine what they want for themselves, to make a self- evaluation, and to follow through with action plans includes assisting them in determining how intensely they are willing to work to attain the changes they desire. Commitment is not an all-or-nothing matter; it exists in degrees. Wubbolding (2007, 2011, 2016, 2021a) maintains that it is important for a therapist to ask about clients’ level of commitment, or how much they are willing to work to bring about change. This communicates in an implicit way to clients that they have within them the power to take charge of their life. It is essential that those clients who are reluc- tant to make a commitment be helped to express and explore their fears of failing. Clients are helped by a therapist who does not easily give up believing in their ability to make better choices, even if they are not always successful in completing their plans. In his workshops, Wubbolding often mentions this axiom of reality therapy: “To fail to plan is to plan to fail.”

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Application to Group Counseling With the emphasis on connection and interpersonal relationships, reality therapy is well suited for various kinds of group counseling. Groups provide members with many opportunities for exploring ways to meet their needs through the relation- ships formed within the group. In particular, the WDEP system can be applied to helping group members satisfy their basic needs. If members talk about their past experiences or make excuses for their current behavior, the group leader redirects them to what they are presently doing. From the very beginning of a group, the members can be asked to take an honest look at what they are doing and to clarify whether their behavior is getting them what they say they want. Once group mem- bers get a clearer picture of what they have in their life now and what they want to be different, they can use the group as a place to explore alternative courses of behavior.

This model lends itself to expecting the members to carry out homework assign- ments between the group meetings. However, it is the members, with the help of the leader, who evaluate their own behavior and decide whether they want to change some aspect of their life. Members also take the lead in deciding what kinds of homework tasks they will set for themselves as a way to achieve their goals. Group leaders often meet with resistance if they make poorly timed suggestions and plans for how the members should best live. To their credit, reality therapists continue asking the members to evaluate for themselves whether what they are doing is get- ting them what they want. If the members concede that what they are doing is not working for them, their resistance is much more likely to melt, and they tend to be more open to trying different behaviors.

Once the members make some changes, reality therapy provides the structure for them to formulate specific plans for action and to evaluate their level of success. Feedback from the members and the leader can help individuals design realistic and attainable plans. Considerable time is devoted during the group sessions for devel- oping and implementing plans. If members do not carry out a plan, it is important to discuss with them what stopped them. Perhaps they set their goals unrealistically high, or perhaps there is a discrepancy between what they say they want to change and the steps they are willing to take to bring about change.

I also like reality therapy’s insistence that change will not come by insight alone; rather, members have to begin doing something different once they determine that their behavior is not working for them. I am skeptical about the value of cathar- sis as a therapeutic vehicle unless the release of pent-up emotions is eventually put into some kind of cognitive framework and is followed up with an action plan. In the groups that I facilitate, group members are challenged to look at the futility of waiting for others to change. I ask members to assume that the significant people in their life may never change, which means that they will have to take a more active stance in shaping their own destiny. I appreciate the emphasis of reality therapy on teaching clients that the only life they can control is their own and the focus placed on helping group members change their own patterns of acting and thinking.

For a more detailed discussion of reality therapy in groups, see Corey (2023, chap. 14).

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Application of Reality Therapy to School Counseling

This section was provided by Sheri Bauman, PhD, a former school counselor and a professor emerita of counseling at the University of Arizona. Her research focuses on bullying and cyberbullying.

The school counselor’s role differs from the role of mental health counselors. The most obvious difference is the context in which they work: School counselors func- tion in an environment in which the primary purpose is academic instruction, not counseling, and teaching is an important part of their role. Due to their large case- loads, school counselors are limited to brief (sometimes single meeting) interven- tions. They need a theory that incorporates teaching and does not require many sessions. Reality therapy/choice theory (RT/CT) satisfies both of those criteria.

William Glasser’s experience in a school was instrumental in the development of his theory. Glasser’s rejection of the concept of “mental illness” is consistent with school counseling practice; school counselors do not provide diagnosis or treatment of disorders. They focus on the present rather than on examining the origins of a problem, which makes sessions more efficient. Past history is not irrelevant, but the target of change is in the present.

Consistent with the educational mission of schools, school counselors provide education to all students in the form of “guidance lessons.” These are preventive in nature, and the key concepts of RT/CT can be taught for the prevention of relation- ship and developmental problems. Students learn to apply the principles of RT/CT to their own situations. Students in classes in which I taught principles of RT/CT were eager to offer real scenarios on which to practice. Using their own problems convinced them that this is a tool they could use and apply in their lives.

RT/CT is also well-suited for school counselors in their roles as consultants. In The Quality School: Managing Students Without Coercion, Glasser (1990) addressed how reality therapy can be applied to school settings. When this book was published, I was working as a counselor in an alternative high school, and the faculty decided to read and discuss the book. We were so intrigued that we procured funding to send teams to the schools identified in the book and returned with new ideas that enriched our program. Although the focus of the book is classroom management and school climate, the counselors were leaders for incorporating RT/CT into the school ethos. Not only the counselor but the teachers and administrators used the RT/CT framework to conceptualize the school philosophy and approach.

RT/CT is a good fit for school counselors in many ways. In addition to the WDEP process, the emphasis on choice and responsibility is appealing to children and adolescents, who often feel as though adults control everything. When formu- lating an action plan, encouraging students to generate ideas and choose the plan that they are most likely to enact provides some control. Helping youth understand that the goal is to find positive ways to fulfill their basic needs gives them a sense of agency that leads to progress.

For me, the most challenging step in using the WDEP model with students was the first step: W—“What do you want?” For example, “I want to be happy” is too broad to tackle; I guided students to decide on a component of happiness (usually a relationship) that is within their control. Another W that I often heard was some

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version of “I want my mother/teacher/boyfriend to change.” Adolescents were con- vinced that their problem was someone else’s behavior. Choice theory teaches that the only person one can change is oneself. Adolescents sometimes questioned that concept, and it can require some effort to persuade them of its validity. However, when young people really grasp it, a major shift in their thinking is often the result. The counselor then coaches students through the rest of the WDEP steps until the process becomes part of their personal repertoire.

An Expert’s Perspective on Choice Theory/Reality Therapy In this section, Robert E. Wubbolding, EdD, professor emeritus of counseling at Xavier University, Cincinnati, Ohio, and the director of the Center for Reality Therapy in Cincinnati, answers the following questions.

1. What is the most important contribution of choice theory/reality therapy for the practice of individual therapy? The most important contribution of choice theory/reality therapy is the sense of hope it offers individuals based on their needs as internal motiva- tors. Clients learning to formulate plans learn a kind of metacommunication message. They quickly come to believe that a better life is possible for them. They need not be trapped in their victimhood, their sense of alienation or loneliness, or a depression that includes myriad debilitating emotions such as guilt, shame, anger, and rage. Reality therapy is a mental health system, not a mental disorder system. Consequently, the accurate use of reality therapy emphasizes discussions that focus on the possible improvement of mental health rather than on the reasons and symptoms for a life characterized by hopelessness. The desired outcome is a genuine improvement in clients’ sense of happiness and well-being. Thus, they journey from a sense of victimhood to a sense of inner control.

2. What two or three key concepts of choice theory/reality therapy are espe cially applicable to the practice of individual counseling or therapy? The skillful reality therapist uses a structured but flexible system in coun- seling clients. It is useful to teach it to clients so that they can implement the system outside the counseling sessions and after the termination of the counseling relationship. Clients learn that their problems become more manageable when they satisfy their five motivational needs more effectively: survival or self-preservation, love and belonging, inner control or power, freedom or independence, and fun or enjoyment. They also derive knowl- edge and skill in utilizing the WDEP system: defining what they want; identifying their behaviors; evaluating the effectiveness of their actions, cognitions, and feelings; and formulating plans for change. Thus, they become drivers of their own behavioral cars rather than passengers.

3. What two or three techniques from choice theory/reality therapy have practical value for practitioners of individual therapy? Asking clients to define their wants occupies a central place in the prac- tice of reality therapy. The reality therapist assists clients in identifying,

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clarifying, and precisely defining what they want from family, friends, job, society, religious institutions, and especially what they want from them- selves, and from the counseling process. The art of assisting clients in evalu- ating their total behavior and their wants is paramount in the practice of reality therapy. In fact, from a reality therapy point of view, self-evaluation is a sine qua non—an indispensable prerequisite for change.

4. How does choice theory/reality therapy address diversity, mul- ticultural, and social justice issues for the practice of individual counseling? As with any counseling approach, reality therapy needs to be adapted to indi- vidual clients. Clients are products of many cultures, and the reality therapist attempts to establish the absolute prerequisite for successful counseling—the therapeutic alliance. When a reality therapist openly identifies and admits to cultural barriers, the obstacles paradoxically become less important. Real- ity therapy began in a mental hospital and a correctional institution where residents represented a wide and diverse range of cultural backgrounds. As documented in several publications, the use of reality therapy proved to be quite effective. In addition, an abundance of research studies from around the world illustrate the efficacy of reality therapy. The WDEP system focuses on the perception of clients, many of whom feel “put upon” by society. Real- ity therapy focuses on choices available to clients. Practitioners of reality therapy believe with Viktor Frankl that we always have choices. Frankl was imprisoned in a Nazi concentration camp for three years and believed he still retained his power of choice—the choice to see this horrible experience as having purpose and meaning for him and for others. As with any counseling theory, reality therapists can intervene in the institutions and in the commu- nity to increase the choices available to clients.

5. In what ways can choice theory/reality therapy be applied to brief therapy (or time-limited counseling)? In the beginning, reality therapy was critiqued as merely a short-term, problem-solving system that dealt only with symptoms. Since then reality therapy has added many dimensions to solution-focused, rapid, and short- term counseling. It augments the practice of brief therapy by providing a structure that can be adapted to most presenting problems. Moreover, the underlying theory is compatible with treatment planning in that clients can formulate specific objectives related to belonging or involvement with other people, activities that satisfy their sense of inner control or power, that add to their repertoire of choices, and that provide new learning through enjoy- able activities such as hobbies. The goal of each session is the formulation of a specific attainable plan of action.

6. From your perspective, what is the current status and the future of choice theory/reality therapy? Even if reality therapy is used on a short-term basis, it can have lasting outcomes. Changing behavior results in opening new neuropathways. It is clearly congruent with recent findings of neuroscience. Reality therapy has gained respect as a freestanding system connected to cognitive behav- ioral theories. It has enjoyed a slow but gradual increase in acceptance and

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esteem by professional authors and practitioners. When students and train- ees learn accurate principles and applications of reality therapy, they see the depth of its underlying philosophical concepts, the theory (choice theory) as well as the methodology summarized as “the WDEP system of reality therapy.” Moreover, reality therapy has gained recognition by the European Association for Psychotherapy (EAP) as a “scientifically proven system of psychotherapy.” Currently there are working institutes on every continent, except Antarctica, through which qualified faculty members conduct train- ing programs. This commitment to helping professional people increase their skills provides an optimistic and promising sign for the future.

Discussion Questions Related to the Choice Theory/Reality Therapy Perspective

1. Asking clients to define their wants occupies a central place in the practice of reality therapy. How can you enlist client cooperation by beginning counseling with focusing on what clients want in their life?

2. Dr. Wubbolding states: “The art of assisting clients in evaluating their total behavior and their wants is paramount in the practice of reality therapy.” What could you do to encourage your clients to make an honest evaluation of their current behavior?

3. What value do you place on expecting your clients to create an action plan as a way to make the changes they desire?

Choice Theory/Reality Therapy From a Multicultural Perspective

Strengths From a Diversity Perspective The core principles of choice theory and reality therapy have much to offer in the area of multicultural counseling. Reality therapy practitioners demonstrate their respect for the cultural values of their clients by helping them explore how satisfying their current behavior is both to themselves and to others. Once clients make this assessment, they can formulate realistic plans that are consistent with their cultural values. It is a further sign of respect that the counselor refrains from deciding what specific behaviors should be changed. Historically, many cultural groups have been denied a choice in where they can live, work, study, or even how they can wear their hair. Often aspects of a person’s cultural identity had to be silenced to survive in Western society. Therapists must be cognizant of this and work to co-create a plan of action moving forward in therapy within the cultural context of their clients.

Through skillful questioning on the counselor’s part, clients from diverse eth- nic backgrounds can be helped to determine the degree to which they have become acculturated into the dominant society. Is it possible for them to find a balance, retaining their ethnic identity and values while integrating some of the values and practices of the dominant group? Is it necessary? Again, the counselor does not determine this balance for clients but works with them to arrive at their own

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answers. With this focus on thinking and acting rather than on exploring feelings, many clients are less likely to display resistance to counseling.

Wubbolding (2007, 2011, 2016) asserts that the principles underlying choice theory are universal, which makes choice theory applicable to a diverse range of indi- viduals. All of us have internal needs, we all make choices, and we all seek to influence the world around us. Putting the principles of choice theory into action demands creativity, sensitivity to cultures and individuals, and flexibility in implementing the procedures of reality therapy. Reality therapy principles and procedures need to be applied differently in various cultures and must be adapted to the psychological and developmental levels presented by individuals (Wubbolding, 2016).

Based on the assumption that reality therapy must be modified to fit the cul- tural context of people other than North Americans, Wubbolding (2000, 2011) has expanded the practice of reality therapy to multicultural situations. Wubbolding’s experience in conducting reality therapy workshops in Japan, Taiwan, Hong Kong, Singapore, Korea, India, Kuwait, Morocco, Malta, Romania, Australia, Slovenia, Croatia, and countries in western Europe has taught him the difficulty of gen- eralizing about other cultures. Growing out of these multicultural experiences, Wubbolding (2000) has adapted the cycle of counseling in working with Japanese clients. He points to some basic language differences between Japanese and Western cultures. North Americans are inclined to say what they mean and to be assertive. In Japanese culture, assertive language is not appropriate between a child and a par- ent or between an employee and a supervisor. Ways of communicating are more indirect. To ask some Japanese clients what they want may seem harsh and intrusive to them. Because of these style differences, adaptations may be needed to make the practice of reality therapy relevant to Japanese clients:

◆ The reality therapist’s tendency to ask direct questions may need to be softened, with questions being raised more elaborately and indirectly. It may be a mistake to ask individualistic questions built around whether specific behaviors meet the client’s need. Confrontation should be done only after carefully considering the context.

◆ There is no exact Japanese translation for the word “plan,” nor is there an exact word for “accountability,” yet both of these are key dimensions in the practice of reality therapy and are central to Japanese culture.

◆ In asking clients to make plans and commit to them, Western counsel- ors do not settle for a response of “I’ll try.” Instead, they tend to push for an explicit pledge to follow through. In Japanese culture, however, the counselor is likely to accept “I’ll try” as a firm commitment.

These are but a few illustrations of ways in which reality therapy might be adapted to non-Western clients. Even though all people have the same basic needs (survival, love and belonging, power, freedom, and fun), the way these needs are expressed depends largely on the cultural context. In working with culturally diverse clients, the therapist must allow latitude for a wide range of acceptable behaviors to satisfy these needs. As with other theories and the techniques that flow from them, flexibility is a foremost requirement.

A key strength of reality therapy is that it provides clients with tools to make the changes they desire. This is especially true during the planning phase, which is

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central to the process of reality therapy. The focus is on positive steps that can be taken, not on what cannot be done. Clients identify those problems that are caus- ing them difficulty, and these problems become the targets for change. This type of specificity and the direction that is provided by an effective plan are certainly assets in working with diverse client groups. Reality therapy is an open system that allows for flexibility in application based on the needs of culturally diverse individuals.

Reality therapy needs to be used artfully and to be applied in different ways with a variety of clients. Many of its principles and concepts can be incorporated in a dynamic and personal way in the style of counselors, and there is a basis for integrating these concepts with most of the other therapeutic approaches covered in this book.

Shortcomings From a Diversity Perspective One of the shortcomings of reality therapy in working with clients from certain ethnic groups is that it may not take fully into account some very real environmen- tal forces that operate against them in their everyday lives. Counselors need to be broadly trained and be able to compensate for the limitation inherent in all counsel- ing theories. Reality therapy gives only limited attention to helping people address environmental and social problems. Discrimination, racism, sexism, homophobia, heterosexism, ageism, negative attitudes toward disabilities, and other social injus- tices are unfortunate realities, and these forces do limit many individuals in getting what they want from life. It is important for therapists to acknowledge that people do not choose to be the victims of various forms of discrimination and oppression. Openly addressing social injustice issues and having an honest conversation with clients regarding how these injustices affect clients’ day-to-day existence is critical. If therapists do not accept these environmental restrictions or are not interested in bringing about social justice as well as individual change, clients are likely to feel misunderstood. There is a danger that some reality therapists may overstress the ability of these clients to take charge of their lives and not pay enough attention to systemic and environmental factors that can limit the potential for choice.

Some reality therapists may make the mistake of too quickly or too forcefully stressing the ability of their clients to take charge of their lives (Glasser, 2011). Wub- bolding (2013) acknowledges that some people have fewer choices available to them because of oppression and discrimination but emphasizes that they do have choices. Although focusing on choices clients do have is useful, I believe clients may need to talk about the ways their choices are restricted by environmental circumstances. Therapists would do well to consider how both they and their clients could take even small steps toward bringing about societal changes, as do feminist therapists (see Chapter 12). Counselors must be willing to do their part in creating a more just society through deliberate action. Counselors have a responsibility to advocate and act for social justice. They have the responsibility of serving as role models for proactive, deliberate change.

Another shortcoming associated with reality therapy is that some clients are reluctant to assert their own needs. If their cultural values and norms put what is good for the social group ahead of individual wants, counselors must “soften” real- ity therapy somewhat. If reality therapy is to be used effectively with clients from other cultures, the procedures must be adapted to the life experiences and values of members of that culture (Wubbolding, 2000, 2011; Wubbolding et al., 2004).

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Reality Therapy Applied to the Case of Stan As a reality therapist, I am guided by the key concepts of choice theory to identify Stan’s behavioral dynam- ics, to provide a direction for him to work toward, and to teach him about better alternatives for achieving what he wants. Stan has not been effective in getting what he needs—a satisfying relationship.

Stan has fallen into a victim role, blaming others, and looking backward instead of forward. Initially, he wants to tell me about the negative aspects of his life, which he does by dwelling on his major symptoms: de- pression, anxiety, inability to sleep, and other psycho- somatic symptoms. I listen carefully to his concerns, but I hope he will come to realize that he has many options for acting differently. I operate on the prem- ise that therapy will offer the opportunity to explore with Stan what he can build on—successes, produc- tive times, goals, and hopes for the future.

After creating a relationship with Stan, I am able to show him that he does not have to be a victim of his past unless he chooses to be, and I assure him that he has rehashed his past miseries enough. As counseling progresses, Stan learns that even though most of his problems did indeed begin in childhood, there is little he can do now to undo his childhood. However, he can adopt a different perspective on his past experiences and the meaning they hold for him today. He eventual- ly realizes that he has a great deal of control over what he can do for himself now.

I have Stan describe how his life would be different if he were symptom free. I am interested in knowing what he would be doing if he were meeting his needs for belonging, achievement, power, freedom, and fun. I explain to him that he has an ideal picture of what he wants his life to be, yet he does not possess effective behaviors for meeting his needs. I talk to him about all of his basic psychological needs and how this type of therapy will teach him to satisfy them in effective ways. I also explain that his total behavior is made up of acting, thinking, feeling, and physiology. Even though he says he hates feeling anxious most of the time, Stan learns that much of what he is doing and thinking is directly leading to his unwanted feelings and physiological reactions. When he complains of

feeling depressed much of the time, anxious at night, and overcome by panic attacks, I let him know that I am more interested in what he is doing and thinking because these are the behavioral components that can be directly changed.

I help Stan understand that his depressing is the feeling part of his choice. Although he may think he has little control over how he feels, over his bodily sensations, and over his thoughts, I want him to un- derstand that he can begin to take different action, which is likely to change his depressing experience. I frequently ask this question, “Is what you are choosing to do getting you what you want?” I lead Stan to begin to recognize that he does have some indirect control over his feelings. This is best done after he has made some choices about doing something different from what he has been doing. At this point, he is in a better place to see that the choice to take action has contrib- uted to feeling better, which helps him realize that he has some power to change.

Stan tells me about the pictures in his head, a few of which are becoming a counselor, acting confident in meeting people, thinking of himself as a worthwhile person, and enjoying life. Through therapy he makes the evaluation that much of what he is doing is not getting him closer to these pictures or getting him what he wants. After he decides that he is willing to work on himself to be different, the majority of time in the sessions is devoted to making plans and discuss- ing their implementation. We both focus on the spe- cific steps he can take right now to begin the changes he would like.

As Stan continues to carry out plans in the real world, he gradually begins to experience success. When he does backslide, we talk about this together and fine tune his plan. I am not willing to give up on Stan even when he does not make major progress, and Stan lets me know that my support is a source of real inspiration for him to keep working on himself.

I teach Stan about choice theory and the WDEP sys- tem and encourage him to do some reading that can stimulate his thinking about changes in his life. Stan brings some of what he is learning from his reading

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into his sessions, and eventually he is able to achieve some of his goals. The combination of working with a reality therapist, his reading, and his willingness to put what he is learning into practice by engaging in new behaviors in the world assist him in replacing ineffective choices with life-affirming choices. Stan comes to accept that he is the only person who can control his destiny.

Questions for Reflection ◆ If Stan complains of feeling depressed most of the

time and wants you to “fix” him, how would you proceed?

◆ If Stan persists, telling you that his mood is get- ting the best of him and that he wants you to work with his physician in getting him on an antidepres- sant drug, what would you say or do?

◆ What are some of Stan’s basic needs that are not being met? What action plans can you think of

to help Stan find better ways of getting what he wants?

◆ Would you be inclined to do a checklist on alcohol- ism with Stan? Why or why not? If you determined that he was addicted to alcohol, would you insist that he attend a program such as Alcoholics Anon- ymous in conjunction with therapy with you? Why or why not?

◆ What interventions would you make to help Stan explore his total behavior?

Refer to the MindTap for The Case of Stan Video Quiz for Chapter 11, Session 9 (“Reality Therapy”), for a demonstration of my approach to counseling Stan from this perspective. This session deals with assisting Stan in forming an action plan.

*Dr. Kellie Kirksey writes about her ways of thinking and practicing using a reality therapy perspective and applying this model to Gwen.

Reality Therapy Applied to the Case of Gwen* Gwen has lived for a long time believing therapy was for weak and crazy people, and certainly not for an African American woman of strong faith. Gwen has not been in therapy before, and I need to establish a climate of trust and respect so she feels it is safe to ex- press her feelings. As we develop our working alliance, I help Gwen understand that she has already begun the change process by doing something different and coming in for therapy.

Therapist: Tell me what you want your life to be like? [Inquiry about her quality world]

Gwen: I want to feel appreciated and relaxed. I don’t want work to be the most important as- pect of my life. I want to feel strong and healthy in my body. I am tired of feeling achy and over-

whelmed. I want to feel respected and loved by my family. I am tired of feeling like I have to do everything alone.

Therapist: Think back over this past week and tell me something you did to move yourself closer to the life you want.

Gwen: I took a beginner’s yoga class, and it helped me relax. I didn’t feel as achy the next day, so I signed up for an eight-week class. [Gwen tries out a new behavior]

Therapist: That’s great. I am proud of you! You sound committed.

Gwen has gotten into the habit of letting life happen to her rather than taking the steering wheel and driv-

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ing in the direction of her hopes and dreams. For real change to occur, Gwen must “do” something different. The yoga class is a good start for her plan.

Therapist: Now think about what you can do differ- ently in another aspect of your life to move closer to your ideal scene.

Gwen: I feel like I am doing a lot already.

Therapist: You are doing a lot. Is that what you want to continue to do? [A reality check]

Gwen: I know I need to prioritize my life and put my- self first. I know I take on too much. It’s a bad habit, and it is wearing me out. [Self-evaluation]

Therapist: How well is taking on the role of “a go to” person working for you? [No criticism is implied]

Gwen: Not at all! I watched my grandmother wear herself out taking care of the entire family. I need to pull back.

I will not abandon Gwen if she does not meet her goals or if her plans are unsuccessful. I do challenge her in an empathic and supportive manner to discuss what she can do to get back on course. I stay committed to Gwen and help her make the small incremental chang- es that she desires.

Therapist: What are you willing to do differently this week that you can commit to?

Gwen: I can make sure I get more time for myself. I will definitely do the yoga at least twice a week to help me with my flexibility and stress management. I can set up Meals on Wheels for my mom. That could really free up some of my time.

Therapist: Those are good first steps. You are on your way to creating a healthy action plan for your life. Taking these steps can help relieve some of the anxiety you have been feeling. I will check in with you next week at the beginning of our session to see how well you carried out your plan.

Before she leaves, I encourage Gwen to consider read- ing a book I suggest. We will build on her action plan at the next session.

Therapist: Do you think you could find time to read a short book that is easy to read? [I give her Wubbolding and Brickell’s (2001) book, A Set of Directions for Put- ting and Keeping Yourself Together.] This will give you some ideas on action steps you might want to take in other areas of your life. Start by picking just one or two of the activities that you think you can use.

Gwen: What other changes do you think I should make?

The success of our work together depends not only on my skill and ability to establish a relationship with Gwen but also on her willingness to take responsibility for her behavior and her willingness to make alternative choic- es. I want to support Gwen as she discovers her own an- swers to that question. I refrain from telling her what to choose for her action plan. Her success must come from her own evaluation of what needs to shift in her life.

Therapist: This is your journey, and you know best what changes could be beneficial for you. Keep your hands on the steering wheel of your life and notice how you begin to feel once you get in the habit of saying “yes” to your health and well-being. Take things slowly. There is no need to rush and make a lot of changes right away.

I hope Gwen will notice a difference in her anxiety lev- el as she begins to implement her action plan. As she feels more comfortable with taking charge of her life, I believe that she will be able to tackle more significant changes, such as setting clear boundaries with her adult children. Gwen is beginning to venture down a new road. She is stepping up to a new level of personal responsibility and is moving away from being a passive victim of her life circumstances.

Questions for Reflection ◆ What interventions did the therapist make to help

Gwen evaluate her current behavior? ◆ Assess the usefulness of this question in working

with Gwen: “Is what you’re doing helping you get what you want?”

◆ To what degree do you think Gwen is ready to make an action plan?

◆ How would you describe the interaction and the relationship between the therapist and Gwen.

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Summary and Evaluation Summary

The reality therapist functions as a teacher, a mentor, and a model, confronting clients in ways that will help them evaluate what they are doing and whether their behavior is fulfilling their basic needs without harming themselves or others. The heart of reality therapy is learning how to make better and more effective choices and gain more effective control. People take charge of their lives rather than being the victims of circumstances beyond their control. Practitioners of reality therapy focus on what clients are able and willing to do in the present to change their behavior. Practitioners teach clients how to make significant connections with others. Thera- pists continue to ask clients to evaluate the effectiveness of what they are choosing to do to determine if better choices are possible.

The practice of reality therapy weaves together two components, the counsel- ing environment and specific procedures that lead to changes in behavior. This therapeutic process enables clients to move in the direction of getting what they want. The goals of reality therapy include behavioral change, better decision mak- ing, improved significant relationships, enhanced living, and more effective satis- faction of all the psychological needs.

Contributions of Choice Theory/Reality Therapy Among the advantages of reality therapy are its relatively short-term focus and the fact that it deals with conscious behavioral problems. Insight and awareness are not enough; the client’s self-evaluation, a plan of action, and a commitment to fol- lowing through are the core of the therapeutic process. I like the focus on strongly encouraging clients to engage in self-evaluation, to decide if what they are doing is working or not, and to commit themselves to doing what is required to make changes they desire. The existential underpinnings of choice theory are a major strength of this approach, which accentuates taking responsibility for what we are doing. People are not viewed as being hopelessly and helplessly depressed. Instead, people are viewed as doing the best they can, or making the choices they hope will result in fulfilling their needs. With the emphasis on responsibility and choice, indi- viduals can acquire a sense of self-direction and empowerment.

Too often counseling fails because therapists have an agenda for clients. The reality therapist helps clients conduct a searching inventory of what they are doing. If individuals determine that their present behavior is not working, they are then much more likely to consider acquiring a new behavioral repertoire. Many clients approach counseling with a great deal of skepticism. Reality therapy can be used effectively with individuals who manifest reluctance and ambivalence to change. For example, in working with people with addictions, reality therapy strategies can be used to help clients evaluate where their behavior is leading them and to pro- vide clients with options to bring about positive changes in their behavior. Real- ity therapy has been effectively used in addiction treatment and recovery programs for more than 30 years (Wubbolding & Brickell, 2005). Addressing what clients are presently doing and asking clients to evaluate what they want to change fits well in various settings. Reality therapy is an effective, short-term approach, often requiring

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10 sessions or less, that can enable people to make life changes without prolonged therapy (Wubbolding, 2016).

Significant contributions also have been made by applying the basic ideas of reality therapy to the classroom and to school counseling. Although much of what has been written about applying choice theory and reality therapy to schools per- tains to classroom dynamics and the overall structure of a school system, the basic philosophy of choice theory is highly applicable to counseling children and adoles- cent in school settings. Counseling can be designed to assist students in exploring the degree to which they are meeting their needs for love and belonging, power, free- dom, and fun. A significant aim of school counseling is to assist students in design- ing useful action plans to change their behavior.

Using the WDEP system described earlier in this chapter, children and adoles- cents can be invited to explore their wants, needs, and perceptions. The personal char- acteristics of the counselor is key in creating an open climate and in establishing and maintaining a safe atmosphere that will facilitate productive work in the schools. Students can be encouraged to take an honest look at what they are doing and to clarify whether their behavior is getting them what they say they want. The emphasis on present behavior is a plus when it comes to working with children and adoles- cents because counseling is generally time limited in the school context. Depending on their developmental level, children and adolescents can be taught how to make evaluations of what they are doing and how to use self-evaluation to determine if they want to behave in any different ways. Once young people get a clearer picture of what they want, they can begin to make plans that will help them attain their goals.

Limitations and Criticisms of Choice Theory/Reality Therapy From my perspective, one of the main limitations of reality therapy is that it does not give adequate emphasis to the role of the unconscious, the power of the past and the effect of traumatic experiences in early childhood, the therapeutic value of dreams, and the place of transference. Because reality therapy focuses almost exclusively on consciousness, it does not take into account factors such as repressed conflicts and the power of the unconscious in influencing how we think, feel, behave, and choose.

Dealing with dreams is not part of the reality therapist’s repertoire. According to Glasser (2001), it is not therapeutically useful to explore dreams, an idea that I find limiting in this approach. For Glasser, spending time discussing dreams can be a defense used to avoid talking about one’s behavior and, thus, is time wasted. From my perspective, dreams are powerful tools in helping people recognize their internal conflicts. I believe that there is richness in dreams, which can be a short- hand message of clients’ central struggles, wants, hopes, and visions of the future. Asking clients to recall, report, share, and relive their dreams in the here and now of the therapeutic session can help unblock them and can pave the way for clients to take a different course of action.

Similarly, I have a difficult time accepting Glasser’s view of transference as a misleading concept, for I find that clients are able to learn that significant people in their lives have a present influence on how they perceive and react to others. To rule out an exploration of transference that distorts accurate perception of others seems narrow in my view.

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Wubbolding (2017) admits that reality therapy can lend itself to focusing on problem solving, and inexperienced or inadequately trained counselors may impose their own values on clients. Reality therapy is a brief approach to treatment, but Wubbolding emphasizes that it is not a quick fix. Generally, clients need to engage in a process of courageous self-evaluation to determine how well certain behaviors are working and what changes they may want to make. It is the client’s responsibility to determine the behaviors that are the targets for change.

Finally, because reality therapy is easily understood, it may appear to be easy to implement. This is not the case. Effective practice of reality therapy requires practice, supervision, and continuous learning (Wubbolding, 2011, 2016, 2023). Wubbolding (2017) states that there are limits to applying reality therapy, but he contends that “many perceived drawbacks are due to misinterpretations or to the less than artful practice of reality therapy” (p. 199). Competent reality therapists have a thorough understanding of choice theory and have mastered the art of applying reality therapy procedures when working with diverse clients with a range of clinical problems.

Self-Reflection and Discussion Questions 1. What do you think of reality therapy’s focus on present behavior and

lack of interest in past events? 2. How could you help clients make a self-evaluation to determine if what

they are doing is working for them? 3. If you are working with involuntary clients, how could you use choice

theory and reality therapy principles to increase their cooperation with the therapy program?

4. What potential do you see in combining reality therapy with some of the other therapies you have studied? Which theory would you most be inclined to integrate with reality therapy?

5. Think of a behavior you would like to change. What are some steps you would take in creating an action plan to get what you want?

Where to Go From Here Free Podcasts for ACA Members

You can download ACA Podcasts (prerecorded interviews) at www.counseling.org; click on the Resource button and then the Podcast Series. For Chapter 11, Reality Therapy, look for these podcasts:

Podcast ACA088, “Reality Therapy, Choice Theory: What’s the Differ- ence?” by Dr. Robert Wubbolding.

Podcast ACA194, “William Glasser: A Retrospective and Why His Ground- breaking Work Will Continue to Matter in Professional Counseling,” by Dr. Robert Wubbolding.

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Other Resources DVDs offered by the American Psychological Association that are relevant to this chapter include R. Wubbolding (2007), Reality Therapy.

Psychotherapy.net is a comprehensive resource for students and professionals that offers videos and interviews on demonstrating reality therapy working with addictions, adults, and children. New video and editorial content is made available monthly. DVDs relevant to this chapter are available at www.psychotherapy.net and include the following:

Wubbolding, R. (2000). Reality Therapy (Psychotherapy With the Experts Series)

Wubbolding, R. (2000). Reality Therapy for Addictions (Brief Therapy for Addictions Series)

Wubbolding, R. (2002). Reality Therapy With Children (Child Therapy With the Experts Series)

Wubbolding, R. (2014). Choice Theory/Reality Therapy Demonstration: Couple Counseling “Elroy and Judy” (Center for Reality Therapy)

Another source is the video published by the American Counseling Asso- ciation: Reality Therapy and Self-Evaluation (https://aca.digitellinc.com/aca /sessions/10960/view).

The programs offered by William Glasser International are designed to teach the concepts of choice theory and the practice of reality therapy. More than 7,800 therapists have completed the training in reality therapy and choice theory. The institute offers a certification process, which starts with a three-day introductory course known as “basic training” in which participants are involved in discus- sions, demonstrations, and role playing. For those wishing to pursue more exten- sive training, the institute offers a five-part sequential course of study leading to certification in reality therapy, which includes basic training, a basic practi- cum, advanced training, an advanced practicum, and a certification week. This 18-month training program culminates in a Certificate of Completion. For com- plete information on this program, contact William Glasser International (www .wglasserinternational.org).

The Center for Reality Therapy in Cincinnati provides training in the prin- ciples of choice theory/reality therapy applied to counseling, coaching, classroom management, addictions, corrections, and families. Robert Wubbolding is the director and is a frequent presenter at state, national, and international confer- ences. The three-day workshops apply to certification in reality therapy. For more information, contact the Center for Reality Therapy (www.realitytherapywub .com).

The International Journal of Choice Theory and Reality Therapy (free online journal) focuses on concepts of internal control psychology, with particular emphasis on research, development, and practical applications of choice theory and reality ther- apy principles in various settings. For more information about this journal, contact Tom Parish, PhD, Editor, email: [email protected].

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Recommended Supplementary Readings for Chapter 11 Counseling With Choice Theory: The New Reality Therapy (Glasser, 2001) represents the author’s sig- nificant thinking about choice theory and develops the existential theme that we choose all of our total behaviors. Case examples demonstrate how choice theory principles can be applied in helping people establish better relationships. Reality Therapy and Self-Evaluation: The Key to Client Change (Wubbolding, 2017) is an excellent book explaining and extending the role of clients in self- evaluating their behavior. The core concepts of self- evaluation and the WDEP system of reality therapy are addressed, and practical ways of working with

both motivated and unmotivated clients are described. Special attention is given to multicul- tural counseling. Reality Therapy (Wubbolding, 2011) updates and extends previous publications on choice theory and reality therapy. Part of the APA theories of psycho- therapy series, this is a well-written and comprehen- sive overview of reality therapy and choice theory. Case Approach to Counseling and Psychotherapy (Corey, 2013) illustrates how prominent reality therapists Drs. William Glasser and Robert Wubbolding would counsel Ruth from their different perspec- tives of choice theory and reality therapy.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi. org/10.1176/appi.books.9780890425596 Corey, G. (2013). Case approach to counseling and psychotherapy (8th ed.). Brooks/Cole, Cengage Learning. Corey, G. (2023). Theory and practice of group counseling (10th ed.). Cengage Learning. Forrest, G. (2021). Therapeutic alliance in integrative addictions-focused psycho therapy and counseling. Charles C. Thomas. Gerdes, P., Wubbolding, S., & Wub- bolding, R. (2012). Expanding the practical use of the perceptual system. International Journal of Choice Theory and Reality Therapy, 32(1), 16–19. Glasser, W. (1990). The quality school: Managing students without coercion. Harper & Row. Glasser, W. (1992). Reality therapy. New York State Journal for Counseling and Development, 7(l), 5–13. Glasser, W. (1998). Choice theory: A new psychology of personal freedom. HarperCollins. Glasser, W. (2001). Counseling with choice theory: The new reality therapy. HarperCollins. Glasser, W. (2003). Warning: Psychiatry can be hazardous to your mental health. HarperCollins. Glasser, W. (2005). Defining mental health as a public health issue: A new leadership

role for the helping and teaching professions. William Glasser Institute. Glasser, W. (2011). Take charge of your life. iUniverse. Rotter, J. B. (1954). Social learning and clinical psychology. Prentice Hall. Wubbolding, R. E. (2000). Reality therapy for the 21st century. Brunner-Routledge. Wubbolding, R. E. (2007). Glasser quality school. Group Dynamics: Theory, Research and Practice, 11(4), 253–261. Wubbolding, R. E. (2011). Reality therapy. American Psychological Association. Wubbolding, R. E. (2013). Reality therapy. In J. Frew & M. D. Spiegler (Eds.), Contemporary psychotherapies for a diverse world (pp. 339–372). Routledge, Taylor & Francis. Wubbolding, R. E. (2016). Reality therapy/choice theory. In D. Capuzzi & M. D. Stauffer (Eds.), Counseling and psychotherapy: Theories and interventions (6th ed., pp. 311–338). American Counseling Association. Wubbolding, R. E. (2017). Reality therapy and self-evaluation: The key to client change. American Counseling Association. Wubbolding, R. E. (2021a). From “maybe” to “I will”: Level of commitment and self-evaluation. International Journal of Reality Therapy, 40(2), 22–29.

Wubbolding, R. E. (2021b). Locus of control and self-evaluation. International Journal of Choice Theory and Reality Therapy, 41, no. 1 (Fall 2021): 59–65. Wubbolding, R. E. (2022). Reality therapy/choice theory. In D. Capuzzi & M. D. Stauffer (Eds.), Counseling and psychotherapy: Theories and interventions (7th ed., pp. 263–286). American Counseling Association. Wubbolding, R. E. (2023). Cycle of counseling, therapy, coaching, managing, supervising, & parenting (chart, 22nd revision). Center for Reality Therapy. Wubbolding, R. E., & Brickell, J. (2005). Reality therapy in recovery. Directions in Addiction Treatment and Prevention, 9(1), 1–10. Hatherleigh Company. Wubbolding, R. E., & Brickell, J. (2009). Perception: The orphaned component of choice theory. International Journal of Reality Therapy, 28(2), 50–54. Wubbolding, R. E., & Brickell, J. (2015). Counseling with reality therapy (2nd ed.). Speechmark. Wubbolding, R. E., Brickell, J., Imhof, L., Kim, R., Lojk, L., & Al-Rashidi, B. (2004). Reality therapy: A global perspective. International Journal for the Advancement of Counselling, 26(3), 219–228.

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Coauthored by Barbara Herlihy and Gerald Corey*

1. Identify the key figures and their contributions to the development of feminist therapy.

2. Examine the different forms of feminist therapy.

3. Differentiate among the six interrelated principles associated with feminist therapy.

4. Identify the therapeutic goals that guide feminist therapists in their work.

5. Explain the roles of gender and power in the therapeutic process.

6. Describe the importance of an egalitarian relationship and how collaboration works in the therapy process.

7. Identify and discuss standard feminist therapy procedures such as therapist self-disclosure,

reframing, relabeling, gender-role analysis and intervention, power analysis and intervention, and social action.

8. Explain the value of empowerment as a basic strategy.

9. Describe the role of social action in therapy.

10. Examine the application of feminist principles to group counseling.

11. Discuss the application of feminist concepts and techniques to school counseling.

12. Explain the relationship between feminist therapy and multicultural therapy.

13. Identify the key contributions and main limitations of feminist therapy.

Learning Objectives

Feminist Therapy12

*I invited a colleague and friend, Barbara Herlihy PhD, a professor of counselor education at the University of Texas at San Antonio, to coauthor this chapter and to continue to revise the chapter over several editions. We have coau- thored two books (Herlihy & Corey, 2015a, 2015b), which seems like a natural basis for collaboration on a project that we both consider valuable. We want to acknowledge Carolyn Zerbe Enns, PhD, for her comprehensive review and suggestions for revision of this chapter and for contributing two original sections to this chapter.

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Some Contemporary Feminist Therapists Feminist therapy does not have a single founder. Rather, it has been a collective effort by many. We have selected a few individuals who have made significant contributions to feminist therapy for inclusion here,

recognizing full well that many other equally influen- tial scholar-practitioners could have appeared in this space. Feminist therapy is truly founded on a theory of inclusion.

Jean Baker Miller (1927– 2006) was a clinical professor of psychiatry at Boston Uni- versity School of Medicine and director of the Jean Bak- er Miller Training Institute at the Stone Center, Wellesley College. She wrote Toward a New Psychology of Women (1986) and coauthored The Healing Connection: How

Women Form Relationships in Therapy and in Life (Mill- er & Stiver, 1997) and Women’s Growth in Connection (Jordan et al., 1991). Miller collaborated with diverse groups of scholars and colleagues on the development of relational-cultural theory. She made important con- tributions toward expanding this theory and exploring new applications to complex issues in psychotherapy and beyond, including issues of diversity, social action, and workplace change.

Carolyn Zerbe Enns (b. 1951) is professor emerita in the Department of Psychology as well as the Gender, Sexu- ality, and Women’s Stud- ies program at Cornell Col- lege in Mount Vernon, Iowa. Enns became interested in feminist therapy while she was completing her PhD in counseling psychology at

the University of California, Santa Barbara. She has devoted much of her writing to exploring how di- verse forms of feminist theory are likely to influence the priorities and psychotherapy practices of feminist therapists. She is the author of Feminist Theories and

Feminist Psychotherapies: Origins, Themes, and Varia- tions (2004), which traces the development of diverse forms of feminist therapy, including the impact of women of color and transnational influences on femi- nist therapy. Her more recent efforts have focused on articulating the importance of multicultural femi- nist therapies and teaching practices, and explor- ing transnational feminist therapy practice around the world (especially in Japan). Carolyn has coordi- nated edited book and special journal projects such as Oxford Handbook of Feminist Multicultural Counsel- ing Psychology (coedited with Elizabeth Nutt Williams, 2013), Psychological Practice With Women: Guidelines, Diversity, Empowerment (coedited with Joy K. Rice and Roberta L. Nutt, 2015), and a Women & Therapy special issue on Transnational Feminist Theory and Practice (coedited with Lillian Comas-Díaz and Thema Bryant Davis, 2021).

Thema Bryant-Davis (b. 1974), educator and sacred artist, is a professor of psychology in the Pepperdine University Gradu- ate School of Education and Psychology. She is a trauma psychologist who incorporates spirituality and the expres- sive arts as cultural resources for healing and posttraumatic

growth. She received her PhD in clinical psychology from Duke University and completed her postdoc- toral training at Harvard Medical Center’s Victims of Violence Program. Thema Bryant-Davis, a trauma sur- vivor, has dedicated her work to understanding and enhancing the cultural context of trauma recovery. She is a past president of the Society for the Psy- chology of Women, a past American Psychological

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Association representative to the United Nations, and president elect (2022) of the American Psycho- logical Association (APA). She has been honored by the California Psychological Association, American Psychological Association, and Institute of Violence, Abuse, and Trauma for her contributions to the field in leadership, scholarship, mentorship, and media. Bryant-Davis has authored and edited texts on the intersection of religion and psychology, womanist and mujerista psychologies, liberation psychology, multicultural feminist psychology, the societal trau- ma of racism, and the cultural context of interper- sonal and medical traumas.

Lillian Comas-Diaz (b. 1950) was born in Chicago, Illinois, and moved to Puerto Rico— her parents’ homeland—at age six. During her early twenties, Lillian returned to the continental United States, where she experi- enced a traumatic translo- cation due to discrimina-

tion, gendered racism, classism, linguistic terrorism, and xenophobia. These experiences strengthened Lillian’s passion for multiculturalism, a commitment to feminism of color, cultivation of psychospirituality, and a thirst for social justice activism and liberation psychology. She earned her PhD from the University of Massachusetts, Amherst. Lillian Comas-Díaz is a psychologist in private practice and a clinical profes- sor at George Washington University Department of Psychiatry and Behavioural Sciences. She is the re- cipient of the 2019 American Foundation/American Psychological Association Gold Medal Lifetime Award in the Practice of Psychology. Her recent books in- clude Liberation Psychology: Theory, Method, Practice,

and Social Justice (Comas-Diaz & Torres Rivera, 2020); Multicultural Care: A Clinician’s Guide to Cultural Competence (Comas-Diaz, 2012); Latina Psychologists: Thriving in the Cultural Borderlands (Comas-Diaz & Vazquez, 2018); Womanist and Mujerista Psycholo- gies: Voices of Fire, Acts of Courage (Bryant-Davis & Comas-Diaz, 2016); Psychological Health of Women of Color (Comas-Diaz & Greene, 2013); and Women Psychotherapists: Journeys in Healing (Comas-Diaz & Weiner, 2011). As an activist, Lillian has participated in fact-finding delegations investigating human right abuses in Chile, the former Soviet Union, Eastern Europe, and South Africa.

Laura S. Brown (b. 1952) is a founding member of the Feminist Therapy Institute, an organization dedicated to the support of advanced practice in feminist therapy, and a member of the theory workgroup at the National Conference on Education and Training in Feminist Practice. She received her

PhD from Southern Illinois University. She has written several books considered core to feminist practice in psychotherapy and counseling. Subversive Dialogues: Theory in Feminist Therapy (1994) is considered by many to be the foundational book addressing how theory informs practice in feminist therapy. Her most recent book is Feminist Therapy (2018). Brown has made important contributions to thinking about ethics and boundaries and the complexities of ethi- cal practice in small communities. Her current inter- ests include feminist forensic psychology and the application of feminist principles to treatment of trauma survivors.

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Introduction Although feminist therapy originated as a “therapy for women, by women,” the broad scope of contemporary feminist thought goes far beyond the gender con- siderations that were its original focus. Current feminist practice also emphasizes

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a diverse approach that includes an understanding of multiple oppressions, power, privilege, multicultural competence, social justice, and the oppression of all mar- ginalized people. Feminist counseling/therapy puts intersections of gender and other social identities, social location, and power at the core of the therapeutic pro- cess. Feminist counseling is built on the premise that it is essential to consider the social, cultural, and political context that contributes to a person’s problems to be able to understand that person. This perspective has significant implications for the development of counseling theory and for how practitioners intervene with diverse client populations.

Feminist psychotherapy is a philosophical orientation that lends itself to an integration of feminist, multicultural, and social justice concepts and uses a variety of psychotherapy approaches (Enns et al., 2013). A central concept in femi- nist therapy is the importance of understanding and acknowledging psychologi- cal oppression and the constraints imposed by the sociopolitical status to which women and underrepresented marginalized individuals have been relegated. A feminist perspective offers a unique approach to understanding the roles that women and men with diverse social identities and experiences have been socialized to accept and to bringing this understanding into the therapeutic process. The socialization of women with multiple social identities inevitably affects their iden- tity development, self-concept, goals and aspirations, and emotional well-being (Gilligan, 1982; King, 2013). As Natalie Rogers (1995) has observed, socialization patterns tend to result in women giving away their power in relationships, often without being aware of it. Feminist counselors keep knowledge about gender socialization, sexism, and related “isms” in mind in their work with all clients. For some women, ethnicity or race may be experienced as a more salient identity than gender; for others, identity and the oppression associated with gender may be fused with racism.

The majority of clients in counseling are women, and the majority of psycho- therapy practitioners at the master’s level are women. However, most theories that are traditionally taught—including all of the other theories in this book— were founded by White males from Western (American or European) cultures and are not universally applicable. Only Adler assumed a pro-feminist stance in early theory development. The need for a theory that evolves from the think- ing and experiencing of women seems self-evident. Theories are developed from the experiences of the “developer,” and feminist theory is the first therapeutic theory to emerge from a collective effort by women to include the experiences of multiple voices.

Feminist therapists have challenged male-oriented assumptions regarding what constitutes a mentally healthy individual. Early feminist therapy efforts focused on valuing women’s experiences, recognizing political realities, and understanding the unique issues facing women within a patriarchal system. Contemporary practice keeps the impact of gender socialization in the forefront when working with clients but also emphasizes a diverse approach that includes an understanding of multiple oppressions, power, privilege, multicultural com- petence, social justice, and the oppression of all marginalized people (Ameri- can Psychological Association, 2018b; Enns & Byars-Winston, 2010). Feminists believe that gender cannot be considered apart from other identities related to

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race, ethnicity, socioeconomic class, age, and sexual orientation. Recent develop- ments relevant to social justice in counseling have led to an integration of key themes of multiculturalism and feminism (Enns et al., 2013). The contemporary version of feminist therapy and the multicultural and social justice perspectives to counseling practice have a great deal in common (Crethar et al., 2008). All of these approaches provide a systemic perspective based on understanding the social context of clients’ lives and are aimed toward affecting social change as well as individual change.

History and Development The history of feminist therapy is relatively brief when compared with the history of most other approaches found in this book. No single individual can be identified as the founder, which reflects a central theme of feminist collaboration. Feminist therapy was developed by several feminist therapists, all of whom shared the same vision—to improve mental health treatment for women (Evans & Miller, 2016). The beginnings of feminism (often referred to as the first wave) can be traced to the late 1800s, but the women’s movement of the 1960s (the second wave) laid the foundation for the development of feminist therapy. In the 1960s, women began uniting their voices to express their dissatisfaction with the limiting and confining nature of traditional female roles. Consciousness-raising groups, in which women came together to share their experiences and perceptions, helped individual women become aware that they were not alone. A sisterhood developed, and some of the services that evolved from women’s collective desires to improve society included shelters for battered women, rape crisis centers, and women’s health and reproduc- tive health centers.

Believing that personal counseling was a legitimate means to effect change, fem- inist therapists viewed therapy as a partnership between equals and built mutuality and collaboration into the therapeutic process. They took the stance that therapy needed to move away from an intrapsychic perspective on psychopathology (in which the sources of a woman’s unhappiness reside within her) to a focus on under- standing the social, political, and cultural forces in society that damage, oppress, and constrain girls and women, as well as boys and men.

Gilligan’s (1982) work on the development of a morality of care in women and the work of Miller (1986) and the Stone Center scholars in developing the self-in-relation model (now called the “relational-cultural” model) were influen- tial in the evolution of a feminist personality theory. New theories emerged that honored the relational and cooperative dimensions of women’s experiencing (Enns, 1991, 2000, 2004). Feminist therapists began to formally examine the relationship of feminist theory to traditional psychotherapy systems, and integrations with

Refer to the MindTap for this book to interact with video quizzes and various video programs to expand your knowledge on topics relevant to Chapter 12.

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various existing systems were proposed. Some counselors identified themselves as psychoanalytic feminist therapists or as Adlerian-feminist counselors, to mention just two possible integrations.

By the 1980s feminist therapy had changed dramatically, becoming more diverse as it focused increasingly on specific problems and issues such as body image, abu- sive relationships, eating disorders, incest, and other forms of sexual abuse (Enns, 1993). The feminist philosophies that guided the practice of therapy also became more diverse.

The variety within feminist theories provides a range of overlapping perspec- tives from which to work. Brown (2018) defines feminist therapy as a postmodern, technically integrative approach that emphasizes the analysis of gender, power, and social location as strategies for facilitating change. Feminist therapists, both male and female, believe that understanding and confronting gender-role stereotypes and power are central to therapeutic practice and that addressing a client’s problems requires adopting a sociocultural perspective: namely, understanding the impact of the society and culture in which a client lives.

Key Concepts Constructs of Feminist Theory

Worell and Remer (2003) describe the constructs of feminist theory as being gen- der fair, flexible-multicultural, interactionist, and life-span-oriented. Gender-fair and culturally inclusive approaches explain differences in the behavior of women and men in terms of socialization processes rather than as our “innate” natures, thus avoiding dichotomized stereotypes in social roles and interpersonal behavior. This construct also acknowledges that a focus on gender to the exclusion of other identities fails to encompass the experiences of women of color and women from diverse cultures. A flexible-multicultural perspective uses concepts and strategies that apply equally to individuals and groups regardless of age, race, culture, gender, ability, class, or sexual orientation, or other social positionality. The interactionist intersectionality view contains concepts specific to the thinking, feeling, and behav- ing dimensions of human experience and accounts for contextual and environmen- tal factors. A life-span perspective assumes that human development is a lifelong process and that personality and behavioral changes can occur at any time rather than being fixed during early childhood.

Feminist Perspective on Personality Development Feminist therapists emphasize that societal gender-role expectations profoundly influence a person’s identity from the moment of birth, or even prior to birth once the sex is identified, and become deeply ingrained in adult personality. In the 1970s, Gilligan (1977) recognized that theories of moral development were based almost exclusively on research with White males. Gilligan was the first to recognize that male development was presented as the norm and that development of women, although different, was judged by male norms. As a result of her studies on women’s moral and psychosocial development, Gilligan came to believe that women’s sense

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of self and morality are based in issues of responsibility and care for other people and are embedded in a cultural context. She posited that the concepts of connect- edness and interdependence—virtually ignored in male-dominated developmental theories—are central to women’s development.

Kaschak (1992) used the term engendered lives to describe her belief that gen- der is the organizing principle in people’s lives. She has studied the role gender plays in shaping the identities of females and males and believes the masculine defines the feminine. In most cultures, what is considered attractive in a female is defined by men in that culture. For instance, because men pay great attention to women’s bodies in Western society, women’s appearance is given tremendous importance. It is easy to see how this perspective gets reified in both eating disorders and various forms of depression. Men, as the dominant group, also define and determine the roles that women play. Because women occupy a subordinate position, to survive and thrive in society they must be able to interpret the needs and behaviors of the dominant group. To that end, women develop “women’s intuition” and an internal- ized belief that women are less important than men.

Females are raised in a culture grounded in sexism, and understanding and acknowledging internalized oppression is central in feminist therapy. Like all mar- ginalized groups, women are bicultural. They share their own culture with other women and they also have a deep understanding of the male culture that perpetu- ates patriarchy. Men, on the other hand, do not have to understand the culture of women to be able to survive and thrive.

Feminist practitioners remind us that traditional gender stereotypes of women are still prevalent in cultures throughout the world. They teach their clients that uncritical acceptance of traditional roles can greatly restrict their range of freedom. Today many women and men are resisting being so narrowly defined. Women and men in therapy learn that, if they choose to, they can experience mutual behavioral characteristics such as accepting themselves as being interdependent, giving to oth- ers, being open to receiving, thinking and feeling, and being tender and strong. Rather than being cemented to a single behavioral style, women and men who reject traditional roles are saying that they are entitled to express the complex range of characteristics that are appropriate for different situations and that they are open to their vulnerability as human beings.

Recent Trends in Feminist Therapy Most models of human growth and development emphasize a struggle toward inde- pendence and autonomy, but feminists recognize that many women are searching for a connectedness with others as well as possibilities for autonomy. In feminist therapy, women’s relational qualities are seen as strengths and as pathways for healthy growth and development; they are not identified as weaknesses or defects.

Relational-cultural theory (RCT) shares its origins with feminist therapy and emphasizes that growth occurs in connection (Jordan, 2010; Jordan et al., 1991; Miller, 1986, 1991; Miller et al., 1999; Miller & Stiver, 1997; Surrey, 1991; Trepal, 2010). RCT was originally developed to better understand the experi- ences of women, but current practice includes members of other marginalized groups. RCT describes a process of relational movement in which people move

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through connections, disconnections, and enhanced transformative relation- ships throughout their lives (Comstock et al., 2008; Herlihy & Cruz, 2022). Thera- pists recognize that both disconnections and opportunities for growth occur at the sociopolitical as well as at the individual level. They pay attention to the way societal practices such as stereotyping and stratifying affect people’s sense of con- nection and disconnection. Therapists emphasize the qualities of authenticity and transparency that contribute to the flow of the relationship; being empathi- cally present with the suffering of the client is at the core of treatment (Surrey & Jordan, 2012). Therapists aim to reduce the suffering caused by disconnection and isolation, increase clients’ capacity for relational resilience, develop mutual empathy and mutual empowerment, and foster social justice (Jordan, 2010). According to Jordan, people find that they can bring more of themselves into rela- tionships through mutual empathy, and in this process they become more open to learning and change and increase their involvement in the world. Relational- cultural therapy practitioners emphasize deep respect for the client, understand how disconnections affect the individual, and create a therapeutic relationship that is healing (Surrey & Jordan, 2012). For empathy to result in healing and decreased isolation, clients must be able to feel the therapist’s empathic response. Both RCT and feminist therapy foster mutuality, equality, relational capacities, and growth in connection.

Transnational feminism, a recent development in feminist therapy, seeks to encompass the complexity of massive changes that have occurred and are occurring in the 21st century. Its broad, global lens aims to move feminist therapy further toward inclusiveness, particularly for those who have remained at the margins. The focus is on the diverse experiences of women across the globe, particularly those who live in cultural borderlands and in spaces between cultures such as immigrants, refu- gees, and displaced persons. This expansion of the vision of feminist therapy moves beyond Euro-American feminisms and highlights the voices of those who have been silenced. Transnational feminists practice reflexivity, which entails self-examina- tion regarding how they rely on Euro-centric knowledge and unconsciously support oppressive patriarchal systems. Positionality, a related concept, involves therapists examining their own multiple and intersecting social identities and sources of power and privilege.

Transnational feminists emphasize global structural and historical forces that reinforce the dominant ways of thinking and behaving. They draw from multiple sources of knowledge, including womanist, multicultural, decolonizing, and indig- enous women’s perspectives. According to Enns, Bryant-Davis, and Comas-Diaz (2021) and Enns, Bryant-Davis, and Comas-Diaz (2021), transnational feminists seek to examine gendered experiences both within and across cultures, analyze their interdependency, and build coalitions around the world to support critical con- sciousness and social, political, and societal change.

Principles of Feminist Therapy A number of feminist writers have articulated the interrelated and overlapping core principles that form the foundation for the practice of feminist therapy:

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1. The personal is political and critical consciousness. This principle is based on the assumption that the personal or individual problems that individu- als bring to counseling originate in a political and social context. For females this is often a context of marginalization, oppression, subordi- nation, and stereotyping. Acknowledgment of the political and societal impact on an individual’s life is perhaps the most fundamental tenet that lies at the core of feminist therapy.

2. Commitment to social change. Feminist therapies aim not only for indi- vidual change but also for societal change. A distinctive feature of feminist therapy is the assumption that direct action for social change is one of the responsibilities of therapists. For example, counselors who work with women survivors of sexual violence also work to educate and transform the rape culture in which we live. The “#MeToo” movement is a current example of how women survivors can empower themselves by raising their collective voices. It is important for clients who engage in the therapy process to recognize how some of their social identities may grant them unearned privileges and advantages as well as to recognize how they have suffered from oppression as members of a subordinate group and that they can join with others to right these wrongs. Counsel- ors cannot help clients recognize privilege and oppression if they do not understand how these identities have affected their own lives. The goal is to advance a different vision of societal organization that frees both women and men from the constraints imposed by gender-role and social class expectations. This vision of counseling, which moves away from the traditional focus on change from within the individual out into the realm of social activism and societal change, distinguishes feminist therapy from other historically accepted approaches.

3. Women’s and girls’ voices and ways of knowing, as well as the voices of others who have experienced marginalization and oppression, are valued, and their experiences are honored. Traditional therapies operate on androcentric, heterosexist norms embedded in White middle-class heterosexual val- ues and describe women and other marginalized individuals as deviant. Feminist therapists replace patriarchal and other forms of “objective truth” with feminist and social justice consciousness and encourage clients to use their personal experience as a touchstone for determin- ing what is “reality.” Shifting women’s experiences from being ignored and devalued to being sought after and valued is strongly encouraged by feminist therapists (Evans & Miller, 2016). When women’s voices are acknowledged as authoritative, invaluable sources of knowledge, women and other marginalized people can contribute to profound change in the body politic of society.

4. The counseling relationship is egalitarian. Attention to power is central in feminist therapy. The egalitarian relationship, which is marked by authenticity, mutuality, and respect, is at the core of feminist therapy (Pusateri & Headley, 2015). Feminist therapists recognize that there is a power imbalance in the therapeutic relationship, and they strive to shift power and privilege to the voices and experiences of clients

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and away from themselves. An open discussion of power and role dif- ferences in the therapeutic relationship helps clients understand how power dynamics influence both counseling and other relationships and also invites a dialogue about ways to reduce power differentials (Enns, 2004; Evans & Miller, 2016). Brown (2018) has referred to this type of relationship as liberatory, in that clients are freed from the constraints of typical power relationships.

5. A focus on strengths and a reformulated definition of psychological distress. Fem- inist therapy has a conflicted and ambivalent relationship with diag- nostic labeling and the “disease model” of mental illness (Brown, 2018). In feminist therapy, psychological distress is reframed as a communica- tion about unjust systems. When contextual variables are considered, symptoms can be reframed as survival strategies. Feminist therapists talk about problems in the context of living and coping skills rather than pathology (Enns, 2004; Worell & Remer, 2003). For example, a client who is a survivor of childhood sexual abuse may present with dis- sociation, which is understood as a way of coping to be able to survive as a child.

6. All types of oppression are recognized along with the connections among them. Clients can best be understood in the context of their sociocultural envi- ronments. Feminist practitioners acknowledge that social and political inequities have a negative effect on all people. Feminist therapists work to help individuals make changes in their lives, but they also are com- mitted to working toward social change that will liberate all members of society from stereotyping, marginalization, and oppression. Diverse sources of oppression, not simply gender, are identified and interactively explored as a basis for understanding the concerns that clients bring to therapy. Framing clients’ issues within a cultural context leads to empowerment, which can be fully realized only through social change (Evans & Miller, 2016; Worell & Remer, 2003).

7. Reflexivity and positionality are key practices for feminist therapists. Reflexiv- ity, described previously in the discussion of transnational feminism, emphasizes the centrality of therapist self-reflection. Feminist thera- pists also work to be aware of and acknowledge their own positionality. Transnational feminists, in particular, have emphasized the need for cultural humility and avoiding the subtle imposition of one’s uncon- scious/unexamined values.

The Therapeutic Process Therapeutic Goals

Goals of feminist therapy include empowerment, valuing and affirming diversity, striving for change rather than adjustment, equality, balancing independence and interdependence, social change, and self-nurturance (Enns, 2004). A key goal of feminist therapy is to assist individuals in viewing themselves as active agents on their own behalf and on behalf of others. At the individual level, feminist and other

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social justice–oriented therapists work to help individuals recognize, claim, and embrace their personal power. A related goal is to help individuals come together to strengthen collective power. Through empowerment, clients are able to free them- selves from the constraints of their gender-role socialization and other internalized limitations and to challenge ongoing institutional oppression.

According to Worell and Remer (2003), feminist therapists help clients

◆ Become aware of their own gender-role socialization process. ◆ Identify their internalized messages of oppression and replace them

with more self-enhancing beliefs. ◆ Understand how sexist and oppressive societal beliefs and practices

influence them in negative ways. ◆ Acquire skills to bring about change in the environment. ◆ Restructure institutions to rid them of discriminatory practices. ◆ Develop a wide range of behaviors that are freely chosen. ◆ Evaluate the impact of social factors on their lives. ◆ Develop a sense of personal and social power. ◆ Recognize the power of relationships and connectedness. ◆ Trust their own experience and their intuition.

Feminist therapists strive to empower all people to create a world of equality that is reflected at individual, interpersonal, institutional, national, and global levels (Enns & Byars-Winston, 2010). Making oppression transparent is the first step, but the ultimate goal is to replace sexism and other forms of discrimination and oppres- sion with empowerment for all marginalized groups (Brabeck & Brabeck, 2013; Worell & Remer, 2003). Feminist counseling strives for transformation for both the individual client and for society as a whole.

Therapist’s Function and Role Many therapeutic orientations articulate a belief in a therapeutic milieu that is free of biased assumptions about women and other oppressed and marginalized groups and assert that all clients should be treated with respect. The difference between these approaches and feminist therapy is that feminist therapy is based firmly in feminist philosophy that centralizes the sociocultural context of problems that cli- ents bring to counseling.

Theories and techniques are based on the lives and experiences of individu- als (lived experiences) as well as research supporting gender and other inequities (Evans et al., 2011). Feminist therapists hold shared assumptions about therapy, but they come from diverse backgrounds and have various lived experiences that may affect how techniques are applied as well as how clients are conceptualized. In Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 10), three feminist thera- pists (Drs. Evans, Kincade, and Seem) team up to demonstrate a variety of feminist interventions in their work with Ruth. They also conceptualize the case of Ruth from a feminist therapy perspective.

Feminist practitioners have integrated feminism, multiculturalism, and other social justice perspectives into their approach to therapy and into their lives. Their actions and beliefs and their personal and professional lives are congruent. They are

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committed to monitoring their own biases and distortions, especially the social and cultural dimensions of women’s experiences. Feminist and social justice therapists are also committed to understanding oppression in all its forms—including but not limited to sexism, racism, heterosexism, agism, and ableism—and they consider the impact of oppression and discrimination on psychological well-being. They value being emotionally present for their clients, being willing to share themselves during the therapy hour, modeling proactive behaviors, and being committed to their own consciousness-raising process (Evans et al., 2005).

Feminists share common ground with Adlerian therapists in their emphasis on social equality and social interest, with existential therapists who emphasize therapy as a shared journey that is life changing for both client and therapist, and with their basic trust in the client’s ability to move forward in a positive and constructive manner (Bitter et al., 2009). Feminist therapists believe the therapeutic relationship should be a nonhierarchical, person-to-person relationship, and they aim to empower clients to live according to their own values and to rely on an internal (rather than external or societal) locus of control in determining what is right for them. Like person-centered therapists, feminist therapists convey their genuineness and strive for mutual empa- thy between client and therapist. Unlike person-centered therapists, however, feminist therapists do not see the therapeutic relationship alone as being sufficient to produce change. Insight, introspection, and self-awareness are only springboards to action.

Feminist therapists share with postmodern therapists (see Chapter 13) an emphasis on the politics and power relationships in the therapy process and a con- cern about power relations in the world in general. Both feminist and postmodern thought asserts that psychotherapists must not replicate societal power imbalances or foster dependency in the client. Rather, therapist and client take active and equal roles, working together to determine goals and procedures. A common denomina- tor of both feminist and postmodern approaches is recognizing that the therapist is not an all-knowing expert.

Client’s Experience in Therapy Clients are partners in the therapeutic process. It is important that clients tell their stories and give voice to their experiencing. Clients determine what they want from therapy and are the experts on their own lives. A male client, for example, may choose to explore ways in which he has been both limited and privileged by his gender-role socialization. In the safe environment of the therapeutic sessions, he may be able to fully experience emotions of sadness, tenderness, uncertainty, and empathy. As he transfers these ways of being to daily living, he may find that relationships change in his family, his social world, and at work.

Feminist practitioners recognize that gender is only one identity and source of marginalization and oppression, and they value the complex ways in which multiple identities shape a person’s concerns and preferences. Worell and Remer (2003) write that clients acquire a new way of looking at and responding to their world. They add that the shared journey of empowerment can be both frightening and exciting—for both client and therapist. Clients need to be prepared for major shifts in their way of viewing the world around them, changes in the way they perceive themselves, and transformed interpersonal relationships.

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Relationship Between Therapist and Client In feminist therapy, the very structure of the client–therapist relationship models how to identify and use power responsibly. A defining theme of the client–counselor relationship is the inclusion of clients in both the assessment and the treatment pro- cess, keeping the therapeutic relationship as egalitarian as possible. Feminist thera- pists state some of their values during the informed consent process to reduce the chance of value imposition. This allows clients to make a choice regarding whether or not to work with the therapist. It is also a step in demystifying the process.

As mentioned, although there is an inherent power differential in the therapy relationship, feminist therapists are aware of ways they might abuse their own power in the therapy relationship, such as by diagnosing unnecessarily, or without the cli- ent’s knowledge and input, by interpreting or giving advice, by staying aloof behind an “expert” role, by engaging in excessive and inappropriate self-disclosure, or by discounting the impact the power imbalance between therapist and client has on the relationship. Because feminist therapists remain aware of complex cultural iden- tities rather than focusing exclusively on gender, they identify a number of assets that clients bring to counseling, such as the strengths that women of color bring to navigating power differences. They work to demystify the counseling relationship by sharing with the client their own perceptions about what is going on in the relation- ship, by conveying clearly that the client is the expert on her or his life, and by using appropriate and timely self-disclosure on behalf of the client.

Application: Therapeutic Techniques and Procedures The Role of Assessment and Diagnosis

Feminist therapists have been sharply critical of the classification system of past versions of the Diagnostic and Statistical Manual of Mental Disorders as well as of the current DSM-5-TR (Marecek & Gavey, 2013). This critique is based on research indi- cating that gender, culture, and race may influence assessment of clients’ symptoms (e.g., Enns, 2000; Eriksen & Kress, 2005). To the degree that conceptualization and assessment are influenced by subtle forms of sexism, racism, ethnocentrism, hetero- sexism, ageism, or classism, it is extremely difficult to arrive at a meaningful concep- tualization, assessment, or diagnosis.

From the perspective of feminist therapy, diagnoses are based on the dominant culture’s view of normalcy and therefore cannot account for cultural differences (Pusateri & Headley, 2015). Feminist therapists refer to distress rather than psycho- pathology (Brown, 2018), and they use diagnostic labels quite carefully, if at all. They believe diagnostic labels are severely limiting for these reasons: (1) they focus on the individual’s symptoms and not the social factors that cause distress and dysfunc- tional behavior; (2) they are part of a system developed mainly within psychiatry, an institution that reinforces dominant cultural norms and may become an instru- ment of oppression; (3) they may reflect the inappropriate application of power in the therapeutic relationship; (4) they can lead to an overemphasis on individual solutions rather than social change; and (5) they have the potential to dehumanize the client through labeling.

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Feminist therapists believe that external factors and contextual factors are as important as internal dynamics in understanding the client’s presenting problems (Evans & Miller, 2016). The feminist approach emphasizes that many symptoms can be understood as coping or survival strategies rather than as evidence of pathology. Due to the cultural and gender limitations of diagnoses, Eriksen and Kress (2005) encourage therapists “to be tentative in diagnosing those from diverse backgrounds, and to, as a part of a more egalitarian relationship, co-construct an understand- ing of the problem with the client, rather than imposing a diagnosis on the client” (p. 104). Reframing symptoms as resistance to oppression and as coping skills or strategies for survival and shifting the etiology of the problem to the environment avoids “blaming the victim” for her or his problems. Assessment is viewed as an ongoing process between client and therapist and is connected to treatment inter- ventions. In the feminist therapy process, diagnosis of distress becomes secondary to identification and assessment of strengths, skills, and resources (Brown, 2018).

The emphasis of feminist therapy is on wellness rather than disease, resilience rather than deficits, and a celebration of diverse strengths (Brabeck & Brabeck, 2013). Diagnosis, when used, results from a shared dialogue between client and ther- apist. The counselor is careful to review with the client any implications of assigning a diagnosis so the client can make an informed choice, and discussion focuses on helping the client understand the role of socialization and culture in the etiology of these problems.

Techniques and Strategies Feminist therapy does not prescribe any particular set of interventions; rather, it tailors interventions to clients’ strengths with the goal of empowering clients while evoking their feminist consciousness (Brown, 2018). Nonetheless, therapists have developed several unique techniques and have borrowed others from traditional approaches. Particularly important are consciousness-raising techniques that help women differentiate between what they have been taught is socially acceptable or desirable and what is actually healthy for them. Some of the techniques described by Worell and Remer (2003), Enns (1993, 2004), Evans, Kincade, and Seem (2011), and Evans and Miller (2016) are discussed in this section, using the case example of Alma to illustrate how these techniques might be applied.

Alma, age 22, comes to counseling reporting general anxiety about a new job she began a month ago. She states that she has struggled with depression off and on throughout her life because of bullying as a child and rejection from much of her family after coming out as a lesbian at age 14. Alma identifies as Dominican and continues to struggle with the loss of her place within her family of origin. She now believes coming out was a selfish mistake and is trying to make amends by keeping her feelings regarding her sexual and affectional orientation hidden. Due in part to past experiences, if she comes out to her coworkers, she is worried that the com- pany might find a reason to fire her. Alma says, “I would like to cut my hair short again because it is more manageable and I also prefer to wear what is considered to be more masculine clothing, but I am worried this will cause people at work to question my femininity. I really like my job, and I worked very hard to get it. I am afraid if I show them who I really am, they won’t want me there anymore.”

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Considering Alma’s unique cultural identity, a feminist counselor might integrate indigenous values, role models, and spirituality to augment traditional methods of working with her.

Empowerment At the heart of feminist strategies is the goal of empowering the client. Feminist therapists work in an egalitarian manner and use empowerment strategies that are tailored to each client (Brown, 2018; Evans et al., 2011). Alma’s therapist will pay careful attention to informed consent issues, discussing ways Alma can get the most from the therapy session, clarifying expectations, identifying goals, and working toward a contract that will guide the therapeutic process.

Informed consent offers a place to begin a relationship that is egalitarian and collaborative. By explaining how therapy works and enlisting Alma as an active part- ner in the therapeutic venture, the therapy process is demystified and Alma becomes an equal participant. Alma will learn that she is in charge of the direction, length, and procedures of her therapy. Alma’s therapist might ask her, “What is the most powerful thing you could do for yourself right now?” The intent of this question is to “interrupt the trance of powerlessness” by inviting Alma to notice how power is actually available to her (Brown, 2018). Given Alma’s cultural background, it may be particularly important to address power within the therapeutic relationship because Alma may view the therapist as an expert who holds the answers she is seeking.

Self-Disclosure Feminist therapists use therapeutic self-disclosure in the best interests of the client to equalize the client–therapist relationship, to provide modeling, to normalize women’s collective experiences, to empower clients, and to establish informed consent. The counselor engages in self-disclosure only when it is judged to be therapeutically helpful to the client. For example, Alma’s therapist may briefly disclose her own difficulties in relating to members of her family of origin, acknowledging that at times hiding information seems important for the sake of keeping the peace. The counselor might share how she decides when and when not to be open about her personal life. The counselor could then discuss with Alma ways in which they have both experienced cultural and social pressures to conform to a hetero-normative ideal. Alma benefits from this modeling by a woman who does not meet society’s expectations for female behavior and appearance but is comfortable with the image she has developed and how it has worked for her, not against her. The counselor’s disclosure would happen over time, for it is crucial that the counselor does not overshadow the client’s time to explore the concerns that bring her to therapy.

Self-disclosure goes beyond sharing information and experiences; it also involves the quality of presence the therapist brings to the therapeutic sessions. Effective therapist self-disclosure is grounded in authenticity and a sense of mutuality. The therapist explains to Alma the therapeutic interventions that are likely to be employed. Alma, as an informed consumer, will be involved in evaluating how well these strate- gies are working and the degree to which her personal goals in therapy are being met.

Gender-Role and Social Identity Analysis A hallmark of feminist therapy, gender-role analysis assists clients in identifying the impact that their own gender- role socialization has played in shaping their values, thoughts, and behaviors (Evans & Miller, 2016). Some feminist therapists prefer the term social identity analysis

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because it reflects the importance of assessing all relevant aspects of a client’s identity, including multiple memberships in both socially disempowered and privileged groups. For example, Alma identifies as a female, a lesbian, and a Dominican—all marginalized identities within the dominant culture. Social identity and gender-role analysis begins with clients identifying the societal messages they received about how women and men should be and act as well as how these messages interact with other important aspects of identity (Remer, 2013). The therapist begins by asking Alma to identify messages she has received related to sexuality, race/ethnicity, and appearance from her culture, society, her peers, the media, and her family. The therapist talks about how body image expectations differ between females and males in our culture and how they may differ in other cultures. The therapist explains how expectations related to appearance could intersect with beliefs about what it means to be gay or straight in Alma’s culture, family, and society as it relates to her working environment. As Alma identifies the messages playing in her head and the voices behind those messages, she is living with a mindfulness of her internalized oppression. Alma decides what messages she would prefer to have in her mind and keeps an open awareness when the discounting messages play in her head. The goal is for Alma to adopt realistic and affirming internal messages.

Gender-Role and Social Role Intervention Using this technique, the therapist responds to Alma’s concern by placing it in the context of society’s role expectations for women. Gender-role and social role interventions provide Alma with insight into the ways social issues are affecting her. The therapist responds to Alma’s worries about changing her hair and clothing style with this statement:“Our society really focuses on sometimes unrealistic beauty ideals with females. The media bombards girls and women with the message that they must be thin, have long straight hair, and wear attractive clothing. The message is so ingrained that many girls are struggling with self-esteem issues related to their appearance as early as elementary school to avoid being bullied or to fit in.” By placing Alma’s concern in the context of societal expectations, the therapist gives Alma insight into how these expectations have affected her psychological condition and have contributed to her feeling depressed and anxious about judgment from others. The therapist’s statement also paves the way for Alma to think more positively about her unity with other women and even to think about how she might contribute as a role model for girls and young women in the future. Alma is increasing her awareness of the strong role media play in perpetuating oversexualized images of women and how those images affect her self-esteem. Alma may decide to begin a dialogue with other women to discuss ways to create significant change.

Power Analysis Power analysis is an assessment strategy that helps women and other members of marginalized groups understand their devalued stance in society and helps all clients become aware of the power differences between the sexes (Herlihy & Cruz, 2022). Power analysis is also used to help clients become aware of differential power that is related to privilege or lack of privilege in their social context. Alma will become aware of the power difference between women and men as well as the power differences associated with sexual orientation and ethnic status in our society. Specific

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issues related to Alma’s cultural perspective also are explored. The power analysis may focus on helping Alma identify alternate kinds of power she may exercise and learn how to challenge the gender-role and social role messages that prohibit the exercise of that kind of power. Alma choreographs the changes she wants to make in her life. Interventions are aimed at helping Alma learn to appreciate herself as she is, regain her self-confidence based on the personality attributes she possesses, and set goals that will be fulfilling to her within the context of her cultural values.

Bibliotherapy Carefully chosen nonfiction books, psychology and counseling textbooks, autobiographies, self-help books, educational videos, films, and even novels can all be used as bibliotherapy resources. Reading about feminist and multicultural perspectives on common issues in women’s lives (incest, rape, domestic violence, and sexual harassment) may challenge a woman’s tendency to blame herself for these problems (Remer, 2013). The therapist describes a number of books that address issues of relevance to Alma, and she selects one to read over the next few weeks. Providing Alma with reading material increases knowledge and decreases the power difference between Alma and her therapist. Reading can supplement what is learned in the therapy sessions, and Alma can enhance her therapy by exploring her reactions to what she is reading. For women with diverse social identities, books, biographies, and memoirs written by women with similar or related identities can provide concrete examples of empowerment and can facilitate growth.

Assertiveness Training By teaching and promoting assertive behavior, women become aware of their interpersonal rights, transcend stereotypical gender roles, change negative beliefs, and implement changes in their daily life. Alma may learn how sexism has contributed to keeping females passive. For example, a woman behaving in an assertive way is often labeled “aggressive,” but similar behavior in a man may be viewed as “assertive.” Prevailing views of assertive behavior among women in Alma’s culture are also important considerations. She and the therapist will consider what is culturally appropriate, and Alma will decide when and how to be assertive, balancing the potential costs and benefits of assertiveness within her ecological context. The therapist helps Alma evaluate and anticipate the consequences of behaving assertively, which might range from criticism to actually getting what she wants.

Through learning and practicing assertive behaviors and communication, Alma may increase her own power, which will ameliorate her depression and anxiety. Alma learns that it is her right to ask for what she wants and needs in the workplace.

Reframing and Relabeling Like bibliotherapy, therapist self-disclosure, and assertiveness training, reframing is not unique to feminist therapy. However, reframing is applied uniquely in feminist therapy. Reframing includes a shift from placing the problem internally and “blaming the victim” to a consideration of social factors in the environment that contribute to a client’s problem. Rather than dwelling exclusively on intrapsychic factors, the focus is on examining societal or political dimensions. Alma may come to understand that her depression and anxiety are linked to social pressures to behave within hetero-normative gender- role expectations and to develop an appearance that matches these culturally and societally prescribed ideals.

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Relabeling is an intervention that changes the label or evaluation applied to some behavioral characteristic. Alma can change certain labels she has attached to herself, such as being inadequate or socially unwanted because she does not conform to ideals commonly associated with femininity. An example might be that Alma is encouraged to talk about herself as a strong and healthy woman rather than as being “selfish” or too “masculine.”

Social Action An essential quality of feminist counseling is social action, or social activism (Enns et al., 2013; Evans et al., 2011; Evans & Miller, 2016). As clients become more grounded in their understanding of feminism, therapists may suggest that clients become involved in activities such as volunteering at a rape crisis center, lobbying lawmakers, or providing community education about gender issues. Participating in such activities can empower clients and help them see the link between their personal experiences and the sociopolitical context in which they live. Alma might decide to join and participate in organizations that are working to change societal stereotypes about female beauty expectations for women or social groups that affirm people who identify with a variety of sexual and affectional orientations. Participating in social action can increase self-esteem and a sense of personal power.

The Role of Men in Feminist Therapy Men can be feminist therapists, and feminist therapy can be practiced with male cli- ents. It is an erroneous perception that feminist therapy is conducted only by women and for women, or that feminist therapy is anti-men because it is pro-women (Evans et al., 2011; Herlihy & Park, 2016). Although the original feminist therapists were all women, men have now joined their ranks. Male feminist therapists are willing to understand and “own” their male privilege, confront sexist behavior in themselves and others, redefine masculinity and femininity according to other than traditional values, work toward establishing egalitarian relationships, and actively engage in and support women’s efforts to create a just society (Englar-Carlson et al., 2014).

The principles and practices of feminist psychotherapy are useful in working with male clients, individuals from diverse racial and cultural backgrounds, and people who are committed to addressing social justice issues in counseling practice (Enns, 2004; Worell & Remer, 2003). Social mandates about masculinity such as restric- tive emotionality, overvaluing power and control, the sexualization of emotion, and obsession with achievement can be limiting to males (Englar-Carlson, 2014).

Female counselors who work with male clients have an opportunity to create an accepting, authentic, and safe climate in which men can reflect on their needs, choices, past and present pain, and hopes for their future. By using relational- cultural theory, female counselors provide a forum for men to consider the contexts that helped shape them (Duffey & Haberstroh, 2014). Any presenting issue of male clients can be dealt with from a feminist perspective.

For a comprehensive treatment of counseling men in specialized modalities and settings, intersections of identity, and specialized populations and concerns, see Englar-Carlson, Evans, and Duffey (2014). In addition, it would be wise for thera- pists to familiarize themselves with the APA Guidelines for Psychological Practice with Boys and Men (American Psychological Association, 2018a).

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Application of the Feminist Approach to Group Work Feminist therapists often encourage their clients to make the transition from indi- vidual therapy to a group format such as joining a support group or a political action group as soon as this is realistic (Herlihy & Park, 2016). Although these groups are as diverse as the women who comprise them, they share a common denominator of emphasizing support for the experience of women. Women who join these groups eventually realize that they are not alone and gain validation for their experiences by participating in the group. These groups can provide women with a social network, decrease feelings of isolation, create an environment that encourages sharing of experiences, and help women realize that they are not alone in their experiences (Eriksen & Kress, 2005). Groups provide a place where women are valued and affirmed and where they can share and begin to critically explore the messages they have internalized about their self-worth and their place in society. The self-disclosures of both the members and the leader foster deeper self-exploration, a sense of universality, and increased levels of cohesion. Members learn to use power effectively by providing support to one another, practicing behavioral skills, con- sidering social/political actions, and by taking interpersonal risks in a safe setting (Enns, 2004). Through their group participation, women learn that their individual experiences are frequently rooted in problems within the system. Participation in a group experience can inspire women to take up some form of social action. Indeed, a form of homework can be to carry out what women are learning in the group to bring about changes in their lives outside of the group.

Alma and her therapist will likely discuss the possibility of Alma joining a women’s support group, a gay-straight alliance, or another type of group as a part of the process of terminating individual therapy. Participating in a group can enhance Alma’s sense of community. She will witness the journey of personal and collective transformation and growth as she adds to her group of supporters, encouragers, and teachers. Other women can provide her with nurturance and support, and Alma will have the chance to be significant to other women as they engage in their healing process.

Feminist Social Justice Principles Applied to School Counseling

This section was provided by Carolyn Zerbe Enns, PhD, an emerita professor of psychology at Cornell College in Mt. Vernon, Iowa. She has authored and coau- thored numerous chapters, journal articles, and books on feminist multicultural counseling.

During the school years, students experience rapid and extensive gender-related social, psychological, physiological, and developmental/maturational changes that occur in a complex ecological cultural system. This discussion builds on the guide- lines for psychological practice with girls and women (APA, 2018b) and boys and men (APA, 2018a) that articulate feminist social justice principles relevant to school counseling. These principles include (a) the costs of traditional gender socializa- tion as well as dominant masculinities and femininities; (b) intersectionality and the ways in which gender-related identities interact with factors such as culture, immigration status, race/ethnicity, and sexual orientation; and (c) the importance

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of using sociocultural and ecological contexts to understand students’ concerns. In addition, counselors are encouraged to (a) use strengths-based and resilience frame- works when choosing interventions, (b) implement nontraditional interventions relevant to students’ needs, and (c) become involved in social change and advocacy on behalf of students, their families, and school systems.

Traditional gender socialization, which is conveyed through many aspects of culture, often limits the potential and well-being of students. For boys, traditional gender-related socialization and dominant masculinity ideologies are linked to sex- ism, restricted emotional behavior and intimacy, risky sexual behavior, aggression, hypercompetitiveness, and homophobia (APA, 2018a). For girls, “feminine” cultural messages and pressures are linked to issues such as body image concerns and eat- ing disorders, feelings of powerlessness, submission to or compliance with tradi- tional femininity, limited career aspirations, and/or vulnerability to sexual coercion and assault (APA, 2018b). In addition, students who hold queer, gay, bisexual, or other nonnormative identities are often seen as violating norms and may experience ostracism or verbal and physical abuse that contributes to mental health problems. Helping students transcend gender-related pressures is a crucial aspect of school counseling.

One of the hallmarks of feminist assessment is social identity and gender role analysis, which can be used to help students understand their experiences from a holistic perspective. Social identity analysis facilitates exploration of how gender- related challenges are related to complex intersecting identities, privileges, injus- tices, and ecological systems. Tools for helping students construct an identity wheel or identity pie chart are available from multiple Internet sources (e.g., https://equity .cps.edu/tools/social-identity-wheel) and provide ways for students to visualize aspects of their identities (e.g., gender, race/ethnicity, sexual orientation, religion, and related “isms”). Social identity exploration supports students’ understanding of the expectations, costs, and benefits of diverse influences such as peer influences, families, culture, religion, and social/mass media. It also reveals unique challenges as well as sources of strength that students can build on as they make decisions about their values, consider ways to resist gender imperatives and other social pressures, and consider possibilities for challenging marginalization or discrimination. School counselors can integrate social identity exploration with educational curricula, psy- choeducational activities, or group and individual counseling.

Feminist and social justice perspectives prioritize helping students understand how their difficulties (e.g., trauma, body image issues, bullying, or harassment) are related to their complex sociocultural locations. Awareness of these environments can help students reframe their difficulties, gain awareness of how personal and external factors are interconnected, redirect their energy away from self-blame and excessive personalization, identify sources of resilience, and develop more positive self-concepts. Feminist counselors avoid formal diagnosis whenever possible, noting that diagnosis often lodges the source of problems within individuals, may rein- force gender-biased perspectives, and often ignores the coping and survival aspects of symptoms. Caution about labeling is especially appropriate for school-aged stu- dents, who are typically experiencing major developmental changes that are modifi- able through early attention. Instead of emphasizing diagnosis, feminist counselors are likely to help students understand their problems in context and prioritize

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the development of coping skills, agency and initiative, and the enhancement of strengths.

Some of the earliest counseling efforts of feminist therapists addressed trauma- related experiences, especially those of girls and women, that encompassed sexual and interpersonal violence, assault, and sexual harassment. The importance of trauma-based services in schools is noted by the National Child Traumatic Stress Network (NCTSN, 2017), which reported that two-thirds of children have experi- enced a potentially traumatic event by age 16. School counselors need to be cogni- zant of the vulnerability of school-aged students to various forms of violence and to be alert to the behaviors and emotional states of girls and boys who may be contend- ing with the impact of violence in the home or community, in peer relationships, and within school. Well-prepared school counselors build skill sets for providing crisis intervention, counseling traumatized children and adolescents, referring stu- dents for specialized services, participating in activist antiviolence programs, and collaborating with community-based programs such as domestic violence shelters, sexual assault prevention and intervention programs, and child abuse assessment programs. Organizations such as the NCTSN (www.nctsn.org) also offer a variety of tools for recognizing signs of trauma and retraumatization as well as building trauma-informed programs across the school system.

A feminist social justice approach is adapted to the needs of students and may diverge from typical counseling. For example, various expressive arts therapies (art, dance, theater) may be used to explore and express gender-related concerns. To make counseling more attractive to boys and men, action-based instrumental activities, shorter interventions, and informal settings may be used (APA, 2018a). Counselors may also invest energy in activities such as support groups for students of color or with LGBTQ identities, psychoeducational groups related to positive body image, science and math career exploration options for girls, and student-led groups that promote positive conflict management and challenge sexual or gun violence. Finally, a social justice approach encourages both counselors and students to invest energy in social change at local, state, or national levels (e.g., working on school policies that enhance student safety and collaborating with agencies that offer program- ming or services relevant to sexual assault or child abuse).

An Expert’s Perspective on Feminist Therapy In this section, Carolyn Zerbe Enns, PhD, emerita professor of psychology at Cornell College in Mt. Vernon, Iowa, and author of numerous books and journal articles on feminist multicultural counseling, provides answers to the following questions.

1. What is the most important contribution of feminist therapy for the practice of individual therapy? Feminist psychotherapy speaks to the importance of understanding indi- viduals within their ecological spheres. This biopsychosocial approach is also attentive to barriers that individuals face, such as personal and systemic racism, sexism, heterosexism, xenophobia, and other external challenges.

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Feminist therapy offers an important antidote to the labeling of individual problems as symptoms that need to be removed or adjustments that indi- viduals need to make to conform to norms and expectations that may be restrictive or harmful rather than liberating. As a result of its emphasis on social context, feminist counseling allows us to see how restrictive or abu- sive environments contribute to problems. This approach encourages us to think critically about the power structures that affect our lives and to emphasize the importance of social change as well as individual change.

2. What two or three key concepts of feminist therapy are especially applicable to the practice of individual counseling or therapy? Three broad concepts are particularly applicable to individual counseling:

Critical consciousness, consciousness raising, and the personal is political: The personal is political refers to the importance of developing awareness of the intricate connections between our life experiences and problems and the contexts that affect our lives. This phrase reminds us that we cannot view individuals in isolation but must consider how influences such as power, privilege, barriers, “isms,” and culture shape experience. Critical consciousness, or conscious- ness raising, involves developing the ability to see social, economic, and political injustices that shape our lives, which then provides a founda- tion for fighting for social justice at individual and systemic levels. Crit- ical consciousness informs us of the complexity of living and heightens our awareness of the valiant efforts of individuals to cope with difficult circumstances; it also instills the courage to make both personal and social changes.

Agency, resilience, and strength: Resilience emphasizes personal strength, coping, and personal capacity but also recognizes the realities and consequences of hardships, suffering, and oppressions on the lives of individuals. Even when a person’s efforts to cope appear problem- atic, these “symptoms” can be framed as efforts to grow and survive. The strengths-based focus of feminist therapy identifies the resource- fulness of clients and helps individuals redirect energy that otherwise may result in symptoms that limit their options toward productive growth. Exploring how clients’ difficulties are affected by social set- tings and power differences facilitates letting go of self-blame, which enables individuals to use their new knowledge to work toward holistic change.

Intersectionality: Various social identity markers and oppressions are socially constructed and multidimensional, and these multiple identi- ties and oppressions are overlapping, interconnected, and inseparable. For example, race/ethnicity and gender may be fused, resulting in gen- dered racism. The results of intersecting identities may vary, potentially conferring privilege in some settings and resulting in oppression or disadvantage in others. Attention to intersectional complexity facili- tates our understanding of uniqueness and difference and is central to multicultural feminist therapy.

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3. What two or three techniques from feminist therapy have practical value for practitioners of individual therapy? Feminist therapy is less about techniques than it is about how counselors and clients think about life’s difficulties and well-being. Feminist therapy offer a way to organize one’s conceptual assumptions and goals related to counseling. A wide range of techniques associated with diverse counseling approaches are compatible with a feminist framework provided they can be used to empower clients and enact social change; facilitate egalitarian goals, equity, and power sharing; and facilitate social structural as well as individual change. For example, feminist therapists may draw from cognitive behavioral techniques, humanistic techniques, mindfulness practices, advocacy tools, or indigenous traditions that are relevant to a person’s experiences.

As a foundation for using specific techniques, social identity analysis (or gender-role analysis) is a useful feminist multicultural technique for assess- ing and understanding the complex world in which clients live. Social iden- tity analysis involves inquiring about and being attentive to the many social identities clients hold, the “isms” and oppressions they experience (related to gender, age, race/ethnicity, social class, and so forth), and the intersectional features of these identities. The therapist seeks to be attentive to identities that are most salient and important to clients, how the identities are linked or interact, and how various identities confer privilege or disadvantage. Social identity analysis can be conducted using open-ended assessment questions as well as by paying attention to how clients speak about themselves. Social identity analysis can also be facilitated through the use of structured frame- works, such as Pamela Hays’s (2022) ADDRESSING framework: A=age/ generation, D=developmental disability, D=acquired disability, R=religion/ spirituality, E=ethnicity/racial identity, S=socioeconomic status, S=sexual ori- entation, I=indigenous heritage, N=national origin, G=gender. As clients gain deeper and richer understandings of their multiple intersecting identities, they acquire greater knowledge of how these influences contribute to disem- powerment, resilience, options for change, and health. For feminist therapists to develop self-awareness and knowledge of their positionalities, an ongoing social identity analysis and personal reflection are important for uncovering and correcting previously unrecognized assumptions and biases, especially those relevant to working with a diverse range of clients.

4. How does feminist theory address diversity, multicultural, and social justice issues for the practice of individual counseling? I value the perspective of feminist theorist bell hooks, who noted that femi- nism is for everybody. Feminism involves a commitment to equality and efforts to eradicate all forms of bias and oppression including gender bias, racism, ethnocentrism, classism, colonialism, ableism, ageism, heterosex- ism, and any other abuses of power. Social justice and social change have been important commitments of feminist therapy from its earliest days. It is also important to note, however, that women of color have critiqued versions of feminist therapy that reflected the lives and concerns of White middle- and upper-class women more effectively than the diverse realities experienced by most people. Centralizing the perspectives of women and

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others whose experiences have been previously marginalized is crucial to transformative and liberatory feminist and social justice approaches. Inter- sectional perspectives are especially central to valuing diversity and differ- ence rather than any “one approach fits all” options.

Although psychotherapy and individual change are highly valued aspects of feminist counseling, feminist therapy is built on the assumption that movement toward a society in which equity exists requires a commit- ment to activism and advocacy. Feminist therapists are encouraged to devote at least some of their efforts to being informed about and combating social problems and injustices around them.

5. In what ways can feminist theory be applied to brief therapy (or time-limited counseling)? Because feminist therapists see their clients as individuals with substantial strengths and as experts on their own lives, they also believe that clients have the capacity to build on the initial experiences and perspectives they may gain in short-term psychotherapy. In addition to brief therapy, feminist counselors view other psychoeducational and advocacy efforts as empower- ing. Clients or former clients may benefit from support and self-help groups, bibliotherapy and narratives about coping with distress, spirituality and culturally valued rituals, and other community involvements that can aug- ment or expand on counseling. Feminist counselors have historically viewed group work as an important way to help clients experience support, offer insights to peers, and practice skills that may be developed initially in indi- vidual counseling. Educational experiences and skill-building experiences that range from self-defense classes to communication skills and profes- sional skills development are valuable for reinforcing growth and enabling individuals to build on skills and perspectives they gained in brief therapy.

6. From your perspective, what is the current status and the future of the feminist approach? Feminist therapy is becoming more intersectional, multicultural, and trans- national as it continues to evolve. Feminist therapy is not about gender alone; it is relevant to myriad identities and global cultures and to complex sources of oppression and privilege that exist around the world. Feminist therapists of color have also expanded on multicultural approaches such as womanist and mujerista psychologies (e.g., Bryant-Davis, 2019; Bryant- Davis & Comas-Díaz, 2016). As a multicultural and social justice approach, feminist therapy is often integrated and blended with other approaches committed to critiquing status quo concepts of mental health and chal- lenging the assumed neutrality of dominant psychologies of the WEIRD world (Henrich et al., 2010). (WEIRD is an acronym that refers to Western, educated, industrialized, rich, democratic countries that produce most psy- chological knowledge, but make up just 12% of the world’s population.)

Some psychotherapists may work toward egalitarian goals and offer therapy that is consistent with many feminist goals but may be hesitant to use the label “feminist” because of widespread social misunderstandings or cultural distortions of what it means to be a feminist. Feminist practice and feminist theories offer overlapping but divergent perspectives, and the

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phrase feminist therapies (along with additional specifiers) represents a more accurate portrayal of diversity within feminist therapy. Counselors fre- quently use terms such as “feminist social justice therapy” or “multicultural feminist therapy” to highlight the intersectional and integrative nature of their work. Although the labels we use may become more complex, the need to challenge inequity in mental health practice continues to exist.

Despite the greater inclusivity of feminist therapy during recent years, feminist therapists have increasingly recognized the need for self-examination and the decolonization of feminist practice. When feminist therapists are not involved in ongoing self-evaluation, they are capable of inadvertently support- ing the “status quo” and subtle biases rather than transformation. For exam- ple, transnational feminists point out ways in which dominant feminisms of “the West” can be exported and imposed on other cultures in ways that minimize the importance of indigenous and culture-specific values. Cultural humility and egalitarian collaboration across cultures represent important tasks throughout the 21st century. I believe feminist consciousness and femi- nist psychotherapies, especially multicultural and transnational approaches, will continue to be important influences throughout the 21st century.

Discussion Questions Related to the Feminist Therapy Perspective 1. A wide range of techniques associated with diverse counseling

approaches are compatible with a feminist framework provided they can be used to empower clients and enact social change; facilitate egali- tarian goals, equity, and power sharing; and facilitate social structural as well as individual change. What are some techniques used in femi- nist therapy that you particularly like?

2. Feminist therapy rests on the assumption that movement toward a society in which equity exists requires a commitment to activism and advocacy. If you accept this premise, how would this affect your role as a counselor?

3. Feminist therapy involves a commitment to equality and efforts to eradicate all forms of bias and oppression including gender bias, rac- ism, ethnocentrism, classism, colonialism, ableism, ageism, heterosex- ism, and any other abuses of power. What practical implications does this commitment to eradicate all forms of bias and oppression have for you as a counselor?

Feminist Therapy From a Multicultural and Social Justice Perspective

Strengths From a Diversity Perspective Of all the theoretical approaches to counseling and psychotherapy in this book, feminist therapy has the most in common with the multicultural and social justice perspectives. Historically, multicultural approaches evolved in response to societal

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oppression, discrimination, and marginalization faced by people of color. Over time, the multicultural perspective has made counseling more inclusive. Contem- porary counselors who infuse their work with a multicultural perspective address a wide variety of inequities that limit full participation in society. The social justice perspective in counseling aims to empower the individual as well as to confront injustice and inequality in society.

Although multicultural, feminist, and social justice counseling have been viewed as disparate models, they have many common threads (Crethar et al., 2008). All three approaches emphasize the need to promote social, political, and environmental changes within the counseling context. Practitioners of all three perspectives strive to create an egalitarian relationship in which counselor and client co-construct the client’s problems from a contextual perspective and collaborate in setting goals and choosing strategies. All three approaches reject the “disease model” of psychopathol- ogy; they view clients’ problems as symptoms of their experiences of living in an unjust society rather than as having an intrapsychic origin. For example, a hypervigilant and anxious client is viewed through the lens of society and those factors that exist in our world that legitimately create a fear for survival in many diverse communities.

Feminist therapy’s primary tenet, “the personal is also the political,” has been embraced by the multicultural and social justice perspectives. None of the perspec- tives rests solely on individual change; they all emphasize direct action for social change as a part of the role of therapists. Williams and Enns (2013) encourage ther- apists to become activists by making a commitment to social change: “Make the political personal—understand your own history and roots and work to own your own privilege. Perhaps most important, you should choose to do social justice work for you” (p. 488). Therapists must assume the real challenge of taking an honest look at themselves and seeing how they benefit from doing nothing and maintaining the status quo in society. As counseling professionals, we must ask ourselves what our privilege looks like and how we can use our privilege to make society a more just environment. It is not enough to say that we are not racist; we must become an anti- racists and work for system change in society. If we are doing nothing to change the unjust systems in our society, then perhaps we are a part of the problem.

Culture encompasses the sociopolitical reality of people’s lives, including how the privileged dominant group (in Western societies: males, Whites, Christians, het- erosexuals, and the rich) treats those who are different from them. Feminist thera- pists believe psychotherapy is inextricably bound to culture, and, increasingly, they are being joined by thoughtful leaders in the field of counseling practice.

Culturally competent feminist therapists look for ways to work within the con- text of the client’s culture by exploring consequences and alternatives. They appre- ciate the complexities involved in changing within one’s culture, but they do not view culture as sacrosanct (Worell & Remer, 2003). It is important to understand and respect diverse cultures, but most cultural contexts have both positive and toxic aspects, and the toxic aspects that oppress and marginalize groups of people need to be explored and challenged. Feminist therapists are committed to taking a critical look at cultural beliefs and practices that discriminate against, subordinate, and restrict the potential of groups of individuals. Seeing the world through this feminist lens creates activists and allies of those who are culturally humble and who seek a more just society.

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Shortcomings From a Diversity Perspective Feminist practitioners advocate for change in the social structure, especially in the areas of inequality, power in relationships, the right to self-determination, freedom to pursue a career outside or inside the home, and the right to an education. This agenda could pose some problems when working with women who do not espouse these goals. Remer (2013) acknowledges that if therapists do not fully understand and respect the cultural values of clients from diverse groups, they run the risk of imposing their own values. Remer claims “a potential danger inherent in feminist counseling is that counselors’ values will too strongly influence clients or will conflict with clients’ values” (p. 404). Transnational feminists also have cautioned counselors to be aware of the potential for values imposition when working with women from cultures that endorse culturally pre- scribed roles that keep women in a subservient place or are grounded in patriarchy.

Consider this scenario. You are a feminist therapist working with a Vietnamese woman who is struggling to find a way to be true to her culture yet also to follow her own educational and career aspirations. Your client is a student in a helping profes- sion who is being subjected to extreme pressure from her father to return home and take care of her family. Although she wants to complete a degree and eventually help others in the Vietnamese community, she feels a great deal of guilt when she consid- ers “selfishly” pursuing her education when her family at home needs her.

In this complex situation, the therapist is challenged to work together with the client to find a path that enables her to consider her own individual goals without ignoring or devaluing her collectivistic cultural values. The therapist’s job is not to take away her pain or struggle, or to choose for the client, but to be present in such a way that the client will truly be empowered to make significant decisions. The feminist counselor must remain aware that the price may be very high if this woman chooses to go against what is culturally expected of her, and that the client is the one to ultimately decide which path to follow. As can be seen from this example, it is essential that therapists understand how their own cultural perspectives are likely to influence their interventions with culturally diverse clients. A safeguard against value imposition is for feminist therapists to clearly present their values to clients early in the course of the counseling relationship so that clients can make an informed choice about continuing this relationship (Remer, 2013).

Feminist Therapy Applied to the Case of Stan See the APA (2018a) “Guidelines for Psychological Prac- tice with Boys and Men” for instructions on how to ap- ply these new guidelines for understanding Stan.

Stan’s fear of women and his gender-role socializa- tion experiences make him an excellent candidate to benefit from feminist therapy. A therapeutic relation- ship that is egalitarian will be a new kind of experience for Stan.

Stan has indicated that he is willing and even eager to change. Despite his low self-esteem and negative self-evaluations, he is able to identify some positive at- tributes. These include his determination, his ability to articulate his feelings, and his gift for working with chil- dren. Stan knows what he wants out of therapy and has clear goals: to stop drinking, to feel better about him- self, to relate to women on an equal basis, and to learn

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to love and trust himself and others. Operating from a feminist orientation, I will build on these strengths.

In the first session, I focus on establishing an egali- tarian working relationship to help Stan begin to regain his personal power. It is important that the therapeutic relationship does not replicate other relationships Stan has had with significant figures in his life. I consciously work to demystify the therapeutic process and equalize the relationship, conveying to Stan that he is in charge of the direction of his therapy. I spend time explaining my view of the therapy process and how it works.

A gender-role analysis is conducted to help Stan become aware of the influence of gender-role expec- tations in the development of his problems. First, I ask him to identify gender-role messages he received while growing up from his parents, teachers, the media, faith community, and peers. In his autobiography Stan has written about some of the messages his parents gave him, and this provides a natural starting point for his analysis. He remembers his father calling him “dumb” and his mother saying, “Why can’t you grow up and be a man?” Stan wrote about his mother “continually harping at” his father and telling Stan how she wished she hadn’t had him. He describes his father as weak, passive, and mousy in relating to his mother and re- members that his father compared him unfavorably with his siblings. Stan internalized these messages, of- ten crying himself to sleep and feeling very hopeless.

I ask Stan to identify the damaging self-statements he makes now that are based on these early experi- ences. As we review his writings, Stan sees how soci- etal messages he received about what a man “should” be were reinforced by parental messages and have shaped his view of himself today. For example, he wrote that he feels sexually inadequate. It appears that he has introjected the societal notion that men should always initiate sex, be ready for sex, and be able to achieve and sustain an erection. Stan also sees that he has already identified and written about how he wants to change those messages, as exemplified in his state- ments that he wants to “feel equal with others” and not “feel apologetic” for his existence and develop a loving relationship with a woman. Stan begins to feel capable and empowered as I acknowledge the important work he has already done, even before he entered therapy.

I follow this gender-role analysis with a gender-role intervention to place Stan’s concerns in the context of societal role expectations.

Therapist: Indeed, it is a burden to try to live up to so- ciety’s notion of what it means to be a man, always having to be strong and tough. Sometimes real strength comes through our vulnerability. Those aspects of yourself that you would like to value— your ability to experience your feelings, being good with children—are qualities society tends to label as “‘feminine.”

Stan: [Replies wistfully] Yeah, it would be a better world if women could be strong without being seen as domineering and if men could be sensitive and nurturing without being seen as weak.

Therapist: Are you sure that’s not possible? Have you ever met a woman or a man who was like that?

Stan ponders for a minute and then with some animation describes the college professor who taught his Psychol- ogy of Adjustment class. Stan saw her not only as very accomplished and strong, but also as someone who em- powered him by encouraging him to find his own voice through writing his autobiography. He also remembers a male counselor at the youth rehabilitation facility where he spent part of his adolescence as a man who was strong as well as sensitive and nurturing. I ask Stan if there are other people in his life now who might support his efforts to be more accepting and affirming of his androgyny.

As the first session draws to a close, I invite Stan to talk about what he learned from our time together. Stan says two things stand out for him. First, he is be- ginning to believe he doesn’t need to keep blaming himself. He knows that many of the messages he has received from his parents and from society about what it means to be a man have been undesirable and one- dimensional. He acknowledges that he has been lim- ited and constrained by his gender-role socialization. Second, he feels hopeful because there are alternatives to those parental and societal definitions—people he admires have been able to successfully combine “mas- culine” and “feminine” traits. If they can do it, so can he. I ask Stan whether he chooses to return for another session. When he answers in the affirmative, I give him

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W. S. Pollack’s (1998) book Real Boys to read. I explain that this book descriptively captures the gender-role socialization that many boys experience.

Stan comes to the following session eager to talk about his homework assignment. He tells me that he gained some real insights into his own attitudes and beliefs by reading Real Boys. What Stan learned from reading this book leads to a further exploration of his relationship with his mother. He finds it helpful to un- derstand his parents’ behavior in the context of soci- etal expectations and stereotypes rather than continu- ing to blame them. I help Stan to see how our culture tends to hold extreme positions about mothers—that they are either perfect or wicked—and that neither of these extremes is true. We talk briefly about what he has learned about mothers as saints or sinners. As Stan learns to reframe his relationship with his mother, he develops a more realistic picture of her. He comes to realize, too, that his father has been oppressed by his own socialization experiences and by an idealistic view of masculinity that he may have felt unable to achieve.

Stan continues to work at learning to value the nur- turing and sensitive aspects of himself. He is learning to value the “feminine” as well as the “masculine” as- pects of his personality. He continues to monitor and make changes in his self-talk about what it means to be a man. He is gaining awareness of these messages that come from current sources such as the media and friends, and each day he adds to his journal, noting how these messages are transmitted and the ways that he is challenging them.

Throughout our therapeutic relationship, we dis- cuss with immediacy how we are communicating and relating to each other during the sessions. I am self-disclosing and treat Stan as an equal, continually acknowledging that he is the “expert” on his life.

Questions for Reflection ◆ What unique values do you see in working with

Stan from a feminist perspective as opposed to working from the other therapeutic approaches you’ve studied thus far?

◆ If you were to continue working with Stan, what self-statements regarding his view of himself as a man might you focus on, and what alternatives might you offer?

◆ In what ways could you integrate cognitive behavior therapy with feminist therapy in Stan’s case? What possibilities do you see for integrating Gestalt ther- apy methods with feminist therapy? What other ther- apies might you combine with a feminist approach?

Refer to the MindTap for The Case of Stan Video Quiz for Chapter 12, Session 10 (“Feminist Therapy”), for a demonstration of my approach to counseling Stan from this perspective. This session deals with Stan’s exploration of his gen- der-role identity and messages he has incorpo- rated about being a man.

Feminist Therapy Applied to the Case of Gwen* Powerlessness is the theme I hear from Gwen at the beginning of this session. She talks about her sadness in seeing her granddaughter going through the same things she experienced as a young girl. Gwen feels invisible and unappreciated. I want to help Gwen be- come aware of how gender-role socialization has in- fluenced her and help her reclaim her personal power.

Gwen: I can’t tell you how many times in one day I tell myself that I’m not worth anything.

Therapist: Give me an example of something that happens to you and the message you hear inside yourself.

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

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Gwen: Well, in a meeting at work with the partners, I may make a suggestion about something we might do, but I’m ignored. Then Joe, this White guy, makes the same suggestion with just a little twist and the partners are all over it.

Therapist: So your voice is ignored, but the White man gets heard. What do you tell yourself?

Gwen: I get really angry! If I say something, I am ac- cused of “always making it about race.” Then I say to myself, “they are right because most of the time it is about race.” I usually think, “here we go again!”

Therapist: Even though you push back against their message, a part of you believes them—that you are making too big a deal out of your voice being ignored.

Gwen: No, I don’t believe that. Some things are about being a woman of color and not being heard, and that’s just how it is. Society ignores it, but it is real. When someone does not know what it’s like to be invisible and unheard, they are privileged! This is an old, tired story for me.

Therapist: What did you learn growing up about the value of your voice and your value as a girl and a young woman?

Gwen: I learned that boys were valued more than girls. I received the message that being a girl meant you were not strong enough, not smart enough, and that you were required to be in the kitchen clean- ing up after a meal.

I asked Gwen to write a gender-role analysis before our next session. In it she provides more information about the gender-role expectations in her home and in her community as she was growing up. Gwen also writes about telling an adult that her older cousin had touched her inappropriately. She was told to be quiet about the situation, and her sexual abuse was never spoken of again. Gwen learned early that her voice did not matter. In this session, I work toward validating her experiences and the value of her voice. I acknowledge her pain and let her know that society has perpetuated this unequal and devaluing view of women and girls globally.

Therapist: Gwen, I read your gender-role analysis thor- oughly, and I really appreciate you trusting me with the information you shared.

Gwen: It was hard.

Therapist: I’m sure it was. I was especially struck with how early in your life you learned a lesson that too many girls learn—that your voice didn’t count and that your body was not yours. I am so sorry that you had the experience of sexual abuse as a child [It is important to name the reality of her experience and not side-step it].

Gwen: I don’t think I realized until this moment what a strong message was sent to me that day—the day I tried to share with my mother what had happened to me.

Therapist: What message did you receive?

Gwen: My mother said, “Are you sure that happened? I think you are making it up to get him in trouble!”

Therapist: In a culture where males are valued more than females and where males have much more power than females, the response you got from your mother is often given directly or indirectly to girls and women when they tell their truth about being abused.

Gwen: I thought my mother would believe me and would support me.

Therapist: You were and still are disappointed be- cause your mother, a person you trusted, silenced you. And you’re confused about why she, as a woman, would do this.

Gwen: Yes, I am.

Therapist: Keep in mind that your mother was raised in the same culture in which the men are raised. Women hear the same messages discounting females that the men hear.

Gwen: You know, at work I get more angry at the women than at the men. When I’m being discounted

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and being told that I’m too angry and using the “race card,” I rage more at the women than I do at the men.

Therapist: What do you think that is about?

Gwen: Perhaps it is that I’m more disappointed in the women for not standing with me. Or perhaps, like my mother, I value the men more. It really hurts me to believe that might be true.

By placing Gwen’s issue in a larger societal context, she begins to understand that her experiences resonate with the experiences of other women. It helps her to un- derstand that she, too, might be working from a model of males being valued more than females. If she can get a clear understanding of this, she can move more easily to a place of truly believing in her own value.

Gwen is a professional woman with an MBA from a prestigious university. She has had to continuously negotiate minefields of racism, sexism, and multiple forms of inequality. Institutional racism perpetuates the oppression she has experienced and continues to experience, but she sees that using her voice might be- gin the process of healing her personal wounds from this societal injustice. I discuss with Gwen the potential risks of using her voice (becoming more outspoken) in her present professional environment.

Gwen: I’m really tired of feeling angry all the time, but I can tell you I’m also really tired of being treated as “less than.”

Therapist: Tell me more about your experiences of be- ing treated as less than.

Gwen: If I raise my voice or express frustration at work—even if I’m not angry—I am told that I’m too emotional and too angry. I really feel that I’ve been labeled “the angry black woman,” and no matter how appropriate I am with my frustration or with my voice, it is always seen as “there goes that angry black woman again.”

Therapist: So, people at work have written this story about you—angry black woman—and many things that you do are filtered through the lens of that story.

Gwen: Yes, that’s right.

Therapist: Think about the times when you are ap- propriately speaking your mind and sharing your frustration. Tell me what words you use to describe yourself.

Gwen: [Pause] Sometimes I am angry, and I have a right to be, but I would say that I am being passion- ate and assertive.

Therapist: I really like that! How might it be for you to make sure that you restate in your own head that message: “Gwen, you are being passionate and as- sertive.” This is a way to define yourself.

Gwen: It is definitely something I would like to do.

Therapist: You have walked a path cluttered with micro-aggressions for over 50 years, sometimes experiencing these toxic messages multiple times a day. As a woman of color, you are bombarded with the messages from a culture that devalues people of color and women. We can draw on the strength of those who came before us. We are standing on the shoulders of those who fought for our rights as people of color and as women. We know there is injustice in the fabric of our society. What will you do to make changes that are important to you?

Gwen: [Listening intently and reflecting on ways she has been slighted] It feels good to talk about all this.

Therapist: You are an intelligent, passionate, creative, and strong woman. I’m wondering how you might use these parts of you to design your life to be more the way you want it to be.

Gwen: I’m not sure. I do know that I want to be more proactive in my community and more patient with my mother. I’m learning that I still hold resentments from my childhood, and I want to let that go.

Therapist: That sounds like a good place to start.

Gwen: I also want to make sure that I handle my voice and my frustration in the workplace appropriately.

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I want my voice to be heard. Perhaps I can assert- ively ask not to be interrupted when folks start to interrupt me. When someone else is getting credit for my idea, I will remind them that I had shared it earlier. I will ask why it wasn’t heard when I present- ed it. I could do this calmly, but consistently.

Therapist: I think that is an excellent idea.

Gwen has been sitting on the curb of her life watch- ing the traffic go by for far too long. She does not realize her own strength to create change. I share with Gwen some of my challenges with racism. My self-disclosure is intended to join with her in affirming that her experi- ence of oppression is, in fact, valid. As Gwen hears that she is not alone and that she can begin to stand up and use her authentic voice, it is my hope that Gwen will realize she can join with others to make some change in society through conscious action.

I collaborate with Gwen in identifying her resources and deciding how she can make fuller use of them in daily life. I become an ally and supporter as she begins to create a plan of action for social and personal trans- formation.

Therapist: You have shared some of the ways that you want to be more visible in your work environment and more assertive in your daily living. You have also shared some ways that you plan on engag- ing with your mother differently. I’m wondering if there are any social groups you could become part of that would help you feel more connected and involved in the community? Do you know some

other women who are also strong and with whom you could find and offer support?

Gwen: There is a women’s group in my church that is made up of professional women. I’ve avoided being a part of it because I’m so busy and because I was afraid that I wouldn’t fit in. There is one woman in the group I trust, and I think I will talk with her about ways I’m trying to restructure my life and see if she thinks the group would be a good fit for me.

Therapist: So, she would serve for a while like your mirror. She could reflect how she perceives you as you interact with these women.

Gwen: I wasn’t thinking of it exactly in that way. It will just feel good to have someone in the group who I know and feel comfortable with.

As we continue our discussions in future sessions, my goal is to help Gwen reclaim her power, increase her self-esteem, and ultimately reach her full potential as a valuable and significant member of her community.

Questions for Reflection ◆ What reactions do you have to the therapist’s

interventions with Gwen? ◆ What differences do you see when working with

Gwen from a feminist perspective rather than from other theoretical frameworks?

◆ What are your reactions to the therapist’s self-disclosure?

◆ What are potential dangers for Gwen if she increas- ingly speaks her mind in professional settings?

Summary and Evaluation Summary

Feminist therapy largely grew out of the recognition by women that the traditional models of therapy suffer from basic limitations due to the inherent bias of earlier White male theoreticians. Feminist therapy emphasizes these concepts:

◆ Viewing problems in a sociopolitical and cultural context rather than on an individual level

◆ Recognizing that clients are experts on their own lives

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◆ Striving to create a therapeutic relationship that is egalitarian through the process of self-disclosure and informed consent

◆ Demystifying the therapeutic process by including the client as much as possible in all phases of assessment and treatment, which increases client empowerment

◆ Viewing women’s and other marginalized and oppressed groups’ experi- ences from a unique perspective

◆ Understanding that gender never exists in isolation from other aspects of identity

◆ Understanding and appreciating the lives and perspectives of diverse women and other marginalized and oppressed groups

◆ Challenging traditional ways of assessing the psychological health of women and other marginalized and oppressed groups

◆ Emphasizing the role of the therapist as advocate as well as facilitator ◆ Encouraging clients to get involved in social action to address oppres-

sive aspects of the environment

The feminist approach is aimed at both personal and social change. This theo- retical orientation is continually evolving and maturing. The major goal is to replace the current patriarchal system with feminist consciousness and thus create a society that values equality in relationships, embraces diversity, stresses interdependence rather than dependence, and encourages both women and men to define themselves rather than being defined by societal stereotypes.

Feminist practice tends to be diverse because it has been developed and expanded by multiple voices. As the feminist approach has matured, it has become more self- critical and varied. Feminist therapists and other therapists who infuse their work with multicultural and social justice perspectives share a number of basic assump- tions and roles: they engage in appropriate self-disclosure; they make their values and beliefs explicit so that the therapy process is clearly understood; they establish egalitarian roles with clients; they work toward client empowerment; they emphasize the commonalities among women and other marginalized and oppressed groups while honoring their diverse life experiences; and they all have an agenda to bring about social change.

Feminist practitioners are committed to actively breaking down the hierarchy of power in the therapeutic relationship through the use of various interventions. Some of these strategies are unique to feminist therapy, such as gender-role analysis and intervention, power analysis, assuming a stance of advocate in challenging con- ventional attitudes toward appropriate roles for women, and encouraging clients to take social action. Other therapeutic strategies are borrowed from various therapy models, including bibliotherapy, assertiveness training, cognitive restructuring, reframing and relabeling, counselor self-disclosure, role playing, identifying and challenging untested beliefs, and journal writing. Feminist therapy principles and techniques can be applied to a range of therapeutic modalities such as individual therapy, couples counseling, family therapy, group counseling, school counseling, and community intervention. Regardless of the specific techniques used, the over- riding goals are client empowerment and social transformation.

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Contributions of Feminist Therapy and Multicultural and Social Justice Perspectives

A major contribution feminist theorists and practitioners have made to the field of counseling and psychotherapy is paving the way for gender-sensitive practice and an awareness of the impact of the cultural context and multiple oppressions. By focusing attention on our attitudes and biases pertaining to gender and culture, feminists have expanded the awareness of therapists of all theoretical orientations regarding how social justice issues may affect clients. A significant contribution of feminist therapy is the emphasis on social change, which can lead to a transforma- tion in society. Feminist therapists have brought about significant theoretical and professional advances in counseling practice. Some of these contributions include power sharing with clients, cultural critiques of both assessment and treatment approaches, and the validation of women and their experiences. Feminist therapists have also made important contributions by questioning the androcentricity and ethnocentrism of traditional counseling theories and models of human develop- ment. Most theories place the cause of problems within individuals rather than with external circumstances and the environment. This has led to holding individu- als fully responsible for their problems and not giving recognition to social and political realities that create or exacerbate them. Feminist theorists and practitio- ners continue to remind all of us that the proper focus of therapy includes address- ing oppressive factors in society rather than expecting individuals to merely adapt to expected role behaviors. This emphasis on social justice issues has expanded the role of therapists to be advocates for clients. For a discussion of adaptations to tra- ditional approaches to counseling women, see Enns (2017).

The feminist movement has contributed significantly in the area of ethics in psychology and counseling practice (Brabeck & Brabeck, 2013). The unified femi- nist voice called attention to the extent and implications of child abuse, incest, rape, sexual harassment, and domestic violence. Feminists pointed out the consequences of failing to recognize and take action when children and women were victims of physical, sexual, and psychological abuse.

Feminist therapists demanded action in cases of sexual misconduct at a time when male therapists misused the trust placed in them by their female clients. Not too long ago the codes of ethics of the major professional organizations were silent on the matter of therapist and client sexual liaisons. Brown and Courtois (2021) credit the Feminist Therapy Institute Code of Ethics (1990) for bringing attention to sex- ual misconduct in therapy relationships. This code made it clear that sexual con- tact between therapist and client was an ethical violation and a form of abuse. Now virtually all of the professional codes of ethics prohibit sexual intimacies with cur- rent clients and with former clients for a specified time period. Largely due to the efforts and input of women on ethics committees, the existing codes are explicit with respect to sexual harassment and sexual relationships with clients, students, and supervisees (Brown & Courtois, 2021; Herlihy & Corey, 2015b).

Feminist theory has been applied to supervision, teaching, consultation, ethics, research, and theory building as well as to the practice of psychotherapy. Building com- munity, providing authentic mutual empathic relationships, creating a sense of social awareness, and addressing social injustices are all significant strengths of this approach.

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The principles and techniques of feminist therapy can be incorporated in many other contemporary therapy models and vice versa. Both feminist and Adlerian ther- apists view the therapeutic relationship as egalitarian. Both feminist and person- centered therapists agree on the importance of therapist authenticity, modeling, and self-disclosure; empowerment is the basic goal of both orientations. When it comes to making choices about one’s destiny, existential and feminist therapists are speaking the same language—both emphasize choosing for oneself instead of living a life determined by societal dictates.

Although feminist therapists have been critical of psychoanalysis as a sexist ori- entation, a number of feminist therapists believe psychoanalysis can be an appropri- ate approach to helping women. Object-relations theory may help clients examine internalized object representations that are based on their relationships with their parents. Indeed, relational-cultural therapy has roots in object-relations theory. Psy- chodynamic approaches might include an examination of unconscious learning about women’s roles through the mother–daughter relationship to provide insights into why gender roles are so deeply ingrained and difficult to change.

Cognitive-behavioral therapies and feminist therapy are compatible in that they view the therapeutic relationship as a collaborative partnership, with the client being in charge of setting goals and selecting strategies for change. These approaches are committed to demystifying therapy, and both aim to help cli- ents take charge of their own lives. Both the cognitive behavior therapist and the feminist therapist assume a range of information-giving and teaching functions so clients can become active partners in the therapy process. A feminist therapist could employ action-oriented strategies, such as assertiveness training and behav- ioral rehearsal, and suggest homework assignments for clients to practice in their everyday lives. A useful source for further discussion of feminist cognitive behavior therapy is Worell and Remer (2003).

Limitations and Criticisms of Feminist Counseling Feminist therapists do not take a neutral stance; they advocate for change in social structures. A potential limitation pertains to therapists who may impose their val- ues on clients regarding the need to challenge the status quo. Feminist therapists need to identify any sources of bias and work toward restructuring or eliminating biased aspects in any theories or techniques they employ. This is indeed a demand- ing endeavor, and it may involve the counselor’s own therapeutic work, as well as work with a consultant. It is possible for feminist therapists to unduly influence clients, especially those who lack a strong sense of their own values. Feminist thera- pists must remain aware of their own values pertaining to individual and social change and explicitly share these values with clients in an appropriate, timely, and respectful manner to reduce the risk of value imposition.

Feminist therapists call attention to clients’ unexamined choices, and they must honor clients’ choices so long as those choices are indeed informed. Once clients understand the impact of gender and cultural factors on their choices, the therapist must guard against providing specific directions for client growth. Femi- nist therapists are committed to helping clients weigh the costs and benefits of

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their current life choices, but therapists should not push clients too quickly toward changes they are not ready or willing to make. Lenore Walker (1994) raised this issue with regard to working with abused women. Although Walker focuses on the importance of asking questions that enable women to think through their situa- tions in new ways and of helping women develop “safety plans,” she emphasizes how critical it is to understand those factors in a woman’s life that often pose dif- ficulties for her in making changes.

Looking at contextual or environmental factors that contribute to a woman’s problems and moving away from exploring the intrapsychic domain can be both a strength and a limitation. Instead of being blamed for her depression, the cli- ent is able to come to an understanding of external realities that are oppressive and are contributing to her state of depression. A client can make some internal changes even in those circumstances where external realities may largely be con- tributing to her problems. Therapists must balance an exploration of the outer and inner worlds of the client if the client is to find a way to take action in her own life.

Factors that inhibit the growth of feminist therapy include training that is often offered only sporadically in a nonsystematic way (Brown, 2018) and the lack of quality control. No credentialing organization confers official status as a qualified feminist therapist, so formalized training and credentialing need to be addressed in the future. In addition, evidence-based research on the effi- cacy of feminist therapy is lacking, as is an understanding of feminist therapy as an integrative approach that can inform therapeutic practice for counselors of varied theoretical orientations. It is not widely understood that feminist and most other social justice psychotherapies do integrate evidence-based treatment approaches (e.g., CBT and trauma-focused interventions) within a social justice value system.

Self-Reflection and Discussion Questions 1. What key concepts or principles of feminist therapy could you incor-

porate in your counseling practice regardless of your theoretical orientation?

2. Feminist therapists engage in self-disclosure only when it is judged to be therapeutically helpful to the client. How could you assess the degree to which your personal disclosures are appropriate, timely, and helpful to your client?

3. Feminist therapy aims to include social change as well as individual change. How competent will you be in facilitating work with your cli- ents in the area of social action?

4. This approach to therapy places value on exploring issues of power, privi- lege, oppression, and discrimination. Do you see yourself as being comfort- able with and interested in exploring these facets with your clients?

5. A number of feminist therapy techniques are described in this chapter. What one technique do you find particularly interesting? Why?

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Where to Go From Here Other Resources

DVDs offered by the American Psychological Association that are relevant to this chapter include L. S. Brown (2009), Feminist Therapy Over Time (APA Psychotherapy Video Series).

Psychotherapy.net is a comprehensive resource for students and professionals that offers videos and interviews on feminist therapy. New video and editorial con- tent is made available monthly. DVDs relevant to this chapter are available at www .psychotherapy.net and include the following:

Walker, L.(1994). The Abused Woman: A Survivor Therapy Approach

Walker, L. (1997). Feminist Therapy (Psychotherapy With the Experts Series)

The Jean Baker Miller Training Institute offers workshops, courses, profes- sional training, publications, and ongoing projects that explore applications of the relational-cultural approach and integrate research, psychological theory, and social action. This relational-cultural model is based on the assumption that growth- fostering relationships and disconnections are constructed within specific cultural contexts. For more information, contact the Jean Baker Miller Training Institute (www.wellesley.edu/JBMTI/).

The American Psychological Association has two divisions devoted to spe- cial interests in women’s issues: Division 17, Counseling Psychology’s Section on Women (www.div17.org) and Division 35, Psychology of Women (www.apa.org /divisons/div35). For more information, contact the American Psychological Asso- ciation (www.apa.org).

The Association for Women in Psychology (AWP) sponsors an annual confer- ence dealing with feminist contributions to the understanding of life experiences of women. AWP is a scientific and educational feminist organization devoted to reevaluating and reformulating the role that psychology and mental health research generally play in women’s lives. For more information, contact the Association for Women in Psychology (www.awpsych.org).

The Psychology of Women Resource List, or POWR online, is cosponsored by APA Division 35, Society for the Psychology of Women, and the Association for Women in Psychology. This public electronic network facilitates discussion of cur- rent topics, research, teaching strategies, and practice issues among people inter- ested in the discipline of the psychology of women. Most people with computer access to Bitnet or the Internet can subscribe to POWR-L at no cost. To subscribe, send the command below via email to:

LISTSERV@URIACC (Binet) or [email protected]

Subscribe POWR-L Your name (Use first and last name)

The University of Kentucky offers a minor specialty area in counseling women and feminist therapy within the Counseling Psychology graduate programs. For information, contact Dr. Pam Remer, Department of Educational and Counseling Psychology (www.uky.edu/Education/edphead.html).

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Recommended Supplementary Readings for Chapter 12 Feminist Perspectives in Therapy: Empowering Diverse Women (Worell & Remer, 2003) is an outstanding text that clearly outlines the foundations of empowerment in feminist therapy. The book covers a range of topics: integrating feminist and multicultural perspectives on therapy, changing roles for women, feminist views of counseling practice, feminist transformation of counseling theories, and a feminist approach to assessment and diagnosis. There also are excellent chapters dealing with depression, surviving sexual assault, confronting abuse, choosing a career path, and lesbian and ethnic minority women.

Oxford Handbook of Feminist Multicultural Counseling Psychology (Enns & Williams, 2013) is a 26-chapter handbook that integrates feminist and multicultural scholarship and applies the perspective to a variety of women’s diverse identities related to race/ethnicity, social class, disability, religion, culture, and so forth. Multiple chapters focus on the practice of feminist multicultural therapy, pedagogy, mentoring, and social advocacy.

Psychological Practice With Women: Guidelines, Diversity, Empowerment (Enns et al., 2015) discusses the assessment of women’s social identities and diversity and features chapters that focus on psychotherapy with African American women; Latinas; Asian American and Pacific Islander women; Native American women; lesbian, bisexual, and transgender women; women with disabilities; and women in transnational practice. Each chapter includes the application of the APA (2007) guidelines through one or more case studies.

Feminist Therapy (Brown, 2018) provides an interesting perspective on the history of feminist therapy and speculates about future developments of the approach. Brown clearly explains key concepts of feminist theory and the therapeutic process.

Introduction to Feminist Therapy: Strategies for Social and Individual Change (Evans et al., 2011) emphasizes the practical applications of feminist theory to clinical practice. They provide useful information on social change and empowerment, the importance of establishing an egalitarian relationship, and intervention strategies when working with people from diverse cultural backgrounds.

References American Psychological Association. (2007). Guidelines for psychological practice with girls and women. American Psychologist, 62, 949–979. American Psychological Association. (2018a). APA guidelines for psychological practice with boys and men. http://www.apa .org/about/policy/psychological-practice -boys-men-guidelines.pdf American Psychological Association. (2018b). APA guidelines for psychological

practice with girls and women. American Psychological Association. http://www .apa.org/about/policy/psychological -practice-girls-women.pdf Bitter, J. R., Robertson, P. E., Healey, A., & Cole, L. (2009). Reclaiming a profeminist orientation in Adlerian therapy. Journal of Individual Psychology, 65(1), 13–33. Brabeck, M. M., & Brabeck, K. M. (2013). Feminist and multicultural ethics

in counseling psychology. In C. Z. Enns & E. N. Williams (Eds.), Oxford handbook of feminist multicultural counseling psychology (pp. 27–44). Oxford University Press. Brown, L. S. (1994). Subversive dialogues: Theory in feminist therapy. Basic Books. Brown, L. S. (2018). Feminist therapy (2nd ed.). American Psychological Association. Brown, L. S., & Courtois, C. A. (2021). Sexual misconduct in the feminist therapy

Texas Women’s University offers a training program with emphasis in women’s issues, gender issues, and family psychology. For information, contact Texas Wom- en’s University (www.twu.edu/as/psyphil/Counseling_Home.htm).

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A counselor’s guide to working with men (pp. 1–31). American Counseling Association. Englar-Carlson, M., Evans, M. P., & Duffey, T. (2014). A counselor’s guide to working with men. American Counseling Association. Enns, C. Z. (1991). The “new” relationship models of women’s identity: A review and critique for counselors. Journal of Counseling & Development, 69, 209–217. Enns, C. Z. (1993). Twenty years of feminist counseling and therapy: From naming biases to implementing multifaceted practice. The Counseling Psychologist, 21(1), 3–87. Enns, C. Z. (2000). Gender issues in counseling. In S. D. Brown & R. W. Lent (Eds.), Handbook of counseling psychology (3rd ed., pp. 601–638). Wiley. Enns, C. Z. (2004). Feminist theories and feminist psychotherapies: Origins, themes, and diversity (2nd ed.). Haworth. Enns, C. Z. (2017). Contemporary adaptations of “traditional” approaches to the counseling of women. In M. Kopala & M. Keitel (Eds.), Handbook of counseling women (2nd ed.; pp. 51–62). SAGE. Enns, C. Z., Bryant-Davis, T., & Comas-Díaz, L. (2021). Transnational feminist therapy: Recommendations and illustrations. [Special issue] Women and Therapy, 44(1/2), 212–233. https://doi.org /10.1080/02703149.2020.1776021 Enns, C. Z., & Byars-Winston, A. (2010). Multicultural feminist therapy. In H. Landrine & N. F. Russo (Eds.), Handbook of diversity in feminist psychology (pp. 367–388). Springer. Enns, C. Z., Comas-Díaz, L., & Bryant- Davis, T. (2021). Transnational feminist theory and practice: An introduction. [Special issue] Women and Therapy, 44(1/2), 11–26. https://doi.org/10.1080/02703149 .2020.1774997 Enns, C. Z., Rice, J. K., & Nutt, R. L. (Eds.). (2015). Psychological practice with women: Guidelines, diversity, empowerment. American Psychological Association. Enns, C. Z., & Williams, E. N. (Eds.). (2013). Oxford handbook of feminist multicultural counseling psychology. Oxford University Press. Enns, C. Z., Williams, E. N., & Fassinger, R. E. (2013). Feminist multicultural psychology: Evolution, change, and challenge. In C. Z. Enns & E. N. Williams (Eds.), Oxford handbook of

feminist multicultural counseling psychology (pp. 3–26). Oxford University Press. Eriksen, K., & Kress, V. E. (2005). Beyond the DSM story: Ethical quandaries, challenges, and best practices. SAGE. Evans, K. M., Kincade, E. A., Marbley, A. F., & Seem, S. R. (2005). Feminism and feminist therapy: Lessons from the past and hopes for the future. Journal of Counseling & Development, 83(3), 269–277. Evans, K. M., Kincade, E. A., & Seem, S. R. (2011). Introduction to feminist therapy: Strategies for social and individual change. SAGE. Evans, K. M., & Miller, M. (2016). Feminist therapy. In I. Marini & M. A. Stebnicki (Eds.), The professional counselor’s desk reference (2nd ed., pp. 247–251). Springer. Feminist Therapy Institute. (1990). Feminist Therapy Institute code of ethics. In H. Lerman & N. Porter (Eds.), Feminist ethics in psychotherapy (pp. 37–40). Springer. Gilligan, C. (1977). In a different voice: Women’s conception of self and morality. Harvard Educational Review, 47, 481–517. Gilligan, C. (1982). In a different voice. Harvard University Press. Hays, P. A. (2022). Addressing cultural complexities in counseling and clinical practice: An intersectional approach (4th ed.). American Psychological Association. Henrich, J., Heine, S. J., & Norenzayan, A. (2010). The weirdest people in the world? Behavioral and Brain Sciences, 33(2–3), 61–83. https://doi.org/10.1017/ S0140525X0999152X Herlihy, B., & Corey, G. (2015a). ACA ethical standards casebook (7th ed.). American Counseling Association. Herlihy, B., & Corey, G. (2015b). Boundary issues in counseling: Multiple roles and responsibilities (3rd ed.). American Counseling Association. Herlihy, B., & Cruz, T. (2022). Feminist theory. In D. Capuzzi & M. D. Stauffer (Eds.), Counseling and psychotherapy: Theories and interventions (7th ed., pp. 309–333). American Counseling Association. Herlihy, B., & Park, C. N. (2016). Feminist theory. In D. Capuzzi & M. D. Stauffer (Eds.), Counseling and psychotherapy: Theories and interventions (6th ed., pp. 367–390). American Counseling Association. Jordan, J. V. (2010). Relational-cultural therapy. American Psychological Association.

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Jordan, J. V., Kaplan, A. G., Miller, J. B., Stiver, I. P., & Surrey, J. L. (Eds.). (1991). Women’s growth in connection: Writings from the Stone Center. Guilford Press. Kaschak, E. (1992). Engendered lives. Basic Books. King, A. R. (2013). Mixed messages: How primary agents of socialization influence adolescent females who identify as multiracial–bisexual. Journal of LGBT Youth, 10(4), 308–327. https://doi.org/10. 1080/19361653.2013.825198 Marecek, J., & Gavey, N. (2013). DSM-5 and beyond: A critical feminist engagement with psychodiagnosis. Femi- nism & Psychology, 23(1), 3–9. https://doi. org/10.1177/0959353512467962 Miller, J. B. (1986). Toward a new psychology of women (2nd ed.). Beacon. Miller, J. B. (1991). The development of women’s sense of self. In J. V. Jordan, A. G. Kaplan, J. B. Miller, I. P. Stiver, & J. L. Surrey (Eds.), Women’s growth in connection (pp. 11–26). Guilford Press. Miller, J. B., Jordon, J., Stiver, I. P., Walker, M., Surrey, J., & Eldridge, N.

S. (1999). Therapists’ authenticity (Work in progress no. 82). Stone Center Working Paper Series. Miller, J. B., & Stiver, I. P. (1997). The healing connection: How women form relationships in therapy and in life. Beacon Press. National Child Traumatic Stress Network, Schools Committee. (2017). Creating, supporting, and sustaining trauma- informed schools: A system framework. http:// www.nctsn.org Pollack, W. S. (1998). Real boys. Henry Holt. Pusateri, C. G., & Headley, J. A. (2015). Feminist therapy. In E. Neukrug (Ed.), SAGE encyclopedia of theory in counseling and psychotherapy (vol. 1, pp. 414–418). SAGE. Remer, P. (2013). Feminist therapy. In J. Frew & M. D. Spiegler (Eds.), Contemporary psychotherapies for a diverse world (pp. 373– 414). Routledge, Taylor & Francis. Rogers, N. (1995). Emerging woman: A decade of midlife transitions. PCCS Books. Surrey, J. L. (1991). The “self-in-relation”: A theory of women’s development. In J.

V. Jordan, A. G. Kaplan, J. B. Miller, I. P. Stiver, & J. L. Surrey (Eds.), Women’s growth in connection (pp. 51–66). Guilford Press. Surrey, J., & Jordan, J. V. (2012). The wisdom of connection. In C. K. Germer & R. D. Siegel (Eds.), Wisdom and compassion in psychotherapy: Deepening mindfulness in clinical practice (pp. 163–175). Guilford Press. Trepal, H. (2010). Exploring self-injury through a relational-cultural lens. Journal of Counseling & Development, 88(4), 492–499. Walker, L. (1994). Abused women and survivor therapy: A practical guide for the psychotherapist. American Psychological Association. Williams, E. N., & Enns, C. Z. (2013). Making the political personal. In C. Z. Enns & E. N. Williams (Eds.), Oxford handbook of feminist multicultural counseling psychology (pp. 485–489). Oxford University Press. Worell, J., & Remer, P. (2003). Feminist perspectives in therapy: Empowering diverse women (2nd ed.). Wiley.

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1. Identify how the postmodern approaches differ from the modernist approaches.

2. Describe the historical roots of social constructionism.

3. Explain the collaborative language systems approach.

4. Examine the distinguishing features and key concepts of solution- focused brief therapy.

5. Identify the role of the therapeutic relationship in the solution- focused approach.

6. Describe the techniques often used by solution-focused brief therapists.

7. Describe the application of solution-focused therapy to group counseling.

8. Understand how solution-focused counseling can be applied to school counseling.

9. Examine the key concepts and principles of motivational interviewing and the stages of change.

10. Describe how motivational interviewing can be applied in School Counseling.

11. Identify the distinguishing features and key concepts of narrative therapy.

12. Discuss the role of the therapeutic relationship in narrative therapy.

13. Describe the techniques often used by narrative therapists.

14. Examine the application of narrative therapy to group counseling.

15. Identify the strengths and shortcomings of the postmodern approaches from a multicultural perspective.

16. Describe the contributions and limitations of the postmodern approaches.

Learning Objectives

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Some Contemporary Founders of Postmodern Therapies The postmodern approaches do not have a single founder. Rather, it has been a collective effort by many. I have highlighted two cofounders of solution-focused brief therapy, a founder of motivational interviewing, and two cofounders of narra- tive therapy who have had a major impact on the development of these therapeutic approaches. These cofounders are introduced at the beginning of the sections on these therapies.

Introduction to Social Constructionism Each of the models of counseling and psychotherapy we have studied so far has its own version of “reality.” The simultaneous existence of multiple and often conflict- ing “truths” has led to increasing skepticism that a singular, universal theory will one day explain human behavior and the systems in which we live. We have entered a postmodern world, and truth and reality are often now understood as representing points of view bounded by history and context rather than being objective, immu- table facts.

Modernists believe in the ability to describe objective reality accurately and assume that it can be observed and systematically known through the scientific method. They also believe reality exists independent of any attempt to observe it. Modernists believe people seek therapy for a problem when they have deviated too far from some objective norm. For example, clients may think they are abnormally depressed when they experience sadness for longer than they think is normal. They might then seek help to return to “normal” behavior.

Postmodernists, in contrast, do not believe realities exist independent of obser- vational processes and of the language systems within which they are described. Social constructionism is a psychological expression of this postmodern world- view; it values the client’s reality without disputing whether it is accurate or rational (Gergen, 1991, 1999; Weishaar, 1993). To social constructionists, any understanding of reality is based on the use of language and is largely a function of the situations in which people live. Our knowledge about realities is socially constructed. For example, people are depressed when they adopt a definition of self as depressed. Without the cultural conditions that accept the concept of depression, talking about a person as depressed would mean nothing. Once a definition of self is adopted, it is hard to rec- ognize behaviors counter to that definition; for example, it is hard for people suffer- ing from depression to acknowledge the value of a periodic good mood in their life.

In postmodern thinking, forms of language and the use of language in stories create meaning. There may be as many meanings as there are people to tell the sto- ries, and each of these stories expresses a truth for the person telling it. Even science is not free from the influence of such processes of social construction. Every person involved in a situation has a perspective on the “reality” of that situation, but the range of truths is limited due to the effects of specific historical events and the lan- guage uses that dominate particular social contexts. In practice, therefore, the range of possible meanings is not infinite. When Kenneth Gergen (1985, 1991, 1999) and others began to emphasize the ways in which people make meaning in social rela- tionships, the field of social constructionism was born.

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In social constructionism, the therapist disavows the role of expert, preferring a more collaborative or consultative stance. Clients are viewed as experts about their own lives. The collaborative partnership in the therapeutic process is consid- ered more important than assessment or technique. Understanding narratives and deconstructing language processes (discourses) are the focus for both understand- ing individuals and helping them construct desired changes.

Social constructionist theory is grounded on the premise that knowledge is con- structed through social processes. What we consider to be “truth” is a product of interactions between people in daily life. Thus, there is not a single or “right” way to live one’s life or to understand the world. Social constructionism explains how values are transmitted through language by the social milieu and suggests that indi- viduals are constantly changing with the ebb and flow of the influences of family, culture, and society (Neukrug, 2016).

Refer to the MindTap for this book to interact with video quizzes and various video programs to expand your knowledge on topics relevant to Chapter 13.

Historical Glimpse of Social Constructionism A mere hundred years ago, Freud, Adler, and Jung were part of a major paradigm shift that transformed psychology as well as philosophy, science, medicine, and even the arts. In the 21st century, postmodern constructions of alternative knowledge sources seem to be one of the paradigm shifts most likely to affect the field of psy- chotherapy. Postmodernist thought is influencing the development of many psy- chotherapy theories and contemporary psychotherapeutic practice. The creation of the self, which so dominated the modernist search for human essence and truth, is being replaced with the concept of socially storied lives. Diversity, multiple frame- works, and integration—collaboration of the knower with the known—are all part of this new social movement, which provides a wider range of perspectives in counsel- ing practice. For some social constructionists, the process of “knowing” includes a distrust of the dominant cultural positions that permeate families and society today (White & Epston, 1990), particularly when the dominant culture exerts a destruc- tive impact on the lives of those who live beyond the margins of what is generally considered normal. Change begins by deconstructing the power of cultural narra- tives and then proceeds to the co-construction of a new life of meaning.

Among the best-known postmodern perspectives on therapy practice are the collaborative language systems approach (Anderson & Goolishian, 1992), solution- focused brief therapy (de Shazer, 1985, 1988, 1991, 1994), solution-oriented therapy (Bertolino & O’Hanlon, 2002; O’Hanlon & Weiner-Davis, 2003), narrative therapy (White & Epston, 1990), motivational interviewing (Miller & Rollnick, 2013), and feminist therapy (Brown, 2018). The next section examines the collaborative lan- guage systems approach, but the heart of this chapter addresses three of the most significant postmodern approaches: solution-focused brief therapy, motivational interviewing, and narrative therapy.

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The Collaborative Language Systems Approach When people seek therapy, they are often “stuck” in a dialogic system that has a unique language, meaning, and process related to “the problem.” Therapy is another conversational system that becomes therapeutic through its “problem- organizing, problem-dissolving” nature (Anderson & Goolishian, 1992, p. 27). It is therapists’ willingness to enter the therapeutic conversation from a “not-knowing” position that facilitates this caring relationship with the client. In the not-knowing position, therapists still retain all of the knowledge and personal, experiential capacities they have gained over years of living, but they allow themselves to enter the conversation with curiosity and with an intense interest in discovery. The aim here is to enter a client’s world as fully as possible. Clients become the experts who are informing and sharing with the therapist the significant narratives of their lives. The not-knowing position is empathic and is most often characterized by questions that “come from an honest, continuous therapeutic posture of not understanding too quickly” (Anderson, 1993, p. 331).

Based on the referral or intake process, the therapist enters the session with some sense of what the client may wish to address. The questions the therapist asks are informed by the answers the client-expert has provided. The client’s answers provide information that stimulates the interest of the therapist, still in a posture of inquiry, and another question proceeds from each answer given. The process is similar to the Socratic method without any preconceived idea about how or in which direction the development of the stories should go. The intent of the conversation is not to con- front or challenge the narrative of the client but to facilitate the telling and retelling of the story until opportunities for new meaning and new stories develop: “Telling one’s story is a representation of experience; it is constructing history in the present” (Anderson & Goolishian, 1992, p. 37). By staying with the story, the therapist–client conversation evolves into a dialogue of new meaning, constructing new narrative possibilities. This not-knowing position of the therapist has been infused as a key concept for both the solution-focused and the narrative therapeutic approaches.

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Insoo Kim Berg (1934–2007) was a Korean-born American psychotherapist and a pio- neer of solution-focused brief therapy (SFBT). In 1978 she and her husband, Steve de Shazer, cofounded the Brief Family Therapy Cen- ter in Milwaukee, Wisconsin. As a leader in the practice of SFBT, she provided work- shops in the United States,

Japan, South Korea, Australia, Denmark, England, and Germany. Berg published 10 groundbreaking books that elucidated the application of SFBT in a wide variety of clinical settings, among them are Family Based Services: A Solution-Focused Approach (Berg, 1994), Working With the Problem Drinker: A Solution-Focused Approach (Berg & Miller, 1992), and Interviewing for Solutions (De Jong & Berg, 2013). Berg’s colleagues described her as inspiring, humble, and passionate. She was committed to her work and rarely took time off, but she did enjoy a wide range of physical activities: stretching exercises, yoga, walking, and gardening.

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Solution-Focused Brief Therapy Introduction

Solution-focused brief therapy (SFBT) is a future-focused, goal-oriented thera- peutic approach to brief therapy developed initially by Steve de Shazer and Insoo Kim Berg at the Brief Family Therapy Center in Milwaukee in the early 1980s. SFBT emphasizes strengths and resiliencies of people by focusing on exceptions to their problems and their conceptualized solutions. SFBT is an optimistic and antideter- ministic approach based on the assumption that clients have the potential to find new and alternative possibilities for change rather than repeating problem-satu- rated experiences. There is a relationship between SFBT and positive psychology. Solution-focused counselors believe that people have the strengths, abilities, and skills to effectively solve the problems they bring to counseling (Grothaus et al., 2019).

De Shazer credits the American psychiatrist Milton Erickson for signifi- cantly influencing the development of solution-focused therapy. Erickson is considered to be one of the most innovative psychotherapists. He was opposed to diagnostic labels and did not view individuals as being sick; rather, he saw them as being stuck. He believed that clients are the best teachers of what works and what does not work in therapy, and he recognized that small changes individu- als make often result in larger changes. Erickson was convinced that solutions to the problems clients bring to therapy can be found in a brief time without detailed information about problems. From his perspective, the quickest route to solutions is to build on a client’s strengths and resources. Erickson did not believe therapy had to be a lengthy process to be effective. Both de Shazer and Berg incorporated many of Erickson’s principles and therapeutic methods in solution-focused brief therapy.

Steve de Shazer (1940–2005) was one of the pioneers of solution-focused brief ther- apy. For many years, he was the director of research at the Brief Family Therapy Center in Milwaukee, where solution- focused brief therapy was developed. He wrote several books on solution-focused- brief-therapy (SFBT), includ-

ing Keys to Solutions in Brief Therapy (1985), Clues: Investi- gating Solutions in Brief Therapy (1988), Putting Difference to Work (1991), and Words Were Originally Magic (1994).

De Shazer loved baseball, was a gourmet cook, and made time for long daily walks. Some of his leisure pursuits included reading philosophy tracts in the original German or French, listening to jazz, and perusing esoteric cookbooks. He was trained as a classical musician and played several instru- ments at a professional level. During his youth he made his living as a jazz saxophonist. He presented workshops, trained, and consulted widely in North America, Europe, Australia, and Asia. While on a teaching tour in Europe in 2005, de Shazer went to a hospital in Vienna for medical help; he died several hours after being admitted.

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Key Concepts

Unique Focus of SFBT The solution-focused philosophy rests on the assumption that people can become mired in unresolved past conflicts and blocked when they focus on past or present problems rather than on future solutions. Solution-focused brief therapy differs from traditional therapies by eschewing the past in favor of both the present and the future (Franklin et al., 2012). Therapists focus on what is possible, and they have little or no interest in gaining an understanding of how the problem emerged. Behavior change is viewed as the most effective approach to assisting people in enhancing their lives. De Shazer (1988, 1991) suggests that it is not necessary to know the cause of a problem to solve it and that there is no necessary relationship between the causes of problems and their solutions. Assessing clients or their problems is not necessary for change to occur. If knowing and understanding problems are unimportant, so is searching for “right” or absolute solutions. Any person might consider multiple solutions, and what is right for one person may not be right for others.

It is within the scope of SFBT practice to allow for some discussion of present- ing problems to validate clients’ experience and to let them describe their pain, struggles, and frustrations (Murphy, 2013, 2023). Listening to problems can open up the opportunity to appreciate and celebrate a client’s strength and resources (Sabella, 2020). However, this brief exploration differs from the lengthy discourse into the history and causes of problems common to some other types of therapy. In solution-focused brief therapy, clients choose the goals they wish to accomplish; little attention is given to diagnosis, history taking, or exploring the emergence of the problem (O’Hanlon & Weiner-Davis, 2003).

Positive Orientation Solution-focused brief therapy is grounded on the optimistic assumption that people are healthy and competent and have the ability to construct solutions that can enhance their lives. An underlying assumption of SFBT is that we already have the ability to resolve the challenges life brings us, but at times we lose our sense of direction or our awareness of our competencies. Regardless of what shape clients are in when they enter therapy, solution-focused therapists believe clients are competent. The therapist’s role is to help clients recognize the competencies they already possess and apply them toward solutions. The essence of therapy involves facilitating conversations that acknowledge and build on clients’ hope and optimism by creating positive expectations that change is possible. Solution-focused brief therapy has parallels with positive psychology, which concentrates on what is right and what is working for people rather than dwelling on deficits, weaknesses, and problems (Murphy, 2023). SFBT is a positive intervention because it emphasizes evoking clients’ strengths and successes, assessing and using their resources, focusing on a preferred future, and collaboratively creating specific and achievable goals (Grothaus et al., 2019). By emphasizing positive dimensions, clients quickly become involved in resolving their problems, which makes this a very empowering approach.

Because clients often come to therapy in a “problem-oriented” state, even the few solutions they have considered are wrapped in the power of the problem ori- entation. Clients often have a story that is rooted in a deterministic view that what

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has happened in their past will certainly shape their future. Solution-focused practi- tioners counter this negative client presentation with optimistic conversations that highlight a belief in achievable and usable goals. Therapists can be instrumental in assisting clients in making a shift from a fixed problem state to a world with new possibilities. SFBT helps to liberate people from the tyranny of their troubled past (Sabella, 2020). One of the goals of SFBT is to shift clients’ perceptions by refram- ing what White and Epston (1990) refer to as clients’ problem-saturated stories through the counselor’s skillful use of language.

Looking for What Is Working The emphasis of SFBT is to focus on what is working in clients’ lives, which stands in stark contrast to the traditional models of therapy that tend to be problem-focused. Individuals bring stories to therapy, some of which are used to justify the client’s belief that life can’t be changed or, worse, that life is moving them further and further away from their goals. Solution- focused brief therapists assist clients in paying attention to the exceptions to their problem patterns, or their instances of success. They promote hope by helping clients discover exceptions, or times when the problem is less intrusive in their life. SFBT focuses on finding out what people are doing that is working and then helping them apply this knowledge to eliminate problems in the shortest amount of time possible. Identifying what is working and encouraging clients to replicate these patterns is extremely important (Murphy, 2023). A key theme of SFBT is: When you know what is working, do more of it. If something is not working, try something different (Hoyt, 2015).

There are various ways to assist clients in thinking about what has worked for them. De Shazer (1991) prefers to engage clients in conversations that lead to pro- gressive narratives whereby people create situations in which they can make steady gains toward their goals. De Shazer might say, “Tell me about times when you felt a little better and when things were going your way.” It is in these stories of life worth living that the power of problems is deconstructed and new solutions are manifest and made possible.

Basic Assumptions Guiding Practice Walter and Peller (1992, 2000) think of solution-focused therapy as a model that explains how people change and how they can reach their goals rather than a model of the causes of problems. Here are some of their basic assumptions about solution-focused therapy:

◆ Individuals who come to therapy do have the capability of behaving effectively, even though this effectiveness may be temporarily blocked by negative cognitions. Problem-focused thinking prevents people from recognizing effective ways they have dealt with problems.

◆ There are advantages to a positive focus on solutions and on the future. If clients can reorient themselves in the direction of their strengths using solution-talk, there is a good chance therapy can be brief.

◆ There are exceptions to every problem, or times when the problem was absent. By talking about these exceptions, clients can get clues to effective solutions and can gain control over what had seemed to be an insurmountable personal difficulty. Rapid changes are possible when

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clients identify exceptions to their problems and begin to organize their thinking around these exceptions instead of around the problem.

◆ Clients often present only one side of themselves. Solution-focused thera- pists invite clients to examine another side of the story they are presenting.

◆ No problem is constant, and change is inevitable. What people need to do is become aware of any positive changes that are happening. Small changes pave the way for larger changes, and these changes are often all that is needed to resolve the problems clients bring to counseling (Guterman, 2013).

◆ Clients are doing their best to make change happen. Therapists should adopt a cooperative stance with clients rather than devising strategies to control resistive patterns. When therapists find ways to cooperate with people, resistance does not occur.

◆ Clients can be trusted in their intention to solve their problems. Thera- pists assume that clients want to change, can change, and will change under cooperative and empowering therapeutic conditions. There are no “right” solutions to specific problems that can be applied to all peo- ple. Each individual is unique and so, too, is each solution.

Characteristics of Brief Therapy The average length of therapy is three to eight sessions, with the most common length being only one session (Hoyt, 2015). The main goal of brief therapy is to help clients efficiently resolve problems and to move forward as quickly as possible. Some of the defining characteristics of brief therapy include the following (Hoyt, 2009, 2011, 2015):

◆ Rapid working alliance between therapist and client ◆ Clear specification of achievable treatment goals ◆ Clear division of responsibilities between client and therapist, with

active client participation and a high level of therapist activity ◆ Emphasis on client’s strengths, competencies, and adaptive capacities ◆ Expectation that change is possible and realistic and that improvement

can occur in the immediate future ◆ Here-and-now orientation with a primary focus on current functioning

in thinking, feeling, and behaving ◆ Specific, integrated, pragmatic, and eclectic techniques ◆ Periodic assessment of progress toward goals and outcomes ◆ Time sensitive, including making the most of each session and ending

therapy as soon as possible

The core task is for SFBT practitioners to learn how to rapidly and systemati- cally identify problems, create a collaborative relationship with clients, and intervene with a range of specific methods. Because most therapy is time-limited, therapists should learn to practice brief therapy well (Hoyt, 2011).

The Therapeutic Process In SFBT the therapeutic process rests on the foundation that clients are the experts on their own lives and often have a good sense of what has or has not worked in the

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past and what might work in the future. Solution-focused counseling emphasizes building a collaborative change-focused relationship, which is in contrast to the educative stance that is typically associated with most traditional models of therapy. If clients are involved in the therapeutic process from beginning to end, the chances are increased that therapy will be successful. In short, collaborative and cooperative relationships tend to be more effective than hierarchical relationships in therapy.

De Shazer (1991) believes clients can generally build solutions to their problems without any assessment of the nature of their problems. Given this framework, the structure of solution building differs greatly from traditional approaches to prob- lem solving, which can be seen in this brief description of the steps involved (De Jong & Berg, 2013):

1. Clients are given an opportunity to describe their problems. The thera- pist listens respectfully and carefully as clients answer the therapist’s question, “How can I be useful to you?”

2. The therapist works with clients in developing well-formed goals or preferred futures as soon as possible. The question is posed, “What will be different in your life when your problems are solved?”

3. The therapist asks clients about those times when their problems were not present or when the problems were less severe. Clients are assisted in exploring these exceptions, with special emphasis on what they did to make these events happen.

4. At the end of each solution-building conversation, the therapist offers clients summary feedback, provides encouragement, and suggests what clients might observe or do before the next session to further solve their problem.

5. The therapist and clients evaluate the progress being made in reaching satisfactory solutions by using a rating scale. Clients are asked what needs to be done before they see their problem as being solved and also what their next step will be.

Therapeutic Goals SFBT reflects some basic notions about change, about interaction, and about reaching goals. The solution-focused therapist believes people have the ability to define meaningful personal goals and that they have the resources required to solve their problems. Goals are unique to each client and are constructed by the client to create a richer future (Prochaska & Norcross, 2018). A lack of clarity regarding client preferences, goals, and desired outcomes can result in a rift between therapist and client. Identifying therapeutic goals is a collaborative process. During the early phase of therapy, it is important that clients be given the opportunity to express what they want from therapy and what concerns they are willing to explore. Clients are best positioned to choose the goals they want to achieve in counseling (Bitter, 2021). From first contact, the therapist strives to create a climate that will facilitate change and encourage clients to think in terms of a range of possibilities. Grothaus, Runyan, and Sacco-Bene (2019) capture the essence of the aim of this therapeutic process: “By adopting a respectful and humble position of curiosity and ‘not knowing,’ the counselor can learn from the client how the work will be done” (p. 176).

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Solution-focused therapists concentrate on small, realistic, achievable changes that can lead to additional positive outcomes. Because success tends to build upon itself, modest goals are viewed as the beginning of change. The therapist looks for ways to amplify the client’s movement in the desired direction as quickly as possible (Hoyt, 2015). Solution-focused therapists use questions such as these that presup- pose change, posit multiple answers, and remain goal-directed and future-oriented: “What did you do, and what has changed since last time?” or “What did you notice that went better?” (Bubenzer & West, 1993).

Murphy (2023) emphasizes the importance of assisting clients in creating well- defined goals, or preferred futures, that include three main criteria:

1. Start-based (stated in positive terms as the start or presence of some- thing the client wants)

2. Specific (concrete, observable, measurable, detailed, behavioral description)

3. Social (description of what significant others would notice, how they might respond, and how their responses would affect the client)

Counselors should not too rigidly impose an agenda of getting precise goals before clients have a chance to express their concerns. Clients must feel that their concerns are heard and understood before they can formulate meaningful personal goals. In a therapist’s zeal to be solution-focused, it is possible to get lost in the mechanics of therapy and not attend sufficiently to the interpersonal aspects. Ther- apists need to be mindful of not becoming overly technique driven at the expense of the therapeutic alliance.

Solution-oriented therapy offers several forms of goals: changing the viewing of a situation or a frame of reference, changing the doing of the problematic situation, and tapping client strengths and resources (O’Hanlon & Weiner-Davis, 2003). Therapists monitor the language they use, so they can increase their clients’ hope and optimism and their openness to possibilities and change. Clients are encouraged to engage in change-talk or solution-talk rather than problem-talk. This is based on the assump- tion that what we talk about most will be what we produce. Talking about problems can produce ongoing problems; talking about change can produce change.

Therapist’s Function and Role Clients are much more likely to get involved in the therapeutic process if they believe they are determining the direction and purpose of the conversation. Much of what the therapeutic process is about involves clients’ thinking about their future and what they want to be different in their lives. Consistent with the postmodern and social constructionist perspective, solution- focused brief therapists adopt a not-knowing position to put clients in the position of being the experts about their own lives. Therapists do not assume that by virtue of their expert frame of reference they know the significance of the client’s actions and experiences (Anderson & Goolishian, 1992). This model casts the role and function of a therapist in quite a different light from traditionally oriented therapists who view themselves as experts in assessment and treatment. The therapist-as-expert is replaced by the client-as-expert, especially when it comes to what the client wants in life and in therapy. It is important that therapists actually believe that their clients are the true experts on their own lives. Although therapists have expertise in the

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process of change, clients are the experts on what they want changed. Clients will have their own ways of building their preferred futures, even if this is often not clear to them when they begin therapy. The therapist’s task is to point clients in the direction of change without dictating what to change (George et al., 2015; Grothaus et al., 2019).

Therapists strive to create a climate of mutual respect, dialogue, and affirma- tion in which clients experience the freedom to create, explore, and coauthor their evolving stories. A key therapeutic task consists of helping clients imagine how they would like life to be different and what it would take to make this transformation happen. One of the functions of the therapist is to ask questions and, based on the answers, generate further questions. Useful questions include “What do you hope to gain from coming here?” “If you were to make the changes you desire, how would that make a difference in your life?” and “What steps can you take now that will lead to these changes?”

The Therapeutic Relationship The quality of the relationship between therapist and client is a determining factor in the outcomes of SFBT, so relationship building or engagement is a basic step in SFBT. The attitude of the therapist is crucial to the effectiveness of the therapeutic process. It is essential to create a sense of trust so clients will return for additional sessions and will follow through on homework suggestions. The therapeutic process works best when clients become actively involved, when they experience a positive relationship with the therapist, and when counseling addresses what clients see as being important (Murphy, 2023). One way of creating an effective therapeutic partnership is for the therapist to show clients how they can use the strengths and resources they already have to construct solutions. Clients are encouraged to do something different and to be creative in thinking about ways to deal with their present and future concerns.

De Shazer (1988) has described three kinds of relationships that may develop between therapists and their clients:

1. Customer : client and therapist jointly identify a problem and a solution to work toward. Clients realize that personal effort will be required to attain their goals.

2. Complainant : the client describes a problem but is not able or willing to assume a role in constructing a solution, believing that a solution is dependent on someone else’s actions. In this situation, the client gener- ally expects the therapist to change the person to whom the client attri- butes the problem.

3. Visitor : the client comes to therapy because someone else (a spouse, parent, teacher, or probation officer) thinks the client has a problem. These clients may not agree that they have a problem and may be unable to identify anything to explore in therapy.

De Jong and Berg (2013) recommend using caution and avoid boxing clients into static identities. These three roles are only starting points for conversation. Rather than categorizing clients, therapists can reflect on the kinds of relationships that are developing between their clients and themselves. For example, clients who tend to place the cause of their problems on another person or persons in their lives (complainants) may be helped by skilled intervention to begin to see their own role

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in their problems and the necessity for taking active steps in creating solutions. How the therapist responds to different behaviors of clients has a lot to do with bringing about a shift in the relationship. In short, both complainants and visitors have the capacity for becoming customers.

Application: Therapeutic Techniques and Procedures Some of the key techniques solution-focused practitioners use include looking for differences in doing, exception questions, scaling questions, and the miracle question. If these techniques are used in a routine way without developing a collaborative working alliance, they will not lead to effective results. Murphy (2023) reminds us that these solution-focused techniques should be used flexibly and tailored to the unique circumstances of each client. Therapy is best guided by the client’s goals, perceptions, resources, and feedback. Therapy should not be determined by any absolutes or rigid standards outside the therapeutic relationship (namely, evidence-based treatments).

Pretherapy Change Simply scheduling an appointment often sets positive change in motion. During the initial therapy session, it is common for solution-focused counselors to ask, “What changes have you noticed that have happened or started to happen since you called to make the appointment for this session?” (de Shazer & Dolan, 2007, p. 5). By asking about such changes, the therapist can elicit, evoke, and amplify what clients have already done by way of making positive change. These pretherapy changes cannot be attributed to the therapy process itself, so asking about them tends to encourage clients to rely less on their therapist and more on their own resources to accomplish their treatment goals.

Questioning Solution-focused practitioners use questions as a way to better understand a client’s experience rather than simply to gather information. Counselors do not raise questions to which they think they know the answer. Questions are asked from a position of respect, genuine curiosity, sincere interest, and openness. The questions SFBT counselors ask are typically informed by the answers the client-expert has provided. The client’s answers provide information that catches the interest of the counselor, and another question arises from each answer given.

Exception Questions SFBT is based on the notion that there were times in clients’ lives when the problems they identify were not problematic. These times represent news of difference (Bateson, 1972). Solution-focused therapists ask exception questions to direct clients to times when the problem did not exist, or when the problem was not as intense. Exceptions are those past experiences in a client’s life when it would be reasonable to have expected the problem to occur, but somehow it did not (de Shazer, 1985; Murphy, 2023). These instances of success can be useful in considering further changes. This exploration reminds clients that problems are not all-powerful and have not existed forever; it also provides a field of opportunity for evoking resources, engaging strengths, and positing possible solutions. The therapist asks clients what has to happen for these exceptions to occur more often.

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The Miracle Question Therapy goals are developed by using what de Shazer (1988) calls the miracle question, which is a main SFBT technique. The therapist asks, “If a miracle happened and the problem you have was solved overnight, how would you know it was solved, and what would be different?” Clients are then encouraged to enact “what would be different” in spite of perceived problems. If a client wants to feel more confident and secure, the therapist might say: “Let yourself imagine that you leave the office today and that you are on track to acting more confidently and securely. What will you be doing differently?” This process of considering hypothetical solutions reflects O’Hanlon and Weiner-Davis’s (2003) belief that changing the doing and viewing of the perceived problem changes the problem.

De Jong and Berg (2013) identify several reasons the miracle question is a useful technique. Asking clients to consider that a miracle takes place opens up a range of future possibilities. Clients are encouraged to allow themselves to dream as a way of identifying the kinds of changes they most want to see. This question has a future focus; clients can begin to consider a different kind of life that is not dominated by a particular problem. This intervention shifts the emphasis from both past and cur- rent problems toward a more satisfying life in the future.

Bitter (2021) asks counselors who support a multicultural perspective to reflect on these solution-focused questions:

◆ What were the times when you felt empowered? ◆ If a miracle happened and the world in which you live no longer

oppressed or marginalized people, what would you be able to do differ- ently with your life?

◆ If there were improvement in the community in which you live with regard to racism, sexism, and other forms of discrimination, what dif- ferences would you notice?

Scaling Questions Solution-focused therapists also use scaling questions when change in human experiences are not easily observed, such as feelings, moods, or communication, and to assist clients in noticing that they are not completely defeated by their problem (de Shazer & Berg, 1988). For example, a client reporting feelings of panic or anxiety might be asked: “On a scale of 0 to 10, with zero being how you felt when you first came to therapy and 10 being how you feel the day after your miracle occurs and your problem is gone, how would you rate your anxiety right now?” Even if the client has only moved away from 0 to 1, this is an improvement. How did the client do that? What does the client need to do to move another number up the scale? Scaling questions enable clients to pay closer attention to what they are doing and how they can take steps that will lead to the changes they desire.

Formula First Session Task The formula first session task (FFST) is a form of homework a therapist might give clients to complete between their first and second sessions. The therapist might say: “Between now and the next time we meet, I would like you to observe, so that you can describe to me next time, what happens in your (family, life, marriage, relationship) that you want to continue to have happen”

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(de Shazer, 1985, p. 137). At the second session, clients can be asked what they observed and what they would like to have happen in the future. This kind of assignment offers clients hope that change is inevitable. It is not a matter of if change will occur but when it will happen. According to de Shazer, this intervention tends to increase clients’ optimism and hope about their present and future situation. The FFST technique emphasizes future solutions rather than past problems (Murphy, 2023).

Therapist Feedback to Clients Solution-focused practitioners generally take a break of 5 to 10 minutes toward the end of each session to compose a summary message for clients. During this break therapists formulate feedback that will be given to clients after the break. The summary might contain strengths the therapist has noticed about the client during the session, signs of hope and identifying exceptions to a problem, and a commentary on what the client is already doing that is useful in moving in a desired direction (George et al., 2015).

De Jong and Berg (2013) describe three basic parts to the structure of the sum- mary feedback: compliments, a bridge, and suggesting a task. Compliments are genu- ine affirmations of what clients are already doing that is leading toward effective solutions. It is important that complimenting is not done in a routine or mechani- cal way, but in an encouraging manner. This feedback creates hope and conveys the expectation to clients that they can achieve their goals by drawing on their strengths and successes. Second, a bridge links the initial compliments to the suggested tasks that will be given. The bridge provides the rationale for the suggestions. The third aspect of feedback consists of suggesting tasks to clients, which can be considered as homework. Observational tasks ask clients to simply pay attention to some aspect of their lives. This self-monitoring process helps clients note the differences when things are better, especially what was different about the way they thought, felt, or behaved. Behavioral tasks require that clients actually do something the therapist believes would be useful to them in constructing solutions. De Jong and Berg (2013) stress that a therapist’s feedback to clients addresses what they need to do more of and do differently to increase the chances of obtaining their goals.

Terminating From the very first solution-focused interview, the therapist is mindful of working toward termination. Once clients are able to construct a satisfactory solution, the therapeutic relationship can be terminated. The initial goal-formation question that a therapist often asks is, “What needs to be different in your life as a result of coming here for you to say that meeting with me was worthwhile?” Through the use of scaling questions, therapists can assist clients in monitoring their progress and determining when they no longer need to come to therapy (De Jong & Berg, 2013). Establishing clear goals from the beginning of therapy lays the groundwork for effective termination (Murphy, 2023). Prior to ending therapy, therapists assist clients in identifying things they can do to continue the changes they have already made into the future. Clients can also be helped to identify hurdles or perceived barriers that could get in the way of maintaining the changes they have made. Because this model of therapy is brief, present-centered, and addresses specific complaints, it is very possible that clients will experience other developmental concerns at a later time. Clients can be invited to ask for additional sessions whenever they feel a need to get their life back on track or to update their story.

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Dr. John Murphy puts many SFBT techniques into action as he illustrates assessment and treatment from a solution-focused brief therapy approach in the case of Ruth in Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 11).

Applying SFBT to Group Counseling The solution-focused group practitioner believes that people are competent, and when given an opportunity to experience their competency, people are able to solve their own problems, enabling them to live a richer life. From the beginning, the group facilitator sets a tone of focusing on solutions (Metcalf, 1998), although group mem- bers are given an opportunity to describe their problems briefly. A facilitator might begin a new group by requesting, “I would like each of you to introduce yourself. As you do, give us a brief idea as to why you are here and tell us what you would like for us to know about you.” Facilitators help members to keep the problem external in con- versations, which tends to be a relief because it gives members an opportunity to see themselves as less problem-saturated. It is the facilitator’s role to create opportunities for the members to view themselves as being resourceful. Because SFBT is designed to be brief, the leader has the task of keeping group members on a solution track rather than a problem track, which helps members move in a positive direction.

The group leader works with members in developing well-formed goals as soon as possible. Leaders concentrate on small, realistic, achievable changes that may lead to additional positive outcomes. Because success tends to build upon itself, modest goals are viewed as the beginning of change. Questions used to assist members in formulating clear goals might include “What will be different in your life when each of your problems is solved?” and “What will be going on in the future that will tell you and the rest of us in the group that things are better for you?” Sometimes mem- bers talk about what others will be doing or not doing and forget to pay attention to their own goals or behavior. At such times, members can be asked, “And what about yourself? What will you be doing differently in that picture? As a result of your doing things differently, how would you imagine others responding to you?”

The facilitator asks members about times when their problems were not present or when the problems were less severe. The members are assisted in exploring these exceptions, and special emphasis is placed on what they did to make these events happen. The participants engage in identifying exceptions with each other. This improves the group process and promotes a solution focus, which can become quite powerful. Exceptions are real events that take place outside of the problem context. In individual counseling, only the therapist and the client are observers of compe- tency. An advantage of group counseling is that the audience widens and more input is possible (Metcalf, 1998).

The art of questioning is a main intervention used in solution-focused groups. Questions are asked from a position of respect, genuine curiosity, sincere interest, and openness. Group leaders use questions such as these that presuppose change and remain goal-directed and future-oriented: “What did you do and what has changed since last time?” or “What did you notice that went better?” Other group members are encouraged to respond along with the group leader to promote group interac- tion. Facilitators may pose questions like these: “Someday, when the problems that brought you to this group are less problematic to you, what will you be doing?” “As

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each of you listened to others today, is there someone in our group who could be a source of encouragement for you to do something different?” The leader is attempt- ing to help members identify exceptions and begin to recognize personal resiliency and competency. Creating a group context in which members are able to learn more about their personal abilities is key to members learning to resolve their own con- cerns. For a more detailed discussion of SFBT in groups, see Corey (2023, chap. 15).

Solution-focused counseling (SFC) offers a great deal of promise for practitio- ners who want a practical and time-effective approach to interventions in school settings. Rather than being a cookbook of techniques for removing students’ prob- lems, school counselors can provide a collaborative framework aimed at achieving small, concrete changes that enable students to discover a more productive direc- tion. In the next section, Dr. Murphy explains a three-step approach when working with students in the school setting.

Application of Solution-Focused Counseling to School Counseling

This section was provided by John J. Murphy, PhD, is a licensed psychologist and professor emeritus of psychology and counseling at the University of Central Arkansas. He has worked as a high school teacher, school psychologist, therapist, and consultant/trainer for national and international agencies.

Solution-focused counseling (SFC) invites students and others to describe what they want from counseling, apply what they have toward achieving it, and consider small signs and steps toward hoped-for outcomes. This collaborative approach has become increasingly popular among school counselors worldwide because it is efficient, evidence-based, and culturally respectful. The simple, straightforward nature of SFC is appealing to students and practitioners alike. From my work as a school psychologist in numerous schools and districts, I can personally attest to the approach’s practicality as captured in its three pragmatic guidelines: If it’s not broken, don’t fix it. If it works, do more of it. and If it doesn’t work, do something different.

Solution-focused counselors and conversations are guided by three questions: “What does the student want from counseling? What does the student have to do toward achieving it? What progress has the student already made, and what are possible next signs or steps toward further progress?” These questions translate into three main tasks (setting a direction, building on exceptions and resources, and exploring progress) and three main techniques (asking useful questions, listening to students’ responses, and amplifying aspects of students’ responses and lives that support hoped-for counseling outcomes). When being purely solution-focused, there is rarely anything I do outside of these activities. Here I illustrate how I work on the three main tasks in this mode with the help of some brief excerpts and descrip- tions from my work with a young student named Sam (Murphy, 2023).

1. Setting a direction based on what the student wants from counseling. Possible questions I ask students: How will you know today’s meeting was use- ful? What are your best hopes from talking with me? Imagine that a miracle happens while you’re sleeping tonight and your school problems

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vanish—what is the first thing you would notice tomorrow morning to tell you the miracle happened (this question is typically longer in actual prac- tice)? Then what? What else will be different? Who else will notice?

JM: So, Sam, if this meeting ends up helping you at school, how would you know that?

Sam: I won’t get in trouble as much.

JM: What would you rather be doing instead of getting in trouble? “Instead” questions help students formulate positively stated counseling goals or outcomes that describe something they want versus don’t want. For Sam, it was “being happier at school.” All subsequent questions and conversations were designed to help him achieve this outcome, including the miracle question and other detail-generating questions and discussions about exceptions, resources, and progress toward being happier at school.

2. Building on exceptions that are already happening and other resources avail- able in the student’s life. When doesn’t the problem happen? What small pieces of the miracle day you just described are already happening, even just a little? What would it take to increase those times? Who (or what) might help?

JM: Tell me about a recent time when you were a little happier at school.

Like most clients, Sam was unable to immediately think of such a time. With some gentle persistence on my part, he eventually told me that last Monday was noticeably better at school. We explored the details of this exception, with special attention to what Sam did to make it happen. It turns out that he arrived at school early that day and helped one of his teachers rearrange some classroom items—which was followed by several other productive events and positive interactions with teachers.

3. Exploring progress toward desired outcomes. How did you move two points higher on the “being happier at school” (0–10) scale? What’s better? How did you manage to stay at it when things got worse last Friday?

Follow-up conversations and sessions revolved around exploring and amplifying Sam’s progress (“On a scale of 0 to 10, where 10 is being as happy as you want to be in school and 0 the opposite of that, where are you now?”) and exploring how he made improvements or kept things from get- ting worse (“What’s been better to make it a 6 instead of a lower number?”).

Although Sam continued to display some behavioral problems, he was generally able to maintain progress and successfully complete the school year. For a comprehen- sive treatment of this subject, see Solution-Focused Counseling in Schools (Murphy, 2023).

An Expert’s Perspective on Solution-Focused Brief Therapy In this section, John J. Murphy, PhD, a licensed psychologist and professor of psychology and counseling at the University of Central Arkansas, provides answers to the following questions.

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1. What is the most important contribution of solution-focused brief therapy (SFBT) for the practice of individual therapy? Centering therapeutic questions and conversations on what clients want versus don’t want (solutions versus problems) and have versus lack (strengths versus deficits) is a major contribution of solution-focused practice. The related solution-focused notion that clients and therapists can co-construct effective solutions in the absence of a thorough assess- ment or understanding of the problem represents an important shift from the more traditional and prevalent medical model focus on diagnosing and remediating clients’ deficiencies.

2. What two or three key concepts of SFBT are especially applicable to the practice of individual counseling or therapy? Solution-focused practitioners invite clients to participate in every aspect of their care from setting a direction or goal for counseling through deter- mining when to stop meeting. In addition to honoring core principles of multiculturalism and social justice, tailoring therapeutic services to clients’ hopes, resources, and feedback results in better outcomes. Another key concept of solution-focused counseling is that clients are motivated and capable of improving their lives when they are working toward personally meaningful, self-selected outcomes. This concept cautions counselors against viewing clients in narrow ways based on diagnostic categories, experiences with “similar” clients, or other limiting criteria. Psychother- apy outcome research strongly suggests that the client is the key ingredi- ent of change, and that the success of individual therapy rests largely on the extent to which we incorporate “as much of the client as possible” into therapeutic questions, conversations, and solutions. Clients make counseling work, not the other way around. Treating clients as resource- ful and capable of improving their lives does not deny the seriousness or pain of their problems. It simply invites them to focus their attention and efforts on what they want instead, which creates solution-building oppor- tunities that might otherwise be overlooked.

3. What two or three techniques from solution-focused brief therapy have practical value for practitioners of individual therapy? Building on exceptions is a versatile SFBT technique that seems relevant to helping people change regardless of one’s theoretical orientation. The fatigue and discouragement of experiencing a chronic problem make it hard for clients to notice times when the problem is absent or less intense, much less to use these exceptions as foundations for further improvements. Building on exceptions is based on the well-established idea that nothing happens constantly, including the problems clients bring to therapy. Exception-based questions and conversations remind counselors and cli- ents that the problem is not as constant as it seems and that clients are always doing “something” to help themselves. Listening intently to key words and phrases that clients use in responding to questions—and form- ing “next questions” from their previous answers—is another SFBT tech- nique that validates clients’ perceptions, experiences, and contributions to

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therapy. Finally, the solution-focused practice of inviting clients to describe their preferred future in great detail appears to make it more realistic, noticeable, and attainable to them.

4. How does SFBT address diversity, multicultural, and social justice issues for the practice of individual counseling? Solution-focused brief therapy involves clients in all aspects of their care, which includes having therapists collaborate with clients to develop custom- ized goals and action plans that boost clients’ ownership and involvement in the counseling process. The collaborative, client-driven nature of SFBT is responsive to the fact that persons from minoritized and underrepresented backgrounds often experience disempowerment and marginalization in their interactions with helping professionals. Solution-focused brief therapy ensures that clients’ perceptions and feedback are given top priority, that ther- apy revolves around their hoped-for outcomes, and that therapeutic solutions are fueled by clients’ input, strengths, successes, and other resources. These elements of SFBT support socially just, culturally responsive services by put- ting clients first and keeping them there throughout the counseling process.

5. In what ways can the solution-focused approach be applied to brief therapy (or time-limited counseling)? The conceptual simplicity of SFBT—find what works and do more of it— makes it particularly well-suited to a brief therapy format. As the name implies, SFBT is brief by design. When asked how many sessions are required in SFBT, Steve de Shazer would say “as many as necessary and not one more.” Research conducted at the Brief Family Therapy Center in Milwaukee and other solution-focused agencies, as well as my own experi- ence, indicates that most clients successfully reach their goals in four or fewer sessions. The decision to end therapy is made in close collaboration with clients, and clients are never coerced into ending therapy. The brief aspect of the solution-focused approach does not mean ignoring clients’ problems or rushing them into solutions against their will; in other words, solution-focused practice is neither problem-phobic nor solution-forced. The efficiency of SFBT results largely from activating the core ingredients of effective change by discovering and accommodating clients’ hopes, strengths, and resources from the very outset of services. Along these same lines, I’m never thinking “brief” when I’m working with clients—it just seems to be a by-product of working with people in this way.

6. From your perspective, what is the current status and the future of SFBT? The current and future status of SFBT appears to be very solid as a result of ongoing empirical and clinical developments. Psychotherapy outcome research increasingly supports the benefits of actively involving clients in setting therapeutic goals, evaluating services, and participating in other key aspects of their care to the extent that they are able and willing to do so. Client involvement and collaboration have always played a central role in solution-focused work, which bodes well for the approach’s current and future status. SFBT has proven useful with persons from a wide range of

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cultures (Kim, 2014) experiencing trauma, substance misuse, relationship problems, schizophrenia, depression, anxiety, and other social, emotional, and behavioral challenges. The increasing scope of SFBT research and clini- cal applications throughout the world suggest that this practical postmod- ern approach will continue to grow in the future.

For more information about Dr. Murphy’s work and training work- shops, see Solution-Focused Counseling in Schools (Murphy, 2023) and www .drjohnmurphy.com, or contact him at [email protected].

Discussion Questions Related to the Solution-Focused Brief Therapy Perspective

1. “Psychotherapy outcome research strongly suggests that the client is the key ingredient of change, and that the success of individual therapy rests largely on the extent to which we incorporate ‘as much of the client as possible’ into therapeutic questions, conversations, and solutions.” How could you incorporate the client as fully as possible in the process?

2. What value do you see in building on exceptions? How could you incorpo- rate this in your practice with clients?

3. A key concept of solution-focused counseling is that clients are moti- vated and capable of improving their lives when they are working toward personally meaningful, self-selected outcomes. How can you assist clients in working toward personally meaningful, self-selected outcomes?

William R. Miller (b. 1947) is emeritus distinguished professor of psychology and psychiatry at the Univer- sity of New Mexico, where he joined the faculty in 1976 after receiving his PhD in clinical psychology from the University of Oregon. He served as director of Clinical

Training for UNM’s APA-approved doctoral program in clinical psychology and as codirector of UNM’s Center on Alcoholism, Substance Abuse and Addictions (CASAA). Miller and Stephen Rollnick are the cofounders of moti- vational interviewing.

Miller’s professional interests include the treatment of addictive behavior, self-regulation, and motivation for

change. He has written 40 books and more than 400 articles and chapters on these topics. He has served as principal investigator for numerous research grants and contracts, founded a private practice group, and served as a consultant to many organizations includ- ing the United States Senate, the World Health Or- ganization (WHO), the National Academy of Sciences (NAS), and the National Institutes of Health (NIH). In recognition of his research contributions, Miller is a re- cipient of the international Jellinek Memorial Award, two career achievement awards from the Ameri- can Psychological Association, and an Innovators in Combating Substance Abuse Award from the Robert Wood Johnson Foundation. He maintains an active interest in pastoral counseling and the integration of spirituality and psychology.

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Motivational Interviewing Motivational Interviewing (MI) is a humanistic, client-centered, psychoso- cial, and modestly directive counseling approach that was developed by William R. Miller and Stephen Rollnick in the early 1980s. Motivational interviewing is a psychotherapeutic method that is evidence-based, relatively brief, specifiable, appli- cable across a wide variety of problem areas, complementary to other active treat- ment methods, and useful for a broad range of mental health professionals (Miller & Rose, 2009). MI can be a significant factor in assisting clients in making a com- mitment to the therapy process, thus improving client involvement, adherence, and retention in cognitive behavioral and other action-oriented therapies. MI has earned appeal and relevance among clinicians because of its scholarly and research commitments (Cormier et al., 2017).

Motivational interviewing was initially designed as a brief intervention for prob- lem drinking, but more recently this approach has been applied to a wide range of clinical problems including substance abuse, compulsive gambling, eating dis- orders, anxiety disorders, depression, suicidality, chronic disease management, and health behavior change practices (Arkowitz & Miller, 2008; Arkowitz & Westra, 2009). MI stresses client self-responsibility and promotes an invitational style for working cooperatively with clients to generate alternative solutions to behavioral problems. MI provides multiple ways to address the impasses clients often experi- ence during the change process.

The MI Spirit Motivational interviewing is based on humanistic principles and has many basic similarities with both person-centered therapy and solution-focused brief therapy. These approaches are based on the belief that clients possess abilities, strengths, resources, and competencies. MI clinicians assume that clients have the inner resources to change and the counselor’s role is to evoke it from clients so that they are able to recognize this potential and take action to make changes (Iarussi, 2019). The MI spirit is the bedrock attitude of therapists as they apply their skills based on a person-centered philosophy.

Common Ground With Person-Centered Therapy MI is rooted in the philosophy of person-centered therapy, but with a “twist.” Unlike the nondirective and unstructured person-centered approach, MI is deliberately directive while staying within the client’s frame of reference. The primary goal is to reduce client ambivalence about change and increase the client’s own motivation for change. Miller and Rollnick (2013) believe that “MI is about arranging conver- sations so that people talk themselves into change, based on their own values and interests” (p. 4). It is essential that therapists function within the spirit of MI—that is, within the relational context of therapy—rather than simply applying the strate- gies of the approach. The attitudes and skills in MI are based on a person-centered philosophy and include using open-ended questions, employing reflective listening, creating a safe climate, affirming and supporting the client, expressing empathy, responding to resistance or reluctance in a nonconfrontational manner, guiding

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a discussion of ambivalence, summarizing and linking at the end of sessions, and eliciting and reinforcing “change talk” (Dean, 2015). MI therapists avoid arguing with clients and reframe resistance as a healthy response. MI therapists do not view clients as opponents to be defeated but as allies who play a major role in their pres- ent and future success. Practitioners assist clients in becoming their own advocates for change and the primary agents of change in their lives.

In both person-centered therapy and motivational interviewing, the counselor provides the conditions for growth and change by communicating attitudes of accu- rate empathy and unconditional positive regard. Therapist authenticity, or genuine- ness, is of paramount importance for clients to develop trust in the therapist. In MI, the therapeutic relationship is as important in achieving successful outcomes as the specific theoretical model or school of psychotherapy from which the therapist operates (Miller & Rollnick, 2013). Both MI and person-centered therapy are based on the premise that individuals have within themselves the capacity to generate an intrinsic motivation to change. Once clients believe that they have the capacity to change and heal, new possibilities open up for them.

The Basic Principles of Motivational Interviewing Miller and Rollnick (2013) formulated the following basic principles of MI:

1. Therapists strive to experience the world from the client’s perspec- tive without judgment or criticism. MI emphasizes reflective listening, which is a way for practitioners to better understand the subjective world of clients. Expressing empathy is foundational in creating an accepting and safe climate for clients to explore their ambivalence about change. When clients are slow to change, they likely have compelling reasons to remain as they are as well as having reasons to change.

2. MI is designed to evoke and explore both discrepancies and ambivalence. MI counselors reflect discrepancies between the behaviors and values of clients to increase the motivation to change. Counselors pay particular attention to clients’ arguments for changing compared to their arguments for not changing. Therapists elicit and reinforce change-talk by employing specific strategies to strengthen discussion about change. Clinicians encourage clients to determine whether change will occur, and if so, what kinds of changes will occur and when.

3. Reluctance to change is viewed as an expected part of the therapeutic process. Although individuals may see advantages to making life changes, they also may have many concerns and fears about changing. People who seek therapy are often ambivalent about change, and their motivation may ebb and flow during the course of therapy. Ambivalence reflects an internal struggle and is intrapersonal, whereas resistance is between peo- ple and is interpersonal in nature. In MI, resistance is referred to as discord in the counseling relationship. MI practitioners aim to work with clients to resolve ambivalence about change as well as to diminish client discord in the therapeutic relationship (Iarussi, 2019). MI therapists assume a respectful view of resistance and work therapeutically with any reluc- tance or caution on the part of clients. Resistance is often exemplified

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when client and counselor do not agree on goals. MI practitioners avoid disagreeing with, arguing with, or persuading clients because this only entrenches resistance. Instead, MI therapists roll with the resistance, which tends to reduce clients’ defensiveness (Corbett, 2016).

4. Practitioners support clients’ self-efficacy, mainly by encouraging them to use their own resources to take necessary actions that can lead to success in changing. MI clinicians strive to enhance client agency about change and emphasize the right and inherent ability of clients to for- mulate their own personal goals and to make their own decisions. MI focuses on present and future conditions and empowers clients to find ways to achieve their goals.

5. When clients show signs of readiness to change through decreased resis- tance to change, a resolution of ambivalence to change, and increased talk about change, a critical phase of MI begins. In this stage, clients may express a desire and ability to change, show an interest in ques- tions about change, experiment with making changes between sessions, and envision a future picture of how their life will be different once the desired changes have been made. At this time, therapists shift their focus toward strengthening clients’ commitments to change and help- ing them implement a change plan. The counselor and client collab- oratively develop an action plan for change, which involves actions the client is willing to take to put change into motion (Iarussi, 2019).

Marshall and Nielsen (2020) state that good action plans have six common characteristics: (1) they are specific, rewarding, observable, and measurable; (2) goals are clear, concrete, and achievable; (3) the client is responsible for making the plan to bring about change; (4) specific steps are identified to facilitate change; (5) the client assumes ownership of the plan; and (6) the client must be committed to implement- ing the plan. An aim of MI is to assist clients in resolving ambivalence to determine whether a change is worth the effort. Once individuals decide they want to change, the change plan provides a road map to follow when implementing the change.

The Stages of Change The stages of change model assumes that people progress through a series of five identifiable stages in the counseling process (Krebs et al., 2019). In the precontempla- tion stage, there is no intention of changing a behavior pattern in the near future. In the contemplation stage, people are aware of a problem and are considering overcoming it, but they have not yet made a commitment to take action to bring about the change. At this stage, people struggle with deciding whether to maintain the status quo or put time and energy into making behavioral changes. In the preparation stage, individuals intend to take action immediately and report some small behavioral changes. In the action stage, individuals are taking steps to modify their behavior to solve their problems. This action involves making overt behavioral changes and requires a commitment. Dur- ing the maintenance stage, people work to consolidate their gains and prevent relapse.

People do not pass neatly through these five stages in linear fashion, and a client’s readiness can fluctuate throughout the change process. If change is initially unsuc- cessful, individuals may return to an earlier stage (Prochaska & Norcross, 2018).

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MI therapists strive to match specific treatment strategies with whatever stage of change clients are experiencing. It is important to match relationships of choice as well as treatment strategies of choice. If there is a mismatch between process and stage, movement through the stage will be impeded and is likely to be manifested in reluctant behavior. When clients demonstrate any form of reluctance or resistance, this could be due to a therapist’s misjudgment of a client’s readiness to change.

Common Ground With Solution-Focused Brief Therapy Motivational interviewing and solution-focused therapy share many common fac- tors. A confluence between these two approaches can enhance therapeutic practice, regardless of a therapist’s primary theoretical orientation. Some of these common- alities are discussed next.

Nonpathological, Health-Promoting Emphasis Both MI and SFBT emerged as a reaction against the prevailing medical model that focuses on problems. Both of these approaches are based on the philosophy of positive psychotherapy, which emphasizes clients’ abilities, strengths, resources, and competencies. The assumption is that clients want to be healthy and desire positive change. Counselors are mainly interested in exploring what is working well for individuals rather than dwelling on their problems.

Reframing Resistance Resistance is typically viewed as a phenomenon that resides within the client, and traditional therapy approaches often assume that clients who are “stuck” are resistant to change. MI and SFBT hold that labeling clients as “resistant” gets in the way of understanding clients’ behavior and impedes development of a collaborative partnership with clients. MI and SFBT practitioners take a respectful view of resistance and work with it therapeutically. SFBT theory avoids ascribing or interpreting client motivations but assumes that every client wants something and will work toward it. The counselor’s job is to find out what clients want from counseling (goal/preferred future) and help them apply existing successes, strengths, and resources toward achieving it.

MI encourages counselors to reflect on their style of interacting with clients to better understand their own part in creating relationships where there is resistance or discord. By reframing resistance as an interactional phenomenon between clients and counselors, the functions resistance serves are illuminated and counselors can adapt their approach to it. People who seek therapy often are ambivalent about mak- ing life changes, and their motivation may ebb and flow during the course of therapy. Counseling is about exploring an individual’s values and goals. When we are able to understand what people value, we have a key to what motivates them. MI is a phe- nomenological approach, which means the counselor attempts to view life from the client’s perspective. A central goal of MI is to increase internal motivation to change that is based on the personal goals and values of the client (Miller & Rollnick, 2013).

Use of Client Strengths and Resources Both MI and SFBT rest on the premise that people have strengths and resources that can be tapped in their efforts to bring about positive change. MI practitioners emphasize that the responsibility for change lies with clients, not with the counselor. MI counselors create a collaborative relationship with their clients, and clients are expected to assume an active role in

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their counseling. The counselor takes on the role of a skilled guide to help clients navigate the change process (Iarussi, 2019). Both therapist and client share a sense of hope and optimism that change is possible. When individuals believe they have the capacity to change, their motivation is increased, which helps them reach their personal goals. SFBT practitioners also work cooperatively and collaboratively with clients; clients experience support from therapists, which facilitates openness toward future possibilities and new directions.

Skills Improve With Deliberate Practice Skilled MI and SFBT clinicians may give the appearance that these methods are easy to implement, but these techniques cannot be mastered simply by reading about them or attending a workshop. Deliberate practice and feedback is required to help counselors improve both the technical skills and interpersonal therapeutic skills that influence client outcomes (Miller & Moyers, 2021). Miller and Moyers explain that deliberate practice means intentionally engaging in activities designed to improve therapists’ competence through repetition and successive refinement. It takes a great deal of skill for therapists to guide clients in engaging in change-talk that results in a commitment to change. Both evidence-based treatment procedures and the therapeutic relationship are related to successful therapy outcomes.

Application of Motivational Interviewing to School Counseling

This section was provided by Jennifer Melfie, MEd, a professional school coun- selor in Fairfax County Public Schools, Virginia. She supports 7th- and 8th-grade students in their academic, career, and social/emotional development.

Motivational interviewing (MI) comprises the foundation for most of the conver- sations I facilitate during individual sessions with my middle school students. As a school counselor, I have very limited time with each student, and this approach partners empathy and change-talk in a time-efficient manner. Ultimately, my goal in individual sessions is to foster students’ propensity and willingness to change in accordance with their personal goals. I do this by using reflective statements that encourage students to acknowledge and elaborate their reasons for change. I draw out students’ values and encourage students to ponder how making a change ver- sus not making a change would fulfil their values. If I asked students, “What are your top values?” most of them would reply, “I don’t know.” Instead of direct ques- tions, I identify their values by listening to them and reflecting back what I hear them saying. For example, if I’ve deduced that they value novelty, I might say, “It is important to you that you try new things.” Then I give the student the opportunity to agree and elaborate or to correct my misunderstanding. I believe it is critical that I refrain from judging my students’ values or decisions. Students are quick to look for any sign from me that can help them discern what they think I want them to say or do. At times, it feels as if middle school students come on a spectrum ranging from intentionally resisting adult opinion to desperately searching for adult valida- tion before making any decisions. I refrain from advice giving or problem solving, instead empowering students with the tools, skills, and a safe place to express their feelings and explore their thoughts.

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Throughout these sessions, students often interrupt their change-talk with talks of stagnation. I actively choose not to react or respond to the talks of stagnation. For example, a student might say, “I want to make an effort to improve my science grades, but it’s so hard.” I might reply with a simple reflection, “You want to bring up your science grade.” Then I direct the conversation back toward the change-talk. As a counselor, I strive to reduce student ambivalence about change and increase students’ own motivation for change. Another MI strategy I use to get students to brainstorm reasons for change is to ask them to rank how important it is for them to change on a scale of 1 to 10. If they say 4, I might ask, “Why a 4 and not a 3?” Again, I am not dis- missing their response but redirecting their energy into the change-talk. I also might challenge students to explore the extremes in choosing to make no change versus making a change. When I ask students to illustrate what life might look like when they make a change, they are generally able to illustrate the benefits or drawbacks.

Another strategy of MI that I rely on is asking what I’ve mentally labeled as “So what?” questions. I do this to encourage students to brainstorm their own reasons something matters to them. I might say, “Okay, so you fail your Algebra class. So what? Who cares?” Students are usually quick to list endless reasons why they care and why it matters. By highlighting things students share with me that support the change or action, students are able to reflect on the change they are debating, and I find that most middle school students will elaborate with more details. This enables me to serve as a sounding board for them, without inserting my own values or beliefs. When students believe they have the capacity to change, I find that their motivation is increased, which helps them reach their personal goals.

Michael White (1949–2008) was the cofounder, with David Epston, of the narrative therapy movement. He founded the Dulwich Centre in Adelaide, Australia, and his work with families and communities has

attracted widespread international interest. Among his many books are Narrative Means to Therapeutic Ends (White & Epston, 1990), Reauthoring Lives: Interviews and Essays (White, 1995), Narrative of Therapists’ Lives (White, 1997), and Maps of Narrative Practice (White, 2007). Michael White died in April 2008 while visiting San Diego for a teaching workshop.

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David Epston (b. 1944) is one of the developers of narrative therapy. He is an international traveler, presenting lectures and workshops in Australia, Europe, and North America. He is a coauthor of Narrative Means to Therapeutic Ends

(White & Epston, 1990); Playful Approaches to Serious Problems: Narrative Therapy With Children and Their Families (Freedman et al., 1997); Biting the Hand That Starves You (Maisel et al., 2004); Narrative Therapy in Wonderland: Connecting with Children’s Imaginative Know-How (Marsten et al., 2016); and Collaborative and Indigenous Mental Health Therapy: Tātaihono—Stories of Māori Healing and Psychiatry (NiaNia et al., 2017).

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Narrative Therapy Introduction

Of all the social constructionists, Michael White and David Epston (1990) are best known for their use of narrative in therapy. According to White (1992), individu- als construct the meaning of life in interpretive stories, which are then treated as “truth.” Because of the power of dominant culture narratives, individuals tend to internalize the messages from these dominant discourses, which often work against the life opportunity of the individual.

Adopting a postmodern, narrative, social constructionist view sheds light on how power, knowledge, and “truth” are negotiated in families and other social and cultural contexts (Freedman & Combs, 1996). Narrative therapy is a strengths- based approach that emphasizes collaboration between client and therapist to help clients view themselves as empowered and living the way they want (Rice, 2015).

Key Concepts The narrative approach involves adopting a shift in focus from most traditional theories. Therapists are encouraged to establish a collaborative approach with a spe- cial interest in listening respectfully to clients’ stories; to search for times in clients’ lives when they were resourceful; to use questions as a way to engage clients and facilitate their exploration; to avoid diagnosing and labeling clients or accepting a totalizing description based on a problem; to assist clients in mapping the influence a problem has had on their lives; and to assist clients in separating themselves from the dominant stories they have internalized so that space can be opened for the creation of alternative life stories (Freedman & Combs, 1996).

The Role of Stories One of the theoretical underpinnings of narrative therapy is the notion that problems are manufactured in social, cultural, and political contexts. We live our lives by the stories we tell about ourselves and that others tell about us. Our stories shape reality in that they construct and constitute what we see, feel, and do. The stories we live by grow out of conversations in a social and cultural context. Change occurs by exploring how language is used to create and maintain problems (Rice, 2015). Therapy clients have vivid stories to recount. When stories are changed, not only is the person telling the story changed but the therapist who is privileged to be a part of this unfolding process is also changed (Monk, 1997).

Listening With an Open Mind All social constructionist theories emphasize listening to clients without judgment or blame, affirming and valuing them. Narrative practice goes further in deconstructing the systems of normalizing judgment that are found in medical, psychological, and educational discourse. Normalizing judgment is any kind of judgment that locates a person on a normal curve and is used to assess intelligence, mental health, or normal behavior. Because these kinds of judgments claim to be objective measures, they are difficult for individuals to resist and usually are internalized. Narrative therapists argue that suspending

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personal judgment is of little value if you participate in normalizing judgment. Deconstruction involves turning the tables and asking what clients think of the judgments they have been assigned. Narrative practitioners might be said to invite people to pass judgment on the judgments that have been working them over. They help clients judge social norms that are unhelpful to them. Narrative therapists help clients modify their painful beliefs, values, and interpretations as clients create meaning and new possibilities from the stories they share (Winslade & Del Corso, 2019). Therapists do not impose their value system, and interpretations flow from clients’ stories rather than from a preconceived and ultimately imposed theory of importance and value.

Narrative therapists strive to listen to the problem-saturated story of the cli- ent without getting stuck. Therapists stay alert for details that give evidence of the client’s competence in taking stands against oppressive problems. Winslade and Monk (2007) maintain that the therapist believes the client’s abilities, talents, positive intentions, and life experiences can be the catalysts for new possibilities for action. The narrative therapist demonstrates faith that these inner resources and competencies can be identified, even when the client is having difficulty rec- ognizing them.

During the narrative conversation, attention is given to avoiding totalizing language, which reduces the complexity of the individual by assigning an all- embracing, single description to the essence of the person. Therapists begin to sepa- rate the person from the problem in their mind as they listen and respond (Winslade & Monk, 2007). This is called double listening.

The narrative perspective focuses on the capacity of humans for creative and imaginative thought, which is often found in their resistance to dominant discourse. Narrative practitioners do not assume that they know more about the lives of clients than their clients do. Clients are the primary interpreters of their own experiences. People are viewed as active agents who are able to derive meaning from their expe- riential world, and they are encouraged to join with others who might share in the development of a counter story.

The Therapeutic Process This brief overview of the steps in the narrative therapeutic process illustrates the structure of the narrative approach (O’Hanlon, 1994, pp. 25–26):

◆ Collaborate with the client to come up with a mutually acceptable name for the problem.

◆ Personify the problem and attribute oppressive intentions and tactics to it.

◆ Investigate how the problem has been disrupting, dominating, or dis- couraging to the client.

◆ Invite clients to see their story from a different perspective by inquiring into alternative meanings for events.

◆ Discover moments when the client wasn’t dominated or discouraged by the problem by searching for exceptions to the problem.

◆ Find historical evidence to bolster a new view of the client as competent enough to have stood up to, defeated, or escaped from the dominance

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or oppression of the problem. (At this phase the person’s identity and life story begin to be rewritten.)

◆ Ask clients to speculate about what kind of future could be expected from the strong, competent person who is emerging. As clients become free of problem-saturated stories of the past, they can envision and plan for a less problematic future.

◆ Find or create an audience for perceiving and supporting the new story. It is not enough to recite a counter story. The client needs to live the counter story outside of therapy. Because the person’s problem initially developed in a social context, it is essential to involve the social environ- ment in supporting the new life story that has emerged in the conversa- tions with the therapist.

Winslade and Monk (2007) stress that narrative conversations do not follow the linear progression described here; it is better to think of these steps in terms of cycli- cal progression containing the following elements:

◆ Move problem stories toward externalized descriptions of problems. ◆ Map the effects of a problem on the individual. ◆ Invite the individual to evaluate the problem and its effects. ◆ Make meaning of identified problems in relation to both their

espoused values and lived beliefs. ◆ Listen to signs of strength and competence in an individual’s problem-

saturated stories that are in alignment with what the individual values. ◆ Build a new story of competence and document these achievements.

Therapy Goals A general goal of narrative therapy is to invite people to describe their experience in new and fresh language. In doing this, they open new vistas of what is possible. This new language enables clients to develop new meanings for problematic thoughts, feelings, and behaviors (Freedman & Combs, 1996). Narrative therapy almost always includes an awareness of the impact of various aspects of dominant culture on human life. Narrative practitioners seek to enlarge the perspective and facilitate the discovery or creation of new options that are unique to the people they see.

Therapist’s Function and Role Narrative therapists are active facilitators. The concepts of care, interest, respectful curiosity, openness, empathy, contact, and even fascination are seen as a relational necessity. The not-knowing position, which allows therapists to follow, affirm, and be guided by the stories of their clients, creates participant-observer and process-facilitator roles for the therapist and integrates therapy with a postmodern view of human inquiry.

A main task of the therapist is to help clients construct a preferred story line. The narrative therapist adopts a stance characterized by respectful curiosity and works with clients to explore both the impact of the problem on them and what they are doing to reduce the effects of the problem. One of the main functions of the therapist is to ask questions of clients and, based on the answers, to generate further questions.

White and Epston (1990) start with an exploration of the client in relation to the presenting problem. It is not uncommon for clients to present initial stories in

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which they and the problem are fused, as if one and the same. White uses questions aimed at separating the problem from the people affected by the problem. This shift in language begins the deconstruction of the original narrative in which the person and the problem were fused; now the problem is objectified as external to the client.

The narrative therapist tends to avoid using language that embodies diagnosis, assessment, treatment, and intervention. Functions such as diagnosis and assess- ment often grant priority to the practitioner’s “truth” over clients’ knowledge about their own lives. The narrative approach gives emphasis to understanding clients’ lived experiences and de-emphasizes efforts to predict, interpret, and pathologize.

Monk (1997) emphasizes that narrative therapy will vary with each client because each person is unique. For Monk, narrative conversations are based on a way of being, and if narrative counseling “is seen as a formula or used as a recipe, clients will have the experience of having things done to them and feel left out of the conversation” (p. 24).

The Therapeutic Relationship Narrative therapists place great importance on the values and ethical commitments a therapist brings to the therapy venture. They are deeply concerned about the dimensions of power in the therapeutic relationship and they strive for a spirit of egalitarianism (Winslade & Del Corso, 2019). They prize attitudes such as optimism and respect, curiosity and persistence, valuing the client’s knowledge, and creating a special kind of relationship characterized by a real power-sharing dialogue (Winslade & Del Corso, 2019; Winslade & Monk, 2007). Collaboration, compassion, reflection, and discovery characterize the therapeutic relationship. The strengths-based and future-focused nature of narrative therapy lends itself to a more collaborative relationship than problem-based approaches that emphasize the therapist as the expert in the relationship (Rice, 2015). If this relationship is to be truly collaborative, therapists need to be aware of how power manifests itself in their professional practice. This does not mean that therapists do not have authority as professionals. They use this authority, however, by treating clients as experts in their own lives.

Winslade, Crocket, and Monk (1997) describe this collaboration as coauthoring or sharing authority. Clients function as authors when they have the authority to speak on their own behalf. In the narrative approach, as in the solution-focused brief therapy approach, the therapist-as-expert is replaced by the client-as-expert (Winslade & Del Corso, 2019). This notion challenges the stance of the therapist as being an all-wise and all-knowing expert.

Clients are often stuck in a pattern of living a problem-saturated story that does not work. When clients have a limited perception of their capacities due to being saturated in problem thinking, it is the job of the therapist to elicit other strength- related stories to modify clients’ perceptions. The history of the problem often dom- inates the client’s understanding, but narrative therapists argue that there is another history that should not be neglected. It is the history of the counter story, which is constructed in conversation with the client and becomes the foundation for a differ- ent future. Narrative therapists contend that individuals can reconstruct their past by exploring new stories in the present. The past can be changed by creating new stories (Prochaska & Norcross, 2018).

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Application: Therapeutic Techniques and Procedures The effective application of narrative therapy is more dependent on therapists’ atti- tudes or perspectives than on techniques. In the practice of narrative therapy, there is no recipe, no set agenda, and no formula that the therapist can follow to assure posi- tive results (Drewery & Winslade, 1997). When externalizing questions are approached mainly as a technique, the intervention will be shallow, forced, and unlikely to pro- duce significant therapeutic effects (Freedman & Combs, 1996; O’Hanlon, 1994).

Narrative therapists are in agreement with Carl Rogers on the importance of the therapist’s way of being rather than being technique driven. A narrative approach to counseling is more than the application of skills; it is based on the therapist’s per- sonal characteristics that create a climate that encourages clients to see their stories from different perspectives. Recent works on narrative therapy highlight the signifi- cance of attending to the human body, including that of both therapist and client, as stories get told in the therapy room (Monk & Zamani, 2019). Voice tone, cadence, body positioning, and facial expressions are all important dimensions to the narra- tives shared (Denborough, 2019; Zimmerman, 2018).

Questions . . . and More Questions The questions narrative therapists ask may seem embedded in a unique conversation, part of a dialogue about earlier dialogues, a discovery of unique events, or an exploration of dominant culture processes and imperatives. Whatever the purpose, the questions are often circular, or relational, and they seek to empower clients in new ways. To use Gregory Bateson’s (1972) famous phrase, they are questions in search of a difference that will make a difference.

Like solution-focused therapists, narrative therapists use questions as a way to generate experience rather than to gather information. The aim of questioning is to progressively discover or construct the client’s experience so that the client has a sense of a preferred direction. Questions are always asked from a position of respect, curiosity, and openness. Both solution-focused therapists and narrative therapists ask questions from a not-knowing position, showing curiosity and intense interest in discovery rather than having a preconceived idea about clients.

Through the process of asking questions, therapists provide clients with an opportunity to explore various dimensions of their life situations. This questioning process helps bring out the unstated cultural assumptions that contribute to the original construction of the problem. The therapist is interested in finding out how the problems first became evident, and how they have affected clients’ views of them- selves (Monk, 1997). Narrative therapists attempt to engage people in deconstructing problem-saturated stories, identifying preferred directions, and creating alternative stories that support these preferred directions. The therapist aims to help people reflect on how they can become authors of their experience and how they can assume greater agency in their lives (Winslade & Del Corso, 2019). For a more complete dis- cussion of the use of questions in narrative therapy, see Madigan (2019).

Externalization and Deconstruction White (1989) believed that “the person is not the problem; the problem is the problem” (p. 6). These problems often are products of the cultural world or of the power relations in which this world is located. Living life means relating to problems, not being fused with them. Narrative therapists

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help clients deconstruct these problematic stories by disassembling the taken-for- granted assumptions that are made about an event, which then opens alternative possibilities for living (Winslade & Del Corso, 2019).

Externalization is one process for deconstructing the power of a narrative. This process separates the person from identification with the problem. When clients view themselves as “being” the problem, they are limited in the ways they can effec- tively deal with the problem. When clients experience the problem as being located outside of themselves, they create a relationship with the problem. For example, there is quite a difference between labeling someone an alcoholic and indicating that alcohol has invaded the person’s life. Separating the problem from the individual facilitates hope and enables clients to take a stand against specific story lines, such as self-blame. By understanding the cultural invitations to blame oneself, clients can deconstruct this story line and generate a more positive, healing story.

The method used to separate the person from the problem is referred to as exter- nalizing conversation, which opens up space for new stories to emerge. This method is particularly useful when people have internalized diagnoses and labels that have not been validating or empowering of the change process (Bertolino & O’Hanlon, 2002). Externalizing conversations counteract oppressive, problem-saturated sto- ries and empower clients to feel competent to handle the problems they face. Two stages of structuring externalizing conversations are (1) to map the influence of the problem in the person’s life, and (2) to map the influence of the person’s life back on the problem (McKenzie & Monk, 1997).

Mapping the influence of the problem on the person generates a great deal of useful information and often results in people feeling less shamed and blamed. Mapping-the-influence questions consist of inviting clients to explore the con- sequences of the problem in all areas of their life (Winslade & Del Corso, 2019). A common question is, “When did this problem first appear in your life?” When this mapping is done carefully, it lays the foundation for coauthoring a new story line for clients. Often clients feel outraged when they see for the first time how much the problem is affecting them. The job of the therapist is to assist clients in tracing the problem from when it originated to the present. Therapists may put a future twist on the problem by asking, “If the problem were to continue for a month (or any time period), what would this mean for you?” This question can motivate the client to join with the therapist in combating the impact of the problem’s effects. Other use- ful questions are “To what extent has this problem influenced your life?” and “How deeply has this problem affected you?”

It is important to identify instances when the problem did not completely dom- inate a client’s life. This kind of mapping can help the client who is disillusioned by the problem see some hope for a different kind of life. Therapists look for these “sparkling moments” as they engage in externalizing conversations with clients (White & Epston, 1990).

The case of Brandon illustrates an externalizing conversation. Brandon says that he gets angry far too much, especially when he feels that his wife is criticizing him unjustly: “I just flare! I pop off, get upset, fight back. Later, I wish I hadn’t, but it’s too late. I’ve messed up again.” Questions about how his anger occurs, com- plete with specific examples and events, can help chart the influence of the problem. However, it is questions like the ones that follow that externalize the problem: “What

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is the mission of the anger, and how does it recruit you into this mission?” “How does the anger get you, and how does it trick you into letting it become so power- ful?” “What does the anger require of you, and what happens to you when you meet its requirements?” “What cultural supports (in your family/community/world) have shaped the role that anger plays for you?”

Search for Unique Outcomes In the narrative approach, externalizing questions are followed by questions searching for unique outcomes. The therapist talks to the client about moments of choice or success regarding the problem. This is done by selecting for attention any experience that stands apart from the problem story, regardless of how insignificant it might seem to the client. The therapist may ask: “Was there ever a time in which anger wanted to take you over, and you resisted? What was that like for you? How did you do it?” These questions are aimed at highlighting moments when the problem has not occurred or when the problem has been dealt with successfully. Unique outcomes can often be found in the past or the present, but they can also be hypothesized for the future: “What form would standing up against your anger take?” Exploring questions such as these enables clients to see that change is possible. Linking a series of such unique outcomes together starts to form a counter story. It is within the account of unique outcomes that a gateway is provided for alternative versions of a person’s life (White, 1992).

Following the description of a unique outcome, White (1992) suggests pos- ing questions, both direct and indirect, that lead to the elaboration of preferred identity stories:

◆ What do you think this tells me about what you have wanted for your life and about what you have been trying for in your life?

◆ How do you think knowing this has affected my view of you as a person? ◆ Of all those people who have known you, who would be least surprised

that you have been able to take this step in addressing your problem’s influence in your life?

◆ What actions might you commit yourself to if you were to more fully embrace this knowledge of who you are? (p. 133)

The development of unique outcome stories into solution stories is facilitated by what Epston and White (1992) call “circulation questions”:

◆ Now that you have reached this point in life, who else should know about it?

◆ I guess there are a number of people who have an outdated view of who you are as a person. What ideas do you have about updating these views?

◆ If other people seek therapy for the same reasons you did, can I share with them any of the important discoveries you have made? (p. 23)

These questions are not asked in a barrage-like manner. Questioning is an integral part of the context of the narrative conversation, and each question is sensitively attuned to the responses brought out by the previous question (White, 1992).

McKenzie and Monk (1997) suggest that therapists seek permission from the client before asking a series of questions. By letting clients know that they do not have answers to the questions they raise, therapists are putting clients in control of the therapeutic process. Asking permission of the client to use persistent question- ing tends to minimize the risk of inadvertently pressuring the client.

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Alternative Stories and Reauthoring Constructing counter stories goes hand in hand with deconstruction, and the narrative therapist listens for openings to counter stories. People can continually and actively reauthor their lives, and narrative therapists invite clients to author alternative stories through unique outcomes; these events could not be predicted from listening to the dominant problem-saturated story and are not included in any narrative about the person (Winslade & Del Corso, 2019). The narrative therapist asks for openings: “Have you ever been able to escape the influence of the problem?” The therapist listens for clues to competence in the midst of a problematic story and builds a story of competence around it. Madigan (2019) suggests that a person’s life story is probably much more interesting than the story being told. He maintains a therapist’s main task is to help people remember and reinvent a richer and more meaningful alternative story.

A turning point in the narrative interview comes when clients make the choice of whether to continue to live by a problem-saturated story or to state a preference for an alternative story (Winslade & Monk, 2007). Through the use of unique pos- sibility questions, the therapist moves the focus into the future. For example: “Given what you have learned about yourself, what is the next step you might take?” “When you are acting from your preferred identity, what actions will it lead you to do more of?” These questions encourage people to reflect on what they have achieved and what their next steps might be.

White and Epston’s (1990) inquiry into unique outcomes is similar to the exception questions of solution-focused therapists. Both seek to build on the com- petence already present in the person. The development of alternative stories, or narratives, is an enactment of ultimate hope: Today is the first day of the rest of your life.

Refer to Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 11) for two concrete examples of a narrative approach to working with Ruth from the per- spectives of Dr. Gerald Monk and Dr. John Winslade.

Documenting the Evidence Narrative practitioners believe that new stories take hold only when there is an audience to appreciate and support them. Gaining an audience for the news that change is taking place needs to occur if alternative stories are to stay alive, and an appreciative audience to new developments is consciously sought.

One technique for consolidating the gains a client makes involves a therapist writing letters to the person. Narrative therapists have pioneered the development of therapeutic letter writing. These letters provide a record of the session and may include an externalizing description of the problem and its influence on the client, as well as an account of the client’s strengths and abilities that are identified in a ses- sion. Letters can be read again at different times, and the story that they are part of can be reinspired. The letter highlights the struggle the client has had with the prob- lem and draws distinctions between the problem-saturated story and the developing new and preferred story (McKenzie & Monk, 1997).

Epston has developed a special facility for carrying on therapeutic dialogues between sessions through the use of letters (White & Epston, 1990). His letters may be long, chronicling the process of the interview and the agreements reached, or

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short, highlighting a meaning or understanding reached in the session and asking a question that has occurred to him since the end of the previous therapy visit. Usually the letters include many direct quotations from clients and encourage clients, noting what they said about their own accomplishments in relation to handling problems or speculating on the meaning of their accomplishments for others in their community. Letters documenting the changes clients have achieved tend to strengthen the signifi- cance of the changes, both for the client and for others in the client’s life.

Narrative letters reinforce the importance of carrying what is being learned in the therapy office into everyday life. The message conveyed is that participating fully in the world is more important than being in the therapy office. In an informal survey of the perceptions of the value of narrative letters by past clients, the average worth of a letter was equal to more than three individual sessions (Nylund & Thomas, 1994). This finding is consistent with McKenzie and Monk’s (1997) statement: “Some nar- rative counselors have suggested that a well-composed letter following a therapy ses- sion or preceding another can be equal to about five regular sessions” (p. 113).

Application of Narrative Therapy to Group Counseling

This section was provided by Gerald Monk, PhD, who has been involved in the practice and teaching of narrative work since its inception in the early 1980s. He has coauthored six books on narrative therapy and taught this approach on four continents. He is a professor in marriage and family therapy at San Diego State University.

Many personal struggles that drive people to therapy are based on problems usually viewed as some kind of personality or psychological deficit—either within them- selves or with persons who are causing them distress. Narrative therapy groups are particularly helpful in disrupting this human proclivity for locating problems inside people where problem issues are normally understood as separate from their immediate environment, such as family, school and work history, and negative soci- etal pressures.

In contrast to this internalizing pathologizing approach, the narrative group facilitator places emphasis on the cultural, political, and social elements that are often neglected in understanding how human problems get created in the first place. The narrative group facilitator pays close attention to negative forces such as patriarchy, racism, economic hardship, assault, ableism, and all manner of social injustices that can create family and personal trauma.

The narrative group facilitator understands group members’ problems as being products of social forces arising outside of themselves. Thus, the work of the narra- tive group facilitator is to help group members position themselves as being chal- lenged by the societal threats to their well-being rather than seeing these problems as internal deficits of individuals. The group facilitator’s job is to create a context in which group members join forces to go on the offensive against the externalized societal forces of harm. Members are encouraged to mobilize their internal resources to diminish the effects of harmful cultural elements.

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An important part of narrative group practice is gathering an appreciative audi- ence to bear witness to hearing of changes group members are making in their lives. Narrative therapists have developed an approach to supporting people in the pro- cess of addressing problems in their lives called outsider witnessing (Carey & Russell, 2003). Outsider witnesses have an invested interest in listening to both the effects of troublesome problem stories people share and witnessing the preferred stories of people who share themes pertaining to things such as resilience, courage, determi- nation, and persistence. When narrative counseling groups invite group members to be outsider witnesses, group participants telling their story can feel deeply cared for and reinforced for making difficult changes in their lives.

Witnesses are encouraged to notice any unique outcomes, which are small events that illustrate clients’ actions to overcome the problem situation. Using this approach, group members telling the story can internalize small moments of success that propel them forward to greater involvement in their preferred narrative. Out- sider witnesses engage the witnessing team with questions such as “What important values, beliefs, and hopes were expressed that you noted?”

A new contribution is made by the outsider witness team members when they ask each other about what they noted in the story teller’s narrative that had them reflecting on their own personal and professional experiences and stories. This change of focus invites the group into a sense of community, helping join the story teller’s narrative with the witnessing team’s responses and the counseling group as a whole. Finally, in the outsider witness protocol, story tellers are asked to reflect on any statement from the outsider witness team that caught their attention.

The entire counseling group builds off of the outsider witness protocol and is mobilized to share their heartfelt responses about new thoughts, ideas, and feelings that mobilize their own behaviors to challenge the externalized problems. In addi- tion, new identities can be tried out in groups and then performed in their lives.

Winslade and Monk (2007) claim that the narrative emphasis on creating an appreciative audience for new developments in an individual’s life lends itself to group counseling: “Groups provide a ready-made community of concern and many opportunities for the kind of interaction that opens possibilities for new ways of liv- ing . . . new identities can be rehearsed in groups and then performed in their lives and tried out into a wider world” (p. 135). They provide several examples of work- ing in a narrative way with groups in schools: getting back on track in schoolwork, an adventure-based program, an anger management group, and a grief counseling group. For a detailed description of these narrative groups, see Narrative Counseling in Schools (Winslade & Monk 2007, chap. 5).

An Expert’s Perspective on Narrative Therapy In this section, John Winslade, PhD, professor of counseling at California State University, San Bernardino, coauthor of 10 books on narrative therapy, and pre- senter at numerous workshops on narrative practice in North and South America, Asia, Europe, Australasia, and the Middle East, provides answers to the following questions.

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1. What is the most important contribution of narrative therapy for the practice of individual therapy? Narrative therapy’s special contribution lies in its response to shifts in the conditions of living. People’s problems are not the same as they were when Freud developed psychoanalysis or when the humanistic therapies of the 1960s were developed. In particular, narrative therapy responds critically to the trend toward normalizing judgment (evaluating people as normal or abnormal rather than as good or bad) as a means of social control, and the widespread pathologizing of individuals with mental health labels. Narra- tive therapy is based on a critique of the dominant forms of power in the modern world.

Narrative therapy has a relational emphasis rather than one that places the individual at the center of the universe. Individuals are considered to be members of relationships, families, communities, and social networks, and such membership is often recognized and included in the therapeu- tic process. In the relationship between counselors and clients, narrative therapy cautions counselors not to impose their own assumptions on their clients. It is profoundly concerned with the ethics of practice and not just its outcomes.

Narrative therapy has contributed many new ideas to the therapy field. These include systematic therapeutic letter writing and asking many new questions. It is also widely known for the idea of externalizing. Narrative therapy celebrates people’s multistoried lives; shifting from one story to another shifts emotions, thoughts, and actions.

2. What two or three key concepts of narrative therapy are especially applicable to the practice of individual counseling or therapy? Discourse. The concept of discourse is central to the practice of nar- rative therapy. The world of the individual is constructed out of domi- nating discourses, and therapy teases out these influences so people can more consciously resist their influence and make informed choices about how to live.

Deconstruction. Unpacking the powerful discourses and their effects on people’s lives is achieved by asking questions about the effects of whatever is externalized. Deconstruction opens up space for new pos- sibilities of living to emerge.

Unique Outcomes. The moments in life when a dominant story does not dominate often lie in the shadows of a person’s experience and are scarcely recognized. These unique outcomes can, however, form the basis of a counter story that can replace the dominant problem story, but only when incorporated into a viable story. To become viable, a counter story needs to develop a plot (a series of events), characterization (persons with skills and intentions), and themes (meanings). Forming such a story often begins with a single unique outcome and extends through asking about the lived experi- ence of the client.

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3. What two or three techniques from narrative therapy have practi- cal value for practitioners of individual therapy? Externalizing. This is the most widely known technique in narrative practice. Externalizing is a way of speaking that separates the problem from the person and refers to a person as being affected by a problem rather than as being a problem person. Externalizing addresses what individuals uncritically accept about themselves and subjects this to examination.

Double Listening. This nuanced listening skill is an advance on the conventional practice of active listening. It involves listening to someone’s expression of a problem story and, at the same time, to the expression of a counter story. Double listening contrasts the problem story and the counter story and keeps that contrast alive so the client can choose which story to invest energy in.

Questioning. The main tool for bringing about change in narrative therapy is through questioning. Narrative questions aim to gener- ate shifts in experience by mapping the influence of the problem in a person’s life; inviting the person to evaluate the problem; eliciting a person’s resistance to the problem story; highlighting unique outcomes and generating a counter story from the person; linking the counter story to cherished commitments and values; and circulating the recog- nition by others of the counter story.

4. How does the narrative approach address diversity, multicul- tural, and social justice issues for the practice of individual counseling? Narrative therapy grew out of the same era of thinking as the multicul- tural movement in therapy. Cultural concerns are not so much tacked onto existing theory as built into the central core of narrative practice. Narrative practice avoids building up a theory of core human nature, coated with culture on the outside. It assumes that human experience is shot through with cultural influences. The theory of the person is cultural from the start.

From its beginnings, narrative therapy aligned itself with the feminist slogan “The personal is political” and was concerned that therapy worked for greater social justice, not just individual mental health. This leads nar- rative therapists to be concerned about the politics and ethics of therapy (politics refers to how power governs relational exchange and has little to do with electoral politics).

At the same time, narrative therapy adopts a particular approach to diversity and social justice issues. Social change happens primarily through shifts in discourse rather than through law changes or through changes in individual hearts. Narrative conversations are important because it is in conversation of all kinds that discourse originates. Narrative therapy is opti- mistic about counseling as a site for social change as well as for individual adjustment.

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5. In what ways can narrative therapy be applied to brief therapy (or time-limited counseling)? Narrative therapy helps people shift from one story to a different one. It is not aimed at personality reconstruction and does not dig up pain- ful memories from a person’s family of origin. It also embraces the language of the client rather than educating the client in the jargon of therapy. Externalized descriptions of a problem emerge from the cli- ent’s language rather than from diagnostic manuals or therapeutic theory. Therefore, no time need be spent on the client learning the lan- guage of therapy. Narrative therapy grew out of work with children and is uniquely attuned to children’s language and to their concentration spans. Therapeutic letters also maximize the value of counseling sessions and shorten the overall length of therapy. For these reasons, narrative therapy is usually a brief therapy.

6. From your perspective, what is the current status and the future of the narrative approach? Narrative therapy has shown steady growth around the world since the 1980s. Its center of gravity is in Australia and New Zealand, but it has a following in the United States, Canada, and parts of Europe as well. It is also well-established in many contexts in Africa, Asia, and Latin America. This growth has been fed by international conferences and training programs. The narrative therapy network has been established and maintained by enthusiasts and entrepreneurs outside of the main- stream, but it now needs to find longer-term lodging in the larger world of therapy.

Many therapists are more concerned about their own positions in mainstream social contexts than about social justice and are thus cau- tious about adopting narrative practices. In contexts dominated by “evidence-based practice” and insurance reimbursement dictates, nar- rative therapy is sometimes squeezed out because many narrative prac- titioners are suspicious of the required research that objectifies people. Narrative therapy is supported by many small qualitative research stud- ies but is not suited to experimental, control group studies. Hence, it is sometimes granted limited exposure in some mainstream North Ameri- can contexts.

The death of Michael White in 2008 left narrative therapy at a crossroads. Cofounder David Epston continues to advocate for ongoing development in narrative therapy, and many others have continued to research and practice narrative ideas. Its further development depends on whether narrative therapy generates innovative responses to modern conditions of living, which are now subtly different from those of the 1980s. Ongoing growth depends on continuing development of narra- tive therapy publications, the systematic training programs that have appeared around the world, and the recognition that books like this one afford.

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Discussion Questions Related to the Narrative Therapy Perspective

1. Dr. Winslade describes three narrative therapy techniques: externaliz- ing, double listening, and questioning. Which technique(s) can you see yourself using?

2. What do you imagine it would be like for you to be a client in narrative therapy?

3. What aspects of narrative therapy would you want to incorporate into your counseling approach?

Postmodern Approaches From a Multicultural Perspective

Strengths From a Diversity Perspective Social constructionism is congruent with the philosophy of multiculturalism. One of the problems that culturally diverse clients often experience is the expectation that they should conform their lives to the truths and reality of the dominant soci- ety of which they are a part. With the emphasis on multiple realities and the assump- tion that what is perceived to be a truth is the product of social construction, the postmodern approaches are a good fit with diverse worldviews.

The social constructionist approach to therapy provides clients with a frame- work to think about their thinking and to determine the impact stories have on what they do. Clients are encouraged to explore how their realities are being con- structed out of cultural discourse and the consequences that follow from such con- structions. Within the framework of their cultural values and worldview, clients can explore their beliefs and provide their own reinterpretations of significant life events. The practitioner with a social constructionist perspective can guide clients in a manner that respects their underlying values. This dimension is especially impor- tant in those cases where counselors are from a different cultural background or do not share the same worldview as their clients.

Narrative therapy is grounded in a sociocultural context, which makes this approach especially relevant for counseling culturally diverse clients. Narrative ther- apists operate on the premise that problems are identified within social, cultural, political, and relational contexts rather than existing within individuals. They are very much concerned with considering the specifications of gender, ethnicity, race, disability, sexual orientation, social class, and spirituality and religion as therapeutic issues. Furthermore, therapy becomes a place to reauthor the social constructions and identity narratives that clients are finding problematic. There is a liberation in being able to reauthor our experiences and view our life events with a new lens that is compassionate and possibly empowering.

Narrative therapy is a relational and anti-individualistic practice. Michael White believes that to address clients’ struggles in therapy without a relational and con- textual understanding of their story is entirely absurd (as cited in Madigan, 2019). Narrative therapists concentrate on problem stories that dominate and subjugate

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at the personal, social, and cultural levels. The sociopolitical conceptualization of problems sheds light on those cultural notions and practices that produce domi- nant and oppressive narratives. From this orientation, practitioners take apart the cultural assumptions that are a part of a client’s problem situation. People are able to come to an understanding of how oppressive social practices have affected them. This awareness can lead to a new perspective on dominant themes of oppression that have been such an integral part of a client’s story, and with this cultural aware- ness new stories can be generated.

In their discussion of the multicultural influences on clients, Bertolino and O’Hanlon (2002) approach clients without a preconceived notion about their experience and learn from their clients about their experiential world. Bertolino and O’Hanlon practice multicultural curiosity by listening respectfully to their clients, who become their best teachers. Here are some questions Bertolino and O’Hanlon suggest as a way to more fully understand multicultural influences on a client:

◆ Tell me more about the influence that [some aspect of your culture] has played in your life.

◆ What can you share with me about your background that will enable me to more fully understand you?

◆ What challenges have you faced growing up in your culture? ◆ What, if anything, about your background has been difficult for you? ◆ How have you been able to draw on strengths and resources from your

culture? What resources can you draw from in times of need?

Questions such as these can shed light on specific cultural influences that have been sources of support or that contributed to a client’s problem. This manner of inquiry and deep listening is a positive way to begin the therapeutic relationship. The underlying message is: “Teach me who you are and where you have been. I want to see you more fully and holistically so we can more effectively work together in meeting your therapeutic goals.”

Shortcomings From a Diversity Perspective A potential shortcoming of the postmodern approaches pertains to the not- knowing stance the therapist assumes, along with the assumption of the client-as- expert. Individuals from many different cultural groups tend to elevate the profes- sional as the expert who will offer direction and solutions for the person seeking help. If the therapist is telling the client, “I am not really an expert; you are the expert; I trust in your resources for you to find solutions to your problems,” this may engender lack of confidence in the therapist. To avoid this situation, therapists using a solution-focused or a narrative orientation need to convey to clients that they have expertise in the process of therapy but that clients are the experts in know- ing what they want in their life and where they have been on their life journey. The postmodern approaches stress being transparent with clients and honoring their hopes and expectations in therapy. This emphasis creates a context for providing culturally responsive services.

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Postmodern Approaches Applied to the Case of Stan I operate from an integrative perspective by combining concepts and techniques from the solution-focused and narrative approaches. From this framework, I am philosophically opposed to assessment and diagnosis using the DSM-5 model, and I do not begin therapy with a formal assessment. Instead, I engage Stan in col- laborative conversations centered on change, compe- tence, preferences, possibilities, and ideas for making changes in the future.

I begin my work with Stan by inviting him to tell me about the concerns that brought him to therapy and what he expects to accomplish in his sessions. I also provide Stan with a brief orientation of some of the ba- sic ideas that guide my practice and describe my view of counseling as a collaborative partnership in which he is the senior partner. Stan is somewhat surprised by this because he expected that I was the person with the experience and expertise. He informs me that he has very little confidence in knowing how to proceed with his life, especially because he has “messed up” so often. I am aware that he has self-doubts when it comes to assuming the role of senior partner. However, I work to demystify the therapeutic process and estab- lish a collaborative relationship, conveying to Stan that he is in charge of the direction his therapy will take. I also promise to explore the undermining effects of the self-doubts in his life and how he has managed to live life in spite of these.

Soon after this orientation to how therapy works, I inquire about some specific goals that Stan would like to reach through the therapy sessions. Stan gives clear signs that he is willing and eager to change. However, he adds that he has become convinced that he suf- fers from low self-esteem. As he tells me more about how self-doubts cripple him regularly and lead to a negative evaluation of himself as “messed up,” I begin to externalize the idea of self-doubts and inquire into the history of their appearance in his life. I also care- fully map the effects of self-doubts in his life. Then I start to focus Stan on looking for exceptions to the self-doubts. I pose an exception question (solution- focused therapy): “What is different about the contexts or times when you have not experienced self-doubts?”

Stan is able to identify some positive characteristics: his courage, determination, and willingness to try new things in spite of his self-doubts, and his gift for working with children. Stan knows what he wants out of therapy and has clear goals: to achieve his educa- tional goals, to enhance his belief in himself, to relate to women without fear, and to feel more joy instead of sadness and anxiety. I invite Stan to talk more about how he has managed to make the gains he has in spite of struggling with the problem of self-doubt.

I allow Stan to share his problem-saturated story, but I do not get stuck in this narrative. I invite Stan to think of his problems as external to the core of his self- hood. I help him to notice the cultural forces that have recruited him into a story of thinking less about him- self. Even during the early sessions, I encourage Stan to separate his being from his problems by posing ques- tions that externalize his problem.

Although Stan presents several problem areas that are of concern to him, I work with him on identifying one particular problem. Stan says he is depressed a great deal of the time, and he worries that his depres- sion might someday overwhelm him. After listening to Stan’s fears and concerns, I ask Stan the miracle ques- tion (solution-focused technique): “Let’s suppose that a miracle were to happen while you are asleep tonight. When you wake up tomorrow, the problems you are mentioning are gone. What would be the signs to you that this miracle actually occurred and that your prob- lems were solved? How would your life be different?” With this intervention, I am shifting the focus from talking about problems to talking about solutions. I explain to Stan that much of his therapy will deal with finding both present and future solutions rather than dwelling on past problems. Together we engage in a conversation that features change-talk rather than problem-talk.

To a great extent, Stan has linked his identity story with his problems, especially depression. He doesn’t think of his problems as being separate from himself. I want Stan to realize that he personally is not his prob- lem, but instead that the problem is the problem. When I ask Stan to give a name to his problem, he eventually

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comes up with “Disabling depression!” He then relates how his depression has kept him from functioning the way he would like in many areas of his life. I then use externalizing questions (narrative technique) as a way to separate Stan from his problem: “How long has de- pression gotten the best of you?” “What has depres- sion cost you?” “What conclusions about yourself does it talk you into?” “What do you think of what it has been doing to mess up your life?” “Have there been times when you stood up to depression and did not let it win?” Of course, I briefly explain to him what I am doing by using externalizing language, lest he think this is a strange way to counsel. I talk more about the advan- tages of engaging in externalizing conversations. I also talk with Stan about the importance of mapping the effects of the problem on his life. This process involves exploring how long the problem has been around, the extent to which the problem has influenced various aspects of his life, and how deeply the problem contin- ues to affect him.

As the sessions progress, there is a collaborative ef- fort aimed at investigating how the problem has been a disrupting, dominating, and discouraging influence. Stan comes to view his story from a different perspec- tive. I continue talking with Stan about those moments when he has not been dominated or discouraged by depression and anxiety and continue to search for ex- ceptions to these problematic experiences. Stan and I participate in conversations about unique outcomes, or occasions when he has demonstrated courage and persistence in the face of discouraging events. Some of these “sparkling moments” include Stan’s accom- plishments in college, volunteer work with children, progress in curbing his tendencies to abuse alcohol, willingness to challenge his fears and make new ac- quaintances, talking back to self-defeating internal messages, accomplishments in securing employment, and his willingness to create a vision of a productive future.

With my help, Stan accumulates evidence from his past to bolster a new view of himself as competent enough to have escaped from the dominance of prob- lematic stories. At this phase in his therapy, Stan makes a decision to create an alternative narrative. Several

sessions are devoted to reauthoring Stan’s story in ways that are lively, creative, and colorful. Along with the process of creating an alternative story, I explore with Stan the possibilities of recruiting an audience who will reinforce his positive changes. I ask, “Who do you know who would be least surprised to hear of your re- cent changes, and what would this person know about you that would lead to person not being so surprised?” Stan identifies one of his early teachers who served as a mentor to him and who believed in him when Stan had little belief in himself. Some therapy time is devot- ed to discussing how new stories take root only when there is an audience to appreciate them.

After five therapy sessions, Stan brings up the mat- ter of termination. At the sixth and final session, I intro- duce scaling questions, asking Stan to rate his degree of improvement on a range of problems we explored in the past weeks. On a scale of 0 to 10, Stan ranks how he saw himself prior to his first session and how he sees himself today on various specific dimensions (scaling technique). We also talked about Stan’s goals for his future and what kinds of improvements he will need to make to attain what he wants. I then give Stan a letter I wrote summarizing both the problem story and its effects and also the counter story that we have been developing in therapy. In my narrative letter, I describe Stan’s determination and cooperation in his own words and encourage him to circulate the news of the differences he has brought about in his life. I also ask some questions that invite him to develop the new story of identity more fully.

Questions for Reflection ◆ As Stan’s therapist, I borrowed key concepts and

techniques common to both solution-focused and narrative orientations. In your work with Stan, what specific concepts would you borrow from each of these approaches? What techniques would you draw from each of the approaches? What pos- sible advantages do you see, if any, in applying an integration of solution-focused and narrative mod- els in your work with Stan?

◆ What unique values, if any, do you see in work- ing with Stan from a postmodern perspective as

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opposed to working with Stan from the other therapeutic approaches you’ve studied thus far?

◆ I asked many questions of Stan. List some addi- tional questions you would be particularly inter- ested in pursuing with Stan.

◆ In what ways could you integrate SFBT and narra- tive therapy with feminist therapy in Stan’s case? What other therapies might you combine with the postmodern approaches? What other therapies would not combine so well with these postmod- ern therapies?

◆ At this point, you are very familiar with the themes in Stan’s life. If you were to write a narrative letter that you would then give to Stan, what would you

most want to include? What would you want to talk to him about regarding his future?

Refer to the MindTap for The Case of Stan Video Quizzes for Chapter 13, Session 11 (SFBT) and Session 12 (narrative therapy), for a demon- stration of my approach to counseling Stan from this perspective. Session 11 illustrates techniques such as identifying exceptions, the miracle question, and scaling. Session 12 focuses on Stan’s work in creating a new story of his life.

Postmodern Approaches Applied to the Case of Gwen*

Solution-Focused Brief Therapy With Gwen This session begins with Gwen expressing how over- whelmed she is with the number of assignments she has at work.

Gwen: I don’t think I can handle the pressure of these new assignments.

Therapist: On a scale of zero to 10, where zero is no pressure and 10 is extreme pressure, where would your feeling of pressure be on the scale?

Gwen: 8! I should have just kept quiet and not taken on any new projects. I always do this to myself. I wish I could start over and not take on so much. I am missing out on time with my family and friends because I have piled the work on so high! I don’t know why I create so much work for myself. I know people at work can see that I am on the edge. I am not feeling good about anything I am doing these days. I know I’m ruining my reputation because I

just can’t get things done. I am missing in action in my own life.

Therapist: Tell me about some times when you did not feel this way. What were you doing when things were getting done that you are not doing now?

I encourage Gwen to think about some time when her stress was not so overwhelming and what she did to better manage her stress. This focus on discovering Gwen’s strengths puts Gwen in the position of being the expert on her own life. I am confident that Gwen has the a capacity to find solutions to her challenges.

Gwen is so accustomed to her story of anxiety and feeling overwhelmed that it is difficult for her to shift gears and observe that she is doing several things well in her life. My interventions are aimed at assisting her in seeing herself as more than being highly anxious.

Therapist: In the midst of your busy life, you have remained committed to therapy. I find that very impressive given your schedule and the number

*Dr. Kellie Kirksey writes about her ways of thinking and practicing from a postmodern perspective, first using SFBT and then using narrative therapy, and applying these models to Gwen.

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of obligations you are juggling. I wonder what else might be going well in your life.

Gwen: I have been arriving at work on time, and that feels pretty good. Also, I took time for a swimming lesson even though I was stressed out about get- ting my projects done. I must say that I felt so much better afterward.

Therapist: If you had a magic wand and could solve your problem today, how would you know it was solved? [The miracle question]

Gwen: I would know it was solved if I did not have a stomach ache, did not triple book meetings, didn’t have five projects due all at once, felt com- fortable taking time for relaxation, had time to go out with friends, and didn’t have stacks of paper around my house and office just waiting for me to handle it all.

Therapist: What would you be doing or feeling that would be different?

Gwen: I would be able to go home at a reasonable time after work. I would feel more rested. I would have healthy and balanced meals, and I would have more quality time with my husband and children. At work, I would feel good about the projects I was finishing, and I would resist taking on too many projects at the same time.

The miracle question, or the magic wand question as I call it, is a way to assist Gwen in projecting into the future to the life she wants to experience. I emphasize that doing one thing differently could be a significant step in finding a solution.

Therapist: I invite you to rip up your canvas of anxiety and create a new portrait of calm in your life by doing one thing differently. What do you think you can change this week?

Gwen: I will begin my day with prayer and some stretch- ing exercises to help me loosen up and to reduce my stress level. And I think it is time to resign from one of the committees I am on now.

Therapist: Those are great choices you are making. I look forward to hearing how you did when we meet next week.

I compliment Gwen on the progress she is making, and in our next session I will follow up on her homework. I hope Gwen will discover that the answers she is seek- ing reside within herself.

Questions for Reflection ◆ What interventions helped Gwen begin to think

more about her resources and strengths than about her problems?

◆ What do you think of the application of the miracle question with Gwen? What steps did Gwen decide to take as a result of her answer?

◆ If you were counseling Gwen and she was unable to recall any time when the problem did not exist, how would you move forward with her?

Narrative Therapy With Gwen Words have the power to heal and transform our lives. Words also have the power to keep us spiraling down- ward, accepting a negative story line that perpetu- ates feelings of depression, scarcity, fear, anxiety, self- loathing, and more. Our stories fuel our thoughts and behaviors, and we must make sure that these stories are not a source of negative programming that keeps us stuck. If Gwen is willing to keep a journal and write about her younger self, I think she will begin to recon- struct the story of her true self today.

Therapist: Words can become our medicine and our tool for transformation and healing. I would like you to use this journal to write about your story of lone- liness. Try to identify when loneliness first appeared in your life. Let the words present themselves in whatever way they come.

Gwen: I think I could write volumes about feeling unimportant, invisible, and insignificant when I was a child.

Therapist: Before you begin writing, sit quietly for 5 minutes and connect to your younger self who first experienced these feelings of loneliness.

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Summary and Evaluation Summary

In social constructionist theory, the therapist-as-expert is replaced by the client-as- expert. Although clients are viewed as experts on their own lives, they are often stuck in patterns that are not working well for them. Solution-focused therapists, narra- tive therapists, and motivational interviewing practitioners enter into dialogues in an effort to elicit the perspectives, resources, and unique experiences of their clients. The therapeutic endeavor is a highly collaborative relationship in which the client is the senior partner. The qualities of the therapeutic relationship are at the heart of the effectiveness of SFBT, motivational interviewing, and narrative therapy. This has resulted in many therapists giving increased attention to creating a collabora- tive relationship with clients. Collaborative therapists adjust their approach to each client instead of requiring clients to adapt to their approach. Thus, therapy may look very different for one client than for another.

The not-knowing position of the therapist has been infused as a key con- cept of both the solution-focused and narrative therapeutic approaches. The not- knowing position, which allows therapists to be curious about, affirm, and be guided

LO16

Give that part of yourself a name and become a loving companion to that lonely little girl inside of you.

My goal is to help Gwen externalize the problem she is experiencing and move it outside of herself. As Gwen separates herself from her problem-saturated story, she can release the old patterns associated with the old story and literally rewrite her life to include peace, joy, and connection.

Gwen writes about staying in the house to avoid be- ing called names by the kids on her street; being the odd child in the family and wanting to hide because she was different; waiting days for her dad to return home; hiding her precious items in a special box so they wouldn’t get stolen when the house was broken into; being the only Black child in the Catholic Church and feeling like she was under a microscope; and how she began to stay busy to keep herself safe. I work with Gwen to help her view her stories through a lens of compassion, growth, and healing.

As Gwen began to reconstruct her story, she was able to see that her parents did the best they could. She looked at the entire cast of her narrative with deeper compassion and saw that through the

challenges of her childhood she had become a strong, creative, resilient woman. From a position of adult strength, Gwen began to sooth the lonely little girl that still resides in her heart. Through writing, Gwen could see that she was wounded but not broken. Narrative therapy helped Gwen come closer to a place of self- love and forgiveness, and her anxiety began to lessen as she released the repressed emotions that had kept her isolated and lonely. In her final session, Gwen and I developed a written “graduation speech” together in which we formalized the fact that she is no longer a child and has moved beyond her history.

Questions for Reflection ◆ What therapeutic purpose is served when the

therapist helps Gwen separate herself from the problem?

◆ What value do you see in journal writing as a tool to assist Gwen in reconstructing her story?

◆ What is one other technique from narrative ther- apy that you would want to use with Gwen?

◆ How do you experience hearing about Gwen’s sto- ries of loneliness?

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by the stories of their clients, creates participant-observer and process- facilitator roles for the therapist and integrates therapy with a postmodern perspective of human inquiry. Practitioners approach their clients with respectful curiosity, and they view every client as a unique individual and every therapeutic interaction as a cross-cultural exchange. The “not-knowing” stance assumed by therapists allows them to take on the role of learners and treat clients as experts on themselves. Thera- pists collaborate with their clients to co-construct solutions based on clients’ ideas, feedback, and resources (Murphy & Sparks, 2018).

Solution-focused brief therapy, motivational interviewing, and narrative therapy are based on the optimistic assumption that people are healthy, competent, resource- ful, and possess the ability to construct solutions and alternative stories that enhance their lives. These therapeutic approaches share common concepts with positive psy- chology. In SFBT the therapeutic process provides a context whereby individuals focus on creating solutions rather than talking about their problems. Some common techniques include the use of miracle questions, exception questions, and scaling questions. Motivational interviewing stresses client self-responsibility and promotes an invitational style for working cooperatively with clients to generate alternative solutions to behavioral problems. Motivational interviewing, which is based on the philosophy of person-centered therapy, is deliberately directive while staying within the client’s frame of reference. The primary goal is to reduce client ambivalence about change and to increase the client’s own motivation for change. Motivational interviewing is a culturally sensitive approach that can be effective across popula- tion domains, including gender, age, ethnicity, and sexual orientation (Levensky et al., 2008). In narrative therapy the therapeutic process attends to the sociocultural context. Clients are assisted in separating themselves from their problems and are afforded the opportunity to author new stories. A central goal of narrative therapy is to help clients reauthor their problem stories, changing their perspective on their experience of life. This approach promotes healing by opening up and expanding on stories of strength, resilience, and perseverance (Winslade & Del Corso, 2019).

Practitioners with solution-focused and narrative orientations tend to engage clients in conversations that lead to progressive narratives that help clients make steady gains toward their goals. Honoring the goals, resources, and feedback of cli- ents is a hallmark of these orientations (Murphy & Sparks, 2018). Therapists often ask clients: “Tell me about times when your life was going the way you wanted it to.” These conversations illustrate stories of life worth living. On the basis of these conversations, the power of the problem story is diminished (deconstructed), and new directions and solutions are manifest and made possible. After exploring the problem story through deconstruction, the therapist helps the client identify other experiences that could challenge a negative story and allow for a counter story to emerge (Winslade & Del Corso, 2019).

Contributions of Postmodern Approaches Social constructionism, SFBT, motivational interviewing, and narrative therapy are making many contributions to the field of psychotherapy. We especially value the optimistic orientation of these postmodern approaches that rest on the assumptions that people are competent and can be trusted to use their resources in creating better

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solutions and more life-affirming stories. Many postmodern practitioners and writers have found that clients are able to make significant moves toward building more sat- isfying lives in a relatively short period of time (Bertolino & O’Hanlon, 2002; De Jong & Berg, 2013; de Shazer, 1991; Freedman & Combs, 1996; Hoyt, 2009, 2015; Miller et al., 1996; Murphy, 2023; Murphy & Sparks, 2018; O’Hanlon & Weiner-Davis, 2003; Walter & Peller, 1992, 2000; Winslade & Del Corso, 2019; Winslade & Monk, 2007).

The nonpathologizing stance characteristic of practitioners with a social con- structionist, solution-focused, motivational interviewing, or narrative orientation is a major contribution to the counseling profession. Rather than dwelling on what is wrong with a person, these approaches view the client as being competent and resourceful. People cannot be reduced to a specific problem nor accurately labeled and identified with a disorder. Even practitioners who are expected to formulate a diagnosis can learn the value of a respectful way to relate to clients. Practitioners with a solution-focused or narrative orientation do not believe that diagnosis pro- vides useful information to help clients change. They view diagnosis as unnecessary and potentially harmful to the change process (Murphy & Sparks, 2018).

A major strength of solution-focused brief therapy, motivational interviewing, and narrative therapy is the use of questioning, which is the centerpiece of these approaches. Open-ended questions about the client’s attitudes, thoughts, feeling, behaviors, and perceptions are one of the main interventions. Especially useful are future-oriented questions that get clients thinking about how they are likely to solve potential problems in the future. Questions can assist clients in developing their story and discovering better ways to deal with their concerns. Effective questioning can help individuals examine their story and find new ways to present it. Practi- tioners facilitate future-oriented conversations by obtaining specific details about clients’ desired future. Clients describe what their ideal future would look like, how they can know when they are achieving it, and how achieving the future they want could influence their overall quality of life (Murphy & Sparks, 2018).

To its credit, solution-focused therapy is a brief approach, of about five sessions, that seems to show promising results (de Shazer, 1991). SFBT tends to be very brief, even among the time-limited therapies. It should be noted that the brevity comes from the client being in charge of goal setting and determining which issues are of immediate concern. This differs from many other models in which the therapist determines the direction therapy should take. Clients are the experts on their goals, and SFBT practitioners are the experts on the structure and process of therapy. Pro- chaska and Norcross (2018) explain that “the fundamental relationship, then, is like a multidisciplinary collaboration between experts” (p. 375).

A strength of solution-focused counseling is its growing base of efficacy (Guterman, 2013). One particular area where the solution-focused approach shows promise is in group treatment with domestic violence offenders. Lee, Sebold, and Uken (2003) describe a cutting-edge treatment approach that seems to create effec- tive, positive change in domestic violence offenders. This approach is dramatically different from traditional approaches in that there is virtually no emphasis on the presenting problem of domestic violence. The approach focuses on holding offend- ers accountable and responsible for building solutions rather than emphasizing their problems and deficits. The process described by Lee and colleagues is brief when measured against traditional program standards, lasting only eight sessions

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over a 10- to 12-week period. Lee, Sebold, and Uken report research that indicates a recidivism rate of 16.7% and completion rates of 92.9%. In contrast, more traditional approaches typically generate recidivism rates between 40% and 60% and comple- tion rates of less than 50%.

Limitation and Criticisms of Postmodern Approaches To effectively practice solution-focused brief therapy, it is essential that therapists are skilled in brief interventions. Although it may appear that SFBT is simple and easy to implement, therapists practicing within this framework must be able to make assessments, assist clients in formulating specific goals, and effectively use a range of appropriate interventions. Some inexperienced or untrained therapists may be enamored by the variety of techniques: the miracle question, scaling ques- tions, the exception question, and externalizing questions. But effective therapy is not simply a matter of relying on any of these interventions. The attitude of thera- pists and their ability to use questions that are reflective of genuine respectful inter- est are crucial to the therapeutic process.

Like solution-focused therapy, although narrative therapy is based on some sim- ple ideas, it is a mistake to assume that the practice is simple. McKenzie and Monk (1997) express their concerns over those counselors who attempt to employ narra- tive ideas in a mechanistic fashion. They caution that a risk in describing a map of a narrative orientation lies in the fact that some beginners will pay more attention to following the map than they will to following the lead of the client. In such situ- ations, McKenzie and Monk are convinced that mechanically using techniques will not be effective. Some solution-focused and narrative practitioners now acknowl- edge the problem of relying too much on a few techniques, and they are placing increased importance on the therapeutic relationship and the overall philosophy of these approaches (Lipchik, 2002; Murphy, 2023; Murphy & Sparks, 2018).

A vast amount research has been conducted confirming that motivational inter- viewing is an effective treatment for a variety of clinical problems, but the approach is not a panacea, nor was it designed to be a comprehensive approach to treatment. It is a method for addressing reluctance or ambivalence within a person who is con- sidering dealing with a specific problem. MI is clearly not designed to address all problems that people bring to counseling, nor is it meant to help clients explore existential choices (Miller & Rollnick, 2013).

Despite these limitations, the postmodern approaches have much to offer prac- titioners, regardless of their theoretical orientation. Many of the basic concepts and techniques of solution-focused brief therapy, motivational interviewing, and narrative therapy can be integrated into the other therapeutic orientations discussed in this book.

Self-Reflection and Discussion Questions 1. Both solution-focused brief therapy and narrative therapy emphasize

viewing the client-as-expert, creating new stories, establishing a collab- orative therapeutic relationship, discovering resources and strengths of the client, and separating the problem from the person. What are your thoughts about these ideas?

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2. What key concept are you most drawn to in SFBT? In motivational interviewing? In narrative therapy? What do you find of interest in this key concept?

3. A SFBT practitioner has many techniques to choose from in helping clients create their own solutions. Which of these techniques would you like to become skilled at using?

4. In motivational interviewing, the concept of resistance is replaced with the notion of discord between client and counselor. Clients are not viewed as being resistant; rather, clients are seen as attempting to resolve their ambivalence about change. What do you think about the notion of replacing resistance with ambivalence?

5. Narrative therapists talk about deconstructing a problem-saturated story and reauthoring a life-enhancing story. What do you think of this idea?

Where to Go From Here Free Podcasts for ACA Members

You can download ACA Podcasts (prerecorded interviews) at www.counseling.org: click on the Resource button and then the Podcast Series. For Chapter 13, Postmod- ern Approaches, look for the following:

Interview with Dr. John Murphy on Solution-Focused Counseling in Schools (Podcast 5)

Lorraine Hedtke and John Winslade, Remembering Lives, Conversations With the Dying and Bereaved

Other Resources Psychotherapy.net is a comprehensive resource for students and professionals that offers videos and interviews on the postmodern approaches. New video and edito- rial content is made available monthly. DVDs relevant to this chapter are available at www.psychotherapy.net and include the following:

Madigan, S. (2002). Narrative Therapy With Children (Child Therapy With the Experts)

Madigan, S. (1998). Narrative Family Therapy (Family Therapy With the Experts)

Murphy, J. (2002). Solution-Focused Therapy With Children (Child Therapy With the Experts)

If you are interested in keeping up to date with the developments in brief therapy, the Journal of Brief Therapy is a useful resource. It is devoted to develop- ments, innovations, and research related to brief therapy with individuals, couples, families, and groups. The articles deal with brief therapy related to all theoreti- cal approaches, but especially to social constructionism, solution-focused therapy, and narrative therapy. For subscription information, contact Springer Publishing (www.springerpub.com).

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Another useful journal is the International Journal of Narrative Therapy and Community Work. For more information, contact the Dulwich Centre (http:// dulwichcentre.com.au).

Training in Solution-Focused Therapy Approaches The Solution Focused Institute at Texas Wesleyan University was founded in January 2009 in Fort Worth, Texas, to provide training to mental health practi- tioners and school teachers and counselors who want to implement a solution- focused approach in their work. The institute provides training on- and off-site in solution-focused therapy and offers supervision to individuals and groups. For additional information, contact the Solution Focused Institute (www .Solutionfocusedinstitute.com).

Change-Focused Practice in Schools (CFPS) was initiated by John Murphy in 2005 to translate psychotherapy research into practical applications in schools and other settings. CFPS offers international training, supervision, and consultation on solution-focused/client-directed approaches to helping young people change in ways that honor their strengths, resources, and feedback. For more information, contact Department of Psychology and Counseling, University of Central Arkansas (www.drjohnmurphy.com).

Training in Narrative Therapy Evanston Family Therapy Institute (www.narrativetherapychicago.com/)

Dulwich Centre (www.dulwichcentre.com.au/)

Bay Area Family Therapy Training Associates (www.baftta.com)

The Houston-Galveston Institute (www.talkhgi.com)

Recommended Supplementary Readings for Chapter 13 Interviewing for Solutions (De Jong & Berg, 2013) is a practical text aimed at teaching and learning solution-focused skills. It is written in a conversational and informal style and contains many examples to solidify learning.

Solution-Focused Counseling in Schools (Murphy, 2023) is a clearly written and practical book that offers efficient strategies for addressing a range of prob- lems from preschool through high school. Numer- ous case examples illustrate the foundations, tasks, and techniques of solution-focused counseling. The book also describes how the principles of client- directed, outcome-informed practice can be inte- grated in solution-focused counseling.

Strengths-Based Therapy (Murphy & Sparks, 2018) clearly describes the distinctive theoretical fea- tures of strengths-based therapy; it also provides concise explanations of the practical interven- tions. Strengths-based therapy has applications for both solution-focused brief therapy and narrative therapy.

Brief Psychotherapies: Principles and Practices (Hoyt, 2009) is an excellent resource for learning more about brief psychotherapy as it applies to solution- focused brief therapy and to narrative therapy and as well to many other theoretical approaches.

Motivational Interviewing: Helping People Change (Miller & Rollnick, 2013) explains current thinking

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about the process of behavior change, presents the principles of MI, and provides detailed guidelines for putting these principles into practice. Case examples illustrate key points and demonstrate the benefits of MI in addictions treatment and other clinical contexts. The authors also discuss the pro- cess of learning MI.

Motivational Interviewing and CBT: Combining Strate- gies for Maximum Effectiveness (Naar & Safren, 2017) shows how integrating CBT with motivational inter- viewing can result in better outcomes than reliance on either approach on its own.

Effective Psychotherapists: Clinical Skills That Improve Client Outcomes (Miller & Moyers, 2021) is a clear and practical work that describes atti- tudes and therapeutic skills that are basic to motivational interviewing: accurate empathy, acceptance, positive regard, genuineness, focus,

hope, evocation, and offering advice. The authors identify and explore clinical skills that improve client outcomes.

Narrative Means to Therapeutic Ends (White & Epston, 1990) is the most widely known book on narrative therapy.

Maps of Narrative Practice (White, 2007) is Michael White’s final book, which brings together much of his work over several decades in one accessible volume.

Narrative Therapy (Madigan, 2019) provides an updated discussion of the theory and therapeutic process of narrative therapy.

Narrative Counseling in Schools (Winslade & Monk, 2007) is a basic and easy-to-read guide to applying concepts and techniques of narrative therapy to school settings

References Anderson, H. (1993). On a roller coaster: A collaborative language system approach to therapy. In S. Friedman (Ed.), The new language of change (pp. 324–344). Guilford Press. Anderson, H., & Goolishian, H. (1992). The client is the expert: A not-knowing approach to therapy. In S. McNamee & K. J. Gergen (Eds.), Therapy as social construction (pp. 25–39). SAGE. Arkowitz, H., & Miller, W. R. (2008). Learning, applying, and extending motivational interviewing. In H. Arkowitiz, H. A. Westra, W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological disorders (pp. 1–25). Guilford Press. Arkowitz, H., & Westra, H. A. (2009). Introduction to the special series on motivational interviewing and psychotherapy. Journal of Clinical Psychology, 65(11), 1149–1155. Bateson, G. (1972). Steps to an ecology of mind. Ballantine. Berg, I. K. (1994). Family based services: A solution-focused approach. Norton. Berg, I. K., & Miller, S. D. (1992). Working with the problem drinker: A solution- focused approach. Norton.

Bertolino, B., & O’Hanlon, B. (2002). Collaborative, competency-based counseling and therapy. Allyn & Bacon. Bitter, J. R. (2021). Theory and practice of couples and family counseling (3rd ed.). American Counseling Association. Brown, L. S. (2018). Feminist therapy (2nd ed.). American Psychological Association. Bubenzer, D. L., & West, J. D. (1993). William Hudson O’Hanlon: On seeking possibilities and solutions in therapy. The Family Journal: Counseling and Therapy for Couples and Families, 1(4), 365–379. Carey, M., & Russell, S. (2003). Outsider- witness practices: Some answers to commonly asked questions. International Journal of Narrative Therapy and Community Work. Dulwich Centre. Corbett, G. (2016). Motivational interviewing. In I. Marini & M. A. Stebnicki (Eds.), The professional counselor’s desk reference (2nd ed., pp. 235–240). Springer. Corey, G. (2013). Case approach to counseling and psychotherapy (8th ed.). Brooks/Cole, Cengage Learning. Corey, G. (2023). Theory and practice of group counseling (10th ed.). Cengage Learning.

Cormier, S., Nurius, P. S., & Osborn, C. J. (2017). Interviewing and change strategies for helpers (8th ed.). Cengage Learning. Dean, L. M. (2015). Motivational interviewing. In E. Neukrug (Ed.), SAGE encyclopedia of theory in counseling and psychotherapy (vol. 2, pp. 668–672). SAGE. De Jong, P., & Berg, I. K. (2013). Interviewing for solutions (4th ed.). Brooks/ Cole, Cengage Learning. De Shazer, S. (1985). Keys to solutions in brief therapy. Norton. De Shazer, S. (1988). Clues: Investigating solutions in brief therapy. Norton. De Shazer, S. (1991). Putting difference to work. New York: Norton. De Shazer, S. (1994). Words were originally magic. Norton. De Shazer, S., & Berg, I. (1988). Doing therapy: A post-structural revision. Journal of Marital and Family Therapy, 18, 71–81. De Shazer, S., & Dolan, Y. (with Korman, H., Mccollum, E., Trepper, T., & Berg, I. K.). (2007). More than miracles: The state of the art of solution-focused brief therapy. Haworth. Denborough, D. (2019). Narrative practice, neuroscience, bodies, emotions

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and the affective turn. International Journal of Narrative Therapy, 3(1), 13–53. Drewery, W., & Winslade, J. (1997). The theoretical story of narrative therapy. In G. Monk, J. Winslade, K. Crocket, & D. Epston (Eds.), Narrative therapy in practice: The archaeology of hope (pp. 32–52). Jossey-Bass. Franklin, C., Trepper, T. S., Gingerich, W. J., & McCollum, E. E. (Eds.). (2012). Solution-focused brief therapy: Research, practice, and training. Oxford University Press. Freedman, J., & Combs, G. (1996). Narrative therapy: The social construction of preferred realities. Norton. Freedman, J., Epston, D., & Lobovits, D. (1997). Playful approaches to serious problems: Narrative therapy with children and their families. Norton. George, E., Iveson, C., & Ratner, H. (2015). Solution-focused brief therapy. In E. Neukrug (Ed.), SAGE encyclopedia of theory in counseling and psychotherapy (vol. 2, pp. 946–950). SAGE. Gergen, K. (1985). The social constructionist movement in modern psychology. American Psychologist, 40, 266–275. Gergen, K. (1991). The saturated self. Basic Books. Gergen, K. (1999). An invitation to social construction. SAGE. Grothaus, T., Runyan, H., & Sacco- Bene, C. (2019). Solution-focused counseling as a positive intervention. In G. McAuliffe, Positive counseling: A guide to assessing and enhancing client strength and growth (pp. 173–183). Cognella Academic. Guterman, J. T. (2013). Mastering the art of solution-focused counseling (2nd ed.). American Counseling Association. Hoyt, M. F. (2009). Brief psychotherapies: Principles and practices. Zeig, Tucker & Theisen. Hoyt, M. F. (2011). Brief psychotherapies. In S. B. Messer & A. S. Gurman (Eds.), Essential psychotherapies: Theory and practice (3rd ed., pp. 387–425). Guilford Press. Hoyt, M. F. (2015). Brief therapy. In E. Neukrug (Ed.), SAGE encyclopedia of theory in counseling and psychotherapy (vol. 1, pp. 144–147). SAGE. Iarussi, M. (2019). Motivational interviewing. In G. McAuliffe, Positive counseling: A guide to assessing and enhancing

client strength and growth (pp. 287–305). Cognella Academic. Kim, J. S. (Ed.). (2014). Solution-focused brief therapy: A multicultural approach. SAGE. Krebs, P. M., Norcross, J. C., Nicholson, J. M., & Prochaska, J. O. (2019). Stages of change. In J. C. Norcross & B. E. Wampold (Eds.), Psychotherapy relationships that work. Volume 2: Evidence- based responsiveness (3rd ed., pp. 296–328). Oxford University Press. Lee, M. Y., Sebold, J., & Uken, A. (2003). Solution-focused treatment of domestic violence offenders: Accountability for change. Oxford University Press. Levensky, E. R., Kersh, B. C., Cavasos, L. L., & Brooks, J. A. (2008). Motivational interviewing. In W. O’Donohue & J. E. Fisher (Eds.), Cognitive behavior therapy: Applying empirically supported techniques in your practice (2nd ed., pp. 357–366). Wiley. Lipchik, E. (2002). Beyond technique in solution-focused therapy: Working with emotion and the therapeutic relationship. Guilford Press. Madigan, S. (2019). Narrative therapy (2nd ed.). American Psychological Association. Maisel, R., Epston, D., & Borden, A. (2004). Biting the hand that starves you: Inspiring resistance to anorexia/bulimia. Norton. Marshall, C., & Nielsen, A. S. (2020). Motivational interviewing for leaders in the helping professions: Facilitating change in organizations. Guilford Press. Marsten, D., Epston, D., & Markham, L. (2016). Narrative therapy in wonderland: Connecting with children’s imaginative know- how. Norton. McKenzie, W., & Monk, G. (1997). Learning and teaching narrative ideas. In G. Monk, J. Winslade, K. Crocket, & D. Epston (Eds.), Narrative therapy in practice: The archaeology of hope (pp. 82–117). Jossey-Bass. Metcalf, L. (1998). Solution-focused group therapy: Ideas for groups in private practice, schools, agencies and treatment programs. Free Press. Miller, S. D., Hubble, M. A., & Duncan, B. L. (Eds.). (1996). Handbook of solution- focused brief therapy. Jossey-Bass. Miller, W. R., & Moyers, T. B. (2021). Effective psychotherapists: Clinical skills that improve client outcomes. Guilford Press.

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press. Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. American Psychologist, 64(6), 527–537. Monk, G. (1997). How narrative therapy works. In G. Monk, J. Winslade, K. Crocket, & D. Epston (Eds.), Narrative therapy in practice: The archaeology of hope (pp. 3–31). Jossey-Bass. Monk, G., & Zamani, N. (2019). Narrative therapy and the affective turn: Theoretical concepts /Part One. Journal of Systemic Therapies, 38(2), 1–19. Murphy, J. J. (2013). Conducting student- driven interviews: Practical strategies for increasing student involvement and addressing behavior problems. Routledge. Murphy, J. (2023). Solution-focused counseling in schools (4th ed.). American Counseling Association. Murphy, J., & Sparks, J. A. (2018). Strengths-based therapy. Routledge. Neukrug, E. (2016). The world of the counselor: An introduction to the counseling profession (5th ed.). Cengage Learning. NiaNia, W., Bush, A., & Epston, D. (2017) Collaborative and indigenous mental health therapy: Tataihono—Stories of Maori healing and psychiatry. Routledge. Nylund, D., & Thomas, J. (1994). The economics of narrative. The Family Therapy Networker, 18(6), 38–39. O’Hanlon, W. H. (1994). The third wave: The promise of narrative. Family Therapy Networker, 18(6), 19–26, 28–29. O’Hanlon, W. H., & Weiner-Davis, M. (2003). In search of solutions: A new direction in psychotherapy (Rev. ed.). Norton. Prochaska, J. O., & Norcross, J. C. (2018). Systems of psychotherapy: A transtheoretical analysis (9th ed.). Oxford University Press. Rice, R. (2015). Narrative therapy. In E. Neukrug (Ed.), SAGE encyclopedia of theory in counseling and psychotherapy (vol. 2, pp. 695–700). SAGE. Sabella, R. A. (2020). Solution-focused school counseling: The missing manual. Sabella Associates. Walter, J. L., & Peller, J. E. (1992). Becoming solution-focused in brief therapy. Brunner/Mazel.

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Walter, J. L., & Peller, J. E. (2000). Recreating brief therapy: Preferences and possibilities. Norton. Weishaar, M. E. (1993). Aaron T. Beck. SAGE. White, M. (1989). The externalizing of the problem in the reauthoring of lives and relationships. In Selected Papers, Dulwich Centre Newsletter. Dulwich Centre. White, M. (1992). Deconstruction and therapy. In Experience, contradiction, narrative, and imagination: Selected papers of David Epston and Michael White, 1989–1991 (pp. 109–151). Dulwich Centre.

White, M. (1995). Reauthoring lives: Interviews and essays. Dulwich Centre. White, M. (1997). Narrative of therapists’ lives. Dulwich Centre. White, M. (2007). Maps of narrative practice. Norton. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. Norton. Winslade, J., Crocket, K., & Monk, G. (1997). The therapeutic relationship. In G. Monk, J. Winslade, K. Crocket, & D. Epston (Eds.), Narrative therapy in practice: The archaeology of hope (pp. 53–81). Jossey-Bass.

Winslade, J., & Del Corso, J. J. (2019). Narrative therapy. In G. McAuliffe, Positive counseling: A guide to assessing and enhancing client strength and growth (pp. 185–208). Cognella Academic. Winslade, J., & Monk, G. (2007). Narrative counseling in schools (2nd ed.). Corwin Press, SAGE. Zimmerman, J. (2018). Neuro-narrative therapy: New possibilities for emotion-filled conversations. Norton.

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1. Identify the key figures and major schools of family therapy.

2. Identify the commonalities among all models of family systems therapy.

3. Describe how family systems therapy is different from individual therapy.

4. Differentiate the key concepts and goals associated with each of the separate schools of family therapy.

5. Identify recent innovations in family therapy.

6. Describe the multilayered process of family therapy.

7. Discuss the application of the family systems approach to school counseling.

8. Describe the strengths and shortcomings of family systems therapy from a diversity perspective.

9. Identify the contributions and limitations of the family systems approaches.

Learning Objectives

Coauthored by James Robert Bitter and Gerald Corey

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Introduction The seeds of a North American family therapy movement were planted in the 1940s, but it wasn’t until the 1950s that systemic family therapy began to take root (Becvar & Becvar, 2013). During the early years of its evolution, working with families was considered to be a revolutionary approach to treatment. In the 1960s and 1970s, psychodynamic, behavioral, and humanistic approaches (called the first, second, and third force, respectively) dominated counseling and psychotherapy. Today the various approaches to family systems represent a paradigm shift that we might even call the “fourth force.” Family systems therapy is represented by a variety of theories and approaches, all of which focus on the relational aspects of human problems.

The Family Systems Perspective Perhaps the most difficult adjustment for counselors and therapists from Western cultures is the adoption of a “systems” perspective. Our personal experience and Western culture often tell us that we are autonomous individuals, capable of free and independent choice. Yet we are born into families, and most of us live our entire lives attached to one form of family or another. Within these families, we discover who we are; we develop and change; and we give and receive the support we need for survival. We create, maintain, and live by often unspoken rules and routines that we hope will keep the family (and each of its members) functional.

A family systems perspective holds that individuals are best understood through assessing the interactions between and among family members. The development and behavior of one family member is interconnected with others in the family. Symptoms are often viewed as an expression of a set of habits and patterns within a family. It is revolutionary to conclude that the identified client’s problem might be a symptom of how the system functions, not just a symptom of the individual’s mal- adjustment, history, and psychosocial development. This perspective is grounded on the assumptions that a client’s problematic behavior may (1) serve a function or purpose for the family; (2) be unintentionally maintained by family processes; (3) be a function of the family’s inability to operate productively, especially during devel- opmental transitions; or (4) be a symptom of dysfunctional patterns handed down across generations. All these assumptions challenge the more traditional intrapsy- chic frameworks for conceptualizing human problems and their formation.

The central principle agreed upon by family therapy practitioners, regardless of their particular approach, is that the client is connected to living systems. Attempts at change are best facilitated by working with and considering the family or set of relationships as a whole. Therefore, a treatment approach that comprehensively addresses the family as well as the “identified” client is required. Because a family is an interactional unit, it has its own set of unique traits. It is not possible to accurately assess an individual’s concern without observing the interaction of the other family members, as well as the broader contexts in which the person and the family live.

Family therapy perspectives call for a conceptual shift from evaluating indi- viduals to focusing on system dynamics, or how individuals within a system react to one another. Actions by any individual family member will influence all other family members, and their reactions will have a reciprocal effect on the individual. When change occurs, a ripple effect flows throughout the family system. Effective

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changes support the family system and the new behaviors of the individual or family (Lambert et al., 2016). Goldenberg, Stanton, and Goldenberg (2017) point to the need for therapists to view all behavior, including all symptoms expressed by the individual, within the context of the family and society. They add that a systems ori- entation does not preclude dealing with the dynamics within the individual, but that this approach broadens the traditional emphasis on individual internal dynamics.

Differences Between Systemic and Individual Approaches There are significant differences between individual therapeutic approaches and sys- temic approaches. A case may help to illustrate these differences. Ann, age 22, sees a counselor because she is suffering from a depression that has lasted for more than two years and has impaired her ability to maintain friendships and work produc- tively. She wants to feel better, but she is pessimistic about her chances. How will a therapist choose to help her?

Both the individual therapist and the systemic therapist are interested in Ann’s current living situation and life experiences. Both discover that she is still living at home with her parents, who are in their 60s. They note that she has a very successful older sister, who is a prominent lawyer in the small town in which the two live. The therapists are impressed by Ann’s loss of friends who have married and left town over the years while she stayed behind, often lonely and isolated. Finally, both thera- pists note that Ann’s depression affects others as well as herself. It is here, however, that the similarities tend to end:

The individual therapist may: The systemic therapist may:

Focus on obtaining an accurate diagno- sis, perhaps using the DSM-5 (American Psychiatric Association, 2013)

Explore the system for family process and rules, perhaps using a genogram

Begin therapy with Ann immediately Invite Ann’s mother, father, and sister into therapy with her

Focus on the causes, purposes, and cogni- tive, emotional, and behavioral patterns involved in Ann’s depression and coping

Focus on the family relationships within which the continuation of Ann’s depression “makes sense”

Be concerned with Ann’s individual experiences and perspectives

Be concerned with transgenerational meanings, rules, and cultural and gender perspectives within the system, and even in the community and larger systems affecting the family

Intervene in ways designed to help Ann cope

Intervene in ways designed to help change Ann’s context

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Systemic therapists do not deny the importance of the individual in the family system, but they believe an individual’s systemic affiliations and inter- actions have more power in the person’s life than a single therapist could ever hope to have. By working with the whole family (or even community) system, the therapist has a chance to observe how individuals act within the system and participate in maintaining the status quo; how the system influences (and is influenced by) the individual; and what interventions might lead to changes that help the couple, family, or larger system as well as the individual express- ing pain.

In Ann’s case, her depression may have organic, genetic, or hormonal compo- nents. It may also involve cognitive, experiential, or behavioral patterns that inter- fere with effective coping. Even if her depression can be explained in this manner, however, the systemic therapist is very interested in how her depression affects others in the family and how it influences family processes. Her depression may signal both her own pain and the unexpressed pain of the family. Indeed, many family systems approaches would investigate how the depression serves other family members; distracts from problems in the intimate relationships of others; or reflects her need to adjust to family rules, to cultural injunctions, or to pro- cesses influenced by gender or family life-cycle development. Rather than losing sight of the individual, family therapists understand the person as specifically embedded in larger systems.

Development of Family Systems Therapy Family systems theory has evolved throughout the past 100 years, and today thera- pists creatively employ various perspectives when tailoring therapy to a particular family. Alfred Adler (1927) and Rudolf Dreikurs (1950, 1973) and their associates were the first known practitioners of family therapy, often using a model now called open-forum family counseling (Christensen, 2004). Adler introduced phenomenol- ogy to our understanding of the family system (or family constellation). Assessment is based on the subjective descriptions that family members use to define them- selves and the interactions that occur in everyday life. It is within these interactions that Adlerians seek to discover the purposes and goals of behavior (Bitter, 2021; Bitter et al., 2002).

Take a moment and think about two different family experiences in your own life. When you were little, what descriptions would you have used for your par- ents? What do these descriptions tell you about what was important to you? Let’s say that one’s father is described as kind, generous, and childlike. The mother is described as beautiful, very hard working, and sacrificing. No adjective or descrip- tion exists outside of the relationship. When the person says the father was kind, this means that the father was kind to the person as a child. When the mother is described as very hard working, the person is suggesting that access to mother was difficult to get. Still, mother’s hard work has a purpose: she is sacrificing for the child. What else can we know from these descriptions? Father was generous and childlike: “he played with me.” He may not have been very oriented toward

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discipline. Mother was beautiful. The message is that for women appearances are important.

Now, think about your current family situation, either your family of origin or a new family you have started. What descriptions would family members use to describe you? What does that tell you about your place or role in the family? Finally, think about a recent family interaction that was difficult for you. What goals or pur- poses did you have for your part of the interaction? What goals or purposes might have been involved for those interacting with you? You can generally discover the goal or purpose of behavior by looking at the consequence of that behavior in the responses of others: “What do people do when I act in one way or another?”

We now take a look at the most prominent models and what they have contrib- uted to the evolution of family systems therapy.

Murray Bowen (1913– 1990) believed families could best be understood when analyzed from a three-generation perspec- tive because patterns of interpersonal relationships connect family members across generations. Two of his objectives in therapy were to help family mem-

bers develop a rational, nonreac- tive approach to living (called a differentiation of self ) and to detangle family interactions that involved two people pulling a third person into the couple’s prob- lems and arguments (or triangulation).

Bowen’s observations led to his interest in patterns across multiple generations. He contended that prob- lems manifested in one’s current family will not signifi- cantly change until relationship patterns in one’s fam- ily of origin are understood and directly challenged. His approach operates on the premise that a predict- able pattern of interpersonal relationships connects the functioning of family members across genera- tions. According to Kerr and Bowen (1988), the cause of an individual’s problems can be understood only by viewing the role of the family as an emotional unit. Within the family unit, unresolved emotional reactiv- ity to one’s family must be addressed if one hopes to

achieve a mature and unique personality. Emotional problems will be transmitted from generation to gen- eration until unresolved emotional attachments are dealt with effectively. Change must occur with other family members and cannot be done by an individual in a counseling room.

Murray Bowen (1978) was one of the original devel- opers of mainstream family therapy. His family systems theory, which is a theoretical and clinical model that evolved from psychoanalytic principles and practices, is sometimes referred to as multigenerational family therapy. The goal of this approach is to differentiate self within a system and to understand one’s family of origin. Bowen and his associates implemented an in- novative approach to schizophrenia at the National Institute of Mental Health where Bowen hospitalized entire families so that the family system could be the focus of therapy.

Bowen’s emphasis on a multigenerational per- spective laid a foundation for work by two of Bowen’s most prominent colleagues, Betty Carter and Monica McGoldrick, who almost single-handedly initiated both a developmental and a multicultural perspec- tive in family therapy. Indeed, McGoldrick’s work includes the field’s most important work on geno- grams (McGoldrick et al., 2020) and family life cycle (McGoldrick et al., 2011), as well as gender (McGoldrick et al., 1991) and race (MeGoldrick et al., 2005; McGoldrick & Hardy, 2019).

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Structural-Strategic Family Therapy The origins of structural family therapy can be traced to the early 1960s when Salvador Minuchin was conducting therapy, training, and research with delinquent boys from poor families at the Wiltwyck School in New York. Minuchin’s (1974) central idea was that an individual’s symptoms are best understood from the van- tage point of interactional patterns, or sequences, within a family. He further stated that structural changes must occur in a family before an individual’s symptoms can be reduced or eliminated. The goals of structural family therapy include (1) reduc- ing symptoms of family dysfunction and (2) bringing about structural change within the system by modifying the family’s transactional rules and establishing more appropriate boundaries.

In the late 1960s, Jay Haley joined Minuchin at the Philadelphia Child Guid- ance Clinic. The work of Haley and Minuchin shared so many similarities in goals and process that many clinicians in the 1980s and 1990s began to question whether the two models were distinct schools of thought. Indeed, by the late 1970s, structural-strategic approaches were the most used models in family systems therapy. The interventions generated in these models became synonymous with a systems approach; they included joining, boundary setting, unbalancing, reframing, ordeals, paradoxical interventions, and enactments.

If you divided your family of origin into subsystems, who would be in the parental subsystem? The spousal subsystem? The sibling subsystem? What rules

Virginia Satir (1916–1988) developed conjoint family therapy, a human valida- tion process model that emphasizes communication and emotional experienc- ing. Like Bowen, she used an intergenerational model, but she worked to bring family patterns to life in the present through family sculpting and family recon-

structions. Claiming that techniques were second- ary to relationship, she concentrated on the personal relationship between therapist and family to achieve change. The core of Satir’s model relied on the power of congruence to help family members communicate with emotional honesty. Her presence with people encouraged them to get in touch with what was sig- nificant within, to become more fully human, and to share the individual’s best self with a significant other.

Satir called this experience “making contact,” and she believed that it extended the peace one had within to a peace between people and, eventually, to a peace among people.

At about the same time that Bowen was developing his approach, Virginia Satir (1983) began emphasizing family connection. Her therapeutic work had already led her to believe in the value of a strong, nurturing rela- tionship based on interest and fascination with those in her care. Unlike Bowen, Satir could envision and sought to support the development of a nurturing triad: two people, for example parents, working for the well-being of another, perhaps a child. Satir thought of herself as a detective who sought out and listened for the reflec- tions of self-esteem in the communication of her clients. She placed a strong emphasis on the importance of communication and meta-communication in family in- teractions, and the value of therapeutic validation in the process of change (Satir & Bitter, 2000). From Satir, fam- ily therapy gets it model for empathic listening, thera- peutic presence, and nurturance (Satir et al., 1991).

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and boundaries were set around each subsystem? Were the boundaries ever crossed? By whom and with what result? What were common interactional sequences in your family? Who had the power in your family, and how was it exercised? Who was aligned with whom, and what did they use that alignment to achieve? These are just a few of the assessments structural-strategic therapists taught us to consider.

Recent Innovations in Family Therapy In the last decade, feminism, multiculturalism, and postmodern social construc- tionism have all entered the family therapy field. These models are more collabora- tive, treating clients—individuals, couples, or families—as experts in their own lives. The therapeutic conversations start with the counselor in a “not-knowing” position in which clients are approached with curiosity and interest. The therapist is socially active and aids clients in taking a preferred stand in relation to the dominant cul- ture that may be oppressing them.

Feminist, multicultural, and postmodern therapists are extremely aware of the power they have entering into already established systems, and they work to pro- mote understanding through curiosity and interest rather than through formal assessments. Adopting a decentered position allows them to be part of the system without taking it over. Feminist, multicultural, and postmodern approaches to family therapy seek to reduce or eliminate the power and impact of the family ther- apist. Taken together, postmodern approaches represent a real paradigm shift in the field of family therapy.

Just as couples, families, communities, and cultures are all systems, each indi- vidual is also a system of parts. These internal parts are similar to family systems in that each part has a role and function, and sometimes these parts can be pushed into extreme reactions because of trauma or abuse or family-of-origin issues. All parts seek a balance just as individual aspects of any system do, and when the individual’s internal family system is out of balance, it often presents the individual as clinically distressed (Schwartz & Sweezy, 2020; Schwartz, 2021) or replaying old issues in new relationships.

Most individual parts are designed to keep us safe, to protect us, and to help us navigate the world and situations we encounter. These parts are called managers, and when they are working, they keep us calm and functional. Sometimes, however, we are hurt, embarrassed, shamed, or frightened, and the feelings and parts associ- ated with these experiences are sent into exile. An extreme version of this is called dissociative identity disorder (American Psychiatric Association, 2013). Still, the feelings and pain from these exiles occasionally seep out, and other parts of us will impul- sively attempt to override the exiled parts. Abusing drugs, overeating, disappearing into work, or inappropriate sexual activity are all examples of what internal family systems counselors call firefighters. In internal family systems work, there are no bad parts (Schwartz, 2021).

At our core, every one of us has a self, imbued with certain leadership parts and practices that oversee our multilayered brains and our complex parts system. Among these leadership qualities are awareness, perspective, and acceptance; courage and confidence; and self-care, compassion, and gratitude for life and others. It is these parts that are accessed when helping people to heal.

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This brief discussion of the various systemic viewpoints in family therapy pro- vides a context for understanding the development of family therapy. For an in- depth treatment of the schools of family therapy, see Theory and Practice of Couples and Family Counseling (Bitter, 2021).

A Multilayered Process of Family Therapy Families are multilayered systems that both affect and are affected by the larger sys- tems in which they are embedded. Families can be described in terms of their individ- ual members and the various roles they play, the relationships between the members, and the sequential patterns of the interactions and the purposes these sequences serve. Both the members and the system can be assessed based on power, alignment, organization, structure, development, culture, and gender (Breunlin et al., 1997; Pinsof et al., 2018). Even individuals can be considered from the perspective of an internal family system (Schwartz & Sweezy, 2020). In addition, nuclear families in a global community are often part of extended, if distant, families; multiple families make up a community; multiple communities make up both regions and cultures, which in turn constitute nations (or societies). The power of these macrosystems to influence family life—especially in the areas of gender and culture—is significant. Given our presuppositions about families and the larger systems in which families are embedded, a multilayered process of family therapy is essential.

Several forms and structures have been proposed for integrative models of family counseling and therapy (Carlson et al., 2005; Gladding, 2019; Hanna, 2007; Nichols & Davis, 2017; Pinsof et al., 2018). The integrative model we have chosen to present here allows for an enlarged integration of ideas from multiple models of family therapy. Similar to a piece of classical music, the process of family ther- apy, it seems to us, has movements. These movements can be described as separate experiences embedded in the larger flow of therapy. In this section, we describe four general movements, each with different tasks: forming a relationship, conducting an assessment, hypothesizing and sharing meaning, and facilitating change. In rare instances, these four movements might occur within a single session; in most cases, however, each movement requires multiple sessions.

Forming a Relationship Over the years, family systems therapists have used a wide range of metaphors to describe the role of the therapist and the therapeutic relationship. The emergence of feminist and postmodern models in therapy has moved the field of family therapy toward more egalitarian, collaborative, cooperative, co-constructing relationships (see Andersen, 1987, 1991; Anderson, 1993; Anderson & Goolishian, 1992; Epston & White, 1992; Luepnitz, 2002).

The debate Carl Rogers (1980) first introduced to individual therapy in the 1940s has reemerged within family therapy in the form of these questions:

◆ What expertise does the therapist have in relation to the family, and how should that expertise be used?

◆ How directive should therapists be in relation to families, and what does that say about the uses of power in therapy?

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We believe a multilayered approach to family therapy is best supported by a col- laborative therapist–client relationship in which mutual respect, caring, empathy, and a genuine interest in others is primary. In addition, we believe directed actions and enact- ments are most useful when they are a joint venture of both the therapist and the family.

Therapists begin to form a relationship with clients from the moment of first contact. In most cases, we believe therapists should make their own appointments, answer initial questions clients may have, and give clients a sense of what to expect when they come for their first session. This is also a time when counselors can let families know their position on whether all members should be present. Some fam- ily therapists will work with any of those members of the family who wish to come; others will only see the family if everyone is a part of the therapy session.

From the moment of first face-to-face contact, good therapeutic relationships start with efforts at making contact with each person present (Satir & Bitter, 2000). Whether it is called joining, engagement, or simple care and concern, it is the ther- apist’s responsibility to meet each person with openness and warmth. Generally, a focused interest on each family member helps to reduce the anxiety the family may be feeling. It is important for family members to introduce themselves and to express their concerns, but the therapist should not focus too tightly on content issues. Understanding family process is almost always facilitated by how questions.

All change in human systems starts with understanding and accepting things just as they are (Satir & Baldwin, 1983). The family practitioner’s skill in communicating that understanding and empathy through active listening lays the foundation for an effective working relationship. Those counselors and ther- apists who use validation and encouragement, who support family resilience, and who elicit cooperation experience the greatest amount of success in therapy.

Conducting an Assessment The multiple layers we have noted provide numerous entry points for conducting family assessments, but beginning counselors will often find that more formal assess- ment procedures, such as genograms (McGoldrick et al., 2020), enable the family structure and stories to be presented in a clearer, more orderly manner. In some cases, formal tests and rating scales also can be useful (see, for example, Gottman, 1999).

Let’s start with the process for co-constructing a genogram. Most family prac- titioners start with a map of the family that comes to therapy. The parents are listed with their name, age, and date of birth in either a rectangle (for ales) or a circle (for females). If there are multiple relationships involved in the parental subsystem, they are generally indicated in chronological order with males listed on the left and females on the right.

Mary Age 35

12/22/86

John Age 35

2/27/86

Ralph Age 41

1/17/80

m. 2006//d. 2008 m. 2015

In the above genogram, Mary married Ralph when she was 20 and Ralph was 26; their marriage lasted about two years, and then they were divorced. In 2015,

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Mary and John were married. If John and Mary had decided to live together, but not commit to a formal marriage, the genogram would use a broken line (or dashes) to indicate an informal relationship, like this:

Mary Age 35

12/22/86

John Age 35

2/27/86

If Ralph had died instead of divorcing Mary, it would look like this:

d. 2008 m. 2006 Mary

Age 21 12/22/86

Ralph Age 28

1/17/88

When Mary and John have children, their genogram may look like this:

John, Jr. Age 5

4/20/16

m. 2015

Ann Age 2

3/12/19

Mary Age 35

12/22/86

John Age 35

2/27/86

In the above genogram it is now 2021, and John and Mary have been married for six years. When they had been married for one year, Mary gave birth to their first child, a boy that they named John Jr. A year later, Mary had a miscarriage, indicated by a black oval at the end of a child line. Two years ago, they adopted (indicated by a solid line next to a broken line) their daughter Ann. If we extend John and Mary’s genogram to three generations and if we assume that both John and Mary were only children, the basic three generation family genogram would look like this:

John, Jr. Age 5

4/20/16

His Parents

m. 2015

Her Parents

Ann Age 2

3/12/19

Mary Age 35

12/22/86

John Age 35

2/27/86

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Many other symbols are used in a genogram, including a double square or a double circle to indicate the index person, or person on whom the genogram is focused. An upside-down triangle in a square or circle is used to indicate a gay man or a lesbian woman. We shade the bottom half of a square or circle to indicate sub- stance abuse. We use double parallel lines to indicate a strong relationship between two people and three parallel lines to indicate a fused or enmeshed relationship. A dotted line indicates a distant relationship, and conflict is indicated with lines that look like this: /\/\/\/\/\/\/. Later in the chapter, we use a genogram in our work with Stan. You now have enough information to construct your own genogram, and we highly recommend that you get a large piece of paper and get started. It works best if two people interview each other so that you are both drawing the genogram and telling each other the story of your family.

As the therapist listens to family members describe the story of their family, it may be difficult to know where to start with a family. Family members are often the best people to choose a focus. Family practitioners may use circular or relational question- ing to get at the systemic issues presented in the family story that will provide meaning for the therapist and the family. For example, suppose Tammy is upsetting the family system by ignoring the curfew her parents have set for her. The therapist might ask: “What will happen if Tammy stays out past curfew and is picked up by the police? Who will be most upset by this?” Here is Tammy’s father’s reply:

I will probably be the most upset on the outside. I tend to go off before I think, and then I regret it later. On the other hand, her mother may not show it imme- diately, but her hurt will stay with her longer, and then she will get mad at me for “letting Tammy off the hook.” She will say that Tammy is manipulating me, but I just don’t see why we should keep fighting about things. It doesn’t do any good. We fight, and Tammy disappears. She wants to run with the big kids, some of whom are in college, over 18, and have no curfew.

From this father’s response, the therapist can choose from a number of points of entry into the life of this family. The counselor might choose to work with the anger or guilt expressed by the members and present in their interactions. Sequen- tial patterns were clearly articulated by the father when the family members are try- ing to resolve conflict and handle problems. His description also includes implied positions on the roles of men, women, and female children in families—as well as developmental issues related to Tammy wanting to be older than she is.

In the assessment process, it is helpful to inquire about family perspectives on issues inherent in each of these layers. In addition to the points of entry we have noted, here are some other questions that might be included in a more detailed assessment.

◆ What does each family member bring to the session? ◆ How do family members describe themselves? ◆ What are the goals of each family member? What goals does each fam-

ily member have for the other people in the family? ◆ What routines support the daily living of each member of the family? ◆ Who makes decisions? How are conflicts resolved or problems handled? ◆ What parts are involved in the most common sequences in the family? ◆ What is a typical day like?

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◆ Are the parents effective leaders of the family, and is the process of lead- ership balanced or imbalanced?

◆ How do the children respond to parental leadership? What are the chil- dren’s goals in responding the way they do?

◆ Where is each person in the family in relation to personal biological, cognitive, emotional, and social development?

◆ Where is the family in the family life cycle, and how are they handling transitions?

◆ What cultures are in the family backgrounds of each of the family members?

◆ In what culture or region is the family currently living, and is immigra- tion or migration a recent family experience?

◆ How do economics, education, ethnicity, religion, race, regional back- ground, gender, sexual orientation, ableness, and age affect family processes—and how is the fit between the family practitioner and the family with regard to these aspects of family life?

◆ What effects has racism, patriarchy, or heterosexism had on this family and its members?

◆ What ideas in relation to gender need to be affirmed or challenged? ◆ Where is this family in the process of change? ◆ What resources (internal or external) need to be accessed?

Hypothesizing and Sharing Meaning To hypothesize is to form a set of ideas about people, systems, and situations that focus meaning in a useful way. In family therapy, hypothesizing flows from the ideas and understandings generated in the assessment process. Two questions are germane to the form of hypothesizing one chooses to do: (1) How much faith do the therapist and the family have in the ideas they generate? (2) How much of an influence is the therapist willing to be in the lives of people and families?

Family counselors, like individual therapists, cannot avoid influencing the family and its members. But what kind of influence will the counselor bring to the session? Satir and Bitter (2000) suggest that family therapists cannot be in charge of the people, but they need to be in charge of the process; that is, they own the responsibility for how therapy is conducted. Feminists and social constructionists are, perhaps, the most expressive of their concerns about the misuse of power in therapy. They are joined by multiculturalists, person-centered therapists, Adlerians, and existentialists, to name a few, who have also witnessed the often unconscious imposition of “dominant culture” in therapy. In the early days of family therapy, the mostly male therapists often ignored the effects on family life of patriarchy, poverty, racism, cultural discrimination and marginalization, homo-prejudice, and other societal problems. At the strategic-structural end of the continuum, therapists were more likely to claim a certain expertise in systems work that allowed them to make direct interventions in the enactment of “needed” changes in the family. To counter- act therapeutic abuses and what some perceived to be an ongoing misuse of power in therapy, some narrative therapists adopted a decentered position in relation to the

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family (White, 1997, 2007). Like person-centered therapists before them, decentered therapists seek to keep families and family members at the center of the therapeutic process.

It is important for families to be invited into respectful, essentially collaborative dialogues in therapeutic work. The different perspectives discovered in this work tend to coalesce into working hypotheses, and sharing these ideas provides the fam- ily with a window into the heart and mind of the therapist as well as themselves. Sharing hypotheses almost immediately invites and invokes feedback from various family members. And it is this feedback that enables the therapist and the family to develop a good fit with each other, which in turn tends to cement a working relationship.

The tentative hypothesizing and sharing process that Dreikurs (1950, 1997) developed is well designed for the kind of collaborative work envisioned here. Dreikurs would use a passionate interest and curiosity to ask questions and gather together the subjective perspectives of family members. Indeed, he would honor the ideas that individuals brought to their joint understanding. When he had an idea that he wanted to share, he would often seek permission for his disclosure:

1. I have an idea I would like to share with you. Would you be willing to hear it?

2. Could it be that . . .

The value of this way of presenting hypotheses is that it invites families and family members to consider and to engage without giving up their right to discard any- thing that does not fit. When a suggested idea does not fit, the counselor is then clear about letting it go and letting the family redirect the conversation toward more useful conceptualizations.

Facilitating Change Facilitating change is what happens when family therapy is viewed as a joint or col- laborative process. Techniques are more important to models that see the therapist- as-expert and in charge of making change happen. Collaborative approaches require planning. “Planning can still include what family therapy has called techniques or interventions, but with the family’s participation” (Breunlin et al., 1997, p. 292). Two of the most common forms for facilitation of change are enactments and assign- ment of tasks. Both of these processes work best when the family co-constructs them with the therapist—or at least accepts the rationale for their use. Pinsof et al. (2018) provide multiple planning metaframeworks, including action planning, meaning/emotion planning, biobehavioral planning, family-of-origin planning, internal representation planning, and self-planning (pp. 143–191).

Within the change process, the number of possible outcomes is only limited by the resources available internally and externally to the family. This does not mean, however, that the family practitioner is without a guide for preferred or desired out- comes. In general, the internal parts of family members function best when they are balanced (not polarized) and when the individual experiences personal parts as resources. Being able to think is usually more useful than emotional reactivity; being able to feel is better than not feeling; good contact with others is more rewarding

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than isolation or self-absorption; and taking reasonable risks in the service of growth and development is more beneficial than stagnation or a retreat into fear.

Furthermore, knowing the goals and purposes for our behaviors, feelings, and interactions tends to give us choices about their use. And understanding the patterns we enact in face-to-face relationships, the ebbs and flows of life, or across generations pro- vide multiple avenues for challenging patterns and the enactment of new possibilities.

Application of Family Systems Approaches to School Counseling

This section was provided by James Robert Bitter, EdD, a professor of counsel- ing in the Department of Counseling and Human Services at East Tennessee State University.

Even though school system personnel interact with children and families on a daily basis, family counseling, as a model used in helping students fully function in the school setting, is almost never used. In so many ways, this is a loss for both the student and the system. A systems perspective can help students see how their behavioral choices directly affect the responses that they receive from others. This knowledge can support either a change in student behavior or a change in the sys- tem when needed. The problems that affect the child at home are often and easily transferred into problems in learning or behavior at school. And most important, school counselors with a relational focus can advocate for students by helping teachers, parents, and administrators replace evaluations of good/bad or right/ wrong with an understanding of purpose, goals, and needs for growth and develop- ment. Indeed, school counselors are often a student’s last defense against the often discouraging perceptions of exhausted adults.

John, a 4th grade student who has been an excellent student from kindergarten on, starts to show up late for class. His homework is incomplete or not done at all, and his grades are falling. When his parents come to school for a meeting, the school counselor asked to meet with them first. With a simple question—Is there anything different happening at home?—the counselor discovered that the father had recently decided to take a new job in a different state. Not wanting to disturb their child’s regular routines, they had decided not to tell him “just yet,” and they were quietly packing at night. When the counselor asked the child if anything was different at home, he started to cry and said that he thought his parents were going to leave him.

In an era when No Child Left Behind has translated into No Teacher Left Stand- ing, the pressure on teachers to produce learning often leads to misunderstand- ings and miscommunications. Ms. Johnson is teaching a lesson on extinction to elementary school children, and she is using the one animal that every child knows is gone—dinosaurs.

Jeffrey is a student in this class. His mother and father are in jail on drug charges, and his grandmother is raising him. His grandmother belongs to a small, Pentecos- tal religious group in Appalachia, and she takes Jeffrey with her to church three times a week. They pray and read the Bible together every night.

Jeffrey raises his hand in Ms. Johnson’s class, and says, “If God wanted to bring the dinosaurs back, He could.”

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“No.” Ms. Johnson says, “Once an animal is extinct, Jeffrey, it never comes back.” Now Jeffrey raises his body up, feeling called upon by the Lord. “But if God

wanted to bring them back, He would!!” “Jeffrey, that’s not how extinction works. Once gone, gone forever.” Now Jeffrey is yelling, “You are a heathen. God can do all things! You are saying

God can’t, but He can! He can!” “Jeffrey, go to the office.” Ms. Johnson says in resignation. And Jeffrey leaves like

the warrior for God he is. How Jeffrey feels is important. What the teacher needs to be able to do to teach

a science lesson is also important. What brings clarity to his actions in the class- room, however, is an understanding of the relational layers of his family life. Jeffrey is clinging to his grandmother and her religion as the only true salvation in his life. He rarely sees his parents, and when he does, it is not pleasant. He is doing in school what his grandmother and the preacher would want him to do. He is a “good” boy, not a bad one. The teacher is doing her job in a room with almost 30 kids, trying to teach a prescribed lesson for everyone’s benefit. In the end, it is a systemic school counselor who brings them together, helps them to communicate calmly and with- out animosity, and finds a way for Jeffrey’s point of view to be expressed without him losing standing in her class.

An Expert’s Perspective on Family Systems Therapy In this section, James Robert Bitter, EdD, a professor of counseling in the Depart- ment of Counseling and Human Services at East Tennessee State University, pro- vides answers to the following questions.

1. What is the most important contribution of family systems ther- apy for the practice of individual therapy? The most important contribution of family therapy to individual therapy is the infusion of systemic thinking and a systemic orientation into under- standing people. With a systemic perspective, the notion of intrapsychic etiology of human dysfunction is replaced with a more interactive and consequential approach to understanding human behavior and disordered processes. This perspective also leads to different kinds of questions and interventions in therapy. For example, assume that a person comes to counseling with concerns over not being able to manage anger. The intra- psychic therapist would want to know about unresolved issues with author- ity or behavioral patterns that serve the person’s mistaken belief that they should get what is wanted when it is wanted. Perhaps this therapist would conceptualize the person’s difficulties as a problem with impulse control. Family therapists would say, “Not so fast,” and explore a number of ideas: At whom is the person angry and for what purpose? What do others do to trigger the anger or to maintain it once it starts? Are there patterned interactions or communications that serve to keep the status quo or simply block change from happening? Systemically, anger is an interactive process that almost always involves more than one person. The systemic perspective

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does not focus so much on what is wrong with the person as it does on an assessment of the relationships and contexts that make the anger useful or merely keep it going.

2. What two or three key concepts of family systems therapy are especially applicable to the practice of individual counseling or therapy? Differentiation of self. Bowen noted that people, especially within their families of origin, were often emotionally reactive. That is, it was easy to push their buttons or trigger an excessive emotional response. Old fam- ily patterns often support such emotional reactivity. Bowen believed that people could be coached into having a differentiated self. People can be taught to remain calm under duress, to use rational thought to overcome automatic emotional reactions, and to go into an observer role rather than being drawn into interactions that are unpleasant and useless.

Congruence and becoming more fully human. As we grow up in families, Satir noticed, we observe our parents when they are in dis- tress. Under these circumstances, people tend to use dysfunctional communication, including blaming, placating, acting or being super reasonable, and becoming irrelevant or distracting. A more healthy communication stance is to be congruent, or emotionally honest. When I am congruent, I am aware of the experience I am in, the people involved, the feelings I have, and I can communicate these parts of me to others in a way that expresses accurately how these feelings match the experience I am having. People who can adopt this kind of congru- ence in the face of stress manage to keep themselves from turning their stress into distress. They are more fully aware, more able to access both internal and external resources, more able to make decisions and imple- ment them, and they live life more fully.

Attachment theory. More and more, we are learning that early emo- tional support and security can make all the difference in how a child develops into an adolescent and then an adult. The ideal is for a parent, usually a mother, to be emotionally tuned to the needs of a child and to adapt herself and the environment to meet the child’s needs. This enables the child to form a healthy attachment early in life. Even when this experi- ence does not happen in infancy, we are learning that it can be added later with many beneficial effects. One of the most important places for it to exist is in counseling sessions. Here, we talk about the therapist cre- ating a “holding space” where clients can reconnect to security and safety and can experience emotions without the fear of being lost.

3. What two or three techniques from the family systems approach have practical value for practitioners of individual therapy? Joining. Salvador Minuchin used the term joining to cover a host of processes from careful listening to validation to unbalancing a sys- tem to becoming part of the systemic process. It may seem difficult to transfer all of these interventions to individual therapy, but the spirit of joining is an essential ingredient in being fully present with any client.

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It speaks to joining the client’s perspective and being able to not only know about it from the inside out but to interact with it in a way that enhances the client’s life. Joining rests on inquiry, interest, even fascina- tion, but it also seeks to move the relationship between counselor and client forward toward mutually desired goals.

Genograms. Genograms are family maps. The process of develop- ing these maps was first codified by Monica McGoldrick and Randy Gerson, but it grew out of the work of many family therapy pioneers, including Murray Bowen, Virginia Satir, Salvador Minuchin, and Jay Haley. The desire to understand people by exploring their past, their families of origin, dates back to Freud and Adler, but genograms provide a pictorial diagram that often carry both the lines of commu- nication and the emotional impact of the family on the individual. Tra- ditional genograms used the term identified patient, and later index person, to name the individual who was the focus of the work, but I have always preferred Satir’s term, “the star.” In individual therapy, the cli- ent is the star of the genogram, the person around whom the drama of family life has unfolded. It is a process that both illuminates the early and current life of a client and provides an assessment tool for under- standing the life dynamics the individual developed at an early age.

Enactments. Much of individual counseling is centered on listening. Counselors seek to join with clients in an exploration of self as well as a remediation of problems, but change is difficult and often resisted. Minuchin used enactments with multiple family members, sometimes to assess what would happen if a change were introduced and sometimes to let people practice a different approach to living with each other. When applied to individuals, the notion of enactment is still a very valu- able intervention. Asking a client to try something out, to act “as if,” to adopt a new approach, to change the way the client interacts with the counselor—all of these are enactments—can be used both to assess where the client is in the change process and to implement and practice new possibilities.

4. How does family systems therapy address diversity, multicul- tural, and social justice issues for the practice of individual counseling? For almost a decade into the family therapy movement of the 1970s, the model did very little to incorporate diversity, multicultural, and social justice issues with couples or families. Thanks to the work of a number of feminists, and most notably the work of Monica McGoldrick, family therapy in the last three decades has been at the forefront of integrating the perspectives of race, ethnicity, gender equality, poverty, ability and disability, and differences in sexual/affectional orientations. To be sure, social justice played some part in family therapy even in Alfred Adler’s work, starting in the early 1900s. Minuchin and his colleagues worked with the poor from the very beginning of their efforts. However, the

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literature and focus of family therapy on such issues took a giant leap forward with McGoldrick. From her we get the mandate to study our own culture before trying to counsel people from a different culture. McGoldrick urges us to extend our knowledge into a study of difference with the goal of learning to appreciate difference. From her, we come to understand the power that race, ethnicity, gender, sexual orientation, and poverty play in shaping who we are and how we live. Every coun- selor can benefit from reading McGoldrick’s work.

5. In what ways can the family systems therapy approach be applied to brief therapy (or time-limited counseling)? We originally thought family therapy would in practice be a brief therapy. After all, the counselor was working with the whole system, not just the individual, and if change in the system could be achieved, then the individual would get the benefits more quickly. In some cases, this turned out to be true, but it is also true that the time it takes to complete therapy is heavily dependent on who the client(s) is/are. The more dysfunctional the communication, interactions, or align- ments, the longer it takes to be effective in facilitating and promoting change. Family therapy has not focused on being brief but rather on how effective it can be with severe problems and very difficult systemic processes. In this regard, family therapy has had phenomenal suc- cess, precisely because it does not deal with the individual alone. This model would suggest, however, that if speed in therapy is a necessity, the individual is far better off being seen as part of a couple or family or system than being seen alone. After all, the counselor of individuals is betting that one hour a week is more powerful than the other 112 hours the person spends in a family or as part of a couple or in the larger systems that make up the person’s life. Way too often this is a losing bet.

6. From your perspective, what is the current status and the future of the family systems approach? The future of the family systems approach cannot be clearly defined. Most states have a couples and family license available, and training programs for couples and family therapists are still going strong and attracting very good practitioners both in universities and at train- ing institutes. However, many clinical mental health facilities remain focused on individuals, and billing processes are especially tied to indi- vidual diagnosis and treatment. Young family counselors often go to work hoping to do relational work but find themselves incorporated into an assembly line of individual therapy practices. Almost all of the great pioneers and innovators of family therapy have died, and we now await a new generation of innovators. For those of us dedicated to the practice of family therapy and counseling, the rewards are great. The opportunity to affect and improve so many lives in each session continues to feel both powerful and essential to community mental health.

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Discussion Questions Related to the Family Systems Therapy Perspective

1. From reading Dr. Bitter’s discussion of family therapy, how do you imagine that it would be for you to be in such a session with your family?

2. To what extent do you see yourself drawing on a family systems orien- tation in your work with individuals?

3. Would you be interested in facilitating family therapy sessions as a counselor? Why or why not?

Family Systems Therapy From a Multicultural Perspective Strengths From a Diversity Perspective

One of the strengths of the systemic perspective in working from a multicultural framework is that many ethnic and cultural groups place great value on the extended family. If therapists are working with an individual from a cultural background that gives special value to including grandparents, aunts, and uncles in the treatment, it is easy to see that family approaches have a distinct advantage over individual therapy. Family therapists can do some excellent networking with members of the extended family.

Within the field of family therapy, Monica McGoldrick has been the most influ- ential leader in the development of both gender and cultural perspectives and frame- works in family practice (see McGoldrick et al., 1991, 2005; McGoldrick & Hardy, 2019). In many ways, McGoldrick and her colleagues approach families like systems anthropologists. They see each family as a unique culture whose particular charac- teristics must be understood. Like larger cultural systems, families have a unique language that governs behavior, communication, and even how to feel about and experience life. Families have celebrations and rituals that mark transitions, protect them against outside interference, and connect them to their past as well as to a projected future.

Similarly, families cannot escape the sexism and patriarchy that are inherent in all cultures. The roles for men and women are prescribed in different societies, but in every culture women tend to come out on the short end more often than not. The roles that women as mothers play in the family, in the world of work, and in the community set the model for female children often for generations to come. Because family life is where the roles of women can be most limited, a consideration of gen- der issues in families is an essential framework for family therapy (McGoldrick et al., 1991). Perhaps the most difficult integration of all is figuring out how to honor different cultures in therapy without supporting marginalization or oppression of women. Toward this end, it is important to remember that there are feminist voices in every culture throughout the world.

Just as differentiation means coming to understand our family well enough to be a part of it—to belong—and also to separate and be our own person, under- standing cultures enables therapists and families to appreciate diversity and to contextualize family experiences in relation to the larger cultures. Today, family

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therapists explore the individual culture of the family, the larger cultures to which the family members belong, and the host culture that dominates the family’s life. They look for ways in which culture can both inform and modify family work. Interventions are no longer applied universally, regardless of the cultures involved: rather, they are adapted and even designed to join with the cultural systems. Fam- ily counselors must respectfully join with the family system and learn the roles, norms, alliances, and all the nuances that exist in the culture of a particular family system. Counselors must be willing to set aside any beliefs they may have about the culture of families. They need to show up like a blank slate, ready to learn about the individual family constellation in front of them at the moment. More important, they need to appreciate the strengths and stories that the culture pro- vides for creating resilience within the family.

Shortcomings From a Diversity Perspective Given the multicultural focus and collaborative approach of family systems therapy, it is difficult to find shortcomings from a diversity perspective. This model of family therapy embraces attitudes, knowledge, and skills that are essential to a multicultural perspective. Perhaps the major concern for non- Western cultures would be with regard to the balance that this model advocates for the individual versus the collective. The process of differentiation occurs in most cultures, but it takes on a different shape due to cultural norms. For instance, a young person may become separate from her parents yet not move out of the house. When ethnic-minority families immigrate to North America, their children often adapt to a Western concept of differentiation. In such cases, the intergenerational process of therapy is appropriate if the therapist is sensitive to the family-of-origin’s cultural roots. Although a multilayered approach addresses the notion of togetherness and individuality from a bal- anced perspective, many non-Western cultures would not embrace a theory that valued individuality above loyalty to family in any form. Nor would non- Western cultures have the same conceptualizations of time or even emotions. Family counselors, regardless of their model of therapy, need to find ways to enter the family’s world and honor the traditions that support the family. Counselors could benefit from doing their own individual work around their personal family dynamics to gain more empathy and respect for the challenges of joining with a family.

A possible shortcoming of the practice of family therapy involves practitioners who assume Western models of family are universal. Indeed, there are many cultural variations to family structure, processes, and communication. Family therapists are finding ways to broaden their views of individuation, appropriate gender roles, fam- ily life cycles, and extended families. Some family therapists focus primarily on the nuclear family, which is based on Western notions, and this could clearly be a short- coming in working with clients in extended families. As counselors, we must invite families to tell us about the primary members of their family and what those rela- tionships look like. We are challenged to remain open-minded and listen for what clients are telling us, and not what we expect to hear and be told.

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Family Therapy Applied to the Case of Stan In our work with Stan in this modality, we include ex- amples of forming a relationship and joining, read- ing Stan’s genogram, a multilayered assessment, re- framing, boundary setting in therapy, and facilitating change. There are many useful models and ways to work with families; this discussion represents some possible ways to work with Stan from a multilayered perspective.

At an intake interview, a family therapist meets with Stan to explore his issues and concerns and to learn

more about him and his life situation. As they talk, the therapist brings an intense interest and curios- ity to the interview and wonders out loud about the familial roots of some of Stan’s problems. It does not take much of an inquiry to learn that Stan is still very much engaged with his parents and siblings, no mat- ter how difficult these relationships have been for him. This initial conversation involves the development of a genogram of Stan’s family of origin (see Figure 14.1). This map will serve both Stan and the therapist as a

Judy b. 1963

Mary b. 1963

Joseph b. 1907

Oris b. 1938

Matthew Stan

b. 1988

Frank Sr. b. 1940

Matt b. 1960 Frank Jr.

b. 1966

Stan b. 1970

Karl b. 1972

Seth b. 1942

Emma b. 1917

m. 1937

d. 1977 (Cancer)

d. 1968 (Vietnam)

Martha b. 1921

Margie b. 1944

Angie b. 1942

m. 1940

m. 1962

Tom b. 1920

= Problem with alcohol

Figure 14.1 Three Generation Genogram of Stan’s Family

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guide to the people and the processes that influence Stan’s life.

Stan’s genogram is a family picture, or map, of his family-of-origin system. In this genogram, we learn that Stan’s grandparents tend to have lived fairly long lives. Stan’s maternal grandparents are both alive. The shaded lower half of their square and circle indicates that each had some problem with alcohol. In the case of Tom, Stan reports that he was an admitted alcoholic who recommitted himself to Christ and found help through Alcoholics Anonymous. Stan’s maternal grandmother always drank a little socially and with her husband, but she never considered herself to have a problem. In her later years, however, she seems to secretly use alcohol more and more, and it is a source of distress in her mar- riage. Stan also knows that Margie drinks a lot, because he has been drinking with his aunt for years. She is the one who gave him his first drink.

Angie, Stan’s mother, married Frank Sr. after he had stopped drinking, also with the help of AA. He still goes to meetings. Angie is suspicious of all men around al- cohol. She is especially upset with Stan and with Judy’s husband, Matt, who “also drinks too much.” The geno- gram makes it easy to see the pattern of alcohol prob- lems in this family.

The jagged lines /\/\/\/\ between Frank Sr. and An- gie indicate conflict in the relationship. The three solid lines === between Frank Sr. and Frank Jr., and between Angie and Karl, indicate a very close or even fused re- lationship. The double lines ==== between Karl and Stan are used to note a close relationship only. As we will see, Karl actually looks up to Stan in this family. The dotted lines . . . . . between Frank Sr. and Stan and between Frank Jr. and Stan indicate a distant or even disengaged relationship.

Because the family therapist believes that the whole family is involved in Stan’s use of alcohol, she spends a good part of the first session exploring with Stan pro- cesses for asking his other family members to join him in therapy. Stan may have many difficulties, but at the moment his difficulty with alcohol is the primary focus. Alcohol is a negative part of his life, and as such it has systemic meaning. It may have started out as a symptom of other problems, but now the alcohol is a problem in it-

self. From a systemic perspective, the questions are “How does this problem affect the family?” and “Is the family using this problem to serve some other purpose?”

In the first therapy session with the family, the ther- apist’s main focus is in forming a relationship with each of the family members, but even here, a variety of ap- proaches present themselves.

Therapist [to Frank Sr.]: I know coming here was an inconvenience for you, but I want you to know how appreciative I am that you came. Can you tell me what it’s like for you to be here? [Forming a relation- ship through joining]

Frank Sr.: Well, I have to tell you that I don’t like it much. [Pause] Things are a lot different today than they used to be. We didn’t have counseling 20 years ago. I had a problem with drinking at one point, but I got over it. I just quit—on my own. That’s what Stan needs to do. He just needs to stop.

Therapist: So I’m hearing that life is better for you without alcohol, and you would like Stan’s life to be better too. [Reframing]

Frank Sr.: Yeah. I’d like his life to be better in a lot of different ways.

Therapist: Angie, what about you? What is it like for you to be here? [Forming a relationship with each member]

Angie: It’s heartbreaking. It’s always heartbreaking. He [Referring to Frank Sr.] makes it sound as if he just summoned up his own personal power and quit drinking through his own strength of character. That’s a laugh. I threatened to leave him. That’s what really happened. I was ready to get a divorce! And we’re Catholics. We don’t get divorced. [Possible face- to-face sequence around family stress and coping]

Therapist: So you’ve been through this before.

Angie: Oh my, yes. My father and mother drank. Dad still does. My sister won’t admit it, but she drinks too much. She goes crazy with it. Judy’s husband has a problem. I’m surrounded by alcoholics. I get so angry. I wish they would all just die or go away.

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[Possible transgenerational family sequence: an entry point for exploring values, beliefs, and rules]

Therapist: So this is something the whole family has been dealing with for a long time.

Angie: Not everyone. I don’t drink. Frankie and Judy don’t drink. And Karl doesn’t seem to have a problem.

Therapist: Is that how the family gets divided: into those who drink and those who don’t? [Possible organization perspective]

Judy: Drinking isn’t the only problem we have. It’s probably not even the most important.

Therapist: Say more about that.

Judy: Stan has always had it hard. I feel sorry for him. Frankie is clearly Dad’s favorite [Frank Sr. protests, saying he doesn’t have favorites], and things have always come easily for me. And Karl, he gets whatever he wants. He’s Mom’s favorite. Mom and Dad have fought a lot over the years. None of us have been that happy, but Stan seems to have the worst of it. [Again, possible sequence and organization perspectives]

Frank Jr.: As I remember it, Stan gave Dad and Mom a lot to fight about. He was always messing up in one way or another.

Therapist: Frankie, when your father was talking earlier, I sensed he had some disappointment about Stan too, but he also wanted to see things work out better for him. Is that true for you too? [Reframing Frankie’s comment, maintaining a focus on new possibilities and new relations that might be developed]

Frank Jr.: Yes. I would like his life to be better.

The initial part of this counseling session has been devoted to meeting family members, listening in- tently to the multiple perspectives they present, and reframing Stan’s problem into a family desire for a positive outcome. Although there is a long way to go, the seeds of change have already been planted. There

is evidence in these early interactions that Stan’s prob- lem has a multigenerational context. If this context is explored, family sequences that support and maintain alcohol as a problem may be identified. It is possible to track these interactions and to work toward more con- gruent communications. Evolving relational, organiza- tional, developmental sequences might be explored as a means of freeing family members for new possibili- ties in their life together. Among other possibilities still to be explored are perspectives related to gender and culture. If the therapist were just listening to Stan, only one point of view would be evident. In this family ses- sion, multiple perspectives and the entire interactive process become clear in a very short time.

As the family interview proceeds, a number of pos- sibilities are presented for consideration. The thera- pist considers and may structure therapy around any or all of the following possibilities: 1. Stan’s parents have not been a well-functioning

leadership team for a long time, and both their spousal relationship and their parenting have suffered.

2. The adult siblings need a new opportunity to func- tion together without the influence and distractions continually imposed by the parents.

3. Stan has been reduced to a single part (his alcoholic part), and his description and experience of himself needs to be enlarged—both for his own perspective and in the eyes of others.

A new place for Stan in the family, a better way of relating, and an ability to access “lost” parts of his in- ternal system are all critical to winning his battle with alcohol. As therapy continues, it becomes clear that two separate relational–organization hypotheses must be explored. One is that the spousal relation- ship has been defined by the problem of alcohol too, and it has not evolved or developed in any kind of positive way over the years. Second, the transgen- erational sequences have targeted Stan and assigned him to a fixed role that he has been expected to play that has blocked development past his middle to late adolescence, which was the period in which he started drinking.

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Questions for Reflection ◆ What unique values do you see in working with

Stan from a multilayered, systemic perspective as opposed to an individual therapy approach?

◆ What internal parts might Stan reaccess as he continues in therapy? What parts of him might be polarized?

◆ Assuming that Stan was successful in getting at least some of his family members to another

session, where would you begin? Would you get everyone involved in the sessions? If so, how would you do that?

◆ What are some specific ways to explore other per- spectives with this family?

◆ What hypotheses are you developing, and how would you share them with the family?

◆ Are there systemic interventions that you would find hopeful in terms of facilitating change?

Family Therapy Applied to the Case of Gwen* As a family therapist, I look at Gwen as the index per- son in the context of her family system. Gwen has a strong extended family system and kinship ties that go beyond blood relatives to close friends who are called aunts, uncles, and cousins. When Gwen be- gins to experience episodes of depression and feels overwhelmed, the entire family is affected. African American families often become enmeshed due to our collectivistic nature. The cultural theme most of- ten expressed is that “when something happens to one of us, it happens to all of us.” It has been challeng- ing to get Gwen’s entire family in for a session, but she has managed it. The extended family is a great strength in the African American community, and Gwen’s family has provided her with a great deal of love and support. I want to validate these efforts and let the family know that they are already doing many things to support Gwen.

I invite everyone in, greeting each one individually. My first step with the family is to join with them by finding out how they feel about being in session.

Ron: [Gwen’s husband ] I rushed from work to be here, because, well, I want Gwen to feel better. I have to say I was not so sure about this when she first brought it up. I am not used to talking to strangers

about my business, but I trust Gwen. I want what is best for her.

Therapist: Thanks Ron, I appreciate you being here. I know that you all have busy lives. But what is it that you want for yourself from these sessions?

Ron: Well, Gwen, she is an amazing woman, but . . . when she has these episodes of depression, I feel helpless and nervous. I want to figure this thing out and get past it. I want my wife to feel better, and I want to help her however I can.

Therapist: I get the feeling that you would move heaven and earth to help your wife be happier than she is right now.

Ron: Yes, I certainly would.

Therapist: I appreciate that. And Lisa, what about you?

Lisa: [the youngest daughter, age 26] I want Mom to feel better, she is such a powerhouse. She helps every- one else, and then she crashes. I am a little nervous to be here. I don’t want to find out that she is going through this because of something I did. She helps me out with my bills, and I know I could do more

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

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for her. I never help her with grandma, and I know that is just more work for her.

Therapist: Lisa, I am sure that is important for your mother to hear. But before I ask her to respond, I would like to hear from other family members.

Brittany: [the eldest daughter, age 29] I have been really busy trying to get my career established. Mom has been helping me, and I really had no idea she was feeling overwhelmed and depressed. I am not sure I really understand what is happening. I love my mom, and I want to be here for her. She has always had these ups and downs. Is this any different? I love my mom, but she is so busy that I have given up on trying to keep up with her. So when I hear she wants to have a session, I am confused. Dad is so good with her. He keeps everything rolling when she is feeling down.

Therapist: I hear both your confusion and your willing- ness to be here for your mom. Gwen, what is this like for you?

Gwen: I am so thankful that I have such a loving family that is willing to come talk to a complete stranger so that I can get the help I need. Right now I am feeling overwhelmed with life, and I am tired of it. I am juggling so many things and feel like nothing is getting done. I know this has been going on for long time, but I am ready to find a better way of living. I know this pattern has not been easy for any of you, and I feel guilty over that too. I don’t want to hide in bed anymore, like I remember my mom do- ing. I am not getting any younger, and I am so ready to show up in life in a healthier way.

Therapist: What would that look like?

Gwen: Well, I don’t know for sure. I would be happy, I guess. I would not be worried about work or the family so much.

Therapist: And what would your family be doing if you were happier and healthier?

Gwen: I guess they would be happier too. It seems like if I am happy, then they are too.

Therapist: But how can you be happy and healthy with all these burdens hanging on you?

Gwen: I am hoping you can tell me.

Therapist: Would it be OK with you if I gave that a try?

Gwen: Yes, please.

Therapist: Here is what I think is almost always true. A super responsible person is always surrounded by people who will let her take charge and handle everything.

Gwen: What do you mean by that?

Therapist: It means, Gwen, that you have been in charge for a very long time, and you have forgotten how to ask for help. Maybe you never knew how to do that. But as long as you keep pushing forward, your family will let you.

Gwen’s Mother: That’s right there!

Ron: Wait a minute. I do everything I can to keep things moving! What else do you need?

Gwen: I don’t know. I am just hearing that I need help.

Therapist: So that’s the issue for this family. Mom is the only one that knows everything that needs to happen. She knows how to do everything, but she is overloaded. She doesn’t know how to ask for help, and everyone else is hoping she won’t because everyone is busy and overloaded. And, Gwen, even if you did ask for help from others, would you worry whether they were doing it right?

Brittany: Are you kidding? She would be supervising everything anyway.

Therapist: And how many of you would know how to mess it up just enough so that mom would take over again? [pause while family members look at each other; some smile a bit; some hang their heads] Wow. That brought everything to a standstill. Where do we go from here?

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Summary and Evaluation Summary

Let’s first review the themes that unite the many approaches to family therapy, with particular emphasis on the multilayered approach.

Basic Assumption If we hope to work therapeutically with individuals, it is critical to consider them within the family system. An individual’s problematic behavior grows out of the interactional unit of the family as well as the larger community and societal systems.

Focus of Family Therapy Most of the family therapies tend to be brief because families who seek professional help typically want resolution of some problematic symptom. Changing the system can stimulate change quickly. In addition to being short-term, solution-focused, and action-oriented, family therapy tends to deal with present interactions. The main focus of family therapy is on here-and-now interactions in the family system. One way in which family therapy differs from many individual therapies is its emphasis on how current family relationships contribute to the development and maintenance of symptoms.

Role of Goals and Values Specific goals are determined by the practitioner’s orie- ntation or by a collaborative process between family and counselor. Global goals include using interventions that enable individuals and the family to change in ways that will reduce their distress. Tied to the question of what goals should guide a therapist’s interventions is the question of the therapist’s values. Family therapy is grounded on a set of values and theoretical assumptions. Ultimately, every

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Ron: Maybe we need to go home and think about this. We definitely need to do something differ- ently. I want to talk to your brother and let him know how much pressure your mom is under so he can start taking care of his own business. We better start by making a list of everything Gwen has been doing and see where we need to step up. [pause] And maybe Gwen needs to stay out of this part.

Therapist: Let’s see where that goes.

We set a time for future sessions, and I let them know that coming in for therapy shows their commitment to Gwen and to each other as a family unit. I want them to know that I understand what it took for them to make it in the door and that their efforts are commendable.

Questions for Reflection ◆ What did you think of the way the therapist inter-

vened to get family members connected in their first family therapy session?

◆ What do you imagine it would be like for you to be a participant in this family therapy session with this therapist?

◆ What value do you see for Gwen in having a fam- ily therapy session in addition to her individual therapy sessions?

◆ Beginning therapists are usually anxious about having so many people in the room because it can be confusing. How did the therapist in this case manage the session so that it did not become chaotic?

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intervention a therapist makes is an expression of a value judgment. It is critical for counselors, regardless of their theoretical orientation, to be aware of their values and monitor how these values influence their practice with families.

How Families Change An integrative approach to the practice of family therapy includes guiding principles that help the therapist organize goals, interactions, observations, and ways to promote change. Some perspectives of family systems therapy focus on perceptual and cognitive change, others deal mainly with changing feelings, and still other theories emphasize behavioral change. Regardless of the perspectives that a family therapist operates from, change needs to happen in relationships, not just within the individual.

Techniques of Family Therapy The intervention strategies therapists employ are best considered in conjunction with their personal characteristics. Bitter (2021); Gladding (2019); Goldenberg, Stanton, and Goldenberg (2017); and Nichols and Davis (2017) emphasize that techniques are tools for achieving therapeutic goals but that these intervention strategies do not make a family therapist. Personal characteristics such as respect for clients, compassion, empathy, and sensitivity are human qualities that influence the manner in which techniques are delivered. It is also essential to have a rationale for the techniques that are used, with some sense of the expected outcomes. Faced with meeting the demands of clinical practice, practitioners will need to be flexible in selecting intervention strategies. The central consideration is what is in the best interests of the family.

A multilayered approach to family therapy is more complex than models with a singular focus. At least initially, some of the confidence and clarity that might be gained from a single approach may be lost, but in time the flexibility to change directions is an asset. We have presented a structure for therapy that is useful across models. We have integrated a multilayered process of family therapy in assessment, hypothesizing, and facilitating change. This chapter has described a collaborative process for therapy in which both the family and the therapist share influence according to the needs of the situation.

Contributions of Family Systems Approaches One of the key contributions of most systemic approaches is that neither the indi- vidual nor the family is blamed for a particular dysfunction. The family is empow- ered through the process of identifying and exploring internal, developmental, and purposeful interactional patterns. At the same time, a systems perspective rec- ognizes that individuals and families are affected by external forces and systems, among them illness, shifting gender patterns, culture, and socioeconomic consider- ations. If change is to occur in families or with individuals, therapists must be aware of as many systems of influence as possible.

Most of the individual therapies considered in this textbook do not focus pri- marily on the systemic factors influencing the individual. Family therapy redefines the individual as a system embedded within many other systems, which brings an entirely different perspective to assessment and treatment. An advantage to this viewpoint is that an individual is not scapegoated as the “bad person” in the family. Rather than blaming either the “identified patient” or a family, the entire family has

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an opportunity (a) to examine the multiple perspectives and interactional patterns that characterize the unit and (b) to participate in finding solutions.

Limitations and Criticisms of Family Systems Approaches In the early days of family therapy, therapists all too often got lost in their consid- eration of the “system.” In adopting the language of systems, therapists began to describe and think of families as being made up of “dyads” and “triads”; as being “functional” or “dysfunctional,” “stuck” or “unstuck,” and “enmeshed” or “disen- gaged”; and as displaying “positive” and “negative” outcomes and “feedback loops.” It was as if the family was a well-oiled machine or perhaps a computer that occa- sionally broke down. Just as it was easy to fix a machine without an emotional con- sideration of the parts involved, some therapists approached family systems work with little concern for the individuals as long as the “whole” of the family “func- tioned” better. Enactments, ordeals, and paradoxical interventions were often “done to” clients—sometimes even without their knowledge (see Haley, 1963, 1976, 1984; Minuchin & Fishman, 1981; Selvini Palazzolli et al., 1978).

Feminists were perhaps the first, but not the only, group to lament the loss of a personal perspective within a systemic framework. As the field moves now toward an integration of individual and systemic frameworks, it is important to reinvest the language of therapy with human emotional terminology that honors the place real people have always held in families. It is our hope that this chapter gives you enough of an introduction to the diverse field of family therapy that you will want to learn more through reading as well as watching the many videos currently available.

Self-Reflection and Discussion Questions 1. Several different approaches to family therapy are described in this

chapter. Which of these approaches most interests you, and why? 2. How do you imagine it would be for you to be with your family as

a participant in family therapy? What do you think you could learn about yourself from this experience?

3. What do you think you will need to learn and to experience before you will be able to effectively work with a family?

4. How do the family systems therapy approaches differ from other theo- ries that you have studied thus far?

5. What are some major advantages of working with a family therapy per- spective? Can you think of any disadvantages?

Where to Go From Here You may want to consider joining the American Association for Marriage and Fam- ily Therapy, which has a student membership category. You must obtain an official application, including the names of at least two Clinical Members from whom the association can request official endorsements. You also need a statement signed by the coordinator or director of a graduate program in marriage and family therapy in

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a regionally accredited educational institution, verifying your current enrollment. Student membership may be held until receipt of a qualifying graduate degree or for a maximum of five years. Members receive the Journal of Marital and Family Therapy, which is published four times a year, and a subscription to six issues yearly of The Family Therapy Magazine. For a copy of the AAMFT Code of Ethics, member- ship applications, and further information, contact the American Association for Marriage and Family Therapy (www.aamft.org).

The American Counseling Association has a division devoted to couples and family counseling called the International Association of Marriage and Family Counseling (IAMFC). This division publishes The Family Journal and The Family Digest and provides access to couples and family training and programs at the ACA con- vention. For more information, contact the International Association of Marriage and Family Counseling (www.iamfconline.org/public/main.cfm).

Theory and Practice of Couples and Family Counseling (Bitter, 2021) is a comprehensive textbook that seeks to develop personal and professional growth in fam- ily practitioners as well as orient the reader to the theories that make up the field of family therapy and counseling. Family Therapy: Concepts and Methods (Nichols & Davis, 2017) is an AAMFT-based text that covers seven of the major contemporary family systems models. The final chapter presents an integration of key themes among diverse approaches to family therapy. Family Therapy: History, Theory, and Practice (Gladding, 2019) is an overview of family therapy models and therapeutic interventions designed pri- marily for counselors associated with ACA. No Bad Parts: Healing Trauma and Restoring Wholeness With the Internal Family Systems Model

(Schwartz, 2021) describes healing trauma and restoring wholeness based on the internal family systems model. This model is a compassionate way of relating internally (to our parts) and externally (to the people in our life).

Ethnicity and Family Therapy (McGoldrick et al., 2005) is the seminal work on culture in family therapy. The authors review the importance of cultural consid- erations in relation to family therapy and provide chapters on the background, research, and therapy issues of more than 15 cultures.

Genograms: Assessment and Interventions (McGold rick et al., 2020) is the most important family systems assessment tool fully explained with multiple exam- ples and diagrams.

Recommended Supplementary Readings for Chapter 14

References Adler, A. (1927). Understanding human nature (W. B. Wolfe, Trans.). Fawcett. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books .9780890425596 Andersen, T. (1987). The reflecting team: Dialogue and metadialogue in clinical work. Family Process, 26(4), 415–428.

Andersen, T. (1991). The reflecting team: Dialogues and dialogues about the dialogues. Norton. Anderson, H. (1993). On a roller coaster: A collaborative language system approach to therapy. In S. Friedman (Ed.), The new language of change (pp. 324–344). Guilford Press. Anderson, H., & Goolishian, H. (1992). The client is the expert: A not-knowing approach to therapy. In S. McNamee

& K. J. Gergen (Eds.), Therapy as social construction (pp. 25–39). SAGE. Becvar, D. S., & Becvar, R. J. (2013). Family therapy: A systemic integration (8th ed.). Pearson. Bitter, J. R. (2021). Theory and practice of couples and family counseling (3rd ed.). American Counseling Association. Bitter, J. R., Roberts, A., & Sonstegard, M. A. (2002). Adlerian family therapy. In J. Carlson & D. Kjos (Eds.), Theories and

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strategies of family therapy (pp. 41–79). Allyn & Bacon. Bowen, M. (1978). Family therapy in clinical practice. Jason Aronson. Breunlin, D. C., Schwartz, R. C., & Mackune-Karrer, B. (1997). Metaframe- works: Transcending the models of family therapy (Rev. ed.). Jossey-Bass. Carlson, J., Sperry, L., & Lewis, J. A. (2005). Family therapy techniques: Integrating and tailoring treatment. Brooks/Cole, Cengage Learning. Christensen, O. C. (Ed.). (2004). Adlerian family counseling (3rd ed.). Educational Media Corp. (Original work published 1983) Dreikurs, R. (1950). The immediate purpose of children’s misbehavior, its recognition and correction. Internationale Zeitschrift fur Individual-psychologie, 19, 70–87. Dreikurs, R. (1973). Counseling for family adjustment. In R. Dreikurs, Psychodynamics, psychotherapy, and counseling (Rev. ed.). Alfred Adler Institute. (Original work published 1949) Dreikers, R. (1997). Holistic medicine. Individual Psychology, 53(2), 127–205. Epston, D., & White, M. (1992). Consulting your consultants: The documentation of alternative knowledges. In Experience, contradiction, narrative and imagination: Selected papers of David Epston and Michael White, 1989–1991 (pp. 11–26). Dulwich Centre. Gladding, S. T. (2019). Family therapy: History, theory, and practice (7th ed.). Pearson. Goldenberg, I., Stanton, M., & Goldenberg, H. (2017). Family therapy: An overview (9th ed.). Cengage Learning. Gottman, J. M. (1999). The marriage clinic: A scientifically based marital therapy. Norton.

Haley, J. (1963). Strategies of psychotherapy. Grune & Stratton. Haley, J. (1976). Problem-solving therapy: New strategies for effective family therapy. Jossey-Bass. Haley, J. (1984). Ordeal therapy. Jossey-Bass. Hanna, S. M. (2007). The practice of family therapy: Key elements across models (4th ed.). Brooks/Cole, Cengage Learning. Kerr, M. E., & Bowen, M. (1988). Family evaluation: An approach based on Bowen theory. Norton. Lambert, S. F., Carmichael, A., & Williams, L. (2016). Guidelines in counseling families. In I. Marini & M. A. Stebnicki (Eds.), The professional counselor’s desk reference (2nd ed., pp. 351–356). Springer. Luepnitz, D. A. (2002). The family interpreted: Feminist theory in clinical practice. Basic Books. McGoldrick, M., Anderson, C., & Walsh, F. (1991). Women in families: A framework for family therapy. Norton. McGoldrick, M., Carter, B., & Garcia- Preto, N. (Eds.). (2011). The expanded family life cycle: Individual, family, and social perspectives (4th ed.). Pearson. McGoldrick, M., Gerson, R., & Petry, S. (2020). Genograms: Assessment and intervention (4th ed.). Norton. McGoldrick, M., Giordano, J., & Garcia-Preto, N. (Eds.). (2005). Ethnicity and family therapy (3rd ed.). Guilford Press. McGoldrick, M., & Hardy, K. V. (2019). Revisioning family therapy: Addressing diversity in clinical practice (3rd ed.). Guilford Press. Minuchin, S. (1974). Families and family therapy. Harvard University Press. Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Harvard University Press.

Nichols, M. P., & Davis, S. D. (2017). Family therapy: Concepts and methods (11th ed.). Pearson. Pinsof, W. M., Breunlin, D. C., Russell, W. P., Lebow, J. L., Rampage. C., & Chambers, A. L. (2018). Integrative systemic therapy: Metaframeworks for problem solving with individuals, couples, and families. American Psychological Association. Rogers, C. R. (1980). A way of being. Houghton Mifflin. Satir, V. (1983). Conjoint family therapy (3rd ed.). Science and Behavior Books. Satir, V., & Baldwin, M. (1983). Satir: Step-by-step. Science and Behavior Books. Satir, V. M., Banmen, J., Gerber, J., & Gomori, M. (1991). The Satir model: Family therapy and beyond. Science and Behavior Books. Satir, V. M., & Bitter, J. R. (2000). The therapist and family therapy: Satir’s human validation process model. In A. M. Horne (Ed.), Family counseling and therapy (3rd ed., pp. 62–101). F. E. Peacock. Schwartz, R. C. (2021). No bad parts: Healing trauma and restoring wholeness with the internal family systems model. Sounds True. Schwartz, R. C. & Sweezy, M. (2019). Internal family systems therapy (2nd ed.). Guilford Press. Selvini Palazzoli, M., Boscolo, L., Cecchin, F. G., & Prata, G. (1978). Paradox and counterparadox. Aronson. White, M. (1997). Narratives of therapists’ lives. Dulwich Centre. White, M. (2007). Maps of narrative practice. Norton.

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

2. Identify some specific advantages of psychotherapy integration.

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

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

5. Discuss how spiritual and religious values can ethically and effectively be integrated into counseling practice.

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

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

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

Learning Objectives

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Introduction This chapter will help you think about areas of convergence and divergence among the 11 therapeutic systems covered in this book. Although these approaches all have some goals in common, they have many differences when it comes to the best route to achieve these goals. Some therapies call for an active and directive stance on the therapist’s part, and others place value on clients being the active agent. Some therapies focus on experiencing feelings, others stress identifying cognitive patterns, and still others concentrate on actual behavior. The key task is to find ways to inte- grate certain features of each of these approaches so that you can work with clients on all three levels of human experience.

The field of psychotherapy is characterized by a diverse range of specialized models. With all this diversity, is there any hope that a practitioner can develop skills in all of the existing techniques? How does a student decide which theories are most relevant to practice? Looking for commonalities among the systems of psychotherapy is relatively new (Norcross & Beutler, 2019). Practitioners have been battling over the “best” way to bring about personality change dating back to the work of Freud. For decades, counselors resisted integration, often to the point of denying the validity of alternative theories and of ignoring effective methods from other theoretical schools. The early history of counseling is full of theoretical wars.

Since the early 1980s, psychotherapy integration has developed into a clearly delineated field. It is now an established and respected movement that is based on combining the best of differing orientations so that more complete theoretical models can be articulated and more efficient treatments developed (Goldfried et al., 2019). The Society for the Exploration of Psychotherapy Integration, formed in 1983, is an international organization whose members are professionals working toward the development of therapeutic approaches that transcend single theoretical orientations. As the field of psychotherapy has matured, the concept of integration has emerged as a major force (Norcross & Beutler, 2019).

In this chapter I consider the advantages of developing an integrative perspective for counseling practice. I also present a framework to help you begin to integrate con- cepts and techniques from various approaches. As you read, start to formulate your own personal perspective for counseling. Look for ways to synthesize diverse elements from different theoretical perspectives. As much as possible, be alert to how these sys- tems can function in harmony.

Refer to the MindTap for this book to interact with video quizzes and various video programs to expand your knowledge on topics relevant to Chapter 15.

The Movement Toward Psychotherapy Integration A large number of therapists identify themselves as “eclectic,” and this category covers a broad range of practice. At its worst, eclectic practice consists of haphazardly picking techniques without any overall theoretical rationale. This is known as syncretism, wherein the practitioner, lacking in knowledge and skill in selecting

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interventions, looks for anything that seems to work, often making little attempt to determine whether the therapeutic procedures are indeed effective. Such an uncritical and unsystematic combination of techniques is no better than a narrow and dogmatic orthodoxy. Pulling techniques from many sources without a sound rationale results in syncretistic confusion, which is detrimental to the successful treatment of clients (Corey, 2019; Norcross & Beutler, 2019).

Pathways Toward Psychotherapy Integration Psychotherapy integration is best characterized by attempts to look beyond and across the confines of single-school approaches to see what can be learned from other perspectives and how clients can benefit from a variety of ways of conducting therapy. The majority of psychotherapists do not claim allegiance to a particular therapeutic school but prefer, instead, some form of integration (Norcross & Alexander, 2019; Norcross & Beutler, 2019). In a 2007 survey, only 4.2% of respondents identified themselves as being aligned with one therapy model exclusively. The remaining 95.8% claimed to be integrative, meaning they combined a variety of methods or approaches in their counseling practice (Psychotherapy Networker, 2007). A panel of psychother- apy experts has predicted an increase in the popularity of integrative therapies in the next decade, particularly with regard to mindfulness, cognitive behavioral, multicul- tural, and integrative theories (Norcross et al., 2013).

The integrative approach is characterized by openness to various ways of integrat- ing diverse theories and techniques. The ultimate goal of integration is to enhance the efficiency and applicability of psychotherapy. Four of the most common path- ways toward the integration of psychotherapies are technical integration, theoretical integration, assimilative integration, and the common factors approach. All of these approaches to integration look beyond the restrictions of single approaches, but they do so in distinctive ways (Norcross & Alexander, 2019; Norcross & Beutler, 2019).

Technical integration aims at selecting the best treatment techniques for the individual and the problem. It tends to focus on differences, chooses from many approaches, and is a collection of techniques. This path calls for using techniques from different schools without necessarily subscribing to the theoretical positions that spawned them. For those who practice from the perspective of technical inte- gration, there is no necessary connection between conceptual foundations and tech- niques. Therapists have a variety of tools in their tool kit to use with clients. One of the best-known forms of technical integration, which Lazarus (2008) refers to as technical eclecticism, is the basis of multimodal therapy. Multimodal therapists bor- row from many other therapeutic models, using techniques that have been demon- strated to be effective in dealing with specific clinical problems. Whenever feasible, multimodal therapists employ empirically supported techniques.

In contrast, theoretical integration refers to a conceptual or theoretical creation beyond a mere blending of techniques. This route has the goal of pro- ducing a conceptual framework that synthesizes the best aspects of two or more theoretical approaches under the assumption that the outcome will be richer than either theory alone. This approach emphasizes integrating the underlying theories of therapy along with techniques from each. Examples of this form of integration are dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT),

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both of which are described in Chapter 9. Emotion-focused therapy (EFT), introduced in Chapter 7, is another form of theoretical integration. This approach is informed by the role of emotion in psychotherapeutic change. Greenberg (2017), a key figure in the development of EFT, conceptualizes the model as an empirically supported, integrative, experiential approach to treatment. Emotion-focused therapy is rooted in a person-centered philosophy, but it is integrative in that it synthesizes aspects of Gestalt therapy, experiential therapy, and existential therapy. Emotion-focused ther- apy blends the relational aspects of the person-centered approach with the active phenomenological awareness experiments of Gestalt therapy.

The assimilative integration approach is grounded in a particular school of psychotherapy, along with an openness to selectively incorporating practices from other therapeutic approaches. Assimilative integration combines the advantages of a single coherent theoretical system with the flexibility of a variety of interventions from multiple systems. An example of this form of integration is mindfulness-based cognitive therapy (MBCT), which integrates aspects of cognitive therapy and mindful- ness-based stress reduction procedures. As you may recall from Chapter 9, MBCT is a comprehensive integration of the principles and skills of mindfulness that has been applied to the treatment of depression (Segal et al., 2013).

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

The common factors explanation for the general equivalence of diverse therapeu- tic interventions has resulted in the dominance of integrative practice in routine care by implying that the dogmatic advocacy of a particular theoretical school is not supported by research. Research also suggests that common factors can become the focal point for integration of seemingly diverse therapy techniques. (p. 314)

Some of these common factors include empathic listening, support, warmth, developing a working alliance, opportunity for catharsis, practicing new behav- iors, feedback, positive expectations of clients, working through one’s own con- flicts, understanding interpersonal and intrapersonal dynamics, change that occurs outside of the therapy office, client factors, therapist effects, and learning to be self-reflective about one’s work (Norcross & Beutler, 2019; Prochaska & Norcross, 2018).These common factors are thought to be far more important in accounting for therapeutic outcomes than the unique factors that differentiate one theory from another. Specific treatment techniques make relatively little difference in outcome when compared with the value of common factors, especially the human elements (Elkins, 2016). Among the approaches to psychotherapy integration, the common factors approach has the strongest empirical support (Duncan et al., 2010).

Of all of the common factors investigated in psychotherapy, none has received more attention and confirmation than a facilitative therapeutic relationship (Lambert, 2011). The importance of the therapeutic alliance is a well-established critical component of effective therapy. Research confirms that the client–therapist relationship is central to therapeutic change and is a significant predictor of both effectiveness and retention of therapy outcomes (Elkins, 2016; Miller et al., 2015).

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Advantages of Psychotherapy Integration An integrative approach provides a general framework that enables practitioners to make sense of the many aspects of the therapy process and provides a map giving direc- tion to what practitioners do and say (Corey, 2019). One reason for the movement toward psychotherapy integration is the recognition that no single theory is compre- hensive enough to account for the complexities of human behavior, especially when the range of client types and their specific problems are taken into consideration. Because no one theory contains all the truth, and because no single set of counseling techniques is always effective in working with diverse client populations, integrative approaches hold promise for counseling practice. Norcross and Wampold (2019) maintain that effective clinical practice requires a flexible and integrative perspective. Psychotherapy should be flexibly tailored to the unique needs and contexts of the individual client. Using an identical therapy relationship style and treatment method for all clients is inappropriate and can be unethical (Norcross & Cooper, 2021; Norcross & Wampold, 2019). Norcross and Alexander (2019) conclude that “psychotherapy integration is an intellectually vibrant, clinically popular, demonstrably effective, and maturing inter- national movement” (p. 22). They predict that “psychotherapy integration will most certainly be a therapeutic mindstay of the twenty-first century” (p. 22).

The 11 systems discussed in this book have evolved in the direction of broad- ening their theoretical and practical bases and have become less restrictive in their focus. Many practitioners who claim allegiance to a particular system of therapy are expanding their theoretical outlook and developing a wider range of therapeu- tic techniques to fit a more diverse population of clients. There is a growing recog- nition that psychotherapy can be most effective when contributions from various approaches are integrated (Norcross & Goldfried, 2019).

Practitioners who are open to an integrative perspective will find that several theories play a crucial role in their personal counseling approach. Each theory has its unique contributions and its own domain of expertise. By accepting that each theory has strengths and weaknesses and is, by definition, “different” from the oth- ers, practitioners have some basis to begin developing a theory that fits for them and their clients. It takes considerable time to learn the various theories in depth. It is not realistic for any of us to expect that we can integrate all the theories. Instead, integration of some aspects of some theories is a more realistic goal. Developing an integrative perspective is a lifelong endeavor that is refined with clinical experience, reflection, reading, supervision, and discourse with colleagues.

The Challenge of Developing an Integrative Perspective A survey of approaches to counseling and psychotherapy reveals that no common philosophy unifies them. Many of the theories have different basic philosophies and views of human nature (Table 15.1). As the postmodern therapists remind us, our philosophical assumptions are important because they influence which “real- ity” we perceive, and they direct our attention to the variables that we are “set” to see. A word of caution then: Beware of subscribing exclusively to any one view of human nature. Remain open and selectively incorporate a framework for counseling that is consistent with your own personality and belief system and that validates clients’ belief systems as well.

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Table 15.1 The Basic Philosophies

Psychoanalytic therapy Unconscious motives and conflicts are central in present behavior. Early development is of critical importance because later personality problems have their roots in repressed childhood conflicts.

Adlerian therapy Humans are motivated by social interest, by striving toward goals, by inferiority and superiority, and by dealing with the tasks of life. People have the capacity to interpret, influence, and create events. Each person at an early age creates a unique style of life, which tends to remain relatively constant throughout life.

Existential therapy The central focus is on the nature of the human condition, which includes a capacity for self-awareness, freedom of choice to decide one’s fate, responsibility, anxiety, the search for meaning, being alone and being in relation with others, striving for authenticity, and facing living and dying.

Person-centered therapy Positive view of people; we have an inclination toward becoming fully functioning. In the context of the therapeutic relationship, the client experiences feelings that were previously denied to awareness. The client moves toward increased awareness, spontaneity, trust in self, and inner-directedness.

Gestalt therapy The person strives for wholeness and integration of thinking, feeling, and behaving. Some key concepts include contact with self and others, contact boundaries, and awareness. As an experiential approach, it is grounded in the here and now and emphasizes awareness, personal choice, and responsibility.

Behavior therapy Behavior is the product of learning. We are both the product and the producer of the environment. Contemporary behavior therapy has branched out in many directions, including mindfulness and acceptance approaches.

Cognitive behavior therapy Individuals tend to incorporate faulty thinking, which leads to emotional and behavioral disturbances. Cognitions are the major determinants of how we feel and act. Therapy is primarily oriented toward cognition and behavior, and it stresses the role of thinking, deciding, questioning, doing, and redeciding. This is a psychoeducational model, which emphasizes therapy as a learning process and acquiring more effective ways of coping with problems.

Choice theory/Reality therapy Based on choice theory, this approach assumes that we need quality relationships to be happy. Choice theory is an explanation of human nature and how to best achieve satisfying interpersonal relationships.

Feminist therapy Feminists criticize many traditional theories to the degree that they are based on gender- biased concepts. The constructs of feminist therapy include being gender fair, flexible, interactionist, and life-span-oriented. Gender and power are at the heart of feminist therapy. This is a systems approach that recognizes the cultural, social, and political factors that contribute to an individual’s problems.

Postmodern approaches Based on the premise that there are multiple realities and multiple truths, postmodern therapies reject the idea that reality is external and can be grasped. People create meaning in their lives through conversations with others. The postmodern approaches avoid pathologizing clients, take a dim view of diagnosis, avoid searching for underlying causes of problems, and place a high value on discovering clients’ strengths and resources. Rather than talking about problems, the focus of therapy is on creating solutions in the present and the future.

Family systems therapy The family is viewed from an interactive and systemic perspective. The family provides the context for understanding how individuals function in relationship to others and how they behave. Treatment deals with the family unit.

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Despite the divergences in the various theories, creative syntheses among some models are possible. For example, an existential orientation does not necessarily pre- clude using techniques drawn from behavior therapy or from some of the cognitive theories. Each point of view offers a perspective for helping clients in their search for self. I encourage you to study all the major theories and to remain open to what you might take from the various orientations as a basis for an integrative perspective that will guide your practice.

In developing a personal integrative perspective, it is important to be alert to the problem of attempting to mix theories with incompatible underlying assumptions. Examine the key concepts of various theories as you begin to think about integra- tion (Table 15.2). By remaining theoretically consistent, but technically integrative, practitioners can spell out precisely the interventions they will employ with various clients, as well as the means by which they will select these procedures.

Table 15.2 Key Concepts

Psychoanalytic therapy Normal personality development is based on successful resolution and integration of psychosexual stages of development. Faulty personality development is the result of inadequate resolution of some specific stage. Anxiety is a result of repression of basic conflicts. Unconscious processes are centrally related to current behavior.

Adlerian therapy Key concepts include the unity of personality, the need to view people from their subjective perspective, and the importance of life goals that give direction to behavior. People are motivated by social interest and by finding goals to give life meaning. Other key concepts are striving for significance and superiority, developing a unique lifestyle, and understanding the family constellation. Therapy is a matter of providing encouragement and assisting clients in changing their cognitive perspective and behavior.

Existential therapy Essentially an experiential approach to counseling rather than a firm theoretical model, it stresses core human conditions. Interest is on the present and on what one is becoming. The approach has a future orientation and stresses self-awareness before action.

Person-centered therapy The client has the potential to become aware of problems and the means to resolve them. Faith is placed in the client’s capacity for self-direction. In therapy attention is given to the present moment and on experiencing and expressing feelings.

Gestalt therapy Emphasis is on the “what” and “how” of experiencing in the here and now to help clients accept all aspects of themselves. Key concepts include holism, awareness, unfinished business and avoidance, contact, and energy.

Behavior therapy Focus is on overt behavior, precision in specifying goals of treatment, development of specific treatment plans, and objective evaluation of therapy outcomes. Therapy is based on the principles of learning theory. Normal behavior is learned through reinforcement and imitation. Abnormal behavior is the result of faulty learning.

Cognitive behavior therapy Although psychological problems may be rooted in childhood, they are reinforced by present ways of thinking. A person’s belief system and thinking is the primary cause of disorders. Internal dialogue plays a central role in one’s behavior. Clients focus on examining faulty assumptions and misconceptions and on replacing these with effective beliefs.

Choice theory/Reality therapy The basic focus is on what clients are doing and how to get them to evaluate whether their present actions are working for them. The approach rejects the medical model, the notion of transference, the unconscious, and dwelling on one’s past.

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One of the challenges you will face as a counselor is to deliver therapeutic ser- vices in a brief, comprehensive, effective, and flexible way. Many of the theoretical orientations addressed in this book can be applied to brief forms of therapy. One of the driving forces of the psychotherapy integration movement has been the increase of brief therapies and the pressures to do more for a variety of client populations within the limitations of 6 to 20 sessions. Short-term and very-short-term therapies are increasing. Time-limited brief therapy refers to a variety of time-sensitive, goal- directed, efficiency-oriented methods. These methods can be incorporated in any theoretical approach (Hoyt, 2015). Lambert (2011) believes the future direction of theory, practice, and training will see (1) the decline of single-theory practice and the growth of integrative therapies, and (2) the increase in short-term, time-limited, and group treatments that seem to be as effective as long-term individual treatments with many client populations.

An integrative perspective at its best entails a systematic integration of underly- ing principles and methods common to a range of therapeutic approaches. The strengths of systematic integration are based on its ability to be taught, replicated, and evaluated (Norcross & Beutler, 2019). To develop this kind of integration, you will eventually need to be thoroughly conversant with a number of theories, be open to the idea that these theories can be connected in some ways, and be willing to continually test your hypotheses to determine how well they are working. Neukrug (2016) reminds us that “the ability to assimilate techniques from varying theoretical perspectives takes knowledge, time, and finesse” (p. 139).

Integration of Multicultural Issues in Counseling Multiculturalism is a reality that cannot be ignored by practitioners if they hope to meet the needs of diverse client groups. I believe current theories, to varying degrees, can and should be expanded to incorporate a multicultural dimension. If contempo- rary theories do not account for the cultural dimension, they will have limited appli- cability in working with diverse client populations. For some theories, this transition is easier than for others.

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Feminist therapy Core principles of feminist therapy are that the personal is political, therapists have a commitment to social change, women’s voices and ways of knowing are valued and women’s experiences are honored, the counseling relationship is egalitarian, therapy focuses on strengths, and all types of oppression are recognized.

Postmodern approaches Therapy tends to be brief and addresses the present and the future. The person is not the problem; the problem is the problem. The emphasis is on externalizing the problem and looking for exceptions to the problem. Therapy consists of a collaborative dialogue in which therapist and client co-create solutions. By identifying instances when the problem did not exist, clients can create new meanings for themselves and fashion a new life story.

Family systems therapy Problems in relationships are likely to be passed on from generation to generation. Key concepts vary depending on specific orientation but include family-of-origin dynamics, functional versus dysfunctional interaction patterns, and dealing with here-and-now interactions. The present is more important than exploring past experiences.

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Clients can be harmed if they are expected to fit all the specifications of a given theory, whether or not the values espoused by the theory are consistent with their own cultural values. Rather than stretching the client to fit the dimen- sions of a single theory, practitioners need to tailor their theory and practice to fit the unique needs of the client. This calls for counselors to possess knowledge of various cultures, to be aware of their own cultural heritage, and to have skills to assist a wide spectrum of clients in dealing with the realities of their culture. Psychotherapy integration stresses tailoring interventions to the individual cli- ent rather than to an overarching theory, making this approach particularly well suited to considering cultural factors and the unique perspective of each client. Comas-Diaz (2019) believes that cultural competence enables counselors to work effectively in most clinical settings. Practitioners demonstrate their cultural com- petence by becoming aware of their own and their clients’ worldviews, and by being able to use culturally appropriate interventions to reflect their cultural beliefs, knowledge, and skills. This is a good time to review the discussion of the culturally skilled counselor in Chapter 2 and to consult Tables 15.7 and 15.8, which appear later in this chapter.

In your role as a counselor, you need to be able to assess the special needs of clients. The client’s ethnicity and culture and the concerns that bring this person to counseling challenge you to develop flexibility in utilizing an array of therapeutic strategies. Some clients will need more direction and guidance; others will be hesi- tant to talk about themselves in personal ways, especially during the early phase of the counseling process. What you may see as resistance could be the client’s response to years of cultural conditioning and respect for certain values and traditions. Basi- cally, it comes down to your familiarity with a variety of theoretical approaches and your ability to employ and adapt your techniques to fit the person-in-the- environment. It is not enough to merely assist your clients in gaining insight, expressing suppressed emotions, or making certain behavioral changes. The chal- lenge is to find practical strategies for adapting the techniques you have developed to enable clients to examine the impact their culture continues to have on their life and to make decisions about what, if anything, they want to change.

Being an effective counselor involves reflecting on how your own culture influences you and your interventions in your counseling practice. This awareness is critical in becoming more sensitive to the cultural backgrounds of the clients who seek your help. Using an integrative perspective, therapists can encompass social, cultural, spiritual, and political dimensions in their work with clients.

Integration of Spirituality and Religion in Counseling The counseling process can help clients gain insight into the ways their core beliefs and values are reflected in their behavior. Current interest in spiritual and religious beliefs has implications for how such beliefs might be incorporated in therapeutic relationships (Frame, 2003; Johnson, 2013; Young & Cashwell, 2020). Survey data from members of both the American Psychological Association and the American Counseling Association indicate that spiritual/religious values are therapeutically relevant, ethically appropriate, and potentially significant topics for the practice of counseling in secular settings (Delaney et al., 2007; Young et al., 2007).

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

Clients who are experiencing a crisis situation may find a source of comfort, support, and strength in drawing on their spiritual resources. For some clients, spiri- tuality entails embracing a religion, which can have many different meanings. Other clients value spirituality but do not have any ties to a formal religion. Whatever one’s particular view of spirituality, it is a force that can help the individual find a purpose (or purposes) for living. Spiritual or religious beliefs can be a major sustaining power that supports clients when all else fails. Other clients may be affected by depression and a sense of worthlessness due to guilt, anger, or sadness created by their unexam- ined acceptance of spiritual or religious dogma. Counselors must remain open and nonjudgmental in conversations about religion or spirituality. Furthermore, coun- selors cannot ignore a client’s spiritual and religious values if they want to practice in a culturally competent and ethical manner (Johnson, 2013; Young & Cashwell, 2020). It is essential for counselors to be aware of and understand their own spiritual or religious attitudes, beliefs, values, and experiences if they expect to facilitate an exploration of these issues with clients.

Common Goals Spiritual values have a major part to play in human life and stru- ggles. Exploring these values has a great deal to do with providing solutions for clients’ struggles. Because spiritual and therapeutic paths converge in some ways, integration is possible, and dealing with a client’s spirituality will often enhance the therapy process. Themes that have healing influences include loving, caring, learning to listen with compassion, challenging clients’ basic life assumptions, accepting human imperfection, and going outside of self-oriented interests (social interest). Both a spiritual perspective and counseling can help people ponder questions of “Who am I?” and “What is the meaning of my life?” Pursuing these existential questions can foster healing.

Implications for Assessment and Treatment Traditionally, when clients come to a therapist with a problem, the therapist explores all the factors that contributed to the development of the problem. A background of involvement in religion can be part of a client’s history, and thus it can be a part of the intake assessment and can be explored in counseling sessions. Frame (2003) presents many reasons for including spirituality in the assessment process: understanding clients’ worldviews and the contexts in which they live, assisting clients in grappling with questions regarding the purpose of their lives and what they most value, exploring religion and spirituality as client resources, and uncovering religious and spiritual problems. This information

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will assist the therapist in choosing appropriate interventions. Young and Cashwell (2020) maintain that counselors must assess whether clients’ spiritual or religious beliefs may be exacerbating or helping clients’ psychological problems.

Your Role as a Counselor It is critical that counselors not be judgmental when it comes to their clients’ beliefs and that counselors create an inviting and safe climate for clients to explore their values and beliefs. There are many paths toward fulfilling spiritual needs, and it is not your role as a counselor to prescribe any particular pathway. By conducting a thorough assessment on a client’s background, you will obtain many clues regarding personal themes for potential exploration. If you remain finely tuned to clients’ stories and to the purpose for which they sought therapy, clients’ concerns about spiritual or religious values, beliefs, and practices will surface. It is critical that you listen for how clients talk about existential concerns of meaning, values, mortality, and being in the world. Remain open to how your clients define, experience, and access whatever helps them stay connected to their core values and their inner wisdom (Johnson, 2013).

Ethical and clinical considerations are equally important when providing therapy for clients who are nonreligious (Sahker, 2016). These clients may need a safe place to discuss their doubts related to internal conflicts involving non- belief. Some who have left the religion of their family of origin may have been rejected by family members and may want to express and explore the pain they experience as a result of their choice. To practice ethically and effectively with these clients, therapists must gain competence in making assessments and in providing appropriate treatment.

From my vantage point, the emphasis on spirituality will continue to be important in counseling practice, which makes it imperative that you prepare yourself to work competently with the spiritual and religious concerns that your clients bring up. For further reading on the topic of integrating spirituality and religion into counseling, I highly recommend Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice (Cashwell & Young, 2020) and Spiri- tuality in Counseling and Psychotherapy: An Integrative Approach That Empowers Clients (Johnson, 2013).

The Therapeutic Process Therapeutic Goals

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

◆ Restructuring the personality ◆ Uncovering the unconscious ◆ Creating social interest ◆ Finding meaning in life ◆ Curing an emotional disturbance ◆ Examining old decisions and making new ones ◆ Developing trust in oneself

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

Table 15.3 Goals of Therapy

Psychoanalytic therapy To make the unconscious conscious. To reconstruct the basic personality. To assist clients in reliving earlier experiences and working through repressed conflicts. To achieve intellectual and emotional awareness.

Adlerian therapy To challenge clients’ basic premises and life goals. To offer encouragement so individuals can develop socially useful goals and increase social interest. To develop the client’s sense of belonging.

Existential therapy To help people see that they are free and to become aware of their possibilities. To challenge them to recognize that they are responsible for events that they formerly thought were happening to them. To identify factors that block freedom.

Person-centered therapy To provide a safe climate conducive to clients’ self-exploration. To enable clients to move toward openness, greater trust in self, and increased spontaneity and aliveness. To find meaning in life and to experience life fully. To become more self-directed.

Gestalt therapy To assist clients in gaining awareness of moment-to-moment experiencing and to expand the capacity to make choices. To foster integration of the self.

Behavior therapy To eliminate maladaptive behaviors and learn more effective behaviors. To identify factors that influence behavior and find out what can be done about problematic behavior. To encourage clients to take an active and collaborative role in clearly setting treatment goals and evaluating how well these goals are being met.

Cognitive behavior therapy To teach clients to confront faulty beliefs with contradictory evidence that they gather and evaluate. To become aware of automatic thoughts and to change them. To assist clients in identifying their inner strengths, and to explore the kind of life they would like to have.

Choice theory/Reality therapy To help people become more effective in meeting all of their psychological needs. To enable clients to get reconnected with the people they have chosen to put into their quality worlds and teach clients choice theory.

Feminist therapy To bring about transformation both in the individual client and in society. To assist clients in recognizing, claiming, and using their personal power to free themselves from the limitations of gender-role socialization. To confront all forms of institutional policies that discriminate or oppress on any basis.

Postmodern approaches To change the way clients view problems and what they can do about these concerns. To collaboratively establish specific, clear, concrete, realistic, and observable goals leading to increased positive change. To help clients create a self-identity grounded on competence and resourcefulness so they can resolve present and future concerns.

Family systems therapy To help family members gain awareness of patterns of relationships that are not working well and to create new ways of interacting. To identify how a client’s problematic behavior may serve a function or purpose for the family. To understand how dysfunctional patterns can be handed down across generations. To understand how past family-of-origin experiences continue to have an impact on individuals.

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This diversity can be simplified by considering the degree of generality or speci- ficity of goals. Goals exist on a continuum from specific, concrete, and short term on one end, to general, global, and long term on the other. The cognitive behavioral approaches stress the former; the relationship-oriented therapies tend to stress the latter. The goals at opposite ends of the continuum are not necessarily contradic- tory; it is a matter of how specifically they are defined (Corey, 2019).

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

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

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

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

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

As you saw through your study of the 11 therapeutic approaches, a central issue of each system is the degree to which the therapist exercises control over clients’ behavior both during and outside the session. Cognitive behavior therapists and reality therapists, for example, operate within a present-centered, directive, didac- tic, structured, and psychoeducational context. As a collaborative endeavor, they frequently design homework assignments to assist clients in practicing new behav- ior outside therapy sessions. In contrast, person-centered therapists operate with a much looser and less defined structure. Solution-focused and narrative therapists view clients as experts on their own life; they assist the client in reflection outside of the session that might result in self-directed change. Although they are active ques- tioners, they are not prescriptive in their practice.

Structuring depends on the specific circumstances clients bring to the therapy situation. From my perspective, clear structure is most essential during the early phase of counseling because it encourages the client to talk about the problems that led to seeking therapy. In a collaborative way, it is useful for both counselor and cli- ent to make some initial assessment that can provide a focus for the therapy process. As soon as possible, the client should be given a significant share of the responsibil- ity for deciding on the content and agenda of the sessions. From early in the therapy process the client can be empowered if the counselor expects the client to become an active participant in the process.

Client’s Experience in Therapy Most clients share some degree of suffering, pain, or at least discontent. There is a discrepancy between how they would like to be and how they are. Some individu- als initiate therapy because they hope to cure a specific symptom or set of symp- toms. They want to get rid of migraine headaches, free themselves of chronic anxiety

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attacks, lose weight, or get relief from depression. They may have conflicting feelings and reactions, may struggle with low self-esteem, or may have limited information and skills. Many seek to resolve conflicts in their close relationships. I believe people are increasingly entering therapy with existential problems. Their complaints often relate to these existential issues: a sense of emptiness, meaninglessness in life, rou- tine ways of living, unsatisfying personal relationships, anxiety over uncertainty, a lack of intense feelings, and a loss of their sense of self.

The initial expectation of many clients is that results will come quickly. They often have great hope for major changes in their life and rely on direction from the therapist. As therapy progresses, clients discover that they must be active in the pro- cess, selecting their own goals and working toward them, both in the sessions and in daily living. Some clients can benefit from recognizing and expressing pent-up feel- ings, others will need to examine their beliefs and thoughts, others will most need to begin behaving in different ways, and others will benefit from talking with you about their relationships with the significant people in their lives. Most clients will need to do some work in all three dimensions—feelings, thoughts, and behaviors— because these dimensions are interrelated.

Norcross and Cooper (2021) contend that the goal of most therapeutic models is to tailor treatment to the needs of clients and their preferences, personal characteris- tics, and culture. Norcross and Cooper emphasize that the one-size-fits-all approach is ineffective and can be unethical. Adapting treatment to clients’ race/ethnicity and to their spirituality/religion is demonstrably better. Research shows that accommo- dating client preferences works: “Respectfully and collaboratively inquiring about client preferences can exert dramatic effects on their treatment experiences. It is something for clinicians of all orientations and professions to prioritize” (p. 36).

In deciding what interventions are most likely to be helpful, it is important to take into account the client’s cultural, ethnic, and socioeconomic background. Moreover, the focus of counseling may change as clients enter different phases in the counseling process. Although some clients initially feel a need to be listened to and allowed to express deep feelings, they can profit later from examining the thought patterns that are contributing to their psychological pain. At some point in therapy, it is essential that clients translate what they are learning about themselves into con- crete action. The client’s given situation in the environment provides a framework for selecting interventions that are most appropriate.

Relationship Between Therapist and Client Most approaches share common ground in accepting the importance of the thera- peutic relationship. The existential, person-centered, Gestalt, Adlerian, and post- modern views emphasize the personal relationship as the crucial determinant of treatment outcomes. Rational emotive behavior therapy, reality therapy, cognitive behavior therapy, cognitive therapy, and behavior therapy do not ignore the rela- tionship factor but place less emphasis on the relationship and more emphasis on the effective use of techniques (Table 15.4).

Counseling is a personal matter that involves a personal relationship, and evidence indicates that honesty, sincerity, acceptance, understanding, and spontaneity are basic ingredients for successful outcomes. Therapists’ degree of caring, their interest and

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ability in helping clients, and their genuineness influence the relationship. Therapists can become more effective by developing their personal qualities and their interpersonal abilities. Psychotherapy is primarily a human and relational endeavor that depends on the quality of the interpersonal connection between participants (Duncan, 2014; Elkins, 2016). Both client and therapist bring origins, culture, expectations, biases, defenses, and strengths to this relationship. How we create and nurture this powerful human relationship can be guided by the fruits of research (Norcross & Wampold, 2019).

Table 15.4 The Therapeutic Relationship

Psychoanalytic therapy The classical analyst remains anonymous, and clients develop projections toward the therapist. The focus is on reducing the resistances that develop in working with transference. The analyst makes interpretations to teach clients the meaning of current behavior as it relates to the past. In contemporary relational psychoanalytic therapy, the relationship is central and emphasis is given to here-and-now dimensions of this relationship.

Adlerian therapy The emphasis is on joint responsibility, on mutually determining goals, on mutual trust and respect, and on equality. The focus is on identifying, exploring, and disclosing mistaken goals and faulty assumptions within the person’s lifestyle.

Existential therapy The therapist’s main tasks are to accurately grasp clients’ being in the world and to establish a personal and authentic encounter with them. The immediacy of the client– therapist relationship and the authenticity of the here-and-now encounter are stressed.

Person-centered therapy The relationship is of primary importance. The qualities of the therapist, including genuineness, warmth, accurate empathy, respect, and being nonjudgmental—and communication of these attitudes to clients—are stressed. Clients use this genuine relationship with the therapist to help them transfer what they learn to other relationships.

Gestalt therapy Central importance is given to the I/Thou relationship and the quality of the therapist’s presence. The therapist’s attitudes and behavior count more than the techniques used. The therapist does not interpret for clients but assists them in developing the means to make their own interpretations. Clients identify and work on unfinished business from the past that interferes with current functioning.

Behavior therapy The therapist is active and directive and functions as a teacher or mentor in helping clients learn more effective behavior. Clients must be active in the process and experiment with new behaviors. Although a quality client–therapist relationship is not viewed as sufficient to bring about change, it is considered essential for implementing behavioral procedures.

Cognitive behavior therapy In REBT the therapist functions as a teacher and the client as a student. The therapist is highly directive and teaches clients an ABC model of changing their cognitions. In CT the focus is on a collaborative relationship. Using a Socratic dialogue, the therapist assists clients in identifying dysfunctional beliefs and discovering alternative rules for living. The therapist promotes corrective experiences that lead to learning new skills. Clients gain insight into their problems and then must actively practice changing self-defeating thinking and acting.

Choice theory/Reality therapy A fundamental task is for the therapist to create a good relationship with the client. Therapists are then able to engage clients in an evaluation of all of their relationships with respect to what they want and how effective they are in getting this. Therapists find out what clients want, ask what they are choosing to do, invite them to evaluate present behavior, and help them make plans for change.

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Feminist therapy The therapeutic relationship is based on empowerment and egalitarianism. Therapists actively break down the hierarchy of power and reduce artificial barriers by engaging in appropriate self-disclosure and teaching clients about the therapy process. Therapists strive to create a collaborative relationship in which clients can become their own expert.

Postmodern approaches Therapy is a collaborative partnership. Clients are viewed as the experts on their own life. Therapists use questioning dialogue to help clients free themselves from their problem- saturated stories and create new life-affirming stories. Solution-focused therapists assume an active role in guiding the client away from problem-talk and toward solution-talk. Clients are encouraged to explore their strengths and to create solutions that will lead to a richer future. Narrative therapists assist clients in externalizing problems and guide them in examining self-limiting stories and creating new and more liberating stories.

Family systems therapy The family therapist functions as a teacher, coach, model, and consultant. The family learns ways to detect and solve problems that are keeping members stuck, and it learns about patterns that have been transmitted from generation to generation. All family therapists are concerned with the process of family interaction and teaching patterns of communication.

As you think about developing your personal counseling perspective, give consider- ation to the issue of the match between client and counselor. I certainly do not advocate changing your personality to fit your perception of what each client is expecting; it is important that you be yourself as you meet clients. You also need to consider the reality that you will probably not be able to work effectively with every client. Some clients will work better with counselors who have another type of personal and therapeutic style than yours. Be sensitive in assessing what your client needs, and use good judgment when determining the appropriateness of the match between you and a potential client.

Although you do not have to be like your clients or have experienced the same problems to be effective with them, it is critical that you be able to understand their world and respect them. Ask yourself how well prepared you are to counsel clients from a different cultural background. To what degree do you think you can suc- cessfully establish a therapeutic relationship with a client of a different race? Ethnic group? Gender? Age? Sexual orientation? Spiritual/religious orientation? Socioeco- nomic group? Do you see any potential barriers that would make it difficult for you to form a working relationship with certain clients? It is also important to consider the client’s diagnosis, resistance level, treatment preferences, and stage of change. Thera- peutic techniques and styles should be selected to fit the client’s personal characteris- tics. Psychotherapists have the task of creating a new therapy for each client (Norcross & Cooper, 2021). Norcross and Beutler (2019) point to the value of customizing psy- chological treatments and therapeutic relationships to the specific needs of individual clients: “Our integrative therapy is expressly designed to transcend the limited appli- cability of single-theory or ‘school bound’ psychotherapies” (p. 530).

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

Effective therapists incorporate a wide range of procedures in their therapeutic style. Much depends on the purpose of therapy, the setting, the personality and style of the

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therapist, the qualities of the particular client, and the problems selected for inter- vention. Regardless of the therapeutic model you may be working with, you must decide what relationship style to adopt; what techniques, procedures, or interven- tion methods to use; when to use them; and with which clients. Take time to review Table 15.5 on therapeutic techniques and Table 15.6 on applications for each approach. Pay careful attention to the focus of each type of therapy and how that focus might be useful in your practice.

Table 15.5 Techniques of Therapy

Psychoanalytic therapy The key techniques are interpretation, dream analysis, free association, analysis of resistance, analysis of transference, and countertransference. Techniques are designed to help clients gain access to their unconscious conflicts, which leads to insight and eventual assimilation of new material by the ego.

Adlerian therapy Adlerians pay more attention to the subjective experiences of clients than to using techniques. Some techniques include gathering life-history data (family constellation, early recollections, personal priorities), sharing interpretations with clients, offering encouragement, and assisting clients in searching for new possibilities.

Existential therapy Few techniques flow from this approach because it stresses understanding first and technique second. The therapist can incorporate techniques from other approaches. Issues addressed are freedom and responsibility, isolation and relationships, meaning and meaninglessness, living and dying.

Person-centered therapy This approach uses few techniques but stresses the attitudes of the therapist and a “way of being.” Therapists strive for active listening, reflection of feelings, clarification, “being there” for the client, and focusing on the moment-to-moment experiencing of the client.

Gestalt therapy A wide range of experiments are designed to intensify experiencing and to integrate conflicting feelings. Experiments are co-created by therapist and client through an I/Thou dialogue. Therapists have latitude to creatively invent their own experiments. Formal diagnosis and testing are not a required part of therapy.

Behavior therapy The main techniques are reinforcement, shaping, modeling, systematic desensitization, relaxation methods, flooding, eye movement and desensitization reprocessing, cognitive restructuring, social skills training, self-management programs, mindfulness and acceptance methods, behavioral rehearsal, and coaching. Questions concentrate on “what,” “how,” and “when” (but not “why”). Contracts and homework assignments are also typically used.

Cognitive behavior therapy Therapists use a variety of cognitive, emotive, and behavioral techniques; diverse methods are tailored to suit individual clients. This is an active, directive, time-limited, present- centered, psychoeducational, structured therapy. Some techniques include engaging in Socratic dialogue, collaborative empiricism, debating irrational beliefs, carrying out homework assignments, gathering data on assumptions one has made, keeping a record of activities, forming alternative interpretations, learning new coping skills, changing one’s language and thinking patterns, and role playing.

Choice theory/Reality therapy This is an active, directive, and didactic therapy. Skillful questioning is a central technique used for the duration of the therapy process. Various techniques may be used to get clients to evaluate what they are presently doing to see if they are willing to change. If clients decide that their present behavior is not effective, they develop a specific plan for change and make a commitment to follow through.

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Feminist therapy Although techniques from traditional approaches are used, feminist practitioners tend to employ consciousness-raising techniques aimed at helping clients recognize the impact of gender-role socialization on their lives. Other techniques frequently used include gender- role analysis and intervention, power analysis and intervention, demystifying therapy, bibliotherapy, journal writing, therapist self-disclosure, assertiveness training, reframing and relabeling, cognitive restructuring, identifying and challenging untested beliefs, role playing, psychodramatic methods, group work, and social action.

Postmodern approaches In solution-focused therapy the main technique involves change-talk, with emphasis on times in a client’s life when the problem was not a problem. Other techniques include creative use of questioning, the miracle question, and scaling questions, which assist clients in developing alternative stories. In narrative therapy, specific techniques include listening to a client’s problem-saturated story without getting stuck, externalizing and naming the problem, externalizing conversations, and discovering clues to competence. Narrative therapists often write letters to clients and assist them in finding an audience that will support their changes and new stories.

Family systems therapy A variety of techniques may be used, depending on the particular theoretical orientation of the therapist. Some techniques include genograms, teaching, asking questions, joining the family, reframing, restructuring, enactments, and setting boundaries. Techniques may be experiential, cognitive, or behavioral in nature.

Table 15.6 Applications of the Approaches

Psychoanalytic therapy Candidates for analytic therapy include professionals who want to become therapists, people who have had intensive therapy and want to go further, and those who are in psychological pain. Analytic therapy is not recommended for self-centered and impulsive individuals or for people with psychotic disorders. Techniques can be applied to individual and group therapy.

Adlerian therapy Because the approach is based on a growth model, it is applicable to such varied spheres of life as child guidance, parent–child counseling, marital and family therapy, individual counseling with all age groups, correctional and rehabilitation counseling, group counseling, substance abuse programs, and brief counseling. It is ideally suited to preventive care and alleviating a broad range of conditions that interfere with growth.

Existential therapy This approach is especially suited to people facing a developmental crisis or a transition in life and for those with existential concerns (making choices, dealing with freedom and responsibility, coping with guilt and anxiety, making sense of life, and finding values) or those seeking personal enhancement. The approach can be applied to both individual and group counseling, and to couples and family therapy, crisis intervention, and community mental health work.

Person-centered therapy This approach has wide applicability for individual and group counseling. It is especially well suited for the initial phases of crisis intervention work. It is a useful approach for teaching, parent–child relations, and for working with groups of people from diverse cultural backgrounds.

Gestalt therapy This approach addresses a wide range of problems and populations: crisis intervention, treatment of a range of psychosomatic disorders, couples and family therapy, awareness training of mental health professionals, behavior problems in children, and teaching and learning. It is well suited to both individual and group counseling. The methods are powerful catalysts for opening up feelings and getting clients into contact with their present-centered experience.

(continued)

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Table 15.6 Applications of the Approaches (continued)

Behavior therapy This pragmatic approach is based on empirical validation of results. It enjoys wide applicability to individual, group, couples, and family counseling. Some problems to which the approach is well suited are phobic disorders, depression, trauma, sexual disorders, children’s behavioral disorders, stuttering, and prevention of cardiovascular disease. Beyond clinical practice, its principles are applied in fields such as pediatrics, stress management, behavioral medicine, education, and geriatrics.

Cognitive behavior therapy This approach has been widely applied to treatment of depression, anxiety, relationship problems, stress management, skill training, substance abuse, assertion training, eating disorders, panic attacks, performance anxiety, and social phobias. CBT is especially useful for assisting people in modifying their cognitions. Many self-help approaches utilize its principles. CBT can be applied to a wide range of client populations with a variety of specific problems.

Choice theory/Reality therapy Reality therapy teaches people ways of using choice theory in everyday living to increase effective behaviors. It has been applied to individual counseling with a wide range of clients, group counseling, working with youthful law offenders, and couples and family therapy.

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

Postmodern approaches Solution-focused therapy is well suited for people with adjustment disorders and for problems of anxiety and depression. Narrative therapy is now being used for a broad range of human difficulties including eating disorders, family distress, depression, and relationship concerns. These approaches can be applied to working with children, adolescents, adults, couples, families, and the community in a wide variety of settings. Both solution-focused and narrative approaches lend themselves to group counseling and to school counseling.

Family systems therapy This approach is useful for dealing with marital distress, problems of communicating among family members, power struggles, crisis situations in the family, helping individuals attain their potential, and enhancing the overall functioning of the family.

It is critical to be aware of how clients’ cultural backgrounds contribute to their perceptions of their problems. Each of the 11 therapeutic approaches has both strengths (Table 15.7) and limitations (Table 15.8) when applied to culturally diverse client populations. Although it is unwise to stereotype clients because of their cul- tural heritage, it is useful to assess the bearing cultural context has on their con- cerns. Some techniques may be contraindicated because of a client’s socialization. The client’s responsiveness (or lack of it) to certain techniques is a critical barometer in judging the effectiveness of these methods.

Effective counseling involves proficiency in a combination of cognitive, affec- tive, and behavioral techniques. Such a combination is necessary to help clients think about their beliefs and assumptions, to experience on a feeling level their conflicts and struggles, and to translate their insights into action programs by behaving in new ways in day-to-day living. Table 15.9 outlines the contributions of various approaches, and Table 15.10 describes some of the limitations of the various therapeutic approaches. These tables will help you identify elements that you may want to incorporate in your own counseling perspective.

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Table 15.7 Contributions to Multicultural Counseling

Psychoanalytic therapy

Its focus on family dynamics is appropriate for working with many cultural groups. The therapist’s formality appeals to clients who expect professional distance. Notion of ego defense is helpful in understanding inner dynamics and dealing with environmental stresses.

Adlerian therapy Its focus on social interest, helping others, collectivism, pursuing meaning in life, importance of family, goal orientation, and belonging is congruent with the values of many cultures. Focus on person-in-the-environment allows for cultural factors to be explored.

Existential therapy The focus is on understanding client’s phenomenological world, including cultural background. This approach leads to empowerment in an oppressive society. Existential therapy can help clients examine their options for change within the context of their cultural realities. The existential approach is particularly suited to counseling diverse clients because of the philosophical foundation that emphasizes the human condition.

Person-centered therapy

The focus is on breaking cultural barriers and facilitating open dialogue among diverse cultural populations. Main strengths are respect for clients’ values, active listening, welcoming of differences, nonjudgmental attitude, understanding, willingness to allow clients to determine what will be explored in sessions, and prizing cultural pluralism.

Gestalt therapy Its focus on expressing oneself nonverbally is congruent with those cultures that look beyond words for messages. Provides many experiments in working with clients who have cultural injunctions against freely expressing feelings. Focus on bodily expressions is a subtle way to help clients recognize their conflicts.

Behavior therapy The focus on behavior, rather than on feelings, is compatible with many cultures. Strengths include a collaborative relationship between counselor and client in working toward mutually agreed-upon goals, continual assessment to determine if the techniques are suited to clients’ unique situations, assisting clients in learning practical skills, an educational focus, and stresses self-management strategies.

Cognitive behavior therapy

This is a collaborative approach that offers clients opportunities to express their areas of concern. The psychoeducational dimensions are often useful in exploring cultural conflicts and teaching new behavior. The emphasis on thinking (as opposed to identifying and expressing feelings) is likely to be acceptable to many clients. The focus on teaching and learning tends to avoid the stigma of mental illness. Clients are likely to value the active and directive stance of the therapist.

Choice theory/ Reality therapy

The focus is on clients making their own evaluation of behavior (including how they respond to their culture). Through personal assessment clients can determine the degree to which their needs and wants are being satisfied.

Feminist therapy Both individual change and social transformation are addressed. A key contribution is that both the women’s movement and the multicultural movement have called attention to the negative impact of discrimination and oppression for both women and men. Emphasizes the influence of expected cultural roles and explores client’s satisfaction with and knowledge of these roles.

Postmodern approaches

The focus is on the social and cultural context of behavior. Stories that are being authored in the therapy office need to be anchored in the social world in which the client lives. Therapists do not make assumptions about people and honor each client’s unique story and cultural background. Therapists take an active role in challenging social and cultural injustices that lead to oppression of certain groups. Therapy becomes a process of liberation from oppressive cultural values and enables clients to become active agents of their destinies.

Family systems therapy

The focus is on the family or community system. Many ethnic and cultural groups place value on the role of the extended family. Many family therapies deal with extended family members and with support systems. Networking is a part of the process, which is congruent with the values of many clients. There is a greater chance for individual change if other family members are supportive. This approach offers ways of working toward the health of the family unit and the welfare of each member.

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Table 15.8 Limitations in Multicultural Counseling

Psychoanalytic therapy Its focus on insight, intrapsychic dynamics, and long-term treatment is often not valued by clients who prefer to learn coping skills for dealing with pressing daily concerns. Internal focus is often in conflict with cultural values that stress an interpersonal and environmental focus.

Adlerian therapy This approach’s detailed interview about one’s family background can conflict with cultures that have injunctions against disclosing family matters. Some clients may view the counselor as an authority who will provide answers to problems, which conflicts with the egalitarian, person-to-person spirit as a way to reduce social distance.

Existential therapy Values of individuality, freedom, autonomy, and self-realization often conflict with cultural values of collectivism, respect for tradition, deference to authority, and interdependence. Some may be deterred by the absence of specific techniques. Others will expect more focus on surviving in their world.

Person-centered therapy Some of the core values of this approach may not be congruent with the client’s culture. Lack of counselor direction and structure may be unacceptable for clients who are seeking help and immediate answers from a knowledgeable professional.

Gestalt therapy Clients who have been culturally conditioned to be emotionally reserved may not embrace Gestalt experiments. Some may not see how “being aware of present experiencing” will lead to solving their problems.

Behavior therapy Family members may not value clients’ newly acquired assertive style, so clients must be taught how to cope with resistance by others. Counselors need to help clients assess the possible consequences of making behavioral changes.

Cognitive behavior therapy Before too quickly attempting to change the beliefs and actions of clients, it is essential for the therapist to understand and respect their world. Some clients may have serious reservations about questioning their basic cultural values and beliefs. Clients could become dependent on the therapist choosing appropriate ways to solve problems.

Choice theory/Reality therapy This approach stresses taking charge of one’s own life, yet some clients are more interested in changing their external environment. Counselors need to appreciate the role of discrimination and racism and help clients deal with social and political realities.

Feminist therapy This model has been criticized for its bias toward the values of White, middle-class, heterosexual women, which are not applicable to many other groups of women nor to men. Therapists need to assess with their clients the price of making significant personal change, which may result in isolation from extended family as clients assume new roles and make life changes.

Postmodern approaches Some clients come to therapy wanting to talk about their problems and may be put off by the insistence on talking about exceptions to their problems. Clients may view the therapist as an expert and be reluctant to view themselves as experts. Certain clients may doubt the helpfulness of a therapist who assumes a “not-knowing” position.

Family systems therapy Family therapy rests on value assumptions that are not congruent with the values of clients from some cultures. Western concepts such as individuation, self-actualization, self-determination, independence, and self-expression may be foreign to some clients. In some cultures, admitting problems within the family is shameful. The value of “keeping problems within the family” may make it difficult to explore conflicts openly.

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Table 15.9 Contributions of the Approaches

Psychoanalytic therapy More than any other system, this approach has generated controversy as well as exploration and has stimulated further thinking and development of therapy. It has provided a detailed and comprehensive description of personality structure and functioning. It has brought into prominence factors such as the unconscious as a determinant of behavior and the role of trauma during the first six years of life. It has developed several techniques for tapping the unconscious and shed light on the dynamics of transference and countertransference, resistance, anxiety, and the mechanisms of ego defense.

Adlerian therapy A key contribution is the influence that Adlerian concepts have had on other systems and the integration of these concepts into various contemporary therapies. This is one of the first approaches to therapy that was humanistic, unified, holistic, and goal-oriented and that put an emphasis on social and psychological factors.

Existential therapy Its major contribution is recognition of the need for a subjective approach based on a complete view of the human condition. It calls attention to the need for a philosophical statement on what it means to be a person. Stress on the I/Thou relationship lessens the chances of dehumanizing therapy. It provides a perspective for understanding anxiety, guilt, freedom, death, isolation, and commitment.

Person-centered therapy Clients take an active stance and assume responsibility for the direction of therapy. It is an open system. People without advanced training can benefit by translating the therapeutic conditions to both their personal and professional lives. Basic concepts are straightforward and easy to grasp and apply. It is a foundation for building a trusting relationship.

Gestalt therapy The emphasis on direct experiencing and doing rather than on merely talking about feelings provides a perspective on growth and enhancement, not merely a treatment of disorders. It uses clients’ behavior as the basis for making them aware of their inner creative potential. The approach to dreams is a unique, creative tool to help clients discover basic conflicts. Therapy is viewed as an existential encounter; it is process-oriented, not technique-oriented.

Behavior therapy Emphasis is on assessment and evaluation techniques, thus providing a basis for accountable practice. Specific problems are identified, and clients are kept informed about progress toward their goals. The approach has demonstrated effectiveness in many areas of human functioning. The roles of the therapist as reinforcer, model, teacher, and consultant are explicit. The approach has undergone extensive expansion, and research literature abounds. No longer is it a mechanistic approach, for it now makes room for cognitive factors and encourages self-directed programs for behavioral change.

Cognitive behavior therapy Major contributions include emphasis on a comprehensive therapeutic practice; numerous cognitive, emotive, and behavioral techniques; an openness to incorporating techniques from other approaches; and a methodology for challenging and changing faulty or negative thinking. Most forms can be integrated into other mainstream therapies. REBT makes full use of action-oriented homework, various psychoeducational methods, and keeping records of progress. CT is a structured therapy that has a good track record for treating depression and anxiety in a short time. Strengths-based CBT is a form of positive psychology that addresses the resources within the client for change.

Choice theory/Reality therapy This is a positive approach with an action orientation that relies on simple and clear concepts that are easily grasped in many helping professions. It can be used by teachers, nurses, ministers, educators, social workers, and counselors. Due to the direct methods, it appeals to many clients who are often seen as resistant to therapy. It is a short-term approach that can be applied to a diverse population, and it has been a significant force in challenging the medical model of therapy.

(continued)

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Table 15.9 Contributions of the Approaches (continued)

Feminist therapy The feminist perspective is responsible for encouraging increasing numbers of women to question gender stereotypes and to reject limited views of what a woman is expected to be. It is paving the way for gender-sensitive practice and bringing attention to the gendered uses of power in relationships. The unified feminist voice brought attention to the extent and implications of child abuse, incest, rape, sexual harassment, and domestic violence. Feminist principles and interventions can be incorporated in other therapy approaches.

Postmodern approaches The brevity of these approaches fit well with the limitations imposed by a managed care structure. The emphasis on client strengths and competence appeals to clients who want to create solutions and revise their life stories in a positive direction. Clients are not blamed for their problems but are helped to understand how they might relate in more satisfying ways to such problems. A strength of these approaches is the question format that invites clients to view themselves in new and more effective ways.

Family systems therapy From a systemic perspective, neither the individual nor the family is blamed for a particular dysfunction. The family is empowered through the process of identifying and exploring interactional patterns. Working with an entire unit provides a new perspective on understanding and working through both individual problems and relationship concerns.

Table 15.10 Limitations of the Approaches

Psychoanalytic therapy Requires lengthy training for therapists and much time and expense for clients. The model stresses biological and instinctual factors to the neglect of social, cultural, and interpersonal ones. Its methods are less applicable for solving specific daily life problems of clients and may not be appropriate for some ethnic and cultural groups. Many clients lack the degree of ego strength needed for regressive and reconstructive therapy. It may be inappropriate for certain counseling settings.

Adlerian therapy Weak in terms of precision, testability, and empirical validity. Few attempts have been made to validate the basic concepts by scientific methods. Tends to oversimplify some complex human problems and is based heavily on common sense.

Existential therapy Many basic concepts are fuzzy and ill-defined, making its general framework abstract at times. Lacks a systematic statement of principles and practices of therapy. Has limited applicability to lower functioning and nonverbal clients and to clients in extreme crisis who need direction.

Person-centered therapy Possible danger from the therapist who remains passive and inactive, limiting responses to reflection. Many clients feel a need for greater direction, more structure, and more techniques. Clients in crisis may need more directive measures. Applied to individual counseling, some cultural groups will expect more counselor activity.

Gestalt therapy Techniques lead to intense emotional expression; if these feelings are not explored and if cognitive work is not done, clients are likely to be left unfinished and will not have a sense of integration of their learning.

Behavior therapy It may change behavior but not feelings; it ignores the relational factors in therapy; it does not provide insight; it ignores historical causes of present behavior; it involves control by the therapist; and it is limited in its capacity to address certain aspects of the human condition.

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Cognitive behavior therapy Tends to play down emotions, does not focus on exploring the unconscious or underlying conflicts, de-emphasizes the value of insight, and sometimes does not give enough weight to the client’s past. CBT might be too structured for some clients.

Choice theory/Reality therapy Discounts the therapeutic value of exploration of the client’s past, dreams, the unconscious, early childhood experiences, and transference. The approach is limited to less complex problems. It is a problem-solving therapy that tends to discourage exploration of deeper emotional issues.

Feminist therapy A potential for therapists to impose a new set of values on clients—such as striving for equality, power in relationships, defining oneself, freedom to pursue a career outside the home, and the right to an education. Therapists need to keep in mind that clients are their own best experts, which means it is up to them to decide which values to live by.

Postmodern approaches With little empirical validation of the effectiveness of therapy outcomes, some critics contend that these approaches endorse cheerleading and an overly positive perspective. Some are critical of the stance taken by most postmodern therapists regarding assessment and diagnosis, and also react negatively to the “not-knowing” stance of the therapist. Because some of the solution-focused and narrative therapy techniques are relatively easy to learn, practitioners may use these interventions in a mechanical way or implement these techniques without a sound rationale.

Family systems therapy Limitations include problems in being able to involve all the members of a family in the therapy. Some family members may be resistant to changing the structure of the system. Therapists’ self-knowledge and willingness to work on their own family-of-origin issues is crucial, for the potential for countertransference is high. It is essential that the therapist be well trained, receive quality supervision, and be competent in assessing and treating individuals in a family context.

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

Evaluating how well psychotherapy works is far from simple. Therapeutic sys- tems are applied by practitioners who have unique individual characteristics, and clients themselves have much to do with therapeutic outcomes. For example, effects resulting from unexpected and uncontrollable events in the client’s social environ- ment can lessen the impact of gains made in psychotherapy. Moreover, practitioners who adhere to the same approach are likely to use techniques in various ways and to relate to clients in diverse fashions, functioning differently with different clients and in different clinical settings.

How effective is psychotherapy? A meta-analysis of psychotherapy outcome lit- erature conducted by Smith, Glass, and Miller (1980) concluded that psychother- apy was highly effective and that all psychotherapeutic approaches worked about equally well. Prochaska and Norcross (2018) note that controlled outcome research

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consistently supports the effectiveness of psychotherapy. They point out that more than 10,000 individual studies and more than 800 meta-analyses have been con- ducted on the effectiveness of psychotherapy; these studies demonstrate that well- developed therapy interventions have meaningful, positive effects on the intended outcomes. In short, not only does psychotherapy work, but research demonstrates that therapy is remarkably effective. Psychotherapy is an efficacious approach to helping people who experience psychological distress improve their functioning (Miller et al., 2015).

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

Although it is clear that therapy works, there are no simple explanations of how it works. Research indicates that a variety of treatments are equally effective—when administered by therapists who believe in them and when they are accepted by the client. Wampold (2010) concludes that “there is little evidence that the specific ingredients of any treatment are responsible for the benefits of therapy” (p. 71).

The various therapy approaches and techniques work equally well because they share the most important ingredient accounting for change—the client. Data point to the conclusion that the engine of change is the client (Bohart & Tallman, 2010; Bohart & Wade, 2013), and we can most productively direct our efforts toward ways of employing the client in the process of change.

Feedback-Informed Treatment Listening to client feedback about the therapy process is of the utmost importance. Feedback-informed treatment (FIT) is designed to evaluate and to improve the quality and effectiveness of counseling services. FIT is an evidence-based approach that translates the best available research about what works in therapy into practice (Maeschalck et al., 2019). FIT involves consistently obtaining feedback from clients regarding the therapeutic relationship and their clinical progress, which is then used to tailor therapy to their unique needs. If therapists learn to listen to clients’ feedback throughout the therapeutic process, clients can become full and equal par- ticipants in all aspects of their therapy (Maeschalck et al., 2019; Miller et al., 2015).

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

Duncan (2014) believes that systematic client feedback should be integrated into all psychotherapeutic approaches because of its proven effectiveness in helping clients monitor and improve their therapy experience. Scott Miller and his associates at the International Center for Clinical Excellence (ICCE) developed two four-item instruments to measure client progress and to rate the quality of the therapeutic

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relationship. These rating instruments are brief, well-validated, client-rated scales. The Outcome Rating Scale (ORS) assesses the client’s therapeutic progress through ratings of a client’s personal experience of well-being in their individual, interper- sonal, and social functioning. The Session Rating Scale (SRS) measures a client’s perception of the quality of the therapeutic relationship, which includes the rela- tional bond with the therapist, the perceived collaboration around specific tasks in therapy, and agreement on goals, methods, and client preferences (Miller et al., 2015).

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

An Integrative Approach Applied to the Case of Stan In this section, I describe how I would integrate con- cepts and techniques from the 11 theoretical perspec- tives in counseling Stan on the levels of thinking, feeling, and doing. I indicate what aspects from the various the- ories I would draw on in working with Stan at the vari- ous stages of his therapy. As you read the Questions for Reflection at the end of this section, think about how you would work with Stan from your own integrative perspective.

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

Clarifying the Goals of Therapy With respect to setting goals, precision and clarity are essential. Once we have identified some goals, Stan can begin to observe and measure his own behavior, both in the sessions and in his daily life. This self-monitoring is a vital step in any effort to bring about change. I will be asking for Stan’s feedback throughout the therapeu- tic process and will use his feedback as a basis for mak- ing modifications in our therapeutic alliance.

Throughout our time together, I ask Stan to decide time and again what he wants from his therapy and to assess the degree to which our work together is help- ing him meet his goals. It is important that Stan pro- vide the direction in which he wants to travel on his journey. Once I have a clear sense of the specific ways Stan wants to change how he is thinking, feeling, and acting, I am likely to take an active role in co-creating experiments with Stan that he can do both in the ther- apy sessions and on his own away from our sessions.

Working With Stan’s Past, Present, and Future Dealing With the Past In my integrative approach, I tend to give weight to understanding, exploring, and

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working with Stan’s early history and to connecting his past with what he is doing today. My view is that themes running through our life can become evident if we come to terms with significant experiences in our childhood. I favor the Gestalt approach of asking Stan to bring into the here and now those people in his life with whom he feels unfinished. A variety of role-playing techniques in which Stan addresses significant others through sym- bolic work in our sessions will bring Stan’s past intensely to life in the present moment of our sessions.

Dealing With the Present Being interested in Stan’s past does not mean that we get lost in history or that we dwell on reliving traumatic situations. By paying at- tention to what is going on in the here and now dur- ing the counseling session, I get significant clues about what is unfinished from Stan’s past. He and I can direct attention to his immediate feelings as well as to his thoughts and actions. It seems essential to me that we work with all three dimensions—what he is thinking, what he is actually doing, and how his thoughts and behaviors affect his feeling states.

Dealing With the Future If Stan decides that his present behavior is not getting him what he wants, he is in a good position to think ahead about the changes he would like to make and what he can do now to actualize his aspirations. The present-oriented behavioral focus of reality therapy is a good reference point for getting Stan to dream about what he would like to say about his life five years hence. Connecting present behavior with future plans is an excellent way to help Stan formulate a concrete plan of action, which can give him a way to create his future.

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

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

The Thinking Dimension in Therapy Once Stan has experienced some intense feelings and perhaps released pent-up feelings, some cognitive work is essential. To bring in this cognitive dimension, I focus Stan’s attention on messages he incorporated as a child and on the decisions he made. I get him to think about the reason he made certain early deci- sions. Finally, I challenge Stan to look at these deci- sions about life, about himself, and about others and to make necessary revisions that can lead him to cre- ate a life of his own choosing.

The cognitive behavioral therapies have a range of cognitive techniques that can help Stan recognize con- nections between his cognitions and his behaviors. Over a number of sessions we work on specific beliefs. My role is to promote corrective experiences that will lead to changes in his thinking. Eventually, our goal is some cognitive restructuring work by which Stan can learn new ways to think, new things to tell himself, and new assumptions about life. I have given Stan a number of homework assignments aimed at helping him identify a range of feelings and thoughts that may be problematic for him. This provides a basis for change in his behavior.

Doing: Another Essential Component of Therapy Feeling and thinking are not a complete therapy pro- cess. Doing is a way of bringing these feelings and thoughts together by applying them to real-life situ- ations in various action programs. I ask Stan to think of as many ways as possible of actually bringing into his daily living the new learning he is acquiring in our

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sessions. Homework assignments (preferably ones that Stan gives himself ) are an excellent way for Stan to be- come an active agent in his therapy. He must do some- thing himself for change to occur. The degree to which he will change is directly proportional to his willingness to experiment. Thus, each week we discuss his progress toward meeting his goals, and we review how well he is completing his assignments, as well as how his action plan is working.

Moving Toward Termination of Therapy Termination of therapy is as important as the initial phase, and the key task is to put into practice what he has learned in the sessions by applying new skills and attitudes to daily social situations without profes- sional assistance. When Stan brings up a desire to “go it alone,” we talk about his readiness to end therapy and his reasons for thinking about termination. I also share with him my perceptions of the directions I have seen him take. This is a good time to talk about where he can go from here. We spend time developing an action plan and talking about how he can best maintain his new learning.

In a behavioral spirit, evaluating the process and outcomes of therapy seems essential. This evaluation can take the form of devoting some time to discuss- ing Stan’s specific changes in therapy. A few questions for focus are: “What stands out the most for you, Stan? What did you learn that you consider the most valu- able? How did you learn these lessons? What can you do now to keep practicing new behaviors? What will you do if you experience a setback?” We explore potential difficulties he expects to face when he no longer comes to weekly counseling sessions. At this point, I introduce some relapse prevention strategies to help Stan cope constructively with future problems. By addressing po- tential problems and stumbling blocks that he might encounter, Stan is less likely to become discouraged if he experiences any setbacks. If any relapses do occur, we talk about seeing these as “learning opportunities” rather than as signs that he has failed. I let Stan know that his termination of formal therapy does not mean that he cannot return for a visit or session when he con- siders it appropriate.

Commentary on the Thinking, Feeling, and Doing Perspective Although the steps I described with Stan may appear relatively structured and even simple, actually work- ing with clients is more complex and less predictable. If you are practicing from an integrative perspective, it would be a mistake to assume that it is best to al- ways begin working with what clients are thinking (or feeling or doing). Effective counseling begins where the client is, not where a theory indicates a client should be.

In summary, depending on what clients need at the moment, I may focus initially on what they are think- ing and how this is affecting them, or I may focus on how they feel, or I may choose to direct them to pay attention to what they are doing. If Stan can change his thoughts, I believe he is likely to change some of his behaviors and his feelings. If he changes his feelings, he might well begin to think and act differently. If he changes certain behaviors, he may begin thinking and feeling differently. Because these facets of human ex- perience are interrelated, one route generally leads to the other dimensions.

A person-centered focus respects the wisdom within the client and uses it as a lead for where to go next. As counselors, a mistake we can make is getting too far ahead of our clients by thinking, “What should I do next?” By staying with our clients and asking them what they want, they will tell us which direction to take either directly or indirectly. We can learn to pay attention to our own reactions to our clients and to our own energy. By doing so we can engage in a ther- apeutic connection that is helpful for both parties in the relationship.

Questions for Reflection ◆ What themes in Stan’s life do you find most signifi-

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

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

◆ Identify some key techniques from the various

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therapies that you are most likely to employ in your therapy with Stan.

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

◆ Knowing what you do about Stan, what do you imagine it would be like to be his therapist? What problems, if any, might you expect to encounter in your counseling relationship with him?

An Integrative Approach Applied to the Case of Gwen* There are multiple pathways to health and well- being, and I believe Gwen can benefit from a vari- ety of counseling theories and holistic practices. The integrative approach embraces an attitude that affirms the intrinsic value of each individual. It is a unifying approach that attends to the person at the affective, behavioral, cognitive, and physiological levels of func- tioning. It also addresses the spiritual dimension of a client’s life.

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

In my initial interview with Gwen, I let her know that I am not a purist in my approach to therapy and that I will draw from different counseling theories to create a treatment approach that is tailored to her needs. I begin establishing a therapeutic alliance with Gwen by draw- ing heavily from a client-centered orientation. It is im- portant for me to extend unconditional positive regard in the midst of acknowledging the suffering and anxiety

Gwen is experiencing in her day-to-day life. I want Gwen to know that she is the expert on her life and that she is in charge of our work together. I will introduce ideas and techniques, and I let Gwen know that she is free to say what does not work for her in our sessions.

When Gwen and I began our therapeutic journey together, I was very interested in learning about her family history. I encouraged Gwen to create a geno- gram that depicted three generations and indicated educational levels, health issues, relationship pat- terns, and religious orientation. This approach was borrowed from family therapy and assisted us in see- ing family patterns that have given her strength and support (her spirituality), as well as patterns that have caused challenges for her (taking on family mem- bers’ problems). Through exploring her family history, Gwen begins to slowly recognize she has taken on characteristics that don’t necessarily belong to her. Generational transmission—passing down traits, hab- its, and values from one generation to the next—has predisposed Gwen to be a rescuer like many of her fe- male relatives. She explores some of the old automatic negative thoughts that were passed on from other generations that keep her feeling overwhelmed. One of Gwen’s faulty beliefs is that “If I don’t do it, no one else will.” This particular cognitive distortion keeps her

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

Refer to MindTap for The Case of Stan Video Quiz for Chapter 15, Session 13 (“An Integra- tive Approach”), for a demonstration of my approach to counseling Stan from this per- spective. This session deals with termination and takes an integrative view of Stan’s work.

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in a spiral of doing everything without reaching out to others for assistance or support. Her belief that no one else can assist her has caused fatigue and frustration. Through cognitive behavior therapy, Gwen becomes more aware of the thoughts she is thinking and how they affect how she feels about herself.

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

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

Bringing in the dimension of spirituality reconnects Gwen to a daily practice of reading scripture in the morning and listening to praise music on the way to the office. Gwen notices that her mood is not as nega- tive when she engages in her daily spiritual practice. She hadn’t realized that she had stopped engaging in activities that kept her focused and uplifted. The stress of taking care of her mother and juggling work and family life created an imbalance that perpetuated faulty cognitions and behaviors.

In our early sessions Gwen engaged in automatic negative thinking and made statements such as these: “I am never going to feel healthy again.” “My children never want to spend time with me.” “I will always feel isolated.” Examining Gwen’s cognitive distortions

and assisting her in noticing and challenging them helped her to become increasingly aware of how these thought patterns cause her distress.

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

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

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

To decrease Gwen’s symptoms of depression and anxiety, I introduce her to a process I call “transforma- tive movement and reflection.” I teach Gwen a variety of techniques, ranging from subtle to dynamic, that come from global healing practices such as yoga, tai chi, drumming, and yogic pranayama, to mention a few. These activities increase mindfulness, present mo- ment awareness, and help Gwen release tension and stress from her body and mind. The movement practic- es also assist in healthy emotional expression. Gwen is not very interested in drumming, but listening to mu- sic and moving is relaxing for her while in session and

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at home. Gwen begins to see that she has resources and tools that she can use in moments of stress in her daily life. My goal is to introduce Gwen to mul- tiple tools to heal on the levels of mind, body, and spirit. I am sensitive to Gwen’s personal goals from the moment she walks into my office, and I remain open to the possibilities that lie ahead of us until the very end.

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

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

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

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

to customize the therapy to the individual needs and characteristics of each client. Ongoing client feedback provides practitioners with a simple, practical, and mean- ingful method for documenting the usefulness of treatment. The practice of FIT involves a growth mindset, which encourages therapists to pursue improvement of their performance (Maeschalck et al., 2019)

Summary Creating an integrative stance is truly a challenge. Therapists cannot simply pick bits and pieces from theories in a random and fragmented manner. In forming an integrated perspective, it is important to ask a three-part question: Which theories provide a basis for understanding the cognitive dimensions? What about the feeling aspects? And how about the behavioral dimension? Most of the 11 therapeutic orientations discussed here focus primarily on one of these dimensions of human experience. Although the other dimensions are not necessarily ignored, they are often given short shrift.

Developing an integrated theoretical perspective requires an accurate, in- depth knowledge of the various theories. Without such knowledge, you cannot formulate a true synthesis. Simply put, you cannot integrate what you do not know (Norcross & Beutler, 2019). A central message of this book has been to remain open to each theory, to do further reading, and to reflect on how the key con- cepts of each approach fit your personality. Building your personalized orienta- tion to counseling, which is based on what you consider to be the best features of several theories, is a long-term venture.

In addition to considering your own personality, think about what concepts and techniques work best with a range of clients. It requires knowledge, skill, art, and experience to be able to determine what techniques are suitable for particular prob- lems. It is also an art to know when and how to use a particular therapeutic inter- vention. Although reflecting on your personal preferences is important, I hope that you balance your preferences with evidence from the research studies. Developing a personal approach to counseling practice does not imply that anything goes. Indeed, in this era of managed care and evidence-based practice, your personal preferences will not likely be the sole determinant of your psychotherapy practice. In counseling clients with certain clinical problems (such as depression and generalized anxiety), specific techniques have demonstrated their effectiveness. For instance, behavior

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therapy, cognitive behavior therapy, cognitive therapy, mindfulness-based cognitive therapy, and short-term psychodynamic therapy have repeatedly proved successful in treating depression. Your use of techniques must be grounded on solid theoreti- cal constructs. Ethical practice implies that you employ efficacious procedures in dealing with clients and their problems, and that you are able to provide a theoreti- cal rationale for the interventions you make in your clinical work.

This is a good time to review what you have learned about counseling theory and practice. Identify a particular theory that you might adopt as a foundation for establishing your counseling perspective. Consider from which therapies you would be most inclined to draw (1) underlying assumptions, (2) major concepts, (3) thera- peutic goals, (4) therapeutic relationship, and (5) techniques and procedures. Also, consider the major applications of each of the therapies as well as their basic limita- tions and major contributions. The tables presented in this chapter are designed to assist you in conceptualizing your view of the counseling process.

Concluding Comments At the beginning of the introductory course in counseling, my students typically express two reactions: “How will I ever be able to learn all these theories, and how can I see the differences among them?” and “How can I make sense out of all this infor- mation?” By the end of the course, these students are often surprised by how much work they have done and by how much they have learned. Although an introductory survey course will not turn you into accomplished counselors, it generally provides the basis for selecting from among the many models to which you are exposed.

At this point you may be able to begin putting the theories together in some meaningful way for yourself. This book will have served its central purpose if it has encouraged you to read further and to expand your knowledge of the theories that most caught your interest. I hope you have seen something of value that you can use from each of the approaches described. You will not be in a position to conceptual- ize a completely developed integrative perspective after your first course in coun- seling theory, but you now have the tools to begin the process of integration. With additional study and practical experience, you will be able to expand and refine your emerging personal philosophy of counseling.

The book will have been put to good use if it has stimulated you to think about the ways in which your philosophy of life, your values, your life experiences, and the person you are becoming are vitally related to the caliber of counselor you can become and to the impact you can have on those who establish a relationship with you personally and professionally. This book and your course may have raised ques- tions for you regarding your decision to become a counselor. Seek out at least one of your professors and explore any questions you may have.

In closing, check the dedication in the front of this book. I have dedicated this book to you. When you take your place in one of the mental health professions, my sincere hope is that you recognize the importance of your knowledge and skills. Do not underestimate your ability to make a significant difference in the lives of those who seek your help. Helping professionals face many challenges, but your work can bring about healing and influence positive change. I hope you discover your

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passions and recognize that you have unique gifts. I encourage you to dream—then take action to turn your dreams into reality.

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

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

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

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

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

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

Where to Go From Here Other Resources

The ICCE is a worldwide web-based community of practitioners, health care managers, administrators, educators, policymakers, and researchers dedicated to promoting excel- lence in behavioral health care services. This online community facilitates sharing best practices and innovative ideas specifically designed to improve behavioral health care practice and enable practitioners and managers to achieve their personal best as helping professionals. The ORS and the SRS rating scales described in the text are free and can be downloaded at the website.

The ICCE manuals on FIT consist of a series of six guides covering the most important information for practitioners and agencies implementing FIT as a part of routine care. The manuals cover the following content areas:

Manual 1. What Works in Therapy: A Primer

Manual 2. Feedback-Informed Clinical Work: The Basics

Manual 3. Feedback-Informed Supervision

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

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

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

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

Scott D. Miller’s website has additional information on workshops on clinical excel lence: Scott D. Miller (www.scottdmiller.com).

Recommended Supplementary Readings for Chapter 15 Psychotherapy Integration (Stricker, 2010) is a concise presentation that deals with the theory, therapeu tic process, evaluation, and future developments of integrative approaches.

The Human Element of Psychotherapy: A Nonmedical Model of Emotional Healing (Elkins, 2016) develops the thesis that psychotherapy is decidedly a rela tional, not a medical, endeavor. This book summa rizes research supporting the notion that the quality of the interpersonal connection between client and therapist is what determines effectiveness, not the therapist’s theory or techniques.

Handbook of Psychotherapy Integration (Norcross & Goldfried, 2019) is an excellent resource for concep tual and historical perspectives on therapy integra tion. This edited volume provides a comprehensive overview of the major current approaches, such as theoretical integration and technical eclecticism.

The Art of Integrative Counseling (Corey, 2019) is designed to assist students in developing their own integrative approach to counseling.

Case Approach to Counseling and Psychotherapy (Corey, 2013) illustrates each of the 11 contemporary theo ries by applying them to the single case of Ruth. I also demonstrate my integrative approach in coun seling Ruth in the final chapter.

Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice (Cashwell & Young, 2020) offers a concrete perspective on how to provide counseling in an ethical manner, consistent with a client’s spiritual beliefs and practices. The authors help practitioners develop a respectful stance that honors the client’s worldview and works within this framework in a collaborative fashion to achieve the client’s goals.

Bohart, A. C., & Tallman, K. (2010). Clients: The neglected common factor in psychotherapy. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed., pp. 83–111). American Psychological Association. Bohart, A. C., & Wade, A. G. (2013). The client in psychotherapy. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed., pp. 219–257). Wiley. Cashwell, C. S., & Young, J. S. (Eds.). (2020). Integrating spirituality and religion into counseling: A guide to competent practice (3rd ed.). American Counseling Association.

Comas-Diaz, L. (2019). Multicultural theories of psychotherapy. In D. Wedding & R. J. Corsini (Eds.), Current psychotherapies (11th ed., pp. 561–598). Cengage Learning. Corey, G. (2013). Case approach to counseling and psychotherapy (8th ed.). Brooks/Cole, Cengage Learning. Corey, G. (2019). The art of integrative counseling (4th ed.). American Coun seling Association. Delaney, H. D., Miller, W. R., & Bisono, A. M. (2007). Religiosity and spirituality among psychologists: A survey of clinician members of the American Psychological Association. Professional Psychology: Research and Practice, 38(5), 538–546.

Duncan, B. (2014). On becoming a better therapist: Evidence-based practice one client at a time (2nd ed.). American Psychological Association. Duncan, B. L., Miller, S. D., & Sparks, J. A. (2004). The heroic client: A revolutionary way to improve effectiveness through client-directed, outcome-informed therapy. JosseyBass. Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (Eds.). (2010). The heart and soul of change: Delivering what works in therapy (2nd ed.). American Psychological Association. Elkins, D. N. (2016). The human elements of psychotherapy: A nonmedical model of

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emotional healing. American Psychological Association. Frame, M. W. (2003). Integrating religion and spirituality into counseling: A comprehensive approach. Brooks/Cole, Cengage Learning. Goldfried, M. R., Pachankis, J. E., & Goodwin, B. J. (2019). A history of psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (3rd ed., pp. 28–63). Oxford University Press. Greenberg, L. S. (2017). Emotion-focused therapy (Rev. ed.). American Psychological Association. Hoyt, M. F. (2015). Brief therapy. In E. Neukrug (Ed.), SAGE encyclopedia of theory in counseling and psychotherapy (vol. 1, pp. 144–147). SAGE. Hubble, M. A., Duncan, B. L., Miller, S. D., & Wampold, B. E. (2010). Introduction. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed., pp. 23–46). American Psychological Association. Johnson, R. (2013). Spirituality in counseling and psychotherapy: An integrative approach that empowers clients. Wiley. Lambert, M. J. (2011). Psychotherapy research and its achievements. In J. C. Norcross, G. R. Vandenbos, & D. K. Freedheim (Eds.), History of psychotherapy (2nd ed., pp. 299–332). American Psychological Association. Lazarus, A. A. (2008). Multimodal behavior therapy. In W. O’Donohue & J. E. Fisher (Eds.), Cognitive behavior therapy: Applying empirically supported techniques in your practice (2nd ed., pp. 342–346). Wiley. Maeschalck, C. L., Prescott, D. S., & Miller, S. D. (2019). Feedback informed treatment. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy

integration (3rd ed., pp. 105–121). Oxford University Press. Miller, S. D. (2011). Psychometrics of the ORS and SRS. Results from RCTs and meta- analyses of Routine Outcome Monitoring & Feedback. The available evidence. http:// w w w. s l i d e s h a r e . n e t / s c o t t d m i l l e r /measures-and-feedback-january-2011 Miller, S. D., Hubble, M. A., & Seidel, J. (2015). Feedback-informed treatment. In E. Neukrug (Ed.), SAGE encyclopedia of theory in counseling and psychotherapy (vol. 1, pp. 401–403). SAGE. Neukrug, E. (Ed.). (2015). SAGE ency- clopedia of theory in counseling and psycho- therapy (vols. 1 & 2). SAGE. Neukrug, E. (2016). The world of the counselor: An introduction to the counseling profession (5th ed.). Cengage Learning. Norcross, J. C., & Alexander, E. F. (2019). Primer on psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (3rd ed., pp. 4–27). Oxford University Press. Norcross, J. C., & Beutler, L. E. (2019). Integrative psychotherapies. In D. Wedding & R. J. Corsini (Eds.), Current psychotherapies (11th ed., pp. 527–560). Cengage Learning. Norcross, J. C., & Cooper, M. (2021). Personalizing psychotherapy: Assessing and accommodating patient preferences. American Psychological Association. Norcross, J. C., & Goldfried, M. R. (Eds.). (2019). Handbook of psychotherapy integration (3rd ed.). Oxford University Press. Norcross, J. C., Pfund, R. A., & Prochaska, J. O. (2013). Psychotherapy in 2022: A Delphi poll on its future. Professional Psychology: Research and Practice, 44(5), 363–370. Norcross, J. C., & Wampold, J. C. (Eds.). (2019). Psychotherapy relationships that work, Volume 2: Evidence-based responsiveness (3rd ed.). Oxford University Press.

Prochaska, J. O., & Norcross, J. C. (2018). Systems of psychotherapy: A transtheoretical analysis (9th ed.). Oxford University Press. Psychotherapy Networker. (2007). The top 10: The most influential therapists of the past quarter-century. Psychotherapy Networker, 31(2), 24–37. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression (2nd ed.). Guilford Press. Sahker, E. (2016). Therapy with the nonreligious: Ethical and clinical considerations. Professional Psychology: Research and Practice, 47(4), 295–302. Smith, M. L., Glass, G. V., & Miller, T. I. (1980). The benefits of psychotherapy. Johns Hopkins University Press. Stricker, G. (2010). Psychotherapy integration. American Psychological Association. Wampold, B. E. (2010). The research evidence for the common factors models: A historical situated perspective. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed., pp. 49–81). American Psychological Association. Worthington, E. L., Jr. (2011). Integration of spirituality and religion into psychotherapy. In J. C. Norcross, G. R. Vandenbos, & D. K. Freedheim (Eds.), History of psychotherapy (2nd ed., pp. 533– 544). American Psychological Association. Young, J. S., & Cashwell, C. S. (Eds.). (2020). Integrating spirituality and religion into counseling (3rd ed.). American Counseling Association. Young, J. S., Wiggins-Frame, M., & Cashwell, C. S. (2007). Spirituality and counselor competence: A national survey of American Counseling Association members. Journal of Counseling and Development, 85(1), 47–52.

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567

Name Index

Adames, H. Y., 42, 64, 65 Adams, M., 166, 169, 174, 176, 177,

196, 197 Adams-Clark, A. A., 64 Adler, A., 6, 110, 113, 114, 116–118,

120, 122, 129, 131, 140, 141, 151, 152, 155, 159, 326, 411, 450, 505, 530

Akatsuka, N., 322 Al-Rashidi, B., 407 Alcee, M., 178, 196 Alexander, E. F., 534, 536, 566 Alle-Corliss, L., 15, 17 Alle-Corliss, R., 16, 17 Alpert, J. L., 57, 64, 65, 272, 446 American Counseling Association

(ACA), 25, 41, 49, 64 American Counseling Association

Presidential Task Force on Evidence-Based Practice, 55, 64

American Psychiatric Association, 64, 115, 156, 380, 384, 407, 508, 530

American Psychological Association (APA), 26, 41, 411, 425–428, 434, 445

Andersen, T., 509, 530 Anderson, C., 531 Anderson, H., 450, 451, 457, 499, 509,

530 Angel, E., 197 Ansbacher, H. L., 113, 122, 152, 156 Ansbacher, R. R., 122, 156 Antony, M. M., 276, 281, 292, 317,

320 Arboleda, G., 15, 16 Arciniega, G. M., 146, 147, 156 Arkowitz, H., 468, 499 Arlow, J. A., 105, 108 Armerding, C., 138, 156 Arredondo, P., 30, 41, 43 Asnaani, S. G., 375 Austin, J., 41, 42 Austin, S. B., 233 Axelsson, L. S., 237, 238, 249, 250,

271, 272

Bailey, C., 273 Baldwin, M., 510, 531 Bandura, A., 7, 274–275, 276, 278,

320 Banmen, J., 531 Barnett, J. E., 23, 27, 41, 43, 51, 64 Bateson, G., 459, 478, 499 Batten, S. V., 304, 320

Bauman, S., 86, 182, 394 Bayne, H. B., 26, 41 Beck, A. T., 7, 152, 326, 338–339, 340,

341, 343, 344–346, 347, 369–371, 373, 374–376

Beck, J. S., 7, 339–340, 345, 372–374, 376

Becnel, A., 348 Becvar, D. S., 503, 530 Becvar, R. J., 503, 530 Beisser, A. R., 239, 272 Bemak, F., 51, 52, 64 Berenson, B., 234 Berg, I. K., 7, 451, 452, 456, 458, 460,

461, 495, 498, 499 Bergin, A. E., 320 Bernal, G., 43 Bertolino, B., 450, 479, 488, 495, 499 Bertram, B., 50, 64, 65 Bettner, B. L., 133, 156 Beutler, L. E., 65, 376, 534, 535, 539,

547, 562, 566 Binensztok, V., 127, 128, 133, 136,

155, 157 Binswanger, L., 164, 196 Bisono, A. M., 566 Bitter, J. R., 111, 120, 129, 131, 132,

135, 136, 138, 141–146, 152, 156, 157, 348, 375, 419, 445, 456, 460, 499, 502, 505, 507, 509, 510, 513, 515, 516–520, 528, 530, 531

Black, M. J., 92, 108 Blau, W., 81, 94–97 Bluvshtein, M., 146, 156 Bodiforde McNeil, C., 276, 320 Bohart, A. C., 200, 208, 213, 214, 222,

232, 233, 556, 565 Borden, A., 500 Boscolo, L., 531 Boss, M., 164, 196 Bowen, M., 7, 506, 517, 518, 531 Bowman, C., 272 Bozarth, J. D., 201, 202, 213, 214, 233 Brabeck, K. M., 418, 421, 441, 445 Brabeck, M. M., 418, 421, 441, 445 Bracke, P. E., 192, 196 Breulin, D. C., 509, 514, 531 Brew, L., 16 Brickell, J., 391, 403, 407 Brodsky, A., 60, 64 Bromley, D. B., 64 Brooks, J. A., 500 Brown, L. S., 7, 410, 413, 417, 420–

422, 441, 443–445, 450, 499

Brown, S., 41, 446 Brownell, P., 237, 238, 245, 250, 272 Bryant-Davis, T., 7, 409–410, 415,

431, 446 Bubenzer, D. L., 457, 499 Buber, M., 163, 164, 178, 196, 261 Bugental, J., 162, 165–166, 176, 178,

181, 192, 194–197 Burns, A. B., 64 Burton, A., 156 Bush, A., 500 Byars-Winston, A., 411, 418, 446 Byrd, R., 138, 156

Cain, D. J., 196, 200, 208–213, 222, 223, 228–234, 272

Cannon, K., 446 Captari, I. E., 27, 41, 42 Capuzzi, D., 156, 197, 233, 320, 376,

407, 446 Carey, M., 483, 499 Carkhuff, R., 234 Carlson, J., 22, 43, 110, 111, 124, 125,

134, 136, 146, 152–157, 374, 375, 509, 530, 531

Carmichael, A., 531 Carter, B., 506, 531 Cashwell, C. S., 42, 540–542, 565, 566 Castaldo, J. E., 346, 375 Cavasos, L. L., 500 Cecchin, F. G., 531 Chambers, A. L., 531 Chambless, D. L., 346, 375 Chang, Y., 233 Chavez-Duenas, N. Y., 42, 64, 65 Christensen, O. C., 138, 156, 505, 531 Chung, R., 51, 52, 64 Ciarrochi, J. V., 304, 320 Clark, A., 131, 156 Clark, A. J., 211, 233 Clark, D. M., 347, 375 Clark, K. B., 146, 156 Clarkin, J., 92, 107, 108 Cole, L., 156, 445 Comas-Diaz, L., 7, 409, 410, 415, 431,

446, 540, 565 Combs, G., 474, 476, 478, 495, 500 Comstock, D. L., 415, 446 Conyne, R. K., 253, 257, 272 Cooper, M., 20, 42, 56, 65, 166, 186,

193, 196, 197, 213, 228, 233, 536, 545, 547, 566

Corbett, G., 470, 499 Corey, C., 42, 52, 64

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568 Name Index

Corey, G., 17, 25, 29, 32, 38–42, 45–47, 49, 52, 57, 58, 64, 65, 81, 86, 107, 132, 139, 148, 156, 175, 179, 182, 192, 194, 196, 213, 216, 233, 249, 258, 272, 282, 286, 295, 305, 320, 331, 334, 348, 375, 393, 407, 408, 418, 441, 446, 462, 463, 481, 499, 502, 534, 536, 544, 565

Corey, M., 41, 42, 46, 52, 64, 196, 258 Cormier, S., 273, 281, 282, 286–288,

294, 307–309, 319, 320, 468, 499 Correia, E. A., 196 Corsini, R. J., 272, 374, 375, 565, 566 Council for Accrediation of

Counseling and Related Educational Programs (CACREP), 29, 42

Courtois, C. A., 57, 64, 65, 272, 441, 445, 446

Craig, M., 161, 173, 177, 178, 196 Craske, M. G., 288, 289, 290, 321 Crethar, H. C., 412, 433, 446 Crocket, K., 477, 500, 501 Cruz, T., 415, 423, 446 Cukrowicz, K. C., 55, 64 Curtis, R. C., 78, 80, 81, 82, 83, 84, 90, 107

Dailey, S. F., 55, 64 Dalai Lama, 39, 42, 118, 156 Dattilio, F. M., 64, 192, 196, 274, 278,

321, 344–348, 371, 375, 376 David, D., 304, 321, 509 Davis, D., 41, 42 Davis, S. D., 528, 530, 531 Davison, G. C., 288, 320 De Jong, P., 456, 458, 460, 461, 495,

498, 499 de Shazer, S., 7, 452–454, 456, 458–461,

495, 499 Dean, L. M., 469, 499 Deegear, J., 55, 64 Del Corso, J. J., 475, 477, 478, 479,

481, 494, 495, 501 Delaney, H. D., 540, 566 Denborough, D., 478, 499 DeRubeis, R. J., 340, 343, 344, 345,

346, 369, 375 Deurzen, E. van, 166, 169, 173–181,

183–186, 191–193, 196, 197 Di Pietro, R., 130, 131, 152, 157 Dienes, K. A., 324, 375 DiGiuseppe, R., 315, 321, 329, 367, 368,

375 Dinkmeyer, D., Jr., 136, 156 Disque, J. G., 136, 156 Dobson, D., 315, 320, 374 Dobson, K. S., 315, 320, 321, 372,

374, 375, 376

Dolan, Y., 459, 499 Domenech Rodriguez, M., 43 Donovan, D. M., 360, 376 Doyle, K. A., 321, 329, 367, 375 Dozois, D. J. A., 320, 321, 374, 375,

376 Dreikurs, R., 6, 113–115, 122, 127,

129, 138, 140, 141, 156, 505, 514, 531

Drewery, W., 478, 500 Driscoll, K. A., 64 Dryden, W., 196 Dudley, R., 350, 376 Duffey, T., 425, 446 Duncan, B. L., 19, 42, 214, 229, 232,

233, 500, 535, 546, 556, 565, 566

Edgar, T., 111 Edwards, J. A., 55, 56, 64 Eldridge, N., 447 Elkins, D. N., 19, 20, 42, 179, 191,

193, 197, 200–202, 207, 228, 230, 232, 233, 535, 546, 556, 565, 566

Ellenberger, H. R., 197 Elliott, R., 212, 233 Ellis, A., 7, 152, 324, 325, 327–334,

336, 368, 370, 371, 374, 375 Ellis, D. J., 323–328, 330–335, 336–

338, 368, 370–375 Ellman, S. J., 108 Emery, G., 374 Englar-Carlson, M., 124, 125, 134,

136, 146, 152, 153, 155, 156, 425, 446

Enns, C. Z., 7, 105, 107, 408–412, 413, 415, 417, 418, 420, 421, 425, 426, 428–432, 433, 441, 445–447

Epicetus, 326 Epp, L. R., 197 Epstein, N. B., 346, 375 Epston, D., 7, 450, 454, 473, 474, 476,

479, 480, 481, 486, 500, 501, 509, 531

Erickson, M., 452 Eriksen, K., 420, 421, 426, 446 Erikson, E. H., 68, 72–73, 74–75, 89,

102, 103, 107 Erikson, K. M., 320, 328, 375 Evans, K. M., 412, 416–419, 421, 422,

425, 445, 446 Evans, M. P., 446 Evans, T. D., 134, 156

Fang, A., 375 Farber, B. A., 210, 211, 233 Farha, B., 172, 179, 197 Fassinger, R. E., 446 Faulkner, William, 384

Feder, B., 258, 271, 272 Feminist Therapy Institute, 446 Filmore, J. M., 42 Fisher, J. E., 321, 375, 376, 500, 566 Fishman, H. C., 529, 531 Foley, V. K., 78, 84, 108 Follette, V. M., 320 Forman, E. M., 295, 321 Forrest, G., 381, 407 Fowler, D., 15, 17 Frame, M. W., 540, 541, 566 Frank, M. L. B., 175, 197 Frankel, F., 276, 292, 321 Frankl, V., 6, 152, 159, 169, 172–173,

197, 381, 396 Franklin, C., 453, 500 Freedheim, D. K., 42, 43, 108, 234,

566 Freedman, A., 340 Freedman, J., 474, 476, 478, 495, 500 Freeman, A., 345, 346, 368, 371, 375,

376 Freeman, S. E. M., 368, 375 Freiberg, H. J., 234 Freud, A., 89 Freud, S., 6, 67–68, 72, 74–75, 83, 87,

102–105, 152, 159, 256, 450 Frew, J., 156, 197, 233, 240, 241,

249–252, 258, 260–262, 271, 272, 407, 447

Friedman, S., 530 Fromm, E., 113, 152 Fruzzetti, A. E., 295, 300, 320, 328,

375 Fulton, P. R., 320, 321

Gabbard, G., 107 Gandhi, M., 118 Garcia-Preto, N., 531 Garfield, S. L., 320 Gavey, N., 420, 447 Gelder, M., 375 Geller, J. D., 22, 42 Gelso, C. J., 107 George, E., 458, 461, 500 Gerber, J., 531 Gerdes, P., 389, 407 Gergen, K. J., 449, 499, 500, 530 Germer, C. K., 295, 298, 299, 315,

319, 320, 321, 447 Gerson, R., 531 Gill, C. S., 64 Gilligan, C., 411, 412, 413, 446 Gingerich, W. J., 500 Ginicola, M. M., 26, 42 Giordano, J., 531 Gladding, S. T., 509, 528, 530, 531 Glass, G. V., 555, 566

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Name Index 569

Glasser, W., 7, 152, 378, 380–384, 387, 394, 399, 404, 407

Gold, S. H., 23, 42 Goldberg, S. B., 107 Goldenberg, H., 504, 528, 531 Goldenberg, I., 504, 528, 531 Goldfried, M. R., 288, 320, 536, 565,

566 Goldman, R., 202, 203, 233, 234, 268,

272 Goldried, M. R., 376, 533 Goldstein, A. P., 376 Gomez, J. M., 57, 64 Gomori, M., 531 Goodwin, B. J., 566 Goolishian, H., 450, 451, 457, 499,

509, 530 Gottman, J. M., 510, 531 Gould, W. B., 197 Granvold, D. K., 346, 375 Greden, L. R., 42 Green, J. W., 361, 376 Greenberg, L. S., 202, 203, 231, 233,

234, 535, 566 Greenberger, D., 345, 347, 355,

374–376 Greene, B., 446 Griffith, J., 129, 155, 157 Griner, D., 43 Gross, A. M., 288, 321 Gross, D. F., 156 Grothaus, T., 452, 453, 456, 458, 500 Grunwald, B. B., 156 Gurman, A. S., 197, 375 Guterman, J. T., 455, 495, 500 Gutheil, T. G., 60, 64

Haberstroh, S., 425, 446 Hackmann, A., 375 Haddock, L. R., 298, 320 Haigh, E. A. P., 341, 343, 347, 374 Haley, J., 507, 518, 529, 531 Hammer, T. R., 446 Hanna, S. M., 509, 531 Hardy, K. V., 506, 520, 531 Harness, L., 26, 41 Harris, A. S., 89, 107, 303 Harris, R., 302, 320 Hawes, C., 156 Hayes, J. A., 80, 107 Hayes, S. C., 295, 302–304, 317, 320,

321 Hays, D., 131, 156 Hays, P. A., 362, 363, 375, 430, 446 Hazler, R. J., 228, 233 Hazlett-Stevens, H., 288–290, 321 Head, L. S., 288, 321 Headley, J. A., 416, 420, 447

Healey, A., 156, 445 Hedges, L. E., 90, 108 Hedtke, L., 497 Heidegger, M., 162, 163, 164, 197 Heimberg, R. G., 315, 321, 376 Heine, S. J., 446 Heinrich, J., 431, 446 Hembree-Kigin, T. L., 320 Henry, J. S., 292, 293, 304, 321 Herbert, J. D., 295, 321 Herlihy, B., 24, 25, 42, 46, 49, 50, 54,

57, 58, 65, 408, 415, 423, 425, 426, 441, 446

Hermann, M. A., 42 Hill, C. E., 173, 197 Hilsenroth, M. J., 23, 42 Hindman, M. L., 258 Hoffman, E., 110, 156 Hofmann, S. G., 340, 346, 369, 375 Hogan, T. P., 55, 56, 65, 233 Hollon, S. D., 315, 321, 346, 375 Hook, J. N., 27, 41, 42 Horne, A. M., 531 Horney, K., 113, 152, 326, 376 Houts, A., 321 Hoyt, M. F., 152, 156, 454, 455, 457,

495, 498, 500, 539, 566 Hoyt, W., 41, 42 Hubble, M. A., 42, 232, 233, 500, 556,

565, 566 Huynh, C., 15

Iarussi, M., 468, 469, 470, 472, 500 Imhof, L., 407 Iveson, C., 500

Jacobs, L., 272 Jacobs, N. N., 332, 345, 376 Jacobson, E., 286, 321 Jencius, M., 50, 61, 65 Jennings, L., 22, 42 Johnson, J., 153, 156, 197 Johnson, R., 540–542, 566 Johnson, W. B., 27, 41, 51, 64 Joiner, T. E., 64 Jones, J., 41 Jordan, J. V., 414, 415, 446, 447 Joseph, S., 213, 229, 233 Josselson, R., 167, 174, 175, 177–179,

181, 197 Jung, C. G., 68, 87–89, 108, 450

Kabat-Zinn, J., 295–298, 321 Kane, B., 26, 41 Kanel, K., 15, 16 Kanfer, F. H., 376 Kaplan, A. G., 447 Karl, S. L., 64

Kaschak, E., 414, 447 Kaslow, N. J., 107, 108, 197, 233, 234 Kazantzis, N., 283, 321, 343, 345, 346,

374, 376 Kazdin, A. E., 276, 278, 321 Keefe, J. R., 343, 375 Keenan, K., 196, 209, 233, 234, 272 Keitel, M., 446 Kelley, G. B., 294, 321 Kemper, T. S., 64 Kendall, P. C., 346, 375 Kernberg, O., 91, 92, 107, 108 Kerr, M. E., 506, 531 Kersh, B. C., 500 Kierkegaard, S., 162, 163, 184, 201 Kim, J. S., 467, 500 Kim, R., 407 Kincade, E. A., 418, 421, 446 King, A. M., 300, 301, 321 King, A. R., 411, 447 Kirksey, K. N., 13, 17, 100, 149, 189,

225, 266, 306, 313, 366, 401, 436, 491, 525, 560

Kirschenbaum, H., 200, 228, 232, 233 Kivlighan, M., 107 Kjos, D., 530 Klein, M., 91, 108, 233 Knapp, S. J., 45, 65 Knaus, W., 374, 375 Kocet, M. M., 24, 25, 42 Kohut, H., 89, 92, 108 Kolden, G. G., 210, 230, 233 Kolmes, K., 60, 65 Koltko-Rivera, M. E., 205, 233 Koocher, G. P., 55, 56, 65, 233 Kopala, M., 446 Kottman, T., 154 Krebs, P. M., 470, 500 Kress, V. E., 292, 293, 304, 321, 420,

421, 426, 446 Kriss, A., 78, 84, 108 Krug, O., 166, 168, 176, 186, 192,

195–197, 204, 207, 234 Kutash, I. L., 234 Kuyken, W., 350, 376

Lambert, M. J., 19, 20, 22, 41, 42, 55, 56, 65, 107, 232, 233, 535, 556, 566

Lambert, S. F., 504, 531 Landrine, H., 446 Latner, J., 240, 272 Laugeson, E. A., 276, 292, 321, 322 Lawson, D. M., 55, 64 Lazarus, A. A., 294, 321, 534, 566 Lazarus, C. N., 294, 295, 321 Leahy, R. L., 375 Lebow, J. L., 531

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570 Name Index

Ledley, D. R., 315, 321, 332, 334, 374, 376

Lee, C. C., 28, 42, 65 Lee, M. Y., 495, 496, 500 Lehrer, P. M., 376 Lehrhaupt, L., 295, 296, 297, 321 Lent, R. W., 446 Lenton-Brym, A. P., 320 Lerman, H., 446 Leszcz, M., 161, 181, 197 Levant, R. F., 65 Levensky, E. R., 494, 500 Levenson, H., 93–94, 105–108 Levine, S. B., 57, 65 Levitsky, A., 253, 272 Levy, K. N., 108 Lew, A., 133, 156 Lewis, J. A., 531 Lichtanski, K., 168, 169, 174, 197 Lillis, J., 295, 303, 304, 321 Linehan, M., 7, 105, 108, 275, 295,

300–302, 320, 321 Lipchik, E., 496, 500 Lisiecki, J., 157 Lobovits, D., 500 Locke, D., 41 Lojk, L., 407 Luborsky, E. B., 76, 77, 105, 108 Ludgate, J., 375 Luepnitz, D. A., 509, 531 Lynch, D. A., 233

Mackune-Karrer, B., 531 Madigan, S., 478, 481, 487, 497, 499,

500 Maeschalck, C. L., 556, 562, 566 Maggio, L. A., 55, 56, 65, 233 Mahler, M. S., 90–92, 108 Maisel, R., 500 Maniacci, M., 110, 124, 153, 156, 157 Maracek, J., 420, 447 Marbley, A. F., 446 Marini, I., 108, 156, 375, 446, 531 Markham, L., 500 Marlatt, G. A., 360, 376 Marshall, C., 470, 500 Marsten, D., 500 Martell, C. R., 280, 321 Marx, B. P., 315, 321, 376 Maslow, A., 152, 204, 205, 206, 233 Masterson, J. F., 92, 108 Maurer, R., 252, 272 May, R., 6, 152, 160, 176, 177, 194,

195, 197, 231 McAuliffe, G., 500, 501 McCollum, E. E., 500 McDavis, R. J., 30, 43 McDonald, A. R., 203, 233

McElroy, S. E., 42 McElroy-Heltzel, S. L., 41 McElwain, B., 193, 197 McGoldrick, M., 506, 510, 518–520,

530, 531 McKenzie, W., 479, 480, 481, 482,

496, 500 McLean, C., 320, 328, 375 McNamee, S., 499, 530 McWilliams, N., 68, 75–78, 80, 82, 84,

89, 90, 94, 104, 106–108 Meibert, P., 295–297, 321 Meichenbaum, D., 7, 324, 356–361,

370–373, 376 Melfie, J. M., 472 Melnick, J., 250, 272 Messer, S. B., 107, 108, 197, 233, 234,

375 Metcalf, L., 462, 500 Miller, J. B., 7, 409, 414, 421, 422,

425, 447 Miller, M., 412, 416, 417, 446 Miller, S. D., 42, 225, 232, 233, 495,

500, 535, 556, 565, 566 Miller, T. I., 555, 566 Miller, W. R., 212, 233, 283, 321, 450,

467–469, 468, 469, 471, 472, 496, 498, 499, 566

Milliren, A. P., 134, 156 Miltenberger, R. G., 276, 281, 284,

285, 321 Minton, C. A. B., 64 Minuchin, S., 507, 517, 518, 529, 531 Mitchell, S. A., 90, 92, 108 Miura, Y., 322 Mohri, I., 322 Monk, G., 474–483, 496, 499–501 Mooney, K. A., 350–352, 370, 371,

373, 376 Moore, T., 156 Moreno, J., 253 Morgan, S. T., 299, 321 Morgan, W. D., 299, 321 Mosak, H. H., 115, 129, 130, 131, 136,

140, 152, 157 Moyers, T. B., 212, 233, 472, 499 Mozdzierz, G. J., 136, 157 Muratori, M., 41, 42, 196 Murphy, D., 213, 229, 233 Murphy, J., 453, 454, 457–459, 461–

464, 464–467, 494–498, 500

Naar, S., 283, 321, 499 Nakanishi, M., 322 Napoleon, J., 156 Nash, S., 446 National Child Traumatic Stress

Network (NCTSN), 428, 447

Neff, K. D., 299, 315, 321 Nelson, J., 138, 157 Neukrug, E., 156, 157, 197, 272, 320,

321, 322, 376, 447, 450, 499, 500, 566

Neville, H. A., 43, 65, 108, 157, 234, 272, 376

Nevis, S., 250, 272 Newbauer, J. F., 134, 156 Newlon, B. J., 146, 147, 156 Newman, C., 346, 376 NiaNia, W., 500 Nichols, M. P., 509, 528, 530, 531 Nicholson, J. M., 500 Nicoll, W. G., 132, 135, 139, 144, 156,

157 Nielsen, A. S., 470, 500 Nietzsche, F., 159, 162, 163 Noll, L. R., 64 Norcross, J. C., 19, 20, 22, 32, 40–43,

55, 56, 65, 93, 107, 108, 186, 197, 213, 228, 230, 233, 234, 291, 315, 321, 325, 330, 376, 456, 470, 477, 495, 500, 533–536, 539, 545, 546, 547, 555, 562, 565, 566

Norenzayan, A., 446 Nurius, P. S., 320, 499 Nutt, R. L., 446 Nye, R. D., 274, 321 Nylund, D., 500

Oaklander, V., 258, 259, 260, 270, 272 O’Donohue, W., 321, 375, 376, 500,

566 O’Hanlon, B., 450, 479, 488, 499 O’Hanlon, W. H., 453, 457, 460, 475,

478, 495, 500 Oi, M., 322 Okuno, H., 322 O’Reilly-Landry, M., 105, 108 Orlinsky, D. E., 22, 42 Osborn, C., 320, 499

Pachankis, J. E., 566 Padesky, C. A., 7, 323, 339, 340, 345–

347, 349–350, 351, 352, 353–355, 370–376

Panjares, F., 275, 321 Pantaleno, A., 296, 298, 321 Parish, T., 406 Park, C. N., 425, 426, 446 Parsons, J., 446 Paul, G. L., 280, 321 Pavlov, I., 277 Peller, J. E., 454, 495, 500, 501 Pelonis, P., 157 Pelonis-Peneros, P. P., 139, 157 Peluso, P. R., 157

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Name Index 571

Pepper, F. C., 156 Perls, F., 7, 237, 238, 252, 253, 256,

262, 268, 271, 272 Perls, L., 7, 238, 249, 272 Perryman, K., 258 Persons, J., 372 Peterman, M., 346, 375 Petry, S., 531 Pew, W. L., 113, 157 Pfund, R. A., 566 Pinsof, W. M., 509, 514, 531 Podina, I. R., 304, 321 Pollack, W. S., 447 Polster, E., 7, 236, 238, 240–243, 246,

247, 249, 250, 251, 270–272 Polster, M., 7, 236–237, 238, 240–243,

248–251, 271, 272 Pope, K. S., 42, 50, 64, 65 Porter, N., 446 Powers, R. L., 129, 155, 157 Prata, G., 531 Prescott, D. S., 566 Presidential Task Force on Evidence-

Based Practice, 55, 64 Pretzer, J., 346, 376 Prochaska, J. O., 93, 108, 291, 315,

321, 456, 470, 477, 495, 500, 535, 555, 566

Psychotherapy Networker, 534, 566 Pusateri, C. G., 416, 420, 447

Rampage, C., 531 Rashid, T., 233 Raskin, N. J., 201, 234 Rasmussen, P. R., 111, 115, 117, 119,

124, 125, 133, 134, 137, 155, 157 Ratner, H., 500 Reamer, F. G., 60–61, 65 Reinecke, M. A., 346, 375, 376 Reitzel, L. R., 64 Remer, P., 413, 417, 418, 419, 421,

423, 424, 425, 433, 434, 445, 447 Remley, T. P., 50, 54, 65 Resnick, R. W., 237, 238, 249, 253, 267, 272 Rice, J. K., 446 Rice, R., 474, 477, 500 Riskind, J. H., 346, 376 Rivera-Flores, M., 16 Rizvi, S. L., 300, 301, 321 Roberts, A., 530 Robertson, P. E., 156, 445 Rochlen, A. B., 197, 321 Rodriguez, M. N., 269, 272 Roemer, L., 320 Rogers, C., 7, 143, 152, 164, 199–202,

205–207, 209, 210, 211, 214, 216– 218, 220, 222, 228, 229, 232–234, 330, 509, 531

Rogers, N., 7, 199–200, 215–218, 219– 221, 228, 231, 232, 411, 447

Rollnick, S., 283, 321, 468, 469, 471, 496, 498–500

Ronnestad, M. H., 22, 42 Rose, G. S., 468, 500 Rose, J., 231 Rotter, J. B., 388, 407 Rousmaniere, T., 233 Rubin, S., 168, 169, 174, 196, 197,

209, 233, 234, 272 Ruitenbeck, H. M., 156 Runyan, H., 456, 500 Rush, A., 374 Russell, D. E., 200, 234, 483 Russell, J. M., 169, 176, 179, 193, 197 Russell, S., 499 Russell, W. P., 531 Russo, N. F., 446 Rutan, J. S., 79, 86, 89, 107, 108

Sabella, R. A., 453, 454, 500 Sacco-Bene, C., 456, 500 Sackett-Maniacci, L., 124, 156 Safran, J., 76, 77, 78, 80, 84, 106, 107,

108 Safren, S. A., 283, 321, 499 Sahker, E., 542, 566 Salazar, G., 446 Salkovskis, P. M., 375 Sanchez, J., 41 Sartre, J. P., 163, 164–165, 168, 197 Satir, V., 7, 152, 507, 510, 513, 517,

518, 531 Sauerheber, J. D., 157 Sawyer, A. T., 375 Schneider, K. J., 166, 168, 176, 177,

180, 186, 187, 192, 194–197, 204, 207, 234

Schultz, D. P., 87, 88, 108, 114, 157 Schultz, S. E., 87, 88, 108, 114, 157 Schulz, F., 250, 252, 272 Schuyler, E. J., 111, 124, 133, 134, 157 Schwartz, R. C., 508, 509, 530, 531 Sebold, J., 495, 496, 500 Seem, R. R., 418, 421, 446 Seeman, J., 233, 272 Segal, Z. V., 295, 298, 299, 320, 321,

535, 566 Segrin, C., 292, 321 Seidel, J., 566 Seligman, M., 205, 233, 234, 326 Selvini Palazzoli, M., 529, 531 Selye, H., 118, 157 Sera, H., 139 Sergin, C., 321 Shapiro, F., 290, 291, 321, 322 Sharp, J. G., 162, 181, 197

Shaw, B., 361, 374 Shaw, S., 376 Shay, J. J., 89, 108 Shulman B. H., 129, 157 Siegel, R. D., 295, 298, 319–322, 447 Sime, W., 376 Sisti, M., 296, 298, 321 Skinner, B. F., 7, 274, 322 Skovholt, T. M., 22, 38, 42 Smith, C., 42 Smith, E. W. L., 272 Smith, L., 43, 65, 108, 157, 234, 272,

376 Smith, M. L., 555, 566 Smith, T. B., 43 Solomon, R., 290, 322 Sonstegard, M. A., 111, 139, 157, 530 Soto, A., 29, 43 Sparks, J. A., 494, 495, 496, 498, 500,

556, 566 Sperry, J., 111, 114, 126, 127, 136, 157 Sperry, L., 22, 43, 111, 114, 126,

127, 128, 133, 136, 155–157, 375, 531

Spiegler, M., 156, 197, 233, 272, 276, 281, 284, 287, 288, 290, 291, 310, 315, 316, 319, 322, 407, 447

Spotts-De Lazzer, A., 60, 65 St. Clair, M., 89, 91, 108 Stadler, H., 41 Stanton, M., 504, 528, 531 Stauffer, M. D., 197, 233, 320, 376,

407, 446 Stebnicki, M. A., 108, 156, 192, 197,

375, 446, 531 Steen, S., 216 Steinberg, A., 57, 64, 65, 272, 446 Stern, D. N., 91, 108 Stewart, M. O., 375 Stiver, I. P., 414, 447 Stone, W. N., 89, 108 Stopa, L., 320, 322 Strentzsch, J., 446 Stricker, G., 565, 566 Strosahl, K. D., 321 Strumpfel, U., 268, 272 Strunk, D., 375 Strupp, H. H., 92, 108 Stuart, R., 317 Sue, D., 43, 65, 108, 157, 234, 272,

376 Sue, D. W., 29, 30, 43, 51, 65, 98, 108,

128, 146, 147, 157, 223, 234, 264, 272, 361, 363, 376

Sullivan, H. S., 113 Surrey, J. L., 414, 415, 447 Suziki, J. Y., 233 Sweeney, D. S., 272

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572 Name Index

Sweeney, T. J., 124, 125, 155, 157 Sweezy, M., 508, 509, 531 Swenson, C. R., 301, 302, 322

Tallman, K., 200, 232, 556, 565 Tanaka, K., 322 Taniike, M., 322 Tapia, N., 16 Tausch, R., 201, 202, 214, 233 Teasdale, J. D., 298, 299, 321, 566 Terner, J., 113, 157 Tharp, R. G., 293, 294, 322 Thomas, J., 500 Tillich, P., 171, 197 Toman, S., 270, 271, 272 Tompkins, M. A., 344, 376 Toporek, R., 41 Torres-Harding, S., 375 Torres Rivera, E., 446 Trepal, H., 414, 447 Trepper, T. S., 500 Trotter-Mathison, M., 38, 42 Tsukidate, N., 322

Uken, A., 495, 496, 500

VandeCreek, L., 45, 65 Vandenbos, G. R., 40–43, 108, 234,

321, 566 Vasquez, C. I., 446 Vasquez, M. J. T., 42, 64, 65 Vaz, A., 233 Vernon, A., 321, 372 Vonk, I. J. J., 375 Vontress, C. E., 170, 173, 174, 179,

186, 193, 197 Vorus, N., 108 Vos, J., 196

Wachtel, P., 106 Wade, A. G., 208, 232, 556, 565 Walker, L., 442–443, 444, 447

Walker, M., 447 Walsh, F., 531 Walsh, R., 38, 39, 43, 193, 197 Walter, J. L., 454, 495, 500, 501 Walters, R. H., 274, 278, 320 Wampold, B. E., 19, 20, 22, 32, 42,

43, 228, 230, 232, 233, 500, 556, 565, 566

Wampold, J. C., 536, 546, 566 Wang, C., 233 Warfield, M., 26, 41 Watkins, K. A., 156 Watson, D. L., 293, 294, 322 Watson, J. C., 204, 206, 212–214, 222,

228, 232–234 Watts, R. E., 110, 128, 131, 135, 136,

152, 153, 156, 157 Watzlawick, P., 152 Wedding, D., 272, 374, 375, 565, 566 Weiner, M. B., 446 Weiner-Davis, M., 450, 453, 457, 460,

495, 500 Weishaar, M. E., 324, 339, 341, 344–

346, 371, 374, 376, 449, 501 Wells, A., 375 Wenzel, A., 108 West, J. D., 457, 499 Westra, H. A., 468, 499 Wheeler, A. M., 50, 64, 65, 238, 271 Wheeler, G., 237, 249, 250, 272 White, B. A., 64 White, J. R., 340, 376 White, M., 7, 450, 454, 473, 474, 476,

478–481, 486, 487, 499, 501, 509, 514, 531

Wiggins-Frame, M., 566 Wigren, J., 108 Williams, E. N., 433, 445, 446, 447 Williams, J. M. G., 298, 299, 321, 566 Williams, L., 531 Wilson, K. G., 321 Wilson, M., 156

Winslade, J., 475, 476, 477, 478, 479, 481, 483–486, 494, 495, 497, 499–501

Wise, E. H., 23, 43 Wiseman, H., 22, 42 Woldt, A., 270, 271, 272 Wolf, A., 234 Wolitzky, D. L., 67, 68, 75, 76, 78, 80,

84, 90, 92, 98, 108 Wolpe, J., 280, 322 Woolfolk, R. L., 376 Worell, J., 413, 417, 418, 419, 421,

425, 433, 442, 445, 447 Worthington, Jr., E. L., 41, 42, 541,

566 Wubbolding, R. E., 7, 377, 379, 381,

382, 384–392, 395–397, 398, 399, 403–407

Wubbolding, S., 377, 389, 407

Yalom, I., 6, 105, 108, 160–161, 162, 167, 174, 175, 177–179, 181, 194–197

Yalom, M., 161, 197 Yamada, T., 292, 322 Yamamoto, T., 322 Yeomans, F., 107, 108 Yontef, G., 237, 238, 239, 245, 247–

249, 250, 252, 257, 267, 269, 272 Young, J. S., 540–542, 565, 566

Zamani, N., 478, 500 Zeig, J. K., 108, 272, 374, 376 Zimmerman, J., 478, 501 Zimring, F. M., 201, 202, 214, 233,

234 Zinker, J., 238, 244, 269, 272 Zur, O., 58, 59, 64, 65

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573

Subject Index

ABA. See Applied behavioral analysis (ABA) ABC model, 281 ABC model of personality, 327–328 ABCT. See Association for Behavioral

and Cognitive Therapies (ABCT) ACA Code of Ethics, 25, 26, 49, 57, 61 Academy of Cognitive Therapy, 373 Acceptance, 295 Acceptance and commitment therapy

(ACT), 302–304, 309, 534 Acceptance of others, 335 Accurate empathy, 212 Accurate emphatic understanding,

211–212 ACT. See Acceptance and commitment

therapy (ACT) Action-oriented phase, 135 Action-oriented therapies, 8 Actualizing tendency, 206 ADDRESSING framework, 430 Adlerian brief therapy, 144–145 Adlerian pattern-focused therapy, 136 Adlerian therapy, 8, 109–157

adaptive reorientation and reeducation, 133–137

application of approach, 549 basic philosophy, 537 birth order, 122–123 brief therapy, 144–145, 152 case of Gwen, 149–151 case of Stan, 148–149 change and search for new

possibilities, 135 community feeling, 117 contributions of, 553 crucial Cs, 133, 134 culture, race and ethnicity, 123–124 early recollections (ERs), 130–132,

143–144 encouragement process, 134–135 expert’s perspective (James Robert

Bitter), 141–146 family atmosphere, 121 family constellation and family values,

120, 130 family counseling, 138 further information (podcasts/videos/

training institutes), 155 gender guiding lines and gender

identities, 121 goal, 151 goal-directed movement, 114–115, 116

goal orientation and unity of personality, 115–117

goals of therapy, 543 group counseling, 138–139 human nature, 113–114 individual psychology, 137–138, 141 key concepts, 538 key figures, 110–112 life tasks, 120–121, 142 limitations and criticisms, 153, 554 multiculturalism, 144, 146–147, 551,

552 overview, 6 pattern-focused therapy, 143 presence, 143 private logic, 118–119 push-button technique, 136–137 resourceful, flexible therapists, 152 school counseling, 139–141 self-understanding and insight,

132–133 sibling relationships, 122–123 social interest, 117 systemic holism, 123–124 therapeutic alliance, 128, 129 therapeutic process, 124–127 therapeutic relationship, 125–127, 546 therapeutic techniques and

procedures, 548 therapists - making a difference,

136–137 time-limited approach, 144–145, 152 use, psychology of, 142 Z factor, 119

ADPCA. See Association for the Development of the Person- Centered Approach (ADPCA)

Advising clients, 36–37 Aloneness, 171 Alternative story, 481 Ambiguity, 35 Ambivalent movement, 114, 116 American Association for Marriage and

Family Therapy, 530 American Counseling Association (ACA),

406 American Psychoanalytic Association,

107 American Psychological Association,

194, 231, 444 Anal stage, 72, 74 Analytical psychology, 87 Androcentricity, 441

Anger, 126 Anger management training, 292 Angst, 163 Anima, 88 Animus, 88 Antecedent events, 281 Anxiety, 32

Adlerian therapy, 126 existential therapy, 163, 174, 184 Freud, Sigmund, 70

Applied behavioral analysis (ABA), 283 Arbitrary inference, 342 Archetype, 88 Aspirational ethics, 45 Aspirational practice, 45 Assertiveness training, 424 Assessment, 214 Assessment and diagnosis, 52–55 Assimilative integration, 535 Association for Behavioral and Cognitive

Therapies (ABCT), 277 Association for Humanistic Psychology,

232 Association for the Development of

the Person-Centered Approach (ADPCA), 231

Association for Women in Psychology (AWP), 444

Attachment theory, 517 “Attending to the obvious,” 239 Authenticity, 169 Automatic thoughts, 347 Autonomy vs. shame and doubt, 74 Awareness, 244

BASIC I.D. assessment model, 295 Basic mistakes, 125 Bay Area Family Therapy Training

Associated, 498 Behavior modification, 284 Behavior therapy, 8, 273–322

acceptance and commitment therapy (ACT), 302–304

application of approach, 550 applied behavioral analysis (ABA), 283 basic characteristics and assumptions,

279–280 basic philosophy, 537 brief therapy, 308–309 case of Gwen, 313–314 case of Stan, 311–312 contributions of, 553 cornerstone of, 314

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574 Subject Index

dialectical behavior therapy (DBT), 300–302

evidence-based therapy (EBT), 316 expert’s perspective (Sherry Cormier),

307–309 exposure therapy, 288–290 eye movement desensitization and

reprocessing (EMDR), 290–291 flooding, 289–290 further information (videos/DVDs/

websites), 318–319 goals of therapy, 543 group counseling, 304–305 historical background, 276–277 key concepts, 538 limitations and criticisms, 316–317,

554 major areas of development, 277–279 mindfulness strategies, 295–299, 308 multiculturalism, 309–311, 551, 552 multimodal therapy, 294–295 operant conditioning techniques,

283–284 overview, 7 progressive muscle relaxation, 285–

286, 308 reinforcement, 283 school counseling, 306–307 self-management strategies, 293–294,

308 social skills training, 292 systematic desensitization, 286–288 therapeutic process, 280–283 therapeutic relationship, 283, 546 therapeutic techniques and

procedures, 548 Behavioral analysis, 281 Behavioral assessment interview, 281 Being-in-the-world, 164 Being with, 260 Belonging and love, 205 Betweenness, 164 Bibliotherapy

cognitive behavior therapy (CBT), 332 feminist therapy, 424 rational emotive behavior therapy

(REBT), 332 Birth order, 122–123 Blank screen approach, 75 Blocked energy, 244 Boom-boom-boom therapy, 252 Borderline personality disorder, 92 Boundary crossing, 59 Boundary disturbance, 242 Boundary violation, 60 BPT. See Brief psychodynamic therapy

(BPT)

Bracketing, 24 Brief Family Therapy Center, 452 Brief psychodynamic therapy (BPT),

93–94 Brief therapy

Adlerian therapy, 144–145, 152 behavior therapy, 308–309 existential therapy, 181 family systems therapy, 519 feminist therapy, 431 gestalt therapy, 262 narrative therapy, 486 person-centered therapy, 221 psychoanalytic therapy, 93–94 rational emotive behavior therapy

(REBT), 334 solution-focused brief therapy (SFBT),

451–467 Brown v. The Board of Education, 146 Burnout, 37

Case of Gwen. See Gwen, case of Case of Stan. See Stan, case of Catastrophizing, 342 Catch themselves, 135 CBM. See Cognitive behavior

modification (CBM) CBT. See Cognitive behavior therapy

(CBT) Center for Gestalt Development, 271 Center for Reality Therapy, 406 Change-Focused Practice in School

(CFPS), 498 Change-talk, 457 Choice theory/reality therapy (CT/RT),

377–407 application of approach, 550 case of Gwen, 401–402 case of Stan, 400–401 characteristics of reality therapy,

382–384 choice, 383 choice theory explanation of behavior,

382 contributions of, 403–404, 553 counseling environment, 387 cycle of counseling, 386, 391 expert’s perspective (Robert

Wubbolding), 395–397 further information (podcasts/videos/

training institutes), 405–406 goals of therapy, 543 group counseling, 393 human nature, 380–381 key concepts, 538 key figures, 378–379 limitations and criticisms, 404–405, 555 multiculturalism, 397–399, 551, 552

overview, 7, 380 procedures leading to change,

387–388 responsibility, 383, 404 school counseling, 394–395 therapeutic process, 384–386 therapeutic relationship, 546 therapeutic techniques and

procedures, 548 transference, 383, 404 WDEP system, 388–392

Classical conditioning, 277–278 Classical psychoanalysis, 73 Client-centered therapy, 201–202 Client-therapist relationship

Adlerian therapy, 125–127 behavior therapy, 283 choice theory/reality therapy, 386 cognitive therapy (CT), 345–346 egalitarian counseling relationship,

416–417 existential therapy, 177–178, 191 family systems therapy, 509–510 feminist therapy, 416–417, 420 gestalt therapy, 248–249 narrative therapy, 477 person-centered therapy, 209–212 psychoanalytic therapy, 78–80, 104 psychotherapy integration, 545–547 rational emotive behavior therapy

(REBT), 330 solution-focused brief therapy (SFBT),

458–459 strengths-based cognitive behavior

therapy (SB-CBT), 351 therapeutic alliance, 104, 128, 129

Clinical behavior therapy, 294 Codes of ethics, 46–47 Cognitive behavior modification (CBM),

356–361 cognitive narrative perspective,

360–361 contributions of, 369 how behavior changes, 357–358 key figures, 356 limitations and criticisms, 371 stress inoculation training (SIT), 357,

358–360 Cognitive behavior therapy (CBT), 278–

279, 323–376 application of approaches, 550 basic philosophy, 537 case of Gwen, 366–367 case of Stan, 364–365 CBM. See Cognitive behavior

modification (CBM) contributions of individual

approaches, 368–370, 553

Behavior therapy (continued )

64428_subject_index_ptg01.indd 57464428_subject_index_ptg01.indd 574 21/11/22 3:17 PM21/11/22 3:17 PM

Subject Index 575

CT. See Cognitive therapy (CT) expert’s perspective (Christine A.

Padesky), 353–355 feminist therapy, 442 further information (podcasts/videos/

training institutes), 372–373 goals of therapy, 543 key concepts, 538 limitations and criticisms, 370–372,

555 multiculturalism, 361–363, 551, 552 overview, 7 REBT. See Rational emotive behavior

therapy (REBT) SB-CBT. See Strengths-based cognitive

behavior therapy (SB-CBT) school counseling, 348–349 therapeutic relationship, 546 therapeutic techniques and

procedures, 548 Cognitive diffusion, 302 Cognitive distortions, 342 Cognitive narrative perspective, 360–361 Cognitive restructuring, 357 Cognitive structure, 357 Cognitive therapy (CT), 8, 338–348

applications, 346–348 basic principles, 343–344 cognitive distortions, 342 contributions of, 369, 553 family therapy, 347–348 generic cognitive model, 341–343 key figures, 338–340 limitations and criticisms, 371 REBT, contrasted, 344 theoretical assumptions, 341 therapist-client relationship, 345–346,

546 Collaborative language systems

approach, 451 Collective unconscious, 88 Commitment to action

behavior therapy, 303 choice theory/reality therapy, 391

Common factors approach, 535 Community feeling, 117 Compensation, 72 Concern-based ethics, 45 Confidentiality, 49–50 Confluence, 241–242 Confrontation, 252 Congruence, 210 Conjoint therapy, 507 Conscious, 70 Consciousness raising, 4259 Consequences, 281

Constancy of self and object, 92 Contemporary psychoanalysis, 73 Counseling, 4

advising clients, 36–37 ambiguity, 35 author’s philosophy, 4 client demands, 34 countertransference, 35–36, 79 ethics. See Ethics feedback-informed treatment (FIT),

556–557, 562, 564–565 humor, 36 integrative approach. See

Psychotherapy integration lack of commitment from clients, 34–35 LGBTQ+ clients, 25–26 multicultural competence, 28–32 practitioners. See Therapist/counselor professional burnout, 37 professional organizations, 62–63 religious and spiritual values, 26–28 silence, 34 values, 24–25, 28

Counselor. See Therapist/counselor Counter story, 475 Countertransference, 35–36, 79, 95, 96 Courage, 124 Courage to be, 171 COVID-19

existential therapy, 192 psychoanalytic therapy, 105–106 services gap, 309

Creative Connection, The, 219 Crisis, 73 Crisis intervention, 215 Critical consciousness, 416, 429 Crucial Cs, 133, 134 CT. See Cognitive therapy (CT) CT/RT. See Choice theory/reality therapy

(CT/RT) Culturally inclusive approach, 413 Culture, 31–32, 123. See also

Multiculturalism Cycle of counseling, 386, 391

Dasein, 164 Daseinanalysis, 164 DBT. See Dialectical behavior therapy

(DBT) Death, 175 Death instincts, 68 Deconstruction, 478–479, 484 Defense mechanisms, 71–72 Deflection, 241 Denial, 71 Depression, 126 Desensitization, 287 Diagnosis, 53–54

Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 53–54

Dialectical behavior therapy (DBT), 105, 300–302, 309, 534

Dialectics, 300 Dichotomous thinking, 342 Differentiation of self, 517 Direction and doing, 389–390 Displacement, 71 Dissociative identity disorder, 508 Distress, 118 Distress tolerance, 301 Diversity-competent practitioners, 29–31 Dominant culture, 123–124 Dominant story, 474 Double listening, 475, 485 Dream analysis, 83 Dream work, 83, 255–257 DSM-5. See Diagnostic and Statistical

Manual of Mental Disorders (DSM-5) Dual or multiple relationships, 56–61 Dulwich Centre, 498

Early recollections (ERs), 130–132, 143–144

EBT. See Evidence-based therapy (EBT) EFT. See Emotion-focused therapy (EFT) Egalitarian counseling relationship,

416–417 Ego, 69 Ego-defense mechanisms, 71–72 Ego psychology, 73, 103 Electra complex, 74 EMDR. See Eye movement

desensitization and reprocessing (EMDR)

Emotion-focused therapy (EFT), 202– 203, 535

Emotional regulation, 301 Empathy, 211–212 Empowerment, 422 Empty-chair technique, 253–254 Enactments, 518 Encouragement, 124, 134 Encouragement process, 134–135 Engendered lives, 414 Ericksonian principle, 384 Erikson’s psychosocial perspective,

72–73, 74–75 ERs. See Early recollections (ERs) Ethics, 44–65. See also Legal

considerations assessment and diagnosis, 52–55 becoming an ethical counselor, 61 boundaries, 59–61 codes of ethics, 46–47 decision making, 47–48 environmental factors, 52

Cognitive behavior therapy (CBT) (continued )

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576 Subject Index

evidence-based practice (EBP), 55–56 multicultural perspective, 50–52 multiple relationships, 56–61 professional organizations, 62–63 sexual relationships, 57 social media, 60–61 technology, 49–50 terminology, 45

Ethics codes, 46–47 Ethnocentrism, 441 European Association for Psychotherapy

(EAP), 397 Evanston Family Therapy Institute, 498 Evidence-based practice (EBP), 55–56 Evidence-based therapy (EBT), 316 Exaggeration exercise, 255 Exception question, 459 Exercises, 249 Existential analysis, 164 Existential anxiety, 163, 174 Existential approach, 3, 8 Existential guilt, 169 Existential-Humanistic Institute (EHI),

195 Existential-humanistic practitioners, 204 Existential neurosis, 173 Existential therapy, 158–197

aloneness, 171 anxiety, 163, 174, 184 application of approach, 549 basic philosophy, 537 basic premise, 162 brief therapy, 181 case of Gwen, 189–190 case of Stan, 188–189 clients appropriate for existential

counseling, 180 contributions of, 553 courage to be, 171 COVID-19, 192 death, 175 existential-humanistic practitioners,

204 expert’s perspective (Emmy van

Deurzen), 183–186 freedom and responsibility, 168–170,

184 further information (podcasts/DVDs/

training institutes), 194–195 goal, 161 goals of therapy, 543 group counseling, 181–182 human nature, 166–167 I/it relationship, 178 I/Thou relationship, 178 key concepts, 538 key figures, 159–166

limitations and criticisms, 193, 554 meaning in life, 172, 173, 184 meaninglessness, 172–173 multiculturalism, 186–188, 551, 552 nonbeing, 175 overview, 6 personal identity, 170, 172 phases of existential counseling, 180 relatedness, 171–172 responsibility, 162, 168–170 school counseling, 182–183 search for meaning, 172, 173 self-awareness, 167–168 therapeutic process, 175–178 therapeutic relationship, 177–178,

191, 546 therapeutic techniques and

procedures, 548 values, 172, 184

Existential tradition, 166 Existential vacuum, 173 Existentialism, 162, 204 Experiment, 249–251, 261–262 Exposure therapy, 288–290 Externalization, 479, 485 Extinction, 284–285 Eye movement desensitization and

reprocessing (EMDR), 290–291

Family atmosphere, 121 Family constellation, 120, 130 Family counseling, 138 Family sculpting, 507 Family systems therapy, 4, 8, 502–531

application of approach, 550 assessment process, 510–513 basic assumption, 527 basic philosophy, 537 brief therapy, 519 case of Gwen, 525–527 case of Stan, 522–525 cognitive therapy (CT), 347–348 contributions of, 528–529, 554 expert’s perspective (James Robert

Bitter), 516–520 facilitating change, 514–515 further information (podcasts/videos/

training institutes), 529–530 genogram, 510–512, 518 goals and values, 527–528 goals of therapy, 543 hypothesizing and sharing meaning,

513–514 key concepts, 517, 539 key figures, 506–507 limitations and criticisms, 529, 555 multiculturalism, 520–521, 551, 552 multilayered approach, 509–515, 528

overview, 7 recent innovations, 508 school counseling, 515–516 structural-strategic family therapy,

507–508 systemic/individual approaches,

compared, 504–505 therapeutic relationship, 509–510, 547 therapeutic techniques and

procedures, 549 Family therapy. See Family systems therapy Family Therapy Magazine, The, 530 Family values, 120 Fear-based ethics, 45 Feedback-informed treatment (FIT),

556–557, 562, 564–565 Feminist therapy, 3–4, 8, 408–447

application of approach, 550 assessment and diagnosis, 420–421 basic philosophy, 537 basic principles, 415–417 brief therapy, 431 case of Gwen, 436–439 case of Stan, 434–436 cognitive behavior therapy (CBT), 442 constructs of feminist theory, 413 contributions of, 441–442, 554 expert’s perspective (Carolyn Z. Enns),

428–432 further information (podcasts/videos/

training institutes), 443–445 goals of therapy, 543 group counseling, 426 history and development, 412–413 key concepts, 439–440, 539 key figures, 409–410 limitations and criticisms, 442–443, 555 men, role of, 425 multiculturalism, 432–434, 551, 552 overview, 7 personality development, 413–414 relational-cultural theory (RCT),

414–415 school counseling, 426–428 therapeutic process, 417–420 therapeutic relationship, 416–417,

420, 547 therapeutic techniques and

procedures, 421–425, 549 transnational feminism, 415, 432

FFST. See Formula first session task (FFST)

Field theory, 239 Figure, 239 Figure-formation process, 240, 268 First-order change, 124, 133 First World Congress for Existential

Therapy, 185

Ethics (continued )

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Subject Index 577

FIT. See Feedback-informed treatment (FIT)

“Fleshing out a flash,” 247 Flexible-multicultural perspective, 413 Flooding, 289–290 Formula first session task (FFST), 460–461 Free association, 76, 82 Freedom, 169 Freedom and responsibility, 168–170, 184 Freud, Sigmund. See also Psychoanalytic

therapy anxiety, 70 biography, 67–68 conscious and unconscious, 70, 95 development of personality, 72 ego, 69 Erikson, compared, 74–75 human nature, 68 id, 69 overview, 74–75 structure of personality, 68–69 superego, 69

Frustration tolerance, 335 Functional assessment, 280 “Fundamental rule,” 76 Future projection technique, 254

Gemeinschaftsgefühl, 117 Gender-fair approach, 413 Gender guiding lines and gender

identities, 121 Gender-role analysis, 422–423 Gender role intervention, 423 Generativity vs. stagnation, 75 Generic cognitive model, 341–343 Genital stage, 74–75 Genogram, 510–512, 518 Genuineness, 210 Gestalt Directory, 271 Gestalt therapy, 8, 235–272

application of approach, 549 basic assumption, 239 basic philosophy, 537 basic principles, 239–240 brief therapy, 262 case of Gwen, 266–267 case of Stan, 264–265 cautionary note, 269 confrontation, 252 contacts and resistances to contact,

240–242 contributions of, 553 energy and blocks to energy, 244 experiments, 249–251, 261–262 expert’s perspective (Jon Frew), 260–262 further information (DVDs/

training programs/professional associations), 269–270

goals of therapy, 543 group counseling, 257–258 human nature, 238–239 integration sequence, 248 interventions, 253–257 “It” talk, 246 key concepts, 538 limitations and criticisms, 268–269,

554 multiculturalism, 263–264, 551, 552

The Now, 242–243 “now” awareness, 242–243 overview, 7 school counseling, 258–260 therapeutic process, 244–249 therapeutic relationship, 248–249, 546 therapeutic techniques and

procedures, 548 unfinished business, 243–244 “You” talk, 246

Givens of existence, 174 Goal-directed movement, 114–115, 116 Ground, 239 Group counseling, 85–86

Adlerian therapy, 138–139 behavior therapy, 304–305 choice theory/reality therapy, 393 existential therapy, 181–182 gestalt therapy, 257–258 narrative therapy, 482–483 person-centered therapy, 215–216 rational emotive behavior therapy

(REBT), 334 solution-focused brief therapy (SFBT),

462–463 Gwen, case of

Adlerian therapy, 149–151 background, 12 behavior therapy, 313–314 choice theory/reality therapy, 401–402 cognitive behavior therapy (CBT),

366–367 of Existential therapy, 189–190 family systems therapy, 525–527 feminist therapy, 436–439 gestalt therapy, 266–267 intake session, 14 person-centered therapy, 225–227 postmodern approaches, 491–493 psychoanalytic therapy, 100–102 psychotherapy integration, 560–562 video, 15–17

Holism, 239 Holistic narrative, 129 Homework, 330, 331 The Houston-Galveston Institute, 498 Human nature

Adlerian therapy, 113–114 choice theory/reality therapy, 380–381 existential therapy, 166–167 Freud, Sigmund, 68 gestalt therapy, 238–239 person-centered therapy, 206–207

Human validation process model, 507 Humanism, 204 Humanistic psychology, 204–206 Humor, 36, 333

I/it relationship, 178 I/Thou relationship, 164, 178 Id, 69 Id psychology, 73 Identification, 72 Identity vs. role confusion, 74 Imaginal flooding, 290 Immediacy, 213 Impasse, 243 In vivo exposure, 289 In vivo flooding, 289 Inauthenticity, 168 Individual psychology, 137–138, 141 Individuation, 88 Industry vs. inferiority, 74 Inferiority feeling, 118 Informed consent, 48–49, 422 Initiative vs. guilt, 74 Insight, 132 Integrative approach. See Psychotherapy

integration Integrity vs. despair, 75 Interactionist intersectionality view, 413 Internal dialogue, 253, 357 International Association of Marriage and

Family Counseling (IAMFC), 530 International Center for Clinical

Excellence (ICCE), 556, 564 International Collaborative of

Existential Counselor and Psychotherapists, 195

International Journal of Choice Theory and Reality Therapy, 406

International Journal of Narrative Therapy and Community Work, 498

International Society for Existential Psychotherapy and Counselling, 195

Interpersonal effectiveness, 301 Interpersonal empathy, 211–212 Interpretation, 82–83, 133 Interruptions in contact, 242 Intersectionality, 4259 Intersubjectivity, 172 Intimacy vs. isolation, 74 Introjection, 72, 241 Irrational beliefs, 326, 331 “It” talk, 246

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578 Subject Index

Jean Baker Miller Training Institute, 444 Journal of Brief Therapy, 497 Journal of Marital and Family Therapy, 530 Jung, Carl, 87–89

Labeling and mislabeling, 342 Latency stage, 74 Latent content, 83 Legal considerations

confidentiality, 49–50 ethics. See Ethics informed consent, 48–49 privacy, 48–49 privileged communication, 49–50

LGBTQ+ clients, 25–26 Libido, 68 Life-changing psychotherapy, 165 Life instincts, 68 Life-span perspective, 413 Life tasks, 120–121, 134, 142 Lifestyle, 116 Lifestyle assessment, 116, 126 Logotherapy, 159, 173

Magnification and minimization, 342 Mahler, Margaret, 90–92 Maintaining the analytic framework, 81–82 Making-the-rounds intervention, 254 Mandatory ethics, 45 Manifest content, 83 Mapping-the-influence question, 479 Maslow’s hierarchy of needs, 204–205 MBCT. See Mindfulness-based cognitive

therapy (MBCT) MBSR. See Mindfulness-based stress

reduction (MBSR) Meaning in life, 172, 173, 184 Meaninglessness, 172–173 Melissa Institute for Violence

Prevention, 373 Memories, Dreams, Reflections (Jung), 87 Mental health professionals. See

Therapist/counselor #MeToo movement, 416 MI. See Motivational interviewing (MI) MI spirit, 468 Middle child, 122 Mindfulness, 301 Mindfulness-based cognitive therapy

(MBCT), 298–299, 309, 535 Mindfulness-based stress reduction

(MBSR), 296–298 Mindfulness strategies, 295–299, 308 Minor psychotherapy, 127 Miracle question, 460 Miracle Question, The, 142 Modernism, 449 Moral anxiety, 70

Motivational interviewing (MI), 467–473 basic principles, 469–470 key figures, 467 MI spirit, 468 person-centered therapy, compared,

468–469 school counseling, 472–473 solution-focused brief therapy,

compared, 471–472 stages of change, 470–471

Movements, 114–116, 117–118 Multiculturalism

Adlerian therapy, 144, 146–147 behavior therapy, 309–311 choice theory/reality therapy,

397–399 cognitive behavior therapy (CBT),

361–363 counseling and therapy, 28–32 ethics, 50–52 existential therapy, 186–188 family systems therapy, 520–521 feminist therapy, 432–434 gestalt therapy, 263–264 person-centered therapy, 222–223 postmodern approaches, 487–488 psychoanalytic therapy, 98–99 psychotherapy integration, 539–540

Multigenerational family therapy, 506 Multimodal therapy, 294–295 Multiple relationships, 56–61

Narcissistic personality, 91 Narrative therapy, 473–487

brief therapy, 486 expert’s perspective (John Winslade),

483–486 group counseling, 482–483 key concepts, 474–475, 484 key figures, 473 therapeutic process, 475–477 therapeutic techniques and

procedures, 478–482, 485 NASAP. See North American Society of

Adlerian Psychology (NASAP) Need for esteem, 205 Negative cognitive triad, 340 Negative punishment, 285 Negative reinforcement, 284 Neurosis, 118 Neurotic anxiety, 70, 174 NEW Paradigm, 351, 352–353 New School of Psychotherapy and

Counselling (NSPC), 166, 195 Non-directive counseling, 201 Nonbeing, 175 Normal anxiety, 174 Normalizing judgment, 474

North American Society of Adlerian Psychology (NASAP), 155

The Now, 242–243 “Now” awareness, 242–243

Object relations, 89 Object-relations therapy, 89, 103, 104 Objective empathy, 211–212 Objective interview, 129 Oedipus complex, 74 OLD system, 352–353 Oldest child, 122 Only child, 123 Operant conditioning techniques, 278,

283–284 Oral stage, 72, 74 Organismic self-regulation, 240 ORS. See Outcome rating scale (ORS) Outcome rating scale (ORS), 225, 557 Overgeneralization, 342

Paining behaviors, 382 Paradoxical theory of change, 239 Pattern-focused therapy, 143 PECA. See Person-centered expressive

arts (PECA) PEERS. See Program for the Evaluation

and Enrichment of Relational Skills (PEERS)

Perfectionism, 33 Person-centered expressive arts (PECA),

217–221 Person-centered therapy, 8, 198–234

application of approach, 549 assessment, 214 basic philosophy, 537 brief therapy, 221 case of Gwen, 225–227 case of Stan, 224 contributions of, 553 crisis intervention, 215 emotion-focused therapy (EFT),

202–203 existentialism and humanism,

203–204 expert perspective (Natalie Rogers),

219–221 further information (podcasts/

DVDs/professional organizations), 231–232

goals of therapy, 543 group counseling, 215–216 historical overview, 201–202, 212–213 human nature, 206–207 humanistic psychology, 204–206 key concepts, 538 limitations and criticisms, 229–230, 554 Maslow’s hierarchy of needs, 204–205

64428_subject_index_ptg01.indd 57864428_subject_index_ptg01.indd 578 21/11/22 3:17 PM21/11/22 3:17 PM

Subject Index 579

motivational interviewing, compared, 468–469

multiculturalism, 222–223, 551, 552 overview, 7 person-centered expressive arts

(PECA), 217–221 positive psychology, 205–206 research, 229 Rogers, Carl and Natalie, 199–200 school counseling, 216–217 therapeutic process, 207–212 therapeutic relationship, 209–212, 546 therapeutic techniques and

procedures, 548 Personal identity, 170, 172 Personal values, 24–25, 28, 88 Personality development, 413–414 Personality disorders, 115 Personalization, 342 Personal model of resilience (PMR), 352 Phallic stage, 72, 74 Phenomenological existentialism, 163 Phenomenological inquiry, 242 Phenomenology, 162 Physiological needs, 205 Picture album, 381, 389 Planning and action, 391–392 Pleasure principle, 69 PMR. See Personal model of resilience

(PMR) Political and critical consciousness, 416,

429 Positionality, 415, 417 Positive psychology, 205–206, 453 Positive punishment, 285 Positive reinforcement, 284 Postmodern approaches, 448–501

application of approaches, 550 basic philosophy, 537 case of Gwen, 491–493 case of Stan, 489–491 collaborative language systems

approach, 451 contributions of, 494–496, 554 further information (podcasts/videos/

training institutes), 497–498 goals of therapy, 543 key concepts, 539 limitations and criticisms, 496, 555 MI. See Motivational interviewing (MI) modernists, compared, 449 multiculturalism, 487–488, 551, 552 narrative therapy. See Narrative

therapy overview, 7, 9 SFBT. See Solution-focused brief

therapy (SFBT)

social constructionism, 449–450, 493 therapeutic relationship, 547 therapeutic techniques and

procedures, 549 Power analysis, 423–424 POWR online, 444 POWR-L, 444 Practitioners. See Therapist/counselor Presence, 143, 164, 165, 213 Pretherapy changes, 459 Privacy, 48–49 Private logic, 118–119 Privileged communication, 49–50 Problem-saturated story, 454 Professional burnout, 37 Professional codes of ethics, 46–47 Professional organizations, 62–63 Program for the Evaluation and

Enrichment of Relational Skills (PEERS), 292

Progressive muscle relaxation, 285–286, 308

Projection, 71, 75, 241, 256 Psychoanalytic therapy, 3, 8, 66–108

application of approach, 549 basic philosophy, 537 brief psychodynamic therapy (BPT),

93–94 case of Gwen, 100–102 case of Stan, 99–100 conscious and unconscious, 70, 95 contributions of, 553 countertransference, 79, 95, 96 COVID-19, 105–106 defense mechanisms, 71–72 dream analysis, 83 Erikson’s psychosocial perspective,

72–73, 74–75 expert’s perspective (William Blau),

94–97 free association, 82 Freud. See Freud, Sigmund further information (DVDs/

supplemental readings/websites), 106–107

goals of therapy, 543 group counseling, 85–86 interpretation, 82–83 Jung, Carl, 87–89 key concepts, 538 limitations and criticisms, 105, 554 Mahler, Margaret, 90–92 maintaining the analytic framework,

81–82 multiculturalism, 98–99, 551, 552 nonjudgmental interpretation, 96 object-relations therapy, 89, 104 overview, 6

psychodynamic psychotherapy, 77 relational psychodynamic model, 90 resistance, 83–84 school counseling, 86–87 silence, 96 six basic techniques, 81 Strupp’s perspective on direction of

therapy, 92–93 therapeutic process, 75–80 therapeutic relationship, 78–80, 104, 546 therapeutic techniques and

procedures, 548 traditional therapy, contrasted, 81 transference, 78–79, 84–85, 95 usefulness, 103

Psychodynamic psychotherapy, 77 Psychodynamics, 76 Psychological contact, 143 Psychological distress, 417 Psychological muscle, 124, 133, 134 Psychology of use, 142 Psychology of Women Resource List, 444 Psychosexual stages, 72 Psychosocial stages, 72 Psychotherapy, 4 Psychotherapy integration, 532–566

advantages/challenges, 536–539 assimilative integration, 535 case of Gwen, 560–562 case of Stan, 557–560 client-therapist relationship, 545–547 common factors approach, 535 defined, 534 drawing on techniques from various

approaches, 547–555 effectiveness of counseling and

therapy, 555–556 further information (podcasts/videos/

training institutes), 564–565 multiculturalism, 539–540 spirituality and religion, 540–541 technical integration, 534 theoretical integration, 534–535 therapeutic process, 542–547

Psychotherapy.net, 107, 231, 270, 373, 444 Punishment, 285 Push-button technique, 136–137

Question, The, 129, 142

Race and ethnicity, 123–124 Rational behavior therapy, 8 Rational emotive behavior therapy (REBT)

ABC framework, 327–328 behavioral techniques, 334 brief therapy, 334 cognitive methods, 331–332 cognitive therapy, contrasted, 344

Person-centered therapy (continued )

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580 Subject Index

contributions of, 368–369, 553 emotional disturbance, 326–327 emotive techniques, 332–333 expert’s perspective (Debbie Joffe

Ellis), 336–338 group counseling, 334 key figures, 325 limitations and criticisms, 370–371 school counseling, 335 therapeutic process, 328–330 therapist-client relationship, 330, 546

Rational emotive imagery (REI), 332–333

Rationalization, 71 RCT. See Relational-cultural theory

(RCT) Reaction formation, 71 Reality anxiety, 70 Reality principle, 69 Reality therapy, 8, 382–384. See also Choice

theory/reality therapy (CT/RT) Reauthoring, 481 REBT. See Rational emotive behavior

therapy (REBT) REBT Self-Help Form, 331 Reflexivity, 415, 417 Reframing, 424 Reframing resistance, 471 Regression, 71 Rehearsal exercise, 255 REI. See Rational emotive imagery (REI) Reinforcement, 283 Relabeling, 425 Relapse prevention, 360 Relatedness, 171–172 Relational-cultural theory (RCT), 412,

414–415 Relational Gestalt therapy, 238. See also

Gestalt therapy Relational psychodynamic model, 90 Relaxation techniques, 285–286, 308 Religion and spirituality, 540–541 Religious and spiritual values, 26–28 Reorientation, 133 Repression, 71 Research, 229 Resilience, 4259 Resistance, 83–84, 165 Respondent conditioning, 277 Responsibility

choice theory/reality therapy, 383 existential therapy, 162, 168–170

Restricted existence, 176 Retroflection, 241 Reversal exercise, 255 Role-playing, 3, 333

Safety needs, 205 SAMIC3, 391 SB-CBT. See Strengths-based cognitive

behavior therapy (SB-CBT) Scaling question, 460 Schema, 347 School counseling

Adlerian therapy, 139–141 behavior therapy, 306–307 choice theory/reality therapy, 394–395 cognitive behavior therapy (CBT),

348–349 existential therapy, 182–183 family systems therapy, 515–516 feminist therapy, 426–428 gestalt therapy, 258–260 motivational interviewing (MI),

472–473 person-centered therapy, 216–217 psychoanalytic therapy, 86–87 rational emotive behavior therapy

(REBT), 335 solution-focused brief therapy (SFBT),

463–464 Search-and-discovery process, 54 Search for meaning, 172, 173 Second child, 122 Second-order change, 133 Selective abstraction, 342 Self-acceptance, 335 Self-actualization, 204–205 Self-and-world construct, 165 Self-awareness, 167–168 Self-care, 38–40 Self-compassion, 315 Self-directed behavior, 293 Self-disclosure

counselor, 33 feminist therapy, 422

Self-efficacy, 278 Self-evaluation, 390–391 Self-in-relation model, 412 Self-management strategies, 293–294,

308 Self-monitoring, 37–38, 46–47, 59 Self-observation, 357 Self psychology, 103 Self-statement, 357 Self-transcendence, 205 Self-understanding and insight, 132–133 Sense of humor, 36 Separation-individuation process, 91,

92 SEPTIMUS, 195 Session rating scale (SRS), 557 Sexual relationships, 57 SFBT. See Solution-focused brief therapy

(SFBT)

SFC. See Solution-focused counseling (SFC)

Shadow, 88 Shame-attacking exercises, 333 Sibling relationships, 122–123 Silence, 34, 96 SIT. See Stress inoculation training (SIT) Social action, 425 Social change, 416 Social-cognitive theory, 278 Social constructionism, 449–450, 493 Social identity analysis, 422–423 Social interest, 117 Social learning approach, 278 Social media, 60–61 Social role intervention, 423 Social skills training, 292 Society for Humanistic Psychology, 232 Society for the Exploration of

Psychotherapy Integration, 533 Society of Existential Analysis, 195 Society of Individual Psychology, 113 Socratic dialogue, 344, 345, 351, 354,

358, 361, 546 Solution-focused brief therapy (SFBT),

451–467, 495 basic assumptions, 454–455 characteristics of brief therapy, 455 expert’s perspective (John Murphy),

464–467 group counseling, 462–463 key concepts, 453–455, 465 key figures, 451–452 motivational interviewing, compared,

471–472 school counseling, 463–464 termination of counseling, 461 therapeutic process, 455–459 therapeutic techniques and

procedures, 459–461 Solution-focused counseling (SFC),

463–464, 495–496 Solution Focused Institute, 498 Spiritual and religious values, 26–28 Spirituality and religion, 540–541 SRS. See Session rating scale (SRS) Stages of change, 470–471 Stan, case of, 311–312

Adlerian therapy, 148–149 background, 9–10 choice theory/reality therapy, 400–401 cognitive behavior therapy (CBT),

364–365 existential therapy, 188–189 family systems therapy, 522–525 feminist therapy, 434–436 gestalt therapy, 264–265 intake interview, 10–12

Rational emotive behavior therapy (REBT) (continued )

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Subject Index 581

overview of key themes, 12 person-centered therapy, 224 postmodern approaches, 489–491 psychoanalytic therapy, 99–100 psychotherapy integration, 557–560 video, 12

Strengths-based cognitive behavior therapy (SB-CBT)

applications, 351–353 basic principles, 350–351 client-therapist relationship, 351 contributions of, 369, 553 key figures, 349–350 limitations and criticisms, 371 main idea, 350

Stress, 118 Stress inoculation training (SIT), 357,

358–360 Structural-strategic family therapy,

507–508 Student-centered teaching, 202 Style of living, 115 Subjective empathy, 211–212 Subjective interview, 129 Subjective units of distress scale (SUDS),

289 Sublimation, 71 SUDS. See Subjective units of distress

scale (SUDS) Superego, 69 Symbiosis, 91 Systematic desensitization, 286–288 Systemic holism, 123–124

Technical eclecticism, 294, 534 Technical integration, 534 Texas Women’s University, 445 Theoretical integration, 534–535 Therapeutic alliance, 104, 128, 129

Therapeutic lifestyle changes (TLCs), 38 Therapeutic relationship, 128. See also

Client-therapist relationship Therapist/counselor. See also Counseling

anxiety, 32 beginning therapists, 32–37 being yourself, 33 burnout, 37 defining your role, 37 diversity-competent practitioners,

29–31 effectiveness, 20–21 limitations, 34 perfectionism, 33 personal therapy, 22–24 required skills, 5, 9 self-care, 38–40 self-disclosure, 33 self-monitoring, 37–38 sense of humor, 36 sharing responsibility with client, 36 therapeutic lifestyle changes (TLCs),

38 therapeutic relationship. See Client-

therapist relationship Third force in therapy, 203 Third-order change, 133 Third School of Viennese

Psychoanalysis, 159 Thought records, 347 “Thrown-ness,” 164 Time-limited counseling. See Brief

therapy Time-limited dynamic psychotherapy,

93–94 TLC. See Therapeutic lifestyle changes

(TLCs) Top dog and underdog, 253 Total behavior, 382 Totalizing language, 475

Transference, 78–79, 84–85, 95, 383, 404 Transference relationship, 75 Transnational feminism, 415, 432 Trust vs. mistrust, 74

Unconditional acceptance of others, 335 Unconditional positive regard, 210–211 Unconditional self-acceptance, 335 Unconscious, 70, 95 Unfinished business, 243–244 Unique outcomes, 480, 484 University of Kentucky, 445 Use, psychology of, 142

Values counseling, 24–25, 28 existential therapy, 172, 184 family, 120 family systems therapy, 527–528 personal, 24–25, 28, 88

Wants, 388–389 WDEP system, 388–392

direction and doing, 389–390 planning and action, 391–392 self-evaluation, 390–391 wants, 388–389

WEIRD, 431 William Glasser International, 406 Working-through, 78

“You” talk, 246 Youngest child, 123

Z factor, 119 Zen Buddhist principles, 301

Stan, case of (continued )

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Cover
IFC
IBC
ES3
FM
Copyright
Contents
Preface
Chapter 1: Introduction and Overview

Introduction
Where I Stand
Suggestions for Using the Book
Overview of the Theory Chapters
Introduction to the Case of Stan

Intake Interview With Stan
Overview of Some Key Themes in Stan’s Life

Introduction to the Case of Gwen

Meet Dr. Kellie Kirksey
Background on the Case of Gwen
Intake Session

Video on Counseling Sessions with Gwen

Overview of Video MindTap Program for The Case of Gwen
Chapter 1 Intake Session
Chapter 2 Multicultural Perspectives
Chapter 3 Informed Consent Session
Chapter 4 Psychoanalytic (Psychodynamic) Therapy
Chapter 5 Adlerian Therapy
Chapter 6 Existential Therapy
Chapter 7 Person-Centered Therapy
Chapter 8 Gestalt Therapy
Chapter 9 Behavior Therapy
Chapter 10 Cognitive Behavior Therapy
Chapter 11 Choice Theory/Reality Therapy
Chapter 12 Feminist Therapy/Social Justice
Chapter 13 Postmodern Approaches: Solution-Focused Brief Therapy
Chapter 14 Family Systems Therapy
Chapter 15 Integrative Approaches

Chapter 2: The Counselor: Person and Professional

Introduction
The Counselor as a Therapeutic Person

Personal Characteristics of Effective Counselors

Personal Therapy for the Counselor
The Counselor’s Values and the Therapeutic Process

The Role of Values in Counseling
Can Counselors Who Self-Identify as Religious Provide Value-Free Counseling to LGBTQ+ Clients?
Addressing Religious and Spiritual Values in Counseling
The Role of Values in Developing Therapeutic Goals

Becoming an Effective Multicultural Counselor

Acquiring Competencies in Multicultural Counseling
Incorporating Culture in Counseling Practice

Issues Faced by Beginning Therapists

Dealing With Anxiety
Being Yourself and Self-Disclosure
Avoiding Perfectionism
Being Honest About Your Limitations
Understanding Silence
Dealing With Demands From Clients
Dealing With Clients Who Lack Commitment
Tolerating Ambiguity
Becoming Aware of Your Countertransference
Developing a Sense of Humor
Sharing Responsibility With the Client
Declining to Give Advice
Defining Your Role as a Counselor

Maintaining Your Vitality as a Person and as a Professional
Summary
Self-Reflection and Discussion Questions
Recommended Supplementary Readings for Chapter 2
References

Chapter 3: Ethical Issues in Counseling Practice

Introduction
Putting Clients’ Needs Before Your Own
Ethical Decision Making

The Role of Ethics Codes as a Catalyst for Improving Practice
Some Steps in Making Ethical Decisions

The Right of Informed Consent
Dimensions of Confidentiality

Ethical Concerns With the Use of Technology
Exceptions to Confidentiality and Privileged Communication

Ethical Issues From a Multicultural Perspective

Are Current Theories Adequate in Working With Culturally Diverse Populations?
Is Counseling Culture-Bound?
Focusing on Both Individual and Environmental Factors

Ethical Issues in the Assessment Process

The Role of Assessment and Diagnosis in Counseling

Ethical Aspects of Evidence-Based Practice
Managing Multiple Relationships in Counseling Practice

Perspectives on Multiple Relationships

Becoming an Ethical Counselor
Summary
Self-Reflection and Discussion Questions
Where to Go From Here
Recommended Supplementary Readings for Chapter 3
References

Chapter 4: Psychoanalytic Therapy

Introduction
Key Concepts

View of Human Nature
Structure of Personality
Consciousness and the Unconscious
Anxiety
Ego-Defense Mechanisms
Development of Personality

The Therapeutic Process

Therapeutic Goals
Therapist’s Function and Role
Client’s Experience in Therapy
Relationship Between Therapist and Client

Application: Therapeutic Techniques and Procedures

Maintaining the Analytic Framework
Free Association
Interpretation
Dream Analysis
Analysis and Interpretation of Resistance
Analysis and Interpretation of Transference
Application to Group Counseling
Applying the Psychoanalytic Approach to School Counseling

Jung’s Perspective on the Development of Personality
Contemporary Trends: Object-Relations Theory, Self Psychology, and Relational Psychoanalysis

Summary of Stages of Development
Some Directions of Contemporary Psychodynamic Therapy

An Expert’s Perspective on Psychoanalytic Therapy

Discussion Questions Related to Dr. Blau’s Psychoanalytic Perspective

Psychoanalytic Therapy From a Multicultural Perspective

Strengths From a Diversity Perspective
Shortcomings From a Diversity Perspective

Psychoanalytic Therapy Applied to the Case of Stan
Psychoanalytic Therapy Applied to the Case of Gwen
Summary and Evaluation

Summary
Contributions of the Classical Psychoanalytic Approach
Contributions of Contemporary Psychoanalytic Approaches
Limitations and Criticisms of Psychoanalytic Approaches

Self-Reflection and Discussion Questions
Where to Go From Here
Recommended Supplementary Readings for Chapter 4
References

Chapter 5: Adlerian Therapy

Introduction
Key Concepts

View of Human Nature
Goal-Directed Movement
Goal-Orientation and the Unity of the Personality
Community Feeling and Social Interest
Private Logic
Life Tasks
Influences on Individual Development
Birth Order and Sibling Relationships
Culture, Race, and Ethnicity: Systemic Holism

The Therapeutic Process

Therapeutic Goals
Therapist’s Function and Role
Client’s Experience in Therapy
Relationship Between Therapist and Client

Application: Therapeutic Techniques and Procedures

Phase 1: Establishing the Relationship
Phase 2: Assessing the Individual’s Psychological Dynamics
Phase 3: Encourage Self-Understanding and Insight
Phase 4: Adaptive Reorientation and Reeducation
Application for Individual Psychology
Application for Family Counseling
Application for Group Counseling
Applying the Adlerian Approach to School Counseling

An Expert’s Perspective on Adlerian Therapy

Discussion Questions Related to Dr. Bitter’s Adlerian Perspective

Adlerian Therapy From a Multicultural Perspective

Strengths From a Diversity Perspective
Shortcomings From a Diversity Perspective

Adlerian Therapy Applied to the Case of Stan
Adlerian Therapy Applied to the Case of Gwen
Summary and Evaluation

Summary
Contributions of the Adlerian Approach
Limitations and Criticisms of the Adlerian Approach

Self-Reflection and Discussion Questions
Where to Go From Here

Free Podcasts for ACA Members
Other Resources

Recommended Supplementary Readings for Chapter 5
References

Chapter 6: Existential Therapy

Introduction

Historical Background in Philosophy and Existentialism
Key Figures in Contemporary Existential Psychotherapy

Key Concepts

View of Human Nature
Proposition 1: The Capacity for Self-Awareness
Proposition 2: Freedom and Responsibility
Proposition 3: Striving for Identity and Relationship to Others
Proposition 4: The Search for Meaning
Proposition 5: Anxiety as a Condition of Living
Proposition 6: Awareness of Death and Nonbeing

The Therapeutic Process

Therapeutic Goals
Therapist’s Function and Role
Client’s Experience in Therapy
Relationship Between Therapist and Client

Application: Therapeutic Techniques and Procedures

Phases of Existential Counseling
Clients Appropriate for Existential Counseling
Application to Brief Therapy
Application to Group Counseling
Applications of Existential Approach to School Counseling

An Expert’s Perspective on Existential Therapy

Discussion Questions Related to Dr. Deurzen’s Existential Perspective

Existential Therapy From a Multicultural Perspective

Strengths From a Diversity Perspective
Shortcomings From a Diversity Perspective

Existential Therapy Applied to the Case of Stan
Existential Therapy Applied to the Case of Gwen
Summary and Evaluation

Summary
Contributions of the Existential Approach
Limitations and Criticisms of the Existential Approach

Self-Reflection and Discussion Questions
Where to Go From Here

Free Podcasts for ACA Members
Other Resources

Recommended Supplementary Readings for Chapter 6
References

Chapter 7: Person-Centered Therapy

Introduction

Four Periods of Development of the Approach
Emotion-Focused Therapy
Existentialism and Humanism
Abraham Maslow’s Contributions to Humanistic Psychology

Key Concepts

View of Human Nature

The Therapeutic Process

Therapeutic Goals
Therapist’s Function and Role
Client’s Experience in Therapy
Relationship Between Therapist and Client

Application: Therapeutic Techniques and Procedures

Early Emphasis on Reflection of Feelings
Evolution of Person-Centered Methods
The Role of Assessment
Application of the Philosophy of the Person-Centered Approach
Application to Crisis Intervention
Application to Group Counseling
Application of the Person-Centered Approach With Children and Adolescents in School Counseling

Person-Centered Expressive Arts Therapy

Principles of Expressive Arts Therapy
Creativity and Offering Stimulating Experiences

An Expert’s Perspective on Person-Centered Expressive Arts

Discussion Questions Related to the Person-Centered Expressive Arts Perspective

Person-Centered Therapy From a Multicultural Perspective

Strengths From a Diversity Perspective
Shortcomings From a Diversity Perspective

Person-Centered Therapy Applied to the Case of Stan
Person-Centered Therapy Applied to the Case of Gwen
Summary and Evaluation

Summary
Contributions of the Person-Centered Approach
Limitations and Criticisms of the Person-Centered Approach

Self-Reflection and Discussion Questions
Where to Go From Here

Free Podcasts for ACA Members
Other Resources

Recommended Supplementary Readings for Chapter 7
References

Chapter 8: Gestalt Therapy

Introduction
Key Concepts

View of Human Nature
Some Principles of Gestalt Therapy Theory
Contact and Resistances to Contact
The Now
Unfinished Business
Energy and Blocks to Energy

The Therapeutic Process

Therapeutic Goals
Therapist’s Function and Role
Client’s Experience in Therapy
Relationship Between Therapist and Client

Application: Therapeutic Techniques and Procedures

The Experiment in Gestalt Therapy
Preparing Clients for Gestalt Experiments
The Role of Confrontation
Gestalt Therapy Interventions
Application to Group Counseling
Application of the Gestalt Approach to School Counseling

An Expert’s Perspective on Gestalt Therapy

Discussion Questions Related to the Gestalt Therapy Perspective

Gestalt Therapy From a Multicultural Perspective

Strengths From a Diversity Perspective
Shortcomings From a Diversity Perspective

Gestalt Therapy Applied to the Case of Stan
Gestalt Therapy Applied to the Case of Gwen
Summary and Evaluation

Summary
Contributions of Gestalt Therapy
Limitations and Criticisms of Gestalt Therapy

Self-Reflection and Discussion Questions
Where to Go From Here

Other Resources
Training Programs and Associations

Recommended Supplementary Readings for Chapter 8
References

Chapter 9: Behavior Therapy

Introduction

Historical Background
Four Areas of Development

Key Concepts

Current Trend in Behavior Therapy
Basic Characteristics and Assumptions

The Therapeutic Process

Therapeutic Goals
Therapist’s Function and Role
Client’s Experience in Therapy
Relationship Between Therapist and Client

Application: Therapeutic Techniques and Procedures

Applied Behavioral Analysis: Operant Conditioning Techniques
Progressive Muscle Relaxation
Systematic Desensitization
In Vivo Exposure and Flooding
Eye Movement Desensitization and Reprocessing
Social Skills Training
Self-Management Programs and Self-Directed Behavior
Multimodal Therapy: Clinical Behavior Therapy
Mindfulness and Acceptance-Based Approaches
Application to Group Counseling
Applying the Behavioral Approach to School Counseling

An Expert’s Perspective on Behavior Therapy

Discussion Questions Related to the Behavior Therapy Perspective

Behavior Therapy From a Multicultural Perspective

Strengths From a Diversity Perspective
Shortcomings From a Diversity Perspective

Behavior Therapy Applied to the Case of Stan
Behavior Therapy Applied to the Case of Gwen
Summary and Evaluation

Summary
Contributions of Behavior Therapy
Limitations and Criticisms of Behavior Therapy

Self-Reflection and Discussion Questions
Where to Go From Here

Other Resources
Mindfulness and Acceptance-Based Approaches

Recommended Supplementary Readings for Chapter 9
References

Chapter 10: Cognitive Behavior Therapy

Introduction
Albert Ellis’s Rational Emotive Behavior Therapy

Introduction

Key Concepts

View of Emotional Disturbance
ABC Framework

The Therapeutic Process

Therapeutic Goals
Therapist’s Function and Role
Client’s Experience in Therapy
Relationship Between Therapist and Client

Application: Therapeutic Techniques and Procedures

The Practice of Rational Emotive Behavior Therapy
Applications of REBT as a Brief Therapy
Application of REBT to Group Counseling
Application of REBT to School Counseling

An Expert’s Perspective on Rational Emotive Behavior Therapy

Discussion Questions Related to the REBT Perspective

Aaron Beck’s Cognitive Therapy

Introduction
A Generic Cognitive Model
Basic Principles of Cognitive Therapy
The Client–Therapist Relationship
Applications of Cognitive Therapy
Applying Cognitive-Behavioral Counseling With Adolescents in Schools

Christine Padesky and Kathleen Mooney’s Strengths-Based Cognitive Behavior Therapy

Introduction
Basic Principles of Strengths-Based CBT
The Client–Therapist Relationship
Applications of Strengths-Based CBT

An Expert’s Perspective on Cognitive Behavior Therapy

Discussion Questions Related to Dr. Christine Padesky’s Cognitive Behavior Perspective

Donald Meichenbaum’s Cognitive Behavior Modification

Introduction
How Behavior Changes
Stress Inoculation Training
A Cognitive Narrative Approach to Cognitive Behavior Therapy

Cognitive Behavior Therapy From a Multicultural Perspective

Strengths From a Diversity Perspective
Shortcomings From a Diversity Perspective

Cognitive Behavior Therapy Applied to the Case of Stan
Cognitive Behavior Therapy Applied to the Case of Gwen
Summary and Evaluation

Summary
Contributions of the Cognitive-Behavioral Approaches
Limitations and Criticisms of the Cognitive-Behavioral Approaches

Self-Reflection and Discussion Questions
Where to Go From Here
Recommended Supplementary Readings for Chapter 10
References

Chapter 11: Choice Theory/Reality Therapy

Introduction
Key Concepts

View of Human Nature
Choice Theory Explanation of Behavior
Characteristics of Reality Therapy

The Therapeutic Process

Therapeutic Goals
Therapist’s Function and Role
Client’s Experience in Therapy
Relationship Between Therapist and Client

Application: Therapeutic Techniques and Procedures

The Practice of Reality Therapy
The Counseling Environment
Procedures That Lead to Change
The “WDEP” System
Application to Group Counseling
Application of Reality Therapy to School Counseling

An Expert’s Perspective on Choice Theory/Reality Therapy

Discussion Questions Related to the Choice Theory/Reality Therapy Perspective

Choice Theory/Reality Therapy From a Multicultural Perspective

Strengths From a Diversity Perspective
Shortcomings From a Diversity Perspective

Reality Therapy Applied to the Case of Stan
Reality Therapy Applied to the Case of Gwen
Summary and Evaluation

Summary
Contributions of Choice Theory/Reality Therapy
Limitations and Criticisms of Choice Theory/Reality Therapy

Self-Reflection and Discussion Questions
Where to Go From Here

Free Podcasts for ACA Members
Other Resources

Recommended Supplementary Readings for Chapter 11
References

Chapter 12: Feminist Therapy

Introduction

History and Development

Key Concepts

Constructs of Feminist Theory
Feminist Perspective on Personality Development
Recent Trends in Feminist Therapy
Principles of Feminist Therapy

The Therapeutic Process

Therapeutic Goals
Therapist’s Function and Role
Client’s Experience in Therapy
Relationship Between Therapist and Client

Application: Therapeutic Techniques and Procedures

The Role of Assessment and Diagnosis
Techniques and Strategies
The Role of Men in Feminist Therapy
Application of the Feminist Approach to Group Work
Feminist Social Justice Principles Applied to School Counseling

An Expert’s Perspective on Feminist Therapy

Discussion Questions Related to the Feminist Therapy Perspective

Feminist Therapy From a Multicultural and Social Justice Perspective

Strengths From a Diversity Perspective
Shortcomings From a Diversity Perspective

Feminist Therapy Applied to the Case of Stan
Feminist Therapy Applied to the Case of Gwen
Summary and Evaluation

Summary
Contributions of Feminist Therapy and Multicultural and Social Justice Perspectives
Limitations and Criticisms of Feminist Counseling

Self-Reflection and Discussion Questions
Where to Go From Here

Other Resources

Recommended Supplementary Readings for Chapter 12
References

Chapter 13: Postmodern Approaches

Some Contemporary Founders of Postmodern Therapies
Introduction to Social Constructionism

Historical Glimpse of Social Constructionism
The Collaborative Language Systems Approach

Solution-Focused Brief Therapy

Introduction
Key Concepts
The Therapeutic Process
Applying SFBT to Group Counseling
Application of Solution-Focused Counseling to School Counseling

An Expert’s Perspective on Solution-Focused Brief Therapy

Discussion Questions Related to the Solution-Focused Brief Therapy Perspective

Motivational Interviewing

The MI Spirit
Common Ground With Person-Centered Therapy
The Basic Principles of Motivational Interviewing
The Stages of Change
Common Ground With Solution-Focused Brief Therapy
Application of Motivational Interviewing to School Counseling

Narrative Therapy

Introduction
Key Concepts
The Therapeutic Process
Application: Therapeutic Techniques and Procedures
Application of Narrative Therapy to Group Counseling

An Expert’s Perspective on Narrative Therapy

Discussion Questions Related to the Narrative Therapy Perspective

Postmodern Approaches From a Multicultural Perspective

Strengths From a Diversity Perspective
Shortcomings From a Diversity Perspective

Postmodern Approaches Applied to the Case of Stan
Postmodern Approaches Applied to the Case of Gwen
Summary and Evaluation

Summary
Contributions of Postmodern Approaches
Limitation and Criticisms of Postmodern Approaches

Self-Reflection and Discussion Questions
Where to Go From Here

Free Podcasts for ACA Members
Other Resources
Training in Solution-Focused Therapy Approaches
Training in Narrative Therapy

Recommended Supplementary Readings for Chapter 13
References

Chapter 14: Family Systems Therapy

Introduction

The Family Systems Perspective
Differences Between Systemic and Individual Approaches

Development of Family Systems Therapy

Structural-Strategic Family Therapy
Recent Innovations in Family Therapy

A Multilayered Process of Family Therapy

Forming a Relationship
Conducting an Assessment
Hypothesizing and Sharing Meaning
Facilitating Change
Application of Family Systems Approaches to School Counseling

An Expert’s Perspective on Family Systems Therapy

Discussion Questions Related to the Family Systems Therapy Perspective

Family Systems Therapy From a Multicultural Perspective

Strengths From a Diversity Perspective
Shortcomings From a Diversity Perspective

Family Therapy Applied to the Case of Stan
Family Therapy Applied to the Case of Gwen
Summary and Evaluation

Summary
Contributions of Family Systems Approaches
Limitations and Criticisms of Family Systems Approaches

Self-Reflection and Discussion Questions
Where to Go From Here
Recommended Supplementary Readings for Chapter 14
References

Chapter 15: An Integrative Perspective

Introduction
The Movement Toward Psychotherapy Integration

Pathways Toward Psychotherapy Integration
Advantages of Psychotherapy Integration
The Challenge of Developing an Integrative Perspective
Integration of Multicultural Issues in Counseling
Integration of Spirituality and Religion in Counseling

The Therapeutic Process

Therapeutic Goals
Therapist’s Function and Role
Client’s Experience in Therapy
Relationship Between Therapist and Client

The Place of Techniques and Evaluation in Counseling

Drawing on Techniques From Various Approaches
Evaluating the Effectiveness of Counseling and Therapy
Feedback-Informed Treatment

An Integrative Approach Applied to the Case of Stan
An Integrative Approach Applied to the Case of Gwen
Summary
Concluding Comments
Self-Reflection and Discussion Questions
Where to Go From Here

Other Resources

Recommended Supplementary Readings for Chapter 15
References

Name Index
Subject Index