Counseling And Psychotherapy: A Christian Perspective [PDF ...

For further information on Adler's life and work, see P. Bottome (1957), ... of action that follows the acronym SAMIC³ described by Wubbolding (1988, 2000, ... Home Categories Technique History Mathematics Linguistics Computers OtherSocialSciences Foreign Psychology Biology Education Physics Medicine Economy Housekeeping,leisure Art Religion Literature Chemistry Business Jurisprudence Programming Philosophy Pedagogy Law Contact Login Register Home CounselingAndPsychotherapy:AChristianPerspective[PDF] Includes Multipleformats Nologinrequirement Instantdownload Verifiedbyourusers CounselingAndPsychotherapy:AChristianPerspective[PDF] Authors: Siang-YangTan PDF AddtoWishlist Share 9345views Download Embed Thisdocumentwasuploadedbyouruser.Theuploaderalreadyconfirmedthattheyhadthepermissiontopublish it.Ifyouareauthor/publisherorownthecopyrightofthisdocuments,pleasereporttousbyusingthisDMCA reportform.ReportDMCA E-BookOverview Combiningcutting-edgeexpertisewithdeeplyrootedChristianinsights,thistextfromaleadingfigureintheChristiancounselingcommunityoffersreadersacomprehensivesurveyoftenmajorcounselingandpsychotherapyapproaches.Foreachapproach,Siang-YangTanfirstprovidesasubstantialintroduction,assessingtheapproach'seffectivenessandthelatestresearchfindingsorempiricalevidenceforit.HethencritiquestheapproachfromaChristianperspective.Tanalsoincludeshypotheticaltranscriptsofinterventionsforeachmajorapproachtohelpreadersgetabettersenseoftheclinicalworkinvolved.ThisbookpresentsaChristianapproachtocounselingandpsychotherapythatisChristcentered,biblicallybased,andSpiritfilled. E-BookContent CounselingandPsychotherapy _Tan_Counseling_BB_mw.indd1 9/21/104:33:50PM _Tan_Counseling_BB_mw.indd2 9/21/104:33:50PM CounselingandPsychotherapyAChristianPerspective Siang-YangTan K_Tan_Counseling_BB_mw.indd3 9/21/104:33:50PM ©2011bySiang-YangTanPublishedbyBakerAcademicadivisionofBakerPublishingGroupP.O.Box6287,GrandRapids,MI49516-6287www.bakeracademic.comPrintedintheUnitedStatesofAmericaAllrightsreserved.Nopartofthispublicationmaybereproduced,storedinaretrievalsystem,ortransmittedinanyformorbyanymeans—forexample,electronic,photocopy,recording—withoutthepriorwrittenpermissionofthepublisher.Theonlyexceptionisbriefquotationsinprintedreviews.LibraryofCongressCataloging-in-PublicationDataTan,Siang-Yang,1954–Counselingandpsychotherapy:aChristianperspective/Siang-YangTan.p.cm.Includesbibliographicalreferencesandindex.ISBN978-0-8010-2966-0(pbk.)1.Counseling—Religiousaspects—Christianity.2.Counseling.3.Psychotherapy—Religiousaspects—Christianity.4.Psychotherapy.I.Title.BR115.C69T362011261.8322—dc222010026145ScripturequotationsarefromtheHOLYBIBLE,NEWINTERNATIONALVERSION®.NIV®.Copyright© 1973,1978,1984byInternationalBibleSociety.UsedbypermissionofZondervan.Allrightsreserved.11 12 13 14 15 16 17   7 6 5 4 3 2 15219315 _Tan_Counseling_BB_mw.indd4 9/21/104:33:50PM ToCarolynLi-JunTan,mydaughter,forherhonestandhelpfuleditorialfeedbackthathasmadethisbookabetterone,withdeepgratitude,love,andprayers. _Tan_Counseling_BB_mw.indd5 9/21/104:33:50PM _Tan_Counseling_BB_mw.indd6 9/21/104:33:50PM Contents Preface    ixAcknowledgments    xiPart1BasicIssuesinthePracticeofCounselingandPsychotherapy1.OverviewofCounselingandPsychotherapy:Theory,Research,andPractice    12.ThePersonoftheCounselor    143.LegalandEthicalIssuesinCounselingandPsychotherapy    24Part24.5.6.7.8.9.10.11.12. MajorCounselingandPsychotherapyTheoriesandTechniquesPsychoanalyticTherapy    35AdlerianTherapy    58JungianTherapy    80ExistentialTherapy    102Person-CenteredTherapy    128GestaltTherapy    155RealityTherapy    180BehaviorTherapy    206CognitiveBehaviorTherapyandRationalEmotiveBehaviorTherapy    24713.MaritalandFamilyTherapy    283 Part3AChristianApproachtoCounselingandPsychotherapy14.ChristianTheologyinChristianCounseling:ABiblicalPerspectiveonHumanNatureandEffectiveCounselingandPsychotherapy    325vii _Tan_Counseling_BB_mw.indd7 9/21/104:33:50PM viii Contents 15.ChristianFaithinClinicalPractice:ImplicitandExplicitIntegration    33916.TheHolySpiritandChristianSpiritualityinCounselingandPsychotherapy    36317.LegalandEthicalIssuesinChristianCounselingandPsychotherapy    374 Appendix:IsPsychotherapyEffective?    389References    401NameIndex    473SubjectIndex    483 _Tan_Counseling_BB_mw.indd8 9/21/104:33:51PM Preface S everalgoodintroductorytextsoncounselingandpsychotherapyareavailable,buttheyarewrittenmainlyfromasecularperspective(e.g.,Corey2009;CorsiniandWedding2008;ProchaskaandNorcross2010;Sharf2008).However,thereisasignificantlackoftextswrittenfromadistinctivelyChristianperspective.StantonJonesandRichardButman(1991)wroteaveryhelpfulandcomprehensiveChristianappraisalandcritiqueofmodernpsychotherapiesoverfifteenyearsago,buttheydidnotadequatelycovercounselingtechniques.DonBrowningandTerryCooper(2004)haveupdatedtheirbookonreligiousthoughtandthemodernpsychologiesorpsychotherapies,butitcontainsmainlytheoreticalandtheologicalcritiquesandperspectives.Morerecently,MarkYarhouse,RichardButman,andBarrettMcRay(2005)haveprovidedacomprehensiveChristianappraisalandcritiqueofmodernpsychopathologies,butitdoesnotfocusoncounselingandpsychotherapyperse.NeilAnderson,TerryZuehlke,andJulianneZuehlke(2000)coauthoredatextonChrist-centeredtherapy,butitisnotacomprehensivesurveyofthemajorapproachestocounselingandpsychotherapy.Similarly,severalrecentbooksonChristiancounseling(includingClintonandOhlschlager2002;Clinton,Hart,andOhlschlager2005;Collins2007;MalonyandAugsburger2007;andMcMinnandCampbell2007),althoughhelpful,donotincludecomprehensivedescriptionsofthemajorapproachestocounselingandpsychotherapythatareusuallycoveredinintroductorytextsinthisarea.Thepresenttexthasthereforebeenwrittentomeetacrucialneedforabookoncounselingandpsychotherapythatprovidessubstantialdescriptionsoftenmajorapproachestocounselingandpsychotherapy,withappropriatebiblical,Christiancritiquesandperspectivesoneachmajorapproach.Hypotheticaltranscriptsofinterventionsineachmajorapproachareincludedix _Tan_Counseling_BB_mw.indd9 9/21/104:33:51PM x Preface togivereadersandstudentsabettersenseoftheclinicalworkinvolved.Thelatestresearchfindingsarealsocovered.Inadditiontothesemajorfeatures,auniquepartofthepresenttextisthefinalsection,whichconsistsofseveralchaptersdescribingaChristianapproachtocounselingandpsychotherapythatisChristcentered,biblicallybased,andSpiritfilled.ThisnewtextoncounselingandpsychotherapyfromaChristianperspectivewillbeusefultoprofessorsorteachersandstudentsinChristianundergraduateandgraduateprogramsincounselingandrelatedpeople-helpingfieldssuchasclinicalpsychology,counselingpsychology,professionalcounseling,maritalandfamilytherapy,socialwork,psychiatry,psychiatricnursing,andpastoralcounseling;clinicians,especiallyChristiancounselorsandpsychotherapistsinpractice;pastors,chaplains,laycounselors,andothercaregiversinchurchesandparachurchorganizations;seminarystudents;Christianswhohavegraduatedfromseculargraduateprogramsincounseling-relatedfields;andanyoneelseinterestedinincreasinghisorhercounselingknowledgeandskillsfromadistinctivelyChristianperspective.Itrustandpraythatthisnewtextwillbearealblessingtoyouasyoureadanduseit. _Tan_Counseling_BB_mw.indd10 9/21/104:33:52PM Acknowledgments I thastakenmeafewyearstocompletethewritingofthismajortextbookoncounselingandpsychotherapyfromaChristianperspective.Icouldnothavedoneitwithoutthesupportandprayersofmanypeople—andthegraceofGod.First,IwanttothankBrianBolger,managingeditoratBakerAcademic,whoapproachedmeaboutwritingthistextbookandhelpedmeinthefinalprocessofgettingitpublished,andJimKinney,associatepublisherandeditorialdirectorofBakerAcademicandBrazosPress,whopatientlysupportedmeduringtheeditorialrevisionofthebook.IamdeeplygratefultoJimforhishelpandunderstandingwhendeadlineshadtobeextendedandforhisexcellenteditorialfeedback.AnanonymousindependentreaderprovidedhelpfulsuggestionsandcommentsforwhichIamgrateful.IalsowanttothankthemanyfriendsandintercessorswhoprovidedprayersupportformewhenIwaswritingthisbook,especiallytheWednesdaynightprayermeetinggroupandthepastoralandchurchstaffatmychurch,theprayerpartnersofRENOVAREandtheRENOVAREBoard/Team,andthemembersofmysmallgroup.Ialsowanttomention,withdeepgratitude,twoofmyspecialprayerpartnersatFuller:JeffreyBjorckandJohnMartin,bothprofessorsofpsychology.SpecialthankstoFullerTheologicalSeminaryforgraciouslygrantingmetwoone-quartersabbaticalsinthefallof2007and2008,duringwhichIwrotemuchofthebook.Igratefullyacknowledgetheexcellentadministrativeandword-processinghelpofJannekeLastandDanielGroot,aswellasofSharonNambiar,KatyRiddell,andMarciaHydeatFullerandLynnMoriatmychurch.Mydaughter,Carolyn,providedmuchhonestandhelpfuleditorialfeedback,whichhasmadethebookabetterone.Iamverygratefultoherfordoingthisxi _Tan_Counseling_BB_mw.indd11 9/21/104:33:52PM xii Acknowledgments whilecompletingherstudiesandgraduatingfromLoyolaLawSchoolinLosAngeles.Ihavethereforededicatedthisbooktoher.Iamalsodeeplythankfulforthelove,patience,support,andprayersofAngela,mywife,andfortheinterestandsupportofAndrew,myson.Aboveall,IwanttohumblythankGodforhisguidance,wisdom,andstrengthwithoutwhichthisbookcouldnothavebeencompleted.Tohimbealltheglory! _Tan_Counseling_BB_mw.indd12 9/21/104:33:52PM Part1 BasicIssuesinthePracticeofCounselingandPsychotherapy _Tan_Counseling_BB_mw.indd13 9/21/104:33:52PM _Tan_Counseling_BB_mw.indd14 9/21/104:33:52PM 1OverviewofCounselingandPsychotherapyTheory,Research,andPractice S igmundFreud(1856–1939),thefounderofpsychoanalysis,isoftencreditedwiththebirthofpsychotherapy,orthe“talkingcure.”However,thedeeprootsofcounselingandpsychotherapygobackmanycenturiesbeforeFreud.Todaythefieldofcounselingandpsychotherapyislargeanddiverse.Therehasbeenaproliferationofmajortherapiesinthepastfiftyyears:fromthirty-sixsystemsofpsychotherapyidentifiedbyR. A.Harperin1959tooverfourhundredtoday(ProchaskaandNorcross2010,1).Eventhedefinitionsofcounselingandpsychotherapydifferfromauthortoauthorandfromtextbooktotextbook.Mostpeoplethinkofcounselingandpsychotherapyasinvolvingaprofessionalcounselorortherapisthelpingclientstodealwiththeirproblemsinliving.Letustakeacloserlookatsomedefinitionsofcounselingandpsychotherapyinthisintroductoryoverviewchapter.DefinitionsofCounselingandPsychotherapyTherearemanydifferentdefinitionsofpsychotherapy,noneofwhichisprecise(CorsiniandWedding2008).JamesProchaskaandJohnNorcross(2010)havechosentousethefollowingworkingdefinitionofpsychotherapy(fromNorcross1990,218):“Psychotherapyistheinformedandintentionalapplicationofclinicalmethodsandinterpersonalstancesderivedfromestablished1 _Tan_Counseling_BB_mw.indd15 9/21/104:33:53PM 2 BasicIssuesinthePracticeofCounselingandPsychotherapy psychologicalprinciplesforthepurposeofassistingpeopletomodifytheirbehaviors,cognitions,emotions,and/orotherpersonalcharacteristicsindirectionsthattheparticipantsdeemdesirable”(3–4).Similarly,therearealsoseveralpossibledefinitionsofcounseling.ChristianpsychologistGaryCollinshasdefinedcounselingas“arelationshipbetweentwoormorepersonsinwhichoneperson(thecounselor)seekstoadvise,encourageand/orassistanotherpersonorpersons(thecounselee[s])todealmoreeffectivelywiththeproblemsoflife”(1972,13).Hefurtherstates:“Unlikepsychotherapy,counselingrarelyaimstoradicallyalterorremoldpersonality”(14).Someauthorsthereforetrytodifferentiatecounselingandpsychotherapyonacontinuum,withpsychotherapydealingwithdeeperproblemsandseekingtosignificantlychangepersonality.However,mostauthorsinthementalhealthfieldtodaydonotdifferentiatebetweencounselingandpsychotherapy(see,e.g.,Corey2009;Day2004;Fall,Holden,andMarquis2004;Parrott2003;J. Sommers-FlanaganandSommers-Flanagan2004),agreeingwithCharlesTruaxandRobertCarkhuff(1967),who,yearsago,alreadyusedthetwotermsinterchangeably.Infact,C. H.Pattersonemphaticallyassertsthatnoessentialdifferencesexistbetweencounselingandpsychotherapy(1973,xiv).ThisistheviewItakeinthistextbookoncounselingandpsychotherapyfromaChristianperspective.JohnSommers-FlanaganandRitaSommers-Flanaganalsousecounselingandpsychotherapyinterchangeablyanddefineitasaprocessthatinvolves“atrainedpersonwhopracticestheartfulapplicationofscientificallyderivedprinciplesofestablishingprofessionalhelpingrelationshipswithpersonswhoseekassistanceinresolvinglargeorsmallpsychologicalorrelationalproblems.Thisisaccomplishedthroughethicallydefinedmeansandinvolves,inthebroadestsense,someformoflearningorhumandevelopment”(2004,9,italicsinoriginal).PsychotherapyandPsychologicalTreatmentsMorerecently,DavidBarlow(2004,2005,2006)hasattemptedtodifferentiatepsychotherapyfrompsychologicaltreatments,whichmayaddmoreconfusionratherthanclaritytothealreadydiversedefinitionsavailableforcounselingandpsychotherapy.Hesuggeststhat“psychologicaltreatments”shouldrefertothosedealingprimarilywithpathology,while“psychotherapy”shouldrefertotreatmentsthataddressadjustmentorgrowth(2006, 216).Psychologicaltreatmentsarethereforethosethatareclearlycompatiblewiththeobjectivesofhealth-caresystemsthataddresspathology.Hefurtherstressesthatthetwoactivitiesofpsychologicaltreatment(whichismorespecific)andpsychotherapy(whichismoregeneric)wouldnotbedistinguishedbasedontheory,technique,orevidence,butonlyontheproblemstheydealwith.Heisawarethatthesearecontroversialrecommendations.However,IbelieveBarlow’s _Tan_Counseling_BB_mw.indd16 9/21/104:33:54PM OverviewofCounselingandPsychotherapy 3 (2006)recommendationisnotonlycontroversial,butitisalsopotentiallyconfusingandmaynotreallyhelptoclarifythedefinitionofterms.ExamplesofpsychologicaltreatmentsprovidedbyBarlowinclude“assertivecommunitytreatment,cognitive-behavioraltherapy,communityreinforcementapproaches,dialecticalbehaviortherapy,familyfocusedtherapy,motivationalinterviewing,multisystemicinterpersonaltherapy,parenttraining(forexternalizingdisordersinchildren),personaltherapyforschizophrenia,andstressandpainmanagementprocedures”(2004,873,italicsinoriginal).Wecanseethatmanyoftheseexamplesofpsychologicaltreatmentsarealreadypartandparcelofcounselingandpsychotherapy.OverviewofCounselingandPsychotherapy:TheoryAlthoughoverfourhundredvarietiesofcounselingandpsychotherapypresentlyexist,mostofthemcanbesubsumedunderthemajorschoolsofcounselingandpsychotherapythatareusuallycoveredintextbooksinthisfieldofpeople-helping.Therearetentotwelvemajorones,dependingontheauthorandthetext.Inthisbookthefollowingtenmajortheoreticalapproachestocounselingandpsychotherapywillbecoveredinsomedetail,basedonthetheoriesandtechniquesdevelopedbytheirfoundersandpractitioners:psychoanalytictherapy,Adleriantherapy,Jungiantherapy,existentialtherapy,person-centeredtherapy,Gestalttherapy,realitytherapy,behaviortherapy,cognitivebehaviortherapyandrationalemotivebehaviortherapy,andmaritalandfamilytherapy.PsychoanalyticTherapy.ThekeyfigureofpsychoanalysisandpsychoanalytictherapyisSigmundFreud.Heoriginatedatheoryofpersonalitydevelopmentfocusedonexperiencesinthefirstsixyearsoflifethatdeterminethesubsequentdevelopmentofpersonality.Freudianorpsychoanalytictheoryemphasizesunconsciousfactors,especiallysexualandaggressivedrivesinmotivatinghumanbehavior.Psychoanalytictherapyemploystechniquessuchasfreeassociation(allowingtheclienttosaywhatevercomestohisorhermindwithoutcensorship);dreamanalysis(interpretingthelatentorhiddenmeaningofthedreammainlythroughtheuseofsymbolsthathaveconsistentsignificanceforalmosteveryperson);andanalysisoftransference(whentheclientrespondstotheanalystortherapistasasignificantpersonofauthorityfromhisorherlife,therebyrevealingchildhoodconflictsheorshehasexperienced).Thegoalofpsychoanalytictherapyistohelpmaketheunconsciousconsciousandstrengthentheego.Contemporaryversionsofpsychoanalytictherapysuchasobject-relationstheoryfocusmoreonattachmentandhumanrelationshipneedsratherthanonsexualandaggressivedrives.AdlerianTherapy.AlfredAdlerfoundedAdleriantherapy,whichwasoriginallycalledindividualpsychology.AnothermajorfigureinthisapproachisRudolphDreikurs,whowasresponsibleformakingitbetterknowninthe _Tan_Counseling_BB_mw.indd17 9/21/104:33:54PM 4 BasicIssuesinthePracticeofCounselingandPsychotherapy UnitedStates.Adleriantherapyisbasedonagrowthmodelofthehumanperson.Itemphasizestheneedfortheclienttotakeresponsibilityinmakingchoicesthathelpdetermineone’sowndestiny,andthatprovidemeaninganddirectionforone’slife.Adleriantherapyusestechniquessuchasinvestigatingtheclient’slifestyleorbasicorientationtowardlifebyexploringbirthorder,earlyrecollectionsfromchildhoodyears,anddreams;asking“TheQuestion”(“Whatwouldbedifferentifyouwerewell?”);andparadoxicalintention(encouragingclientstodoorexaggeratetheverybehaviorstheyareattemptingtoavoid).JungianTherapy.ThekeyfigureofJungiantherapy,oranalyticalpsychology,isCarlJung.Jung’sinterestinmysticaltraditionsledhimtoconcludethathumanbeingshaveasignificantandmysteriouspotentialwithintheirunconscious.Hedescribedbothapersonalunconsciousaswellasacollectiveunconscious.Jungiantherapyencouragesclientstoconnecttheconsciousandunconsciousaspectsoftheirmindinconstantdialogue,withthegoalofindividuationorbecomingone’sownperson.Jungiantherapytechniquesincludetheextensiveuseofdreamanalysisandtheinterpretationofsymbolsinordertohelpclientsrecognizetheirarchetypes(orderingororganizingpatternsintheunconscious).Examplesofarchetypalimagesincludemajoronessuchasthepersona,theshadow,theanimaandanimus,andtheSelf,aswellasotherssuchastheearthmother,thehero,andthewiseoldman.ExistentialTherapy.ThekeyfiguresofexistentialtherapyincludeVicktorFrankl,thefounderoflogotherapy;RolloMay;LudwigBinswanger;MedardBoss;JamesBugental;andIrvinYalom.Itfocusesonhelpingclientsexperiencetheirexistenceinanauthentic,meaningful,andresponsibleway,encouragingthemtofreelychooseordecide,sothattheycancreatemeaningintheirlives.Existentialtherapythereforeemphasizesmoretherelationshipandencounterbetweentherapistandclientratherthantherapeutictechniques.Corelifeissuesoftendealtwithinexistentialtherapyincludedeath,freedom,meaninglessness,isolation,andtheneedtobeauthenticandrealinresponsiblychoosingone’svaluesandapproachtolife.Existentialtherapistscanbeoptimisticorpessimistictothepointofbeingnihilistic,andtheyincludethosewhoarereligiousaswellasthosewhoareantireligious.Althoughtechniquesarenotstressedinexistentialtherapy,Franklhasdevelopedseveraltechniquesinlogotherapy,aparticularapproachtoexistentialtherapy.Someexamplesaredereflection(encouragingtheclienttoignoretheproblemandfocusattentionorawarenessonsomethingmorepleasantorpositive);paradoxicalintention(askingtheclienttodoorexaggeratetheverybehaviorheorshefearsdoing);andmodifyingtheclient’sattitudesorthinking(especiallyaboutthepast,whichcannotbechanged,sothatmoremeaningfulorhopefulwaysoflookingatthingsbecomethefocus).Person-CenteredTherapy.CarlRogersfoundedperson-centeredtherapy,whichwaspreviouslycallednon-directivecounselingorclient-centeredtherapy. _Tan_Counseling_BB_mw.indd18 9/21/104:33:56PM OverviewofCounselingandPsychotherapy 5 Person-centeredtherapyassumesthateachpersonhasadeepcapacityforsignificantandpositivegrowthwhenprovidedwiththerightenvironmentandrelationships.Theclientistrustedtoleadintherapyandisfreetodiscusswhateverheorshewishes.Person-centeredtherapyisthereforenotfocusedonproblemsolvingbutaimsinsteadtohelpclientsknowwhotheyareauthenticallyandtobecomewhatRogerscalls“fullyfunctioning”persons.AccordingtoRogers,threetherapeuticconditionsareessentialforfacilitatingclientchangeandgrowth;thesearethemajorperson-centeredtherapy“relationshiptechniques”:congruenceorgenuineness;unconditionalpositiveregard(valuingtheclientwithrespect);andaccurateempathy(empathicunderstandingoftheclient’sperspectiveorinternalframeofreference).GestaltTherapy.Frederick(Fritz)PerlsandLauraPerlsfoundedGestalttherapy,anexperientialtherapythatemphasizesincreasingtheclient’sawareness,especiallyofthehereandnow,andintegrationofbodyandmind.TheGestalttherapistassumesaveryactiveroleinhelpingclientsbecomemoreawaresothattheycansolvetheirproblemsintheirownwayandtime.ExamplesofGestalttherapytechniquesthatfocusondoingincludedreamworkthatisexperiential;convertingquestionstostatements;usingpersonalnouns;assumingresponsibility;theemptychair;exaggeration;andconfrontation.RealityTherapy.WilliamGlasserfoundedrealitytherapy,whichfocusesonthepresentandemphasizestheclient’sstrengths.ItisbasedonchoicetheoryasdevelopedbyGlasser,whichassertsthatpeopleareresponsibleforchoosingtheirownthinkingandactions,whichthendirectlyinfluencetheiremotionalandphysiologicalfunctioning.Choicetheoryalsopositsfivebasicneedsofallhumanbeings:survival,loveandbelonging,power,freedom,andfun.Realitytherapyhelpsclientstobecomemoreresponsibleandrealisticandthereforemoresuccessfulinachievingtheirgoals.Examplesofrealitytherapytechniquesincludestructuring;confrontation;contracts;instruction;roleplaying;support;skillfulquestioning(e.g.,“Doesyourpresentbehaviorenableyoutogetwhatyouwantnow,andwillittakeyouinthedirectionyouwanttogo?”);andemphasizingchoice(e.g.,bychangingnounsandadjectivesintoverbs).BehaviorTherapy.ThekeyfiguresofbehaviortherapyincludeJosephWolpe,HansEysenck,ArnoldLazarus,AlbertBandura,B. F.Skinner,andDonaldMeichenbaum.Behaviortherapyappliesnotonlytheprinciplesoflearningbutalsoexperimentalfindingsfromscientificpsychologytothetreatmentofparticularbehavioraldisorders.Itisthereforeanempiricallybasedapproachtotherapythatisbroadlysociallearningorientedintheory.Behaviortherapistsviewhumanbeingsasproductsoftheirenvironmentsandlearninghistories.Thebehaviortherapistplaysanactiveanddirectiveroleintherapy.Behaviortherapyhasdevelopedmanytechniquesthatcontinuetoberefinedthroughsystematicempiricalresearch.Examplesoftherapeutictechniquesusedinbehaviortherapyincludepositivereinforcement(rewardfordesirable _Tan_Counseling_BB_mw.indd19 9/21/104:33:56PM 6 BasicIssuesinthePracticeofCounselingandPsychotherapy behavior);assertivenesstraining(role-playingwithclientstohelpthemlearntoexpresstheirthoughtsandfeelingsmorefreely);systematicdesensitization(pairingofaneutralorpleasantstimuluswithonethathasbeenconditionedtoelicitfearoranxiety);andflooding(exposingtheclienttostimulithatelicitmaximalanxietyforthepurposeofeventuallyextinguishingtheanxiety).CognitiveBehaviorTherapyandRationalEmotiveBehaviorTherapy.Thekeyfiguresofcognitivebehaviortherapy(CBT)andrationalemotivebehaviortherapy(REBT)areAaronBeck,thefounderofcognitivetherapy(CT),andAlbertEllis,thefounderofREBT.DonaldMeichenbaum,alreadymentionedintheprecedingdiscussionofbehaviortherapy,isalsooftennotedasanimportantfigureinCBTbecausehedevelopedcognitivebehaviormodification(CBM)andstress-inoculationtraining(SIT),whichareincorporatedintoCBT.Beck’sCTapproachfocusesonhowmaladaptiveanddysfunctionalthinkingaffectsfeelingsandbehavior.Itattemptstohelpclientsovercomeemotionalproblemssuchasdepression,anxiety,andangerbyteachingthemtoidentify,challenge,andmodifyerrorsinthinkingorcognitivedistortions.Similarly,EllisdevelopedREBTasanactiveanddirectiveapproachtotherapythatfocusesonchangingclients’irrationalbeliefsthatareviewedastherootofemotionalproblems.CBTandREBTassumethatclientshavethecapacitytochangetheirmaladaptivethinkingandhencetochangeproblemfeelingsandbehaviors.CBTandREBTemployawiderangeoftherapeutictechniques,manyofwhichhavebeenempiricallysupportedbydocumentedresultsorsystematicresearch.ExamplesofCBTtechniquesincludecopingskillstraining(helpingclientsusecognitiveandbehavioralskillstocopemoreeffectivelywithstressfulsituations);cognitiverestructuring(helpingclientstochangeormodifymaladaptive,dysfunctionalthoughts);andproblemsolving(helpingclientstoexploreoptionsandimplementparticularsolutionstospecificproblemsandchallenges).ExamplesofREBTtechniquesincludeuseoftheA-B-CtheoryofREBT(AreferstoActivatingEvents,BtoIrrationalBeliefs,andCtoConsequences—emotionaland/orbehavioral—ofsuchbeliefs)andmorespecificallykeepinganA-B-Cdiaryofdailyexperiences;disputation(ofirrationalbeliefs);andactionhomework.MaritalandFamilyTherapy.Maritalandfamilytherapyisanumbrellatermreferringtoovertwentysystemictherapies.TheimportantfiguresinthisapproachincludeSalvadorMinuchin,thefounderofthestructuralapproach;JayHaleyandtheMilanGroup,whodevelopedthestrategicapproach;MurrayBowen,whodevelopedfamilysystemstheoryandtransgenerational(multigenerational)familytherapy;andVirginiaSatir,whodevelopedconjointfamilytherapy.Morerecently,SusanJohnsonandLeslieGreenberghavebecomewellknownfortheirdevelopmentofemotionallyfocusedtherapyforcouples.OtherkeyfiguresincludeNathanAckerman,CarlWhittaker,IvanBoszormenyi-Nagy,StevedeShazer,MichaelWhite,NeilJacobsen,JohnGottman,andAlanGurman.Maritalandfamilytherapy _Tan_Counseling_BB_mw.indd20 9/21/104:33:58PM OverviewofCounselingandPsychotherapy 7 approachesassumethatthecrucialfactorinhelpingindividualstochangeistounderstandandworkwiththeinterpersonalsystemswithinwhichtheyliveandfunction.Inotherwords,thecoupleandthefamilymustbeconsideredineffectiveorefficacioustherapyforindividualproblemsaswellasmaritalandfamilyissues.Examplesofmaritalandfamilytherapytechniquesthatseektomodifydysfunctionalpatternsofinteractionincouplesandfamiliesandeffecttherapeuticchangeincludereframing(seeingproblemsinamoreconstructiveorpositiveway);boundarysetting(eithertoestablishfirmerlimitsorlinesofseparationortobuildmoreflexibleboundariesfordeeperconnection);communicationskillstraining;familysculpting(askingacoupleorfamilymemberstophysicallyputthemselvesinparticularpositionstoreflecttheirfamilyrelationships);andconstructingagenogram(athreegenerationalfamilytreeorhistory).Amoredetaileddiscussionincludingbiblicalperspectivesandcritiquesappearsinthechapterdevotedtoeachofthesetenmajortheoreticalapproachestocounselingandpsychotherapy.Counselingtheoryisimportant.Itprovidesaframeworkofunderstandingandpracticethatguidesthecounselorandpsychotherapistintheirattemptstohelpclients(seeTruscott2010).Everyoneofushashisorherownimplicit,ifnotexplicit,theoryofcounseling.Wemay,ormaynot,beawareofourbasicassumptionsandviewsofhowtobesthelppeoplewiththeirproblemsinliving.KevinFall,JaniceHolden,andAndreMarquishaveprovidedthefollowingquestionsforclarifyingandarticulatingone’stheoryofcounseling,whichyoumayfindusefulinformulatingyourowntheory,nomatterhowbasicitmaybe:1.Humannature:Arepeopleessentiallygood,evil,orneutral?Howmuchofpersonalityisinbornordeterminedbybiologicaland/orotherinnatefactors?Arethereinborndrives,motives,tendencies,orotherpsychologicalorbehavioralcharacteristicsthatallhumanbeingshaveincommon?Howmuchofaperson’sindividualityisdeterminedbyheredityorotherinnatefactors?2.Roleoftheenvironmentinpersonalitydevelopment:Howinfluentialisone’sphysicaland/orsocialenvironmentinone’spersonalitydevelopment,andhowdoestheenvironmentaffectpersonalitydevelopment?3.Modeloffunctionality:Whatconstitutesfunctionality/mentalhealthordysfunctionality/mentalunhealthinanindividual?Howdoinnateandenvironmentalfactorsinteractininfluencingaperson’sfunctioning,beitrelativelyhealthyorunhealthy?4.Personalitychange:Howdoespersonalitychangeafteritistosomeextentdeveloped?Whatconditionsarenecessarybutnotalonesufficientforpersonalitychangetooccur,andwhatconditionsarebothnecessaryandsufficient?(seeFall,Holden,andMarquis2004,9–10) _Tan_Counseling_BB_mw.indd21 9/21/104:33:59PM 8 BasicIssuesinthePracticeofCounselingandPsychotherapy Thesearethekindsofquestionsweneedtoaskourselvesinreflectingonourowntheoryofcounseling.Wewillalsoasksuchquestionsofthetenmajortheoreticalapproachestocounselingandpsychotherapythatwillbecoveredinmoredepthanddetaillaterinthisbook.Combs(1989)hasnotedthatmanycounselingtheoristsvalueatheoryofcounselingthatiscomplete,clear,consistent,concrete,current,creative,andconscious,thatis,thathasthesevenCs(seeFall,Holden,andMarquis2004,10–11).OverviewofCounselingandPsychotherapy:ResearchTheoryplaysanimportantroleinguidingthecounselorortherapistinhelpingclients.However,everytheorymustbesubjectedtoresearchtodetermineitstruthorvalidity,aswellastheefficacyandeffectivenessofitsapplicationsinactualpractice.Researchisthereforeanothercrucialdimensioninthefieldofcounselingandpsychotherapy.Scientificandsystematicresearchontheprocessesandoutcomesofcounselingandpsychotherapyonlybeganinthe1940swhenCarlRogersstartedrecordinghistherapysessions,whichcouldsubsequentlybestudiedandevaluated.Sincethen,researchinthisfieldhasmushroomed,althoughsomecontroversiesandissuesstillremain.Seetheappendixforareviewofresearchinthefieldofcounselingandpsychotherapy,focusingonthequestion“Ispsychotherapyeffective?”andwhy.OverviewofCounselingandPsychotherapy:PracticeInthisfinalsectionoftheoverviewofcounselingandpsychotherapy,wewillbrieflycoverthefollowingtopics:primarytheoreticalorientationsofcounselorsandpsychotherapistsinpracticeintheUnitedStates;majortypesoftherapistsormentalhealthpractitionersandthesettingsinwhichtheypractice;severalcontemporarydevelopmentsinthepracticeofcounselingandpsychotherapy;andexamplesofmajorprofessionalorganizationsandtheirWebsitesforcounselorsandpsychotherapists.PrimaryTheoreticalOrientationsofCounselorsandPsychotherapistsProchaskaandNorcrosshavesummarizedthemajorfindingsfromseveralsurveysorstudiesoftheself-identifiedprimarytheoreticalorientationsofclinicalpsychologists,counselingpsychologists,socialworkers,andcounselorsintheUnitedStates(2010, 3).Themostpopulartheoreticalorientationself-reportedbymostofthesementalhealthprofessionalshasbeeneclectic/integrativetherapy(usingtheoriesandtechniquesfromvariousapproaches):29percentofclinicalpsychologists,34percentofcounselingpsychologists,and26percentofsocialworkers.However,cognitivetherapyisself-reportedasthe _Tan_Counseling_BB_mw.indd22 9/21/104:33:59PM OverviewofCounselingandPsychotherapy 9 primarytheoreticalorientationby28percentofclinicalpsychologistsand29percentofcounselors(thehighestpercentageforcounselors).Only23percentofcounselorsselectedeclectic/integrativetherapyastheirprimarytheoreticalorientation.JudithToddandArthurBohart(2006)notethatwhileeclecticismisthemostpopularapproachamongpracticingpsychotherapists,cognitivetherapiesandtheoriesarenowthedominanttherapeuticorientationinmanyprofessionalcontextsincludinguniversityclinicalpsychologyprograms.ProchaskaandNorcross(2010)havealsosummarizedthemainfindingsofaDelphiPolltheyconductedwithsixty-twoexpertpanelists;itscompositeratingsindicatewhatwillhappeninthefieldofpsychotherapyoverthenexttenyears.Intermsofprimarytheoreticalorientationsofthefuture,cognitivebehaviortherapywasrankedfirstforthegreatestincreaseoverthenextdecade,followedcloselybyculture-sensitive/multiculturaltherapy,cognitivetherapy(Beck),interpersonaltherapy(IPT),technicaleclecticism,theoreticalintegration,behaviortherapy,andsystems/familysystemstherapy.Therewasalsoconsensusthatpsychotherapywillbecomemoredirective,psychoeducational,technological,problemfocused,andbriefinthenexttenyears.Oneofthemajorpredictionsconcernsthelengthoftherapy:long-termtherapywillsignificantlydecrease,whileshort-termtherapywillbecomepredominant.MajorTypesofMentalHealthPractitionersandPracticeSettingsThereareoveradozenmajortypesofmentalhealthpractitionersintheUnitedStateswhomayprovidecounselingandpsychotherapy.LesParrottliststhefollowing(see2003,14–16):1.Psychiatristsaremedicaldoctorswhohavespecializedtraininginthediagnosisandtreatmentofmentaldisorders.Theyarequalifiedtoprescribepsychotropicmedicationsandcanpracticecounselingandpsychotherapy.Somepsychiatristshavealsobeentrainedinpsychoanalysis.2.PsychoanalystshavereceivedadvancedtrainingofatleastthreeyearsinFreudianpsychoanalysisorsomeothermorecontemporaryversionofpsychoanalysisatinstitutesofpsychoanalytictraining.Suchtraininginstitutesoftenrequiretheirpsychoanalytictraineestobelicensedpsychologistsorpsychiatrists.3.Clinicalpsychologistsareeducatedatthedoctorallevel(PhD,PsyD,orEdD),includinginternshiptraininginpsychologicalassessmentandpsychotherapy.Theymustbelicensedinthestateinwhichtheypractice.4.Counselingpsychologistsareusuallyeducatedatthedoctorallevelwithinternshiptraininginhelpingpeopledealmoreeffectivelywiththeirproblemsinliving.Counselingpsychologistsalsomustbelicensedtobeinindependentpractice.Theyfunctionverymuchlikeclinicalpsychologistsdo,exceptthatcounselingpsychologiststendtoseeclientswith _Tan_Counseling_BB_mw.indd23 9/21/104:34:00PM 10 BasicIssuesinthePracticeofCounselingandPsychotherapy lessseverepsychopathology,althoughthisislessoftenthecasetodaythaninthepast.5.Schoolpsychologistsareusuallyeducatedatthedoctoralleveltocloselyworkwitheducatorsandotherstofacilitatetheholisticdevelopmentofchildreninschool.Theyoftenassessandcounselchildrenwithdifferenttypesofproblems,aswellasconsultwithteachers,parents,andotherschoolstaff.6.Industrial/organizationalpsychologistsareeducatedatthedoctorallevel.Theyareinvolvedinenhancingtheeffectivenessoforganizationsandhelpingtoimproveproductivityandthewell-beingofemployeesaswellasmanagementstaff.7.Marriageandfamilytherapistsaretrainedatthemaster’sordoctorallevelinmaritalandfamilytherapy.Inmoststatestheymustbelicensedtopracticeasmarriage,family,andchildcounselors(MFCC)ormaritalandfamilytherapists(MFT).8.Socialworkersusuallyhaveamaster’sdegreeinsocialwork.Theyalsomustbelicensedinmanystatesasclinicalsocialworkersinordertodoindividualaswellasfamilycounselingandtherapy.9.Psychiatricnurseshaveanassociate’sorbaccalaureatedegree,specializinginpsychiatricservices.Apsychiatricnursewithamaster’sdegreeinnursing(MSN)andpsychiatric/mentalhealthcertificationcanalsodoprivatepractice.10.Pastoralcounselorsareministers,usuallywithmaster’sdegreesintheologyordivinity,whoalsohavehadspecialtrainingandexperienceincounselingfromaspiritualperspective.ManyofthemhavereceivedtrainingfromaclinicalpastoraleducationcenterintheUnitedStates,whichhasover350suchcenters.11.Vocationalcounselorshaveamaster’sdegreethatpreparesthemtocounselpeopleinordertohelpthemintheirvocationalchoicesandprofessionaldevelopment.12.Occupationalcounselorshaveabachelor’sormaster’sdegreeandinternshipexperiencethatpreparesthemtohelppeoplewithphysicalchallengestomakethebestuseoftheirresources.13.Schoolcounselorshaveanadvanceddegreeincounselingpsychologyandareinvolvedinhelpingpeoplewithcareerandeducationalissues.14.Substance-abusecounselorshavebachelor’sormaster’sdegreesandcounselpeoplewithalcoholand/ordrugaddictionsorsubstance-abuseproblems.15.Paraprofessionalorlaycounselorshavelimitedtrainingincounselingbutdonothaveadvanceddegreesincounselingandarenotlicensedmentalhealthprofessionals.Theyusuallydotheircounselingworkunderthesupervisionofalicensedmentalhealthprofessional. _Tan_Counseling_BB_mw.indd24 9/21/104:34:01PM OverviewofCounselingandPsychotherapy 11 AnothergroupofmentalhealthpractitionersnotmentionedbyParrott(2003)isthecategoryofprofessionalcounselorsorlicensedprofessionalcounselors(LPCs)withmaster’sdegreesincounselingwhohavealsobeenlicensedinthestateinwhichtheypractice.Thereareseveralmajorpracticesettingsinwhichmentalhealthprofessionalsdocounselingandrelatedworkincluding:privatepractice,communitymentalhealthcenters,hospitals,humanserviceagencies,andschoolsandworkplaces(seeParrott2003,16).SomeContemporaryDevelopmentsinCounselingandPsychotherapySeveralsignificantcontemporarydevelopmentsincounselingandpsychotherapyhaveoccurredinrecentyears.Notsurprisingly,giventhecomputerandInternetrevolutioninthisinformationage,onesuchdevelopmenthasbeenintheareaoftechnologicalapplicationsandinnovations.Examplesincludetheuseofcomputertechnologyinvirtualtherapy,inwhichvirtualrealityisusedasatherapyinterventionforthetreatmentofanxietydisorders.Psychotherapycanalsobeprovidedbytelephone,videoconferencing,andvideotelephone,inwhathasbeencalledtelepsychotherapy.Suchtherapies,ofcourse,raiseseriousethicalandlogisticalissues,butsuchtechnologicalinnovationsinpsychotherapyareheretostay(seeProchaskaandNorcross2010).Anothercontemporarydevelopmentinclinicalpracticeistheintegrationofreligionorspiritualityandpsychotherapy(seeTan1996c,2001b).SinceAllen E.Bergin(1980)publishedhisseminalarticleonpsychotherapyandreligiousvaluesoverthreedecadesago(seealsoS. L.Jones1994),religiouslyorspirituallyorientedpsychotherapyhasbecomeanimportantpartofthecurrentpracticeofcounselingandpsychotherapy(formorerecentexamples,seeAtenandLeach2009;Pargament2007;Plante2009;Richards2006;RichardsandBergin2000,2004,2005;SperryandShafranske2005).Morespecifically,Christianapproachestotherapyhavefurtherdevelopedinrecentyears(see,e.g.,N. T.Anderson,Zuehlke,andZuehlke2000;Clinton,Hart,andOhlschlager2005;ClintonandOhlschlager2002;Collins2007;MalonyandAugsburger2007;McMinnandCampbell2007;seealsoS. L.JonesandButman1991;YarhouseandSells2008),andresearchfindingssofarhaveprovidedsomesupportfortheefficacy(seeWorthingtonandSandage2001)andeffectivenessinactualclinicalsettings(seeWade,Worthington,andVogel2007)ofChristiantherapy(seealsoT. B.Smith,Bartz,andRichards2007).Contemporaryclinicalpracticehasalsobeensignificantlyimpactedbymulticulturalperspectives,feministtherapy,andpostmodernapproachessuchasnarrativetherapy,solution-focusedbrieftherapy,andsocialconstructionism(seeCorey2009). _Tan_Counseling_BB_mw.indd25 9/21/104:34:01PM 12 BasicIssuesinthePracticeofCounselingandPsychotherapy Asafinalexampleofanothersignificantcontemporarydevelopmentintherapeuticpractice,letusturntoamajormovementinpsychologytodaycalledpositivepsychology.MartinSeligmanandMihalyCzikszentmihalyi(2000)introducedtheemergingscienceofpositivepsychologyoveradecadeago,referringtothestudyofpositiveemotion,positivecharacter,andpositiveinstitutionsandhowtonurturethem.Thismovementhasreallytakenoffwithamushroomingbodyofliteratureaswellasrecentempiricalattemptstovalidateorsupportpositivepsychologyinterventions(M. E. P.Seligman,Steen,Park,andPeterson2005;seealsoTan2006aforareviewandbiblicalperspectiveandcritiqueofappliedpositivepsychology).MartinSeligman,TayyabRashid,andA. C.Parks(2006)reportedfindingsfromtworesearchstudiesthatprovidedempiricalsupportfortheeffectivenessofpositivepsychotherapy(basedonpositivepsychology)employingexercisesorinterventionsexplicitlyaimedatincreasingpositiveemotion,engagement,andmeaningintreatingdepression.Amorerecentmeta-analysisof51positivepsychologyinterventionswithatotalof6,018participants(SinandLyubomirsky2009)showedsignificantenhancementofwell-being(effectsize=.29)andsignificantalleviationofdepressivesymptoms(effectsize=.32).Positivepsychology(includingpositivepsychotherapy)focusesmoreonidentifyingthecharacterstrengthsandvirtuesofclientsandlessontheirpsychopathologiesorpsychologicaldeficits(seeLinleyandJoseph2004;C. PetersonandSeligman2004).ExamplesofMajorProfessionalOrganizationsforCounselorsandPsychotherapistsThefollowinglistincludesexamplesofmajorprofessionalorganizationsandtheirWebsitesthatarerelevanttocounselorsandpsychotherapistsinclinicalpractice:•AmericanCounselingAssociation(ACA),www.counseling.org•AmericanPsychologicalAssociation(APA),www.apa.org•AmericanAssociationforMarriageandFamilyTherapy(AAMFT),www.aamft.org/index_nm.asp•NationalAssociationofSocialWorkers(NASW),www.naswdc.orgTwoexamplesofspecificallyChristianprofessionalorganizationsandtheirWebsitesare•ChristianAssociationforPsychologicalStudies(CAPS),www.CAPS.net•AmericanAssociationofChristianCounselors(AACC),www.AACC.net _Tan_Counseling_BB_mw.indd26 9/21/104:34:02PM OverviewofCounselingandPsychotherapy 13 RecommendedReadingsCastonguay,L. G.,&Beutler,L. E.(Eds.).(2006).Principlesoftherapeuticchangethatwork.NewYork:OxfordUniversityPress.Corey, G.(2009).Theoryandpracticeofcounselingandpsychotherapy(8thed.).Belmont,CA:Brooks/Cole.Linley,R. A.,&Joseph, S.(Eds.).(2004).Positivepsychologyinpractice.Hoboken,NJ:Wiley.Nathan,P. E.,&Gorman,J. M.(Eds.).(2007).Aguidetotreatmentsthatwork(3rded.).NewYork:OxfordUniversityPress.Norcross,J. C.(Ed.).(2002).Psychotherapyrelationshipsthatwork.NewYork:OxfordUniversityPress.Prochaska,J. O.,&Norcross,J. C.(2010).Systemsofpsychotherapy:Atrans­theoreticalanalysis(7thed.).Belmont,CA:Brooks/Cole. _Tan_Counseling_BB_mw.indd27 9/21/104:34:02PM 2ThePersonoftheCounselor C hapter1providedanoverviewofthefieldofcounselingandpsychotherapy,focusingontheory,research,andpracticeareas.Researchfindingshaveshownthatingeneral,therapeuticchangeinclientsresultsfromclientandtherapistfactorsmorethanfromtechniques(LambertandBarley2002;seealsoHubble,Duncan,andMiller1999).Thepersonofthecounselorortherapististhereforecrucialineffectivetherapy.Althoughknowledgeandskillsareimportantinconductingeffectivecounseling,thepersonofthecounselorisoneofthemostimportantdeterminantsandinstrumentsofeffectivetherapeuticwork(Corey2009).Whoyouareasapersonandaprofessionalinthecounselingfieldisthereforethefocusofthischapter.Inpractice,thepersonandtheprofessionalareactuallyintegratedorintertwinedentitiesthatcannotbeseparated(Corey2009).However,wewillconsiderthecounselorwithregardtothesetwointimatelyconnectedcategories:thecounselorasaprofessionalandthecounselorasaperson.TheCounselorasaProfessional:PersonalCharacteristicsofEffectiveCounselorsThecounselorasaprofessional,oratherapeuticperson,isusuallydescribedassomeonewithparticularhelpfulcharacteristics.GeraldCoreyhasprovidedalistofpersonalcharacteristicsofeffectivecounselors(emphasizingthatthe14 _Tan_Counseling_BB_mw.indd28 9/21/104:34:03PM ThePersonoftheCounselor 15 crucialqualityinvolvesthecounselor’swillingnesstostruggletobecomeamoretherapeuticperson),includingthefollowing:“Effectivetherapistshaveanidentity;respectandappreciatethemselves;areopentochange;makechoicesthatarelifeoriented;areauthentic,sincere,andhonest;haveasenseofhumor;makemistakesandarewillingtoadmitthem;generallyliveinthepresent;appreciatetheinfluenceofculture;haveasincereinterestinthewelfareofothers;possesseffectiveinterpersonalskills;becomedeeplyinvolvedintheirworkandderivemeaningfromit;andareabletomaintainhealthyboundaries”(2009,18–19).Noonecounselorortherapistpossessesallthesedesirablecharacteristicsofaneffectivecounselor.However,everycounselorshouldbewillingtodevelopthesetraits.Otherpersonalqualitiesofeffectivecounselorsbasedonareviewoftheresearchliteratureavailableonthistopicincludepsychologicalhealth,genuineinterestinothers,empathicabilities,personalwarmth,self-awareness,toleranceofambiguity,andawarenessofvalues(seeParrott2003,24–35).GaryCollins(2007)addedthreeotherimportantcounselortraits:integrity,courage,andgenuineabilitytocare.WhilesuchpersonalqualitiesofeffectivecounselorsapplytobothChristianandseculartherapists,therearesomeuniquecharacteristicsofdistinctivelyChristiancounselorsthatwarrantfurtherdescription.UniqueCharacteristicsofChristianCounselorsChristiancounselingcanbesimplydefinedascounselingorpsychotherapythatisChristcentered,biblicallybased,andSpiritfilled(seeTan2001b,24).Christiancounselingalsoprimarilyconcernscharacter,includingthepersonalgodlinessofthecounselorortherapist.Thisemphasisisconsistentwiththischapter’sfocusonthepersonofthecounselorandJamesGuy’s(1987)classicbookonthepersonallifeofthepsychotherapist.Personalorintrapersonalintegrationreferringtoaperson’sownappropriationoffaithandintegrationofpsychologicalandspiritualexperienceisthereforefoundationalinallintegrationwork(i.e.,integrationofChristianfaithandpsychologyorcounseling)thatincludesprincipled(theoryandresearch),professional(practice),andpersonalintegration(Tan2001b).AsIhavenoted:CarterandNarramore(1979)havesuggestedseveralessentialattitudesandattributesrelevanttointrapersonalorpersonalintegration,whichcoverbothpsychologicalandspiritualaspects,includingthefollowing:humilityandanawarenessoffinitelimitations,toleranceforambiguity,balancedexpressionofone’sintellectandemotions,opennessinsteadofdefensivenessduetopersonalanxietiesandinsecurities,andaneternalperspectiveonourworkaspartofhumanity’sGod-ordainedtaskofreconcilinghumanbeingstoGod,themselves,andothers.Crabb(1977). . .hasemphasizedtheneedforChristianpsycholo- _Tan_Counseling_BB_mw.indd29 9/21/104:34:04PM 16 BasicIssuesinthePracticeofCounselingandPsychotherapy giststodothefollowing:spendasmuchtimeintheregularandsystematicstudyoftheBibleasinthestudyofpsychology;havebothageneralgraspofthestructureandoverallcontentofScriptureaswellasworkingknowledgeofBibledoctrine;andbeinvolvedinthefellowshipofaBible-believingchurch.(Tan1987b,35) ThespiritualityorspiritualgrowthoftheChristiancounseloristhereforeauniqueanddistinctiveaspectofthepersonoftheChristiancounselor.Inthiscontext,theuseofspiritualdisciplinesinagrace-filledway,empoweredbytheHolySpirit,iscrucialinfacilitatingpersonalandspiritualgrowthintodeeperChristlikenessinboththeChristiancounselorandtheclient(Tan1998;seealsoEck2002).Spiritualdisciplinesincludepracticessuchassolitudeandsilence,listeningandguidance,prayerandintercession,Biblestudyandmeditation,repentanceandconfession,yieldingandsubmission,fasting,worship,fellowship,simplicity,service,andwitness(TanandGregg1997).TheyshouldbepracticednotinalegalisticwaybutindependenceonthepowerandpresenceoftheHolySpiritandGod’sgrace.Theyaretherefore“disciplinesoftheHolySpirit”(TanandGregg1997).TheuniquenessoftheChristiancounselorcanbecharacterizedbyatleastfourdistinctivesofChristiancounseling:(1)uniqueassumptionsthatarebasedontheBible,includingbeliefsaboutGod’sattributes(e.g.,Godisacompassionate,sovereignGod),thenatureofhumanpersons,therealityofsin,theauthorityoftheBible,theforgivenessofsinsandsalvationthroughJesusChrist,andhopeforthefuture;(2)uniquegoalsthatincludenotonlyalleviatingsymptomsorreducingpsychologicalandemotionalsufferingbutalsofacilitatingspiritualgrowthwhenappropriatebasedonChristianorbiblicalvalues;(3)uniquemethodsthatgobeyondstandardcounselingskillsandtechniques,forexample,avoidingimmoralorunbiblicalmethodssuchasencouragingextramaritalorpremaritalsex,andusingspiritualinterventionssuchasprayerandScriptureethicallyandappropriatelyincounselingsessions;(4)uniquegiftednessfromGodintheworkofcounselingorpeople-helping(includinghavingspiritualgiftsfromtheHolySpiritsuchasencouragementorexhortation)(seeCollins2007,18–21).AChristiancounseloristhereforeacounselorwhopracticesinaChristcentered,biblicallybased,andSpirit-filledway.AdditionalelementsofsuchadistinctiveoruniqueapproachtocounselingfromaChristian,biblicalperspectivewillbeprovidedinthelatterpartofthisbook.IssuesandPotentialPitfallsFacingBeginningCounselorsNovicecounselorsortherapistsfacecertainissuesandpotentialpitfallsastheybegintheircounselingwork.Itcanbehelpfulforbeginningcounselorstobeawareoftheseissuesandpossiblepitfallsearly,sothatunnecessary _Tan_Counseling_BB_mw.indd30 9/21/104:34:04PM ThePersonoftheCounselor 17 anxietyorpaincanbeavoided.Iwillbrieflyreviewtwohelpfullistsoftheseissuesandpitfalls.Coreyhaslistedandbrieflydescribedthefollowingissuesthatnovicecounselorsusuallyfaceastheybeginseeingclientsinclinicalpractice(see2009,29–35):(1)dealingwiththeiranxietiesandself-doubts,bytalkingthemoverwithasupervisorandotherbeginningcounselors;(2)beingthemselvesanddisclosingtheirexperiences,whilemaintainingaproperbalancebetweenhidingbehindaprofessionalfacadeandsharingtoomuchaboutthemselvesandburdeningclientsasaresult;(3)avoidingperfectionismortryingtobeaperfectcounselor,whichisimpossible;insteadbeingopentomakingmistakesandlearningfromthem,especiallyinsupervision;(4)beinghonestabouttheirlimitations,sothattheylearnwhichclientsandproblemstheycanorcannoteffectivelycounsel,aftersufficientexposuretodiverseclients,problems,andsettings;(5)understandingsilencesothattheyexploreitsmeaningwiththeirclientsandarenotafraidofsilenceorreactanxiouslytoit;(6)dealingwithdemandsfromclients,especiallyiftheyareunrealisticorunreasonabledemands;settingclearexpectationsandboundariesinthefirstsessionwithclientscanbehelpful;(7)dealingwithclientswholackcommitment,especiallyinvoluntaryclients,forexample,thosewhohavebeenmandatedbyacourtordertohavetherapy;itmayhelptopreparesuchclientsfortheprocessofcounseling;(8)toleratingambiguity,forexample,whenclientsdonotseemtobeimprovingatall;sometimesclientsgetworsebeforetheygetbetter,socounselorsneedtobepatientwithsuchambiguityforawhile;(9)avoidinglosingthemselvesintheirclients,forexample,byworryingtoomuchaboutthemortakingontoomuchresponsibilityforthem;counselorsneedtoengageintheirownself-explorationwithasupervisor,peer,oreventheirowntherapist;(10)developingasenseofhumorthatisappropriate,sothattheydonottakethemselvesandtheirworktooseriouslyyetdonotunderratethepainandsufferingoftheirclients;(11)sharingresponsibilitywiththeclient,sothatultimatelytheclientisempoweredtomakehisorherowndecisions,withthecounselor’shelpandsupport;(12)decliningtogiveadviceallthetimetoclientswhoneedtogrowinmakingtheirowndecisions;counselorsneedtolearntoprovideguidanceandmakesuggestionsonlyjudiciously,withproperrespectfortheclient’sdecision-makingprocessandresponsibility(unlessthereisacrisissituationwhentheclientisunabletofunctionormakedecisions);(13)definingtheirroleasacounselor;thismaychangeovertimeandalsointheparticularclinicalsettingwithspecifictypesofclientsandproblems;(14)learningtousetechniquesappropriately,withcarefulselectionoftechniquesthatmaybestfitandhelpaparticularclientwithaspecificproblem;(15)developingtheirowncounselingstyleovertimeandwithenoughexperience,sothatthecounselorachievesauniqueanddistinctiveapproachtocounselingthatiscongruentwithhisorherpersonalityandgiftednessorstrengths;(16)stayingaliveasapersonandasaprofessionaltoavoidprofessionalburnout; _Tan_Counseling_BB_mw.indd31 9/21/104:34:07PM 18 BasicIssuesinthePracticeofCounselingandPsychotherapy self-carestrategiesarecrucial,andtheywillbedescribedanddiscussedinmoredetaillaterinthischapter.Inasimilarvein,Parrotthaslistedandbrieflydescribedthefollowingcommonpitfallsthatbeginningcounselorsmayface:prematureproblemsolving,settinglimits,fearofsilence,interrogating(oraskingtoomanyquestionsofclients),impatience,moralizing,andreluctancetorefer(see2003,35–39).Novicecounselorswillbenefitfromreviewingthesetwolistsandpreparingthemselvestodealwithsuchpotentialorcommonpitfallsbeforetheyactuallyencounterthem.TheCounselorasaPersonThecounselorasaperson,withhumanstrengthsandweaknesses,facesseveralotherareasofpotentialconcern.Collins(2007)haslistedafew,includingthefollowing:thecounselor’smotivation,thecounselor’smistakes,thecounselor’sburnout,andthecounselor’scounselors.Withregardtothecounselor’smotivation,thecounselormayhaveseveralpersonalneedsthatarepotentiallyharmfultotheclientandthecounselingprocess.Examplesofsuchneedsincludetheneedtocontrolorrescue;theneedforrelationships;theneedforinformationbasedmostlyonunhealthycuriosity;theneedforaffirmation,acceptance,andapproval;andtheneedforassistancewiththecounselor’sownpersonalproblems(seeCollins2007,31–32).Withregardtothecounselor’smistakes,itishelpfultobearinmindthatallcounselorsmakemistakes.However,thefollowingcommonmistakesshouldbeavoidedasfaraspossible:visitingorengagingincasualconversationswiththeclientinsteadofcounseling;attemptingtosolveproblemsprematurely;askingtoomanyquestionstooquickly;showingadisrespectfulorjudgmentalattitude;beingtooemotionallyinvolved;beingdistantorsuperficial;beingdefensivewhenfeelingthreatenedorchallenged(seeCollins2007,32).Withregardtothecounselor’sburnout,counselingcanbeemotionallydrainingworkandthusentailsahighriskofburnout.Burnoutsymptomsincludeexhaustion,afeelingofdetachmentfromclients,andthetendencytowithdraw.Topreventorrecoverfromburnout,counselorsneedspiritualstrength,socialsupportfromotherpeople,freedomfromthedrivetoachieve,awarenessthattheycannotdoeverything,periodsoftimetobeawayfrompeople,continueddevelopmentoftheircounselingskills,andotherpeoplewithwhomtheycansharetheirloadorburdens(seeCollins2007,32).Strategiesforself-care,includingpreventingburnout,willbecoveredinmoredetaillaterinthischapter.Finally,withregardtothecounselor’scounselors,counselorsareencouragedtohaveothercounselorfriendswhocanprovidesupportandperspectiveandcanpointthemtoJesusChrist,theultimateCounselorwhogivesushope, _Tan_Counseling_BB_mw.indd32 9/21/104:34:08PM ThePersonoftheCounselor 19 strength,anddirectionthroughtheHolySpirit(seeCollins2007,32).ChristiancounselorscancasttheircaresandclientsupontheLordJesusthroughprayerintheirownindividuallivesandwalkwithGod.Inthelastsectionofthischapter,wewillexamineinmoredetailthecrucialtopicofself-careforthecounselor.Self-CarefortheCounselorSelf-careisessentialforthewell-beingofthecounselor,aswellasfortheefficient,effective,andethicalpracticeofcounselingandtheultimatebenefitoftheclient(seeNorcrossandGuy2007).Somepeoplemaymisunderstandtheterm“self-care”tomean“selfishcare”or“self-centeredcare”foroneself.Selfcareforthecounselor,however,referstohealthyandwisestrategiesfortakinggoodcareofoneselfasacounselorinordertomanagestresswellandpreventburnout.Theeventualeffectofgoodself-care,whichisanethicalimperativethroughoutacounselor’sprofessionallife,istheabilitytofunctionwellandeffectivelyasacounselorandthereforetobetterhelpclients(Barnett,Baker,Elman,andSchoener2007).Itisthuslovingandwisetoengageinproperself-carethateventuallyleadstothehelpingandhealingofothers.TheResilientPractitioner:BurnoutPreventionandSelf-CareStrategiesforCounselorsandOthersThomasSkovholt(2001)haswrittenaveryhelpfulandpracticalbookthatcomprehensivelycoversburnoutpreventionandself-carestrategiesforcounselors,therapists,teachers,andhealthprofessionals.Suchself-carestrategiescanhelpacounselorbecomearesilientpractitionerwhohaslearnedtopreventburnoutandtogrowinbalancedwellnessinphysical,spiritual,emotional/social,andintellectualareasofhealth.Skovholtemphasizesthecounselor’sneedtotakecareoftheselfjustastheoperasingermusttakecareofthevoice,thebaseballpitcherthearm,thecarpenterthetools,theprofessorthemind,thephotographertheeyes,andtheballerinathelegs(2001,ix).Beforewemorecloselyexaminethespecificself-carestrategiesforproducingtheresilientpractitioner,itmaybehelpfultofirstconsiderthepoorself-caredeadlydozenthatSkovholthaslisted.Thesepitfallsshouldbeavoidedasfaraspossiblebycounselorswhowanttopreventburnoutandgrowinbalancedwellness:1.Toxicsupervisorandcolleaguesupport2.Littlefuninlifeorwork3.Unclearunderstandingofone’sownneeds4.Lackofprofessionaldevelopmentprocessthathelpstransformexperienceintogreatercompetenceandreducedanxiety5.Absenceofenergy-givingpersonallife _Tan_Counseling_BB_mw.indd33 9/21/104:34:08PM 20 BasicIssuesinthePracticeofCounselingandPsychotherapy 6.Inabilitytoturndownunreasonablerequests7.Accumulatedeffectsofvicarioustraumatization8.Personalrelationshipsthataremainlyone-waywithselfasgiverorproviderofcaring9.Perfectionismintasksatwork10.Ambiguousprofessionallossesthatremainunresolved11.Needtobeneededthatisstrong12.Professionalsuccessdefinedonlyintermsofclientpositivechangeorappreciation(seeSkovholt2001,210)Self-CareStrategies:SustainingtheProfessionalSelfThefollowingarestrategiesfornurturingandsustainingtheprofessionalselfofthecounselor:avoidingtheimpulsetowardgrandiosity;thinkinglongterm;puttingtogetherandactivelyapplyinganindividualdevelopmentmethodorplan;cultivatingprofessionalself-understanding;creatingaprofessionalgreenhouse(environmentforgrowth)atwork;havingleadershipthatfacilitatesbalancebetweenself-careandcaringforothers;drawingonprofessionalsocialsupportfrompeers;gettingsupportfrombosses,supervisors,andmentors;beingnurturedfromworkasmanagers,supervisors,andmentors;learninghowtobebothplayfulandprofessional;releasingemotionsofdistressthroughprofessionalventing;learningtobea“goodenoughpractitioner”;understandingtherealityofearlyprofessionalanxiety,whichispervasive;reinventingoneselftoincreaseexcitementandreduceboredom;dealingwithambiguousprofessionallossbyminimizingit;learningtorefuseunreasonablerequests(seeSkovholt2001,206–7,130–44).Self-CareStrategies:SustainingthePersonalSelfIntheareaofnurturingandsustainingthepersonalselfofthecounselor,Skovholtfocusesonself-careactivitiestonurturetheemotionalself,thefinancialself,thehumorousself,thelovingself,thenutritiousself,thephysicalself,theplayfulself,thepriority-settingself,therecreationalself,therelaxationandstress-reductionself,thesolitaryself,andthespiritualorreligiousself(2001,208–9,148–62).Basedonresearchdonewithtraumatherapists(PearlmanandMacIan1995),thetoptenhelpfulactivitiesforself-careoftraumatherapistsare:discussingcaseswithcolleagues;attendingworkshops;havingtimewithfamilyorfriends;enjoyingtravel,vacations,movies,hobbies;talkingwithcolleaguesbetweensessions;socializing;exercising;controllingcaseload;developingspirituallife;andreceivingsupervisioningeneral.Inmorerecentresearchonself-careandburnout,severalinterestingfindingshavebeenreported.Astudyofinternself-carewith363psychologypredoc- _Tan_Counseling_BB_mw.indd34 9/21/104:34:09PM ThePersonoftheCounselor 21 toralinternsfoundthatsomeofthemostSidebar2.1frequentlyusedstrategiesforself-careduringtheinternshipyearweresocialsupportTenActivitiesforSelf-Carefromfamilyandfriends,activeproblem(seeSkovholt2001,212)solving,andhumor(Turneretal.2005).Themosteffectivestrategieswerereceiv1.Beingwithfamilyingsocialsupportfromfamilyandfriends,2.Trainingoreducationforjobskillsseekingpleasurableexperiences,andcul3.Pursuingahobbythatisfuntivatinghumor.Womenweremorelikely4.Engaginginphysicalactivitytoemployself-carestrategiesandalsore5.Readingportedmoreeffectivenessfromtheiruse.6.ReceivingsupervisionorAnotherstudy,focusingongenderandconsultationwork-settingdifferenceincareer-sustaining7.Socializingatworkbehaviorsandburnoutamongprofessional8.Havingtimealonepsychologists,foundthatthefollowingsix9.Spendingtimewithfriends,partstrategieswerehighlyimportantforallner,spouse595psychologistssurveyed:maintaining10.Takingavacationasenseofhumor;maintainingself-awareness/self-monitoring;maintainingbalancebetweenpersonalandprofessionallives;maintainingprofessionalidentity/values;engaginginhobbies;andspendingtimewithspouse,partner,orfamily(RupertandKent2007).Thoseworkinginsoloorgroupindependentpracticereportedagreatersenseofpersonalaccomplishment,moresourcesofsatisfaction,fewersourcesofstress,andmorecontrolatworkthanthoseworkinginagencysettings.Womenworkinginindependentpracticereportedlessemotionalexhaustionthanwomenworkinginagencysettings.AnotherexampleofrecentresearchonburnoutandcopinginhumanservicepractitionersisastudyinSpainof211professionals,eitherchild-protectionworkersorin-homecaregivers,whocompletedaninventoryoncopingandaninventoryonburnout(Jenaro,Flores,andArias2007).Burnoutwasconceptualizedasconsistingofemotionalexhaustion,depersonalization,andareductionofpersonalaccomplishment.Copingstrategieswereclassifiedasproblemfocused(e.g.,planningandactivecoping,focusoneffortstosolvetheproblemorsituation,socialsupport,personalgrowth,andpositivereinterpretation)andemotionfocused(e.g.,religion,humor,alcohol/drugintake,disengagement,focusonemotionsandventingthem,acceptance,denial,andrestraintcoping).Thisstudyfoundthatcopingstrategiesbythemselvesmayhelppreventworkerturnoverbutdonotprecludeburnout.Italsoreportedthathighjobandsalarysatisfaction,togetherwithactivecopingstrategies,playanimportantroleinenhancingpersonalaccomplishment,whereaslowjobandsalarysatisfactiontogetherwithpassiveoremotionalcopingstrategiespredicthigheremotionalexhaustion. _Tan_Counseling_BB_mw.indd35 9/21/104:34:10PM 22 BasicIssuesinthePracticeofCounselingandPsychotherapy Self-Care:SomeReflectiveQuestionsandFurtherSuggestionsInbringingthischapteronthepersonofthecounselortoaclose,IwouldliketobrieflyreviewthehelpfulinsightsprovidedbyMichael J.Mahoney,awell-knownpsychologistwhohasmorerecentlydevelopedconstructivepsychotherapy(2003).InanearlierandsignificantSidebar2.2bookonhumanchangeprocessesandthescientificfoundationsofpsychotherapy,Self-CareStrategiesforCounselorsheliststwenty-threereflectivequestionsandPsychotherapistsforcounselorstoaskthemselvesinorder(NorcrossandGuy2007,xvii)toengageinbetterandhealthierself-care(1991,370).Someexamplesofthesehelp1.Valuingthepersonofthefulreflectivequestionsforself-carearepsychotherapist“Howhappyareyoumostofthetime?2.RefocusingontherewardsHowdoyoufeelaboutyourself?Doyou3.Recognizingthehazardsseekandaccepthelporcomfortfromoth4.Mindingthebodyers?Isyourrestusuallyadequateandsat5.Nurturingrelationshipsisfying?Whatareyourfears?Whatgives6.Settingboundariesmeaningorpurposetoyourlife?What7.Restructuringcognitionsareyourhopes?Whatcouldyoudotobe8.Sustaininghealthyescapesmoreself-caring?Withwhomcanyoutalk9.Creatingaflourishingaboutyourinnerlife?Doyoulaughandenvironmentcry?Whatformsofmusicandmovement10.Undergoingpersonaltherapydoyouenjoy?Whatareyourspiritual11.Cultivatingspiritualityandneedsandcomforts?Ifyoucouldchangemissionthreethingsinyourlife,whatwouldthey12.Fosteringcreativityandgrowthbe?”(370).Mahoneyemphasizestheimportanceforthecounselortobevigilantlysensitivetohisorherownphysical,emotional,andpsychospiritualneeds,allofwhichareinterdependent.Morerecently,Mahoneyhasmadeseveralhelpfulrecommendationsforcounselorortherapistself-careinthecontextofdoingconstructivepsychotherapy(whichintegratesideasfromconstructivistandnarrativetherapywithinsightsfromcognitive-behavioral,humanistic,systems-based,psychodynamic,andothertherapeuticapproaches):1.Begentlewithyourself;honoryourownprocess.2.Getadequaterest.3.Makeyourselfcomfortable.4.Moveyourbodyoften.5.Developaritualoftransitionforleavingworkattheoffice.6.Receiveregularprofessionalmassages.7.Cherishyourfriendshipandintimacywithfamily. _Tan_Counseling_BB_mw.indd36 9/21/104:34:11PM ThePersonoftheCounselor 23 8.Cultivateyourcommitmenttohelping;honortheprivilegeofourprofession.9.Askforandacceptcomfort,help,andcounsel(includingpersonaltherapy).10.Createasupportnetworkamongyourcolleagues.11.Enjoyyourself.12.Followyourheartandembraceyourspiritualseeking.(2003, 260–61)FromamoredistinctivelyChristianperspective,theregularuseorpracticeofthespiritualdisciplinesmentionedearlierinthischapter(seeTanandGregg1997)canbeveryhelpfulinpreventingburnoutbyfacilitatingspiritualgrowthandcenteringinChrist,withthepowerandpresenceoftheHolySpirit.SpecificmeansofGod’sgracetoenabletheChristiancounselortoentermoreintoGod’srestortoexperienceGod’speaceinarestlessworldincludeShepherd-centerednessinChrist,Spirit-filledsurrendertoGod,solitudeandsilence,simplicity,Sabbath-keeping(onedayaweekceasingfromgainfulemployment—restingandworshipingGod),sleep,spiritualcommunity,servanthood,andstressmanagementfromabiblicalperspectivethatemphasizesvaluessuchaslove,faithfulness,andhumility,ratherthansuccess,competitiveness,andperfectionism(seeTan2003d;Tan2006b).LearningtorestinChrist(Matt.11:28–30;seealsoMark6:31;Luke10:38–42)inthesewayswillhelpaChristiancounselortobettermanagestressandpreventburnout(seealsoHart1995,1999).Self-carefortheChristiancounselor,likeself-careforanycounselor,isthereforeanessentialandbiblicallysoundaspectofthepersonandexperienceofthecounselororpsychotherapist.Thisissobecauseappropriateandhealthycounselorself-careeventuallyleadstomoreeffectiveandethicalhelpingandhealingofclients(seeNorcrossandGuy2007).RecommendedReadingsGuy,J. D.(1987).Thepersonallifeofthepsychotherapist.NewYork:Wiley.Mahoney,M. J.(2003).Constructivepsychotherapy:Apracticalguide.NewYork:GuilfordPress.Norcross,J. C.,&Guy,J. D.(2007).Leavingitattheoffice:Aguidetopsychotherapistself-care.NewYork:GuilfordPress.Skovholt,T. M.(2001).Theresilientpractitioner:Burnoutpreventionandself-carestrategiesforcounselors,therapists,teachers,andhealthprofessionals.NeedhamHeights,MA:Allyn&Bacon.Tan,S. Y.(2003).Rest:ExperiencingGod’speaceinarestlessworld.Vancouver,BC:RegentCollege. _Tan_Counseling_BB_mw.indd37 9/21/104:34:12PM 3LegalandEthicalIssuesinCounselingandPsychotherapy C ounselingorpsychotherapyisauniquekindofworkthatplacesthewelfareandwell-beingoftheclientaboveandbeyondtheneedsofthecounselorortherapist.However,therearepotentialpitfallsanddangersindoingsuchtherapeuticwork,withtheever-presentpossibilityofharmingtheclient.Thetherapistthereforemustbeawareofthemajorlegalandethicalissuesinvolvedinconductingtherapyinordertoavoidcertainpitfallsandpreventpossibleharmtotheclient.Legalissuesinvolvethelawsofaparticularcountry,state,orprovincethatgovernthepracticeofcounselingorpsychotherapyinthatgeographicalareaorpoliticalentity.Legalissuesfacingtherapistsarethereforethosethatrelateto“stateandfederallawsandregulations,bindingcaselaw,administrativerules,orcourtorders”(Knapp,Gottlieb,Berman,andHandelsman2007,54).Ethicalissuesarebroaderandencompassprofessionalstandardsofrightandwrongthatguidetheworkofcounselorsandtherapists,helpingthemtoenhancethewell-beingandwelfareoftheirclientsandavoidharmingthem.Professionalcounselorsandorganizationsofcounselorsandtherapistshavesimilarethicalcodesgoverningtheirpractice,suchastheAmericanPsychologicalAssociation’sEthicalPrinciplesofPsychologistsandCodeofConduct,orAPAEthicsCode(AmericanPsychologicalAssociation[APA]2002)forpsychologists.Moreoftenthannot,thelawsthatregulatethepracticeofcounselorsandtherapistsareconsistentwiththeethicalprinciplesthatgovernandguidesuchcounselorsin24 _Tan_Counseling_BB_mw.indd38 9/21/104:34:12PM LegalandEthicalIssuesinCounselingandPsychotherapy 25 theirprofessionalwork.Forexample,SamuelKnappandhiscolleaguesnotethatmostethicaltherapistsorpracticingpsychologistswouldagreewiththefollowingstandards:sexwithclientsisprohibited;informationaboutclientsmustbekeptconfidential(withfewexceptions);therapistsshouldbecompetentintheservicestheyprovide;andtherapistsmustrefrainfrominsurancefraud(Knapp,Gottlieb, Berman, andHandelsman2007,54).However,therearetimeswhenlawsandethicsmaycollideorconflictwitheachotherinparticularsituationswithspecificclients.Atsuchtimes,thetherapistmaychoosetofollowthelawdespitetheethicaldilemmasheorshemaybestrugglingwith,orthetherapistmaydecidethatthemostethicalpositionwouldbethatofconscientiousobjectiontoaparticularlaw.Knappandhiscolleaguesprovideahelpfulreviewofthesedifficultsituationsandissuesandmakesuggestionsforaconstructivedecision-makingprocessattimeswhenlawsandethicsmaycollide(Knapp,Gottlieb, Berman, andHandelsman2007;seealsoKnappandVandeCreek2006).Usually,however,ethicaltherapistswillfollowthelawsregulatingtheirpracticeaswellastheethicalcodesoftheirprofessionalorganizations.Althoughwhatislegalmaysometimesnotbeethical,andviceversa,mostoftentheethicalchoiceisthelegalone,andviceversa.LegalIssuesinCounselingandPsychotherapyCounselorsandtherapistsareaffectedbythelawintheirpracticeinvariousways.ToddandBohart(2006,440–44)notethatlegislationpassedintheUnitedStatesregardingprivacyandsecurityissuescandirectlyorindirectlyimpacttheprofessionalpracticeoftherapists;anexampleistheHealthInsurancePortabilityandAccountabilityAct(HIPAA)passedbyCongressin1996.Anotherexampleislicensinglawsthatdirectlygoverntheprofessionalpracticeoftherapistsorcounselors,whomustpossesstherequisiteeducationaldegreesandhoursofsupervisedclinicalexperienceandpassspecificlicensingexaminationsinaparticularstatebeforetheyarelegallyqualifiedtobeinindependentpracticeinthatstate.Thereareotherlawsthatapplytohealthcareingeneralbutthataffecttheprofessionalpracticeofcounselorsandtherapists.ToddandBohart(2006)alsoemphasizeanotherareaoflawthatimpactstherapists:litigationorlawsuitsfiledagainstcounselorsandtherapistsformalpracticeornegligence.Courtdecisionsmadeinsuchlawsuitsbecomelegalprecedentsthatsubsequentlydirectlyaffectprofessionaltherapeuticpractice.Forexample,havingasexualrelationshipwithacurrentclientisnotonlyunethicalbutalsoillegalinmanystatesintheUnitedStatesatthistime.Mandatoryreportingofchild,elder,anddependentadultabuseandofclientsconsideredadangertoselfortoothershasalsobecomelawinmoststates.Counselorsandtherapistsengagedinprofessionalpracticethereforemustbeawareofsuchlegalissuesthatdirectlyorindirectlyaffectthem(see,e.g.,Levicoff1991;OhlschlagerandMosgofian1992). _Tan_Counseling_BB_mw.indd39 9/21/104:34:14PM 26 BasicIssuesinthePracticeofCounselingandPsychotherapy EthicalIssuesinCounselingandPsychotherapyTheAPAEthicsCodemostrecentlyrevisedandpublishedin2002“isintendedtoprovidespecificstandardstocovermostsituationsencounteredbypsychologists.Ithasasitsgoalsthewelfareandprotectionoftheindividualsandgroupswithwhompsychologistsworkandtheeducationofmembers,students,andthepublicregardingethicalstandardsofthediscipline”(APA2002, 1062).TheAPAEthicsCodecanalsobeused,withsomeadaptation,byothercounselorsandtherapistswhomaynotbeprofessionalpsychologists.Otherprofessionalorganizationsinthementalhealthfield,ofcourse,alsohavetheirownethicscodes(e.g.,AmericanCounselingAssociation[ACA],AmericanAssociationofMarriageandFamilyTherapy[AAMFT],andtheNationalAssociationofSocialWorkers[NASW]).TheAPAEthicsCodebeginswithasectiononfiveaspirationalgeneralprinciplesmeanttoreflecttheveryhighestethicalidealsofpsychologists;thecodethendelineatesspecificethicalstandardsrepresentingtheparticularobligationsofproperprofessionalconduct.Herearethefivegeneralprincipleswithsomeexplanatorytext(APA2002,1062–63).PrincipleA:BeneficenceandNonmaleficence“Psychologistsstrivetobenefitthosewithwhomtheyworkandtakecaretodonoharm.Intheirprofessionalactions,psychologistsseektosafeguardthewelfareandrightsofthosewithwhomtheyinteractprofessionallyandotheraffectedpersons,andthewelfareofanimalsubjectsofresearch. . . .Psychologistsstrivetobeawareofthepossibleeffectoftheirownphysicalandmentalhealthontheirabilitytohelpthosewithwhomtheywork”(APA2002,1062).PrincipleB:FidelityandResponsibility“Psychologistsestablishrelationshipsoftrustwiththosewithwhomtheywork.Theyareawareoftheirprofessionalandscientificresponsibilitiestosocietyandtothespecificcommunitiesinwhichtheywork.Psychologistsupholdprofessionalstandardsofconduct,clarifytheirprofessionalrolesandobligations,acceptappropriateresponsibilityfortheirbehavior,andseektomanageconflictsofinterestthatcouldleadtoexploitationorharm”(APA2002,1062).PrincipleC:Integrity“Psychologistsseektopromoteaccuracy,honesty,andtruthfulnessinthescience,teaching,andpracticeofpsychology.Intheseactivitiespsychologistsdonotsteal,cheat,orengageinfraud,subterfuge,orintentionalmisrepresentationoffact”(APA2002,1062). _Tan_Counseling_BB_mw.indd40 9/21/104:34:14PM 27 LegalandEthicalIssuesinCounselingandPsychotherapy PrincipleD:Justice“Psychologistsrecognizethatfairnessandjusticeentitleallpersonstoaccesstoandbenefitfromthecontributionsofpsychologyandtoequalqualityintheprocesses,procedures,andservicesbeingconductedbypsychologists”(APA2002,1062).PrincipleE:RespectforPeople’sRightsandDignity Sidebar3.1EthicalStandardsContainedintheAPAEthicsCodeThemorespecificethicalstandardscontainedintheAPAEthicsCode(APA2002,1063–73)coverthefollowingtenareas:1.Resolvingethicalissues2.Competence3.Humanrelations4.Privacyandconfidentiality5.Advertisingandotherpublicstatements6.Recordkeepingandfees7.Educationandtraining8.Researchandpublication9.Assessment10.Therapy “Psychologistsrespectthedignityandworthofallpeople,andtherightsofindividualstoprivacy,confidentiality,andself-determination. . . .Psychologistsareawareofandrespectcultural,individual,androledifferences,includingthosebasedonage,gender,genderidentity,race,ethnicity,culture,nationalorigin,religion,sexualorientation,disability,language,andsocioeconomicstatus,andconsiderthesefactorswhenworkingwithmembersofsuchgroups”(APA2002,1063).Inthiscontext,theneedforamulticulturalperspectiveinethicalclinicalpracticehasbeenemphasized(seeCorey2009).Ethicsthereforearethemoralprinciplesandstandardsthatguideagrouporapersonregardingrightbehavior.GeraldCorey,MarianneCorey,andPatrickCallanan(2007)differentiatebetweenprincipleethicsandvirtueethicsinthecontextofcounselingandtherapy.Principleethicsarethespecificrulesforrightbehaviorinparticularsituations.Virtueethicsarethehighestethicalidealstowhichcounselorsortherapistsaspireandthusfocusmoreonthecharacterofthecounselorortherapistthanonspecificbehavior.ThefivegeneralprinciplesoftheAPAEthicsCodecanbeviewedasvirtueethics,andthemorespecificEthicalStandardsasmainlyprincipleethics(seealsoBarnettandJohnson2008).Confidentiality,Competence,andChoiceMajorethicalissuesincounselingandpsychotherapycanalsobesummarizedinthreemajorcategories,asW. W.Becker(1987)hasdone(inhisapplicationofethicalandlegalissuesmorespecificallytotheareaofparaprofessionalor _Tan_Counseling_BB_mw.indd41 9/21/104:34:15PM 28 BasicIssuesinthePracticeofCounselingandPsychotherapy laycounseling):confidentiality,competence,andchoice,aimedeventuallyatmaintainingtrustinthecounselingrelationshipsincetrustistheessenceofsucharelationship.Inthecategoryofconfidentiality,ethicalcounselorswillkeepconfidentialanythingaclientrevealsordisclosestothemintheprocessofcounseling.Thereareexceptions,however.Manystatesnowrequirebylawthatprofessionalcounselorsreportsituationsinvolvingchild,elder,ordependentadultabuseorthoseinwhichaclientmaypotentiallyharmhimselforothers.Inthecategoryofcompetence,professionalcounselorsmustreceivetherequisiteacademicoreducationaldegrees,supervisedclinicaltrainingandexperience,andlicensing(afterpassinglicensingboardexaminationsinparticularstates)inordertobeinindependentpractice,chargingfeesfortheirservices(withsomeprobonoorfreeworkattimes).Theyshouldalsopracticewithinthelimitsoftheirprofessionalexpertiseorcompetenceandreferclientstoother,better-qualifiedortrainedprofessionalcounselorswhensuchclientspresentclinicalproblemsbeyondtheirownprofessionalcompetencetotreat.However,clinicalcompetenceforpracticingpsychologistsorcounselorsisnotaseasytodefineasitmayseem,anditsdefinitionshouldbeviewedmoreas“aworkinprogress”(Barnett,Doll,Youngren,andRubin2007,510;seealsoN. J.Kaslowetal.2007).Nevertheless,graduatestudenteducatorsandclinicalsupervisors,asgatekeepersoftheprofessionofcounselingandpsychotherapy,needtobeethicallyresponsibleandadequatelydealwithprofessionalcompetenceproblemsintraineesorsupervisees(W. B.Johnsonetal.2008),includingthoseinChristianpractitionertrainingprograms(Palmer,White,andChung2008;seealsoW. B.Johnson2007b;M. L.Nelson,Barnes,Evans,andTriggiano2007).Finally,inthecategoryofchoice,theclient’sfreedomtodecidewhethertoparticipateincounselingmustbeprotected.Informedconsentmustbeobtainedfromclientsbeforetherapyisstarted.However,theexactparametersofwhatacounselorortherapistshouldsharewithaclientinobtaininghisorherinformedconsentbeforestartingtherapyarenotalwaysclearcut.Moreover,obtaininginformedconsentshouldalsoapplytootherrolesthatpsychologistsorcounselorsmayhavesuchasconductingclinicalassessment,research,orclinicalsupervision(seeBarnett,Wise,Johnson-Greene,andBucky2007).J. E.Barnetthaspointedoutthatforinformedconsenttobelegallyvalid,thefollowingthreeconditionsmustbefulfilled(seeGross2001):theinformationpresentedmustbeunderstoodbytheclient,theclientmustprovidetheconsentvoluntarily,andtheclientmusthavethecompetenceneededtoprovidetheconsent(Barnett2007a, 181).HealsocitesfromtheAPAEthicsCodethateachinformedconsentagreementinthetherapycontextshouldincludeinformationabout“thenatureandanticipatedcourseoftherapy,fees,involvementofthirdparties,andlimitsofconfidentiality”(APA2002,1072)andadds“reasonablealternativesavailable,theirrelativerisksandbenefits, _Tan_Counseling_BB_mw.indd42 9/21/104:34:16PM LegalandEthicalIssuesinCounselingandPsychotherapy 29 andtherighttorefuseorwithdrawfromtreatment”(Barnett2007a,180).Barnettemphasizesthatinformedconsentshouldnotbeviewedasaone-timeeventthattakesplacejustbeforetherapyisstarted.Instead,itshouldbeseenasanongoingprocessbecausesignificantchangesinthetherapyprovidedmaysometimesbeproposedinthecourseoftreatment,andhencefurtherinformedconsentmaybeneeded.ThereareofcoursemanyotherethicalprinciplesandstandardsthattheAPAEthicsCodecovers,anditshouldbereadandconsultedformoredetailedinformationthatwillbehelpfulinethicaldecisionmaking(seeAPA2002).However,noethicalcodeissufficientinandofitselftoprovideconcreteanswerstoallethicaldilemmasthatcounselorsmayface.Counselorsandtherapiststhereforeneedtolearnthestepsnecessarytoengageinaconstructiveprocessofethicaldecisionmaking.TheProcessofEthicalDecisionMakingCorey,Corey,andCallanan(2007)haveprovidedahelpfulintegratedmodelconsistingofthefollowingstepstohelpacounselorcarefullyreflectonpotentialethicalproblemsintheprocessofethicaldecisionmaking:identifytheethicalissueorproblemandclarifywhetheritisprimarilymoral,legal,ethical,clinical,orprofessionalinnature;identifythevariousaspectsoftheethicaldilemma,includingtherights,responsibilities,andwelfareofeverypersoninvolvedinit;consultappropriateethicscodesforanyguidancethatmaybehelpfulandrelevanttotheethicalissuebeingfaced;beawareoflawsandregulationsthatarerelevanttotheethicalproblem;consultvarioussources,includingotherprofessionals,inordertoreceivedifferentperspectivesontheethicalissueathand;exploreallpossibleoptionsforaction,withfurtherdiscussionofvariousoptionswithotherprofessionalsaswellaswiththeclientifappropriate;considertheconsequencesofeachoftheoptionsavailableforaction,andespeciallyhowitwouldaffecttheclient;choosewhatseemstobethemostappropriateorbestethicaloptionforactionandthenexecuteit,withfollow-upevaluationoftheresultstoseeifanyfurtheractionmaybeneeded.Differentcounselorsmaysometimescomeupwithdifferentsolutionsforcomplexanddifficultethicaldilemmas(Knapp,Gottlieb,Berman,andHandelsman2007;seealsoPopeandVasquez2007),includingsituationswheretheremaybeconflictinvaluesofdiversecultures(KnappandVandeCreek2007).Thecrucialtaskbeforeacounseloristoengageinaprocessofconstructiveandmatureethicaldecisionmaking,keepinginmindalwaysthewelfareandwell-beingoftheclient,andtodonoharmtotheclient.Oneparticularethicalissuethatoftencomesupfordiscussionamongcounselorsandtherapistsconcernsboundaryissuesanddualormultiplerelationshipswithclients,whichwewillnowexamine. _Tan_Counseling_BB_mw.indd43 9/21/104:34:17PM 30 BasicIssuesinthePracticeofCounselingandPsychotherapy BoundaryIssuesandDualandMultipleRelationships:ACrucialEthicalIssueinCounselingBoundariesandmultiplerelationships(includingdualrelationships)areamongthemostcommonlydiscussedanddebatedethicalissuesinthecontextofclinicalpractice(seePopeandWedding2008).Someauthorsandcounselorswilladvocateavoidingalldualandmultiplerelationshipswithclientsasanethicalboundaryinordertopreventanypossibleexploitationoforharmtotheclient.Othershaveadvisedengagingindualandmultiplerelationshipswithclientsonlywhennecessaryandinclinicallyhelpfulsituations,suchaspracticingincertainruralormilitarysituationsandculturallydiversecontexts(seeBarnett,Lazarus,Vasquez,Moorehead-Slaughter,andJohnson2007).TheAPAEthicsCodestatesthefollowingaspartofStandard3.05on“MultipleRelationships”:Amultiplerelationshipoccurswhenapsychologistisinaprofessionalrolewithapersonand(1)atthesametimeisinanotherrolewiththesameperson,(2)atthesametimeisinarelationshipwithapersoncloselyassociatedwithorrelatedtothepersonwithwhomthepsychologisthastheprofessionalrelationship,or(3)promisestoenterintoanotherrelationshipinthefuturewiththepersonorapersoncloselyassociatedwithorrelatedtotheperson.Apsychologistrefrainsfromenteringintoamultiplerelationshipifthemultiplerelationshipcouldreasonablybeexpectedtoimpairthepsychologist’sobjectivity,competence,oreffectivenessinperforminghisorherfunctionsasapsychologist,orotherwiserisksexploitationorharmtothepersonwithwhomtheprofessionalrelationshipexists.Multiplerelationshipsthatwouldnotreasonablybeexpectedtocauseimpairmentorriskexploitationorharmarenotunethical.(APA2002, 1065) Itisclearfromthelastsentencequotedthatnotallmultipleanddualrelationshipswithclientsareunethicalbecausesuchrelationshipsdonotautomaticallyoralwayscauseimpairmentorriskexploitationorharmtotheclient.TheAPAEthicsCodethereforedoesnotprohibitalldualormultiplerelationships.Boundarycrossingsintoclinicallyhelpfulmultiplerelationshipswithclientscanthereforebeappropriateandethical,andsuchcrossingsshouldbedifferentiatedfromboundaryviolationsthatcauseimpairmentandharmtoclients.Anexampleofaboundarycrossingistotouchaclientontheshoulderorforearmasanexpressionofcomfortwhenthatclientisexperiencingdeepgriefoverthelossofalovedone.Anexampleofaboundaryviolationistotouchaclientinasexuallyexplicitway(seeBarnett2007b).TheAPAEthicsCodeisveryclearthatpsychologistsshouldnotgetinvolvedinexploitativemultiplerelationships,suchasengaginginsexualintimacieswithclientstheyarestilltreating(APA2002,Standard10.05)orwithrelativesorsignificant _Tan_Counseling_BB_mw.indd44 9/21/104:34:18PM LegalandEthicalIssuesinCounselingandPsychotherapy 31 othersofsuchclients(Standard7.07).Psychologistsalsoshouldnotprovidetherapytoformersexualpartners(Standard10.07).Ontheotherhand,thereareotherkindsofmultiplerelationshipsthatdonotinvolveboundaryviolationsandarethereforenotunethical(LazarusandZur2002;seealsoZur2007).ArnoldLazarus(2007)hasrecentlyemphasizedtheneedtostronglychallengerestrictivedraconianviewssuchasprohibitingallmultipleordualrelationshipsinclinicalpractice:Oneofthemostcontentiousissueshasrevolvedarounddeepconcernsinseveralquartersaboutdualormultiplerelationships.Thus,whenIarguedthattherapeuticbenefitsaccruedwhenIselectivelytranscendedstrictprofessionalboundariesand“partiedandsocializedwithsomeclients,playedtenniswithothers,tooklongwalkswithsome,graciouslyacceptedsmallgifts,andgavepresents(usuallybooks)toafairnumber”(Lazarus1994,p. 257),Iwasassailedbyeightcritics,whosawmeasadangerous,iconoclasticmaverick. . . .Itmustbeclearlyunderstoodthattheforegoingboundarycrossingswerenotcarriedoutinarashorcapriciousmannerwithoutcarefulconsideration.Dualrelationshipsarerarelyadvisablewithborderline,histrionic,violent,antisocial,orotherseriouslydisturbedclients.AswasunderscoredbyLazarusandZur(2002),“beforeenteringintoadualrelationshiptakeintoconsiderationthewelfareoftheclient,. . .avoidanceofharm,exploitationandconflictofinterest,andtheriskofimpairmentofclinicaljudgment”(p. 474).Theraisond’êtrebehindanyboundarycrossingisthepsychotherapist’sconfidencethatitislikelytoprovebeneficialtotheclient.(Lazarus2007, 405) Therefore,itisnecessarytoclarifywhichdualormultiplerelationshipsshouldbeavoidedandwhichonesareacceptableorevennecessary(Barnett2007b).Forexample,incertainruralareaswithsmallpopulations,thecounselorortherapistmayhavetotreatsomeoneinthecommunitywhomheorsheknowsquitewell,suchasthechurchpastororthelocalbanker,inanecessaryandpotentiallyhelpfuldualormultiplerelationshipwiththeclient.W. B.Johnsonemphasizestheneedforvirtueethicsthatfocusnotonlyontheethicalguidelinesandprinciplesfordealingwithboundariesanddualandmultiplerelationshipswithclientsbutalsoonthepersonorcharacterofthepsychologistortherapistand“clearmoralvirtuessuchasprudence,integrity,andcompassion”(2007a, 440).Counselorsandtherapiststhereforeneedtopersonallygrowintheprocessofbecomingethicalhelpingprofessionals(R.Sommers-FlanaganandSommers-Flanagan2007).ChristianorbiblicalperspectivesonethicsthatemphasizeagapeloveandvirtueethicsandethicalpracticebyChristiancounselorsortherapistsarealsocrucial(seeBrowning2006;OhlschlagerandClinton2002;R. K.Sanders1997;Tjeltveit1992,1999).TherearedistinctivelyChristiancodesofethicsgoverningthepracticeofChristiancounselorsandtherapists(see,e.g.,AmericanAssociationofChristianCounselors2004fortheAACCCodeofEthics).Theseperspectivesand _Tan_Counseling_BB_mw.indd45 9/21/104:34:19PM 32 BasicIssuesinthePracticeofCounselingandPsychotherapy codeswillbecoveredinthelastchapterofthisbook,whichfocusesonlegalandethicalissuesinChristiancounselingandpsychotherapy.RecommendedReadingsAmericanAssociationofChristianCounselors.(2004).AACCcodeofethics:TheY2004finalcode.Forest,VA:AACC.AmericanPsychologicalAssociation.(2002).Ethicalprinciplesofpsychologistsandcodeofconduct.AmericanPsychologist,57,1060–73.Barnett,J. E.,&Johnson,W. B.(2008).Ethicsdeskreferenceforpsychologists.Washington,DC:AmericanPsychologicalAssociation.Corey, G.,Corey, M.,&Callanan, P.(2007).Issuesandethicsinthehelpingprofessions(7thed.).Belmont,CA:Brooks/Cole.Pope,K. S.,&Vasquez,M. J. T.(2007).Ethicsinpsychotherapyandcounseling:Apracticalguide(3rded.).SanFrancisco:Jossey-Bass. _Tan_Counseling_BB_mw.indd46 9/21/104:34:19PM Part2 MajorCounselingandPsychotherapyTheoriesandTechniques _Tan_Counseling_BB_mw.indd47 9/21/104:34:19PM _Tan_Counseling_BB_mw.indd48 9/21/104:34:19PM 4PsychoanalyticTherapy S igmundFreud,thefounderofpsychoanalysis,isstillatoweringfigureinthefieldofcounselingandpsychotherapy.Someauthorsandtextbookshaveerroneouslycreditedhimforbeingthefounderofpsychotherapy,butotherimportantfiguressuchasPaulDubois(1848–1918)andPierreJanet(1859–1947)werealsoinfluentialinthehistoryofmodernpsychotherapy(seeCorsiniandWedding2008,11–12).Infact,therapeuticworkinthecareofsoulsprecededFreudbymanycenturies.However,thetheoriesandtherapeutictechniquesdevelopedbyFreudinpsychoanalysisarestilluniqueandsubstantial.AlthoughtheFreudianpsychoanalyticapproachisnolongeraspopularorwidespreadtoday,itisstillinfluentialinthedevelopmentofmorerecentpsychoanalyticormorebroadlypsychodynamicapproachestotherapythathavegonebeyondsomeofFreud’soriginalideas.Examplesofsuchcontemporarypsychoanalytictherapiesincludeegopsychology,objectrelationspsychology,selfpsychology,andrelationalpsychoanalysis,whichwillbebrieflydescribedlaterinthischapter.Ofcourse,otherschoolsoftherapyhavebeendevelopedinreactiontoFreud’spsychoanalyticviewsandeveninoutrightrejectionofmanyofhisideasandtechniques.BiographicalSketchofSigmundFreudSigmundFreudwasborntoJewishparentsinFreiburg,Moravia(formerlyinAustria,nowintheCzechRepublic),onMay 6,1856,theeldestofeight35 _Tan_Counseling_BB_mw.indd49 9/21/104:34:19PM 36 MajorCounselingandPsychotherapyTheoriesandTechniques children(fivedaughtersandthreesons).TheFreudfamilymovedtoViennawhenSigmundwasfouryearsoldsothathisfather,whowasawoolmerchant,wouldhavebetterbusinessprospects.Intheircrowdedapartment,Sigmundhadhisownstudyandbedroom.Hismotherfavoredhimandhadhighexpectationsforhimtoexcelacademicallyandprofessionally.Hisfatherwasveryauthoritarian,likemanyfathersinthateraandculture(E. Jones1953).Freudexcelledinhisacademicworkandgraduatedsummacumlaudefromsecondaryschool.Hewasfluentinseverallanguages,includingGreek,Latin,andHebrew,theclassicallanguages,aswellasEnglish,Italian,French,andSpanish(Ellenberger1970).FreudeventuallydecidedonacareerinmedicineandobtainedhismedicaldegreefromtheUniversityofViennain1881,whenhewastwenty-fiveyearsold.HemarriedMarthaBernaysin1886,andtheyhadsixchildren.Theiryoungestchild,AnnaFreud,eventuallybecameawellknownpsychoanalystherself,focusingonthetreatmentofchildrenandonthedevelopmentoftheegoorthatsystemofpersonalityinFreudiantheorythatinteractswiththereality-basedexternalworld.FreudhadbeenexposedtotheworkofJosefBreueronhystericalillnessduringthesixyearsheworkedwithErnstBrucke,awell-knownphysiologist,whilestillinmedicalschool.Duetofinancialreasons,FreudleftBruckeandbeganaresidencyinsurgery.In1883,hetrainedinneurologyandpsychiatryattheVienneseGeneralHospital.Healsospentfourmonthsin1885inPariswithJeanCharcot,arenownedneurologistwhousedhypnosistotreathystericalsymptoms.ThisexperienceenabledFreudtorecognizethesignificanceoftheunconsciousmind,althoughhelaterquestionedtheusefulnessofhypnosisasatherapeutictechnique.HealsodiscussedwithJosefBreuerhowBreuerhelpedhispatientAnna O.,whohadexhibitedhystericalsymptoms,bymentioningemotionalmaterialwhileshewasunderhypnosis.Freudbeganusingthistechniquewithhisownpatients,andheandBreuerpublishedStudiesonHysteriain1895.Freud’sfatherdiedin1896;aroundthistimehiscollaborationwithBreueralsobegantodeteriorate.Freud’sradicalviewsonhowtraumaticsexualexperiencesinchildhoodcancausehysteriadidnotsitwellwithothers,includingBreuer.In1897,inhisearlyforties,Freudbeganapainfulthree-yearprocessofpsychoanalysisonhimself,includinganalyzinghisdreamsandexploringhisownchildhoodmemories.Hesufferedfromsignificantemotionalproblemsatthistime,suchasseriousworriesabouthisfinancesandphobiasofdeathandheartdisease.Hecametorealizethroughhisself-analysisthathehadstrongfeelingsofhostilitytowardhisfatherandsexualfeelingsasachildtowardhismother.Fromhisownself-observationsandreflections,aswellashistreatmentofpatients,Freudcontinuedtodevelophisuniquepsychoanalytictheoryandpsychoanalysisasamajortherapeuticapproach.Hepublishedhisbest-knownwork,TheInterpretationofDreams,in1900,afterthisintensivethree-yearperiodofself-analysis. _Tan_Counseling_BB_mw.indd50 9/21/104:34:20PM PsychoanalyticTherapy 37 In1902,FreudformedtheWednesdayPsychologicalSociety,whichmetinitiallyathishometodiscusshispsychoanalyticideas.In1908,thisgroupbecametheViennaPsychoanalyticSociety,numberingamongitsmembersprominentandbrilliantcolleaguesofFreud,suchasAlfredAdler,CarlJung,andOttoRank.However,Freud’sinabilitytotoleratedissentingviewsandhisinsistenceonhavingabsolutecontrolofwhatconstitutedpsychoanalysis,asitsfounder,alienatedmanyofhiscolleagues.Asaresult,keyfiguressuchasAdlerandJungeventuallylefttheViennaPsychoanalyticSociety.Adlerwentontofoundhisownschoolofpsychotherapy,calledindividualpsychology;Junglikewisefoundedanotherschoolofpsychotherapy,calledanalyticalpsychology.Freudthusspentthelaterpartofhisprofessionallifeinrelativeisolation,workingmoreonhisownwhile,ironically,becomingmorerenownedandsuccessful.Hecontinuedtokeepagruelingschedule,workingeighteen-hourdays,seeingpatientsandwriting.Freudhabituallysmokedtwentycigarsalmostdaily,andin1923hewasdiagnosedwithbonecancerofhisjawandmouth.Heeventuallyunderwentthirty-threeoperations,butdespitehispainfulstrugglewithbonecancerforthelastalmosttwodecadesofhislife,hecontinuedtoworklonghoursandproducedmanysignificantwritings.FreudreluctantlyleftViennaforLondonin1938,justbeforeWorldWar II.Ayearlater,inSeptember1939,hedied,mostprobablyfromphysician-assistedsuicide,usingalethaldoseofmorphine(Gay1988).Freudleftbehindwhatmanystillconsidertobethemostcomprehensiveandsubstantialtheoryofpersonality,psychopathology,andpsychotherapyinhisuniqueapproachofpsychoanalysis.Hispublishedcollectedworksultimatelyincludetwenty-fourvolumes(seeStandardEditionoftheCompleteWorksofSigmundFreud,publishedbyHogarthPress,London).Freud’slifeandworkhavebeendescribedinmoredetailbyseveralauthors.ForfurtherinformationanddetailsofFreud’slifeandprofessionalcareerseeE. Jones(1953,1955,1957,also1961),whogivesthemostcompleteaccount,aswellasH. F.Ellenberger(1970),PeterGay(1988),PaulRoazen(2001),andA.Demorest(2005),asrecommendedbyRichardSharf(2008).MajorTheoreticalIdeasofFreudianPsychoanalysisPerspectiveonHumanNatureFreud’sviewofhumannaturewasmainlypessimisticandatbestsomewhatneutral.Itwasalsoadeterministicview,inwhichhumanactionsorbehaviorsareunderstoodascausedbyirrationalforces,mainlyunconscious,calleddrivesorinstincts.Theseinnateinstinctsevolvethroughseveralstagesofpsychosexualdevelopmentinaperson’schildhoodsothathisorherpersonalityisessentiallyformedbytheageofsix. _Tan_Counseling_BB_mw.indd51 9/21/104:34:21PM 38 MajorCounselingandPsychotherapyTheoriesandTechniques Freuddividedsuchhumandrivesorinstinctsintotwomajortypes:thelifeinstincts(Eros),orlibido,originallyreferringtosexualenergybuteventuallybroadenedtoincludealllifeenergythatseekstoexperiencepleasureandavoidpain,andthedeathinstincts(Thanatos),whichareassociatedwithdeathandaggression.Bothofthesesexualandaggressivedrives,orlifeanddeathinstincts,arecrucialmotivatorsofhumanactionorbehavior,accordingtoFreud.TheUnconsciousandLevelsofConsciousnessFreud’sconceptsoftheunconsciousandofthedifferentlevelsofconsciousnessthatexistinapersonareoftenviewedashismostsignificantcontributionstothementalhealthfield.Hedescribedthreelevelsofconsciousness:theconscious,thepreconscious,andtheunconscious.Theconscious,orwhatoneisawareofexperiencingataparticularmoment,suchasholdingapeninone’shandorfeelingpainfulsensations,isactuallyonlyasmallpartofaperson’smentallife.Thepreconsciousincludesmemoriesthatcanbeeasilyrecalled,suchasrememberingwhatoneateforlunchyesterdayordetailsfromamovieseenlastweekend.Thelargestlevelofconsciousness,however,istheunconscious,whichcontainsmemoriesandexperiencesthathavebeenrepressedorpushedoutofconsciousnessbecausetheyaretoothreatening,suchasfeelingsofhostilitytowardaparentorpainfulchildhoodmemoriesofsexualabuse.Theunconsciousalsoreferstoeverythingthatoneisunawareof,includinghiddenneedsandmotivations.Freudviewedtheconsciouslevelasonlyasmallpartofthemind,liketheproverbialtipoftheiceberg.Theunconscious,whichexistsbelowthelevelofawareness,isthelargestpartofthemindandinfluencesorcontrolsmostpsychologicalfunctioning.Itcannotbedirectlyobservedbutcanbeinferredfromphenomenasuchasdreams,forgettingawell-knownfactorname,andslipsofthetongue(e.g.,saying“nipple”insteadof“ripple”).Themajorgoalofpsychoanalysisisthereforetomaketheunconsciousconscious,sothatapersoncanhavemorefreedomtochoose.PersonalityStructureFreud’spsychoanalytictheorypostulatesthreemajorsystemsinthepersonalitystructureofeachperson:theid,theego,andthesuperego.Thesepsychologicalsystemsshouldnotbeunderstoodliterallyasreferringtothreephysicallyseparatepartsofaperson.However,thethreesystemsareseenasconsistingofpsychicenergythatislimitedinitsavailability.Theidcanbeconceptualizedasthebiologicalsystem,theegoasthepsychologicalsystem,andthesuperegoasthesocialsystemofpersonality,broadlyspeaking(Corey2009),butallthreesystemsfunctiontogetherasawhole.Inanutshell,theid _Tan_Counseling_BB_mw.indd52 9/21/104:34:22PM PsychoanalyticTherapy 39 referstopowerfulbiologicalforces,thesuperegototheconscience,andtheegototherationalsystemofone’spersonalitythatinteractswithexternalrealityandmediatesbetweentheidandthesuperego.TheId.Theid(or“it”)istheoriginal,unconscioussystemofpersonality.Apersonisbornwithhisorherid,andonemightsaythataninfantisallid.Theidisfullofpsychicorinstinctualenergywaitingtobedischargedsothathomeostasiscanbemaintained.Itisdrivenbythepleasureprinciple,seekingalwaystoavoidpainandexperiencepleasureandsatisfactionofitsseethingneeds.Theidremainssothroughoutaperson’slife,wishingandactingtofulfilldesireswithoutrationalthinking.Theidthereforeischaracterizedbyprimaryprocessthinkingthatisirrationalandprimitive,andthatseeksselfgratificationwithnoconcernforothers.Thetwobasicinstinctsoperatingintheidarethelife(orsexual)anddeath(oraggressive)instinctsordrives.Thenewborninfantthereforeinvestsenergyorcathectsinobjectsthatwillimmediatelymeetorfulfillitsdemandingneeds.Theobjectmaybeanippleorablanketthatservestoreducetheinfant’sneeds.TheEgo.Theego(the“I”)isthesystemofpersonalitythatinteractswiththerealworld“outthere.”Itcanbelikenedtoanexecutivewhoprovidescontrolandregulationofone’spersonality.Itbeginsfunctioningaroundagesixtoeightmonthstohelptheidfulfillitsdemandingneedsandimpulsesinamoreappropriateandacceptablewayintherealworld.Theegothereforeactstocontrolconsciousnessandregulatetheprimitivedrivesorinstinctsoftheid.Theegofollowstherealityprinciple,usingrationalandrealisticthinking,orsecondaryprocessthinking,thatresultsinactionplansformeetingneedsthatdonotimpulsivelyfollowthepleasureprinciplebutinsteadsuspendorcontrolit.Itthereforecensorsandrestrainstheid,afunctiondescribedasanticathexis.Theego,inthiscontext,helpsaninfantoryoungchildnottoactoutangrilyorcrywhenhisorherwishesarenotfulfilled.TheSuperego.Thesuperegoisthesocialorjudicialsystemofpersonalitythatcontainsthesocialandparentalvaluesandstandardstowhichapersonhasbeenexposed.Itfollowsthemoralityprincipleandguidesapersonindecidingwhetheraparticularbehaviorisrightorwrong,goodorbad.Thesuperegothereforeprovidesamoralcodebyintrojection(theprocessofincorporatingintooneselfthevaluesandstandardsofparentsandsociety).Theidimpulsesarecontrolledorrestrainedbythesuperego,buttheegoisalsoinfluencedbythesuperegotoaimforperfectionandmoralisticidealsratherthanmorerealisticandreasonablegoals.Thesuperegothereforestrivesforperfection,notpleasure,andcanpushapersonintoanextremeorlegalisticsubmissiontoperfectionisticandpathologicalstandardsthatcannotbeattained.Whenthishappens,whenthesuperegoisfunctioningagainstboththeidandtheego,neurosesorpsychologicaldisorderscandevelop.Anxietyisoftenexperiencedbyapersonwhentheid,theego,andthesuperegoareinsuchconflict. _Tan_Counseling_BB_mw.indd53 9/21/104:34:23PM 40 MajorCounselingandPsychotherapyTheoriesandTechniques AnxietyAnxietyisacentralconceptinpsychoanalytictherapy.Itreferstoafeelingofdreadandtensionresultingfrompreviouslyrepressedfactors,suchasfeelings,experiences,andmemories,comingtoawareness.Anxietyfunctionsasawarningofpotentialdangerthatalsomotivatespeopletoactinparticularways(seeCorey2009,63).Freudconceptualizedanxietyasconsistingofthreemajortypes:reality,neurotic,andmoral.Realityanxietyisthefearofanexternalsituationthatisappropriatetothedegreeofrealdangerpresent,suchasfearofanearbypoisonoussnakeabouttostrike.Neuroticanxietyisthefearofbeingoverwhelmedbyone’sinstinctsordrives(id)sothatoneendsupdoingsomethingthatwillbepunished.Moralanxietyisthefearofviolatingone’sownconscienceorinternalizedparentalandsocietalstandards(superego).Neuroticandmoralanxietiesarethereforerelatedtoconflictsorthreatswithintheperson.Whenanindividualexperiencesanxiety,theegocopesorrespondsbyusingdefensemechanisms.DefenseMechanismsTheegoemploysdefensemechanismstodealwiththepainofanxietybydistortingorevendenyingreality.Defensemechanismsoperateattheleveloftheunconscious.Whentheegousestheminfrequentlyandappropriately,theycanserveaconstructivepurposebyreducingstressoranxietyandenablingthepersontocopemoreeffectively.However,iftheyareusedtooofteninordertoavoidthepainofanxietybydenyingorblockingoutreality,theycanbecomedestructiveandpathological,resultinginmore-severepsychologicaldisorders.Commondefensemechanismsincluderepression,denial,displacement,sublimation,reactionformation,projection,rationalization,regression,intellectualization,andidentification.Repression.Freudconsideredrepressionthemostfundamentalorimportantdefensemechanism,oneonwhichhispsychoanalytictheorywasfounded.Repressionistheunconsciousattemptoftheegotoblockoutofconsciousness(i.e.,repress)negativeexperiencesthataretoopainfulorthreateningforapersontoacknowledge.Particularlypainfulexperiencesormemoriesofthefirstfivetosixyearsofaperson’schildhoodarerepressed,sothattheyarestoredintheunconscious.However,theystillaffectandmotivatethethoughts,feelings,andbehaviorsofthepersonlaterinhisorherlife.Anexampleofrepressionwouldbeamanwhohasfeelingsofhostilityandhatredtowardhisfather,butthesefeelingsareentirelyrepressedorblockedfromconsciousawarenessbecausetheyaretoooverwhelmingforthepersontoacknowledge.Suchrepressedfeelingsarenotunderthevoluntarycontrolofanindividualbecauserepressionoperatesattheunconsciouslevel.Denial.Denialisadefensemechanismthatusuallyfunctionsatmorepreconsciousandevenconsciouslevels,wherebyanindividualrefusestoaccept _Tan_Counseling_BB_mw.indd54 9/21/104:34:24PM PsychoanalyticTherapy 41 therealityofagivensituationoreventthatisnegative,painful,oranxietyprovoking.Thismechanismthereforedeniesreality.Forexample,anindividualrefusestoacceptthenewsthatheorshehascancerandcontinuestoliveasiftherewerenocancer,withoutgettingmuch-neededmedicaltreatment.AnotherexampleissomefanaticalfansofElvisPresleywhostilldenythatheisdead!Displacement.Displacementisadefensemechanismwherebyanindividualcopeswithanxietybyshiftingthedischargeofhisorherimpulsesfromathreateningobjectorpersontoamuchsafersubstitute.Forexample,averymild-manneredmanwhohasreceivedastrongreprimandfromhissupervisoratworkcomeshomeandkickshisdog(outoffrustrationandangeractuallyathissupervisorbutnowdisplacedorredirectedtohisdog).Sublimation.Sublimationisthedefensemechanismthatredirectssexualoraggressivedrivesintomoresociallyacceptablebehaviors.Freudviewedsublimationasthehealthywayofcopingwithdemandingandoftenunacceptableimpulsesordrives,althoughitwillstillnotcompletelysatisfysuchdrivesorimpulses.Anexamplewouldbesomeonewhohasveryaggressivedriveschannelingthemintoactiveparticipationinmartialartsandmartialartscompetitions,inwhichhewinstrophiesandtheadulationoffansandspectators.ReactionFormation.Inreactionformation,anindividualexpressestheoppositeoftheimpulsethatheorsheisreallyexperiencingasadefenseagainsttheobjectionableimpulse.Forexample,awomanwhoreallyhatesherhusbandendsupbeingextremelyniceandkindtohim,cookinghimhisfavoritemealsandgivinghimmanycompliments.Freudviewedreactionformationasaninferiorversionofsublimation.Projection.Projectionisthedefensemechanismofunconsciouslyattributingtoothersone’sownobjectionableimpulsesanddrives,usuallysexualoraggressiveinnature.Inotherwords,projectionoccurswhenapersonblamesothersforhisorherownshortcomings.Anexamplewouldbeaboywhohateshisfatherbutassertsandbelievesthathisfatherhateshim.Rationalization.Rationalizationisanindividual’sattempttoexplainawaypainfulexperienceswithreasonsorexcusesthatarenotaccurateortrue.Forexample,amanwhodoesnotgetamuchanticipatedanddesiredjobpromotionbelievesthathereallydidnotwantthepromotionbecauseofalltheextrastressesandresponsibilitiesthatcomewithit,includingmuchinternationaltravel.Regression.Whentheegoisthreatened,anindividualmayusethedefensemechanismofregressiontoreturntoanearlierstageofdevelopmentthatwaslessstressfulbutalsouseslessmatureorlessappropriatebehaviorstocopewiththecurrentanxiety.Anexamplecanbefoundinafirst-graderwhoisfailingacademicallyandthenresortstoinfantilebehaviorssuchascryingforhermotherandsuckingherthumb. _Tan_Counseling_BB_mw.indd55 9/21/104:34:25PM 42 MajorCounselingandPsychotherapyTheoriesandTechniques Intellectualization.IntellectualizationisadefensemechanismwherebyapersondetachesfromapainfulemotionalexperiencebyfocusingonlyonhisorherFreudianDefensethoughtsandtheminutedetailsinvolvedintryingtoMechanismsanalyzeandexplainthenegativeemotionalexperience.Forexample,amotherwhojustreceivednewsthather1.Repressiontwo-year-oldsonwaskilledbyadrunkendriverbegins2.Denialalongdiscussionofthemeaningoflifeanddeathand3.Displacementhowitisallfatedandbeyondanyone’scontrol,instead4.Sublimationofdealingwithherfeelingsofshock,grief,loss,and5.Reactionformationangeratthedrunkendriver.6.ProjectionIdentification.Identificationisadefensemechanism7.Rationalizationwherebyanindividualwhoisthreatenedbyanxietyor8.Regressionothernegativefeelingsassumesthecharacteristicsof9.Intellectualizationotherswhomaybemoresuccessfulorassociatesor10.Identificationidentifieshimselforherselfwiththem.Anexamplewouldbeamaleadolescentwhostruggleswithdeepfeelingsoffailureandinferiority,butendsupidentifyinghimselfwithafamousrockbandbydressinglikethebandmembersandmimickingtheirspeech.Sidebar4.1 PersonalityDevelopment:Freud’sPsychosexualStagesofDevelopmentFreudwasradicalinhistimewhenhedescribedthepsychoanalytictheoryofpsychosexualstagesofdevelopmentthateverypersongoesthrough.Hebelievedthatthepersonalitydevelopmentofanindividualisbasicallycompletedbyaroundagefiveorsix.Histheoryisbiologicallybased,focusingontheflowofsexualorlibidinalenergythroughthefollowingpsychosexualstagesofnormalhumandevelopment:oral,anal,phallic,latency,andgenital.Theoral,anal,andphallicstagesofpsychosexualdevelopmentoccurbyagefiveorsix,afterwhichcomestherelativelycalmlatencystage,whichlastsforaboutsixyears.Thenthegenitalstageinadolescenceoccurs,aroundtheonsetofpuberty.GratificationofthesexualdriveiscentraltoFreud’stheory,butthisisexperiencedindifferentpartsofthebodyasapersonmatures,eventuallyculminatinginthegenitalarea.Ifapersonexperiencescertaintraumaticeventsinearlychildhoodinanyofthesepsychosexualstagesofdevelopment,fixationmaythenoccurataspecificstage,withsuchabnormaldevelopmentresultinginanindividualbeingmorevulnerabletostressandcrisislaterinlife.OralStage.Theoralstagetakesplaceinthefirsteighteenmonthsoflife.Itfocusesmainlyonthemouthforexperiencinggratificationoftheinfant’sneedsanddrives,whicharevirtuallyallid-drivenatthisfirstandearlieststage.Theinfantinitiallyisunabletodifferentiatebetweenselfandothersorthe _Tan_Counseling_BB_mw.indd56 9/21/104:34:25PM PsychoanalyticTherapy 43 environment.Dependenceonthemotherforgratificationoftheinfant’sneedsthroughsuckingandeatingiscrucial;therefore,themother-infantrelationshipiscentralintheoralstage.Themouthisalsoinvolvedinotheractivitiessuchasbiting,spitting,holdingonto,andclosing,besideseatingandsucking.Thespecificexperiencesoftheinfantorchildintheoralstagewillaffecthisorheradulthood.Forexample,ifthechilddependstoomuchonthemotherandsheoverindulgesthechild,thechildmayexperiencefixationatthisoralstageandbecomeanoverdependentadultlateron.However,ifthemotherunderindulgesthechildandprovidesirregularorinattentivefeeding,thechildmaybecomeinsecureandhavetroubletrustingothersorformingintimaterelationshipswithothersasanadult.AnalStage.Theanalstageoccursbetweentheagesofeighteenmonthsandthreeyears,whenthefocusofgratificationandpleasureistheanalarea,involvingtheholdingorreleasingoffecesorthedefecationprocesses,aswellasurination.Itisduringthisanalstagethattheegobeginstodifferentiatefromtheid.Childrenarealsolearningtohavemorecontrolovertheirownbodilyprocessesaswellascontroloverothers(e.g.,byoftensaying,“No”).Toilettrainingisacentraldevelopmentaltaskintheanalstage.Dependingonhowstrictparentsareintoilettrainingtheirchildren,thechildmaylaterdevelopanobsessionwithcleanlinessandorderlinesswithafixationonthisstagedescribedasbeinganal-retentive,orthechildmaybecomedisorderlyandevendestructive,thatis,anal-expulsive.PhallicStage.Thephallicstageoccursaroundtheageofthreetofiveorsixyears,whenthegratificationofsexualneedsmovesfromtheanalareatothegenitalarea.Self-stimulationofthepenisforboysandtheclitorisforgirls(masturbation)leadstopleasurableexperiences.Therealizationthatboyshavepenisesbutgirlsdonotisacrucialpartofthephallicstage,leadingtowhatFreudcalledpenisenvy(orwishingtohaveapenisofone’sown)ingirlsandcastrationanxiety(orthefearoflosingone’sownpenis)inboys.Boysalsohaveanunconscioussexualdesirefortheirmothersandwishtogetridofthefatherasarival.TheyresolvethisOedipuscomplexbyidentifyingwiththefatherandchannelingtheirsexualwishesintomoreacceptableoutlets.Girlsinasomewhatdifferentwayhaveanunconsciousdesirefortheirfathers(whohavetheirdesiredobject,apenis)andahatredfortheirmothers;CarlJungandothershavelabeledthistheElectracomplex,atermthatFreudhimselfwasreluctanttouse.Girlsalsoneedtoresolvethiscomplexbyidentifyingwiththeirmotherssothattheycanvicariouslyhavethedesiredobject.ThisaspectofFreudianpsychoanalytictheoryhasreceivedstrongcriticismfromothertheoristsandfeminists.Problemsleadingtofixationatthisphallicstagemayresultinsexualidentitydifficultiesinadulthoodandpossibledifficultiesinrelationshipswiththeoppositesexorwiththesamesex.LatencyStage.Thelatencystageoccursfromaroundtheageofsixtotwelveyearsorpuberty.Itisaperiodofrelativecalm,withsexualdrivesbeingmore _Tan_Counseling_BB_mw.indd57 9/21/104:34:26PM 44 MajorCounselingandPsychotherapyTheoriesandTechniques repressed.Childrenatthislatencystagespendmoreoftheirenergyfocusingonschoolandfriendsanddevelopingimportantsocialandtechnicalskillstopreparethemtofunctionwellasadultsinsociety.Theirpersonalitieshavealreadybeenformedinthepreviousstagesofpsychosexualdevelopment,byagefiveorsix,afterwhichFreudbelievedthatsignificantpersonalitychangeisalmostimpossible.GenitalStage.Atpuberty,aroundagetwelve,anindividualentersthegenitalstage,whenpleasureisexperiencedmoredirectlythroughgenitalstimulationinthecontextofheterosexualrelationships.Thefocusnowisonothersratherthanontheself,intheexperienceofgenitalsexualsatisfaction.Ifapersonhasgonethroughtheotherearlierstagesofpsychosexualdevelopmentwithoutsignificantfixationsortraumas,thenthereissufficientlibidinalenergyavailableforhimorhertolivearelativelynormallife.Suchalifemeanshavingtheabilitytoloveandtowork,theidealsofpersonalmaturitythatpsychoanalyststrytohelptheirpatientsachieveinsuccessfulpsychoanalysis.Freud’stheoryofpsychosexualstagesofdevelopmenthasbeenstronglychallengedandcriticizedbyotherpsychoanalytictheorists.ErikErikson(1902–94),forexample,emphasizedmuchmorethepsychosocialstagesofdevelopment,focusingnotonlyonchilddevelopmentbutalsoontheentireadultspanofhumandevelopmentuntildeath.Briefly,Erikson(1950)delineatedanddescribedthefollowingstagesofpsychosocialdevelopment:infancy(firstyearoflife)focusingondevelopingtrustversusmistrust;earlychildhood(agesonetothree)focusingondevelopingautonomyversusshameanddoubt;preschoolage(threetosix)focusingondevelopinginitiativeversusguilt;schoolage(agessixtotwelve)focusingondevelopingindustryversusinferiority;adolescence(agestwelvetoeighteen)focusingondevelopingidentityversusroleconfusion;youngadulthood(ageseighteentothirty-five)focusingonintimacyversusisolation;middleage(agesthirty-fivetosixty)focusingondevelopinggenerativityversusstagnation;andlaterlife(agessixtyplus)focusingondevelopingintegrityversusdespair.Morerecently,inherninetiesJoanErikson,Erikson’swifeforsixtyfouryears,includedanotherstagethatshetermed“disgustversuswisdom”(agesintheeightiesandnineties)focusingondevelopinggerotranscendence(Sharf2008).Thisninthstageofpsychosocialdevelopmentinvolvesmovingfromarationalandmaterialisticperspectivetoadeeperfocusonspiritualityandexperiencingpeaceofmind(Erikson1997).OtherchallengesandmodificationstotraditionalpsychoanalytictheoryasoriginallydescribedbyFreudhavecomefrommorecontemporaryapproachestopsychoanalytictherapyand,inparticular,thefourmajorschools:egopsychology,objectrelationspsychology,selfpsychology,andrelationalpsychoanalysis.EgoPsychologyEgopsychologyfocusesmoreontheegoanditsconsciousandadaptivefunctionsratherthanontheidandunconsciousdrives,whichseemedto _Tan_Counseling_BB_mw.indd58 9/21/104:34:27PM PsychoanalyticTherapy 45 preoccupyFreud.AnnaFreud(1895–1982),SigmundFreud’sdaughter,madesignificantcontributionstoegopsychologybyemphasizingtheegoinchilddevelopmentinherdescriptionofdevelopmentallines,anexampleofwhichisthegradualevolvingofmoreother-centeredbehaviorsratherthanself-centeredbehaviorsasachildmatures(A. Freud1965).Shealsoexpandedthenotionofdefensemechanismstoincludenormalandconstructiveonesthatenableanindividualtodealmoreeffectivelywiththeworld(A. Freud1936).Asalreadymentioned,ErikEriksonisanothermajortheoristinegopsychology,notedespeciallyforhisdescriptionofthepsychosocialstagesofhumandevelopmentovertheentirelifespanofanindividual.Otherwell-knownfiguresinegopsychology,sometimeslabeledas“theAmericanschool,”includeHeinzHartmann(1958)andDavidRapaport(1951).ObjectRelationsPsychologyTheobjectrelationsperspectivefocusesmorespecificallyonhowpastchildhoodrelationshipsbetweenachildandhisorhersignificantothers,especiallythemother,orotherloveobjectsinthechild’slifeaffectpersonalitydevelopmentandlateradultlife.Italsoemphasizespastinternalizedrelationshipsorobjectrelationsratherthaninternalsexualoraggressivedrivesinthedeterminationofone’spresentandfuturebehavioralpatterns.Aspecificprocessdescribedbyobjectrelationstheoristsasindividuationreferstohowanindividualcanseparatefromhisorhermotheranddevelopintoanindependentperson.Well-knowntheoristsinobjectrelationspsychology,sometimesdescribedas“theBritishschool,”includeDonaldWinnicott(1966),W. R. D.Fairbairn(1954),MelanieKlein(1957,1975),MargaretMahler(1968,1979a,1979b),andOttoKernberg(1975,1976).MoredetaileddescriptionsofobjectrelationsapproachescanbefoundinSt. ClairandWigren(2004).SelfPsychologyTheselfpsychologyschoolisbasedonthemajorcontributionsofHeinzKohut(1913–81),whowroteseveralsignificantbooks(1971,1977,1984)thatdefineanddescribehistheoreticalconceptoftheself(seealsoSt. ClairandWigren2004).Heemphasizedhowrelationshipswithotherpeople,especiallyparentalfiguresinchildhoodexperiences,haveaprofoundinfluenceonthedevelopmentofthesenseofselfinanindividual.Ifsuchchildhoodexperienceshavebeennurturingandhealthy,astablesenseofselfwillresultsothatoneisabletodevelopmaturerelationshipswithothersasanadult.However,ifearlychildhoodexperienceshavebeenmorenegativeandemotionallydepriving,thenalesshealthysenseofselfwillresultandtheperson’sabilitytorelatetootherswellwillbesignificantlylimited.Kohutparticularlyfocusedonthe 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treatmentofnarcissisticandborderlinedisordersthatinvolveaperson’ssenseofadamagedorinadequateself.RelationalPsychoanalysisAmorerecentdevelopmentinpsychoanalytictheoryandtherapyhasbeenthesignificantworkofStephen A.Mitchell(1988,2000)andhiscolleagues(seeJ. R.Greenberg2001;J. R.GreenbergandMitchell2003)onrelationalpsychoanalysis.Thisapproachemphasizesthemutualityofthetherapeuticrelationshipbetweentheanalystandtheclient.Inotherwords,boththeanalystandtheclientinfluenceeachotherontheconsciousandunconsciouslevelssuchthattheanalyticortherapeuticrelationshipcannotbeviewedasneutral,withtheanalystobjectivelyobservingandanalyzingtheclientinaunilateralway.Thisrelationalperspectivehasbeendescribedasintersubjective(seeOrange,Atwood,andStolorow1997;Stolorow,Atwood,andBrandchaft1994;Stolorow,Brandchaft,andAtwood1997),interpersonal,orrelational(seealsoWachtel2008).Mitchellalsofocusedonhowcultureaffectsboththeanalystandtheclient,thuscritiquingandmovingbeyondFreud’soriginalideaofunconsciousbiologicaldrivesthataffecteveryindividualbecausetheyaresupposedtobeuniversalinnature.ThesefourmajorschoolsofcontemporarypsychoanalyticapproacheshavecritiquedandmodifiedtraditionalFreudianpsychoanalysis.Psychoanalytictherapytodayismorediverseandlessauthoritarian,especiallyregardinghowtheanalyticrelationshipisviewedandexperienced.Agreateremphasisontheconsciousandadaptivefunctionsoftheego(andlessontheunconsciousdriveoftheid),onobjectrelationsorinternalizedrelationshipswithsignificantothersorloveobjects,onthedevelopmentoftheself,andonamoremutualandreciprocalanalyticrelationshipbetweentheanalystandtheclientareexamplesofthenewerapproachestopsychoanalytictheoryandpractice.Thetherapeuticprocessandrelationshipaswellasthemajortherapytechniquesandinterventionsofmoretraditionalpsychoanalytictherapywillnowbediscussed.TherapeuticProcessandRelationshipTraditionalFreudianpsychoanalysis(withtheanalystseeingtheclientusuallyfourtimesaweek,sittingbehindtheclientwholiesonacouch)andpsychoanalytictherapy(withtheanalystseeingtheclientonetothreetimesaweek,usuallyface-to-face)havetwomaingoalsoftherapy:tohelpbringtheunconscioustoconsciousawarenessandtostrengthentheegosothatanindividualislessinfluencedbyinstinctualdrives(sexualandaggressive)oftheidordemandingperfectionisticstandardsofthesuperegoandfreertoactinmorerealisticways.Psychoanalysisthereforeaimsatrestructuringone’spersonality 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andnotsimplyattenuatingsymptomsorsolvingSidebar4.2problems.InsightorunderstandingofchildhoodexperiencesisachievedbyanalyzingthemthroughPsychoanalyticTherapytheuseofseveralmajorpsychoanalyticmethodsTechniquesoftherapy.Suchinsightisseenasakeycurative(Corey2009)factorinsuccessfulpsychoanalysis.However,itisnotmerelyintellectualinsightorunderstanding;it1.Maintainingtheanalyticisinsightbasedonworkingthroughorexperiencframeworkingparticularmemoriesandfeelings,especially2.Freeassociationfromchildhood.3.DreamanalysisThetherapist’sfunctionorroleintraditional4.Interpretationpsychoanalysisisapassiveone,aimedatmaintain5.Analysisoftransferenceingneutralityoranonymity,withalmostnoself6.Analysisofresistancedisclosureatall.Theanalystthereforebehaveslikea“blankscreen”tofacilitatethedevelopmentofatransferencerelationshipinwhichtheclientwillprojectortransferunconsciouslyontotheanalystfeelingsandexperiencesthatoriginallywereassociatedwithpastparentalfigures,especiallyinearlychildhood.Theanalystdoeshisorherbesttoachieveagoodworkingallianceortherapeuticrelationshipwiththeclient.Mostofthetime,theanalystissimplylisteningtotheclient,occasionallyaskingkeyquestions,murmuringtheproverbialFreudian“Um-hmm,”andjudiciouslyandinfrequentlyinterpretingtheclient’sunconsciousmaterialaswellasresistances.Psychoanalysisandpsychoanalytictherapyarethereforeveryintensiveformsofpsychotherapythatrequireaclienttocommithimselforherselftoalong-termtherapeuticrelationshipthatcanlastforseveralyears.Theclientmustbewillingtofollowthe“fundamentalrule”offreeassociation,orsayingwhatevercomestomindwithoutanyevaluationorcensorship,inordertorevealunconsciousmaterialfortheanalystandtheclienttoexplore.Thisishardwork,andtheclient’smotivationorreadinesstochangeiscrucialforpsychoanalysisandpsychoanalytictherapytobesuccessful.Psychoanalytictherapyisusuallyconsideredmodestlysuccessfulifithaseffectivelyhelpedtheclienttobeabletoloveandworkinlife.MajorTherapeuticTechniquesandInterventionsSeveralmajortherapeutictechniquesorinterventionsintraditionalpsychoanalytictherapyhavebeensomewhatmodifiedinmorecontemporaryapproachestosuchtherapy(seeMcWilliams2004).However,theprimarymethodsoftraditionalpsychoanalytictherapyarestillfoundational.Atleastsixofthemarebasictopsychoanalytictherapy:maintainingtheanalyticframework,freeassociation,dreamanalysis,interpretation,analysisoftransference,andanalysisofresistance(Corey2009). 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MaintainingtheAnalyticFrameworkTraditionalpsychoanalytictherapyinvolvesseveralessentialelementsrelatingtotherapeuticstyleandprocedurethatpsychoanalytictherapistsdotheirbesttopreserveinmaintainingtheanalyticframework.Examplesofsuchelementsincludetheanalystbeingasneutralandanonymousaspossiblewithverylittleornoself-disclosure,schedulingtherapysessionsonaregularandconsistentbasis,andensuringthatsessionsbeginandendontime.Beingconsistentinthesewaysisitselfacrucialtherapeuticpartoftheanalyticframework.FreeAssociationFreeassociationisthebedrockfoundationalmethodofpsychoanalytictherapyandhasalsobeencalledthe“fundamentalrule.”Itinvolvesencouragingtheclienttosaywhatevercomestomind,withoutanyevaluationorcensorship.Inthisway,unconsciousmaterialissupposedtosurfacefortheanalysttoexplorewiththeclientandtointerprettohelptheclientgaininsightintounderlyingunconsciousdynamics.Traditionalpsychoanalysisrequirestheclienttolieonacouch,withtheanalystoutofsightbehindtheclient.Thisphysicalarrangementissupposedtofacilitatemorefreeassociationsontheclient’spart.Theanalystlistensintentlytotheclientandhisorherfreeassociations,payingparticularattentiontodisruptionsorblockagesinfreeassociation,whichmayindicatethepresenceofrepressedanxiety-provokingmaterialthatisbeginningtoemergeintoconsciousness.Theanalystlistensespeciallyforhiddenmeaningsintheclient’sfreeassociationsandnoticesslipsofthetongue,orFreudianslips,thatmaybeduetounconsciousconflicts.Theanalystthereforedoesnottakewhatevertheclientexpressesatfacevalue.Theanalyst,inusingthetechniqueoffreeassociation,ultimatelyidentifiesandinterpretsunconsciousmaterialandconflictsthatmayemerge,sothattheclientcangaindeeperinsightandunderstanding.DreamAnalysisFreudconsidereddreams“theroyalroadtotheunconscious.”Dreamsaretherawmaterialoftheunconscious.Dreamanalysisisthereforeanothercrucialtechniqueormethodinpsychoanalytictherapy.Theanalystencouragestheclienttorecordandreporthisorherdreamsandfreeassociatetothem,sayingwhatevercomestomindasheorshedescribesthedreams.Theanalystthendiscussesandinterpretstheclient’sdreamsandfreeassociationstothedreamsorpartsofthemthatcanbeviewedontwolevels:themanifestcontentofadream,referringtothesurfacematerialordetailsofthedream,andthelatentcontentofadream,referringtoitsunconsciousorhiddenmeaning.Theanalystisparticularlyinvolvedinpointingoutandinterpretingthelatentcontentandmeaningofadream. _Tan_Counseling_BB_mw.indd62 9/21/104:34:31PM PsychoanalyticTherapy 49 Freuddescribedseveralsymbolsindreamsoftenreportedbyclientsthatseemtohaveconsistentmeaningsforalmosteveryclient.Examplesaretreetrunksandcandlesrepresentingthepenis,andstepsandladderssymbolizingsexualintercourse.However,thereisadangerofovergeneralizingsuchsymbolicmeaningsindreams,sodreamsshouldstillbeinterpretedinthepropercontextofaparticularclient’slife.InterpretationInterpretationisthepsychoanalytictechniquewherebytheanalystclarifiesandexplainstotheclientthemeaningofcertainunconsciousmaterialemergingintheclientthroughdreams,freeassociation,experiencesinthetherapeuticrelationshipbetweentheanalystandtheclient,andresistancesorblockages.Throughtheuseofinterpretation,theanalystenablestheclienttogaininsightintounconsciousmaterialthatissurfacingandtohelphisorheregodealwithsuchmaterialmoreeffectivelyandrealistically.Interpretationmustbewelltimedandbasedonsufficientunconsciousmaterialtosubstantiatetheaccuracyofaparticularinterpretation.Otherwise,“wildanalysis”orwildinterpretationthatisofftargetcanoccur,tothepossibledetrimentofthetherapeuticprocessandtherelationshipwiththeclient.Thereadinessoftheclienttoacceptaspecificinterpretationisalsoacrucialfactor.Interpretationsaremosthelpfuliftheyinvolvematerialthatispreconsciousorbeginningtobecomeconscious;iftheybeginwithmoresurfacematerialandproceedtodeeperlevelsofmeaningonlyasfarastheclientisreadytogo;andiftheydealwithadefenseorresistancefirstbeforepointingoutthepossibledeepermeaningofthefeelingorconflictunderlyingthedefenseorresistancethathasbeenidentified(Corey2009).AnalysisofTransferenceAnotherimportanttechniqueofpsychoanalytictherapyistheanalysisandinterpretationoftransference.Transferenceoccurswhentheclientunconsciouslyrelatestotheanalystasifheorshewereaparentalfigurefromtheclient’searlierlife,usuallychildhood.Bothpositive(e.g.,admiration)andnegative(e.g.,anger)experiencesandfeelingscanoccurintransferencetotheanalystortherapist.Theanalystallowsthetransferencetodevelopandtheninterpretsitsmeaningtotheclient.Thisanalysisofthetransferencehelpstheclienttoachievedeeperinsightintohisorherpastexperiencesandhowtheymaystillbeaffectingandinfluencingpresentrelationshipsandexperiences.ThetraditionalFreudianviewisthattheanalysisoftransferenceisanessentialpartofpsychoanalytictherapy.Theanalystalsoneedstobecarefulofhisorherownunconsciousresponsestotheclientthatactuallyreflectunresolvedissueswithsignificantfiguresfromtheanalyst’sownpastrelationships,espe- 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ciallyinchildhood,aphenomenonknownascountertransference.Analystsarethereforerequiredtohavetheirownpersonalortraininganalysisandfurtherconsultationorsupervisionwhennecessaryinordertobecomemoreawareofandminimizecountertransferencetotheirclients.More-contemporaryapproachestopsychoanalytictherapy,however,alsofocusonhowtoconstructivelyusecountertransferencetobetterunderstandtheclient,ratherthanalwaysviewingcountertransferenceasaninappropriateorunhealthyphenomenonrequiringconstantvigilanceandcontrolbytheanalyst.AnalysisofResistanceResistanceisabasicpsychoanalyticconceptthatreferstoaclient’sblockingordefendingagainstbringingunconsciousandrepressedmaterialintoconsciousawareness,mainlybecauseitisemotionallypainfulandprovokesanxietytodoso.Resistancethereforeisamajorbarriertotherapeuticprogressinpsychoanalytictherapy.Aclientcanshowresistanceinavarietyofwayssuchasbeingconsistentlylateforappointments,notproducingmuchbywayoffreeassociations,talkingincessantlyaboutsuperficialtopicslikethetrafficorsports,and,especially,abruptlyterminatingpsychoanalytictherapyearlyinthetherapeuticprocess.Theanalystwillanalyzeandinterprettheclient’sresistancessothattheclientcanovercomethemandbecomemoreawareofhisorherunconsciousissuesandrepressedfeelings,memories,orexperiences.Itiscrucial,however,fortheanalysttofirstinterpretresistancesthatareclearorobvioustotheclientsothattheclientwillbemoreacceptingoftheinterpretationratherthanfurtherresisttheanalyst’sinterpretation.Theanalysisandinterpretationofresistancemustbeconductedinadeeplyempathicandclinicallysensitivewaysothattheclient’sdefensesarenottooquicklyorharshlyconfronted.Otherwise,furtherresistancemayresult. TraditionalPsychoanalysisandPsychoanalyticTherapyinPracticeAHypotheticalTranscript _Tan_Counseling_BB_mw.indd64 Client:I’mfeelinganxiousagaintoday. . .likeIusuallyfeel. . .andfornogoodreasontoo.Idon’thaveanythingpressingorstressfultodotodayandyetI’mhavingthisdreadfulanxietyalmostallthetime . . .Analyst:(doesnotsayanythingandremainsquiet)Client:It’sreallyhardformetodealwiththesehorribleanxiousfeelingswhenIdon’tknowwhyorwherethey’recomingfrom . . .Analyst:(continuestobequietandsimplywaits)Client:SometimesIfeellikeI’mgoingtoexplodeordieofa 9/21/104:34:32PM PsychoanalyticTherapy 51 heartattackorsomethinghorrible,becauseoftheseintensefeelingsofanxietyandfear . . .Analyst:Um-hmm . . .Client:Iguessmyanxietymaybeabitworsetoday,especiallyasIwasthinkingofcominghereformysessionwithyou,andwonderingwhatelsewillcomeupinoursessiontogether . . .Analyst:Whatcomestomind?Client:Well. . .Iknowthatyou’veaskedmetokeeparecordofmydreamsandtotalkaboutmydreamsopenlyherewithyou. . .andIdidhaveahorribledream,almostlikeanightmare,justlastnight,andI’mfeelingreallyanxiousalreadyjustbringingitup . . .Analyst:Um-hmm. . .Client:IguessIshouldtellyouaboutthisdreamornightmare . . .Analyst:(remainsquiet)Client:Well. . .IhadascarydreamlastnightthatIwasallaloneinthisbig,hugehouse,andsuddenlyitcaughtonfire. . .andIwasinsidethehouseallbymyselfandpanickingseeingthefireandsmellingthethicksmoke. . .andItriedtogetoutbytryingtofindadoororexit. . .butIkeptonrunningincircleswiththefirecomingclosertome,andIcouldn’tfindanexit!IreallyfeltoverwhelminganxietyandfearandwassosurethattheflameswouldengulfmeandIwouldquicklybeburnedtodeath,upinsmokeforsure. . .butthenIwokeup,tremblinginsweat!Analyst:Whatelsecomestomindnow?Whatotherfeelings,thoughts,orexperiences? Thishypotheticaltranscriptofasmallpartofatraditionalpsychoanalysisorpsychoanalytictherapysessionillustratestheuseoffreeassociationandthebeginningofdreamanalysis,twomajortechniquesintraditionalpsychoanalytictherapy.Theanalystalsomaintainsamoretraditionalanalyticframework,insayingverylittleandremainingneutralandanonymous,withnoself-disclosureinthisexample.CritiqueofPsychoanalyticTherapy:StrengthsandWeaknessesTraditionalpsychoanalysisandpsychoanalytictherapyarebasedonFreud’stheories,whichmanystillconsidertobethemostcomprehensiveviewofpersonality,psychopathology,andpsychotherapy.Severalpsychoanalyticconcepts _Tan_Counseling_BB_mw.indd65 9/21/104:34:32PM 52 MajorCounselingandPsychotherapyTheoriesandTechniques suchastheunconscious,defensemechanisms,transferenceandcountertransferenceinthetherapeuticrelationship,andresistancearestillhelpfulonesbeingusednotonlybypsychoanalystsandpsychoanalytictherapistsbutalsobyotherpsychotherapists.Sometherapistshavefoundthepsychoanalyticapproachtobetherichestanddeepestintheoryandpracticeamongthemanypsychotherapiesavailabletoday.However,Freudianpsychoanalytictherapyhasseveralsignificantweaknessesandlimitations.First,althoughFreud’spsychoanalytictheoryiscomprehensive,someofhisideasarenoteasilytranslatedintotestablehypothesesthatcanbeverifiedbyempiricalresearch,forexample,theid,theego,andthesuperego,orEros(lifeinstinct)andThanatos(deathinstinct).Second,histheorynarrowlyfocusesonsexualandaggressivedrivesandemphasizeshisconvictionthatbiologyisdestiny.However,thereareothermotivationalforcesordrivesthatFreuddidnotconsiderthatmaybeequallyorevenmoreimportantthansexualandaggressiveinstinctsininfluencinghumanbehavior.Othertheoristsandtherapeuticapproacheshaveemphasizedotherdrivesormotivations(e.g.,socialorspiritual),whichwillbediscussedinlaterchaptersofthisbook.Third,someofFreud’soriginalideashavebeenviewedassexist,especiallybywomenandfeministtherapists.Forexample,penisenvy,theOedipuscomplex,andthetendencytoblamethemotherinpoorparent-childrelationshipsthatsupposedlyleadtoadultpsychologicaldisordershaveallbeencriticizedfordenigratingwomenandviewingthemasinferiortomen.Fourth,traditionalpsychoanalysisorpsychoanalytictherapyisanintensive,long-term,andhenceexpensiveformofpsychotherapythatonlytherelativelywealthycanafford.Itisthereforenotassuitableformanagedcare,whichemphasizesandcoversshorter-termandbrieftherapies.Italsofocusesonintrapsychicorpersonalconflictsanddynamics,oftenwithoutpayingsufficientattentiontootherreal-lifeconcernssuchasemployment,poverty,andsocialissuesthatmaybemoreimportantandrelevanttopeoplefrommorediversesocioeconomicandculturalbackgrounds.Fromamulticulturalperspective,psychoanalysisandpsychoanalytictherapymaythereforenotbeasmeaningfulorappropriateforsomeclientsfromcertainethnicandculturalgroups,whomaypreferamoredirect,problem-solvingapproachtotherapy.Fifth,theneutralandanonymoustherapeuticstanceoftheanalystintraditionalpsychoanalysismaybedifficultforsomeclientstotolerate.Itmayalsobeexperiencedbycertainclientsinapotentiallyharmfulorantitherapeuticway.Thetraditionalanalyticapproachalsorequiresaminimallevelofegostrengthonthepartoftheclient,inordertoparticipateinandbenefitfromsuchanintensiveanddemandingformoftherapy.Somecontemporaryapproachestopsychoanalytictherapysuchasrelationalpsychoanalysishavethereforemodifiedtheanalyticrelationshipintoonethatismoremutualandreciprocalbetweenanalystandclient. _Tan_Counseling_BB_mw.indd66 9/21/104:34:33PM PsychoanalyticTherapy 53 Finally,theempiricalorresearchsupportfortheefficacyoftraditionalpsychoanalysisiseithernonexistentorscarce.Thereissomeempiricalsupportfortheefficacyofshort-termpsychodynamictherapy,whichhasmodifiedthetraditionalpsychoanalyticapproach(seeChamblessandOllendick2001;seealsoSummersandBarber2009).Amorerecentmeta-analysisconcludedthatlong-termpsychodynamicpsychotherapy(similartopsychoanalytictherapy)isaneffectivetreatmentforcomplexmentaldisordersandsignificantlybetterthanshorterformsoftreatment(LeichsenringandRabung2008).However,seriousmethodologicalproblemswiththismeta-analysisdonotallowmoredefinitiveconclusionstobemadeatthistime(seethesectionon“Research”laterinthischapter).ABiblicalPerspectiveonPsychoanalyticTherapyFreud’sviewofhumannaturewassomewhatnegativeandpessimistic:apersonmuststrugglewiththebasicaggressiveandsexualinstinctsoftheidaswellastheperfectionisticstandardsanddemandsofthesuperego,withtheegomediatingtheseextremeforcestorealisticcompromisessothatthepersoncanlearntoloveandworksatisfactorilyinlife.Thebiblicalviewofhumannatureassinfulandfallen(Rom.3:23)issomewhatconsistentwithFreud’sdescriptionofthehumanpsyche.However,thisisonlyhalfthestory.TheBiblealsoteachesthatwearecreatedintheimageofGod(Gen.1:26–27)andthereforehavethepotentialtobesomewhatlikeGodinourcharacter,especiallyifweareinChrist,whomakesusnewcreations(2 Cor.5:17)capable,bythepoweroftheHolySpirit,tobetransformedintodeeperChristlikeness(Rom.8:29).ThepotentialforchangethroughChrististhereforegreaterthanapurelyFreudianviewwouldallow,especiallyinitsdeterministicnotionthatone’spersonalityisalreadyformedbyagefiveorsix(seeS. L.JonesandButman1991).Second,Freud’semphasisontheunconsciousandtheneedtogaininsightthatisnotonlyintellectualbutalsoexperientialinmakingtheunconsciousconsciousandresolvingintrapsychicconflictpointstotheneedforwisdomandawarenessofthedarkersideandinteriorpartofhumannature,aviewthatcanbeseenasconsistentwithbiblicalteaching(Ps.57:6;Jer.17:9).However,hisnarrowfocusonaggressiveandsexualinstinctsinthemotivationofhumanbehaviorisunbalanced.ThereareotherhumanmotivationssuchasspirituallongingsforGod,includingagapeloveforGodandforneighborortheother(cf.Mark12:30–31),thatarerealandnotillusoryorapathologicalobsessionalneurosis,asFreud(1927)claimedinhisantireligiousviewsemphasizingthatwecreatedGodinourimageinwishfulfillmentofalongingforafather,ratherthanthatGodcreatedusinhisimage.Third,thetraditionaltherapeuticstanceoftheanalystortherapistinstayingasneutralandanonymousaspossible,withaclinicalaloofnessthatisassumedtofacilitatetransference,whichcanthenbeinterpretedbytheanalyst,canbe _Tan_Counseling_BB_mw.indd67 9/21/104:34:34PM 54 MajorCounselingandPsychotherapyTheoriesandTechniques viewedasproblematicfromabiblicalperspectivethatemphasizesthecentralityofagapeloveinallhumanrelationships(1 Cor.13),includingtherapeuticrelationships(seeBrowningandCooper2004).Contemporaryapproachestopsychoanalytictherapysuchasrelationalpsychoanalysis,however,havemodifiedthistraditionalanalyticstancesothatamoremutualandreciprocalrelationshipbetweentheanalystandtheclientcanbeachieved,basedmoreonagapelovefromaChristianapproachtorelationalpsychoanalysis(seeM. Hoffman2007).SeveralChristianapproachestocontemporarypsychoanalytictherapyhaverecentlybeendescribedinaspecialissueoftheJournalofPsychologyandTheology(35,no. 1,2007)devotedtopsychoanalyticpsychotherapyandreligion,usingacasestudyapproach,editedbyB. D.Strawn(2007).ItwaspublishedinhonorofthelateChristianpsychologistandcontemporarypsychoanalystRandallLehmanSorensonandhisrecentmajorwork,MindingSpirituality(2004),whichfocusesontheintegrationofspiritualityorreligionandpsychoanalysis.Itshouldbepointedout,however,thatsomeChristianpsychoanalystswillmaintainthatthetraditionalpsychoanalyticstanceoftheanalystisactuallyamanifestationofdeepagapeloveandempathyfortheclient.Research:EmpiricalStatusofPsychoanalysisandPsychoanalyticTherapyMostoutcomeevaluationsoftheeffectivenessofpsychoanalysisandpsychoanalytictherapyhaveinvolveduncontrolledcasestudiesandclinicalsurveysoverthelastseveraldecadesorso(seeBlomberg,Lazar,andSandell2001;Galatzer-Levy,Bachrach,Skolnikoff,andWaldron2000;Sandelletal.2000;Wallerstein1986,1996,2001).Thebest-knownandmostwidelypublishedstudyreportedbyRobert S.Wallerstein,calledtheMenningerproject,involvedathirty-yearextensiveassessmentandfollow-upofforty-twopatientsseenintraditionalpsychoanalysisorpsychoanalytictherapy.Wallersteinconcludedthattraditionalpsychoanalysiswaslesssuccessfulthanexpected,whereassupportivepsychoanalytictherapywasmoresuccessfulthanexpected,butbothwererelativelybeneficial.Healsonotedthattherapeuticchangeisnotcontingentoninnerconflictresolution,andinteriorstructuralchangecannotbeclearlydifferentiatedfromexternalbehavioralchange.Theuncontrolledcasestudiesandclinicalsurveysconductedsofarhavefoundthatpsychoanalysisandpsychoanalytictherapyproducesimilartherapeuticorpositivebenefits(withreportedimprovementratesof60percentorbetter).However,controlledoutcomedatafrommore-scientificresearchstudiesarestilllackingorlimited,soacommonassertionisthatnodefinitivestatementscanpresentlybemaderegardingtheeffectivenessoftraditionalpsychoanalysisandpsychoanalytictherapy(ProchaskaandNorcross2010;seealsoFisherandGreenberg1996).Amorerecentmeta-analysisinvolving23studies(11randomizedcontrolledtrialsand12observationalstudies)withatotalof1,053patientsconcluded _Tan_Counseling_BB_mw.indd68 9/21/104:34:35PM PsychoanalyticTherapy 55 thatlong-termpsychodynamicpsychotherapy(withaminimumof50sessionsorayearoftreatment)isaneffectivetreatmentforcomplexmentaldisorderswithsignificantlybettertherapeuticoutcomesthanshorterformsofpsychotherapy(LeichsenringandRabung2008;seealsoGlass2008).Thereare,however,severalseriousmethodologicalproblemswiththismeta-analysisthatprecludemoredefinitiveconclusionsabouttheeffectivenessoflong-termpsychodynamicorpsychoanalytictherapy(seeBeckandBhar2009;Kriston,Holzel,andHarter2009;RoepkeandRenneberg2009;Thombs,Bassel,andJewett2009;seealsoLeichsenringandRabung2009).However,JonathanShedler(2010)hasmorerecentlyreviewedtheoutcomeresearchonpsychodynamicorpsychoanalyticpsychotherapy,whethershorttermorlongterm,andconcludedthattheempiricalevidenceavailablesupportstheefficacyofpsychodynamictherapy.Effectsizesforpsychodynamictherapyareaslargeasthosefoundforotherempiricallysupportedorevidencebasedtreatments.FutureDirectionsManyauthorsandcounselorshavepredictedthedemiseofpsychoanalysisandpsychoanalytictherapyinthelastfewdecades,butithasnothappened.Infact,interestinpsychoanalysisandpsychoanalytictherapycontinuestobestrong,evenamongChristiantherapists(seeStrawn2007).However,thepercentageofpsychotherapistsintheUnitedStateswhoendorsedpsychoanalytictherapyastheirprimarytheoreticalorientationisstillsmall,about3percentofclinicalpsychologists,1percentofcounselingpsychologists,5percentofsocialworkers,and2percentofcounselors(ProchaskaandNorcross2010,3).SeveralcrucialmodificationstotraditionalFreudiantheoryhavebeenmadeinrecentyears.Asnotedearlier,thetherapeuticrelationshipinpsychoanalytictherapyisnowmoreoftenviewedasmutualandinterpersonal.Thereisalsomoreopennesstoandintegrationofotherpsychotherapyapproaches,suchashumanisticandcognitivetherapies,aswellastheintegrationofneuroscienceandpsychoanalysis,calledneuropsychoanalysis(ProchaskaandNorcross2010;seealsoE. B.Luborsky,O’Reilly-Landry,andArlow2008).Relationaltheoryhasbeenfurtherdevelopedandrefinedsothatrelationalpsychoanalyticconceptscanbeintegratedwithotherpsychotherapeuticapproaches,includingcognitive-behavioraltherapies(Wachtel2008).Traditionalorclassicalpsychoanalysisisbeingprovidedtolessthan1percentofallclientsreceivingcounselingorpsychotherapytoday.Itwillbecomelessimportantasshorter-termversionsofrelationalpsychoanalysisandtime-limitedpsychoanalytictherapybecomemorewidespreadandpopular,ashiftthatisalreadyhappening(ProchaskaandNorcross2010).Aspecificdevelopmentinthiscontextistheuseoftreatmentmanualsthatprovidedetailedinstructionforconductingtime-limitedorbriefpsychoanalyticormorebroad-basedpsychodynamictherapy(Sharf2008).TheCoreConflictualRela- _Tan_Counseling_BB_mw.indd69 9/21/104:34:36PM 56 MajorCounselingandPsychotherapyTheoriesandTechniques tionshipThememethoddevelopedbyLesterLuborskyandhiscolleagueshasbeendescribedindetailintreatmentmanuals(Book1998;L. Luborsky1984;L. LuborskyandCrits-Christoph1998).Thismethodisasixteen-sessionmodelforconductingbriefpsychodynamicorpsychoanalytictherapy.Thetherapistfocusesonrelationshipsthattheclientbringsup,clarifyingtheclient’swish,aresponsefromtheother,andaresponsefromtheself.Thetherapistmakescarefullytimedinterpretationsofclienttransference,reflectingtheclient’sattitudesandbehaviorsfrompast,earlyrelationshipsthatstillinfluencecurrentrelationshipswithothers,includingtherelationshipwiththetherapist(seeSharf2008,60).Despitethesecurrentchangesandfuturedirectionsofpsychoanalysisandpsychoanalytictherapy,severalimportantconceptsfromFreudstillremaintoday,basedonsubstantialempiricalandclinicalsupport.Theyincludetheimportanceoftheunconscious;thecrucialroleofchildhoodtraumasandexperiencesinthedevelopmentofbehavioralproblems;thepervasivenessofinnerconflictinthelivesofhumanbeings,whomustthendevisecompromisesolutions;andthepowerfulimpactthatmentalrepresentationsofself,others,andrelationshipshaveonthecurrentfunctioningofindividuals(Westen1998).Formaltrainingtobeapsychoanalystusuallyrequiresaminimumoffouryearsofcoursework,afteroneobtainsadoctoraldegree(PhDorPsyD)inclinicalpsychologyorcompletesapsychiatryresidencyandisadmittedintoapsychoanalyticinstituteoftraining.Someinstitutesalsoadmitsocialworkersinclinicalpractice.Theformaltrainingincludesthepersonalanalysisofthecandidateintrainingbyaseniorpsychoanalyst,aswellassupervisedtreatmentofclientsoranalysandsseenbythecandidatethreetofivetimesaweekforafewyears.TheAmericanPsychoanalyticAssociation(www.apsa.org),foundedin1911andpartoftheInternationalPsychoanalyticalAssociation,isthelargestpsychoanalyticsocietyintheUnitedStates,withtwenty-nineprofessionaltrainingprogramsandforty-twoaffiliatesocieties.Division39,ortheDivisionofPsychoanalysisoftheAmericanPsychologicalAssociation,hasalistofninety-twotrainingprogramsinpsychoanalysis.Manypsychoanalyticjournalsarealsobeingpublished,includingtheInternationalJournalofPsychoanalysisandtheAmericanJournalofPsychoanalysis(E. B.Luborsky,O’Reilly-Landry,andArlow2008,28–29).Psychoanalysisandpsychoanalytictherapywillthereforecontinuetobeasignificantpartofcontemporarycounselingandpsychotherapy.RecommendedReadingsInadditiontoFreud’sownworks(atotaloftwenty-fourvolumesoftheStandardEditionpublishedbyHogarthPressinLondon),thefollowingbooksarerecommendedforfurtherreading: _Tan_Counseling_BB_mw.indd70 9/21/104:34:37PM PsychoanalyticTherapy 57 Brenner,C.(1974).Anelementarytextbookofpsychoanalysis(Rev.ed.).GardenCity,NY:Doubleday(Anchor).Hall,C. S.(1999).AprimerofFreudianpsychology.NewYork:Meridian.Jones, E.(1961).ThelifeandworkofSigmundFreud(Abridgeded.).NewYork:BasicBooks.McWilliams, N.(2004).Psychoanalyticpsychotherapy:Apractitioner’sguide.NewYork:GuilfordPress.Mitchell,S. A.(2000).Relationality:Fromattachmenttointersubjectivity.Hillsdale,NJ:AnalyticPress.Person,E. S.,Cooper,A. M.,&Gabbard,G. O.(2005).Textbookofpsychoanalysis.Washington,DC:AmericanPsychiatricPublishing.St. Clair, M.,&Wigren, J.(2004).Objectrelationsandselfpsychology:Anintroduction(4thed.).Belmont,CA:Brooks/Cole. _Tan_Counseling_BB_mw.indd71 9/21/104:34:37PM 5AdlerianTherapy A lfredAdler,thefounderofindividualpsychology(orAdleriantherapy),wasoriginallypartoftheinnercircleofSigmundFreud’sViennaPsychoanalyticSocietyandevenservedasitspresidentandeditorofitsjournal.However,AdlerhadsubstantialdisagreementswithmanyofFreud’spsychoanalyticviews,whichFreudcouldnottolerate.AdlerthereforepartedwayswithFreudin1911,foundinghisownschooloftherapyaswellasanewsocietyandjournal.Individualpsychology,orAdleriantherapy,emphasizessocialmotivationandsubjectiveperceptionmorethansexualdrivesinhumanbehavior.Inparticular,Adlerwasmuchlessdeterministicandmoreoptimisticinhisviewofhumannature.Hefocusedmoreonthesignificantinfluenceoflifegoalsonbehavior,thecrucialroleofabasicstrivingforsuperiorityineveryindividual,theimportanceofsocialinterestandconnectingwiththecommunity,theeffectsofbirthorder,andespeciallythesubstantialinfluenceofaperson’scoreassumptionsandbeliefs(erroneousorvalid)onhisorherlifestyle,withsomefreedomofchoice(Corey2009).Adler’sgreatimpactoncontemporarycounselingandpsychotherapyisnotlimitedtohisownindividualpsychologyorAdleriantherapyschool.Histheoreticalideasandtherapeutictechniqueshavesignificantlyinfluencedso-calledneo-FreudianssuchasKarenHorneyandErichFromm,aswellasfoundersofotherschoolsoftherapylikeCarlRogersandAlbertEllis,aswellasViktorFranklandRolloMay.Healsohelpedtopopularizehisideasforthegeneralpublic,whooftenassociateAdlerwiththeconceptoftheinferioritycomplex.58 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BiographicalSketchofAlfredAdlerAlfredAdlerwasbornonFebruary7,1870,inasmallAustrianvillagenearVienna.Hewasthesecondson(andthirdchild)inafamilyofsixchildrenwithHungarian-Jewishparents.HegrewupinanethnicallydiverseneighborhoodandwasmoreViennesethanJewishinhisidentity.HebecameaProtestantwhenhewasthirty-fouryearsold.Adlerhadanunhappyearlychildhoodfilledwithemotionallypainfulexperiencesandvariousseriousillnesses,includingabrushwithdeathduetopneumoniawhenhewasfiveyearsold.Twoyearsearlier,whenAdlerwasthreeyearsold,ayoungerbrotherdiedinabednexttohim.Adlerhimselfwasseriouslyinjuredinacoupleofbadstreetaccidentsnearhishome.Hisolderbrotherwasverysuccessfulandtalented,andAdlerwasdeeplyenviousofhimandfeltinferiortohim.Adlerdidnotdowellacademicallyasayoungchild,somuchsothathisteacheradvisedhisfathertoapprenticehimtoashoemakersothathecouldlearnatraderatherthancontinueinschool.However,hisfatherignoredthisteacher’sadviceandinsteadencouragedAdlertopursuefurtherschooling.Adlerdidsoandultimatelydidwellacademically.HechosetostudymedicineattheUniversityofViennaandgraduatedwithhismedicaldegreein1895.Hischildhoodexperiencesobviouslyhadastrongeffectonhissubsequentideas,suchasthoseregardinginferiorityandtheinferioritycomplexandthebasicstrivingforsuperiorityormasteryandperfection.AdlermarriedRaissaEpsteinin1897,andtheyhadfourchildren,twoofwhomalsopursuedcareersinpsychiatryandpsychotherapy.Hiswife,whowasfromRussia,wasseriouslycommittedtosocialismandfeminism.ShehadasignificantinfluenceonAdlerandhisemphasisontheequalityofwomenandmen.In1898Adlerbeganhisprivatepracticeasanophthalmologistbutchangedtogeneralpractice.Later,hespecializedinneurologyandpsychiatry.Asapracticingpsychiatrist,hetookakeeninterestinthewholeperson,payingattentiontothepsychological,social,andphysicalaspectsofanindividual’slife.In1902FreudinvitedAdlertobecomepartofthepsychoanalyticgroupthatFreudwasformingatthetime.Adlerwasoneofthefouroriginalmembersofthegroup,andin1910hesucceededFreudaspresidentoftheViennaPsychoanalyticSociety.However,hehadseriousdisagreementswithmanyofFreud’sideas,especiallywithFreud’semphasisonsexualdrives.Adlerfocusedmoreonsocialmotivationsandsubjectiveperceptionsinexplaininghumanbehavior.Healsodidnotundergopsychoanalysisforhimself.FreudwasunabletotolerateAdler’ssignificantdifferenceswithhim,andAdlerpartedwayswithFreudin1911.AdlerfoundedtheSocietyforFreePsychoanalyticResearchorInvestigation,whichwaslaterrenamedtheSocietyfor _Tan_Counseling_BB_mw.indd73 9/21/104:34:38PM 60 MajorCounselingandPsychotherapyTheoriesandTechniques IndividualPsychology,andin1914heandacolleaguelaunchedtheJournalofIndividualPsychology.AdlerinterruptedhistheoreticalworktoserveasamedicalofficerintheAustrianarmyduringWorldWar I.Afterthewar,hedemonstratedhissocialinterest,especiallyinchildren,byestablishingoverthirtychildguidanceclinicsintheViennaschoolsystem.Healsobegantrainingotherprofessionalstousehisideasandthetechniquesofindividualpsychology,whichfocusedonthewholeortotalindividual.Adleradvocatedforschoolreformsandbetterchild-rearingpracticesandspokeoutagainstprejudicesthatwereresponsibleforconflict.Adleralsowroteforthegeneralpublicandwasabletopopularizehisideasandthemethodsofindividualpsychology.HisbookUnderstandingHumanNature(1959)becameawidelyreadbestsellerintheUnitedStates.AdlerfirstvisitedtheUnitedStatesin1926andsubsequentlymademanytripstolectureintheUnitedStatesandothercountries.In1935heandhiswifemovedtoNewYork,whereheheldafacultypositionatLongIslandCollegeofMedicine.Adlerkeptaverybusy,gruelingschedule.Althoughhisfriendsurgedhimtoslowdown,Adlerignoredtheirwarnings.HediedofaheartattackonMay28,1937,inAberdeen,Scotland,duringalecturetour.AfterAdler’sdeath,RudolphDreikursplayedamajorroleintheexpansionofindividualpsychologyintheUnitedStates.ForfurtherinformationonAdler’slifeandwork,seeP. Bottome(1957),H. Orgler(1963),J. Rattner(1983),E. Hoffman(1994),T. J.Sweeney(1998),H. H.MosakandM. Maniacci(1999),andJ. Carlson,R. E.Watts,andM. Mani­acci(2006).MajorTheoreticalIdeasofAdlerianTherapyPerspectiveonHumanNatureAdler’sperspectiveonhumannaturewasmuchlesspessimisticanddeterministicandmoreoptimisticthanFreud’sview.Adleremphasizedtheindividual’sfreedomtoresponsiblychoosehisorherlifegoalsandpurposeinlife,whichwillguideone’slifeandlifestyle.HehasthereforebeenconsideredaforerunnertotheexistentialschooloftherapybyexistentialtherapistssuchasRolloMayandViktorFrankl,whoalsoemphasizedone’sfreedomtochooseandbefullyresponsibleforone’sownlife.AlthoughAdleracknowledgedthataperson’sbasicapproachtolifeisalreadyformedwithinthefirstsixyearsofchildhood,hefocusedmoreonone’sinterpretationofthemeaningofearlychildhoodexperiencesandalongingforsocialconnectednessascrucialmotivationsofhumanbehavior.Adleralsoemphasizedtheteleological,orgoal-oriented,natureofhumanbeings,focusingonconsciouschoicemorethantheunconscious,inseekingfulfillmentandmeaninginlife. 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AmajoraspectofAdler’stheoryishisSidebar5.1descriptionofinferiorityfeelings,whichareseenasnormal,occurringineveryhumanTheoreticalIdeasofAdlerianperson.EveryindividualhassomeareaofTherapydeficiencythatwillleadtofeelingsofinfe(seeCorey2009)riority.However,inordertocompensateforsuchfeelings,apersonwillbemotivatedto1.Subjectiveperceptionorinterstriveformastery,competence,orsuccess:pretationofrealityabasicstrivingfor“superiority”orperfec2.Unityandholisticdeveloption,butnotnecessarilyinanarrogantway.mentofpersonalityAdlerwasthereforebasicallyoptimisticinhis•Goal-orientedandpurposeviewofhumanbeingsascapableofpositivefulbehaviorcompensationforinferioritywithacreative•Inferiorityandstrivingforstrivingforsuperiority.superiorityAdleralsoemphasizedthewholeperson•Lifestyleortotalpersonalityofanindividual,with3.Socialinterestandcommunityattentiontoallaspectsoffunctioning,infeelingcludingthesocialandsystemiccontextand4.Birthorderthepsychologicalandphysicaldimensions.Hecalledhisapproachtotherapyindividualpsychologytoemphasizethatitfocusedonthewholepersoninsocialcontextinsteadofbeingreductionisticandnarrowlyattendingtoonlytheinternalpsychologicalorbiologicalaspectsoftheindividual.ThemajortheoreticalideasofAdleriantherapyaresubjectiveperceptionorinterpretationofreality;unityandholisticdevelopmentofpersonality(includinggoal-orientedandpurposefulbehavior,inferiorityandabasicstrivingforsuperiority,andthelifestyleofanindividual);socialinterestandcommunityfeeling;andbirthorder(Corey2009).SubjectivePerceptionorInterpretationofRealityAdlerianstakeaphenomenologicalapproachtounderstandingtheirclientsbyfocusingonhowaclientperceivesorinterpretsrealityandgivesmeaningtohisorherexperiences.Inotherwords,thecrucialelementisaclient’ssubjectiveexperienceofrealityintermsofhisorherownperceptions,interpretations,assumptions,beliefs,values,thoughts,andfeelings,notsomeobjectiverealityoutthere.Thissubjective,phenomenologicalviewoftheclient’sexperienceofrealityasamajorinfluenceonhumanbehaviorisakeyconceptnotonlyinAdleriantherapybutalsoinmanyothercontemporaryapproachestocounselingandtherapy,suchasperson-centeredtherapy,Gestalttherapy,existentialtherapy,realitytherapy,cognitive-behavioraltherapies,andsomesystemictherapiesandpostmoderntherapies(Corey2009).Recently,attempts _Tan_Counseling_BB_mw.indd75 9/21/104:34:40PM 62 MajorCounselingandPsychotherapyTheoriesandTechniques havebeenmadetointegrateAdleriantherapywithcognitiveandconstructivetherapies(Watts2003).UnityandHolisticDevelopmentofPersonalityAdlerviewedhumanpersonalityholistically,withtheindividualdevelopinginaunifiedwaybyself-selectingabasiclifegoalformedinthecontextofhisorheruniquelifeexperiencesaswellasparticularfamily,social,andculturalenvironments.TheinterpersonalrelationshipsinthesocialcontextofanindividualareconsideredinAdleriantherapymuchmorethantheperson’sinternalorpsychologicaldynamics.ThreemajorconceptsinAdleriantherapyrelatingtohumanpersonalitydevelopmentinaholisticwayaregoal-orientedandpurposefulbehavior,inferiorityandabasicstrivingforsuperiority,andlifestyle.Goal-Oriented and PurposefulBehavior InadditiontoFreud,withwhomheincreasinglydisagreedovertime,Adlerwasalsoinfluencedbyseveralsignificanthistoricalfigures,includingPierreJanet,whoassertedthatthegeneralreasonforneurosisisanunderlyingsenseofinferiority;FriedrichNietzsche,whostressedthecentralsignificanceoftheindividualaswellasthestrivingforperfection;KarlMarxandhisideasonsocialismandsocialforcesasthemajorinfluenceonhumanbehavior;andespeciallyHansVaihinger,aphilosopherwhowroteThePsychologyof“AsIf”(1911),emphasizingthatpeopleformtheirownperceptionsoftruthorrealityandlivebytheirownself-selectedpurposesandfictionalgoals(Parrott2003).Adleriansthereforeviewhumanbehaviorasbeinggoalorientedandpurposeful,motivatedmorebyfuturegoalsthanpastexperiences,ateleologicalexplanationratherthanadeterministicone.FictionalfinalismisatermoftenusedbyAdlerianstorefertoaself-selected,imaginedlifegoalthatinfluencesanindividual’sbehaviorandactions.However,Adlerhimselfeventuallyreplacedthistermwithotherssuchas“goalofperfection”or“guidingself-ideal”torefertoaperson’sbasicstrivingformasteryorsuperiority(WattsandHolden1994).Clientscanchoosetheirownsubjectivelifegoalthatwillhelpthemtoactinwaysconsistentwithitandtoperceiveandinterprettheirexperiencesaccordingly.Inferiority and Striving for Superiority Adlerassumedthatfundamentalfeelingsofinferiorityandtheneedfortheircompensationexpressedinabasicstrivingforsuperiorityorperfectionorcompletionareinnateinallhumanbeings.Earlierhehadwrittenaboutorganinferiority,referringtophysicaldefectsorpersonalitydeficiencies,inthecausationofneurosis(1917).However,Adlerwasoptimisticthathuman _Tan_Counseling_BB_mw.indd76 9/21/104:34:40PM AdlerianTherapy 63 beingscancompensatefortheirfeelingsofinferiorityoriginatinginchildhoodbystrivingforsuperiorityorcompetenceandmastery,resultingoftenincreativeandsuccessfulachievementsinlife.Nevertheless,feelingsofinferioritycanbecomeabnormalwhentheyformaninferioritycomplex,inwhichanindividualappearstohimselfandtoothersassomeonewhoisunabletosolveaprobleminasociallyusefulway(AnsbacherandAnsbacher1956).Abnormalfeelingsofinferioritycanalsoresultinasuperioritycomplex,wherebyapersonappearstoherselfandtoothersassomeonewhoiscapableandstrong,buttheexternalappearanceofself-importanceandinflatedself-confidenceactuallymaskdeepandabnormalfeelingsofinferiority(Sharf2008).LifestyleAperson’slifestyleintheAdleriancontextreferstoaplanforlivingorastyleoflifebasedonone’sfundamentalbeliefsthatpullstogetherrealityforthepersonandlendsmeaningtolifeexperiences.One’slifestyleisthusthetypicalwaythatonelivesormovestowardaself-selectedlifegoal.Adleriansviewpeopleasproactiveparticipantsinlifeandsociety.Althoughtheybelievethatanindividual’slifegoalismainlysetwithinthefirstsixyearsoflife,heorshecanstillcorrectfaultyorinvalidassumptionsandbeliefsandconsciouslychooseamoreappropriatelifegoalbasedonmoreaccurateandvalidassumptionsandbeliefsandhenceanewlifestyleguidedbytherevisedlifegoal(Corey2009).SocialInterestandCommunityFeelingAdler’sideasaboutsocialinterestandcommunityfeelingmaybehismostuniqueandimportanttheoreticalcontributionstoindividualpsychology(Ansbacher1992).Socialinterestreferstoaperson’ssenseofempathyandidentificationwithothersandinterestinachievingabetterfutureforallhumanity.Socialinterestisusuallydemonstratedthroughsharedsocialactivitieswithrespectforothers.Alderviewedsocialinterestasacrucialcharacteristicofmentalhealth.Communityfeelingiscloselyassociatedwithsocialinterestandreferstoasenseofbelongingandsocialconnectednesswithothersinthecontextsoffamilyandsociety(Corey2009).Adlerdescribedthefollowingthreelifetasksthateveryoneseekstosuccessfullyaccomplish:(1)thesocialtaskofbuildingfriendships;(2)thelovemarriagetaskofachievingintimacy;and(3)theoccupationaltaskofworkormakingsignificantcontributionstosociety(seeDreikursandMosak1966).ThreeotherlifetasksthatAdlerianshaveaddedare:(4)theself-acceptancetaskoflearningtogetalongwithoneself(DreikursandMosak1967);(5)thedevelopmentofspiritualitytask,whichinvolvesgrowinginone’slifegoals,meaning,values,andrelationshipwiththecosmosoruniverse(Mosakand 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Dreikurs1967);and(6)theparentingandfamilytask(Dinkmeyer,Dinkmeyer,andSperry1987).BirthOrderAdlerviewedbirthorderandsiblingrelationshipsasanothercrucialfactorinfluencingaperson’ssocialrelationshipsandlifestyle.Heemphasizedthatthepsychological,orperceived,birthorderofthechildismoresignificantthantheactual,orchronological,birthorder.Heprovidedpossibleinfluencesofbirthorderontheoldestchild(whoistreatedlikeanonlychildwithsomepamperinguntilthenextchildcomesalong),thesecondchild(whomustshareattentionwithanotherchild,oftenwithsomecompetitivestruggle),themiddlechild(whooftenfeelsforgottenorsqueezedoutandcanbeaproblemchildorapeacemaker),theyoungestchild(whotendstobethemostpamperedchild),andtheonlychild(whoisoftenpamperedbyparentsandmayhavetroublesharingwithothers)(seeCorey2009,103–4).Adleriansoftencriticizebirth-orderresearchthatfocusesonlyonactualpositionorbirthorderinthefamily.AgoodexamplethatillustratestheneedtolookmoreattheperceivedorpsychologicalbirthorderratherthansimplyatactualbirthorderinafamilyisprovidedbySharf,usingthemodelofafamilywiththreechildren,inwhichthefirstchildisoneyearolderthanthesecond(ormiddlechild),whointurnistwelveyearsolderthantheyoungest(orthirdchild).Adleriantherapistsmayapproachthisparticularfamilyasconsistingoftwosubsystems:thefirstasafamilywithayoungerandanoldersibling(thefirsttwochildren),andthesecondasafamilywithanonlychild,withtheyoungestchildviewedmorelikeanonlychild(2008, 118).TherapeuticProcessandRelationshipInhelpingtheirclients,Adleriantherapistsuseamodelthatismorepsychoeducationalthanmedical.Theydonotviewtheirclientsasmentallyillandinneedofacure.Instead,Adleriantherapistsbelievethatthemajorproblemfortheirclientsisthattheyarediscouragedindealingwithproblemsandstrugglesinliving.EncouragementisthereforethemostimportanttherapeuticmethodemployedinAdleriantherapy,whichalsoinvolvesdirectlyprovidinginformation,teaching,andguidingclientstohelpthemchangetheirfaultyassumptionsandthemistakengoalsintheirprivatelogicorthinking,sothattheycanbereeducatedtolivemoreontheusefulratherthantheuselesssideoflife.Clientswillthenexperiencemoresocialinterestandcommunityfeeling,withgreatercourageandself-confidence to livethisway.ThetherapeuticrelationshipbetweentheAdleriantherapistandtheclientisawarmandcollaborativeoneinwhichtheycanworktogethertomakethe 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changesnecessaryfortheclienttoliveamoremeaningfulandfulfillinglife.TheAdleriantherapistfocusesonstronglyencouragingandaffirmingtheclient,inordertocounterthesignificantdiscouragementthatoftenbringsclientsintotherapyinthefirstplace.TheAdleriantherapististhereforeactiveanddirective,butalsoveryempathic,supportive,andencouraging.Theclientneedstobeopenandwillingtodisclosepersonalandfamilyinformation.Forexample,theAdleriantherapistwilluseaquestionnairetoassesstheclient’sfamilyconstellation,orrelationshipsandexperienceswithparents,siblings,andotherswhoarelivingwiththeclientathome.Thetherapistwillalsoasktheclienttoprovideearlyrecollections,ormemoriesofparticulareventsinchildhood,thattheclientisabletoreexperience,inordertofurtherassesshowtheclientviewshimselforherselfandothers,aswellasthefuture.TheAdleriantherapistusessuchmethodstoassesstheclient’slifestyle,sothatclearergoalsfortherapycanbecollaborativelyset.Adleriantherapytendstoberelativelyshortterm,usuallylastingfromseveralmonthstoayearorso.SomeofAdleriantherapy’smainpsychoeducationalgoalsfortheclientincludefosteringsocialinterest,counteringdiscouragementandreducingfeelingsofinferiority,andmodifyingfaultyassumptionsandmistakengoals—thatis,changingaperson’slifestyle,changingfaultymotivationandvalues,encouraginganindividualtohaveasenseofequalitywithothers,andhelpingapersontobecomeaproductivememberofsociety(seeMosakandManiacci2008,79).MajorTherapeuticTechniquesandInterventionsAdleriantherapyisusuallyconductedinthefollowingflexibleandsometimesoverlappingphases(Dreikurs1967):1.Establishingatherapeuticrelationship2.Conductinganassessmentoftheclient’sdynamics3.Providinginsightandinterpretation4.FacilitatingreorientationandreeducationMore-specifictherapeutictechniquesandinterventionsineachofthesefourmajorphasesofAdleriantherapywillnowbebrieflydescribed.ItshouldbenotedthatAdleriantherapistsarequitepragmaticandeclecticintheparticulartherapeutictechniquestheyusetohelpclientsachievetheirtherapeuticgoals.EstablishingaTherapeuticRelationshipTheAdleriantherapistworksatformingawarm,empathic,andcollaborativerelationshipwiththeclientbasedongenuinecaring,encouragement,and 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mutualrespectandtrust.Thetherapistdoesnotrushintoproblem-solvebutinsteadprovidesmuchsupportandunderstandingtofacilitateclientexplorationanddisclosure.Inthisfirstphaseoftherapy,theAdleriantherapistemploysthefollowingtherapeutictechniques:listeningandattendingwithdeepempathy,sensitivelyunderstandingandtrackingtheclient’ssubjectiveexperiencesasfaraspossible,clarifyingandsettinggoals,andmakingtentativeinterpretationsofthepossiblepurposesoftheclient’sbehaviorsandsymptoms(Corey2009).ConductinganAssessmentoftheClient’sDynamicsThissecondphaseofAdleriantherapyusestwomaintypesofinterview:thesubjectiveinterviewandtheobjectiveinterview(Dreikurs1997).Inthesubjectiveinterview,theAdleriantherapist,throughactivelisteningwithdemonstrateddeepinterest,supportstheclientintellinghisorherlifestoryasfullyaspossible.Thetherapistattemptstoidentifythepurposesandmeaningsoftheclient’slifeexperiences.Theclientisoftenaskedtowardtheendofthissubjectiveinterviewwhetherheorshehasanythingelsetosharewiththetherapistsothatthetherapistcanbetterunderstandtheclientandhisorherconcerns.Inordertofurtherclarifytheclient’sproblemsandgoals,Adleriantherapistsoftenendthesubjectiveinterviewbyasking“TheQuestion”:“Howwouldyourlifebedifferent,andwhatwouldyoubedoingdifferently,ifyoudidnothavethissymptomorproblem?”(Corey2009,109).AshorterversionofTheQuestionis:“Whatwouldbedifferentifyouwerewell?”(Parrott2003,135).Theobjectiveinterviewseekstoobtaininformationinthefollowingareas:thehistoryoftheclient’sproblems;precipitatingevents,ifany;medicalhistory,withpastandpresentmedicationusage;socialhistory;reasonsfortheclientcomingtotherapyatthisparticulartime;theclient’swayofcopinganddealingwithlifetasks;andanassessmentoftheclient’slifestyle(Corey2009).Adlerconceptualizedlifestyleasconsistingoffourmajorcomponents:theself-concept,orone’sviewofoneselfbasedonreality;theself-ideal,orone’sviewofoneselfasonewouldliketobe;thepictureoftheworld,orone’sviewofthereasonsforthingsworkingthewaytheydointheexternalworld;andone’sethicalconvictions.Thislifestyle,orbasicstrategyormapforliving,influencesone’schoicesandbehaviors.Therearethreemajor“entrancegatestomentallife”thatAdleriantherapistsexplorewithclientsinordertoassessandbetterunderstandtheirlifestyles:birthorderandthefamilyconstellation,earlyrecollectionsormemories,anddreams(Parrott2003).BirthOrderandFamilyConstellation.Birthorder,orperceivedpsychologicalbirthorder,isanimportantpartoftheassessmentoftheclient’sfamilybackgroundandexperiencesorfamilyconstellation.TheAdleriantherapistexploreswiththeclientnotonlyhisorherbirthorder,butalsoexperiences _Tan_Counseling_BB_mw.indd80 9/21/104:34:44PM AdlerianTherapy 67 withhisorhermotherandfather,siblings,andothersinthefamily;themaritalrelationshipbetweentheclient’smotherandfather,includinghowtheydealtwithconflicts;andthedisciplinarymethodstheyusedwiththechildren.Adlerviewedsuchfamily-of-originexperiencesashavingacrucialeffectonthepersonalitydevelopmentofanindividual.EarlyRecollectionsorMemories.Adleremphasizedthecrucialsignificanceofaperson’searliestmemoriesorrecollectionsofspecific,cleareventsorexperiences,especiallyinchildhood,forunderstandinghisorherpresentlifestyleorcurrentviewoflife.TheAdleriantherapistwilloftenaskthefollowingquestioninordertoguideaclienttorecallsuchearlymemoriesorrecollections:“Iwouldliketohearaboutyourearlymemories.Thinkbacktowhenyouwereveryyoung,asearlyasyoucanremember(beforetheageoften),andtellmesomethingthathappenedonetime”(Corey2009,111).Ashorterversionofthisquestionwouldbe:“Thinkasfarbackasyoucanandtellmeyourearliestmemoryfromyourchildhoodyears”(Parrott2003,126).Thetherapistwillaskformorespecificdetailsaboutaparticularrecollectionandnotsettleforvague,generalmemories.Clientsoftenprovideseveralspecificearlyrecollections,whichtheAdleriantherapistwillrecordinordertoidentifypossiblethemesthatmaybeconnectedtotheclient’scurrentlifestyleorviewoflife.Dreams.Adlervieweddreamsnotaswishfulfillments(asFreuddid)butasanindividual’sattemptstodealwithfuturedifficulties.Themoodsoremotionsexperiencedinadreammayalsoberelatedtothenextday’santicipatedevents.Adlerfurtherinterpreteddreamsaspossiblereflectionsofprogress(orthelackofit)inAdleriantherapy.Henotedthatdreamsmaybecomemoreactiveastherapyprogressesmoresuccessfullyandtheclientmakesmoretherapeuticchangesinhisorherlifeandlifestyle.Dreamscanthereforebeusedinconjunctionwithfamilyconstellation,includingbirthorder,andearlyrecollectionsormemoriestoassessaclient’slifestyleinAdleriantherapy.Inadditiontothesethreemajorwaysoflifestyleassessment,Adleriantherapistsmayalsousetwoothers:assessmentofbasicmistakesandassessmentofaclient’sassets(Sharf2008,124).Basicmistakesarebasedonearlyrecollectionsandrefertothenegative,self-defeatingaspectsofaclient’slifestyle.HaroldMosakandMichaelManiacci(2008,82)describefivecategoriesofbasicmistakes:1.Overgeneralizations,forexample,“Lifeisdangerous.”2.Falseorimpossiblegoalsofsecurity,forexample,“Ihavetopleaseeverybody.”3.Misperceptionsoflifeandlife’sdemands,forexample,“Lifeissohard.”4.Minimizationordenialofone’sworth,forexample,“Iamstupid.”5.Faultyvalues,forexample,“Befirstevenifyouhavetoclimboverothers.” 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Identifyingbasicmistakescanbehelpfulintheassessmentofaclient’slifestyle,butcorrectingormodifyingsuchmistakesinthinkingorworldviewismoredifficultbecauseaclientmaynotbeconsciouslyawarethatheorsheismakingbasicmistakesinthinking.Theassessmentofassetsinvolvesfocusingonwhatisgoodandpositiveinaclientratherthanonwhatisdeficientandnegative.Inassessingandidentifyingaclient’sassets,suchasacademicskills,athleticabilities,orintegrity,Adleriantherapistscanprovidestrongencouragementtoaclientbygivingdirectandaffirmingfeedbackabouthisorherparticularstrengths.ProvidingInsightandInterpretationInthisthirdphase,Adleriantherapistsproceedtointerpretmaterialcollectedintheprocessoflifestyleassessmentinordertofacilitatetheclient’sself-understandingorinsightintohisorherbehavior.InAdleriantherapy,thetherapistmakesinterpretationsonlywithregardtotheclient’sgoalsandpurposes,andnotabouthisorherinternalpsychologicaldynamics(Dreikurs1967).Interpretationsareprovidedinatentativeandwell-timedmanner,sothatclientsarelesslikelytoreactinadefensivewayorwithresistance.Adleriantherapistsoftenpresentaninterpretationintheformofatentativesuggestionorquestion,usingstatementssuchas,“Iwonderif . . . ,”“Itseemstomethat . . . ,”and“Coulditbethat . . .”Clientsaremorelikelytoacceptinterpretationsphrasedinthissensitiveandtentativestyleandthusdevelopdeeperinsightandself-understandingintothepurposesandgoalsoftheircurrentfunctioningaswellasdysfunctioning,includingsymptoms.Theymayalsorealizehowtheycangoaboutchangingorcorrectingtheirbasicmistakesinthinkingorintheirprivatelogicandintheirmistakengoals.FacilitatingReorientationandReeducationThelastphaseofAdleriantherapyisactionorientedandfocusesonfacilitatingtheclient’sreorientationandreeducationorhelpingtheclienttotranslateinsightsintoactions.Adleriantherapistsemployseveraltherapeutictechniquestodothis,butthecrucialinterventionistheuseofencouragement.Clientsareencouragedaswellaschallengedtotakecourageousstepsandrisksinordertobringaboutconstructiveandpositivechangesintheirlives.Someclientsmayneedtomakeenormouschanges,butmanyclientsneedonlytobereorientedtowhatiscalledtheusefulsideoflife.Thistermreferstoseveralcharacteristicssuchascourage,beingvalued,havingasenseofbelongingandconnectednesswiththecommunity,caringforothersandtheirwell-being,embracingimperfection,confidence,asenseofhumor,awillingnesstocontribute,andfriendlinessthatisshownoutwardly.Incon- 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trast,theuselesssideoflifeinvolvesselfSidebar5.2protectionandself-absorption,avoidingengagementinlifetasks,andcommittingAdlerianTherapeuticTechniquesnegativeactsagainstotherpeople(Corey(seeSharf2008,126–30)2009).Adleriantherapyseekstohelpclientsmovefromtheuselesssideoflife,1.Encouragementwhichisassociatedwithlessfunctionality2.Immediacyandmorepsychopathology,totheuseful3.Asking“TheQuestion”sideoflife.4.Acting“AsIf”Thefollowingarethemaintherapeu5.CatchingoneselftictechniquesusedinAdleriantherapyto6.Spittingintheclient’ssoupfacilitatereorientationandreeducationin7.Avoidingthetarbabyclients:encouragement,immediacy,ask8.Push-buttontechniqueing“thequestion,”acting“asif,”catching9.Paradoxicalintentiononeself,spittingintheclient’ssoup,avoid10.Tasksettingandcommitmentingthetarbaby,push-buttontechnique,11.Homeworkparadoxicalintention,tasksettingand12.Lifetasksandtherapycommitment,homework,lifetasksand13.Terminatingandsummarizingthetherapy,andterminatingandsummarizinginterviewtheinterview(seeSharf2008,126–30;seealsoBitter,Christensen,Hawes,andNicoll1998;BitterandNicoll2000;J. Carlson,Watts,andManiacci2006;DinkmeyerandSperry2000).Encouragement.EncouragementisthemostsignificantanduniquetherapeutictechniqueusedbyAdleriantherapiststosupportandaffirmclientsasanantidotetotheirdiscouragementinlife.Encouragementisespeciallycrucialinhelpingclientstobelievethattheycanmakethechangestheywantandneedtomakeandtoactuallytakeactionandevenriskstowardtherapeuticandconstructivechange.Encouragementdoesnotconsistonlyofcommentssuchas,“Keepontrying;Iknowthatyouarecapableofdoingthis.”Adleriantherapistsusecreativityanddeepcaring,aswellascourage,tostronglyaffirmandsupporttheirclients.Adlerhimselfwasonceconfrontedbyayoungwomansufferingfromschizophrenia.Eventhoughshephysicallyhithim,herespondedwithfriendlinessinsteadofretaliation.Hedidthisinordertoencourageandaffirmher,whichledtoherrenewedcourage.Shethenbrokehisglasswindowandcutherhandasaresult.Insteadoflockingherinherroom,Adlerbandagedherhandwithoutreproachingherandagainengagedincreativelyandcourageouslyencouragingher.SherespondedwelltoAdlerandthesetherapeuticinterventions(seeAnsbacherandAnsbacher1956,316–17,citedinSharf2008,126–27).Immediacy.Withthistechnique,anAdleriantherapistcommentsonwhatheorsheispresentlyexperiencingwiththeclientintheactualtherapysessionasitisunfolding.Itmayinvolveverbalornonverbalcommunicationbythe 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clientthatsomehowrelatestothetherapygoalsalreadyagreeduponwiththetherapist.Thetherapistwillmakeanimmediacyresponseorcommentinatentativewayandwilloftenaskaquestionattheendofthecommentsuchas,“Isthatright?”or“Isthiscorrect?”Thisprocesswillhelptheclienttobemoreopenandlessdefensivesothatheorshecanrespondtothetherapist’simmediacyexpressionbyfurtherexploringwhatmaybeblockingtheachievementoftherapeuticgoals.Asking“TheQuestion.”AnotherAdleriantherapeutictechniqueistoask“TheQuestion”:“Whatwouldbedifferentifyouwerewell?”Thiscrucialquestionhelpsclientsclarifywhatandhowtheyreallywanttochange.Adlerinitiallyusedthisquestiontohelphimassesswhetheraclient’sproblemsweremainlyphysiologicalorpsychological.Althoughitistypicallyusedinearlierphasesoftherapyasanassessmenttool,itcanbeusedatanytimeinthetherapyprocess.Forexample,ifaclientwhocomplainsofpainanswers“TheQuestion”bysaying,“Iwouldbeabletosleepbetteratnightwithoutpain,”itmightindicateamorephysiologicalbasisforthecomplaint.Ontheotherhand,iftheclientrespondsbysaying,“Iwouldbeabetterhusbandandfather,”itmightindicatethattheclient’spainisawayofavoidingpsychologicalissues.However,thewayinwhichanAdleriantherapistcaninterpretaclient’sanswerto“TheQuestion”maynotbesoclearcut.Thus,itmaybebettertosimplyusethistechniquetohelpclientsfocusmoreclearlyonwhattheyreallywanttochangeandhowtheycangoaboutdoingso.Acting“AsIf.”Inthistechnique,theAdleriantherapistaskstheclienttoact“asif”hewerecapableofexecutingordoingcertainactionsthatheisafraidtotryandactuallytodothemasahomeworkassignmentintheweekahead.Forexample,averyshyclientmaybeencouragedbythetherapisttoact“asif”shewereaconfidentpersonandtotrytoassertherselfatworkbyaskingthebossforalong-overduepayraise.Thetherapistmayalsorole-playthisbehaviorinthetherapysessionwiththeclient,beforetheclientattemptsitinreallifeinthecomingweek.CatchingOneself.Thetechniqueof“catchingoneself”involvesinstructingaclienttocatchhimselforherselfjustbeforeengaginginanegativeorproblematicbehavior,andthereforetobeawareofitintimetochangeitbeforeitoccursoutofhabit.Overtime,aclientmaybeabletocatchhimselforherselfjustbeforeratherthanafterengaginginaparticularself-defeatingbehaviorandtostopjustintimetoreplaceitwithamoreconstructiveandhelpfulbehavior.SpittingintheClient’sSoup.Thistechnique’snameisbasedonabadhabitthatchildrenatboardingschoolsusedtopracticeinordertogetanotherperson’ssoupbyspittinginit.TheAdleriantherapistusesthistechniquebymakingacommentaboutaspecificclientbehaviorthattakestherewardorattractionoutofit.Forexample,amothermayexpresshowmuchshesacrificesinordertoprovideforherchildren.Thetherapistmaythencommenton _Tan_Counseling_BB_mw.indd84 9/21/104:34:47PM AdlerianTherapy 71 howsaditisthatthemotherhasnotimeforherselfandherownenjoymentoflife,thusremovingtheheroicaspectoutofherself-sacrifice.AvoidingtheTarBaby.Adlerusedthephrase“tarbaby”torefertoanissuethatissticky(tar)ordifficultforaclienttoface.Aclientmaythereforebeparticularlysensitivetohowthisissueisaddressedandbedefensiveorresistantifthetherapistdealswithitinaninsensitiveorconfrontationalway.Forexample,aclientmayfeelthatcolleaguesatworktendtoignorehimandnowwondersifthetherapistmayalsonotbereallyinterestedinhisproblemsandthusmaybeignoringhim.Toavoidthetarbaby,theAdleriantherapistreassurestheclientbyaskingmorequestionsaboutwhatishappeningintheclient’sworksituation.Push-ButtonTechnique.ThisAdleriantechniquedescribedbyMosak(1985)involvesaskingaclienttoclosehiseyesandfirstimagineaverypleasantmemory(suchasabeautifulsunsetorasuccessexperience)andattendtothepositivefeelingsassociatedwithit.Theclientisnextinstructedtoimagineahorriblememory(suchasthedeathofalovedoneorafailureexperience)andattendtothenegativefeelingsassociatedwithit.Thethirdandfinalpartofthistechniqueinvolvesaskingtheclienttoimagineagainanotherverypleasantmemoryorgobacktothefirstpleasantmemoryandexperiencethepositivefeelingsassociatedwithit.Attheendofthisthree-partimagerytechnique,theclientopenshiseyesandrealizesthathecanhavesomecontroloverhisfeelingsbythethoughtsormemorieshechooses.TheAdleriantherapistthereforehelpstheclientlearnthispush-buttontechnique:thatonecancontrolone’sfeelingsthroughthethoughts,memories,orimagesonechooses,orbythebuttonsonepushesinone’smind.ParadoxicalIntention.Withthistechnique,theAdleriantherapistencouragesclientstoactuallypracticeandevenexaggeratetheverysymptomsorproblematicbehaviorstroublingthem.Adlerhasdescribedthisinterventionas“prescribingthesymptom.”Forexample,thetherapistwillinstructacompulsivehand-washertowashhisorherhandsevenmorefrequently.Insodoing,theAdleriantherapistexpectstheclienttofindtheinappropriatebehavior,nowexaggerated,tobelessattractiveandthereforebemorelikelytostopitorchangeit.TaskSettingandCommitment.ThistherapeutictechniqueinvolvestheAdleriantherapistcollaborativelyworkingcloselywithaclienttoplanspecificstepsofactiontoovercomecertainproblemsorachieveparticulargoals.Theclientchooseswhatheorsheiswillingtodoandthereforemakesthecommitmenttoperformcertaintaskstoachievehisorhergoals.Thetherapistthenhelpstheclienttoplanandimplementthestepsneededtoaccomplishataskthathasbeenbrokendowntoamanageablesize,withagreaterlikelihoodofsuccess.Forexample,aclientwhohasdecidedtoreturntoworkaftertakingmedicalleavetohavesurgerywillbeaskedbythetherapistwhatspecificstepsheor 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shewouldtake,suchaslookingatjobadsandpostings,applyingforrelevantjobopenings,goingforjobinterviews,andfinallyacceptingajobofferifappropriate.Thetherapistencouragestheclienttofocusmoreongettinggoodjobleadsorpossibilitiesfirst,ratherthanongettingajob,astheinitialtasksetbeforetheclient.Homework.Adleriantherapistsfrequentlyassignhomeworkforclientstocompletebetweensessions,tohelpclientsaccomplishthetaskstheyhavechosentodo.Thehomeworkneedstobesomethingthatisclear,concrete,andrelativelyeasy.Forexample,thetherapistmaysuggesttoaclientwhoislookingforajobthatheorshecontactasocialworkerforpossiblejobleadsbeforetheirnextcounselingappointment.Theycanthendiscussthejoboptionsandplanthenextstepsfortheclienttotake.LifeTasksandTherapy.Thistechniqueinvolvesthetherapistaskingtheclienttoratehisorherlevelofsatisfactionorhappinessinparticularlife-taskareas,suchasfamily,work,friends,andcommunity.Indoingthis,theclientmaydiscoverissuesneedingworkthatwerepreviouslyunrecognizedbytheclient.Thistechniquecanalsobehelpfulinassessingtherapeuticchangeandprogresstowardachievingthegoalsoftherapythroughoutthecourseoftherapy.TerminatingandSummarizingtheInterview.Thistechniqueinvolvessettingcleartimelimitsforatherapysessionsothatthetherapistendsasessionontimewithaclient(e.g.,thirty-minutesessionsforachildandforty-five-tofifty-minutesessionsforanadultclient).TheAdleriantherapistwillusuallysummarizetheinterviewattheendofthesessionwithaclientandassignappropriatehomework.ItshouldbeclearbynowthatAdleriantherapistsuseavarietyoftherapeutictechniquestohelptheirclients.Theyalsofreelygiveappropriateandwelltimedadvice,suggestion,anddirectioninthereorientationphaseofAdleriantherapy,whichismoreaction-oriented,afterinsightandinterpretationhavealreadybeenprovided.HelpfuladviceisthereforeseenasanappropriatetherapeuticinterventioninAdleriantherapy(seeJ. Sommers-FlanaganandSommers-Flanagan2004, 101). AdlerianTherapyinPracticeAHypotheticalTranscript Client:I’mfeelingtiredandlethargic. . .likeIhavenoenergytodoanything,andIdon’tfeellikedoinganything. . . .IguessI’mfeelingdepressedagain. . .andstuckwithnorealmeaningordirectioninmylife.AdlerianTherapist:You’refeelingdownandfatiguedagain,aswellassomewhatlostandaimlessinyourlife.Whatwouldbedifferentifyouwerewell? _Tan_Counseling_BB_mw.indd86 9/21/104:34:49PM AdlerianTherapy 73 Client:IfIwerewellandnotsotiredoutanddepressedandaimless?Well. . .Iamtiredofbeingsotiredanddepressed!Itwouldbenicetobewellagain. . . .IguessifIwerewellIwouldofcoursefeelbetterandwanttodomorethingslikeIusedto . . .AdlerianTherapist:Whatthingswouldyoudomoreof,ifyouwerefeelingbetter,ifyouwerewell?Client:IguessIwouldgobowlingmoreoften,somethingIusedtoenjoysomuchthatIbelongedtoabowlingteamandplayedinbowlingleagues.Thatwasyearsago. . .Ijustdon’thavetheinterestorenergytodothisanymore.IfIwerewell,IwouldalsobemoreinvolvedincommunityservicesuchastutoringinnercitykidsinmathandEnglish,whichIdidforacoupleofmonthssometimeago.Iwouldalsotakeuppaintingagain,asahobby . . .AdlerianTherapist:Great!Soundslikeyouactuallydohaveseveralenjoyableandfulfillingactivitiesyouwouldliketodoifyouwerewell,likebowling,tutoring,andpainting.Iactuallybelievethatyoucanbegintotakesmall,babystepstodosomeofthesethings,toact“asif”youwerebetteroralmostwellagain. . . .Whatdoyouthink?Client:I’mnotsure. . .thisconstantfatiguereallydragsmedown.Mydoctorhasdoneallkindsoftestsandnotfoundanythingphysicallywrongwithme.However,IdofeelalittlehopeandinterestasIthinkofmyselfbeingwellanddoingsomeofthesethingssuchasbowlingandpainting. . . .Thetutoringisabitmoredifficultformeatthistime.So,areyouaskingmetoactasifIwerebetteroralmostwellandperhapsstartabitofpaintingagain?AdlerianTherapist:Yes,you’regettingthehangofit,thatifyoubegintoactasifyouwerebetteroralmostwell,youmaybeabletoactuallydosomeofthesemeaningfulandenjoyableactivitiesyoumentioned.Yourideaofstartingtodosomesimplepaintingagainsoundsgreat,andI’mwonderingifyoucantellmemorehowyouplantogoabouttryingtoaccomplishthisinthecomingweek. ThishypotheticaltranscriptofasmallpartofanAdleriantherapysessiondemonstratestheusebythetherapistofseveralAdleriantherapeutictechniques:asking“TheQuestion,”acting“asif,”andjudiciouslybutclearly _Tan_Counseling_BB_mw.indd87 9/21/104:34:49PM 74 MajorCounselingandPsychotherapyTheoriesandTechniques providingencouragement,suggestion,andsomedirectionfortheclient.Thetherapistisalsobeginningtoformulatehomeworkfortheclient,incollaborativeplanningwiththeclient.CritiqueofAdlerianTherapy:StrengthsandWeaknessesAdler’stheoreticalideasandtherapeutictechniqueswerefaraheadofhistimeandhavehadapervasiveandsignificantinfluenceontheentirefieldofcounselingandpsychotherapy.Hisemphasesonhowone’sthinkingsignificantlyaffectsone’sfeelingsandbehavior,howone’sfuturegoalsandcurrentvaluesinfluenceone’slife,howonecanchoosetochangeone’slifestyle,andhowoneismotivatedbysocialfactorssuchassocialinterestandcommunityfeelinghaveallgreatlyimpactedotherschoolsorapproachestocounselingandpsychotherapybutoftenwithoutacknowledgmenttoAdler(Ellenberger1970).However,AlbertEllisdidacknowledgeAlderasthe“truefatherofmodernpsychotherapy”(Ellis1970,11).Adleriantherapyhasbeenusedtohelpclientswithawiderangeofpsychologicaldisordersorproblemssuchasanxietydisorders,someaffectivedisorders,personalitydisorders,conductdisorders,andantisocialdisorders(L. Seligman1986).Ithasbeenappliedinvarioussettingsandwithdifferentagegroups,forexample,withchildren,parents,adolescents,families,teachergroups,andothersocialsegments.Itisthereforeaversatileandbroadlyapplicableapproachtotherapy(Parrott2003).Ithasalsobeenappliedtoeducation,parenteducation,couplescounseling,familycounseling,andgroupcounseling(Corey2009).Adleriantherapyisalsoacomprehensiveapproachthatdealswiththewholeortotalperson—hencetheterm“individualpsychology,”whichemphasizestreatingtheindividualinaholisticorcomprehensiveway,focusingonthephysical,psychological,social,andevenspiritualaspectsofhumanlife.TheemphasisonsocialmotivationmakesAdleriantherapymoreopenandsensitivetosocial,cultural,anddiversityissues,comparedtoamoretraditionalFreudianpsychoanalyticapproach,whichtendstofocustoomuchoninternalorintrapsychicconflictsanddynamics.Adler’semphasisontheequalityofwomenandmenhasshapedAdleriantherapytobeanegalitarianapproachtocounselingthatcanbeincorporatedmoreeasilywithincontemporarytherapiessuchasfeministandpostmodernapproaches.Adleriantherapyalsousesseveralpracticalandhelpfultherapeutictechniqueswiththeclear,overarchingtherapeuticprincipleoffacilitatingencouragementofclients.Someofthesecounselinginterventionsaresimpleandstraightforward,basedonamorecommonsenseapproachtohelpingclients.Adleriantherapyalsoviewsthejudiciousprovisionofadvice,suggestion,anddirectionastherapeuticallyhelpfulandvaluable.Adleriantechniquescan _Tan_Counseling_BB_mw.indd88 9/21/104:34:50PM AdlerianTherapy 75 thereforebeusednotonlybycounselorsortherapistsbutalsobyteachers,parents,andtheclergy,duetotheirsimplicityandwideapplicability.Finally,Adleriantherapycanbepracticedwithinatime-limited,shorttermmodelofhelpingclientswithinseveralmonthstoayear.Thisisanotherstrengthofthisapproachsinceeffectiveorefficaciousshort-termtherapiesareparticularlyvaluedbymanagedcareinthecurrenthealth-carecontextintheUnitedStates.Adleriantherapy,however,hasseveralweaknesses.First,Adlerwasnotthatsystematicandthoroughinthedevelopmentanddescriptionofhistheoreticalideasandtherapeutictechniques.Manyofhiswritingsandpublicationsconsistoflectureshehadgiven.Heemphasizedteachingandpracticemorethancareful,systematictheorybuildingandclearoperationalizationanddefinitionoftermsusedinindividualpsychology.Infact,evencallinghisapproachindividualpsychologymaybemisleadingsincehisuniqueemphasisisonsocialmotivationratherthanindividualdynamics.Second,somecriticsregardAdleriantherapyassomewhatsuperficialandsimplistic,sinceitemphasizeseventualreorientationandreeducationoftheclientandpayslessattentiontoinsightandinterpretation,althoughitdoesnotignoreinterpretationandtheneedtoexploreearlychildhoodrecollections.Adleriantherapy,however,divergessignificantlyfromtraditionalFreudianpsychoanalytictherapy,whichfocusesmainlyoninterpretationofunconsciousintrapsychicdynamicsandconflicts.ThusAdleriantherapyhasbeencriticizedbytraditionalFreudiansfornotbeingdeepenough.Third,Adleriantherapymaynotbethemostappropriateapproachforhelpingclientswhoneedmoredirectassistancewithaddressingimmediateconcernsandstresses,suchaspoverty,unemployment,andviolence.AlthoughAdleriantherapyismoredirectiveandshorttermthanFreudianpsychoanalysis,itstillrequiresclientstoexploretheirearlyrecollectionsanddreamsaswellasengageinlifestyleassessments.Finally,Adleriantherapyhasnotbeensufficientlyevaluatedinwell-controlledtherapyoutcomestudies.MostoftheevaluationsofAdleriantherapyhavebeenuncontrolledcasestudies,whichcanbebiasedandmethodologicallyflawed.DefinitiveconclusionsabouttheeffectivenessofAdleriantherapythereforecannotbedrawnatthistime.ABiblicalPerspectiveonAdlerianTherapyAdler’sviewofhumannatureismoreoptimisticandlessdeterministicthanthatofFreud.AlthoughAdlerbelievedthatanindividual’sbasicapproachtolifeisformedwithinthefirstsixyearsoflife,heallowedforchangetooccurthroughaperson’sfreedomtochoosenewgoalsandnewwaysofthinkingandperceivingreality.Hismorepositiveviewofhumannature,emphasizingchoiceandthepossibilityofchange,issomewhatconsistentwiththebiblical 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view,whichalsoemphasizestheneedtochoose(cf.Deut.30:19;Josh.24:15).However,Adler’sviewmaybetoooptimisticorpositive,payinginsufficientattentiontothedarkersideofhumannaturethatisfallenandsinful(Jer.17:9;Rom.3:23)andinneedofredemptionandsalvationthroughJesusChrist(Rom.6:23;2 Cor.5:17).Adler’sfocusonhowfuturegoalscanmotivateanddirectaperson’sbehaviorisagoodcorrectivetoFreud’soveremphasisonthedeterministicinfluenceofearlychildhoodandpastexperiencesonanindividual’spersonalityandcurrentfunctioning.Itisalsomoreconsistentwithabiblicalperspectivethatisfutureoriented,viewingChrist’ssecondcomingorheavenandeternalrealitiesascrucialmotivationalgoalsthatChristianslookforwardto,inawaythatpurifiesandpositivelyaffectstheirpresentbehaviorandlife(seeTitus2:11–14;1 John3:2–3).Adler’semphasisontheneedtoidentifyandcorrectmistakengoalsandbasicmistakesinthinkingisalsoconsistentwiththebiblicalperspectiveontheneedtobetransformedbytherenewingofourmind(seeRom.12:2).One’sthinkingdoesgreatlyaffectone’sfeelingsandbehavior,andtruthful,biblicalthinkingisespeciallycrucialfromaChristianperspective.AnotheraspectofAdleriantheorythatisconsistentwithabiblicalperspectiveisitsfocusonsocialinterestandcommunityfeeling.Adleremphasizedtheneedforeverypersontobeconnectedwithhisorhercommunityandtocontributetoothers’welfarebyhavingagenuinesocialinterestinotherpeople.ScripturealsoemphasizestheneedforotherpeopleandconnectionnotonlyinterpersonallybutalsospirituallyasmembersofthebodyofChrist(1 Cor.12),servingoneanotherwithgenuineagapelove(1 Cor.13),whichisdeeperthansocialinterest.TheAdlerianideaofsocialinterestisthereforemoreinaccordancewiththeBible’semphasisonbodylifeandcommunity.ThecrucialroleofencouragementinAdleriantherapyisanotheraspectthatagreeswiththeBible’semphasisonencouragingoneanother(see,e.g.,1 Thess.5:11,14;Heb.3:13;10:25),especiallywiththespiritualgiftofencouragementifoneisblessedwithitbytheHolySpirit(Rom.12:8).Thespiritualgiftofencouragementmaybeparticularlyhelpfulincounselingandpeople-helpingministries(Tan1999b).ThereorientationandreeducationphaseofAdleriantherapy,whichisactionoriented,makesitamorebalancedcounselingapproachthatdoesnotnarrowlyfocusoninsightandinterpretationofpersonal,internaldynamics.TheBiblesimilarlyemphasizestheneedtotakestepsoffaith,tohaveappropriateworksofobedience,becausefaith,withoutresultingworks,isdeadornottruefaithatall(James2:17,26).Suchactionsteps,however,shouldstillbedoneindependenceonGodandthepoweroftheHolySpirit,andnotsimplybyself-effort.Finally,thecomprehensiveassessmentoflifetasksinanindividual’slifeinAdleriantherapyincludesthespiritualdimensionasanimportantandvalid 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partofhumanlife.ThisisagoodcorrectivetoFreud’sreductionisticviewofreligiouslongingsasanobsessionalneurosisbasedonwishfulfillmentandlongingforafather.However,theAdlerianviewofthespiritualdimensionisstillsomewhatvagueandgenericanddoesnotnecessarilyrefertoGodorreligiousbeliefs.TheBible’sviewofspiritualityismoresubstantialandspecificandultimatelyChristcentered,emphasizingourgoaltobecomemorelikeJesusinauthenticChristianspirituality(Rom.8:29).OthercriticismsofAdleriantherapycanbemadefromabiblicalperspective.Theemphasisonbeingactionorientedwiththeuseofsomesimpletechniquestoencouragechangecanbesomewhatsuperficialandsimplistic.AlthoughAdleriantherapistsdouseinterpretationtohelpclientsgaininsight,itmaybenecessarytofocusonthisaspectmoreanddealwiththedeeperanddarkerissuesofthehumanheart,whichisfallenandsinful(Ps.57:6;Jer.17:9).AnotheremphasisofAdleriantherapyisthephenomenologicalorsubjectiveviewofone’sperceptionofreality.ThisAdlerianviewcanconflictwiththeBible’sviewofeternalbiblicaltruth,whichismoreobjective.TheAdlerianperspectiveisactuallysomewhatcontradictorybecauseitdoesidentifymistakengoalsandfaultyassumptionsanddelineatesseveralbasicmistakesinthinkingthatassumesomeobjectivemeasureoftruth.Finally,theAdlerianfocusoninferiorityandthecompensatorystrivingforsuperiority(perfectionorcompetence)ineveryindividualasafoundationalmotivationcanbeproblematicfromabiblicalperspective.Althoughsuchcompensatorystrivingforsuperiorityneednotbepridefulorarrogant,itneverthelessfocusesonthehumantendency,evenifcreative,toemphasizestrengthandmasteryinoneself.Pridemayverywellbepresent,insubtle,ifnotobvious,ways.Evenifthestrivingforsuperioritydoesnotdeteriorateintoamorepathologicalandnegativesuperioritycomplex,itisneverthelessdangerouslyclosetosinfulpridebecauseitfocusesonself-achievementandstrengthinoneself.TheBible’semphasisonhumility(see,e.g.,Phil.2:3–5;1 Pet.5:5–6)andhowGod’spowerismadeperfectinweakness(2 Cor.12:9–10)andnotinstrengthorsuperiorityisnoteasilyreconciledwithAdler’sfocusonstrivingforsuperiority.Ultimately,suchstrivingmustbesurrenderedtotheLordJesus,whowillenableustoexperiencesufficientgraceandstrengthinweaknesssothatdelightfulsecurityandstabilityinhimwillreplacebothfeelingsofinferiorityandthestrivingforsuperiority.OurgoalswillalsobedirectedbyGodandhiswillforus,ratherthansettingourownlifegoals,whichagainmaybemistaken.Research:EmpiricalStatusofAdlerianTherapyWhilesomeaspectsofAdleriantheoryhavereceivedattentioninresearchorempiricalevaluation,suchastheeffectsofbirthorder(seeDerlega,Winstead,andJones2005)andsocialinterest(seeWatkinsandGuarnaccia1999),there 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hasbeenlimitedempiricalevaluationoftheeffectivenessofAdleriantherapyitself.ThefewoutcomestudiesofAdleriantherapy(seeM. L.Smith,Glass,andMiller1980)whetherwithchildren(seeWeisz,Hawley,andDoss2004)orwithadults(seeGrawe,Donati,andBernauer1998)arenotwellcontrolledenoughandaretoofewinnumbertoallowanydefinitiveconclusionsabouttheeffectivenessofAdleriantherapyatthistime.ThebesttentativeconclusionthatcanbedrawnfromthelimitedempiricalevidenceavailableisthatAdleriantherapyisbetterthannotreatmentandseemstobeaseffectiveasclient-centeredtherapyandpsychoanalytictherapyinseveralstudies(seeProchaskaandNorcross2010,84).Adleriantherapistshavepreferredthecasemethod,oruncontrolledclinicalcasestudies,overcontrolledoutcomeresearchtoevaluatetheeffectivenessofAdleriantherapy(MosakandManiacci2008).ItishopedthatAdleriantherapywillbesubjectedtomorewell-controlledoutcomestudiesinthenearfuture,sothattheempiricalstatusforitseffectivenesscanbemoresolid.FutureDirectionsAdlerhashadagreatimpactoncontemporarycounselingandpsychotherapy.Itisironicthatthesuccessandpopularityofmanyofhisideasandtherapeutictechniqueshaveresultedintheirincorporationintootherapproachestocounselingandtherapy,sothatthedistinctivenessofAdleriantherapyhasbecomemoredilutedastimehasgoneby(J. CarlsonandEnglar-Carlson2008).Atthesametime,Adleriantherapistsarealsobecomingmoreeclecticintheirviewsandtherapeuticpractice,incorporatingideasandtechniquesfromotherschoolsofcounselingandtherapy.SomeauthorshavethereforeconcludedthatAdleriantherapymaybecomelessdistinctiveandlessimportantinthefuture(ProchaskaandNorcross2010).However,MosakandManiacci(2008)recentlypaintedamoreoptimisticpictureofthefutureofAdleriantherapyasthatofarespectable,viable,andgrowingtherapeuticsystem.Individualpsychologysocietiescurrentlyexistinoveradozencountries.TherearemanyloyalpractitionersofAdleriantherapy,aswellastraininginstitutesandschools,includingtheAdlerSchoolofProfessionalPsychologyinChicago(www.adler.edu).TheJournalofIndividualPsychologyispublishedbytheNorthAmericanSocietyofAdlerianPsychology(www.alfredadler.org),whichhasaroundtwelvehundredmembers.Althoughlessthan1 percentofpsychotherapistssurveyedintheUnitedStatesindicatedAdleriantherapyastheirprimarytheoreticalorientation(ProchaskaandNorcross2010,3),theactualnumberofAdleriantherapistsinpracticeislarger.Adleriansarealsobetterknownfortheirworkineducationalsettingsandpublicschools(Sharf2008).AdleriantherapywillsurviveandevenflourishifcurrentpractitionerspreserveitsuniqueapproachevenwithfurtherrefinementsofAdler’sideasand _Tan_Counseling_BB_mw.indd92 9/21/104:34:53PM AdlerianTherapy 79 techniquesandifmorecontrolledoutcomeresearchisconductedtoestablishastrongerempiricalbase.RecommendedReadingsAdler, A.(1958).Whatlifeshouldmeantoyou.NewYork:Capricorn.Carlson, J.,Watts,R. E.,&Maniacci, M.(2006).Adleriantherapy:Theoryandpractice.Washington,DC:AmericanPsychologicalAssociation.Dinkmeyer,D. C.,&Sperry, L.(2000).Counselingandpsychotherapy:Anintegratedindividualpsychologyapproach(3rded.).UpperSaddleRiver,NJ:Merrill/Prentice-Hall.Mosak,H. H.,&Maniacci, M.(1999).AprimerofAdlerianpsychology.Philadelphia:Brunner/Mazel.Sweeney,T. J.(1998).Adleriancounseling:Apractitioner’sapproach(4thed.).Philadelphia:AcceleratedDevelopment. _Tan_Counseling_BB_mw.indd93 9/21/104:34:54PM 6JungianTherapy C arlGustavJung,thefounderofanalyticalpsychology(Jungiantherapyoranalyticalpsychotherapy)wasSigmundFreud’scolleague.Theyfirstmetin1907butagreedtoendtheircloserelationshipin1913becauseofgrowingdifferencesJunghadwithFreud’spsychoanalyticviews.JungalsoresignedthenaspresidentoftheInternationalPsychoanalyticAssociationandaseditorofthePsychoanalyticYearbook.FreudhadearliertreatedJungwithdeeprespectandappreciationandevenconsideredhimtobethecrownprinceofpsychoanalysisorFreud’ssuccessorin1909.BothJungandAdlereventuallypartedwayswithFreudandwentontodeveloptheirownapproachestotherapy,whichdifferedfromFreud’spsychoanalysisinsignificantways.TherewerealsotensionsanddifferencesbetweenJungandAdler.AlthoughJung’sanalyticalpsychologyhassomefoundationinFreudianandAdlerianviews,itgoesbeyondthem.Jung’suniquecontributionishisideaofacollectiveunconsciousinadditiontoapersonalunconsciousineachperson.InJungiantherapy,clientsareencouragedtoconnecttheunconsciousandtheconsciouslayersoftheirmindinconstantdialogue.Jungiantherapistsusetechniquessuchasdreamanalysisandtheinterpretationofsymbolstohelpclientsbemoreawareoftheirarchetypes,thatis,theorganizingpatternsintheirunconsciousthataremoretranspersonalorcollective.ThegoalsofJungiantherapyincludeselfknowledge,reintegration,andindividuation,allofwhichcanbestbeachievedinthecontextofahealingandprofoundencounterandrelationshipbetweentheJungiantherapistandtheclient(Douglas2008).80 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BiographicalSketchofCarlJungCarlGustavJungwasbornin1875inthesmallvillageofKesswilinSwitzerland.Hewastheeldestsoninhisfamilyandhadasisternineyearsyounger.Hisfatherwasaclergymanwhoseownfatherwasawell-knownphysicianandclassicalscholar.Hismother’sancestorsincludedmanytheologians,includingherownfather.Infact,eightofJung’suncleswerepastors.HewasthereforeexposedtoProtestanttheologyandchurchtraditionfromanearlyage.HealsoreceivedanexcellenteducationthatincludedclassicalGreekandLatin.Laterinhislife,Jungstruggledwiththereligiousbeliefsthathewasbroughtupwith.Jung’schildhoodwasnotahappyone.Heoftenfeltlonelyandhadanumberofinsecuritiesandfears.Healsotendedtobeanintrospectiveperson.Whenhewasthreeyearsold,hismotherbecameillandhadtobehospitalizedandabsentfromthehomeforasignificantperiodoftimeduringwhichJungfeltabandoned.Jungwasclosetohismother,butheexperiencedherinadividedway,involvingtwosidesofherpersonality:onewastheintuitiveside,whichincludedaninterestinparapsychologyandmoremysteriousthingsthathefeared,andtheotherwasherwarmandmaternalside,whichcomfortedhim.Jung’srelationshipwithhisfather,however,waslessclose.Notsurprisingly,Jungdevelopedaparticularattractiontointuitivewomenwhoweresimilartohismother.Manyofhispatientswerewomen.Heespeciallyrememberedanursemaidwhoattendedtohimwhilehismotherwasrecoveringfromherillnessinthehospitalforafewmonths.HiscousinHelenePreiswerk,whoconductedseveralparapsychologicalexperiments,alsogreatlyinfluencedhim.Heevenwrotehismedicalschooldissertationbasedonherexceptionalpsychicexperiencesandexperimentswithséancesthathehadwitnessed(Douglas2008).Afterearlierconsideringtrainingintheologyandarchaeology,JungenrolledattheUniversityofBaselin1895tostudymedicine.Hereadwidelyindiversedisciplines,includingphilosophy,anthropology,theology,science,andmythology.Jungwasinfluencedbyseveralwell-knownphilosopherssuchasImmanuelKant,CarlGustavCarus,EduardvonHartmann,GottfriedLeibniz,andArthurSchopenhaueraswellasearlyculturalanthropologistsincludingJohannBachofer,AdolfBastian,andGeorgeCreuzer(seeSharf2008,76).Familiaritywiththesethinkershelpedhimdevelophisideasofthecollectiveunconsciousandarchetypes.Afterhecompletedmedicalschoolin1900andchosepsychiatryashisspecialty,Jungalsotrainedwithtwowell-knownpsychiatrists,EugenBleulerinZurichandPierreJanetinParis(in1902).HeworkedwithBleulerattheBurgholzliPsychiatricHospitalfrom1902to1909andsawmanymentallydisturbedpatients,especiallythosesufferingfromschizophrenia.Hewroteamajorworkonschizophrenia,ThePsychologyofDementiaPrecox,in1907.Healsodeveloped 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thewell-knownwordassociationtestandconductedvariousstudieswithitthatsupportedtheexistenceoftheunconscious.Asaresultofhisstudiesandwork,JungbegantocorrespondwithSigmundFreud(Douglas2008).FreudinitiallyappreciatedJungandrespectedhissignificantwork.Theymetin1907,afterwritingtoeachotherin1906.FreudappointedJungpresidentoftheInternationalPsychoanalyticSocietyandeditorofitsjournal.JungtraveledwithFreudin1909totheUnitedStatestogivelecturesontheirrespectiveperspectivesonpsychoanalysisatClarkUniversityinWorcester,Massachusetts.FreudevenconsideredJungtobehissuccessor.However,Jung’stheoreticalideasincreasinglydifferedfromFreud’spsychoanalyticviews,andhewasquitebluntinhisprivatecorrespondencewithFreudaboutthesedifferences.FreudeventuallywrotetoJunginJanuary1913,proposingthattheyabandontheirpersonalrelationshipcompletely.JungagreedinhisresponsetoFreud,andtheypermanentlyceasedwritingtoeachother.In1903,JungmarriedEmmaRauschenbach,andtheyhadonesonandfourdaughters.AfterleavingtheBurgholzliHospitalin1909,heeventuallyenteredprivatepractice.Jungbegantrainingothersinhisanalyticpsychologyapproachtotherapy,includinghiswife,whowasoneoftheearliestJungianoranalyticaltherapists.AfterpartingwayswithFreudin1913,Jungexperiencedasix-yearperiodofdeepintrospectionandexplorationofhisownunconsciousbyanalyzinghisvisionsanddreams.Itwasatimeofsufferingandwhatsomeconsideredacreativeillnessforhim(Ellenberger1970).Hedidnotdomuchwritingorresearchduringthesesixyears.However,heemergedfromthisdarkperiodofhislifewithgreatercreativityandpublishedanimportantwork,PsychologicalTypes,in1921.Atthisstageofhislife,Jungbecamemuchmoreproductiveinhisteaching,writing,andpractice,andbegantravelingwidelyandfrequently.Hevisitedpeopleinprimitiveculturestolearnmoreaboutsymbols,myths,andfolkloreinordertohaveabettergraspofthecollectiveunconsciousandarchetypes,crucialaspectsofhistheory.Forexample,in1924,hetraveledtoNewMexicotomeetthePueblopeoplethere.In1925,hewenttoTanganyikatovisitanAfricantribe.HealsovisitedAsia,andstudiedChinesefolkloreandwritings,aswellasastrology,alchemy,clairvoyance,fortune-telling,anddivination.Heaccumulatedanoutstandinglibraryofbooksandwritingsonmedievalalchemyandusedthesymbolismfoundintheseworkstohelpdevelophisideasofthecollectiveunconsciousandarchetypalimagery(Sharf2008).Jung’sproductivitywasexceptional,andmostofhiswork,totalingtwentytwovolumes,hasbeenpublishedbyPrincetonUniversityPress.Healsoreceivedmanyawardsandhonors,includinghonorarydegreesfromOxfordandHarvard.JungremainedbusyandproductiveuntilhisdeathonJune6,1961,attheageofeight-five.JungiantherapyandJung’stheoreticalviewscontinuetoexertsignificantinfluence. 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ForfurtherinformationonJung’slifeandwork,seeD. Bair(2003),H. F.Ellenberger(1970),B. Hannah(1976),A. S.Harris(1996),CarlJung(1961),R. Papadopolous(2006),S. Shamdasani(2003),A. Storr(1983),andE. C.Whitmont(1991),aswellasJung’sowncollectedworkspublishedbyPrincetonUniversityPress.MajorTheoreticalIdeasofJungianTherapyPerspectiveonHumanNatureJung’sperspectiveonhumannaturewasmoreoptimisticandpositivethanFreud’spessimisticanddeterministicviewemphasizingconflictualsexualandaggressivedrivesintheunconscious.Jung’sviewoftheunconsciouswentbeyondbasicinstinctualorbiologicaldrivestoincludethecollectiveunconscious,withtranspersonalanduniversalarchetypesbasedonsymbol,folklore,myth,andevenmystery.Hefocusedmoreonthetremendouspotentialandcreativitywithinpeople,individuallyandcollectively,intheunconscious,whichcontainedbothpowerfullypositiveaswellasdarkernegativeaspects(J. Sommers-FlanaganandSommers-Flanagan2004).Jungiantherapy,oranalyticalpsychotherapy,emphasizeshelpingclientstoachievewholenessandself-realization,withthetherapeuticgoalsofselfknowledge,reintegration,andindividuation.ThedeepandhealingtherapeuticrelationshipbetweentheJungiantherapistandtheclientisconsideredacrucialfactorinachievingthetherapeuticgoalsfortheclient.Thetherapeuticprocessinvolvinghelpingtheclienttoknowandunderstandthearchetypesinhisorherpersonalandcollectiveunconsciousandtoexpresstheminhisorherlifeassumesthataclientiscapableofsuchinsightandgrowthandeventualindividuationandself-realization(Vitz1994).TheJungianapproachtocounselingandtherapythereforeisbasedonanessentiallyoptimisticandpositiveviewofhumannatureandthehumanabilityforself-realization,althoughitdoesacknowledgethedarkersideofpersonality.PersonalityTheoryJungianpersonalitytheorycanbedescribedandsummarizedunderfourmajorareas:levelsofconsciousness,archetypes,personalityattitudesandfunctions,andpersonalitydevelopment(Sharf2008).Levels of Consciousness Jungdescribedthreelevelsofconsciousness:theconscious,thepersonalunconscious,andthecollectiveunconscious.Theconsciouslevelofpersonalityisanindividual’saccessibleside,withconsciousawarenessofthoughts,feelings,senses,desires,andbehaviors.Itis _Tan_Counseling_BB_mw.indd97 9/21/104:34:56PM 84 MajorCounselingandPsychotherapyTheoriesandTechniques thataspectofapersonthatheorshecanknoworaccessdirectlyandbeawareof.TheconsciouslevelbeginsatbirthanddevelopsinthecourseofMainAreasofJungianone’slife,sothatasadeeperlevelofconsciousPersonalityTheorynessisexperienced,greaterindividuationorde(Sharf2008)velopmentofthewholepersonisachieved.Jungusedtheterm“psyche”todescribethe1.Levelsofconsciousnesstotalpersonalityofanindividual.Theegoisat2.Archetypesthecenterofconsciousnessandorganizesthe3.Personalityattitudesandconsciousmind.Itselectswhatanindividualwillfunctionsbeawareorconsciousofandscreensoutorre4.Personalitydevelopmentpressesotherthoughts,feelings,andmemories,whichwillremainattheunconsciouslevel.Theego,therefore,istheunifyingorintegratingforceinthepsyche.Itisoneaspectofbutnotidenticaltothepsyche.Theegoisactuallyacomplex,thatis,aconstellationofthoughtsbroughttogetherasawhole,usuallybyaunifyingfeeling.Acomplexofconsciousthoughtsandmemoriesenablesanindividualtohaveasenseofcontinuityandidentity.Asapersondevelopsandexperiencesmoreindividuationorself-realization,integratingallaspectsofthepsycheinbalance,anewcenter,theself,emergestoreplacetheego,whichstillexists,butasonlyoneaspectofthepsyche(Ryckman2008).Thepersonalunconsciousisthataspectofpersonalityinwhichthoughts,feelings,experiences,andperceptionsthattheegohasscreenedoutofconsciousawarenessarestoredbelowthelevelofconsciousness.Thisstoredmaterialmaybetrivial,oritmayincludeunresolvedconflictsorconcernsoremotionallyladenthoughtsthattheegohasrepressed.Materialkeptinthepersonalunconsciousoftenappearsindreams.Whenrelatedthoughtsareunified,typicallybyapowerfulfeelingwithanobviousemotionaleffectontheperson,acomplexhasdeveloped.Jung’sideaofacomplexfocusedespeciallyontheemotionalimpactofagroupofconnectedthoughts,feelings,andmemories.Healsoemphasizedthearchetypalcoreofcomplexes,whichincludesmaterialnotonlyfromthepersonalunconsciousbutalsofromthecollectiveunconscious,whichismoreuniversalandtranscendent.Someexamplesofcomplexeswitharchetypalrootsincludethefathercomplex,themothercomplex,themartyrcomplex,andthesaviorcomplex.Complexesarepartoftheunconscious,andthereforeneedtobemadeconscious,usuallywiththehelpofaJungiantherapist.Theycanhavebothpositiveandnegativedimensions.Whenapositivecomplexbecomesanegativeone,thetranscendentfunctionistriggered.Thisprocessinvolvesbridgingtwooppositeconditionsorattitudes(e.g.,anunconsciousinfluenceandaconsciousthought),whichresultsinathirdforcethatisusuallyoperativeintheformofanemergingsymbol(Sharf2008;seealsoJ. C.Miller2004).Sidebar6.1 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ThecollectiveunconsciousisauniqueJungianconcept;itisadeeperlevelwithinthepsychethatisnotconsciousandcontainsmaterialsthataretranspersonalanduniversaltoallhumanbeingsintheircommonancestry.Jungdidnotproposethatparticularimagesormemoriesareuniversallyinheritedbyallhumanbeings.Instead,heemphasizedthatitisthepredispositiontowardspecificideas,archetypes,thatisinherited.Archetypes,accordingtoJung,areparticularwaysofstructuringandperceivingexperiences.Jung’sideaofarchetypesiscrucialandfoundationaltohisanalyticalpsychology(Sharf2008).ArchetypesArchetypeshaveformbutnotcontent.Theyprovidepossiblewaysofperceivingexperiencesinparticularpatternsorthemesthatarepresentacrossculturesandhistory.Archetypesalsoconnectthecollectiveunconscioustotheconsciousandthereforecaninfluencebehaviorinanindividual.Theycanbeconsideredorganizingpatternsthatareunconscious(J. Sommers-FlanaganandSommersFlanagan2004).Junghadaspecialinterestinarchetypesthathaveenduredforalongtimeinthehistoryofhumankind,withstrongemotionalaspects.ExamplesofsucharchetypesaccordingtoJungaredeath,birth,power,thechild,thehero,thewiseoldman,theearthmother,thegod,thedemon,thesnake,andunity.Theyaremanifestedasarchetypalorprimordialimagesorsymbols.However,Jungemphasizedthatthemostcrucialarchetypesinthemake-upofone’spersonalityarethepersona,theanimaandtheanimus,theshadow,andtheself.Thepersonaismostrelevanttodailyfunctioning,whiletheselfismostcriticaltoproperpersonalityfunctioning(Sharf2008;seealsoShamdasani2003).Thepersona(“mask”inLatin)referstothewayonepresentshimselforherselfinpublic.Itisliterallythemaskwewearinordertointeractwithpeopleinsociallyappropriateways.Thepersonaisanarchetypethatisuniversallypresentinallhumanbeings.Itcanbehelpfulincontrollingone’sthoughts,feelings,andactionsinparticularcontextsandsituations.However,thepersonacanalsobeoverused,blockingdeepfeelings,andresultinginshallownessandsuperficialityinanindividual.Theanimaandtheanimusarecharacteristicsoftheothersexthatanindividualhasandmustintegratewithinhimselforherselfinordertoexperienceahealthyandwholesomebalanceinpersonalityfunctioning.Thisideaispartlybasedonthebiologicalfactthateachpersonhasvaryinglevelsofmaleandfemalehormones.Theanimaisthefemininearchetypeinaman’spsyche,andtheanimusisthemasculinearchetypeinawoman’spsyche.Theanimaisassociatedwithfeelingsandemotionalexperiencing,whiletheanimusisrelatedmoretorationalthinkingandlogic.However,theanimacanalsohavemorenegativecharacteristicssuchasmoodinessandvanity,andtheanimuslikewisewithmanifestationssuchassocialinsensitivityandargumentativeness.AlthoughJungviewedtheanimaandtheanimusasuniversalarchetypes,somecriticshavechargedhimwithbeinginfluencedbyculturalstereotypesofmenandwomenandthereforeofbeingsomewhatsexistandpatriarchal(Ryckman2008). 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Theshadowreferstothedark,potentiallyevilsideofhumannature,whichexertsapowerfulinfluenceonpeople’slives.Theshadowincludesrepressedorunacceptablesexualandaggressiveinstinctsinthepersonalunconsciousaswellaseviltendenciesinthecollectiveunconscious.Suchnegativecharacteristicsoftheshadowtendtobeprojectedontoothers,whichcanleadtoconflictsandevenwars.Thepersonaarchetypethattriestomaintainsociallyappropriatebehaviorhelpstokeeptheshadowundercontrol.Aswithallarchetypes,theshadowhasbothnegativeandpositiveaspects.Althoughtheshadowisdescribedmainlyasanegativearchetypethatispotentiallydangerousandevil,itcanalsobemanifestedmorepositivelyinexperiencesofcreativity,spontaneity,andvitality.Theselfisthecenterofpersonalityandincludestheconsciousandtheunconsciouslevelsinanindividual.Theselfintegratesconsciousandunconsciousaspectsandorganizesone’spersonalityfunctioning.Itencompassesthewholepsycheortotalpersonality,whereastheegoisonlypartofthepsycheandislimitedtoconsciousness.AccordingtoJung,weareallonapathtowardself-realizationandindividuation,thatis,tomaturingintoouruniqueself(andnottoegotismorselfishindividualism).Everyonestrivesforthegoalofdeeperknowledgeanddevelopmentoftheself,whichisanarchetypalpotentialityineachperson.Thisgoalisdifficulttoattainandinfactisneverfullyachieved.Itrequiresanindividualtobeintouchwithbothconsciousandunconsciousmaterialandtohaveenoughexperienceinlifetodealwithconflictsandtointegrateoppositesinhisorherpsyche.Strivingtowardthisgoalresultsinmorehealthyandbalancedpersonalityfunctioning.Jungthereforebelievedthatprogresstowardself-realizationcannotbesubstantiallymadeuntilatleastmiddleage(Ryckman2008).Dreamsandreligiousorspiritualexperiencescanbeveryhelpfulinmakingtheunconsciousconsciousandinintegratingconsciousandunconsciousprocesses.Archetypesdonothavecontentbutareexpressedthroughsymbols,whicharethecontentofarchetypalimagesthatonlyhaveform.Suchsymbolsappearindreams,visions,fantasies,myths,art,folklore,fairytales,andotherways.Jungengagedinextensivestudyofmanysymbolsacrossvariousculturesthathefoundtobearchetypalimagescontainingtheaccumulatedwisdomofhumanandprehumanhistory.Withsuchknowledgeofthehistoryandmeaningofsymbols,Jungwasabletouseamplification,orelaborationofthemeaningofadreamorsomeunconsciousmaterial,foraparticularpatient.ItisthereforeimportantforJungiantherapiststolearnasmuchaspossibleaboutsymbolsandtheirmeaningsinvariouscultures.Jungdescribedmanysymbolsthatrepresentparticulararchetypes.Forexample,thesymbolofthemaskforthepersonaarchetype,thesymbolsoftheMonaLisaortheVirginMaryfortheanimaarchetypeinmen,thesymbolsofKingArthurorChristfortheanimusarchetypeinwomen,andthesymbolsofevilsuchasHitlerandthedevilfortheshadowarchetype.Themandalaisaverysignificantsymbolforthearchetypeoftheself;itusually _Tan_Counseling_BB_mw.indd100 9/21/104:34:59PM 87 JungianTherapy hasfourmainsectionsinacircularshape,representingasearchforwholeness(Sharf2008).PersonalityAttitudes and Functions Jungviewedpersonalityasconsistingoftwomajordimensions,withconsciousandunconsciouselements:attitudesandfunctionsthattogetherformspecificpersonalitytypes.ExtraversionandintroversionarethetwomainpersonalityattitudesdescribedbyJung.Extraversionisanorientationtoorpreferencefortheouterworldconsistingofpeople,activities,andthings,whereasintroversionisanorientationtoorpreferencefortheinnerworldconsistingofideas,concepts,andinnerexperience.Extravertstendtoenjoysocialactivitiesandhavemanyfriendsandareenergizedbybeingwithpeople,whereasintrovertstendtoenjoyspendingtimebythemselvesandhavefewerfriendsandareusuallynotcomfortableinsocialsituations.Althoughanindividualmayexhibitsomecharacteristicsofbothanextravertandanintrovert,thereisusuallyapreferenceforone.However,Jungbelievedthatatmidlifeanindividualmaychangefromonepersonalityattitudetotheother(J. Sommers-FlanaganandSommers-Flanagan2004).Jungalsodescribedfourmainfunctionsofpersonality:thenonrationalorirrationalfunctionsofsensingandintuitingforperceivingtheworldandoneself,andtherationalfunctionsofthinkingandfeelingforjudgingexperiences.Sensinginvolvesusingthesensesoftaste,smell,touch,sight,andhearing,andresponsestosensationsoneexperiences,whereasintuiting,orintuition,involveshavingaguessorhunchaboutsomethingorsomeonethatisdifficulttoclearlyarticulate.Thesetwopersonalityfunctionsofsensingandintuitingareprimarilyengagedinperceivingandrespondingtostimuli.Thinkinginvolvesusingintellectualandrationalprocessestounderstandtheworldandideas,whereasfeelingreferstomakingevaluationsorjudgmentsaboutone’sexperiencesbasedonhavingnegativeorpositivefeelingsorvaluesaboutthem.Theselattertwopersonalityfunctionsofthinkingandfeelingareprimarilyengagedinmakingjudgmentsanddecisions(Sharf2008).Jungdevelopedatheoryofpsychologicaltypesbasedonthetwobasicpersonalityattitudesandthefourmainpersonalityfunctions.Hefocusedoneightmajorpersonalityorpsychologicaltypes:introvertedandextraverted,thinking,feeling,sensing,andintuitivetypes(seeRyckman2008,91–94).Jungwasveryconcerned,however,thatpeoplewouldbetooquicklyandinaccuratelylabeledasoneoftheseeightpersonalitytypes.ItisimportanttoberemindedofJung’semphasisontheuniquenessofeachhumanperson.PersonalityDevelopmentJung’stheoreticalconceptualizationofpersonalitydevelopmentisnotassystematicorwelldevelopedasFreud’sstagesofpsychosexualdevelopment. 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Jungdescribedfourmajorstagesofpersonalitydevelopment:childhood,adolescence(oryouthandyoungadulthood),middleage,andoldage.Hewasparticularlyinterestedinmiddleage(seeSharf2008,86–87).AccordingtoJung,childreninthechildhoodstagehavemainlyinstinctualpsychicenergythatisexpressedinactivitiessuchaseatingandsleeping.Jungbelievedthatparentsneedtohelptheirchildrenchanneltheirenergyinmoreconstructiveanddisciplinedways.Herelatedchildren’sproblemstoparentalconflictsathome.Ifparentalconflictsarereducedorresolved,children’sdisruptivebehaviorandotherdifficultieswillalsobeameliorated.Childrenarealsoinaprocessofgrowingintheirsenseofpersonalidentityandthereforeneedtoseparatefromtheirparentsindoingso.Inthestageofadolescence,theindividualmustdealwithseveralmajordecisionsinhisorherlife,includingchoosinganappropriateeducationandeventuallyacareerorprofession.Adolescentsalsoneedtograpplewiththeirsexualdrivesandlearntorelatetomembersoftheoppositesex.Theywillrespondorreactdifferentlydependingonwhethertheyaremoreinclinedtowardintroversionorextraversion.However,theyallneedtodevelopanappropriatepersonathatgoesbeyondtheirparents’influenceinordertocopewiththeexternalworldandsocialdemands.Astheygrowintoyoungadulthood,theymustcontinuetobetheirownuniqueperson.Inthemiddleagestage,Jungbelievedthatcrucialquestionsandissuesemergesuchassearchingforthemeaningoflife,becauseadeepersenseofemptinessandmeaninglessnessisoftenexperiencedbypeopleinthisstageoflife.Thisexperienceissometimescalledthemidlifecrisis.Junghimselfwentthroughsuchaperiodinhislifeforsixyearsduringwhichheengagedindeepintrospectionandanalysisofhisowndreamsandvisions,comingtoknowbetterhisownunconscious.Itwasapainfulanddarktimeofsufferingandstruggleforhim,butheemergedfromitmorecreativeandinsightful.ManyofJung’spatientswereinthisstageoflifeandthereforeweresimilarlydealingwithlosses,emptiness,andmeaninglessnessintheirlives.Religiousandspiritualexperiencesareoftenacrucialpartofmiddleage.Inthestageofoldage,individualsspendevenmoretimeconnectingwiththeirunconscious,andJungbelievedthatolderpeopleshouldtaketimefordeeperreflectionsothattheycangrowinwisdomfromtheirexperiencesandfindgreatermeaningintheirlives.Deathandmortalityarecommonpreoccupationsofolderpeople,whocancontinuetogrowanddeveloppsychologicallyastheyallowthemselvestoreflectmoreandbeindeepertouchwiththeirunconscious.TherapeuticProcessandRelationshipJungiantherapyfocusesonhelpingclientsnotonlytomaketheunconsciousconsciousbutalsotointegratetheunconsciouswiththeconscioussothattheycanbecomemorewholepersonsintheprocessofindividuation,orbe- 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comingone’sownuniqueperson.ThisistheoverarchinggoalofJungiantherapy:theindividuationoftheclient.Therecanalsobesecondarygoalsoftherapyrelevanttoaparticularstageofpersonalitydevelopment.Forexample,thegoalmaybetohelpclientsinmidlifedevelopadeepermeaningintheirlives,oftenwithspiritualandreligiouselements,andthereforetogobeyondjustpragmaticconcernssuchasmakingmoneyandtakingcareofafamily.Inpursuingtherapeuticgoals,Jungiantherapistsoranalystsuseavarietyoftherapeutictechniquesorinterventionssuchasdreamanalysis,activeimagination,anddealingwithtransferenceandcountertransferenceinthetherapeuticrelationship.However,themostimportantfactorinJungiantherapyisthetherapeuticoranalyticrelationshipbetweentheJungiantherapistoranalystandtheclient.Jungplacedmajoremphasisonthetherapeuticrelationshipandbelievedthatthetherapist’spersonalitycanhavetherapeuticeffectsontheclient’spersonality.Forthistotakeplace,theJungiantherapistmustbearelativelymatureandethicalpersonwhoisintegratinghisorherownunconsciousandconscious.Therefore,havinghadone’sowntraininganalysisisessential.TheJungiantherapistalsorelatestotheclientinamorehumanandegalitarianwaythatismutuallyrespectfulandrelational.JungdidnotusethecouchasFreuddid,butsawhisclientsfacetofaceinstead.Transferenceandcountertransference,includingprojectionsthatoccurinthecontextofthetherapeuticrelationshipandinteractionbetweentheJungiantherapistandclient,canbeexploredandinterpreted.ThetherapeuticrelationshipiscentraltoJungiantherapybecauseitcanbeviewedasprovidingacontainerforthepersonalityoftheclient,muchlikeanalchemicalvesselinwhichthedifferentaspectsofaclient’spsychecanbecontainedandeventuallychangedinatherapeuticway(Sanford1999).JungiananalysisisusuallyrelativelylongtermandinvolvesmeetingseveraltimesaweekwithaJungiananalyst,whereasJungiantherapyingeneralismoreflexible.Theterm“Jungiananalyst”appliesonlytosomeonewhohasreceivedformaltrainingandcertificationbytheInternationalAssociationforAnalyticalPsychology.Jungiananalystscomefromvariousprofessionalbackgrounds,andmanyhavecompletedtheirofficialtraininginpursuitofasecondcareer(Sharf2008).MajorTherapeuticTechniquesandInterventionsBeforedescribingthemajortherapeutictechniquesandinterventionsofJung­iantherapy,weshouldnotethatJungwroteaboutfourmainstagesoftherapyinaflexibleandnotnecessarilysequentialorevenessentialway:confession,elucidation,education,andtransformation(seeDouglas2008,122–23).Inthefirststage,confession,theJungiantherapistlistensintentlytotheclientinawarm,accepting,andempathicwaysothattheclientcanopenup 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andfreelysharehisorherfeelingsandsecretsaswellasbasicconsciousandunconsciousmaterial.ItisatimeforcatharsisandreleaseofemotionsthatmayhavebeenJungianStagesofrepressedorblockedforsometime.TheclientisthereforeTherapyhelpedtofeelmorehumanagain.However,theclientmay(fromDouglasalsocometodependontheJungiantherapistandexperi2008,122–23)encesometransference.Inthesecondstage,elucidation,theJungiantherapist1.Confessioninterpretsthetransferencerelationshipbetweentheclient2.Elucidationandthetherapist.Thetherapistdoessoinordertohelpthe3.Educationclientgaininsight,bothintellectualandemotional,into4.Transformationthechildhoodoriginsoftheclient’stransferenceexperienceswiththetherapist;thisprocessissimilartotheapproachthataFreudianpsychoanalystwoulduse.DreamsandfantasiesarealsoexploredandinterpretedbytheJungiantherapistincollaborationwiththeclient.Inthethirdstage,education,theJungiantherapisthelpstheclienttobemoreconnectedtosociety,dealingmorewithhisorherpersonaandtasksthatareegorelated.FollowingaprocesssimilartothatofanAdleriantherapist,theJungiantherapistencouragestheclienttoengageinsociallyresponsiblebehaviorsthatareconstructiveandpositiveforhimorheraswellasforthesocialcommunity.Inthefinalstage,transformation,theJungiantherapistisevenmoredeeplyinvolvedinthetransference-countertransferencerelationshipwiththeclient,whoismotivatedtodelvemoreintoarchetypalmaterialfromhisorhercollectiveunconscious.Clientsinthisstageareofteninmidlifeorolder.ManyclientsinJungiantherapydonotprogresstothisfinalstageoftherapy.Theclientswhodoproceedtothetransformationstageusuallyexperiencedeeperself-actualizationorindividuationintoamoremature,balanced,andwholeuniqueperson,valuingbothconsciousandunconsciousexperiences.TheJungiantherapist’sownunconsciousexperience,especiallythroughhisorherowndreams,isoftencarefullybroughtintothetherapysessionstohelpclarifyandinterpretthetransference-countertransferencephenomenathatusuallyoccurinthetherapeuticrelationshipwiththeclientatthisstageoftherapy.Althoughthesefourstagesoftherapycanoverlaporevenoccurconcurrently,Jungbelievedthatacompleteanalysisortherapywillincludeallfourstages.However,thelengthofeachstageandtheorderinwhicheachstageoccursarenotfixed(Douglas2008).JungiantherapyusesdifferenttherapeutictechniquesdependingontheparticularJungiantherapistandhisorherprofessionalbackgroundandtraining.However,thefollowingarethemajortherapeutictechniquesorinterventionsinJungiantherapyusingananalyticalpsychologyapproach:analysisandinterpretationoftransferenceandcountertransference,dreamanalysis,andactiveimagination(Douglas2008).Sidebar6.2 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AnalysisandInterpretationofTransferenceandCountertransferenceTransferencereferstotheclient’sunconsciouslyprojectingortransferringaspectsofhimselforherselforsignificantothersontothetherapist.Countertransferencereferstothetherapist’sprojecting,orcountertransferring,unconsciousfeelingsontoaclient.BothtransferenceandcountertransferencephenomenathatoccurinthetherapeuticrelationshipbetweentheJungiantherapistandtheclientmustbeidentifiedandanalyzed.Doingsobenefitstheclient,whocanthenacknowledgeherownprojectionsortransferenceandgaininsightintoherownpersonalandcollectiveunconscious.AccordingtoJung,therearefourstagesoftheanalysisofthetransference.Thefirststageinvolvespointingouttheclient’sprojectionsofchildhoodorearlyrelationshipsandexperiencesontothetherapistasifthetherapistweretheproblematicfigurefromtheclient’spast.Theclientisthushelpedtoseeandacknowledgehisownprojections,toremovesuchprojectionsfromthetherapist,andtointegratethemmoreconsciouslyintohisownpersonality(Douglas2008).Inthesecondstage,theclientcomestorealizewhichprojectionsarefromhispersonalunconsciousandwhicharefromthecollectiveunconsciousandisenabledtostopsuchprojections.Inthethirdstage,theuniquepersonalityoftheJungiantherapistbecomesclearertotheclient,whocannowbegintorelatemorenormallytothetherapistasaperson.Inthefourthandfinalstage,theclientcontinuestoconnectwiththetherapistindeeperandhealthierwayswithanevenmoreaccurateperceptionofthetherapist,asthetransferenceisresolved.Theclientusuallyexperiencesmoreself-realizationandgreaterself-knowledgeinthisfinalstageoftheanalysisofthetransference.TheanalysisandinterpretationoftransferenceandcountertransferencephenomenainthetherapeuticrelationshipbetweentheJungiantherapistandtheclientarethereforeacrucialtherapeutictechniqueinJungiantherapy.DreamAnalysisAnothermajortherapeutictechniqueinJungiantherapy,similartoFreudianpsychoanalysis,istheanalysisorinterpretationofdreams.Jung,likeFreud,believedthatdreamsarecrucialpathwaysintotheunconscious,buthedidnotagreewithFreudthatdreamsareusuallyreflectionsofrepressedunconsciousmaterialorwishfulfillmentsthatcanbeinterpretedfollowingstandarddreamsymbols.Instead,Jungfeltthatdreamsshouldbeviewedassignificantreminderstoanindividualofwhatheorsheshouldbepayingattentionto.Dreamsthereforecanhaveavarietyofpossiblefunctions.Theymayreflectfearsandwishes,orexpresshidden,repressedimpulses,orleadtosolutionstoproblemsintheinternalorexternalworldoftheindividual.Theycanalsoserveaprospectivepurposeofhelpingpeopleanticipatetheirfutureandprepareforit,aswellasacompensatoryfunctioninhelpingpeopletobe 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morebalancedwithbetterintegrationofoppositesintheirpersonalities(seeCorey2009,80).DreamsanddreamanalysisarecrucialinJungiantherapyforthedeeperunderstandingoftheclient’sunconsciousinnerlifeandalsoforidentifyingchangesintheclient’spsyche,especiallyoverthecourseoftherapy(Douglas2008).Sinceclientsdonotallrememberorrecalltheirdreams,Jungiantherapistsusuallyasktheirclientstorecordtheirdreamsonpaperorwithataperecorderassoonaspossibleafterthedreamshaveoccurred.Asmuchdetailaspossibleaboutthedreamshouldberecorded.Jungdifferentiated“little”dreamsfrom“big”dreams.Littledreamsaremorecommon;theycomefromtheclient’spersonalunconsciousandoftenincludeelementsfromthedailyactivitiesoftheclient.Bigorsignificantdreams,however,usuallycontainimagesorsymbolsthatmaybefromthecollectiveunconscious.Suchbigdreamsareusuallyrememberedthroughoutthelifetimeofaparticularindividual(Sharf2008).ThestructureofdreamsaccordingtoJungusuallyincludesfourmainelements.Thefirstpartofthedreamencompassesbasicdescriptions,suchastheplace(andtime)ofthedream,themaincharactersinvolvedinthedream,andthedreamer’srelationshiptothesituationrecurringinthedream.Thesecondpartisthedream’splotanditsdevelopment,oftenincludingconflictsandtensions.Thethirdpartofthedreamusuallyinvolvesacriticalordecisiveeventthatleadstoasignificantchangeinthedream.Finally,thelastpartofthedreamconcernsasolutionorconclusion.Jungiantherapistswilllookforallfourpartsofadream,butasnotedearlier,clientsdonotalwaysrememberorrecallallaspectsorpartsoftheirdreams.Dreaminterpretationofpartialorfragmentarydreamsshouldbemorecautiouslyconductedthaninterpretationofdreamsthataremorefullyrecalled(Sharf2008).Indreamanalysisorinterpretation,theJungiantherapistusuallybeginsbyusinganobjectiveinterpretationinwhichthecharactersorobjectsinthedreamareviewedasactuallyrepresentingthemselves.However,thetherapistcanalsouseasubjectiveinterpretationofthedreaminwhicheachcharacterorobjectinthedreamisviewedasrepresentingaparticularpartoftheclient.Jungiantherapistsalsofindithelpfultoanalyzeseveraldreamstogether,connectingcurrentorlaterdreamstoearlierones,forclearerinterpretationofthepossiblemeaningsofthedreams(Sharf2008).Jungalsobelievedthatdreamscontainreligiousorspiritualmeaningsandhaveatranscendentsource(J. Sommers-FlanaganandSommers-Flanagan2004).Jungiantherapistsoftenfindthefollowingtypesofdreamstobeparticularlyhelpfulanduseful:theinitialdreamatornearthebeginningofJungiantherapy;recurrentdreamsthatoccurseveraltimes;dreamswithmaterialfromtheclient’sshadowsuchasthoseinvolvingviolence,rage,orimmoralbehavior;anddreamsthatinvolvethetherapistorthetherapy(whichmayreflecttheclient’sunconscioustransferencefeelingstowardthetherapist).Dreamscanalsobeabarriertoprogressintherapyiftheclientfillstheentiretherapyses- 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sionwithanoverloadofdreammaterial,becomesstuckinhisorherdreamworldratherthandealingwithreal-lifeissues,orresistsexpressinghisorheremotionalresponsestothedreams.TheJungiantherapistwillpointoutsuchdefensivebehaviorsonthepartoftheclientatanappropriatetimeandhelphimorherunderstandwhatisreallyhappening(Douglas2008).ActiveImaginationActiveimaginationisanothermajorJungiantherapeutictechnique.Itusesmeditativeimageryinwhichtheclientclearshisorhermindandthenfocusesintenselyonaparticularinnerimageorfigurethatmayhaveemergedfromadreamorsomeotherunconsciousmaterial.Theclientcontinuesthisactiveimaginationuntilheorsheisinvolvedinthesceneandbecomespartofwhatishappeningintheimagination.Aclientmusthaveastrongenoughegotoengageinsuchactiveimagination,whichattemptstodealwithunconsciousimagesinadirectandintenseway(Douglas2008).ThisJungiantherapeutictechniqueofactiveimaginationisthereforeaninterventionthatenablestheegoasthecenterofconsciousnesstoconnectwiththecollectiveunconscious(Sharf2008).OtherTechniquesJungiantherapistsmayalsouseseveralothertherapeutictechniquestofacilitateaclient’sintegrationofunconsciousprocessesintoconsciousness.Theyincludecreativeinterventionsortechniquessuchaspaintinganddrawing,poetry,anddanceandmovementtherapy;theempty-chairtechnique,oftenusedinGestalttherapy,inwhichaclienttalkstoanimaginedpersoninanunoccupiedchair;andthesandtrayconsistingofasandboxandsmallformsandfigurestowhichaclient(adultorchild)cangiveparticularmeanings(Sharf2008).JungiantherapistsalsopayattentiontoaconceptthatJungtermedsynchronicity,referringtocoincidencesorrandomeventsoccurringclosetogetherthatneverthelessleadtonewknowledgeorananswer.Thefollowingareexamplesofsynchronicity:premonitionsthatactuallycometrue,theclienthavingdreamsthatareverysimilartothetherapist’sdreams,andasolutionsuddenlyappearingtoavexingproblem(seeJ.Sommers-FlanaganandSommers-Flanagan2004, 124). JungianTherapyinPracticeAHypotheticalTranscript _Tan_Counseling_BB_mw.indd107 Client:I’vebeenhavingarecurrentdream. . .threetimesalreadyinthelasttwoweeks. . .andsoIthoughtIhadbetterbringitupinoursessiontoday. 9/21/104:35:05PM 94 MajorCounselingandPsychotherapyTheoriesandTechniques JungianTherapist:Tellmemoreaboutthedream.Itusuallyhassignificantmeaningforyouifit’soccurringsooften.Client:OK.Inthisrecurrentdream,thereisapriestwhoisveryprimandproperandwhocommandsgreatrespectfromhisparishioners,whoreallyappreciatehimandhiseloquentpreaching.However,asheispreachingoneofhissermonsfromthepulpit,hisheadsuddenlyturnsintoamonstrous-lookingface,fullofred-hotangerandrage,asifhewereabouttoburst.HethensuddenlystopspreachingfromtheBibleandinsteadspewsoutcursesandswearwordsathiscongregation,whoareshockedbyhisbehaviorandhorriblewords.Hethentakesoutamachinegunandshootsathisparishioners,butonlyevilandcursewordscomeoutofthegun. . .andsomeofhisparishionersactuallygetkilledbythewordslikebulletscomingoutinquicksuccessionfromhismachinegun.It’sahorribleandweirddreamthatI’vehadthreetimesalready.JungianTherapist:Um-hmm. . .Whodoyouthinkthepriestinyourdreammayrepresent?Client:Idon’tknow. . .maybeitcouldrepresentmesinceI’maprimandpropersortofguywhoisveryreligiousandconservative.Iamusuallyveryself-controlledandsoft-spokeninsocialsituations,andIholdhighmoralandethicalstandardsthatcenteronlovingGodandlovingpeople.JungianTherapist:Let’sjustassumethatthepriestinyourrecurrentdreamisyou,whatotherpartsofthedreammayhavemeaningforyou?Client:Well. . .I’mnotsurebutIfeellikemaybethemonstrouspartofthepriestfullofrageandanger,andcursesandswearwordsusedlikebulletstokillorhurtpeopleinthecongregationmaymeanthatthereisadarkersidetomypersonalitytoo . . .JungianTherapist:Adarkersidelike . . .Client:Well. . .likeadarker,hiddensideofmethatmayhavealotofangerandrage,thatwantstostrikeoutatallthenicepeopleouttherewhowantmetoalwaysbesoprimandproper.JungianTherapist:Doyouthinkthatyoudohavethisdarkerorshadowside?Client:Idogetangryonceinawhile,andIsensethepresence _Tan_Counseling_BB_mw.indd108 9/21/104:35:06PM JungianTherapy 95 ofsuchadarkerorshadowsideofmeatsuchtimes.ButI’mafraidofwhat’sinsidethatpartofme,soIquicklygetovermyoccasionalangerandtrytobeniceandself-controlledagain.JungianTherapist:Soyou’vebecomesomewhatawareofthislessattractivesideofyourpersonality.Doyouthinkyoumayneedtobemoreconnectedtoit,tobemoreawareofit,sothatyoucanintegrateitintoyourconsciousnessinamoreconstructivewayratherthandenyitorblockitoutorrunawayfromit?Client:YoumeanIshouldreflectonthisangrysideofmemoreandseewhatIcanlearnfromit?JungianTherapist:Itmaybehelpfulforyoutodojustthat.Onewayisforustotakealittlemoretimetoanalyzeyourrecurrentdreamandseewhatelseitmaymeantoyou.Whatelsecomestomind? ThishypotheticaltranscriptofasmallpartofaJungiantherapysessiondemonstratestheuseofdreamanalysisandinterpretationandempathicunderstandingbythetherapist,whoishelpingtheclienttounderstandhisrecurrentdreamandcometotermswithhisshadow,whichisexpressingrageandangerinthedream.CritiqueofJungianTherapy:StrengthsandWeaknessesJung’sanalyticalpsychologyapproachtounderstandingthehumanpersonalityandconductingtherapywithclientsisinsomewayssimilartoFreud’spsychoanalyticapproach,forexample,inemphasizingtheunconsciousandthecrucialroleofdreamsanddreamanalysisinconnectingwiththeunconscious.However,Jung’suniquecontributionishisideaofthecollectiveunconsciousandthearchetypalimagescontainedinit,whichareuniversalandtranscendculture.Histheoryofpersonalityisquitecomprehensive,andJungtouchedonawidevarietyofotherareassuchascreativity,education,marriage,religion,andeventheoccult(Ryckman2008).Hiscontributionshaveinfluencednotonlythefieldofpsychologybutalsootherdisciplines,suchasliterature,art,history,philosophy,andmetaphysics,withperhapsevenmoresignificantimpact(ToddandBohart2006).Jungmadeanothersignificantcontributionwithhisdescriptionofpsychologicalorpersonalitytypes,whichhasbeenpopularizedbythewidelyusedMyers-BriggsTypeIndicator(MBTI),althoughtherearesomemethodologicalproblemsorlimitationswiththisinstrument(seeR. B.Johnson1999).Nevertheless,Jung’sdelineationofthebasicpersonalityattitudesofextraversionandintroversion,andofthemainpersonalityfunctionsofthinking- 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feelingandsensing-intuiting,isahelpfulwayofunderstandingpersonalityfunctioning.AthirdstrengthoftheJungianapproachisthefocusonmidlifeandthesearchformeaninginlifethatacknowledgestheimportanceofreligiousandspiritualaspectsandexperiences.AfourthstrengthisJung’semphasisonthetremendouswisdomandpotentialcontainedintheunconscious,whichenableanindividualtocontinuetogrowthroughouthisorherlifebyconnectingtheunconscious,bothpersonalandcollective,withtheconscious.Jung’sviewoftheunconsciousisthereforemorehopefulandpositivethanFreud’s(J.Sommers-FlanaganandSommers-Flanagan2004).AnotherstrengthisJung’sfocusontheneedtointegratethedarkersideofhumanpersonalitysothatanindividualcangrowintoamorematureandbalancedperson.Jungdidnotdenythepotentialforevilanddestructivetendencies,especiallyintheshadowofeachperson.However,hebelievedthatacknowledgingandacceptingsuchadarker,shadowpartofone’spersonalitywithoutyieldingtoitwillhelpapersontobemorewholeandbalanced.Finally,Jungiantherapyalsodevelopedseveralusefultherapeutictechniquessuchasanalysisofthetransferenceandcountertransferenceinthecontextofamoremutuallyrespectfulandwarmtherapeuticrelationship,dreamanalysisinauniquewaythatincludedpayingattentiontoboththepersonalandthecollectiveunconsciousanditsarchetypes,andactiveimaginationandothercreativeinterventions.SomeofthesetechniquesareusednotonlybyJungiantherapistsbutalsobyothercounselorsandpsychotherapistspracticingfromothertheoreticalapproachestotherapy.Thereare,however,severalweaknessesinJungiantheoryandtherapy.First,Jung’sideaofthecollectiveunconsciousandhisbeliefthatitsarchetypesareuniversalandtranspersonalhavebeencriticizedassomewhatmysticalandfuzzy,withconfusingdescriptions.Itisalsoalmostimpossibletooperationalizethecollectiveunconsciousandtosubjectittoempiricalverification.However,recentresearchintheareasofneurobiologyandcognitivesciencehasledsomecognitivepsychologiststoconcludethatinbornorinnatewaysoforganizinginformationmayexist,similartoJung’sideaofarchetypesthatareuniversaltoallhumanbeings(ToddandBohart2006;seealsoStevens1982;andBrowningandCooper2004).Hisfocusontheunconscious,bothpersonalandcollective,isneverthelessanintrapsychiconethattendstopayinsufficientattentiontobiologicalandsocioculturalfactorsthatcanalsoaffectanindividual’spsychologicalfunctioninganddysfunctioning.Second,thepsychologicalorpersonalitytypesdescribedbyJunghavebeenpopularizedtosuchanextentthattheymaybeusedtoerroneouslylabelorcategorizeindividualsasoversimplifiedpersonalitytypes.Therehasthereforebeensomeresistancefromthepsychologicalcommunity,includingmany 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Jung­iantherapists,totheinappropriateusesofmeasuresofpersonalitytypes,suchastheMBTI.Third,althoughJung’sfocusonmidlifeandthesearchformeaning,includingreligiousandspiritualaspectsandexperiences,isagoodcorrectivetoFreud’santireligiousstance,Jungisstillsomewhatbiasedagainstdogmaandreligiousbeliefsthatseemtobemorecerebralorcognitiveandnotexperientialinnature.(Thismayhavebeenpartlyareactiontohisfather’saridanddryformofreligiousbelief.)Fourth,Jung’semphasisonbecomingawareandacceptingofthedarker,shadowsideofone’spersonalityinordertogrowinwisdomandmaturebalancemaybesomewhatnaive.Althoughheacknowledgedtherealityofevil,hedidnotdealadequatelywiththefullnatureandmeaningofevilandhowtoovercomeit.Fifth,someofthetherapeutictechniquesofJungiantherapymustbeusedwithgreatclinicalandethicalcaution.Forexample,theuseofactiveimaginationanddeeperanalysisofdreams,whichcanbeespeciallyfrighteningordisturbing,maynotbeappropriatewithclientswhomayhavefragileegosorwhomaybeprepsychotic.Jungwasawareofthisdanger,however,andherefrainedfromusingsuchtechniqueswithmoreseverelydisturbedclients.Dreamsmayalsonotalwaysbethepathwaytotheunconscious,andtheycansometimesbeoverinterpreted,withspuriousormisleadingmeaningsimposedonthem.Finally,becauseJungiantherapyisacomplex,intense,usuallylong-termapproachtohelpingclients,thereislittleempiricalevaluationintermsofcontrolledoutcomestudiesofitstherapeuticefficacyoreffectiveness.ABiblicalPerspectiveonJungianTherapySeveralstrengthsandweaknessesofJungiantheoryandtherapyhavealreadybeennoted.Fromabiblicalperspective,Jung’sattemptstounderstandthedepthsofaperson’spsycheor“soul,”acknowledgingboththetremendouswisdomandthepotentialresidinginone’spersonalandcollectiveunconsciousaswellasinthedarker,shadowsideofhumanpersonality,whichiscapableofevilanddestructivetendencies,aremorebalancedthanFreud’s.Theyarealsosomewhatconsistentwiththebiblicalviewofhumankindasfallenandsinful(Jer.17:9;Rom.3:23)yetcreatedintheimageofGod(Gen.1:26–27).However,Jung’sconceptualizationofevilisinadequate,withanambivalenttheoryofevilthatcanbeconfusing(BrowningandCooper2004).HedoesnotultimatelyseethefullextentandsubstanceofevilandtheneedtoovercomeitortheneedforredemptionfromsinandevilthroughthesavingworkofChrist.Jungemphasizedtheneedtobecomeawareofandtoacceptthedarker,shadowsideofone’spersonality,asifthiswereenoughtodealwitheviltendencies.Toacknowledgesinfultendenciesdeepwithinone’sbeing,however,isonlythe 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firststepindealingwithevil.OtheressentialstepsincludeturningtoChristforredemptionandcleansingandtotheHolySpiritforpowertoovercomesinandevilwiththegoodnessandgraceofGod,inwhomthereisnoevil,contrarytowhatJungbelievedaboutGodbeingamoralorhavingpotentialitiesforbothgoodandevil,likeahumanbeing(BrowningandCooper2004;seealsoS. L.JonesandButman1991).Therealityoftheevilone,thedevilasourarchenemy,andspiritualwarfare(Eph.6:10–18)alsoneedtobeemphasizedinamorebiblicalandfullerperspectiveonevil.TheJungianperspectivecanthereforebetoooptimisticandpositiveabouthumannature.Jung’sviewsontheimportanceofdreamsandhowtheycanbereligiousmessagesfromatranscendentsourcebeyondtheindividualhavebeenwellreceivedbysomeChristiantherapistsandclergywhoalsoseedreamsaspossiblemessagesfromGod.ThereareseveralexamplesinScriptureofhowGodspoketopeoplethroughdreams,butdreamscanbeoverinterpretedandarenotnecessarilythechiefwaythatGodspeakstopeople.AlthoughJungusesreligiousandspirituallanguageandsymbols,hedoesnotseemtobelieveinapersonalTriuneGodandinthehistoricityofthedeathandresurrectionofJesusChristtosaveandtransformsinfulhumanbeings(S. L.JonesandButman1991).Jung’sanalyticalpsychologycomesclosetobeingareligionitself,butwithagnosticapproachemphasizingtheneedtoknowoneselfandone’spersonalandcollectiveunconsciousthroughamysticalarchetypalforcethatguidesonetobecomeauniqueperson.AsPaulVitzhasobserved:“Thisgoalofself-realizationorself-actualizationisatheartaGnosticone,inwhichthecommandment‘knowandexpressthyself’hasreplacedtheJudeo-Christiancommandment‘LoveGodandothers.’(Inmanyrespects,allmodernpsychologyofwhatevertheoreticalpersuasion,becauseoftheemphasisonspecial,somewhatesotericknowledge,canbeinterpretedaspartofavastGnosticheresy.)”(1994, 3).ImplicitintheJungianideaofself-realizationisanoptimisticrelianceontheindividual’sabilitytoengageinsuchindividuation(normallywiththehelpofaJungiantherapist),leadingtowhatBrowningandCooperhavecalled“ethicalegoism”(2004,150),anethicthatfallsshortoftheChristianethicoflovingGodandothers.Jungcanthereforebeviewed“asaparticularlycomplexexampleof. . .thepsychologicalcultureofjoy”(2004,151).Jung’sfocusonreligiousandspiritualexperience,includingmysticalexperienceratherthanaridanddrydogmaticbeliefs,isanotherareaforconcernfromabiblicalperspective.Jungiswellknownforastatementhemadein1961,shortlybeforehedied:“SuddenlyIunderstoodthatGodwas,formeatleast,oneofthemostcertainandimmediateexperiences. . . .Idonotbelieve;Iknow.Iknow”(seeKelsey1972,119,quotedinHurding1985,80).ItisdifficulttointerpretaccuratelywhatJungreallymeantbythisstatement.ExperiencingGod,basedonwhatweknowofhimthroughScripture,involvesencounteringareal,personalGodwhoisthere.ThisisnotthesameaspsychologicalexperiencesofanideaofGodthatisinourcollectiveunconsciousasanarchetypal 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image.CautionisneededinusingsomeJungianconceptsbecausetheymaynotbebiblicallyconsistenteveniftheysoundfamiliar.Ontheotherhand,RogerHurding(1985,357)haspointedoutthattheJung­ianapproachcanchallengeChristianstotakemoreseriouslytheChristianmysticaltradition,whichemphasizesdevotionalpractice(e.g.,contemplationandmeditation)andgodlinessoflife.ThistraditioncanhelpusknowGodinamoreexperientialway,butonestillbasedonScripture,intheinnerjourneyofourlives.HurdingespeciallyreviewedandcritiquedthewritingsofChristopherBryant,WilliamJohnston,andMortonKelsey,whoattemptedtointegrateJungianpsychologywiththeChristianmysticaltradition(seeHurding1985,334–60).Jungiantherapy,however,doeshavesomenoteworthyaspectsthatChristiansandChristiantherapistscanappreciate:theuseofawarmandempathictherapeuticrelationshipthatismutualandcollaborative;theseriousfocusondreamsanddreamanalysisinordertoconnectdeeperunconsciousmaterialtoone’sconsciousness,includinghonestlyfacingone’sdarker,shadowside;andtheexplorationofreligiousandspiritualexperiencesandthesearchformeaninginlife(especiallyatmidlifeandafter)thatcomesclosetotheprocessofspiritualdirection.However,Jung’sdelvingintotheoccultandEasternmysticismcanbepotentiallydangerousbecausesomeChristiansviewthisasdelvingintothedemonicandspirituallyevilrealm.OneconclusionwithregardtoabiblicalChristianperspectiveonJungiantheoryandtherapyisthefollowingsomewhatcriticalstatementprovidedbyJonesandButman:“C. G.Jungwasaprolificandcreativethinkerwithfewequalsinthiscentury. . . .Butwhiletheissuesheraisedandquestionsheaskedarevital,theanswersJunggeneratedareofdeepconcern. . . .AndthepsychologyofJung,withitsdeeplyflawedunderstandingofourreligiousnatureandthemostfundamentalreligioustruths,wouldbeapoorguideonthatinnerjourney”(1991,139–40).However,morerecently,Ann B.UlanovandAlvinDueck(2008)haveprovidedamorenuancedandappreciativeperspectiveonwhatChristianscanlearnfromCarlJung.Research:EmpiricalStatusofJungianTherapySomeofJung’stheoreticalideassuchaspsychologicalorpersonalitytypes,especiallyasmeasuredbytheMBTI,andhistheoryofdreamshavereceivedsomeempiricalsupport(seeRyckman2008,94–96;Sharf2008,103–4;andDouglas2008,127–28,forsummariesoftheresearchliterature).However,theevaluationoftheeffectivenessofJungiantherapyhasconsistedmostlyofclinicalcasestudies,usuallysinglecasestudiesusingclinicalobservationofaclientoverthecourseofJungiantherapy(Douglas2008).RandomizedcontrolledoutcomestudiesevaluatingtheefficacyofJungiantherapyarelackingatthistime.NodefinitiveconclusionscanthereforebepresentlymaderegardingtheeffectivenessofJungiantherapy. 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ItisparticularlydifficulttoconductcontrolledoutcomestudiesofJungiantherapybecausetherearerelativelyfewclinicianswhodescribethemselvesassolelyJungiantherapistsoranalysts.However,someoutcomeresearchevaluatingtheefficacyoflong-termJungiantherapyisbeingundertakenattheJungInstituteinSwitzerlandinastudysponsoredbytheSwissSocietyofAnalyticalPsychology.FurtherdetailsofthisresearchprojectcanbeobtainedattheJungInstituteWebsite(www.jung.edu)(seeJ. Sommers-FlanaganandSommers-Flanagan2004, 132).FutureDirectionsSomeauthorsoftextbooksinthefieldofcounselingandpsychotherapyhaverecentlyreducedorleftoutdetailedcoverageofJungiantheoryandtherapybecauseofanapparentdecreaseininterestinJungiantherapy(see,e.g.,Corey2009;Day2004;Fall,Holden,andMarquis2004;Parrott2003;ProchaskaandNorcross2010).Jungwasespeciallypopularinthe1950sand1960s,butinterestinJungandJungiantherapyseemstohavesignificantlydecreased;lessthan1percentofpsychotherapistsintheUnitedStateshaveidentifiedthemselvesasJungiansinrecentsurveysconducted(seeProchaskaandNorcross2010, 61).However,otherauthorshavereachedquitedifferentconclusionsconcerningthecurrentstatusandfuturedirectionsofJungiantherapy.ClaireDouglas,whoisaJungiananalystherselfinindependentpracticeinMalibu,California,hasrecentlydescribedthegrowthofJungiantherapyandtheapparentincreaseininterestinJung’sanalyticalpsychologyapproach.ShenotedthattheInternationalAssociationforAnalyticalPsychology(www.iaap.org)hadmorethan2,860certifiedanalystmembersin28countries,57professionalsocietiesincluding19intheUnitedStates,and19developinggroups,accordingto2006statistics.SeveralprofessionaljournalsfocusonJungiantheoryandtherapy,includingthewell-knownBritishJournalofAnalyticalPsychology(Douglas2008,113).ThereisalsotheSocietyofAnalyticalPsychology(www.Jungian-analysis.org).TraininginJungiananalysisisrigorous,requiringsixtoeightyearsontheaveragebeforeatherapistcanbeformallycertifiedasaJungiananalyst.Anessentialandrequiredpartofthetrainingisthepersonalortraininganalysisofthetherapist,whichusuallylastsmanyyears,ofteninvolvingworkwithtwodifferentJungiananalysts.OtherrequirementsintheformaltrainingleadingtocertificationasaJungiananalystintheUnitedStatesusuallyincludefouryearsofcourseworkorseminarsinclinicaltheoryandpracticefromJungianaswellasneo-Freudianperspectives,archetypalpsychology,anddreamanalysis;personalinterviews;oralandwrittenexaminations;andaclinicaldissertation(Douglas2008,113–14).Douglas(2008,114)alsodescribesexcitingcurrentandfuturedevelopmentsinJungiantheoryandtherapy,includingintegratingobjectrelations 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psychologywithJungiananalyticalpsychologyandintegratingmoremulticulturalandfeministperspectiveswithJungiantheoryandtherapy.However,shealsonotesthatmore-conservativeJungiansarereactingtosomeofthesecontemporarydevelopmentswithabacklash,assertingthatJung’soriginalviewsshouldbepreservedandnotdilutedandreinterpretedinwaysthathemightnotagreewithtoday.Inasimilarvein,Sharf(2008,101–2)notesthatinadditiontoJung’sideasbeingpopularizedwiththeAmericanpublicrecentlythroughthepublicationofcertainbooksandthebroadcastoftelevisionseriesfocusingonmyth,Jung’scollectiveunconscious,andarchetypes,twoothersignificantinfluencesareimpactingthecurrentandfuturedevelopmentofJungiantherapy:postmodernperspectivesandpost-Jungianviews.Jungiantheoryandtherapy,therefore,seemtobedoingwellenoughandmayactuallybegrowingininfluence.DouglashasnotedagrowingnumberoftherapistswhohavenotundergonetherigoroustrainingrequiredtobecomeacertifiedJungiananalyst,butwhoneverthelessconsiderthemselvestobe“Jungian-orientedtherapists”(2008, 113),althoughtheyarenotJungiananalysts.Surveysshowingthatlessthan1percentoftherapistsidentifythemselvesasJungiansthusmaybesomewhatmisleadingbecausethetherapistsparticipatinginthesurveysmaybeinterpreting“Jungian”inthestrictsensetomeanJungiananalysts,ratherthanmorebroadlytoincludeJungian-orientedtherapists.TheactualnumberofcounselorsandclinicianswhopracticeasJungian-orientedtherapistsmaythereforebegreaterthanthesesurveysindicate.TheempiricalsupportfortheeffectivenessofJungiantherapy,however,isstilllacking.Additionalresearchisneededbeforemore-definitiveconclusionscanbereachedregardingthetherapeuticoutcomesandefficacyofJungiantherapy.ItisencouragingtoknowthatsuchresearchiscurrentlybeingconductedattheJungInstituteinSwitzerland.RecommendedReadingsInadditiontoJung’sowncollectedworks(atotaloftwenty-twovolumespublishedbyPrincetonUniversityPress),thefollowingbooksarerecommendedforfurtherreading:Bair, D.(2003).Jung:Abiography.Boston:Little,Brown.Harris,A. S.(1996).Livingwithparadox:AnintroductiontoJungianpsychology.Albany,NY:Brooks/Cole.Jung,C. G.(1961).Memories,dreams,reflections.NewYork:RandomHouse.Papadopolous, R.(Ed.).(2006).ThehandbookofJungianpsychology.NewYork:Routledge.Storr, A.(1983).TheessentialJung.Princeton,NJ:PrincetonUniversityPress. _Tan_Counseling_BB_mw.indd115 9/21/104:35:12PM 7ExistentialTherapy E xistentialtherapyisreallymoreaphilosophicalattitudeorapproachincounselingratherthanaparticularschooloftherapywithspecifictechniques,althoughsometherapeuticinterventionshavebeendevelopedandusedbyexistentialtherapists.Existentialtherapyisthereforenotaunitaryapproach,anditwouldbemorecorrecttodescribethisapproachasconsistingofseveralexistentialpsychotherapies(R. A.WalshandMcElwain2002).Nevertheless,theterm“existentialtherapy”willbeusedinthischaptertorefertocounselingandtherapyapproachesthatarebasedonexistentialphilosophy.Existentialtherapyfocusesonhelpingclientsexperiencetheirexistenceinanauthentic,meaningful,andresponsibleway.Itisbasedonanexistentialphilosophythatviewshumanbeingsashavingfreedomaswellasresponsibilitytochooseinordertocreatemeaningintheirlives.Althoughpeoplemayhavesomelimitingcircumstancestodealwithintheirparticularlifecontexts,theystillhavethefreedomtochoosehowtheywanttohandletheirownlifesituation.Crucialissuesthateveryhumanbeingmustultimatelydealwithincludedeathandmortality,freedom,meaninglessnessoremptiness,isolation,andtheneedtoberealandauthenticinchoosingone’sapproachandvaluesinlifeinaresponsibleway.Existentialtherapyemphasizesthetherapeuticrelationshipandauthenticencounterbetweentheexistentialtherapistandtheclientmorethantherapeutictechniques.Existentialtherapistsvaryintheirbasicviewofhumannature,rangingfromoptimistictopessimistic,toevennihilistic,andtheyinclude102 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religiousaswellasantireligiousadherents.TheapSidebar7.1proachofexistentialtherapyhasbeenstronglyinfluencedbyseveralnineteenth-andtwentieth-centuryImportantFiguresinphilosophersandthinkers,includingSørenKierkeExistentialTherapygaard(1813–55),aDanishphilosopherwhowroteaboutangst,ordreadandanxiety;FriedrichNietz1.LudwigBinswangersche(1844–1900),aGermanphilosopherwhowrote2.MedardBossaboutsubjectivityandthe“willtopower”neededto3.ViktorFranklmaximizethehumanpotentialfororiginalityandcre4.RolloMayativity;MartinHeidegger(1889–1976),aphilosopher5.JamesBugentalandkeyfigureinthedevelopmentofphenomenology6.IrvinYalomorphenomenologicalexistentialism,whichfocusesonauthenticlivingandchoosingtolivewiselyanddeeplyeachday;Jean-PaulSartre(1905–80),aFrenchphilosopherandnovelistwhoemphasizedevenmoretheradicalfreedomthateachhumanbeinghasinchoosinghisorherownvaluesandhisorherownperson,nomatterwhatone’spastmayhavebeen;andMartinBuber(1878–1965),atheologianwhoemphasizeddialogicalconversationinan“IThou”authenticpersonalrelationshipwiththerealpresenceofthetwopeopleinvolvedinsucharelationship(seeCorey2009,134–36).OtherimportanttheologicalphilosophersfromanexistentialperspectivebesidesBuberincludeGabrielMarcel(1889–1973),aCatholictheologianwhoemphasizedtrust,andPaulTillich(1886–1965),aProtestanttheologianwhofocusedoncourage.EdmundHusserl(1859–1938)andKarlJaspers(1883–1969),twootherexistentialphilosophers,andseveralplaywrightsandnovelists,includingFyodorDostoyevsky,AlbertCamus,andFranzKafka,alsoinfluencedthedevelopmentofexistentialtherapy.Theviewsofthetheologicalphilosopherstendtobemoreoptimistic,whereastheviewsoftheexistentialwritersaregenerallymorepessimisticandsometimesevennihilistic(pointingtotheultimatemeaninglessnessornothingnessoflife)(seeSharf2008,147–49;seealsoVanDuerzenandKenward2005).BiographicalSketchesofOriginatorsandImportantFiguresinExistentialTherapyWewillnowbrieflyexaminethelivesofseveraloriginatorsandimportantfiguresinexistentialtherapy:LudwigBinswanger,MedardBoss,ViktorFrankl,RolloMay,JamesBugental,andIrvinYalom(seeCorey2009,132–33,136–39;Sharf2008,149–51).LudwigBinswanger(1881–1966)wasaSwisspsychiatristwhobecameanexistentialanalyst.InitiallyexposedtoFreud’sviewsoninstinctualdrivesandmotives,hewasultimatelymoreinfluencedbyHeidegger’s(1962)phenomenologicalexistentialism.Binswangeremphasizedtheindividual’sfreedom 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tochooseandabilitytoperceivemeaninginhisorherownlife.AccordingtoBinswanger,existentialanalysisfocusesonthespiritualandsubjectiveaspectsofhumanlifeandexistenceandregardscrisesintherapyassignificanttimesfortheclienttomakecrucialchoices(Binswanger1963).BinswangerbecamethechiefmedicaldirectoroftheSanitariumBellevueinKreulinger,Switzerland,in1911,followinginhisfather’sfootsteps,andhebeganusinghisexistentialtherapyideasthere.Healsocompletedaninternshipunderthewell-knownpsychiatristEugenBleuleranddevelopedadeep,lifelonginterestinstudyingtheexistentialdimensionsofpatientssufferingfromsignificantpsychologicaldisorders.Heretiredin1956butcontinuedhisworkuntilhisdeath,attheageofeighty-five,in1966(seeProchaskaandNorcross2010,95–96).MedardBoss(1903–91),anotherSwisspsychiatrist,wasoriginallytrainedinpsychoanalysisandwasanalyzedbyFreudhimself.HealsotrainedunderEugenBleuler.However,likeBinswanger,BosswaseventuallygreatlyinfluencedbyHeidegger’s(1962)existentialideas.BossattemptedtointegrateexistentialismwithpsychoanalysiswhenhewroteDaseinanalysisandPsychoanalysis(1963).BossservedformanyyearsasaprofessorofpsychoanalysisinthemedicalschoolattheUniversityofZurich,whichisstillthecenterinEuropeofDaseinanalysis,theexistentialanalysisthatwasdevelopedbyBoss.Hediedin1991,attheageofeighty-eight(seeProchaskaandNorcross2010, 96).BothBinswangerandBosswereearlyoriginatorsofexistentialtherapyandexistentialanalysis.Twootherkeyfigureshelpeddevelopexistentialtherapyasweknowittoday:ViktorFranklandRolloMay.ViktorFranklwasthefounderoflogotherapy,anexistentialtherapythatliterallymeans“therapythroughmeaning,”focusingonanindividual’swilltomeaningorsearchformeaninginlifeasthemostfundamentalofhumanmotivations.Franklwasbornin1905inViennaandwaseducatedattheUniversityofVienna,whereheearnedhismedicaldegreein1930andhisPhDinphilosophyin1949.HetaughtattheUniversityofViennaandwasalsoavisitingprofessoratseveralAmericanuniversities,includingHarvardandStanford.Franklisrenownedforhisbest-sellingandwidelyreadbookMan’sSearchforMeaning(1963).HedescribedhispersonalexperiencesduringWorldWar IIasaprisonerintheNaziconcentrationcampsatAuschwitzandDachaufrom1942to1945.Manyofhisfamilymembersdiedinthecamps,includinghiswifeandchildrenandhisparentsandbrother.Throughhisownsufferingandexperiences,hecametohisexistentialconclusionsthatloveisthehighestaspirationanyhumanbeingcanhave,thatfreedomtochooseone’sattitudesandvaluescanneverbetakenawayfromanindividualevenundertheworstcircumstances,thatthesearchformeaningisthemostfundamentalofhumanmotivations,andthatmeaningcanbediscoveredbyexperiencingvaluessuchasloveorsignificantworkorbyenduringsuffering. _Tan_Counseling_BB_mw.indd118 9/21/104:35:15PM ExistentialTherapy 105 FranklwasexposedtoFreudandhispsychoanalyticviewsbutrejectedFreud’sdeterministicideasinfavorofmore-existentialperspectivesemphasizingfreedom,choice,meaning,andresponsibility.Hiswritingsarenowavailableinovertwentylanguages,andhislogotherapyapproachhasbecomeasignificantpartofcontemporaryexistentialtherapy.Hisimpactonthefieldofcounselingandpsychotherapyhasbeensosubstantialthathehasbeencalledthefounderofthe“ThirdSchoolofViennesePsychoanalysis”(seeCorey2009, 132;andFrankl1997;seealsoGould1993).Franklalsodevelopedseveraltherapeutictechniquesinlogotherapy,suchasdereflection(encouragingtheclienttoignoretheproblemandfocusattentiononsomethingmorepleasantorpositive)andparadoxicalintention(askingtheclienttodoorexaggeratetheparticularbehaviorheorshefearsdoing),althoughexistentialtherapyonthewholedoesnotemphasizetherapytechniques.Frankldiedin1997.Someauthors(e.g.,Sharf2008)considerFrankloneoftheoriginatorsofexistentialtherapy,togetherwithBinswangerandBoss.RolloMayisusuallyconsideredthebest-knowncontemporaryauthorandadvocateofexistentialtherapy(Sharf2008),althoughheissometimesalsodescribedasanearlyexistentialtherapisttogetherwithBinswangerandBoss(ProchaskaandNorcross2010).Maywasbornin1909inAda,Ohio,butwhenhewasstillayoungchildhisparentsmovedthefamilytoMichigan.Maydescribedhischildhoodasanunhappyone,althoughhisparentsfavoredhim,astheoldestchild,overhissisterandfivebrothers.Theparentswereapparentlyverystrictandauthoritarian,andtherewerefrequentmaritalconflictsathome.Hisfatherwasoftenawayonbusinesstrips,andhismothersufferedfromdepressionandloneliness.Mayhadhisownexistentialstrugglesinlifeandexperiencedtwomarriagefailures.MayattendedOberlinCollege,wherehemajoredinEnglishwithaminorinGreekhistoryandliterature,andgraduatedwithaBAdegreein1930.HethenwenttoGreecetoteachforthreeyears.HevisitedViennaduringthesummersandstudiedunderAlfredAdlerinseminarsthatAdlerconducted.HecamebacktotheUnitedStatesafterhisteachingexperienceinGreeceandenteredUnionTheologicalSeminaryinNewYork.Aftertakingayearofftohelpsupporthisyoungersiblingsfollowinghisparents’divorce,heresumedhisstudiesatUnion,wherehewasgreatlyinfluencedbyPaulTillich,aProtestanttheologianwhobecameafriendandmentortoMay.TillichintroducedhimtotheexistentialviewsofKierkegaardandHeidegger,whichhadaprofoundimpactonMay.In1938hegraduatedcumlaudefromUnionwithabachelorofdivinitydegreeandthenspenttwoyearsasapastorinVerona,NewJersey.Itwasadisappointingexperienceforhim,however,andheeventuallyenteredadoctoralprograminclinicalpsychologyatColumbiaUniversity(seeParrott2003,148–49).Whileworkingonhisdoctorate,Maycontractedtuberculosis.Duringhistwo-yearstayinasanitariuminupstateNewYork,hehadtofacehisown 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existentialanxietyovermortalityandpossibledeath.HereadthewritingsofKierkegaard,whichinfluencedhissubsequentdevelopmentofanexistentialapproachtotherapy,includingwritinghiswell-knownbookbasedonhisdoctoraldissertation,TheMeaningofAnxiety(1950).HeobtainedhisPhDfromColumbiain1949.Mayemphasizedthatanxietyiscrucialtohumanexistenceandshouldnotalwaysbeviewedasabnormalorpathological.Healsofocusedonhelpingclientsfindmeaningastheylearnedtodealwiththeproblemsofbeingandexistenceratherthansimplytryingtosolveproblemsanddifficultiesintheirlives.Examplesofproblemsofbeingincludeissuessuchasaging,dealingwithdeathandmortality,andsexandintimacy(Corey2009, 133).Hedidnotdevelopasystemorschoolofexistentialtherapyassuch,butdescribedanexistentialperspectiveorattitudeinconductingtherapythatwouldbelabeledasexistentialtherapytoday.Afterhisrecoveryfromtuberculosis,Maycontinuedwriting,teaching,andpracticingtherapy.Hewasavisitingprofessoratseveraluniversities,includingHarvard,Princeton,andYale,andpublishedseveralwidelyreadbooksonexistentialpsychologyandtherapy.Healsoreceivednumerousawardsandhonorsforhissignificantcontributionstopsychology.HediedinOctober1994ofcongestiveheartfailureinhishomeinTiburon,California,attheageofeighty-five(seeRyckman2008,475–77;seealsoAbzug1996;DeCarvalho1996).Afewotherimportantfiguresincontemporaryexistentialtherapyshouldbementioned.JamesBugentalhasdevelopedanapproachtoexistentialtherapythatfocusesontheimmediatehere-and-nowexperiencesduringthetherapysessionitself(Bugental1999)inordertohelpclientsincreasetheirself-awarenessandcapacitytoself-actualize.Bugentalalsofavorsahumanisticemphasisonlivingwithauthenticityandintegrityforeachpersonaccordingtohisorherownchosenanswerstolife’sexistentialquestions(seeBugental1987).CommonexistentialthemesengagedbyBugentalincludechange,contingency,responsibility,andrelinquishment(seeSharf2008,151).IrvinYalomisanotherkeyfigureinexistentialtherapytodayandhasdescribedperhapsthemostsystematicandcomprehensiveapproachtoexistentialtherapytodateinhisclassictext,ExistentialPsychotherapy(1980).Heintegratestheexistentialviewsofseveralphilosophers,theologians,andtherapists,suchasKierkegaard,Nietzsche,Heidegger,Sartre,Buber,andFrankl.Yalom’sapproachtoexistentialtherapyspecificallyfocusesonfourultimatehumanconcerns:death,freedom,isolation,andmeaninglessness.Hehasalsopublishedseveraldetailedcasestudiesonhisapproachtoexistentialtherapy(seeYalom1989,1999),andcoauthoredatextongrouppsychotherapy(YalomandLeszcz2005).Mostrecently,hehaswrittenabookonovercomingtheterrorofdeathfromanexistentialperspective(Yalom2008).TwoBritishexistentialtherapistswhohavealsohadanimpactonthedevelopmentofcontemporaryexistentialtherapyareR. D.Laing(seeLaing1959, 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1961),andEmmyVanDuerzen(formerlyVanDuerzen-Smith)(seeVanDuerzen2001;VanDuerzenandKenward2005;VanDuerzen-Smith1990,1997,1998).LaingcreatedatherapeuticcommunityforverydisturbedpsychoticpatientsinEngland,usinganexistentialapproachthatshoweddeeprespectforthepatients(M. Cooper2003).VanDuerzenhasbeeninstrumentalindevelopingastronginterestinexistentialtherapyinEngland,fosteringwhatisknownastheBritishSchoolofExistentialPsychotherapy(seeSharf2008,151).ShealsofoundedtheSocietyforExistentialAnalysisin1988inEngland.Thusexistentialtherapyisnotaunitaryschoolorsystemofcounselingandpsychotherapybutratheraphilosophicalapproachtotherapybasedonexistentialismanditsdifferentvarieties.However,therearestillsomecommonalitiesacrossthediverseexistentialperspectives,whichwillnowbediscussed.MajorTheoreticalIdeasofExistentialTherapyPerspectiveonHumanNatureExistentialtherapistsareadiversegroupwithdifferentperspectivesonhumannature,dependingontheirparticularversionofexistentialism.Therearereligious,atheistic,andantireligiousexistentialistswhomayviewhumannaturemorepositivelywithsomeoptimismandhope,ormorenegatively,focusinginsteadonmeaninglessness,emptiness,nothingness,anddespair(seeParrott2003,152).Nevertheless,theexistentialapproachemphasizesthefreedomthateveryhumanbeinghastochoosehisorherownvaluesandmeaninginlife.Basicorfoundationalexistentialquestionsthateveryindividualmusteventuallyfaceandanswerinclude“WherehaveIcomefrom?WhyamIhere?WhereamIgoing?WhatdoIvalue?”(MendelowitzandSchneider2008, 299).Existentialtherapydoesnothaveafixedviewofhumannature.Eachindividualisconstantlychangingandevolvinginbecomingwhoeverheorshechoosestobe.Althoughexperiencesandfutureaspirationsandgoalshavesomeinfluenceandeffectontheperson,presentawarenessismorecrucialinchoosingfreelyandresponsiblywhoeachindividualisbeingorbecoming,accordingtohisorherownvaluesandmeaninginlife.Theexistentialperspectiveonhumannatureisthereforenotatalldeterministicorfatalistic.Itemphasizesinsteadthecapacityofallhumanbeingstofreelychoosetheirownpersonanddestiny.Suchfreedomofchoiceinevitablyleadstotheexperienceofexistentialanxietyineveryperson.PersonalityTheoryExistentialtherapydescribesseveralcharacteristicsofhumanbeingsastheyexistintheworld,buttheyarenotthesameasparticularorfixedtraitswithinaperson. 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Existentialtherapistsemphasizeexistencefirstwithoutanyfixedoressentialpersonalitytraitsforeachhumanbeing.Suchexistenceisoftendescribedasbeing-in-theworld,orDasein,wherethebeingandtheworldofahumanpersonarenotdualisticallysplitbutareinsteadaunityexperiencedbyanindividualinthewayhesubjectivelyorphenomenologicallychoosestoperceiveorconstructit.Therearethreelevelsoftheworldtowhicheachpersonrelatesasheexistsintheworld,designatedbytheGermantermsUmwelt,Mitwelt,andEigenwelt(Binswanger1963;Boss1963).Umweltreferstothephysicalandbiologicaldimensionsoftheworld,includinglivingaswellasinanimateobjects.TheMitweltisthesocialworldofpeople.TheEigenweltisone’sowninnerworldofexperiencesthatonecansubjectivelyperceive,evaluate,andreflecton.Umweltcanbesimplytranslatedasbeing-in-nature,Mitweltasbeing-with-others,andEigenweltasbeing-for-oneself(ProchaskaandNorcross2010,97–98).Everyhumanbeingisfreetochoosehowheorsherelatestothesethreelevelsoftheworld:being-in-nature,being-with-others,andbeing-for-oneself.Theexistentialperspectiveemphasizesthatthebestoptionistochoosetobeauthentic—transparent,open,andhonestwithouthidinganythingfromourselves.Anauthenticexistenceisthereforeviewedasahealthyexistencethathasaharmoniousandspontaneousrelationshipwithallthreelevelsofbeingintheworld(nature,others,andself).However,itisnoteasytoliveauthenticallybecausethelevelofawarenessrequiredinevitablyleadstoexperiencingdread,orexistentialanxiety(Tillich1952).Thereareseveralsourcesofsuchexistentialanxiety:deathornonbeing(whicheachofuswillexperiencesoonerorlater),theneedtoact,meaninglessness,andisolationorfundamentalalonenessinthisworld.Allthesesourcesofexistentialanxietyreallypointtotheultimatecharacteristicthatistrueofallhumanbeings:ourfiniteness.Theyhavealsobeendescribedasthebasiccontingenciesoflifeorexistentialgivensthatarecertaintiesinlifeforeveryperson.Forexample,everyonemustdie,andeveryonemustact.However,outofthecertaintyofdeathcancomelife,outofmeaninglessnesscancomemeaning,andoutofisolationandalonenesscancomeintimacy.Inotherwords,outofnonbeingcancomethecreationofbeing.Anauthenticpersonthereforedoesnotavoidnonbeingandtheinevitableexistentialanxiety.Insteadoneembracesthefreedomtochooseanditsaccompanyingexistentialanxiety:onechoosestochoosebecausenottochooseisalreadyachoicethatisinauthentic.Anauthenticpersonalsorealizesthatexistenceitselfisanongoingcycleorflowfromnonbeingtobeingandbacktononbeingagain(orultimatelydeath).Dailylifeissimilarlyacycleorflowfromtheyesterdaythatdoesnotexistanymoreintothepresentofconsciousexperience,andeventuallyintothetomorrowthatdoesnotyetexistandthereforeisnonbeingfornow.Authenticbeingthusisanexperiencethatoccursonlyinthepresent(ProchaskaandNorcross2010,99–101). 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Morerecently,VanDuerzen-Smith(1997,1998)addedafourthwayofbeing-in-the-worldcalledÜberweltinGerman.TheÜberweltencompassesone’sbeliefsabouttheworldthatareusuallyspiritualorreligiousinnature;itreferstoone’sidealworldortheworldasonewantsittobe(seeSharf2008, 153).AccordingtoMay(1961)therearesixmajorcharacteristicsofanauthenticperson,oran“existingperson”:1.Humanbeingsarecenteredinthemselves,andanxietyisonlyonewaythattheyprotecttheirowncenterofexistence.2.Humanbeingsusuallyexperienceanxietyexistentiallybecausetheystruggleagainstwhatwoulddestroytheirbeing.3.Humanbeingshaveaneedtopreservetheircenterandthereforeusetheirwilltobeself-affirming.4.Humanbeingsareabletomovefromtheircenterednesstointeractionwithotherpeople,althoughsomeriskisunavoidableindoingso.5.Awarenessreferstothesubjectiveaspectofcenteredness—humanbeingsarecapableofbeingsubjectivelyawareofwhatevertheyareincontactwith.6.Humanbeingsareuniqueinbeingabletoexperienceself-consciousnessorawarenessofthemselvesinrelatingtotheworld,includingawarenessofexternalthreatsanddangerstotheirexistence.Frankl(1963)hasaddedaseventhcharacteristictoMay’slist:7.Thesearchformeaningistheprimaryforceormotivationinhumanbeings.Eachindividualneedstousehisorherwilltofindhisorherownparticularanduniquemeaninginlife(seeParrott2003,153–55).DevelopmentofPsychopathologyTheexistentialapproachtotherapyviewstheavoidanceofexistentialanxietyandnonbeingbylyingtoourselvesaswellastoothers,andthuschoosingnottoliveauthenticallyandtruthfully,asthefundamentalreasonfordevelopingpsychologicalproblems.ProchaskaandNorcrossputitbluntlyandsuccinctly:“Lyingisthefoundationofpsychopathology”(2010, 101).Lyingorlivinginauthenticallyleadstoneuroticanxiety,asexistentialanxietyisavoided.Neuroticanxietycanthenleadtootherpsychopathologicalsymptomsandbehaviors(e.g.,obsessive-compulsivecheckingbehaviors).Psychopathologyisusuallyassociatedwithanoveremphasisononelevelofbeing-in-the-worldwhileignoringtheotherlevelsinanimbalancedway.Forexample,anindividualmayspendmostofhistimeinsocialsituationswithpeopleinordertoavoidneuroticanxietythatisaconsequenceofrun- _Tan_Counseling_BB_mw.indd123 9/21/104:35:19PM 110 MajorCounselingandPsychotherapyTheoriesandTechniques Sidebar7.2FundamentalDimensionsofBeingHumanInsummarizingtheviewsofexistentialphilosophersandtherapistsonthebasicorfundamentaldimensionsofbeinghuman,Corey(2009,139)listsanddescribesthefollowingsixpropositions:1.Thecapacityforself-awareness2.Freedomandresponsibility3.Creatingone’sidentityandestablishingmeaningfulrelationshipswithothers4.Thesearchformeaning,purpose,values,andgoals5.Anxietyasaconditionforliving6.AwarenessofdeathandnonbeingSuchpropositionsorcharacteristicsofthehumanconditionareoftenexploredanddealtwithinexistentialtherapy. ningawayfromaninneremptinesswhenheisalone.Thispersonisoverdoingbeing-with-othersandnotattendingenoughtobeing-in-natureandbeingfor-oneself.Lyingcanalsooccuratthedifferentlevelsofexistence.Therecanbelying-in-nature(asinthecaseofahypochondriacwholiestoherselfabouthowillnessescanbeavoidedsimplybyconsultingthedoctorquicklyandfrequently),lying-to-others(asinthecaseofsomeonedoingwhateverittakestofakeagoodfrontorappearancetopleaseothers,gettheirapproval,orwinabusinessdeal),andlying-for-oneself(asinthecaseofaworkaholicwhoerroneouslybelievestheliethathecanperformperfectlyandthusavoidrejectionorcriticismsimplybyworkingharderandlonger).Suchlyingisattherootofpsychopathologyaccordingtotheexistentialperspective(seeProchaskaandNorcross2010,101–4).TherapeuticProcessandRelationshipExistentialtherapistshelptheirclientspursuethefollowingtherapeuticgoals:toembracetheirfreedomtochooseandactinresponsibleways;toexperienceasfullyaspossibletheirexistenceandgrowinself-awareness;tosearchforanddiscovermeaningandpurposeintheirlives;andtobemoreauthentic,real,andtruthful,thuslettinggoofself-deceptionandlying.Authenticitythenisthemostfundamentalgoalofexistentialtherapy(M. Cooper2003).Coreissuesoftenexploredandaddressedinexistentialtherapyincludeanxiety,livinganddying,freedomandresponsibility,isolationandlovingorintimacy,andmeaningandmeaninglessness(Sharf2008, 160). 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Thetherapeuticrelationshipbetweentheexistentialtherapistandtheclientisthecrucialfactorinhelpingtheclientadequatelyexploreanddealwiththesecoreexistentialissues.Itshouldbeanauthentic,respectful,warm,andpersonallyconnectingrelationshipinwhichtheexistentialtherapistandclientcanexperienceadeeplytherapeuticencounter(May1958)andmeaningfuldialogue—whatMartinBuberhasdescribedasan“I-Thou”relationship.Theexistentialtherapistgenuinelycaresfortheclientwithwhathasbeencalled“therapeuticlove”(Sharf2008,163);heorshedevelopsaprofoundlyhelpingrelationshipwiththeclient,whatYalomhasdescribedasa“lovingfriendship”(1980, 407).Itisthistherapeuticrelationshipthatheals(Yalom1980,401).Thepersonalauthenticityandintegrityoftheexistentialtherapistareessentialifsuchatherapeuticrelationshipistooccurandbeexperiencedbytheclient.Theexistentialtherapistasa“woundedhealer”(seeMendelowitzandSchneider2008,312–13)willthereforeberealandtransparentandshareordisclosehimselforherselfwiththeclientinappropriateandhelpfulwaystofacilitatetheclient’sownself-awarenessandhonesty.AsMayhasnoted,thegoalofexistentialtherapyisnotsomuchto“cure”clientsoftheirsymptomsorpsychopathology,butrathertohelpthemtobecomemoreself-awareandtobefreefromtheroleofbeingvictimsintheirlives(1981,210).Theultimatetherapeuticresponsibilityinexistentialtherapylieswiththeclient,whohasthefreedomtomakechoicesevenabouttherapy.Existentialtherapiststhusarenotparticularlyfocusedonusingspecifictherapeutictechniquesinhelpingtheirclients.Thepersonofthetherapistandthetherapeuticrelationshiparemorecrucialandessentialinexistentialtherapy.Someexistentialtherapistsevencriticizetheuseofspecifictherapeutictechniquesasaformofobjectificationofclientsandtheirproblems.Theyfearthatclients’phenomenological,subjectiveexperiencingofthemselvesandtheirexistence,whichisthehallmarkofexistentialtherapy,maybelostinanoveremphasisontechniquesandthetechnologyoftherapeuticchange.Thefocusintherapyshouldbemoreonexistentialissuesratherthanproblemsandproblemsolvingperse.Nevertheless,severaltherapeutictechniqueshavebeenusedinexistentialtherapy,mostnotablyinlogotherapyasdevelopedbyViktorFrankl,althoughdifferentexistentialtherapistswillusequitedifferenttherapeutictechniquesorveryfewspecifictechniques.Existentialtherapyisstillbasicallyaphilosophicalapproachtotherapyratherthanaspecificschooloftherapywithaparticularsetoftherapeuticinterventions.Existentialtherapyisnotusuallyshortterm.Althoughitcanbemorestructuredandtimelimited,itsgoalsinsuchinstancesmayneedtobemorerestricted.Existentialanalysis,followingpsychoanalysisbutwithanexistentialperspective,canbeintense,withseveraltherapysessionsaweek,overarelativelylongperiodoftimethatcanlastseveralyears.Althoughissuesoftransferenceandresistancemayariseandbeinterpreted,thetherapistwill 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notfocusmuchontransferencebecausedoingsocaninterferewithhavingatrulyauthenticrelationshipwiththeclient(Cohn1997).MajorTherapeuticTechniquesandInterventionsforDealingwithCoreExistentialIssuesThepersonofthetherapistoruseofthetherapist’sselfandtheauthentictherapeuticrelationshipbetweenthetherapistandtheclientarethecrucial“methods”inexistentialtherapy.Inthiscontext,VanDuerzen-Smith(1997)emphasizesthatopennesstothecreativityanduniquenessofboththetherapistandtheclientisthefundamentalgroundrulefortheuseofmorespecifictherapeutictechniquesinexistentialtherapy,whichbasicallydeemphasizestechniques.Whateverinterventionsareeventuallyemployedbyexistentialtherapistswillbeadaptedtofittheparticularneedsofeachclientaswellastheuniquepersonalityandstyleofthetherapist,toensureauthenticityintheuseoftherapeutictechniques.Thevarietyoftechniquesusedmayinclude“advocacy,empathy,concern,sincerepersonalinterest,reflection,action,environmentalmodification,orsupport”(Parrott2003,157).Theymayalsoincludepsychoanalyticinterventionssuchasinterpretationanddreamanalysis,especiallywhenthetherapistattemptstointegratepsychoanalysiswithexistentialism.Indealingwiththecoreexistentialissuesoflivinganddying;freedom,responsibility,andchoice;isolationandloving(orintimacy);andmeaningandmeaninglessness,theexistentialtherapistmayuseseveraldifferenttherapeuticinterventions(seeSharf2008,165–69).LivingandDyingAcentralexistentialissuethateveryindividualmustfaceistherealityofdeath.Yalom(1980)hasdescribedthevariouswaysthatpeopleavoidtheissueofdeath,includingclingingtounrealisticfantasiesoftheirowninvulnerabilitytosicknessordeathorbelievinginamagicalrescuerwhowillsomehowpreventthemfromdying.Thedenialofdeath(seeE. Becker1973)isstillaveryrealphenomenonofcontemporaryAmericancultureandsociety.However,havingtodealwiththedeathofalovedonesuchasaparent,child,sibling,spouse,friend,orpetbringsonefacetofacewiththerealityofone’sownmortalityandeventualdeath.Italsorequiresthepersontodealwithgriefoversuchlosses,includingassociatedpainfulfeelingssuchasanger,guilt,ambivalence,anxiety,sorrow,anddepression.Theexistentialtherapistwillhelptheclientfacingtheissueofdeathtochoosenonethelesstoembracelivinglifeasauthenticallyaspossiblewhilerealisticallyacceptingmortalityandgrievingoversignificantlosses.AlthoughsomeexistentialtherapistssuchasYalom(1980)wouldprefertofocusondiscussingissueslikedeathanddying _Tan_Counseling_BB_mw.indd126 9/21/104:35:22PM ExistentialTherapy 113 directlywiththeclientratherthanusespecifictechniques,otherexistentialtherapistsmaybeopentousingtechniquessuchasguidedimageryorfantasy,inwhichaclientimagineshisowndeathandfuneral;writinganepitaphorobituaryforoneself;andtalkingwithanelderlypersonorsomeonewhoisterminallyill(seeSharf2008, 166).Freedom,Responsibility,andChoiceExistentialtherapistsbelievethattheirclientshavethefreedomtochoosetoliveasauthenticallyaspossibledespitetheirpasthistories,whichmayincludemuchpain,trauma,orabuse.Theythereforehelpclientsnottodwellonthepastbutinsteadtobemoreawareoftheirpresentexperienceandespeciallytheirfreedomtochoosetheirownvaluesandmaketheirowndecisionsintheirlifecircumstancesandthustodiscovertheirownmeaninginlife.Existentialtherapistsalsoemphasizetheimportanceofclientstakingresponsibilityfortheirownchoicesandactions.Thetherapistwillusegentlebutfirmconfrontationtohelpclientsrecognizehowtheymayberunningawayfromacceptingpersonalresponsibilityforparticularactions,includingtheirbehaviortowardthetherapist.Authenticityorhonestyiscrucialinexistentialtherapy,andthetherapistwillconfronttheclientwiththeneedfortheclienttotakeresponsibilityforhisorherownactionsandchoices,insteadofdenyingsuchresponsibilityorblamingothers.Choiceisusuallyviewedbyexistentialtherapistsasaprocesswiththreeaspects,asdescribedbyMay(1969):wishing,willing,anddeciding.Clientsareencouragedtobeintouchwiththeirfeelingssothattheyaremoreawareoftheirinnerwishes,desires,andvalues.Theyarethenhelpedtoreachthepointofbeingwilling,thatis,whentheyarereadytochooseandmakeadecision.Finallytheymakeachoiceresponsiblyandaresupportedintakingactiontofollowthroughwiththeirdecision.Clientstakefullresponsibilityinthisprocessofchoiceinvolvingtheirownwishing,willing,anddeciding.Theexistentialtherapistthereforeusesempathiclistening,authenticdialoguewithgentlebutfirmconfrontationwhennecessary,support,encouragement,andself-disclosure,orauthenticsharingofthetherapist’sownexperiencingoftheclientduringasession,tohelptheclientdealwiththecoreexistentialissuesoffreedom,responsibility,andchoice.IsolationandLoving(Intimacy)Theessentialisolationoralonenessofeachhumanbeingasanindividualpersonwhocameintothisworldaloneandwhowilldieandleavethisworldaloneisanexistentialrealitythateveryonemustface.Thestrugglewithone’sisolationoralonenessandtheyearningforlovingrelationshipsandintimacy _Tan_Counseling_BB_mw.indd127 9/21/104:35:23PM 114 MajorCounselingandPsychotherapyTheoriesandTechniques withothersarecrucialissuesthatareexploredandaddressedinexistentialtherapy.Theprovisionofadeeplycaringrelationshipbasedontherapeuticlove(Yalom1980)bytheexistentialtherapistcanhelptheclienttodealmoreauthenticallywithhisorhersenseofexistentialisolation.Thismayresultintheclienthavingenoughcouragetochangeandreachouttoothersinordertodevelopmutuallylovingandreciprocallycaringrelationshipswiththem.However,Bugental(1981)haspointedoutthedangeroftheclientbecomingsooverdependentonthetherapist’stherapeuticloveandgenuinecaringthatheorshedoesnotseektoestablishintimacyinrelationshipswithothersoutsidethetherapysession.Thetherapeuticrelationshipisnotreciprocalinnature:theclientreceivesthetherapeuticloveorgenuinecaringfromthetherapistbutdoesnotneedtoreciprocateorgivesuchloveandcaringbacktothetherapist.Awiseandlovingexistentialtherapistwillhelpaclientseetheneedtodevelopintimatefriendshipsandrelationshipsthataremorereciprocalinnature,withotherpeopleoutsidetherapy.Suchatherapistwillalsosetappropriateboundarieswiththeclientintheirtherapeuticrelationshiptopreventtheclientfromdevelopinganunhealthyoverdependencyonthetherapist,forexample,bylimitingthenumberofphonecallsandmeetingseachweek,exceptinseriousemergencies.MeaningandMeaninglessnessSomeexistentialphilosopherssuchasSartreandCamushaveaverypessimisticviewofexistenceandbeing-in-the-world,tothepointofbeingnihilisticaboutlifeinemphasizingitsultimatemeaninglessness,emptiness,andnothingness.Suicideisevenviewedasarationaloptiontochooseinthecontextofsuchultimatemeaninglessness.However,otherexistentialtheoristsandtherapistshaveamoreoptimisticandaffirmingperspectiveonmeaninglessnessoremptinessinlifeandemphasizethewilltomeaningoranauthenticsearchformeaningastheprimaryforceormotivationinhumanbeings.Frankl(1963,1969,1978,1997)developedlogotherapyasaspecificapproachtoexistentialtherapythatfocusesonmeaningasthefundamentalexistentialissueandneedofeveryindividual,andasthekeycharacteristicofsomeonewhoismentallyhealthy(seealsoWong,Wong,McDonald,andKlaassen2007).However,Franklalsoparadoxicallyemphasizedthatonecannotfindmeaningorhappinessinoneselforbysimplysearchingforthem.Rather,happinessisaby-productofcommittingoneselftosomeoneorsomethingthattranscendstheself.Self-absorption,orfocusingtoomuchononeself,willnotleadtoahappylifebutinsteadwillcauseonetoloseameaningfulperspectiveonlife.Meaningthatcomesoutoftheexistentialrealitiesofmeaninglessnessoremptinessinlifeisoftendiscoveredorexperiencedwhenoneisconnectedindeeplyauthenticwayswithotherpeopleinlovingrelationshipsorincreative 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andsignificantworksuchaswritingorpainting,Sidebar7.3andeveninsuffering.ReligiousandspiritualbeliefsandexperiencescanalsohelponefindultimateFourTechniquesUsedinmeaninginlifeinone’sÜberwelt,asVanDuerzenLogotherapySmith(1997,1998)hasobservedanddescribedasthefourthwayofbeing-in-the-world.1.SocraticdialogueFranklhasdescribedmore-specifictherapeutic2.Paradoxicalintentiontechniquesinlogotherapythanmostotherexis3.Dereflectiontentialtherapistshaveinthevariousapproachesto4.Attitudemodificationexistentialtherapy.Infact,someexistentialtherapistssuchasYalom(1980)havecriticizedFrankl’slogotherapyforfocusingtoomuchontechniquesratherthanoncoreexistentialissues.Nevertheless,logotherapyhasbecomeawidelyknownapproachtoexistentialtherapythatisoftenappreciatedforitsmorepracticaltherapeutictechniques,whichcanbeusedtohelpclientsinconcreteways.Franklhasdevelopedatleastfourspecifictherapeutictechniquesthatareoftenusedinlogotherapytohelpclients(Hillmann2004):Socraticdialogue,paradoxicalintention,dereflection,andattitudemodification.Socraticdialogueinvolvesdiscussingwithclientsseveralissuesintheirlives,includingassessmentoftheirpresentcircumstances,discoveryoftheirstrengths,andthesearchformeaningintheirlives,usingquestionsthathelpclarifytheclients’basicassumptionsandbeliefssothattheirerroneousnotionscanbecorrectedwiththetherapist’sinput.Clientsarethenencouragedtobelessself-focusedandmoreconcernedaboutothersinordertoexperiencemoremeaningintheirlives.SomeauthorssuchasDavidGuttman(1996)considerSocraticdialoguetobethemajortherapeutictechniqueoflogotherapy.Paradoxicalintentionisatherapeutictechniquethatrequiresclientstoexaggeratetheirsymptomsordoevenmoreoftheverybehaviortheyfear.ItisalsoanAdlerianinterventionthathasnowbeenincorporatedintomanyotherapproachestocounselingandpsychotherapy.Anexampleofparadoxicalintentionwouldbeanexistentialtherapistorlogotherapistaskingaclientwhoisafraidofexcessivesweatingwhentalkingtoasupervisoratworktosweatasprofuselyaspossiblewhenheisfacingthissupervisor.Thisprocessusuallyhelpstheclienttobecomelessself-focusedandtoseemoreclearlytheironyandhumorofthesituationheorshefears,oftenresultinginareductioninfearoranxiety.Dereflectionisanothertechniqueinlogotherapythatinvolvesencouragingclientstoturnawayfromfocusingontheirownproblemsandinsteadtodirecttheirattentionorawarenesstosomethingelsethatismorepleasant,positive,ormeaningful.Forexample,aclientwhohassufferedseveralfinanciallossesinthelastyearisencouragedtofocusmoreonthespirituallessonsshehaslearnedaboutbeinglessmaterialisticandcountingherotherblessings,such _Tan_Counseling_BB_mw.indd129 9/21/104:35:25PM 116 MajorCounselingandPsychotherapyTheoriesandTechniques asthebirthofahealthyfirstgrandchild.Suchdereflectioncanhelpclientstoputthingsinbetterperspective,tobelessabsorbedwiththeirownproblems,andtoenjoyothermoremeaningfulandpositiveexperiencesintheirlives.Finally,thefourththerapeutictechniqueinlogotherapyinvolvesattitudemodification,ormodifyingorchangingtheclient’sattitudesorthinkingaboutsomethingthatcannotbechangedsuchasanegativepasteventormemory,sothatmoremeaningfulorhopefulperspectivescanemergefortheclient.Alogotherapistusingattitudemodificationwillencourageaclientwhoisdepressedoverthesuddendeathofaverygoodfriendtoseethemorepositivesideofthemanygoodyearsofagenuinelycaringfriendshipthattheyhadasarealblessingforwhichheshouldbethankful.Theclientcanalsobehelpedtofacetheexistentialissueofdeathanddyingandtheneedtodevelopdeepermeaninginhisownlife.Thelogotherapistusuallyconductsattitudemodificationinadirectway,usingother,moregeneraltherapeuticinterventionssuchasreasoning,persuasion,interpretation,confrontation,andselfdisclosureorsharingonthepartofthetherapist.Attitudemodificationisthereforeverysimilartothetechniqueofcognitiverestructuringincognitivetherapy.Logotherapyfocusesevenmoreonmeaningintherapythansomeotherexistentialapproachestotherapyandismoresimilartoshort-termpsychodynamictherapies,whereasexistentialanalysisiscloserinpracticetopsychoanalysis(seeProchaskaandNorcross2010,118).AnotherexistentialtherapytechniquecalledembodiedmeditationhasbeenrecentlydevelopedanddescribedbyKirkSchneider,acontemporaryexistentialtherapist(1998,2007).Inthistherapeuticintervention,theclientisintroducedtoasimplegroundingexercisethatusuallyinvolvesprogressiverelaxationorbreathingawarenesswitheyesclosed.Theclientisthenaskedtobecomemoreawareofbodilyexperiencesandsensations,includingspecificareasoftensions.Theclientproceedstodescribeasvividlyandasclearlyaspossibletheareaoftensiononceitislocatedandidentified.Iftheclientisabletogoon,sheisaskedtoplaceherhandontheareaoftensionandthentofreelyassociateanyexperiencessuchassensations,feelings,orimagesthatmaybeconnectedtocontactwiththisbodilyarea.Schneiderhasreportedthatclientsmayexperiencepowerfulanddeepemotionsreleasedthroughthistechnique,butthereisalsoadangerthatsomeclientsmayfeeloverwhelmedbysuchanexperience.Anawareness-intensivetherapeuticinterventionsuchasembodiedmeditationshouldthereforeonlybepracticedcautiouslyandethicallybyanexistentialtherapistwhoissensitivelyattunedtotheneedsandcapacitiesofparticularclients(seeMendelowitzandSchneider2008,309).Existentialtherapyismosthelpfultoclientswhoarefacingdevelopmentalcrises(e.g.,dealingwithidentityissuesinadolescence,experiencingdisappointmentsinmiddleage,copingwithchildrenleavinghome,facingfailuresatworkorinmarriage,orstrugglingwiththechallengesandlimitationsof _Tan_Counseling_BB_mw.indd130 9/21/104:35:27PM 117 ExistentialTherapy aging),experiencinggriefoverlosses,encounteringdeath,andhavingtomakeimportantdecisions(MayandYalom2000).Itisalsoparticularlyappropriateforclientswhoareexperiencingemptinessandalienationintheirlivesandthusarelookingforamoremeaningfulexistence(VanDuerzen-Smith1990),includingclientswhoarestrugglingwithalackofasenseofidentity(BugentalandBracke1992).EdwardMendelowitzandKirkSchneiderhavenotedthatclientswhoareexperiencinganexistentialcrisisarefrequentlyeasiertoworkwithcomparedwiththosewhoarepreoccupiedwitheverydayneuroticcomplaints(see2008,310–11).Nevertheless,existentialtherapyhasbeenusedwithawidevarietyofclientsandclinicalproblems(seeSchneider2007)andeveninshort-termintervention(LantzandWalsh2007).Ithasalsobeenappliednotonlyinindividualtherapybutalsoingrouptherapyandtherapywithcouplesandfamilies. ExistentialTherapyinPracticeAHypotheticalTranscript Client:Idon’tunderstandwhyI’mfeelingsoemptyandalmostdeaddeepinsidethecoreofmybeing,despiteallmysuccessinmybusinessventures,whichhavebroughtmemorefinancialprofitsthisyearthaneverbefore. . . .Maybeit’smyage.Iturnedfortythisyear. . . .AmIhavingwhat’scalledamidlifecrisis?ExistentialTherapist:(remainssilentforafewmoments)Whatdoyouthink?Whatareyouexperiencingdeepwithinyou?Client:Idon’tknowforsurewhetherI’mexperiencingamidlifecrisis,butIsurehavebecomemoreawareofthisinnersenseofemptinessandmeaninglessness. . .andthemoneydoesn’tmeanmuchanymore.ExistentialTherapist:Soundslikeyouaregoingthroughsomethinglikeamidlifecrisis,butthelabelingisn’tthatimportant.Let’sexploremorewhatthisemptinessmaymeanforyou,andwhymoneydoesn’tseemtobethatcrucialanymore.. . .Whatdoyouthink?Client:Well,IguessI’mlearningthatmaterialthingsthatmoneycanbuysuchasmybig,lovelyhouse,beautifulclothes,andareallynicecardon’tbringmeaningfulhappinessdeepinsidemyheart.Ilongforsomethingmoremeaningfulandfulfillinginmylife. . . .I’mtiredofdoingthesameold,sameoldbusinessstuffalthoughI’mreallygoodatit.ButIfeelkindofstuck. . .andIdon’tknowwhattodoaboutthis. _Tan_Counseling_BB_mw.indd131 9/21/104:35:27PM 118 MajorCounselingandPsychotherapyTheoriesandTechniques ExistentialTherapist:(remainssilentforafewmoments)Let’sexplorethiskeyissueoflongingorsearchingformoremeaningandfulfillmentinyourlife.Whatwouldbringdeepermeaningforyouatthistime?Andrememberthatyouhavethefreedomtoexploreyouroptionsandtochooseordecide.Client:Well. . .Idon’treallyknow. . .butyoukeepremindingmethatit’suptometochooseanddecidewhatwouldbemeaningfulorsignificanttomeinmylife. . . .I’vethoughtsometimesofbeinginvolvedinsomekindofvolunteerworktohelpdisadvantagedchildren. . .suchastheBigBrotherprogram. . .togetoutsidemyownworldofbusinessdealsandmakingmoney. . .tobeinvolvedwithhelpingotherpeoplemore.ExistentialTherapist:Itlookslikeyouarenowreallyexercisingyourfreedomtochooseyourvaluesandactionsandtobeinvolvedinsomethingthatismeaningfultoyou. . .liketheBigBrotherprogram. . . .Whatareyouexperiencingnowandhowdoyoureallyfeelaboutdoingsomethinglikethis?Client:Iactuallyfeelsomeenergyandinspirationwellingupinside. . .likethiswillactuallyhelpmetoexperiencemoremeaningandfulfillmentinmylifeasIreachouttohelpothers. . . .PerhapsI’vebeentooself-absorbedandevenselfish. . .andIamstillsingleatforty!PerhapsIshouldalsoexploreseriouslydatingwomenagaintoseeifIcanreallyfindalifepartnertoloveandhaveadeeprelationshipwith,inmarriage . . .ExistentialTherapist:Soyou’rethinkingnotonlyofhelpingoutwiththeBigBrotherprogrambutalsoofbeginningtoseriouslydatewomenagainwiththepossibilityofsettlingdowninmarriage. . .thatthisalsoseemspotentiallymeaningfultoyou,havingaloving,committedrelationshipwithawoman?Client:Iguessso. . .butIhaven’thadmuchsuccessinmydatingexperiencesbefore. . .soIhaven’tseriouslydatedforafewyearsnow,insteadjustthrownmyselfalmostcompletelyintomyworkandbusinessdeals. . . .IhavetoadmitthatI’mactuallyquitenervouswhenIdateawoman,andIgetsweatypalmsandamafraidtoshakeherhandorholdherhandincaseshenoticesmysweatypalm. _Tan_Counseling_BB_mw.indd132 9/21/104:35:28PM ExistentialTherapy 119 ExistentialTherapist:Isee. . .butyoustillseemtowanttopursueseriousdatingagainexceptforyourfearofyourdatenoticingyoursweatypalms. . .right?Client:Yes,yougotit!I’mnotsurewhattodowiththisfearIhave,thatholdsmebackfrominitiatingdates. . . .Otherwise,I’maprettygoodconversationalist,andpeople,includingwomen,seemtoenjoytalkingwithme.ExistentialTherapist:Letmesuggestthatyoudealwithyourfearofhavingsweatypalmsbydoingsomethingthatmaysoundsillyorcrazytoyouatfirstbutthatmayactuallyhelpyou.Inyourimagination,canyoudoyourbesttomakeyourpalmssweatevenmoreandasprofuselyaspossiblewhilegoingonyourfirstdatewithawoman?Client:Youmeanrightnow. . .inmyimagination?I’mwillingtotryifyou’llguideme.ExistentialTherapist:Allright.Pleasecloseyoureyesandtakeaslow,deepbreathtoclearyourmind. . . .NowIwantyoutoimaginegoingoutonyourfirstdatewithawomanyouareinterestedinandattractedto. . . .Asyoumeetherforthefirsttimeandbegintoshakehandswithher,youfeelyourpalmssweating. . .andsweating. . .andreallysweatingprofusely,withhugedropsofsweat. . . .Goonandimaginethishappeningasvividlyandasclearlyaspossible. . . .What’shappeningandwhatareyouexperiencingnow?Client:I’mtrying. . .butit’snotworking!I’mtryingtosweatmoreandsweatreallyprofusely. . .buttheharderItry,thelessitseemsIamsweating. . .andI’mrealizinghowfunnyandsillythisallis!Andironically,Idon’tfeelasfearfulanymore.ExistentialTherapist:Good!I’mgladthatyou’vefoundthisinterventionhelpful. Thishypotheticaltranscriptofasmallpartofanexistentialtherapysessionthatincludedlogotherapydemonstratestheexistentialtherapist’suseofSocraticdialogueandattitudemodificationinvolvingaseriesofquestions,aswellasparadoxicalintentionfocusingontheclient’sfearofhavingsweatypalms.Theexistentialtherapistalsoengagedingenuineencounterandauthenticdialoguewiththeclientusingempathicunderstanding,support,encouragement,andgentleconfrontationtohelptheclientfindmeaningandpurposeinhislife,aswellasaccepthisresponsibilityandfreedomtochooseanddecide. _Tan_Counseling_BB_mw.indd133 9/21/104:35:28PM 120 MajorCounselingandPsychotherapyTheoriesandTechniques CritiqueofExistentialTherapy:StrengthsandWeaknessesExistentialtherapyhasanumberofstrengths.First,itfocusesonthepersonwithauniqueanddeepexistentialperspective,emphasizingtheindividual’sself-awareness,freedomtochoose,andresponsibilitytoliveanauthenticlifewithmeaning.Ithasagenuinerespectforthepersonandopposesanydehumanizingapproachthatobjectifiesahumanbeingasathing.Second,itdirectlydealswithcorehumanorexistentialissuessuchasdeath,freedom,isolation,andmeaninglessness,insteadofavoidingthem.Third,itviewsthetherapeuticrelationshipasthecentralhealingfactorintherapyforaclient.Itemphasizesthecrucialsignificanceoftherapeuticloveorgenuinecaringfortheclientinatherapeuticrelationshipthatinvolvesauthenticencounterandhonest,genuinedialoguebetweenthetherapistandtheclient.Fourth,italsoviewsthepersonofthetherapistortheuseofthetherapist’sselfascrucialineffectiveexistentialtherapyanddoesnotsubscribetonotionsofprofessionalobjectivityanddistancingoftenfoundinmoremechanicalapproachestotherapythatemphasizetechniques.Theexistentialtherapistthereforeisawoundedhealerwhoopenlyshareshisorherownexistentialstruggleswithauthenticity,honesty,andintegrityinwalkingtogetherwithaclientonlife’sjourney,whichisfilledwithcoreexistentialorultimatehumanconcerns.Fifth,itisparticularlyhelpfulandappropriateforclientswhoarefacingdevelopmentalcrisesorimportantchoicepointsinlife,orwhoareexperiencingemptinessoralackofasenseofidentityandadeeplongingformeaninginlife.However,existentialtherapyalsohasseveralweaknesses.First,itsmajortheoreticalconceptshavebeencriticizedforbeingvagueandunclearandattimesevenconfusing.Termssuchas“authenticity,”“livinginthehereandnow,”and“takingresponsibilityforoneself”canbeinterpretedinvariouswaysbydifferenttherapistsorclients(ToddandBohart2006, 240).Itisalsodifficulttoconductempiricalresearchwhensuchconceptsortermscannotbeeasilyoperationalizedorclearlydefined.Second,inordertobeauthentic(realorhonest)intherapy,someexistentialtherapistsmaybemoreconfrontationalthanisappropriateorhelpfulforcertainvulnerableclientswhomaynotbeabletohandlesuchconfrontationseveniftheyareauthentic.Authenticconfrontationofthewrongkindcanthereforebepotentiallyharmfulforsomeclients(seeToddandBohart2006,240).Third,whileoneofexistentialtherapy’sstrengthsisitsfocusoncoreexistentialissuessuchasdeath,freedom,isolation,andmeaninglessness,andonfindingmeaninginlife,thisisalsoapotentialweakness.Someclientsarenotinterestedinexploringanddealingwiththeseultimatehumanconcerns,preferringinsteadtosticktosymptomalleviationofpsychologicalproblemslikeanxietyanddepressionormaritalconflicts.Theexistentialtherapistmayinadvertentlyimposeanexistentialagendaonsuchclients,whomaynotwanttodiscussissueslikemeaninglessnessandmeaninginlife.However,existen- 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tialtherapistsdoemphasizetheclient’sfreedomtochoose,soimposinganexistentialagendaontheclientisunlikelythoughpossible.Fourth,existentialtherapydoesnotemphasizetherapeutictechniquesorcleartherapeuticstructureandprocess,sotheactualpracticeofexistentialtherapyissomewhatvagueandcanvaryfromoneexistentialtherapisttoanother.Logotherapyasanexistentialapproachtotherapyis,however,abitmorestructured,timelimited,andtechniqueoriented.Nevertheless,existentialtherapyismoreanattitudeorphilosophicalapproachtocounselingandtherapy,andthereforeitisdifficulttoempiricallyevaluateitseffectivenesswithclientsbecauseitstherapeutictechniquesandstructurearehardtooperationalizeandstandardize.Existentialtherapistsarealsooftennegativeaboutscientificresearchonthetherapeuticoutcomesofspecifictherapeuticapproachesortechniques.Fifth,existentialtherapy’sfocusontheexperientialaspectsofanindividual’sexistenceandhisorherfreedomtochoosemaynotgivesufficientattentiontobiologicalaswellassocioculturalfactorsinthedevelopmentofpsychologicaldisorders.Sometypesofpsychopathologysuchasmajordepressivedisorder,bipolardisorder,schizophrenia,obsessive-compulsivedisorder,andattentiondeficitdisordermayhavebiologicalbasesandmayneedappropriatepsychiatricmedications(seeDay2004,188).Also,someproblemsinlivingareduetonegativeenvironmentalandsocioculturalfactorssuchaspoverty,unemployment,homelessness,discrimination,andracism,whichmayrequiresocialandenvironmentalinterventionandnotsimplychoosingone’sattitudesandresponsesorreactionstosuchadversecircumstances.Althoughattitudemodificationorchoosingmeaningfulandhopefulwaysofthinkingiscrucial,environmentalorsocialmodificationisoftenalsocritical.However,whenenvironmentalandsocioculturalfactorscannotbeeasilymodifiedorchanged,clients,includingthosefromculturallydiversebackgrounds,mayfinditparticularlyhelpfultoberemindedbyexistentialtherapiststhattheystillhavethefreedomtochoosetheirattitudesandfindmeaningeveninthemidstofadverseandhorriblecircumstances.Finally,existentialtherapy,especiallyifitispracticedasexistentialanalysis,whichismoresimilartopsychoanalysis,isnotusuallybriefandstructured,withlogotherapybeingapossibleexception.Itfocusesnotonsymptomalleviationbutonhelpingclientslivemoreauthenticallyandfindmeaningintheirlives.Thusmedicalinsurancecompaniesormanagedhealth-careprovidersmayresistpayingforexistentialtherapybecausetheynowprefertopayforshortertermtreatmentsthateffectivelyalleviatethesymptomsofclients’psychologicalproblems(seeToddandBohart2006,241).However,short-termexistentialinterventionortherapyhasrecentlybeendeveloped(describedinLantzandWalsh2007).ABiblicalPerspectiveonExistentialTherapyExistentialtherapyhasadeeprespectforthepersonandthehumancapacityforfreelyandresponsiblychoosingtoliveanauthenticlifewithmeaning.It 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alsodirectlydealswithcoreexistentialissuesorultimatehumanconcernssuchasdeath,freedom,isolation,andmeaninglessness.TheseconcernsarealsofoundinScripture,andhenceexistentialtherapycanbeseenasthetherapeuticapproachthatbestmirrorsbiblicalconcernsorbasicissuesoftheChristianfaith,especiallyasdescribedinEcclesiastes(seeHaden1987).Theexistentialquestionsorconcernsraisedbyexistentialtherapyarerightontarget,buttheanswersprovidedbysecularexistentialtherapyareofteninadequate,incomplete,misleading,andattimessimplyunbiblicalandwrong(seeS. L.JonesandButman1991,289–300,forahelpfulChristiancritiqueofexistentialtherapy).Existentialtherapyemphasizestheindividual’sfreedomtochooseanddefinehimselforherselfandtodosoauthenticallyandhonestly.Therearenoabsoluteorobjectivelytruewaysofbeingauthentic.Anysubjective,self-originatinganswerthatisauthenticwilldo.However,fromabiblicalperspective,suchrelativismandself-autonomyinanindividual’sbecominganauthenticpersonaremisplacedbecausetheBible’sviewisthathumanbeingsaremeanttocentertheirlivesinobjectivevaluesthatarerealbecauseGodexistsandisthesourceofsucheternal,objectivevalues(Tweedie1961,165).Subjectiveself-chosen,arbitraryvaluesmayconflictwithbiblicalvaluesandGod’swill,whichultimatelyfocusesonourspiritualformationandgrowthintodeeperChristlikenessinourbeingorcharacteraswellaslifestyle(Rom.8:29),includingthepracticeofspiritualdisciplinesandthecultivationofChristianvirtuesorthefruitoftheSpirit(Gal.5:22–23).Existentialtherapycanalsobecomestoicalandevennihilisticifitoveremphasizestheultimateemptinessandmeaninglessnessoflifeandtheisolationandalonenessofeachindividualinthisworldandcosmos,especiallyinthefaceofmortalityanddeath.ItcanbespirituallyhopelesswithoutthegospelofJesusChrist,whodiedandroseagainforfallen,sinfulhumanbeingssothattheycanhaveeternallife(whichistheultimateanswertodeathandmortality)andfilltheirGod-shapedvacuumorexistentialemptinessintheirheartsbysimplefaithinChristastheirpersonalLordandSavior.TheChristian,biblicalperspectiveismorecompleteandwhole:thecoreexistentialemptinessandmeaninglessnessinsideeachhumanbeingpointstotheneedformeaninginlifeandsalvationthatonlyJesusChristcanprovidebecauseofwhathehashistoricallydoneonthecrossinhisdeathandresurrection,sothateachfallen,sinfulhumanmaybereconciledtoGod(2 Cor.5:17–21).JesusChristisalsotheultimateanswertodeath,havingconquereddeathbyhisresurrection(see1 Cor.15:50–57),andheofferseternallifenowandforeverinheaven(seeAlcorn2004)tothosewhoturntohiminsimpletrust(seeJohn3:16;seealsoLucado2007).However,existentialtherapyremindsusoftheneedtodealdeeplyandauthenticallywithsuchcorehumanconcernsasinneremptinessandmeaninglessnessandnotgivereligiousanswerstooquicklyorsuperficially.SomeformsofexistentialtherapysuchasFrankl’slogotherapydoacknowledgetheimportanceofspiritualorreligiousvalues,beliefs,andexperiencesin 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helpinghumanbeingsfinddeepermeaningandpurposeintheirlives(seeWong,Wong,McDonald,andKlaassen2007).However,secularexistentialtherapysuchaslogotherapytendstobeuniversalisticinitsviewoffaithandreligiousandspiritualbeliefs.Forexample,Franklsawallreligionsanddenominationsasequal,andnoneassuperiorormoretruethanothers.Healsobelievedthatasone’sfaithgrowsstronger,onewouldbelessdogmatic(seeTweedie1961).Again,theuniversalismandrelativismofsecularexistentialtherapyinitsapproachtoreligiousfaitharenotbiblical.Theexistentialemphasisonexperienceratherthandogmaisalsoproblematicfromabiblicalperspectivethatemphasizestheimportanceandneedforobjectivetruthandvalues,especiallyasrevealedinScriptureasinspiredrevelationfromGod(2 Tim.3:16).AChristianapproachtoexistentialtherapywillthereforedeeplyandauthenticallydealwithanxiety,emptinessormeaninglessness,andisolation,aswellassinanddespair.ItwilldosoinspirituallymeaningfulandtransformingwaysthathelpgroundanindividualinGodastheultimateandtruegroundofbeing,thatis,spiritgroundedinSpirit,asKierkegaardputit,orselfgroundedinSelf(FinchandVanDragt1999;seealsoEvans1990;Finch1982;Malony1980).Existentialtherapyemphasizesthetherapeuticrelationshipasbeingthekeyhealingfactorinhelpingclients,aswellasthepersonofthetherapistandhisorherprovisionoftherapeuticloveorgenuinecaringfortheclient.Thesearecommendableemphasesthataremoreconsistentwiththebiblicalperspective,whichconsidersagapelove(1 Cor.13)thatdeeplycaresforothers(Mark12:31)acrucialvalueinhumanrelationships,includinghelpingortherapeuticrelationships,comparedtoothertherapeuticapproachesthatmayoveremphasizetechniqueandthetechnologyoftherapeuticchangeandpotentiallydehumanizetheclient.Nevertheless,suchtherapeuticloveandauthenticvulnerabilityonthepartoftheexistentialtherapistasawoundedhealercanalsohavelimitationsanddangers.Therapeuticloveisnotthesameasagapelove,whichisthefruitoftheHolySpirit(Gal.5:22–23)andcomesonlyfromGod.Asafallen,imperfecthumanbeing,theexistentialtherapistcanonlygosofarwiththerapeuticloveandauthenticvulnerability.Thedarkersideofhumanpersonality,orthefallen,sinfulnatureineveryhumanbeing,isalsopresentintheexistentialtherapist.Thedangerexiststhattheexistentialtherapistwilltrytoohardtobetherapeuticallylovingandauthenticallyvulnerableandultimatelydosoinwaysthatarepotentiallyharmfultotheclient.Examplesincludegenuinelycaringfortheclientbutwithoutappropriateboundaries,forinstance,allowingtoofrequentphonecallsandsessionsthatmaynotbewarranted,possiblyleadingtooverdependencyonthetherapist;andengagingininappropriatetouchtocomforttheclient,withthetherapistbeingunawareofhisorherowncountertransferencephenomena,whichmaybesexualinnature.Agapelove,whichcomesfrombeingfilledwiththeHolySpirit,ispureanddeeperthantherapeuticlove,buteventheChristianexistentialtherapistmustbecarefulandprayerfullydependentontheHolySpiritforhishelpand 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guidanceinthetherapeuticrelationshipandprocessofhelpingclients.Anyintimatehelpingrelationship,especiallyonesteepedintherapeuticloveasinexistentialtherapy,hasitsdangers,whichmustnotbeoverlooked.Theexistentialtherapistalsoassumesaheavyresponsibilityintheroleofhelpingclientsfindmeaninginlifeinthemidstofpainfulexistentialstruggles.Suchatherapeuticrolecomesveryclosetotheroleofapriest,pastor,orspiritualdirector,inbeinga“midwife”(Evans1989)tohelpclients“birth”moreauthenticityandmeaningintheirlives.Therearepotentialdangersinherentinsucharolebecausetheexistentialtherapistcaninadvertentlyinfluencetheclienttoembracecertainsecularvalues,suchasauthenticatheism,thatmaymaketemporarysensetothembutareultimatelyspirituallybankruptfromabiblicalperspective.AChristianapproachtoexistentialtherapywillbecarefultodirectclientsultimatelytoGodsothattheycanbecomeaselfgroundedinSelforaspiritgroundedinSpirit(seeS. L.JonesandButman1991,299–300),andnotjustintheautonomousselfoftheindividual.Fromabiblicalperspectivetheautonomousselfwillnotfillthedeepexistentialvacuumineachperson,whichisultimatelyGodshapedandwhichonlyGodcanfill.Franklcorrectlyaffirmsthathumanbeingsaremorelikelytofindfulfillmentandmeaninginlifeiftheyarefocusedmoreonsomethingorsomeonebeyondthemselves,thatis,iftheyengageinself-transcendence.Buthedoesnotgofarenoughtorecognizeandaffirmthatthisself-transcendencemustbecenteredultimatelyinwhattheBiblerevealsasthetranscendentrealityofGodhimself,whoobjectivelyandtrulyexists(seeHurding1985,136–37;Tweedie1961,175).Furthermore,theemphasisontheclient’scapacityforactiveself-healinginexistentialtherapyisanotheraspectofitsfocusontheautonomousself,anditcanresultintoomuchself-effortandconfidenceinoneself(cf.Vitz1994).ThebiblicalperspectiveemphasizesinsteadtheneedtodependonthepoweroftheHolySpiritandtobefilledwiththeSpirit(Eph.5:18;Gal.5:16–25)andnottodependonone’sfallen,sinfulnatureorold,falseself.DependenceonGodiscrucialforhealingandwholenessaswellasholinessinChrist.Inconclusion,existentialtherapyishelpfulinraisingkeyexistentialquestionsanddescribinghowtodealwiththeminadeepandauthenticway,inthecontextofatherapeuticallylovingorgenuinelycaringrelationshipwiththeclient.However,theultimateanswerstothesevexingexistentialquestionscenteringonmeaninglessness,mortality,isolation,andfreedomtochoosecannotbefoundinsecularexistentialismorexistentialtherapyitself.TheBible,asGod’sinspiredrevelation,providesultimateandobjectivelytrueanswerscenteredinJesusChristandthegospel.Research:EmpiricalStatusofExistentialTherapyExistentialtherapistsgenerallydonotconductorappreciatecontrolledoutcomestudiesevaluatingtheeffectivenessofaparticulartherapyapproachwith 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clientssufferingfromaspecificpsychologicaldisorder.Theyhave,however,describedseveral“eloquentcasestudies”(Schneider2003,169).Nocontrolledoutcomeresearchseemstohavebeenconductedtodateontheeffectivenessofexistentialtherapy(seeProchaskaandNorcross2010,121–22).Someresearch,however,hasbeendoneontheeffectivenessofparadoxicalinterventionsingeneralandincludesFrankl’slogotherapytechniqueofparadoxicalintentionbutalsootherformsofparadoxicalinterventions.Meta-analysesofsuchresearchstudieshaveshownparadoxicalinterventionsingeneraltobeaseffectiveasothertypicaltreatmentinterventions,butnotmoreeffective.Theirmeaneffectsizecomparedtono-treatmentcontrolswas0.99,meaningthataclientreceivingparadoxicalinterventionswouldbemoreimprovedthan84percentofclientsreceivingnotreatment(K. Hill1987).Inonemetaanalysis,paradoxicalinterventionswerealsofoundtobemoreeffectivethanothertreatmentsofmoreseverecases(Shoham-SalomonandRosenthal1987).Theseresearchfindings,however,donotapplytologotherapyorexistentialtherapyperse.Alittle-knownstudybyLorenMosher(2001)showsevidencethatschizophreniatreatedwithanexistentiallybasedgrowth-orientedapproachthatprovidedcaring,empathic,supportiverelationshipswithoutroutinepsychiatrictreatmentatSoteriaHouseintheSanFranciscoBayareaofCaliforniahadbettertherapeuticoutcomescomparedtothosewhoreceivedconventionalpsychiatrictreatmentormedication,attwo-yearfollow-up(seealsoSchneider2003,120;andToddandBohart2006,233,239).Theoutcomemeasuresusedfocusedonrehospitalization,psychopathology,independentliving,andsocialandoccupationalfunctioning.Schneider(2003)assertsthatthereisnowasignificantthoughsmallbaseofempiricalsupportforexistential-humanistictherapy,andespeciallyforsomeofthemajorconceptsofexistentialtherapy,suchasthetherapeuticrelationship,thetherapist’spersonalityorpresence,andtheclient’sactiveself-healing(seeMendelowitzandSchneider2008,317).However,Schneiderandothers(e.g.,ToddandBohart2006)havelumpedtogetherexistentialtherapywiththebroaderrangeofexperientialandhumanistictherapies(suchasCarlRogers’sperson-centeredorclient-centeredtherapyandFritzPerls’sGestalttherapyplusotherexperientialtherapies)intheirreviewofresearchstudiesevaluatingtheeffectivenessofexistentialtherapy.Thisisconfusingbecauseexistentialtherapyisnotequivalenttootherexperientialorhumanistictherapies,althoughitmaysharesimilaritieswiththem.Atthistime,itisbesttoconcludewithProchaskaandNorcross(2010)thatthereisstillalackofwell-controlledoutcomedataavailable.Thusnodefinitiveconclusionscanbepresentlymadeaboutthetherapeuticeffectivenessofexistentialtherapy.However,itisencouragingtoseetheexpansionofempiricalworkbeingdoneonexistentialconceptsandexistentialtherapy(see,e.g.,R. A.WalshandMcElwain2002)asSchneider(2003)hasnoted.Sharf 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(2008,177–79),inhisbriefreviewofresearchonexistentialtherapy,concludedthatthereissupportfortheviewthatexistentialthemescanbesuccessfullycoveredanddealtwithinexistentialgrouptherapy.Someresearchhasalsoinvestigatedexistentialconceptssuchasconcernswithdeath,meaninglessness,andfindingmeaninginlife,forexample,byusingthePurposeinLifeTest(PIL)(Crumbaugh1968;CrumbaughandHenrion1988).Muchmorewell-controlledoutcomeresearchspecificallyevaluatingtheeffectivenessofexistentialtherapyforparticularpsychologicaldisordersisstillneeded,however.FutureDirectionsThepercentageofpsychotherapistssurveyedintheUnitedStateswhoindicatetheexistentialapproachtotherapyastheirprimarytheoreticalorientationissmall,around1percentofclinicalpsychologists,4percentofsocialworkers,5percentofcounselingpsychologists,and5percentofcounselors(seeProchaskaandNorcross2010, 3).However,theinfluenceofexistentialtherapyisactuallymoresubstantialandpervasiveinthefieldofcounselingandpsychotherapy,withmanyschoolsoftherapyincorporatingcoreexistentialconcepts(ProchaskaandNorcross2010,126–27).Associetybecomesmoretechnologicallyoriented,thereisagreatertendencyforpeopletobedehumanizedandalsotofeelvictimized.Morepeopleinthedecadesaheadmayfindexistentialtherapyparticularlyhelpfulindealingwithemptinessandtheirsearchformeaning,withanemphasisagainontheirfreedomtoresponsiblychoosetoliveanauthenticlife.InterestinexistentialtherapyfromaprofessionalpointofviewcontinuestobealiveandisparticularlystronginEurope,whereseveralorganizationssupportandfurthertheapproach,includingtheSocietyforExistentialAnalysis(www.existentialanalysis.co.uk),foundedin1988inEngland;theInternationalFederationforDaseins-analyse;andtheEasternEuropeanAssociationforExistentialPsychotherapyinLithuania.AprofessionalorganizationbasedinthishemisphereistheSouthAmericanExistentialAssociationinColombia.Trainingprogramsinexistentialtherapyarecurrentlyavailableinoveradozencountries,includingseveralEuropeancountriesandtheUnitedStates.Earlierexistentialtherapistscamemainlyfrompsychoanalyticbackgrounds,buttodaytherapistsschooledinotherorientationssuchasperson-centeredtherapy,Gestalttherapy,Jungiantherapy,feministtherapy,andsomecognitive-behavioraltherapies(e.g.,rational-emotivebehaviortherapy)havealsoincorporatedexistentialperspectivesintotheirclinicalpracticewithclients.Logotherapyinparticularhasgrowninmanypartsoftheworld,withtheViktorFranklInstituteofLogotherapystillpublishingajournal,theInternationalForumforLogotherapy.TherearealsologotherapycentersinGermanyandSouthAmericaandtheInternationalNetworkonPersonalMeaning(www.meaning.ca)withPaulT. P.WonginCanadaasitsfoundingpresident(see 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Wong,Wong,McDonald,andKlaassen2007).ItshouldbenotedthatmanyreligiousworkersandclergyhavebeeninterestedinlogotherapybecauseofFrankl’semphasisonthespiritinapersonandthesearchformeaninginlifeastheprimaryhumanmotivation(seeSharf2008,176–77).Morerecently,theInterpersonalSocietyforExistentialPsychotherapyandCounselling(www.existentialpsychotherapy.net)wasestablishedin2006,inLondon,England(seeCorey2009,160).Existentialideashavealsobeeninfluentialinareasotherthantherapy,forexample,inart,literature,music,film,andreligion.Schneiderhasespeciallyfocusedontheexistentialconceptofaweandthe“rediscoveryofawe”(Schneider2004,2007),referringtohowwerelatetomysterywithwonder,boldness,constraint,andhumility.DuetothepredominanceofmanagedhealthcareintheUnitedStatesandthegrowingimpactofbiologicalandmedicalizedapproachestothetreatmentofpsychologicaldisorders,clientswhoundergoexistentialtherapymayhavedifficultyreceivingreimbursementforthesetherapeuticservices;short-termexistentialintervention,however,isnowavailable(LantzandWalsh2007).Nevertheless,someclientswillstillbeinterestedinreceivingexistentialtherapy,whetherwithinoroutsidethemanaged-caresystem,becausetheywanthelpwiththeircoreexistentialstrugglesandsearchformeaningandamoreauthenticlife.Theoutlookforexistentialtherapyhasthereforebeendescribedas“guardedyetpromising”(MendelowitzandSchneider2008,303).Theempiricalbasesupportingtheeffectivenessofexistentialtherapyiscurrentlylackingandneedstobestrengthenedifitsfutureistobeevenmorepromising.Christianapproachestoexistentialtherapyalsoneedfurtherelaborationanddevelopment.RecommendedReadingsFrankl, V.(1963).Man’ssearchformeaning:Anintroductiontologotherapy.Boston:Beacon.May, R.(1953).Man’ssearchforhimself.NewYork:Dell.VanDuerzen, E.(2001).Existentialcounsellingandpsychotherapyinpractice(2nded.).ThousandOaks,CA:Sage.VanDuerzen, E.,&Kenward, R.(2005).Dictionaryofexistentialpsychotherapyandcounselling.London:Sage.Yalom,I. D.(1980).Existentialpsychotherapy.NewYork:BasicBooks. _Tan_Counseling_BB_mw.indd141 9/21/104:35:39PM 8Person-CenteredTherapy P erson-centeredtherapy,originallycallednondirectivetherapyinthe1940sandthenclient-centeredtherapyinthe1950s,wasfoundedanddevelopedbyCarlRogers.Hebeganwhatsomehaveconsideredarevolutioninthecounselingandtherapyfieldbyemphasizingthatcertaincoretherapeuticconditions(i.e.,congruence,unconditionalpositiveregard,andempathicunderstanding)providedbythetherapistintherelationshipwiththeclientarenecessaryandsufficienttofacilitateclientchange.Rogersalsohadanoptimisticviewofhumanbeings,includingtherapyclients,believingintheircapacityforpositivechangeandgrowthintofullyfunctioningpersons,givenappropriatesupportandsafety.Rogers’sperson-centeredapproachfocusesonthecapacityoftheclienttohealandtogrowinthecontextofawarm,empathic,andgenuinetherapeuticrelationshipwiththetherapist.Hedeemphasizedtechniquesanddiagnosesthattendtodehumanizepeople.Instead,Rogersplacedtheclientasapersonandthetherapeuticrelationshipinthecenterofeffectivecounselingandtherapy.Thiswasrevolutionaryatatimewhenmore-deterministicviewsprevailed,suchasFreud’spsychoanalyticapproachandthebeginningsofsomebehavioristicconditioningapproachesthatemphasizedtheclinicalexpertiseofthetherapistandtherapeutictechniquesforhelpingclientschange.Rogersusedtheterm“client”ratherthan“patient”torefertothepersonreceivingtherapy,becausehedidnotperceivetheclientassomeonewhois“sick”andinneedofacure.Rogerseventuallyexpandedhisperson-centeredtherapyapproachtoareasotherthancounselingandtherapysuchasmarriage,education,businessand128 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management,administration,andpolitics.Inhislateryears,heevenbecameinvolvedinapplyinghisideasandapproachtoeffortsatreducinginternationalconflictsandenhancingworldpeace.BiographicalSketchofCarlRogersCarlRansomRogerswasbornonJanuary8,1902,inOakPark,Illinois,asuburbofChicago.Hewasthefourthchildinafamilyofsixchildren,fiveofwhomwereboys.Hisfatherwasacontractorandcivilengineerwhodidwellprofessionallyandfinancially.Althoughhisparentswerewarmandloving,theywerealsolegalisticandcontrolling,influencedbytheirfundamentalistProtestantreligiousbackgroundthatfrownedonactivitiessuchasdancing,drinking,cardplaying,andgoingtothetheater(seeC. R.Rogers1961).WhenRogerswastwelveyearsold,heandhisfamilymovedtoalargefarmnearChicago.Asensitive,shyintrovert,Rogerswasnotverysociableandpreferredtospendtimewithhisbooksandinhisownworldofthought(H. E.Rogers1965).Rogersalsospentmuchofhistimeinthesummersusingfarmequipmentanddevelopinghisinterestinagricultureandscientificmethodsinfarming(Kirschenbaum1979).HeinitiallypursuedscientificagricultureashismajorattheUniversityofWisconsin.RogersbecameinvolvedwiththeYMCAoncampusandwasselectedtobeoneofthetwelvestudentsfromtheUnitedStateswhotraveledtoPeking(nowBeijing),China,in1922asdelegatestotheWorldStudentChristianFederationConference.Inmeetingotherbrightandcreativestudentswhohadreligiousbeliefsthatdifferedfromthestrictfundamentalisticbeliefsofhisparents,Rogersexperiencedadeeptransformationofhisownreligiousviews,becomingmoreopenandliberal.Healsobecamemoreofhimself(Bankart1997,292),withhistruepersonalityemergingafterbeingawayforsixmonthsonthissignificanttrip.RogerschangedhismajorfromagriculturetohistoryandgraduatedfromtheUniversityofWisconsinin1924.Twomonthslaterhemarriedhischildhoodsweetheart,HelenElliott,andtheydrovetoNewYorkCity,wherehestudiedatUnionTheologicalSeminary,aschoolthatwasmoreliberalthanhisparentswouldhavepreferred(Thorne2003).HisfatherhadofferedtofundhistheologicalstudiesatPrinceton,butRogersexercisedhisindependencebygoingtoUnioninstead.AftertwoyearsatUnion,wherehetookafewpsychologycourses,helefttheseminaryandbeganaPhDprograminclinicalandeducationalpsychologyatneighboringColumbiaUniversity.Rogerscompletedthisdoctoralprogramin1931.RogersworkedfortwelveyearsintheChildStudyDepartmentattheSocietyforthePreventionofCrueltytoChildreninRochester,NewYork,wherehegainedvaluableclinicalexperienceworkingwithunderprivilegedanddelinquentchildrenreferredbysocialagenciesandthecourtsystem(C. R.Rogers1961). 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Healsotrainedandsupervisedotherpsychologistsandsocialworkers.Rogerseventuallywentbeyondthetraditionalpsychoanalyticapproachtotherapyandbegantodevelopamorenondirectivecounselingapproach.HewroteTheClinicalTreatmentoftheProblemChild(1939)duringhistimeinRochester.RogersmovedtoColumbus,Ohio,tobecomeafullprofessoratOhioStateUniversityin1940.Hegaveagroundbreakinglecturetitled“NewerConceptsinPsychotherapy”attheUniversityofMinnesotaonDecember11,1940,andrecalledthisdateasthe“dayonwhichclient-centeredtherapywasborn”(Kirschenbaum1979,112).Thissignificantlectureandhissubsequentbook,CounselingandPsychotherapy(C. R.Rogers1942),sparkedamajorresponsefrommentalhealthprofessionals,withbothenthusiasticsupportforandscathingcriticismofhisnondirectivecounselingideas(Thorne2003),whichdeemphasizedtechniqueanddiagnosis.Rogersthereforebecamea“quietrevolutionary”(seeFarson1975).Rogers’searlyideasonnondirectivecounseling,orclient-centeredtherapy,werepartlyinfluencedbyOttoRank,who,likeJungandAdler,hadbrokenawayfromFreudandhispsychoanalyticgroup.Rogersattendedathree-dayseminarinRochesterconductedbyRank.HewasthusexposedtoRank’sideasemphasizingtheuniquenessandexperienceoftheclientandtheneedforthetherapisttorelinquishtheroleofanauthorityandinsteadbecomemoreofanonjudgmentalhelper(Rank1945).Rogers’sthinkingwasalsoinfluencedbytwootherpeoplewithwhomhehadcontact:ElizabethDavis,aRankiantrainedsocialworkerattheRochesterclinic,andJessieTaft,whowasoneofRank’sstudents(C. R.RogersandHaigh1983).In1945,RogerswenttotheUniversityofChicago,wherehebecameaprofessorofpsychologyandthedirectoroftheuniversitycounselingcenter.Hefurtherdevelopedhistheoreticalideasandalsoengagedinresearchwithhiscolleaguesandgraduatestudentstoevaluatetheeffectivenessofhisnondirectivecounselingapproach,whicheventuallywasrenamedclient-centeredtherapyinthepublicationofhissignificantbookClient-CenteredTherapy:ItsCurrentPractice,Implications,andTheory(C. R.Rogers1951).In1956,RogersreceivedthefirstdistinguishedScientificContributionAward,presentedtohimbytheAmericanPsychologicalAssociation,anorganizationhehadservedaspresidentin1946–47.Hethusbecameawell-knownfigureinthecounselingandtherapyfield,andclient-centeredtherapyestablisheditselfasamajorapproachtotherapy.RogerslefttheUniversityofChicagoin1957toassumeanewpositionattheUniversityofWisconsinintheDepartmentofPsychologyandthenintheDepartmentofPsychiatry.HehadadifficulttimeintheDepartmentofPsychology,disagreeingwithhowgraduatestudentsweretreatedinasomewhatoppressiveeducationalenvironmentthatdidnotofferthemenoughfreedomandsupporttodeveloptheirowncreativeideasandwork.Asaresult,hehadfrequentconflictswithhiscolleagues(Thorne2003;P. Sanders2004a). _Tan_Counseling_BB_mw.indd144 9/21/104:35:42PM Person-CenteredTherapy 131 Rogersundertookalargeresearchprojectthatevaluatedtheimpactofthetherapeuticrelationshiponschizophrenicswhowerehospitalized(C. R.Rogers,Gendlin,Kiesler,andTruax1967),butthestudyencounteredseveralproblemsandyieldedfewstatisticallysignificantfindings.However,twoconclusionscouldbemadefromtheresultsofthisresearchproject:clientswhoexperiencedthehighestlevelofaccurateempathywerethemostsuccessful,andclients’evaluationofthetherapeuticrelationshipcorrelatedmorehighlywiththerapeuticsuccessorfailurethanthetherapists’evaluation.Rogersmanagedtowriteandpublishanothersubstantialbook,OnBecomingaPerson(1961),whichledtoevengreaterrenownforhim.In1957,hehadalsopublishedwhatisnowaclassicarticleonthenecessaryandsufficientconditionsoftherapeuticpersonalitychange,focusingoncongruence,unconditionalpositiveregard,andempathy.HeresignedfromtheUniversityofWisconsinin1962.In1964,RogersmovedtoLaJolla,California,wherehebecamearesidentfellowattheWesternBehavioralSciencesInstituteforfouryears.Afterleavingtheinstitutein1968,hehelpedformtheCenterforStudiesofthePersoninLaJolla,wherehealsobecamearesidentfellow.Thecenterwasthebasefromwhichhetraveledaroundtheworldtodealwithinternationalconflictsandtoworkonpeacemakingefforts.Hecontinuedtopublishsignificantbooksonawidervarietyoftopicscoveringtheapplicationofperson-centeredideastoareassuchaseducation(1969,1983),encountergroups(1970),marriage(1972),andpersonalpowerincludingpsychotherapy,familylife,administration,education,andpolitics(1977).Rogerscontinuedtotravel,write,andworkoninternationalprojectsandglobalissuesuntilthelastdaysofhislife.Hereceivedmanyawardsandhonorsinhislifetime,includingtheDistinguishedProfessionalContributionAwardfromtheAmericanPsychologicalAssociationin1972.HewasevennominatedfortheNobelPeacePrizeasaresultofhistirelesseffortsintryingtoresolveglobalconflictsinapeacefulway.In1987,Rogersbrokehishipinafall.Hehadsuccessfulsurgeryforthebrokenhip,butdiedshortlythereafterfromaheartattackonFebruary4,1987(Cain1987a).Rogershasbeendescribedasamanwholivedhislifeinawaythatwasconsistentwithhisperson-centeredtheory,andasanauthor,therapist,andpersonhewasconsistentlythesameman(Cain1987b).MajorTheoreticalIdeasofPerson-CenteredTherapyPerspectiveonHumanNaturePerson-centeredtherapyasdevelopedbyRogershasapositiveandoptimisticperspectiveonhumannature.Itviewsthepersonasbasicallygoodandtrustworthy,withaninnerandinnatetendencytowardgrowthandwholenessleadingthepersontobealltheycanbe.Thisactualizingtendency,whichis 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themajormotivationineveryhumanperson,movesanindividualtowardselfactualizationorbecomingmatureandautonomous,underappropriateconditionsthataresupportiveandsafefortheperson(seeC. R.Rogers1961, 35).Rogersalsodescribedtheorganismicvaluingprocessthatguidestheactualizingtendencywithaninnatecapacitytochoosewhatwillbeself-enhancingorself-actualizingratherthanwhatwillbeself-destructive.Hebelievedthatwhenperson-centeredtherapistsprovidethetherapeuticconditionsofcongruence(realnessorgenuineness),unconditionalpositiveregard(warmthandacceptanceorrespect),andaccurateempathicunderstanding(oftheclient’sinner,subjectiveworld)inawaythattheclientcanexperiencethem,thentherightconditionsofsupportandsafetyenabletheclienttogrowandselfactualize.Ontheotherhand,ifnegative“conditionsofworth”areimposedonapersonoraclient,usuallybysocietyandparentalfiguresorotherfamilymembers,thentheactualizingtendencyisalienated,andtheindividualmaythendevelopdefensiveandmaladaptivereactionstoanenvironmentthatheorsheexperiencesasoppressiveanddangerous.Thebehaviorthateventuallyresultsmayincludeevilactsofcrueltyandhatred,whichRogersacknowledgedcananddooccur.However,hewasconvincedthatthisisnottheinnatenatureofahumanbeingbutratheranacquiredaspectofhumanbehavior(seeParrott2003,178).Rogersbelievedthatgivenappropriateconditionsfosteringgrowth,humanbeingsarebasicallygoodandtrustworthy,capableofchoosingtheirowndirectioninconstructiveandinsightfulwaysandabletobeproductiveandeffectiveintheirlives(Cain1987b).Person-centeredtherapythereforefocusesontheclientandhisorhercapacityforhealing,growth,andself-actualizationaswellasself-determination.Itdoesnotviewthetherapistasanauthoritativeexpert.Theultimateresponsibilityforhealingandgrowthintherapylieswiththeclient(seeCorey2009,169–70),whoiscapableofbecomingafullyfunctioningpersonwhentheactualizingtendencyisallowedtoblossomandbeexpressed.Person-CenteredTheoryofPersonalityRogershasdevelopedanddescribedbothatheoryofpersonalityaswellasatheoryofpsychotherapyfromaperson-centeredperspective(C. R.Rogers1959).Histheoryofpersonalityconsistsofnineteenpropositionsthataresomewhatcomplex,andithasthereforeattractedmuchlessattentionthanhistheoryofpsychotherapy(C. R.Rogers1980,60).Rogers’s(1959)theoryofpersonality(includingatheoryofpsychopathology)fromaperson-centeredperspectivewithitsnineteenpropositionscanbecondensedintofourmajorfeaturesaccordingtoJ. Sommers-FlanaganandSommers-Flanagan(2004,179–82).Thefirstfeatureofaperson-centeredtheoryofpersonalityisthatitismainlyaself-theory(Bankart1997).Rogersdescribedtheorganismasthelocusofa 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person’stotalpsychologicalexperienceandSidebar8.1theselfasthatpartoftheorganismthatis“me,”whetherconsciousorunconscious.FeaturesofPerson-CenteredThusaperson’sexperienceofselfcandifferTheoryfromhisorhertotalpsychologicalexperi(seeJ. Sommers-Flanagan&enceasanorganism.RogerslabeledsuchaSommers-Flanagan2004,179–82)discrepancyasincongruence.Ontheotherhand,whenaperson’sselfexperiencesare1.Self-theoryinlinewithhisorhertotalexperiencesas2.Phenomenologyandthevaluanorganism,congruenceexistsbetweenselfingofexperienceandorganism,ahighlypositivesituationthat3.Learningandgrowthpotentialfacilitatesthedevelopmentandgrowthofthe4.Conditionsofworthindividualintoamoremature,autonomous,andfullyfunctioningperson.ThesecondfeatureofRogers’stheoryofpersonalityishisemphasisonphenomenologyandthevaluingofexperience.Ithighlyvaluespersonal,subjectiveexperiencethatisdirectandnonverbal,whathasbeencalled“intuitiveknowing”(Bohart1995,91).Person-centeredtherapyseekstohelpclientsbemoreopentotheirownwidevarietyofsubjective,personalexperiencingandtodecidewhichexperiencescanhelpthembecomemorefullyfunctioningpersons.Thethirdfeatureofaperson-centeredtheoryofpersonalityisitsfocusonlearningandgrowthpotential.Rogersemphasizedthateverypersonhasaninnateactualizingtendencythatmoveshimorherinthepositivedirectionofgrowth,maturity,andautonomy,becomingmorewhoheorshereallyis.Itisapotentialforlearningandgrowthineverymomentofone’slifeandone’sexperiences.Rogersobserved:“Thereisonecentralsourceofenergyinthehumanorganism.Thissource. . .ismostsimplyconceptualizedasatendencytowardfulfillment,towardactualization,involvingnotonlythemaintenancebutalsotheenhancementoftheorganism”(1980, 123).Thefourthandfinalfeatureofaperson-centeredtheoryofpersonalityconcernsconditionsofworth.Inadditiontoanindividual’sinnateactualizingtendencytomaintainandenhancehimselforherselfasanorganism,therearealsotwoimportantlearnedoracquiredneeds:theneedforpositiveregardandtheneedforself-regard.Iftheneedforpositiveregardorapprovalfromsignificantothers,especiallyparentsorparentalfiguresinone’slife,isnotmetbecausedisapprovalornegativefeedbackissometimesgiventothepersonforparticularbehaviors,thenconditionsofwortharesetupforhimorher.Theindividualwillthenexperiencepositiveregardorapprovalfromothersforsomeofhisorherbehaviors,butnegativeregardordisapprovalforotherbehaviors.Thiswillresultinasimilarmixofinternalizedpositiveandnegativeself-regardandanincongruentsenseofself,withdiscrepanciesbetweenthesocialselfbasedonothers’expectationsandthetrueself 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basedonone’sactualfeelingsaboutone’sexperiences.Internalgenuinevaluesthatareunconsciouslyappreciatedorganismicallybythepersonoftenclashwithexternallyimposedandconsciouslyincorporatedvaluesfromsignificantothers.Underconditionsofworththatarenotsupportiveorsafe,anindividualwillusuallybecomeincreasinglyoutoftouchwithhisorhertrueself,thatis,becomemoreincongruentandthereforeultimatelyunabletolearnorgrowfromexperience,leadingtopsychopathology.Itisthereforecrucialforanindividualtoexperienceunconditionalpositiveregardinorderforhimorhertohaveappropriateself-regardandtorecoverfrompsychopathologyandgrowagainasaperson.WeshouldalsonotethatRogersviewedpeopleascapableofperceptionwithoutawareness,aprocesscalledsubception.InadditiontothesefourmajorfeaturesofRogers’sperson-centeredtheoryofpersonality,healsoprovideddescriptionsoffullyfunctioningpersonsthatindividualsaremotivatedtobecomeastheyallowtheirorganismicvaluingprocessestobemorefullyutilized.AccordingtoRogers(1961,187–96,italicsassetinoriginal),“Fullyfunctioningpersonsareopentoexperience,arecharacterizedbyexistentialliving,trusttheirorganisms,arecreative,andlivericherlivesthandootherpeople”(seeRyckman2008,454).Helaterexpandedandelaboratedonthesecharacteristicsofthefullyfunctioningpersontoincludethefollowingdescriptionsofwhathetermedemergingpersons(e.g.,corporateexecutiveswhoarecommittedtolivingasimplerlife,counterculturalyoungpeople,nunsandpriestswhohaveovercomedogmatismtolivemoremeaningfully,andethnicallydiversepeopleandwomenwhohaveovercomepassivitytolivemoreassertiveandconstructivelives):“Theyarehonestandopen;theyareindifferenttomaterialcomfortsandrewards;theyarecaringpersons;theyhaveadeepdistrustofcognitivebasedscienceandatechnologythatusesthatsciencetoexploitandharmnatureandpeople;andtheyhaveatrustintheirownexperienceandaprofounddistrustofallexternalauthority”(C. R.Rogers1977,255–74,italicsassetinoriginal;seealsoRyckman2008,455–56).TherapeuticProcessandRelationshipRogers’stheoryofpsychotherapy,comparedtohistheoryofpersonality,ismuchbetterknownandmorewidelyappliedinthepracticeofcounselingandpsychotherapy.Itfocusesonthetherapeuticprocessandthetherapeuticrelationshipbetweenthetherapistandtheclientasthecrucialfactorsineffectivetherapy.Rogersbelievedthataclientshouldleadintheprocessoftherapyandbefreetochoosehisorherownspecificgoalsordirectionintherapy.Thebasicaimofperson-centeredtherapyisnottosolveproblemsbuttoprovidethenecessaryandsufficienttherapeuticconditionsofcongruence,unconditionalpositiveregard,andempathicunderstandingsothatthe 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clientcanfreelygrowtobecomemoreofafullyfunctioningpersoninasafeandsupportivetherapeuticenvironment.ClientswhoarebecomingmorefullyfunctioningormoreactualizedhavebeendescribedbyRogers(1961)asbeingopentoexperience,trustinginthemselves,evaluatingthemselvesmoreinternallythanexternally,andbeingwillingtocontinuegrowing.Morespecifically,Rogersdescribedthefollowingnecessaryandsufficientconditionsoftherapeuticpersonalitychangeinhistheoryofpsychotherapy:“Forconstructivepersonalitychangetooccur,itisnecessarythattheseconditionsexistandcontinueoveraperiodoftime:1.Twopersonsareinpsychologicalcontact.2.Thefirst,whomweshalltermtheclient,isinastateofincongruence,beingvulnerableandanxious.3.Thesecondperson,whomweshalltermthetherapist,iscongruentorintegratedintherelationship.4.Thetherapistexperiencesunconditionalpositiveregardfortheclient.5.Thetherapistexperiencesanempathicunderstandingoftheclient’sinternalframeofreferenceandendeavorstocommunicatethisexperiencetotheclient.6.Thecommunicationtotheclientofthetherapist’sempathicunderstandingandunconditionalpositiveregardistoaminimaldegreeachieved.”(1957, 95)Rogerswasfirmlyconvincedthatthesecoreconditionsalonearesufficientandnecessaryfortherapeuticorpositivepersonalitychangetooccurinanyclient.Hebelievedthatnootherconditionsortherapeuticmethodsarenecessaryfortherapeuticpersonalitychangetotakeplaceinaclient.Suchapersoncenteredapproachplacesmajoremphasisontheequalityandmutualityofthetherapist-clientrelationshipinwhichthetherapistisafellowtravelerwiththeclientontheclient’sjourneythroughlife.Thetherapistisnotviewedasanexpertwithspecializedknowledgeforaccuratediagnosisoftheclientandtechniquesforsolvingtheproblemsoftheclient.Insteadthetherapistisaguidewhoprovidesandcommunicatescongruenceorgenuineness,unconditionalpositiveregardoracceptance,andaccurateempathicunderstandingtotheclienttofacilitatetheclient’sgrowthintoamorefullyfunctioningperson.However,thistherapeuticprocessisnotaseasytoachieveasonemightthink.Thetherapistmusttrusttheclientandprovidethisspecialkindoftherapeuticrelationshipwiththeclient(seeJ. Sommers-FlanaganandSommers-Flanagan2004, 182),bothofwhicharemoredifficulttomaintainthantheyseem.Boththetherapistandtheclientareimperfecthumanbeings,withobviouslimitations.Therefore,atherapist,evenaperson-centeredtherapist,cannotbeexpectedtoalwaysbereal,accepting,andunderstanding(withcongruence, 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unconditionalpositiveregard,andaccurateempathicunderstanding)withandforeveryclient.However,theperson-centeredtherapistwillattempttodevelopthesetherapeuticconditionsandattitudestowardaclient.Rogersrealizedthathistheoryofpsychotherapyisradicalandcontroversialbecausehestronglyassertedthathissixconditionsoftherapeuticpersonalitychangearetheonlysufficientandnecessaryonesforclients,aswellasforotherpeople,togrowandbecomemorefullyfunctioning.Hethereforedisagreedwiththerapistswhoinsistedonothernecessaryconditions,suchasspecifictherapeutictechniques,tobringabouttherapeuticchange.However,evenwhentherapistsviewRogers’scoreconditionsofcongruence,unconditionalpositiveregard,andempathicunderstandingasneithernecessarynorsufficient,orasnecessarybutnotsufficient,toproducetherapeuticchange,mostofthemstillappreciatetheseconditionsashelpful.Theyareoftentaughtastheclinicalfoundationsforanyeffectiveapproachtocounselingandpsychotherapy,andthereforetheyhavebeenincorporatedintoalmosteverycontemporaryschoolofcounselingandpsychotherapy.Congruenceorgenuineness,unconditionalpositiveregardoracceptance,andempathicunderstandingoraccurateempathywillnowbecoveredinmoredetailascrucialcomponentsofthetherapeuticrelationship,especiallyinperson-centeredtherapy.CongruenceCongruenceinthetherapistisalsoreferredtoasgenuineness,orauthenticityandtransparency.Inotherwords,aperson-centeredtherapistwhoiscongruentorintegratedinthetherapeuticrelationshipwiththeclientisreal,honest,andopen,engaginginappropriateself-disclosuretotheclient,involvingbothpositiveaswellasnegativefeelings.Whenthecongruenttherapistisgenuinewiththeclient,theclientisenabledtobemorerealaswell,andhencetobemoretrulyintouchwithhisorherrealself.Congruenceorgenuinenessisthereforeessentialforeffectivecounselingandpsychotherapyfromapersoncenteredperspective(seeC. R.Rogers1961).UnconditionalPositiveRegardUnconditionalpositiveregardisalsoreferredtoasacceptance,warmth,prizing,orrespect.Itisanonpossessivedeepandrealcaringfortheclientthatisnonjudgmentalandpositive,allowingandacceptingtheclienttohavethefeelingsheorsheisexperiencingatthemomentinthetherapeuticrelationship.Thereisalsoatotalprizingorvaluingoftheclientinanunconditionalway,respectingtheclientregardlessofhisorherbehavior.SuchunconditionalpositiveregardofthetherapistfortheclientwillmorelikelyleadtoforwardmovementortherapeuticchangeaccordingtoRogers(1986,198).Fall,Holden,andMarquis(2004, 202)havenoted,however,thatunconditionalpositive 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regardactuallygoesbeyondacceptancebecauseitisatotalrespectfortheclientandhisorherhumanity,regardlessofthebehaviortheclientmaybeshowingatthemoment.Thisunconditionalpositiveregardofthetherapistfortheclientwillenhancetheclient’sownunconditionalself-regardandthereforehelptheclienttogrowandbecomeamorefullyfunctioningperson,becauseconditionsofworthhavebeenreducedorremoved.Rogerswasawarethattherapistsarenotperfectpeople,andthereforecannotexperienceandcommunicateunconditionalpositiveregardtoalltheirclientsallthetime.However,itisessentialfromaperson-centeredtherapyperspectivefortherapiststohavedeeprespectandgenuinecaringorwarmthfortheirclientsineffectivetherapy(C. R.Rogers1977;seeCorey2009,175).EmpathicUnderstandingorAccurateEmpathyEmpathicunderstanding,oraccurateempathy,referstothetherapist’sabilitytoenterdeeplyintotheclient’ssubjectiveworldorinternalframeofreferenceandfeelwiththeclientassensitivelyandaccuratelyaspossible.Althoughitinvolvesdeeplistening,itismorethanjustreflectionoftheclient’sfeelings.Itisanenteringintotheclient’ssubjectiveexperiences,feelingtheclient’sfeelingswithoutlosingthetherapist’sownidentityorbeingoverwhelmedbytheclient’sfeelings.Suchempathicunderstandingexperiencedandexpressedbythetherapisttotheclientwillhelptheclientbeindeepertouchandunderstandingofhisorherownsubjectiveexperiencesorfeelings,includingthosethatmaynotbeasclearorobviousinitially.Therearethereforeatleasttwolevelsofaccurateempathy,orempathiclistening(seeC. R.Rogers1975,1980):empathicunderstandingofwhattheclientisfeelingorexperiencing,anddeeperempathiclisteningandunderstandingofmeaningsoftheclient’sexperiencesofwhichtheclientishardlyawareorconscious.Thislatterdeeperempathyissometimescalledadvancedempathy,wherebythetherapistdeeplyhearsthemessagebehindthemessage(Egan2002).Empathyisactuallyamultidimensionalratherthanasimpleconstruct,withseveralcomponents(seeBuie1981;J. Sommers-FlanaganandSommersFlanagan2003).Thethreemainonesareintellectualempathy,whichisviewingtheworldfromtheclient’sperspectivebutinanobjective,intellectual,ordistantway;emotionalempathy,whichisthetherapist’semotionalresponsetoaclient’sfeelingsorwords;andimaginativeempathy,whichreferstoatherapist’saskingtheempathyquestionposedbyCarkhuff(1987):“HowwouldIfeelifIwereinmyclient’ssituation?”(seeJ. Sommers-FlanaganandSommers-Flanagan2004,185).Empathyhasbeenthemostresearchedanddiscussedofthethreecoretherapeuticconditionsofcongruence,unconditionalpositiveregard,andempathicunderstandingdescribedbyRogersinpersoncenteredtherapy(seeBohartandGreenberg1997;J. C.Watson2002).Ithas 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beenacknowledgedbyalmosteverymajorapproachtocounselingandpsychotherapyasacrucialfactorineffectivetherapy.TechniquesinHowever,inreviewingthewritingsofPerson-CenteredTherapyRogersonthesethreecoretherapeuticor(seeJ. Sommers-Flanagan&therapistconditions,JeraldBozarthconSommers-Flanagan2004,190–98)cludedthatgenuinenessandempathicunderstandingcanbeviewedasthetwocon1.Experiencingandexpressingtextualattitudesfortheprimaryconditioncongruenceoftherapeuticchange:unconditionalpositive2.Experiencingandexpressingregard(1996, 44).Bozarththereforebelievesunconditionalpositiveregardthatunconditionalpositiveregard,together3.Experiencingandexpressingwithgenuinenessandempathicunderstandempathicunderstandinging,shouldallbeconsideredasinglecrucialconditionfortherapeuticchangetooccurintheclient,andthisconditionisessentiallyanattitudethatthetherapistmusthavetowardtheclientforeffectivecounselingandtherapytotakeplace(seealsoTyler1999).Person-centeredtherapyultimatelyrequiresthiskindoftherapeuticattitudeonthepartofthetherapist,andnottechniques;onlywhenthetherapistthussuccessfullycommunicatespositiveregardcantheclientbetherapeuticallychanged.Sidebar8.2 MajorTherapeuticTechniquesandInterventionsPerson-centeredtherapyasdevelopedbyRogersdoesnotespousespecifictherapeutictechniquesorinterventions.Italsodoesnotformallyengageinpsychologicaldiagnosisbutrathertreatseachclientasauniqueindividual(althoughsomecontemporarypractitionersofperson-centeredtherapymayprovidediagnosesfortheirclientsforthesakeofmedicalinsurancereimbursement).Rogershimselffeltthatformalpsychologicaldiagnosisisnotnecessaryfortherapyandmayevenhavedeleteriouseffectsontheprocessoftherapy(C. R.Rogers1957, 220).Moretraditionalperson-centeredtherapyfollowingRogersemphasizesthatonlysixconditionsarenecessaryfortherapeuticchangetooccurintheclient.Thefirsttwoconditionsfocusonaclientwhoisexperiencingincongruence,withfeelingsofvulnerabilityoranxiety,butwhoisinpsychologicalcontactortherapeuticrelationshipwithatherapist.Theotherthreeconditionsfocusonthetherapistbeingcongruent,experiencingunconditionalpositiveregardfortheclient,andexperiencingempathicunderstandingoftheclient’sinternalframeofreferenceandcommunicatingthistotheclient.Thefinalconditionrequiresthecongruenttherapistcommunicatingempathicunderstandingandunconditionalpositiveregardtotheclienttothedegreethattheclientperceivesandexperiencesthisunderstandingandregard.Thekeytherapeutic 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“technique”orinterventioninperson-centeredtherapythusconcernsthetherapisthavingtherighttherapeuticattitudetowardtheclientandeffectivelycommunicatingorexpressingittotheclient.Althoughtherearenospecifictechniquesinthepracticeoftraditionalperson-centeredtherapy,thetherapeuticattitudeoftheperson-centeredtherapisttowardtheclientcanbedescribedasconsistingofthreemajor“techniques”orinterventions:experiencingandexpressingcongruence,experiencingandexpressingunconditionalpositiveregard,andexperiencingandexpressingempathicunderstanding(J. Sommers-FlanaganandSommers-Flanagan2004,190–98).ExperiencingandExpressingCongruenceForthetherapisttobecongruentmeansthatthetherapistisreal,open,genuine,andhonestinrelatingtotheclient.However,thisdoesnotmeanthatthetherapistengagesintotalself-disclosureorshareseverythoughtorfeelingthatheorshemayhaveduringthetherapysessionwiththeclient.Somediscernmentandself-controlarestillneededsothatthetherapistsharesonlywhatisappropriateandhelpfultotheclient.Itcanincludesharingnegativefeelingssuchasfeelingbored,butsomefeelings,suchassexualattractionfortheclient,maybebettersharedwithaclinicalsupervisororconsultantthanwiththeclient,whomayfeelthreatenedbythetherapist’sdisclosureofsuchfeelings.Rogersseemstohavebelievedthattherapistscanusetechniquesintherapybutonlyiftheyoccurspontaneously,andnotinapreplannedway(J. SommersFlanaganandSommers-Flanagan2004, 193).Inotherwords,iftechniquesareeverappropriateintherapy,theyshouldcomeupinagenuineandspontaneousway,consistentwiththebehaviorofacongruenttherapist.More-contemporarypractitionersofperson-centeredtherapy,therefore,mayusetechniquesattimesbutinagenuinewayappropriatetoparticularclients(seeBozarth,Zimring,andTausch2002;Cain2002a).ExperiencingandExpressingUnconditionalPositiveRegardExperiencingandexpressingunconditionalpositiveregardfortheclientisanothercoretherapeuticconditionaccordingtoRogers.Bozarth(1996)concludedthatunconditionalpositiveregardistheprimaryconditionfortherapeuticchangetooccurintheclient.Itisanattitudeofwarmth,respect,deepcaringfor,andacceptanceoftheclient,inwhichtheclientisvaluedsimplyforwhoheorsheisasaperson,withoutanyconditionsofworth(C. R.Rogers1959).Rogersclarifiedthatsuchunconditionalpositiveregardisakindoflovethatisequivalenttoagape,atermusedbytheologians,butnotrelatedtotheromanticandpossessivemeaningsusuallyassociatedwiththeword“love”(seeC. R.Rogers1962, 422). 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Sincetherearenoperfecthumanbeingsorperfecttherapists,itisimpossibleinpracticeforevenperson-centeredtherapiststoexperienceandexpressunconditionalpositiveregardforeveryclientallthetime.However,theperson-centeredtherapistwillstriveasmuchaspossibleforanattitudeofunconditionalpositiveregardforaclient.Unconditionalpositiveregardcanbecommunicatedorexpressedtoaclientinvariousways.Themoredirectwayofsimplysaying,forexample,“Ivalueandprizeyouasawholeperson”or“Iacceptyouandcareaboutyouforwhoyouareasaperson”or“Iwon’tjudgeyou”oftentimesmaynotbethemostappropriatemeansofexpressingunconditionalpositiveregard.Clientsmaybeoverwhelmedbysuchdirectstatementsandreactwithunrealisticexpectationsofperfectcaringandevenromanticlovefromthetherapistorrespondwithfearordistancingbecauseoftheirdiscomfortwithsuchcaringintimacyofferedbythetherapist(seeJ. Sommers-FlanaganandSommers-Flanagan2004,195).However,sometimesadirectexpressionofunconditionalpositiveregardorwarmthanddeepcaringcanbehelpful,forexample,whenRogershimselfrespondedtoaclientwhodidn’tcarewhathappenedwith:“Youjustdon’tcarewhathappens.AndIguessI’djustliketosay—Icareaboutyou.AndIcarewhathappens”(C. R.Rogers,Gendlin,Kiesler,andTruax1967,409).Otherappropriatewaysofindirectlyexpressingunconditionalpositiveregardincludeestablishingarelationshipofrespectandwarmthwiththeclientbykeepingappointments,addressinghiminthewayhewouldliketobeaddressed,andlisteningintentlyandcaringlytohim;lettingtheclientfreelytalkaboutherselfinwhatevermanneriscomfortableforher;hearingandrememberingparticulardetailsoftheclient’sstory,forexample,byusingparaphrases,summaries,andoccasionallyinterpretations;respondingwithempathyandcompassionwhentheclientexpressesemotionalpainandconflicts;andmakinganintentionalefforttoacceptandrespecttheclientinawarmandcaringway(seeJ. Sommers-FlanaganandSommers-Flanagan2003,108).ExperiencingandExpressingEmpathicUnderstandingAlthoughitisimpossibletofullyanddirectlyexperienceanotherperson’sfeelings(C. R.Rogers1959),person-centeredtherapistsdotheirbesttoexperienceandexpressempathicunderstandingoftheirclient’sinternalframeofreferenceorsubjectivefeelingswithasaccurateempathyaspossible.BasedonRogers’sdescriptionofwhatbeingempathicreallymeans(seeC. R.Rogers1975, 4),J. Sommers-FlanaganandSommers-Flanaganbrieflydescribethefollowingfourmajorcomponentsofexperiencingandexpressingempathicunderstandingtotheclient:“EnteringandBecomingatHomeintheClient’sPrivatePerceptualWorld;BeingSensitivefromMomenttoMomentwiththeClient’sChangingMeaningsandEmotions;TemporarilyLivingandMoving _Tan_Counseling_BB_mw.indd154 9/21/104:35:52PM Person-CenteredTherapy 141 AboutDelicatelyintheClient’sLife;andSensingDeepMeanings,butNotUncoveringFeelingsThatAreTooFarOutofAwareness”(2004,197,italicsassetinoriginal).Withregardtotemporarilylivingandmovingaboutdelicatelyintheclient’spersonalworld,thereisarealdangerofthetherapistbecomingtooinvolved,somuchsothattheempathictherapistloseshisorherownsenseofselfinawaythatisunhealthyandpotentiallyharmfultothetherapistaswellastotheclient.Rogershimselfbecametooinvolvedinthesubjectiveworldofoneofhisfemaleclientsandultimatelylosthissenseofselfintherelationship(seeC. R.Rogers1967,367;seealsoC. R.Rogers1972).Nevertheless,empathicunderstandingof,oraccurateempathyfor,theclientisacoretherapeuticconditioninperson-centeredtherapy,andvirtuallyeveryschoolofcounselinghasacknowledgeditasanintegralpartofeffectivetherapy.Itiscrucialtorememberthatempathicunderstandingismorethanmerelyreflectingfeelingsorparaphrasingthefeelingsexpressedbyaclient,whathasbeendescribedasthebasiccounselingtechniqueofactivelistening.Rogershimselfstoppedwritingaboutreflectionoftheclient’sfeelingsearlyinhisprofessionalcareerbecausemanyclinicianserroneouslyconcludedthatempathysimplyinvolvesparaphrasingandsummarizingthefeelingsexpressedbytheclient.Rogerschoseinsteadtoemphasizetheneedforaperson-centeredtherapisttohaveanempathicattituderatherthanfocusonreflectingaclient’sfeelingsorlisteningempathically(C. R.Rogers1975).Carkhuff(1971,170–71)hasextendedRogers’sthreecoretherapeuticconditionstosixcoreconditions:thefacilitativeconditionsofempathy(orunderstanding),respect(orunconditionalpositiveregard),andconcreteness(orbeingspecific);andtheactionconditionsofgenuineness(orbeingrealorcongruent),confrontation(ortellingitlikeitis),andimmediacy(orwhatisreallygoingonbetweenthetherapistandtheclient).Theextracoretherapeuticconditionthatismostoftenaddedtocongruence(orgenuineness),unconditionalpositiveregard(orrespect),andempathicunderstanding(orempathy)isconcretenessorspecificity(see,e.g.,Egan2006).Traditionalperson-centeredtherapystillfocusesonthethreecoretherapeuticconditionsandthesixnecessaryandsufficientconditionsoftherapeuticpersonalitychangefirstdescribedbyRogers(1957).Ithasbeenappliednotonlyinindividualtherapybutalsoinplaytherapy(Axline1947)andclient-centeredworkwithchildren(K. Moon2002),client-centeredgroupprocess,classroomteaching,theintensivegrouporbasicencountergroup,andpeaceandconflictresolutionbetweenlargergroupsandevennations(seeRaskin,Rogers,andWitty2008,172–74).Asnoted,more-contemporaryversionsofperson-centeredtherapyhavebuiltonandgonebeyondRogers’sapproach,withawiderarrayoftherapeutictechniquesandpractices.Suchinnovationsincludeperson-centeredexpressiveartstherapy(N. Rogers1993,1995;J. Sommers-Flanagan2007);“focusing”asanexperientialtechniquetodeeperclientexperiencing(Gend- _Tan_Counseling_BB_mw.indd155 9/21/104:35:53PM 142 MajorCounselingandPsychotherapyTheoriesandTechniques lin1996);evocativetechniquestohelpclientsreexperiencecrucialtroublingfeelingsthatstillbotherthem(RiceandGreenberg1984);perceptualpsychology(Combs1988,1989,1999);newfrontiersinthetheoryandpracticeofperson-centeredtherapy(MearnsandThorne1999,2000);collaborativegenderandpowerissuesintheperson-centeredapproach(Natiello2001);facilitationofemotionalchangeintherapyandmore-advancedmethodsofperson-centeredtherapy(L. S.Greenberg,Korman,andPaivio2002;L. S.Greenberg,Rice,andElliott1993);focusontheinnerworkingsoftheprocessoftherapy(Rennie1998);deeperunderstandingofempathyinthepracticeoftherapy(Bohart2003;BohartandGreenberg1997;BohartandTallman1999);empathywhenfunctioninginallitsmultifaceteddimensions(cognitive,affective,andinterpersonal)asoneofthemostpotenttoolsofthetherapist(J. C.Watson2002);client-centeredtherapyasauniversalsystemoftherapy(C. H.Patterson1995);andtheclient-centeredrelationshipunderstoodasessentialinallapproachestotherapy(Hubble,Duncan,andMiller1999),tonamebutafew(seeCorey2009,190).Motivationalinterviewing(MI)isawell-knownandmorespecificcontemporaryversionofaperson-centeredapproachtotherapythatincludesspecifictechniques.ItwasdevelopedbyWilliam R.Miller,basedonhisclinicalworkandresearchonproblemdrinkingandaddiction.DescribedbyMillerasCarlRogersinnewclothes(ProchaskaandNorcross2010,147),MIhasbeendefinedas“adirective,client-centeredcounselingstyleforelicitingbehaviorchangebyhelpingclientstoexploreandresolveambivalence”(RollnickandMiller1995, 326).Itfocusesonenhancingtheintrinsicmotivationtochangeinaclientbyusingaperson-centeredstylewithwarmth,empathy,andanegalitariantherapeuticrelationship,inconjunctionwithperson-centered“techniques”suchasreflectivelisteningandaskingkeyquestions.However,MIalsoaddsothertherapeutictechniquesthatgobeyondtraditionalperson-centeredtherapy,suchasusingspecifictherapeuticinterventionstohelpclientsmovetowardbehaviorchangeandincludingthetherapist’sgoalsfortherapeuticchangesintheclient(MoyersandRollnick2002).WilliamMillerandStephenRollnick(1991,2002)haveidentifiedanddescribedfourmajorprinciplesforthepracticeofMI(seeProchaskaandNorcross2010, 148)basedontheirviewofRogers’sapproachtoperson-centeredtherapy(whichtheyfeltwasnotnondirectivebecauseRogersdidguidehisclients,thoughgently,toexploretheirpain,agitation,orconfusion,andstaywithsuchexperiencesinordertoworkthroughthem):1.Expressempathybyusingreflectivelisteningskillstounderstandtheclientandconveysuchempathicunderstandingaswellasgenuinecaringtotheclient.2.Developdiscrepancybetweentheclient’sdeepvaluesandpresentbehavior.Thetherapisthelpstheclienttoperceiveornoticesuchadis- _Tan_Counseling_BB_mw.indd156 9/21/104:35:54PM 143 Person-CenteredTherapy crepancy,whichcanpowerfullymotivatetheclienttoinitiatechangethattheclientdesires.Itistheclientwhoarguesforchangeandtalksaboutchanging,notthetherapist.3.Rollwithresistancebyrespondingtoclientresistancewithreflectioninsteadofconfrontation.Clientresistanceisviewedasanexpressionofambivalenceaboutchange,andthetherapistshouldnotconfrontitdirectlyortrytopersuadetheclienttochange.Thetherapistshouldinsteadrollwiththeresistancebyusingempathicreflectionandunderstanding.4.Supportself-efficacybyactivelycommunicatingtotheclientthatheorsheiscapableofchange,buildingoptimism,usingbriefandsmallinterventionsthatallowchangetosuccessfullyoccur,andreinforcingoptimismforfurtherchange.However,thetherapiststillletstheclientleadincomingupwithpossiblesolutionsforchange.Morerecently,anewseriesofbooksfocusingonapplicationsofMIisbeingpublished,includingMIfortreatingpsychologicalproblemssuchasanxiety,posttraumaticstressdisorder,obsessive-compulsivedisorder,depression,suicidaltendencies,eatingdisorders,problemandpathologicalgambling,medicationadherenceinschizophrenia,patientswithdualdiagnoses,andpatientsinthecriminaljusticeorcorrectionalsystem(Arkowitz,Westra,Miller,andRollnick2008);andMIinhealth-carecontexts,helpingpatientschangebehaviortoimprovetheirhealthinareassuchasweightloss,exercise,smokingcessation,medicationadherence,andsafersexpractices(Rollnick,Miller,andButler2008).ApractitionerworkbookisalsoavailableforbuildingMIskills(Rosengren2009).WilliamMillerandGaryRoserecentlyproposedatheoryofMIwithtwomajorcomponents:“arelationalcomponentfocusedonempathyandtheinterpersonalspiritofMI,andatechnicalcomponentinvolvingthedifferentialevocationandreinforcementofclientchangetalk”(2009, 527). Person-CenteredTherapyinPracticeAHypotheticalTranscriptClient:Ilostmyjobagain. . .thesecondtimeinjustamonth!Ifeellikealoser,andthatpeoplemustbelaughingatmeandthinkingthatI’mafailure,thatI’mgoodfornothing.Person-CenteredTherapist:Youjustlostyourjob,twiceinonemonth. . .andyou’refeelinglousyaboutit,likebeingaloser,andyoufeelthatothersarelookingdownonyou,thinkingofyouasnogoodandafailure. _Tan_Counseling_BB_mw.indd157 9/21/104:35:55PM 144 MajorCounselingandPsychotherapyTheoriesandTechniques Client:Yeah,. . .andithurtsrealbadinsidebecauseI’vetriedveryhardtokeepmyjobs. . .butIguessI’mnotgoodenoughandneverwillbegoodenough. . .(withtearswellingup)Person-CenteredTherapist:Um-hmm. . .It’sreallypainful,especiallywhenyoutriedsohardtokeepyourjobs,andfeelingyou’renotgoodenough. . .andwillneverbegoodenough?. . .(silenceforafewmoments,withmoretearsfromtheclient)Client:It’s. . .It’sreallyhard. . .tofeellikenomatterhowmuchItry,it’snouse. . .it’snotgoingtomakeadifferenceatall. . .becauseI’mnogoodatallatkeepingajob. . .orevenatanythingelse. . .I’msuchafailure,suchaloser. . .(weepsalittle).Person-CenteredTherapist:Um-hmm. . .HerearesomeKleenexifyou’dlikesome. . . .Youreallyfeelcrushedinside. . .likeyou’reatotalfailure,andnomatterwhatyoudoorhowhardyoutry,it’snotgoingtoworkout. . .it’snotgoingtobegoodenough. . .aboutyourjob. . .aswellasaboutanythingelseinyourlife. . . .Isthatwhatyousaid?AmIgettingitright?Client:Yeah,yeah. . .that’sright.Idon’tknowwheretogofromhereandwhattodo. . .butIfeelI’mjustatotalnothing,abigzero. . .whocan’tdoanythingright. . .(weepsalittlemore)(silenceforafewmoremoments)Person-CenteredTherapist:Soundslikeyou’reexperiencinganoverwhelmingfeelingofbeingacompletefailure. . .beingatotalnobody. . .andyoufeelstuck,notknowingwhattodoorwheretogofromhere. . .anditjusthurts. . .andhurts. . .andhurts. . .moreandmoredeeply. . .(clientbeginstoweepmore)Client:Yeah. . .it’sjustsohard. . .andithurtssomuchdeepinside. . .(sobsforafewseconds)(silenceforafewmoments)Person-CenteredTherapist:Um-hmm. . .somuchpaininside. . .ithurtssobadlyanddeeplythatthetearsjustflow. . .Client:Um-hmm. . .(weepsforafewmoreseconds)Person-CenteredTherapist:(remainsquietforafewsecondswhilehandingmoreKleenextotheclient) Thishypotheticaltranscriptofasmallpartofatraditionalperson-centeredtherapysessiondemonstratestheexperienceandexpressionofunconditionalpositiveregard(warmthanddeepcaring)aswellasempathicunderstand- _Tan_Counseling_BB_mw.indd158 9/21/104:35:56PM Person-CenteredTherapy 145 ingbyagenuineorcongruentperson-centeredtherapistforaclientwhoisstrugglingwithmuchdeepemotionalpainandfeelsoverwhelmedbyit.Theperson-centeredtherapistengagesinintensereflectivelisteningandconveysunconditionalpositiveregardandempathicunderstandingbyusingparaphrasesandbriefsummariesoftheclient’sfeelingsandexperiences,aswellasbybeingpresentindeeplycaringmomentsofsilenceandofferingtheclientKleenexatappropriatetimeswhentheclientiscrying.Theperson-centeredtherapistdoesnotuseotherspecifictherapeutictechniquessuchasproblemsolvingofthejobsituation,orcognitiverestructuringoftheclient’sthinking,orbehavioralmethodsforemotionalcontrol.CritiqueofPerson-CenteredTherapy:StrengthsandWeaknessesPerson-centeredtherapyhasseveralstrengths,manyofthemsimilartothestrengthsofexistentialtherapycoveredinthepreviouschapterofthisbook.First,person-centeredtherapyinvolvesagenuineanddeeprespectfortheclientasaperson.Itisthusclientcentered,withadeeptrustintheindividual’sactualizingtendencytolearnandgrowtobecomeamorefullyfunctioningperson.Ithasabasicallypositiveviewofthegoodnessofhumannature.Asahumanisticapproachsimilartoexistentialtherapy,itstronglyopposesanytherapeuticattempttodehumanizeorobjectifytheclientandthereforedoesnotfocusontherapeutictechniquesperseoronformaldiagnosisandpsychologicaltestingandassessmentoftheclient.Second,itemphasizesthetherapeuticrelationshipasthekeyfactorineffectivecounselingandtherapyforallclients.Infact,accordingtoRogers,thereareonlysixnecessaryandsufficientconditionsfortherapeuticpersonalitychangetooccurintheclient,chiefamongthem:congruence,unconditionalpositiveregard,andempathicunderstanding,whichthetherapistneedstoexperienceandcommunicatetotheclient.Traditionalperson-centeredtherapythereforeexaltssuchatherapeuticrelationshiptothehighestlevelofnecessityfortherapeuticchangeintheclienttooccur,withouttheneedforanyothertherapeutictechniquesorinterventions.Nootherapproachtocounselingandtherapyplacessuchapremiumonthetherapeuticrelationshipastheessentialandonlyhealingfactorineffectivecounselingandtherapy.Empathyinparticularhasreceivedtremendousattentionandresearchsupportforitscrucialandessentialroleineffectivetherapy(J. C.Watson2002).Third,arelatedstrengthofperson-centeredtherapyisitsfocusonthepersonofthetherapistandtheneedforcongruenceorgenuinenessandmaturityonthepartoftherapistssothattheyeffectivelyexperienceandexpressunconditionalpositiveregardandempathicunderstandingtotheirclients.Thepersonofthetherapistismoreimportantthantechniques.Fourth,Rogershasbeencreditedwithopeningthecounselingandtherapyfieldtoempiricalscrutinyandresearch.Hetriedtoputhisperson-centered _Tan_Counseling_BB_mw.indd159 9/21/104:35:57PM 146 MajorCounselingandPsychotherapyTheoriesandTechniques ideasintohypothesesthatcouldbeempiricallytestedinresearch(seeCain2002a,2002b;Combs1988).Healsoinsistedonallowingtherapysessionstoberecordedandthenobjectivelyratedbyimpartialjudgesorresearcherstoinvestigatetherelationshipofthecoretherapeuticconditionsofgenuineness,unconditionalpositiveregard,andempathicunderstandingorempathytotherapeuticoutcomes.Person-centeredtherapyhasthereforecontributedsignificantlytoresearchontherapyprocessandoutcome,despiteitseschewingoftechniqueanddiagnosis.Fifth,person-centeredtherapyhasgreatlyinfluencedvirtuallyeverymajorapproachtocounselingandtherapy,butthisimpacthasnotalwaysbeenexplicitlyacknowledgedorsufficientlyappreciated(Farber1996).Nevertheless,innovationsinmore-contemporaryperson-centeredapproachestotherapyhavebeenmade,withappropriateacknowledgmentsofthepioneeringworkandinfluenceofRogers,apartiallistofwhichwasbrieflyreviewedearlierinthischapter.Sixth,andfinally,person-centeredtherapymaybeparticularlyhelpfultoclientswhoneedspaceanddeepacceptanceandgenuinecaringfromatherapist,inordertoexploreissuesandtheirowninnerexperiencesandfeelings,withoutbeingjudgedorhavingexternalconditionsofworthimposedonthem.Suchclientshavetypicallyincludedmiddle-classcollegestudentsandothersstrugglingwithdevelopmentalandidentityissues,manyofwhomwereseeninearlyclient-centeredtherapy,theforerunnerofperson-centeredtherapy.Person-centeredtherapyalsohasseveralweaknesses.First,theradicalfocusontheindividualanddeeprespectandtrustinhisorherinnategoodnessandactualizingtendencycanresultinanoverlyoptimisticrelianceontheclienttoprovideself-appraisalsthatareaccurateandtoengageinhealthygrowthoractualizationasaperson.Suchanindividualisticfocusontheselfanditsultimateimportanceandautonomymaywellleadtogrosserformsofindividualismandinflatedviewsoftheselfthatareunhealthyandmayevenbecomepathological.Humanbeingsarecapablenotonlyofhealthyandconstructivegrowthbutalsoofmorenegativeanddestructiveactionssuchascrimeandwar,andnotonlybecauseofconditionsofworthimposedonthem(seeParrott2003,190–91).Second,theindividualisticfocusonperson-centeredtherapytendstoneglecttheimportanceofotherfactorssuchassocial,cultural,political,economic,andbiologicalforcesthatcanleadtopsychopathologyinindividuals.Amoreholisticandcontextualviewofanindividual’sfunctioninganddysfunctioningisneededforperson-centeredtherapytobemorebalancedandcomprehensive.Third,theemphasisonself-actualizationandtheimportanceandautonomyoftheselfinperson-centeredtherapyisalsoproblematicinacrossculturalcontextandfromamulticulturalperspective.ItmayreflectaWesternculturalbiasinvaluingindividualism.Othercultures,suchasthoseofAsia, _Tan_Counseling_BB_mw.indd160 9/21/104:35:58PM Person-CenteredTherapy 147 valuesocialandfamilyrelationshipsmorethanWesternculturesdo,andhencepersonalitytheoriesfromAsianculturalperspectivesemphasizemoretheimportanceofrelationshipsinthedevelopmentoftheindividual(Pedersen1983).ForsomeAsiantheoriesofpersonality,afocusonself-actualizationisviewedasdetrimentaltoaperson’soptimaldevelopment(seeToddandBohart2006, 215).Fourth,traditionalperson-centeredtherapy’sradicalemphasisonthetherapeuticrelationshipbasedonthecoreconditionsofcongruence,unconditionalpositiveregard,andempathicunderstanding,astheessentialhealingfactorineffectivecounselingandtherapy,istooexclusiveandextreme.Althoughthetherapeuticrelationshipisanimportantfactorineffectivetherapy,itisnottheonlyfactor.Infact,basedonearlierresearch(see,e.g.,Lambert,DeJulio,andStein1978;Parloff,Waskow,andWolfe1978),evenperson-centeredtherapistshaveacknowledgedthatthecoreconditionsdescribedbyRogersarenotnecessaryorsufficient,butcanbehelpfulfortherapeuticchangetooccurinclients(seeRaskin1992).Fifth,traditionalperson-centeredtherapy’sshunningofspecifictherapeutictechniqueshasbeenquestioned.Althoughtechniquesarenotalwaysthemostimportantfactorineffectivetherapy,theyarestillimportant,andinsomepsychologicaldisorderstheyarecrucialforeffectivetreatment.Examplesofspecializedtherapytechniquesthatempiricalresearchhasfoundtobesuperiorintheireffectivenessinthetreatmentofparticularpsychologicaldisordersincludeexposuretreatmentsforspecificphobias,responsepreventionforobsessive-compulsivedisorders,cognitiverestructuringandexposureforagoraphobia,gradualpracticewithsomesexualdisorders,anduseofamoresupportiveapproachininterpretationinshort-termpsychodynamictherapy,takingclientsymptomseverityintoconsideration(LambertandBarley2002;LambertandOgles2004).Arelatedweaknessofperson-centeredtherapyisitseschewingofformaldiagnosisandpsychologicalassessmentanditsassumptionthatitcanbeeffectiveforallclientsandallpsychologicaldisorders.Itisclearthatonesizedoesnotfitallinthiscontext;hence,diagnosisandassessmentareimportant,andsoaresometherapeutictechniquescrucialtotheeffectivetreatmentofparticularpsychologicaldisorders.Sixth,theemphasisonthepersonofthetherapistandtheneedforthetherapisttoexhibitthecoretherapeuticconditionsinperson-centeredtherapyisatallorderforanytherapist.Notherapistisperfect;hence,notherapistcanexperienceandexpressunconditionalpositiveregardandempathicunderstandingallthetimetoallclients,withtherapistcongruencerequiredaswell.Theotherdangeristhepossibilitythataperson-centeredtherapistwilltrysohardtoempathicallyenterintotheclient’sinternalframeofreferenceorsubjectiveworldofexperiencethatthetherapistendsuplosinghisorherownsenseofselfandclinicalobjectivity.Rogershimselfhadsuchanexperiencewithawomanclient,asmentionedearlierinthischapter. 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Seventh,anothercloselyrelatedweaknessofperson-centeredtherapyisitsclaimtobenondirectiveandunconditionalinthepositiveregardorvaluingoftheclient.Inrealityitisimpossibleforatherapisttobecompletelynondirectiveorvaluefreeandunconditionalinhisorherpositiveregardfortheclient.Everytherapist,asaperson,hasvalues,eveniftheyarenotstatedexplicitlyorverbally.Values,ofcourse,shouldnotbeimposedontheclient,buttheymustbeclarifiedandsharedopenlywhenappropriate.EvenRogershasbeenobservedinhistherapysessionswithhisclientstobedirectiveattimes,howevergently,respondingtothemwithmoreinterestorempathywhenevertheyexpressedtheirfeelingsmoreopenlyorseemedtobemovinginamoreactualizingdirection.Eighth,clientswithphysicaldisabilities(See1985),moreseverepsychologicaldisorders,ormorespecificsymptomssuchassimplephobias,sexualdysfunction,andobsessive-compulsivedisordersmayneedmorethanwhattraditionalperson-centeredtherapistscanofferintermsofthecoretherapeuticconditions.Inthebroaderarenaofdealingwithracialconflictsandpoliticaltensionsbetweennations,Rogersstillfocusedonprovidingthecoretherapeuticconditionstofacilitategroupdiscussionandunderstanding.Althoughthispracticemaybehelpfultosomeextent,itisarathernaiveorsimplisticapproachtopeacemakingthatdoesnottakeintosufficientconsiderationotherpowerfulhistorical,political,economic,cultural,tribal,andsocialforcesthatmaymakeconflictresolutionandconstructivechangeverydifficult,ifnotimpossible.Finally,althoughRogerswasinstrumentalinadvancingempiricalresearchintheprocessandoutcomeoftherapy,andspecificallyofperson-centeredtherapy,therearemethodologicalweaknessesandflawsinmanyoftheresearchstudiesthathavebeenconductedonperson-centeredtherapy.Examplesofsuchmethodologicalweaknessesincludetheabsenceofno-treatmentandattention-placebocontrolgroups,andassessmentthatdependsonratingsoftheclient’ssubjectiveexperiencesratherthantheactualfunctioningorbehaviorofclients(seeProchaskaandNorcross2010, 153).ABiblicalPerspectiveonPerson-CenteredTherapyPerson-centeredtherapyhasseveralphilosophicalperspectives,similartoexistentialtherapy,thatcanbeappreciatedfromabiblical,Christianperspective,includingitsdeeprespectandgenuinecaringforthepersonanditsemphasisontheindividual’sfreedomtochooseandtogrow.However,severalsignificantandseriousproblemswithperson-centeredtherapyemergewhenitiscritiquedfromabiblicalperspective.First,Rogershadtoooptimisticaviewofhumanbeingsasinnatelygoodwithanactualizingorgrowthtendency.Abiblicalperspectiveonhumannaturewillalsoemphasizethedarkersideofhumannaturethatissinfulandfallen _Tan_Counseling_BB_mw.indd162 9/21/104:36:00PM Person-CenteredTherapy 149 (Jer.17:9;Rom.3:23).Humanbeingsarethereforealsocapableofevilandsin.Theydonotautomaticallyengageinconstructivegrowthbecauseofaninnatelygoodactualizingtendency.Second,person-centeredtherapy’ssupremeregardfortheprimacyandautonomyoftheselfortheindividualisproblematicbecauseitcanleadtoself-worshipandevenself-obsession,whichisatoddswithtrueworshipandloveofGodandlovingcommunitywithothers(Mark12:29–31).Theeventualresultmaybeallowingandevenencouragingtheclientto“slideintoaselfgratifying,narcissisticworld”asVitz(1994,110)haspointedout.HurdingdrewthefollowingconclusionaboutRogersandhisperson-centeredtherapyfromaChristianperspective:“FrancisSchaefferhasdescribedhumanitynotonlyasaruin,butasagloriousruin.Rogers’optimisticviews,althoughcompatiblewiththe‘glory,’donotaccordwiththe‘ruin’ofmankind.Schaeffer’s‘gloriousruin’hasbecomea‘do-it-yourself’structurewheremenandwomendonotbearthedivineimagebutaremadeintheimageofthemselves.Sadly,suchanedificeisbuiltontheshakygroundofhumanautonomyandisdoomedtoultimatecollapse”(1985, 123).Third,RogersalsoviewedGodorbiblicalauthorityassecondary,ifnotunnecessaryinanindividual’sself-actualization,placingthehighestauthorityinsteadinthesubjectiveexperienceoftheperson.Rogerswrotethesestrongwords:“Experienceis,forme,thehighestauthority.Thetouchstoneofvalidityismyownexperience.Nootherperson’sideasandnoneofmyownideasareasauthoritativeasmyexperience.ItistoexperiencethatImustreturnagainandagain;todiscoveracloserapproximationtotruthasitisintheprocessofbecominginme.Neitherthebiblenortheprophets—neitherFreudnorresearch—neithertherevelationsofGodnorman—cantakeprecedenceovermyowndirectexperience”(1961, 23).Suchaviewoftheultimacyandhighestauthorityofpersonalexperienceisseriouslyflawedfromabiblicalperspective,whichemphasizestheultimacyofGod,andthehighestauthorityintheBible,God’sinspiredWord.Person-centeredtherapyemphasizesthesovereigntyofthehumanperson(Raskin,Rogers,andWitty2008, 181)whereastheBibleemphasizesthesovereigntyofGod.Fourth,unconditionalpositiveregardisoftenequatedwithagapeloveasdescribedinScripture(1 Cor.13).Rogershimselfdescribedunconditionalpositiveregardasakindoflovethatisequivalenttoagape(C. R.Rogers1962, 422).Althoughhistherapeuticconditionsofcongruence,unconditionalpositiveregard,andempathicunderstandingasatriadcomeclosetoagapelove,theyarenotequivalenttoagapelove(S. L.JonesandButman1991, 270).AgapeloveinScriptureisdeeper,purer,divinelove(1 Cor.13)thatistrulyothercenteredandfocusedontheultimatewelfareandwell-beingofothers.Italsofirmlyholdspeopleaccountabletoultimatebiblicaltruth,whichdoesnotignoresinandevil.Agapelovewillthereforecaringlyandcompassionatelyconfronttheclientwhennecessary. 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Fifth,person-centeredtherapy’sradicalemphasisonthetherapeuticrelationshipandthepersonofthetherapistineffectivecounselingandtherapyisoverallagoodonethatisconsistentwiththeBible’sfocusontheimportanceoftherelationaldimensioninlife.However,theneedfortheHolySpirit’spowerandpresenceinproducingthespiritualfruitorvirtueofagapeloveinthetherapistiscrucialfromabiblicalperspective(seeTan1999b),sothatthegenuinelycaringtherapistcanmaintainadeeplyempathicrelationshipwiththeclientinahealthyandholyway,withoutlosinghisorhersenseofselforfallingintoamoresexualizedversionoflove.Theburdenistooheavyfortheimperfecthumantherapisttotryonhisorherownstrengthtobecongruentwithunconditionalpositiveregardandempathicunderstandingallthetimewitheveryclient.Sixth,theultimatehumanneedisnotforso-calledunconditionalpositiveregardfromanotherhumanbeing,butforeternalagapelovefromGodhimself,whichhasbeendemonstratedthroughJesusChrist,wholovedusandgavehimselfforusinhisdeathandresurrection(Gal.2:20;Rom.5:8).Furthermore,self-actualizationofthedeepestkindcanonlyberealizedandexperiencedinapersonalrelationshipwithJesusChristasourLordandSavior.WethenwilldiscoverourtrueselfinChrist,aswesurrendertohimandhisagapelove,aligningourselveswithhiswillandhisheart,whichalwaysdesirethebestforusandourultimateandeternalwelfare(seeBenner2003,2004,2005a).ThisistheChristian,biblicalanswertounconditionalpositiveregardandself-actualization.ItholdsinbalancesinandgraceasMarkMcMinn(2008)hasemphasized,whereasRogersseemstofocussolelyongracewithoutadequatelydealingwiththerealityofsinandfallenhumannature.Infact,asMcMinnhasnoted,God’sgraceissoamazingonlybecauseoursinissogreat.Finally,agapeloveincludesmutualloveforothersthatinvolveslovingothersfortheirownsakeandnotforthesolepurposeofself-actualization.Mutuallovethereforerequiresadegreeofself-transcendencethatisnotpresentinperson-centeredtherapyandotherhumanistictherapies.Person-centeredtherapyisbasedon“nonhedonisticethicalegoism,”inwhichself-actualizationisthemajorgoalandregardforothersisonlyasecondaryconsequence,asBrowningandCooper(2004,81–82)havepointedout.Theythusconcludethatifweweretotakethehumanistictherapies,includingperson-centeredtherapy,seriously,theeventualresultwouldbemoresocialturmoilandconfusionratherthanmorehealth(85).Research:EmpiricalStatusofPerson-CenteredTherapyResearchonperson-centeredtherapycanbecategorizedintotwomaintypes:empiricalstudiesoftheimportanceofthecoreconditionsofcongruence(genuineness),unconditionalpositiveregard(warmthoracceptance),and 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empathicunderstanding(empathy)fortherapeuticpersonalitychange;andempiricalstudiesontheeffectivenessofperson-centeredtherapycomparedtoothertherapiesand/orcontrolconditionssuchasano-treatment,wait-listcontrolgroup,oranattention-placebocontrolgroup.Researchonthecoreconditionshasincludedthedevelopmentofscalestomeasurethem,withsubsequentcriticismsofthescalesandtheirshortcomings(seeBarkhamandShapiro1986).Amorerecentmeasurethatmaybeparticularlyhelpfulforassessingclients’perceptionsofthecoreconditionsintherapyistheClientEvaluationofCounselorScale(Hamilton2000).Empiricalevidencehasshownamoderaterelationshipbetweenempathyandpositivetherapeuticoutcomeinameta-analysisofforty-sevenstudies(Bohart,Elliott,Greenberg,andWatson2002),amoderatelypositiverelationshipbetweenunconditionalpositiveregard(warmth)andtherapeuticoutcome(FarberandLane2002;seealsoW. R.Miller2000),andamoremixedbutstillpositiverelationshipbetweencongruence(genuineness)andtherapeuticoutcome(M. H.Klein,Kolden,Michels,andChrisholm-Stockard2002).However,suchmoderatetomixedrelationshipsbetweenthesethreecoreconditionsandtherapeuticoutcomearenotstrongenoughtoconcludethattheyarenecessaryandsufficientconditionsfortherapeuticpersonalitychange(seealsoBeutler,Crago,andArezmendi1986;Lambert,DeJulio,andStein1978;Parloff,Waskow,andWolfe1978).Theyarecertainlyfacilitativeorhelpfulandthusimportant(Raskin1992;seealsoKirschenbaumandJourdan2005),butRogers’sassertionthatthesecoreconditionsarenecessaryandsufficienthasnotbeensupportedbyresearchtodate.Rogersseemstohaveoverstatedhiscaseaboutthecoretherapeuticconditions.However,hisviewthatthetherapeuticrelationshipistheessentialfactorineffectivetherapyhasreceivedmoreconsistentresearchsupportfromempiricalstudiesthathaveshownthetherapeuticalliancetobemoreimportantoverallthantechniquesacrossdifferenttherapiessuchaspsychodynamic,cognitive,andhumanistic(Lambert1992;seealsoToddandBohart2006, 213).Therapistempathyinparticularhasbeenfoundtobeanessentialfactorineffectivetherapyregardlessofthetherapeuticmodality;italsoappearstobethestrongestpredictorofclienttherapeuticprogresswhenclientratingsoftherapistempathyareused(J. C.Watson2002).Researchontheeffectivenessofperson-centeredtherapyhasyieldedthefollowingconclusionstodate,basedmainlyonmeta-analyses(M. L.SmithandGlass1977;M. L.Smith,Glass,andMiller1980;seealsoGrawe,Donati,andBernauer1998;KirschenbaumandJourdan2005;ShapiroandShapiro1982;Weisz,Weiss,Alicke,andKlotz1987;Weiszetal.1995):(1) person-centeredtherapyismoreeffectivethannotreatment;(2) itissomewhatmoreeffectivethanplacebotreatment;and(3) itissomewhatlesseffectivethancognitiveandbehavioraltreatments(seeJ. Sommers-FlanaganandSommers-Flanagan2004,205).Person-centeredtherapyhasbeenfoundoveralltobeeffectivein 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thetreatmentofawidevarietyofpsychologicaldisordersincludinganxietydisordersandpersonalitydisorders(Bohart2003).Earlieroutcomeresearchonperson-centeredtherapywaslimitedprimarilytocollegestudentsandclientswhoweremildlydisturbed(ProchaskaandNorcross2010,152).Theresearchonmotivationalinterviewing(MI)shouldalsobebrieflymentioned(seeProchaskaandNorcross2010,149–50).InalargetherapyoutcomestudycalledProjectMATCH,twomajorrandomizedclinicaltrialsconductedinparallelbutindependently,comparedanearly,briefversionofMI(foursessions)toCognitive-BehavioralCopingSkillTraining(twelvesessions)andtoTwelve-StepFacilitationTherapy(twelvesessions),with952alcoholdependentclientsseeninoutpatienttherapyinonestudy,and774clientsseeninaftercaretherapyaftertheiralcoholinpatienttreatmentintheotherstudy(ProjectMATCHResearchGroup1993,1997).Ofthefoursessions,MIwasasignificantcomponentofthefirsttwosessions,withthelasttwosessionsservingmainlyasboostersessions(W. R.Miller,Zweben, DiClemente,andRychtarik1992).ThebriefformofMIwasfoundtobeaseffectiveasthetwolongertreatmentsateachfollow-upperiod.TheoutcomeliteratureonMIisnowlargerthanthatonperson-centeredtherapy,withoveronehundredrandomizedclinicaltrialsonMI(ProchaskaandNorcross2010, 150).MIhasbeenfoundtohavelargeeffectsevenwiththeuseofsmallorbriefinterventions(Burke,Arkowitz,andDunn2002).Infact,MIwasaseffectiveaslongerandactivetreatmentsforavarietyoftargetbehaviors,butespeciallyforsubstanceoralcoholabuse,accordingtotheresultsofameta-analysisofseventy-twocontrolledclinicaltrials(Hettema,Steele,andMiller2005;seealsoBurke,Arkowitz,andMenchola2003).However,MIwasnotfoundtobeeffectiveforsmokingcessation.Ethnic-minorityclientsandresistantclientsdidparticularlywellwithMIanditssupportiveandnonconfrontationalstyle(Hettema,Steele,andMiller2005).MIcanalsobesuccessfullytaughttolicensedsubstance-abuseprofessionalsorcounselorsthroughsystematictraining,especiallyifitinvolvesaclinicalworkshopplusfeedbackandcoaching(W. R.Milleretal.2004).FutureDirectionsOntheonehand,person-centeredtherapyanditsemphasisonthecoretherapeuticconditionsandthetherapeuticrelationshipaswellasonthepersonofthetherapist,ratherthanontechnique,havebeenincorporatedintomanyotherapproachestocounselingandtherapy.Ontheotherhand,person-centeredtherapyhasalsobeenchallengedtoadaptandintegrateotherapproachestotherapyintoitsownpractice,especiallyfocusing-oriented,experiential,andexistentialtherapiesthatsharemuchincommonwithperson-centeredtherapy(P. Sanders2004b).Althoughperson-centeredtherapyinitstraditionalpracticegenerallyshunstechniques,therehavebeenattemptstointegrate 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behavioralinterventionssuchasrelaxationtechniques(Tausch1990)andcognitive-behavioraltherapy(Keijsers,Schaap,andHoogduin2000)withperson-centeredtherapy.Motivationalinterviewing(MI)hasbeenaparticularlypowerfulandeffectiveintegrationofperson-centeredtherapywithtechniquestohelpclientschangebehaviortoenhancetheirphysicalandmentalhealthortoovercomeaddictions.MIisarelativelybrieforshort-termapproachthathasrecentlyshownafreshhowtherapistempathyandtheautonomyoftheclientarecrucialfactorsineffectivecounselingandtherapy.Rogershasthusoftenbeenrankedasthepsychologistwhohasmostgreatlyimpactedthefieldofcounselingandpsychotherapy(D. Smith1982)becauseofthepervasivewayinwhichperson-centeredtherapyhasbeenincorporatedintovirtuallyeverymajorapproachtotherapy.However,onlyasmallpercentageofclinicalpsychologists(1 percent),counselingpsychologists(3 percent),socialworkers(1 percent),andcounselors(10percent)intheUnitedStatesidentifiedthemselvesasperson-centeredtherapistsinrecentsurveys(ProchaskaandNorcross2010, 3).Nevertheless,thedevelopmentofperson-centeredtherapyhasprogressed,despiteRogers’sownreluctancetoformaformalassociationorschoolofperson-centeredtherapy.TheAssociationfortheDevelopmentofthePerson-CenteredApproach(ADPCA)wasinauguratedinSeptember1986withameetingatInternationalHouse,UniversityofChicago,whichRogersattendedonlymonthsbeforehisdeath.Thefirstworkshopontheperson-centeredapproachwasheldFebruary11–15,1987,inWarmSprings,Georgia,aweekafterthedeathofRogers,andithasbeenheldannuallyinWarmSpringssince1987.TheADPCAalsoholdsannualmeetings;furtherinformationcanbefoundattheorganization’sWebsite(www.adpca.org)(Raskin,Rogers,andWitty2008,150–51).DavidCainfoundedthePerson-CenteredReviewin1986;in1992,itwasrenamedthePerson-CenteredJournal,withJeroldBozarthandFredZimringservingascoeditors.TheWorldAssociationforPerson-CenteredandExperientialPsychotherapyandCounseling(WAPCEPC)wasformedinPortugalattheInternationalForumforthePerson-CenteredApproach(formoreinformation,visitwww.pce-world.org).Arecentlylaunchedreviewedjournal,Person-CenteredandExperientialPsychotherapies,publishestheoretical,qualitative,andempiricalarticlesthatareofinteresttohumanisticresearchersandpractitioners(Raskin,Rogers,andWitty2008, 151;seealsoKirschenbaumandJourdan2005).Person-centeredtherapyisneverthelessonthedeclineintheUnitedStatesatthepresenttime,althoughitisstillgoingstronginEurope(ProchaskaandNorcross2010,157).Formaltraininginperson-centeredtherapyisdifficulttoobtainintheUnitedStates,sincetheChicagoCounselingCenteristheonlyinstitutioncurrentlyofferingaformaltrainingprogram.Moretrainingprogramsinperson-centeredtherapyareavailableinEuropeandGreatBritain. 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Forexample,theUniversityofStrathclydeinScotlandhasawell-developedmodelfortraininginperson-centeredtherapythatusesaperson-centeredapproach(Mearns1997a,1997b).Thereareapproximatelythirty-fivetrainingprogramsavailableinGreatBritain;formaltrainingprogramsarealsoofferedinothercountries,includingFrance,Germany,Greece,Switzerland,andtheSlovakRepublic(Sharf2008,208).Afinaltrendconcernsthecontinuedworkonusingperson-centeredtherapyprincipleswithlargegroupstodealwithpoliticaltensions,internationalconflict,andracialproblems.SomesuccessfulworkhasbeendoneinSouthAfricawithgovernmentalgroups(Cilliers2004),andwithraciallymixedSouthAfricansinexile(SaleyandHoldstock1993).TheCarlRogersInstituteforPeaceinLaJolla,California,hascontinuedtosponsorsuchworkinconflictresolutionandpeacemaking(Sharf2008, 207).Person-centeredtherapywillcontinuetobeasignificantpartofcontemporarycounselingandpsychotherapy(seeCain2010),butitsdistinctivenessmayironicallybereducedasitsinfluenceonotherapproachestocounselingandtherapybecomesevenmorepervasiveandwidespread.RecommendedReadingsCain,D.J.(2010).Person-centeredpsychotherapies.Washington,DC:AmericanPsychologicalAssociation.Levitt,B. E.(Ed.).(2005).Embracingnon-directivity:Reassessingpersoncenteredtheoryandpracticeinthe21stcentury.Ross-on-Wye,England:PCCSBooks.Rogers,C. R.(1951).Client-centeredtherapy.Boston:HoughtonMifflin.Rogers,C. R.(1961).Onbecomingaperson.Boston:HoughtonMifflin.Rogers,C. R.(1980).Awayofbeing.Boston:HoughtonMifflin.Sanders,P. (Ed.).(2004).Thetribesoftheperson-centerednation.Ross-onWye,England:PCCSBooks.Thorne, B.(2003).CarlRogers(2nded.).London:Sage. _Tan_Counseling_BB_mw.indd168 9/21/104:36:06PM 9GestaltTherapy F rederickSolomon“Fritz”PerlsisoftencreditedasthefounderofGestalttherapy.However,inamorerecentaccountofthehistoricaldevelopmentofGestalttherapy,CharlesBowmannotesthattwoothernamesarecrucialinthefoundingandestablishingofGestalttherapy:LauraPerls(Fritz’swife,whosemaidennamewasLorePosner)andIsadoreFrom.Bowmanemphasizesthat“ifFrederickPerlswasthefatherofGestalttherapy,LauraPerlswascertainlythefirstladyandIsadoreFromthedeanoftheschool”(2005,11).FromplayedanimportantroleinthehistoricaldevelopmentofGestalttherapynotonlybecauseofhisdeepcommitmenttoGestalttherapyandhisarticulateteachingofit,butalsobecausePaulGoodman,anotherkeyfigureinearlyGestalttherapy,abandonedGestalttherapyandhadanuntimelydeathatagesixty-onein1972(Bowman2005,11–12).Gestalttherapyhasrootsinpsychoanalysisbutdevelopedintoauniqueandindependentapproachtotherapythatisgroundedintheexperientialandexistentialorhumanisticperspectives.Itfocusesparticularlyonenhancingtheclient’sawareness,withtheGestalttherapisttakingaveryactiveandevendirectiverole,fullyengaginginauthenticdialogueandrelationshipwiththeclient.Gestalttherapyisaholistic,integrativeapproachtotherapythatusesavarietyoftherapeutictechniquesorinterventionstohelptheclientdevelopgreaterawarenessinordertomorefreelychoosehisorherowndirectioninlife(YontefandJacobs2008).Gestalttherapyfocusesmoreonexperientialmethodsratherthanmerelyverbalones.Examplesofwell-knownGestalttherapytechniquesincludethe155 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emptychair,convertingquestionsintostatements,andexperientialdreamwork(Parrott2003).BiographicalSketchofFritzPerlsFritzPerls,themaindeveloperofGestalttherapy,wasbornin1893inBerlin,theonlysonandmiddlechildoflowermiddle-classGermanJewishparents.Hisparentshadfrequentandintensearguments.Perlswasclosetohismotherbutdidnotrespecthisfather,whowasaheavydrinkerandatravelingwinesalesperson.HewasalsoclosertoGrete,hisyoungersister,butdislikedElsie,hisoldersister,wholaterdiedinaconcentrationcamp(Shepard1975).Perlswasdifficulttomanageasachild,creatingtroubleatschoolandathome.Hefailedseventhgradetwiceandevenhadtoleaveschoolforawhile,duringwhichtimehebrieflyworkedforamerchant.Hereturnedtoschoolwhenhewasfourteenyearsold.Perlseventuallymanagedtoattendmedicalschoolandobtainedhismedicaldegree.HeservedasamedicintheGermanarmyduringWorldWar I.Afterthewar,PerlsspenttimeworkingasanassistantwithKurtGoldsteininFrankfurtattheInstituteforBrainInjuredSoldiers.PerlslearnedaGestaltpsychology,orholisticperspective,fromGoldstein,viewingthesoldiers’perceptionsofthemselvesandtheirenvironmentascrucial,withthewholeconsistingofmorethenmerelythesumofitsparts.Perlsalsometotherpeoplewholatergreatlyinfluencedhim,includingLaura,whomhemarriedin1930.PerlsreceivedpsychoanalytictrainingattheViennaandBerlinInstitutesofPsychoanalysis.HewasparticularlyaffectedbyWilhelmReich,histraininganalyst.OtherpsychoanalystswhoinfluencedPerlsatthistimeincludeOttoFernichel,KarenHorney,andHeleneDeutsch.PerlsalsocameintopersonalcontactwithJung,Adler,andFreud.DuetotheriseofNazismandHitler’santi-SemiticpoliciesinGermanyinthe1930s,Perls,withhiswifeandtheirtwo-year-olddaughter,immigratedtoAmsterdam,wheretheylivedforayearundermiserableconditions.In1934,theyleftAmsterdamforSouthAfrica,wherePerlsacceptedapsychoanalyticpositioninJohannesburgthatErnstJoneshadannounced.Perlsestablishedhispsychoanalyticpractice,andin1935foundedtheSouthAfricanInstituteforPsychoanalysis.HeandLaurahadathrivingpsychoanalyticpracticeinJohannesburgforoveradecadeandenjoyedanaffluentlifestyle.PerlswasexposedtotheholisticideasofSouthAfricanprimeministerJanChristianSmuts,whowroteaninfluentialbook,HolismandEvolution(Smuts1926/1996),thatstronglyimpressedPerls(Bowman2005, 9).PerlsmetFreudin1936ataninternationalpsychoanalyticconference,butonlyforabrieffewminutes.PerlsdescribeditasanegativeexperienceinwhichhefeltshockanddisappointmentatbeingsobadlytreatedbyFreud,whoseemedtohavebrushedhimoff(Perls1969c, 56).Thiswasasignificant 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experienceforPerls,whothenfeltfreetoletgooftraditionalFreudianorpsychoanalyticthinkingandbegindevelopinghisownuniqueapproachtopsychotherapyandcounseling(withsignificanthelpfromhiswife,Laura):Gestalttherapy.PerlsleftSouthAfricain1946afterlivingtherefortwelveyearsbecauseoftheriseofapartheidandmovedtoNewYorkCity.HeeventuallyestablishedtheNewYorkInstituteforGestaltTherapy,togetherwithLauraPerlsandPaulGoodman,in1952.PerlslivedinNewYorkfornineyears,afterwhichhemovedandtraveledextensively,settingupGestalttherapytrainingcentersinUScitiessuchasLosAngeles,SanFrancisco,andMiami,aswellasinCanada,Japan,Israel,andothercountries.Healsoseparatedfromhiswifeatthistime.PerlsthenbecameinvolvedwiththeEsalenInstituteinBigSur,California,andworkedasanassociatepsychiatristtherefrom1964to1969.In1969,hemovedtoCowichanLakeonVancouverIsland,inBritishColumbia,wherehesetupatherapeuticcommunity,oraspecial“Gestaltcommunity,”asatrainingcenterwheretherapistscouldstudywithhimforlongerperiodsoftime(e.g.,forafewmonths).Perlsdiedshortlythereafter,in1970.SomeoftheimportantbooksthatPerlsauthoredorcoauthoredindevelopingGestalttherapyincludeEgo,Hunger,andAggression,firstpublishedin1947(F. Perls1947/1969a),withLauraPerlscontributingacoupleofchapters,buthersignificantworkwasnotsufficientlyacknowledged,duepartlytoFritzPerls’sownflamboyantandsomewhategotisticalstyle(seeRosenfeld1978);GestaltTherapy:ExcitementandGrowthintheHumanPersonality,coauthoredwithRalph F.HefferlineandPaulGoodmanin1951(Perls,Hefferline,andGoodman1951/1994);GestaltTherapyVerbatim(F. Perls1969b);andInandOutoftheGarbagePail(F. Perls1969c),whichincludesmuchautobiographicalmaterialsummarizedinthisbiographicalsketchofFritzPerls(seealsoSharf2008,220–21;andParrott2003,202–3).Twootherbookswerepublishedposthumously:TheGestaltApproach(F. Perls1973)andLegacyfromFritz(Baumgardner1975).LauraPosnerPerls(1905–90),wifeofFritzPerls,deservesrecognitionasacofounderanddeveloperofGestalttherapy.ShewasborninPforzheim,Germany.Musicandmoderndancewerecrucialpartsofherlife,bothasachildandasanadult.Shewasagiftedpianist,withavariedandricheducationalbackground,havingstudiedlaw,Gestaltpsychology,philosophy,andpsychoanalysis.ShecofoundedtheNewYorkInstituteforGestaltTherapyin1952,withFritzPerlsandPaulGoodman,andmadesignificantcontributionsinthedevelopmentofGestalttherapyandintrainingGestalttherapists.Infact,atthetwenty-fifthanniversaryoftheNewYorkInstituteforGestaltTherapy,sheinsistedthatwithoutthesupportandhelpofherandotherfriends,FritzPerlswouldnothavewrittenorfoundedanything(seeL. Perls1990, 18). 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Laurafocusedonrelationshipsandtheimportanceofsupportandcontact,incontrasttoFritz’semphasisonawarenessandtheindividual.ShealsounderscoredtheneedforeachGestalttherapisttodevelophisorherownuniquestyleintherapy(Humphrey1986;seealsoCorey2009, 199).MajorTheoreticalIdeasofGestaltTherapyPerspectiveonHumanNatureGestalttherapyisanexperientialtherapythatseekstoincreasetheclient’sawareness,especiallyofthehereandnowaswellastheholisticandbalancedintegrationofmindandbody.FritzPerlsfocusedonhelpingclientstobeselfsufficientsothattheycandealwiththeirproblemsinlivingbythemselves(Perls1969b).Inordertoachievethisautonomy,Perlsworkedwithclientsinadirective,active,andevenconfrontationalstyletomovethemfromdependingonothersortheirenvironment(environmentalsupport)todependingonthemselves(self-support)andtofacilitatethereintegrationofdisownedorblockedoffpartsoftheirpersonalities.Gestalttherapyassumesthatclientshaveaninherentcapacitytobecomemoreawareandincontactwiththeirinternalandexternalworlds,sothattheyareabletosolvetheirproblemsintheirownwayandtimeandengageinselfregulation.Itthereforehasasomewhatpositiveperspectiveonhumannatureanditspotentialforchangeandgrowthandhenceisrootedinexistentialandhumanisticworldviews.Gestalttherapy’semphasisonself-sufficiencyandselfsupportintheself-actualizationoftheindividualperson,however,reflectsaharshlyrealisticandsomewhatpessimisticviewofhumanrelationships(S. L.JonesandButman1991, 307).ThisismoretrueofFritzPerls’soriginalviews,whereascontemporaryGestalttherapistsemphasizemoretheimportanceoftheinterpersonaldimensionsandamoremutualanddialogicalrelationshipbetweentheGestalttherapistandtheclient.BasicTheoreticalPrinciplesofGestaltTherapyCoreyhassummarizedthebasictheoreticalprinciplesofGestalttherapyas“Holism,FieldTheory,theFigure-FormationProcess,OrganismicSelfRegulation,TheNow,UnfinishedBusiness,ContactandResistancestoContact,EnergyandBlockstoEnergy”(2009, 201–6).Holism.Gestalttherapistsfocusonthewholeperson,emphasizingthatthewholeismorethanthesumofitsparts.Thustheydonotregardanyonepartofaclient’sexperiencesasmoreimportantthanotherparts.Aclient’sfeelings,behaviors,thoughts,bodilysensations,dreams,andotherexperiencesareallconsideredbytheGestalttherapistwithequalweight.GestaltisaGermanwordthatmeansacompletewholethatcannotbebrokendown 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intoitsparticularpartswithoutlosingitsesSidebar9.1sentialnature,andGestalttherapyisrootedinsuchholism.PrinciplesofGestaltTherapyFieldTheory.Fieldtheoryiscloselyrelated(Corey2009,201–6)toholism.Itemphasizesthatone’sexperienceisinfluencedbyone’senvironmentorcon1.Holismtext,thatis,one’sfield,withinterconnected2.Fieldtheorypartsorelements.AccordingtoGaryYon3.Thefigure-formationprocesstefandLynneJacobs,“Holismassertsthat4.Organismicself-regulationhumansareinherentlyself-regulating,that5.Thenowtheyaregrowth-oriented,andthatpersons6.Unfinishedbusinessandtheirsymptomscannotbeunderstood7.Contactandresistancestoapartfromtheirenvironment.Holismandcontactfieldtheoryareinterrelatedingestalttheory.8.EnergyandblockstoenergyFieldtheoryisawayofunderstandinghowone’scontextinfluencesone’sexperiences”(2008, 329).TheFigure-FormationProcess.Thenotionoffigure-formationprocessisbasedontheworkofGestaltpsychologistsintheareaofvisualperception;itreferstohowapersonorganizeshisorherexperience,momentbymoment,dependingonwhatcomestotheforeground,thatis,thefigure,andwhatstaysorrecedesinthebackground,thatis,theground.Thisprocessisstronglyinfluencedbytheparticularneedsofapersonataspecificmomentofexperience.OrganismicSelf-Regulation.Organismicself-regulationisanindividual’scapacitytomoveinthedirectionofgrowthandwholeness,bybeingconsciouslyawareoforintouchwithhisorherpresentexperienceandneedsorwantsandworkingtowardequilibrium.Organismsorindividualsregulatethemselvessothattheyexperienceequilibrium,growth,andchangeasurgentneedsintheforegroundaremet.YontefandJacobsemphasizethatorganismicself-regulation“requiresknowingandowning—thatis,identifyingwith—whatonesenses,feelsemotionally,observes,needsorwants,andbelieves,”andmovingtowardwholenessfurtherincludes“beinghonestwithselfandothersaboutwhatoneisactuallyableandwillingtodo—ornotwillingtodo”(2008, 329).TheNow.Gestalttherapistsemphasizethepowerofthenow,orthepresent,tohelpclientsnotbecomemiredinthepastorpreoccupiedwiththefuture.ThisemphasisonthenowisalsoevidentinGestalttherapy’sfocusonthewhatandhow,andnotonthewhy.Gestalttherapistsengageinphenomenologicalinquiry,inwhichtheyaskclients“what”and“how”questionstohelpclientsbeintouchwiththepresentmomentandtheirimmediateexperience;andtheydonotask“why”questionswhichoftenresultinintellectualizingorcognitivereasoningthatmayimpedetheawarenessofcurrentexperience.Gestalt 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therapistsuseavarietyoftherapeuticinterventionstohelpclientsfocusonthehereandnow,andthewhatandhow.Thesetherapeuticinterventionswillbedescribedlaterinthechapter.UnfinishedBusiness.Clientsexperienceunfinishedbusinesswhenunexpressedfeelingsorunresolvedissuesfromthepastaffecttheirpresentexperience,forexample,havingunexpressedfeelings,suchasanger,hatred,fear,guilt,grief,andabandonment,ofwhichtheyarenotfullyaware.Unfinishedbusinesscanalsobemanifestedinobsessionswithsexormoneyorinproblematicphysicalsensationsandblockageswithinone’sbody.Gestalttherapistshelptheirclientstodealwithunfinishedbusinessbyencouragingthemtostaywiththeimpasse,orpointwheretheyarestuck;tofullyexperiencetheirimpasseandbeintouchwiththeirfrustrations;andtoacceptthemselvesandtheirexperiencesmorefully.Asclientsdothis,withoutbeingrescuedortoofrustratedbytheGestalttherapist,theyarebetterabletocompletetheGestalt,thatis,resolvetheunfinishedbusinessfromthepastbyfeeling,thinking,andactinginnewwaysthataremoreself-actualizing.Gestalttherapyassumesthatindividualshaveinherentself-actualizationorgrowth-orientedtendenciesandcapacities.ContactandResistancestoContact.Contactreferstotheconnectionorrelationshipbetweenapersonandothersandbetweenapersonandhisorherenvironment.Contactinvolvesusingthesensessuchashearing,touching,seeing,smelling,andmoving.InGestalttherapy,contactisviewedascrucialforgrowthandchange.TheGestalttherapistthereforehelpstheclienttohaveconstructiveandauthenticcontactwithpeopleandwiththeenvironment,withouttheclientlosingasenseofself,sothattheclientdoesnotbecomefusedwithothersortheenvironment(PolsterandPolster1973).Appropriatehealthyboundariesmustbemaintainedfortwomainreasons:boundarieshelppeopletobeincontact;andtheyhelppeopletoseparatesothatfusionwithothersortheenvironmentdoesnottakeplace.Perls(1969b,1969c,1970)describedvariouslevelsofcontactasfivelayersofneurosesthatpeoplemustremovesothattheycangrowintopsychologicalmaturitybybeingingreatercontactwithothersandtheirenvironment.Thesefivelayersare:(1) thephonylayer,whichinvolvesinteractingwithothersinpatternedorinauthenticways,forexample,beingnicetootherstogetsomethingfromthem;(2) thephobiclayer,whichavoidsordeniesemotionalpain,forexample,notadmittingthatacloserelationshipwithsomeonehasended;(3) theimpasselayer,thatis,thepointwhereapersonfeelsstuckandafraidtomakeamoveorchange,forexample,nolongerbeinginlovewithone’sspouseandfeelingstuckinthemarriage;(4) theimplosivelayer,whereonebeginstobeawareofone’srealselfandexperiencesfeelingsmore,butmaystillnotdomuchaboutthem;and(5)theexplosivelayer,wherethepersonismoreauthenticandreal,withoutpretense,andexperiencesfeelingsfully.Apersonwillbeinmoreauthenticcontactwithself,others,andtheenvironmentifall 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fivelayersofneurosesareexperiencedandeventuallystrippedaway,sothatheorshecanexperiencethepresentmorefully(seeSharf2008,225–26).Contactboundariesareprocessesbywhichapersonconnectswithorseparatesfromothersortheenvironment.ErvingPolsterandMiriamPolster(1973)havedescribedthefollowingtypesofcontactboundaries:(1)bodyboundaries,whichmakecertainbodilysensationsoff-limitsoratleastrestrictsthem;(2) valueboundaries,orvaluesthatpeopleholdstronglyorrigidlythataredifficulttochange;(3) familiarityboundaries,whichinvolvebehaviorsoreventsthatoccurfrequentlyandroutinelywithoutmuchthoughtorchallenge,suchasdrivingthesameroutetoworkeverydayformanyyears;(4) expressiveboundaries,whichinvolvebehaviorslearnedearlyinlife,suchasnotyellingorwhining,and—particularlyformeninAmericanculture—notcrying(seeSharf2008,226).Contactboundariescanbebroken,resultinginresistancestocontact,sothatone’sexperiencesofthepresentarecurtailed.PolsterandPolster(1973)havedescribedfivetypesofcontactboundarydisturbances(seeSharf2008, 227):(1) introjection,thewholesaleoruncriticalacceptanceoftheviewsandvaluesofothersbyanindividualwithoutfurtherreflectionorintegration,forexample,achildintrojectingortakinginalloftheparents’valuesandstandardswithoutfurthercriticalreflection;(2) projection,thedisowningofparticularaspectsofoneselfbyassigningthemtoothersortheenvironment,forexample,blamingothersforone’sownfaultsormistakes;(3) retroflection,inwhichanindividualdoestoherselfwhatsheactuallywantstodotosomeoneelse,oranindividualdoesforhimselfsomethingthatheactuallywantssomeoneelsetodoforhim,forexample,amanwhoengagesinself-injuriousbehaviorbecausehedirectsaggressionathimselfinsteadofdirectingitoutwardtowardothers;suchself-directedretroflectioncanleadtodepressionandotherpsychosomaticsymptoms(Corey2009, 205);(4) deflection,whichinvolvesdifferentdegreesofavoidingcontactwithothersortheenvironment,forexample,talkingincessantlyaboutdetailsandbeatingaroundthebush,talkingconstantly,andbeingextremelypolite,allofwhichenableapersontoavoidauthenticcontactwithothersortheenvironment;(5) confluence,inwhichtheboundarybetweenoneselfandothersortheenvironmentislessenedandblurred,sothatthedemarcationbetweeninnerexperiencesorfeelingsofoneselfandtheexperiencesandfeelingsofothersinexternalrealityisnolongerclear,forexample,whenthepeopleinvolvedininterpersonalrelationshipsperceivethattheyallshareexactlythesamefeelingsandthoughts,andthereisnoconflictorangerwhatsoever.Individualswhoengageinconfluenceusuallyhaveanextremeneedtobelikedandaccepted,andtheythereforeallowenmeshmentandblurredboundariestooccurbetweenthemandothers.Genuinecontactwithsuchpersonsisverydifficult.Gestalttherapiststrytohelptheirclientsbecomeawareofsuchcontactboundarydisturbancesorresistancestoauthenticcontactbecausetheyregardcontactascrucialforgenuinegrowthandself-actualizationtotakeplace. 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EnergyandBlockstoEnergy.TheGestalttherapistpaysspecialattentiontothelocationofenergyintheclient,whereandhowitmaybeblocked,andhowitmaybebetterusedbytheclient.Blockedenergyisviewedasanothermanifestationofdefensivebehavioronthepartoftheclient.Examplesofblockedenergyincludetensionincertainpartsofthebody,shallowbreathing,notlookingatpeoplewheninteractingwiththem,cuttingoffcertainsensationsorfeelings,andclosingoffortighteningone’sbody.TheGestalttherapistwillhelpclientsbecomemoreawareofwhereandhowtheyareblockingtheirenergy,sothattheycanreleasetheirenergyanduseitinmoreconstructivewaystofacilitategrowthandself-actualization.OnewayofdoingthisinvolvestheGestalttherapistencouragingclientstomorefullyexperiencetensionintheirbodiesbyexaggeratingtensionstatessuchastightenedjawsandshakinglegsratherthanignoringthem(Corey2009,206).TherapeuticProcessandRelationshipGestalttherapistsdonothavepresetgoalsforclients.However,theydohaveafundamentalaimorgoalofhelpingclientsachievedeeperawarenessandhencemorefreedomtochoose(Corey2009, 206)sothatclientscangrowtowardself-actualizationandpersonalintegration.Agoodtherapeuticrelationshipisseenasessentialinthisprocessofhelpingclients(seeSharf2008, 229).Perls(1969b, 16)believedthatawarenessinandofitselfcanbecurativeforclients.Gestalttherapiststhereforefocusonenhancingclients’awarenessofboththemselvesandtheirenvironments.J. Zinker(1978,96–97)hasprovidedthefollowingspecificexamplesofincreasedawarenessinclients:experiencingdeeperawarenessoftheiremotions,physicalsensations,andenvironment;owningtheirexperiencesratherthanmakingothersresponsibleforthem;learningtobeconsciousoftheirneedsandhavingtheskillstofulfillsuchneedswithoutviolatingtherightsofothers;havingmorecontactwithalltheirsenses(sight,hearing,smell,touch,andtaste)sothattheymorefullyexperiencethemselvesineveryaspect;beingabletosupportthemselvesratherthanblamingothers,complaining,ormakingothersfeelguilty;becomingmoresensitivetotheirenvironmentsbutwithappropriateprotectionfromwhatmaybedangeroustothem;anddevelopingresponsibilityfortheirbehaviorsandconsequences.Sharf(2008)hasnotedthatGestalttherapymaybeespeciallyhelpfulforclientswhoareinhibitedoroverlysocializedandconstricted,suchasphobic,depressed,orperfectionisticindividuals.TheprocessoftherapeuticchangeandgrowthinclientsundergoingGestalttherapyhasbeendescribedbyMiriamPolster(1987)asathree-stageintegrationsequence.Thefirststageofdiscoveryinvolvesclientsachievinganewviewofthemselvesoranewperspectiveonanoldsituation.Thesecond 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stageofaccommodationinvolvesclientsrealizingthattheyhavechoices,andthereforetheycanexperimentwithnewordifferentbehaviors,especiallywiththerapeuticsupportthatiscrucialatthisstage.Finally,thethirdstageofassimilationinvolvesclientslearninghowtoimpacttheirenvironment,includingbeingmoreassertiveinexpressingandobtainingwhattheywantfromothersorfromtheirenvironment.ThetherapeuticrelationshipiscrucialineffectiveGestalttherapy,whichemphasizesanexistentialapproachtotheclient.GestalttherapyhasbeeninfluencedbyCarlRogersandhisemphasisonempathyandtheneedforthetherapisttobesensitivelyattunedtotheclient’ssubjectiveexperience.IthasalsobeeninfluencedbyMartinBuber’semphasisonanauthenticI-Thourelationshipbetweenthetherapistandtheclient.Morerecently,Gestalttherapyhasalsobeenaffectedbyintersubjectivitytheory,whichhasemphasizedamoremutuallyrespectfulandinteractionalrelationshipbetweenclientandtherapistinpsychoanalytictherapy.Ameaningfulrelationshipwiththetherapististhereforeessentialforfacilitatinggrowthintheclientthroughdeepenedawareness(YontefandJacobs2008).Thistherapeuticrelationshiphasbeendescribedasadialogicrelationshipfocusingonanauthenticmeetingandunderstandingoftheotherperson,andnotonanyparticularoutcomes(seeHycnerandJacobs1995).Gestalttherapyhasdevelopedseveraluniquetherapeutictechniquestohelpclientsdevelopdeeperawareness.However,itisimportanttoemphasizethatthetherapeuticrelationshipisseenasthecrucialfactorineffectiveGestalttherapy,ratherthansimplythetechniques.AsCoreyhasobserved,“ContemporaryGestalttherapistsplaceincreasingemphasisonfactorssuchaspresence,authenticdialogue,gentleness,moredirectself-expressionbythetherapist,decreaseduseofstereotypicexercises,andgreattrustintheclient’sexperiencing”(2009, 211).ThusGestalttherapytodayhasgonebeyondthetherapeuticpracticesofitsearlierhistory,whenFritzPerlsemphasizedconfrontationandmorespecifictechniques.MajorTherapeuticTechniquesandInterventionsGestalttherapyemphasizestheexperientialratherthantheverbalanddoingmorethantalking.Itfocusesespeciallyonthehereandnow,orpresentmoment.Ithasdevelopedsomeofthemostcreativeandinnovativetherapeutictechniquesandinterventionsavailable(Parrott2003).BeforeweexaminethemajorGestalttherapytechniques,itmaybehelpfultoclarifythedifferencebetweenexperimentsandexercises(ortechniques).Exercisesrefertosettechniquesthatcanbeusedtoproducespecificoutcomesduringatherapysessionortoattainatherapeuticgoal.ExperimentsaremorespontaneousandemergefromthedialogicinteractionbetweentheGestalttherapistandtheclient.Theyhelptofacilitateexperientiallearningforclientsandareone-of-a-kind 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interventionscreativelytailoredforparticularclients.Experimentshaveoftenbeenconfusedwithexercises(MelnickandNevis2005).TechniquesofGestaltTherapyTheexperimentisacrucialandfoundationalpartofGestalttherapyasitispracticedtoday.(seeParrott2003,213–17,Infullcollaborationwiththeclient,theGeandJ. Sommers-FlanaganstalttherapistcreativelydevelopsexperimentsandSommers-Flanagan2004,tohelptheclientexperiencedeeperlevelsof159–60)awarenessandemotionsinordertogainfreshinsight(StrümpfelandGoldman2002).Miriam1.ExperientialdreamworkPolster(1987)hasspecificallyfocusedonhow2.Convertingquestionstoanexperimentcanhelpaclientworkthroughstatementshisorherstickingpoints,byencouragingspon3.Usingpersonalpronounstaneousandinnovativewaysofdramatizing4.Assumingresponsibilityaninternalconflictorstickingpoint,inthe5.Playingtheprojectionsafetyandimmediacyofthetherapysession.6.Theempty-chairtechniqueExamplesofsuchGestalttherapyexperiments7.Makingtheroundsincludevisualizingafutureeventthatmaybe8.Exaggerationthreatening,role-playinganinteractionbe9.Confrontationtweentheclientandanotherimportantper10.“MayIfeedyouasentence?”son,playingouttheexperienceofapainful11.Stayingwiththefeelingmemory,role-playingone’sfatherormother,12.TheReversalTechniqueandcreatingadialoguebetweentwopartsofanindividualthatareinconflict.Experimentsmustbeimplementedinasupportive,timely,andcustomizedwayforaspecificclient.Theyshouldchallengeaclientwithoutoverwhelminghimorher(seeCorey2009,212–13).ImportanttherapeutictechniquesorinterventionsoftenusedinGestalttherapyincludeexperientialdreamwork;convertingquestionstostatements;usingpersonalpronouns;assumingresponsibility;playingtheprojection;theempty-chairtechnique;makingtherounds;exaggeration;confrontation;asking,“MayIfeedyouasentence?”(seeParrott2003,213–17);andstayingwiththefeelingandthereversaltechnique(seeJ. Sommers-FlanaganandSommers-Flanagan2004,159–60).Sidebar9.2 ExperientialDreamWorkDreamworkisacrucialpartofGestalttherapy.FritzPerlsbelievedthatthedreamis“theroyalroadtointegration”(F. Perls1947/1969a, 66)andthemainstayofGestalttherapy.However,Gestalttherapistsdonotengageintheinterpretationofdreams.Instead,theybelievethatdreamsaretobeexperienced;henceGestaltdreamworkisexperientialandnotanalytical.TheclientisfullyresponsibleforhisorherdreamsandsharesthemwiththeGestalttherapist,whothenencour- _Tan_Counseling_BB_mw.indd178 9/21/104:36:17PM GestaltTherapy 165 agestheclienttoidentifyhimselforherselfwitheveryaspectofeachdream.Everycharacteranddetailofeachdreamisviewedasrepresentingsomepartoftheclientthattheclientneedstoowninfullyexperiencingthedream.Gestaltexperientialdreamworkinvolvesfoursteps.First,theclientdescribeshisorherdreamtothetherapist.Second,theclientisaskedbythetherapisttotalkaboutthedreaminthepresenttenseinsteadofthepasttense.Third,theclientisencouragedtoplaytheroleofadirector,organizingthedreamlikeaplayanddescribingitsdetailsandsequence,includingitscharactersandobjects.Finally,inthefourthstep,theclientactsoutasfullyaspossiblethedream,identifyingwitheachcharacterorobjectbyusing“I”languagetopersonalizetheidentificationandmoredeeplyexperiencethedream.Perlsalsooftenaskedhisclientstoaddthefollowingrepetitivestatementaftereachbriefphrasedescribingadream(orfantasyorimage):“andthisismyexistence,”eventhoughthismayinitiallyfeelfakeorsillytotheclient.Hedidthistohelpfacilitatedeeperclientinsightandexperienceofthedream(seeJ. Sommers-FlanaganandSommers-Flanagan2004,163–64).Gestaltexperientialdreamworkismeanttohelpclientsbemoreintouchwiththemselves,especiallypartsofthemselvestheymayhaveblockedfromawareness,byidentifyingpersonallywithdifferentcharactersorobjectsanddetailsintheirdreams.Clientscanthenbecomemoreintegratedpersonsastheygrowintheirself-awarenessandtakemoreresponsibilityforthemselvesandtheirexperiences.ConvertingQuestionstoStatementsTheGestalttherapist,followingPerls,oftenasksclientstochangetheirquestionsintostatements,sothatclientscannothidebehindquestionsthatmayreflectmanipulation,denialofpersonalresponsibility,passivity,andsoforth.Forexample,whenaclientasksaquestionlike“Doyoureallyfeelthat?”theGestalttherapistwillasktheclienttoconvertthisquestionintoastatement,sothattheclientsays:“Idon’tthinkyoureallyfeelthat.”Thistechniqueofaskingclientstoconvertquestionstostatementsismeanttohelpclientsacknowledgetheirownbeliefsandfeelingsandtakeresponsibilityforthem.UsingPersonalPronounsClientstendtotalkaboutthemselvesbyusingwordssuchas“you,”“we,”or“it,”therebydistancingthemselvesfromfullyexperiencingwhattheyaredescribingaboutthemselves.Forexample,aclientmightsay:“It’ssoboringtoattendthismeeting.”TheGestalttherapistwillthenasktheclienttousethepersonalpronoun“I”insteadoftheword“it,”andsayinstead:“Ifinditissoboringtoattendthismeeting,”thusowninghisorherownexperienceorbehaviorandtakingresponsibilityforit. 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AssumingResponsibilityEmployingamethodsimilartousingpersonalpronouns,theGestalttherapistalsoofteninstructsclientstoaddthefollowingstatementattheendofeveryexpressionoffeelingsorthoughts:“AndItakeresponsibilityforit.”Tousethepreviousexampleagain,theclientwillnowsay:“Ifinditsoboringtoattendthismeeting,andItakeresponsibilityforit.”Anothermethodforhelpingclientstoassumeresponsibilityistoaskthemtochangetheword“can’t”to“won’t,”andtheword“but”to“and.”Forexample,aclientmightsay:“Ican’tdothat!”TheGestalttherapistwillasktheclienttosayinstead:“Iwon’tdothat!”Asanotherexample,aclientmightsay:“Iwanttoattendtheconcert,butIhaven’tpurchasedaticketforityet.”TheGestalttherapistwillinstructtheclienttosayinstead:“Iwanttoattendtheconcert,andIhavenotpurchasedaticketforityet.”Thesetechniquesforhelpingclientsassumeresponsibilityareimportantbecauseclientseventuallyrealizethattheydonothavetodependsomuchonothersortheenvironment.PlayingtheProjectionClientsoftenprojectontootherswhattheythemselvesareexperiencingorstrugglingwith,butatanunconsciouslevel.Gestalttherapistswillaskclientstorole-playoractoutaparticularqualitytheydon’tlikeinsomeoneelse,thatis,“playtheprojection.”Forexample,ifaclientsays,“Myfriendisareallyloudandaggressiveperson,”theGestalttherapistwillasktheclienttotakeontheroleofthefriendandactinaloudandaggressiveway.Perlsbelievedthatprojectionfrequentlyoccursininterpersonalrelationships.PlayingtheprojectionisanimportantGestaltinterventiontohelpclientsacknowledgetheirprojectionsandgaindeeperawarenessoftheirownexperienceandbehavior,includingtheirtendencytoprojectontoothers.TheEmpty-ChairTechniqueTheempty-chairtechniqueisthebest-knownandbest-researchedGestalttherapyintervention(L. S.GreenbergandFoerster1996;L. S.GreenbergandMalcolm2002;PaivioandGreenberg1995).IthasbeenusednotonlyinGestalttherapybutalsoinotherapproachestotherapy.Gestalttherapyusestheempty-chairtechniqueintwowaystohelpclientsbecomemoreawareofandreclaimpartsofthemselvesthattheymayhaveblockedfromconsciousness.Thefirstwayinvolvesinstructingtheclienttorole-playtwopolarizedpartsofhisorherpersonalitythatareinconflictwitheachother:the“topdog,”representingthelegalisticsideortherighteousconscienceorsuperegoofone’spersonality,andthe“underdog,”representingthesidethatisweakandoftenfrustratingtotheperson(F. Perls1973,125).Thetopdogisthereforethemoralistic,demanding,andcriticalsideoftheclient,andtheunderdogisthe 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passive,weak,andneedyside(StrümpfelandGoldman2002).Intheemptychairtechnique,theGestalttherapistaskstheclienttositinonechairandassumetheroleofthetopdogtalkingtotheemptychairinfrontoftheclient.Theclientisthenaskedtomovetothepreviouslyemptychairandassumetheroleoftheunderdogtalkingtothechairthatisnowempty.Theclientmovesfromchairtochair,repeatingthisprocessseveraltimeswhileguidedbytheGestalttherapist.Eventually,theclientexperiencesbothsidesorpolaritiesofhisorherpersonalitythatareofteninconflictandbeginstobetterintegratethetopdogandunderdogpartsofhimselforherself,findingmore-effectivecompromisesolutionstounfinishedbusiness(L. S.GreenbergandMalcolm2002;seealsoElliott,Watson,Goldman,andGreenberg2004).Thesecondwayofusingtheempty-chairtechniqueinGestalttherapyinvolvesaskingaclientwhoisexperiencingareal-lifeconflictwithasignificantothertorole-playthetwopeopleinvolvedintheconflict(i.e.,theclientandsomeoneelse)byusingtwochairsfacingeachother.Forexample,ifawomanclientishavingaconflictwitharudebrother,withfeelingsofhurtandangertowardthisbrother,sheisaskedtofirstassumetheroleofherselfandexpressthosefeelingstothebrother,whomsheimaginestobesittingintheemptychairacrossfromher.Sheistheninstructedtomoveintothepreviouslyemptychairandtakeontheroleofthebrotherandspeaktotheclientnowimaginedtobesittinginthechairacross.ThisprocessisrepeatedseveraltimeswiththeguidanceoftheGestalttherapist,sothattheclientishelpedtomorefullyexperiencetheconflict,withdeeperawarenessofherownfeelingsaswellasmoreempathyforthefeelingsofherbrother.Thiscanhelptheclienttoreintegratepartsofherselfthatmayhavebeenblockedbefore.Theempty-chairtechniqueseemstobemoreeffectiveinhelpingclientsresolveunfinishedbusinesswhenitinvolveshighlyemotionalexperiencingandprocessingbytheclient(L. S.GreenbergandMalcolm2002).MakingtheRoundsThisGestalttherapytechniqueisoftenusedinthecontextofgrouptherapy.Forexample,ifaclientsays,“Everyoneissocoldinthisgroup,”theGestalttherapistwillasktheclienttogoaroundandsaythistoeachmemberofthegroup:“Youaresocold.”Theclientthusengagesin“makingtherounds”witheachmemberofthegroupandtherebymorefullyexperienceshisowninnerfeelingsandbecomesmoreawareofwhatishappeningwithinhimself.Makingtheroundscanalsobeusedwithpositivefeelings,notjustwithnegativefeelings.ExaggerationThisGestalttherapytechniqueinvolvesthetherapistaskingtheclienttoexaggerate,oractoutmoreintensivelyandexpansively,aparticularbehavior, 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usuallynonverbal,tohelptheclientbecomemoreintouchwithunderlyingfeelingsandthusincreaseself-awareness.Forexample,aclientmaystartbitingherfingernailseverytimeshetalksabouttheharshbossatwork.TheGestalttherapist,inusingexaggerationasanintervention,willasktheclienttobiteherfingernailsevenmorewhilecontinuingtotalkabouttheboss,andtofocusmoreattentiononwhatthisexaggeratedbehavioroffingernailbitingfeelslikeandmaymeantotheclient.Previouslyblockedfeelingsoffearandangertowardthebossmaysurfaceintotheclient’sawareness.ConfrontationWhenclientsshowdiscrepanciesintheirfeelingsandbehaviors,theGestalttherapistwilloftenusethetechniqueofconfrontation,bypointingoutthesecontradictionstotheclient.Thetherapistwillusehowandwhatquestionsratherthanwhytoavoidintellectualizationorrationalization.Forexample,aclientmaysayverysoftly,“Idon’tlikeitwhenmymothercriticizesmeforlittle,pettythings.”TheGestalttherapistwillthenpointoutthediscrepancybetweentheverysoftvoiceandthestrongfeelingofdislikeandpossiblyevenangeratthemotherbyaskingtheclient,“Whatareyouexperiencingdeepinsidewhenyoustateyourdislikeofyourmother’scriticismofyouinsuchasoftvoice?Howareyoureallyfeeling?”Thisgentleconfrontationcanhelptheclientbecomemoreawareofinnerfeelingsandbetterintegratethem.MayIFeedYouaSentence?AGestalttherapistmaysuggestasentencefortheclienttorepeat,tohelptheclientverbalizeanunderlying,implicitmessageorattitudethatisunclear.Thetherapistwillthensaytotheclient,“MayIfeedyouasentence?”and asktheclienttorepeatthatsentence.Forexample,ifthetherapistsensesthatthe clientishavingsometroubleverbalizingfeelingsofbeinghurtbyafriend, thetherapistmaysaytotheclient:“MayIfeedyouasentence?”and“Here’sthesentenceIwantyoutorepeatafterme:‘IfeeldeeplyhurtanddisappointedbymyfriendJoan,whoisveryprecioustome.’ ”Theclientwillrepeatthissentencealoudandindoingso,maybecomemoreawareofherowninnerfeelingsandgrowininsightaswell.StayingwiththeFeelingGestalttherapistsusethisgeneralstrategywithallclientstohelpthemstaywithandexperiencetheirimmediatefeelingsinthepresent,insteadofblockingthemoravoidingthem.SeveralspecifictechniquescanbeusedinGestalttherapytohelpclientsstaywiththefeeling.First,particularquestionscanbeusedrepeatedly,such 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as,“Whatareyouexperiencingnow?”or“Whatareyouawareofatthisverymoment?”Second,thetherapistcaninstructclientstolettheirfeelingsspeakforthemselvesortogive“voice”totheirfeelings(e.g.,“Letyourdepressionhaveavoiceandspeaknow”).Third,thetherapistcanencourageclientstoactoutorrole-playtheirfeelingsrightinthesessionatthemomentofexperiencingthem(seeJ.Sommers-FlanaganandSommers-Flanagan2004, 159).Stayingwiththefeelinghelpsclientstobemoreintouchwiththeirpreviouslyblockedfeelingsandtoownthemandreintegratethemintotheircurrentawarenessandfunctioning.TheReversalTechniqueTherapistsusethisGestalttherapytechniquetohelpclientsbecomemoreintouchwithaspectsofthemselvesthathavebeenblockedordenied.Forexample,theGestalttherapistwillaskaclientwhoisveryloudandaggressivetoreversehisbehaviorandtalkandactinamoregentle,quietway.Thereversaltechniquecanbeusedingrouptherapyaswellasinindividualtherapy.Forinstance,theGestalttherapistwillaskaverypassiveandintrovertedclientwhohardlytalksingrouptherapytoreversesuchbehaviorbytalkingthemostinthegrouptherapysession. GestaltTherapyinPracticeAHypotheticalTranscript Client:Ihaveanarticletowriteforascientificjournalwithadeadlineinafewdays.I’vetriedtowriteit,butIgetstuck. . . .Ijustcan’tdoit!GestaltTherapist:Pleasechangetheword“but”to“and,”andtheword“can’t”to“won’t”andmakeyourstatementagain!Client:OK. . .I’vetriedtowriteit,andIgetstuck. . . .Ijustwon’tdoit!GestaltTherapist:Iwouldlikeyoutorepeatyourstatementbutthistimeadd,“AndItakeresponsibilityforit”attheendofthestatement.Client:Well,I’lltryagain. . . .Ihavetriedtowriteit,andIgetstuck. . . .Ijustwon’tdoit!AndItakeresponsibilityforit!GestaltTherapist:Howdoyoufeelnow?What’sgoingonwithinyouatthismoment?Client:I’mfeelingmystucknessmoreandalsothatI’mresponsibleforit. . .thatI’vesomehowchosennottowritethearticleinsteadofthatIcannotwriteit. . . _Tan_Counseling_BB_mw.indd183 9/21/104:36:22PM 170 MajorCounselingandPsychotherapyTheoriesandTechniques thatmaybeIcandosomethingaboutit. . .andyetIstillstruggleinsidemewithapartofmethatsays,“Comeon,youhavetodoit!”andanotherpartofmethatsays,“Yes,I’lltry,butIdon’tthinkIcanmakeit!”It’sarealconflict!GestaltTherapist:It’stoughtohavethesetwosidesorpartsofyoufightingeachother,likeatopdogdemandingthatyougetthearticledoneandanunderdoghelplesslypleadingweaknessandinabilitytodoso.Letmesuggestanexperimentforyoutotrythatmayhelpyoudealwiththesetwosidesofyou.You’renowsittinginonechair,andIwouldlikeyoutospeakandexpressthepartofyouthatisharshlydemandingthatyoufinishwritingthearticlebythedeadline,thetopdoginyou,inthischair.Thenmovetotheemptychairacrossfromyou,andinthissecondchairIwouldlikeyoutospeakandexpressthepartofyouthatisweakandhelpless,feelingthatyoucan’tmakeitbythedeadline,theunderdoginyou.Iwouldlikeyoutocontinuethisdialogueorinteractionbetweenthetwopartsofyoubyswitchingbackandforthbetweenthetwochairs,andlet’sseewhathappens,OK?Client:OK,I’lltry.GestaltTherapist:OK,goaheadandspeaktotheotherpartofyouintheemptychairasyoulookattheemptychair.Client:(sittinginthefirstchair)Youreallyneedtopullyourselftogetherandgetthisarticlewrittenontime.You’rewastingalotoftimeworryingaboutit,andthenwatchingalotofTVasanescape.You’rebeinglazyandflakyagain.Youwillreallyblowitifyoudon’tgetthisarticledone!Yourchancesofgettingpromotedtoassociateprofessorwillbebadlyaffected!So,comeonandgetgoingandjustdoit!GestaltTherapist:Good!Nowmoveintotheemptychairandexpresstheotherpartofyouwhilelookingatthefirstchairyousatin.Client:(movestotheemptychairandsitsinit)OK,OK. . .IknowIhavetofinishwritingthearticlebythedeadline. . .butit’stoomuchworkandtoomuchpressureforme!Idon’tthinkthatIcanfinishitontime. . . .Ionlyhaveafewdaysleftbeforethedeadline,andthisisdrivingmecrazy!Ineedabreakandthat’swhyIwatchTV.I’mnotflakyorlazy,andIdowanttogetpromotedinmydepartment! _Tan_Counseling_BB_mw.indd184 9/21/104:36:24PM GestaltTherapy 171 GestaltTherapist:OK,nowmovebacktothefirstchairandswitchbacktotheharsh,demandingpartofyouagain,andseewhathappens. . . . ThishypotheticaltranscriptofasmallpartofaGestalttherapysessiondemonstratestheGestalttherapist’suseofassumingresponsibilityaswellastheempty-chairtechniquetohelptheclienttakemoreresponsibilityandalsotobemoreawareofthetopdogandunderdogpartsofhimselforherselfthatareinconflictandneedtobemoreintegrated(e.g.,bycomingupwithcompromisesolutionssuchasplanningamorespecificscheduleofwritinginterspersedwithsomebreakstowatchTVandaskingforashortextensionofthedeadlinefromthejournal’seditor).CritiqueofGestaltTherapy:StrengthsandWeaknessesGestalttherapyhasseveralstrengths.First,itemphasizesfocusingonthehereandnowandexperiencingthepresentmoment.Manyclientsarestuckinthepastanditspainandregretsorarepreoccupiedwithworryaboutthefutureanditsconcerns.TheGestalttherapist’sfocusonhelpingclientsexperiencethenow,inthepresentmoment,isagoodcorrectiveandbalance.Itisalsoconsistentwiththegrowingcontemporaryemphasisonmindfulness,orattendingtopresentexperience,withgentleacceptanceinvariousapproachestotherapy(see,e.g.,Baer2006;Germer,Siegel,andFulton2005).Second,Gestalttherapyhighlyvaluesawarenessandbeingintouchwithone’sfeelingsandpresentexperience.Thisisagoodcorrectivetotherapeuticapproachesthattendtooveremphasizethecognitiveprocessesofthinking,whichcanleadtotheclientintellectualizingandrationalizingasdefensesagainstpainfulexperiencesthatheorshemaywanttodeny,distort,ordisown.Third,Gestalttherapyattemptstofacilitateself-actualizationorself-regulationintheclient,whoisassumedtohaveaninherentcapacitytowardintegrationandself-actualization.Theclientthereforeultimatelydependsmuchlessonothersortheenvironmenttofulfillhisorherownneedsandbecomesmoreself-reliantandself-sufficient.However,whilegrowingtobemorematureandlessdependentonexternalsourcesofsupportcanbeahealthydevelopmentforaperson,thereisadangeroffallingintogrossindividualismandself-centeredness.Fourth,Gestalttherapyfocusesonhelpingclientsfinishorresolveunfinishedbusinessintheirlives.TheGestalttherapistwillthusconfrontclients(evenifmoregentlyincontemporaryGestalttherapythanFritzPerlsdid)withtheirself-deceptions,layersofneuroses,andotherdiscrepancies,inordertofrustratetheirneurosessothattheycanfacerealityandgrowtowardself-actualization.AuthenticityiscrucialinGestalttherapy,whichisalsoaformofexistential 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therapythatishumanisticandexperiential.Clientsarethereforehelpedtoovercomeplayinggameswiththemselvesandothers.Fifth,Gestalttherapyhasmorerecentlyemphasizedtheimportanceofthetherapeuticrelationshipandamorereciprocal,gentle,anddialogicalinteractionbetweenthetherapistandtheclient.Thisisagoodbalanceandacorrectivetotheoftenflamboyant,authoritarian,andevenabrasivestyleofFritzPerlsandhisearlierfollowersintheirpracticeofGestalttherapy,whichwasmoreconfrontationalandlessrelational.Sixth,Gestalttherapyhasdevelopedseveralhelpfulandcreativetherapyinterventionsormethods,includingthewidelyknownandresearchedemptychairtechnique.Asanexistentialandexperientialtherapy,ithasmoreconcreteandspecifictherapyinterventionsthanotherexistentialtherapies.However,thisisbothastrengthandapotentialweaknesssinceGestalttherapytechniquescanbemisusedwhentheyareinsensitivelyappliedtoclients,withoutappropriateunderstandingortraining.Seventh,Gestalttherapyisaflexible,open,andcreativeapproachtotherapy,anditcanbeadaptedforusewithdifferentethnicgroupsandcultures,nationallyandinternationally,especiallyingroupworkandgrouptherapycontexts(seeCorey2009,219–21).Finally,Gestalttherapyhasrecentlybeensubjectedtomoreempiricalresearchevaluatingitseffectivenessorefficacyintermsoftherapeuticoutcomes(see,e.g.,StrümpfelandGoldman2002;seealsoElliott,Greenberg,andLietaer2004).FritzPerlswasnotinterestedinconductingsuchresearchintheearlieryearsofGestalttherapy,insteademphasizingindividualcaseswithsubjectivereportsoftherapeuticgrowth.However,theempiricalevidencerelatedtoGestalttherapyhasgrowninrecentyears,includingmoreresearchonspecifictherapeuticinterventionssuchastheempty-chairtechnique.Gestalttherapyalsohasseveralweaknesses.First,asahumanisticandexistentialtherapy,ittendstoregardtoopositivelyhumannatureandanindividual’sinherentcapacitytogrowtowardself-actualizationorself-regulation.Itsfocusonhelpingaclientbecomemoreself-sufficientcaneasilyleadtonarcissisticself-centerednessandgrossindividualism.Gestalttherapydoesnotsufficientlyconsiderthedarkersideofhumannaturethatiscapableofevilanddestructivebehaviorsuchascrimeandwar(Parrott2003).However,itdoesconfrontclientswiththeirself-deception,layersofneuroses,anddiscrepanciesthatreflecteffortsatdenying,disowning,ordistortingrealityintheirlives.Second,Gestalttherapy’semphasisonfocusingonthehereandnowandone’sexperienceinthepresentmomentmayresultinaclientnotadequatelydealingwiththepastorthefuture.Clientsaremotivatedoraffectedbyfuturegoalsandconcernsaswellasbypastissues.AlthoughGestalttherapistsdoworkwithclientsonresolvingorfinishingunfinishedbusinessfromthepast,theiremphasisisstillonthepresentexperienceoftheclient.Suchafocuscan 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overemphasizepresentexperience,resultingintherapythatisimbalancedorinsufficientlyholistic.Third,Gestalttherapy’sfocusonenhancingtheclient’sawarenessandhelpinghimorhermorefullyexperiencefeelingscanalsobeimbalanced,sincethisfocususuallyignoresorevennegatesrationalthinking.One’sthoughtscanaffectone’sfeelingsandbehaviors,asthecognitive-behavioraltherapistshaveemphasized.Gestalttherapy’seschewingofrationalthinkingorcognitionisaweakness.ReasonableorrationalthinkingisnotalwaysequivalenttorationalizationorintellectualizationasadefenseasFritzPerlsassumedandassertedinhisanti-intellectualstance(Perls1947/1969a).Anotherrelatedweaknessisthe“philosophicalsloppiness”ofGestalttherapy’stheoreticalviews,whicharenotrigorouslysystematicorcomprehensiveandarephilosophicallyweak.Gestalttherapyisprimarilyapragmaticapproachtotherapythatcombinesideasandmethodsfromvarioussourcesbutnotalwaysinacoherentway(seeDay2004,230).SomeofthetermsGestalttherapyuses,borrowedfromGestaltpsychologyandotherexistentialschools,arealsosometimeslooselyusedwithmeaningsthatmaybesomewhatdifferentfromtheiroriginalsources.Fourth,Gestalttherapy,althoughmoregentleandrelationalnowthaninitsearlieryears,isstillasomewhatconfrontationalanddirectivetherapy.Clientsareconfrontedwiththeirunfinishedbusiness,defenses,andlayersofneurosesandself-deception.Thereisadangerofsuchconfrontationbeingtoooverwhelmingforsomeclientsandthereforepotentiallyharmful.Thisisapotentialdangerforallconfrontational,intenselyemotionaltypesoftherapy(Lilienfeld2007;seealsoTan2008c).Fifth,Gestalttherapymaybehelpfultoclientswhoareinhibitedandoutoftouchwiththeirdeeperfeelingsandimpulses,butitmaynotbeappropriateforthosewhoareimpulsive,reckless,andinsensitivetoothers’feelingsandneeds,suchassociopaths,delinquents,andindividualswholackempathyforothers(seeDay2004,221–22;Shepherd1970).Sixth,Gestalttherapy,unlikesomeotherapproachestoexistentialtherapysuchaslogotherapy(see,e.g.,Wong,Wong,McDonald,andKlaassen2007),doesnotadequatelyaddressthelargerquestionsoflifeconcerningmeaningandpurposeinlife.Gestalttherapistsdonotask“Why,”but“How”and“What”questions.However,manyclientsdostrugglewiththeexistentialquestionsoflifethatarerelatedtofearofdeathandmeaninginlife.Askingthebigger“Why”questionsmaythereforebecrucialattimesforsomeclients,andGestalttherapyisweakindealingwithsuchquestions(seeS. L.JonesandButman1991, 313).Seventh,althoughGestalttherapyhasdevelopedsomeusefulspecifictechniquessuchastheempty-chairtechnique,aweaknessliesintherapistsmisusingorabusingthem.InexperiencedorinadequatelytrainedtherapistscanapplysuchGestalttechniquesinasimplisticandmechanicalmanner,withoutbeingsufficientlysensitivetoclientsandtheiractualneedsandstruggles.Theap- 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propriateandethicaluseofGestalttherapyinterventionsmustbesafeguarded(seeLee2004)becauseofthepotentialharmclientscansufferwhenthesetechniquesaremisusedorabused.Eighth,althoughGestalttherapycanbeflexiblyadaptedforusewithotherethnicgroupsorcultures,itnonethelesstendstobesaturatedwithmiddleclassNorthAmericancultureandvalues,focusingonself-actualization,selfsufficiency,andevenself-centeredness.Clientsfromcountrieswithmorecollectivisticandcollaborativeculturesmayvaluefamilyandsocialrelationshipsmorehighly.Infact,someAsianculturesviewanemphasisonself-actualizationnegatively,becauseitisseenasbeingdetrimentaltoaperson’shealthydevelopment(ToddandBohart2006,215).ArelatedweaknessinGestalttherapy’sfocusontheindividualisthetendencytoneglectotherimportantfactorsthatcanalsocontributetothedevelopmentofpsychopathologyinpeople,suchassocial,cultural,political,economic,spiritual,andbiologicalforces.Finally,empiricalresearchontheeffectivenessorefficacyofGestalttherapyisstilllimited.AlthoughmoreresearchhasbeendoneonspecificGestaltinterventionssuchastheempty-chairtechnique,morecontrolledoutcomeresearchisneededtoevaluatetheeffectivenessofGestalttherapyasawholefordifferentclientswithdifferentdisorders.ABiblicalPerspectiveonGestaltTherapyGestalttherapyhasanumberofstrengthsthathavealreadybeenmentioned,someofwhichareconsistentwithabiblicalperspectiveorworldview.Forexample,theemphasisonbeingrealandauthentic,confrontingandovercomingself-deceptionandlayersofneuroses,andtakingresponsibilityforoneselfandone’sgrowthcanbeappreciatedfromabiblical,Christianperspective,whichalsoaffirmstheneedtofaceandexperiencetruthinordertobesetfree(John8:32)andtotakeresponsibilityforone’schoicesandbehaviors.Thefocusonthehereandnowandpresentexperience,inthemoment,isalsoagoodcorrectivetobeingstuckinthepastorpreoccupiedwiththeworriesofthefuture.Itissomewhatconsistentwithabiblical,Christianviewofattendingtothe“sacramentofthepresentmoment”(Caussade1989)andfocusingononedayatatimeandnotworryingabouttomorrow,asJesustaughtintheSermonontheMount(Matt.6:34).However,Gestalttherapyalsopresentsseveralsignificantproblemswhenitiscritiquedfromabiblicalperspective.First,thefocusofGestalttherapyonthehereandnow,recentlypopularizedevenmorebyEckhartTolle(2005)withthesupportofOprahWinfrey,canbeoveremphasizedtothepointofnegatingabiblicalhopeforthefuture,includingeternityinheavenbecauseofwhatJesusChristhasdoneforthoseofuswhobelieveinhim.TrueandeternalhopeencouragesanappropriateandbiblicalfocusonthefuturetohelpuslivemorefaithfulandobedientlivesnowonearthforGodandhiskingdom(seeMatt.6:33;Rom.8:18;2 Cor. 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4:16–18).ItshouldbenotedthatthereareotherseriousproblemswithTolle’sviewsfromabiblicalperspective(seeAbanes2008).Second,Gestalttherapy’semphasisonpresentexperiencetodeepenawareness,valuingintenseemotionalprocessing,andnegatingtheimportanceofthinking,includingrationalandintellectualprocessing,isanotherseriousproblemfromabiblicalperspective.TheBibleemphasizesinsteadthewholepersonandvaluestheimportanceofthinking(aswellasfeelingsandbehaviors)inthetransformationoftheperson.Wearetransformedbytherenewingofourminds(Rom.12:2),andwearesetfreeknowingandexperiencingthetruth(John8:32).BiblicalthinkingandsounddoctrinearecrucialtotrueChristianspiritualityandpersonaltransformationintodeeperChristlikeness,whichisGod’sultimatewillforus(Rom.8:29).Third,Gestalttherapyholdstoopositiveaviewofhumannature,withitsassumptionthatindividualshaveaninherentcapacitytogrowtowardselfregulationorself-actualization.Abiblicalperspectiveonhumannaturewillalsoconsiderthedarkersideofhumannature,whichissinful,fallen,andcapableofevil(Jer.17:9;Rom.3:23).Ashumanbeingswearenotsimplyinclinedtowardgrowthandself-actualization.WealsohaveatendencytowardsinandevilfromwhichonlyJesusChristcanadequatelyredeemandhealus.Fourth,Gestalttherapy,asadvocatedbyFritzPerls,emphasizesindividualself-actualizationorself-regulationsomuchthatitcaneasilydeteriorateintogrossindividualismandevensinfulself-worship(Vitz1994).Thewell-knownGestaltprayerwrittenandpopularizedbyPerlsinthe1960scapturesthisattitudewell:Idomythingandyoudoyourthing.IamnotinthisworldtoliveuptoyourexpectationsAndyouarenotinthisworldtoliveuptomine.YouareyouandIamI.Ifbychancewefindeachother,it’sbeautiful.Ifnot,itcan’tbehelped.(seeDay2004,229) Abiblicalperspectiveemphasizesinsteadagapelove(1 Cor.13)andlovingGodandlovingothers(Mark12:29–31).Theinterdependentandcommunityaspectsofhumaninterpersonalinteractionandfunctioningarethereforeviewedasessentialtohumanfulfillmentandharmony(see1 Cor.12),andinovercomingthesinfultendencytowardselfishnessandgrossindividualism(seealsoPhil.2:3–4),whichultimatelyleadstoisolationandmoraldecay.Similartoperson-centeredtherapy,Gestalttherapyisbasedon“nonhedonisticethicalegoism”(BrowningandCooper2004, 81),withitsultimatevalueofselfactualizationorself-regulation,whichreducescaringorconcernforotherstoonlyasecondaryconsequence.Trueagapelove,however,ischaracterizedbyself-transcendenceandmutualloveforothersthatinvolveslovingothers _Tan_Counseling_BB_mw.indd189 9/21/104:36:29PM 176 MajorCounselingandPsychotherapyTheoriesandTechniques fortheirownwelfare,andnotforself-actualizationitself.Suchadegreeofself-transcendenceisnotpresentinGestalttherapyandtheotherhumanistictherapies,whichcaneventuallyleadtomoreconfusionandsocialturmoilratherthanhealth(seeBrowningandCooper2004,81–85).Fifth,Gestalttherapydoesnotadequatelydealwiththelargerexistentialandspiritualorreligiousquestionsaboutdeathandtheultimatemeaningtolife:the“why”questions(seeS. L.JonesandButman1991, 313).Abiblicalperspectivewillseriouslyandauthenticallydealwiththeselarger-meaningquestions(seeWong,Wong,McDonald,andKlaassen2004),butitwillcentertheanswersultimatelyinJesusChristastheway,thetruth,andthelife(John14:6).RecentdevelopmentsinGestalttherapy,however,haveincludedattemptstointegrategenericorpersonalspiritualitywithGestalttherapy(see,e.g.,Ingersoll2005).Sixth,Gestalttherapy’sfocusonsubjectiveexperienceasthefoundationofone’slifeandgrowthtowardself-actualizationnegatesmoralabsolutesofrightandwrong,thusresultinginaradical“situationalethics.”Thereisnoultimatetruthormeaninginlifeandnomoralabsolutestofollow(seeHurding1985,206–7).AbiblicalperspectivewillupholdabsolutetruthandmoralabsolutesasrevealedintheBibleastheinspiredWordofGod(Matt.24:35;2 Tim.3:16),butwithcarefulinterpretationofScripture.Gestalttherapythereforepresentsseveralseriousproblemsfromabiblicalperspective.However,asJonesandButman(1991)havecommented,“perhapsGestalttherapyhassomethingtoteachusaboutwhatitmeanstoloveoneanotherintruthandhonesty”(1991, 321),inwhatClintonMcLemore(1984)hascalled“honestChristianity,”becauseofitsemphasisonbeingrealandauthenticandconfrontingandovercomingself-deceptionorlayersofdeceit.YettheBible’sbalancedteachingisthattruthshouldalwaysbespokeninlove,sothatwewillgrowupintoChristanddeeperspiritualmaturity(Eph.4:15).Research:EmpiricalStatusofGestaltTherapyMaryLeeSmith,GeneGlass,andThomasMiller(1980),inanearlierquantitativereviewofresearchontheoutcomesofvariousapproachestotherapy,foundthatGestalttherapyhadanaverageeffectsizeof.64,whichisinthemoderateeffectrange.SuchaneffectsizemeansthatGestalttherapyisbetterthannotreatmentbutnotmuchbetterthanplacebointerventions.More-recentreviewsofthelimitednumberofoutcomestudiesonGestalttherapyhaveconcludedthatitissignificantlybetterthanno-treatmentandwaitlistcontrolgroups,withnodirectcomparisonstoan“active”placebogroup(Elliott,Greenberg,andLietaer2004).Gestalttherapyhasbeenevaluatedwithotherformsoftherapyinfivedirectcomparisons,withGestalttherapyshowingslightlyinferioroutcomesinfourofthem(Greenberg,Elliott,andLietaer1994).Gestalttherapyisthereforemoreeffectivethannotreatment,butitisnotmoreeffectivethan 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otherformsoftherapywithadultclients.Itseffectivenesswithchildrenandadolescentshasnotbeenadequatelyresearchedtodate(seeProchaskaandNorcross2010,185–87;ToddandBohart2004,239–40).InthecomparisonsofGestalttherapyandotherexperientialtherapieswithcognitive-behavioraltherapies,theslightstatisticalsuperiorityofcognitivebehavioraltherapiesmayhavebeenpartlyduetomethodologicalproblems,especiallywhathasbeencalledtheresearcherallegianceeffect(Luborskyetal.1999).RobertElliott,LeslieGreenberg,andGermainLietaer(2004)havenotedthataresearcherallegianceeffectoccurswhenadvocatesofexperientialtherapies,includingGestalttherapy,findsignificantlybetteroutcomesofthesetherapiescomparedtocognitive-behavioraltherapies.Similarly,thiseffectoccurswhenproponentsofnonexperientialtherapies,includingcognitivebehavioraltherapies,reportsignificantlybetteroutcomesforsuchtherapiescomparedtoexperientialtherapies,includingGestalttherapy.ItshouldbenotedthatresearchonexperientialtherapiesincludesmorethanjustGestalttherapy;hence,conclusionsbasedonsuchresearchcannotbeovergeneralizedtoGestalttherapy.Forexample,L. Beutler,A. Consoli,andG. Lane(2005)reportedtheresultsofseveralstudiesthatcomparedaGestalt-basedgrouptreatmentcalledfocusedexpressivepsychotherapy(Daldrup,Beutler,Engle,andGreenberg1988)withcognitivetherapyandsupportiveself-directedtherapyingrouptherapywithdepressedoutpatients,meetingweeklyfortwentyweeks.Therewerenosignificantdifferencesinoveralleffectivenessofthethreegrouptreatments.However,overlysocialized,low-resistant,internalizingclientsdidbetterwithGestalt-basedtherapy.TheGestalt-basedtherapywasanexperientialfocusedexpressivetherapythatwentbeyondstandardGestalttherapy.Itintensifiedemotionalarousalbyenhancingawarenessandtheprocessingofunwantedfeelings.TheimportantworkofLeslieGreenbergandhiscolleaguesonprocessexperientialtherapy,recentlydevelopedintoamoreintegrativeapproachcalledemotion-focusedtherapy(seeElliott,Watson,Goldman,andGreenberg2004),isanotherexampleofanexperientialtherapythatisnotsynonymouswithGestalttherapy.ItincludeselementsofGestalttherapyandperson-centeredtherapy,aswellasotherexperientialtherapies,andthereforegoesbeyondGestalttherapy(seeSharf2008, 219;seealsoPos,Greenberg,andElliott2008, 87).InanotherreviewofoutcomeresearchonGestalttherapy,UweStrümpfelandRhondaGoldman(2002)optimisticallyreportedthefollowingsignificantresults:Gestalttherapyisequaltoorbetterthanothertherapiesforanumberofdisorders;Gestalttherapyiseffectivewithpersonalitydisorders,substanceaddictions,psychosomaticproblems,andvariousotherpsychologicaldisorders;andGestalttherapyhaslastingtherapeuticeffects,accordingtofollow-upevaluationsconductedfromonetothreeyearsaftertheendoftreatment(seealsoStrümpfelandCourtney2004).Someoftheseconclusionsmaybetoopositiveinlightofmore-nuancedconclusionsfromotherrecentreviewsalreadymentioned. 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MoreresearchhasalsobeendonetoevaluatetheeffectivenessofspecificGestalttherapytechniques,especiallytheempty-chairtechnique(L. S.GreenbergandFoerster1996;L. S.GreenbergandMalcolm2002;PaivioandGreenberg1995).Forexample,theempty-chairtechniquehasbeenfoundtobeeffectiveinhelpingclientsresolveconflictualfeelings.Ithasalsohelpedclientstobeexperientiallyinvolvedinthetherapeuticprocessmorequicklythanthetechniqueofreflectionoffeelingsasdevelopedinperson-centeredtherapy.AlthoughmoreempiricalresearchontheeffectivenessofGestalttherapyhasbeenconductedinrecentyears,thenumberofcontrolledoutcomestudiesavailableisstillrelativelysmall.MoreandbettercontrolledoutcomeresearchisneededinordertoexpandandstrengthentheempiricalbasefortheefficacyofGestalttherapy.However,Gestalttherapistsmaynotembracesuchquantitativeapproachestooutcomeresearch,especiallyrandomizedcontrolledtrials(RCTs).YontefandJacobs(2008)thereforerecentlyasserted:“Whenqualitativeresearch—researchnotgovernedbytheRCTprotocol—isincluded,thereisconsiderableevidenceoftheefficacyofgestalttherapy”(2008,354).FutureDirectionsOnly1percentofclinicalpsychologistsandsocialworkersand2percentofcounselingpsychologistsandcounselorssurveyedintheUnitedStatesindicateGestalt/experientialtherapyastheirprimarytheoreticalorientation(seeProchaskaandNorcross2010, 3).Thenumberof“purist”GestalttherapistsisthereforesmallintheUnitedStates.However,theinfluenceofGestalttherapyasanexperientialandhumanistictherapeuticapproachinthefieldofcounselingandpsychotherapyingeneralhasrecentlyincreasedagain.Emotionhasbecomeamajorfocusinpsychotherapyinthelastdecadeorso,whereascognitionwaspredominantinthe1980sand1990sandbehaviorinthe1970s(ProchaskaandNorcross2010).Gestalttherapyisthereforebeingincorporatedinvariousways,largeandsmall,intoothertherapeuticapproachesthatareessentiallyexperiential(e.g.,emotion-focusedtherapy)aswellasthosethatarenot(e.g.,cognitive-behavioraltherapiesthatutilizesomeGestaltmethodssuchastheempty-chairtechniquetohelpclientsaccessemotionallyladenor“hot”cognitions).However,onemustbecautiouswiththeuseofGestalttherapyandotherexperientialtherapiesthatfocusonevokingintenseemotionalexperiences,whichmaynotbeappropriateforcertaintypesofvulnerableclientswhocanbenegativelyaffectedbysuchtherapies(seeLilienfeld2007).OvercontrolledandinhibitedclientswithrelativelylowresistancemayneverthelessrespondwelltoGestalttherapy.YontefandJacobs(2008)haveobservedthatGestalttherapyhasrecentlyundergonesomesignificantshiftsinitsviewofpersonalityandtherapy.Forexample,agreaterappreciationofinterdependenceandadeeperunderstanding _Tan_Counseling_BB_mw.indd192 9/21/104:36:32PM GestaltTherapy 179 ofshameprocesseshaveledGestalttherapiststobecomelessconfrontationalandmoresupportiveintheirtherapeuticstylewiththeirclients.YontefandJacobs(2008)alsodescribethesignificantgrowthorproliferationofGestalttherapytraininginstitutesorcentersandliteratureavailableallovertheworld.In2007therewereapproximately120GestalttherapytraininginstitutesintheUnitedStates,withatleastoneineverymajorUScity.Around180GestalttherapytraininginstitutesoperateinEurope,SouthAmerica,Canada,andAustralia(seeYontefandJacobs2008, 336;Corey2009,227).TheInternationalGestaltTherapyAssociation(IGTA)(www.gestalt.org/igta.htm)wasfoundedin2000(Sharf2008,221)andhelditsfirstconferenceinMontreal,Quebec,Canada,in2002(Fall,Holden,andMarquis2004, 243).Otherwell-knownprofessionalorganizationsincludetheAssociationfortheAdvancementofGestaltTherapy(AAGT)(www.aagt.org)intheUnitedStates,theEuropeanAssociationforGestaltTherapy(EAGT)(www.eagt.org),andGestaltAustraliaandNewZealand(GANZ)(www.ganz.org.au).TheGestaltJournalanditssuccessor,theInternationalGestaltJournal,arenolongerpublished,buttwomajorEnglishlanguageGestalttherapyjournalsareavailabletoday:theGestaltReview(www.gestaltreview.com)andtheBritishGestaltJournal(www.britishgestaltjournal.com).TheGestaltDirectory,containinginformationaboutGestalttherapistsandtrainingprogramsworldwide,canbeobtainedatnocostfromtheCenterforGestaltDevelopment,Inc.(www.gestalt.org).Thecenteralsooffersaudiotapes,videotapes,andbooksonGestalttherapy(Corey2009,228–29).Aspreviouslynoted,Gestalttherapyhasrecentlyexperiencedrenewedinterestandgrowththatwilllikelycontinueintothenearfuture.AlthoughtheactualnumberofGestalttherapistsmaybesmall,theinfluenceofGestalttherapyhasincreasedandbecomemorepervasiveinthefieldofcounselingandpsychotherapy,whichisbecomingmorefocusedonemotion.RecommendedReadingsPassons,W. R.(1975).Gestaltapproachesincounseling.NewYork:Holt,Rinehart&Winston.Perls, F.(1969).Gestalttherapyverbatim.Moab,UT:RealPeoplePress.Perls, F.(1969).Inandoutofthegarbagepail.Moab,UT:RealPeoplePress.Polster, E.,&Polster, M.(1973).Gestalttherapyintegrated:Contoursoftheoryandpractice.NewYork:Brunner/Mazel.Wheeler, G.(1991).Gestaltreconsidered:Anewapproachtocontactandresistance.NewYork:Gardner.Woldt,A. S.,&Toman,S. M.(Eds.).(2005).Gestalttherapy:History,theory,andpractice.ThousandOaks,CA:Sage. _Tan_Counseling_BB_mw.indd193 9/21/104:36:33PM 10RealityTherapy W illiamGlasseristhefounderofrealitytherapy(W. Glasser1965),anapproachtotherapythatfocusesonthepresentandemphasizesaclient’sstrengthsandabilitytomakechoicesandcontrolhisorherbehavior.RealitytherapyisbasedonchoicetheoryasdevelopedbyGlasserandhisrevisionsandmodificationsofcontroltheory.Glasserassertsthatpeopleareresponsibleforchoosingtheirownthinkingandactionsthatthendirectlyaffecttheiremotionalandphysiologicalfunctioning.Accordingtochoicetheory,allhumanbeingshavefivebasicneeds:survival,loveandbelonging,powerorachievement,freedomorindependence,andfun,withtheneedtoloveandtobelongbeingtheprimaryneed(W. Glasser2001,2005).Realitytherapyhelpsclientstobecomemoreresponsibleandrealisticandthereforemoresuccessfulinachievingtheirgoalsandmeetingtheirneeds.Glasserwasdisappointedwiththeweaknessesandlimitationsofpsychoanalysis.Hedevelopedrealitytherapyinthe1960sasamorerationalanddirectapproachtotherapythatalsohasexistentialandhumanisticrootsinitsemphasisonone’sfreedomandcapacitytochooseandalsoone’sresponsibilitytoauthenticallymakechoicesinone’slife.Realitytherapyhasabasicallypositiveviewofhumannatureandpotentialforchange.Severaltherapeutictechniquesoftenusedinrealitytherapyincludestructuring,confrontation,contracts,instruction,role-playing,support,skillfulquestioning(e.g.,asking,“Doesyourpresentbehaviorenableyoutogetwhatyouwantnow,andwillittakeyouinthedirectionyouwanttogo?”),and180 _Tan_Counseling_BB_mw.indd194 9/21/104:36:33PM RealityTherapy 181 emphasizingchoice(e.g.,bychangingnounsandadjectivesintoverbs)(seeParrott2003).BiographicalSketchofWilliamGlasserWilliamGlasserwasbornonMay11,1925,inCleveland,Ohio,theyoungestofthreechildrenofBenandBettyGlasser.Hisfather,whoownedasmallbusiness,hademigratedtotheUnitedStatesasachildwithhisRussianJewishfamilytoescapepersecution.Glasserhasdescribedhismotherasverycontrolling,whereashisfatherwastheopposite,thepersonificationofchoicetheory(W. Glasser1998a,90).Henotedthatdespitesuchabasicincompatibilitybetweenhisparents,theywereconsistentlylovingintheirrelationshipwithhim.Glasserwenttocollege,likehisolderbrotherandsister,andmajoredinchemicalengineering.HewasstillastudentwhenhemarriedNaomiJudithSilver,hisfirstwife,whoduringforty-sixyearsofmarriagewasalsohisprofessionalcollaboratoruntilherdeathin1992.GlasserenrolledinaPhDprograminclinicalpsychology,buthisdissertationwasrejected.Hegraduatedwithamaster’sdegreeinclinicalpsychologyin1948,afterwhichheattendedmedicalschoolatCaseWesternReserveUniversityandobtainedhisMDdegreein1953,attheageoftwenty-eight.GlassermovedtosouthernCaliforniaforhispsychiatricresidencyatUCLAandattheWestLosAngelesVeteransAdministrationHospital,whichhecompletedin1957.Hewasboardcertifiedinpsychiatryin1961.HissupervisorandmentoratUCLAwasapsychiatristnamedG. L.Harrington,whosupportedGlasser’sseriousstruggleswithtraditionalpsychiatryandpsychoanalytictheoryandthesubsequentdevelopmentofrealitytherapyintheearly1960s(W. Glasser1961,1965).GlasseralsoworkedattheVenturaSchoolforGirls,aresidentialinstitutionfordelinquentadolescentgirls,in1956.Heconductedindividualandgrouptherapyandwasalsoinvolvedintrainingstaff.Hefocusedonfosteringakindandrespectfulrelationshipwiththegirlsattheschoolwhileexpectingthemtoberesponsiblefortheirownchoicesandbehavior.Healsoverballypraisedthemforappropriatebehaviors.Hisnewapproachtohelpingthemprovedtobeveryeffective,whichpromptedhimtobeginconsultingintheCaliforniaschoolsystem.Glasserhassignificantlyimpactedteachersandschoolsystemshereandabroadwiththeapplicationofhisrealitytherapyprinciplesandmethodsorchoicetheorytothepositivedevelopmentandlearningofstudents(seeW.Glasser1969,1986,1998b,2000a).HefoundedaneducationtrainingcenterasafurtherextensionoftheWilliamGlasserInstituteestablishedinCalifornia.Healsokeptafullscheduleofteaching,lecturing,andconductingaprivatepractice,inadditiontoconsultingwithschoolsystemsashecontinuedtofurtherdeveloprealitytherapy.Hepublishedhisclassicbook,RealityTherapy,in1965. 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Glasserwasexposedin1977totheworkofWilliamPowersthroughhisbookBehavior:TheControlofPerception(1973)andbeganusingsomeofPowers’sideasforfurthertheoreticaldevelopmentofrealitytherapyusingcontroltheory.GlasserwroteStationsoftheMind(1981)asasomewhattechnicalversionofcontroltheoryanditsapplicationstopeople’slives.AmorepopularbookoncontroltheorywaspublishedasControlTheory:ANewExplanationofHowWeControlOurLives(W. Glasser1985).Glasserthusbasedrealitytherapyoncontroltheoryashedescribedit.ThemaintheoreticalideaheborrowedfromPowerswasthenotionthat“people’schoicesareattemptstocontroltheirperceptionthattheirneedsarebeingmetintheworld”(Fall,Holden,andMarquis2004,249).However,Glassereventuallyrevisedhistheoryandrenameditchoicetheoryinsteadofcontroltheoryinthelate1990s(W. Glasser1998a).Hedidnotwantpeopletomisunderstandcontroltheorybyerroneouslythinkingthatitinvolvescontrollingotherswhenitreallyconcernsself-controlandmakingone’sowndecisionsinaresponsibleway.Hethereforereplacedtheword“control”with“choice,”whichbetterreflectsrealitytherapy’semphasisonmakingresponsiblechoicesforoneself;hence,choicetheoryisnowthetheoreticalfoundationforrealitytherapy.Glasserhaswrittenseveralotherbooksonchoicetheoryanditsapplications,includingCounselingwithChoiceTheory(2001);TheLanguageofChoiceTheory,withhissecondwife,Carleen,whoisinvolvedintheuseofrealitytherapyinschools(W. GlasserandGlasser1999);andGettingTogetherandStayingTogether,alsowithCarleen(W. GlasserandGlasser2000).Amorerecentbook,Warning:PsychiatryCanBeHazardoustoYourMentalHealth(W. Glasser2003),advanceshiscriticalviewoftheuseofpsychiatricmedicationsindealingwithpersonalproblems,basedonhisbeliefthatsuchmedicationscanadverselyaffecttheprocessbywhichpeoplemakechoicesinaresponsibleway.ItshouldbenotedthatGlasser’sfirstwife,Naomi,wasinvolvedineditingseveralofhisbooks,aswellaseditingtwosignificanttextsherselfonthepracticalapplicationsofrealitytherapy(N. Glasser1980),includingcasestudies(N. Glasser1989).Glasserisstillactivelyinvolvedinteachingchoicetheoryandrealitytherapyaroundtheworld.HefoundedtheInstituteofRealityTherapyin1967butchangeditsnametotheWilliamGlasserInstitutein1996sincehisdevelopmentofchoicetheoryanditsapplicationshavegonebeyondrealitytherapy.GlasserhasevenappliedhischoicetheoryideastoacommunityoftwentythousandpeopleinCorning,NewYork,beginningin1997.Heremainsanenergeticandvisionaryadvocateforchoicetheoryandrealitytherapy(seeW. Glasser2002,189–90).(ForfurtherbiographicalinformationonWilliamGlasser,seeFall,Holden,andMarquis2004,247–49;Parrott2003,341–42;Sharf2008,374–76;andJ.Sommers-FlanaganandSommers-Flanagan2004,297–98,329–30.) 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MajorTheoreticalIdeasofRealityTherapyPerspectiveonHumanNatureRealitytherapyhasexistentialroots.GlasserwasinfluencedbytheideasofHellmuthKaiser,oneoftheearliestexistentialtherapistsintheUnitedStates(ProchaskaandNorcross2010,119).However,sincerealitytherapyalsocombinesexistentialideassuchastheindividual’sfreedomtochooseandabilitytocontrolhisorherownbehaviorwithpracticalbehavioraltechniquesforimplementingbehavioralchangeandaction,itissometimesviewedasabehavioraltherapyoraneclectictherapy.Itisneverthelessuniqueinitsemphasisonhumanfreedomandchoiceandhencecannotbeeasilycategorizedasabehavioraloreclectictherapy.Realitytherapyisprobablybestdescribedasauniquetherapywithexistentialroots(Wubbolding2000).Glasserhimselfstronglyopposesbehaviorismorthephilosophicalfoundationofbehavioralapproachestotherapybecauseoftheirfocusonexternalcontrolofbehavior,whichhecritiquesasexternalcontrolpsychology(W. Glasser1998a).Hebelievesthatsuchexternalcontrolpsychologyisactuallythecauseofmuchofthehumansufferingandsocialproblemstoday.Inrealitytherapyorchoicetheory,Glasseradvocatesaninternalcontrolpsychologythatemphasizeshumanchoice.Healsoassertsthatwecancontrolonlyourownbehavior,andnotthebehaviorsofothers.Realitytherapythereforehasabasicallypositiveviewofhumannatureandanindividual’scapacityforchange.Italsofocusesmoreonthepresentandemphasizesaclient’sstrengths.BasicTheoreticalPrinciplesofRealityTherapyRealitytherapyisgroundedinchoicetheory(W. Glasser1998a,2001),whichisarevisionofcontroltheory(W. Glasser1985).Thefollowingarethebasictheoreticalprinciplesofrealitytherapyorchoicetheory:basichumanneeds,one’squalityworldorinnerpicturealbum,totalbehavior,choosingbehavior,andtheTenAxiomsofChoiceTheory(seeFall,Holden,andMarquis2004,250–54;Sharf2008,376–79;andJ. Sommers-FlanaganandSommers-Flanagan2004,300–311).BasicHumanNeedsGlasser(1998a)believesthatallhumanbehaviorisbasicallymotivatedorgovernedbyfivebasichumanneedsthataregeneticallyencodedineveryindividual:1.Survival2.Loveandbelonging3.Power(achievement) _Tan_Counseling_BB_mw.indd197 9/21/104:36:36PM 184 MajorCounselingandPsychotherapyTheoriesandTechniques 4.Freedom(independence)5.Fun(enjoyment) Survivalisabasichumanneedthatismainlybiological:aneedforcurrentsurvivalaswellasfuturesurvival.Itcanbemetbyengaginginbehaviorsthatenhanceanindividual’sprobabilityofsurvival,forexample,eating,exercising,andhavingadequateshelter,aswellasthosethatincreasetheprobabilityofthesurvivalofthehumanrace,forexample,Sidebar10.1sexualbehavior.Glasser(1998a)consideredloveandPrinciplesofRealityTherapybelongingtobethemostimportantorprimaryofallthefivebasichumanneeds,1,Basichumanneedsbecauseweusuallymustfirsthaverela2.One’squalityworldorinnerpictionshipswithothersinordertomeettheturealbumotherfourbasicneeds.Thisneedforlove3.Totalbehaviorandbelongingisexpressedinbehaviors4.Choosingbehaviorsuchassocializingwithpeople,establish5.TheTenAxiomsofChoiceTheoryingdeepandcaringfriendships,andbeinginvolvedinsexuallyintimaterelationships.However,choicetheorynotesthatthisprimaryhumanneedforloveandbelongingcanbeadverselyaffectedbyanotherbasichumanneed:theneedforpower.Thebasichumanneedforpowerisoftenregardedasnegative,butRobertWubbolding(2000)hasprovidedmorepositivealternativesfordescribingitasaneedforachievement,accomplishment,orinternalcontrol.Theneedforpowercanconflictwiththeneedforloveandbelonging,especiallyinacloserelationshipsuchasmarriage,inwhichapowerstrugglebetweenthemaritalpartnersleadstoalackofcompromiseandanultimatebreakdownofalovingandcaringrelationshipwitheachother(W. Glasser1985,1998a;W. GlasserandGlasser2000).However,theneedforpowercanbefulfilledinconstructivewayssuchasgettinggoodgradesincollege,doingwellinathleticevents,oreffectivelyhelpingothers.Nevertheless,GlasserwarnsagainsttheexcessiveneedforpowerthatisstillprevalentinWesternculture;itsdestructiveeffectscanbeseeninthepowerstrugglesinalmosteveryareaoflifeaspeckingordersareestablished(seeW.Glasser1998a, 38).Thebasichumanneedforfreedom(orindependence)isalongingineveryindividualforautonomyandtheabilitytochoosefromavarietyofpossibilities,relativelyunhamperedbyothers.Adolescentsinparticularoftenmanifestthisbasicneedforfreedombywantingtodothingstheirownway,sometimesevenrebellingagainsttheirparents’externalcontrol.Accordingtochoicetheory,humancreativityisclearlyconnectedtothefulfillmentoftheneedforfreedom.Withoutasenseoffreedom,itisdifficulttobecreative 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inaconstructiveway.Whentheneedforfreedomisnotmet,otherdestructivebehaviorscanresult,includingsymptomsofpsychopathologysuchashysteria.Finally,thebasichumanneedforfuninvolvesthequestorlongingforenjoymentandplayfulness.Glasser(1998a)directlyconnectsthisneedforfuntoplay,andplaytolearning.Peoplelearnthroughplaythatisenjoyableorfun.Healsoviewstheneedforfunastheeasiestonetofulfillandnotesthatlaughteristhebestdefinitionoffun.Funisalsousuallycloselyconnectedwiththeprimaryhumanneedforloveandbelonging.Allfivebasichumanneedscanbemetinresponsibleandconstructivewaysorinirresponsibleanddestructivebehaviors.Realitytherapistshelpclientstofulfillthesefivebasicneedsinhealthy,responsible,andconstructivewaysthatdonotharmothersintheprocessofmeetingone’sownneeds.Clientsarealsoremindedthattheycancontrolonlytheirownchoicesandbehaviors;theycannotcontrolothers,althoughtheycaninfluencethem.Whenone(ormore)ofthesefivebasichumanneedsisnotfulfilled,peoplefeelbadandaremotivatedtotrytomeettheunsatisfiedneeds.One’sQualityWorld or InnerPictureAlbum Accordingtochoicetheory,shortlyafterbirthandthroughoutourlivesourbasicneedsarenotdirectlysatisfied.Instead,becauseweareonlysomewhatawareofourfivebasicneedsingeneral,wekeeptrackmorespecificallyofwhateverwedothatmakesusfeelverygood.Overtime,webuildourownmentallistofspecificwantsandneeds,akindofinnerpicturealbumofspecificmemoriesandimagesofpeople,things,orexperiences,andbeliefsthathavemadeusfeelgoodbecausetheysatisfiedourbasicneeds(seeW. Glasser1998a;Wubbolding2000).Thisinnerpicturealbumisalsocalledone’squalityworld,orpersonalShangri-la,anidealworldinwhichonewouldliketoliveifpossible(seeCorey2009,318).Thequalityworld,orinnerpicturealbum,differsfrompersontopersonandalsowithinapersonovertime.Inotherwords,itcanberevisedasanindividualhasnewexperiences.Itisthereforecrucialforrealitytherapiststoempathicallyunderstandeachclient’ssubjectivequalityworld.Theyalsoneedtoenterintotheclient’squalityworldbyestablishinggenuine,caring,andrespectfultherapeuticrelationshipswithhimorhersothattheclientexperiencesloveandbelongingintherapyandallowsthetherapisttoenterintothatqualityworld.TotalBehaviorChoicetheoryemphasizesthatthekeycharacteristicofallhumanbeingsfrombirthtodeathisthefactthattheybehave.Suchbehaviorisdescribedbychoicetheoryastotalbehaviorconsistingoffourspecificbutconnectedpartsthatarealwaysfunctioningsimultaneously:acting,thinking,feeling, 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andphysiology.Actingreferstoparticularbehaviorssuchaswalking,moving,talking,andeating,andmaybevoluntaryorinvoluntary.Thinkingreferstoalltypesofthoughts,voluntaryorinvoluntary,includingdreams.Feelingreferstoemotionalexperience,bothpleasantorpainful,suchasjoy,sadness,anger,andsatisfaction.Physiologyreferstobodilyfunctions,voluntaryorinvoluntary,suchasheartrateandsweating.Thetotalbehaviorofanindividualinacting,thinking,feeling,andphysiologyhasoftenbeendescribedusingGlasser’scaranalogy(1990).Theengineofthecarcontainstheindividual’sbasicneeds(survival,loveandbelonging,power,freedom,andfun),whichprovidethepowerforthewholesystemofthecar.Thewantsofthepersonarelikethesteeringwheelmovingthecarinthedirectionofhisorherqualityworld.Actingandthinkingarelikethetwofrontwheelsofthecar,whichanindividualcandirectlycontrolinordertosatisfyparticularwantsandneeds.ThoughtsandbehaviorsarebothchosenbyapersonaccordingtoGlasser.Feelingsandphysiologyarelikethetworearwheelsofthecar,whichcanbeindirectlycontrolledbyanindividual.Glasser(2000b)emphasizesthatonecandirectlychooseonlyone’sactionsandthoughts,butonecanalsoindirectlycontrolone’sfeelingsandphysiologybychoosingtochangeone’sactionsandthoughts.ChoosingBehaviorGlasserholdstheradicalviewthatso-calledmentalillnessdoesnotexist(seeW.Glasser1965,85;2002,2)exceptforextremeconditionswherethereisobviousbrainpathology,forexample,braintraumaandAlzheimer’sdisease.Hiscriticalviewonmentalillnessechoessimilarviewsvoicedbyotherwell-knownpsychiatristssuchasThomasSzasz(1970,1971)andPeterBreggin(1991).Glasserbelievesinsteadthatpsychologicaldisorderisduetoanindividual’spersonalchoice.Heisalsoverycriticaloftheuseofpsychiatricmedicationstotreatpsychopathology(W. Glasser2003).Heholdsanextremepositionthatpeoplechoosetheirownbehaviorandarethereforefullyresponsiblefortheirproblems,whetherbehavioral,emotional,orphysical.Glasseradvocatesusingactiveverbstodescribehumansufferingandproblems.Insteadoftheusualwayofsayingthat“Iamdepressed”or“Ihaveaheadache”or“Iamangry”or“Iamanxious,”allofwhichreflectpassivityandtendtobeincorrectandtoreinforceadenialofpersonalresponsibility,Glasserpreferstousemoreaccurateverbformsinsaying“Iamdepressing,”or“Iamheadaching,”or“Iamangering,”or“Iamanxietying”!Thiswayofspeakingchallengesclientstorememberthattheyarechoosingtheirownbehavior,andhencetheyareactuallydepressingthemselves,orangeringthemselves,ormakingthemselvesanxious.Theyarethusheldresponsibleforchoosingtheirownsufferingwithinarangeof“paining”behaviors,thebestbehaviorstheycanmanagetotrytomeettheirwantsandneeds(Corey2009,318–19). 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Glasser’sradicalviewofchoosingbehavior,includingpsychopathologyandhumansuffering,asanall-pervasivefreedomandresponsibilityforeveryhumanbeingcansoundharshandmaynotbefullyacceptedbyalltherapists,includingsomerealitytherapists.However,thisradicalviewofchoicetheoryandpsychopathologycanstillbecommunicatedinanempathicwayinthetherapeuticprocessofrealitytherapy,whichisbasedonthetherapisthavingacaring,genuine,andrespectfulrelationshipwiththeclient.Ultimately,realitytherapyuseschoicetheorytoempowertheclienttomakehisorherownchoicesinaresponsibleandconstructivelyfulfillingway(seeJ. Sommers-FlanaganandSommers-Flanagan2004,307–10).Glasser(1985)providesfourmainreasonsforwhyindividualsmaychoosepathologicalbehaviororhumansufferingandmisery.First,manypeoplechoosetomakethemselvesanxiousordepressthemselvesinordertocontrolorrestrainanger.Forexample,peopleusuallyachievemorecontrolorpoweroverothersbydepressingthemselvesthanbyangering.Second,individualsmaychoosetomakethemselvesanxiousordepressedinanattempttogethelpfromothers.Depressingoneselfespeciallycanbeaneffectivemeansofgettinghelpandsympathyfromothers,includingmentalhealthprofessionals,aswellasofcontrollingsignificantpeopleinone’slife,inordertomeetone’sbasicneedsforloveandbelongingandalsoforpower.Third,peoplemaychoosetodepressthemselvesormakethemselvesanxiousinordertoavoidthingsthattheydonotwanttodealwithorfaceintheirlives.Itmaybeeasierforsomeonewhohasbeenlaidofffromworktoremainfrozeninfearortobeanxiousthantotakedifficultstepstowardfindingajob.Glasserwouldchallengepeopletryingtoavoiddealingwithadifficultsituationlikethistoeitherchangewhattheywantortochangetheirbehavior(W. Glasser1998a,83).Fourthandfinally,peoplemaychoosetomakethemselvesanxiousordepressthemselvesinordertoachievesignificantcontroloverotherpeopleandgetotherstodothingsforthem.Glasser(1985,2001)alsoviewsso-calledcrazybehavior,suchashallucinationsanddelusions,ascreativebehaviorwiththepurposeofgainingcontroloverone’slife,inadesperateway.TenAxiomsofChoiceTheoryGlassersummarizesthebasictheoreticalprinciplesofrealitytherapyastheTenAxiomsofChoiceTheory(1998a):1.Theonlyperson’sbehaviorwecancontrolisourown.2.Allwecangiveanotherpersonisinformation.3.Alllong-lastingpsychologicalproblemsarerelationshipproblems.4.Theproblemrelationshipisalwayspartofourpresentlife.5.Whathappenedinthepasthaseverythingtodowithwhowearetoday,butwecanonlysatisfyourbasicneedsrightnowandplantocontinuesatisfyingtheminthefuture. 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6.Wecansatisfyourneedsonlybysatisfyingthepicturesinourqualityworld.7.Allwedoisbehave.8.Allbehavioristotalbehaviorandismadeupoffourcomponents:acting,thinking,feeling,andphysiology.9.Alltotalbehaviorischosen,butwehavedirectcontrolonlyovertheactingandthinkingcomponents.Wecancontrolourfeelingandphysiologyonlyindirectlythroughhowwechoosetoactandthink.10.Alltotalbehaviorisdesignatedbyverbsandnamedbythepartthatisthemostrecognizable(seeJ. Sommers-FlanaganandSommers-Flanagan2004, 311).TherapeuticProcessandRelationshipGlasser(1965)emphasizesthreemajorfoundationalprinciplesofrealitytherapy:reality,responsibility,andrightandwrong.Hebelievesthatwhenindividualschoosetoengageinresponsiblebehaviorwithinthelimitsofrealityinordertomeettheirbasicneedsinwaysthatdonothurtothers,theirbehaviorisrightormoral.Theywillthenbeabletogiveandreceiveloveandhaveadeepsenseofself-worth.Realitytherapistshelptheirclientshavesatisfyingrelationshipswithotherssothattheirownbasicneedsforsurvival,loveandbelonging,power,freedom,andfuncanbefulfilledinresponsibleandconstructiveways.Therealitytherapistfunctionslikeamentor,teacher,orcoachtotheclientandthereforeoftenassumesadirectiveandeducationalroleintherapy.However,itisstillcrucialfortherealitytherapisttoestablishagenuine,caring,andconnectedtherapeuticrelationshipwiththeclient.Realitytherapyemphasizesthetherapeuticalliancebasedonanempathicandsupportiverelationshipwiththeclientbutdoesnotviewitassufficientforeffectivetherapytooccur.Realitytherapists,followingGlasser,believethatafriendlytherapeuticrelationshipthatalsoincludesfirmnesshelpstoprovideanappropriatecounselingenvironmentfortheclient,whobasicallyhasunsatisfyingrelationshipsornorelationshipswithothers.Therealitytherapistconnectswiththeclientbyengaginginagenuine,caring,andsupportiverelationshipandattemptstoentertheclient’squalityworld.Specifictechniquesarethenalsoneededtofurtherhelpclientschooseandchangetheirbehavior,inadditiontoestablishingafriendlytherapeuticrelationshipinwhatiscalledthecycleofcounseling(seeSharf2008, 381).Glasser(1998a)hasprovidedmoreguidelinesforestablishingagoodtherapeuticrelationshipwiththeclientbydescribing“sevencaringhabits”thatrealitytherapistswoulddowelltocultivate:supporting,encouraging,listening,accepting,trusting,respecting,andnegotiatingdifferences.Glasser(2002,13)alsolists“sevendeadlyhabits”ofharshconfrontationthatshouldbeavoidedbyrealitytherapists:criticizing,blaming,complaining,nagging,threatening,punishing,andrewardingtocontrol(seeJ. Sommers-FlanaganandSommers- _Tan_Counseling_BB_mw.indd202 9/21/104:36:42PM RealityTherapy 189 Flanagan2004,324–25).Realitytherapists,however,alsodonotacceptexcusesfromclients,donotcriticizeorargue,andarepersistentincaringfortheirclientsandthereforedonotgiveupeasily.Instead,theytrytoalwaysbecourteous,determined,enthusiastic,firm,andgenuinewiththeirclients,tofocusonthepresent,tousehumor,andtoappropriatelyuseempathicconfrontation(seeWubbolding1988;WubboldingandBrickell1998).TheprocessofrealitytherapyhasbeenfurtherelaboratedanddescribedbyWubbolding(2000,2007,2008)usingtheWDEPsystemofrealitytherapy.Wstandsforwantsandneeds,Dfordirectionanddoing,Eforself-evaluation,andPforplanning(seeCorey2009,325–29).IntheWstageorcomponentofrealitytherapy,thetherapisthelpstheclienttoexploreherwants,needs,andperceptions.Thekeyquestionthattherealitytherapistaskstheclientis:“Whatdoyouwant?”Theclient’sanswersaboutherwantswillberelatedtothefivebasichumanneeds:survival,loveandbelonging,power,freedom,andfun.Therealitytherapistusesskillfulquestioningtoencouragetheclienttoexploreherinternalpicturealbumandfurtherclarifyherdeeperwantsandneeds,whichmaynotbecurrentlyfulfilled.IntheDstageorcomponentofrealitytherapy,thetherapisthelpstheclienttofocusonthepresentandonwhatheisdoing,askingthekeyquestion:“Whatareyoudoing?”Therealitytherapistwillalsohelptheclienttoexploreandclarifythefuturedirectionofhislife,byaskinganothercrucialquestion:“Whatdoyouseeforyourselfatthistimeandinthefuture?”Theclientthereforefocusesondirectionanddoing,oronpresentactualbehavioranddirectionforthefuture,ratherthandwellingonfeelingsoronthepast.IntheEstageorcomponentofrealitytherapy,thecorepartoftherapyiscovered,withthetherapisthelpingtheclienttoengageinthefollowingcrucialself-evaluation:“Doesyourpresentbehaviorenableyoutogetwhatyouwantnow,andwillittakeyouinthedirectionyouwanttogo?”Usuallytheclientisstrugglingwithseriousrelationshipproblemsthatarecausinghermuchemotionalpain.Anotherkeyquestiontherealitytherapistoftenaskstheclientis:“Isyourpresentbehaviorbringingyouclosertopeoplewhoareimportanttoyou,orisitdrivingyoufartherapartfromthem?”Therealitytherapistusesskillfulquestioningtohelptheclientevaluatehertotalbehaviorintermsofheracting(doing),thinking,feeling,andphysiology,andempowerhertochoosemore-constructivewaysofbehavingandthinkingthatwillhelphersatisfyherwantsandneeds.InthePstageorcomponentofrealitytherapy,thetherapisthelpstheclienttofocusonplanningandactioninaspecificandconcreteway,withthegoalofmeetingtheclient’swantsandneedsthatwereearlierexpressed.Theclientisagainempoweredtomakeresponsibleplanstofulfillhiswantsandneedswithouthurtingothers.TherealitytherapistwillhelptheclienttodeviseaneffectiveplanofactionthatfollowstheacronymSAMIC³describedbyWubbolding(1988,2000,2007,2008):simple,attainable,measurable,immediate, _Tan_Counseling_BB_mw.indd203 9/21/104:36:43PM 190 MajorCounselingandPsychotherapyTheoriesandTechniques Sidebar10.2EightStepsoftheProcessofRealityTherapy(seeParrottandTan2003,347)1.Beinginvolvedwiththeclientinacaringandencouragingrelationship2.Focusingonbehavior3.Focusingonthepresent4.Makingaspecificplan5.Gettingacommitment6.Acceptingnoexcuses7.Eliminatingpunishment8.Nevergivingup controlled(bytheplanner),committedto,andcontinuouslydone.TheWDEPsystemofrealitytherapycanbeusedinbothindividualandgrouptherapycontexts.Morespecifictechniquesusedinrealitytherapywillnowbediscussed.Itshouldbenotedthattherealitytherapisthasmuchfreedomtobeflexibleandcreativeinconductingtherapywithclients.MajorTherapeuticTechniquesandInterventions Glasser(1965,1981)originallydescribedtheprocessofrealitytherapyasconsistingofeightstepsbutwithmuchflexibilityonthepartoftherealitytherapistinapplyingthemtoclients.Theeightstepsofrealitytherapyare(1) beinginvolvedwiththeclientinacaringandencouragingrelationship;(2) focusingonbehavior(andnotjustfeelings);(3) focusingonthepresent(andnotthepast);(4) makingaspecificplan;(5) gettingacommitment;(6) acceptingnoexcuses;(7) eliminatingpunishment;(8) andnevergivingup(seeParrottandTan2003, 347).Themajortherapeutictechniquesandinterventionsoftenusedbyrealitytherapistsarestructuring,confrontation,contracts,instruction,skillfulquestioning(e.g.,“Doesyourpresentbehaviorenableyoutogetwhatyouwantnow,andwillittakeyouinthedirectionyouwanttogo?”),emphasizingchoice(e.g.,byusingverbsinplaceofadjectivesandnouns),role-playing,support,constructivedebate,humor,self-disclosure,positiveaddictions,andassessment(seeParrott2003,348–52),aswellastheuseofmetaphorsandparadoxicaltechniques(seeSharf2008,387–90).StructuringStructuringisthetechniqueofhelpingclientssetuptheirexpectationsfortherapy,includingspecificaspectsoftherapysuchasfees,anticipatednumberofsessions,goalsoftherapy,andwhatrealitytherapyinvolves.Throughsuchstructuring,therealitytherapisthelpstheclienttohavemorerealisticexpectationsaswellashopeforpossiblechange.ConfrontationConfrontationisaninterventionthatwilleventuallybeusedbecauseclientexcusesarenotacceptedbyrealitytherapists,whopersevereanddonotquickly _Tan_Counseling_BB_mw.indd204 9/21/104:36:44PM RealityTherapy 191 giveupintheirtherapeuticworkwithclients.Confrontation,however,doesnothavetobeconductedinaharshway.Realitytherapistsoftenuseconfrontationintheformofempathicyetfirmquestionsorcommentsthatchallengeclientstoacknowledgetheirownresponsibilityinchoosingtoactorthinkinparticularwaysandtohonestlyfacetheconsequencesoftheiractions.Clientsarealsoconfrontedwithhowseriouslycommittedtheyaretotheirchoices.Thefollowingisanexampleoftheuseofconfrontationbyarealitytherapistwithaclient: Client:Ididn’tcallmybrotherasIplannedto,forthepurposeoftryingtoresolveaconflictwehadrecently.Butit’sOK,becausethisisnotthatimportanttomeanyway!RealityTherapist:Yousaidlastweekthatthiswasreallyimportanttoyou,butifitisn’tthatimportant,thenwhatisreallyimportanttoyou? Therealitytherapistcanalsorespondtothisclientbysaying,“Youtalkedalotaboutmakingthiscalltoyourbrotherinourlastsession,andyousaiditwasreallyimportanttoyoutomakethecall.Ibelievethatitstillisimportanttoyou!”Confrontationisthusatechniquethatcanbeusedindifferentformsandwaysdependingonthestyleandpersonalityoftherealitytherapist,aswellastheparticularclient.ContractsContractsinvolvetheuseofwrittenagreementssignedbytheclientandtherealitytherapist,withcleardescriptionsofwhattheclienthasfreelycommittedhimselforherselftodoing,asaplanofaction,formeetingtheclient’swantsandneedsinaresponsiblewaythatdoesnothurtothers.Asignedcontractcanhelpclientstomaketheircommitmenttofollowthroughwiththeirplansofactionmoreconcreteandfirm.Itcanalsobearecordoftheirsuccessfulexecutionoftheirplansandachievementoftheirgoals.InstructionRealitytherapistswilloftenfunctioninateachingorcoachingrole,instructingclientsinspecificskillssothattheycanexecutetheirplansandmeettheirneedsandgoalsinaresponsibleway.Ifaparticularclientneedsinstructioninanareaofknowledgethattherealitytherapistlacks,thetherapistwillrefertheclienttoanotherpersonoragency.SkillfulQuestioningAkeyquestionusedbyrealitytherapistsinconductingskillfulquestioningis:“Doesyourpresentbehaviorenableyoutogetwhatyouwantnow, 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andwillittakeyouinthedirectionyouwanttogo?”(seeParrott2003,350).Thisquestionwillhelpaclienttoreflectonhisorherbehavior,wantsandneeds,aswellasgoalsandplans,andthereforetoengageinproductiveselfevaluation.OtherdirectquestionsthatrealitytherapistscanuseinskillfulquestioningincludethefollowingsuggestedbyWubbolding(1988,2000):“Iswhatyouaredoingnowwhatyouwanttobedoing?Isyourbehaviorworkingforyou?Iswhatyouwantagainsttherules?Iswhatyouwantrealisticorattainable?Aftercarefullyexaminingwhatyouwant,doesitappeartobeinyourbestinterestandinthebestinterestofothers?Howcommittedareyoutothetherapeuticprocessandtochangingyourlife?”(seeCorey2009,327).Suchskillfulquestioningenablestherealitytherapisttounderstandtheclient’sworldmoreempathicallyandempowerstheclienttoassumemoreresponsibilityandcontrolforhisorherlifeandchoices.However,questionsshouldnotbeoverusedbutratherbeintegratedwithothertypesofresponsessuchasactiveandreflectivelistening(Wubbolding1996).EmphasizingChoiceRealitytherapyemphasizesthefreedomoftheclienttochoosehisorherownvalues.Theclientisconfrontedwithpersonalresponsibilityforhisorherowntotalbehavior(directlyforactionsandthoughtsandindirectlyforfeelingsandphysiology).Emphasizingchoiceisatechniqueinwhichthetherapistusesverbsinplaceofadjectivesornounsinordertostronglyemphasizetheclient’sresponsibilityinchoosinghisorherownbehaviors.Forexample,whenaclientsays,“I’mangry,”therealitytherapistwillasktheclienttoreplace“angry”with“angering”andsayinstead,“I’mangering.”Similarly,“I’mdepressed”willbereplacedwith“I’mdepressing”and“Ihaveaheadache”with“I’mheadaching.”Therealitytherapistusessuchverbformsofexpressioninemphasizingchoicetotheclientandhelpingtheclienttorealizethatheorsheisactuallychoosingto“depress”(fordepression)orto“anxietize”(foranxiety)himselforherself.Clientsthereforelearntochoosemore-constructiveandhealthierwaysofacting,thinking,feeling,andphysicallyfunctioningwhentheyrealizetheyhavechoicesandarenottotallyunderthecontrolofexternalforces.Thisradicalemphasisonchoiceinrealitytherapycanbetooextremeattimeswhenbiological,spiritual,orotherfactorsmayactuallybecontrollingtheclient’sbehaviorandexperiences.Emphasizingchoiceisatherapeuticinterventionthatmustbeusedinanempathicandsensitivewayratherthaninaharshmanner,sothattheclientfeelsempoweredtomakechoicesresponsibly,ratherthancrushedandblamed.Role-PlayingRole-playingisthetechniqueofpracticingandrehearsingspecificbehaviorsthattheclientwantstotryoutinreallife,inthesafetyoftherapyfirst,with _Tan_Counseling_BB_mw.indd206 9/21/104:36:46PM RealityTherapy 193 therealitytherapistprovidingcoachingandencouragement.Role-playinginrealitytherapyalsoincludesrehearsingthepossibleconsequencesofspecificbehaviorsinwhichtheclientwantstoengage,suchashisorherfeelingsafterexecutingthebehaviors.J. R.Cockrum(1993)hasdescribedhowrole-playingconcretesituationswitharealitytherapistoftenhelpsclientswithproblemsininterpersonalrelationships.SupportAsclientslearntoacceptpersonalresponsibilityfortheirchoicesandbehaviors,theyneedsupportfromtherealitytherapistinordertofollowthroughwiththeiractionplans.Clientswithahistoryofpastfailuresanda“failureidentity”thatexpectsfailureasawayoflifeareespeciallyinneedofsupportfromtherealitytherapist.Supportthereforeisthetechniqueofprovidingencouragementandpositivefeedbacktoclientssothattheyfeelmoreempoweredandmotivatedtomakechangesintheirlivesinconstructiveways.ConstructiveDebateConstructivedebateisthetechniqueinwhichtherealitytherapistchallengestheclient’sideasandvalues,andviceversa.Thischallengingisdonewithrespectfortheclientandwithoutforcingthetherapist’sownvaluesontheclient.Inconstructivedebate,therealitytherapistencouragestheclienttospeakupandhaveherownstrongvoiceassheexpressespersonalideasandvalues,whichtherealitytherapisttakesseriously,evenastheyengageinhealthyandmutualdebate.Theclientisalsoempoweredtomakesignificantcontributionstotherapybyspeakingup.HumorHumorisatherapeuticinterventioninrealitytherapythatinvolvesthetherapistandtheclientlaughingtogetheratajokeoratthemselvesorothersinasensitiveandappropriateway.SincefunisabasichumanneedaccordingtoGlasser,itisoftenexperiencedinaplayfulcontext,withlaughter.Humorintherapycanhelpmeettheclient’sneedforfuninasmallway.Therealitytherapistalsoengagesinafriendly,caringtherapeuticrelationshipwiththeclientinwhichhumorcanmorenaturallyoccur.However,humormustbeusedcarefullyandcannotbeforced,andthetherapistmustbewillingtolaughathimselforherselffirst.Ifusedappropriately,humorcanhelpclientstobemoreobjectiveandtobeabletolaughatthemselvesandtakethemselveslessseriouslysothattheycanenjoylifemore(W. GlasserandZunin1979).Ifhumorinvolvessarcasmordemeanstheclient,itisbeingusedinappropriatelyinawaythatcanharmtheclient.Suchdestructivehumorshouldbeavoidedintherapy. 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Self-DisclosureRealitytherapyemphasizesacollaborative,friendly,caring,andmutuallyopentherapeuticrelationshipbetweenthetherapistandtheclient.Realitytherapiststhereforeengageinself-disclosure,orsharingtheirownfeelings,struggles,andweaknesses.Suchtherapistvulnerabilityinhonestself-disclosurehelpstheclienttofeellessvulnerableandmoreempoweredtolivemorerealisticallyandresponsibly.PositiveAddictionsGlasser(1976)hasdescribedpositiveaddictionsasactivitiesorbehaviorsthatleadtoanaturalorhealthyhigh,onaregularbasis,thatdonotrequireexcessivetimeorconcentration.Examplesofpositiveaddictionsincludejogging,meditation,orvisitingwithfriends.Realitytherapistsencouragetheirclientstochoosepositiveaddictionsintheirlivessothattheycanliveinamorefulfillingandhealthyway.AssessmentRealitytherapistsdonottypicallyuseformaltestingtodiagnoseclients,buttheydoengageinassessmentormonitoringoftheirclients’progressintherapyandinachievingtheirgoals.Realitytherapistswillespeciallynoteanystepthatclientshavesuccessfullytakentoliveinamoreresponsibleway.Clientsareconsideredreadyforterminationoftherapywhentheyacceptresponsibilityandactmoreresponsiblyinmeetingpersonalneedswithouthurtingothersorthemselves(W. GlasserandZunin1979).MetaphorsMetaphorsinvolvetherealitytherapistusingtheclient’sspecificlanguage,especiallymetaphoricalorsymboliclanguage,inordertocommunicatedeeperempathytotheclient(WubboldingandBrickell1998).Anexampleoftheuseofmetaphorsinrealitytherapyiswhenaclientsays,“WhenIgotthepromotionatworkandapayraise,lifejustseemedbrighter!”andtherealitytherapistrespondswith,“Tellmemoreaboutwhatitfeelsliketobeinsuchbrightsunshine”(seeSharf2008,388).ParadoxicalTechniquesUsuallyrealitytherapistshelptheirclientsmakeplansandexecutethemindirectways.However,sometimesclientsmayresistchange.Atsuchtimes,realitytherapistsmayuseparadoxicaltechniques,referringtotheprovisionofcontradictoryinstructionstoclientsinordertohelpthemovercomeresistance _Tan_Counseling_BB_mw.indd208 9/21/104:36:48PM 195 RealityTherapy andmoveinthedirectionoffurthertherapeuticchange(WubboldingandBrickell1998).Oneexampleisinstructingaclientobsessedwithnotmakingmistakesatworktogoaheadandmakemistakesatwork.Iftheclientattemptstomakemistakesatworkasinstructed,hehasshownsomecontroloverthetargetbehavior.Iftheclientdoesnotfollowthetherapist’sinstructions,thenhisundesirablebehaviorendsupbeingcontrolledorterminated(Sharf2008,389).Paradoxicaltechniquesarecomplexandnoteasytoconduct.Theyalsopresentethicalandclinicaldangers.Twospecifictypesofparadoxicaltechniquesarereframingandprescriptions(seeSharf2008,390).Reframinginvolveshelpingclientschangetheirwayofthinkingaboutsomething.Forexample,ifahusbandcomplainsofhiswife’snagging,hecanbeinstructedtoreframehernaggingascaring.Paradoxicalprescriptionsrefertoinstructingtheclienttoactuallyperformaparticularsymptom(i.e.,prescribingthesymptom).Forexample,ifaclientisafraidofhavingapanicattack,sheisinstructedtogoaheadandtrytohaveapanicattack.Orifaclientisafraidofblushing,sheistoldtogoaheadandblushasmuchaspossibleandtellpeoplearoundherhowmuchandhowoftensheblushes.Paradoxicaltechniquescanthushelpclientstoregainasenseofcontrolandchoiceovertheirsymptoms.Paradoxicaltechniquescanbeconfusingandpotentiallydangerousiftheyareusedinappropriatelyandinsensitively.GeraldWeeksandLucianoL’Abate(1982)haveemphasizedthatinvolvementandsafetyareessentialintheeffectiveuseofparadoxicaltechniques.Theyshouldthereforenotbeusedwithsuicidal,sociopathic,orparanoidclients,orwiththosewhoareincrisessuchassufferingthelossofalovedoneorajob.Nevertheless,paradoxicaltechniquescanbehelpfultherapeuticinterventionsthatrealitytherapistscanusewiththeirclientstohelpthemachievemorecontrolovertheirsymptomsandtoovercometheirresistance. RealityTherapyinPracticeAHypotheticalTranscript Client:Ioftenfeelanxious,especiallywhenIhavetogiveatalkordoapresentationbeforeanaudience. . .Ihavethisanxietycreepingup. . .andthenIhaveheadachestoo!RealityTherapist:Weoftenexpressourfeelingsandexperiencessuchasanxietyandhavingheadachesasiftheyjusthappentous,asiftheyarewaybeyondourcontrol,asifwehaveabsolutelynochoice.Butwedohaveachoice,andtohelpyourememberthatyoualwayshaveachoiceIwouldlikeyoutotrysaying,“I’manxietizingmyselfwhenIhavetogiveatalk”insteadof“Ioftenfeel _Tan_Counseling_BB_mw.indd209 9/21/104:36:49PM 196 MajorCounselingandPsychotherapyTheoriesandTechniques anxiouswhenIhavetogiveatalk.”Changetheword“anxious”intoaverb“anxietize”!Goaheadandtrysayingthis.Client:OK. . .I’manxietizingmyselfwhenIhavetogiveatalkordoapresentationinpublic . . .RealityTherapist:Good!Nowgoonandtrysaying,“I’mheadachingmyself”insteadof“Ihaveheadaches”too.Client:OK. . .I’mheadachingmyself . . .RealityTherapist:You’regettingthehangofitprettywell!Nowcombinebothsentencesaboutanxietizingandheadachingyourselfandseehowyoufeel.Client:Well. . .I’manxietizingmyselfespeciallywhenIhavetogiveatalkordoapresentationbeforeanaudience. . . .Ianxietizemyselfmoreandmore. . .andthenIamheadachingmyselftoo!RealityTherapist:Good. . .nowthatyouareabletosaythatyouareanxietizingyourselfandheadachingyourself,howdoyoufeel?Client:Itfeelskindofweird. . .butIdofeelthatIhavesomechoiceinmyanxietyandheadaches. . .thatIhavesomeresponsibilityandcontrol,insteadofbeingapassivevictimtomyfeelingsandphysicalsensations.Realitytherapist:You’redoingreallywell. . . .Yourealizenowthatyoudohavesomechoiceinyouranxietizingandheadaching.Nowdoyouthinkthatwhatyou’redoing—anxietizingandheadachingyourself—ishelpingorhurtingyou?Client:It’sdefinitelyhurtingmebecauseIwanttobeabletogiveaneffectivepresentationthatwillreallyhelpthepeoplelistening.IguessIdohaveabasicneedforsomepowerorachievement.Ialsowanttoconnectwithmyaudience,tofeelappreciatedandlikedorlovedbymylisteners,tomeetmybasicneedforloveandbelonging,Iguess.RealityTherapist:You’veexpresseditwellandhaveagoodunderstandingofbasicneedsthataremotivatingyoutogiveaneffectiveandhelpfulpresentationthatwillactuallyhelpyourlistenersaswellasconnectyouandbondyouwiththem.Yetanxietizingandheadachingyourselfishurtingyouinsteadofhelpingyou.Whatelsecanyouchoosetodotohelpyoumeetyourneedsinaresponsiblewaythatdoesnothurtyouorothers?Client:Well,IguessIcanchoosetorelaxmyselfratherthan _Tan_Counseling_BB_mw.indd210 9/21/104:36:50PM RealityTherapy 197 anxietizemyself,toperhapstellmyselfI’llbeabletodoagoodjobinmypresentation.Also,Icanchoosetoputinabitmoretimeandeffortinpreparingmypresentationinsteadofprocrastinatinganddoingitatthelastminuteortheeleventhhour.RealityTherapist:Excellentideasandsuggestions!Nowhowcommittedareyoutomakingthesechangesandfollowingthroughwithyourplans,whichwecandiscussfurthertomakethemevenmoreconcreteandspecific? Thishypotheticaltranscriptofasmallpartofarealitytherapysessiondemonstratestherealitytherapist’suseofthetechniquesofemphasizingchoiceandskillfulquestioning.Thetherapistalsoprovidessupportandencouragementbyverballypraisingtheclientforrespondingwelltothetherapist’sinterventions.Thetherapistcontinuestouseskillfulquestioningtochallengetheclienttocommittomakingchangesandtoleadtheclientontofurtherdiscussionofhowtodevelopevenmoreconcreteandspecificplansforactionandtherapeuticchange.CritiqueofRealityTherapy:StrengthsandWeaknessesRealitytherapyhasseveralstrengths(seeCorey2009,330–36;Fall,Holden,andMarquis2004,264–69;Parrott2003,354–56).First,itsversatilityandadaptabilityhaveresultedinitsapplicationtodiversepopulationsincludingchildren,adolescents,adults,andolderadultsaswellastoavarietyofsettingssuchasschools,prisons,hospitals,andcrisiscenters(N. Glasser1989).Itisarelativelyshort-termtherapyapproachthatisdirectandthereforehasbeenusedforhelpingclientswithaddictionsandthoseinrecoveryprogramsforoverthreedecades(WubboldingandBrickell2005).Itisalsoconsistentwithmanagedcare’semphasistodayonshort-termtreatmentsandbrieftherapy.Second,realitytherapyisconcreteandspecific,focusingonparticularbehavioralgoals,withcontractsoftenspelledoutandsigned,sothatprogresstowardachievingclientgoalscanbemonitoredandmeasured.Again,itisarelativelyshort-termapproachtotherapythatdealsdirectlywithclientneedsandgoals.Third,realitytherapyfocusesonpresentbehaviorandneedsandhelpsclientsmakeconcreteplansforthefuture.Itisthereforeagoodcorrectivetotherapeuticapproachesthatmayfocustoomuchonthepastwiththedangerofclientsgettingstuckthere.Italsoemphasizesexplorationofbehaviorsandthoughtsmorethanfeelingsorsymptomssothatclientsdonotbecomemiredinwhiningorcomplainingabouttheirsymptoms.Fourth,realitytherapyisstillanexistentialapproachtotherapythatemphasizeschoiceonthepartoftheclient.Itchallengesclientstochoosetheir 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ownvaluesandbehaviorsinordertomeettheirbasichumanneedsorwantsinwaysthatareconsistentwithresponsibility,reality,andrightandwrongsothatotherswillnotbehurt.Fifth,realitytherapyasdevelopedbyGlasser,emphasizingchoicetheory,radicallyopposesthemedicalmodelofpsychologicaldisorderormentalillnessanditstreatmentwithpsychiatricmedications.Glasserisextremelycriticalofpsychiatrictreatmentofpsychologicaldisorderscenteredontheuseofpsychotropicmedications.Hebelievesthatsuchpsychiatrictreatmentcanbeharmfultothementalhealthofclients(W. Glasser2003).AlthoughGlasser’sapproachtorealitytherapyandchoicetheoryisradicalandextremeinthisregard,itisneverthelessempoweringtoclients,whocanchoosetochangetheirmaladaptivebehaviorsandthoughtsandeventuallytheirtotalbehaviorincludingfeelingsandphysiology.Thereisarealdangerinthemedicalmodelofpsychopathologythatreducesallpsychologicaldisorderstomentalillnessesandtheprematureandsometimesmistakenuseofpsychiatricmedicationstotreatsuchdisordersinclients.Themythofmentalillnesshasbeenmisappliedtomanyclientswhomaybebetterhelpedwithapproachestotherapysuchasrealitytherapy,whichemphasizestheirownchoiceandresponsibilityinbringingabouttherapeuticchange(seealsoBreggin1991;Szasz1970,1971).Sixth,realitytherapyhasdevelopedanddescribedseveraltherapeutictechniquesandinterventionsthatcanbeofmuchpracticalhelptomanyclients.Realitytherapistscanthereforeusethesetechniquesinconcretewaystofacilitateclienttherapeuticchange,basedonchoicesmadebytheclientinsettinggoalsforsuchchange.Seventh,realitytherapy’semphasisonclientchoicehasbeenfoundtobehelpfulincross-culturalcounseling.Clientsareencouragedtochoosetheirownvaluesandwaysofmeetingtheirneedsthatareculturallysensitiveandconsistent.Furthermore,realitytherapy’sfocusonthoughtsandactionsratherthanfeelingsishelpfultoclientsfromculturesthatdonotvalueorexpressindividualfeelingsasopenlyasWesternculturedoes.Nevertheless,realitytherapyhasrequiredadaptationinworkwithclientsfromothercountriesandcultures,asWubboldinghaspointedoutinhisexperienceconductingrealitytherapyworkshopsinternationally(Wubbolding2000;Wubboldingetal.1998,2004),inplacessuchasJapan,Taiwan,Singapore,India,Korea,Kuwait,Australia,Slovenia,Croatia,andotherEuropeancountries.Eighth,realitytherapyhasbeenfoundtobeusefulinhelpingclientswithdisabilitiesandtheirrehabilitation(see,e.g.,OsoskieandTurpin1985;G. Walker1987),withafocusonclientsmakingrealisticandresponsiblechoicesintheirpersonal,social,andvocationalgoalsandplans(seeParrott2003, 356).Realitytherapyalsohasseveralweaknessesandlimitations.First,realitytherapy,asanexistentialandhumanistictherapy,sharesthesameweaknessasothersimilartherapiessuchasexistentialtherapy,person-centeredtherapy,andGestalttherapy,inhavingtoopositiveaviewofhumannatureandanindividual’s _Tan_Counseling_BB_mw.indd212 9/21/104:36:52PM RealityTherapy 199 capacitytochangeinresponsibleandrealisticways.Thedarkersideofhumannature,whichiscapableofsinandevilandthusofhurtingandharmingothers,isnotadequatelydealtwithinrealitytherapy.Itisnotaseasyforclientstosimplychooseinresponsiblewaysortochangeasrealitytherapypurports.Second,realitytherapydoesnotsufficientlydealwiththepast.Someclientshaveexperiencedtraumaintheirpastthatrequiresmoretherapeuticattentionandhelpfromthetherapist.Althoughrealitytherapy’semphasisondealingwiththepresentandmakingplansforthefutureisagoodcorrectivetogettingstuckinthepast,itneverthelesscommitsthemistakeofnotpayingenoughattentiontounresolvedpainandissuesintheclient’spastthatcanstillinterferewithhisorherpresentfunctioningandproblemsolvingforthefuture.Third,realitytherapy’signoringofunconsciousprocesses,suchastransferenceanddreams,canlimititscomprehensivenessandeffectiveness.Payingadequateattentiontotheseunconsciousprocessescanhelpclientsgaindeeperinsightintotheirthoughts,behaviors,andfeelings,andmakemoreconstructivetherapeuticchangeintheirlives(seeCorey2009,334–35).Fourth,realitytherapyasexpoundedbyGlasser,takesanextremeandradicalviewofpsychologicaldisordersassteepedinbehavioralchoicesmadebytheclient,negatingbiologicalorgeneticfactorsinsuchpsychologicaldisordersandrejectingtherealityofmentalillnessesandtheneedforpsychiatricmedicationstotreatthem.SomerealitytherapistsdonottakeasextremeaviewasGlasserdoes,especiallyregardingseverepsychologicaldisorderssuchasschizophrenia,bipolardisorder,ormajordepressivedisorder,wherepsychotropicmedicationshavehelpedandevensavedthelivesofpatientssufferingfromthesedisorders.Themythofmentalillnessisthereforesometimesamythtoo(i.e.,themythofthemythofmentalillness).Thereissuchathingasmentalillnessforsomeclientswhohaveseverepsychologicaldisorders,anditcanbeharsh,ifnotcruel,toassumethattheyarefreelychoosingtheirseveresymptoms.Fifth,therealitytherapistrisksimposinghisorhervaluesontheclientsincethetherapistfunctionsasacoach,mentor,andteacher(seeWubbolding2008).Therealitytherapistmustbecarefultolettheclientengageinself-evaluationandself-choiceratherthandirecting,lecturing,ormoralizingtheclient.Sixth,thespecific,concretetherapeutictechniquesinrealitytherapycanbemisusedbyinadequatelytrainedorinexperiencedtherapists.Althoughthesetechniquescanbeofpracticalhelptoclientsandusefulfortherapists,theymustbeusedinthecontextofanempathicrelationshipwiththeclientandacomprehensiveunderstandingoftheclient’sclinicalproblems.Appropriateandadequatetraining,experience,andsupervisionarethereforeessentialintheeffective,efficient,andethicaluseofrealitytherapytechniques(Wubbolding2007).Seventh,Glasser’sradicalemphasisonclientsbeingabletofreelychoosetheirthoughtsandactions,values,andplanstofulfilltheirbasicneedsina 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responsiblewaymaynotbesensitiveenoughtoclientswhoareexperiencingactualsocial,political,orenvironmentaloppressionordiscrimination,especiallyclientsfromcertainethnicminoritycultures.Suchclientsarenottrulyfreetochooseinmanyinstancesandcontexts.Realitytherapistsinsuchsituationsfocusontheareasinwhichclientsstillhavesomelimitedchoice(Wubbolding2008).However,suchclientsmaystillneedtoopenlysharetheirexperiencesofoppressionordiscriminationandbeencouragedtotakesmallstepstohelpchangeexternalfactorsthatareobjectivelyoppressive(seeCorey2009, 333).Furthermore,thetherapistmustconsiderotherfactorssuchasbiologicalorspiritualforcesthatmaybestronglyaffecting,ifnotcontrolling,theclient.Eighth,someclientsfromotherculturesandcountrieswhohavemorecollectivisticvaluesmaynotbeascomfortableorassertiveinexpressingindividualneedsandgoalsandplanstofulfillthem.Theymaybemorecomfortablewithexpressingmorecommunalandfamilialneedsandvalues.Realitytherapythusmaynotbesensitiveenoughtosuchmulticulturaldiversityandcontexts.Wubbolding(2000),however,hastriedtoadaptrealitytherapyforuseinotherculturesandcountries.Forexample,hehasadvocatedless-directquestioningandgentlerandmore-carefulconfrontation,useofwordsotherthan“plan”and“accountability,”andacceptanceof“I’lltry”asagenuineexpressionofcommitment(ratherthanasanexcuse)withJapaneseclientsbecauseoftheuniquecharacteristicsofJapaneseculture,includingtheinappropriatenessofassertivelanguage,especiallybetweenparentandchildandemployerandemployee(seeCorey2009,331).Finally,realitytherapyhasnotfocusedsufficientlyonresearchandempiricaloutcomestudiestoevaluateitseffectivenessorefficacyintreatingclientswithvariousdisorders.Althoughsomeempiricalresearchhasbeendonetodate,itisstillquitelimited.ABiblicalPerspectiveonRealityTherapyRealitytherapyhasseveralstrengths,someofwhichareconsistentwithabiblicalperspective.Infact,realitytherapyhadasignificantinfluenceontheearlydevelopmentofvariousChristiancounselingapproachesbecauseofitsemphasisonresponsibility,reality,andrightandwrong(seeHurding1985,276–77;Morris1980,232;seealsoS. L.JonesandButman1991,247–50).PaulMorris,forexample,whodevelopedlovetherapyasaChristiancounselingapproach,yearsagowrote:“WhenIreadthisbook[RealityTherapy],itdawnedonmethatwhathewassayingwasverbatimwhatScripturestaught:Lovinginvolvementwithafocusonresponsibility”(1980,232).Realitytherapy’semphasisonacaringtherapeuticrelationshipwithaclient,withafocusonchoiceandresponsibility,thereforeresonatedwithmanyChristiantherapistsandpastors(seeYoung1982)becauseabiblicalperspectivealsoemphasizesagapelove(1 Cor.13)andchoiceandresponsibility(seeJosh.24:15;Luke _Tan_Counseling_BB_mw.indd214 9/21/104:36:54PM RealityTherapy 201 13:3).However,realitytherapy’sbasicallypositiveviewofhumannatureandanindividual’scapacitytochooseandchange,relyingonhisorherownstrength,isultimatelytoooptimisticandnotfullyconsistentwithabiblicalperspectiveonhumannature,whichalsoemphasizesthedarkersideofhumanbeingsthatiscapableofsin(Rom.3:23).Furthermore,theBibleteachestheneedforGod’sgrace(cf.2 Cor.12:9–10),salvationthroughJesusChrist(Rom.6:23),andthepoweroftheHolySpirit(cf.Zech.4:6;Eph.5:18)ingenuinetransformationofone’slife,exposingthefutilityandvanityofself-effort.Agapelove(1 Cor.13)isalsodeeperandpurerthananinvolvedandcaringtherapeuticrelationship.Second,realitytherapy’sfocusonpresentbehaviorandfutureplansissomewhatconsistentwiththebiblicalviewoftakinglifeonedayatatime(Matt.6:34),withgenuinehopeforthefuturebecauseofeternallifeinChristbothnowandforeverinheaven(seeMatt.6:33;Rom.8:18;2 Cor.4:16–18).However,itsignoringofthepastmustbebalancedwithanappropriatedealingwiththepastinordertoleavethepastbehindorto“forget”whatisbehind(seePhil.3:13–14).Sometimesthismayrequirethejudicioususeofinner-healingprayerorthehealingofmemories(seeTan2003b,2007b).Itmayalsorequirepatientlyworkingthroughunresolvedissuesandpainfulunfinishedbusinessfromthepast,someofwhichmaybeunconscious.Third,realitytherapy’semphasisonmeetingindividualneedsandwantsaslongasothersarenothurtintheprocessisarelativisticandsomewhatself-centeredformofethics.Thepotentialconflictbetweenmeetingone’sneedsandinterferingwithmeetingtheneedsofothersismoresubstantialandproblematicthanGlasserhasacknowledged.Abiblicalperspectivecallsustoahigherstandardofethicallivinggovernedandguidedbyaself-transcendentagapelove(1 Cor.13)thatgenuinelycaresmoreaboutthewelfareandwellbeingofothersthanthoseofoneself.SuchagapeloveisthefruitoftheHolySpirit(Gal.5:22–23),whoempowersChristianstolove;itisnottheresultofself-effort.Fourth,theneedsandvaluesofindividualsseemtobeofparamountimportanceinchoicetheoryandrealitytherapy.Thereisnotranscendent,spirituallyobjectivetruthsuchasinspiredrevelationintheBible(2 Tim.3:16).OurneedsandvaluesultimatelyfindtheirdeepestfulfillmentandgreatestclarificationinGodandhiseternaltruthasrevealedinScripture.Attemptsinrealitytherapytointegratespiritualitystillsubjectspiritualtruthorexperiencetorealitytherapy’sjudgmentofwhatisresponsibleandwhatisnot(seeLinnenberg1997;MickelandLiddle-Hamilton1996).Althoughrealitytherapistsmaypositivelyapproachthespiritualityofclientsasacrucialpartofmanyclients’particularqualityworlds,theywillstillassesswhethersuchspiritualityhelpsorhindersclients’fulfillmentoftheirneedsinaresponsibleway(seeFall,Holden,andMarquis2004,268).Inotherwords,atranscendentandrealspiritualityarenotembraced.BiblicalspiritualityinChristtranscendsmeetingone’sneeds. 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Thereisaspiritualrealitythatisgreaterthanneedsandgreaterthanoneself.Paradoxically,ourdeepestGod-shapedinnervacuumandneedcanonlybemetinareal,transcendentrelationshipwithGodthroughJesusChrist.Fifth,realitytherapycanbedangerousinthehandsofanauthoritarian,moralistic,orlegalistictherapistwhosimplisticallymisusesorabusesitstechniquesandultimatelyimposeshisorherownvaluesontheclient.Becauserealitytherapyemphasizeswhatisresponsible,realistic,and“right,”itcanalsobereducedtoamoralisticsystem.Thisdangerissimilarlypresentinsomeauthoritarianapproachestobiblicalcounseling(seeS. L.JonesandButman1991,249–50).TheBibleemphasizestheneedtospeakthetruthwithlove(Eph.4:15)andtheneedforpatience,encouragement,andsupport,inadditiontoadmonishment,inhelpingothers(1 Thess.5:14).ItalsoteachestheneedtocomfortotherswithGod’slovingcomfort(2 Cor.1:3–4).Realitytherapyhasmorerecentlyembracedagentlerapproachinplaceofitsearlier,somewhatconfrontationalstanceinchallengingclientstotakeresponsibilityforthemselvesandtochoose.Thisisapositivedevelopmentandmoreconsistentwithabiblicalperspectiveonhelpingothers.Finally,realitytherapy’sradicalviewoffreedomtochooseforeachindividual,includingchoosingsymptomsofpsychologicaldisorder,negatesthepossibilityofotherfactorsthatmaycausesuchsymptoms,includingenvironmental,social,political,biological,andevenspiritualordemonicforces.Therealityofspiritualwarfare(seeEph.6)andthepossibilityofdemonizationinsomecasesfromabiblicalperspectivecannotbeaccommodatedoracceptedbyrealitytherapy.Research:EmpiricalStatusofRealityTherapyGlasserhasnotfocusedonresearchasapriority,andthetrainingofcertifiedrealitytherapistsdoesnotincluderesearchtraininginthecurriculum.Theresearchbasefortheempiricalstatusofrealitytherapyisthereforelimited,althoughsomeresearchstudieshavebeenconducted(seeSharf2008,400–401).Mostoftheavailabledataontheeffectivenessofrealitytherapyhavebeenintheformofcasestudiescoveringawidevarietyofpsychologicaldisorders(W. Glasser2000b;seealsoN. Glasser1980,1989).Wubbolding(2000)hasreviewedtheresearchontheeffectivenessofrealitytherapywithclientssufferingfromaddictionanddepressionandwithjuvenileandadultoffenders.Researchstudieshavealsobeenconductedindifferenttypesofeducationalinstitutionsinseveralcountriesinternationally.R. J.KimandJ. G.Hwang(1996)inasmallstudyinKoreawith11middle-schoolgirlswhoreceivedgrouprealitytherapyand12studentsinacontrolgroupfoundthatthosewhoreceivedgrouprealitytherapyshowedimprovementsindiscipline,motivationforachievement,andlocusofcontrol.Inanotherstudyofrealitytherapy,involving25seventh-gradestudents,R. EdensandT. Smyrl(1994) 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foundasignificantdecreaseindisruptivebehavior.A. V. Peterson,C. Chang,andP. L.Collins(1997,1998),inalargerstudyof217undergraduatestudentsinTaiwan,dividedtheirsampleintothreegroups:thosewhoreceivedgrouprealitytherapyforeightweeks,thosewhoreceivedteachingorclassesonchoicetheoryforeightweeks,andthoseinano-treatmentcontrolgroup.Significantpositiveeffectsonself-conceptandlocusofcontrolwereobtainedforthestudentsinboththetherapyandtheteachinggroupswhencomparedtotheno-treatmentcontrolgroup.J. R.Petra(2000)foundpositiveeffectsonchildrenwithdisciplinedifficultiesatschoolaftertheirparents(45ofthem)receivedrealitytherapyandparentingeducationforthirteenhours.Aspecifictopicthathasreceivedsomeattentioninresearchonrealitytherapyisdomesticviolence.A.Gilliam(2004)dividedmenwhohadcommitteddomesticviolenceintotwogroupsoffifteeneach:onegroupreceivedtwelveweeksofgrouprealitytherapy,whiletheothergroupreceivedtwelveweeksofstructuredcognitive-behavioraltherapy.Thegroupthatreceivedrealitytherapyshowedasignificantchangeonaself-controloverviolencescale,whereastheothergroupdidnot.However,nosignificantdifferencesbetweenthetwogroupswerefoundonseveralothermeasuresofpsychologicalandsocialfunctioning.RobertRachor(1995)evaluatedtheeffectivenessofatwenty-onesessionprogramfordomesticviolencewithtwenty-twomenandtwenty-threewomen,usingrealitytherapyconceptsandrealitytherapyforfamilies.Theresultsshowedverylittleornoreporteddomesticviolenceforthewomen,butsomeviolencewasreportedforthemen.Ano-treatmentcontrolgroupwasunfortunatelynotusedinthisstudy.D. H.Lawrence(2004)conductedastudyonself-determinationinadultswithdevelopmentaldisabilities,dividingthemintotwogroupsoffifteeneach:onegroupreceivedsixsessionsofrealitytherapy,whereastheothergroupreceivedsixsessionsofmutualsupport.Therealitytherapygroupshowedsignificantchangesinself-determination,buttheothergroupdidnot.Therearethereforesomepositivefindingsontheeffectivenessofrealitytherapywithstudentswithdisciplineandotherachievementproblems,withadultdomestic-violenceoffenders,withadultswithdevelopmentaldisabilities,andothers(seeWubbolding2000).However,notalltheseresearchstudieshadadequatecontrolgroups.Inameta-analysisofovertwentyoutcomestudiesonrealitytherapy,L. Radtke,M. Sapp,andW. Farrell(1997)foundamediumeffectforrealitytherapy.Controlledoutcomeresearchonrealitytherapy,usingrandomizedclinicaltrials(RCTs),isstillverylimited.Thusnodefinitiveconclusionscanbepresentlymadeontheeffectivenessofrealitytherapy,butpreliminaryfindingssofarareencouraging.Morecontrolledoutcomeresearchonpurerformsofrealitytherapyconductedbyproperlytrainedandcertifiedrealitytherapistsisneededfortheempiricalstatusofrealitytherapytobefurtherstrengthened(seeL. Murphy1997;Wubbolding2000). 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FutureDirectionsAlthoughthepercentageofpsychotherapistssurveyedintheUnitedStateswhoindicatetheexistentialapproachtotherapyastheirprimaryorientationissmall,rangingfrom1 percentofclinicalpsychologiststo5 percentofcounselingpsychologistsandcounselors(seeProchaskaandNorcross2010, 3),theactualnumberofrealitytherapiststodayisprobablymuchhigher.Infact,sinceWilliamGlasseroriginallyusedtheterm“realitytherapy”in1962(O’Donnell1987),realitytherapy’spopularityhassignificantlyincreased.GlasserestablishedtheInstituteforRealityTherapyin1967inLosAngeles,andin1975itbegancertifyingrealitytherapistswhocompletedaneighteenmonthtrainingprogram.Aninternationalorganizationforcertifiedrealitytherapistswasfoundedin1981;thegrouphasgrownsignificantlyandnowholdsannualconventions.Atpresent,oversixthousandpeoplehavecompletedthetrainingprogramandarerealitytherapycertified(RTC).TheInstituteofRealityTherapywasrenamedtheWilliamGlasserInstitutein1996(seeSharf2008, 399)andisnowlocatedinChatsworth,California(www.wglasser.com).ThereisalsoaCenterforRealityTherapydirectedbyRobertE.WubboldinginCincinnati,Ohio(www.realitytherapywub.com).Realitytherapyhashadalargefollowingsince1965,particularlyamongteachers,rehabilitationcounselors,youthguidancecounselors,andsubstanceabusetreatmentcounselors(Parrott2003, 356).Ithasalsoestablisheditselfasamajorapproachtocounselingandpsychotherapythathasbeenusedinmanypracticesettingswithdifferentclientsandclinicalproblems.TheleadingjournalforrealitytherapytodayistheInternationalJournalofRealityTherapy(whichwascalledtheJournalofRealityTherapywhenitbeganpublicationin1981);furtherinformationaboutthisjournalcanbeobtainedatitsWebsite(www.journalofrealitytherapy.com).TheofficialjournaloftheWilliamGlasserInstituteistheInternationalJournalofChoiceTheory;furtherdetailsaboutthisjournalcanbefoundattheinstitute’sWebsite(www.wglasser.com/internat.htm)(seeCorey2009,336–37).Realitytherapyandchoicetheorywillcontinuetobeamajorschoolofcounselingandtherapyaswellasanimportantapproachtoschoolconsultationandthepositivedevelopmentandlearningofstudents.GlasserhasestablishedaneducationtrainingcenterasafurtherextensionoftheWilliamGlasserInstitute,andhecontinuestobeavisionaryandenergeticadvocateforchoicetheoryandrealitytherapyintheUnitedStatesandabroad(seeW.Glasser2002,189–90).RecommendedReadingsGlasser, W.(1965).Realitytherapy:Anewapproachtopsychiatry.NewYork:Harper&Row. _Tan_Counseling_BB_mw.indd218 9/21/104:36:59PM RealityTherapy 205 Glasser, W.(1998).Choicetheory:Anewpsychologyoffreedom.NewYork:HarperCollins.Glasser, W.(2001).Counselingwithchoicetheory:Thenewrealitytherapy.NewYork:HarperCollins.Wubbolding,R. E.(1988).Usingrealitytherapy.NewYork:Harper&Row.Wubbolding,R. E.(2000).Realitytherapyforthe21stcentury.Philadelphia:Brunner-Routledge. _Tan_Counseling_BB_mw.indd219 9/21/104:37:00PM 11BehaviorTherapy B ehaviortherapyfirstappearedasasystematicapproachtocounselingandpsychotherapyinthetreatmentofpsychologicaldisordersinthelate1950sand1960s.Itwasinitiallydefinedas“theapplicationofmodernlearningtheorytothetreatmentofclinicalproblems”(Wilson2008, 223),withanemphasisonclassicalandoperantconditioning.However,behaviortherapyhasdevelopedinsignificantwaysoverthepastseveraldecades,withgreatersophisticationandcomplexity.Contemporarybehaviortherapyappliesnotonlyprinciplesoflearningbutalsoexperimentalfindingsfromscientificpsychologytothetreatmentofspecificbehavioraldisorders.Itisanempiricallybasedapproachtotherapythatisbroadlysocial-learning-orientedintheory.Bythe1970s,behaviortherapyhadbecomeamajorapproachtocounselingandtherapy(SpieglerandGuevremont2003, 25).Behaviortherapydoesnothaveasinglefounder.Instead,ithasseveralkeyfigures,includingJosephWolpe,HansEysenck,B. F.Skinner,ArnoldLazarus,AlbertBandura,andDonaldMeichenbaum(seeCorey2009,233–34;Day2004,244–45;FishmanandFranks1992,161–69;GlassandArnkoff1992,587–99;Parrott2003,267–69;ProchaskaandNorcross2010,246–48,470–71;Sharf2008,256–59;Wilson2008,230–32).Behaviortherapycanbecharacterizedasconsistingofthreemajorthrusts,orthreeCsaccordingtoProchaskaandNorcross(2010):(1) counterconditioning(Wolpe);(2) contingencymanagement(Skinner);and(3) cognitivebehaviormodification(Meichenbaum).Behaviortherapistsviewhumanbeingsasproductsoftheirenvironmentsanduniquelearninghistories.Humannatureisthereforeseenasneitherpositivenornegative.206 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Thebehaviortherapistplaysanactiveanddirectiveroleintherapy,oftenactingascoachorteacher.Someexamplesofwell-knownbehaviortherapytechniquesorinterventionsincludepositivereinforcement(rewardfordesirablebehavior),assertivenesstraining(role-playingwithclientstohelpthemlearnhowtoexpresstheirthoughtsandfeelingsmorefreelyandappropriately),systematicdesensitization(pairingofaneutralorpleasantstimuluswithonethathasbeenconditionedtoelicitfearoranxiety),andflooding(exposingtheclienttostimulithatelicitmaximalanxietyforthepurposeofeventuallyextinguishingtheanxiety)(seeParrott2003).BiographicalSketchesofKeyFiguresinBehaviorTherapyJosephWolpewasborninJohannesburg,SouthAfrica,onApril20,1915.AlthoughhehadareligiousJewishupbringing,WolpealsoreadotherphilosopherssuchasImmanuelKant,DavidHume,andtheatheistBertrandRussell,andeventuallyendedupembracingphysicalmonisminsteadofhisearlierJewishfaith.HegrewupinSouthAfricaandearnedhismedicaldegreefromtheUniversityofWitwatersrandinJohannesburg.WolpehadsomepsychoanalyticinfluenceearlierinhistraininginpsychiatrybuteventuallygravitatedtotheconditioningtheoriesofIvanPavlovandhisworkonclassicalconditioning(orrespondentconditioning)inRussia,andespeciallytothetheoreticalworkofClarkHullonconditioningasexplicatedinhisbook,PrinciplesofBehavior(Hull1943).WolpedidhisMDthesisresearchonanimalneurosesanddiscoveredcounterconditioningprocessesandprocedureswhenhefoundthattheeatingresponseincatscouldbeusedtoinhibit,orcountercondition,aclassicalconditionedanxietyresponsetoabuzzerthatwasinitiallypairedwithelectricshock.In1958,hewroteagroundbreakingbook,PsychotherapybyReciprocalInhibition,inwhichhedescribedalearning-basedapproachtotherapybasedoncounterconditioning.Morespecifically,heuseddeeprelaxationtocounterconditionanxietyandhencedevelopedsystematicdesensitizationasauniquebehavioralinterventionfortreatingphobiasandanxietyproblems.Healsousedassertiveresponsestoinhibitsocialanxiety,leadingtothedevelopmentofassertivenesstraining.Wolpereviewedmorethantwohundredcasesofpatientswithdifferentbehavioralproblemsthathadbeentreatedwithhiscounterconditioningprocedureswithabout90percentsuccessrates(seeProchaskaandNorcross2010,246–48).HeinfluencedagroupofstudentsandcolleagueswhometoftenwithhimattheUniversityofWitwatersrand.ArnoldLazarusandStanleyRachmanparticipatedinthisgroup,andtheyeventuallyhelpedbringWolpe’ssystematicdesensitizationtotheUnitedStatesandGreatBritain.WolpehimselfmovedtotheUnitedStatesin1963(GlassandArnkoff1992).WolpetaughtattheUniversityofVirginiaandTempleUniversityMedicalSchoolinPhiladelphia,wherehewasaprofessorofpsychiatryfrom1965until _Tan_Counseling_BB_mw.indd221 9/21/104:37:01PM 208 MajorCounselingandPsychotherapyTheoriesandTechniques hisretirementin1988.HethenwenttoPepperdineUniversityinCalifornia,wherehespentninemoreyearsasadistinguishedprofessorofpsychiatryuntilhisdeathonDecember4,1997,duetolungcancer.WolpealsodirectedthebehaviortherapyunitattheEasternPennsylvaniaPsychiatricInstitutewhenhewasteachingatTempleUniversity.Wolpewasaleadingfigureinbehaviortherapyandwroteawell-knowntext,ThePracticeofBehaviorTherapy(1990),thatwentthroughfoureditions.HealsohelpedfoundtheAssociationforAdvancementofBehaviorTherapy(AABT),nowcalledtheAssociationforBehavioralandCognitiveTherapies(ABCT),aswellastheJournalofBehaviorTherapyandExperimentalPsychiatry.HecoauthoredoneofthefirstbooksontechniquesofbehaviortherapywithArnoldLazarus,BehaviorTherapyTechniques(1966).Wolpewasalwaysanadvocateforapurerandlessdilutedversionofbehaviortherapythatpreserveditsfoundationsinlearningtheory(Wolpe1989).Hethereforedidnotsupportexpandingtheboundariesofbehaviortherapytomakeitmorecognitive-behavioral,eclectic,ormultimodalasArnoldLazarusandothershavedone(seeGlassandArnkoff1992, 608).HansJürgenEysenckwasborninBerlin,Germany,onMarch4,1916,butmovedtoEnglandinthe1930sbecauseoftheNazimovementinGermany.HeobtainedhisPhDinpsychologyfromtheDepartmentofPsychologyatUniversityCollegeLondon,withSirCyrilBurtashismentoranddissertationsupervisor.EysencktaughtattheInstituteofPsychiatry,MaudsleyHospital,UniversityofLondon,asprofessorofpsychologyfrom1955to1983.HewasoneofEngland’sbest-knownpsychologists,havingmadesignificantcontributionstoseveralareasofpsychology,includingpersonalityandindividualdifferences,intelligenceandtheroleofgeneticsinIQdifferences,andbehaviortherapy.Eysenckwasastrongadvocateforascientificpsychology.In1952,hepublishedascathingcritiqueofpsychotherapyaspracticedinthe1950swithmainlypsychoanalyticandclient-centeredapproaches.Heasserted,basedonthestudieshehadreviewed,thattherewasnoempiricalsupportfortheeffectivenessofpsychotherapyforpatientswithneuroticdisorders.Hedrewtheshockingconclusionthatpsychotherapywasnotmoreeffectivethanspontaneousremissionratesfoundinno-treatmentcontrolpatients(i.e.,aroundtwo-thirdsofneuroticpatientswillrecoverorsignificantlyimproveoveratwo-yearperiodwithouttherapy).More-recentresearchhascontradictedEysenck’searliersweepingconclusions(Eysenck1952);thisresearchindicatesthatspontaneousremissionratesareactuallycloserto43percentandfindspsychotherapytobeeffective(BerginandLambert1978).However,his1952critiqueoftraditionalpsychotherapyasbeingineffectivepreparedthefieldofcounselingandpsychotherapytobemoreopentobehaviortherapyasasystematicapproachfortreatingpsychologicaldisorders.Eysenckplayedaverysignificantroleinhelpingtoestablishbehaviortherapyworldwide.Hemetweeklywithcolleaguesandstudentsathishometofur- 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therdiscussanddevelopthisnewapproachtotherapy,basedonthelearningtheoriesandconditioningviewsofHullandPavlov,thatheeventuallylabeledbehaviourtherapy(orbehaviortherapy).Hedefineditastheapplicationofmodernlearningtheorytotheunderstandingandtreatmentofbehavioralorbehaviorallyrelateddisorders(Eysenck1959).Lazarus(1958)inSouthAfricaalsousedthisterm,behaviortherapy,todescribeWolpe’sapproachtotreatingneuroticpatientswithreciprocalinhibitiontechniques.Interestinglyenough,B. F.Skinner,H. C.Solomon,andO. R.Lindsley(1953)intheUnitedStatesinitiallyusedtheterm“behaviortherapy”inanunpublishedstatusreport,torefertotheiruseofoperantconditioningtechniquestoincreasesocialinteractionsamongpsychoticinpatients(seeFishmanandFranks1992, 172).Inthe1960s,Eysenckalsopublishedtwosignificantbooksthathelpedadvancebehaviortherapyanditspractice:BehaviorTherapyandtheNeuroses(1960)andTheCausesandCuresofNeurosis,withStanleyRachman(EysenckandRachman1965).Eysenckhimselfdidnottreatpatients,buthewasinstrumentalinsupportingthedevelopmentofbehaviortherapytechniquesattheMaudsleyHospitalinthelate1950sand1960s,whenotherwell-knownbehaviortherapistssuchasCyrilFranksandStanleyRachmanwerethere.EysenckwasgivenmuchsupportandencouragementbyM. B.Shapiro,theheadoftheclinicalsectionattheMaudsleyHospital,whothereforealsoplayedasignificantroleinthebirthingofthebehaviortherapymovementinEngland(seeGlassandArnkoff1992, 594).EysenckdiedonSeptember4,1997,inLondon,England,havingachievedthespecialstatusaroundthetimeofhisdeathofbeingthemostfrequentlycitedlivingpsychologistinscientificjournals(Haggbloometal.2002).Healsolaunchedthefirstjournaldevotedsolelytobehaviortherapy,BehaviourResearchandTherapy,in1963,anditisstillbeingpublishedtoday.FurtherdetailsonEysenck’slifeandthedevelopmentofbehaviortherapycanbefoundinhisautobiography,RebelwithaCause(Eysenck1990).B. F.Skinner,whosefullnamewasBurrhusFrederickSkinner,hasbeenlistedasthemostinfluentialpsychologistofthetwentiethcentury(Haggbloometal.2002).HewasborninSusquehanna,Pennsylvania,in1904.Hehadayoungerbrother,Edward,whodiedwhenSkinnerwasvisitinghomefromcollegein1923.AfterEdward’sdeath,Skinner,whowasthenknownasFred,drewclosertohisparentsandbecamemoreactivelyinvolvedwiththefamily.HegraduatedfromHamiltonCollegeinClinton,NewYork,in1926withaBAinEnglishliterature.Skinnerhadaspiredtobeawriter,butafterpursuingawritingcareerforayear,heabandonedthenotion(seeDay2004,244–45).Hehadalwaysbeenabrightstudent,withaspecialinterestinbuildingthings,suchasgadgetsandmachines.Heeventuallymadeseveralsignificantinventionsinexperimentalpsychologythathelpedresearcherstomonitorandrecordbehaviorsinanunobtrusiveway.SkinnerearnedaPhDinpsychologyfromHarvardUniversity 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in1931,afterwhichhecontinuedhisworkinlaboratoryresearchuntil1936,whenheleftHarvardforatimetoteachanddoresearchatotheruniversities.In1936,hewedYvonneBlue,andtheyremainedmarrieduntilherdeathin1997.Theyhadtwodaughters,oneofwhombecameanartistandtheotheraneducationalpsychologist(Corey2009, 233).Skinnerwasaradicalbehavioristwhodidnotbelieveinhumanfreewill.Heisoftenviewedasthefatherofbehavioralpsychology.Hebelievedthatbehaviorisdeterminedbyenvironmentalevents,andespeciallythatbehaviorisgovernedbyitsconsequences.Rewards,orpositiveconsequences,reinforceormaintainspecificbehaviors,whereaspunishment,oraversiveconsequences,decreaseoreliminateparticularbehaviors.Skinnerthereforedevelopedoperantconditioningtechniques,ortheuseofreinforcementcontingenciestomodifybehavior;hencetheterm“behaviormodification”isoftenusedforhisapproach.Thelabel“behaviortherapy”wasinitiallyusedbySkinnerandhiscolleaguesinanunpublishedstatusreportattheMetropolitanStateHospital,inWaltham,Massachusetts(Skinner,Solomon,andLindsley1953).Skinner,likeWolpe,didnotfavorintroducingmorecognitiveconceptsandtechniquesintothefieldofbehaviortherapybecausehefeltthattheyareunnecessaryandwouldweakenthebehavioralapproach(Skinner1990).Skinnerdidmostofhisworkinexperimentalstudiesinthelaboratory,focusingonthebehaviorsofpigeonsandrats,butheultimatelyappliedhisprinciplesandprocedurestohumanbeingsaswell,especiallyinareassuchaseducation,behaviormodificationasatherapeuticapproachforthetreatmentofpsychologicaldisorders,andsocialplanning.Hehaswrittenseveralimportantbooks,includingWaldenTwo(Skinner1948),aboutautopiancommunity,ScienceandHumanBehavior(Skinner1953),abouttheapplicationofbehavioralprinciplestoallareasofhumanbehavior,andBeyondFreedomandDignity(Skinner1971),abouttheneedfordrasticchangesusingscienceandtechnologyforthesurvivalofoursociety(Corey2009,233).Skinnerkeptuphisactivescheduleasalecturerandwriteruntilhisdeathin1990fromleukemia,attheageofeighty-six.ArnoldAllanLazaruswasbornin1932inSouthAfrica,wherehegrewupandreceivedhiseducation(seeProchaskaandNorcross2010,470–71).HeobtainedhisPhDin1960fromtheUniversityofWitwatersrandinJohannesburg.HismentorwasJosephWolpe,oneofthepioneersofbehaviortherapy.Lazaruswrotehisdissertationontheeffectivenessofgroupsystematicdesensitizationinthetreatmentofphobicconditions.Lazarusreceivedhisearlytraininginbehaviortherapyandinitiallyconductedhisclinicalpracticeusingmainlybehavioralinterventions.Heiscreditedwithbeingoneofthefirstauthorstousetheterm“behaviortherapy”inapublishedarticle(Lazarus1958),andhecoauthoredanearlytextonbehaviortherapytechniqueswithJosephWolpe(WolpeandLazarus1966).However,Lazarusfoundthatthebehavioralinterventionsheusedwithhis 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clientsoftenproducedsignificanttherapeuticoutcomesthatdidnotlastatfollow-up.Althoughheisoftenconsideredapioneerinbehaviortherapy,hewasalsooneofthefirsttoadvocatebroad-spectrumbehaviortherapythatincorporatedcognitiveinterventionsratherthannarrow-bandpuristbehaviortherapy(Lazarus1966,1971).Lazaruseventuallybecamedissatisfiedevenwithbroad-spectrumbehaviortherapyandwentontodevelopamoredistinctiveapproachtotherapythathecalledmultimodalbehaviortherapy,inwhichheaddedtobehaviorandcognitionseveralotherdomainssuchasimagery,affect,sensation,interpersonal,andbiological,ortheBASICI.D.(Lazarus1973,1976).Herefinedhisapproachevenmore,advocatingtechnicaleclecticismbutnottheoreticaleclecticism,andfinallycalledhisnewapproachtotherapymultimodaltherapy(Lazarus1981,1985,1989,1997,2008).Hecontinuestoaddnewtherapeutictechniquestotherepertoireofmultimodaltherapyinterventions,whileemphasizingtheneedtomatchthetherapist’sapproachandtechniquestothespecificneedsoftheindividualclient.LazarushastaughtatStanford,Temple,andYaleuniversities,butheeventuallysettledattheGraduateSchoolofAppliedandProfessionalPsychologyatRutgersUniversityinPiscataway,NewJersey.Heisnowadistinguishedprofessoremeritusbutcontinuestopresentworkshopsandtrainingseminarsonmultimodaltherapy.HealsodirectstheLazarusInstituteinPrinceton,NewJersey.Heishighlyregardedandoftencitedasoneofthemostinfluentialpsychotherapiststoday,andremainsaparticularlysignificantvoicefortechnicaleclecticism(ProchaskaandNorcross2010, 471).AlbertBandurawasbornin1925inMundare,Alberta,Canada,theyoungestofsixchildrenfromanEasternEuropeanfamilybackground.HeobtainedhisBAfromtheUniversityofBritishColumbiainVancouver,andthenwenttotheUniversityofIowaforgraduateschool,whereheearnedaPhDinclinicalpsychologyin1952.Afterayearofclinicalinternship,heacceptedafacultypositionatStanfordUniversity,wherehehasremained.Bandurahasmadesignificantcontributionstoseveralareasofpsychology,includingauthoringanearlykeytextonbehaviortherapyandbehaviormodification,PrinciplesofBehaviorModification(1969).Heiswellknownforhisresearchonobservationallearning(modeling)andhisdevelopmentofsociallearningtheory(Bandura1977b),orsocialcognitivetheory,whichhashadatremendousinfluenceoncounselingandpsychotherapy.Healsopublishedagroundbreakingarticlein1977onself-efficacyasaunifyingtheoryofbehavioralchange(Bandura1977a).Sincethenhehasfurtherdevelopedhistheoryofself-efficacy(Bandura1986,1997),whichhasbeenthesubjectofnumerousdoctoraldissertationsindiverseareas.Perceivedself-efficacy,oraself-efficacyexpectation,isthebeliefthatonecansuccessfullyperformthebehaviorrequiredtoproduceaparticularoutcome,andsuchperceivedself-efficacywilldetermineone’spersistenceandultimate 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successincopingwiththreats(Bandura1977a).Perceivedself-efficacycanthereforebesimplydefinedasone’sbeliefthatonecansucceedatatask(SpieglerandGuevremont2003,291).Bandura(1997)hasmorerecentlydescribedthewide-rangeapplicationsofhisself-efficacytheorytomanyareas,includingpsychology,psychiatry,education,health,medicine,humandevelopment,business,athletics,aswellasinternationalaffairsandpoliticalandsocialchange(seeCorey2009,233).Hisself-efficacytheoryofbehavioralchangegreatlyinfluencedthefurtherdevelopmentofbehaviortherapyintobroader-spectrumcognitive-behavioraltherapy.Bandurahasadvocatedamoreopenreciprocaldeterminismthatallowsforsomedegreeofself-reflectionandself-regulationorchoice(Bandura1986,1997).BanduraservedaspresidentoftheAmericanPsychologicalAssociationin1974andhasreceivedmanyhonors,includingtheOutstandingLifetimeContributiontoPsychologyAwardfromtheAmericanPsychologicalAssociationin2004.Inasurveyconductedin2002,hewasfoundtobethefourthmostfrequentlycitedpsychologistofalltime(Haggbloometal.2002).DonaldMeichenbaumwasbornin1940andraisedinNewYorkCity.HecompletedhisundergraduatestudiesattheCityCollegeofNewYorkandobtainedaPhDinclinicalpsychologyfromtheUniversityofIllinois,UrbanaChampaign.Shortlythereafter,in1966,hejoinedthefacultyattheUniversityofWaterlooinWaterloo,Ontario,andcontinuedhisteachingandresearchthereforthirty-threeyearsuntilheretiredin1998.HeisnowadistinguishedprofessoremeritusattheUniversityofWaterloo,andadistinguishedvisitingprofessorattheSchoolofEducationattheUniversityofMiamiinFlorida.HeisalsotheresearchdirectoroftheMelissaInstituteforViolencePreventionandTreatmentofVictimsinMiami,Florida.Meichenbaumhashelpedtofurtherdevelopbehaviortherapyintoabroader-basedcognitive-behavioralapproachbyemphasizingthecrucialroleofself-instruction,orself-talk,intheregulationofone’semotionsandbehaviors.Heconductedimportantresearchonself-instructionaltrainingasacognitive-behavioralinterventiontohelppeopleinstructthemselvestocopebetterwithdifferenttypesofproblemssuchasimpulsivebehaviorinchildrenandbizarrespeechandthoughtsinschizophrenicpatients(seeSpieglerandGuevremont2003,344).Healsoexpandedself-instructionaltrainingintoamorecomprehensiveinterventioncalledstressinoculationtrainingtohelpclientscopemoreeffectivelywithstressfulsituationsandproblemssuchasanxiety,anger,andpain(seeMeichenbaum1977,1985,2003,2007).HisbookCognitive-BehaviorModification,firstpublishedin1977,hasbecomeaclassicinthefieldofcognitivebehaviortherapy.Meichenbaumhasalsodonesignificantworkintheareasofposttraumaticstressdisorder(Meichenbaum1994);anger-controlproblemsandaggressivebehaviors(Meichenbaum2002);treatmentadherence(MeichenbaumandTurk1987);stresspreventionandmanagement(MeichenbaumandJaremko 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1982);andsuicide(Meichenbaum2005).HewasoneofthefoundersofthejournalCognitiveTherapyandResearch.Meichenbaumhasreceivedmanyhonorsandawards,includingtheprestigiousIzaakKilliamFellowshipAwardfromtheCanadaCouncil.HeisalsoafellowoftheRoyalSocietyofCanada.HewasvotedbycliniciansasoneofthetenmostinfluentialtherapistsofthetwentiethcenturyandwasalsofoundtobethemostfrequentlycitedpsychologyresearcheratCanadianuniversitiesduringhisacademiccareer.Hehaslecturedandconductedworkshopsaswellasconsultedwidely,bothnationallyandinternationally.Hecontinuestomakecontributionsintheareasofeducation,violenceprevention,trauma,andsuicide.InadditiontoWolpe,Eysenck,Skinner,Lazarus,Bandura,andMeichenbaum,otherimportantfiguresassociatedwiththedevelopmentofbehaviortherapyincludeCyrilFranksandStanleyRachman,mentionedearlier,andHobartandWillieMowrer.EarlyexperimentalworkthatprovidedtheinitiallearningandconditioningfoundationsforbehaviortherapywasdonebywellknownresearcherssuchasIvanPavlov,John B.Watson,MaryCoverJones,andEdwardThorndikeinthe1920sand1930s(seeSpieglerandGuevremont2003,16–25).AkeyfigurewhosignificantlycontributedtothedevelopmentofbehaviortherapyinCanadainthe1960sandlaterisErnest G.Poser,whowasaprofessorofpsychologyatMcGillUniversityanddirectorofthebehaviortherapyunitattheDouglasHospitalCentreinMontreal,oneofthefirstclinicaltreatmentandteachingfacilitiesofitskind(seePoser1977).HeisnowretiredinVancouver,BritishColumbia.MajorTheoreticalIdeasofBehaviorTherapyPerspectiveonHumanNatureThehistoryofthedevelopmentofbehaviortherapyconsistsofthreemajorgenerationsorwaves(Hayesetal.2006).Thefirstwavewastraditionalbehaviortherapy,whichemergedinthelate1950sanddevelopedfurtherinthe1960sandearly1970s;itemphasizedwhatProchaskaandNorcross(2010)havedescribedascounterconditioning(Wolpe)andcontingencymanagement(Skinner)thrusts.So-calledmodernlearningtheories,particularlyclassicalconditioningfollowingtheworkofIvanPavlovandoperantconditioningbasedonB. F.Skinner’swork,dominatedthefieldofbehaviortherapyinthefirstwave.Conditioningtheoriesoflearningviewedhumanbeingsasbeingcontrolledbyclassicaloroperantconditioning;therefore,earlybehaviortherapytendedtohaveadeterministicviewofhumannature,withlittleornofreedomtochoose.Humannaturewasalsoseenasprimarilyneutral,neitherpositivenornegative.Thesecondwaveofbehaviortherapybeganinthelate1970sandinvolvedthedevelopmentofabroader-basedcognitivebehaviortherapythatincorporated 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thethinkingdimensionofindividuals,ratherthanonlyfocusingnarrowlyonenvironmentalfactors.Cognitivebehaviortherapy,however,FeaturesofDevelopmentinisnowmorethanthirtyyearsold(Hayesetal.BehaviorTherapy2006).Itisthepredominantapproachtodayinbehaviortherapybuthasexpandedtoinclude1.Classicalconditioningnewertreatmentapproachesthatincorporate2.Operantconditioningmindfulnessandacceptance(seeHayes,Fol3.Sociallearningtheorylette,andLinehan2004).4.CognitivebehaviortherapyThethirdwaveofbehaviortherapythathasrecentlydevelopedinthe1990sandtheearlytwenty-firstcenturyinvolvesrelativelycontextualisticapproachesthatarebasedtosomeextentonconceptssuchasmindfulnessandacceptance(Hayesetal.2006).Themajorapproachesinthisthirdwaveofbehaviortherapyincludedialecticalbehaviortherapy(DBT)(Linehan1993);mindfulness-basedcognitivetherapy(MBCT)(Segal,Williams,andTeasdale2002);andacceptanceandcommitmenttherapy(ACT)(HayesandStrosahl2004).ThemorerecentapproachestobehaviortherapyinitssecondandthirdwaveshavemovedbeyondtheearliermechanisticandradicallybehavioristicviewsofhumannatureespousedbytraditionalbehavioristssuchasSkinner.Contemporarybehaviortherapyandcognitivebehaviortherapytendtoviewhumanbeingsashavingsomecapacityforchoiceandself-reflectionandselfcontrol(Kazdin2001;D. L.WatsonandTharp2007).Bandura’ssociallearningorsocialcognitivetheoryandinparticularhisconceptsofself-efficacyandreciprocaldeterminism(Bandura1977a,1977b,1986,1997)haveresultedinamorecomplexviewofhumannatureashavingagreatercapacityforselfregulationandchoiceandthereforesomefreewill.Humanbeingsarestillseenasneutral,however,neitherinherentlygoodnorinherentlyevil.Sidebar11.1 BasicTheoreticalPrinciplesofBehaviorTherapyContemporarybehaviortherapycannolongerbeeasilydefined.MarvinGoldfriedandGeraldDavisonhavebroadlydescribedbehaviortherapyas“reflectingageneralorientationtoclinicalworkthatalignsitselfphilosophicallywithanexperimentalapproachtothestudyofhumanbehavior”(1994, 3).Thefourmajorfeaturesofdevelopmentinbehaviortherapyareclassicalconditioning,operantconditioning,sociallearningtheory,andcognitivebehaviortherapy(seeCorey2009,235–37).Classicalconditioning,orrespondentconditioning,referstothewaybehavioriscontrolledbyitsantecedents,orwhathashappenedbeforethebehavior.Forexample,inhisearlyexperimentalwork,IvanPavlovfoundthatputtingfoodintoadog’smouthwillleadthedogtosalivate.Thissalivation _Tan_Counseling_BB_mw.indd228 9/21/104:37:09PM BehaviorTherapy 215 iscalledtherespondentbehavior,ortheunconditionedresponse(UCR)tothefood,whichistheunconditionedstimulus(UCS).However,iftheUCSoffoodisthenrepeatedlypairedwiththesoundofabellasaconditionedstimulus(CS),presentedjustbeforethefood,eventuallythesoundofthebellitself(CS),presentedwithoutthefood(UCS),willelicitsalivationastheconditionedresponse(CR)ofthedogtotheCS.However,ifthisprocessisdonerepeatedly,presentingtheCSwithouttheUCS,theCRofsalivationwilleventuallydecreaseandbeeliminated.Inthisway,throughtheprocessofclassical(orrespondent)conditioning,neutralstimuli,suchasasound,canelicitconditionedresponses.Fearresponsescanbeconditionedthroughclassicalconditioningprocesses.Wolpe’ssystematicdesensitizationtechnique,orreciprocalinhibitionapproachtotreatingphobiasandanxietydisorders,isbasedonclassicalconditioningandcounterconditioningprocesses.Operantconditioninginvolveslearningprocessesinwhichone’sbehavioriscontrolledbytheconsequencesthatfollowthebehavior.B. F.Skinner’sworkhelpedtoexplicatetheprinciplesandschedulesofoperantconditioning.Ifabehaviorisfollowedbypleasantorrewardingconsequences(positivereinforcement)ortheeliminationofnegative,aversivestimuli(negativereinforcement),thenitismorelikelytoincreaseorbemaintained.Ontheotherhand,ifabehaviorisfollowedbyaversiveornegativeconsequences(punishment)ornoreinforcementatall,thenitislikelytodecreaseorbeeliminated.Reinforcementcontingencies,thatis,thetechniquesofpositiveandnegativereinforcement,punishment,andextinction,arepowerfulinterventionsusedinbehaviortherapyforthemodificationofbehavior,basedonoperantconditioningprinciplesandprocesses.Earlierviewsofclassicalandoperantconditioningdidnotrefertomorecognitiveprocessesthatcouldmediatesuchconditioning.Bandura’ssociallearningtheory,orsocial-cognitiveapproach,paidmuchmoreattentiontosymbolicprocessessuchasobservationallearningormodeling,andhissubsequentdevelopmentofself-efficacytheorygreatlyinfluencedbehaviortherapytomovebeyondsimplisticnotionsofclassicalandoperantconditioning.Behaviortherapytodayhasincorporatedmediationalconceptssuchasanindividual’scognitionsandperceptionsincludingself-efficacyexpectations,whichcansignificantlyaffectone’semotionsandbehavior.Theinterpretationofenvironmentalevents,asopposedtoonlythetangibleinfluenceofenvironmentalevents,isthereforeviewedasacrucialdeterminantofhumanbehavior.Contemporarybehaviortherapyhasthereforedevelopedpredominantlyintocognitivebehaviortherapy,influencedbysociallearningtheoryandself-efficacy.Cognitivebehaviortherapyhasbeensimplydefinedas“amorepurposefulattempttopreservethedemonstratedefficienciesofbehaviormodificationwithinalessdoctrinairecontext,andtoincorporatethecognitiveactivitiesoftheclientintheeffortstoproducetherapeuticchange”(KendallandHollon1979, 1). 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Contemporarybehaviortherapyhasacceptedtheimportanceofanindividual’sself-talk,attitudes,expectations,beliefs,andvaluesorone’scognitionsorthoughtsininfluencingone’sfeelingsandbehavior,andhasincorporatedtechniquestomodifymaladaptivecognitionsorthinkinginbringingaboutbehavioralchange.DevelopmentofPsychopathologyBehaviortherapistsoftenviewmaladaptivebehavior,orpsychopathology,asattributabletoanindividual’sparticularlearninghistory.Suchbehavioriseitherdetrimentalordangeroustooneselfand/ortoothers(seeParrott2003, 273).Morespecifically,earlybehaviortherapistssuchasWolpe(1990)definedpsychopathology,orneurosis,asconsistingofmaladaptivehabitsthathavebeenacquiredthroughconditioning.Forexample,fearandanxietyhavebeenconsideredconditionedresponsestocertainstimuliandcanthusbedeconditionedorcounterconditioned.Maladaptivehabitsthatanindividualhaslearnedthroughpastexperiencescanthereforebeunlearned,andmoreadaptivehabitsorbehaviorscanthenberelearnedorlearnedanew.Similarly,Skinnerandthebehaviormodificationpractitionerswhofollowedhimviewedmaladaptivebehaviorasattributabletooperantconditioningprocesses.Forexample,ayoungboy’stempertantrumsmaybeduetotheprofuseattentionhisparentsgivehimwhenheactsout,eveniftheyarescoldinghim.Theyarereinforcinghisnegativebehaviorofwhining,crying,andyellingbyattendingtohim,thusstrengtheningsuchmaladaptivebehavior.Behaviortherapists,followingSkinner,willuseoperantconditioningprocedures,thatis,rearrangethereinforcementcontingenciesindeliberate,purposefulwaystodecreasethetempertantrumsbyteachingtheparentstoignorethemandtoprovidesocialreinforcement,orpositivepraiseandattention,totheboywhenheisbehavinghimself.Contemporarybehaviortherapists,however,donotviewpsychopathologysimplyaslearnedmaladaptivehabits.Theytendtobemorecognitivebehavioralinorientationandconsidermaladaptivebehaviorandfeelingsasresultingfrominternaldialogues,ortheself-talk,oftheindividual,focusingmoreontheperson’sthoughtsandimages.Negative,irrational,extreme,unreasonable,andillogicalthinkingisoftenseenasunderlyingproblematicfeelingsandbehaviors.Suchthinkingmustbeidentified,challenged,andmodifiedwithmorerational,reasonable,andlogicalthinkingthatcanthenleadtobetteradaptivebehaviorandemotionalexperiencing.Self-criticismorself-contemptinone’sthinkinginparticularcancausemuchemotionalpainandproblembehavior(seeBandura1977b,1986).Behaviortherapiststodaypaymoreattentiontohowobservationallearningormodelingcancontributetomaladaptivebehavior,andtohowsuchmodelingcanbeusedtopromotemoreprosocialandappropriatebehavior. 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TherapeuticProcessandRelationshipThebehaviortherapistisactiveanddirectiveinconductingtherapywithclients.Heorshefunctionsasaproblemsolveraswellasacopingmodelforandwiththeclient(Wilson2008, 238).Althoughthetherapeuticrelationshipisimportantinbehaviortherapy,andthebehaviortherapistdoesshowgenuineconcernandrespectfortheclient,thetherapeuticallianceitselfisnotsufficientforeffectivetherapytooccur(seeDeRubeis,Brotman,andGibbons2005).Inaccountingfortheefficacyofbehaviortherapy,therapeuticinterventionshavebeenfoundtobemoresignificantthanthetherapeuticalliance(Loebetal.2005).Nevertheless,astrong,positivetherapeuticalliancethatiswarm,empathic,genuine,andcollaborativeisstillessentialfortheeffectivenessofbehaviortherapy(see,e.g.,J. S.Beck2005;A. T.Beck,Rush,Shaw,andEmery1979;P. GilbertandLeahy2007),eveninmanual-basedversionsofbehaviortherapy(Wilson2008, 238).Theprocessofbehaviortherapyisrelativelymorestructuredandsystematicthanmanyotherapproachestotherapy(seeMiltenberger2008;SpieglerandGuevremont2003;Wilson2008).Itconsistsofseveralstepsorstages.First,thebehaviortherapistconductsafunctionalassessmentorbehavioralanalysis(Wolpe1990)ofthemajorcomplaints,ortargetbehaviors,thattheclientwantstodealwithandchange.Thisinvolvesaconcretedefinitionoftheclient’sexpressedproblembehaviorsandclarificationoftheantecedentsaswellastheconsequencesofthetargetbehaviors.Thetherapistusuallyasksspecificquestionssuchashow,when,where,andwhatratherthanwhyregardingtheproblembehaviorbeingdiscussed.Thebehaviortherapistmayalsouseothermethodsofassessment(seeWilson2008,239–40)suchasguidedimagery(inwhichtheclientimaginesaparticularsituationandsharesthethoughtsandfeelingsitmaytrigger);role-playing;physiologicalrecording(e.g.,heartrate);self-monitoring(whichinvolvestheclientkeepingcarefuldailyrecordsofspecificbehaviorssuchasfrequencyofhandwashing);behavioralobservation(inwhichtheclientobserveshisorherownbehaviororothersobservetheclient’sbehaviorandrecorditwithratingscales);andsometimespsychologicaltestsandquestionnaires(e.g.,theBeckDepressionInventory[seeA. T.Beck,Rush,Shaw,andEmery1979]asaself-reportmeasureofdepression).Second,thebehaviortherapistobtainsadevelopmentalhistoryoftheclientandtheproblembehaviorsbeingpresented,tofurtherassesstheclient’spastlearningorconditioningexperiencesaswellaspossibleorganicorbiologicalbasesfortheproblems(seeParrott2003, 274).Third,thebehaviortherapisthelpstheclientsetspecificgoalsfortherapyinacollaborativeway.Itisimportantethicallyforthebehaviortherapisttoempowertheclienttoultimatelychoosehisorherowngoals,withthetherapistfunctioningastheexpertorcoachinhelpingtheclientachievethem.AsG. T.Wilsonhasemphasized:“Theclientcontrolswhat;thetherapistcontrolshow”(2008, 238). _Tan_Counseling_BB_mw.indd231 9/21/104:37:13PM 218 MajorCounselingandPsychotherapyTheoriesandTechniques Fourth,andfinally,thebehaviortherapisthelpstheclientchoosethemosteffectivetherapeuticinterventionstobestenabletheclienttochangethe identifiedproblembehaviorsandtoachievethegoalstheclienthasset.Thebehaviortherapistthenadministersthesetherapeutictechniquestohelptheclientindirectandsystematicways,whilemonitoringtheclient’sprogress.Thetherapistissensitiveandflexibleenoughtouseothertechniquesifthecurrentinterventionsarenotworkingeffectivelyfortheclient.MajorTherapeuticTechniquesandInterventionsBehaviortherapyisauniqueapproachtotherapythatfocusesonsolvingproblemsandovercomingsymptomspresentedbytheclient.Itthereforeemphasizestheuseofspecifictechniquesthathavereceivedempiricalsupport.Behaviortherapy(seeEmmelkamp2004)andcognitivebehaviortherapy(seeButler,Chapman,Forman,andBeck2006;HollonandBeck2004)areamongthemostempiricallysupportedtreatmentsforawiderangeofpsychologicaldisorders(ChamblessandOllendick2001;NathanandGorman2007;RothandFonagy2005).Thenumberofbehaviortherapytechniqueshasdramaticallyincreasedsincethelate1950sand1960s,whenbehaviortherapyfirstemergedasasystematictherapeuticapproach.Publishedin1987,theDictionaryofBehaviorTherapyTechniques(BellackandHersen1987)alreadylistedanddescribedover150behaviortherapytechniques.Today,withbroader-spectrumbehaviortherapyandcognitivebehaviortherapyaswellasevenmorecomprehensivemultimodaltherapyasdevelopedbyLazarus(1971,1976,1981,1997),behaviortherapyinterventionshaveincreasedexponentially.Itisthusimpossibletodescribemostoftheminthischapter.However,themajorbehaviortherapytechniqueswillnowbebrieflydescribed.Theyincludebehavioralassessment;operantconditioningtechniques(e.g.,positivereinforcement,negativereinforcement,extinction,andpunishment);tokeneconomies;socialskillstrainingandassertivenesstraining;modeling;relaxationtraining;systematicdesensitization;floodingandinvivoexposure;self-modificationprogramsandself-directedbehavior;multimodaltherapy;andmindfulnessandacceptance-basedcognitivebehaviortherapy(seeCorey2009,241–57;Parrott2003,277–86;seealsoMiltenberger2008;SpieglerandGuevremont2003).BehavioralAssessmentThefirststageofbehaviortherapyinvolvesconductingacomprehensivebehavioralassessmentoftheclientandhisorhertargetproblemsandsymptoms(e.g.,anxiety,anger,ordepression).Thisprocesshasalsobeendescribedasperformingafunctionalassessmentorbehavioralanalysis(Wolpe1990);somedetailsoffunctionalorbehavioralassessmenthavealreadybeenpro- _Tan_Counseling_BB_mw.indd232 9/21/104:37:14PM BehaviorTherapy 219 videdintheprevioussectionofthischapteronthetherapeuticprocessofbehaviortherapy.OperantConditioningTechniquesOperantconditioningtechniquesincludepositivereinforcement,negativereinforcement,extinction,positivepunishment,andnegativepunishment(seeKazdin2001;Miltenberger2008).Positivereinforcementinvolvestheadditionofsomethingthatrewardsanindividualfollowingatargetbehaviorthatistobestrengthenedorincreased.Forexample,inordertoincreasethetargetbehaviorofwriting,apersonisreinforcedwithverbalpraisefromaclosefriendwhenevershecompletesseveralpagesofwriting.Thepositivereinforcementcanbeanythingthatthepersonfindsrewarding,suchasverbalpraise,food,money,orattention.Negativereinforcementinvolvestheremovalofunpleasantoraversivestimulifollowingtheoccurrenceofatargetbehaviorthatistobeincreasedorstrengthened.Forexample,aperson’swritingcanbenegativelyreinforcedwhenaftershehaswrittenafewpages,aclosefriendstopsnaggingheraboutwriting.Theremovalofthenagging,whichisanaversiveorunpleasantstimulus,negativelyreinforcestheperson’swritingsothatthisbehaviorisstrengthened.Bothpositiveandnegativereinforcementaremeanttoincreaseorstrengthenthetargetbehaviorthatisseenasdesirable.Sidebar11.2ExtinctionreferstoremovingreinforcementfromaparticulartargetbehaviorBehaviorTherapyTechniquesorresponsethathasbeenpreviouslyre(seeCorey2009,241–57;Parrottinforced.Forexample,achild’stemper2003,277–86)tantrumsthathavebeenpreviouslyreinforcedbytheattentionhisparentspro1.Behavioralassessmentvidedcanbeextinguishedbytheparents2.Operantconditioningtechniqueswithholdingtheirattentionfromtheir3.Tokeneconomieschildwheneverheactsoutwithtemper4.Socialskillstrainingandassertivetantrums.Extinctionisusuallycombinednesstrainingwithpositivereinforcementofother,more5.Modelingdesirablebehaviors(Kazdin2001).Inthe6.Relaxationtrainingexamplejustdescribed,theparentswill7.Systematicdesensitizationnowpositivelyrewardtheirchildwithat8.Floodingandinvivoexposuretentionandpraisewheneverhebehaves9.Self-modificationprogramsandwellandignorehimwhenhethrowstemself-directedbehaviorpertantrums.10.MultimodaltherapyPunishmentisanotheroperantcondi11.Mindfulnessandacceptancetioningtechnique,alsocalledaversiveconbasedcognitivebehaviortherapytrol,aimedatdecreasinganundesirable _Tan_Counseling_BB_mw.indd233 9/21/104:37:15PM 220 MajorCounselingandPsychotherapyTheoriesandTechniques targetbehavior.Therearetwomainkindsofpunishment:positivepunishmentandnegativepunishment(Miltenberger2008).Positivepunishmentinvolvestheadditionofanaversivestimulusafteraparticulartargetbehaviorhasoccurred,inordertodecreaseorweakenthatbehavior,thatis,makeitlesslikelytooccurinthefuture.Forexample,whenaboyengagesinaggressivebehaviorinclassbyhittingsomeoneelse,hethenmustdotwentypush-upsasaformofunpleasantpositivepunishment,whichshouldleadtolessfrequentaggressivebehavior.Negativepunishmentinvolvestheremovalofapleasantorpositivelyreinforcingstimulusfollowingtheoccurrenceofatargetbehaviorinordertodecreaseorweakenit,thatis,makeitlesslikelytooccurinthefuture.Forexample,whenachildmisbehaves,herparentstakeawayhertelevision-watchingtime,thusnegativelypunishinghermisbehavior,makingitlesslikelythatshewillmisbehaveagaininthefuture.Extinctionandpunishmentcanleadtocertainsideeffects,suchasaggressionandanger.Inappliedbehavioranalysisoroperantconditioning,positivereinforcementisthemajorintervention,withtheuseofpunishmentoraversivecontrolonlywhennecessary(Kazdin2001;Miltenberger2008).Skinner(1948)himselfadvocatedtheuseofpositivereinforcementformodifyingbehaviorandbelievedthatpunishmentshouldrarelybeusedbecauseitwasundesirableandhadlimitedutilityinchangingbehavior(seeCorey2009, 243).Morerecently,behavioralactivationhasbeenfoundtobeparticularlyeffectiveasatreatmentformoreseverelydepressedclientsandforpreventionofrelapse(Dimidjianetal.2006;K. S.Dobsonetal.2008;seealsoCoffmanetal.2007).R. E.ZinbargandJ. W.Griffith(2008)havedescribedbehavioralactivationasaspecificbehaviortherapytechniquebasedprimarilyonpositivereinforcementofhealthybehaviorsandactivityindepressedclients(seealsoLewinsohn1974;Martell,Addis,andJacobson2001;Martell,Dimidjian,andHerman-Dunn2010).Anotherrecentrandomizedcontrolledtrialofbehavioralactivationformoderatelydepresseduniversitystudentsusingonlyastructuredsingle-sessionintervention,withano-treatmentcontrolgroup,yieldedstrongeffectsizes,reflectingsignificantdecreasesindepressionandincreasedenvironmentalreward(Gawrysiak,Nicholas,andHopko2009).TokenEconomiesTokeneconomiesrefertoaspecificapplicationofoperantconditioninginwhichtokensaregiventoclientswhentheyengageinappropriatebehaviors,sothatthesebehaviorsarereinforcedbythetokensearned.Tokenscanalsobelostbecauseofinappropriateorundesirableclientbehaviors.Clientscanthenchoosespecificreinforcersforwhichtheycanexchangetheirtokens,suchasfood,candy,toys,ortheprivilegetowatchamovie.Tokeneconomieshavebeeneffectivelyusedtoshapeandreinforceappropriatesocialbehaviors _Tan_Counseling_BB_mw.indd234 9/21/104:37:16PM BehaviorTherapy 221 ininstitutionalizedpatientsandclientsinresidentialhomes,butalsointheclassroomandforindividuals(SpieglerandGuevremont2003,176–94).SocialSkillsTrainingandAssertivenessTrainingSocialskillstrainingisabehavioralinterventionthatcomprehensivelycovershelpingclientswithinterpersonaldifficultiesordeficitsinsocialskillswheninteractingwithotherpeople.Thebehaviortherapistcoachesandteachestheclienthowtointeractmoreeffectivelyandappropriatelywithothers,especiallyinsocialsituations.Severalspecifictechniquesareusedinsocialskillstraining,includingprovidinginformationaboutappropriatewaysofinteractingwithothers,modelingofsuchsocialskillsfortheclient,reinforcingtheclientwithverbalpraisefortryingmoreeffectivewaysofsocialinteractionthroughbehavioralrehearsal,role-playing,andprovidingfeedbackandfurtherinstructionandcoachingtotheclient.Socialskillstrainingcanalsobeusedasasignificantinterventioninangermanagementtrainingforclientswhohavedifficultycontrollingtheirtempersorthosewithaggressivebehavior.Socialskillstraininghasbeenusedwithchildrenandadolescentsaswellaswithadults,includingadultswithschizophrenia(SpieglerandGuevremont2003,273–78).Assertivenesstraining,orassertiontraining,isatypeofsocialskillstraining(SpieglerandGuevremont2003,278–86)usedtohelpclientswhohavetroubleexpressingthemselvesfreely,whetherinmakingrequestsofothers,saying“no”toothers,statingpositiveornegativesentiments(e.g.,affectionoranger),orinteractingwithotherpeopleinsocialsituations.Clientsaretaughttodifferentiatebetweenpassive,aggressive,andappropriatelyassertivebehaviorsorresponses.Thebehaviortherapistthenusesinstruction,modelingofassertiveresponses,practiceofsuchresponsesbytheclient,role-playingwiththeclient,andfurtherfeedbackandcoachingtohelptheclientimprovehisorherassertivenessresponses;thetherapistprovidesappropriatepositivereinforcementbyverballypraisingtheclientwhenheorsheeffectivelyperformsassertiveresponses.Clientsthereforelearnthatitistheirrighttostandup,speakout,andtalkbackwhereandwhenappropriate(seeAlbertiandEmmons2008).ModelingThebehavioraltechniquesofmodelingarebasedmainlyonBandura’ssignificantworkonobservationallearning(1969,1971,1977b,1986,1997).Modelinginvolvesaclientobservinganotherperson’sbehavioranditsconsequencesandthenimitatingthatbehavior.Modelinghasfivemajorfunctionswhenitisusedinbehaviortherapytohelpclients:teaching,prompting,motivating,reducinganxiety,anddiscour- _Tan_Counseling_BB_mw.indd235 9/21/104:37:17PM 222 MajorCounselingandPsychotherapyTheoriesandTechniques aging(SpieglerandGuevremont2003,263–64).Teachingthroughmodelingoccurswhentheclientlearnsanewbehaviorbyobservingamodel.Forexample,achildlearnslanguagebywatchingandhearinganadultmodelspeak.Promptingthroughmodelingoccurswhentheclientisremindedorcuedtodoaparticularbehaviorafterwatchingamodelperformthatbehavior.Forexample,aclientwatchesamodeltakeaslow,deepbreathtorelaxandthendoeslikewise,beingremindedtorelaxinastressfulsituation.Motivatingthroughmodelingoccurswhentheclientseesamodelreceivingpositivereinforcementorsomerewardforperformingaparticularbehaviorandthenismotivatedtoengageinthatbehaviortooduetothevicariousreinforcementthattheclienthasexperienced.Forexample,astudentvolunteerstoansweraquestioninclassbecauseshehasobservedotherstudentsdoingsoandbeingpraisedbytheteacher.Reducinganxietythroughmodelingoccurswhentheclientwatchesamodelperformingananxiety-provokingbehaviorsafelyandwithlittleornoanxiety,withanxietyreductionvicariouslyexperiencedbytheclient.Forexample,aclientwithaquaphobia,orafearofwaterandswimming,overcomesthisfearbywatchingamodelenjoygoingintothepoolandswimming.Finally,discouragingtheclientthroughmodelingoccurswhentheclientwatchesamodel’sbehaviorthatisfollowedbynegativeorunpleasantconsequences,whichdiscouragestheclientfromengaginginsuchbehavior.Forexample,achildobservesaclassmatebeingpunishedbytheteacherforhittingothers,andthechildisthendiscouragedfromengaginginhittingbehaviortoo.Thesefivefunctionsofmodelingarenotalwaysindependent,andseveralofthemcanoccuratonce.Modelingcanbeusedinvariousways:livemodeling,inwhichtheclientobservesanactualpersonorthetherapist;symbolicmodeling,inwhichtheclientisexposedtomodelsindirectlythroughvideosormoviesandbooks,ormodelinginimagination,calledcovertmodeling,inwhichtheclientimaginessomeoneelseorevenhimselfsuccessfullyperformingaparticulardesirablebehaviorsuchasmakinganeffectivesalespresentationorspeech;role-playing,inwhichthetherapistmodelsspecificbehaviorsthattheclientwantstoperformmoreeffectivelyandappropriatelybyplayingtheroleoftheclientandthenreversingrolessothattheclientcanpracticethebehaviorsasherself,thatis,byengaginginbehaviorrehearsal;andparticipantmodeling,inwhichthetherapistfirstmodelsaparticularbehaviorfortheclientbyexecutingitwell.Forexample,thetherapistwillpetawell-traineddogandthenguidetheclient,whohasafearofdogs,tograduallypetthedogtoo,sothattheclientbecomesaparticipantinthemodelingbythetherapist(seeSharf2008,272–73).RelaxationTrainingRelaxationtrainingisanimportantorcorebehaviortherapytechnique.Itisusedtohelpclientssufferingfromanumberofdifferentclinicaldisor- _Tan_Counseling_BB_mw.indd236 9/21/104:37:19PM BehaviorTherapy 223 derssuchasanxietydisorders,stress,insomnia,headachesandotherchronicpainconditions,asthma,hypertension,eczema(skininflammation),irritablebowelsyndrome,sideeffectsofchemotherapy,postsurgicaldistress,andpanicdisorder(seeCormier,Nurius,andOsborn2009;SpieglerandGuevremont2003).Itshouldbenoted,however,thatrelaxationtrainingforsomepanicproneclientscanbeharmfulratherthanhelpful(Lilienfeld2007).Relaxationtrainingshouldthereforebeconductedinaclinicallysensitiveway,adaptedandtailor-madeforeachclient.Relaxationtrainingtargetstensionanditsalleviationascriticalforthemanagementandreductionofemotionallyintensestatessuchasanxietyandanger.Therearevarioustechniquesforrelaxationtraining,butanimportantoneisprogressivemusclerelaxation,basedontheearlierworkofEdmundJacobson(1938).Itinvolvesthealternatetensingandrelaxingorlettinggoofmajormusclegroups.Jacobson’soriginalversionofprogressivemusclerelaxationwasveryelaborateandtimeconsumingtofollow,withalmosttwohundredhoursoftrainingrequired.Behaviortherapistshaveshortenedprogressivemusclerelaxationtoaroundsixteenmusclegroups(seeGoldfriedandDavison1994;Wolpe1990),andsometimeseventofourmajormusclegroups(Tan1996a).FrankDattilio(2006)hasmadeavailableanexcellentaudiotapedemonstrationofprogressivemusclerelaxation.Hereisanexampleofprogressivemusclerelaxationtraining,usingfourmajormusclegroups,thatcanbedonebyaclientathome:Thisrelaxationtechniqueinvolvesthealternatetensingandthenrelaxingorlettinggoofvariousmusclepartsofyourbody. . . .First,sitinacomfortablechairorrecliner,inaroomandatatimewhenyouwillnotbedisturbed.Giveyourselfatleast15–20minutesofuninterrupted“relaxationtime”topracticetherelaxationexercises,beginningwiththelegmusclesandendingwiththearmmuscles.Legmuscles.Youcantenseyourthighandcalfmusclesbypointingyourtoestowardyourfaceandtensingthesemuscleshard.Holdthetensionfor7–10secondsbycountingslowlyupto5.Thenletgoandallowthemusclestogolimp.Nowuseself-talk:tellyourselfto“justrelax,letgoofallthetension. . .allowthemusclestosmoothout. . .takeiteasy. . .justunwindandrelaxmoreandmore. . .”Continuewiththisrelaxationpatterfor20secondsorsobeforeproceedingtorepeatthisexercise.Dothisexerciseatotalof4times.Thenproceedtothenextone.Upper-bodymuscles.Aftercompletingtheexerciseforthelegmuscles,focusyourattentiononthemusclesofyourupperbody—yourchest,stomach,shoulders,andback.Tensethembytakinginaslow,deepbreath,holdingitforacountupto5(about7–10seconds),pullingyourstomachin,andarchingyourback(unlessyouhaveabackinjuryorbackpain,inwhichcaseyoushouldnotarchyourback).Whenyoureachacountof5,slowlyexhaleandletgotofallthemuscletension,againtellingyourselfmentallytorelaxandtakeiteasy,usingtherelaxationpatterorself-talkforabout20secondsorsobeforerepeatingtheexercise.Doitatotalof4times. . . . _Tan_Counseling_BB_mw.indd237 9/21/104:37:20PM 224 MajorCounselingandPsychotherapyTheoriesandTechniques Faceandneckmuscles.Focusyourattentiononthemusclesofyourfaceandneckregions.Tensethesemusclesbyclosingyoureyestightly,bitingyourteeth,smilingback,pushingyourchindownasiftotouchyourchestbutnotallowingittotouchyourchest.Holdthetensionforacountupto5(7–10seconds),andthenrelaxandletgoofthesemuscles,againusingtherelaxationpatterorself-talkforupto20secondsorso.Repeatthisexerciseforatotalof4timesbeforeproceedingtothefinalexercise.Armmuscles.Nowfocusyourattentiononthemusclesofyourarms.Tensethembyclenchingyourfistsandflexingyourbiceps. . . .Holdthetensionforacountupto5(7–10seconds),andthenrelaxandletyourarmsflopdownlimpbyyoursides.Again,engageintherelaxationpatterorself-talkfor20secondsorsobeforerepeatingtheexercise,doingitatotalof4times. . . .Attheendyoushouldgiveyourselfacouplemoreminutestojustsitquietlyandenjoythefeelingsofdeeperandmorecompletemusclerelaxationthatyouareexperiencingbythistime.Then,countfrom1to5asyouslowlymoveyourmuscles,andeventuallyopenyoureyesatthecountof5,feelingveryrelaxedandrefreshed.(Tan1996a,59–61) Thisversionofprogressivemusclerelaxationtrainingcanalsobeconductedinthereverseorder,startingwiththearmmuscles,thenthefaceandneckmuscles,thentheupperbodymuscles,andendingwiththelegmuscles.AnotherformofrelaxationtrainingoftenusedbybehaviortherapiststodayisanevenmoreabbreviatedversionbasedontheworkofMeichenbaum(1977,1985)onstressinoculationtraining.Inthisstressmanagement,orstressinoculationapproachtorelaxationtraining,thefollowingthreemajorrelaxationtechniquesareused:(1) slow,deepbreathing:theclientisinstructedtotakeinaslow,deepbreath,holditforafewseconds,andthenexhalethetensionoutslowly;thisisrepeatedafewtimes;(2) calmingself-talk:thetherapistinstructstheclienttosayseveralcalmingandrelaxingstatementstohimselforherself,thatis,touseself-talksuchas:“Justrelax,takeiteasy,letgoofallthetension,allowthemusclestosmoothout. . . .”;(3) pleasantimagery:thetherapistinstructstheclienttoimagineorvisualizeasclearlyandasvividlyaspossibleaverypleasant,relaxing,enjoyable,andpeacefulscene,suchaslyingonthebeachinHawaii,watchingabeautifulsunsetorsunrise,ortakingawalkinthewoods.Finally,anotherwell-knownrelaxationtechniquethatcanbeusedtohelpclientsrelaxawaytensionandanxietyisapassive,quietmeditativeexercisedevelopedbyHerbertBensonforactivatingwhathehascalled“therelaxationresponse”(Benson1975).Itinvolvesafewsimplesteps:sitquietlyinacomfortablepositionwithyoureyesclosed;deeplyrelaxallyourmusclesfromyourfeetuptoyourface;breathethroughyournoseandthensayawordsuchas“one”or“peace”whenexhalingorbreathingout;maintainaquietandpassiveattitudethroughoutforatotaltimeofabouttwentyminutes,evenifyouhavedistractingthoughtsattimes. _Tan_Counseling_BB_mw.indd238 9/21/104:37:22PM BehaviorTherapy 225 SystematicDesensitizationSystematicdesensitizationisanothercorebehaviortherapytechniquethathasreceivedmuchempiricalsupportforitseffectivenessasabehavioraltreatmentforanxietydisordersandspecificphobias(Cormier,Nurius,andOsborn2009;SpieglerandGuevremont2003).Ithasalsobeenusedtotreatotherproblemssuchasanger,insomnia,asthma,motionsickness,nightmares,andsleepwalking(Spiegler2008).ItwasoriginallydevelopedbyJosephWolpeoverfiftyyearsagowhenheusedclassicalconditioningprinciplesandprocessestoconductpsychotherapybyreciprocalinhibition(Wolpe1958)inthetreatmentofneuroticdisorders,suchasanxietyproblemsandphobias.Systematicdesensitizationwasthereforethefirstmajorbehaviortherapyintervention(SpieglerandGuevremont2003).Itinvolvespairingananxiety-provokingstimulusthatusuallyelicitsananxietyresponse(astheconditionedresponse,orCR)withacompetingresponse,usuallyrelaxation.Thisprocessisdonerepeatedlyuntileventuallytheparticularanxiety-provokingstimulusnolongerelicitsanxietybecauseitisnowassociatedmorewithrelaxationasacompetingresponsethathasreplacedfear.Thisistheusualprocessandexplanationfortraditionalsystematicdesensitization,whichconsistsofthreesteps:(1) Thebehaviortherapistteachestheclientaresponsethatcompeteswithanxiety,usuallyrelaxation.(2) Thespecificstimulioreventsthatprovokeanxietyintheclientarelistedfromtheleastanxietyprovokingtothemostanxietyprovoking,thusconstructingananxietyhierarchy.AsimpleSubjectiveUnitsofDiscomfortscale(SUDs)isusedtoratetheanxietylevelthattheclientexperiencesona0(noanxiety)to100(maximum,extremeanxiety)foreachoftheanxiety-provokingitemsontheanxietyhierarchy.(3) Thebehaviortherapistthenguidestheclienttorepeatedlyvisualizetheanxiety-provokingitems,inorderofincreasinganxiety,whileengaginginthecompetingresponse,usuallyrelaxation(seeSpieglerandGuevremont2003,204–11).GoldfriedandDavison(1994,124–26)describeWolpe’straditionalsystematicdesensitizationasconsistingofconductingdeeprelaxation,constructingananxietyhierarchy(usuallywithonetotwodozenitems),andpresentinganitemfromit(inorderofincreasinganxiety)forfive,ten,orfifteensecondstotheclientinimaginationwhiletheclientisinadeeplyrelaxedstate.Iftheclientsignalsanxietywhilevisualizingtheitemorscene,heorsheisaskedtoremovethescenefromimaginationandreturntoadeeplyrelaxedstate,atwhichpointtheitemwillbepresentedagain.Thisprocessisrepeateduntiltheclient’sSUDsratingofanxietyforthatparticularitemgoesdowntoabout0.Then,thenextitemfromtheclient’sanxietyhierarchyispresentedinthismannerrepeatedlyuntiltheclientratesitalsowithaSUDsratingof0.Thenanotheritemispresented.Usually,twotofiveitemsfromahierarchyarepresentedineachsessionoftraditionalsystematicdesensitization.Itisthereforeatediousandtime-consumingbehaviortherapytechniquethatmay _Tan_Counseling_BB_mw.indd239 9/21/104:37:23PM 226 MajorCounselingandPsychotherapyTheoriesandTechniques Sidebar11.3SystematicDesensitizationProcedureUsinganAnxietyHierarchyAnexampleofananxietyhierarchyforaclientwithaphobiaorfearofspidersmightincludethefollowingitemsinorderofincreasinganxietywithSUDsratingsinparentheses:1.Readingtheword“spider”inabook(10).2.Seeingapicture/drawingofasmallspiderinabook(20).3.Seeingapicture/drawingofalargespiderinabook(30).4.Seeingasmalldeadspider(40).5.Seeingalargedeadspider(50).6.Seeingasmalllivespider(60).7.Seeingalargelivespider(70).8.Touchingasmalldeadspiderwithapen(80).9.Touchingalargedeadspiderwithapen(85).10.Touchingasmalllivespiderwithapen(90).11.Touchingalargelivespiderwithapen(95).12.Touchingasmallorlargelivespiderwithafinger(100). takebetweentenandthirtysessionstosuccessfullyhelpaclientovercomeaspecificphobiaoranxietyproblem.Itis,however,aneffectiveintervention.Clientsusuallyfindtraditionalsystematicdesensitizationacceptablebecausetheyareexposedtoanxiety-provokingscenesonlyinagradualwayandattheirownpaceandhavecontrolofwhentheywanttoendtheexposuretosuchscenes(SpieglerandGuevremont2003).Wolpeoriginallyexplainedtheeffectivenessoftraditionalsystematicdesensitizationbytheprocessofcounterconditioning,orreciprocalinhibitionoftheanxietyresponsewiththecompetingresponseofrelaxation.Heemphasizedtheneedforathoroughanxietyhierarchyconsistingofonetotwodozenitemsinorderofgraduallyincreasinganxiety,andfortheclient’scompleterelaxationwithvirtuallynoanxiety,aSUDsratingofabout0,beforeproceedingtothenextitemintheanxietyhierarchy.Research,however,hasshownthatWolpe’sapproachandexplanationsarenotnecessarilyvalidfortheeffectivetreatmentofanxietydisorders.Theessentialelementinsystematicdesensitizationanditseffectivenesshasbeenfoundinsteadtobe“repeatedexposuretoanxietyevokingsituationswithouttheclientexperiencinganynegativeconsequences”(SpieglerandGuevremont2003, 213,italicsassetinoriginal).Itemsontheanxietyhierarchycanthereforebepresentedoutoforder,andrelaxationtrainingcanbeomittedineffectivesystematicdesensitization.Infact,emotiveimageryinvolvingtheuseofpleasantimagesandthoughtsaswellashumor _Tan_Counseling_BB_mw.indd240 9/21/104:37:25PM BehaviorTherapy 227 andlaughterhavebeenfoundtobealternativeeffectivecompetingresponsestoanxiety(seeSpieglerandGuevremont2003, 214).TherearealsovariationsinsystematicdesensitizationthatgobeyondWolpe’straditionalversion,suchascopingdesensitizationdevelopedbyMarvinGoldfried(1971),whichfocusesmoreonthebodilysensationsofanxietyandusingcopingresponses(suchasmusclerelaxationbutalsocalmingself-talkandothertechniques);anxietymanagementtraining,developedbyRichardSuinnandFrankRichardson(1971),whichissimilartocopingdesensitizationbutdoesnotuseananxietyhierarchy;andinteroceptiveexposureandcognitivebehaviortherapy,developedbyDavidBarlowandhiscolleagues(Barlow1988,2002;CraskeandBarlow2008),fortreatingpanicattacks,whichincludesartificiallyinducingthesomaticsymptoms(e.g.,increasedheartrateanddizziness)ofpanicattackswhiletheclientimaginespanic-provokingevents,cognitiverestructuringoruseofcopingself-talk,andbreathingretraining,especiallyslow,deep,andsteadydiaphragmaticbreathing(seeSpieglerandGuevremont2003,214–17).FloodingandInVivoExposureFlooding,likesystematicdesensitization,isanotherformofexposuretherapyinwhichtheclientwithaphobiaoranxietydisorderisexposedtotheanxiety-provokingstimulusoreventwithoutthefearedconsequencesoccurring.However,unlikesystematicdesensitization,floodingisabehaviortherapytechniquethatexposestheclienttomaximalanxietyfromthestart(ratherthantominimalanxietyinitially).Whilebeingexposedtotheanxietyprovokingevent,theclientisencouragedtotoleratethehighanxietylevelsuntiltheanxietysubsides.Floodingcanbeconductedinreallife,inwhichcaseitiscalledfloodinginvivo,orinimagination,inwhichcaseitiscalledimaginalflooding.Likewise,systematicdesensitizationcanbeconductedinimagination,whichisusuallythecase,butitcanalsobeconductedinvivo.Anexampleoffloodinginvivoiswhenaclientwithaballoonphobiaisexposedtodozensofballoonsatonetimeinthetreatmentroom,withnorecoursetoleavingtheroomasanescaperesponse,untilthehighanxietylevelexperiencedbytheclientissignificantlyreducedbeforethesessionisterminated.Suchfloodinginvivoisalsocalledinvivoexposurewithresponseprevention,becausetheclientispreventedfromengaginginanymaladaptiveresponsesforanxietyreduction(e.g.,avoidingtheanxiety-provokingsituation,orperformingritualisticorobsessive-compulsivebehaviorssuchascheckingorhandwashing)duringtheexposuretherapy.Anexampleofimaginalfloodingwouldbeaskingaclientwithaballoonphobiatovisualizedozensofballoonsbeforehim,withouthisbeingabletoleaveoravoidthesituation.Thisimaginalfloodingsessioniscontinueduntiltheclient’shighanxietylevelhassubstantiallysubsided.ThomasStampflandDonaldLevis _Tan_Counseling_BB_mw.indd241 9/21/104:37:26PM 228 MajorCounselingandPsychotherapyTheoriesandTechniques Sidebar11.4EyeMovementDesensitizationandReprocessing(EMDR)Eyemovementdesensitizationandreprocessing(EMDR)isarelativelynewexposure-basedtherapythatisstillsomewhatcontroversial.ItwasoriginallydevelopedbyFrancineShapirototreatemotionallydisturbingthoughtsandmemoriesoftraumaticeventssuchascombat-relatedtrauma,sexualassault,androbberyatgunpoint(seeShapiro2001,2002).EMDRinvolvesimaginalfloodingduringwhichtheclientisinstructedtowatchandvisuallytracktheindexfingerofthetherapistasitmovesbackandforth(fromlefttorightabouttwicepersecond,foradozentotwodozentimes)inarapidandrhythmicfashionwithintheclient’svisualfield.Sucheyemovements,accordingtoShapiro,resultinaneurologicaleffect,similartorapideyemovementsseeninintensedreaming,thathelpstheclienttobetterprocessintenseandstressfulexperiencesandmemories.EMDRalsoinvolvescognitiverestructuringoftheclient’sthinking,focusingonadaptivebeliefsassociatedwiththetraumaticimagespresentedtotheclientinimaginalflooding.EMDRhasbeentoutedasaneffectivebreakthroughexposuretreatmentthatproducesrapidandsignificanttherapeuticresultswithclientswhohavetrauma-basedanxietydisorders.However,thecontrolledoutcomestudiesconductedsofarhavenotsupportedtheeffectivenessofEMDRbeyondthatofitsimaginalfloodingcomponent,andtheeyemovementshavenotbeenfoundtobenecessaryforitseffectiveness(seeSpieglerandGuevremont2003,247–49).Itisthereforestillacontroversialexposure-basedtreatmentinneedoffurtherwell-controlledoutcomestudiesbeforemoredefinitiveconclusionsaboutitsefficacyasatreatmentcanbemade. developedanearliervariantofimaginalfloodingcalledimplosivetherapy,inwhichtheprolongedorintenseexposureincludedtherapist-hypothesizedcuesandexaggeratedimaginaryscenes,oftenwithpsychodynamicthemes,thatwentfarbeyondtheclient-reportedscenes(StampflandLevis1967,1973).Implosivetherapyispracticedlessfrequentlytoday.Systematicdesensitizationinvivoinvolvesgraduallyexposingtheclientinreallifetoanincreasingnumberofanxiety-provokingitemsfromtheclient’sanxietyhierarchy.Effectiveexposuretreatmentscanbeconductedingradualorintenseways,invivoorinimagination,andwithindividualclientsoringroups.Effectiveexposuretreatmentsareusuallyprolongedinduration,frequent,andcomprehensive(seePersons1989,94–95).Theyaretypicallyconductedbytherapists,inwhichcasetheyarecalledtherapist-directedexposure.Clientscanalsoperformtheirownexposuretreatmentsinwhatiscalledself-managedexposure.Sometypesofphobias,suchasfearsofnaturaldisasters(e.g.,fires,floods,earthquakes),cannotbepracticallytreatedwithinvivoexposure; _Tan_Counseling_BB_mw.indd242 9/21/104:37:28PM BehaviorTherapy 229 henceimaginalexposureismoreappropriateandfeasibleintreatingthesekindsofphobias.Morerecently,sincethe1980sand1990s,exposuretherapyhasalsobeenconductedusingcomputer-basedvirtualrealitytechnologyinexposingclientstospecificanxiety-provokingscenes.SuchvirtualrealityexposuretherapywaspioneeredbyBarbaraRothbaumandLarryHodges(seeRothbaumandHodges1999).Ithasbeenusedtotreatpanicdisorder,agoraphobia,obsessive-compulsivedisorder,socialphobia,posttraumaticstressdisorder,andspecificphobiassuchasfearsofflying,publicspeaking,driving,spiders,heights,enclosedspaces,andseveralmedicalprocedures(WiederholdandWiederhold2005).Althoughitisstillcostly,itisapromisingapproachtoexposuretreatmentthatwarrantsfurtherresearchandevaluationofitseffectiveness(SpieglerandGuevremont2003).Recentmeta-analyseshave,infact,shownsubstantialdecreasesinsymptomsofanxietyaftervirtualrealityexposuretherapy(ParsonsandRizzo2008)andlargeaverageeffectsizes(M. B.PowersandEmmelkamp2008).Self-ModificationProgramsandSelf-DirectedBehaviorSelf-modificationorself-managementprogramsinbehaviortherapyfocusondevelopingclients’self-directedbehavior,empoweringthemtochoosetheirowngoalswithspecifictargetbehaviorstheywanttomodify,withsomeguidancefromthebehaviortherapist,whocoachestheclientswithspecificbehavioralchangetechniques.Self-modificationinterventionsusuallyincludeself-monitoring,self-contracting,self-reward,stimuluscontrol,andself-as-model(Corey2009, 250).Clientsaretaughtcopingskillstheycanuseindealingwithdifficultproblemsorstressfulsituations.DavidWatsonandRolandTharp(2007)havedescribedthefollowingstepsthataclientneedstotakeinordertosuccessfullyimplementaself-modificationprogram:(1) selectgoalsthatarerealistic,attainable,measurable,andmeaningfultohimorher;(2) translategoalsintotargetbehaviorsthatareclearandconcrete;(3) engageinself-monitoringinwhichheorshekeepsadailybehavioraldiaryofsystematicobservationsofhisorherowntargetbehaviorsandtheirantecedentsandconsequences;(4) developaspecificplanforbehavioralchangeanduseself-reinforcementwhendesirabletargetbehaviorsoccur;(5) evaluateeachactionplan,andmakeadjustmentsorrevisionstoitwherenecessary,tokeepitrealisticandattainable.Self-modificationprogramshavebeenusedtohelpclientsstrugglingwithdepression,panicattacks,fearofthedark,socialanxiety,andpublicspeakinganxietyaswellasforenhancingcreativityandproductivity,controllingsmoking,andincreasingexercise(D. L.WatsonandTharp2007).Self-modificationhasalsobeenevaluatedwithclientssufferingfromhealthproblemssuchasasthma,arthritis,cardiacdisease,cancer,diabetes,headaches,substanceabuse,andvisionloss(Cormier,Nurius,andOsborn2009). _Tan_Counseling_BB_mw.indd243 9/21/104:37:29PM 230 MajorCounselingandPsychotherapyTheoriesandTechniques MultimodalTherapyArnoldLazarusisakeyfigureinthedevelopmentofbehaviortherapyandespeciallyinexpandingittobroad-spectrumbehaviortherapy(Lazarus1966,1971),thenmultimodalbehaviortherapy(Lazarus1973,1976),andeventuallytomultimodaltherapy(Lazarus1981,1985,1989,1997,2008).MultimodaltherapyasdevelopedbyLazarusisacomprehensiveandsystematicapproachtotherapythathasgonebeyondclinicalbroad-spectrumbehaviortherapy,althoughitisstilllargelybasedinsociallearningtheoryandsocialcognitivetheoryandusesmanycognitiveandbehavioraltechniquesintreatingabroadrangeofclinicalproblems.Lazarusstronglyadvocatestechnicaleclecticism,orusingwhatevertherapeutictechniqueshavebeenfoundtobeeffective.However,hedoesnotadvocatetheoreticaleclecticism,whichcanbeconfusing,inconsistent,andincoherent.Multimodaltherapists,likebehaviortherapistsandcognitivebehaviortherapists,areveryactiveanddirectiveinconductingtherapy,comfortablyfunctioningascoaches,consultants,educators,trainers,androlemodelsfortheirclients.Theyalsoengageinappropriatelevelsofself-disclosureandwillopenlyprovideinstructions,suggestions,andconstructivefeedbackaswellasofferpositivereinforcementorverbalpraisetotheirclients(Corey2009, 252).Themultimodalapproachtotherapyisbasedonaviewofhumanpersonalityasconsistingofsevenmajordimensionsoffunctioningthatcanbesummarizedasone’sBASICI.D.(orbasicidentity).BASICI.D.standsforthefollowing:B=Behavior;A=Affect;S=Sensations;I=Images;C=Cognitions;I=InterpersonalRelationships;andD=Drugs/Biology(Lazarus1981,1989,1997,2008).Allsevenmodalitiesorareasofhumanfunctioningcaninteractamongthemselves,buttheycanalsobeseenasseparatedimensions.Theseventhmodality,drugsandbiology,alsoincludesnutritionandexercise.MultimodaltherapyemphasizestheneedforacomprehensiveassessmentoftheclientacrosstheBASICI.D.,coveringeachmodalityordimension,whichyieldsaBASICI.D.profileuniquetotheclient.Amultimodallifehistoryinventory(LazarusandLazarus1991)isoftenusedbymultimodaltherapistsinexploringaclient’shistory.Lazarus(2008)believesthateffectivetherapyshouldbecomprehensive,coveringallthemodalitiesofaclient’sBASICI.D.,usingasmanytherapeuticinterventionsasneededtohelptheclientlearnasbroadarepertoireofcopingskillsaspossibletodealwithhisorherproblemsandtopreventrelapse.MindfulnessandAcceptance-BasedCognitiveBehaviorTherapyThethirdwaveofbehaviortherapyhasexpandedthebehavioralandcognitive-behavioralapproachtotherapytoincludemindfulnessandacceptancebasedtherapies(Hayes,Follette,andLinehan2004;RoemerandOrsillo2009).Suchtherapiesemphasizemindfulness,orfocusingattentiononone’simmedi- _Tan_Counseling_BB_mw.indd244 9/21/104:37:30PM BehaviorTherapy 231 ateexperienceinthepresentmoment,withacceptanceoranopen,curious,andreceptiveorientation,andnotwithajudgmentalorevaluativeattitude.Therearefourmajorapproachestothird-wavebehaviortherapy(seeCorey2009,255–57).Dialecticalbehaviortherapy(DBT).DBTwasdevelopedbyMarshaLinehan(1993)forthetreatmentofborderlinepersonalitydisorder.Itemphasizesacceptanceandmindfulnessinhelpingclientstoregulatetheirintenseemotions.DBT’smajorcomponentsareregulatingaffect,toleratingdistress,improvinginterpersonalrelationships,andtraininginmindfulnessthatisbasedonZenpractice(Corey2009, 255).ClientsneedenoughtimetolearnsuchskillsinDBT,andtherapythereforeusuallylastsforatleastayear,involvingindividualtherapyaswellasgroupskillstraining.DBThasmorerecentlybeenappliedacrossdifferentdisordersandsettings(DimeffandKoerner2007),includinginprivatepractice(Marra2005).Mindfulness-basedstressreduction(MBSR).MBSRwasdevelopedbyJonKabat-Zinn(1990).Itisagroupinterventionthatusuallylastsforeighttotenweeks,duringwhichclientsaretaughtsittingmeditationandmindfulyogaaswellasabody-scanmeditationtohelpthemobserveandexperiencealltheirbodilysensations.Clientspracticemindfulnessmeditationonadailybasisforaboutforty-fiveminutesandlearntoattendtotheirpresentorimmediateexperienceincopingmoreeffectivelywithstressandthusimprovetheirhealth.Mindfulness-basedcognitivetherapy(MBCT).MBCTwasdevelopedbyZindelSegal,MarkWilliams,andJohnTeasdale(2002),basedonKabat-Zinn’sMBSR.Itcombinesmindfulnesstrainingwithcognitive-behavioraltherapyinaneight-weekprogramforthetreatmentofdepressionanditsrecurrence.Itseemstobeeffectiveespeciallyforclientswhohavehadthreeormorepreviousepisodesofdepression.However,furthercontrolledoutcomeresearchisneededbeforemoredefinitiveconclusionscanbemadeabouttheeffectivenessofMBCTfordepressionanditsrecurrence(seeCoelho,Canter,andErnst2007;Williams,Russell,andRussell2008).Acceptanceandcommitmenttherapy(ACT).ACTwasdevelopedbySteven C.Hayesandhiscolleagues(HayesandStrosahl2004;Hayes,Strosahl,andWilson1999;seealsoHayesandSmith2005;Luoma,Hayes,andWalser2007).Thisapproachtotherapyhelpsclientstoacceptpainfulexperiencesratherthanfighttomodifyorcontrolunpleasantfeelings.Itemphasizesacceptanceaswellascommitmenttoone’sownvaluesandtakingactiontoliveaccordingtoone’svalues.ACThassixmajorcomponents:acceptance,cognitivedefusion(emphasizingflexibilityinplaceofrigidity),beingpresent,selfascontextfocusingonatranscendentsenseofself,values,andcommittedaction.Itisapromisingapproachtothird-wavebehaviortherapythatisreceivingincreasingempiricalsupportforitseffectivenessintreatingawiderangeofclinicalproblems(Hayesetal.2006;Hayesetal.inpress;Ost2008). 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CognitiveBehaviorModificationProchaskaandNorcrosshavedescribedthreemajorthrustsorcategoriesofbehaviortherapytechniques:(1) counterconditioning(Wolpe),includingsystematicdesensitization,assertivenesstraining,sexualarousal,behavioralactivation,andstimuluscontrol(ProchaskaandNorcross2010,246–57);(2) contingencymanagement(Skinner),includinginstitutionalcontrol,selfcontrol,mutualcontrol,therapistcontrol,andaversivecontrol(ProchaskaandNorcross2010,257–65);and(3) cognitivebehaviormodification(Meichenbaum)includingMeichenbaum’sself-instructionaltraining(Meichenbaum1977)andstressinoculationtraining(Meichenbaum1985)aswellasbiofeedbackandproblem-solvingtherapy(ProchaskaandNorcross,265–71).Cognitivebehaviormodification(CBM)asdevelopedbyMeichenbaumisabroad-spectrumbehaviortherapythatincludesbothbehavioralcopingskillssuchasrelaxationtechniquesaswellascognitivestrategiessuchascalmingandcopingself-talkorself-instructionaltraining.Itcanalsobeconsideredamajorapproachtocognitivebehaviortherapy.ProchaskaandNorcross(2010)havechosentocategorizecognitivebehaviormodification(CBM)aspartofthecontemporarybehaviortherapies.CBMwillbediscussedonlybrieflyhere,intheformofstressinoculationtraining,becauseitwillreceivemoredetailedcoverageinthenextchapterofthisbook,whichcoverscognitivebehaviortherapyandrationalemotivebehaviortherapy.Meichenbaumwentbeyondself-talkorself-instructionaltrainingwhenhedevelopedamorecomprehensiveapproachtotherapythathecalledstressinoculationtraining(SIT),whichisasubstantialpartofCBM(seeMeichen­baum1985,1993,2003,2007).Itconsistsofthreephases:aconceptualeducationalphase;askillsacquisition,consolidation,andrehearsalphase;andanapplicationphasewithfollowthrough.Intheconceptualeducationalphase,clientsareprovidedwithameaningfulrationaleforstressinoculationtrainingaimedathelpingthemcopemoreeffectivelywithstressfulsituationsintheirlivesbyanticipatingstressandpracticingcopingskillsforstressmanagement.Inthesecondphaseofskillsacquisition,consolidation,andrehearsal,variouscopingskillsarereviewedwithclients,andtheychooseandpracticetheonesmostrelevantandhelpfultothem(e.g.,problemsolving,assertivenesstraining,cognitivereframing,relaxationtechniques,calmingself-talk,pleasantimagery).Inthefinalphaseofapplicationandfollowthrough,theclientusesthecopingskillstomanageexperimentaloractualstressors,orthroughrole-playingandimageryrehearsal(Meichenbaum1985,2003).SIThasbeensuccessfullyusedinhelpingclientscopewithawiderangeofstressfulsituations,includingacutestressorssuchasmedicalproceduresandsurgery,traumaticevents;chronicintermittentstressorssuchasathleticcompetitionsandevaluations;andchronicstressorssuchaschronicpain,anxiety _Tan_Counseling_BB_mw.indd246 9/21/104:37:33PM 233 BehaviorTherapy andangerproblems,andpersistentexposuretooccupationalchallengessuchasthoseinpolicework,nursing,teaching,andcombat(Meichenbaum2003). BehaviorTherapyinPracticeAHypotheticalTranscript Client:Iwasatthegrocerystoretheotherday,waitinginlinetopaythecashierforacoupleofthings.Anothercustomerthencutrightinfrontofme.Ifeltreallyangrybutcouldn’tbringmyselftosayanythingtohim.Hepaidforhisstuffandthenwalkedawayasifnothinghadhappened.Iwasfumingmadinsidebutkeptitalltomyself. . . .IwishIcouldbebolderandhadtoldhimoffforcuttinginfrontofme!BehaviorTherapist:Soundslikeyoureallyfeltupsetatthisguyforcuttinginfrontofyou,butyouhavetroublespeakingupthoughyouwantto.Whatdoyouthinkholdsyouback?What’sgettinginthewayofyousayingwhatyouwanttosaytothisguy?Client:Well. . .IhavetroubleassertingmyselforspeakingupwhenIwantto. . . .Igetnervous,andI’mnotsurewhattosay. . . .Ialsoamafraidoflosingmytemperandgettingreallymadandshoutingattheguy.BehaviorTherapist:Soyouhavesomefeelingsofnervousnessaswellasfearofblowingupinangerattheguy.Client:Yeah. . .I’mnotsurehowtocontrolmyfeelings,excepttostuffthem. . . .I’malsonotsurewhattosaytoexpressmyselfappropriatelytotheguy,tolethimknowthatwhathedidwasn’tright.BehaviorTherapist:OK,let’sseeifwecanhelpyoufirsttomanageyourfeelingsofnervousnessandfearofblowingup.Somesimplerelaxationandcopingtechniquesforcalmingourselvesdownmaybehelpful.Forexample,youcantakeaslow,deepbreath,holditforafewmoments,andthenbreatheoutslowlyandrelax.Youcanthentellyourselfquietly,“Justrelax,takeiteasy,Icanhandlethiswithoutblowingup.”YoucanalsobrieflyvisualizeorimagineyourselflyingonthebeachinHawaiitorelaxyourselfmore.Whatdoyouthink?Client:Yeah,thatsoundsgood!BehaviorTherapist:Let’strypracticingthesethreesimplebutpowerfulstresscontroltechniquesofslow,deepbreathing, _Tan_Counseling_BB_mw.indd247 9/21/104:37:33PM 234 MajorCounselingandPsychotherapyTheoriesandTechniques calmingself-talk,andpleasantimagery.Iwantyoutotakeinaslow,deepbreathnow,holditforafewmomentsasyounoticethetensionrising. . .andnowjustrelaxandbreatheoutslowly. . .quietlytellyourself,“Justrelax,takeiteasy. . .Icanhandlethis . . .”andthenbrieflypictureorimagineyourselflyingonthebeachinHawaii.. . .Justrelaxmoreandmoredeeply. . . .Howareyoufeeling?Client:I’mfeelingmuchmorerelaxed. . . .Thesetechniquesarereallyhelpful!BehaviorTherapist:Good!Nowdoyouthinkitwouldalsobehelpfultoyouifwepracticeinarole-playseveraltimeswhatyoucouldactuallysaytothisguyinanappropriateandboldorassertivewaywithoutlosingyourcool?Client:Yeah. . .Ineedsomesuggestionsandcoachingfromyou!BehaviorTherapist:OK. . .let’sdoabriefrole-playwithyoubeingyourselfandwithmeplayingtheroleoftheguycuttinginfrontofyou.Soheregoes. . .I’vejustcutinfrontofyou. . .andyougoaheadandtrysayingwhatyouwanttosay,tome. . .Client:Well. . .excuseme,doyoumindwaitinginlineliketherestofusinsteadofcuttinginlikethis?BehaviorTherapist:That’snotbadatallforafirsttry.Howdoyoufeelaboutwhatyousaidandhowmightweimproveonit?Client:I’mnotsure. . .butmaybeIdon’thavetosaythelastpartaboutcuttinginlikethis,especiallysinceI’mraisingmyvoicetoo.BehaviorTherapist:That’sagoodobservation!Letmeplaytheroleofyounow,andyoutaketheroleoftheguysothatIcanprovideyouanexampleofwhattosay.. . .“ExcusemebutIwouldappreciateitifyouwaitinlineliketherestofus.. . .Thanks!”Client:Yeah,thatsoundsmuchbetterandlikewhatIreallywanttosay!BehaviorTherapist:OK. . .Let’spracticeitagainbutnowyouplaytheroleofyourselfandI’llplaytheroleoftheguyagain. . .goahead. . .Client:“Excuseme. . .Iwouldappreciateitifyouwaitinlineliketherestofus. . .there’salinehere. . .Thanks!”BehaviorTherapist:That’sgreat!Welldone!Howdoyoufeelnow? _Tan_Counseling_BB_mw.indd248 9/21/104:37:34PM BehaviorTherapy 235 Thishypotheticaltranscriptofasmallpartofabehaviortherapysessiondemonstratesthetherapist’suseofseveralbehavioraltechniques.Theyincludebriefrelaxationandcopingskillstrainingandassertivenesstrainingwithcoaching,modeling,role-playing,providingconstructivefeedback,andgivingpositivereinforcementintheformofverbalpraiseandencouragement.Thebehaviortherapistusedthesetechniquestohelptheclientovercomenervousnessandanxietyaboutpossiblygettingangryandlearnhowtorespondinanappropriatelyassertiveway.Thebehaviortherapistalsointeractedwiththeclientinawarmandempathicmanner.CritiqueofBehaviorTherapy:StrengthsandWeaknessesBehaviortherapyhasseveralstrengths(seeCorey2009,259–66;Fall,Holden,andMarquis2004,291–95;Parrott2003,289–91;ProchaskaandNorcross2010,287–90),manyofwhicharesimilartothestrengthsofrealitytherapy,coveredinthepreviouschapterofthisbook.First,behaviortherapyisaversatileandcomprehensiveapproachtotherapythathasbeenappliedtodiversepopulationsincludingchildren,adolescents,adults,andolderadults;invarioussettingssuchasschools,hospitals,rehabilitationcenters,residentialhomes,clinics,privatepracticeoffices,prisons,andprivatehomes;andforawiderangeofclinicalproblems(seeKazdin2001;Miltenberger2008;SpieglerandGuevremont2003;Wilson2008).Behaviortherapyisusuallyrelativelyshort-termandisthereforealsoconsistentwithmanagedcare’semphasisoneffectiveshort-termtreatmentsandbrieftherapy.Second,behaviortherapyisaconcreteandspecificapproachtotherapythatfocusesonparticularbehavioralgoalssetbytheclientandhowtoachievethem,usingthemostempiricallysupportedoreffectivebehavioralandcognitivebehavioralinterventions.Behaviortherapistsengageinregularmonitoringandmeasurementofclientprogresstowarddesirabletherapeuticorbehavioralchange.Itisanapproachtotherapythatisaccountableandfocusedonachievingthegoalsoftheclientinaclearandmeasurableway.Third,behaviortherapyprimarilyaddressesthecurrentenvironmentalsituationandtheproblemsorsymptomsoftheclient,withemphasisonmakingspecificbehavioralchangesaccordingtothegoalsandneedsoftheclient.Itisthereforeagoodcorrectivetootherapproachestotherapythatmayfocustoomuchonthepastoronexplorationoffeelingsandachievementofinsight,withoutsufficientattentiontopresentenvironmentalconditionsaffectingtheclientandactualbehavioralchange.Fourth,behaviortherapyemphasizesclientchoiceinsettingthegoalsfortherapy,althoughitisnotanexistentialapproachtotherapy,likerealitytherapyorexistentialtherapy,thatmakesone’sfreedomtochoose,inanauthenticandresponsibleway,anall-pervasivecapacityandnecessityforeveryhumanbeing.Althoughbehaviortherapydoesnotoveremphasize _Tan_Counseling_BB_mw.indd249 9/21/104:37:35PM 236 MajorCounselingandPsychotherapyTheoriesandTechniques choiceasrealitytherapytendstodo,itdoesempowerclientstochoosetheirowngoalsfortherapy.Fifth,behaviortherapyisopentotheuseofpsychiatricmedicationsforcertainseverepsychologicaldisorderssuchasmajordepressivedisorder,bipolardisorder,andschizophrenia,unlikeGlasser’sextremeandradicalstanceagainsttheuseofpsychiatricmedicationsintreatingsuchdisordersduetohisoveremphasisonclientchoice,evenassertingthatpeoplechoosetheirsymptomsandmiseryandsuffering(W. Glasser2003).Behaviortherapistshaveexploredtheuseofcombinedtreatmentsforcertainclinicalproblems,suchasantidepressantswithbehaviortherapyincludingexposuretherapyforhelpingclientswithobsessive-compulsivedisorder(OCD)(seeProchaskaandNorcross2010,282–83).Sixth,behaviortherapyisauniqueapproachthatoffersawidearray,orarmamentarium,oftherapeuticinterventionsandtechniquestohelpclientswithmanydifferenttypesofpsychologicalandbehavioraldisorders,withempiricalsupportfortheeffectivenessofthemajorityofthetechniques.Clientswhowantspecificandeffectivehelptoovercomeparticularproblemsorsymptomsincludingsomaticsymptoms(e.g.,hypertension,migraineheadaches,irritablebowelsyndrome)andpsychologicalsymptoms(e.g.,anxietydisorders,depression,eatingdisorders)cangetitfrombehaviortherapistswhohavedevelopedeffectivetherapeuticinterventionsandtechniquesfortreatingsuchproblems(ProchaskaandNorcross2010, 287).Seventh,behaviortherapytakesempiricalresearchveryseriouslyandsubjectsitstechniquesandtherapeuticinterventionstocontrolledoutcomestudiesasmuchaspossible.Itistherefore,togetherwithcognitivebehaviortherapy,themostempiricallysupportedapproachtotherapytoday.Finally,behaviortherapycanbeeasilyusedwithclientsfromdifferentculturesandcountriesinamulticulturalcounselingcontextbecauseitfocusesontreatingsymptomsandproblemsthatcutacrosscultures.Italsogivesclientsthefreedomtochoosetheirowngoalsinaculturallysensitiveway.Itisaproblem-solvingapproachtotherapythatisdirect,systematic,andrelativelyshort-termwithouttheneedformuchintrospectionandexplorationofthepast.Behaviortherapyandcognitivebehaviortherapy,withsomemodificationandadaptation,canbeespeciallyhelpfulwithethnicminorityclients(seeHaysandIwamasa2006),includingChineseAmericanclients(ChenandDavenport2005).Thereisnowsomeaccumulatingresearchevidencesupportingtheeffectivenessofcognitive-behavioraltherapywithadultethnicminorityclients(VossHorrell2008;seealsoMirandaetal.2005).Behaviortherapyalsohasseverallimitationsandweaknesses.First,ittendstotreatsymptomsandproblemsratherthanfocusholisticallyonthewholepersonoftheclient.Itcanthereforebeconductedinamechanisticway,withoutadequateattentiontothepersonandthelifecontextoftheclient.However,contemporarybehaviortherapytendstobemorecomprehensiveinitsbe- _Tan_Counseling_BB_mw.indd250 9/21/104:37:37PM BehaviorTherapy 237 havioralassessmentoftheclientandhisorherlifecontext(see,e.g.,Lazarus1976,1989,1997;Wilson2008).Second,behaviortherapistsemphasizetheirtechniquesandempiricallysupportedinterventionsmorethanthetherapeuticrelationshipwithclients,althoughtheydoacknowledgetheimportanceofhavingawarm,empathic,andsupportiverelationshipwiththeclient(seeWilson2008).Again,thedangerexistsforbehaviortherapytobeconductedinamechanisticwaythatisnotsufficientlysensitivetotheintricaciesandcomplexitiesofthetherapeuticrelationshipbetweenthebehaviortherapistandtheclient.However,behaviortherapistsandcognitivebehaviortherapistshaverecentlybegunpayingmoreattentiontotheimportanceofthetherapeuticrelationshipinthecognitivebehavioraltherapies(seeP. GilbertandLeahy2007;seealsoSafranandSegal1990).Third,behaviortherapydoesnotadequatelyfocusonthepastanditsunresolvedissuesorpainfulmemories,sinceitisaproblem-solvingapproachthatmainlytreatsthepresentingproblemsandcurrentsymptomsoftheclient.Someclientswillneedmoretimetoprocessanddealwithpastissuesandpainthanbehaviortherapiststypicallyprovide.Fourth,behaviortherapyisstillbasedmainlyonsociallearningorsocialcognitivetheory.Ittendstoignoreunconsciousprocessessuchastransferenceanddreams,whichcanberichsourcesofhelpfulinsightsforclientsandforfacilitatingfurthertherapeuticchange.Behaviortherapistsandcognitivebehaviortherapists,however,havetriedtodealwithsuchunconsciousprocessesanddreamsbutwithinacognitive-behavioralframeworkofunderstandingratherthanfromapsychodynamicorpsychoanalyticperspective(see,e.g.,K. S.BowersandMeichenbaum1984;Rosner,Lyddon,andFreeman2003).Fifth,behaviortherapydoesnotadequatelydealwithexistentialissues,whichsomeclientsmaybestrugglingwith,suchasseekingmeaninginlife,choosingauthenticvalues,andovercomingthefearofdeath.Furthermore,traditionalsecularbehaviortherapyalsodoesnotseriouslyincorporatespiritualityandreligion,whichmaybeofcrucialimportancetoreligiousclients.However,significantattemptsandadvanceshavebeenmadeinrecentyearstodevelopamorespirituallyorientedbehaviortherapy(see,e.g.,W. R.MillerandMartin1988)orcognitive-behavioraltherapy(see,e.g.,Tan1987a;TanandJohnson2005;seealsoPropst1988)thatseriouslyintegratesreligionandspiritualityintotherapy.ThethirdwaveofbehaviortherapyalsoincludesapproachessuchasDBT,MBCT,andACTthataremindfulnessbasedandacceptancebased(Hayes,Follette,andLinehan2004),centeredinsomeformofcontemplativeormeditativespirituality,usuallywithinaZenBuddhistframework(butitcanalsobesomeotherreligiousframeworksuchasRomanCatholicorEasternOrthodox).Sixth,behaviortherapyisadirectiveandsystematicapproachtotherapyinwhichthebehaviortherapistfunctionsasacoach,trainer,teacher,consultant, 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androlemodelinhelpingtheclienttoachievehisorhertherapeuticgoals.Thereisarealdangerofthebehaviortherapistactinglikeanexpertandultimatelyinfluencingtheclientwiththetherapist’sownvalues,orevenworse,imposingthetherapist’svaluesontheclient,apotentialethicalproblemthatalsoplaguesotherdirectivetherapiessuchasrealitytherapy(seeWubbolding2008).Behaviortherapiststrytoavoidthispotentialdangerbyencouragingtheclienttoactivelyparticipateintherapyandtochoosehisorherowntreatmentgoals(Wilson2008).Seventh,behaviortherapytechniquescanbesimplisticallyandeasilymisusedandabusedbyinadequatelytrainedorinexperiencedtherapists.Somebehavioralinterventionssuchasfloodingandinvivoexposurerequireadequatetrainingandcarefulclinicalsupervisionbeforetherapistsmakeindependentattemptstoconductthem.Propertrainingandsupervisioninbehaviortherapyarethereforeneededforthecompetentandethicaluseofbehaviortherapytechniques.Eighth,althoughbehaviortherapycanbeadaptedforeffectiveusewithclientsfromotherculturesandcountries,itmaystillnotbesensitiveenoughtothelargersociopoliticalandenvironmentalcontextswithinwhichclientslive.Inotherwords,behaviortherapistsmaystillpaytoomuchandtoonarrowattentiontotheclientandhisorhersymptomsandtargetcomplaints,withoutadequatelyconsideringfactorssuchasdiscrimination,oppression,andmarginalizationinthelargersociopoliticalcontextoftheclient’slife,whichcanhaveasubstantialnegativeimpactontheclient’sfunctioning.Theclientmayneedtobeempoweredtodealmoredirectlywithfactorssuchasdiscriminationandoppression.Finally,behaviortherapistsmaynotbesensitiveenoughtothepossibilitythatsuccessfulbehavioralchangeintheclientmaynegativelyimpactthosearoundhimorher,eventhoughtheclient’sowntreatmentgoalsmaybeachieved(e.g.,becomingmoreassertive).Conflictsbetweentheclient’sgoalsandtheculturalandsocialvaluesofsignificantothersinhisorherlifewillrequiremoreattentionandsensitivityonthepartofthebehaviortherapistworkingwithsuchclientsinamulticulturalcounselingcontextorfromadiversityperspective(seeCorey2009, 260).ABiblicalPerspectiveonBehaviorTherapyBehaviortherapyhasbothstrengthsandweaknessesfromabiblicalperspective(Tan1987a;seealsoBrowningandCooper2004,86–105;S. L.JonesandButman1991,154–70).First,behaviortherapyorbehaviormodification,initsearlierversion,wasmoredeterministicandnaturalisticinitsbasicphilosophy,followingSkinnerandhisradicalbehaviorism,whichhadnoplaceforhumanfreewill.Thisversionalsohadnoplacefortranscendenceandthesupernatural 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sincebehavioralapproachestotherapytendtobereductionisticintheirnaturalisticandmaterialisticassumptions(S. L.JonesandButman1991).Theseearlierphilosophicalassumptionsofbehaviortherapyareproblematicfromabiblicalperspective,whichassumesatleastsomefreewillandfreedomtochooseforhumanbeings(seeJosh.24:15;Luke13:3).TheBiblealsoaffirmsself-transcendenceandtherealityofGodandthesupernatural,includingeternity.However,morerecentversionsofbehaviortherapyarebasedmoreonBandura’ssocialcognitivetheory,whichincludesreciprocaldeterminismthatallowsforsomelimiteddegreeoffreewillandchoiceonthepartoftheindividualperson.Therehavealsobeenseriousattemptstointegratereligionandspirituality,includingtranscendenceandthesupernatural,intobehaviortherapy(e.g.,W. R.MillerandMartin1988)andcognitivebehaviortherapy(e.g.,Tan1987a;TanandJohnson2005;seealsoPropst1988).Second,behaviortherapy’semphasisonenvironmentalcontrolonhumanbehaviorandtheimportanceofconditioning,includingoperantconditioningandreinforcementcontingencies,isagoodreminderofhowhumanbeingsarenottotallyfree,evenascreaturesmadeintheimageofGodthecreator(Gen.1:26–27).Beinghumanmeansthatournaturealsohasananimalsidethatissubjecttoconditioningtoacertainextent(seeBufford1981;BrowningandCooper2004;S. L.JonesandButman1991).TheBiblealsotalksaboutrewardsandincentives,butithasahigherultimateviewofeternalrewardstocomeinheaventhattranscendsimmediategratificationorpositivereinforcementofspecificbehaviorsnow.Paulcanthereforetalkaboutenduringandevenembracingpresentsufferingandtrialsinanticipationoffuturegloryandeternaljoyinheaven(seeRom.8:18;2 Cor.4:16–18).Althoughwearecreatureswithconditionedhabits,wearenottotallyconditioned.WearealsocreatedintheimageofGod(Gen.1:26–27),withsomefreedomtochoose,althoughourcapacitytochooseisnotabsolute,asexistentialtherapistsandrealitytherapistsmaywantustobelieve.Behaviortherapistshavecorrectlyremindedusofourlimitedfreedomtochoose.Third,behaviortherapists’empowermentofclientstochoosetheirowngoals,basedontheirownvalues,isagoodcorrectivetothepotentialdangerofimposingthetherapist’svaluesandgoalsontheclientbecausebehaviortherapyissuchadirectiveapproachtotherapy.However,ultimatevaluesfromabiblicalperspectivecanonlycomefromGodandhisinspiredWordortheScriptures(2 Tim.3:16).Fourth,behaviortherapy’sfocusonpowerfulandeffectivetechniquesofbehaviorchangecanresultinnotonlyself-efficacybutalsosinfulself-sufficiencyandoverdependencyonone’sskillstocopeeffectivelywiththeproblemsinone’slife.AbiblicalperspectivewillemphasizeinsteadsufficiencyandstrengthinChrist(Phil.4:13)anddependenceonthefillingandpoweroftheHolySpirit(Zech.4:6;Eph.5:18)inbringingaboutlastingbehavioralchange. _Tan_Counseling_BB_mw.indd253 9/21/104:37:40PM 240 MajorCounselingandPsychotherapyTheoriesandTechniques Fifth,behaviortherapy’semphasisontechniquesofbehaviorchangemaynotfocusenoughattentiononthetherapeuticrelationship,althoughrecentlytherehavebeenmoredeliberateattemptstomakethetherapeuticrelationshipmorecentralinbehaviortherapyandcognitivebehaviortherapy(see,e.g.,P. GilbertandLeahy2007;seealsoSafranandSegal1990).Abiblicalperspectivewillemphasizetheprimacyofagapelove(1 Cor.13)inthetherapeuticrelationshipandtheimportanceofestablishingawarm,empathic,andgenuinerelationshipwiththeclient.Sixth,behaviortherapytendstofocusoncurrentsymptomsandthepresentingproblemsoftheclient,withlessattentionpaidtothepast.Althoughthisemphasisisagoodcorrectivetotheendlessexploringofpastissuesandexperiences,abiblicalperspectivewillneverthelessdealmoreadequatelywiththepast,especiallywithunresolveddevelopmentalissuesandpainfulmemories,andincludethejudicioususeofthehealingofmemoriesorinnerhealingprayerwhenappropriate(seeTan2003b,2007b).Seventh,behaviortherapydoesnotpaymuchattentiontounconsciousprocesses,includingthedarker,fallensideofhumannature,whichiscapableofsinandevil,aswellasmorecomplexinternalconflicts,inwhattheBiblecallstheinner“heart”ofaperson(seeJer.17:9;Rom.3:23).Abiblicalperspectivewilldealwithsuchcomplexstruggles,includingunconsciousconflicts,moreadequately.Eighth,oneofbehaviortherapy’smajortechniquesisexposuretherapyfortreatingvariousanxietydisorders.TheBiblealsoemphasizestheneedtoconfrontthetruthinordertobesetfree(cf.John8:32),andexposuretherapyisconsistentwiththisteaching,whichalsounderscorestheneedforcognitiverestructuringandrenewalofthemind(Rom.12:1–2)usingbiblicaltruthincognitivebehaviortherapy(Tan1987a).Ninth,behaviortherapyneedstofocusmoreonlargercontextualfactorssuchasfamilial,social,religious,cultural,andevenpoliticalinfluencesaffectingaparticularclient’slifeandfunctioning.Abiblicalperspectivewillemphasizetheneedtomakeuseofcommunityresourcesintherapeuticinterventionswithaclient,includingthechurchasabodyofbelieversavailableformutualsupport,help,andministrytooneanother(1 Cor.12;1 Pet.2:5,9).Finally,behaviortherapy’shallmarkofsubjectingitstechniquestocontrolledoutcomeresearchandusingempiricallysupportedtherapeuticinterventionsisastrengththatcanbeappreciated.However,fromabiblicalperspective,empiricalsupportcannotbeacceptedastheultimatecriterionforusingspecificbehavioralorothertherapeutictechniques.AChristiantherapistwillnotsimplyusewhateverworks.Thetherapeuticinterventionschosenforusemustultimatelybeconsistentwithbiblicaltruth,morality,andethics.Furthermore,theameliorationorreductionofsymptomsandemotionalsufferingisnottheultimategoaloftherapyfromabiblicalperspective.TheultimategoalofChristiantherapyorcounselingismoretranscendentandeternal,centeredin 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becomingmoreChristlike(Rom.8:29)andthereforeinholinessratherthansimplyinhappiness.Thisperspectivemeansthatsometemporalsufferinghasultimatemeaning(cf.Rom.8:18;2 Cor.4:16–18).Research:EmpiricalStatusofBehaviorTherapyOneofthehallmarksofbehaviortherapyisitsemphasisonempiricalresearch,especiallycontrolledoutcomestudiesorrandomizedclinicaltrials(RCTs).Behaviortherapyandcognitivebehaviortherapyhavethereforebeensubjectedtomorecontrolledoutcomestudiesthanotherapproachestotherapy.Closetotwo-thirdsofcontrolledoutcomestudiesontherapywithchildrenandadolescentshaveinvolvedbehaviortherapyinterventions(Kazdin1991;Weisz,Hawley,andDoss2004),andamajorityofsuchstudieswithadultshaveinvolvedbehavioralandcognitive-behavioralinterventions(Grawe,Donati,andBernauer1998;Wampold2001).ProchaskaandNorcross(2010,277–87)haveprovidedahelpfuloverviewofthemanymeta-analysesthathaveevaluatedtheeffectivenessofbehaviortherapyingeneralaswellasseveralspecificbehaviortherapyinterventions,andafewclinicaldisordersinparticular,whichwillnowbebrieflysummarized.Meta-analysesofcontrolledoutcomestudiesontheeffectivenessofbehaviortherapywithchildrenandyouth(coveringthebehavioralmethodsofoperantconditioning[e.g.,reinforcement],desensitization/relaxation,modeling,socialskillstraining,cognitive-behavioral,andmultiplebehavioral)showedeffectsizesindicatingthegreatereffectivenessofbehaviortherapycomparedtoplacebotreatmentandnotreatment.Behaviortherapyhasalsobeenfoundtobemoreeffectivethanothertreatmentssuchasinsight-orientedtherapyandplaytherapy(seeWeiss,Hawley,andDoss2004).Meta-analysesofcontrolledoutcomestudiesontheeffectivenessofbehaviortherapywithadults(coveringbehavioralmethodsofrehearsalandself-control,covertbehavioral,relaxation,desensitization,reinforcement,modeling,andsocialskillstraining)haveyieldedlargeeffectsizesdemonstratingthesuperiorityofbehaviortherapyovernotreatmentandplacebotreatment(seeShapiroandShapiro1982).Anextensivemeta-analysisofcontrolledoutcomestudies(Grawe,Donati,andBernauer1998)foundpositiveandsubstantialeffectsizesforbehaviortherapyandcognitive-behavioraltherapy(e.g.,socialskillstraining,stressinoculation,andproblem-solvingtherapy),whichindicatedtheirsuperiorityovercontroltreatmentsaswellastheirsuperiorityoverpsychodynamictreatmentswhendirectcomparisonswereconducted.Morespecifically,ThomasBowersandGeorgeClum(1988)foundthatthespecificeffectsofbehaviortherapiesweredoublethenonspecificeffectsofplacebotreatments.Meta-analysesofcontrolledoutcomestudiesontheeffectivenessofbehaviortherapywithcouples,calledbehavioralmaritaltherapy(BMT)(e.g.,communicationskillstraining,problem-solvingtraining,andmodificationof 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dysfunctionalrelationshipattributionsandexpectations),haveshownBMTtobesignificantlymoreeffectivethannotreatment(seeHahlwegandMarkman1988;DunnandSchewebel1995;ShadishandBaldwin2005).Theeffectivenessofbehaviortherapywithfamilies,orbehavioralfamilytherapy,hasalsobeensupportedbyameta-analysisofcontrolledoutcomestudies(ShadishandBaldwin2003)thatyieldedmoderatetolargeeffectsizesforbehavioralfamilytherapy,thusindicatingitssuperiorityovernotreatmentandcontroltreatmentandattimesevenoverothernonbehavioralapproachestofamilytherapy(seeProchaskaandNorcross2010, 279).ProchaskaandNorcrossalsoreviewedmeta-analysesofcontrolledoutcomestudiesontheeffectivenessofspecificbehavioralmethodssuchasrelaxationtraining,socialskillstraining,stressinoculation,biofeedback,behavioralactivation,self-statementmodification,contingencymanagement,behavioralparenttraining,andproblemsolving,mainlywithpositiveresultsshowingtheirsuperiorityovernotreatmentorcontrolconditions(2010,280–82).Theyfurtherreviewedmeta-analysesofcontrolledoutcomestudiesontheeffectivenessofbehaviortherapyforspecificdisorderssuchasobsessive-compulsivedisorder(OCD),panicdisorder,mentalretardation,eatingdisorders,attention-deficithyperactivitydisorder(ADHD),schizophrenia,angerdisorders,cigarettesmoking,nocturnalenuresis(bed-wettingatnight),hypertension,migraineheadache,insomnia,andirritablebowelsyndrome,mainlywithpositiveresults(282–87).TheresultsofseveralRCTsalsoshowedthatDBTinparticularisaneffectivetreatmentforborderlinepersonalitydisorderandbetterthannotreatmentortreatmentasusual(283).Thecontrolledoutcomeresearchthereforeshowsthatbehaviortherapyandcognitive-behavioraltherapyareofteneffectiveintreatingbothpsychologicalsymptoms(e.g.,anxiety,depression,eatingdisorders)andsomaticsymptoms(e.g.,hypertension,migraineheadaches,irritablebowelsyndrome).Behaviortherapyisaneffectivetreatmentnotonlyforpsychologicalormentaldisordersbutalsoforsomegeneralhealthconditions.ProchaskaandNorcrossalsoreviewedthecontrolledoutcomeresearchontheeffectivenessofthreeexposuretherapies:implosivetherapy,exposuretherapy,andeyemovementdesensitizationandreprocessing(EMDR).Implosivetherapyhasbeenfoundtobesignificantlybetterthannotreatmentandplacebotreatment,andequallyeffective,ifnotbetter,thancertainothertherapies(see2010,228).Exposuretherapyhasbeenshowntobeaneffectivetreatmentandoneofthetreatmentsofchoiceforposttraumaticstressdisorder(PTSD),obsessive-compulsivedisorder(OCD),socialphobia,andotheranxietydisorders,withgreatereffectivenessthannotreatmentandseveralothertreatments,andgreaterorsimilareffectivenesswhencomparedtopharmacotherapyormedications(see228–31).Finally,EMDRhasbeenfoundtobeaneffectivetreatment,especiallyforPTSD,comparabletoexposuretherapyandbetterthannotreatmentandnonexposuretherapies(see _Tan_Counseling_BB_mw.indd256 9/21/104:37:45PM BehaviorTherapy 243 236–37).However,theeyemovementsinEMDRmaynotbenecessaryforitseffectiveness,whichmaybemainlyduetotheexposurecomponentofthistreatment,withfurtherresearchneededtoclarifytheessentialcomponentsofEMDRresponsibleforitseffectiveness(seePerkinsandRouanzoin2002).Arecentmeta-analysisofthirty-threerandomizedtherapystudiesinvolvingpsychologicalapproachesinthetreatmentofspecificphobiasshowedexposurebasedtreatmentstobesuperioroverothertreatments(Wolitzky-Taylor,Horowitz,Powers,andTelch2008).Wilson(2008,246–51)hasalsorecentlyreviewedtheresearchevidencesupportingtheeffectivenessofbehaviortherapyforawiderangeofpsychologicaldisordersinvariouspopulationsandsettings,includingeducation,medicine,andcommunityliving.Heincludedbehaviortherapyforanxietydisorders(e.g.,panicdisorder,OCD,PTSD),depression(especiallytheuseofbehavioralactivation),eatingandweightdisorders(e.g.,bingeeatingandbulimianervosa,obesity),schizophrenia,childhooddisorders,behavioralmedicine,preventionandtreatmentofcardiovasculardisease,andotherapplicationstodiversehealth-relatedproblems(e.g.,headaches,painconditions,asthma,epilepsy,sleepdisorders,nauseareactionsincancerpatientsreceivingradiationtreatment,children’sfearsregardinghospitalizationandsurgery,andtreatmentcompliance).Wilson(2008)notedthatthemostthoroughandrigorousevaluationsofbothpsychologicalandpharmacologicaltreatmentsandtheireffectivenessorefficacyforvariousclinicaldisordersarethosedonebytheNationalInstituteforClinicalExcellence(NICE)intheUnitedKingdom(see,e.g.,NationalInstituteforClinicalExcellence2004).TreatmentguidelinesissuedbyNICE,basedonresearchdata,aregradedfromA(withrigorousempiricalsupportfromwell-controlledRCTs)toC(withexpertopinionandstrongempiricaldata).Behaviortherapyhasdoneverywell,usuallyreceivingAratingsfromtheNICEevaluations.BehavioralinterventionsarerecommendedbyNICEasthepsychologicaltreatmentsofchoiceforspecificanxietyandmooddisordersandevaluatedasbeingequivalenttopharmacologicaltreatmentineffectiveness.Behaviortherapyhasalsobeenratedasmoreeffectivethanmedicationforeatingdisorders(WilsonandShafran2005).Behaviortherapyhasalsofaredverywellinthelistofempiricallysupportedtreatmentsfirstestablishedin1995byDivision12(SocietyofClinicalPsychology)oftheAmericanPsychologicalAssociation,stilldominatingarecentupdateofsuchalisttogetherwithcognitivebehaviortherapy(seeWoody,Weisz,andMcLean2005).More-recentthird-waveversionsofbehaviortherapyarereceivingmoreempiricalsupportfortheirtherapeuticeffectiveness,suchasDBTforborderlinepersonalitydisorder(Linehanetal.2006),andACTasapromisingtreatmentbutstillneedingfurtherresearchandempiricalsupportfromadditionalcontrolledoutcomestudies(Hayesetal.2006).Amorerecentmeta-analyticreviewofmindfulness-basedtherapy 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(e.g.,MBSR,MBCT)thatincludedthirty-ninestudiesinvolvingatotalof1,140participantsfoundrobusteffectsizesforimprovinganxietyandmoodsymptomsinpatientswithanxietyandmooddisorders(Hofmann,Sawyer,Witt,andOh2010).Wilson(2008)notesthatrecentresearchhasshownthatbehaviortherapyisalsoeffectiveinreal-lifecommunity-basedclinicalsettings(e.g.,Foaetal.2005;seealsoVanIngen,Freiheit,andVye2009;StewartandChambless2009)andwithethnicminorityclients(e.g.,Mirandaetal.2005;seealsoVossHorrell2008).Behaviortherapyisthereforethemostempiricallyresearchedapproachtotherapyandalsothemostempiricallysupportedtreatment(togetherwithcognitivebehaviortherapy)availabletoday.Itsempiricalstatusissubstantialandsolid,anditwillcontinuetobethemostempiricallystudiedofallthemajorapproachestotherapy.FutureDirectionsBehaviortherapyisstillasignificantprimarytheoreticalorientationofpsychotherapistssurveyedintheUnitedStatesasevidencedinthefollowingpercentagesoftherapistsindicatingitassuch(seeProchaskaandNorcross2010, 3):clinicalpsychologists(10percent),counselingpsychologists(5percent),socialworkers(11percent),andcounselors(8percent).Behavioralinterventionsarealsooftenusedbytherapistswhoindicatecognitivetherapyoreclectic/integrativetherapyastheirprimarytheoreticalorientation.TheAssociationforAdvancementofBehaviorTherapy(AABT),foundedin1966intheUnitedStatesasamultidisciplinarygroupinterestedinbehaviortherapy(GlassandArnkoff1992, 597),changeditsnamein2005totheAssociationforBehavioralandCognitiveTherapies(ABCT),reflectingthetrendofbehaviortherapytowardamorecognitive-behavioralorientation.Ithasamembershipofover4,500,consistingofpsychologistsandothermentalhealthprofessionalsandstudentswithaninterestinbehaviortherapy,cognitivebehaviortherapy,behavioralassessment,andappliedbehavioralanalysis.Itpublishestwojournals,BehaviorTherapyandCognitiveandBehavioralPractice,andanewsletter,theBehaviorTherapist.FurtherinformationabouttraininginbehaviortherapyandmembershipinABCTcanbeobtainedthroughitsWebsite(www.abct.org)(seeCorey2009, 266).Therearenownumerousbehaviortherapysocietiesandorganizationsworldwide,includingtheEuropeanAssociationofBehaviourTherapy,whichhasorganizedannualconferencesindifferentEuropeancountriessince1970.Theirtenthannualmeeting,heldinJerusalem,becamethefirstWorldCongressinBehaviorTherapy.SincethepublicationofBehaviourResearchandTherapyasthefirstjournalsolelydevotedtobehaviortherapyin1963,thenumberofjournalsfocusingprimarilyorsolelyonbehaviortherapyanditsvariousoffshootsnowexceedfifty(FishmanandFranks1992, 169).Itshould 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benotedthatanothermajorbehavioralorganizationintheUnitedStates,theAssociationforBehaviorAnalysisInternational(www.abainternational.org),focusesontheapplicationofSkinner’soperantconditioningapproachandresiststhedevelopmentofbehaviortherapytowardamorecognitive-behavioralorientation(FishmanandFranks1992,169).Wilson(2008)hasdescribedtwomajorchallengestobehaviortherapyinthetwenty-firstcentury.Thefirstchallengeistospreadtheuseofempiricallysupportedbehavioralinterventionsandtechniquesforvariouscommonclinicaldisordersmorewidelyandeffectively,withtheconcomitantneedtofurtherdevelopsimplerbehavioralmethodssothatmorementalhealthprofessionalscaneasilylearntousethem.Thesecondchallengeistodevelopevenmoreeffectivebehavioraltreatmentsforawiderrangeofclinicalproblems,withafocusondeterminingwhytheywork.Wilsonalsoemphasizestheneedforbehaviortherapytobemorerootedinthelatestdevelopmentsinexperimentalpsychologyaswellasbiology,especiallyintheareasofgeneticsandneuroscience.Behaviortherapistsmustbetterunderstandbrainmechanismsandtheirimpactonclinicaldisorders(e.g.,Baxteretal.1992)sothattheycandevelopmore-sophisticatedtheoriesandmore-effectivebehavioraltreatmentstoenablebehaviorchange.ProchaskaandNorcross(2010)havepredictedthatbehaviortherapywillcontinuetoexpandandgrowinmanydirectionsinthecomingyearsasoneofthepremiercontemporaryapproachestotherapy.Theyanticipatetwofuturedirectionsforbehaviortherapythatwillbemoreenduring.Thefirstinvolvesthegreaterintegrationofbehaviortherapyanditsmanyeffectivetechniquesforbehavioralchangeintohealth-carepracticeandthehealth-caresystem,focusingonnotonlymentalhealthproblemsbutalsomedicalproblems,includingthoseencounteredinthefieldsofpediatricsandcardiology.Thesecondinvolvesthemorewidespreaduseofacceptance-basedversionsofthird-wavebehaviortherapy(see,e.g.,Hayes,Follette,andLinehan2004;RoemerandOrsillo2009).Bothbehaviortherapistsandtheirclientswillcometomorerealistictermsaboutwhatcanbechangedandwhatcannot,andthereforewhatshouldbeacceptedwithgentlenessandopenness.Furthermore,agrowingemphasisonmindfulnessandacceptanceingeneralinbehaviortherapymayparadoxicallyleadtoincreasedtherapeuticresults.Thethirdwaveofbehaviortherapywillcontinuetodevelopinsignificantandexcitingwaysintheyearsahead.RecommendedReadingsBarlow,D. H.(Ed.).(2008).Clinicalhandbookofpsychologicaldisorders:Astep-by-steptreatmentmanual(4thed.).NewYork:GuilfordPress.Goldfried,M. R.,&Davison,G. C.(1994).Clinicalbehaviortherapy(Expandeded.).NewYork:Wiley. _Tan_Counseling_BB_mw.indd259 9/21/104:37:49PM 246 MajorCounselingandPsychotherapyTheoriesandTechniques Kazdin,A. E.(2001).Behaviormodificationinappliedsettings(6thed.).PacificGrove,CA:Brooks/Cole.Miltenberger,R. G.(2008).Behaviormodification:Principlesandprocedures(4thed.).Belmont,CA:Wadsworth.Roemer, L.,&Orsillo,S. M.(2009).Mindfulness-andacceptance-basedbehavioraltherapiesinpractice.NewYork:GuilfordPress.Spiegler,M. D.,&Guevremont,D. C.(2003).Contemporarybehaviortherapy(4thed.).Belmont,CA:Wadsworth. _Tan_Counseling_BB_mw.indd260 9/21/104:37:50PM 12CognitiveBehaviorTherapyandRationalEmotiveBehaviorTherapy C ognitivebehaviortherapy(CBT)hasbeendefinedas“amorepurposefulattempttopreservethedemonstratedefficienciesofbehaviormodificationwithinalessdoctrinairecontext,andtoincorporatethecognitiveactivitiesoftheclientintheeffortstoproducetherapeuticchange”(KendallandHollon1979, 1).Muchofcontemporarybehaviortherapy,asnotedinthepreviouschapter,hasbecomecognitive-behavioralinorientationandapproach.ThethreemajorapproachestoCBTarecognitivetherapy(CT),foundedbyAaronBeck;rationalemotivebehaviortherapy(REBT),foundedbyAlbertEllis;andtoalesserextent,cognitivebehaviormodification(CBM)includingstressinoculationtraining(SIT),developedbyDonaldMeichenbaum.Beck’scognitivetherapyapproachemphasizeshowmaladaptiveanddysfunctionalthinkingaffectsfeelingsandbehavior.Ithelpsclientsovercomeemotionalproblemssuchasdepression,anxiety,andangerbyteachingthemtoidentify,challenge,andmodifyerrorsinthinkingorcognitivedistortions(A. T.Beck1976).Similarly,EllisdevelopedREBTasanactiveanddirectiveapproachtotherapythatfocusesonhelpingclientschangetheirirrationalbeliefs,whichareviewedastherootofemotionalproblems(Ellis1962).Meichenbaum’sCBMandSITapproach,withitsemphasisonself-talkandothercopingskillsinteachingclientstomoreeffectivelymanagestressand247 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otheremotionalproblems(Meichenbaum1977),hasalreadybeenbrieflydescribedinthepreviouschapteronbehaviortherapy.BesidesBeck,Ellis,andMeichenbaum,otherimportantfiguresintheearlierdevelopmentofcognitivebehaviortherapybasedonintegratingcognitivemediationalconstructswithbehavioraltheoryincludeAlbertBandura(1977a,1977b),MarvinGoldfried(seeGoldfriedandMerbaum1973),GeorgeKelly(1955),ArnoldLazarus(1976,1981),MichaelMahoney(1974),WalterMischel(1973),LynnRehm(1977),andMartinSeligman(1975);Kelly’s(1955)personalconstructtheoryofemotionaldisorderswasacrucialforerunnerofCTandCBT(seeReineckeandFreeman2003, 227).CBT,includingCT,REBT,andCBM,tendstohaveaneutralviewofhumannature,butitdoesassumethatclientshavethecapacitytochangetheirmaladaptivethinkingandhencetochangeproblemfeelingsandbehaviors.CBThasbeenearlierdescribedasconsistingofcognitivelearningtherapies(MahoneyandArnkoff1978)thatincludethreemajorcategories:(1)cognitiverestructuring(helpingclientstochangeormodifymaladaptive,dysfunctionalthoughts);(2)copingskillstherapies(helpingclientsusecognitiveandbehavioralskillstocopemoreeffectivelywithstressfulsituations);and(3)problem-solvingtherapies(helpingclientsexploreoptionsandimplementparticularsolutionstospecificproblemsandchallenges).Morespecifically,REBTemployscognitive-behavioraltechniquessuchastheuseoftheA-B-CtheoryofREBT(AreferstoActivatingEvents,BtoIrrationalBeliefs,andCtoConsequences,emotionaland/orbehavioral,ofsuchbeliefs),withtheclientkeepinganA-B-Cdiaryofdailyexperiences;disputationofirrationalbeliefs;andactionhomework.BiographicalSketchesofKeyFiguresinCognitiveBehaviorTherapyAswithbehaviortherapy,cognitivebehaviortherapyhasnosinglefounder.However,thereareatleastthreemajorfiguresinCBT:AaronBeck,thefounderofCT;AlbertEllis,thefounderofREBT;andDonaldMeichenbaum,whodevelopedCBMandSIT.DonaldMeichenbaum’sbiographicalsketchappearsinthepreviouschapteronbehaviortherapy.BiographicalsketchesofAaronBeckandAlbertElliswillnowbeprovided(seeCorey2009,273–74;Fall,Holden,andMarquis2004,300–301,337–38;ProchaskaandNorcross2010,296–97,312–13;Sharf2008,300–302;334–35;seealsoEllis2004,2008;Padesky2004;Weiner1988;Weishaar1993;YankuraandDryden1994).AaronTemkinBeck,thefounderofcognitivetherapy,wasbornonJuly18,1921,inProvidence,RhodeIsland,theyoungestchildofJewishimmigrantparentsfromRussia.Hehadadifficultchildhoodthatincludedbreakinghisarmwhenhewassevenyearsold,whichresultedinaboneandbloodinfectionrequiringmajorsurgerythatbroughthimclosetodeath.Asaresult,hedevelopedseveralfearsandphobias,suchasblood/injuryphobiaandpublic _Tan_Counseling_BB_mw.indd262 9/21/104:37:52PM CognitiveBehaviorTherapyandRationalEmotiveBehaviorTherapy 249 speakinganxiety.Healsohadtocopewithanemotionallyunstablemotherwhostruggledwithdepressionaswellasanabusiveteacherinfirstgrade.Suchchildhoodexperienceshelpedhimtohaveaspecialsensitivitytowardothersandtheirunpredictablechangesinmood(Weishaar1993).Beckwasabletoovercomeproblemsinschoolresultingfromhishealthissuesandultimatelydidexcellentacademicwork.Oneofhishighschoolfriendsnicknamedhim“Tim,”fromhismiddlename,Temkin,andhiswifeandclosefriendshavecontinuedtousethisnickname(Weishaar1993, 11).Beckgraduatedfromhighschoolfirstinhisclass.WhileattendingBrownUniversity,hemetPhyllisWhitman,whoeventuallybecameaPennsylvaniaSuperiorCourtjudge.WhitmanandBeckmarriedin1950.BeckgraduatedfromBrownin1942andthenenteredYaleUniversitySchoolofMedicine,whereheobtainedhisMDdegreein1946.Hethentrainedinpathologyandneurologybuteventuallycompletedhisresidencytraininginpsychiatry.BeckwascertifiedinpsychiatrybytheAmericanBoardofPsychiatryandNeurologyin1953.HereceivedfurthertraininginpsychoanalysisandgraduatedfromthePhiladelphiaPsychoanalyticInstitutein1956.BeckbecameafacultymemberintheDepartmentofPsychiatryattheUniversityofPennsylvaniaMedicalSchoolin1954,whereheisnowUniversityProfessorEmeritusofPsychiatry.HeisalsopresidentoftheBeckInstituteforCognitiveTherapyandResearchinBalaCynwyd,Pennsylvania,andhonorarypresidentoftheAcademyofCognitiveTherapy,whichisresponsibleforcertifyingcognitivetherapistswithappropriatequalifications.AlthoughBeckinitiallytriedtovalidatesomeofFreud’spsychoanalyticviewsondepression,heeventuallypartedwayswithhisFreudianpsychoanalytictrainingandbackground.Hedevelopedhisownuniqueapproachtotreatingdepressionandotheremotionaldisordersthatfocusedonmodifyingdysfunctionalthinking,involvingcognitiveerrorsordistortions,asarootcauseofsuchdisorders.Beckisthusthefounderofcognitivetherapy(A. T.Beck1961,1963,1964,1967,1976),whichhasbecomeamajorapproachtotherapyandacrucialpartofcontemporarycognitivebehaviortherapy.Hehasauthoredorcoauthoredoverfivehundredarticlesandmorethantwenty-fivebooksoncognitivetherapyandthetreatmentofawiderangeofemotionaldisorders(Sharf2008, 334),includingdepression,bipolardisorder,anxietydisorders andphobias,suicidality,alcoholismandsubstanceabuse,eatingdisorders,maritalproblemsandrelationshipdifficulties,schizophreniaandpsychoticdisorders,personalitydisorders,painandanger,hostilityandviolenceproblems(see,e.g.,A. T.Beck1988,1999;A. T.BeckandEmery,withGreenberg1985;A. T.Beck,Freeman,Davis,andassociates2003;A. T.Beck,Rector,Stolar,andGrant2009;A. T.Beck,Rush,Shaw,andEmery1979;A. T.Beck,Wright,Newman, andLiese1993;ClarkandBeck2009;Newmanetal.2001;Wenzel,Brown,andBeck2009;Winterowd,Beck,andGruener2003;Wright,Thase,Beck,andLudgate1993;seealsoFairburn2008;Leahy2004;Scott,Williams, 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andBeck1989).Hehasalsodevelopedseveralwidelyusedassessmentscalessuchasthosefordepression,suicidalrisk,andanxiety(Corey2009, 274).Cognitivetherapy,asasubstantialpartofcognitivebehaviortherapy,isoneofthemostempiricallysupportedtherapiestoday(seeButler,Chapman,Forman,andBeck2006).Beckandhiswife,Phyllis,havefourchildren.Theirdaughter,JudithBeck,isalsoawell-knownfigureincontemporarycognitivetherapy(seeJ. S.Beck1995,2005).SheiscurrentlythedirectoroftheBeckInstituteforCognitiveTherapyandResearchandclinicalassociateprofessorofpsychologyinpsychiatryattheUniversityofPennsylvania.Beckhasmadesubstantialandrevolutionaryconceptualandempiricalcontributionstocognitivetherapyandthetreatmentofvariousemotionaldisordersthathavegreatlyimpactedthefieldofpsychiatryandpsychotherapy.Hehasbeenawardedmorethantwenty-fiveprestigiousawardsofspecialrecognition,fourofthemlifetimeachievementawards(Padesky2004,3).In2006,hewontheLaskerPrize,anoutstandingawardthatsomeconsiderAmerica’sNobelPrize,forhisdevelopmentofcognitivetherapy(KelloggandYoung2008,73).Hehasalsobeenrecognizedasoneofthetenmostinfluentialpsychotherapists(seeFall,Holden,andMarquis2004,301),andistheonlypsychiatristtodaytohavebeenawardedthehighestresearchawardsfromtheAmericanPsychiatricAssociationaswellastheAmericanPsychologicalAssociation(Weishaar1993,43).Hisachievementsareallthemoreamazinggivenhisearlierstruggleswithchildhooddifficulties,healthproblems,andfearsandphobias,aswellastheinitialnegativereactionsofmanypsychiatristsandtherapiststohisnovelcognitivetherapyideas.Beckcontinuestohelpfurtherdevelopcognitivetherapyanditsapplicationstoanever-wideningrangeofemotionalandpsychologicaldisorders.Hisvisionforthecognitivetherapycommunityisthatitbecomeglobal,inclusive,collaborative,empowering,andbenevolent.Beckhasalwayshadaninternationalorglobalvisionforcognitivetherapy;hehostedthefirstWorldCongressofCognitiveTherapyinPhiladelphia,inspiringtheformationoftheInternationalAssociationofCognitivePsychotherapy,andhelpedtoestablishtheglobalAcademyofCognitiveTherapy,whichcertifiesappropriatelyqualifiedcognitivetherapists.HewasneverinterestedinsettingupasolelyAmericancognitivetherapyassociation(Padesky2004, 17).AlbertEllis,thefounderofrationalemotivetherapy(RET),nowcalledrationalemotivebehaviortherapy(REBT),wasborntoaJewishfamilyonSeptember27,1913,inPittsburgh,Pennsylvania,butthefamilymovedtoNewYorkCitywhenhewasfouryearsold.Hisfatherwasabusinessmanwhowasoftenawayfromhome,andhismotherwasemotionallyabsentandneglectedthefamily.Theoldestofthreechildren,Ellislearnedtobeindependentatayoungageandtookcareofhissiblingsaswellashimself.Hewasfrequentlysickasachild,mainlywithkidneyproblems,andwashospitalizedninetimes. 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Hedevelopedrenalglycosuriawhenhewasnineteenyearsoldanddiabeteswhenhewasforty.EllisdevelopedandappliedREBTprinciplesandmethodstohimselfineffectivelycopingwithhismedicalproblems,familydifficulties,andpersonalfears(e.g.,ofrejectionbywomenandofpublicspeaking),andwasabletoliveafullandenergeticlifeuntilthelasttwoyears,whichwereovershadowedbyseriousillness.ElliscompletedhisundergraduatestudiesatCityCollegeofNewYorkandreceivedaBAdegreeinbusinessin1934.Hehadashortcareerinbusinessandalsotriedwritingfictionforawhilebutwithoutsuccess.HethenbegangraduatestudiesinclinicalpsychologyatTeachersCollege,ColumbiaUniversity,in1942.HeearnedhisPhDin1947,aftertrainingprimarilyinFreudianpsychoanalytictherapy.HeacquiredfurtherpsychoanalytictrainingbyundergoinghisownpersonalanalysiswithRichardHulbeck,apsychiatristwhohadundergoneanalysiswithHermannRorschach,thedeveloperofthewell-knownRorschachinkblottest.HulbeckalsosupervisedEllisinhisearlypsychoanalyticwork.From1947to1953,EllispracticedpsychoanalysisandpsychoanalytictherapybutbecamedissatisfiedwithFreud’sapproachtotherapyanditsinefficiencyandineffectivenesswithmanyclients.Thisexperienceledhimtofoundanddevelopamoredirectandrationalapproachtotherapythatfocusedonchangingclients’irrationalbeliefs,whichheregardedastherootcauseofemotionalproblems.Ellispresentedhisfirstpaperonwhathethencalledrationaltherapyin1956attheannualconventionoftheAmericanPsychologicalAssociation.Hequicklychangedthenameofhisnewrational,directiveapproachtotherapytoRETsothathewouldnotbemisunderstoodasatherapistwhoignoredemotionsorfeelings(seeEllis1962).In1993,EllisdecidedtorenamehisapproachREBTatatwo-dayconferencetitled“AMeetingoftheMinds:IsIntegrationPossible?”(Kernbergetal.1993).HeprefersREBTasamoreaccuratetermthanRETforhistherapyapproach(Ellis1999,2008)becauseofitscognitive,emotive,andbehavioralcomponents(Ellis1993a).Ellishadliberalviewsandvalues,advocatinglong-termhedonismorthemaximizingofpleasure(Ellis2008).Hewasantidogmaticandantireligiousinhisearlieryears,espousingprobabilisticatheismandhumanism(seeEllis1960,1971,1973,1980).Hewasalsoabrasive,direct,andhumorousinhisflamboyantstyleinpublicpresentationsandworkshops.Heevenwroteandsanghumorousrationalsongs(Corey2009, 273).However,inhislateryears,EllisbecameabitmoreopentothenotionthatsomedevoutreligiousorspiritualbeliefscanbehealthyandconsistentwithREBT,butheremainedskepticalofdogmaticandrigidbeliefs(Ellis2000;seealsoNielsen,Johnson,andEllis2001).EllisestablishedtheAlbertEllisInstitutein1959inNewYorkCitytodisseminatetheREBTapproachthroughcoursesandworkshopsonrationalliving,trainingprogramsatthepostgraduatelevel,reasonablypricedclinicsproviding 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individualandgroupREBT,andspecialpublications,includingtheJournalofRational-EmotiveandCognitive-BehaviorTherapy,aswellasaudiovisualmaterials.However,Ellis’srelationshipwiththeinstitutehehadfoundedbecamestrainedwhenitsboardoftrusteesremovedhimfromtheboardandrelievedhimofallhisresponsibilitiesattheinstituteinSeptember2005.HewasreinstatedaftertheStateSupremeCourtinManhattaninJanuary2006ruledthattheboardwaswrongindismissingEllisatameetingatwhichhewasnotpresent.InthesameyeartheAlbertEllisFoundationwasestablishedtopromoteandprotectREBTandEllis’sworks.ItisnotrelatedinanywaytotheAlbertEllisInstitute,andEllisstatedin2006thattheInstitutewasnolongerfollowingaprogramconsistentwithREBT(seeEllis2008,193–94).EllismarriedDebbieJoffe,anAustralianpsychologist,in2004.Hecalledherthegreatestloveofhislife(Ellis2008, 194).Sheassistedhiminhisworkandcollaboratedwithhimashecontinuedtomaintainhishecticschedule,oftenworkingsixteenhoursaday.Hesawnumerousclientsfortherapy,engagedinprolificwriting,andtraveledextensively,presentingworkshopsandtalksnationallyandinternationally.Heauthoredorcoauthoredovereightybooksandtwelvehundredarticlesinhislifetime.However,illnessforcedhimtoslowdowninthelasttwoyearsofhislife.EllisdiedonJuly24,2007.Ellisreceivednumerousawardsfrommanyprofessionalorganizations,includingtheAwardforDistinguishedProfessionalContributionsfromtheAmericanPsychologicalAssociation.HewasrankedthesecondmostinfluentialpsychotherapistinhistoryafterCarlRogersandaheadofSigmundFreudina1982professionalsurvey(D. Smith1982).REBTcontinuestobeamajorandinfluentialapproachtotherapyandacrucialpartofcontemporarycognitivebehaviortherapy.MajorTheoreticalIdeasofCognitiveBehaviorTherapy(CBT)and RationalEmotiveBehaviorTherapy(REBT)PerspectiveonHumanNatureCBT,whichincludesCT,REBT,andCBM/SIT,differsfrombehaviortherapyandbehaviormodification,especiallythosetherapiesfollowingB. F.Skinner,inthatitdoesnotassumeradicalbehaviorismandtheabsenceoffreewillinhumanbeings.CBThasamorecomplexviewofhumannatureandpaysmoreattentiontohowone’sthoughtsinfluenceandaffectone’sbehaviorandfeelings.Itsperspectiveonhumannaturethusincludessomecapacityforchoiceaswellasforself-reflectionandself-control(Kazdin2001;D. L.WatsonandTharp2007).Bandura’ssociallearningorsocialcognitivetheoryhassignificantlyinfluencedCBT,withitsemphasisonself-efficacyandreciprocaldeterminism,whichassumethathumanbeingshavesomedegreeoffreewillandchoiceandthereforeagreatercapacityforself-regulation(Bandura1977a, _Tan_Counseling_BB_mw.indd266 9/21/104:37:58PM CognitiveBehaviorTherapyandRationalEmotiveBehaviorTherapy 253 1977b,1986,1997).TheCBTapproach,however,stillviewshumanbeingsasbasicallyneutral,neitherinherentlygoodnorinherentlyevil.Morespecifically,Ellis’sREBTapproachemphasizesthatone’smaladaptivethinkingintheformofirrationalbeliefsleadstoemotionalproblems.Byvigorouslydisputingsuchirrationalbeliefs,anindividualcanengageinmore-constructive,rationalthinkingsothatheorshecanbecomelessemotionallydisturbed(Ellis2008).Individualsthereforehavethecapacitytochangetheirirrationalthinkingtomorerationalthinking,realizingthattheirideas,attitudes,orbeliefsgreatlyaffecttheirfeelingsandexperiences.Ellis(2008)acknowledgestheinfluenceofAlfredAdler(see,e.g.,Adler1964)onthedevelopmentofsuchviewsinREBT.BasicTheoreticalPrinciplesofCBTCBT,orcognitive-behavioralinterventions,has,atminimum,sixbasictenetsorcharacteristics:(1) thehumanorganismrespondsprimarilytocognitiverepresentationsofitsenvironmentsratherthantotheseenvironmentsperse;(2) mosthumanlearningiscognitivelymediated;(3) thoughts,feelings,andbehaviorsarecausallyinterrelated;(4) attitudes,expectancies,attributions,andothercognitiveactivitiesarecentraltoproducing,predicting,andunderstanding Sidebar12.1BasicTenetsofCognitiveBehaviorTherapy(KendallandBemis1983,565–66)1.Thehumanorganismrespondsprimarilytocognitiverepresentationsofitsenvironmentsratherthantotheseenvironmentsperse.2.Mosthumanlearningiscognitivelymediated.3.Thoughts,feelings,andbehaviorsarecausallyinterrelated.4.Attitudes,expectancies,attributions,andothercognitiveactivitiesarecentraltoproducing,predicting,andunderstandingpsychopathologicalbehaviorandtheeffectsoftherapeuticinterventions.5.Cognitiveprocessescanbecastintotestableformulationsthatareeasilyintegratedwithbehavioralparadigms,anditispossibleanddesirabletocombinecognitivetreatmentstrategieswithenactivetechniquesandbehavioralcontingencymanagement.6.Thetaskofthecognitive-behavioraltherapististoactasdiagnostician,educator,andtechnicalconsultantwhoassessesmaladaptivecognitiveprocessesandworkswiththeclienttodesignlearningexperiencesthatmayremediatethesedysfunctionalcognitionsandthebehavioralandaffectivepatternswithwhichtheycorrelate. 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psychopathologicalbehaviorandtheeffectsoftherapeuticinterventions;(5) cognitiveprocessescanbecastintotestableformulationsthatareeasilyintegratedwithbehavioralparadigms,anditispossibleanddesirabletocombinecognitivetreatmentstrategieswithenactivetechniquesandbehavioralcontingencymanagement;and(6) thetaskofthecognitive-behavioraltherapististoactasdiagnostician,educator,andtechnicalconsultantwhoassessesmaladaptivecognitiveprocessesandworkswiththeclienttodesignlearningexperiencesthatmayremediatethesedysfunctionalcognitionsandthebehavioralandaffectivepatternswithwhichtheycorrelate(KendallandBemis1983,565–66).InanotherearlierreviewofCBTapproaches,MichaelMahoneyandD. B.Arnkoff(1978)havedescribedthemascontemporarycognitivelearningtherapiesinthreemajorcategories:(a)cognitiverestructuring,includingrationalemotivetherapy(RET)(Ellis1962),self-instruction(Meichenbaum1977),andcognitivetherapy(CT)(A. T.Beck1976);(b)copingskillstherapies,includingcovertmodeling(Cautela1971;Kazdin1973),copingskillstraining(Goldfried1971),anxietymanagementtraining(SuinnandRichardson1971),andstressinoculation(Meichenbaum1977);and(c)problem-solvingtherapies,includingbehavioralproblemsolving(D’ZurillaandGoldfried1971),problem-solvingtherapy(Spivack,Platt,andShure1976),andpersonalscience(Mahoney1977).CBTthereforeincludesmanycognitiveandbehavioraltechniquesandinterventionsthataresubsumedunderthesethreemajorcategoriesofcontemporarycognitivelearningtherapies.CBThasbeendefinedasanapproachtotherapythatattemptstopreservetheempiricallysupportedeffectivenessandefficiencyofbehaviormodificationbutinalessbehavioristiccontextthatincludesthecrucialroleoftheclient’sthoughtsinthetherapeuticprocess(seeKendallandHollon1979, 1).ThebasictheoreticalprinciplesofbehaviortherapyalreadycoveredinthepreviouschapterthusapplytoCBT,butwithmoreemphasisonthecognitiveprocessesoftheclientandnotonbehavioralaspectsalone,aswithWolpe’scounterconditioningandSkinner’scontingencymanagement(ProchaskaandNorcross2010).CBTisthereforesupposedlygroundedinamorecomprehensivesocialcognitive,orsociallearning,theoryofhumanfunctioningandchange,whileincorporatingoperantandclassicalconditioning,modeling,andother,earlierlearning-basedprinciples.Morerecently,theCBTtraditionhasbeenexpandedinthethirdwaveofbehaviortherapytoincludemindfulness-basedandacceptance-basedtherapiessuchasDBT,MBCT,andACT(Hayes,Follette,andLinehan2004;seealsoHayesetal.2006),whichhavebeenbrieflycoveredinthepreviouschapter.DevelopmentofPsychopathologyGoingbeyondtraditionalbehaviortherapy’sviewofpsychopathologyasconsistingofconditionedorlearnedmaladaptivehabits(Wolpe1990),contem- 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poraryCBTemphasizesthecrucialroleofmaladaptive,irrationalthinking,orcognitivedistortions,inthedevelopmentofpsychopathology.Theinternaldialogues,orself-talk,ofapersoncanleadtomaladaptivebehaviorandfeelings,especiallyifnegative,irrational,extreme,unreasonable,andillogicalthinkingispresent.CBThelpsclientstoidentify,challenge,andmodifysuchmaladaptivethinkingintomorerational,realistic,reasonable,andlogicalthinking.Morespecifically,Beck’scognitivetherapy(CT)approachfocusesonhowanindividual’sautomaticthoughtsreflecthisorherunderlyingbasicassumptionsaboutlifeandevenearlymaladaptiveschemassetinhisorhermindbecauseofearlychildhoodexperiences.One’sautomaticthoughtsoftencontainlogicalerrors,orcognitivedistortions,thatleadtoemotionaldifficultiesandbehavioralproblems.Someexamplesofsuchcognitivedistortionsinclude(seeA. T.BeckandWeishaar2008, 272)arbitraryinference(makingaconclusionwithoutsufficientevidenceorevenwithcontradictoryevidence,e.g.,aworkingmother,afteraverybusyanddemandingday,saystoherself,“I’manawfulmother”);selectiveabstraction(comingtoaconclusionbasedonlyonadetailtakenoutofcontextwhileignoringotherrelevantinformation,e.g.,amanwhobecomesupsetandjealousofhisgirlfriendatapartybecauseheseeshertalkingtoanotherman,whoisactuallyhercousin);overgeneralization(applyingageneralrulefromisolatedincidentstootherinappropriateorunrelatedsituations,e.g.,afterbeingturneddownforadate,amanconcludes,“Allwomenarealike;I’llnevergetadatewithanyofthem”);magnificationandminimization(viewingsomethingasmuchgreaterorsignificantlylessthanitreallyis,e.g.,whenastudentcatastrophizesinmagnificationbysaying,“IfIfailthistest,it’llbetheendoftheworldoradisasterforme,”orawomanengagesinminimizationbysaying,“Mymotherwillrecoversoonfromtheinfection”whenhermotherhasterminalcancer);personalization(relatingexternaleventstooneselfwithoutanyevidenceforsuchacausalrelationship,e.g.,amanwavestoafriendinacrowdedmallwithnoresponse,andconcludes,“Imusthavedonesomethingthatupsethimandmadehimdislikeme”);anddichotomousthinking(viewingthingsinoneoftwoextremecategories,suchastotalsuccessorcompletefailure,e.g.,astudentconcludes,“IfIdon’tacethisexam,thenIamatotalfailureasastudent”).Beck’sCTapproachalsodescribesthesystematicbiasincognitivelyprocessinginformationthatisfoundinspecificemotionaldisorders(seeA. T.BeckandWeishaar2008,273).Forexample,indepression,itisanegativeviewofself,experience,andthefuture,whereasinpanicdisorder,itisacatastrophicinterpretationofbodilyand/ormentalexperiences.Ellis’sREBTapproachalsoemphasizeshowmaladaptivethinkingisattherootofemotionalproblems.However,Ellisismorespecificaboutthecontentofsuchdysfunctionalthinkingasconsistingofthefollowingirrationalbeliefs(Ellis1962): 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(1)Itisessentialthatapersonbelovedorapprovedbyvirtuallyeveryoneinthecommunity;(2)Apersonmustbeperfectlycompetent,adequate,andachievingtobeconsideredworthwhile;(3)Somepeoplearebad,wicked,orvillainousandthereforeshouldbeblamedandpunished;(4)Itisaterriblecatastrophewhenthingsarenotasapersonwantsthemtobe;(5)Unhappinessiscausedbyoutsidecircumstances,andapersonhasnocontroloverit;(6)Dangerousorfearsomethingsarecauseforgreatconcern,andtheirpossibilitymustbecontinuallydweltupon;(7)Itiseasiertoavoidcertaindifficultiesandself-responsibilitiesthantofacethem;(8)Apersonshouldbedependentonothersandshouldhavesomeonestrongeronwhomtorely;(9)Pastexperiencesandeventsarethedeterminantsofpresentbehavior;theinfluenceofthepastcannotbeeradicated;(10)Apersonshouldbequiteupsetoverotherpeople’sproblemsanddisturbances;and(11)Thereisalwaysarightorperfectsolutiontoeveryproblem,anditmustbefoundortheresultswillbecatastrophic.(SeeDay2004,304–5) Ellis(2008)viewedtheseirrationalbeliefsandchildishdemandingnessasresponsibleforhumanunhappinessandneurosisoremotionalproblems.REBTthereforestronglychallengesclientstogiveupsuch“masturbatory”thinkingconsistingoftermssuchas“must,”“should,”“oughtto,”“haveto,”or“gotto,”andcatastrophizingconclusions(seeProchaskaandNorcross2010,300–301).AlthoughCTandREBTaresimilarintheirfocusonthecrucialroleofmaladaptive,dysfunctionalthinkinginthedevelopmentofpsychopathologyoremotionaldisorders,therearealsosomeimportantdifferencesbetweenBeck’sCTapproachandEllis’sREBT.Ellis(2008,119–200)hasbrieflydescribedthefollowingeightdifferencesbetweenREBTandCT:(1) REBTusuallychallengesclients’irrationalbeliefsmorestronglyanddirectlythanCT;(2) REBTfocusesmoreonabsolutistordogmaticmustsandshouldsthanCT;(3) REBTusespsychoeducationalinterventionssuchasbooks,audiovisualtapes,talks,andworkshopsmorethanCT;(4) REBTclearlydifferentiatesbetweenhealthynegativeemotionssuchassadnessandfrustrationandunhealthynegativeemotionssuchasdepressionandhostility;(5) REBTusesotheremotive-evocativetherapeuticinterventions(e.g.,shame-attackingexercises,imagery,andvigorousself-talk)morethanCT;(6) REBTusesinvivodesensitizationandimplosivetechniquesmorethanCT;(7) REBTusespenaltiesandrewardstomotivateclientstocompletetheirhomeworkassignments;(8) REBTemphasizesdeepphilosophicalacceptanceofoneself,others,andtheworldmorethanCT.Meichenbaum’scognitivebehaviormodification(CBM)approach,whichincludesstressinoculationtraining(SIT),alsoemphasizestheimportanceofconstructiveandcalmingself-talkaswellascopingskillsineffectivemanagementofemotionalproblems.CBMsimilarlyviewsnegativeself-talkandalackofcopingskillsascontributingtothedevelopmentofpsychologicaldisorders(Meichenbaum1977,1985). _Tan_Counseling_BB_mw.indd270 9/21/104:38:03PM CognitiveBehaviorTherapyandRationalEmotiveBehaviorTherapy 257 TherapeuticProcessandRelationshipThecognitivebehaviortherapist,likethetraditionalbehaviortherapist,isactiveanddirectiveinconductingtherapywithclients.ThetherapistinCBT,whetherCT,REBT,orCBM,functionsasadiagnostician,educator,andtechnicalconsultantinhelpingtheclienttoidentifyandchangemaladaptivecognitionsandtheircorrelatedbehavioralandaffectivepatterns(KendallandBemis1983).TheprocessofCBTisalsosimilartothatofbehaviortherapydescribedinthepreviouschapter.Itisastructuredandsystematicapproachtotherapythatbeginsbyhelpingtheclientidentifytargetcomplaintsonaproblemlistandthensethisorherowngoalsfortherapyincollaborationwiththetherapist(seePersons1989,2008).Theconnectionsbetweenthoughts,behaviors,andfeelingsareclarified,withemphasisonhowthoughtsaffectbehaviorsandfeelings.ThecognitivebehaviortherapistcanalsochoosetodoamorecomprehensiveassessmentoftheclientandhisorherproblemsbyusingtheBASICI.D.frameworkfrommultimodaltherapy(Lazarus1981),coveringthesevenmajordimensionsofaperson’sfunctioning:behavior,affect,sensations,images,cognitions,interpersonalrelationships,anddrugs/biology.CognitivetherapistsinparticularusuallybeginasessionofCTbysettinganagendawiththeclientaswellasreviewinganyhomeworkassignmentsfromaprevioussession(A. T.Beck,Rush,Shaw,andEmery1979).TherapistsconductingCBTwillthenhelpclientstodealwithspecificproblemsontheirproblemlistbyusingempiricallysupportedcognitive-behavioralinterventions.ClientprogressiscontinuouslyassessedthroughouttheprocessofCBT,andtherapeuticmethodsareadjustedasthetherapistconductsCBTinaflexibleandsensitiveway.Therapyisgraduallyphasedoutastheclientincreasinglyachievesgoals,withtherapysessionsreducedfromweeklytoonceeverytwoweeksormonthlybeforeterminationofregulartherapy.Follow-upsessionsatthreemonthsorsixmonthsorevenlongerperiodsafterterminationofregulartherapycanalsobeconducted.Clientscanalwayscontactthetherapistforanappointmentifthereisanemergencyoraspecialneedarises(seeReineckeandFreeman2003, 251).ThetherapeuticrelationshipisconsideredimportantinCBTbutnotasthemostcrucialelementineffectiveCBT.BeckviewsapositivetherapeuticrelationshipbetweenthetherapistandtheclientasanecessarybutnotsufficientconditionforsuccessfulCBTorCT(A. T.Beck,Rush,Shaw,andEmery1979).Ellis(2008),however,doesnotbelieveinthetherapisthavingtoomuchempathyfortheclientbecauseitcanbecounterproductiveinREBT,whichrequiresstrong,vigorousdisputationofirrationalbeliefsanddemandingnessintheclientinorderforittobeeffective.CBTthereforeemphasizestheimportanceofspecificcognitiveandbehavioralinterventionsthatgobeyondthetherapeuticeffectsofapositivetherapeuticrelationship.AwarmandcollaborativetherapeuticrelationshipisneverthelessstillhelpfulinCBTorCT(Persons1989),andmoreattentionisbeingpaidtothetherapeuticrelationship _Tan_Counseling_BB_mw.indd271 9/21/104:38:04PM 258 MajorCounselingandPsychotherapyTheoriesandTechniques asacrucialfactoreveninthesetherapies(see,e.g.,SafranandSegal1990;P. GilbertandLeahy2007),especiallyinschematherapy,aspecificformofCTthatfocusesonearlymaladaptiveschemasandthetreatmentofpersonalitydisorders,includingborderlinepersonalitydisorder(seeKelloggandYoung2006,2008;Young2002;Young,Klosko,andWeishaar2003).ThemajortherapeutictechniquesusedinCBTwillnowbereviewed.MajorTherapeuticTechniquesandInterventionsJustastherearenumeroustechniquesandtherapeuticinterventionsinbehaviortherapy,allofwhichcanbeusedifandwhenappropriateinCBT,therearealsomanyCBTmethodsavailabletoday.Thetraditionalbehaviortherapytechniqueshavealreadybeendescribedinthepreviouschapter.ThemajorCBTinterventionsincludethoseusedincognitiverestructuring,copingskillstherapies,andproblemsolvingtherapies(MahoneyandArnkoff1978).TheywillnowbereviewedunderthefollowingthreemajorapproachestoCBT:CT(Beck),REBT(Ellis),andCBM/SIT(Meichenbaum).CognitiveTherapy(CT)(Beck)AaronBeck,thefounderofCT,worksinacollaborativeandrespectfulwaywithclients(J.Sommers-FlanaganandSommers-Flanagan2004,262)thatiscalledcollaborativeempiricism,ormutualworkingtogethertohelpclientsidentifyandchangetheircognitivedistortions(A. T.Beck,Rush,Shaw,andEmery1979;seealsoKuyken,Padesky,andDudley2009).Beck’sapproachisgentlerthanAlbertEllis’sREBTapproach,inwhichEllisisoftenmuchmoreforcefulanddisputationalinvigorousdialogueandevendebatewithclientstohelpthemchallengetheirirrationalbeliefs.Beckdoesnothaveapredeterminedsetofirrationalbeliefs.Instead,hehelpsclientsdiscoverandmodifycognitivedistortionsbyengaginginSocraticdialoguewiththemthatoftenincludestheuseofopen-endedquestions.CThasvariouscognitiveandbehavioraltechniquesthatcanbeusedtohelpclientswithawiderangeofemotionaldisorders(seeReineckeandFreeman2003,244–50;A. T.BeckandWeishaar2008,284–87;seealsoJ. S.Beck1995;K.S.Dobson2009;D. DobsonandDobson2009;Leahy2004;McMullin1999;Persons1989,2008;Persons,Davidson,andTompkins2001).Cognitivetechniqueshelpclientstoidentifyanddirectlymodifytheirdysfunctionalthoughtsorcognitionsthatareassociatedwiththeiremotionaldistress.Theyincludethefollowing(ReineckeandFreeman2003,245–48;seealsoA. T.BeckandWeishaar2008,284–85):IdiosyncraticMeaning.Cognitivetherapistsaskclientstoexploreandclarifythepersonaloridiosyncraticmeaningofspecificwordstheyusetodescribetheirthoughtsandfeelings.ActivelisteningskillsandwiseSocratic _Tan_Counseling_BB_mw.indd272 9/21/104:38:06PM CognitiveBehaviorTherapyandRationalEmotiveBehaviorTherapy 259 questioninganddialogueareusedbythetherapisttosensitivelyunderstandtheidiosyncraticmeaningoftheclient’swordsandthoughts.QuestioningtheEvidence.Clientsaretaughttoquestiontheevidencethattheyareusingtosupporttheirparticularconclusionsorbeliefs.Thecognitivetherapistaskskeyquestionssuchas:“Onwhatbasisdoyousaythis?”and“Whereistheevidenceforyourvieworconclusion?”Evidenceforaswellasevidenceagainstaspecificbelieftheclienthasassumedisexamined.Clientsareencouragedtoquestionandmodifytheirbeliefinthefaceofcontradictoryevidence.Reattribution.Inthistechnique,clientsareencouragedtotesttheirautomaticthoughtsandassumptionsbyexploringotherpossiblewaysoflookingatthingsoralternativecausesofevents.Thecognitivetherapistmayask:“Isthereanotherwayoflookingatthis?”Forexample,amaleclientmighterroneouslyconcludethathisbossdoesnotlikehimandmayfirehimbecausehisbossdidnotsmilebackathimwhenhegreetedhimatwork.Whenaskedbythetherapistifthereisanotherwayoflookingatthisevent,theclientmayrealizethathisbosswasanxiousaboutaboardmeetinglaterthatdayandactuallydidnotsmileatanyofthestaffthatmorning.Theclientmaythenreattributeresponsibilityforhisbossnotsmilingtohisboss’sanxiety,andnotpersonalizeitandblamehimself.RationalResponding.ThisisoneofthemostpowerfultechniquesinCTforhelpingclientstochallengetheirmaladaptivethinking.Rationalrespondingconsistsoffoursteps:(1) systematicallyexploringtheevidenceforandagainstaparticularclientbelief;(2) developinganalternativevieworexplanationthatismoreadaptiveorreasonable;(3) modifyingthebelieftobelessextremeorlesscatastrophic,thatis,decatastrophizingit;and(4) comingupwithconcretebehavioralstepsthatcanbeusedbytheclienttomoreeffectivelycopewiththeproblem.ExaminingOptionsandAlternatives.Thistechniquereferstothecognitivetherapisthelpingtheclienttobrainstormotheroptionsoralternativesolutionstotheclient’sproblem,sothattheclientcanseebeyondhisorherinitiallimitedrangeofpossiblesolutions.Decatastrophizing.ThecognitivetherapistusesSocraticquestioningtohelptheclientseeifheorsheisblowingthingsoutofproportionandhencecatastrophizing,ormakingextremeconclusionsaboutasituationoroutcome.Ifso,thetherapistencouragestheclienttoputthingsinproperandrealisticperspectiveandthusengageindecatastrophizing.FantasizedConsequences.Inthistechnique,thecognitivetherapistguidestheclienttodescribeafantasyofafearedsituationanditspossibleconsequences,oftenexposingtheirrationalityofthefantasizedconsequences.However,ifsuchimaginedconsequencesaredeemedrealistic,thenthetherapistwillhelptheclientlearncopingstrategiestobettermanagetheproblem.AdvantagesandDisadvantages.Thisisaproblem-solvingtechniquethatthecognitivetherapistcanusetohelpclientslookattheprosandconsofan 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option,sothattheycanacquireabroaderandclearerperspectiveaswellastakemorereasonablestepsofaction.TurningAdversitytoAdvantage.Clientsarehelpedinthistechniquetoseehowanegativeexperiencecanbeturnedintoapositiveoutcome.Forexample,aclientwhohasbeenlaidoffduetocutbacksatworkcanbeencouragedtoseehowthisinitiallynegativeexperienceisopeningupopportunitiestopursueanotherjoborcareer.GuidedAssociation/Discovery.Thisinterventionisalsoreferredtoasthevertical/downwardarrowtechniqueinwhichthecognitivetherapistguidestheclienttodiscovermoreconnectionsbetweenhisorherautomaticthoughtsandpossibleunderlyingbasicassumptionsordeeperschemas.Thetherapistusingguidedassociationanddiscoverywillaskquestionssuchas“Andthenwhat?”inresponsetotheclient’sexpressionsofhisorherautomaticthoughts,sothattheclientcandiscoveraseriesofconnectedautomaticthoughtsaswellastheirpossibleunderlyingschemas.UseofExaggerationorParadox.Inthistechniquethecognitivetherapistwilltakeanideaorthoughtthattheclienthasverbalizedtoitsextremeeitherbyusingexaggerationoraparadoxicalintervention(e.g.,prescribingthesymptom)tohelptheclientmovebacktoamorereasonableview.Thetherapistmustbecarefulandsensitiveintheuseofexaggerationorparadoxandshouldnotusethistechniqueifitisinappropriateforcertainclients.Scaling.Forclientswhotendtoviewthingsinextremeall-or-nothingcategories,thetechniqueofscalingmaybehelpful.Thecognitivetherapistaskstheclienttoratehimselforherselfonascaleof0(nothing)to100(all)onaparticulardimensiontheclientishavingtroublewith.Forexample,adepressedclientmaythinkofherselfasincompetent.Theclientisaskedtoidentifythemostincompetentpersonintheworldtoberatedas0,andthemostcompetentandhighlyskilledpersonintheworldtoberatedas100onthescaleof0to100.Theclientthenratesherselfonthis0-to-100competencyscaleandwilloftenachievealessextremeviewofherselfintermsofcompetence,withsomestrengthsandweaknesses(andnotallweaknessesandnocompetence).ExternalizationofVoices.Inthistechnique,thecognitivetherapisthelpstheclienttoexternalizehisorherinternalself-talk,consistingofdysfunctionalthoughts,byfirstverbalizingsuchthoughtsandthenhavingthetherapistmodelrationalresponsesfortheclient.Thetherapistcanproceedtomodelaprogressivelymoredysfunctionalandharshervoicefortheclientsothattheclientcanmoreclearlyseeandheartherationalaswellasthemaladaptivevoicesnowexternalizedandchoosetorespondinmoreadaptiveways.Self-Instruction.BasedontheworkofMeichenbaum(1977),thisselfinstructiontechniqueinvolvesthecognitivetherapistmodelingfortheclientspecificself-statementsthattheclientcanusetomoreeffectivelycopewithstressfulsituationsoremotionalproblems.Clientslearntopracticeanduse _Tan_Counseling_BB_mw.indd274 9/21/104:38:08PM CognitiveBehaviorTherapyandRationalEmotiveBehaviorTherapy 261 copingorcalmingself-statementssuchas“Relax.Takeonestepatatime.Icanhandlethis.”ThoughtStopping.Thistechniqueisusedbythecognitivetherapisttohelptheclientstopaseriesofmaladaptiveautomaticthoughtsorruminationsthatleadtomoreemotionaldistress.Whentheupsettingemotionalstateisinitiallynoticedwithitsaccompanyingnegativeautomaticthoughts,thetherapistsuggeststotheclienttostronglysaytohimselforherself,“Stop!”orelseimagineahugeredstopsign,tomomentarilystoptheruminations.Theclientcanthenengageinothercopingstrategiessuchasrationalrespondingtopreventfurthernegativeself-talkandemotionaldisturbance.Distraction.Thistechniqueinvolvesinstructingclientstorefocustheirattentiononotherthingssuchasdoingcomplexmath,orcountingpeopleinastore,orengaginginpleasantmentalimagery(e.g.,lyingonthebeachinHawaii),insteadoffocusingonanxiety-provokingthoughts.Distractionisashort-termtechniquethatworksonlyforawhile,butlikethoughtstopping,itprovidestheclientwithsometimetorelaxandtheopportunitytouseothercognitivecopingtechniques.DirectDisputation.Cognitivetherapistsusethistechniqueatappropriatetimestodirectlychallengeaclientandhisorherdysfunctionalthinkingbyengaginginvigorousdebate.ThistechniqueismoreoftenusedinREBTthaninCTbecauseCTemphasizesamorecollaborative,gentlestyle,withtheuseofSocraticquestioning,ratherthandirectdisputation,whichEllisadvocatesinREBT.Nevertheless,directdisputationmaybenecessaryandappropriatewithcertainclients,suchassuicidalclients,whoareobviouslyatriskofharmingthemselves.LabelingofDistortions.Thistechniqueinvolvesteachingclientsthemaincognitivedistortionssuchasarbitraryinference,selectiveattention,overgeneralization,magnificationandminimization,personalization,anddichotomousthinkingcoveredearlierinthischapter,andhowtoidentifyandlabelthemwhentheyoccurintheclients’thinking.Aspecificwayofhelpingclientslabeltheircognitivedistortionsistohavethemkeepadailythoughtrecordordiaryoftheirautomaticthoughts,especiallywhentheyareexperiencingemotionaldistresssuchasanger,anxiety,ordepression.Theirrecordedautomaticthoughtscanthenbereviewedandcognitivedistortionsidentifiedwhentheyoccur.Clientscaneventuallycognitivelyrestructuresuchdysfunctionalthoughtsandreplacethemwithmorerealistic,reasonable,andrationalthoughts.DevelopingReplacementImagery.Clientswhohaveanxietyproblemsoftenalsoexperiencefrighteningimagesduringstressfultimesthatexacerbatetheiranxiety.Thetechniqueofdevelopingreplacementimageryinvolveshelpingclientstovisualizeorimaginecalmingandcopingimageryinplaceofthefrighteningimagery.Withsomepractice,clientscanlearntousecalmingandcopingimagerywhenevertheybegintoexperienceanxiety-provokingimagery. _Tan_Counseling_BB_mw.indd275 9/21/104:38:09PM 262 MajorCounselingandPsychotherapyTheoriesandTechniques Bibliotherapy.Thistechniqueinvolvesthecognitivetherapistassigningself-helphomeworkreadingfortheclienttohelptheclientcontinuetomaketherapeuticprogressbetweensessions.Severalexcellent,popularbooks,suchasFeelingGood(Burns1988),LoveIsNeverEnough(A. T.Beck1988),andMindOverMood(GreenbergerandPadesky1995),canbeusedasbibliotherapyforclientsinCT.BehavioraltechniquesarealsofrequentlyusedasmajortherapeuticinterventionsinCTorCBT.Theyincludeactivityscheduling(schedulingweeklyactivitiesthatbringasenseofmasteryoraccomplishment,pleasureorenjoyment,andsocialconnection)withmastery,pleasureandsocialratings,socialskillsorassertivenesstraining,gradedtaskassignments(takingsmall,gradualstepstoachieveaparticulargoal),behaviorrehearsalorrole-playing,invivoexposure,andrelaxationtraining(ReineckeandFreeman2003,248–49;seealsoA. T.BeckandWeishaar2008,286–87).Manyofthesebehavioraltechniqueshavealreadybeendiscussedinthepreviouschapter.AnothercrucialCTtechniqueistheuseofhomework,whetherintheformofareadingassignmentorbibliotherapy,doingrelaxationexercisesdaily,completingadailythoughtrecord,callingsomeoneforasocialeventtogether,orsomeothertask.Therearemanypossiblehomeworkassignmentsinvolvingbothcognitiveandbehavioraltasks.Theyshouldbeclear,relevant,helpful,feasible,andmanageable,withahighprobabilityofsuccessfulcompletionbetweentherapysessions,forthebenefitoftheclient.Homeworkassignmentsshouldbemonitoredateachtherapysession,andthetherapistshouldgivetheclientappropriateverbalpositivereinforcementandotherrewardsforcompletingthehomeworkassigned.Difficultiesinaccomplishinghomeworkassignmentsalsowarrantdiscussionandguidancefromthecognitivetherapist,tohelpmodifythespecifichomeworkgivenincollaborationwiththeclienttoincreasetheprobabilityoftheclient’ssuccessfulcompletionofthehomework.RationalEmotiveBehaviorTherapy(REBT)(Ellis)AlbertEllis,thefounderofREBT,wasacharismatic,oftenflamboyant,andstrongpersonalitywhogaveREBTamoreforceful,active,directive,vigorous,anddisputationaltherapeuticstylethanBeck’scollaborative,gentleSocraticstyleinCT.REBTemployscognitive,emotive,andbehavioralorbehavioristictechniquestohelpclientsmodifytheirirrationalbeliefsandminimizetheircorephilosophiesoflifethatareabsolutistic,rigid,anddogmatic(Ellis2008, 201).ThefollowingaresomeofthemajortherapeutictechniquesusedinREBTinthreemajorcategories:cognitivetechniques,emotivetechniques,andbehavioralorbehavioristictechniques(seeCorey2009,282–85;Sharf2008,311–13;seealsoEllis1996,2004;EllisandDryden1997;EllisandMacLaren1998). _Tan_Counseling_BB_mw.indd276 9/21/104:38:11PM CognitiveBehaviorTherapyandRationalEmotiveBehaviorTherapy 263 CognitivetechniquesaremajortherapeuticinterventionsinREBT,whichfocusesonirrationalbeliefsastherootofemotionaldisorders.Theyincludethefollowing(seeCorey2009,282–83):DisputingIrrationalBeliefs.ThisisacorecognitivetechniqueinREBT.ClientsarefirsttaughttheA-B-Cmodelortheoryofpersonalityfunctioning,inwhichAstandsforActivatingEvents,orsituationsencounteredbythem;BfortheBeliefsthataretriggeredbytheactivatingevents,andsuchbeliefsareusuallyirrational,dogmatic,absolutistic,andnegative;andCfortheConsequences(emotionalandbehavioral)ofthebeliefs,forexample,feelingsofdepressionoranxiety,andavoidanceoffearedsituations.ClientsthuslearnthatAdoesnotleadtoC,butratherAtriggersB,whichthenleadstoC.Theyrealizethattheirirrationalbeliefs,triggeredbyactivatingeventsintheirlives,leadtotheiremotionaldisturbanceandupsetaswellastotheirbehavioralproblems.ThetherapistinREBTthenhelpstheclienttogoontoD,forDisputingtheirirrationalbeliefsinavigorous,active,anddirectiveway,firstbythetherapist,andthenbytheclient.Finally,clientslearntoidentifyE,ortheEffect,oftheirstrongandvigorousdisputingoftheirirrationalbeliefs,usuallyultimatelyexperiencinglessemotionaldisturbanceorfeelingssuchasdepressionandanxiety,andmoresatisfyingandstablefeelingssuchassadness,concern,andevenhappinessandcontentment.ClientsthereforelearntheA-B-C-D-EapproachinREBTtodisputetheirirrationalbeliefs(seeSharf2008,311–14).Aspecificexampleofanirrationalbelief(B)is:“It’stheendoftheworldandawfulifIdon’tgetthepromotionatworkthatIhavebeenworkingsohardfor.”Disputingthisirrationalbelief(D)mayinvolvethetherapistteachingtheclienttosayinstead:“It’llbedisappointingandsadifIdon’tgetthepromotionatworkthatIhavebeenworkingsohardfor,butitwon’tbeawfulanditcertainlywon’tbetheendoftheworld.”Theactivatingevent(A)inthiscasemaybetheclient’santicipationofajobperformancereviewinacoupleofdaystodetermineifheorshewillgetamuchdesiredandsubstantialjobpromotion.Theconsequences(C)oftheirrationalbelief(B)oftheclientmayincludeanxietyanddepression.Theeventualeffect(E)ofdisputingtheirrationalbelief(D)mayincludefeelingsofdisappointmentandsadnessbutnolongeranxietyordepression.DoingCognitiveHomework.ClientsareoftenaskedtodocognitivehomeworkbycompletingadailyA-B-Cdiaryofeventsthattriggercertainirrationalbeliefsleadingtoparticularnegativefeelingsandthentovigorouslydisputetheirirrationalbeliefs(D)andtonotetheeffect(E)ofsuchdisputation.UltimatelytheycompileanA-B-C-D-Ediarythathelpsthemtopracticeidentifyinganddisputingtheirirrationalbeliefsonadailybasis.ThisdiaryhasalsobeencalledanREBTSelf-HelpForm(seeSharf2008,309–10).Clientsareencouragedbythetherapisttoputthemselvesinsomewhatriskyorstressfulsituationssothattheycanfacetheiremotionaldisturbanceconnectedwithparticularirrationalbeliefsandmodifytheminordertoreducetheiremotionalupset. 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CognitivehomeworkinREBTalsooftenincludesbibliotherapyorselfhelpreadingtoreinforcerationalthinkingandfurtherchallengeclients’irrationalthinking.SomeREBTself-helpbooksthatareusedforhomeworkreadingincludeANewGuidetoRationalLiving(EllisandHarper1997,3rded.),FeelingBetter,GettingBetter,andStayingBetter(Ellis2001),andRationalEmotiveBehaviorTherapy:ItWorksforMe—ItCanWorkforYou(Ellis2004).ClientsarealsooftenaskedtolistentotapesoftheirownREBTsessionsandreflectonthem,sothattheycancontinuetolearnandchangebetweentherapysessions.ChangingOne’sLanguageandSelf-Statements.UseoflanguageorselfstatementsthatcontainpreferencesratherthanabsolutisticdemandsisanothercognitivetechniqueoftenusedbytherapistsandclientsinREBT.Clientsaretaughttochangetheiruseofspecificlanguagefromwordssuchas“must,”“ought,”and“should”thatreflectdogmaticandrigiddemandingnesstosofterwordsthatreflectpreferences.Forexample,insteadofsaying,“ImustpassthisexamorelseI’mafailure,andit’shorribleandawfultofail,”aclientistaughtinsteadtosay,“Iwouldliketopasstheexam,butevenifIfailit,it’snottheendoftheworld.”PsychoeducationalMethods.Ellis(2008)hasemphasizedthatREBTusespsychoeducationalinterventionssuchasbooks,audiovisualtapes,talks,andworkshopsmorethanCT.Clientsareencouragedtoavailthemselvesofsuchpsychoeducationalmaterialsandmethodstofurtherreinforceandstrengthentheireffortsatidentifyingandvigorouslychallengingtheirirrationalbeliefsandtomaintaintheirtherapeuticimprovementsandchanges.TeachingOthers.ClientsarealsoencouragedtoteachandapplyREBTprinciplesandmethodstootherpeople,whenappropriate(Sharf2008, 315).Oneofthebestwaysoflearningandreinforcingwhatonehaslearnedistoteachothers,andREBTusesthisasatechniquetohelpclientsfurtherstrengthentheirlearningofREBTprinciplesandprocedures.Itisalsosometimeseasierforclientstoidentifyirrationalbeliefsinothers(EllisandDryden1997).EmotivetechniquesarealsosignificanttherapeuticinterventionsusedinREBT.Theytendtobeemotionallyevocativeandstrong,buttheystillseektodisputetheirrationalbeliefsofclients.Ellis(2008)emphasizes,however,thegoalofclientslearningtohaveunconditionalself-acceptance(USA),andthetherapistofferssuchacceptancetoclientswhilehelpingthemtochallengetheirirrationalbeliefsandmodifytheirself-destructivebehaviors.EmotivetechniquesusedinREBTincludethefollowing(seeCorey2009,283–85):RationalEmotiveImagery.ThisemotivetechniqueinREBTinvolvesteachingclientstousevividandintensementalimagerytovisualizethemselvesbehaving,thinking,andfeelingthewaythattheywouldliketointheiractuallives.Theycanalsousesuchimagerytovisualizenegativeemotionalexperiencesthatupsetthemandthentochangetheirirrationalbeliefssothatthey _Tan_Counseling_BB_mw.indd278 9/21/104:38:14PM CognitiveBehaviorTherapyandRationalEmotiveBehaviorTherapy 265 eventuallyexperienceless-disturbingfeelings.Ellis(2001,2008)believesthatregularuseofrationalemotiveimageryafewtimesaweekforseveralweekscanhelpindividualstoovercomefeelingupsetaboutnegativesituations.UseofHumor.TheuseofhumorinanappropriatewayisanotheruniqueemotivetechniqueoftenusedinREBTtohelpclientstakethemselveslessseriouslyandtoputthingsinproperperspective.Makingfunoforpokingfunatirrationalbeliefsandexposingtheirabsurditiesbyjokes,stronglanguage,andeventhesingingofhumorousrationalsongstowell-knowntunesareexamplesofhowEllisandothertherapistshaveusedhumorinREBTintherapeuticwayswithclients(see,e.g.,Ellis2001).Role-Playing.Thistechniquehascognitive,behavioral,andemotiveaspects,butitcanbehelpfultoclientstorole-playorrehearsewiththetherapistinREBTanemotionallyupsettingorstressfulsituation,sothattheybecomemoreawareoftheirnegativefeelingsaswellasassociatedirrationalbeliefs.Clientscanthenlearntodisputetheirirrationalbeliefsandpracticemore-effectivecopingskillsandbehaviorstoovercometheiremotionaldistress.Shame-AttackingExercises.TheseareuniqueemotivetechniquesdevelopedbyEllisandusedinREBTtohelpclientsintentionallyengageinbehaviorsaboutwhichtheyusuallyfeelshameorembarrassment(seeEllis2001).Thepurposeofshame-attackingexercisesistoenableclientstobelessconcernedaboutotherpeople’sreactionswhentheyperformsuchbehaviorsandthereforetoattacktheshameorembarrassmentthattheyusuallyfeel.Examplesofshame-attackingexercisesincludespeakingloudlyinastore,talkingtostrangers,askingsillyquestionsinclass,orwearingverycolorfulclothesthatotherswillnotice.Theyinvolvebreakingsocialconventionsinsmallways.Theydonotincludeillegalactsorbehaviorsthatwillbedangeroustoothersoroneself.Clientslearnthattheyself-createtheirownfeelingsofhumiliation,andthattheycanbelesssensitivetoothers’negativeopinionsordisapprovalofthem.Theythereforelearntobelessinhibitedandmorespontaneousintheirbehaviors.UseofForceandVigorinSelf-Dialogue.ThisREBTemotivetechniqueinvolvesteachingclientstochallengeanddisputetheirirrationalbeliefsinverystrong,forcefulways,evenraisingtheirvoicestotalkbacktotheirirrationalbeliefs.ThetherapistinREBTcanalsorole-playwiththeclient,includingusingreverserole-playinginwhichthetherapistrole-playstheclientandexpressestheclient’sirrationalbeliefs,withtheclientplayingtheroleofthetherapistandtryingenergeticallyandvigorouslytostronglydisputetheclient’sownirrationalbeliefsthatthetherapistisrole-playing.Ellis(2008)emphasizesthatREBTusessuchvigorousself-talkandotheremotive-evocativetechniqueswithforceandenergymorethanCTdoes.BehavioraltechniquesarealsopartofthetherapeuticinterventionsoftenusedinREBT.Theyincludestandardbehaviortherapytechniquessuchasoperantconditioning,self-modificationstrategies,socialskillstraining,relaxation _Tan_Counseling_BB_mw.indd279 9/21/104:38:14PM 266 MajorCounselingandPsychotherapyTheoriesandTechniques training,invivoexposure,andsystematicdesensitization(seeCorey2009,285),manyofwhichhavebeendescribedinthepreviouschapter.HomeworkassignmentsareoftengiventoclientsinREBT,sothattheycanpracticebetweensessionsthecopingskillstheyhavelearnedintherapy.Actionhomeworkoractivityhomework(seeParrott2003, 317;Sharf2008, 317)usuallyinvolvestheclientengaginginsomeriskybehaviorsuchasaskingforadate,orexposinghimselforherselftoanxiety-provokingsituationsinvivoorinreallife,inordertobecomedesensitizedtothem.ThetherapistinREBTthereforehasawidevarietyofcognitive,emotive,andbehavioraltechniquesthatcanbeusedtohelpclientsdealwithdifferentemotionaldisorders,butwithonemainfocus:tostronglydisputeirrationalbeliefsandeventuallyreplacethemwithmore-rationalthinkingthatreflectspreferencesratherthandogmaticandabsolutisticdemands(Ellis2008).CognitiveBehaviorModification(CBM)andStressInoculationTraining(SIT)(Meichenbaum)DonaldMeichenbaumdevelopedanapproachtoCBTcalledcognitivebehaviormodification(CBM)thatincludesstressinoculationtraining(SIT).CBMisacopingskillstherapyapproachthatincludesrelaxationandothercopingskillstrainingaswellasconstructiveandcalmingself-talkandcognitiverestructuring.CBMandSIThavebeenbrieflyreviewedinthepreviouschapteronbehaviortherapy.AmoredetaileddescriptionofSITwillnowbeprovided.SITwasdevelopedbyMeichenbaumasamorecomprehensiveapproachtoCBMthansimplyself-instructionalorself-talktherapy(seeMeichenbaum1977,1985,1993,2003,2007).Ithasbeeneffectivelyusedtotreatawiderangeofproblems(Meichenbaum2003).SITconsistsofthreemainphases,eachwithspecifictherapeutictechniquesthatcanbeflexiblytailoredtofitparticularclientsandtheirneedsaswellaspreferences.Meichenbaum(2003)hasnotedthatflexibilityisoneoftheuniquestrengthsofSIT,whichhasbeenusedwithindividuals,couples,andgroups.ThelengthoftreatmentinSITvaries,fromonlytwentyminutesinpreparingpatientsforsurgicalprocedurestofortysessionsintherapywithpsychiatricpatientsandpatientswithchronicmedicalconditions.Typically,SITlastsfromeighttofifteensessions,withboosterorfollow-upsessionsspreadoveraperiodofthreetotwelvemonths(Meichenbaum2003, 409).Phase1,ortheConceptual-EducationalPhase,ofSITconsistsofseveraltherapeuticinterventions,including:(1) interviewingtheclientandhisorhersignificantothers,usingimagerytohelptheclienttodescribeatypicalstressfulsituation,andusingpsychosocialandbehavioralassessmentstohelptheclient,inacollaborativeway,todescribehisorherpresentingproblemsorstressorsinmorespecificbehavioralterms;(2) helpingtheclienttoprovideanarrativeaccountofhisorherexperienceswithstressandcoping,noting _Tan_Counseling_BB_mw.indd280 9/21/104:38:16PM CognitiveBehaviorTherapyandRationalEmotiveBehaviorTherapy 267 uniquecopingresourcesandstrengths,andidentifyingmorespecificgoalsfortherapy;(3) askingtheclienttodoself-monitoringtoclarifytheconnectionsbetweenhisorherthoughts,behaviors,andfeelings;(4) exploringwiththeclienthowproblemsincopingmaybeduetospecificdeficitsincopingskillsortootherfactorssuchasnegativethinking,maladaptivebeliefs,lowselfefficacy,andsecondarygains;(5) helpingtheclient,inacollaborativeway,toconceptualizestressreactionsastypicallygoingthroughseveralphases:preparingforthestressor,confrontingthestressor,copingwiththefeelingofbeingoverwhelmed,andreflectingonhowtheclientcopedwiththestressor,usingreinforcingself-statementswhereappropriate;and(6) clearingawayanymisconceptionsaboutstressandcoping(Meichenbaum2003, 409).Phase2,ortheSkillsAcquisition,Consolidation,andRehearsalPhase,ofSITincludesthefollowingtherapeuticinterventions:(1) providingskillstrainingtailor-madetoaspecificclientpopulationandlengthoftraining:(2) discoveringtheclient’spreferredcopingstyleandtechniquesaswellasblockstoeffectivecoping;(3) trainingtheclientintheuseofproblem-focusedinstrumentalcopingskillssuchasproblem-solving,assertivenesstraining,anduseofappropriatesocialsupport;(4) teachingtheclientemotionallyfocusedcopingskillssuchascognitiverestructuringorreframing,perspectivetaking,andemotionalregulation;(5) usingimageryandbehavioralpracticetohelptheclientrehearsecopingskills;and(6) usinggeneralizationmethods,includinganticipatingpossibleblockstoemployingcopingskills,andlearningwaystoovercomesuchbarriers(Meichenbaum2003,409–10).Phase3,ortheApplicationandFollow-ThroughPhase,ofSITinvolvestheuseofseveraltherapeuticinterventions,including:(1) encouragingtheclienttousecopingskillsinmoredifficultstressfulsituations;(2) usingrelapsepreventionstrategies;(3) enhancingtheself-efficacyoftheclientbyattributingsuccessfulcopingtotheclient’sownefforts;(4) phasingouttreatmentsessionsinagradualway,withboosterandfollow-throughsessions;(5) involvingtheclient’ssignificantothersinthetreatmentplan;(6) askingtheclienttocoachsomeoneelsewithasimilarproblem,thusempoweringtheclienttoassumeaconsultativerole;and(7) helpingtheclienttoviewstressorsdifferentlyandmoreadaptivelyeitherbyhimselforherselforwithothers’help(Meichenbaum2003, 410).Morerecently,MeichenbaumhasmovedbeyondtraditionalCBTorCBMtoamorephilosophical-constructivistornarrativeapproachtoCBMandSITthatfocusesonhowclientsactivelyconstructtheirownrealityortheirownstories(see,e.g.,Meichenbaum1997;MeichenbaumandFitzpatrick1993).Basedonthisconstructivenarrativeperspective(CNP),MeichenbaumhasemphasizedthatSITtherapistsortrainersnotonlyteachcopingskillstoclientsbuttheyalsohelpclientstoconstructnewlifestoriesthatshowthemas“survivors,”oreven“thrivers,”ratherthan“victims”(2007, 500).Mahoney(1991,2003)hassimilarlygonebeyondtraditionalCBT(Mahoney1974)indevelopinga _Tan_Counseling_BB_mw.indd281 9/21/104:38:17PM 268 MajorCounselingandPsychotherapyTheoriesandTechniques broaderandmorephilosophical-constructivistapproachtotherapycalledconstructivepsychotherapy(Mahoney2003). CognitiveBehaviorTherapyinPracticeAHypotheticalTranscriptofCT(Beck) Client:Ifeltprettydownanddepressedagainthispastweek.Itwasabadweekforme.CognitiveTherapist:Tellmemoreaboutit. . . .Whathappened,andwhatwentthroughyourmind?Whatwereyouthinkingaboutwhenyoufeltdepressed?Client:Well,Itriedtoaskthiswomanoutonadate.HernameisJoan,andshe’sanattractiveandnicepersonthatImetatafriend’sbirthdaypartyacoupleofweeksago.Wehadagoodtimechatting,andIevengotherphonenumber.ButwhenIcalledtoaskheroutforamovie,sheturnedmedownprettyquickly!CognitiveTherapist:Howdidyoufeelaboutherturningyoudown?Client:Ifeltbad. . .andrejected.Itreallygottome,andIstartedfeelingdepressedandlousy.CognitiveTherapist:Whatthoughtswereyouthinkingasyouwerefeelinglousyanddepressed?Client:Ithoughttomyself:“Imustbeprettyunattractive.ThisisthesecondtimeinamonththatI’vebeenturneddownforadatebytwodifferentwomen.Itfeelsreallylousytoberejectedagain.I’llprobablynevergetadateandwon’tbeabletofindsomeonetomarry.”It’sahorribleandscaryfeeling—seeingthefutureassobleakandhopelessforme,almostlikeit’stheendoftheworld!CognitiveTherapist:Um-hmm. . .itfeelsreallylousyandscary,andyousayit’sliketheendoftheworldandthere’snofutureforyou,nohopeforfindingawife.Onwhatbasisdoyousaythat,orwhere’stheevidenceforyourconclusion?Client:AsIsaid,I’vebeenturneddowntwicealreadybytwodifferentwomen—Joanlastweek,andMaryacoupleofweeksago.Ithinkthatthisprovesnowomanwouldfindmeattractiveenoughtodateme.That’swhyI’velosthopeandthefuturelooksbleak!CognitiveTherapist:So,youfeelitlookshopelessbecausetwowomenhaveturnedyoudownforadate.You’veconcludedthat _Tan_Counseling_BB_mw.indd282 9/21/104:38:19PM CognitiveBehaviorTherapyandRationalEmotiveBehaviorTherapy 269 they’verejectedyou,thatyou’reunattractive,andthatyouwon’tbeabletofindawifeinthefuture.Isthereanotherwayoflookingatallthis,anotherperspectiveordifferentconclusionthatonecancometo?Client:Ican’tquiteseeitanyotherway.Twiceisenoughrejection!CognitiveTherapist:Let’spauseforamomentandreallylookatthesituationasbestandasobjectivelyaswecan.Yourememberourdiscussionfromthelastsessionaboutsomeofthemostcommonerrorswetendtomakeinourthinking—cognitivedistortions,sotospeak?Whatdoyouthinkmaybehappeninghereinyourthinking?Basedontworejections,youconcludeyou’llnevergetanotherdateinthefuture.Client:IguessImaybejumpingtoconclusionstooquickly,basedononlytwosamples—Imaybeovergeneralizing,whichisacognitivedistortionorcommonerrorinthinkingthatwehaddiscussedlastweek.IguessI’mdoingitagain.Butitdoesfeellikethere’snohope!CognitiveTherapist:Um-hmm. . .itdoesfeellikeit’shopeless,ifyouthinkit’shopeless,basedontwocases.Again,isthereanotherwayoflookingatthismoreobjectivelyandaccurately?Client:IguessIcantellmyselfthatit’sonlytwocases.Ican’ttellforsurethatthethirdwomanIaskoutforadatewilldefinitelyturnmedown.IcanstopjumpingtoconclusionsorovergeneralizingandwaitformorecasesordatabeforeImakeamoredefiniteconclusionlikeI’llneverfindsomeonetomarry.IcanseenowthatI’mgoingtoofarahead,toofast.Maybe,justmaybe,there’salittlebitofhope.CognitiveTherapist:Good!You’rereallytellingyourselfthetruthmoreobjectivelyandputtingthewholesituationinbetterormoreproperperspective,seeingitfromanotherangle.Howareyoufeelingnow?Client:Abitbetter. . .withabitofhope.CognitiveTherapist:Good!Youcanseehowyourthinkingcanreallyaffectyourfeelings.WecanalsodiscussfurtheryourreasonsforconcludingthatJoanwasrejectingyou,whenshesimplyturnedyoudownforadate.. . .Whatdoyouthink?Client:Well. . .yeah. . .Ifeltrejected. . .Iconcludedshewasrejectingme,butareyousuggestingshemay _Tan_Counseling_BB_mw.indd283 9/21/104:38:19PM 270 MajorCounselingandPsychotherapyTheoriesandTechniques haverefusedmyrequestforadatebutthisdoesnotnecessarilymeanthatshedoesn’tlikemeatallorthatsheisrejectingmeasaperson?Afterall,wedidenjoytalkingtogetherforquiteawhileatthebirthdayparty,andshedidgivemehertelephonenumber. . .CognitiveTherapist:That’sagoodlogicalanalysisofwhathappened.Again,isthereanotherwayoflookingatJoan’sturningyoudownforadate,besidesrejection?Client:Maybeshedidn’tfeellikeit,orwastoobusyortiredlastweek.Shedidsaythat,butIfeltitwasonlyanexcuseorcover-up.CognitiveTherapist:Youmaywanttocheckthatoutnextweekbyaskingheroutagain,butonlyifyouwantto.Client:Yeah,yeah. . .Iseethepoint.CognitiveTherapist:Let’stakethisdiscussiononestepfurther,toreallyhelpyoudealwithyourunderlyingthinkingorbasicassumptionsaboutlife.JustsupposethatyouaskJoanagainandsheisreallyrejectingyou,thenwhatwouldthismeantoyou?Whatdoesrejectionmeantoyou? Thishypotheticaltranscriptofasmallpartofatypicalcognitivetherapy(orcognitivebehaviortherapy)sessiondemonstratestheuseofcognitiverestructuringbythecognitivetherapisttohelptheclientidentifydysfunctionalthinkingandaspecificcognitivedistortionofovergeneralization,andtochallengeitandmodifyittomorereasonable,rational,andrealisticthinking.Thecognitivetherapistusesthetraditionalcognitivetherapyquestions:“Onwhatbasisdoyousaythat,orwhere’stheevidenceforyourconclusion?”“Isthereanotherwayoflookingatallthis?”and“Supposethisistrue(rejection),whatwoulditmeantoyou?”Thecognitivetherapistisusingthedownwardarrowtechniquetohelptheclientnotonlytoidentifycognitivedistortionsandchangethembutalsotouncovertheclient’sunderlyingbasicassumptionsorschema,inthiscaseaboutrejectionandwhyit’ssohorrible.Thecognitivetherapistalsoshowsempathyfortheclientandengagesinawarmandcollaborativetherapeuticrelationshipwiththeclient,usingSocraticdialogueandgentlequestioning(ratherthandirectivevigorousdisputingoftheclient’sdysfunctionalthinking,whichismorecharacteristicofEllis’sREBTapproach).CritiqueofCBT:StrengthsandWeaknessesThestrengthsandweaknessesofCBTaresimilartothoseofbehaviortherapythathavebeencoveredinthepreviouschapter.However,therearesomeother 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strengthsandweaknessesmoreuniquetoCBT(seeCorey2009,300–309;Parrott2003,328–29;ProchaskaandNorcross2010,328–30).First,CBT,likebehaviortherapy,isacomprehensiveandversatileapproachtotherapythathasbeenusedwithdiversepopulations(e.g.,children,adolescents,adults,andolderadults),toaddressawiderangeofpsychologicaldisordersandclinicalproblems,inavarietyofpracticesettings(seeLeahy2004;SpieglerandGuevremont2003;Wilson2008;seealsoKazdin2001;Miltenberger2008).CBTistypicallyarelativelyshort-termtherapyandthereforeeasilyfitswithmanagedcare’semphasisoneffectivebrieftherapyandshort-termtreatments.Second,CBT,likebehaviortherapy,focusesonspecifictherapygoalssetbytheclientincollaborationwiththetherapist,withregularmonitoringofclientprogressintherapy.Itisthereforeatherapyapproachthatisaccountable,asclientimprovementorlackthereofisassessedandmeasuredinaconsistentandclearway.Third,CBT,somewhatlikebehaviortherapy,focusesmoreonthepresentcomplaintsoftheclient,withanemphasisonboththeclient’sinternalcognitiveactivitiesaswellasenvironmentalconditionsthatmaybecontributingtotheclient’spresentsymptomsandproblems.CBTdoesnotemphasizethepastorexplorationoffeelingsatlengthandisthusagoodcorrectivetotherapyapproachesthatmayinvesttoomuchtimeandenergyinpastissuesandfeelings.Fourth,CBT,likebehaviortherapy,empowerstheclienttosethisorherowngoalsfortherapy,incollaborationwiththetherapist,andthereforegivestheclientchoiceregardingtreatmentgoalsaswellaspreferredtreatmentoptions.Fifth,CBT,likebehaviortherapy,isopentotheuseofpharmacotherapyorpsychiatricmedicationinthetreatmentofseverepsychologicaldisorderssuchasmajordepressivedisorder,bipolardisorder,OCD,andschizophrenia,andhencetotheuseofcombinedtreatmentsofCBTandpsychiatricmedicationsforclientswithsuchdisorders.Sixth,CBThasawiderepertoireoftherapytechniquesthatincludemanycognitiveandbehavioralinterventionsaswellassomeemotiveones(asinREBT)thatcanbeusedtoeffectivelytreatspecificpsychologicaldisordersandsomaticconditions.Clientswithsuchfocusedsymptomsandadesireforstructured,directive,andempiricallysupportedinterventionsinarelativelyshort-termtherapycontextcanreceiveeffectiveandsystematichelpthroughCBT.Seventh,CBT,likebehaviortherapy,greatlyvaluesempirical,controlledoutcomeresearchand,togetherwithbehaviortherapy,isthemostempiricallysupportedtherapyapproachtodayforawiderangeofclinicalproblems.Eighth,CBTisflexibleenoughtobesensitivelyusedwithclientsfromdiverseculturesanddifferentcountriesinamulticulturalcounselingcontext, 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becauseitfocusesontreatingsymptomsandproblemsthatareprevalentacrossculturesandnationsandempowersclientstofreelychoosetheirowntreatmentgoals,consistentwiththeirculturalandsocietalvalues.CBTisadirective,structured,andproblem-solvingapproachtotherapythatdoesnotrequiretoomuchintrospectionorlengthyexplorationoffeelingsandpastissues;therefore,itfitsthepreferencesofmanyclientsfromnon-Westerncultures.CBTwithculturallydiverseclients(see,e.g.,HaysandIwamasa2006;ChenandDavenport2005)isreceivingmoreempiricalsupportforitseffectiveness(VossHorrell2008;seealsoMirandaetal.2005).However,CBT,perhapsmorethantraditionalbehaviortherapy,mayalsobeatgreaterriskforinsensitivelychallengingso-calledirrationalbeliefsofclientsfromnon-Westernculturesbecauseofitsfocusonchangingsuchthinkinginclients.CBTmaythereforeinadvertentlychallengecherishedculturalvaluesthatseemirrationaltotheWesternmind.Hays(2009)hasspecificallysuggestedquestioningthehelpfulnessratherthanthevalidityorrationalityofparticularthoughtsandbeliefsofculturallydiverseclientsinordertoshowthemrespectinculturallyresponsiveCBT.Finally,CBTcanbehelpfultoclientswithphysicaldisabilitiesorchallenges.CBT’sfocusonmodifyingnegativeexpectationsandchallengingirrationalbeliefsthatclientsmayhaveabouttheirphysicaldisabilitiesandlimitations,anditsproblem-solvingandskillstrainingapproachcanbeofparticularbenefittosuchclientsastheylearntocopemoreeffectivelywithlife(seeParrott2003, 329;Halligan1983;Radnitz2000).CBTalsohasseveralweaknesses,similartothoseofbehaviortherapy.First,CBTtendstofocusonthetreatmentoftheclient’spresentingproblemsorsymptoms,suchasanxiety,depression,anger,stress,andmaritaldifficulties,andmaynotpaysufficientattentiontothewholepersonandtheclient’stotallifecontext.CBTcanthereforebeconductedinarathermechanisticway.However,CBTdoesincludeasomewhatcomprehensiveassessmentoftheclientintermsofcognitions,emotions,andbehaviorsandcanalsoincludeabroaderconsiderationoftheclient’sfunctioningintheBASICI.D.frameworkofmultimodaltherapy(Lazarus1981,1997,2008).Second,CBT,likebehaviortherapy,mayplacetoomuchemphasisontechniquesandnotpayadequateattentiontothetherapeuticrelationship.Tobefair,CBTdoesemphasizetheimportanceofestablishingawarm,empathic,andcollaborativerelationshipwiththeclient,butthisisnotconsideredasufficientconditionfortherapeuticchange(A. T.Beck,Rush,Shaw,andEmery1979;Wilson2008).However,CBThasrecentlyfocusedmoreontheimportanceofthetherapeuticrelationshipineffectiveCBT(seeP. GilbertandLeahy2007;seealsoSafranandSegal1990).Third,CBTtendsnottopaymuchattentiontothepastandtheunresolvedissuesorpainfulexperiencesintheclient’slifeandhistory.Someclientswillrequiremoretimetoadequatelyprocessunresolvedissuesfromtheirpast. 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Fourth,CBT,likebehaviortherapy,issupposedlystillmainlybasedonsociallearningorsocialcognitivetheory;henceittendstoignoreunconsciousprocesses,includingtransferenceanddreams,thatcanprovidehelpfulinsightstoclientsandfacilitatefurthertherapeuticimprovements.However,CBThasattemptedtodealwithsuchunconsciousprocessesanddreamsbutnotwithinapsychoanalyticframework(see,e.g.,K. S.BowersandMeichenbaum1984;Rosner,Lyddon,andFreeman2003).ItshouldbenotedthatCBT’ssupposedgroundinginsocialcognitivetheoryoranyotherspecifictheory(seeKazantzis,Reinecke,andFreeman2009)hasbeenstronglycriticizedasinaccurate(see,e.g.,McMinnandCampbell2007,92–94).Fifth,CBT,similartobehaviortherapy,doesnottypicallydealwithexistentialissues,suchasseekingmeaninginlife,choosingauthenticvalues,andfacingthefearofdeath,inafocusedwaybecauseitsproblem-solvingapproachdealsmoredirectlywiththeclient’spresentingproblemsandsymptoms.Clientsstrugglingwithsuchexistentialconcerns,andevenspiritualissues,maynotfindtraditionalCBTsufficientlyhelpful.However,seriousattemptshaverecentlybeenmadetopaymoreattentiontoexistentialconcerns(see,e.g.,Dattilio2002),andespeciallytointegratereligionandspirituality,includingChristianandMuslimspirituality,intoCBT(see,e.g.,Tan1987a,2007b;TanandJohnson2005;seealsoPropst1988;McMinnandCampbell2007;Walker,Reese,Hughes,andTroskie2010).EvenEllisbecamemoreopentointegratingreligionandREBT(seeEllis2000;Nielsen,Johnson,andEllis2001).TheCBTtraditionhasalsorecentlybeenexpandedtoincludemindfulness-basedandacceptance-basedtherapiessuchasDBT,MBCT,andACT,whichhavesomerootsincontemplativeormeditativespirituality,suchasZenBuddhism(Hayes,Follette,andLinehan2004;seealsoRoemerandOrsillo2009).Sixth,CBT,similartobehaviortherapy,isadirective,structured,andsystematictherapyapproachinwhichthetherapistfunctionsasateacher,coach,consultant,androlemodel.Thereis,therefore,arealdangerthatthetherapistintheroleofexpertandtrainermayimposehisorhervaluesontheclient.Forexample,anoverenthusiastictherapistinREBTcanendupdebatingwithaclientinchallengingtheclient’sirrationalbeliefsdefinedaccordingtothetherapist’scriteriaofrationalityandirrationality,basedonWesternculturalvalues.ThiscanbeaseriousprobleminconductingCBTwithinamulticulturalcontext.However,CBTdoesempowertheclienttochoosehisorherowntreatmentgoalsandtocollaborateinthetherapeuticprocesswiththetherapist(A. T.Beck,Rush,Shaw,andEmery1979;seealsoKuyken,Padesky,andDudley2009;Wilson2008).Seventh,theemphasisinCBTonteachingspecificskills(e.g.,relaxationandcopingself-talk,andproblem-solving)totheclientassumesthatthebestwayforclientstolearnandchangeintherapeuticwaysistobedirectlyinstructed.Forexample,Meichenbaum’sSIThasbeencriticizedbyC. H.PattersonandC. EdwardWatkins(1996)formakingthisassumption,whichmaynothold 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trueforallclients,becausesomeofthemdobetterbylearningthroughgradualself-discoveryandmorereflectionandprocessingoftheirfeelings(seeCorey2009, 308–9).Eighth,CBTemploysmanycognitiveandbehavioraltechniquesthatcanbesimplisticallymisusedorabusedbyinexperiencedorinadequatelytrainedtherapists.PropertrainingandsupervisioninCBTtechniquesisneededinorderfortherapiststoconducteffective,efficient,andethicalCBT.Ninth,CBT,similartobehaviortherapy,maynotpayenoughattentiontoother,largersociopoliticalandenvironmentalfactorsthatmaycontributetoaclient’spsychologicalproblemsincertainculturalandnationalcontexts.Suchfactorscanincludeoppression,discrimination,andmarginalizationexperiencedbytheclient,whothereforemustbeempoweredtodealmoredirectlywithsuchexternalstressors,andnotfocusonlyonhisorherownirrationalbeliefs.Finally,CBTneedstobeparticularlysensitivetohowtherapeuticchangesinbehaviorandthinking,includingvalues,intheclientcannegativelyaffectothersintheclient’sfamilialandsocialnetworkofrelationships.Thisnegativeresultisalikelyoutcomeiftheclient’snewwayofthinkingclasheswiththeculturalandsocialvaluesofthesignificantothersintheclient’slife.ABiblicalPerspectiveonCBTAbiblicalperspectiveonCBTwillincludemuchofwhathasalreadybeencoveredinthepreviouschapterregardingabiblicalperspectiveonbehaviortherapy.Seesidebar12.2forasuccinctsummaryofabiblicalapproachtoCBTthatincorporatesabiblicalcritiqueofCBT.KeyquestionsoftenaskedinaChristianapproachtoCBTthatusesbiblicaltruthasthebasisforcognitiverestructuringofdysfunctionalorunbiblicalthinkinginclude:“WhatdoesGodhavetosayaboutthis?”“WhatdoyouthinktheBiblehastosayaboutthis?”and“Whatdoesyourfaithtraditionorchurchordenominationhavetosayaboutthis?”(seeTan2007b, 108).JonesandButmanhavealsowrittenthoughtful,biblicallybasedcritiquesofRETorREBTandCBT.TheyconcludethatRETorREBTisproblematicfromaChristianperspectiveprimarilybecauseofitsveryhumanisticdefinitionofrationality,itsvisionofhumanhealththatisindividualistic,hedonistic,andrationalistic,anditstroublingviewsonrationalityandemotion(1991,193).WithregardtoCBT,JonesandButmanraiseimportantquestionsthatsecularCBTneedstodealwithmoreadequately,forexample,questionsconcerningtranscendenceandspirituality,self-deceptionandevil,complexhumanrelationships,internalconflictswithintheperson,thenatureofemotion,andthemeaningofbeingfullyandtrulyhuman.Theyconclude,however,thatCBTstillhasmanystrengths,andthereforeit“islikelytobeoneofthemorefruitfulmodelsforChristianstoexploreforitsintegrativepotentials”(S. L.JonesandButman1991, 223). 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Sidebar12.2ABiblicalApproachtoCBTAbiblicalapproachtocognitivebehaviortherapywill:•Emphasizetheprimacyofagapelove(1 Cor.13)andtheneedtodevelopawarm,empathic,andgenuinerelationshipwiththeclient.•Dealadequatelywiththepast,especiallywithunresolveddevelopmentalissuesorchildhoodtraumas,andwilluseinnerhealingorhealingofmemoriesjudiciouslyandappropriately.•Payspecialattentiontothemeaningofspiritual,experiential,andevenmysticalaspectsoflifeandfaith,accordingtoGod’swisdomasrevealedinScripturesandbytheHolySpirit’steachingministry(John14:26),andwillnotoveremphasizetherational,thinkingdimension,althoughbiblical,propositionaltruthwillbegivenitsrightfulplaceofimportance.Thepossibilityofdemonicinvolvementinsomecaseswillalsobeseriouslyconsideredandappropriatelyaddressed.•Focusonhowproblemsinthoughtsandbehaviormayoften(notalways,becauseofotherfactors,e.g.,organicorbiological)underlieproblemfeelings(Rom.12:1–2;Eph.4:22–24;Phil.4:8)andusebiblicaltruth(John8:32),notrelativistic,empiricallyorientedvalues,inconductingcognitiverestructuringandbehavioralchangeinterventions.•EmphasizetheHolySpirit’sministryinbringingaboutinnerhealingaswellascognitive,behavioral,andemotionalchange.ItwilluseprayerandaffirmationofGod’sWordinfacilitatingdependenceontheLordtoproducedeepandlastingpersonalitychangeandwillbecautiousnottoinadvertentlyencouragesinfulselfsufficiency(cf.Phil.4:13).•Paymoreattentiontolargercontextualfactors,suchasfamilial,societal,religious,andculturalinfluences,andhenceutilizeappropriatecommunityresourcesintherapeuticintervention,includingthechurchasabodyofbelieversandfellow“priests”tooneanother(1 Cor.12;1 Pet.2:5,9).•Useonlythosetechniquesthatareconsistentwithbiblicaltruthandnotsimplisticallyusewhatevertechniqueswork.Itwillreaffirmscripturalperspectivesonsuffering,includingthepossibilityofthe“blessingsofmentalanguish”(Evans1986),withtheultimategoalofcounselingbeingholinessorChristlikeness(Rom.8:29),notnecessarilytemporalhappiness(Grounds1976).However,suchagoalwillincludebeingmoreopentoreceivingGod’sloveandgraceandtherebybecomingmoreChristlikeandovercomingmentalanguishduetounbiblical,erroneousbeliefs(i.e.,misbeliefs).•Utilizerigorousoutcomeresearchmethodologybeforemakingdefinitivestatementsaboutthesuperiorityofcognitivebehaviortherapy(Tan1987a,108–9). Morerecently,MarkMcMinnandClarkCampbell(2007),intheirattempttodevelopacomprehensiveChristianapproachtotherapycalledintegrativetherapy,includedahelpfulandinsightfulcritiqueofsecularCBT,affirmingthe _Tan_Counseling_BB_mw.indd289 9/21/104:38:27PM 276 MajorCounselingandPsychotherapyTheoriesandTechniques needtointegratebehavioral,cognitive,andinterpersonalmodelsoftherapywithinaChristiantheologicalframeworkforamorebalanced,holistic,andbiblicallyconsistentapproachtoChristiantherapy.TherecentexpansionofCBTtoincorporatemindfulnessandacceptancebasedtherapiessuchasDBT,MBCT,andACT,whicharerootedincontemplativeandmeditativespiritualitysuchasZenBuddhism,canbeofseriousconcernfromaChristianorbiblicalperspective.EasternorBuddhistspiritualtraditionscanbeatoddswithChristianunderstandingsofultimatetruthandtheBible.However,mindfulnessandacceptancearenotnecessarilyBuddhistconcepts.TheycanalsobefoundinChristiancontemplativespiritualityandChristianmeditation(see,e.g.,Caussade1989;Finley2004).Research:EmpiricalStatusofCBTAsnotedinthepreviouschapter,acrucialcharacteristicofCBTandbehaviortherapyistheemphasisonempiricalresearch,especiallycontrolledoutcomestudiesorrandomizedclinicaltrials(RCTs)ontheeffectivenessofthetherapeuticinterventionsusedtotreatparticularclinicalproblems.MorecontrolledoutcomeresearchhasbeenconductedonCBTandbehaviortherapythanonanyothertherapyapproach.ProchaskaandNorcross(2010,281,321–28)haveprovidedahelpfulreviewofthemajormeta-analysesandcontrolledoutcomestudiesthathavebeendoneonREBT(Ellis)andCT(Beck)aswellasameta-analysisofthirty-sevenstudiesdoneonSIT(Meichenbaum),whichwillnowbebrieflysummarized.Theynotethathundredsofcontrolledoutcomestudieshavebeencompletedtodateoncognitivetherapies,includingREBTandCT.EmpiricalStatusofREBTSmith,Glass,andMiller(1980),intheirearliermeta-analysisof475studieswith25,000patients,reportedanaverageeffectsizeof.68forREBT,and1.13forCBT.L. C.LyonsandP. J.Woods(1991)inalatermeta-analysisfoundanoveralleffectsizeof.95forREBT,indicatingthatREBTwassignificantlybetterthancontrolgroupsandnotreatment.However,theoutcomeofREBTwasnodifferentfromthatofbehaviortherapyandcognitivebehaviormodification.Similarfindingswereobtainedinanothermeta-analysisof28well-controlledstudiesthatshowedREBTtobebetterthannotreatmentandplacebo,butnodifferentfromotherbehavioralandcognitivetherapies(Engels,Garnefski,andDrekstra1993).REBTwithabehavioralemphasisdidnotachievebetterresultsthanREBTwithamorecognitiveemphasis.Morespecifically,REBTandothercognitiveandcognitive-behavioraltreatmentshavebeenfoundtobeeffectivewitholderchildrenandadolescents.Ameta-analysisof150outcomestudieswithchildrenandadolescents(Weiszet 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al.1995)foundthatcognitiveandcognitive-behavioraltherapy(in38treatmentgroups)hadanaverageeffectsizeof.67,whichismoderatelylargeandbetterthanthenonbehavioraltreatments.Anothermeta-analysisof19outcomestudiesonrationalemotivetherapy(RET)orREBTwith1,021childrenandadolescentsfoundaneffectsizeof.50forRETorREBT,amoderateandrespectableeffect,especiallyfordisruptiveandconductdisorders(Gonzalezetal.2004).REBThasthusbeenfoundtobeaneffectivetherapyforadultsaswellasforchildrenandadolescents,withsignificantlybetteroutcomesthannotreatmentandplacebo,butusuallyequivalenttoothercognitiveandbehavioraltreatments.EmpiricalStatusofCTandCBTBeck’sCTandmoregenericCBThavebeenthemostresearchedtreatmentswithnumerouscontrolledoutcomestudiesaswellasmeta-analysesconductedinthelastdecadeorso.Themeta-analysesdoneforspecificclinicaldisordersorproblemswillnowbebrieflydiscussed.Fordepression,severalmeta-analyseshavebeenconductedonoutcomestudiesontheeffectivenessofCTandotherrelatedCBTtreatmentsforadults,adolescents,andolderadults.Cognitivetherapy(CTorCBT)isclearlysuperiortonotreatmentandplacebotreatmentsfordepression,foradults,children,adolescents,andolderadults,andprobablyequivalentineffectivenesstootherpsychotherapiesfordepression(seeProchaskaandNorcross2010,322–24).Continuationofcognitivetherapyreducesthelikelihoodoflaterrelapse-recurrence(seeVittengl,Clark,Dunn,andJarrett2007).Morerecently,however,behavioralactivation,aspecificbehaviortherapyapproachthatincludespositivereinforcementofhealthybehaviorsandactivity,hasbeenfoundtobemoreeffectivethanCTinthetreatmentofmoreseverelydepressedclientsandalsoalmostaseffectiveasCTforthepreventionofrelapse(Dimidjianetal.2006;K. S.Dobsonetal.2008;seealsoCoffmanetal.2007).Theeffectivenessofbehavioralactivationinthetreatmentofdepression,especiallymoderatetoseveredepression,raisesthequestionofwhetheritisthebehavioralcomponent(e.g.,activityscheduling)ratherthanthecognitiverestructuringcomponentinCTandCBTthatisthecrucialfactorineffectiveCBTfordepression.Amorerecentmeta-analysisofcomparativeoutcomestudiesontheefficacyoreffectivenessofsevenmajorpsychotherapies(cognitivebehaviortherapy,nondirectivesupportivetreatment,behavioralactivationtreatment,psychodynamictreatment,problem-solvingtherapy,interpersonaltherapy,andsocialskillstraining)formildtomoderatedepressioninadultsrevealedfewsignificantdifferencesamongthem,exceptforinterpersonaltherapybeingsomewhatmoreefficaciousandnondirective,andsupportivetreatmentbeing 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somewhatlessefficacious(Cuijpers,VanStraten,Andersson,andVanOppen2008).Cognitivebehaviortherapyhadasignificantlyhigherdropoutrate,whereasproblem-solvingtherapyhadasignificantlylowerdropoutrate.CBTisthereforenotsuperiortoothermajortherapiesformildtomoderatedepressioninadults.Foranxietydisorders,themeta-analysesofcontrolledoutcomestudiesshowthatCTandCBTaremoreeffectivethanwait-listandplacebocontrolgroups,withlargeaverageeffectsizesfoundforCTusedforgeneralizedanxietydisorderandsocialphobia,butnotbetterthanbehavioraltreatments.CTandCBTalsooutperformmedicationinthetreatmentofanxietydisordersinthelongrunwithbettermaintenanceoftreatmentgains.Forobsessive-compulsivedisorder(OCD),CTandCBThaveactuallydoneaswellasexposuretherapyintherapeuticeffectiveness.Forsocialphobia,thelargesteffectsizeshavebeenfoundwhenCTwascombinedwithexposuretherapy(seeProchaskaandNorcross2010, 324).Forpanicdisorder,meta-analysesandcontrolledoutcomestudieshaveshownthatthemosteffectivetreatmentinvolvesacombinationofcognitiverestructuring(CT)andexposure,andespeciallypaniccontroltherapy(PCT),aCBTapproachdevelopedbyDavidBarlowandhiscolleaguesthatincludesaspectsofCT,behaviortherapy,andexposure(BarlowandLehman1996;seealsoCraskeandBarlow2008).CBThasbeenfoundtobeatreatmentofchoiceforpanicdisorder,andthemostcost-effectivetreatmentforpanicdisorderaswellasgeneralizedanxietydisorder(seeProchaskaandNorcross2010,324–25).Forposttraumaticstressdisorder(PTSD),meta-analyseshaveshownCBTtobeaseffectiveasexposuretherapyandEMDRforbothadultsandchildren.Foreatingdisorders,resultsfromameta-analysisandothercontrolledoutcomestudiesindicatethatCBTisatreatmentofchoiceforbulimia;itismoreeffectivethanmedicationalone,notreatment,andcontroltreatments,andevidencesmoreenduringtherapeuticeffectsatfollow-up.Forchronicpain,meta-analysesshowmulticomponentCBTtreatmentstobeeffectiveforchronicpainreductioninbothadultsandchildren.Forbodydysmorphicdisorder,ameta-analysisfoundantidepressantmedicationstobeeffective,butcognitivetherapywasmoreeffective(seeProchaskaandNorcross2010,325–26).Forpersonalitydisorders,ameta-analysisandcontrolledoutcomestudieshaveyieldedresultsthatsupporttheeffectivenessofdialecticalbehaviortherapy(DBT)(Linehan1993)forborderlinepersonalitydisorder,aswellasCBTforpersonalitydisorders,butitisnotsuperiortopsychodynamictherapy.Forpsychoticdisorders,meta-analyseshaveshownCBTtobeeffectiveforspeedingrecoveryfromacuteschizophreniaanddelayingreoccurrences,althoughmoreresearchisneeded.Formaritaltherapy,ameta-analysishasshownthatcouplestreatedwithCBTmaritaltherapydidsignificantlybetterthancoupleswhoreceivedno 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treatment,butnotbetterthancoupleswhoweretreatedwithinsight-orientedmaritaltherapyorwhohadreceivedbehavioralmaritaltherapy.Ameta-analysisofgroupCBTfoundittobeeffective,similartoCBTmaritaltherapy(seeProchaskaandNorcross2010,326–27).Fordomesticviolence,ameta-analysishasrevealedsoberingresultsshowingthelackofeffectivenessofCBTforreducingdomesticviolenceinmen,aswellasnodifferencesintheeffectsizesfoundforCBTandothertreatments.Finally,ameta-analysisofstudiesconductedontheeffectivenessofhomeworkassignmentsinCBTfoundthathomeworkassignmentsdidproducebettertherapeuticresultsthantreatmentslimitedtoonlyin-sessionintervention(seeProchaskaandNorcross2010, 327).EmpiricalStatusofSITAmeta-analysisinvolvingthirty-sevenstudieswith1,837clientshasbeendoneontheeffectivenessofSIT(Saunders,Drishell,Johnson,andSalas1996).Theoveralleffectsizeof.37onstateanxietyand.51onperformanceanxietyindicatethatSITismoderatelyeffective,andsignificantlybetterthannotreatmentorcontroltreatments(seeProchaskaandNorcross2010, 281).MeichenbaumnotedthatinsometwohundredstudiesSIThasbeenusedwithdifferentpopulations(2003,407–8;seealsoMeichenbaum2007).SIThasbeensuccessfullyusedasapreventativeinterventionwithclientssuchassurgicalpatients,patientshavingtoundergostressfulmedicalprocedures,hemodialysispatients,severalstressfuloccupationalgroups(e.g.,flightattendants,firefighters,policeofficers,teachers,nurses,soldiers,oilrigworkers),stepparents,parentsofchildrenwithcancer,andinternationalstudentsfacingthestressofadjustment.SIThasalsobeenusedasatreatmentinterventionwithmedicalpatientssuchasthosesufferingfrompainconditions,cancer,ulcers,hypertension,burns,genitalherpes,AIDS,childhoodasthma,andtraumaticbraininjury.Ithasbeensuccessfullyemployedtotreatpsychiatricpatients(children,adolescents,andadults)whohaveanxietydisorders(e.g.,phobias,PTSD,dentalanxiety,andperformanceanxiety),angercontrolproblems,addictivedisorders,andotherchronicpsychiatricdisorders.MorecontrolledoutcomeresearchisobviouslyneededtofurtherstrengthentheempiricalbasesupportingtheeffectivenessofSITforawiderangeofclinicalproblemsandapplications,bothasapreventiveinterventionandatreatmentapproach.Arecentreviewofsixteenmethodologicallyrigorousmeta-analyses(involving332studieswith9,995subjects)conductedontheoutcomesofCBT,includingCT,forawiderangeofpsychiatricdisordersyieldedthefollowingfindings:(1) largeeffectsizeswereobtainedforCBTforunipolardepression,generalizedanxietydisorder,panicdisorderwithorwithoutagoraphobia,socialphobia,posttraumaticstressdisorder(PTSD),andchildhooddepressiveandanxietydisorders;(2) effectsizesinthemoderaterangewerefound 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forCBTofmaritaldistress,anger,childhoodsomaticdisorders,andchronicpain;(3) CBTwassomewhatbetterthanantidepressantsinthetreatmentofdepressioninadults;(4) CBTwasaseffectiveasbehaviortherapyinthetreatmentofdepressionandobsessive-compulsivedisorder(OCD)inadults;and(5) largeuncontrolledeffectsizeswereobtainedforCBTforbulimianervosaandschizophrenia(Butler,Chapman,Forman,andBeck2006, 17).Butlerandhiscolleagues(2006)concludedthatthesesixteenmeta-analysesprovideempiricalsupportfortheefficacyoreffectivenessofCBTformanypsychiatricdisorders,althoughsomelimitationsareinherentintheuseofastatisticalmethodsuchasmeta-analysis.Amorerecentmeta-analysisof11effectivenessstudieswithatotalof973clientsfoundthatcognitive-behavioralinterventionsforanxietydisordersgeneralizeintheireffectivenesstorealworldclinicalpractice(VanIngen,Freiheit,andVye2009).Anotherrecentmeta-analysisof56effectivenessstudiesofCBTforadultanxietydisordersinactualclinicalpracticesimilarlyconcludedthatCBTisrobustlyeffectiveinclinicallyrepresentativeconditions,withlargeeffectsizesfound(StewartandChambless2009).ArecentDutchstudy(Giesen-Blooetal.2006)hasprovidedempiricalsupportfortheeffectivenessofschematherapy,aspecificformofCTthatdealswithearlymaladaptiveschemas(Young,Klosko,andWeishaar2003),fortreatingborderlinepersonalitydisorder.Thisthree-yearstudyevaluatedtheeffectivenessofschematherapyversusthatoftransference-focusedtherapybasedonOttoKernberg’swork(Levyetal.2006).Bothtreatmentsshowedreductionsinborderlinepersonalitydisordersymptomatology,withschematherapybeingmoreeffective(45.5percentofschematherapypatientshadfullrecoverycomparedto23.8percentoftransference-focusedtherapypatients).Schematherapypatientsalsohadsignificantlygreaterreductionsofotherpersonalitydysfunctionmeasures,withalowerlikelihoodofdroppingoutoftreatment(seeKelloggandYoung2008, 69).FutureDirectionsCBTshouldbemoreaccuratelycalledcognitivebehaviortherapies,becausevariousversionsofCBTareavailabletoday,includingthethreemajorapproachescoveredinthischapter:CT,REBT,andCBM/SIT.CBT,especiallyCT,isamajorandsignificantschooloftherapytoday,with28percentofclinicalpsychologistsand29percentofcounselorsintheUnitedStatesindicatingCTastheirprimarytheoreticalorientation(seeProchaskaandNorcross2010, 3).CBTisalsothemostpopularandfastestgrowingaswellasthemostempiricallyresearchedofallthecontemporarysystemsofcounselingandpsychotherapyavailable.TherearetwomainreasonsforCBTorCT’spresentdominantposition:itsopennesstoincorporatingotherempiricallysupportedtherapeutictechniques(seeAlfordandBeck1997)anditssolid 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groundinginempiricalresearch,especiallycontrolledoutcomeevaluation(ProchaskaandNorcross2010, 333).Cognitiveandcognitive-behavioralapproachesareamongtheleadingtherapyorientationspredictedbyaDelphipolltothriveinthenextdecade,whentherapyisexpectedtobemoredirective,psychoeducational,problemfocused,technological,andshortterm(seeProchaskaandNorcross2010,517–19).CBThasalreadybeensuccessfullyandeffectivelyappliedtoawiderangeofpsychologicalandmedicaldisordersandwillcontinuetobeaprominentapproachtotreatmentaswellaspreventionofsuchdisorders,includingthemoresevereconditionssuchaspersonalitydisorders,schizophreniaandotherpsychoses,andbipolardisorder.CBT’severwideningempiricalbasesupportingitseffectivenesswillcontinuetomakeitacrucialandsubstantialpartofcontemporaryevidence-basedtreatmentthatisbecomingincreasinglyimportanttomanagedcareandinsurancecompanies.CBThasbeguntoincorporatethethirdwaveofbehaviortherapy,consistingofmindfulnessandacceptance-basedtherapiessuchasDBT,MBCT,andACT,whichhavesomerootsincontemplativeormeditativespirituality,suchasZenBuddhism(Hayes,Follette,andLinehan2004;Hayesetal.2006;Hayesetal.inpress;seealsoRoemerandOrsillo2009).SeriousattemptshavealsobeenmadetodevelopamorespirituallyorreligiouslyorientedCBT,includingChristianandMuslimversions(see,e.g.,TanandJohnson2005).TheintegrationofreligionandspiritualitywithCBTisanareathatwillseefurtherrefinementanddevelopmentaswellasrequiremoreandbetterempiricalresearch(seeT. B.Smith,Bartz,andRichards2007).AnotherareadeservingfurtherdevelopmentinthefutureistheintegrationofpositivepsychologyandCT,focusingonissuesofpositiveaffectorhappiness,lifesatisfaction,andcontentment,includingtheuseofcognitivetherapyorCBTtechniquestotreatclinicalproblems,inwhathasrecentlybeencalledqualityoflifetherapy,developedbyMichaelFrisch(2006).Schematherapy,asaspecificformofCTthathasbeenfoundtobeeffectiveforborderlinepersonalitydisorder(seeKelloggandYoung2008;seealsoKelloggandYoung2006;Young2002;Young,Klosko,andWeishaar2003),willalsoreceivemoreattentionandfurtherrefinementanddevelopmentintheyearsahead.TheAssociationforAdvancementofBehaviorTherapy(AABT)changeditsnametotheAssociationforBehavioralandCognitiveTherapies(ABCT)in2005,reflectingthesignificantimpactCBT(includingCT)hashadonbehaviortherapy.Morespecifically,thereisalsotheInternationalAssociationforCognitiveTherapy(www.cognitivetherapyassociation.orgorwww.the-iacp.com)representingBeck’sCTapproach,withtheJournalofCognitivePsychotherapy:AnInternationalQuarterlyasitsmajorpublication.OtherprimaryjournalsinCTincludeCognitiveTherapyandResearchandCognitiveandBehavioralPractice.TheInternationalCognitiveTherapyNewsletter _Tan_Counseling_BB_mw.indd295 9/21/104:38:35PM 282 MajorCounselingandPsychotherapyTheoriesandTechniques waslaunchedin1985,anditservesasanewsletternetworkthroughwhichtherapistsfromfivecontinentscanexchangeinformationrelatedtoCT.Anonprofitorganization,theAcademyofCognitiveTherapy,wasfoundedin1999tocertifytherapistsskilledorappropriatelytrainedinCT.TheBeckInstituteforCognitiveTherapyandResearch(www.beckinstitute.org)inBalaCynwyd,Pennsylvania,providestrainingprogramsinCTandoutpatientservices.TenothertherapytrainingcentersintheUnitedStatesalsoprovidetraininginCT.TheCenterforCognitiveTherapy,affiliatedwiththeUniversityofPennsylvaniaMedicalSchool,isaresearchinstitutethatalsoprovidesoutpatientservices(seeA. T.BeckandWeishaar2008,269–70).Leahy(2004, x)hasnotedthatcognitivetherapycentersexisttodayinmostmajorcitiesintheUnitedStatesandCBTorganizationsineverymajorcountryworldwide.TheWorldCongressofCognitivePsychotherapyin2004washeldinKobe,Japan.WithregardtoREBT,itsmajorjournalistheJournalofRational-EmotiveandCognitive-BehaviorTherapy.TheAlbertEllisInstitute,foundedbyEllis in1959,isnolongerassociatedwithEllis,whoestablishedtheAlbertEllisFoundationin2006tobetterprotectandpromotehisworksandREBT(Ellis2008).FurtherinformationaboutREBTandavailabletrainingprogramsmaybeobtainedonline(www.rebtnetwork.org;seeCorey2009, 309).CBT,andespeciallyCT,willcontinuetogrowandexpandinsignificantandsubstantialwaysintheyearsahead.Itsfuturelooksextremelybrightasaprimary,ifnotthepremier,contemporaryapproachtotherapy.RecommendedReadingsBeck,A. T.,Rush,A. J.,Shaw,B. F.,&Emery, G.(1979).Cognitivetherapyofdepression.NewYork:GuilfordPress.Beck,J. S.(1995).Cognitivetherapy:Basicsandbeyond.NewYork:GuilfordPress.Beck,J. S.(2005).Cognitivetherapyforchallengingproblems.NewYork:GuilfordPress.Dobson,K. S.(Ed.).(2008).Handbookofcognitive-behavioraltherapies(3rded.).NewYork:GuilfordPress.Ellis, A.,&MacLaren, C.(1998).Rationalemotivebehaviortherapy:Atherapist’sguide.Atascadero,CA:Impact.Leahy,R. L.(Ed.).(2004).Contemporarycognitivetherapy:Theory,research,andpractice.NewYork:GuilfordPress.Meichenbaum, D.(1977).Cognitive-behaviormodification:Anintegrativeapproach.NewYork:Plenum.Persons,J. B.(2008).Thecaseformulationapproachtocognitive-behaviortherapy.NewYork:GuilfordPress. _Tan_Counseling_BB_mw.indd296 9/21/104:38:37PM 13MaritalandFamilyTherapy M aritalandfamilytherapy(MFT)actuallyreferstoovertwentydiversetherapeuticapproachestomaritalandfamilyproblems(Levant1984).Todayitismoreoftenreferredtoascoupleandfamilytherapy(Lebow2008),systemictherapies(ProchaskaandNorcross2010),familysystemstherapy(Corey2009),andfamilytherapy(GoldenbergandGoldenberg2008a,2008b).Morespecifically,maritaltherapyisnowoftencalledcoupletherapy(Gurman2008a).MFThasalsobeenmoreaccuratelyreferredtoasmaritaltherapies(Gurman2003)andfamilytherapies(N. J.Kaslow,Dausch,andCelano2003)toreflectthemanytherapyapproachesthatareincludedinMFT.MFTisthereforeanumbrellatermforovertwentysystemictherapiesthatassumethatthecrucialfactorinhelpingindividualstochangeistounderstandandworkwiththeinterpersonalsystemswithinwhichtheyliveandfunction.Thecoupleandfamilymustbeaddressedandseenineffectivetherapyforindividualproblemsaswellasformaritalorcoupleandfamilyissues.MFThasnosinglefounder,butthekeyfiguresandapproachesinthisareaincludeSalvadorMinuchin,thefounderofthestructuralapproach;JayHaleyandtheMilanGroup,whodevelopedthestrategicapproach;MurrayBowen,whodevelopedfamilysystemstheoryandtransgenerational(multigenerational)familytherapy;VirginiaSatir,whodevelopedconjointfamilytherapy;andSusanJohnsonandLeslieGreenberg,whodevelopedemotionallyfocusedtherapy(EFT)forcouples;aswellasotherssuchasCarlWhittaker,IvanBoszormenyi-Nagy,StevedeShazer,MichaelWhite,NeilJacobson,Andrew283 _Tan_Counseling_BB_mw.indd297 9/21/104:38:37PM 284Sidebar13.1KeyFiguresinMaritalandFamilyTherapy 1.2.3.4.5.6.7.8.9. 10.11.12.13.14.15.16.17. AlfredAdlerNathanAckermanMurrayBowenJayHaleySalvadorMinuchinCarlWhitakerVirginiaSatirCloéMadanesIvanBoszormenyiNagyStevedeShazerMichaelWhiteSusanJohnsonLeslieGreenbergNeilJacobsonAndrewChristensenJohnGottmanAlanGurman MajorCounselingandPsychotherapyTheoriesandTechniques Christensen,JohnGottman,andAlanGurman,andearlierinnovatorslikeAlfredAdlerandNathanAckerman.MFThaditsbeginningsinthe1940s;systemicfamilytherapytookrootinthe1950s(BecvarandBecvar2006).However,itssignificantgrowthanddevelopmentoccurredonlyinthelate1970sand1980s(Parrott2003),followingpsychodynamic(firstforce),behavioral(secondforce),andhumanistic(thirdforce)approaches.MFTcanthereforebeconsideredthe“fourthforce”inthefieldoftherapy(Corey2009, 411),althoughfamilytherapyorcounselingasministryhasinformallybeenaroundforthreehundredyears,sincetheearly1700s(YarhouseandSells2008,46–47;seealsoGladding2007, 56).NumeroustherapeutictechniquesareusedinMFT,includingreframing(seeingproblemsinamoreconstructiveorpositiveway);boundarysetting(eithertoestablishfirmerlimitsorlinesofseparation,ortobuildmoreflexibleboundariestofacilitatedeeperconnection);familysculpting(askingacoupleorfamilymemberstophysicallyputthemselvesinparticularpositionstoreflecttheirfamilyrelationships);andconstructingagenogram(athree-generationalfamilytreeorhistory)(seeParrott2003,378–80). BiographicalSketchesofKeyFiguresinMFTThefollowingarebiographicalsketchesofseveralkeyfiguresinMFT:AlfredAdler,NathanAckerman,MurrayBowen,JayHaley,SalvadorMinuchin,CarlWhitaker,VirginiaSatir,CloéMadanes,IvanBoszormenyi-Nagy,StevedeShazer,MichaelWhite,SusanJohnson,andLeslieGreenberg,aswellasNeilJacobson,AndrewChristensen,JohnGottman,andAlanGurman(seeCorey2009,374,410–11,418–19;Day2004,342–44;Fall,Holden,andMarquis2004,367–76;GoldenbergandGoldenberg2008a,2008b;Gurman2003;N. J.Kaslow,Dausch,andCelano2003;Lebow2008;ProchaskaandNorcross2010,335–74;YarhouseandSells2008,38–286).AlfredAdler(1870–1937),thefounderofindividualpsychology,orAdleriantherapy(seechapter5ofthisbook),wasoneofthefirsttherapiststouseasystemicapproachinfamilytherapy.AfterWorldWarI,heestablishedoverthirtychildguidanceclinicsinVienna.RudolphDreikurslaterappliedAdlerianconceptsandmethodsintheUnitedStateswhenhesetupfamilyeducationcenters.Adlerconductedfamilytherapysessionsinfrontofother _Tan_Counseling_BB_mw.indd298 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familiessotheycouldlearnhowtodealwithproblemsthatAdlerbelievedwerecommonamongfamilies(O. C.Christensen2004).NathanAckermanhasbeencalled“theunofficialfounderoffamilytherapy”(Gurman2003, 464)and“theparentfigureofpsychodynamicfamilytherapy”(YarhouseandSells2008,151),whoearlierassertedthatmaritaltherapywas“thecoreapproachtofamilychange”(Ackerman1970a, 124),butfamilytherapyhasnotembracedhisview.Ackermanwastrainedindoingpsychoanalytictherapywithchildren,butheeventuallyadvocatedseeingthewholefamilyasaunitintherapyinordertoassessandhelptroubledfamilies(Ackerman1966,1970b).HisbookThePsychodynamicsofFamilyLife(Ackerman1958)isoftenconsideredthelandmarktextthathelpedtodefinethenewfieldoffamilytherapy(GoldenbergandGoldenberg2008a, 410).AckermanwasborninBessarabia,Russia,onNovember22,1908,buthisfamilymovedtotheUnitedStatesin1912.HeobtainedhisBAin1929andhisMDin1933fromColumbiaUniversity.HebecamechiefpsychiatristattheMenningerChildGuidanceClinicin1937.AfterWorldWar II,AckermanbecameaclinicalprofessorofpsychiatryatColumbiaUniversity.AckermanestablishedtheInstituteforFamilyStudiesandTreatmentin1960andservedasitsdirectoruntilhisdeathin1971,atwhichtimeitwasrenamedtheNathan W.AckermanInstitute,orsimplytheAckermanInstitute,whichisnowworldrenownedasacenterforfamilypsychology.ItpublishesFamilyProcess,thefirstmajorfamilytherapyjournal.AckermandiedonJune12,1971.MurrayBowenwasbornonJanuary13,1913,inWaverly,Tennessee,theoldestoffivechildreninafamilythatwasrelativelylargeandclose-knit.HegraduatedwithaBSfromtheUniversityofTennesseeinKnoxvillein1934andobtainedhisMDfromtheUniversityofTennesseeMedicalSchoolinMemphisin1937.BowenservedintheU.S.Armyforfiveyears,duringwhichhisinterestsshiftedfromsurgerytopsychiatry.HetrainedinpsychiatryandpsychoanalysisattheMenningerFoundationinTopeka,Kansas,from1946to1954.Bowenfocusedonschizophrenicpatientsandtheirmothers,andthisworkeventuallyresultedinhisconceptofdifferentiationofself,orthedevelopmentofautonomyoftheindividual.In1954,BowenacceptedapositionattheNationalInstituteofMentalHealth,wherehebecamethefirstdirectorofthenewFamilyDivision.Hebegantreatingthewholefamilyasaunitseentogetherintherapysessionsandthereforebecameamajorfigureinthedevelopmentofsystemicfamilytherapy.HemovedtoGeorgetownUniversityinWashington,DC,in1959,whereheremaineduntilhediedin1990oflungcancer,attheageofseventyseven.HewasaclinicalprofessorofpsychiatryintheDepartmentofPsychiatryaswellasdirectoroffamilyprogramsatGeorgetownUniversity.Healsoestablishedafamilycenter.Bowenfurtherdevelopedhisfamilysystemstheory,includingkeyconceptssuchasdifferentiationofself,triangulation, 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andmultigenerationalortransgenerationaltransmission,whicharenowwidelyacceptedintheMFTfield.Hiswell-knownapproachtotherapyhasbeenvariouslylabeledextendedfamilysystemstherapy,transgenerationalormultigenerationalfamilytherapy,orsimplyBowenianfamilytherapy(YarhouseandSells2008).BowenalsohelpedfoundtheAmericanFamilyTherapyAssociationandservedasitsfirstpresidentfrom1978to1982.HismostsignificantpublicationisFamilyTherapyinClinicalPractice(1978).JayDouglasHaley(1923–2007)helpeddevelopstrategicfamilytherapy,anothermajorapproachtoMFT(seeHaley1963,1976;HaleyandRicheportHaley2003,2007).Strategicfamilytherapyisapragmatic,problem-solvingapproachthatdealswiththepresentproblemsofcouplesandfamilieswithoutdelvingintothepasttoachieveinsight.Haleydevelopedideasrelatingtopower,hierarchy,andstrategicinterventionsincludingdirectiveaswellasparadoxicaltechniques.HewasinfluencedbyMiltonEricksonandhistherapeutictechniques(Haley1973).TheMilanGroup,ledbyMaraSelviniPalazzoli(seeSelvini1988)attheCenterforFamilyStudiesinMilan,Italy,alsocontributedtothefurtherdevelopmentofstrategicfamilytherapyintowhatiscalledsystemicfamilytherapy(Boscolo,Cecchin,Hoffman,andPenn1987;Selvini-Palazzoli,Boscolo,Cecchin,andPrata1978),whichisespeciallysuccessfulwithpsychoticandanorecticpatients(GoldenbergandGoldenberg2008a, 412).HaleywasborninMidwest,Wyoming,butmovedwithhisfamilytoBerkeley,California,whenhewasfouryearsold.HeobtainedaBAintheaterartsfromUCLA,abacheloroflibrarysciencedegreefromUCBerkeley,andamaster’sdegreeincommunicationfromStanfordUniversity.Hemarriedhisfirstwife,Elizabeth,in1950,andtheyhadthreechildren.HaleymetGregoryBateson,ananthropologist,whilehewasatStanfordandwasinvitedtobeinvolvedintheDoubleBindCommunicationsProject—latercalledtheBatesonProject—togetherwithBateson,wholaunchedtheprojectin1952;JohnWeakland;andDonaldJackson.JacksonfoundedtheMentalResearchInstitute(MRI)inPaloAltoin1958(withtheinvolvementofVirginiaSatirandPaulWatzlawick),andwhentheBatesonProjectendedin1962,HaleyjoinedMRI,togetherwithWeakland.Thisverycreativeandproductivegroupproducedmanypublications(seeProchaskaandNorcross2010,339–40),includingalandmarkarticlethathelpeddevelopthefieldoffamilytherapy,titled,“TowardaTheoryofSchizophrenia”(Bateson,Jackson,Haley,andWeakland1956),thatfocusedonhowdoublebindsorconflictingcommunicationsinafamilysystemcouldleadtoschizophrenicsymptoms.Inthemid-1960s,HaleytookapositionatthePhiladelphiaChildGuidanceClinic,whereheworkedcloselywithSalvadorMinuchin,whodevelopedstructuralfamilytherapy.HethenfoundedtheFamilyTherapyInstituteinWashington,DC,in1976,withCloéMadanes,hissecondwife,andthey 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continuedtofurtherdevelopstrategicfamilytherapy(seeMadanes1981).Duringthistime,hepublishedProblem-SolvingTherapy(Haley1976),whichbecameoneofthemostsignificantbooksintheMFTfield.HaleyeventuallylefttheFamilyTherapyInstituteandmovedtoSanDiego,whereinthelastfewyearsofhislifehecollaboratedwithhisthirdwife,MadeleineRicheport-Haley,inproducingseveralfilmsonanthropologyandpsychotherapy.Theyalsocoauthoredtwoimportantbooks:TheArtofStrategicTherapy(HaleyandRicheport-Haley2003)andDirectiveFamilyTherapy(HaleyandRicheport-Haley2007).HaleywasascholarinresidenceattheCaliforniaSchoolofProfessionalPsychology,AlliantInternationalUniversity,whenhediedonFebruary13,2007,attheageofeighty-three(seeRay2007).SalvadorMinuchindevelopedstructuralfamilytherapyinthe1960s,initiallybasedonhisworkintherapyandresearchwithdelinquentyouthsfrompoorfamiliesattheWiltwyckSchoolinNewYork(S.Minuchinetal.1967).Structuralfamilytherapycanbebrieflydescribedas“asystemicapproachtofamilyinterventionsthatfocusesonidentifyingtheunderlyingpatternsorrulesthatregulateordictatethespacebetweenpeopleintherelationship”(YarhouseandSells2008, 122).Minuchinbelievedthatstructuralchangesintheorganizationoffamiliesintermsoftheirusualpatternsofinteractionandtypesofrelationshipsarenecessarybeforethesymptomsofindividualmembersofthefamilycanbereduced(Corey2009, 411).Ithadapreeminentplaceinfamilytherapyandtheoryinthe1970sand1980sandisstillamajorapproachtoMFTtoday(seeYarhouseandSells2008,122–23,formoredetailsonMinuchinandthehistoryofstructuralfamilytherapy).Minuchinwasbornin1921inArgentina,wherehisparentshadimmigratedfromEurope.HeobtainedhismedicaltraininginBuenosAiresandservedasamilitaryphysicianintheIsraeliarmyinthelate1940s,asIsraelattemptedtoachievestatehood.HethentrainedtobeapsychiatristinNewYorkbeforereturningtoIsraelin1952tohelpfamiliesandorphansintheaftermathoftheHolocaust.MinuchinreturnedtotheUnitedStatesin1954andreceivedpsychoanalytictrainingattheWilliamAlansonWhiteInstituteinManhattan.HealsoservedasthepsychiatristattheWiltwyckSchoolfordelinquentboys,wherehecollaboratedwithaclinicalsocialworker,BraulioMontalvo,indevelopingstructuralfamilytherapyandtheory.MinuchinhasreferredtoMontalvoashismostinfluentialteacher(GoldenbergandGoldenberg2008b).MinuchinmovedtothePhiladelphiaChildGuidanceClinicin1965tobecomeitsdirector.HeinvitedMontalvoandJayHaleytojoinhimthere,andtheircollaborationfurtheradvancedtheintegrationofstructuralandstrategicfamilytherapyideasandtechniques.TheclinicgrewunderMinuchin’sleadershipandhadbecomeverywellknownbythetimeheleftin1981.MinuchinhasauthoredandcoauthoredseveralsignificantbooksintheMFTfield,including 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theclassicFamiliesandFamilyTherapy(1974)onstructuralfamilytherapyandtheory(seealsoP. Minuchin,Colapinto,andMinuchin2007;S. Minuchin,Rosman,andBaker1978;S. MinuchinandFishman1981;S. Minuchin,Lee,andSimon2006;S. Minuchin,Nichols,andLee2007).Hisstructuralapproachhasalsobeenmorespecificallyappliedtohelpingtroubledcouplesinwhatiscalledstructuralcoupletherapy(Simon2008).HehascontinuedtowriteandtrainfamilytherapistsattheMinuchinCenterfortheFamilyinNewYorkCity(seeProchaskaandNorcross2010, 349).CarlWhitaker,anotherwell-knownfigureintheMFTfield(seeYarhouseandSells2008,195–97),iscreditedwithVirginiaSatirforindependentlydevelopingexperientialfamilytherapyorsymbolic-experientialfamilytherapy.Hisapproachismoreintuitiveandspontaneous,withthefamilytherapistfunctioningactivelyandcreativelyasacoachandparticipantwiththetroubledfamily,helpingitsmemberstobemoreopenandautonomousasindividualswhilemaintainingasenseofconnectionorbelonginginthefamily(Corey2009, 410).Whitakerwasbornin1912andgrewupinupstateNewYorkonadairyfarm.Hewasnotveryoutgoingbuthadafewclosefriendsasanadolescentwhowerehelpfultohimashemadedecisionsandwentthroughhisteenyears,college,medicaltraining,andmedicalpractice.Friendshipwascrucialforhim,andhisrelationshipswithMuriel,hiswife,andwithhissixchildren,wereofparticularsignificancetohim(Whitaker1989;WhitakerandKeith1981).Whitakervaluedcotherapyandadvocatedhavingtwoormoretherapists,orcotherapists,whentreatingatroubledfamily,becauseatherapistworkingaloneismorepronetomistakesandcanbelessobjective.CotherapywasalsoagoodbalanceandcorrectiveforWhitaker’softenunconventionalandradicalinterventions,forhewaswellknown“forbeingspontaneous,unpredictable,funny,bold,confrontationalanddirect”(YarhouseandSells2008, 195).WhitakerobtainedhismedicaltrainingatSyracuseUniversityandspecializedinpsychiatryafterinitiallytryingobstetricsandgynecology.HethenbecameafacultymemberattheUniversityofLouisville.DuringWorldWar II,hewasinvolvedasaphysicianintheOakRidgeResearchfacilityineasternTennessee,wheretheUSgovernmentwassecretlydevelopingtheatomicbomb.Heandhiscotherapist,JohnWarkentin,experiencedverystrongtransferencerelationshipswiththeirpatientswhomighthavehadposttraumaticstressdisordersymptoms.Whitakerthereforelearnedtofunctionasasymbolicmotherandfathertodealwiththetransferenceneedsoffamilymembersseeninfamilytherapybyhimandhiscotherapist.Heusedacombinationofwarmth,humor,self-disclosure,confrontation,andevenradicalandabsurdinterventionsinordertodothis.Hebelievedthatamaturetherapistwillfunctionlikeafosterparentandbeappropriatelyparentaltothepatientsandfamiliestheyseeintherapy.Hefoundedanddevelopedwhatcameto 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beknownassymbolic-experientialfamilytherapy(WhitakerandBumberry1988;WhitakerandKeith1981).WhitakerbecamechairoftheDepartmentofPsychiatryatEmoryUniversityinAtlantain1946andremainedthereuntil1955.HecoauthoredanimportantbookwithThomasMalonein1953,titledTheRootsofPsychotherapy,inwhichtheyemphasizedthatpsychotherapyisessentiallyasacredrelationshipandinvolvesalearningexperiencethatisculturallybasedandshouldnotbequantifiedorobjectified.Psychotherapyshouldthereforenotbeconsideredabranchofmedicalscience(WhitakerandMalone1953).EmoryUniversitypreferredamorepsychoanalyticapproachtotherapy,soWhitakerleftandsetupaprivatepracticeclinicinAtlantawithhiscolleagues,includingThomasMaloneandJohnWarkentin.In1965,hethenmovedtotheUniversityofWisconsinMedicalSchoolinMadison,Wisconsin,tobecomeaprofessorofpsychiatry,apositionheoccupieduntilhisretirementin1989.Thiswasaveryproductiveperiodofhisprofessionallifeduringwhichheandhisstudentsfurtherdevelopedmanyofhisideasonsymbolic-experientialfamilytherapy.Hediedin1995.VirginiaSatirwasalsoresponsiblefordevelopingexperientialfamilytherapy,withwhichCarlWhitakerisusuallyassociated(seeYarhouseandSells2008,193–95).TheymadetheirsignificantcontributionstothismajorapproachtoMFTindependentlyofeachother.SatirwasbornVirginiaPagenkopfonJune26,1916,inNeillsville,Wisconsin,aruralfarmingtown,theeldestoffivechildren.SheandherfamilymovedtoMilwaukeein1929sothatshecouldattendhighschool.SatirgraduatedfromhighschoolwhenshewassixteenyearsoldandthenattendedMilwaukeeTeachersCollege,wheresheobtainedaBAineducationin1936.ShebeganhergraduatestudiesatNorthwesternUniversity,butcompletedhermaster’sdegreeinsocialworkadministrationattheUniversityofChicagoin1943.Satirmarriedanddivorcedtwice,thesecondtimetoNormanSatir,whomshemarriedin1951anddivorcedin1957.Satirbeganherclinicalworkwithfamiliesin1951andsetupaclinicalpsychiatrictrainingprogramattheIllinoisPsychiatricInstitutewithDr.CalmestGyros.IvanBoszormenyi-Nagy,whodevelopedcontextualfamilytherapy,wasoneofSatir’ssuperviseesthen.HersignificantclinicalworkinexperientialfamilytherapyputherintouchwithMurrayBowen,whoconnectedherwithDonJackson.SatirbecametheclinicaldirectoroftheMentalResearchInstitute(MRI)atJackson’sinvitationin1959.Severalyearslater,in1966,shemovedtotheEsalenInstituteinBigSur,California,wheresheservedasitsclinicaldirector.ThiswasasignificantmoveforSatir,whoalsoshiftedfrombeingapuristinsystemictheoryandtherapytobeingmoreahumanistictherapistwhofocusedonself-esteemasthecrucialfactorinhumangrowth.ShehadaprofessionalriftwithSalvadorMinuchininthe1970s,whichresultedinheremphasizinghumanpotentialandgrowthevenmore,withlessemphasison 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familysystems.Satirwaswellknownforhercharismaaswellasherwarmandgentlestyle(seeYarhouseandSells2008,194–95).Satirspecificallydevelopedconjointfamilytherapyasaprocessofhumanvalidation,basedoncommunicationandemotionalexperiencingandcenteredinthetherapeuticrelationshipbetweenthetherapistandthefamilyratherthanintechniques,whichareviewedasbeingsecondary(seeSatirandBitter2000).AlthoughshemadeuseofBowen’smultigenerationalortransgenerationalmodel,shefocusedmoreonmakingcurrentpatternsoffamilyinteractioncometolifeinthetherapysessionbyusinginterventionssuchassculptingandfamilyreconstructions(seeCorey2009,410).ShehasauthoredorcoauthoredseveralsignificantbooksthathavegreatlyinfluencedtheMFTfield(e.g.,Satir1964,1972,1983,1988;SatirandBaldwin1983;Satir,Bauman,Gerber,andGamori1991).Satirisconsideredoneofthemostinfluentialtherapistsaswellasthe“mostcelebratedhumanist”(Nichols2006,199).Shereceivednumerousawardsandhonors,includinganhonorarydoctorateinsocialsciencesfromtheUniversityofWisconsin-Madisonin1978.ShediedonSeptember10,1988.CloéMadanesfoundedtheFamilyTherapyInstituteinWashington,DC,in1976withherthen-husband,JayHaley.ShecollaboratedwithHaleyinfurtherdevelopingstrategicfamilytherapyandauthoredanimportanttextonthisapproach,StrategicFamilyTherapy(Madanes1981;seealsoMadanes1984).Inthe1980s,strategicfamilytherapyasashort-term,problem-solvingtreatmentbecamethemostpopularapproachintheMFTfield(Corey2009, 411).MadanesandHaleyeventuallydivorced,butshewentontoestablishherownuniqueworkandvoiceinotherrelatedareassuchassex,love,andviolence(Madanes1990).Morerecently,shehaspublishedacollectionofherpapersfocusingonherworkasatherapistwhoisahumanist,asocialactivist,andasystemicthinker(Madanes2006).MadanesiscurrentlypresidentoftheRobbins-MadanesCenterforStrategicInterventionandtheMadanesInstituteinLaJolla,California.SheisalsothedirectoroftheProgramforthePreventionofSchoolandFamilyViolenceandtheCouncilforHumanRightsofChildren,attheCenterforChildandFamilyDevelopment,UniversityofSanFrancisco.IvanBoszormenyi-Nagy(pronouncedBoz-er-men-yee-Naj)foundedanddevelopedcontextualfamilytherapy(seeYarhouseandSells2008,171–73),whichisamajorapproachtoMFT.Hiscontextualfamilytherapyapproach(Boszormenyi-NagyandKrasner1986;seealsoBoszormenyi-NagyandSpark1984;HargraveandPfitzer2003)consistsoffourmajordimensions(VanHeus­denandVandenEerenbeemt1987,xiv):facts(e.g.,geneticrootsandfeatures,physicalhealth,andeventssuchasadoption,divorce,unemployment,anddisability);individualpsychologies(e.g.,basicneedsandinternalmotivationsoftheindividual);transactions(systemicinteractionorbehavioralandcommunicationpatternsobservedbetweenpeople,e.g.,structures,subsystems, _Tan_Counseling_BB_mw.indd304 9/21/104:38:47PM MaritalandFamilyTherapy 291 rules,roles,poweralignments);andrelationalethics(referringtofairnessorjusticeinarelationshiporthebalancebetweenobligationsandearnedmerit,withafocusontrust,loyalty,trustworthinessandentitlement,andtheinfluenceofpreviousgenerationsandimplicationsforfuturegenerations).Boszormenyi-Nagy(professionalsoftenrefertohimasNagy)wasborninBudapest,Hungary,onMay19,1920.AftergraduatingfrommedicalschoolinHungary,hecompletedhisresidencytraininginpsychiatryattheUniversityofBudapest.In1950,hemovedtotheUnitedStatesandworkedunderKalmanGyarfas,arelationship-orienteddynamictherapist,attheIllinoisPsychiatricInstituteinChicago;hewasalsosupervisedinhisclinicalworkbyVirginiaSatir.WhileBoszormenyi-Nagywasinfluencedbypsychoanalyticandpsychodynamictheories,includingFreudianpsychoanalysisandtheobjectrelationsviewsofRonaldFairbairn,hehadneverbeenatrainedpsychoanalyst(VanHeusdenandVandenEerenbeemt1987, 5).Hewasalsoinfluencedbytheworkofwell-knowntherapistsinthe1950swhoweretreatingpatientswithschizophrenia,andespeciallybyMartinBuberandhishumanisticemphasisontheI-Thourelationship,whichBoszormenyi-Nagybelievedisachievedinafamilycontextbybuildingtrust(YarhouseandSells2008, 172).In1957,Boszormenyi-NagymovedtotheEasternPennsylvaniaPsychiatricInstitute(EPPI)andworkedinaresearchinpatientserviceforpsychoticpatients,whereheandhisstaffdidintensiveindividualtherapy.However,in1958,heintroducedtheuseoffamilytherapyforallpatients.AtEPPI,hewasabletorecruitagroupoftalentedresearchersandtherapistswhomadesignificantcontributionstothefieldoffamilytherapy,includingJamesFramo,GeraldZuk,GeraldineSpark,andJohnRosen.HealsohadcontactwithotherearlyfamilytherapistssuchasNathanAckerman,MurrayBowen,LymanWynne,andlater,CarlWhitaker(VanHeusdenandVandenEerenbeemt1987,5–6).HediedonJanuary28,2007.StevedeShazerwasoneoftheoriginatorsofsolution-focusedfamilytherapy(seeCorey2009, 374;YarhouseandSells2008,223–25).Heandhiswife,InsooKimBerg,anotherwell-knownfigureintheMFTfield,codevelopedthesolution-focusedapproachtoMFTandwereinvolvedformanyyearswiththeBriefFamilyTherapyCenterinMilwaukee,Wisconsin,wheredeShazerwasdirectorofresearchandBergservedasdirectorofthecenter.Hewroteseveralsignificantbooks(seedeShazer1985,1988,1991,1994;deShazerandDolan2007)asdidBerg(seeBerg1994;BergandMiller1992;DeJongandBerg2008).Solution-focusedfamilytherapyfocusesspecifically“onsolutions,onwhatworksforclients”(Hoyt2008, 259),withthetherapisthelpingclientstothinkdifferentlyabouttheirproblemsandfindingsolutionsbyaskingkeyquestionssuchas:“Supposethatonenight,whileyouwereasleep,therewasamiracleandthisproblemwassolved.Howwouldyouknow?Whatwouldbedifferent?”(deShazer1988,10).Thereisnoattempttodigdeeperforinsightintounconsciousprocesses.Thesolution-focusedapproachdeveloped 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byde ShazerandBergcanalsobeappliedtoindividualtherapyandcoupletherapy(seeHoyt2008,262–63).StevedeShazerwasbornonJune25,1940,inMilwaukee,Wisconsin.Hewasamusicianbeforehebecameatherapist.Hegraduatedwithabachelor’sdegreeinfineartsfromtheUniversityofWisconsin,Milwaukee;helovedjazzmusicandplayedthesaxophone.Helaterobtainedamaster’sdegreeinsocialworkfromthesameuniversity.DeShazer’sspontaneityinjazzmusicinfluencedhisdevelopmentofsolution-focusedfamilytherapy,withitsemphasisoncreativityandspontaneityinboththetherapistandtheclientinexploringsolutionsfortheclientinrelativelybrieftherapy.Hiswork,togetherwithhiswife,attheBriefFamilyTherapyCenterinMilwaukee,Wisconsin,wasveryproductiveandhadasignificantimpactonMFTanditspractice.HediedonSeptember11,2005,inViennawhilehewasonateachingtourinEurope.Hiswifediedin2007.MichaelKingsleyWhitewasthecofounderofthenarrativetherapymovement,togetherwithDavidEpston,whoiscodirectoroftheFamilyTherapyCentreinAuckland,NewZealand(seeCorey2009, 357;YarhouseandSells2008, 266).WhitewascodirectoroftheDulwichCentreinAdelaide,Australia,andbegandevelopingnarrativetherapyinthelate1980sthroughhisworkandwritingsatthecenter.Heiswidelyconsideredthemajorfigureofthenarrativetherapymovement(Lebow2008, 325).HefoundedtheAdelaideNarrativeTherapyCentreinJanuary2008toprovideclinicalservicesandfurthertraininginnarrativetherapy,notonlywithfamiliesandcouplesbutalsowithindividuals,groups,andcommunities.HeauthoredorcoauthoredseveralsignificantbooksthathavegreatlyinfluencedthepracticeofMFT(see,e.g.,M. White2007;M. WhiteandEpston1989,1990).DavidEpston’swritingshavealsomadesubstantialcontributionstothedevelopmentofnarrativetherapy(see,e.g.,M. WhiteandEpston1989,1990;seealsoFreeman,Epston,andLobovits1997;Monk,Winslade,Crocket,andEpston1997),includingthetechniqueofletterwriting,inwhichletterswrittenbythefamilytherapistcanberepeatedlyreadbyclientstohelpthemmaintaintherapeuticgains(YarhouseandSells2008,266).Narrativefamilytherapy,asdevelopedbyWhiteandEpston(seealsoC.BrownandAugustaScott2007),wasinfluencedbytheFrenchpostmodernphilosophersMichelFoucaultandJacquesDerridaaswellasbythetherapeuticideasofGregoryBateson(YarhouseandSells2008,266).AsamajorapproachtoMFT,itemphasizesempoweringfamilymemberstore-authortheirownlifestoriesinmoreconstructiveandlessoppressivewayssothattheyseemoreoptionsastheylearntoviewtheirproblemsasbeingoutsidethemselves,aprocesscalledexternalization(GoldenbergandGoldenberg2008a, 413).MichaelWhitewasbornonDecember29,1948,inAdelaide,SouthAustralia.Heobtainedabachelor’sdegreeinsocialworkfromtheUniversityofSouthAustraliain1979andthenjoinedthestaffofAdelaideChildren’sHospitalas 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apsychiatricsocialworker.In1983,hehelpedfoundtheDulwichCentreinAdelaideandalsobeganaprivatepracticeinfamilytherapy.WhitereceivedseveralhonorsandawardsinrecognitionofhissignificantandinfluentialworkintheMFTfield,particularlyincofoundinganddevelopingnarrativefamilytherapy,whichalsoincludesnarrativecoupletherapy(seeFreedmanandCombs2002,2008).HewasawardedanhonorarydoctorateofhumanelettersbyJohn F.KennedyUniversityinOrinda,California,aswellastheDistinguishedContributiontoFamilyTherapy,Theory,andPracticeAwardfromtheAmericanFamilyTherapyAcademyin1999.WhitediedonApril4,2008.Susan M.Johnson,betterknownasSueJohnson,isoneoftheoriginatorsandthemainproponentofemotionallyfocusedtherapy,oremotion-focusedtherapy(EFT),andexperientialcoupleandfamilytherapy(seeGoldenbergandGoldenberg2008a,411).TogetherwithLeslieGreenberg,JohnsonhasdevelopedEFT,whichhasexperiencedphenomenalgrowthsincethe1990s(YarhouseandSells2008,198).GreenbergandJohnsonintheirearliercollaborativeworkindevelopingEFT,andJohnsoninherlaterworkthatintegratedmoreattachmenttheoryintoemotionallyfocusedcoupletherapy,madeuseoftherapeuticinterventionsderivedfromGestalttherapy.Clientsarethushelpedtoexpressintenseemotionssuchasanger,dealwithdefenses,andworktowardasofteningoffeelingssothatconnectionbetweenacoupleormembersofafamilycanberestoredanddeepened(seeLebow2008,325).Johnsonhasauthoredorcoauthoredseveralsignificantbooks(seeS. M.Johnson2008a)onemotionallyfocusedcoupleandfamilytherapythathavegreatlyimpactedtheMFTfield(see,e.g.,S. M.Johnson2002,2004,2008b;S. M.Johnsonetal.2005;seealsoL. S.GreenbergandJohnson1988).GreenberghasalsowrittenmoregenerallyonEFTasemotion-focusedtherapy,whichhelpsclientstoworkthroughtheirfeelings(L. S.Greenberg2002).Johnsonreceivedherdoctorate(EdD)degreeincounselingpsychologyfromtheUniversityofBritishColumbiain1984.SheisaprofessorofclinicalpsychologyattheUniversityofOttawaanddirectoroftheOttawaCoupleandFamilyInstituteandoftheInternationalCenterforExcellenceinEmotionallyFocusedTherapyinOttawa,Ontario.SheannuallyconductsEFTexternshipsinOttawatotrainothersinEFT.SheisalsoaregisteredpsychologistinOntarioandaresearchprofessoratAlliantUniversityinSanDiego,California,wheresheconductstraininginEFTeveryJanuary.Johnsonisconsideredthemainproponentofemotionallyfocusedcoupletherapyandemotionallyfocusedfamilytherapy.Shehasreceivedseveralhonorsandawardsforherwell-knownworkintheMFTfield,includingtheAmericanAssociationofMarriageandFamilyTherapyOutstandingContributiontotheFieldawardin2000andtheawardforresearchinfamilytherapyfromtheAmericanFamilyTherapyAcademyin2005.ShehasaprivatepracticeinOttawa,wheresheliveswithherhusbandandtwochildren(seeS. M.Johnsonetal.2005, 395). 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LeslieSamuelGreenberg,whohelpeddevelopEFTwithSueJohnson,isaprofessorofpsychologyatYorkUniversityinToronto,Ontario.HeisthecofounderofEFTforcouplesandfamilies(seeL. S.GreenbergandJohnson1988;seealsoL. S.GreenbergandGoldman2008)aswellasEFTtohelpclientsworkthroughtheirfeelings(L. S.Greenberg2002),includingdealingwithdepression(L. S.GreenbergandWatson2006).Greenbergisalsoawell-knownandprominentleaderinexperientialpsychotherapy(see,e.g.,L. S.Greenberg,Watson,andLietaer1998;Pos,Greenberg,andElliott2008).GreenbergwasbornonSeptember30,1945,inJohannesburg,SouthAfrica,buteventuallyemigratedtoCanada.HeismarriedwithtwochildrenandcurrentlylivesinToronto.HehasmadesubstantialcontributionstotheMFTfieldaswellastoexperientialpsychotherapy,inhisdevelopmentofEFTwithcouplesandfamiliesandalsowithindividuals.NeilS.Jacobson(1949–99)initiallymadesignificantcontributionstothedevelopmentofbehavioralmaritaltherapy(BMT)ortraditionalbehavioralcoupletherapy(TBCT)basedonsociallearningandbehaviorexchangeprinciples(N. S.JacobsonandMargolin1979).TBCTisstilltheonlycoupletherapythatcurrentlymeetsthestrictestcriteria(efficacyandspecificity)foranempiricallysupportedtreatment(seeDimidjian,Martell,andChristensen2008, 73).Jacobsonlaterhelpeddevelopintegrativebehavioralcoupletherapy(IBCT)withAndrewChristensen(N. S.JacobsonandChristensen1998;seealsoA. ChristensenandJacobson2000).JacobsonwasaprofessorofpsychologyattheUniversityofWashingtoninSeattleuntilhisdeathin1999.Hewasaprolificauthorofninebooksandtwohundredarticlesandisoneofthemostwidelycitedfamilytherapists.Hemadesubstantialandcutting-edgecontributionsnotonlytotheMFTfieldbutalsotothetreatmentofdepressionanddomesticviolence.Hereceivedmanyhonors,includingprestigiousresearchawardsfromtheAmericanAssociationforMarriageandFamilyTherapy,theAmericanFamilyTherapyAcademy,andtheNationalInstitutesofHealth.AndrewChristenseniswellknownforcodevelopingintegrativebehavioralcoupletherapy(IBCT)withNeilJacobson(seeA.ChristensenandJacobson2000;N. S.JacobsonandChristensen1998;seealsoDimidjian,Martell,andChristensen2008).Hehasalsodonesubstantialresearch,fundedbytheNationalInstituteofMentalHealth,onevaluatingtherelativeeffectivenessofIBCTversusTBCT(traditionalbehavioralcoupletherapy)(seeA. Christensenetal.2004;A. Christensen,Atkins,Yi,Baucom,andGeorge2006;A. Christensen,Atkins,Baucom,andYi2010).ChristensenisaprofessorofpsychologyattheUniversityofCalifornia,LosAngeles(UCLA).Hehaspublishedwidelyoncoupletherapyandcoupleconflict.JohnMordecaiGottman(1942–)developedhisresearch-basedapproach,nowcalledtheGottmanmethodcoupletherapy,incollaborationwithhiswife,JulieSchwartzGottman(seeGottmanandGottman2008).Gottman’smethodofcoupletherapyendeavorstointegratedifferentapproachestoMFT, _Tan_Counseling_BB_mw.indd308 9/21/104:38:53PM MaritalandFamilyTherapy 295 suchasanalytic,behavioral,existential,emotionallyfocused,narrative,andsystems,intoatheory(thesoundrelationshiphousetheory)thatisempiricallyderived,basedonyearsofresearchonwhatmakesrelationshipssucceedorfail.TheGottmanmethodcoupletherapyusesvarioustherapeuticinterventionstoachievethefollowinggoals:“down-regulatenegativeaffectduringconflict,up-regulatepositiveaffectduringconflict,buildpositiveaffectduringnonconflict,bridgemeta-emotionmismatches,andcreateandnurtureasharedmeaningsystem”(GottmanandGottman2008,143–61).JohnGottmanisanemeritusprofessorofpsychologyintheDepartmentofPsychologyattheUniversityofWashingtonanddirectoroftheRelationshipResearchInstituteinSeattle,Washington.HehasauthoredorcoauthoredseveralsignificantbooksthathavegreatlyimpactedtheMFTfield(see,e.g.,Gottman1994a,1994b,1999;GottmanandGottman2007;GottmanandSilver1999).Alan S.Gurmanisapioneerinthedevelopmentofintegrativeapproachestocoupletherapy(seeGurman2008a,vii).Hehasdescribedhisintegrativecoupletherapy(ICT)asadepth-behavioralapproachthatseriouslyconsidersbothinterpersonalandintrapersonalfactorsinhelpingcoupleswithrelationshipdifficulties.ICTisbasedongeneralfamilysystemstheoryandadultdevelopmentaltheory(especiallyattachmenttheory)andmorespecificallygroundedinappliedsociallearningtheory(orbehaviortherapy)andobjectrelationstheory(seeGurman2008b,383).Gurmanhasindependentlyrefinedanddevelopedhisintegrativeapproachtocoupletherapyforthepastthreedecades,althoughICTsharessomesimilaritieswithotherintegrativemodelsofcoupletherapy.ICTwaspreviouslycalledbriefintegrativemaritaltherapy(BIMT)(Gurman2002).Gurmanhascoauthoredorcoeditedseveralinfluentialbooksonfamilytherapy,maritalorcoupletherapy,brieftherapy,andessentialpsychotherapiesthathavegreatlyinfluencedtheMFTfieldaswellasthebroaderfieldofcounselingandpsychotherapy(see,e.g.,BudmanandGurman1988;Gurman2008a;GurmanandJacobson2002;GurmanandKniskern1981,1991;GurmanandMesser2003).GurmanisanemeritusprofessorofpsychiatryanddirectorofFamilyTherapyTrainingattheUniversityofWisconsinSchoolofMedicineandPublicHealthinMadison.HehasservedfortwotermsaseditoroftheJournalofMaritalandFamilyTherapyandwaspresidentoftheSocietyforPsychotherapyResearch.HehasmadesubstantialcontributionstotheMFTfieldandreceivedmanyawardsandhonors,includingawardsforDistinguishedContributionstoFamilyPsychologyfromtheAmericanPsychologicalAssociation,DistinguishedAchievementinFamilyTherapyResearchfromtheAmericanFamilyTherapyAcademy,andDistinguishedContributiontoResearchinFamilyTherapyfromtheAmericanAssociationforMarriageandFamilyTherapy.HewasalsorecentlytherecipientofanationalteachingawardforExcellence 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inInternshipTraining/DistinguishedAchievementinTeachingandTrainingfromtheAssociationofPsychologyPostdoctoralandInternshipCenters.HehasanactiveclinicalpracticeinMadison,Wisconsin.MajorTheoreticalIdeasofMaritalandFamilyTherapyPerspectiveonHumanNatureMFTactuallyhasovertwentydiversesystemictherapiesthathavebeendevelopedtohelpdistressedcouplesandtroubledfamilies.ItisthereforedifficulttoidentifyaparticularperspectiveonhumannaturethatcanadequatelyrepresentsuchdifferentMFTapproaches.Forexample,psychodynamicfamilytherapy(seeYarhouseandSells2008),ormorespecificallyobjectrelationscoupleandfamilytherapy,willhaveaperspectiveonhumannaturethatismoreinlinewithapsychoanalyticorpsychodynamicview.Cognitive-behavioralfamilytherapywillhaveaperspectiveonhumannaturethatisconsistentwithacognitivebehaviortherapy(CBT)view.Suchviewsonhumannatureofthemajorapproachestocounselingandpsychotherapyhavealreadybeencoveredinpreviouschaptersandwillnotberepeatedhere.Thereare,however,somebasicperspectivesonhumannaturethatareconsistentacrossmostMFTapproachesthattakeasystemicviewofhumanfunctioning.SystemicapproachesinMFTfocusonthefamilyasaunitandapplygeneralsystemstheoryasdevelopedbyLudwigvonBertalanffy(1968)beginninginthe1940stofamilyfunctioninganddysfunctioning,emphasizingthesignificanceofinterrelationsbetweenpartsofasystemthatcanresultincircularcausality(e.g.,AmaycauseB,butBalsoaffectsA,whichthenaffectsB,andsoon).Aspecificexampleofsuchfamilysystemsthinkingistheviewthatsymptomsinonememberofthefamilyactuallyreflectfamilydysfunctioninsteadoftheindividual’sownpsychopathology(seeGoldenbergandGoldenberg2008a,409).SystemicMFTapproachessuchasstrategicfamilytherapy,structuralfamilytherapy,Bowenianortransgenerational(multigenerational)familytherapy,contextualfamilytherapy,andpsychodynamicorobjectrelationsfamilytherapy(seeYarhouseandSells2008)tendtohaveamorepessimisticviewofhumannatureandoffamiliesashavingtendenciestowarddysfunction.Thetherapistthereforemustinterveneasanexpert,givingdirectivesorprovidinginterpretationsthatmayhelpfamiliesandfamilymemberstochange.Thepotentialtochangeistherebutinlimiteddegree.Other,morerecentapproachestoMFTthathaveasystemsapproachbutaremodifiedtoincludeamorerespectfulviewofhumannatureandfamiliesasbeingcapableofchoice,change,creativeproblem-solving,andmeaningmaking,includeexperientialfamilytherapy,solution-focusedfamilytherapy,narrativetherapy,andtoacertainextent,cognitive-behavioralfamilytherapyandemotionallyfocusedcoupleandfamilytherapy(seeYarhouseandSells 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2008).Thefamilytherapistintheseapproachesdoesnotassumeanexpertstancebutrathercollaborateswiththefamilymembers,inmutuallyrespectfulandegalitariantherapeuticrelationships,empoweringthemtodeveloptheirowncreativesolutionstotheirfamilyproblems,whileprovidingsomegentleguidance.Cognitive-behavioralfamilytherapyandemotionallyfocusedcoupleandfamilytherapy,however,usuallyinvolverelativelymoredirectivefamilytherapistactionandintervention.ThusthemajorMFTapproachesdifferintheirviewsofhumannatureandthenatureoffamilies.Somehavemorepositiveperspectivesonhumannatureandthepotentialforchangeinfamilies,whereasothershavesomewhatmorepessimisticperspectivesonhumannatureandthelimitedcapacityoffamiliestochooseandmaketherapeuticchanges.MajorApproachestoMFTIreneGoldenbergandHerbertGoldenberg(2008b)haveidentifiedeightmajorapproachestoMFT:(1) objectrelationsfamilytherapy;(2) experientialfamilytherapy;(3) transgenerationalfamilytherapy;(4) structuralfamilytherapy;(5) strategicfamilytherapy;(6) cognitivebehaviorfamilytherapy;(7) socialconstructionistfamilytherapy;and(8) narrativetherapy(seealsoGoldenbergandGoldenberg2008a,411–14).ObjectRelationsFamilyTherapy.ThispsychodynamicfamilytherapydevelopedbyDavidScharffandJillScharff(1987,1991;seealsoJ. S.ScharffandD. E.Scharff2008)assumesanobjectrelationsapproachtocoupleandfamilytherapyemphasizingthatthebasicneedinlifeistohaveasatisfyingrelationshipwithsome“object”oranotherperson.Familymembersbringintrojects(ormemoriesoflossorlackoffulfillmentinSidebar13.2childhood)intotheirpresentinteractionsApproachestoMaritalwithothers,attemptingtofindfulfillmentandFamilyTherapybutalsoaffectingcurrentfamilyrelations(seeGoldenbergandGoldenberginnegativewaysattimes.Familymembersunconsciouslyrelatetooneanother2008a,411–14)basedonchildhoodexpectationsandmotivations.Theobjectrelationsfamily1.Objectrelationsfamilytherapytherapistattemptstohelpfamilymembers2.Experientialfamilytherapyunderstandhowtheyinternalizedobjects3.Transgenerationalfamilytherapyfromtheirpastandgaininsightintohow4.Structuralfamilytherapytheseinternalizedobjectsarestillaffecting5.Strategicfamilytherapytheirpresentrelationships,sothattheycan6.Cognitivebehaviorfamilytherapychangeinconstructiveways.7.SocialconstructionistfamilyExperientialFamilyTherapy.Experitherapyentialfamilytherapyincludesthehuman8.Narrativetherapyvalidationprocessmodel(SatirandBit- 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ter2000),betterknownasconjointfamilytherapydevelopedbySatir(1964,1983),andthesymbolic-experientialfamilytherapydevelopedbyWhitaker(WhitakerandBumberry1988;WhitakerandKeith1981;seealsoWhitaker1989).BothSatirandWhitakeremphasizedthatdisturbedfamiliesneedagrowthexperienceindeeplyconnectingwithanauthentic,involved,andappropriatelyself-disclosingfamilytherapist(ortwoincotherapy),thushelpingsuchfamiliestoopenupandbemorehonestabouttheirrealfeelingsandneeds,andempoweringthemtochoosetochangeinmoreconstructiveways.Satirfocusedmoreonbuildingself-esteemandteachingopenandadequatecommunicationwithfamilies,whereasWhitakerusedhisownfantasiesandinstinctstohelpfamilymembersaccepttheirownsubjectiveexperiencesandexploretheirinnerworldofsymbolicmeaningsinordertogrow.GoldenbergandGoldenberg(2008a, 411)includedemotion-focusedcoupletherapy(EFT)(L. S.Greenberg2002;S. M.Johnson2004,2008a)asacurrentrepresentationofexperientialfamilytherapy,groundedinattachmenttheoryandintegratedwithhumanisticandsystemicperspectives,thathelpscouplestosoftentheirnegativeinteractionsandstrengthentheiremotionalconnectionwitheachother.TransgenerationalFamilyTherapy.ThisapproachhasalsobeencalledmultigenerationalfamilytherapyorsimplyBowenianfamilytherapy(YarhouseandSells2008)becauseitwasdevelopedbyBowen(1978).Hebelievedthatfamilymembersareconnectedtotheirfamilysystem,andthosewiththestrongestemotionalconnections,orfusion,withthefamilyaremoresusceptibletoexperiencingtheirownemotionalreactionstofamilystruggles.Differentiationofself,orone’sabilitytohaveaseparatesenseofselfindependentfromthefamilyandalsoone’sabilitytodifferentiatebetweenone’sintellectandone’sfeelings,iscrucialforthehealthyfunctioningoftheindividualinhisorherfamily.TriangulationisanotherkeyconceptdescribedbyBowen,referringtoaprocessinwhichthreepeopleareinvolvedinatwo-against-oneexperience(seeCorey2009, 415),forexample,whenamarriedcouplewithmaritalconflictandtensionpullintheirteenagedaughterasathirdpersontohelpstabilizetheirconflictratherthandealingwithitmoredirectlybythemselves.Theirattentionisnowdivertedtotheirdaughter,whomayendupactingoutinrebelliousways(seeYarhouseandSells2008,76,78).Bowenalsodescribedhowafamily’semotionalprocessesandproblems,especiallylowlevelsofdifferentiationofself,arepasseddownfromonegenerationtoanotherinwhathecalledamultigenerationaltransmissionprocess.Anexampleiswhenafamilymemberwithlowdifferentiationofselfmarriesaspousewhoalsohasalowdifferentiationofself,andtheiroffspringwhoisleastdifferentiatedalsoendsupmarryingsomeonewithlowdifferentiationofself.Thelowdifferentiationofselfthuscontinuesthroughsucceedinggenerations. 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GoldenbergandGoldenberg(2008a,412)includedcontextualfamilytherapy(seeBoszormenyi-Nagy1987;Boszormenyi-NagyandKrasner1986;Boszormenyi-NagyandSpark1984)asdevelopedbyIvanBoszormenyi-Nagyasanotherexampleoftransgenerationalfamilytherapy.However,BoszormenyiNagyfocusedmoreontheethicaldimensioninfamilyrelationships,inanintergenerationalcontext,withaspectssuchastrust,loyalty,entitlements,andindebtedness.Contextualfamilytherapistshelpfamiliestomaintainfairnessandtofulfilleachfamilymember’spersonalsenseofclaims,rights,andobligationsinhisorherrelationshipswiththeothermembersofthefamily.StructuralFamilyTherapy.ThisapproachtoMFTwasdevelopedbyMinuchin(1974),whodescribedastructuralviewthatfocusedontheorganizationoffamiliesandtherulesthatgoverntheinteractionsbetweenfamilymembers.Attentionisespeciallygiventofamilyrules,roles,alignments,andcoalitions,andalsotohowtheoverallfamilysystemiscomposedintermsofitssubsystemsandboundaries.Structuralfamilytherapiststrytohelpfamiliesfreethemselvesfromtheirusualrigidandrepetitivepatternsofinteractionsothattheycanengageinmoreconstructiveandhealthyreorganizationofthefamily.StrategicFamilyTherapy.ThisapproachtoMFTwasdevelopedmainlybyHaley(1963,1976).Itisapragmatic,problem-solvingtherapythatinvolvestheuseofcreativestrategiesbythestrategicfamilytherapisttoreduceoreliminateunwantedbehaviorinthefamily.Thespecifictherapeutictechniquesusedcanbedirectorindirect,suchasparadoxicaltechniques(e.g.,prescribingthesymptom).Haley’sapproachdoesnotfocusonhelpingfamilymembersgaininsightintothepastorunconsciousprocesses.Instead,itfocusesonthepresentingproblemsofthefamilyandondirectivelyattemptingtosolvethemincreativeandconstructiveways.MaraSelvini-Palazzoliandhercolleagues(Selvini-Palazzoli,Boscolo,Cecchin,andPrata1978)inMilan,Italy,developedavariationofstrategicfamilytherapycalledsystemicfamilytherapy,whichhasbeensuccessfullyusedespeciallywithpsychoticandanorecticpatients.Selvini-Palazzoli(1986)viewsbehavioralsymptomsinchildrenaspartof“dirtygames”inwhichparentsandtheirsymptomaticchildrenengageinpowerstruggles.Childrenthususetheirsymptomsinattemptstodefeatoneparentinordertohelptheotherparent.BoscoloandCecchin(Boscolo,Cecchin,Hoffman,andPenn1987)havefurtherdevelopedinterviewingtechniques(e.g.,circularquestioning)toempowerfamilymemberstoexploretheirfamilybeliefsystemandmakeconstructivechangesandnewchoices.LuigiBoscoloandGianfrancoCecchinalsoviewedthefamilytherapistnolongerastheexpertwhoknowsobjectivelywhatisbestforthefamilybeingseenintherapybutsimplyasaparticipantwiththerestofthefamily.Theythereforehelpedtofacilitatethedevelopmentofmorepostmodern,socialconstructionistapproachestoMFT(seeGoldenbergandGoldenberg2008a, 412). 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CognitiveBehaviorFamilyTherapy.ThisapproachtoMFTincludesthebehavioralperspective,whichfocusesonusingreinforcementcontingenciestoincreasedesirablebehaviorsanddecreasedysfunctionalbehaviorsincouplesandfamiliesandonteachingcommunicationandproblem-solvingskills(see,e.g.,N. S.JacobsonandMargolin1979).Italsoincorporatescognitivetherapy,whichfocusesonidentifyingandrestructuringdistortedthinkingorirrationalbeliefsthatinfluencefeelingsandbehaviors(see,e.g.,BaucomandEpstein1990;Baucom,Epstein,LaTaillade,andKirby2008;Dattilio2009;EpsteinandBaucom2002;Epstein,Schlesinger,andDryden1988).More-recentversionsofbehavioralandcognitivebehaviorfamilytherapyplacegreateremphasisonacceptance,forexample,inintegrativebehavioralcoupletherapy(IBCT)(seeN. S.JacobsonandChristensen1998;A. ChristensenandJacobson2000;seealsoDimidjian,Martell,andChristensen2008)versustraditionalbehavioralcoupletherapy(TBCT).SocialConstructionistFamilyTherapy.ThisapproachtoMFTisamorerecentdevelopment,influencedmainlybypostmodernviews,whichemphasizesubjectiveperceptionsofrealitythatdifferfrompersontopersonorfamilytofamily,dependingonimportantdiversityfactorssuchasethnicity,culture,gender,andsexualorientation(seeGoldenbergandGoldenberg2008, 413).Socialconstructionistfamilytherapythereforevaluesdiversityandchallengestraditionalsystemsperspectivesthatemphasizeasimplecyberneticmodeloffamilyfunctioningwiththefamilytherapistasexpertinassessingandtreatingtroubledfamilies.ThesocialconstructionistapproachtoMFTadvocatesmutuallyrespectfulandtrulycollaborativetherapeuticrelationshipsbetweenfamilytherapistsandfamilymembers.Familiesareempoweredtodeveloptheirowncreativesolutionstotheirproblems,withonlysomegentleguidancefromthetherapist,whodoesnotfunctionastheexpert.Well-knownexamplesofsocialconstructionistfamilytherapyincludesolution-focusedtherapy,developedbyStevedeShazer(see,e.g.,deShazer1985,1988,1991;deShazerandDolan2007),andthecollaborativelanguagesystemsapproach,developedbyHarleneAnderson(1997).NarrativeTherapy.ThisapproachtoMFTemphasizesthatthestoriesindividualsandfamiliestellorbelieveaboutthemselvesgreatlyinfluencetheirsubjectivesenseofrealityandhowitisorganizedandexperienced.MichaelWhitewasthemajorproponentofnarrativetherapy(see,e.g.,M. White2007;M. WhiteandEpston1989,1990;seealsoMonk,Winslade,Crocket,andEpston1997).ThenarrativeapproachtoMFThelpsfamilymembersreducethepowerofstoriesthatarenegative,oppressive,andproblem-centeredbyempoweringthemtore-authortheirliveswithotherstoriesthataremoreconstructive,sothattheycanexploreandtrynewoptionsandpossibilitiesintheirlives.Narrativefamilytherapistsfocusmoreonhowaparticularproblemhasimpactedthefamilyratherthanonhowparticularfamilypatternsmayhavecausedtheproblem.Aspecificinterventionoftenusedisexternalization, _Tan_Counseling_BB_mw.indd314 9/21/104:39:02PM MaritalandFamilyTherapy 301 whichistheprocessofhelpingfamilymembersseetheproblemasbeingoutsidethemselvesinsteadofbeinganinternalpartoftheirbasicidentity.Suchexternalizationcanhelpempowerthefamilytoexploreothermoreconstructivestoriesoroptionsthattheycanchooseinordertoovercometheirproblemsandfeelingsofhelplessness(seeGoldenbergandGoldenberg2008a, 413).MarkYarhouseandJamesSells(2008)havesimilarlysummarizedanddescribedninemajorapproachestoMFTthataresimilartotheeightapproachesmentionedbyGoldenbergandGoldenberg(2008a).ThenineMFTapproachesare(1) Bowenianfamilytherapy;(2) strategicfamilytherapy;(3) structuralfamilytherapy;(4) psychodynamicfamilytherapy;(5) contextualfamilytherapy;(6) experientialfamilytherapy;(7) solution-focusedfamilytherapy;(8) cognitive-behavioralfamilytherapy;(9) andnarrativefamilytherapy.TherapeuticProcessandRelationshipThetherapeuticprocessandrelationshipinMFTwilldependgreatlyonthespecificapproachtoMFTthatisbeingconsidered.Asalreadymentioned,someapproachestoMFTsuchasstrategicfamilytherapy,structuralfamilytherapy,transgenerationalorBowenianfamilytherapy,contextualfamilytherapy,psychodynamicorobjectrelationsfamilytherapy,cognitive-behavioralfamilytherapy,andemotionallyfocusedfamilytherapytendtoemphasizetheroleofthefamilytherapistassomewhatofanexpertinassessingandtreatingcoupleandfamilydysfunction.Awarm,caringtherapeuticrelationshipisstillvaluedbysuchMFTapproaches,butspecifictherapeutictechniquesoffamilytherapy,directorindirect,arealsovaluedandemphasized.OtherapproachestoMFT,especiallythoseinfluencedmainlybypostmodernperspectivesthatvaluesubjectiveperceptionsofrealityanddiversity,suchassocialconstructionistfamilytherapyincludingsolution-focusedfamilytherapy,narrativefamilytherapy,andsomeformsofexperientialfamilytherapy(e.g.,Satir’sconjointfamilytherapy),emphasizethecentralityofthetherapeuticrelationshipbetweenthefamilytherapistandthefamilymembers.ThefamilytherapistintheseMFTapproachesdoesnotassumetheroleofexpert.Instead,heorsheparticipateswiththefamilyinawarm,caring,andmutuallyrespectfultherapeuticrelationshipthatseekstoempowerfamilymemberstodevisetheirowncreativewaysofdealingwiththeirfamilyproblems.Thefamilyisthereforeviewedastheexpert,andthetherapistassumesa“not-knowing,”nonexpertapproachtotherapy(seeH.AndersonandGoolishian1992).TheprocessofMFTalsovariesintermsoflengthoftherapy,dependingonthespecificapproachtoMFTthatisbeingconsidered.ManyMFTapproachesarerelativelyshortterm,whileotherssuchaspsychodynamicorobjectrelationsfamilytherapycanbelong-term.Usuallythecoupleorthefamilyareseentogether.TheprocessoftherapyinMFTtypicallyinvolvesfourmajormovements:“formingarelationship,conductinganassessment(usingmultiple 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lensesorperspectives),hypothesizingandsharingmeaning,andfacilitatingchange”(Corey2009,428–33).CharacteristicsofStrongThegoalsofMFTwillalsovary,deorHealthyFamiliespendingontheneedsofparticularcouplesandfamiliesaswellasthespecificJonesandButman(1991,353)proapproachtoMFTthatisbeingused.MFTvidedthefollowingcharacteristicsofapproachesattempttohelpcouplesandstrongorhealthyfamiliesfromageneralfamiliesreducetheirproblemsandgrowtofamilytherapyperspective:becomehealthierandmorefunctionalin1.Respondpositivelytochalasystemicway(seeParrott2003,376–77).lengesandcrisesTheneedsandproblemsoffamilieswill2.Haveaclearlyarticulatedvary,dependingonwhichstageoftheirworldviewfamilylifecycletheyhavereached.There3.Communicatewellareatleastsixmajorstagesofthefam4.Choosetospendtimetoilylifecycle(B. CarterandMcGoldrickgetherinavarietyoftasks2005):“1. Asingle,youngadultleaves5.Makepromisesandhonorhometoliveamoreorlessindependentcommitmentstoonelife.2. Individualsmarryorbecomeacouanotherpletobuildalifetogether.3. Thecouple6.Knowhowtoexpresstheirhaschildrenandstartsafamily.4. Theloveandappreciationforchildrenbecomeadolescents.5. Theparoneanotherentslaunchtheirchildrenintotheworldandpreparetolivealifewithoutchildren.6. Thefamilyreachesitslateryearswherechildrenmayhavetocareforparentsaswellastheirownchildren,andtheparentspreparefortheendoftheirlives”(Corey2009, 424).Sidebar13.3 MajorTherapeuticTechniquesandInterventionsinMFTTherearemanyapproachestoMFTandevenmoretechniquesavailabletomodifyfamilyfunctioningandfacilitatetherapeuticchange(see,e.g.,J. Carlson,Sperry,andLewis2005;S. MinuchinandFishman1981;seealsoBitter2009;J. Pattersonetal.2009).Someofthebest-knowntherapeutictechniquesoftenusedbyfamilytherapistsarereframing,therapeuticdoublebinds,enactment,familysculpting,circularquestioning,cognitiverestructuring,miraclequestion,andexternalization(GoldenbergandGoldenberg2008a,422–23)aswellasboundarysettingandgenogram(seeParrott2003,378).InordertoprovideamorecoherentframeworkwithinwhichtopracticefamilytherapythatintegratesthemajorapproachestoMFTandtheirtechniques,DouglasBreunlin,RichardSchwartz,andBettyMacKune-Karrer(1997)havedescribedtheirperspectiveofmetaframeworksfortranscendingthediffer- _Tan_Counseling_BB_mw.indd316 9/21/104:39:05PM MaritalandFamilyTherapy 303 entmodelsoffamilytherapy.TheyhaveSidebar13.4proposedthefollowingsixoriginalmainmetaframeworks,whichserveastherapeuSomeFamilyTherapyTechniquesticlensesthatfamilytherapistscanuseto(seeGoldenbergandGoldenbergassessandhelpafamilysystemintrouble:2008a,422–23;Parrott2003,378)internalfamilysystems(i.e.,individual),sequences(i.e.,interactionpatterns),orga1.Reframingnization(ofthefamilysystem),develop2.Therapeuticdoublebindsmental,multicultural,andgender.More3.Enactmentrecently,twomoremetaframeworksor4.Familysculptinglenseshavebeenadded:teleological(i.e.,5.Circularquestioninggoal-orientation),andprocess(seeCorey6.Cognitiverestructuring2009,417–32).Alloranyoftheseeight7.Miraclequestionlensescanbeusedtoguidethefamilyther8.Externalizationapisttoselectspecifictechniquestomeet9.Boundarysettingtheparticularneedsofthefamily(see,e.g.,10.GenogramJ. Carlson,Sperry,andLewis2005).Wewillnowexaminesomeofthemajorfamilytherapytechniquesoftenusedbyfamilytherapists(seeGoldenbergandGoldenberg2008a,422–23;Parrott2003,378).Reframing.Thisfamilytherapytechniqueinvolvesrelabelingbehaviorthatisproblematicwithanew,alternativedescriptionthatismorepositive,emphasizingespeciallythegoodintentionoftheparticularbehaviorbeingdiscussed.Forexample,ateenagesonwhoisupsetbyhismother’snaggingbehaviormayrespondmoreconstructively(ratherthanwithangerandrebellion)ifhismother’sbehaviorisrelabeledorreframedtobeanexpressionofhercaringandconcernforhiswelfare,ratherthancalculatedsimplytobughimwithrepeated“nagging.”Reframingisusedtorestructurethemeaninggiventoaparticularbehaviorwithoutmodifyingordenyingtherealityoftheactualbehavioritself.Itisoftenusedbystrategicfamilytherapiststohelpfamilymembersviewproblematicbehaviorfromamorepositiveperspective,thusenablingthemtochangetheirfamilysystemorinteractionsinmoreconstructiveways.TherapeuticDoubleBinds.Thistechniqueisoftenusedbystrategicandsystemicfamilytherapistswhomaydirectivelyinstructfamiliestopersistintheirproblembehaviors,thusputtingthemintoatherapeuticdoublebind.Thisisusuallydonebyusingparadoxicalinterventionsthatprescribethesymptom,forexample,acouplewhooftenargueareencouragedtoargueevenmore.Iftheydoso,theyareadmittingthattheyareincontroltoincreaseordecreasetheirproblembehaviorofarguing.Iftheydonotdoso,thentheirproblembehaviorwilleventuallybeeliminated.Thistechniqueisthereforeadoublebindinwhichtheclientswillbenefittherapeuticallywhetherornottheyfollowtheparadoxicalintervention. _Tan_Counseling_BB_mw.indd317 9/21/104:39:06PM 304 MajorCounselingandPsychotherapyTheoriesandTechniques Enactment.ThisfamilytherapytechniqueisoftenusedbystructuralfamilytherapistsfollowingMinuchin;itreferstoconductingarole-playofanactualfamilydysfunctionalpatternofinteraction.Insuchenactments,orattemptsatrole-playingactualfamilysituations,inthefamilytherapysessionitself,thefamilytherapistcanobservethedysfunctionalpatternandprovidefeedbacktohelpthefamilymembers“unfreeze”orbreakoutoftheirunhealthy,destructivefamilyinteractionsandreplacethemwithmoreconstructivewaysoffamilyinteraction.GoldenbergandGoldenberg(2008a,423)provideanexampleofMinuchindoinganenactment(seeS. Minuchin,Rosman,andBaker1978)withafamilyconsistingoftwoparentsandananorecticadolescentdaughter;Minuchinarrangedthefirstsessionwiththemtoincludebringinglunchsothattheywerefacedwithanenactmentoftheirusualfamilyinteractionaroundeating.Hecouldthenobservetheparents’strugglesanddysfunctionalwaysoftryingtodealwiththeirdaughter’srefusaltoeatandpointouttheineffectivenessoftheparentalsubsysteminhandlingtheirdaughter’seatingproblem.Hecouldthenguidetheparentstocooperatewitheachothermore(ratherthanfightingwithorcontradictingeachother)inencouragingtheirdaughtertoeat,thusformingamoreunitedfrontthatisstrongerandmoreeffective.Thedaughterwouldthenalsoberelievedofthepositionofpoweranddestructivemanipulationthatshehadbeenmaintaining.Thisenactmentinthetherapysession,withdirectivesuggestionsandfeedbackfromafamilytherapistwithastructuralapproachsuchasMinuchin,canforcethefamilytomoreclearlyseetheirdysfunctionalfamilysystemthattheyhavecreatedsofarandtoexploremore-constructivewaysofinteraction.FamilySculpting.Thisfamilytherapytechniqueinvolvesaskingfamilymemberstotaketurnsactingasa“director”ingettingthedifferentfamilymemberstoplacethemselvesinparticularpositionsphysicallyinspaceinthetherapist’sofficetorepresenttheirfamilyrelationships.Thustheyexpressthemselvesandtheirattitudestowardeachotherinactive,nonverbalbehaviorratherthaninwords.Thefamilymembers’viewsoffamily,roles,alliances,boundaries,andsubsystemscanbefurtherclarifiedforthewholefamilytoseebyusingfamilysculpting,atechniquethatisoftenusedbyexperientialfamilytherapistsfollowingSatir’sapproach.CircularQuestioning.Thistechniqueisfrequentlyusedbysystemicfamilytherapists(seeBoscolo,Cecchin,Hoffman,andPenn1987)todrawattentiontofamilyinteractionsinsteadofindividualpathology.Thefamilytherapistwillaskeachfamilymemberthesamequestionabouthisorherperceptionsofthesameissue,whetheritisaneventorarelationship.Bygoingaroundtoeachfamilymemberusingthistechniqueofcircularquestioning,thefamilytherapistisabletoexploremoredeeplyeachfamilymember’sperceptionsandfeelingswithoutbeingconfrontational.Thefamilycanthenbemorecomfortableinexaminingtheunderlyingrootoftheirfamilyconflict.Suchnonconfrontationalquestioningisusedbysystemicfamilytherapistsasa _Tan_Counseling_BB_mw.indd318 9/21/104:39:08PM MaritalandFamilyTherapy 305 therapeuticprocesstohelpthefamilydealwiththeirfamilyproblemsbysharingtheirviewsoftheirdifficultiesandmodifyingthemintomoreconstructiveperspectives(seeGoldenbergandGoldenberg2008a, 423).CognitiveRestructuring.Thiscognitivetherapytechniqueisoftenusedbycognitive-behavioralfamilytherapiststohelpfamilymembersidentifyandchallengetheirindividualmaladaptive,distortedthoughtsaboutthemselvesandtheirfamilyproblems,andtoreplacesuchdysfunctionalthoughtswithmoreaccurate,realistic,andrationalbeliefs.Forexample,acouplemayinitiallythinkthatbecausetheyarearguingsooften,theyarepersonallyfailuresandtheirmarriageisdoomedtoendindivorce.Cognitiverestructuringofsuchnegativeandcatastrophicthinkingisdesignedtohelpthecoupletothinkmorerationallybytellingthemselvesthatalthoughtheydohaveseriousconflictsthattheyneedtoworkoutandresolvemoreeffectively,theyarenotpersonalfailuresandtheirmarriageisnotdoomedtoendindivorce.Infact,theymayrealizethatmanycouplesstrugglewithconflicts,andsuchconflictsmayactuallybeopportunitiesforthemtolearnbettercommunicationandconflictresolutionskillsandthereforeevenstrengthentheirmarriage.One’sthinkingstronglyinfluencesone’sfeelingsandbehavior.MiracleQuestion.Thisisasolution-focusedfamilytherapytechniquedescribedbydeShazerinwhichclientsareaskedthefollowingmiraclequestion:“Supposethatonenight,whileyouwereasleep,therewasamiracleandthisproblemwassolved.Howwouldyouknow?Whatwouldbedifferent?”(1988,10).Eachfamilymemberisaskedtoanswerthismiraclequestionandthereforespeculatehowdifferentthingswouldbeaswellashoweachfamilymember’sbehaviorwouldchange.Theuseofthemiraclequestioncanhelpfamiliesbreakoutofold,problem-saturatedwaysoflookingattheirfamilyproblemsandchoosenewgoalsandfindpotentialsolutionstotheiroldproblemsthataremorecreative,novel,andconstructive.Externalization.ThistechniqueofexternalizationisoftenusedbynarrativefamilytherapistsfollowingtheworkofMichaelWhiteandDavidEpstontohelpfamiliesfreethemselvesfromtheirold,problem-saturatedstoriesthathavedeadendsandfailuresasoutcomesandthatoftenresultinself-blameforfamilymembers.Thetherapistusesexternalizationtohelpfamilymembersseethattheproblemresidesoutsidethefamilyinsteadofattributingtheproblemtoaninternalfamilydeficitoraparticularfamilymember’spersonalpsychopathology.Thewholefamilyisencouragedtoviewtheproblemasexternaltothemandtopulltogethertoseehowtheycandealwiththeproblemwithmore-constructivesolutions.Forexample,insteadofviewingtheproblemofthemother’sdepressionas“Motherisdepressed,”thefamilyishelpedbythefamilytherapisttoexternalizetheproblembysaying,“DepressionistryingtocontrolMother’slife.”Thefamilymemberscanthenexploreothercreativewaysofdealingmoreeffectivelywiththedepressionthatisaffectingthewholefamily(seeGoldenbergandGoldenberg2008a,423–24). _Tan_Counseling_BB_mw.indd319 9/21/104:39:09PM 306 MajorCounselingandPsychotherapyTheoriesandTechniques InadditiontotheseeightmajortherapeutictechniquesorinterventionsoffamilytherapymentionedbyGoldenbergandGoldenberg(2008a),Parrottaddedatleasttwomore:boundarysettingandgenogram(2003, 378).BoundarySetting.Thisfamilytherapytechniqueinvolveseitherestablishingfirmerlimitsorlinesofseparation(i.e.,“walls”)infamilieswherethefamilymembersaretooenmeshedwithoneanother,orbuildingmoreflexibleorpermeableboundaries(i.e.,“bridges”)tofacilitatedeeperconnectionamongfamilymemberswhomaybetoodisengagedfromoneanother.Thefamilytherapistcanuseboundarysettinginvariousways,forexample,bydirectingcommunicationsothatonlyonefamilymemberspeaksatatimetohelpeachfamilymembertohavehisorherownvoice,orbyhelpingthefamilynegotiateandsetupfamilyrulesthatrespectanadolescent’sneedforpersonalspaceandprivacyandthefamily’sneedfortimetogetherandconnection.Genogram.Agenogramisathree-generationalfamilytreethatisoftenusedbyfamilytherapiststohelpfamilymembersseemoreclearlyfamilypatternsthatmayhavebeentransmittedorpasseddownfromgenerationtogeneration.Genogramsaregraphictoolsthatcanhelpfamilymembersdiscoverhowtheirfamilyhistoryhasimpactedthemandtheirpresentstrugglesandproblems.Therearemanymorefamilytherapytechniques,buttheonesjustdescribedareexamplesofsomeofthebetter-knownandmorefrequentlyusedtherapeuticinterventionsincoupleandfamilytherapy.Recently,commonfactorsincoupleandfamilytherapyhavebeenemphasizedastheoverlookedfoundationforeffectivepractice(Sprenkle,Davis,andLebow2009). MFTinPracticeAHypotheticalTranscriptClient(Father):Myson,John,nevertellsmeanythingaboutwhat’sgoingoninhislife!Ihavetoaskhimmanytimesbuthestillsaysalmostnothing!Client(Son,namedJohn):ButDad,that’sbecauseyoubugmesomuchwithallyournagging,andyoujustgetinmyfaceallthetimeandcomeintomyroomanytimeyouwanttowithoutevenknocking!Client(Mother):Yeah,theygetoneachother’snervessooften,I’mtiredandfedupwithallthis!FamilyTherapist:Wow,youareallreallyupsetaboutthissituation.Dad,youwantJohntosharemoreofwhat’sgoingoninhislifewithyou.John,youfeeldadisnaggingyoutoomuchandnotrespectingyourprivacyandnotgivingyouenoughspace.AndMom,you’refrustratedand _Tan_Counseling_BB_mw.indd320 9/21/104:39:11PM MaritalandFamilyTherapy 307 tiredwithallofthis—amIontherighttrackwitheachofyou?Client(Father):Uh-huh . . .Client(Son):Yup,yougotit!Client(Mother):Yes.FamilyTherapist:Ican’thelpbutwonderifallthisnaggingfromDadisreallyhiswayofshowingyou,John,thathecaresaboutyouandwhat’sgoingoninyourlife;that’swhyhe’sasking,evenifit’stoomanytimes.Whatdoyouthink,John?Client(Father):That’sright!Idocareabouthimbuthedoesn’tappreciateit. . .Client(Son):Therehegoesagain,andIthinkthatyouaskedmethequestion,andnothim,right?FamilyTherapist:That’srightactually,soifyoucanwaitjustamoment,Dad,letmehearwhatJohnhastosay,OK?Client(Father):OK. . . .FamilyTherapist:Good!Sogoahead,John . . .Client(Son):Well,Iguessmydad’snaggingisawayofhisshowingmethathe’sinterestedinmeandmylifeandwhat’sgoingonwithme,andifIlookatitthisway,itdoesn’tfeelasbadornegativeaswhenIlookatitusuallyasnaggingandthenitreallybugsme!Istillwishhewouldnotaskmequestionssooftenorsorepeatedly!FamilyTherapist:Canyousaythisdirectlytoyourdad?Client(Son):OK. . .well,Dad,Iguessyournaggingisyourwayofshowingmeyou’reinterestedinmylifeandthatyoucareabouthowI’mdoing.Idoappreciateit!Butitwouldbeniceifyoudidn’taskmequestionssooften,OK? . . .Client(Father):Well,I’mgladyourealizethatIreallydocareaboutyou,andthatyoufinallyappreciateit!I’lltrytoaskyoulessoften,butitwouldhelptooifyoujusttellmethingsmorespontaneouslyandjustbemoreopenwithmeandtalktomemorewithoutmehavingtoaskyou.Client(Son):I’lltry . . .FamilyTherapist:Good!You’rebeginningtoconnectwitheachotherinmore-constructiveandhelpfulways,andyou’rereallylisteningtoeachotherandgettingit!Mom,whatdoyouthinkaboutwhat’shappeninghere?Client(Mother):I’mglad!They’refinallytalkingtoeachotherorwitheachotherratherthantalkingateachother!Ithinkthere’sanotherissueaboutgivingJohnabitmorespaceandprivacysinceheisalreadysixteenyearsold! _Tan_Counseling_BB_mw.indd321 9/21/104:39:11PM 308 MajorCounselingandPsychotherapyTheoriesandTechniques FamilyTherapist:OK,whatdoyouhavetosayaboutthis,Dad?Client(Father):Well. . .I’mOKwithgivingJohnabitmorespaceorprivacy,butit’llbeeasierifhetellsmewhat’shappeningmoreoften . . .Client(Son):I’lltry,Dad,butIwouldappreciateitifyoudon’tjustwalkintomyroomanytimeyoufeellikeit,especiallyifmydoorisclosed,andyoudon’tknock.Imaybetakinganaporjustneedsomedowntimetobequiet.Pleaseknockifyouneedtotalktomebeforeyoucomeintomyroom,OK?Client(Father):OK . . .FamilyTherapist:That’sgreat!You’rebothsettingappropriateboundariesorguidelinesthatallowyoutocommunicateandstillbeconnectedwhilerespectingJohn’sneedforabitmorespaceandprivacybecausehe’sgrowingupfast!So,Dad,you’reOKwithknockingbeforeenteringJohn’sroom,ifyouwanttotalktohim?Client(Father):Yeah,I’lltrytoremember.FamilyTherapist:Good!AndJohn,you’reOKwithtellingDadwhat’supwithyouandyourlifeabitmoreoften,withouthimhavingtoaskallthetime?Client(Son):Yeah,IguessI’lltrytoo,likeDad!(smilesabithereandlooksatDad)FamilyTherapist:AndMom,you’reOKwithallthis?Client(Mother):Sure!I’vebeentryingtotellmyhusbandthatheshoulddosomethinglikewhatweagreedontoday,becauseJohnisalreadysixteenyearsold,andnottotreathimlikeaten-year-old!Client(Father):Butyoudon’ttellmenicelyandsometimesyounagmetoo!(withasmile)—ButIagree,andwecanworktogethertoconnectbetterwithyou,John.Client(Mother):That’sgood.FamilyTherapist:Itisgood!DadandMomworkingtogethermore,andDadandJohnagreeingtocommunicateandconnectmoreopenlyandspontaneously,withDadrespectingJohn’sspacemore,andJohnrealizingthathisDadreallydoescareforhimeventhroughhisnagging!AreyouallOKwithdoingthisforhomeworkuntilournextsession?Client(Father):Yeah,I’lltry.Client(Son):Sure.Client(Mother):I’lldomybesttosupportthem!FamilyTherapist:Great!Let’sseewhatelseisonyouragendathatyouwanttocoverordealwithfortherestoftoday’ssession . . . _Tan_Counseling_BB_mw.indd322 9/21/104:39:13PM MaritalandFamilyTherapy 309 Thishypotheticaltranscriptofasmallpartofafamilytherapysessionwithasixteen-year-oldadolescentsonandhisparentsdemonstratesthefamilytherapist’suseofreframing(ofthefather’snaggingandfrequentquestionsascaringforandinterestinthesonandwhat’shappeninginhislife)andboundarysetting(byencouragingthefathertorespecthisson’srequestformorespaceandprivacybyknockingbeforeenteringhisson’sroom,andencouragingthesontomorespontaneouslysharewhat’shappeninginhislifewithhisfather).Thefamilytherapistdirectedandmonitoredsothateachfamilymemberhadachancetotalkduringthesession.Thefamilytherapistalsoengagedinawarm,respectful,andempathictherapeuticrelationshipwitheachofthefamilymembersbysummarizingwhattheysaid,askingthemifitwasOKwiththemwhenthetherapistmadespecificsuggestionsafterexploringpossiblesolutionswiththem,andempoweringthefamilymemberstocomeupwiththeirowncreativeproblem-solvingideas.CritiqueofMFT:StrengthsandWeaknessesAgain,itisdifficulttocritiqueMFTbecauseofthemanydifferentapproachestocoupleandfamilytherapythatareincludedinthisfield.However,ingeneral,MFThasseveralstrengthsaswellasweaknesses(seeCorey2009,433–34,439–40;Parrott2003,387–88;ProchaskaandNorcross2010,366–70).Intermsofstrengths,MFT,basedonabroadsystemsperspectiveoncouplesandfamilies,focusesonthefamilyasaunitandthereforetranscendstheindividualisticemphasisoftenfoundinotherapproachestotherapy.MFTdoesnotplaceblameonindividualpsychopathologyandthereforeavoidsscapegoatingorholdingaparticularpersonresponsiblefortheproblemsofthewholefamilysystem.Italsoavoidsblamingthefamilyitselfforitsstrugglesbecauseittendstolookinsteadatthebiggerpictureofthefamilysystemandsubsystems.Second,MFThasnumerousfamilytherapytechniquesthatcanbeusedtoeffectivelyhelpcouplesandfamilieswiththeirproblemsinpracticalways.Whetheritisreframing,therapeuticdoublebinds,enactment,familysculpting,circularquestioning,cognitiverestructuring,askingthemiraclequestion,externalization,boundarysetting,constructingagenogram,communicationskillstraining,problemsolving,orothertherapeuticinterventions,MFTisapractical,usuallyrelativelyshort-termtherapyoftwentysessionsorless(Lebow2008, 328)thatdealswiththeproblemsofcouplesandfamiliesinadirectandconcreteway.Anexceptionwouldbethepsychodynamicorobjectrelationsfamilytherapyapproach,whichcanberelativelylongtermbecauseitfocusesontheunconsciousprocessesandchildhoodexperiencesoftheindividualmembersofthefamilysystem.ManycouplesandfamilieswhowanteffectiveandefficienthelpfortheirdifficultiescanfinditfrompractitionersofMFT. 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Third,MFTtakesintoseriousconsiderationthesystemsandsubsystemsoffamilies,includingthesignificantroleoffactorssuchasethnicity,culture,gender,values,beliefs,spirituality,andreligion(see,e.g.,McGoldrick,Giordano,andGarcia-Preto2005;McGoldrickandHardy2008;F. Walsh2009).Itthereforeattemptstobemulticulturallysensitiveandattentivetolargersystemssuchasracial,social,cultural,gender,andspiritualorreligiouscontextsandinfluences.Fourth,MFTisafieldthatisstillopentoexperimentationandthefurtherdevelopmentofmorecreativeandnovelwaysofhelpingcouplesandfamilies.Itwillcontinuetoevolveandcontributenewideasandtherapeutictechniquestothetheoryandpracticeofcounselingandpsychotherapy.Fifth,althoughearlierMFTapproaches(e.g.,structuralfamilytherapy,strategicfamilytherapy,contextualfamilytherapy,Bowenianortransgenerationalfamilytherapy,andpsychodynamicfamilytherapy)emphasizedtheroleofthefamilytherapistasanexpertwithspecializedknowledgeandskillsforassessingandtreatingfamilyproblemssystemically,morerecentversionsofMFT,especiallythosebasedonpostmodern,socialconstructionistperspectives(e.g.,solution-focusedfamilytherapy,narrativefamilytherapy,andexperientialorconjointfamilytherapy),focusontheclientorthefamilyastheexpert,notthefamilytherapist.Theyemphasizethecentralityofamutuallyrespectful,fullycollaborative,anddeeplycaringtherapeuticrelationshipineffectivefamilytherapy.ThisgentlerapproachthatempowersthefamilytodevelopitsowncreativeandconstructivenarrativesandsolutionstoitsproblemsisastrengthofMFTtoday.Sixth,thesocialconstructionistapproachestoMFTfocusmoreonnarrativesandthebig-picturestoriesoffamilymembersandtheirlives,empoweringthemtoengageinmore-constructivemeaningmakingoftheirlivesandexperiences.Thismoreexistentialemphasis,includingarespectfuluseofspiritualandreligiousresources(seeF.Walsh2009),reflectsagreateropennessinMFTtodaytodealingwithdeeperissuesrelatingtomeaninginlife,andthisisanotheroneofitsstrengths.Seventh,MFTtendstoassumeasystemicperspectiveonfamiliesandfamilyfunctioninganddysfunctioning.Ithasaclearmodelofwhathealthyfamilyfunctioningisandwhatdysfunctionalfamilieslooklike,especiallyenmeshedordisengagedfamiliesfromastructuralviewpoint.Thisperspectiveisastrengthintermsofsystematicassessmentandtreatmentoffamilydysfunctionwithinasystemicandstructuralframework,butitcanalsobeapotentialweaknessifsuchastructuralmodelisimposedonallfamilies.Eighth,MFTdealswiththewholefamily,includingextendedfamilywhenappropriate,infamilytherapysessions.Manyculturesplacesignificantvalueonthefamily,especiallytheextendedfamily.MFTcanthereforebeseenasmorerelevantandsensitivetoculturesthatdonotemphasizeindividualisticvaluesorself-focusedfulfillmentbutinsteadvaluecommunityandextendedfamily _Tan_Counseling_BB_mw.indd324 9/21/104:39:16PM MaritalandFamilyTherapy 311 relationships.PractitionersofMFTcanhelpfamiliesandextendedfamiliesinsuchculturesbetterthanmoreWesternizedtherapistswhopracticeindividualapproachestotherapyfocusingmoreontheselfandself-actualizationandlessontheinterpersonalcontextsoffamilyandcommunity.Finally,manyMFTapproacheshavebeensubjectedtocontrolledoutcomeevaluationsandhaveoverallbeenfoundtobeeffectivetreatments(see,e.g.,ProchaskaandNorcross2010,361–66;Sharf2008,510–12;ToddandBohart2006,358–59).TheempiricaloutcomeresearchthathasbeendoneandthatcontinuestobeconductedonMFTisthereforeanotherstrength.MFTalsohasseveralsignificantweaknesses.First,itsfocusonthefamilyasaunitfromasystemsperspectivecanleadtoalossofappreciationforthepersonhoodoftheindividualfamilymember.Inotherwords,thependulumcanswingtoofarfromindividualisticself-focusedtherapytosystems-focusedMFT,whichcanresultinlosingthepersonoftheclientorfamilymember.SystemicMFTapproachescanbecomemechanisticintreatingthefamilyasawholelikea“machine”thatneedsonlytobetweakedwiththerighttechnique,usingtherightsystemsterminology,andforgettingthatultimatelythefamilystillconsistsofindividualfamilymemberswhoareimportantpersonsintheirownright.Second,MFThasnumeroustherapeutictechniquesthatcanbeusedtohelptroubledcouplesandfamilies,butsuchtechniquescanbesuperficiallyusedormisusedandabused,especiallybyinadequatelytrainedorinexperiencedfamilytherapistswhodonotpaysufficientattentiontothedeeperunconsciousstrugglesofeachindividualfamilymember.Furthermore,individualpsychopathologyisoftenignoredbyMFTpractitioners,whofocusmoreonfamilypathologyordysfunction.Someindividualfamilymembersmayhavesevereformsofpsychopathologysuchasborderlinepersonalitydisorder,bipolardisorder,majordepressivedisorder,orpsychoticdisordersandthereforemaybeespeciallyvulnerabletofamilytherapyinterventionsthataretooconfrontationalorevenconfusingandparadoxical.Suchinterventionsmaybepotentiallydangerousandharmfultotheseclients.Itshouldbenoted,however,thatmoreattemptshaverecentlybeenmadeinMFTtopaymoreattentiontoindividualpsychopathologyincoupleandfamilytherapy,forexample,intreatingdifficultcoupleswhohavecoexistingmentalandrelationshipdisorders(seeSnyderandWhisman2003).Third,althoughMFTtakesseriouslytheimportanceoffactorssuchasethnicity,culture,gender,values,beliefs,spirituality,andreligionindealingwiththesystemsandsubsystemsoffamilies,certainMFTapproachesstilltendtobemorepatriarchal,male-oriented,and“white”intheirpractice.Feministtherapistshaveparticularlycriticizedmostofthepioneersoffamilytherapyasbeinginsensitivetogender,ethnicity,andculture,becausethemajorityofthemweremales(e.g.,MurrayBowenandSalvadorMinuchin),withtheexceptionofVirginiaSatir.Theinfluenceofsuch“fathers”ofMFT,withtheir 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masculinebias,isstillpresentinfamilytherapy(seeProchaskaandNorcross2010, 369;seealsoSilversteinandGoodrich2003).Thisweaknessneedstoberectifiedbypayingmoresensitiveattentiontorace,culture,andgenderintheclinicalpracticeofMFTtoday,inwhathasbeencalledthechallengeof“revisioningfamilytherapy”(McGoldrickandHardy2008).Fourth,MFT’sopennesstoexperimentationandfurtherdevelopmentofcreativeandnoveltherapeutictechniqueshasacorrespondingweakness:thelackofmore-substantialandcoherenttheorieswithadequateempiricalsupport.Advancesintheorydevelopmentaresignificantlylaggingbehinddevelopmentsinfamilytherapytechniquesthatarenotbasedinsolidoradequatetheoreticalconceptualizations.Fifth,althoughmore-recentsocialconstructionistMFTapproachesemphasizethecentralimportanceofthetherapeuticrelationshipineffectivefamilytherapy,includingadeeprespectforthefamilyasexpert,thetendencyofMFTpractitionerstofunctionasexpertsandtoimposetheirsystemicviewsandtechniquesonallfamiliesisstillpresent.Thisweaknessispotentiallydangerousandharmfultosomefamiliesthatmaynotfindsuchsystemic(e.g.,structuralandstrategic)viewsandtechniqueshelpfulatall.Sixth,theflipsideofthefifthweaknessjustmentionedisthatsomefamiliesdoneedamoredirect,structured,anddirectiveformofMFTtohelpthemwiththeirproblemsinpracticalandconcreteways.Theymaybelimitedintheirawarenessofhowtohelpthemselvesandmaynotbeabletodevisecreativesolutionstodealwiththeirdifficulties.SocialconstructionistapproachestoMFTsuchassolution-focusedfamilytherapyandnarrativefamilytherapymaythusbetoooptimisticandpositiveinassumingthatsuchfamiliesaretheirownexpertsandcandeveloptheirownsolutionstotheirproblems.Theexpertiseofthefamilytherapistisstillneededforsuchfamilies,whichcanbenefitmostfromamoredirectiveandstructuredMFTapproachthataffirmstheroleofthefamilytherapistasanexpert,yetinacollaborativeandwarmfashion(e.g.,cognitive-behavioralfamilytherapy).Seventh,someMFTapproachessuchasstructuralandstrategicfamilytherapytendtohaveclear-cutmodelsofhealthyfamiliesversusdysfunctionalfamiliesandspecificfamilytherapytechniquesforeffectingchangeinthefamilysystemandsubsystemsinwaysthatareconsistentwiththeirmodels.Thereisapotentialdangerhereofimposingsuchmodelsandtechniquesonallfamilies,withoutpayingadequateattentiontothediversityoffamiliesintermsofrace,culture,andgenderconsiderations.Onesizedoesnotfitallinhelpingfamilies.Lewis,Beavers,Gossett,andPhilips(1976),infact,foundintheirintensivestudyofpsychologicalhealthinfamilysystemsthattherewasnosinglewayorparticularstructurecharacterizinghowthesehealthyfamiliesfunctioned.MFTmustbemoreinclusiveinitstheorizingandpracticeforpluralisticsocieties,includingtheUnitedStates,wheretherearenowsignificantnumbersofsingle-parentfamilies,familieswithnochildren, _Tan_Counseling_BB_mw.indd326 9/21/104:39:18PM MaritalandFamilyTherapy 313 cohabitingcouples,gay-couplefamilies,blendedfamilies,extendedfamilies,andimmigrantfamilies(seeProchaskaandNorcross2010, 369).Eighth,anotherweaknessofMFTisthatthesystemicperspectivecanbetakentoofarandthereforebemisleading.Forexample,thesystemicviewpresentinmostMFTapproachestreatsthefamilyasasystemorunit.Itisoftenassumedthatiftheidentifiedpatientorscapegoatinadysfunctionalfamilysystemgetsbetterandnolongerhassymptoms,anotherfamilymemberwillnowbecomethenewscapegoatanddevelopsymptoms.ThisscenarioisMFT’sversionof“symptomsubstitution”inindividualtherapy,whereonesymptom,ifeliminated,mayleadtoanewsymptom(usuallyapsychodynamicorpsychoanalyticassumptionthathasnotreceivedempiricalsupport),exceptinMFTitisnow“patientsubstitution”:ifthescapegoatoridentifiedpatientinafamilysystemgetsbetterandisnolongersymptomatic,thentherewillbe“patientsubstitution,”withanotherfamilymembernowbeingthenewscapegoatandthereforebeingsymptomatic.Althoughthissometimeshappensinafamilywhereonefamilymember’simprovementleadstoanotherfamilymember’sworsening,itdoesnotalwayshappen.Infact,thewholefamilymaygetbetterwhentheidentifiedpatientorscapegoatimproves(e.g.,recoversfromsubstanceabuse).Inotherwords,noteveryprobleminafamilyisalwaysasystemsproblem.Systemstheorycanbemisapplied,anditcanalsoattimesbewrong(seeProchaskaandNorcross2010, 370).Finally,whileMFThasastrongempiricalbasegenerallysupportingitsoveralleffectiveness,someapproachestoMFTstilllacksufficientcontrolledoutcomeevaluations.MoreandbetterempiricalresearchevaluatingthetherapeuticeffectivenessofsomeoftheseMFTapproachesforspecificdisordersisthereforeneededtoaddressthisweakness.ABiblicalPerspectiveonMFTThestrengthsandweaknessesofMFTingeneralhavealreadybeencovered.AbiblicalperspectiveandcritiqueofMFTwillnowbeprovided(see,e.g.,S. L.JonesandButman1991,360–72;W.H.Watson1997;YarhouseandSells2008,287–310,493–502).First,MFT’sfocusonthecoupleorfamilyastheunitfortherapyisagoodcorrectivetotheemphasisontheindividualinmostmajortherapyapproachesandtheaccompanyingdangerofindividualismandself-obsession.MFT’suniquesystemsperspectiveissomewhatconsistentwiththeBible’semphasisoncommunityandbodylifeofthechurch(see,e.g.,1 Cor.12),includingahealthyfamilylife(see,e.g.,Eph.5:21–6:4;Col.3:18–21).However,theBiblecontainsmanymorepassagesonthebodylifeofthechurchasacommunityofbelieversinChrist,andonhowtoloveandencourageoneanother,thanonmarriageorfamilylifeinparticular(see,e.g.,Collins2007,588–90).Never- 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theless,suchbiblicalpassagesalsogenerallyapplytomarriageandfamilylife(see,e.g.,Getz1976).Second,thesystemicfocusofMFTonthefamilycanneverthelessbeoveremphasizedtothepointwherethepersonhoodoftheindividualorfamilymembercanbelost.Paradoxically,theBiblealsoemphasizestheworthandpersonhoodoftheindividualhumanbeing,whoisdeeplylovedbyGodandwhomJesuscametosavethroughhisdeathandresurrection(see,e.g.,Luke15:3–7ontheparableoftheonelostsheep,andLuke15:11–32ontheparableofthelostson;John3:16).AbiblicalperspectivewillthereforestillretainabalancedfocusontheindividualasaspecialpersoncreatedintheimageofGod(Gen.1:26–27)aswellasoncommunityandbodylifeinthechurch(see,e.g.,Bolsinger2004;Wilhoit2008),includingmarriageandfamilylife.Third,MFT’sfocusonthecoupleorfamilymayalsonotextendfarenoughtolargersystemsorinterpersonalcontextssuchasthechurchasthebodyofChrist(see,e.g.,1 Cor.12)orthekingdomofGodwhereverandwheneverandinwhomeverGodrulesandreigns.Inotherwords,abiblicalperspectivewillemphasizethelargerbodylifeofthechurchascommunityperspectiveandnotnarrowlyoveremphasizethecoupleorthenuclearfamilyoreventheindividualinaself-centeredway.Attentionshouldalsobeadequatelygiventoadditionalcontextualfactorssuchassociopolitical,cultural,economic,religious,spiritual,andotherenvironmentalfactorsthatmayimpactfamilylife.Fourth,MFTapproachestendtohavetheirowntheoreticalviewsofwhatconstituteshealthyfamilyfunctioningandwhatdoesnot,butsuchmodelsmaybelimited,deficient,andevenerroneousattimes,dependingonthefamiliesbeingseeninfamilytherapy.TheBiblehasvariousexamplesoftroubledaswellasfunctionalfamiliesandhowGodstillworkedinandthroughthem,inthediversityoffamiliesthathehascreated(seeYarhouseandSells2008,15–36).Thefewbiblicalguidelinesavailableonmarriageandfamilylifemustbeconsideredandapplied,butoverall,theBiblegivesampleroomforfamiliestogrowandfunctioninvariousanddiverseways,culturallyandspiritually.MFTpractitionersmustbecarefulnottoimposeaparticularmodelofhowhealthyfamiliesshouldlookandwhattheybelike,especiallyifthemodelisculturallybiasedwithawhite,maleperspective.Fifth,althoughMFTapproacheshavedevelopednumerouseffectivetherapeutictechniquestopracticallyhelptroubledcouplesandfamilies,aChristianfamilytherapistwillbediscerningandnotuseanyandalltechniquessimplybecausetheyworkaccordingtoempiricalresearch.Somefamilytherapytechniquessuchasparadoxicalinterventionsandotherstrategicfamilytherapyapproachesmayinvolveanelementofmanipulating,tricking,andevenlying,inthetherapist’sattemptstobringabouttherapeuticchangeinthefamilyquicklyandeffectively.Biblicalvalues,ethics,andmoralitymustbeupheldandrespected,andsomeofthesetechniquesmaybequestionableandshouldbequestionedbytheChristianfamilytherapist,eveniftheyhavebeenfound _Tan_Counseling_BB_mw.indd328 9/21/104:39:22PM MaritalandFamilyTherapy 315 empiricallytobeeffectiveandefficient.Thekeyquestionfromabiblicalperspectiveiswhethertheyarealsoethical.Sixth,abiblicalperspectivewillemphasizelovingGodandlovingothersasoneselforone’sfamily(Mark12:29–31)andtheprimacyofagapelove(1 Cor.13)asthefruitoftheHolySpirit(Gal.5:22–23),whichisgenuinelyself-transcendentandsacrificial,divinelyinspired,andother-centered,althoughitdoesincludeanappropriatekindofself-careorloveforoneselfandone’sfamily(see,e.g.,Browning2006,143–45;seealsoRoberts1993,12).AChristianperspectiveonMFTwillthereforegobeyondmodelsorgoalsthatfocusonbalance,healthyfunctioning,happinessorfulfillment,andsymptomalleviation.Itwillemphasizesacrificialloveandappropriateservanthood(seeTan2006b)basedonmutualsubmissioninChrist,insacredmarriage(Thomas2000a)andsacredparenting(Thomas2004)thatstrivemoreforholinessandgrowinginChristlikenessthansimplyforhappiness.HelpfulbiblicalorChristianmodelsareavailableformarriagebasedoncovenant,grace,empowerment,andintimacy(e.g.,BalswickandBalswick2006)andforthefamily(e.g.,BalswickandBalswick2007;seealsoR. S.AndersonandGuernsey1985;Ouellet2006).Seventh,abiblicalperspectiveonMFTwillincludenotonlyaChristianunderstandingofmarriageandthefamilybutalsoanintegrativeapproachtoChristianfamilytherapy.YarhouseandSells(2008,15–37,287–310,493–502)haveprovidedahelpfuldescriptionofsuchanintegrativeChristianfamilytherapythatisbiblicallybasedintermsofthreemajoraspectsofmaritalandfamilylife:familyfunctioning(e.g.,individualandsystematic;familyrules;andfamilypatternorsequencesofinteraction);familyrelationships(e.g.,intrapersonal,interpersonal,andgenerationalrelationships);andfamilyidentity(e.g.,culture,gender,religion,socioeconomicstatus;definition,locatingselfintheworld,andworldview;andmeaning,significance),basedonthethemesoffunction,structure,andrelationshipasaspectsoftheimageofGod,orimagoDei,inwhichhumanbeingsarecreated(seeMcMinnandCampbell2007).TheChristianfamilytherapistcanbeeclecticinusingvariousMFTapproachesandtechniquesbutisclearlycommittedtoabiblicalperspectiveonmarriageandthefamily.BasedonbiblicaltextssuchasRuth1:16–18,Ephesians5:21–33,and2 Timothy1:5,YarhouseandSells(2008)emphasizethefollowingcrucialcharacteristicsofChristianfamilyrelationships:dependenceonGod,mutuality,self-denial,perseveranceorresilience,andintegrity(2008,28–32).Eighth,more-recentsocialconstructionistMFTapproachessuchassolution-focusedandnarrativefamilytherapyhaveacollaborativetherapeuticrelationshipwiththefamily,affirmingeachfamilymember’scapacitytochooseandtoengageingrowthandtherapeuticchangebydevelopingtheirowncreativesolutionsandconstructivenarratives.Althoughthisemphasisonthefamilymember’sfreewillandcreativecapacitiesissomewhatconsistent _Tan_Counseling_BB_mw.indd329 9/21/104:39:23PM 316 MajorCounselingandPsychotherapyTheoriesandTechniques withabiblicalperspective,whichalsoaffirmsone’sfreedomtochoose(Josh.24:15)aswellastheimageofGodineachhumanpersoncreatedbyGod(Gen.1:26–27),itdoesnotadequatelyacknowledgeanddealwiththefallen,sinfulnatureofahumanbeing,whichiscapableofevilandevencruelty(Jer.17:9;Rom.3:23).SystemicapproachestoMFTalsodonotfocussufficientattentionontheinnerpartor“heart”ofeachfamilymember(see,e.g.,Pss.51:6;139:23–24;Jer.17:9;Matt.15:18–19),whereinternalconflictsandunconsciousmotivesandevilmotivationsmaybepresentandthereforemustbeaddressed.TheneedforsalvationthroughfaithinJesusChristasLordandSavior(John3:16;Rom.6:23)andtheempoweringpresenceandfillingoftheHolySpirit(Zech.4:6;Eph.5:18)inordertobetrulytransformedaspersons,includingcouplesandfamilies,isemphasizedinScriptureinsteadofself-sufficiency.Creativesolutionsandmeaningfulnarrativesalsomustbebiblicallybasedandgroundedintheobjective,eternaltruthoftheBible,whichcontainsGod’smetanarrative,orbigstory(cf.2 Tim.3:16).Ninth,abiblicalperspectivewillemphasizethecrucialimportanceofforgivenessandrealisticattemptsatreconciliationwhereappropriate(see,e.g.,Matt.5:23–24;18:15–17;Rom.12:18;Eph.4:32).AChristianapproachtoMFTwillthereforegobeyondjusticeorfairnessandfocusonpracticingagapelove,includingforgiveness(see,e.g.,Hargrave1994;Worthington2003,2005a,2005b).Finally,MFTtendstohavepragmaticandutilitarianemphasesinhelpingcouplesandfamilies,focusingmainlyondoingwhatworks,and“fixingthings,”whichcanresultinfamilymembersbeingtreatedasobjectsratherthanvaluedandrespectedaspersonscreatedintheimageofGod(seeS. L.JonesandButman1991, 370).AbiblicalapproachtoMFTwillfocusmoreonscripturalvaluesandstandardsandspiritual,evenmystical,aspectsoftheChristianlife,whicharenotalwaysconsistentwithpragmaticandutilitarianemphases(cf.Tan1987a).Research:EmpiricalStatusofMFTOutcomeresearchontheempiricalstatusofMFT,referringusuallytotheformatofseeingcouplesorfamiliestogetherfortherapyaswellastomorespecificMFTapproachestotherapy,willnowbebrieflysummarized(seeProchaskaandNorcross2010,361–66;Sharf2008,510–12;ToddandBohart2006,358–59).Atleasttwentymeta-analyseshavenowbeenpublishedontheoveralleffectivenessofMFT.W. R.ShadishandS. A.Baldwin(2003),inaquantitativereviewoftwentymeta-analyses,reachedthefollowingconclusionsabouttheempiricalstatusofMFT(seeProchaskaandNorcross2010,362–63):1.TheaverageeffectsizeofMFTwasfoundtobe.65comparedtonotreatmentcontrols,showingMFTtobegenerallyeffectivewitha65percent _Tan_Counseling_BB_mw.indd330 9/21/104:39:25PM MaritalandFamilyTherapy 317 treatmentsuccessratecomparedtoonly34percentinno-treatmentcontrolgroups.2.TreatmenteffectsofMFTdecreasesomewhatovertimewithaneffectsizeof.52atfollow-up.3.Theaverageeffectsformaritalorcoupletherapy(d=.84)aresomewhathigherthantheeffectsoffamilytherapy,withatreatmentsuccessrateofabout80percentformaritalorcoupletherapycomparedto30percentforno-treatmentcontrolgroups.4.MostMFTapproacheswhendirectlycomparedtooneanothershowednosignificantdifferencesamongthemintermsoftheirrelativeeffectiveness.However,Satir’sapproachandperson-centeredtreatmentswerefoundtoberelativelyinferiorandbehavioralmaritaltherapytoberelativelysuperiorintreatmenteffectiveness.5.MFTapproacheshavebeenfoundtobeaseffectiveas,andsometimesmoreeffectivethan,othertypesoftreatment,suchasindividualpsychotherapyandgrouptherapy.Shadishandhiscolleagues(Shadish,Ragsdale,Glaser,andMontgomery1995)earlierconcludedthattheempiricalevidencefrommeta-analysesavailablethenindicatedatiebetweenindividualtherapyandfamilytherapyintermsoftreatmenteffectiveness,withmoderateandfrequentlyclinicallysignificanteffects.ThefieldofMFTcontinuestodevelopdiversemethodologiesinactivelyconductingresearchonfamilytherapy(seeSprenkleandPiercy2005).AlanGurman(2003)andGurmanandPeterFraenkel(2002),intheirreviewsoftheoutcomeresearchmorespecificallyfocusedonmaritalorcoupletherapy,foundtheaverageeffectsizetobe.80orgreater,similartothatreportedbyShadishandBaldwin(2003).ToddandBohart(2006, 358)notedthatthetwomaritalorcoupletherapyapproacheswiththemostoutcomeresearchsupportfortheirtreatmenteffectivenessarebehavioralmaritaltherapy(seealsoShadishandBaldwin2005)andemotion-focusedtherapy(oremotionallyfocusedtherapy),withsomeempiricalsupportfortheeffectivenessofstructuralorstrategicapproaches.Forbehavioralmaritalorcoupletherapy,theresultsofarecentfive-yearfollow-upstudyshowedthatintegrativebehavioralcoupletherapyhadsignificantlybutnotdramaticallybetteroutcomesthantraditionalbehavioralcoupletherapyforthefirsttwoyearsaftertreatmenttermination,butsubsequentfindingsyieldedmoresimilarityandnonsignificantdifferencesinoutcomeoverlongerperiodsoffollow-upbetweenintegrativebehavioralcoupletherapyandtraditionalbehavioralcoupletherapy(A. Christensen,Atkins,Baucom,andYi2010).Withregardtothemorespecificareaoffamilytherapy,positiveandequivalenttreatmenteffectshavebeenfoundforbehavioral,systemic,psychodynamic,andeclecticapproachestofamilytherapy(Shadish,Ragsdale,Glaser,andMontgomery1995).However,forspecificdisorders,ThomasSexton,James 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Alexander,andAlysonMease(2004)reportedthatfunctionalfamilytherapy(SextonandAlexander1999)andmultisystemictherapyor(MST)(Henggeleretal.1998,2009)bothofwhicharebehaviorallyorientedfamilytherapies,aremoreeffectivethanotherfamilytherapyapproachesfortreatingconductdisorderandsubstanceabuse,especiallyinadolescentfamilymembers(seeToddandBohart2006, 359;seealsoSexton,Weeks,andRobbins2003).MSThasalsobeenfoundtobeaneffectivetreatmentforjuvenilesexualoffenders(seeBorduin,Schaeffer,andHeiblum2009).Sharf(2008, 510)concludedthatreviewsofoutcomeresearchontheeffectivenessoffamilytherapyhavegenerallyshownfamilytherapytobehelpfulforvarioustypesofclinicalproblemsandtobeatleastequivalentineffectivenesstootherapproachestotherapy(see,e.g.,FriedlanderandTuason2000;Pinsof,Wynne,andHambright1996).Healsonotedthatsomeresearch(notallcontrolledoutcomestudies)supportstheeffectivenessofBowenian,behavioral,MRI(MentalResearchInstitute),structural,theMilanGroup,andpsychoeducationalapproachestofamilytherapy.Lebow(2008, 329),however,observedthatthereisverylittleresearchsupportforseveralwidelypracticedMFTapproachesincludingBowen,narrative,strategic,andsolutionfocused.ThecontrolledoutcomeresearchontheeffectivenessofMFTapproacheshasalsobeenreviewedforfivespecificdisorders:alcoholdependence,drugabuse,childhoodobesity,conductdisorder,andschizophrenia.Overall,theempiricalevidenceavailabletendstosupporttheeffectivenessofsomeMFTapproachesfortreatingthesedisorders(ProchaskaandNorcross2010,363–65).Morespecifically,Satir’sconjointfamilytherapyorcommunicationapproachhasbeenevaluatedinonlyafewdirectoutcomestudies,whichhavefoundnonsignificanteffectsizes(Shadishetal.1993).Strategicfamilytherapyhasbeenfoundinmeta-analysestoberobustinitstherapeuticeffectivenessfortreatingsubstanceabusers(Shadishetal.1993;StantonandShadish1997)butuncertainfortreatingschizophrenia,anxietydisorders,andpsychosomaticconditions(Gurman,Kniskern,andPinsof1986;Sandbergetal.1997).Basedonafewcontrolledoutcomestudies,structuralfamilytherapyisprobablyeffectiveintreatingsubstanceabuse,conductdisorders,andpsychosomaticconditions(Sandbergetal.1997;StantonandShadish1997),butithasnotbeensufficientlyevaluatedforitseffectivenesswithschizophrenia,anxietydisorders,mooddisorders,andotherchildhooddisorders(ShadishandBaldwin2003).Bowenianfamilytherapyhasapparentlynotbeenevaluatedinrandomized,controlledoutcomestudies(Sandbergetal.1997;ShadishandBaldwin2003)andthereforeremainslargelyuntested(seeProchaskaandNorcross2010,365–66).TheempiricalstatusofMFTisthereforegenerallysolid,withcontrolledoutcomeresearchsupportingtheoveralltherapeuticeffectivenessofmostMFTapproaches.However,furthercontrolledoutcomeresearchisstillneededto 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evaluatetheeffectivenessofsomeMFTapproachesthathaveonlyanecdotaldataoruncontrolledcasestudiesrelatingtotheirpotentialusefulness.FutureDirectionsMFThascontributedauniquesystemicperspectiveontreatingthecoupleorthefamilyasaunitanddoingsomainlyinarelativelyshort-term,problemsolving,orsolution-orientedway,usingnumeroustherapeutictechniquestoeffectivelyhelpcouplesandfamilies.MFTwillthereforecontinuetoreceivegreaterattentionintheyearsaheadasincreasingnumbersofcouplesandfamiliesseekconcrete,practicalhelpfortheirproblems.Italsofitsmanagedcare’spreferenceforfundingempiricallysupported,short-termtherapyapproaches(seeGoldenbergandGoldenberg2008a, 433).MFTcandevelopinseveralpromisingdirectionsinthenearfuture(seeProchaskaandNorcross2010,372–73).First,itwillcontinuetoextendtheapplicationofasystemicperspectiveandtherapytoareasotherthanthenuclearfamily,includinglargersystemsandcontextssuchasorganizations,includingreligiousinstitutions(see,e.g.,Friedman1985),schools,andcommunities.Paradoxically,MFTwillalsobeappliedmorefrequentlytothetreatmentoftheindividualclientwhohascoexistingmentalandrelationshipdisorders(see,e.g.,SnyderandWhisman2003),sothatindividualpsychopathologywillalsobemoreadequatelyaddressedinMFT.Itwillcontinuetobeappliedtomedicalareassuchasfamilysystemsmedicine,whichinvolvestheintegrationoffamilymedicineandfamilytherapy.Morespecifically,familytherapyhasbeeneffectivelyusedtotreatclientswithalcoholdependenceanddrugabuseproblems,andcoupletherapyforthosewithdementia,sexualdifficulties,andcardiovasculardisease(Pinsof,Wynne,andHambright1996;Snyder,Castellani,andWhisman2006).Second,furtherworkwilllikelybedonetoestablishamoreconsensualandconsistentdiagnosticsystemfortheassessmentofdysfunctionalfamilies.TheDSM-IV(AmericanPsychiatricAssociation1994),thecommonlyusedtraditionaldiagnosticsystemforpsychiatricormentaldisorders,doesnotadequatelyfocusontherelationalcontextofindividualpsychopathology.AssessmentofrelationalfunctioninganddysfunctioningmaybeincludedinthenextDSMedition.AsubstantialefforthasalreadybeenmadebyvariousorganizationsinpublishingtheHandbookofRelationalDiagnosisandDysfunctionalFamilyPatterns(F. Kaslow1996),whichwillbeofsignificanthelpinfurtherdevelopingamoreconsensualandformaldiagnosticsystemfordysfunctionalfamilies.Third,MFTapproacheshavegraduallybecomelessdistinctandmoreintegrativeovertheyears,andthismovementtowardgreaterintegrationandeclecticismwillprobablycontinuetogrowinthecomingdecades.Infact,betweenone-thirdandone-halfoffamilytherapistswhorespondedtolarge 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surveysindicatedthattheirtheoreticalorientationiseclectic(see,e.g.,Lebow1997).Fourth,MFTapproacheswillbecomemoresensitivetorace,culture,andgenderissuesinclinicalpracticeasmorefamilytherapistsrespondtothechallengeofrevisioningfamilytherapy(McGoldrickandHardy2008;seealsoMcGoldrick,Giordano,andGarcia-Preto2005).Fifth,justasthebroaderfieldofcounselingandpsychotherapyhasbecomemoresensitivetospiritualandreligiousissuesandtheappropriateuseofspiritualandreligiousresourcesintherapyinrecentyears,theMFTfieldwillalsocontinuetobeinvolvedindevelopingandusingspiritualandreligiousresourcesinfamilytherapy(seeF. Walsh2009).Finally,trainingandcertificationasamaritalandfamilytherapistintheUnitedStateswillincreasinglyrequirethecompletionofagraduatedegreeinMFTfromanaccreditedprogramandbeinglicensedinthestateinwhichtheMFTpractitionerisresidingandengaginginindependentclinicalpractice.However,manygraduateprogramsinprofessionalpsychology(suchasclinicalandcounselingpsychologydoctoralprograms),socialwork,andcounselingorcounseloreducationincludesometraininginMFT.Theinfluenceofsystemictheoriesandtherapyapproacheswillcontinuetobesignificantinthebroaderfieldofcounselingandpsychotherapy,althoughthemoreformalcertificationandrecognitionofMFTpractitionerswhoarelicensedinspecificstatesintheUnitedStateswillbecomestricterandmoreinstitutionalized.TherearemanyMFTorganizationsworldwide,buttwoimportantonesaretheAmericanAssociationforMarriageandFamilyTherapy(AAMFT),foundedin1942,whichpublishestheJournalofMaritalandFamilyTherapyandtheFamilyTherapyMagazine,whichitsmorethantwenty-fourthousandmembersreceiveaspartoftheirmembershipbenefits(www.aamft.org);andtheInternationalAssociationofMarriageandFamilyCounselors(IAMFC),adivisionoftheAmericanCounselingAssociation(ACA),whichpublishestheFamilyJournal,whichitsmembersreceiveaspartoftheirmembershipbenefits(www.iamfc.com)(seeCorey2009,440–41).ThereisalsotheDivisionofFamilyPsychology(Division43)oftheAmericanPsychologicalAssociation(www.apa.org/divisions/div.43/).MFTwillthereforecontinuetogrowasadiversefieldintheyearstocome.RecommendedReadingsBitter,J. R.(2009).Theoryandpracticeoffamilytherapyandcounseling.Belmont,CA:Brooks/Cole.Goldenberg, I.&Goldenberg, H.(2008).Familytherapy:Anoverview(7thed.).Belmont,CA:Brooks/Cole. _Tan_Counseling_BB_mw.indd334 9/21/104:39:31PM MaritalandFamilyTherapy 321 Gurman,A. S.(Ed.).(2008).Clinicalhandbookofcoupletherapy(4thed.).NewYork:GuilfordPress.Sexton,T. L.,Weeks,G. R.,&Robbins,M. S.(Eds.).(2003).Handbookoffamilytherapy:Thescienceandpracticeofworkingwithfamiliesandcouples.NewYork:Brunner-Routledge.Walsh, F.(Ed.).(2009).Spiritualresourcesinfamilytherapy(2nded.).NewYork:GuilfordPress.Yarhouse,M. A.,&Sells,J. N.(2008).Familytherapies:AcomprehensiveChristianappraisal.DownersGrove,IL:IVPAcademic. _Tan_Counseling_BB_mw.indd335 9/21/104:39:31PM _Tan_Counseling_BB_mw.indd336 9/21/104:39:31PM Part3 AChristianApproachtoCounselingandPsychotherapy _Tan_Counseling_BB_mw.indd337 9/21/104:39:31PM _Tan_Counseling_BB_mw.indd338 9/21/104:39:31PM 14ChristianTheologyinChristianCounselingABiblicalPerspectiveonHumanNatureandEffectiveCounselingandPsychotherapy A significantcontemporarydevelopmentinclinicalpracticeistheintegrationofreligionorspiritualityandpsychotherapy(see,e.g.,AtenandLeach2009;CashwellandYoung2005;DowdandNielsen2006;Frame2003;GriffithandGriffith2001;G. Miller2003;W. R.Miller1999;Nelson2009;PaloutzianandPark2005;Pargament1997,2007;Plante2009;RichardsandBergin2000,2004,2005;Shafranske1996;Sorenson2004;SperryandShafranske2005;F. Walsh2009).Morespecifically,theintegrationofChristianfaithandpsychotherapy,orChristiantherapy,hasalsowitnessedtremendousgrowthinrecentyears(seeN. T.Anderson,Zuehlke,andZuehlke2000;Benner1998;ClintonandOhlschlager2002;Clinton,Hart,andOhlschlager2005;Collins2007;I. F.Jones2006;MalonyandAugsburger2007;McMinn1996;McMinnandCampbell2007;Pugh2008;seealsoR. S.Anderson1990;S. L.JonesandButman1991;Stevenson,Eck,andHill2007;Yarhouse,Butman,andMcRay2005;YarhouseandSells2008).ThenextfourchaptersofthisbookwillfocusspecificallyonaChristianapproachtotherapythatisChristcentered,biblicallybased,andSpiritfilled(seeTan2001b;seealsoTan1996c).Inthischapter,abiblicalperspectiveonhumannatureandeffectivetherapywillbediscussed.Itemphasizesthecrucialandcen325 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tralroleofChristiantheologyorScriptureinChristiancounseling(Tan1991,2001b;seealsoCollins1993;Crabb1977,1987;Farnsworth1996;HurleyandBerry1997a,1997b;Porter2010a,2010b;WelchandPowlison1997a,1997b).ChristianTheologyinChristianCounseling:ApproachestoIntegrationofChristianFaithandPsychologyAlthoughtherearevariousapproachestoChristiancounseling,theroleofChristiantheologybasedonScriptureortheBibleinChristiancounselingiscrucialandcentral(Tan2001b).SuchintegrationofChristianfaithorChristiantheologyandcounselingcanbeconceptualizedusingmanydifferentmodels.B. E.Eck(1996)hasprovidedahelpfulsummaryoftwenty-sevenmodelsofintegrationofChristiantheologyandpsychology(includingcounselingandpsychotherapy)thatcanbeorganizedintothreemajorparadigms:thenonintegrativeparadigm,themanipulativeparadigm,andthenonmanipulativeparadigm.Thefollowingishissuccinctdescriptionofthesethreemajorparadigmsofintegration:TheNon-IntegrativeParadigmdoesnotseekintegrationofthedatabutratherbuildsitsunderstandingofGod’struthononedisciplinealone.TheManipulativeParadigmseekstointegratethedataofbothdisciplines,butthedataofonedisciplinemustbealteredbeforebecomingacceptabletotheotherdiscipline.Thefinalparadigm,theNon-ManipulativeParadigm,acceptsthedatafrombothdisciplinesdirectlyintotheintegrativeprocess.Eachparadigmcontainscertainprocessesthatdefinethemethodforhowthedataofeachdisciplinewillbeintegrated.TheNon-IntegrativeParadigmcontainsonlytheRejectsProcess;theManipulativeParadigmcontainsboththeReconstructsProcessandtheTransformsProcess;andtheNon-ManipulativeParadigmutilizestheCorrelatesProcessandtheUnifiesProcess.(Eck1996, 103) Anotherwayofsummarizingthevariousmodelsorparadigmsofintegrationistodescribethemintermsoffourbasicapproaches(seeJ. D.Carter1996;J. D.CarterandNarramore1979):Christianityagainstpsychology(usuallyheldbybiblicallymilitantandconservativeChristians);Christianityofpsychology(usuallyheldbythosewithmoreliberaltheologicalviews);theparallelsmodelorapproach(Christianityandpsychologyareseenasequallyimportantbutessentiallyseparatefields);andChristianityintegratespsychology.Lawrence J.Crabb(1977)hasmoresimplydescribedthesefourbasicapproachestointegrationthus:(1) separatebutequal;(2) tossedsalad(equalandmixable);(3) nothingbuttery(psychologyisunnecessaryandirrelevantbecauseonlytheBibleisneededtodealwithhumanproblemsandneeds);and(4) spoilingtheEgyptians(usingwhateverconceptsortechniquesfromsecularpsychologythatareconsistentwithScriptureortheBible,withtheBiblehavingfinalauthority). _Tan_Counseling_BB_mw.indd340 9/21/104:39:32PM ChristianTheologyinChristianCounseling 327 AnotherdescriptionoffourmajorviewsontherelationshipofpsychologyandChristianityisthefollowing(seeE. L.JohnsonandJones2000;seealsoE. L.Johnson2010):(1) alevels-of-explanation(scientific)view(Myers2000);(2) anintegrationview(Collins2000);(3) aChristianpsychologyview(Roberts2000);and(4) abiblicalcounselingview(Powlison2000).TheapproachtoChristiancounselingthatIproposeanddescribeinthisbookisconsistentwiththeChristianityintegratespsychologyapproach(J. D.CarterandNarramore1979)orthespoilingtheEgyptians(Crabb1977)approachtointegrationofChristianfaithandpsychology(includingcounselingandpsychotherapy).However,itisalsoconsistentwitharecentemphasisongoingbeyondintegrationtodevelopadistinctlyChristianpsychologythatismoresubstantiallygroundedinbiblicalandhistoricaltheologyandultimatelyinScriptureitself,asEricJohnson(2007)hasadvocatedanddescribed(seealsoRoberts2000).TheroleofScriptureorChristiantheologyisthereforecentraltomydescriptionofaChristiancounselingapproachthatisChristcentered,biblicallybased,andSpiritfilled(Tan2001b;seealsoTan1991).ThusScripturehasultimateauthoritybecauseitistheinspiredWordofGodthatdoesdealwiththemajorissuesandproblemsofhumanbeings,especiallywhenproperlyinterpretedinthematicandextendedapplicationcontexts(Crabb1977,1987;seealsoFarnsworth1996;Porter2010a,2010b).TheBibleiscomprehensive,evenifitisnotexhaustive(cf.S. L.Jones1996),regardinghumanbeingsandtheirfunctioninganddysfunctioning,andthereforeitisfoundationalforatrulyChristianpsychologyandChristiancounselingandsoulcare(E. L.Johnson2007).BasicChristiantheologymustbecarefullyunderstood,withthebestofbiblicalinterpretation,andthenappliedtothecontextofChristiantherapy,thusprovidingthebiblicalbasisofChristiancounselingforpeoplehelpers(Collins1993;seealsoCollins2007).MyapproachtoChristiancounselingresonatesmostwiththeintegration(Collins2000),Christianpsychology(Roberts2000;seealsoE. L.Johnson2007),andbiblicalcounseling(Powlison2000)viewsontherelationshipofpsychologyandChristianity(seealsoDueckandLee2005;Entwistle2010;McMinnandPhillips2001;Moriarty2010;Worthington2010).Itbuildsbridgeswithbiblicalcounselorsandappreciatesallthatistrulybiblical(seeMonroe1997).Italsoemphasizespersonalorintrapersonalintegration(i.e.,aperson’sownappropriationofpsychologicalandspiritualexperience,includingone’sspiritualityinChrist)asthemostfoundationalareaofintegration(Tan2001b),withthethreemajorareasofintegration(Malony1995)beingprincipled(theoretical-conceptualandresearch),professional(clinicalorpractice),andpersonal(intrapersonal,includingspirituality).BasicChristiantheologyusuallycoversthefollowingmajortopicsasCollins(1993)hasbrieflydescribedandappliedtoChristiancounseling:Bibliology(thedoctrineofScripture),theologyproper(thedoctrineofGodtheFather),Christology(thedoctrineofGodtheSon),pneumatology(thedoctrineofGodtheHolySpirit),anthropology(thedoctrineofhumanbeings),hamartiology _Tan_Counseling_BB_mw.indd341 9/21/104:39:34PM 328 AChristianApproachtoCounselingandPsychotherapy (thedoctrineofsin),soteriology(thedoctrineofsalvation),ecclesiology(thedoctrineofthechurch),angelology(thedoctrineofangels),andeschatology(thedoctrineofthefuture).ThesearemajorChristiandoctrinesusuallyexplainedinsomedetailinsystematictheologybooks(see,e.g.,Grudem1994).MuchmoreworkmustbedoneinunderstandingandapplyingsuchChristiantheologytoChristiantherapycontexts,especiallywithmoretheologicaldepthandsophistication(seeJ. R.Beck2006).Acrucialtopiccoveredinpreviouschaptersonthemajorapproachestotherapyconcernstheirperspectiveonhumannature.InChristiantherapy,abiblicalperspectiveonhumannatureisalsoacriticalandfoundationaltopic.Muchintegrativeworkinthisareaofbiblicalanthropologyhasbeenrecentlypublished,withsomesubstantialandhelpfulattemptsattheologicalandpsychologicalintegration(e.g.,Balswick,King,andReimer2005;J. R.BeckandDemarest2005;W. S.Brown,Murphy,andMalony1998;BruggerandtheFacultyofInstituteforthePsychologicalSciences2008;Corcoran2006;Green2008;L. W.HoffmanandStrawn2009;Lints,Horton,andTalbot2006;Puffer2007).ABiblicalPerspectiveonHumanNatureAbiblicalperspectiveonhumannature(biblicalanthropology)focusesontheessentialoruniquecharacteristicsofhumanbeings,basedonScripture(seePuffer2007, 45).BiblicallybasedviewsofhumannaturevaryevenamongChristiantheologiansandtherapists.Forexample,animportanttopicinbiblicalanthropologythathasreceivedmuchattentionanddebateinrecentyearsisthenatureofthesoul,andevenwhetherahumanbeinghasasoul(see,e.g.,N. Murphy2006).Themoretraditionalviewsassumesomeformofdualisminahumanbeingwithbody-soulorbody-mindcomposition,oreventrichotomismwithbody,soul,andspiritcomposition(seeN. Murphy2006,95–98).Analternativeviewthathasbeenrecentlygainingsupportisnonreductivephysicalism(N. Murphy2006)whichassumesthatahumanbeing’sessentialnatureisbasicallysynonymouswithhisorherphysicalbody(includingthebrain),andthusthereisnoseparatesouloftheperson,with“soul”referringinsteadtothecapacitytorelatetoGod(seealsoW. S.Brown,Murphy,andMalony1998;Corcoran2006;Green2008;JeevesandBrown2009).However,thisdebatecontinues,withstrongcriticismsofthenonreductivephysicalismview(whichattemptstotakeneuroscienceseriouslyinatheologicalcontext)byotherwell-knownChristianscholarswhoespouseamoretraditionaldualisticviewofthehumanbeing,whodoeshaveabodyandasoulorisabody-soulincomposition(seeJ. R.BeckandDemarest2005,203–9;J. W.Cooper1989;GreenandPalmer2005).Whetheroneacceptsamoretraditionaldualisticviewofthehumanbeingorespousesanonreductivephysicalismviewofhumannature,itisstillcrucial _Tan_Counseling_BB_mw.indd342 9/21/104:39:35PM ChristianTheologyinChristianCounseling 329 tohaveabasicbiblicalperspectiveonhumannaturetoguidetheprocessandpracticeofChristiancounseling.KeithPufferhasrecentlydescribedamodestproposalofsevenessentialbiblicalassumptionsabouthumannatureandsummarizedtheminthefollowingstatement:“HumansarecreatedbeingsfashionedintoGod’simage.Fallenwithasinfulnatureandstrivingtofindmeaning,peoplearealsoredeemable,dwellablebyGod’sSpirit,andtransformableforGod’spurposes”(2007, 46).Heprovidesfurtherimplicationsofthefollowingsevenessentialbiblicalassumptionsabouthumanbeingsorhumannature:theyare(1) createdbeings;(2) fashionedintheimageofGod;(3) fallenwithasinnature;(4) strivingtofindmeaning;(5) redeemable;(6) dwellablebytheSpiritofGod;(7) transformableforGod’spurposes(Puffer2007,47–53).Inproposinganddescribingabiblicalmodelforeffectivelaycounselingsomeyearsago,Iincludedthefollowingsummaryofabasicviewofhumanityorhumannaturefromabiblicalperspective:1.Basicpsychologicalandspiritualneedsincludeneedsforsecurity(love),significance(meaning/impact),andhope(forgiveness).2.Basicproblemissin—butnotallemotionalsufferingisduetopersonalsin.3.UltimategoalofhumanityistoknowGodandhavespiritualhealth.4.Problemfeelingsareusuallyduetoproblembehaviorand,morefundamentally,problemthinking—however,biologicalanddemonicfactorsshouldalsobeconsidered.5.Holisticviewofpersons—allhavephysical,mental/emotional,social,andspiritualdimensions.(Tan1991,50–51)Thisbasicviewofhumannaturefromabiblicalperspectiveisnotanexhaustiveorevencomprehensivetreatmentofthevastandcomplextopicofbiblicalanthropology.ItisanattempttodescribefivebasicbiblicallybasedassumptionsofhumannaturethathaveparticularrelevancetoeffectiveChristiancounseling(seeTan1991,34–39,50–51),whichwillnowbecoveredinmoredetail.First,thebasicpsychologicalandspiritualneedsofhumanbeingsincludetheneedsforsecurity(love)andsignificance(purpose)(Crabb1977)andforhope(forgiveness)(Adams1973).ThebasichumanneedsforsecurityandsignificancehavebeenrephrasedbyCrabbas“deeplongingsinthehumanheartforrelationshipandimpact”(1987,15),whichcanonlybefullymetinthecontextofapersonalrelationshipwithJesusChristasone’sLordandSavior.Suchlongingsorneedswillnotbecompletelysatisfiedwhileonelivesinasinful,fallenworldthatisimperfect;hence,completefulfillmentofthemintheLordcanonlybeexperiencedinheaventocome.However,theycanbesubstantiallysatisfiedbysurrenderingourself-protectivedefensesand 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dependingmorefullyonJesusChristtoempowerustoliveourlivesaccordingtohiswill,includingbeinginvolvedinacaringcommunityofbelieversinalocalchurchcontext.Althoughthebasicpsychologicalandspiritualneedsofhumanbeingscanbedescribedinvariousways,dependingonone’stheoreticalandtheologicalviewpoint,suchbasichumanlongingsincludetheneedsforsecurity(love/relationship),significance(purpose/impact),andhope(forgiveness).Second,fromabiblicalperspectivehumanity’sbasicproblemissin.Allhumanbeingshavesinnedandthereforearefallenpeople(Rom.3:23),yettheyhavebeencreatedintheimageofGod(Gen.1:26–27),withafreedomorcapacitytochoose(Deut.30:19;Josh.24:15).DisobeyingGod’smorallawsasrevealedinScriptureandbelievingthesatanicdeceptionorliethatwecanhandleourownlivesandfulfillourbasicneedsandlongingswithoutGodunderliemostpsychologicaloremotionalproblemsthatdonothaveobviousorganicbases(Crabb1977;seealsoAdams1970).However,thisdoesnotmeanthatallemotionalsufferingisduetopersonalsinoreventhesinsofothers.Sometimes,emotionalpainissimplypartoflivinginafallen,sinful,imperfectworld.Paradoxically,emotionalanguishcanalsoattimeshavenothingtodowithsinatall;itmayinsteadresultfromtheprocessofbeingperfectedbyGodintodeeperChristlikeness(i.e.,sanctification)andthusfromobediencetoGod’swill,andnotsinfuldisobedience.JesushimselfexperienceddeepanguishandemotionalandspiritualsufferingintheGardenofGethsemane(seeGrounds1976)ashestruggledwiththeFather’swillforhimtogotothecrossanddieforsinfulhumanityinordertosaveus(Matt.26:36–39;Mark14:32–36;Luke22:40–44).Yetheneversinned(Heb.4:15).Wemustthereforediscernanddifferentiatebetweensin-inducedemotionalsufferingandanguishthatissometimespartoftheprocessofgrowingasaChristianintodeeperChristlikenessandobediencetoGod’swill.Thereare“mystical”aspectsofthespirituallifeinChristthatincludeprocessesandexperiencesthatarenoteasilycomprehended,suchasthe“darknightofthesoul”accordingtoSt.JohnoftheCross(cf.Isa.50:10).RichardFosterhasdescribedsuchanexperiencethus:The“darknight”. . .isnotsomethingbadordestructive. . . .Thepurposeofthedarknessisnottopunishorafflictus.Itistosetusfree. . . .Whatisinvolvedinenteringthedarknightofthesoul?Itmaybeasenseofdryness,depression,evenlostness.Itstripsusofoverdependenceontheemotionallife.Thenotion,oftenheardtoday,thatsuchexperiencescanbeavoidedandthatweshouldliveinpeaceandcomfort,joyandcelebration,onlybetraysthefactthatmuchcontemporaryexperienceissurfaceslush.ThedarknightisoneofthewaysGodbringsustoahush,astillness,sothatHecanworkoninnertransformationofthesoul.. . .Recognizethedarknightforwhatitis.BegratefulthatGodislovinglydrawingyouawayfromeverydistractionsothatyoucanseeHim.(Foster1978,89–91) _Tan_Counseling_BB_mw.indd344 9/21/104:39:37PM ChristianTheologyinChristianCounseling 331 IhavethuspreviouslywrittenabouttheneedforChristiancounselorsandtherapiststobetterunderstandandthusmoreappropriatelyhelpclientswhoareexperiencingmysticalaspectsofthespirituallifeinChrist,suchasthedarknightofthesoul:Fromapsychologicalperspective,Christianpsychologistsneedtohaveabetteracquaintancewithsuchprocessesofthespirituallifeasthedarknightofthesoul. . .sothattheydonotnaivelyorprematurelyattempttoreduceallpainfulsymptoms,butrathertoappropriatetheirmeaningfirst.Thiswillrequirenotonlypsychologicalassessmentskillsbutspiritualwisdomanddiscernmentaswell.Sometimesthereisnoeasysolutionortherapyorhealing,buttotrustGodandHisgracetohelppeoplegrowthroughsuchdeepeningandpainfulspiritualexperiences.Thebesttherapythenistoprovideunderstanding,support,andmuchprayer.(Tan1987b, 37) Moreattentionhasrecentlybeengiventothephenomenonofspiritualstruggle,whichincludesexperiencessuchasthedarknightofthesoul,intheliteratureonpsychologyandreligion(Pargament,Murray-Swank,Magyar,andAno2005)andinspirituallyintegratedpsychotherapy(Pargament2007).Third,theultimategoalofhumanityistoknowGodandenjoyhimforever;hencespiritualhealthisprimary.TheendgoalinlifeforaChristianistoobeyGod’swillandgrowinmaturityinChristortobecomemorelikeChrist(Rom.8:29).Thismayinvolvesufferingattimes,butGodhaspromisedtoprovidesufficientgraceandtoempowerusinourweakness(2 Cor.12:7–9).Althoughmentalandphysicalhealthareworthwhileandacceptablegoalstoachieve,fortheChristiantheyarealwayssecondaryandsubordinatetotheendgoalofspiritualhealthandmaturityinChrist.Theabsenceofemotionalpain,orhappinessatallcosts,isthereforenottheultimategoaloflifeonearthfortheChristian.Biblicalperspectivesonsuffering,includingwhatC. S.Evans(1986)hascalled“theblessingsofmentalanguish,”needtobeaffirmed.Evanshasalsonotedthat“theprimarygoalofaChristiancounselorisnottohelppeoplebecomemerely‘normal,’buttohelpthemloveGodwithalltheirhearts,mindsandsouls”(1986,29).TheultimategoaloflifeonearthandalsoofChristiancounselingshouldthereforebeholiness,nottemporalhappiness,andspiritualhealthorwholeness,notjustmentalorphysicalhealth(seeGrounds1976,105–11).Fourth,abiblicalperspectiveonhumannatureassumesthatproblemfeelingsareusuallyduetoproblembehavior(cf.Gen.4:3–7)and,morefundamentally,toproblemthinking(John8:32;Rom.12:1–2;Eph.4:22–24;Phil.4:8).Crabb(1977)hasemphasizedthatattherootofnonorganicallycausedmentalandemotionalproblemsareunbiblical,erroneousbasicassumptionsorbeliefs,orwhatBackus(1985)hascalled“misbeliefs”(seealsoBackusandChapian1980),reflectingaChristianapproachtocognitivetherapyorrationalemotivebehaviortherapy.However,thisdoesnotmeanthatproblemfeelingsarealways 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duetoproblembehaviorandproblemthinking.Problemfeelingscanattimesbeduetobiologicalorphysicalfactors,evenifnoknownorganiccausecanbefound,sincecurrentknowledgeofsuchbiologicalfactorsislimitedbuteverexpanding.Medicalorpsychiatrichelp,whereappropriate,shouldbesought.Problemfeelings(aswellasthoughtsandbehaviors)canalsosometimesbeduetodemonicactivity(demonization),whetherdemonicoppressionorpossession,inwhichcasewhenproperlydiscerned,prayerfordeliverancemaybenecessary(e.g.,Bufford1988;MacNutt1995).Somehelpfulcriteria(thoughnotfoolproof)fordiscerningthepresenceofthedemonicversusmentalillnessincludethefollowing:theafflictedperson’sstrong,negativereactiontothenameofJesus(orthereadingofScriptureorthesingingofhymns);aforebodingoralmostoverwhelmingsenseofevilonthepartofthetherapist;theafflictedperson’shistoryofinvolvementwiththeoccultand/orcults;andpossiblyanolfactorycriterioninvolvingasmellofsulfurorrotteneggsassociatedwiththeafflictedperson.Thesearenotdefinitivedifferentialdiagnosticcriteriafordemonizationversusmentalillness.TheyshouldbeusedinconsultationwithotherpastorsorChristiancounselorsexperiencedindeliveranceministriesandpastoralcareandcounseling,aswellaswithmuchprayeranddependenceontheHolySpiritandhisgiftofdiscerningofspirits(1 Cor.12:10).Inabroadersense,fromabiblicalperspectivecounselingandpsychotherapycanbeviewedasinvolvingspiritualwarfarebecausetheyinevitablydealwithgoodandevil,includingthedemonic.Inthiscontext,MargueriteShuster(1987)hasemphasizedtheneedforagapelove,humility,weakness,anddependenceontheLord’sgraceandpoweronthepartofthecounselorortherapistsothatheorshecanconquerevilwithgood.Theneedtokeepagoodbalanceinfocusingnotonlyonproblemthinkingbutonallthreemajorareasofhumanexperience,thatis,feelings,behavior,andthoughts,hasbeenemphasizedbyGaryCollins(1976).Similarly,Crabb(1987)hasnotedtheneedtoattendtoallfourmajorcirclesordimensionsofaperson’sfunctioning:thepersonal,rational,volitional,andemotionalareas.Nevertheless,thecrucialroleofproblemthinkingandproblembehaviorinthedevelopmentofproblemfeelingsmustnotbelostornegated.Fifthandfinally,abiblicalperspectiveonhumannatureassumesaholisticviewofpeoplewithphysical,mental-emotional,social,andspiritualdimensions(cf.Luke2:52).AsJayAdamshasobserved,aclient’sproblem(e.g.,depressionoranxiety)mustbeviewedinthecontextofallareasofhisorherlife,andbiblicalrestructuringshouldalsoinvolvealltheseareasinwhathecalls“totalstructuring”:(1) church,Bible,prayer,witness;(2) work,school;(3) physicalhealth,exercise,diet,sleep;(4) marriage,sex;(5) finances,budget;(6) family,children,discipline;(7) socialactivities,friends;(8) other(e.g.,reading)(see1973,409–12).Asimilarcomprehensivebutsecularapproachtoviewinghumanfunctioninganddysfunctioningisthemultimodaltherapyperspectiveadvocatedby _Tan_Counseling_BB_mw.indd346 9/21/104:39:39PM ChristianTheologyinChristianCounseling 333 ArnoldLazarus,whichwasdiscussedinchapter11ofthisbook.Lazarus(1989,2008)hasdescribedsevenmajordimensionsofhumanpersonalityfunctioning,summarizedasanindividual’sBASICI.D.(orbasicidentity):Behavior,Affect,Sensations,Images,Cognitions,Interpersonalrelationships,Drugs/Biology.TheBASICI.D.doesnotspecificallyincludeorfocusonthecrucialspiritualdimensionoflife.ChristiancounselorscanaddSforthespiritualdimensionsothatitnowreadstheBASICI.D.S.(seeTan1991, 39),orasJeffreyBjorckhassuggested,usethesevendimensionsoftheBASICI.D.toassessthespiritualrealmandone’sexperienceofGod(2007, 145).BasicPrinciplesofEffectiveCounselingandPsychotherapy:ABiblicalPerspectiveIhavefurtherproposedanddescribedthirteenbasicprinciplesofeffectivecounselingandpsychotherapyfromabiblicalperspective.Theyarealsobasedonempiricalresearchandcounselingtheoriesthatareconsistentwithbiblicalviews.Hereismysummaryofthethirteenprinciples:1.TheHolySpirit’sministryascounseloriscrucial;dependonhim.2.TheBibleisabasicandcomprehensive(notexhaustive)guideforcounseling.3.Prayerisanintegralpartofbiblicalcounseling.4.TheultimategoalofcounselingismaturityinChristandfulfillingtheGreatCommission.5.Thepersonalqualitiesofthecounselorareimportant,especiallyspiritualones.6.Theclient’sattitudes,motivations,anddesireforhelpareimportant.7.Therelationshipbetweencounselorandclientissignificant.8.Effectivecounselingisaprocessinvolvingexploration,understanding,andactionphases,withafocusonchangingproblemthinking.9.Thestyleorapproachincounselingshouldbeflexible.10.SpecifictechniquesormethodsofcounselingshouldbeconsistentwithScripture;cognitive-behavioralonesmaybeespeciallyhelpful,withqualifications.11.Culturalsensitivityandcross-culturalcounselingskillsarerequired.12.Outreachandpreventionskillsinthecontextofacaringcommunityareimportant.13.Awarenessoflimitationsandreferralskillsarealsoimportant.(Tan1991,50–52)Thesethirteenbasicprinciplesofeffectivecounselingandpsychotherapyfromabiblicalperspectivewillnowbecoveredinmoredetail(seeTan1991,41–52). _Tan_Counseling_BB_mw.indd347 9/21/104:39:39PM 334 AChristianApproachtoCounselingandPsychotherapy First,theHolySpirit’sministryascounselororcomforteriscrucialineffectiveChristiancounseling(Tan1999b).AsAdams(1973)hasemphasized,therearealwaysatleastthreepersonsinvolvedineverysituationofcounseling:theclient,thecounselor,andtheHolySpirit.PrayerfuldependenceontheHolySpiritandhisworkascounselorisessentialineffectiveChristiancounseling(cf.John14:16–17).TheChristiancounselormustbefilledwiththeHolySpirit(Eph.5:18)anddependontheSpirit’spower,gifts,truth,andfruitinordertohelpclientsinaChrist-centered,biblicallybased,andSpirit-ledway(Tan1999b;seealsoPugh2008).Second,theBibleisthebasicguidefordealingwithproblemsinliving(cf.2 Tim.3:16–17).Itisacomprehensive(thoughnotexhaustive)guideforcounselingbecauseitspeaksmeaningfullytohumanproblemsandneedswhenitiscarefullyinterpretedintermsofitscontents,categories,implications,andimagesaswellasitsextendedapplicationstothecomplexproblemswithwhichpeoplestruggle(Crabb1987;seealsoAdams1973).TheBiblethereforerequiresnotonlyasaccurateandappropriateinterpretationaspossible(exegesisandhermeneutics),butalsopracticalapplicationtolifeanditsdifficultiesforittofunctionasabasicguideforcounseling.TheChristiancounselormusthaveatleastsomebasicknowledgeofScriptureandtheology,becauseChristiantheologyisfoundationalforeffectiveChristiancounseling(Collins1993;Hurding1992;I. F.Jones2006;seealsoCollins2007;Kruis2000;P. A.Miller2002;P.A.MillerandMiller2006).However,theBibleisnotanexhaustiveguideforcounseling.Hence,theoriesandtechniquesfromseculartherapycanbeusedinChristiancounselingaslongastheydonotcontradictScriptureorbiblicalvalues.Thisviewaffirmsthat“alltruthisGod’struth”ortheunityoftruth,andthatGod’sgeneralrevelationandcommongraceallowhistruthtobediscoveredevenbythosewhoarenotChristians,forexample,throughgoodresearch.However,ultimateauthorityisstillgiventoScripture.Third,prayerisanintegralpartofeffectiveChristiancounselingthatisbiblicallybased(cf.James5:16).TheChristiancounselorcanalsouseprayerinvariousways,suchasprayingfortheclientbeforeandinbetweencounselingsessionsandsilentlyduringcounselingsessions.PrayercanalsobeusedexplicitlyduringcounselingsessionswhentheChristiancounselorpraysaloudwiththeclient.InformedconsentfromtheclientmustbeobtainedbeforeusingspiritualresourcessuchasprayerandScriptureincounselingsessions(seeTan1996b).Fourth,theultimategoalofChristiancounselingistomakedisciplesordisciplersofclients(seeCollins1976).Withinformedconsentfromclients,ChristiancounselorscansensitivelypointclientstoChristandthushelptofulfilltheGreatCommission(Matt.28:18–20).Collins(1976)hasthereforedescribedChristiancounselingas“discipleshipcounseling”(seealsoN. T.Anderson2003).Crabb(1977)hassimilarlyemphasizedthatthebasicgoal _Tan_Counseling_BB_mw.indd348 9/21/104:39:41PM ChristianTheologyinChristianCounseling 335 ofChristiancounselingistohelpfreepeopletobetterworshipandserveGodbyguidingthemtowardmaturityinChrist.Fifth,thepersonalqualitiesoftheChristiancounselorareimportantforeffectiveChristiancounseling.Forexample,Christiancounselorsneedtohavequalitiessuchasgoodness(goodwillorlove),knowledgeofGod’sWord,andwisdominapplyingitinpracticalways(Rom.15:14;Col.3:16)(Adams1973).Theymaybeparticularlygiftedforcounselingministrieswithspiritualgiftssuchasencouragement(Rom.12:8)(seeTan1999b).Christiancounselorsmustalsobespirituallymaturetobeeffectiveinhelpingclientswiththeirproblemsinliving(cf.Gal.6:1–2).ThefruitoftheSpiritmanifestedespeciallyinagapelove(Gal.5:22–23;see1 Cor.13)isalsoessentialintheChristiancounselor,whomustbe,atminimum,warm,empathic,andgenuineinrelatingtoclients.Sixth,theclient’sattitudes,motivations,anddesireforhelparealsocrucialfactorsfordeterminingtheoutcomeofcounselingandpsychotherapy(seeCollins1976).Forexample,accordingtoresearchfindingsfromtheVanderbiltPsychotherapyStudy,theprocessvariablethatmostconsistentlypredictedtheoutcomeofcounselingortherapywastheextentofclientinvolvementintherapy(Gomes-Schwartz1978).Morespecifically,clientswhowerenothostileormistrustfulandwhoactivelyparticipatedintheirtherapyshowedmoretherapeuticchangescomparedtoclientswhoweredefensive,withdrawn,orunwillingtobeactivelyinvolvedintheirtherapy(seeGomez-Schwartz1978, 1032).Seventh,therelationshipbetweenthecounselorandtheclientisanothersignificantvariablefordeterminingtheoutcomeofcounselingandpsychotherapy.Carkhuff(1971)hasemphasizedtheimportanceofgoodrapportandcommunicationintherelationshipbetweenthecounselorandtheclientforeffectivecounseling.Hedescribessix“coreconditions”fortherapeuticchange:thefacilitativeconditionsof(1) empathy(orunderstanding);(2) respect(orcaringorwarmth);and(3) concreteness(orbeingspecific);andtheactionconditionsof(4) genuineness(orbeingreal);(5) confrontation(ortellingitlikeitis);and(6) immediacy(orwhat’sreallygoingonbetweenthetwoofyou).Ephesians4:15,inasimilarvein,emphasizesspeakingthetruth(similartoconcreteness,immediacy,confrontation,andgenuineness)inlove(similartorespectorwarmth,empathy,andgenuineness).More-recentresearchonempiricallysupportedtherapyrelationships(ESRs)hasshownthatempathy,therapeuticalliance,cohesioningrouptherapy,andgoalconsensusandcollaborationaredemonstrablyeffective,andpositiveregard(orrespectorwarmth),congruence/genuineness,feedback,repairofallianceruptures,self-disclosure,managementofcountertransference,andqualityofrelationalinterpretationsarepromisingandprobablyeffectiveasgeneralelementsofthetherapyrelationship(seeNorcross2002, 441).Eighth,effectivecounselingisaprocessinvolvingexploration,understanding,andactionphasesthatunfoldcyclically.Itthereforerequiresthecounselor _Tan_Counseling_BB_mw.indd349 9/21/104:39:42PM 336 AChristianApproachtoCounselingandPsychotherapy toexploreandunderstandtheclientandhisorherproblemsbeforeundertakingspecificcoursesofactiontohelptheclient(seeCarkhuff1971;Egan1986).Crabb(1977)hasexpandedthethreemajorphasesofexploration,understanding,andactioninthecounselingprocessintoaseven-stagemodelofeffectivebiblicalcounseling:(stage1)identifyproblemfeelings;(stage 2)identifyproblembehavior;(stage3)identifyproblemthinking;(stage4)teachandclarifybiblicalthinking;(stage5)securecommitment;(stage6)plan/carryoutbiblicalbehavior;and(stage7)identifySpirit-controlledfeelings.Ninth,directive,ornouthetic,counselingisanimportantpartofChristiancounseling,butthestyleorapproachtakeninChristiancounselingandtherapyshouldbeflexible.Noutheticcounselingthatisdirectiveandinvolvescaringconfrontationtobringaboutclientchangeinabiblicalway,asdevelopedbyAdams(1970,1973),isanimportantpartbutnotthewholeofChristiancounseling.BiblicallybasedChristiancounselingismoreappropriatelybasedonparakaleoandparaklesisratherthanonlyonnoutheteoandnouthesia,GreekwordsfoundintheNewTestamentthataremostrelevanttocounseling.Biblicalcounselingthereforeincludesnotonlythenouthetic,ordirective,confrontational,approachbutalsotheparakaleocomponentssuchasencouraging,supporting,andcomforting(J. D.Carter1975).ThespecificstyleorapproachthataChristiancounselortakesinhelpingclientsshouldbeflexibleandappropriatetothespecificclientwithaparticularproblem.FirstThessalonians5:14provideswisebiblicalguidancethatsupportssuchsensitiveflexibilityincounseling:“Andweurgeyou,brothers,warnthosewhoareidle,encouragethetimid,helptheweak,bepatientwitheveryone.”D. E.Carlson(1976)hasalsoobservedfromScripturethatJesus’sstyleofrelatingwasflexible,rangingfromhisprophetic,confrontationalstyletohispriestly,acceptingstyle,withhispastoralstyleinbetween,dependingonthepersontowhomhewasrelating.Tenth,thereisflexibilitywithregardtospecifictechniquesortherapeuticmethodstobeusedincounselingandtherapy,buttheyshouldbeconsistentwithScripture.AcertaintechnicaleclecticismintheuseofspecifictherapytechniquesisacceptableprovidedthattheScripturesareusedastheultimatescreeningdevicefordecidingwhethertoacceptorrejectparticulartherapeuticinterventions(cf.1 Thess.5:21).Whateverisdeemedunbiblicalorantibiblicalshouldberejected,butwhateverisseenasconsistentwithScripture,evenifitisnotintheBible,canbeused.Cognitive-behavioralandbehavioraltechniquescanbeparticularlyhelpfultomanyclientsacrossarangeofclinicalproblems,asalreadycoveredinchapters12and13ofthisbook.However,abiblicalapproachto,andcritiqueof,cognitive-behavioralinterventionsshouldstillbeused(seeTan1987a).McMinnandCampbell(2007)haverecentlydescribedamorecomprehensiveChristianapproachtotherapycalledintegrativepsychotherapy,whichintegratesbehavioral,cognitive,andinterpersonalmodelsoftherapywithinaChristiantheologicalframework. _Tan_Counseling_BB_mw.indd350 9/21/104:39:43PM ChristianTheologyinChristianCounseling 337 Eleventh,effectiveChristiancounselingrequiresculturalsensitivityandcross-culturalormulticulturalcounselingskills.Americansocietyhasbecomeevenmorepluralistic,diverse,andmulticulturalinrecentyears.Christiancounseling,aswellascounselingandtherapyingeneral,mustbeculturallysensitiveandusecross-culturalormulticulturalcounselingskillstobeeffectiveinhelpingclientsfromdiversebackgrounds(see,e.g.,Ridley2005;D. W.SueandD. Sue2008;D. SueandD. M.Sue2008;forChristianperspectives,seealsoAugsburger1986;DueckandReimer2009;Hesselgrave1984;Ridley1986;Uomoto1986;Tan1999a;Yang1996).Twelfth,outreachandpreventionskillsinthecontextofacaringcommunityorthelocalchurchareimportantineffectiveChristiancounseling.J. S.Prater(1987)madethefollowingsixproposals,originallyforlayChristiancounselorstobetrainedininterventionsthatgobeyondindividualcounseling;theyarealsorelevanttoprofessionalChristiancounselorsandtherapists:(1) Christiancounselorsshouldbetrainedtoassesstheroleofenvironmentalstressors(e.g.,poverty,unemployment,racism,sexism,andlackofsocialsupport)inthedevelopmentandmaintenanceofemotionalproblems;(2) Christiancounselorsshouldbetrainedinthetechniquesofcommunityoutreachandempowerment;(3) Christiancounselorsshouldbetrainedinculturalawarenessandsensitivity;(4) Christiancounselorsshouldbetrainedtobeawareofandtomakeuseofexistingsupportsystemsandserviceswithinchurches;(5) Christiancounselorsshouldbetrainedinskillstodevelopnewsupportsystemswithinthechurchwhereneeded(e.g.,prevention-orientedseminarsontopicssuchasstressmanagement,parentingskills,andconflictresolution);and(6)Christiancounselorsshouldbetrainedtocommunicatemoreactivelyandregularlywithotherleadersinvolvedinoutreachministriesofthechurchsothatacoordinatedpackageofministriescanbeestablished.Thirteenthandfinally,awarenessoflimitationsandreferralskillsarealsoimportantineffectiveChristiancounseling.Everycounselorortherapisthaslimitationsandneedstobeawareofthemsothatheorshecanskillfullyandsensitivelymakeappropriatereferralsofclientstootherprofessionals(e.g.,othertherapistsorcounselors,lawyers,psychiatrists,physicians,financialconsultants)whocanbetterhelpsuchclientsbecauseoftheirexpertise.Someexamplesofcounselingsituationsthatmayrequirereferringclientstootherprofessionalsincludethoseinvolvingclientswhoareseverelydisturbedorsuicidal,needmedicalorpsychiatrichelp,haveseriousfinancialneedsorlegalproblems,showextremelyaggressivebehavior,usedrugsoralcoholinexcessiveandharmfulways,orwanttoseeanothertherapist(seeCollins1976, 113).ThecrucialandessentialroleofChristiantheologyinChristiancounselingandtherapyhasbeenemphasizedinthischapter.Abiblicalperspectiveonhumannature,withfivebasicassumptions,andabiblicalapproachtoeffectivecounseling,withthirteenbasicprinciplesthatIhavepreviouslydescribedinthecontextoflayChristiancounseling(Tan1991),havealsobeensumma- _Tan_Counseling_BB_mw.indd351 9/21/104:39:44PM 338 AChristianApproachtoCounselingandPsychotherapy rizedandupdatedinthischapterforapplicationtoChristiancounselingandtherapyasawhole,whetherprofessionalorlay.RecommendedReadingsBeck,J. R.,&Demarest, B.(2005).Thehumanpersonintheologyandpsychology:Abiblicalanthropologyforthetwenty-firstcentury.GrandRapids:Kregel.Collins,G. R.(1993).ThebiblicalbasisofChristiancounselingforpeoplehelpers.ColoradoSprings:NavPress.Crabb,L. J.(1987).Understandingpeople:Deeplongingsforrelationship.GrandRapids:Zondervan.Johnson,E. L.(2007).Foundationsforsoulcare:AChristianpsychologyproposal.DownersGrove,IL:IVPAcademic.Johnson,E. L.,&Jones,S. L.(Eds.).(2000).PsychologyandChristianity:Fourviews.DownersGrove,IL:InterVarsity.Stevenson,D. H.,Eck,B. E.,&Hill,P. C.(Eds.).(2007).PsychologyandChristianity:Seminalworksthatshapedthemovement.Batavia,IL:ChristianAssociationforPsychologicalStudies.Tan,S. Y.(1991).Laycounseling:EquippingChristiansforahelpingministry.GrandRapids:Zondervan. _Tan_Counseling_BB_mw.indd352 9/21/104:39:44PM 15ChristianFaithinClinicalPracticeImplicitandExplicitIntegration C hristianfaithinclinicalpractice,asaspecificexampleofreligionorspiritualityinclinicalpractice(Tan1996c),referstointegrationinthetherapyroom(M. E. L.HallandHall1997;seealsoEck2002).Suchintegrationhasalsobeencalledprofessionalintegration(Tan2001b)orthepracticalintegrationoftheologyandpsychology(N. T.Anderson,Zuehlke,andZuehlke2000).ItinvolvestheactualconductingofChristiancounselingandpsychotherapythatisChristcentered,biblicallybased,andSpiritled(Tan2001b).Asnotedinthepreviouschapter,thisareaofChristiancounselingandtherapyhaswitnessedsignificantgrowthanddevelopmentinrecentyears,ashasthemoregeneralareaofreligiouslyorientedandspirituallyorientedtherapy,especiallyinthelastdecadeorso.Relativelycontextualisticapproachesintheso-calledthirdwaveofbehaviortherapyandcognitivebehaviortherapy,includingacceptanceandcommitmenttherapy(ACT),mindfulness-basedcognitivetherapy(MBCT),anddialecticalbehaviortherapy(DBT),havealsorecentlyemphasizedmindfulnessandacceptance,whichhavespiritualrootsinZenBuddhism(Hayesetal.2006)aswellasothercontemplativereligiousorspiritualtraditions(seeTan2007b).ImplicitandExplicitIntegrationinChristianTherapyChristiantherapyhasbeendescribedasconsecratedcounselingwiththefollowingdistinctives:“CounselingismosttrulyChristianwhenthecounselor339 _Tan_Counseling_BB_mw.indd353 9/21/104:39:45PM 340 AChristianApproachtoCounselingandPsychotherapy hasadeepfaith;counselswithexcellence;holdsaChristianworldview;isguidedbyChristianvaluesinchoosingthemeans,goalsandmotivationsofcounseling:activelyseeksthepresenceandworkofGod;andactivelyutilizesspiritualinterventionsandresourceswithinethicalguidelines”(Bufford1997, 120).TwomajormodelsofprofessionalintegrationintheactualclinicalpracticeofChristiantherapyareimplicitandexplicitintegration,whichcanbedescribedastwoendsofacontinuum:“Implicitintegration. . .referstoamorecovertapproachthatdoesnotinitiatethediscussionofreligiousorspiritualissuesanddoesnotopenly,directlyorsystematicallyusespiritualresources. . . .Explicitintegration. . .referstoamoreovertapproachthatdirectlyandsystematicallydealswithspiritualorreligiousissuesintherapy,andusesspiritualresourceslikeprayer,Scriptureorsacredtexts,referralstochurchorotherreligiousgroupsorlaycounselors,andotherreligiouspractices”(Tan1996c, 368).AChristiantherapistwillpracticeimplicitorexplicitintegrationormovealongthecontinuumbetweenimplicitandexplicitintegration,dependingontheneedsandproblemsoftheclientaswellasthetraining,inclination,andpersonalityoftheChristiantherapist.Itiscrucialtonotethatbothimplicitandexplicitintegrationareequallysubstantialandimportant.Intentionalandprayerfulintegrationisthecriticalfactor,whetheritinvolvesimplicitorexplicitintegrationorboth.ItshouldbeconductedindependenceontheHolySpirit,inaprofessionallycompetent,ethicallyresponsible,andclinicallysensitiveway,withclearinformedconsentfromtheclient(Tan2001b).ImplicitIntegrationinChristianTherapyTheChristiantherapistwhopracticesimplicitintegrationinChristiantherapydoesnotinitiatediscussionofreligiousorspiritualissueswiththeclientanddoesnotopenly,directly,orsystematicallyemployspiritualresourcesorinterventionssuchasprayerandScriptureintherapywiththeclient.ImplicitintegrationisamorecovertapproachtointegratingChristianfaithinclinicalpractice.However,itisstillacrucialandsubstantialapproachthatisintentionalandprayerfullydependentontheHolySpiritforhisguidanceandhealinggraceasclientsarehelpedintherapy.TheChristiantherapistusinganimplicitintegrationapproachwillstillbesilentlyprayingfortheclientandbeauthenticinshowingagapelovetotheclient.TheChristiantherapistthuswillreflectbiblicalvaluesandconvictionswithoutimposingthemontheclientorexplicitlydiscussingsuchreligiousissuesinaverbalwaywiththeclient.ImplicitintegrationisparticularlyhelpfulandappropriatewhentheChristiantherapistishelpingclientswhoarenotbelieversorChristiansandwhoarenotinterestedindiscussingspiritualorreligiousissuesorusingspiritualresourcessuchasprayerandScripture.ItisalsoappropriateincounselingwithChristianclientswhoarenotinterestedinamoreexplicitapproachto _Tan_Counseling_BB_mw.indd354 9/21/104:39:46PM ChristianFaithinClinicalPractice 341 Christiantherapy,whethertheyarepresentlyinactiverebellionagainstGod,orexperiencingasignificantspiritualstruggle,orsimplyfeelingindifferentorcoldtowardGodandthespirituallife.However,astherapyprogresses,suchclientsmaybecomemoreinterestedindiscussingspiritualorreligiousissuesinamoredirectandopenway,includingthepossibleuseofspiritualresourcessuchasprayerandScripture,inwhichcasetheChristiantherapistmaymoveinthecontinuumtoamoreexplicitintegrationapproachintherapy.ImplicitintegrationinChristiantherapymayalsobemoreeasilyadoptedbyChristiantherapistswhopracticefrompsychodynamicandpsychoanalyticperspectives,sincetheseapproachestotherapyrequirethetherapisttobemoreofa“blankslate”andnondirective.Explicitintegration,ontheotherhand,maybemoreeasilyadoptedbyChristiantherapistswhopracticefromcognitive-behavioralandhumanistic-existentialperspectives,sincetheseapproachestotherapyareconsistentwiththetherapistassumingamoredirectivestance(seeI. R.Payne,Bergin,andLoftus1992).Recently,C. JeffreyTerrell(2007)haschallengedthedefinitionofimplicitintegrationpresentedsofar,followingtheoriginalformulationofimplicitandexplicitintegrationthatIprovidedinanearlierwork(Tan1996c).Terrelldescribesinsteadanintentionalincarnationalintegrationapproachinrelationalpsychodynamicpsychotherapy(seealsoS. A.Rogers2007),whichisusuallyviewedasimplicitintegrationaccordingtomyoriginalformulation(Tan1996c).However,itcanbeconceptualizedas“explicit”integrationinanothersensebecausethetherapist’suseofthetherapeuticrelationshipasacatalystforbringingaboutdeeperchangeintheclient’srelationalpatternsisveryintentional.Terrellstates:Inmakingthisargument,IrealizethatIamblurringtheboundariesofexplicitandimplicitintegration. . . .Itis“explicit”initsavowalthatourpatientisworthyoflove.Itis“explicit”initsawarenessofimperfectionandfailureinhimorher.Itis“explicit”initsunflinchingdescriptionofhisorherattemptstomanipulatetheworld.Itis“explicit”initsacceptanceofourpatient,despitehisorherworst,mosthumiliatingexperiences.Inthisway,intentionalandincarnationalintegrationisbeingpracticed,whetherimplicitorexplicitinitsverbalexpression.(2007,162) TerrellthereforeemphasizesthatsuchanintentionalincarnationalintegrationapproachinrelationalpsychodynamicChristiantherapycanbeconceptualizedas“explicit”aswellasimplicitintegration.Heconcludes:“Whenweengagerelationally,ourpatientsbelievewegetthem.Weheartheworstandstillacceptthem.Modelingthegospelstory,ourworkisincarnational(Benner1983).Itisredemptive,integrative,andintentional(Tan2001b),‘explicit’evenwhenitdoesn’tinvolvethedirectuseofscripturaltextsorinsessionprayer”(2007, 164).Inasimilarvein,StevenRogers(2007)hasemphasizedthatafocusontheprocessandthehere-and-nowwithintherapycanitselfbedescribedas _Tan_Counseling_BB_mw.indd355 9/21/104:39:47PM 342 AChristianApproachtoCounselingandPsychotherapy apowerfulspiritualinterventioninobjectrelationspsychotherapy,apsycho­dynamicapproachtotherapy.Thisprocessorientationincludestherapistskillssuchasthetherapistacknowledginghisorherownerrorswhileconductingtherapywiththeclient,andthetherapistusinghisorherownfeelingsinappropriateself-disclosureduringatherapysession.Rogersviewsthisprocessorientationandfocusonthehere-and-nowwithinatherapysessionasahighlyspiritualinterventionbecauseitreflectsGod’swayofrelatingtohumanbeingsandcreatesasacredspaceforclientstodevelopdeeperunderstandingofthemselves,others,andGod.ExplicitIntegrationinChristianTherapyExplicitintegrationisamoreovertapproachtointegratingChristianfaithintoclinicalpractice.Itviewsthespiritualityofboththetherapistandtheclienttobefoundationalforeffectivetherapyaswellasforgrowthandwholeness.Itintegratespsychologicaltherapywithspiritualguidanceordirectiontosomeextent,inthecontextoftherapy(Tan1996c;seealsoTan2003c).TheChristiantherapistwhopracticesexplicitintegrationinChristiantherapywillmoreverbally,directly,andsystematicallydealwithspiritualissuesintherapyandusespiritualresourcessuchasprayer,Scripture,referralstochurchorothersupportgroupsorlaycounselors,andotherreligiouspractices.ExplicitintegrationinChristiantherapyshouldbeconductedinaclinicallysensitive,ethicallyresponsible,andprofessionallycompetentway,sinceitcanpotentiallybemisusedbyoverenthusiastictherapistswhomayunethicallyimposetheirreligiousvaluesandspiritualinterventionsonclients(Tan1996c).SeveralethicalguidelinesareavailablefortheappropriatepracticeofexplicitintegrationinChristiantherapy(see,e.g.,Tan2003c).TheyincludethefollowingthreebasicpracticesproposedbyA. A.NelsonandW. P.Wilson(1984),whostatethatitisethicalfortherapiststousetheirreligiousfaithintherapyif(1)theyaredealingwithclinicalproblemsthatcanbehelpedbyreligiousorspiritualinterventions;(2)theyarenotimposingtheirownreligiousbeliefsandvaluesontheclientandarethusworkingwithintheclient’sbeliefsystem;and(3)theyhaveobtainedinformedconsentfromtheclienttousereligiousorspiritualresourcesandinterventionsaspartofaclearlydefinedtherapycontractwiththeclient.AChristiantherapistthereforeneedstoopenlyandsensitivelydiscusswiththeclientintheinitialintakeinterviewhowtheclientwouldliketodealwithreligiousorspiritualissues,ifatall,sothatthetherapistcanthendecidewhethertouseanexplicitorimplicitintegrationapproachintherapy.Thetherapistcanaskhelpfulquestionsintheintakeinterview,suchas:“Whatisyourreligionorreligiousaffiliation,ifany?”and“Arereligiousorspiritualissuesandresourcessuchasprayerimportantforyouandmetoaddressinourtherapysessions?”Iftheclientisnotinterestedindealingwithreligiousor _Tan_Counseling_BB_mw.indd356 9/21/104:39:48PM ChristianFaithinClinicalPractice 343 spiritualissuesintherapy,thenthetherapistSidebar15.1needstorespecttheclient’swishes.IftheclientexpressesaninterestinhavingamoreThreeAspectsofExplicitexplicitintegrationapproachintherapy,thenIntegrationthetherapistcanproceedtoobtaininformed(seeTan1996c)consentfromtheclient,preferablyinwrittenform.Thetherapycontractclearlyagreed1.Usingreligiousandspiritualupon,withfullandfreeinformedconsentresourcesintherapyfromtheclient,willthereforeincludeopen2.Dealingwithspiritualissuesinanddirectdiscussionofreligiousorspiritualtherapyissuesandtheuseofspiritualresourcesand3.FosteringintrapersonalinteinterventionssuchasprayerandScripture.Itgrationandthedevelopmentwillalsoincludethegoalssetbytheclientforofspiritualityinthetherapisthisorhertherapy.However,ifthetherapistandtheclientdoesnotfeeladequatelytrainedorexperiencedinusinganexplicitintegrationapproachintherapy,thenthetherapistshouldrefertheclienttoanotherChristiantherapistwhomaybemoreexperiencedinconductingexplicitChristiantherapy(Tan1996c).ItisimportanttonotethatimplicitandexplicitintegrationarenottwomutuallyexclusivemodelsforintegratingChristianfaithintherapy.Theyareactuallytwoendsofacontinuumofintegration.AChristiantherapist’sapproachcanrangefrombeingimplicittoexplicitinaddressingreligiousorspiritualissuesandusingspiritualresourcesintherapy.Thetherapistcanalsomovealongthecontinuumwiththeclientatdifferentstagesofthetherapyorevenduringaparticularsession,dependingontheneedsandopennessoftheclient.Thetherapistmustrespondtotheclientinanappropriate,sensitive,andempathicway.AsTerrell(2007)hasemphasized,amorerelationalpsychodynamicapproachtotherapy,whilerelativelymoreimplicit,canalsobeconsideredtohave“explicit”featuresinthatitisveryintentionalinitsChristianintegrationapproach,whichisessentiallyincarnationalinnature,evenifitisnotalwaysverbalindealingwithreligiousissues.ExplicitintegrationinChristiantherapyhasvariouscomponents.Threemajoraspectsofexplicitintegrationare:(1)usingreligiousandspiritualresourcesintherapy;(2)dealingwithspiritualissuesintherapy;and(3)fosteringintrapersonalintegrationandthedevelopmentofspiritualityinthetherapistandtheclient(seeTan1996c).ExplicitIntegration:UseofReligiousandSpiritualResourcesinTherapyAmajorcomponentofexplicitintegrationisthedirect,open,andsystematicuseofreligiousandspiritualresourcesintherapy.Therearemanyexamplesofsuchresources(see,e.g.,Pargament2007;Plante2009;RichardsandBergin _Tan_Counseling_BB_mw.indd357 9/21/104:39:49PM 344 AChristianApproachtoCounselingandPsychotherapy 2005;SperryandShafranske2005),butthreemainonesareprayer,Scripture,andreferraltoreligiousgroups(Tan1996c).PrayerPrayerisamajorspiritualresourceorinterventionoftenusedinexplicitintegration.ItcanbedescribedsimplyascommuningwithGodbutitalsoreferstootherwaysofexperiencingorfocusingonGod(C. B.Johnson1987).Itincludesmeditative(waitingandworshipinginGod’spresence),ritualistic(involvingtheuseofrituals),petitionary(makingspecificrequests),andcolloquial(conversationalandrelational,withgratitude)prayer(PolomaandPendleton1989,1991),aswellasintercessory(askingonbehalfofothers,e.g.,fortheirhealingandblessing)prayer(McCulloughandLarson1999).Aspecificformofprayerhasbeentermed“holynamerepetition,”andChristianexamplesinclude“LordJesusChrist,SonofGod,havemercyonme,”“LordJesushavemercy,”orsimply“Jesus,”allvariantsoftheJesusprayer(seeOmanandDriskill,2003).Richard J.Foster(1992)infactdescribestwenty-onetypesofprayer.Theyhelpusinmovinginward(seekingthetransformationweneed),movingupward(seekingtheintimacyweneed),andmovingoutward(seekingtheministryweneed).ManyChristianshavememorizedthedifferenttypesofprayerasconsistingofAdoration,Confession,Thanksgiving,andSupplication(includingbothpetitionforoneselfandintercessionforothers),orACTS.TherearethereforedifferenttypesofprayerthatcanbeusedinChristiantherapywithaclient(e.g.,quiet,meditative,orcontemplativeprayer;generalprayeraloudwiththeclient;specificprayeraloudwithandfortheclient;inner-healingprayer;orprayerforhealingofmemories).AChristiantherapistcanalsouseprayeratdifferenttimes,suchasbefore,during,orafterthetherapysession,atthebeginningorattheendofthetherapysession,oranyothertimeconnectedwiththetherapysession.TheuseofChristiancontemplativeprayerinpsychotherapyreferstoatypeofprayerthatfocusesone’sfullattentiononrelatingtoGodinanopen,passive,nondefensive,andnondemandingway(seeFinneyandMalony1985a,1985b,1985c).Suchcontemplativeprayer,oranyotherformofprayer,shouldnotbeusedsimplyasatherapeutictechniqueorcopingstrategyformanaginganxietymoreeffectively(FinneyandMalony1985b),butshouldbeusedonlyifspiritualdevelopmentisalsoagoaloftherapy.Prayershouldbeviewedasanendinitselfandnotjustasatool,technique,orstrategy(seeHunsinger2006).PrayeristobeawayoflifefortheChristianinrelationshipwithGod(C. B.Johnson1987).Prayerisultimately“thetransformingfriendship”withGod(Houston1989)inwhichwefindourheart’struehomeinloving,intimaterelationshipwithGod(Foster1992).Relationalprayerthereforecomesbeforepetitionaryprayer(Crabb2006).Prayercanalsobedescribedasa“treeoflife” _Tan_Counseling_BB_mw.indd358 9/21/104:39:50PM ChristianFaithinClinicalPractice 345 thatunifiesChristianspirituality,withfivemajormodelsofprayer:conversation,relationship,journey,transformation,andpresence(Chase2005).Inner-healingprayerorhealingofmemoriesisaspecifictypeofprayerthatcanbedefinedas“aformofprayerdesignedtofacilitatetheclient’sabilitytoprocessaffectivelypainfulmemoriesthroughvividlyrecallingthosememoriesandaskingforthepresenceofChrist(orGod)toministerinthemidstofthispain”(GarzonandBurkett2002,42).FernandoGarzonandLoriBurketthavereviewedfourmajormodelsofhealingofmemoriesdevelopedbyDavidSeamands(1985),myself(Tan1996c),LeannePayne(1991),andEdwardM.Smith(2002/2005),thefounderofTheophosticMinistry,anddescribedtheircommonalitiesaswellasdifferences.TheynotedthatthehistoryofhealingofmemoriescanbetracedbacktoAgnesSanfordandherworkinthe1950s,followedbyotherssuchasFrancisMacNutt,RuthCarterStapleton,andJohnandPaulaSandford(seealsoFlynnandGregg1993;Kraft1993;Richardson2005;Wardle2001).Inner-healingprayerisadistinctivelyChristiantypeofprayerthatcanalsobeusedasaspiritualinterventioninexplicitintegrationinChristiantherapy.Itcanbeespeciallyhelpfultoclientswhohaveunresolvedpainfulmemoriesfromtheirpastthatmayinvolvedeprivationorneglect,abandonment,rejection,harshtreatmentorcriticism,physicalorsexualabuse,andtrauma.Itisusuallynotconductedasastand-alonespiritualinterventionbutratherusedintheprocessofongoingtherapyorpastoralcareandcounseling(Tan2003b).Inner-healingprayershouldbeusedinaclinicallysensitiveway,alwayswithinformedconsentobtainedfromtheclient.Itshouldnotbeused,orusedonlywithcaution,withcertaintypesofclients,forexample,thosewithsubstanceabuseproblems,thoughtdisorders,severedepression,orburnout(GarzonandBurkett2002).Insuchcases,itiscrucialforthetherapisttoengageinadequateclientassessment,propertiming,andcomprehensivetreatment.Ihavedevelopedaseven-stepmodelforinner-healingprayerthatIfirstdescribedin1992(seeTan1992;seealsoTan2003b;TanandOrtberg2004,64–71).ThismodeldoesnothaveasetscriptfortheclientanddoesnotdirectivelyinstructtheclienttovisualizespecificimagesofJesus,unlikesomeotherapproachestoinner-healingprayerorhealingofmemories(e.g.,Seamands1985).Instead,itplacesthefocusonprayerandtheHolySpirit’spresenceandministryduringtheinner-healingprayerprocess,emphasizingwaitingupontheLordtoministertotheclientinwhateverwaytheSpiritleads.Thefollowingarethesevenstepsforinner-healingprayer:1.Beginwithprayerforprotectionfromevil,andaskforthepowerandhealingministryoftheHolySpirittotakecontrolofthesession.2.Guidetheclientintoarelaxedstate,usuallybybriefrelaxationstrategies(e.g.,slow,deepbreathing,calmingself-talk,pleasantimagery,prayer,andBibleimagery). _Tan_Counseling_BB_mw.indd359 9/21/104:39:51PM 346 AChristianApproachtoCounselingandPsychotherapy 3.Guidetheclienttofocusattentiononapainfulpasteventortraumaticexperience,andtofeeldeeplythepain,hurt,anger,andsoforth.4.PrayerfullyasktheLord,bythepoweroftheHolySpirit,tocometotheclientandministerhiscomfort,love,andhealinggrace(evengentlerebukewherenecessary).ItmaybeJesusimageryorotherhealingimagery,music(song/hymn),Scriptures,asenseofhispresenceorwarmth,orothermanifestationoftheSpirit’sworking.Nospecificguidedimageryorvisualizationisprovidedordirectivelygivenatthispoint.5.WaitquietlyupontheLordtoministertotheclientwithhishealinggraceandtruth.GuideandspeakonlyifnecessaryandledbytheHolySpirit.Inordertofollowortrackwiththeclient,thecounselorwillperiodicallyandgentlyask,“What’shappening?Whatareyoufeelingorexperiencingnow?”6.Closeinprayer.7.Debriefanddiscusstheinner-healingprayerexperiencewiththeclient.(Tan2003b,20–21)Homeworkinner-healingprayercanalsobeassignedtotheclienttobeusedduringhisorherowntimesofprayerathome.Thisseven-stepmodelforinnerhealingprayercanbemodifiedoradaptedwherenecessary(Tan2007b). Inner-HealingPrayerAHypotheticalTranscriptThefollowingisahypotheticaltranscriptofaninner-healingprayerinterventionduringalatertherapysessionwithaclientnamedJane,whowasexperiencingfatigue,milddepression,andasuperficial,distantrelationshipwithGod: _Tan_Counseling_BB_mw.indd360 Therapist:Aswediscussedinourlastsession,andyouhavereadaboutthesevenstepsofinner-healingprayer,doyoufeelreadytodaytobeginthisprayerintervention,focusingonthepainfulmemoryyoustillhaveofyouremotionallydistantfather?Client:Yes,Iwouldliketobegininner-healingprayerforthispainfulmemory.Therapist:Good.Beforewebegin,let’srememberthatthisisprayerandnotatechniqueperse.WewillcomebeforetheLordwithyourneedandpainfulmemoryandlethimministertoyouinwhateverwayhewantstoandknowsyouneed.Let’sbeopenandreceptivetowhathemaywanttodotoday,withnospecificexpectationsordemandsonourpart,OK? 9/21/104:39:52PM ChristianFaithinClinicalPractice 347 Client:OK.Therapist:Good.I’llbeginwiththefirststep.Pleasecloseyoureyesandbeinareceptive,prayerfulmode,asIbegininprayer:“DearLord,wepraythatyouwillprotectusfromevil,andcomeinthepresenceandpoweroftheHolySpirit,andministertoJaneyourhealinggraceandtruthforthepainfulmemoryshehas.Thankyouforyourloveandpresencewithus.InJesus’snamewepray.Amen.”Nowkeepyoureyesclosedandcontinueinaprayerfulmode,asImoveontothesecondstep.Client:OK.Therapist:Now,Jane,I’dlikeyoutousetherelaxationtechniquesthatyoulearnedacoupleofsessionsago,tohelpyourelaxasdeeplyandascomfortablyaspossible. . . .I’dlikeyounowtotakeinaslow,deepbreath. . .holditforafewseconds. . .andnowbreatheoutslowlyandrelax. . .lettinggoofalltension. . .justrelaxdeeply. . . .Now,Jane,againtakeinaslow,deepbreath. . .holdit. . .andrelax,breathingoutslowlyandlettinggoofalltension. . . .Nowgobacktonormalbreathing,asyouusethesecondrelaxationtechniqueofcalming,relaxingself-talk . . .sayingquietlytoyourself. . .Justrelax. . .takeiteasy. . .lettinggoofalltension. . .sothatfromthetopofyourheadallthewaydowntoyourtoes. . .youareallowingyourselftorelaxasdeeplyandascomfortablyaspossible. . .good. . . .Now,Jane,usethethirdrelaxationtechniqueofpleasantimagery. . . .Inyourmind’seyeIwantyoutovisualizeorimagineasvividlyandasclearlyaspossibleaveryrelaxing,calming,peaceful,enjoyable,andpleasantscene. . .likelyingonthebeachonabeautifulsunnyday. . .allowthispleasantandenjoyablescenetorelaxyouevenmoredeeply. . .evenmorecomfortably. . . .Howareyoufeelingnow,Jane?Client:I’mfeelingveryrelaxedandcalm,feelingprettygood.Therapist:OK,good.NowI’dlikeyoutoswitchthefocusofyourattentiontosomethingthatisnotaspleasant.Iwouldlikeyoutogobackinyourimaginationandseeyourselfasayounggirlinelementaryorprimaryschoolandpictureyourfatherathomesittinginhischairandreadingthenewspapersandnotpayingmuchattentiontoyou. . . .Canyourelivethatsceneinyourimagination. . . .Isitclear? _Tan_Counseling_BB_mw.indd361 9/21/104:39:53PM 348 _Tan_Counseling_BB_mw.indd362 AChristianApproachtoCounselingandPsychotherapy Client:Yes.Icanseeithappeningagain. . .it’sactuallyquitepainful(witheyesbeginningtotearupabit) . . .Therapist:OK. . .Iwouldlikeyoutocontinuetoseethatsceneclearlyandtoexperienceyourfeelingsasfullyaspossible,andnotavoidthemorblockthemout.Donotjustlookatyourselfinthatscenebuttrytoactuallybeyourselfinthatscene,sothatyou’reactuallyexperiencingthosefeelingsyourselfafreshatthismoment.Client:Icanfeelthepainfulemotions. . .(withsomemoretears)Therapist:Iknowthisishardforyou,butit’simportantforyoutocontinuetoexperiencethesepainfulfeelingsandstaywiththescenewithyourfatherstillreadingthenewspapers . . .Client:OK. . .Therapist:Also,pleasetellmealoudwhilekeepingyoureyesclosed,Jane,. . .whatareyouexperiencingnow,howareyoufeeling,andwhat’shappening?. . .soIcanfollowyouandtrackwithyou.Client:I’mfeelinglonely. . .anddeeplyhurt. . .thatmyfatherisstillhidingbehindhisnewspapersandnotnoticingmealthoughItrytogethisattention. . . .Iwonderifhereallylovesmealthoughhedoesprovidematerialthingsformeandmyfamily. . . .IfeelaloneandisolatedandignoredandIfeellikecrying(withtears) . . .Therapist:(aftersometimehaspassed)Jane,continuewiththatpainfulsceneinimageryandcontinuetofeelthepainfulemotions. . . .Atthispoint,I’dliketopausehereandprayfortheLordtocomeandministertoyou,bythepowerandpresenceoftheHolySpirit,andtotouchyouwithhishealinggraceandtruth,OK?Client:OK. . .Therapist:“DearLord,IpraythatyouwillnowcomebythepoweroftheHolySpirit,towalkwithJaneintothispainfulmemory,andlovinglyministeryourhealinggraceandtruthtoherinwhateverwayisneededorappropriate,accordingtoyourwill.Thankyou,inJesus’sname.Amen.”Now,Jane,justwaitforafewmomentsandbeinareceptive,open,prayerfulmodeallowingtheLordtoministertoyou,tospeaktoyou . . .Client:OK. . .Therapist:(afterafewmomentshavepassed)Jane,pleasetellme 9/21/104:39:53PM ChristianFaithinClinicalPractice 349 nowwhat’sgoingon. . . .Whatareyouexperiencing?. . .Whatareyoufeeling?Client:(withsometearsbutasmileonherface)It’sdeeplytouchingandhealingwhatI’mexperiencing. . . .IactuallysensethepresenceofJesuswithme,althoughIcan’tseehisfaceclearly. . . .Heishavinglunchwithme,spreadingoutablanketwithapicnicbasket. . .andheeatsaleisurelylunchwithme,givingmehisfullandlovingattention. . .andhespeakstomeandtellsmethatIamhisbelovedchildandveryprecioustohim(withsometears). . .Ifeelreallyclosetohim,andmyheartisexperiencingsomewarmthandjoyand. . .deeppeace. . . .IfeelthatIcanexperienceGodmorenowasalovingandpresentheavenlyFatherorParent . . .Therapist:Good. . .justcontinuetolettheLordminister. . .toyou. . .continuetoreceivefromhim . . .Client:OK . . .Therapist:(aftersomemoremomentshavepassed)Canyoutellmenowwhat’shappening,whatyou’refeelingorexperiencingnow?Client:Yes. . .IcontinuetoexperiencethepresenceofJesus. . . .IalsosensethatheisgentlytellingmetoletgoofanyresentmentImayhavetowardmyfather,andtoforgivehim. . .atleastheworkshardtoprovideformymaterialneeds.. . .IcanalsoseemoreclearlynowwithGod’shelpthatthisisthewaymyfatherexpresseshisloveforme. . .andIactuallyfeelmoregratitudeandsomewarmthtowardhimnow,asIletgoofanyresentmenttowardhimandforgivehim. . . .IalsoaskGodtoforgivemeofanyresentmentorwrongattitudesImayhavehadtowardmyfatheralltheseyears. . . .Ifeelmorereleasedandatpeace.Therapist:That’sbeautiful,Jane. . .anythingelsebeforewecloseinprayer?Client:No. . .I’mreadytopray.Therapist:OK,let’scloseinprayer.Wouldyouliketostart?Client:OK. . .“DearLord,thankyousomuchforthisdeeplytouchingandhealingtimewithyou. . .forgivingmesuchahealingimageofyouhavinglunchjustwithme. . . .PleasecontinuetohealmeandmakememorewholesothatIcanknowyoumoredeeplyandserveyoubetter.ThankyouinJesus’sname.Amen.” _Tan_Counseling_BB_mw.indd363 9/21/104:39:54PM 350 AChristianApproachtoCounselingandPsychotherapy Therapist:“DearLord,wethankyouforyourhealinggraceandlovingtruththatyouallowedJanetoexperiencetoday. . . .Continueyourhealingworkinherlife,andbewithusandleadusaswegoonwiththetherapysessionshere.InJesus’sname.Amen.”Jane,justbeforeyougo,doyouhaveanycommentsorquestionsaboutthisexperienceininner-healingprayerthatyou’vejusthad?Let’sdebriefanddiscussitnow.Client:Itwasadeeplytouchingandhealingexperienceforme,thankyou.CouldIusethesestepsofinner-healingprayeronmyown,inmydailyquiettimewiththeLord?Therapist:Yes,that’sagoodidea.Iwasabouttoaskyoutodoexactlythisasa“homeworkassignment.”AreyouOKwithdoingthis?Client:Yes,andthankyouagain!Therapist:You’rewelcome,Jane.TakecareandGodbless!Seeyouagainnextweek.(adaptedfromTan2007b,105–7) Itisimportanttonotethatinner-healingprayerdoesnotalwaysgosowell.Someclientsmayhavedifficultyrecallingtheirpainfulmemoriesinavividwayinimageryandmayneedamorenarrativeapproachinwhichtheysimplytelltheirpainfulstoriesverballyandprayoverthem.Anotheroptionistorole-playthepainfulsituationwithsuchclients,endingwithprayer.Clientsshouldnotbeforcedtokeeptryingtorecallorrelivetheirpainfulmemorieswhentheyarehavingtroubledoingso.Clientswhodonotexperienceanysignificanthealingafteraninner-healingprayertimeneedtobereassuredthattheLordhaspromisedgracesufficientfortheirneed,eveniftheydonotexperiencesignificanthealing(cf.2 Cor.12:9–10).Theimportanceofforgivenessalsoneedstobeaddressed.Inner-healingprayeristhereforenotapanaceaforallpainfulmemoriesandtheirassociatedproblems,butitcanbeapotentiallyhelpfulspiritualinterventioninChristiantherapy,includingChristiancognitivebehaviortherapy(CBT).Itcanhelpfacilitatedeeperlevelsofemotionalprocessingandcognitiverestructuringandchange.Itemphasizesamorereceptiveandcontemplativeprayerfulmodeonthepartofboththeclientandthetherapist,consistentwithmorerecentversionsofCBT,whicharebasedonmindfulnessandacceptance(Tan2007b).AlthoughthereissomeresearchsupportfortheeffectivenessofChristianCBTthatincludestheuseofreligiousorJesusimagerywithChristianclientssufferingfromdepression(e.g.,Propst1980;Propstetal.1992),controlledoutcomestudiesthatspecificallyevaluatetheeffectivenessofinner-healingprayerarestilllacking.Furthermore,thereligiousorJesusimageryusedinthePropststudiesinvolveddealingwithpresentandfuture-orientedsituations,andnotwith _Tan_Counseling_BB_mw.indd364 9/21/104:39:55PM ChristianFaithinClinicalPractice 351 painfulmemoriesfromthepast(GarzonandBurkett2002).Inner-healingprayeralsodoesnotnecessarilyincludeJesusimagery(Tan2007b).Furtherresearchisneededtobetterevaluatetheeffectivenessspecificallyofinner-healingprayer.Arecentdevelopmentthatcombinesinner-healingprayerwiththerepeateduseofatimelineofaclient’slifeconsistingofactualmemorieshasbeendescribedas“thehealingtimeline”byCatherineThorpeinherso-titledbook(2008).Thethreebasicstepsofthisnewapproachare:1.Clientspresentacurrentproblemorsituationtoacounselor.TheclientandcounseloraskGodthroughprayertoleadthemtoaformermemorywhichneedshealinginordertobringrelieftothecurrentproblem.2.TheclientinvitesJesusintothememoryscene.TheclientlistensandwatchesasJesusintervenesandspeaksintothesituation.3.AftertheinternalinteractionwithJesus,thecounselorleadstheclientthroughatimelineofhisorherlifeconsistingofrealmemories.Theclientnodswhenthesememoriesarerecalledandthetimelinecontinueswithoutdiscussionuntiltheclient’scurrentage.SeeingJesusinthememorysceneandrepetitionsofthetimelinearealternateduntilnodistressremainsinthememoryscene.(Thorpe2008,8–9)Thisnewapproachofthehealingtimelinealsoneedsfurtherresearch.Prayerfordeliveranceisanotherformofprayerthatneedstobebrieflymentioned(Tan1996c).Sometimesalsocalledexorcism,prayerfordeliverancemaybenecessaryifaclientseeninChristiantherapyshowssignsofbeingdemonizedoroppressedbydemonsorevilspirits(seeBufford1988;MacNutt1995;seealsoAppleby2006).Thisisacontroversialarea,andmanyChristiantherapistsmayprefertorefersuchclientstopastors,pastoralcounselors,orprayerministryteams,whomayhavemoretrainingindealingwithsuchcases.Nevertheless,aChristiantherapistmayattimeshavetodealwithanobviouslydemonizedclientbyprayingaprayerofdeliverancesuchas:“InthenameofJesus,Icommandyoutoleavethispersonnow,andgowhereJesussendsyou,nevertoreturnagaintoafflictoroppressthisperson.”Informedconsentfromsuchaclientshouldofcoursefirstbeobtained,ifpossible,beforeprayerfordeliveranceoranyotherformofprayerisusedasaspiritualinterventioninexplicitintegrationinChristiantherapy.Prayercanbepotentiallymisusedorabusedintherapy,andtherearedangersinherentinsuperficialinner-healingprayerapproaches(seeAlsdurfandMalony1980;Malony1987),includingusingprayerasanescapefromdealingmoredeeplywithpainfulissuesintherapy.Christiantherapiststhereforedifferinhowexplicitlytheyintegratespiritualinterventions,suchasprayerandtheuseofScriptureandotherspiritualdisciplines,intotherapysessionswithclients,withsomeadvocatingcautionbutnotcensure(e.g.,McMinn1996;McMinnandMcRay1997).However,prayer,includinginner-healingprayer,canbe _Tan_Counseling_BB_mw.indd365 9/21/104:39:56PM 352 AChristianApproachtoCounselingandPsychotherapy usedinaspirituallymeaningfulandtherapeuticallyhelpfulwayintherapy,especiallywithhighlyspiritualorreligiousclientssuchasorthodoxChristians,whomayprefertheexplicituseofprayerandScripture(Gass1984)andopendiscussionofreligiousandspiritualissues(Rose,Westefeld,andAnsley2001).Whenappropriate,explicitintegrationinChristiantherapyshouldbeconductedinaclinicallysensitive,ethicallyresponsible,andprofessionallycompetentway,withfullinformedconsentfromtheclientandappropriatecautionandcarefultimingfollowingtheclient’sleadandpreferences(seeTan1996b,1996c).Thisisimportantbecausesomehighlyreligiousclientsmaynotfindin-sessionprayerhelpful(see,e.g.,Martinez,Smith,andBarlow2007regardingastudyof152ChurchofJesusChristofLatter-DaySaints[LDS]clientsseenatauniversitycounselingcenter);therefore,suchprayershouldnotbeimposedonthem(seealsoMagalettaandBrawer1998).However,arecentsurveyspecificallyoffirst-visitChristianclientsandtheirtherapistsfoundthat82percentofsuchclientswantedaudibleprayerincounseling,butmore-liberal,Catholic,andyoungerclientsmaybelessinterestedinhavingprayerincludedincounselingsessions(WeldandErikson2007).Christiantherapiststhereforemustbecautiousinhowtheyuseprayerintherapysessions.Morebroadly,NathanielWade,EverettWorthington,andDavidVogel(2007)foundthatclientswithhighreligiouscommitmenthadgreaterimprovementintheirpresentingproblemafterreceivingreligiouslytailoredinterventionsinChristiantherapycomparedtoclientswithlowreligiouscommitment.Aclient’slevelofreligiouscommitmentisthereforeimportanttoassessbeforeusingreligiousinterventions,suchasprayer,inChristiantherapy.Itshouldalsobenotedthatarecentstudyonprayerandsubjectivewell-beingfoundthatofsixprayertypes(adoration,confession,thanksgiving,supplication,reception,andobligatoryprayer),threeformsofprayer(adoration,thanksgiving,andreceptioninvolvingacontemplativeattitudeofopenness,receptivity,andsurrender)werepositivelyrelatedtomeasuresofwell-being(WhittingtonandScher2010).ThesethreeformsofprayerseemtobemoreGod-focusedandlessego-focused.Inanotherstudyonthefunctionsofprayerinthecopingprocess,theprayerfunctionsofseekingguidanceandexpressinggratitudewerereportedbyparticipantstobethemosteffective(BadeandCook2008).ScriptureAsecondmajorexampleoftheuseofreligiousandspiritualresourcesinexplicitintegrationinChristiantherapyistheuseofScriptureortheBible(andothersacredtextsinotherreligiousapproachestotherapy),especiallyinChristianCBT(Tan2007b;TanandJohnson2005;seealsoGarzon2005).TheBibleisGod’sinspiredWord(2 Tim.3:16)andcanbeusedintherapywithChristianclientswhowanttodiscussbiblicaltruthsrelevanttotheirstrugglesinlife,forvariouspurposes,suchas:“tocomfort,clarify(guide),correct(cognitivelyre- _Tan_Counseling_BB_mw.indd366 9/21/104:39:57PM ChristianFaithinClinicalPractice 353 structure),changecharacter,cleanse,convict(convert),andcure(orheal)(e.g.,see2 Tim.3:16;John15:3;Ps.119:9,11;Heb.4:12;1 Pet.2:2;Ps.119:105;Ps.119:97–100;1 Pet.1:2,3;Rom.10:17;John8:32)”(Tan2007b, 108).ScripturecanbeusedindifferentwaysinChristiantherapy,includingthefollowing:indirectlybyalludingtobiblicaltruth;directlybutgenerallybyreferringtoexamplesorteachingsintheBiblewithoutcitingchapterandverse;directlybutspecificallybyreferringtoparticulartextsofScripture,citingchapterandverse;byreading,meditating,memorizing,hearing,orstudyingScripture(seeTanandGregg1997,79–91);orbyassigningScriptureforhomeworkreading,study,meditation,ormemorization(seeTan2007b, 108).TheuseofScriptureinChristiantherapyisespeciallyrelevantinChristianCBT,whichfocusesoncognitiverestructuringofdysfunctionalthinkingthatoftenincludesunbiblicalorsinfulassumptions.InadditiontostandardCBTquestionsusedincognitiverestructuring(e.g.,“Onwhatbasisdoyousaythis?Whereistheevidenceforyourconclusion?”“Isthereanotherwayoflookingatthis?”and“Ifyourconclusionistrue,whatdoesitmeantoyou?”),ChristianCBTthatusesScripturetochallengeunbiblicalthinkingwillincludeotherquestionssuchas:“WhatdoyouthinktheBiblehastosayaboutthis?”or“WhatdoyouthinkGodhastosayaboutthis?”(seeTan2007b,108).ThereareseveralhelpfulresourcesthataChristiantherapistcanconsultaboutusingScripturewithclientsintherapy,withcarefulbiblicalinterpretation(see,e.g.,Kruis2000;P. A.Miller2002;P. A.MillerandMiller2006;seealsoClintonandHawkins2007;Hurding1992;Hutchison2005;McKnight2008;Osborne2006;Monroe2008;Takle2008).ScripturecanalsopotentiallybeabusedormisusedinChristiantherapy(C. B.Johnson1987).ThethoughtlessandsuperficialuseofScriptureintherapycanleadtoharmfulconsequences.P. G.Monroe(2008)hasemphasizedtheneedtopaycarefulattentiontoissuesrelatingtocontextualizationintheuseoftheBibleintherapy.HesuggestsseveralkeyquestionsthatChristiantherapistsneedtoaskthemselvesinordertoclarifywhytheymaywanttouseScriptureintherapywithclients,suchas:“WhydoIwanttohavethemreadthistext?WhatdoIhopetoaccomplishthroughit(e.g.,tobeprovoked,taught,comforted,connectedtosomethinggreaterthanself,tochangeone’sfocalpoint,etc.)?Whatbarriersmighthinderthisgoal?Howmighttheymisinterpretmyintervention?”(2008,56). UseofScriptureinTherapyAHypotheticalTranscriptThefollowingisanotherhypotheticaltranscriptshowinghowScripturewasusedtohelpJanechallengeandchangeherdistortedandunbiblicalwayofthinkingaboutanger. _Tan_Counseling_BB_mw.indd367 9/21/104:39:58PM 354 _Tan_Counseling_BB_mw.indd368 AChristianApproachtoCounselingandPsychotherapy Client:IfeelbadlywheneverIexperienceevenmildangeratmyfatherfornotbeingmoreexpressiveofaffectiontowardmewhenIwasachildgrowingup.ItendtoblocktheangeroutordenyitbecauseIbelievethatit’swrongorsinfulformeasaChristiantogetangryatall. . . .Buttheangerdoesn’treallygoawayandIfeelmorefatiguedanddepressedeventually.Therapist:Let’stakeacloserlookatyourspecificthoughtorbeliefthatangerisalwayswrongorsinful. . . .Onwhatbasisdoyoubelieveitistrue?WhatdoyouthinktheBiblehastosayaboutthis?Client:IrememberthereareversesindifferentpartsoftheBiblecommandingustoputawayangerandwrathandmalice,butIcan’trecallthespecificreferencesnow.IfeelguiltywheneverIfeelanger . . .Therapist:OK,wouldyouliketolookattheBiblemorecloselyandseewhatitactuallysaysorteachesaboutanger?Client:Ohyes!I’vebeenstrugglingwiththisissueforquiteawhile . . .Therapist:CanyouthinkofanyotherBibleversesorpassagesthatarerelevanttoourdiscussion?Client:Notreally. . .hmmm. . .waitaminute.IdorecallJesusthrowingoutthemoneychangersinthetemple. . .somaybethereisatypeofangerlikewhenGodgetsangry. . .orJesusgetsangry,andit’snotsinful,it’sOK. . .butIstillfeelthatwhenIgetangry,it’snotOK,becauseI’mnotGod.Therapist:So,youalreadyseethatattheveryleast,whenJesusorGodgetsangry,itisnotsinfulorwrong,sothereisatypeofangerthatmaynotbesinful.Somecallthisrighteousindignation.CanyouthinkofotherBibleversesorpassagesthatmayteachthismoredirectly?Client:Cometothinkofit,didn’tPaulsaysomethingintheBiblelike,“Beangrybutdonotsin”?Therapist:That’sagoodtextyourecalled.It’sactuallyfoundinEphesians4:26. . . .Wouldyouliketoreadthispassage?Client:Sure.(readsfromtheBiblethetherapisthandsovertoher)Therapist:WhatdoyouthinkEphesians4:26means?Client:Well,atleastitsayswecanbeangrybutmustnotsininouranger.Therapist:Itsoundslikeyouareseeingnowthatangerisnotalwayswrongorsinful. . .(adaptedfromTan2007b,108–9) 9/21/104:39:58PM ChristianFaithinClinicalPractice 355 ThisconversationdemonstrateshowaChristiantherapistcanusetheBibleinatherapysessionwithaChristianclientwhowantstoopenlyanddirectlydiscussscripturalteaching(seealsoTanandJohnson2005).Scripturecanbeusedinasensitiveandeffectivewaytohelpinthecognitiverestructuringofclients’unbiblicalordysfunctionalthinking.ItisinterestingtonotethatthelateAlbertEllis,founderofrationalemotivebehaviortherapy(REBT),actuallyacknowledgedthattheBibleasaself-helpbookhasprobablyhelpedmorepeoplethanalltherapistscombined,intermsoffacilitatingsignificantchangesinpersonalfunctioning(Ellis1993b).ReferraltoReligiousGroupsAthirdmajorexampleoftheuseofreligiousandspiritualresourcesinexplicitintegrationinChristiantherapyisreferraloftheclienttoreligiousgroupssuchaschurchesorparachurchgroupswithintheclient’sreligiousbeliefsystem.Thesereligiousgroupsoftenprovidefellowship,support,andprayerthatcanfacilitatedeeperhealingandgrowthforclients.Theycanalsohelpclientstomakeamoreeffectivetransitionthroughtheterminationphaseoftherapy.Examplesofsuchgroupsinclude“smallgroups,Biblestudygroups,recoverygroups,prayergroups,fellowshipgroups,religiouslyorientedorChrist-centered12-stepprograms,youthgroups,andsoforth”(Tan1996c, 376).Manychurchesandparachurchorganizationsalsoprovidelaycounselingserviceswithoutcharge,towhichclientscanbereferredforfurtherhelpandsupport.Thelayorparaprofessionalcounselorsareusuallyselected,trained,andsupervisedinasystematicandcarefulway(seeTan1991,2002b).Referraltolaycounselorsinchurchesandparachurchgroupscanbeparticularlyhelpfultoclientswhomaynotbeabletoaffordtocontinueprofessionaltherapybecauseoffinancialdifficulties.Referraltoreligiousgroupsshouldbedoneinasensitiveandsupportiveway,infullcollaborationwiththeclient,andforthebenefitandwelfareoftheclient.ExplicitIntegration:DealingwithSpiritualIssuesinTherapyAsecondmajorcomponentofexplicitintegrationisdealingwithspiritualissuesintherapy.Clientsoftenseecounselorsandpsychotherapistsforhelpwithproblemsthathavespiritualormoralaspectsandevencauses(see,e.g.,Crabb1987;F. J.White1987).Explicitintegrationinpsychotherapywillinvolvedealingwithsuchspiritualandreligiousissuespresentedbytheclientinanopenanddirectway,withtheclient’sfullinformedconsent.Thiswillfirstrequireaninitialandadequatespiritualassessmentoftheclientandhisorherproblems.KennethPargamenthassuggestedthefollowingkeyquestionsforuseinaninitialspiritualassessmentoftheclientinanintakesession: _Tan_Counseling_BB_mw.indd369 9/21/104:39:59PM 356 AChristianApproachtoCounselingandPsychotherapy “Doyouseeyourselfasareligiousorspiritualperson?Ifso,inwhatway?”(assessingthesalienceofspiritualitytotheclient);“Areyouaffiliatedwithareligiousorspiritualdenominationorcommunity?Ifso,whichone?”(assessingthesalienceofareligiousaffiliationtotheclient);“Hasyourproblemaffectedyoureligiouslyorspiritually?Ifso,inwhatway?”(assessingthesalienceofspiritualitytotheproblem);and“Hasyourreligionorspiritualitybeeninvolvedinthewayyouhavecopedwithyourproblem?Ifso,inwhatway?”(assessingthesalienceofspiritualitytothesolution).(2007, 211) OthersuggestionsforconductinganinitialspiritualorreligiousassessmentoftheclientcanbefoundinH. N.Malony’s(1988)religiousstatusinterviewapproachandM. ScottPeck’s(1993)questionsfortakingaspiritualhistory.Peckactuallyadvocatedthatallpsychiatryresidentsshouldbetaughthowtoobtainaspiritualhistoryoftheirclientsintheirfirstmonthoftraining,alongsidelearninghowtotakeamoregeneralhistoryandconductingamentalstatusexam.Spiritualandreligiousissuescanalsoemergeduringthecourseoftherapywithclients.Theyincludebroadexistentialstrugglessuchassearchingformeaninginlife,dealingwiththefearofdeathandmortality,andchoosingauthenticvaluesinlife(see,e.g.,Wong,Wong,McDonald,andKlaassen2007).Theycanalsobemorespecificspiritualandreligiousissuessuchasdoubts,sins,struggleswithguilt,bitterness,andunforgiveness,“darknightsofthesoul”andotherspiritualstruggles(see,e.g.,Pargament2007),andevenpossibledemonization.Negativeaspectsofspiritualandreligiousexperiencessuchasso-calledtoxicfaith(ArterburnandFelton1991)orreligiousaddiction(Booth1991)areotherspiritualissuesthatmayneedtobeexplicitlyexploredanddealtwithintherapy.NeilAndersonhasemphasizedtheessentialneedforChristianclientstounderstandandappropriatetheiridentityinChristfromabiblicalperspectiveinordertoliveavictoriousChristianlife,inthefollowingthreemainareas:“IamacceptedinChrist”(John1:12;15:15;Rom.5:1;1 Cor.6:17,19–20;12:27;Eph.1:1,5;2:18;Col.1:14;2:10);“IamsecureinChrist”(Rom.8:1–2,28,33–34,35;2 Cor.1:21;Phil.1:6;3:20;Col.3:3;2 Tim.1:7;Heb.4:16;1 John5:18);“IamsignificantinChrist”(Matt.5:13–14;John15:16;Acts1:8;1 Cor.3:16;2 Cor.5:17–20;6:1;Eph.2:6,10;3:12;Phil.4:13)(2003,75–76).HehasalsodescribedsevenstepstofreedominChristinwhichanegativeelementinthefallenworldisreplacedwithabiblicalanswer:1.counterfeitversusreal2.deceptionversustruth3.bitternessversusforgiveness4.rebellionversussubmission5.prideversushumility6.bondageversusfreedom7.acquiescenceversusrenunciation(seeN. T.Anderson,Zuehlke,andZuehlke2000,152–63,384–411) _Tan_Counseling_BB_mw.indd370 9/21/104:40:00PM ChristianFaithinClinicalPractice 357 CollinshaslistedanddescribedseveralimportantspiritualissuesoftenencounteredinChristiantherapy,including“sinfulthoughtsandactions;legalism;self-sufficiency;pride;bitterness;non-Christianvalues;lackof:understandingofspiritualissues,spiritualnourishment,giving,balance,commitment,simplicity,HolySpiritpower,spiritualdisciplines,andinvolvementwiththechurch;suffering;andspiritualwarfare”(2007, 825).ItiscrucialfortheChristiantherapisttohandlespiritualandreligiousissuesinanempathicway,withgentlenessandrespectfortheclient.Thetherapistshouldnotimposehisorherownreligiousconvictionsontheclient.Timingisalsoimportantinhelpingclientsdealwiththeirspiritualandreligiousissues,especiallyiftheyinvolveconflictandspiritualstruggles.Ifsuchissuesareconfrontedtoosoonorinsensitively,theclient’sfaithmaybeimpactedinanegativeway(F. J.White1987).TheChristiantherapistwillthereforebesensitivetotheclient’sreadinessfordiscussingtheseissuesinanopenanddirectwayandfollowtheclient’space.Theclient’sfreedomtochooseandultimateresponsibilityinmakingdecisionsmustalwaysberespected.Formore-severelydisturbedclients,thetherapistwillwiselyrefrainfromconfrontingandchallengingtheirreligiousconvictions,eveniftheyareclearlydysfunctional,untilsuchclientshaveemotionallystabilizedandarebetterableandreadytodealwiththeirdysfunctionalreligiousbeliefs(seeTan1996c).Christiantherapistsalsomustlearnhowtohelpclientsfromdiversereligiousandculturalbackgroundsdealwithmoregeneralreligiousandspiritualissuesbyhavingsomeunderstandingofotherreligions(see,e.g.,RichardsandBergin2000;seealsoDowdandNielsen2006;Lovinger1984,1990).RobertLovinger(1984)hasprovidedsomehelpfulexamplesofcountertransferenceonthepartofthetherapistwhendealingwithreligiousissuesintherapywithclientswhoarereligiouslycommitted.Therapistsmustbecarefulnottofallintothesetherapeuticmistakesthatcomefromtheirowncountertransferenceorunconsciousnegativereactionstowardclients;examplesofsuchmistakesincludearguingwithclientsaboutdoctrinalissues;havinglongdiscussionsaboutphilosophicalandtheologicaltopicswithnotherapeuticpurpose;andnotadequatelyexploringthereasonsforaclienthavingmadeasignificantchangeinreligiousorientation,especiallyinthedirectionofthetherapist’sownreligionordenomination(Lovinger1984).ExplicitIntegration:FosteringIntrapersonalIntegrationandtheDevelopmentofSpiritualityintheTherapistandtheClientIntrapersonalintegrationorpersonalintegration(i.e.,one’sownappropriationoffaithandintegrationofpsychologicalandspiritualexperience)andthespiritualdevelopmentofthetherapistandtheclientarealsocrucialaspectsofexplicitintegrationinChristiantherapy(Tan1996c).Explicitintegrationwill _Tan_Counseling_BB_mw.indd371 9/21/104:40:01PM 358 AChristianApproachtoCounselingandPsychotherapy oftenincludediscussionandapplicationofspiritualdisciplinesasameansofGod’sgraceforhelpingboththetherapistandtheclienttogrowindeeperChristlikeness(Rom.8:29)andspiritualmaturity(seeTan1996b,1998).Severalhelpfulbooksareavailablethatclearlydescribespiritualdisciplinesforspiritualgrowthandtransformation(see,e.g.,Foster1988;Ortberg2002;TanandGregg1997;Whitney1991;Willard1988;seealsoA. A.Calhoun2005).DisciplinesoftheHolySpirit(TanandGregg1997)identifiesthefollowingspiritualdisciplinesasdisciplinesoftheHolySpirit:disciplinesofsolitudeindrawingneartoGod(e.g.,solitudeandsilence,listeningandguidance,prayerandintercession,studyandmeditation);disciplinesofsurrenderinyieldingtoGod(e.g.,repentanceandconfession,yieldingandsubmission,fasting,andworship);anddisciplinesofserviceinreachingouttoothers(e.g.,fellowship,simplicity,service,andwitness).Spiritualdisciplinescan,however,bepotentiallydangerous(cf.Plummer2009).Iftheyarepracticedinawaythatislegalistic,dogmatic,andselfabsorbed,theycanleadtopride,self-sufficiency,andself-righteousness,andthusultimatelyharmone’sspirituallifeanddevelopment.AChristiantherapistwillthereforealsoemphasizewhatGaryThomas(2002)hascalledtheauthenticdisciplinesorcircumstantialspiritualdisciplines(Tang2008)thatarenotwithinourvoluntarycontrol,asvitaladditionstothetraditionalspiritualdisciplines.Theseso-calledauthenticdisciplinesincludeselflessness,waiting,suffering,persecution,socialmercy,forgiveness,mourning,contentment,sacrifice,andhopeandfear(Thomas2002).TheyfocusmoreonGodseekingthefaceofmenandwomenandemphasizeaGod-ordainedspirituality,underhissovereigntyandnotourowncontrol.Theirultimategoalistolearn“tolovewithGod’sloveand. . .servewithGod’spower”(Thomas2002,12).Suchauthenticdisciplines,includingsufferingandpainfulexperiencesthatleadtoultimatespiritualformationandgrowthintodeeperChristlikeness,haverecentlybeencitedinthemoregeneralpsychologicalliteratureashighlystressfullifeeventsandtraumathatleadtoperceivedgrowth,labeled“posttraumaticgrowth,”“stress-relatedgrowth,”and“benefit-finding”(see,e.g.,seeHelgeson,Reynolds,andTomich2006;ParkandHelgeson2006;seealsoL. G.CalhounandTedeschi2006;Park2010).Biblicalmeaningmakingandbenefitfindingcanbepartofdealingwithexperiencesofauthenticdisciplinesthatclientsmayhaveintheirlives.Thetraditionalspiritualdisciplinesshouldbeusedinagrace-filled,nonlegalisticwayintheChristiantherapist’slifetofacilitatethetherapist’sownspiritualgrowthsothatheorshecanmoreeffectivelyhelptheclienttoalsogrowspiritually.TheultimategoalofChristiantherapyisnotonlytoalleviatesymptomsbutalsotodeepenspiritualmaturityintheclient.Appropriatespiritualself-disclosurebytheChristiantherapist(seeDenney,Aten,andGingrich2008)isanimportantpartofsharingtraditionalspiritualdisciplinesandhowtheycanbeusedinsessionsaswellasinbetweensessionsashome- _Tan_Counseling_BB_mw.indd372 9/21/104:40:02PM 359 ChristianFaithinClinicalPractice Sidebar15.2SpiritualDisciplinesandPractices(seeEck2002,273)Eckhascomprehensivelylistedthirty-ninespiritualdisciplinesandpracticesthatincludebothtraditionalspiritualdisciplinesandauthenticdisciplinesandhasexploredtheirtherapeuticuseinclinicalpractice.Hedividesthemintothreemajorcategories:Cognitive:meditation,listening,Scripture,study,prayer,discernmentBehavioral:simplicity,frugality,fasting,chastity,bodycare,sayingno/yes,slowing,Sabbath,solitude,silence,secrecy,service,servanthood,sacrifice,suffering,dyingwellInterpersonal:confession,repentance,forgiveness,submission,humility,worship,Eucharist,singing,celebration,fellowship,community,hospitality,healing,witnessing,testimony,intercession,guidance.Heemphasizesthattheuseofspiritualdisciplinesandpracticesintherapyshouldbedonewith“agracefilled,Godempoweredfocusasameansofgraceandmercy,andnotasalegalisticorcoerciveprocess”(Eck2002,272).Theyshouldthereforebeusedinethicalandappropriatewaysforthespiritualformationandtherapeuticbenefitoftheclientandwithhisorherfullinformedconsent(seeChapelle2000;Tan2003c). workassignments.Itisalsoasignificantpartofengaginginbiblicalmeaningmakingandbenefitfindingasthetherapistandtheclientexploreanddiscussexperiencesofauthenticdisciplines,includingsufferingandpainfuleventsintheirlivesthatcanleadtodeeperspiritualformationandgrowthinChrist.Somedegreeofspiritualdirection,ortheprocessofdiscerningandsurrenderingtoGod’swillanddeepeningone’spersonalrelationshipwithGodinthecontextofone’slifeexperiencesbymeetingwithsomeoneforprayerandspiritualconversation(seeBenner2002, 94),isthereforeanappropriatepartofexplicitintegrationinChristiantherapy(seeTan2003c;seealsoKellemen2005a,2005b).SomeleadersintheChristiantherapyfielddonotadvocateintegratingspiritualdirectionintoChristiantherapy(e.g.,McMinnandCampbell2007).However,manyotherssupportintegratingspiritualdirection,includingtheuseofspiritualdisciplines,intoChristiantherapy(seeTan2003c;seealsoBenner2005b;Crabb2003;G. W.MoonandBenner2004).AlthoughBenner(1988)earlierfeltthatChristiantherapyandspiritualdirectioncannotbeintegratedbecausetheyaresodifferentintheirfocusandroledemands,hehassubsequentlychangedhisviewandissupportiveofaChristianpsychospiritualtherapythatincludesspiritualdirection(Benner1998).Infact,he 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hasdevelopedanapproachcalledtheintensivesoulcareretreat(seeBenner2005b).HealsocitesBernardTyrell’sChristotherapyasanotherexampleofcombiningspiritualdirectionandpsychotherapy(seeTyrell1982).GaryMoonandhiscolleagues(G. W.Moon,Willis,Bailey,andKwasny1993)foundthatoutofalistoftwentyspiritualguidancetechniques,thosemostfrequentlyusedbyChristianpsychotherapists,pastoralcounselors,andspiritualdirectorswerespiritualhistory,discernment,forgiveness,solitudeorsilence,intercessoryprayer,andteachingfromScripture.Thesefindingsareconsistentwithpreviousresearchconductedinthisarea.Moonandhiscolleaguesalsoreportedthatdoctoral-levelreligiousmentalhealthclinicianswerelesslikelythanmaster’s-levelpractitionerstousesuchexplicitspiritualguidancetechniques.Inamorerecentgeneralstudyofninety-sixpsychologistsandtheirreporteduseoftwenty-ninerecommendedreligious/spiritualpsychotherapybehaviors,RoyceFrazierandNancyHansen(2009)foundthatingeneral,andfor90percentofthetwenty-ninebehaviors,thepsychologistspracticedthemlessfrequentlythantheirimportanceratingsindicatedtheyshould.Also,thegreaterthepsychologists’religious/spiritualself-identification,thehigherthelikelihoodofthemreportingengaginginthesebehaviorsinpsychotherapy.Astudywith100therapistssampledmainlyfromalumniofanAPAaccreditedChristiandoctoralprograminclinicalpsychology(Walker,Gorsuch,andTan2005)foundthatcourseworkinintegrationandtheologywasnotsignificantlyrelatedtotheexplicituseofreligiousandspiritualinterventionsintherapy.Instead,itreportedthatclinicaltrainingwithreligiousclients(i.e.,numberofcontacthourswithreligiousclients)andintervention-specifictrainingwithreligiousandspiritualinterventions(i.e.,numberofclinicalsupervisionhoursdevotedtoreligiousandspiritualinterventionsintherapy)weresignificantlycorrelatedwithmore-frequentuseofreligiousandspiritualinterventionsintherapyandalsoself-reportedcompetency.Alaterstudyof162studenttherapistsfromthreeAPA-accreditedChristiandoctoralprogramsinclinicalpsychology(Walker,Gorsuch,Tan,andOtis2008)similarlyfoundintervention-specifictrainingtobepotentiallythemostefficientwayfortrainingtherapiststoexplicitlyusereligiousandspiritualinterventionsinclinicalpractice.TheroleofChristianclinicalsupervisionisthereforecrucialindevelopingtherapistintegrationskills,includingtheexplicituseofChristianspiritualinterventionsandspiritualdisciplinesintherapy(Tan2009a;seealsoTan2007c).Somecautions,mentionedearlierinthischapter,areneededinthepracticeofexplicitintegrationinChristiantherapy,whichincludestheuseofspiritualinterventionssuchasprayer,Scripture,andthespiritualdisciplines(see,e.g.,Martinez,Smith,andBarlow2007;MagalettaandBrawer1998;WeldandEriksen2007).FurtherresearchontheeffectivenessofsuchexplicitlyChristianspiritualinterventionsintherapyisalsoneeded,althoughoutcomeresearch _Tan_Counseling_BB_mw.indd374 9/21/104:40:04PM ChristianFaithinClinicalPractice 361 todatehasyieldedempiricalsupportforboththeefficacy(WorthingtonandSandage2001)andtheeffectivenessinactualclinicalsettings(Wade,Worthington,andVogel2007)ofChristiantherapy(seealsoPargament2007;T. B.Smith,Bartz,andRichards2007).Arecentmeta-analyticreviewofthirtyoneoutcomestudies(eighteenwithtrueexperimentaldesignsandsixwithquasi-experimentaldesigns)ofreligiouslyorspirituallyorientedtherapieswithatotalof1,845clientsyieldedanaverageeffectsizeof0.56(T. B.Smith,Bartz,andRichards2007).Someempiricalsupportwasthereforefoundfortheeffectivenessofsuchtherapies,especiallyintreatingclientssufferingfromdepression,anxiety,stress,andeatingdisorders.ThemajorityoftheclientswereChristian(73percent)andMuslim(24percent)intheirreligiousaffiliation,withmostoftheoutcomestudiesinvolvingChristianorMuslimtherapy(seeAbuRaiyaandPargament2010;TanandJohnson2005).Amorerecentandlargermeta-analyticreviewoffifty-onesamples(includingtwenty-fourCBTsamples)fromforty-sixseparateoutcomestudiesofreligiousandspiritualtherapieswithatotalof3,290clientscametosimilarconclusions,furthersupportingtheefficacyoreffectivenessofsuchtherapies(Worthington,Hook,Davis,andMcDanielinpress).Arecentreviewofempirically-supportedtreatments(ESTs)forChristiancounselingconcludedthatChristianESTsincludeChristiancognitivetherapyfordepressionandthreemarriageenrichmentinterventions(PREP,InterpersonalCommunicationProgram,andHope-FocusedCoupleApproach).AfewotherChristiantherapieshavereceivedsomesupportfortheirefficacybutarenotESTsyet,includingChristianCBTforeatingdisorders,Christianlaycounselingingeneral,Christiangrouptreatmentforunforgiveness,andChristiandevotionalmeditationforanxiety(Worthington,Hook,Davis,andRipley2008).AmorerecentreviewofempiricallysupportedreligiousandspiritualtherapiesingeneralconcludedthatChristianaccommodativecognitivetherapyfordepressionandtwelve-stepfacilitationforalcoholismwereefficaciousandMuslimpsychotherapyfordepressionaswellasforanxietywasefficaciouswhenusedwithmedication.Thefollowingweredeemedpossiblyefficacioustreatments:Christiandevotionalmeditationforanxiety,Taoistcognitivetherapyforanxiety,Christianaccommodativegrouptreatmentforunforgiveness,spiritualgrouptreatmentforunforgiveness,Christianaccommodativegroupcognitive-behavioraltherapyformaritaldiscord,andChristianlaycounselingforgeneralpsychologicalproblems.SpiritualgrouptherapyforeatingdisorderswhencombinedwithexistinginpatienttreatmentandBuddhistaccommodativecognitivetherapyforangerinaprisonsettingwerealsodeemedpossiblyefficacious(Hooketal.2010).ExplicitintegrationinChristiantherapythatincludestheappropriateandethicaluseofspiritualinterventionsandresourcesintherapyandincorporatestheprocessofspiritualdirectiontoacertaindegreecanhavegreatpotential“fordeepblessingandgreaterwholenessandshalomfortheclientwhofreely 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choosessuchapsychospiritualtherapythataimstowardbothpsychologicalandspiritualgrowthaswellasthereductionofpsychologicaldistress”(Tan2003c, 20).Itshouldbeconductedinanethicallyresponsible,clinicallysensitive,andprofessionallycompetentway,forthebenefitandwell-beingoftheclient(Tan1996c).ThischapteronChristianfaithinclinicalpracticehasfocusedmainlyonindividualtherapy,butitcanalsobeappliedtocoupleandfamilytherapy(see,e.g.,Worthington2005b;YarhouseandSells2008),andgrouptherapyandcaregroups(see,e.g.,Greggo2008).RecommendedReadingsAnderson,N. T.,Zuehlke,T. E.,andZuehlke,J. S.(2000).Christ-centeredtherapy:Thepracticalintegrationoftheologyandpsychology.GrandRapids:Zondervan.Benner,D. G.(1998).Careofsouls:RevisioningChristiannurtureandcounsel.GrandRapids:Baker.Bufford,R. K.(1988).Counselingandthedemonic.Dallas:Word.Collins,G. R.(2007).Christiancounseling:Acomprehensiveguide(3rded.).Nashville:ThomasNelson.Crabb,L. J.(1977).Effectivebiblicalcounseling.GrandRapids:Zondervan.McMinn,M. R.,&Campbell,C. D.(2007).Integrativepsychotherapy:TowardacomprehensiveChristianapproach.DownersGrove,IL:IVPAcademic.Moon,G. W.,&Benner,D. G.(Eds.).(2004).Spiritualdirectionandthecareofsouls.DownersGrove,IL:InterVarsity.Pargament,K. I.(2007).Spirituallyintegratedpsychotherapy:Understandingandaddressingthesacred.NewYork:GuilfordPress. 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hristiancounselingorpsychotherapycanbesimplydescribedascounselingconductedbyaChristianwhoisChristcentered,biblicallybased,andSpiritfilled(seeTan1999b).TheroleoftheHolySpirit,thethirdpersonoftheTriuneGod(Father,Son,andHolySpirit),iscrucialandcentralinChristiancounseling.NumerousworksareavailableontheHolySpiritfromatheologicalperspective(seeFee1994;Karkkainen2002;Moltmann1997;Pinnock1996).ThereisalsoasmallbutgrowingliteratureontheministryoftheHolySpiritinthecontextofChristiantherapyandpersonalityfunctioning,botharticlesinjournals(seeCoe1999;Dodds1999;Ingram1996;Parker2008;seealsoDecker2002)andbooks(seeCoeandHall2010;M. G.GilbertandBrock1985,1988;Pugh2008;Vining1995a,1995b;ViningandDecker1996).ThecrucialroleoftheHolySpiritinChristiantherapyissupportedbyScripturethatdescribestheHolySpiritastheCounselor,Comforter,Helper,orAdvocate(John14:16–17).Ineverycounselingortherapysituation,atleastthreepersonsareinvolved:thecounselor,theclientorcounselee,andtheHolySpirit,whoistheCounselorparexcellence(seeAdams1973).TheHolySpiritisalsodescribedasthegiveroflifebytheNiceneCreed,supportedbyScripturesinboththeOldTestamentandtheNewTestament(seeParker2008, 286).HiskeyroleinChristiantherapyastheCounselor,aswellasthegiveroflife,meansthatChristiantherapistsmustacknowledgeanddepend363 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ontheSpirit’spresenceandhealingpowerineverycounselingsituation,withabasicbiblicalunderstandingoftheworkandministryoftheHolySpirit(Tan1999b).TheWorkandMinistryoftheHolySpiritTheworkandministryoftheHolySpiritcanbedescribedandbiblicallyunderstoodinatleastthreemajorways:theSpirit’spower(andgifts),theSpirit’struth,andtheSpirit’sfruit(seeTan1999b, 568).TheSpirit’sPowerandGiftsThepoweroftheHolySpiritisessentialinChristianlifeandministry,includingwitnessingandevangelism(Acts1:8).ChristiansarecommandedinScripturetobecontinuallyfilledwiththeHolySpirit(Eph.5:18),momentbymomentonadailybasis.ThismeansthatweconfessoursinsandyieldtoJesusChristasLordofourlivesandaskfortheHolySpirittofillusandtakecontrolofus,sothatwecanbeempoweredbyhimtobecomemorelikeJesusandtodotheworksofJesus(seeHayford2005),includingcounselingandhelpingothers.AsweprayerfullyyieldtotheSpirit’scontrol,heempowersusandguidesusinourChristianlivesandministries.HealsosovereignlyandsupernaturallygivesusspiritualgiftsaccordingtoGod’swill,toenableustobefruitfulandfaithfulintheareasofministrytowhichhehascalledus,includingcounseling(seeRom.12;1 Cor.12;Eph.4;1 Pet.4).ThesespiritualgiftsareGod’sdropletsofgrace,whichhefreelygivesustoempowerustohaveaneffectiveministrywithlove,gratitude,andhumility,thatglorifieshimandblessesothersforeternity.TheyincludethefollowingspiritualgiftsthatareespeciallyrelevantforaneffectivecounselingministryledbytheHolySpirit:exhortationorencouragement(Rom.12:8);healing(1 Cor.12:9,28);wisdom(1 Cor.12:8);knowledge(1 Cor.12:8);discerningofspirits(1 Cor.12:10);andmercy(Rom.12:8)(seeTan1999b, 568).Otherspiritualgiftsthatareoftenviewedasimportantforcounselingministries,especiallyfromamorecharismaticorPentecostalperspectiveincludeprophecy,teaching,faith,miracles,tongues,andintercession.Helpfuldefinitionsoftwenty-sevenspiritualgiftsandaspiritualgiftsquestionnairetohelpChristiansdiscernanddiscovertheirspiritualgiftscanbefoundinYourSpiritualGiftsCanHelpYourChurchGrow(Wagner1994).TheSpirit’sTruthTheHolySpiritistheSpiritoftruthwhowillteachusandguideusintoalltruth(John14:26;16:13),includingpsychotheologicaltruth.Ultimately, 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sucheternaltruthiswhatwillsetusfree(John8:32),centeredinJesusChrist,whoistheTruth(John14:6)aswellastheWayandtheLife.TheHolySpiritinspiredthewritingofScriptureasGod’sWord.Hisworkandministry,includinginthecounselingcontext,willnevercontradictthetruthofScripturewhenitisproperlyinterpreted.TheHolySpiritwillthereforealwaysupholdtheeternalvalidityofScripture.Hisministryincounselingwillbeconsistentwiththemoralandethicalaspectsofbiblicalteachingandtruth.TheSpirit’sFruitTheHolySpiritproducesthefruitoftheSpiritthatischaracteristicofmatureChristlikeness(Rom.8:29)andthatismentionedinGalatians5:22–23:love,joy,peace,patience,kindness,goodness,faithfulness,gentleness,andself-control.Thisfruitrefersbasicallytothefruitofagape,orChristlikelove,producedbytheSpiritinChristianlivesthatareyieldedtohiscontrolandempowering.TheSpirit’sfruitofagapeispowerfullytherapeuticincounselingsituations.AllthreeaspectsoftheHolySpirit’sministryareessentialandcrucialintheChristianlifeaswellasinChristiantherapy.Theyneedtobepresentinbiblicalbalance.Powerwithoutloveoftenresultsinabuse.Powerwithouttruthcanbecomeheresy.However,powerbasedonbiblicaltruthandusedwithChristlikelovecanproducerenewalandrevivalaswellasthedeepandsubstantialhealingofbrokenlives.TheWorkoftheHolySpiritinCounselingTheHolySpiritcanworkinmanydifferentwaysduringacounselingsessionitself.Inmore-implicitintegrationapproachestoChristiantherapy,suchasinpsychodynamicorpsychoanalytictherapy,theHolySpirit’sworkasgiveroflifemaybemoreemphasized.StephenParker(2008),forexample,hasdescribedtheHolySpirit’screativeworkintherapyusingWinnicott’sobjectrelationstheoryandtheconceptsoftransitionalphenomenaandobjectusage(seeWinnicott1966,1971).ParkerfocusesespeciallyonhowtheSpiritcanhelpclientsby“conferringasenseofidentityandprovidinganenvironmentforemergenceofastrongspiritualself.TheworkoftheHolySpiritwasalsoseenastappingintothecreativepotentialofwhatWinnicott(1971)calls‘transitionalphenomena,’andinengenderingnewlifebymakingGodrealinwaysthattranscendourimaginings”(Parker2008,292).Parkeralsoemphasizesthatthelife-givingworkoftheHolySpiritenablesaclienttostillhaveabasicsenseofhopeevenwhenalltheclient’s“wishes,dreams,disappointments,fears,andfrustrationshavebeenspent”(Parker2008, 292),makingGodrealtotheclientdespitehisorherexperiencingtheabsenceofGod.Similarly,theHolySpiritcanworkinimplicitintegrationthatisintentionalandincarnational,suchasinrelationalpsychodynamictherapy.TheSpirit’swork 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isquietlybutintentionallyembracedandexpressedbytheChristiantherapistintheavowalthattheclientisworthyofloveandtheacceptanceoftheclient’sworstexperiences(seeTerrell2007, 162).StephenRogers(2007)hasalsodescribedhowafocusontheprocessandthehere-and-nowduringatherapysessioninobjectrelationstherapycanbeunderstoodasapowerfulspiritualintervention,quietlyguidedandempoweredbytheHolySpirit.TranscendentmomentsandcreativeexperiencesinChristiantherapymaythereforereflectthedeepbutquietworkoftheHolySpiritincounseling.Psychotherapyitselfcanbetheologicallyviewedas“workintheSpirit”(KunstandTan1996)inbringingwholenesstobrokenlives.JohnPughhasemphasizedthattheHolySpiritworksinandthroughtheday-to-day“awfulexperiencesofhumanexistence”(2008, 280).TheHolySpiritcanalsoworkinexplicitintegrationinChristiantherapy,whichdealswithreligiousandspiritualissuesmoredirectlyandusesspiritualresourcesandreligiousinterventionsmoreovertlyandsystematicallywithclients.ThereareatleastfivewaysthattheHolySpiritcanworkduringaChristiantherapysessioninwhichthetherapistusesamoreexplicitintegrationapproach(Tan1999b).First,theHolySpiritcandirectlyhelptheChristiantherapistquicklyandaccuratelydiscerntherootproblemsoftheclientbyprovidingtheChristiantherapistwithspecificandrelevantwordsofknowledgeorwisdom(1 Cor.12:8).Fromamoreconservativeevangelicalperspective,Swindoll(1994)hasreferredtosuchexperiencesofreceivingwordsofknowledgeorwisdomfromtheSpirit(seeDeere1993,1996)as“innerpromptings”ornudgesoftheSpiritwithintheChristiancounselorwhoisprayerfullyattentivetotheSpirit’sleading.SuchpromptingscanalsohelptheChristiantherapisttoengageindeeperspiritualconversationwiththeclient,or“soultalk”(Crabb2003).TheChristiantherapistcanbemoremindfullyandattentivelydependentontheHolySpiritduringacounselingsessionbyperiodicallypraying“flashprayers”inhisorherheartsuchas“SpiritofGod,pleaseguideme”;“HolySpirit,touchtheclientwithyourhealinggrace”;“HolySpirit,helpusatthispointofimpasse”;“SpiritofGod,protectusandempowerus”;“HolySpirit,pleasecomfortandstrengthentheclient.”Second,theHolySpiritcanprovidespiritualdirectionregardingGod’swilltoboththeChristiantherapistandtheclientastheyparticipateinmoreexplicitintegrationpracticesduringatherapysession,suchasprayingtogether,discussingScripture,andopenlyexploringspiritualissues.Asnotedearlier,theHolySpiritcanalsoguideinmore-implicitintegrationapproachestoChristiantherapyduringatherapysession.Third,theHolySpiritcandirectlytouchaclientinapowerfulwaywithhishealinggraceandpower.ThisexperiencecanoccuranytimespontaneouslyandsupernaturallyinGod’ssovereigntyandbyhisgraceandgoodness,oftenleadingtosignificantor“quantumchange,”aswhensuddeninsightsandepiphaniesbringtransformationofordinarylives(seeW. R.MillerandC’deBaca2001).However,explicituseofprayer,andespeciallyinner-healing 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prayerorhealingofmemories(seeTan2003b;TanandOrtberg2004;seealsoGarzonandBurkett2002),canbeespeciallyhelpfulinfacilitatingtheoccurrenceofsuchtranscendentmoments.Fourth,theHolySpiritcanenabletheChristiantherapisttodiscernthepresenceofthedemonicifthereisdemonizationordemonicoppressionintheclient’slife.Thespiritualgiftofdiscerningofspiritsordistinguishingbetweenspirits(1 Cor.12:10)canbeparticularlyhelpfultotheChristiantherapist,especiallyinmakinganaccuratedifferentialdiagnosisbetweendemonizationandmentaldisorder.Attimes,bothdemonizationandmentalillnessmayafflictaparticularclient.TheHolySpiritcanalsoempowertheChristiantherapisttoengageineffectiveprayersfordeliveranceandprotectionfromthedemonic,ifthisiscalledfor,withproperinformedconsentandfullcollaborationfromtheclient.Itmaybemoreappropriateattimestorefertheclientwithpossibledemonizationtoapastororprayerministryteamexperiencedindeliveranceworkpreferablyintheclient’sownchurchordenomination.Fifth,andfinally,theHolySpiritcanworkdeeplyinspiritualtransformationofboththeclientandthetherapistintogreaterChristlikenessastheypracticethespiritualdisciplines(e.g.,solitudeandsilence,listeningandguidance,prayerandintercession,studyandmeditation,repentanceandconfession,yieldingandsubmission,fasting,worship,fellowship,simplicity,service,andwitness)inthepoweroftheSpirit(TanandGregg1997).Someofthesespiritualdisciplinescanbepracticedinthetherapysessionandothersashomeworkassignmentsfortheclientbetweensessions.TheycanhelpboththetherapistandtheclienttoaccessmoreofthepresenceandpoweroftheSpiritfortheclient’sgrowthandhealing.Itisthereforenottotallytruethatatherapistcanleadaclientonlyasfarasthetherapisthasgonespirituallyorpsychologically.TheSpiritcanbringbothofthembeyondtheirpresentlevel.ThisisthesovereignworkofGodandhisgracealone.TheworkoftheHolySpiritinChristiantherapyisthereforecentralandcrucial.Althoughtrainingandcompetenceintherapyskillsareneeded,ChristiantherapistswillusesuchskillsindependenceontheHolySpirit.TheHolySpiritandChristianSpiritualityinCounselingAdistinctivegoalofChristiantherapyistohelptheclienttogrowspirituallyintodeeperChristlikeness(Rom.8:29),thatis,todeveloptheclient’sChristianspirituality(inadditiontoreducinghisorherpsychologicaldistress).TheHolySpirit’sworkisalsoessentialindevelopingChristianspirituality,whichneedsfurtherdefinitionanddescription.ChristianSpirituality:DefinitionandDescriptionInrecentyears,muchhasbeenwrittenaboutspiritualityingeneral,andChristianspiritualityinparticular(seeAugsburger2006;Benner2002;Bloesch 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2007;Boa2001;Chan1998,2006;Foster1998;FosterandBeebe2009;Howard2008;McKnight2004;E. H.Peterson2005,2006,2007,2008,2010;Webber2006;Willard1998,2002).TherearealsotworelativelynewjournalsdevotedtoChristianspirituality:Conversations:AForumforAuthenticTransformationandJournalofSpiritualFormation&SoulCare.Spiritualityinamoregenericandpsychologicalsensehasdifferentmeanings(ZinnbauerandPargament2005).However,ithasbeendefinedasasearchforthesacred,thatis,thatwhichtranscendstheself(P. C.Hilletal.2000).StevenSandageandF.LeRonShults(2007)haveemphasizedrelationalspiritualityanddefineditas“waysofrelatingtothesacred”(ShultsandSandage2006, 161).Also,arecentmovementinthementalhealthandgeneralhealth-carearenashasfocusedonthesignificantrelationship,oftenpositive(butnotalways),betweenreligion/spiritualityandhealthormentalhealth(e.g.,Koenig1998;Koenig,McCullough,andLarson2001;PlanteandSherman2001;seealsoP. C.HillandPargament2003;W. R.MillerandThoresen2003;Powell,Shahabi,andThoresen2003;Seeman,Dubin,andSeeman2003),buttherearecriticsofthismovement(e.g.,SloanandBagiella2002).Christianspiritualitycanalsobedefinedanddescribedinvariousways.AlisterMcGrathhasdefinedtheessentialmeaningofChristianspiritualityasconsistingof“theshaping,empowering,andmaturingofthe‘spiritualperson’(1 Cor.2:14–15)—thatis,thepersonwhoisalivetoandresponsivetoGodintheworld,. . .andevangelicalspiritualitywillthusbeBible-centered,anditwillbeconcernedmorewiththefacilitationandenhancementofthepersonalredemptiveencounterofthebelieverwithChrist”(1995,125).HeparticularlyemphasizesthelordshipoftheHolySpiritandtheimportanceofChristiancommunityforthespiritualgrowthofChristians(seeTan2008a,28).HealsosuggeststhatevangelicalChristianspiritualitywillhavethefollowingfourmajorcharacteristics:“beScripture-centered;placeconsiderableemphasisonthetransformingcharacteroftheknowledgeofGod;restonasolidandreliablefoundationintheself-revelationofGod;andrediscovertheimportanceofspiritualdiscipline”(McGrath1995,134–37).Christianspiritualitycanalsobedefinedas“thedispositionorinternalconditionofpeoplewheninsuchastateaspreparesthemtorecognizeandfullyappreciatespiritualrealities,andsuchtruespiritualityisultimatelytheresultoftheinworkingoftheHolySpirit(1 Cor.2:14,15;3:1,16—seeUnger1981,p. 1043)”(Tan1987b, 36).E. B.HowardhasrecentlyprovidedacomprehensivedescriptionofChristianspiritualityconsistingofthreelevels:“thelevelofpractice,whichreferstoouractualcultivationandexperienceofrelationshipwithGod;thelevelofdynamics,whichreferstoourformulationofthepatternsofliveddivinehumanrelationship;andthelevelofacademicdiscipline,whichreferstotheformalfieldofstudythatexploresthefirsttwolevelsinasystematicmanner”(2008, 24). _Tan_Counseling_BB_mw.indd382 9/21/104:40:11PM TheHolySpiritandChristianSpiritualityinCounselingandPsychotherapy 369 Christianspirituality,fromabiblical,evangelicalperspective,hasmanyaspectsandfacets(seeTan1987b,36–38).First,itmeanshavingadeephungerorthirstforGod(Ps.42:1–2;Matt.5:6).TheHolySpiritinspiressuchasincerelongingtoknowGodinapersonalandintimateway(seePacker1973).Ineveryperson,thereisaGod-shapedvacuumthatonlyGodcanfillandfulfill.Second,itmeanshavingaloveforGodbasedonpersonalknowledgeofGod,whicheventuallyresultsinworshipofGodandobediencetohisgoodandperfectwill(Matt.22:37,38;John14:21,23;cf.Rev.2:1–7).Third,itmeansbeingfilledwiththeHolySpiritandsurrenderingtoGod’sdeepeningworkofgraceinourheartsandnotyieldingtothesinfulnatureorthefleshinus(Eph.5:18;Gal.5:16;Rom.6:12–13).Theregular,grace-filled,nonlegalisticpracticeofthespiritualdisciplinesinvolvingbothindividualandcommunitylifewillhelpusconnectmoretothepresenceandpoweroftheHolySpirit(seeTanandGregg1997)andexperienceGod’sdeepeningworkofgraceintransformingustobecomemorelikeJesus.Fourth,itmeansdiscoveringandusingthespiritualgiftsgivenbytheHolySpiritforGod’spurposesandglory(seeRom.12;1 Cor.12;Eph.4;1 Pet.4),bearingforththefruitoftheSpiritthatisultimatelyagapeorChristlikelove(Gal.5:22–23),andbecomingmoreChristlikeineverywayinourlivesandcharacter(Rom.8:29).Fifth,itmeansdevelopingbiblicalthinkingandhavingaworldviewthatisconsistentwithGod’seternalperspectiveasrevealedintheBible,hisinspiredWord(cf.Rom.12:2;Phil.4:8;Col.3:16a;2 Tim.3:16–17).Suchbiblicalthinkingwillleadtoabalancedministrytothewholeperson,involvingevangelism,missions,discipleshiptrainingincludingservanthoodandleadership(seeTan2006b,2009),pastoralcareandcounseling,socialaction,andaneschatologicalhopeandlongingfortheLord’sreturnandthefinalconsummationofthekingdomofGod.Sixth,itmeansbeinginvolvedinspiritualwarfarethatrequirestheuseofsupernaturalpowerandresourcesfromGod(cf.1 Cor.4:20;Eph.6:10–18),especiallytheuseofprayerandScriptureinthepoweroftheHolySpirittoovercometheworld,theflesh,andthedevil(Eph.2:2–3).ThiswillincludethecrucifixionofourownministryandthesurrenderingofourambitionstotheserviceofChrist(Purves2007),actualizingthetruththatwehavebeencrucifiedwithChristanditishewholivesinus(Gal.2:20).Finally,itmeansthattherearemysticalaspectsandexperiencesinthedepthsofChristianspirituality,whichtransformustobemoreChristlike,includingsharinginthefellowshipofChrist’ssufferings(Phil.3:10).Attimes,itmayincludeexperiencingthe“darknightofthesoul”asdescribedbySt.JohnoftheCross(cf.Isa.50:10)anddiscussedinchapter15ofthisbook.ItisimportantforChristiantherapists,guidedbytheHolySpiritthroughScriptureandwritingsonChristianspirituality,tounderstandsuchmysticalandpainfulexperiencesofthespirituallifeinChrist,sothatclientscanbebetterhelped _Tan_Counseling_BB_mw.indd383 9/21/104:40:12PM 370 AChristianApproachtoCounselingandPsychotherapy andempathicallysupportedwhentheyaregoingthroughdarknights.Godusestheseexperiencestolovinglydrawusawayfromthemanydistractionsofourlivesandclosertohimsothathecanworkadeeperinnertransformationofthesoul(seeFoster1978,89–91).Whenhelpingclientswhoareexperiencingsuchspiritualstruggles,theChristiantherapist,guidedbytheHolySpirit,willlearnthatthebesttherapyistoprovideempathicunderstanding,caringsupport,andmuchprayer(seeTan1987b, 37).ThereareotheraspectsanddimensionsofChristianspiritualitythatcenteronlovingGodandlovingothers(Mark12:29–31;seeMcKnight2004;seealsoAugsburger2006),butthemajoronesjustdescribedcanhelpChristiantherapistsprovideChristiancounselingthatalsoaimsatspiritualgrowthandChristlikematurityintheclient.Inasimilarvein,Parkerhasrecentlyemphasizedthecruciallife-givingworkoftheHolySpiritinthedevelopmentoftrueChristianspirituality.Henotes:IntheOldTestament,thedominantmetaphorfortheSpiritisruach(wind,breath)andhenceanearlyconnectiontotheideaoftheSpirit’slife-givingquality. . . .IntheNewTestamentthismetaphoroftheSpirit(Greek:pneuma;cf.English“wind”)creatingnewlifeisaddressedinthecontextoftheregenerationofthebeliever(Rom.8:11;1 Cor.6:11;Titus3:5).St.Paulfurtherconnectsthelife-givingworkoftheSpirittothetransformationofthebelieverintotheveryimageorlikenessofChrist(2 Cor.3:17–18).Thus,forPaul,thenewlifeoftheChristiancanbecharacterizedasoneinwhichtheoldlifeofthe“flesh”isexchangedforanewlifedominatedbytheSpirit(Rom.8).(2008, 286) ChristianSpirituality:TypesandApproachesWhileChristianspiritualitycanbedefinedanddescribedtosomedegree(seeHoward2008),therearedifferenttypesof,andapproachesto,Christianspirituality.OnewayoffurtherelaboratingonthetypesofChristianspiritualityavailabletousistofocusonthesixmajortraditionsofChristianfaithasstreamsoflivingwater,asFoster(1998)hasdone.HehasdescribedthefollowingsixtraditionsasessentialtoabalancedapproachtoChristianspirituality:thecontemplativetradition,emphasizingtheprayer-filledlife;theholinesstradition,emphasizingthevirtuouslife;thecharismatictradition,emphasizingtheSpirit-empoweredlife;thesocialjusticetradition,emphasizingthecompassionatelife;theevangelicaltradition,emphasizingtheWord-centeredlife;andtheincarnationaltradition,emphasizingthesacramentallife(seeFoster1998).Similarly,KennethBoa(2001)hasprovideddescriptionsoftwelvemajorbiblicalandpracticalapproachestospiritualformation,eachfocusingonadistinctivefacetofChristianspirituality.Theyare(1) relationalspirituality,focusingonlovingGodcompletely,ourselvescorrectly,andotherscompas- _Tan_Counseling_BB_mw.indd384 9/21/104:40:13PM TheHolySpiritandChristianSpiritualityinCounselingandPsychotherapy 371 sionately;(2) paradigmspirituality,focusingSidebar16.1oncultivatinganeternalversusatemporalperspective;(3) disciplinedspirituality,focusingTwelveMajorApproachestoonengaginginthehistoricaldisciplines;(4) exSpiritualFormationchangedlifespirituality,focusingongrasping(seeBoa2001,11–13)ourtrueidentityinChrist;(5) motivatedspirituality,focusingonasetofbiblicalincentives;1.Relationalspirituality(6) devotionalspirituality,focusingonfallingin2.ParadigmspiritualitylovewithGod;(7) holisticspirituality,focusing3.Disciplinedspiritualityoneverycomponentoflifeunderthelordship4.ExchangedlifespiritualityofChrist;(8) processspirituality,focusingon5.Motivatedspiritualityprocessversusproduct,beingversusdoing;(9)6.DevotionalspiritualitySpirit-filledspirituality,focusingonwalkingin7.HolisticspiritualitythepoweroftheSpirit;(10)warfarespirituality,8.Processspiritualityfocusingonovercomingtheworld,theflesh,and9.Spirit-filledspiritualitythedevil;(11)nurturingspirituality,focusing10.Warfarespiritualityonalifestyleofevangelismanddiscipleship;11.Nurturingspirituality(12)corporatespirituality,focusingonencour12.Corporatespiritualityagement,accountability,andworship(seeBoa2001,11–13).WhilecertainvarietiesofChristianspiritualityfocusonbecomingmorematureinChrist,therearealsopersonalpreferencesregardinghowweapproachGodanddevelopourspiritualmaturity.Spiritualtemperamentsalsovaryamongus,withdifferentpreferencesinspiritualpathwaystoGod.Thomas(2000b)hasthereforeemphasizedthatChristianspiritualityisnot“one-size-fits-all.”Instead,hedescribesninesacredorspiritualpathwaysfromwhichpeoplemaychooseaccordingtotheirpreferences,inordertogrowinChrist:tradition,vision,relationships,intellectualthought,service,contemplation,activism,nature,andworship.Acceptanceofoneanother’sapproachtoChristianspiritualityandspiritualformationinChristiscrucial.InsuchspiritualformationintodeeperChristlikeness,theworkoftheHolySpiritisessential,includingspiritualformationthatoccursinthecontextofChristiantherapy(see,e.g.,CoeandHall2010).ConcludingCommentsInorderfortheHolySpirittodohiscrucialworkinChristiantherapythatalsofocusesonChristianspiritualityandthespiritualformationofclientsintodeeperChristlikeness(Rom.8:29),ChristiantherapistsmusthavefaithinChristasLordofallprofessionalandacademicdisciplines,includingpsychologyandcounseling(E. L.Johnson1997).AsSpirit-filledservantsofJesusChrist,ChristiantherapistswillexercisefaithortrustandfullconfidenceinChristasthemostbrilliantpersonintheuniversewhoisalsobothmasterand _Tan_Counseling_BB_mw.indd385 9/21/104:40:14PM 372 AChristianApproachtoCounselingandPsychotherapy maestroofourfieldandprofessionofcounselingandpsychotherapy(Tan2008b;seealsoWillard2006).ChristiantherapistswhopracticebyfaithaChrist-centered,biblicallybased,andSpirit-filledapproachtocounselingwillexperienceandhelptheirclientsexperiencetheeternallifethatJesuscametogiveus(John3:16;10:10).AsDallasWillardhaswritten:Manycounselorstodayarelearningthatfortheirownwork,deepimmersioninthedisciplinesisnecessary,bothfordevelopingtheirowncharacter,andbeyondthat,accessingspecialpowersofgracefortheirworkincounselingpeople.Manypsychologistsarelearninghowtousetechniquesofprayerandvariouskindsofministrytohaveamuchgreatereffectthantheycouldhaveifalltheyhadtogoonwerejustthethingstheylearnedintheirclinicaltrainingprograms. . . .Ithinkthemostimportantandthemostsolidwayistobegintointegrateprayerandspiritualteachingintothetherapyprocessasitseemsappropriate. . . .Ithinktheissuehereliesdeeperthanevenmattersofintegrationaswecommonlydiscussit.ItisamatterofourunderstandingofthegospelofJesusChristasonewhichbreaksthroughthenaturalworldandbringsitintothespiritualworldandinvitesusasindividualstolearntoliveaneternalkindoflifenow.(Willard1996,19–20) Itisinterestingtonotethatthreedecadesago,J. D.Frank(1982)andIsaacMarks(1978),twoprominentleadersinthefieldofsecularpsychotherapy,hadalreadychallengedtherapyresearcherstopaymoreattentiontotheroleof“healingpower”orfaithhealing,involvingfaithandreligiousprocesses,inpsychotherapyanditseffectsoroutcomes.Furtherresearchisobviouslyneeded,focusingmorespecificallyonreligiousandspiritualhealinginterventions,includinginner-healingprayer,andtheireffectiveness,especiallyinChristiantherapyconductedbyChristiantherapists,whoareempoweredbytheHolySpirit.WeneedtoprayerfullydependontheHolySpiritandhispowerandgiftsandtruthandfruitinordertobeSpirit-filledservantsofJesusChristincounselingandpsychotherapy.TheHolySpiritwillenableustocontinuetodevelopandpracticeatrulyChristianpsychologythatisbiblicallybased.ThisendeavorwillrequireinvolvementwithacommunityofChristianscholarsandChristiancounselorsandpsychologists.OnlybythegraceofGodwillwethuskeepthefaithorbekeptinthefaithinhiminourworkincounselingandpsychotherapy(seeTan2008b, 67).RecommendedReadingsDecker, E.(2002).TheHolySpiritincounseling:AreviewofChristiancounselingjournalarticles(1985–1999).JournalofPsychologyandChristianity21,21–28. _Tan_Counseling_BB_mw.indd386 9/21/104:40:15PM TheHolySpiritandChristianSpiritualityinCounselingandPsychotherapy 373 Fee,G. D.(1994).God’sempoweringpresence:TheHolySpiritinthelettersofPaul.Peabody,MA:Hendrickson.Gilbert,M. G.,&Brock,R. T.(Eds.).(1985).TheHolySpiritandcounseling,Vol. 1:Theologyandtheory.Peabody,MA:Hendrickson.Gilbert,M. G.,&Brock,R. T.(Eds.).(1988).TheHolySpiritandcounseling,Vol. 2:Principlesandpractice.Peabody,MA:Hendrickson.Howard,E. B.(2008).TheBrazosintroductiontoChristianspirituality.GrandRapids:Brazos.Tan,S. Y.,&Gregg,D. H.(1997).DisciplinesoftheHolySpirit.GrandRapids:Zondervan.Vining,J. K.(1995).Spirit-centeredcounseling:Apneumascriptiveapproach.EastRockaway,NY:Cummings&Hathaway. _Tan_Counseling_BB_mw.indd387 9/21/104:40:16PM 17LegalandEthicalIssuesinChristianCounselingandPsychotherapy L egalandethicalissuesinthegeneralfieldofcounselingandpsychotherapyhavealreadybeendiscussedinchapter3.Inthisfinalchapter,thelegalandethicalissuesthatpertainmorespecificallytoChristiancounselingandpsychotherapywillbediscussed.Legalissuesinvolvingtheparticularlawsofacountry,state,orprovincethatarerelevanttotheprofessionalpracticeofcounselingandpsychotherapyalsoapplytotheprofessionalpracticeofChristiantherapy.Examplesprovidedinchapter3inthecontextofAmericansocietyincludetheprohibitionofsexwithclients;therequirementtoprotectclientconfidentiality(withafewexceptionsrelatingtomandatoryreportinglaws,suchasincasesofchildabuseandelderabuse);theneedtoassurethecompetencyoftherapistsintheprofessionalservicestheyprovide;andthemandatetorefrainfrominsurancefraud(seeKnapp,Gottlieb,Berman,andHandelsman2007, 54).Christiantherapistsmustbeawareoflawsthatgoverntheprofessionalpracticeofcounselingandpsychotherapy(see,e.g.,Levicoff1991;OhlschlagerandMosgofian1992).Sincelawscanbechangedorrevised,andnewonescanbeenacted,itisimperativeforChristiantherapists,likealltherapists,tokeepup-to-dateregardinglegalandethicalissuesincounselingandpsychotherapy.InmanystatesintheUnitedStates,professionaltherapistsarerequiredtotakeacontinuingeducationcourseinlegalandethicalissuespertainingto374 _Tan_Counseling_BB_mw.indd388 9/21/104:40:16PM LegalandEthicalIssuesinChristianCounselingandPsychotherapy 375 Sidebar17.1AACCCodeofEthicsTheAACCCodeofEthicsisbuiltonsevenbiblical-ethicalfoundations:1stFoundation:JesusChristandhisrevelationintheOldandNewTestamentsoftheBibleisthepreeminentmodelforChristiancounselingpractice,ethics,andcaregivingactivities.2ndFoundation:Christiancounselingmaintainsacommitted,intimate,anddedicatedrelationshipwiththeworldwidechurch,andindividualcounselorswithalocalbodyofbelievers.3rdFoundation:Christiancounseling,atitsbest,isaSpirit-ledprocessofchangeandgrowth,gearedtohelpothersmatureinChristbytheskillfulsynthesisofcounselor-assistedspiritual,psychosocial,familial,biomedical,andenvironmentalinterventions.4thFoundation:ChristiancounselorsarededicatedtoJesusChristastheir“firstlove,”toexcellenceinclientservice,toethicalintegrityinpractice,andtorespectforeveryoneencountered.5thFoundation:Christiancounselorsaccordthehighestrespecttothebiblicalrevelationregardingthedefenseofhumanlife,thedignityofhumanpersonhood,andthesanctityofmarriageandfamilylife.6thFoundation:Thebiblicalandconstitutionalrightstoreligiousfreedom,freespeech,andfreeassociationprotecttheChristiancounselor’spublicidentity,andtheexplicitincorporationofspiritualpracticesintoallformsofcounselingandintervention.7thFoundation:ChristiancounselorsaremindfuloftheirrepresentationofChristandhischurchandarededicatedtohonortheircommitmentsandobligationsinallsocialandprofessionalrelations.(seeAACC2004, 5) theirareaofprofessionalpracticebeforetheycanbelicensedorrelicensedforindependentpractice.TherestofthischapterwillfocusmoreonethicalissuesandguidelinesthatapplytothepracticeofChristiantherapy.TheseguidelinesarediscussedinthefinalversionoftheAmericanAssociationofChristianCounselors(AACC)CodeofEthicsdraftedbytheAACCLawandEthicsCommitteechairedbyGeorgeOhlschlagerandmadeavailablein2004(seeAmericanAssociationofChristianCounselors[AACC]2004).ItwaspubliclypresentedtoitsfiftythousandmembersinallfiftystatesoftheUnitedStatesandfiftyothernationsasofwinter2003–4(AACC2004, 2).Ethicalissuesandchallengesrelevanttotheincorporationofspiritualityandreligionintopsychotherapyingeneralhavealsoreceivedincreasedattentioninrecentyears _Tan_Counseling_BB_mw.indd389 9/21/104:40:17PM 376 AChristianApproachtoCounselingandPsychotherapy (seee.g.,Gonsiorek,Richards,Pargament,andMcMinn2009;HathawayandRipley2009;Plante2007).AACCCodeofEthics:ABriefReviewoftheY2004FinalCodeAcodeofethicscanbedefinedas“asystematicstatementofethicalstandardsthatrepresentthemoralconvictionsandguidethepracticebehaviorofagroup—inthiscase,thevariouscounselingdisciplines”(OhlschlagerandClinton2002, 245),referringtoChristianandcounselingethics.George W.OhlschlagerandTimothy E.ClintonhavealsoprovidedthefollowingChristiancounselor’sgoldenrulebasedonRomans13:8–10toreflectthecorevaluesandrulesofChristiancounselingethics:Christiancounselor,hearthis:•Donotbeindebtedtoanyclient. . .exceptthedebttolovethem.•Forifyouloveyourclients,youhonorallyourprofessional. . .duties.Youknowtherulesofcounseling. . .:•Donotengageinanyformofsexualmisconductwithyourclients,whethercurrentorpast.•Donot,asfarasitispossiblewithyou,letthemkillorharmthemselvesoranyoneelse.•Donotstealyourclient’smoneyordisregardyourtimewiththem.•DonotharmorenvyorlookdownonormanipulateorfightwithorinanywayexploitthoseChristhassenttoyouforhelp.Infact,tosumitupandstateitconclusively:•PracticetheGoldenRulewithallwisdomandgrace.•Loveyourclientsasyourself.•Don’tdoanythingtoyourclientsorthosetheylovethatyouwouldn’twantdonetoyourself.•Forlovedoesnowrongtoanyclient.Therefore,toloveyourclientsasChristlovesyouistofulfillallyourobligations—allyourmoralethical-legalduties—asaChristiancounselor.(2002, 247) ThecrucialemphasisinChristiancounselingethics(seealsoBrowning2006;R. K.Sanders1997;Tjeltveit1992,1999)isthereforetofollowthebiblicalcommandtoloveoneanotherwithagapeorChristlikelove(John13:34–35)andtoloveourneighborasourselves(Mark12:31).TheAACCCodeofEthics(AACC2004)containseightmajorsections,fiveofthemrelatingtoethicalstandards,andthreeofthemrelatingtoproceduralrules.Thefivesectionsonethicalstandardsare:I.EthicalstandardsforChristiancounselors;II.Ethicalstandardsforsupervisors,educators,researchers,andwriters;III.Standardsandexemptionsforordainedministersandpastoral _Tan_Counseling_BB_mw.indd390 9/21/104:40:17PM LegalandEthicalIssuesinChristianCounselingandPsychotherapy 377 Sidebar17.2SectionsintheAACCCodeofEthicsEthicalStandardsI.II.III.IV.V. EthicalstandardsforChristiancounselorsEthicalstandardsforsupervisors,educators,researchers,andwritersStandardsandexemptionsforordainedministersandpastoralcounselorsStandardsandexemptionsforlayhelpersandotherministersStandardsforresolvinglegal-ethicalconflicts ProceduralRulesVI.Authority,jurisdiction,andoperationoftheLawandEthicsCommitteeVII.ProceduresfortheadjudicationofcomplaintsagainstAACCmembersVIII.Proceduresfollowingactionbychurches,courts,andotherbodies(AACC2004) counselors;IV.Standardsandexemptionsforlayhelpersandotherministers;andV.Standardsforresolvinglegal-ethicalconflicts.Thethreesectionsonproceduralrulesare:VI.Authority,jurisdiction,andoperationoftheLawandEthicsCommittee(LEC);VII.ProceduresfortheadjudicationofcomplaintsagainstAACCmembers;andVIII.Proceduresfollowingactionbychurches,courts,andotherbodies.EthicalStandardsforChristianCounselorsThefirstsectionoftheAACCCodeofEthicscoversethicalstandardsforChristiancounselors(seeAACC2004,6–18).ThefirstmajorstandardisES1–100,First,DoNoHarm.ItcoversaffirmingtheGod-givendignityofallpersons;avoidingclientharm,intendedornot;refusaltoparticipateintheharmfulactionsofclients;prohibitionofsexualmisconduct;anddualandmultiplerelationships.ThesecondmajorstandardisES1–200,CompetenceinChristianCounseling.ItcovershonoringthecalltocompetentChristiancounseling;dutiestoconsultand/orrefer;dutiestostudyandmaintainexpertise;maintainingintegrityinwork,reports,andrelationships;andprotectiveactionwhenpersonalproblemsinterfere.ThethirdmajorstandardisES1–300,InformedConsentinChristianCounseling.Itcoverssecuringinformedconsent;consentforthestructureandprocessofcounseling;andconsentforbiblical-spiritualpracticesincounseling.ThefourthmajorstandardisES1–400,Confidentiality,Privacy,andPrivilegedCommunication.Itcoversmaintainingclientconfidentiality;assert- _Tan_Counseling_BB_mw.indd391 9/21/104:40:18PM 378 AChristianApproachtoCounselingandPsychotherapy ingconfidentialityorprivilegefollowingdemandsfordisclosure;protectingpersonsfromdeadlyharm:theruleofmandatorydisclosure;disclosuresincasesofthird-partypaymentandmanagedcare;disclosuresforsupervision,consultation,teaching,preaching,andpublication;maintainingprivacyandpreservingwrittenrecords;andadvocacyforprivacyrightsagainstintrusivepowers.ThefifthmajorstandardisES1–500,EthicalPracticeinChristianCounselingandEvaluation.ItcoversfeesandfinancialrelationshipsinChristiancounseling;casenotesandproperrecordkeeping;ethicsintesting,assessment,andclinicalevaluation;workingwithcouples,families,andgroups;workingwithpersonsofdifferentfaiths,religions,andvalues;continuityofcareandserviceinterruption;andavoidingabandonmentandimpropercounselingtermination.ThesixthmajorstandardisES1–600,EthicalRelationsintheProfessionalWorkplace.Itcovershonorablerelationsbetweenprofessionalandministerialcolleagues;maintaininghonorableprofessionalandemploymentrelations;Christiancounselorsasemployers;andChristiancounselorsasemployees.TheseventhmajorstandardisES1–700,EthicsinAdvertisingandPublicRelations.Itcoversunethicalstatementsinpubliccommunications;communicationofassociationwiththeAACCandothergroups;communicationofworkproductsandtrainingmaterials;andethicalguidelinesinpublicstatementsbyothers.TheeighthandfinalstandardisES1–800,EthicalRelationswiththeStateandOtherSocialSystems.Itcoversethicalrelationstootherprofessionsandinstitutions;workingforacaringchurch,ajustgovernment,andabettersociety;andbeingsaltandlightinapost-Christianculture.EthicalStandardsforSupervisors,Educators,Researches,andWritersThesecondsectionoftheAACCCodeofEthicsfocusesonethicalstandardsforsupervisors,educators,researchers,andwriters(AACC2004,19–23)thatarerelevanttoChristiancounseling.ThefirstmajorstandardisES2–100,BaseStandardsforSupervisorsandEducators.Itcoversethicsandexcellenceinsupervisionandteaching;andthedutyofsupervisorsandeducatorsnottoexploitstudentsandtrainees.ThesecondmajorstandardisES2–200,EthicalStandardsforChristianCounselingSupervisors.Itcoverscounselorsupervisionprograms;thedutyofsupervisorstoprovideavariedexperience;andsupervisionevaluationandfeedback.ThethirdmajorstandardisES2–300,EthicalStandardsforChristianCounselingEducators.Itcoverscounseloreducationandtrainingprograms;studentandtraineeevaluation;integrationstudyandtraining;andfieldplacement,practicum,andinterntraining. _Tan_Counseling_BB_mw.indd392 9/21/104:40:19PM LegalandEthicalIssuesinChristianCounselingandPsychotherapy 379 ThefourthmajorstandardisES2–400,EthicalStandardsforChristianCounselingResearchers.Itcoversrespectingstandardsofscienceandresearch;protectinghumanresearchparticipantsandhumanrights;informedconsentandconfidentialityinresearch;andreportingresearchresults.ThefifthandfinalmajorstandardisES2–500,WritingandPublicationEthicsinChristianCounseling.Itcoversintegrityinwritingandpublication;submissionofmanuscripts;andavoidingghostwriters.StandardsforResolvingEthical-LegalConflictsSectionfiveoftheAACCCodeofEthicsfocusesonstandardsforresolvingethical-legalconflicts(AACC2004,25-27)thatarerelevanttoChristiancounseling.ThefirstmajorstandardisES5–100,BaseStandardsforEthicalConflictResolution.Itcoversthebaseruleforresolvingethical-legalconflicts.ThesecondmajorstandardisES5-200,ResolvingConflictswithEmployersandColleagues.Itcoversethicalandvaluedifferenceswithemployersandcolleagues;andlawandethicsviolationsbycolleaguesandemployers.ThethirdmajorstandardisES5-300,ResolvingProfessionalandOrganizationalConflicts,whichcoversthehigherethicsofJesusChrist.ThefourthandfinalstandardisES5–400,ResolvingConflictswiththeStateandItsLaws,whichcoversthehigherlawofJesusChrist.ThesethreemajorsectionsoftheAACCCodeofEthics(I,II,andV)arethemostrelevantonesforChristiancounselorsandtherapiststouseinguidingthemintheirprofessionalwork.EthicalIssuesandGuidelinesforIntegratingChristianFaithandSpiritualDirectionintoPsychotherapyTherearemorespecificethicalissuesandguidelinesthatpertaintointegratingChristianfaith,includingspiritualdirectionandspiritualdisciplines,intopsychotherapy(Tan1994,2003c,2004;seealsoRichardsandBergin1997,143–69;RichardsandBergin2005;R. K.Sanders1997).Thefollowingpotentialpitfallsordangersexistinreligiouspsychotherapy,whichincludesintegratingChristianfaithandspiritualdirectionintopsychotherapy.1.Imposingthetherapist’sreligiousbeliefsorvaluesontheclient,thusreducingclientfreedomtochoose.2.Failingtoprovidesufficientinformationregardingtherapytotheclient.3.Violatingthetherapeuticcontractbyfocusingmainlyoronlyonreligiousgoalsratherthantherapeuticgoals,andthusobtainingthird-partyreimbursementinappropriately.(Itis,however,difficultsometimesto _Tan_Counseling_BB_mw.indd393 9/21/104:40:19PM 380 AChristianApproachtoCounselingandPsychotherapy clearlydifferentiatebetweenspiritualandtherapeuticgoalsbecausetheytendtooverlapforreligiousclients.)4.Lackingcompetenceasatherapistintheareaofconvertingclientvaluesethicallyorconductingreligiouspsychotherapyappropriately.5.Arguingoverdoctrinalissuesratherthanclarifyingthem.6.MisusingorabusingspiritualresourcessuchasprayerandScriptures,thusavoidingdealingwithpainfulissuesintherapy.7.Blurringimportantboundariesorparametersnecessaryforthetherapeuticrelationshiptobemaintained.8.Assumingecclesiasticalauthorityandperformingecclesiasticalfunctionsinappropriately,whenreferraltoecclesiasticalleadersmaybewarranted.9.Applyingonlyreligiousinterventionstoproblemsthatmayrequiremedicationorothermedicalorpsychologicaltreatments.(seeTan1994,390)Theethicalissueofwhetheritisappropriatetochargefeesandreceivethird-partyreimbursementfortheuseofspiritualdisciplinesandreligiousinterventionsinpsychotherapyhasbeenraisedbyMarkMcMinnandBarrettMcRay(1997).Theyespeciallyemphasizetheneedtoobtainempiricalsupportfortheefficacyofspiritualinterventionsintherapy.Itisalsoimportanttokeepintactthegoalofhelpingtoreducethepsychologicaldistressofclientsandnotcompletelyreplacetherapywithonlyspiritualdirection(Tan2003c).ItisthereforeethicaltointegrateChristianfaithandspiritualdirectionandtheuseofspiritualresourcesintotherapyif:theclientandthetherapistsharesimilarreligiousorspiritualbeliefs,theclienthasexpressedadesireforspiritualinterventionstobeusedintherapyandthushasgiveninformedconsent,andthereisavalidreasonforusingaspecificspiritualinterventionintherapybecauseitisrelevanttotheclient’sclinicalproblemanditwillhelptoreducetheclient’spsychologicalsymptomsanddistress(seeA. A.NelsonandWilson1984).Inacasewhereaclientstillwantstocontinuetoseehisorhertherapistforonlyspiritualdirectionaftertheclient’spsychologicalsymptomshavebeensignificantlyreducedandtherapygoalshavebeensubstantiallyachieved,thentheChristiantherapisthasseveralethicaloptionsfromwhichtochoose.First,thetherapistcanagreetocontinuetoseetheclientforspiritualdirectionandgrowth,withtheclientpayingforthesesessions,withnothird-partyreimbursements.Second,thetherapistcanprovideafewmoresessionsofspiritualdirectiontotheclientprobono,orfreeofcharge.Finally,thetherapistcanswitchtoasuggesteddonationvoluntarilymadebytheclient,withoutanythird-partyreimbursements(seeTan2003c).ItmaythereforebeethicallysimplertointegratespiritualdirectionintolayChristiancounselingbecausefeesarenotchargedbylaycounselorsinsuchacontext(Tan1991;seealsoTan1997a). _Tan_Counseling_BB_mw.indd394 9/21/104:40:20PM LegalandEthicalIssuesinChristianCounselingandPsychotherapy 381 P. ScottRichardsandAllen E.Bergin(1997,143–69)havecoveredethicalguidelinesandissuesrelatedtoatheistic,spiritualapproachtotherapy(seealsoRichardsandBergin2005).Theydealwithfiveimportantdifficultandchallengingethicalissues:dualrelationships(religiousandprofessional);thedangerofdisplacingorusurpingreligiousauthority;thedangerofimposingreligiousvaluesonclients;thedangerofviolatingwork-setting(churchstate)boundaries;andthedangerofpracticingoutsidetheboundariesofcompetence.Theyalsomentiontwoothersignificantconcerns:becomingenmeshedinsuperstition,andtrivializingthesacredornuminous(seeTan2003c, 16).Theirmanycautiousbuthelpfulethicalguidelinesfordealingwiththesefivemajorethicalissueswillnowbebrieflysummarized(seeTan2003c,17–18).First,regardingtheethicalissueofdualrelationships,RichardsandBergin(1997,147–48)recommendseveralethicalguidelines.Theyincludethefollowingrecommendations:Therapist-religiousleaderdualrelationshipsshouldbeavoidedasageneralguideline.Consultationwithasupervisororprofessionalcolleaguesshouldbesoughtandagreementobtainedbeforeatherapistbecomesinvolvedinadualrelationshipwithaclientthatthetherapisthasdeemedisinthebestinterestoftheclient.Thelimitsandrisksofthedualrelationshipneedtobeclearlyexplainedtotheclient.Thetherapistshouldcontinuetoseekfrequentconsultationfromprofessionalcolleaguesorasupervisorandbereadytoterminatethedualrelationshipandmakeaproperreferraliftheclientappearstobeharmedbythedualrelationship.Properandcarefuldocumentationiscrucialinthissituation.Second,regardingthedangerofdisplacingorusurpingreligiousauthority,RichardsandBergin(1997,151–53)recommendseveralethicalguidelinesforcollaboratingwithreligiousauthorities.Theyincludethefollowingconsiderations:Aclient’sreligiousordenominationaltradition,ifany,shouldbeassessedbyatherapistandthequestionofwhetheraclientviewshisorherreligiousleadersaspotentialsourcesofhelpmustbeclarified.Ifaclientagreesandgiveswritteninformedconsent,thetherapistcancontacttheclient’sreligiousleaderstoconsultwiththemandenlisttheirsupportinhelpingtheclient.Thisshouldbedonewithproperrespectforandclearcommunicationwiththeclient’sreligiousleaders,aswellaswithappreciationfortheirhelpandcooperation.Beforespiritualinterventions(includingspiritualdirectionandspiritualguidancetechniques)areusedintherapy,thetherapistshouldalsoclearlycommunicatetotheclientthatheorshedoesnothaveanyecclesiasticalauthorityovertheclient.Ecclesiasticalfunctionstobeperformedonlybythereligiousleadersoftheclient(e.g.,hearingconfessionsandabsolvingsins)shouldnotbeusurpedbythetherapist.Aclientshouldfeelthataparticularspiritualintervention(e.g.,useofprayerorreligiousimagery)isappropriateintherapybeforeitisusedbythetherapist.Thetherapistshouldnotcriticizeaclient’sreligiousleadersbutinsteadinformtheclientthatthetherapist _Tan_Counseling_BB_mw.indd395 9/21/104:40:21PM 382 AChristianApproachtoCounselingandPsychotherapy generallyviewsreligiousleadersandcommunitiesaspotentialsourcesofhelpandsupport.Third,regardingthedangeroftherapistsimposingtheirreligiousvaluesonclients,RichardsandBergin(1997,158–59)recommendseveralethicalguidelinesforrespectingclientvalues.Theyincludethefollowingsuggestions:Atherapistshouldrespectaclient’srighttohavereligiousbeliefsandconvictionsthataredifferentfromthoseheldbythetherapist.Atherapistshouldthereforenotattempttoproselytizeorconvertaclienttothetherapist’sownreligiousfaithordenomination.Atherapistcanengageinopenandhonestdiscussionofthemoralandspiritualdimensionsandconsequencesofaclient’svaluechoicesandbehaviorsiftheclientisinterestedinpursuingsuchadiscussion.However,thetherapistshouldavoidarrogantlycondemningaclient’schoicesorbehaviorswithwhichthetherapistdoesnotagree.Whensuchvalueconflictsoccurintherapy,thetherapistcanexpresshisorherownviewsbutshouldpreservetheclient’srighttohavedifferentvalues.Thetherapistalsoneedstoassesswiththeclientwhethertheirvalueconflictsmayhaveanegativeeffectontherapyandhencewhetherreferraloftheclienttoanothertherapistwithmoresimilarvaluesmaybethebestoption.Religiousandspiritualgoalsshouldonlybesetandspiritualinterventionsusedintherapyiftheclientisinterestedinsuchgoalsandinterventionsandinformedconsentisobtainedfromtheclient.Fourth,regardingthedangerofviolatingwork-setting(church-state)boundaries,RichardsandBergin(1997,162–63)recommendseveralethicalguidelinesforrespectingchurch-stateboundaries:Atherapistworkingincivicsettingsmustcomplywiththepoliciesandlawsconcerningtheseparationofchurchandstateinsuchwork-settings.Atherapistinacivicsettingshouldnotusespiritualinterventionsinsuchawayastoimposeaparticularreligioustraditiononaclient.Instead,atherapistshouldworkwithinaclient’svaluesystem,asfaraspossible.Writtenconsentfrombothsupervisorandclientshouldbeobtainedbythetherapistbeforeheorsheusesreligiousorspiritualinterventionsintherapy.Atherapistalsomustobtainwrittenparentalconsentbeforeusinganyspiritualorreligiousinterventionintherapywithchildrenoradolescents.Atherapistworkinginpublicschoolsorothercivicsettingsinvolvingchildrenoradolescentsisadvisednottousereligiousorspiritualinterventionssuchasprayerwithclients,discussingScripturewiththem,ordistributingreligiousliteratureforbibliotherapy.Fifthandfinally,regardingthedangerofpracticingoutsidetheboundariesofcompetence,RichardsandBergin(1997, 166)recommendseveralethicalguidelinesforeducationandtrainingstandardsforprofessionaltherapistswhowanttouseatheistic,spiritualapproachintheirtherapeuticwork.Theyincludethefollowingrecommendations:Atherapistshouldbetrainedinthefoundationsofmulticulturalcounselingattitudesandskills(see,e.g.,D. W.SueandD. Sue2008;seealsoSueetal.2007;WhaleyandDavis2007).Relevantandhelpfulscholarlyliteratureincludingjournalsandbooksonreligiousand _Tan_Counseling_BB_mw.indd396 9/21/104:40:23PM LegalandEthicalIssuesinChristianCounselingandPsychotherapy 383 spiritualissuesintherapyandonthepsychologyandsociologyofreligionshouldbereadbytherapistswhowishtouseatheistic,spiritualapproachtotherapy.Suchtherapistsshouldalsoattendatminimumaworkshoporacourseonreligionandmentalhealthandspiritualissuesintherapy,andtakeaclassorreadbooksonworldreligions.Theyshouldgainmoreknowledgeofparticularreligionsandspiritualtraditionsandpracticesthatmayoftenbeencounteredintherapy(see,e.g.,RichardsandBergin2000;seealsoDowdandNielsen2006).Atherapistmustobtainsupervisionorconsultationwhenheorshefirstseesaclientfromareligiousorspiritualtraditionthatthetherapistisnotfamiliarwithandinvolvingissuesthatthetherapisthasnotdealtwithpreviously.Suchsupervisionorconsultationisalsoimportantwhenatherapistfirstbeginstousereligiousorspiritualinterventions,especiallyiftheyarenew,untriedones,intherapywithclients.TheethicalguidelinesrecommendedbyRichardsandBergin(1997)arecautiousandconservative,andnoteveryonewillagreewithallthattheyhavesuggested.Forexample,sometimesitisethicalforaChristiantherapisttosharehisorherfaithinChristandthegospeliftheclientasksforsuchspecificinformationandgiveshisorherfullinformedconsentforthegospeltobeshared.Thismayhappeninthecontextofaclientseekingmeaninginlifeandananswertohisorherfearofdeath—keyexistentialquestionsandspiritualstrugglesthatsometimesemergeintherapy.Althoughaggressiveproselytizationordirectiveeffortstoconverttheclienttothetherapist’sChristianfaithisnotappropriateintherapy,asRichardsandBerginhavenoted,thereisanethicallyappropriateplaceforgentle,noncoercivesharingofthegospelwhenrequestedbyaclientwhogivesfullinformedconsenttoopenlydiscusstheChristianfaith.AnotherexampleistheethicalconcernraisedbyRichardsandBergin(1997)aboutdualrelationshipswiththeclientonthepartofthetherapist.Greatcareandclinicalcautionshouldbeexercisedinengagingindualrelationshipswithclients,becauseclientsmaybepotentiallyharmedbysuchrelationships.However,thereareethicalwaysinwhichatherapistcanenterintoadualrelationshipwithaclient,forthebenefitoftheclient(see,e.g.,Barnett2007b;Lazarus1994,2007;LazarusandZur2002).Furthermore,inthespecialcaseoflayorparaprofessionalhelping,dualrelationshipsareusuallyacceptableinthecontextofpeerorfriendshipcounselinginwhichpeershelponeanotherwiththeirproblems(seeTan1991,1997).Forexample,peerhelpingcanoccurinschoolsoryouthgroupswhereteenscounselotherteenswhoareacquaintancesorfriends(seeSturkieandTan1992,1993).VirtueEthics:FocusingontheCharacteroftheChristianTherapistW. B.Johnson(2007a)hasemphasizedvirtueethics,whichfocusmoreonthecharacterandmoralvirtuesofthetherapist,ratherthanonlyprincipleethics _Tan_Counseling_BB_mw.indd397 9/21/104:40:24PM 384 AChristianApproachtoCounselingandPsychotherapy Sidebar17.3VirtuesThatShouldCharacterizetheChristianTherapist(FromJones,Butman,Dueck,andTan1988andsummarizedinJonesandButman1991,410–12)CompassionasopposedtoelitismServanthoodasopposedtosuperiorityCommunityasopposedtoisolationAccountabilityasopposedtoindependenceandautonomyTransparencyasopposedtoimpressionmanagementLoveasopposedtoRogerianpositiveregardStewardshipasopposedtoprofitmaximizationHolinessasopposedtoanonymityorwholenessWisdomasopposedtomeresecularbrillianceIntegrityasopposedtomereethicalcompliance(toethicalcodes)Aboveall,thekeycharacteristicorvirtueoftheChristiantherapistshouldbeatruedepthofspiritualitycenteredinChristandempoweredbytheHolySpirit(seeTan1987b). (Corey,Corey,andCallanan2007),whichfocusontheethicalguidelinesandrulesgoverningrightandappropriatebehaviorinparticularclinicalsituations(seealsoDueck1995).Collins(2007,83–99)hasprovidedseveralsuggestionstohelpChristiancounselorsdealwithlegal,ethical,andmoralissuesintheirpracticeinbiblicalandGod-honoringways,respectingtheclientasapersonofworthandalwaysseekingtheclient’swelfare.Morespecifically,Collinswarnsaboutthedangeroffallingintounethicalandsinfulsexualintimacieswithclients.Herecommendsthefollowinghelpfulmeansofcounselorself-control:“spiritualprotection;knowingone’svulnerabilities;beingawareofdangersignals;settinglimits;tellingoneselfthetruth;findingsupportandaccountabilitywithothers”(2007, 99).FutureDirectionsinChristianCounselingandPsychotherapyandImplicationsforEthicalPracticeInbringingthischapterandthisbooktoaclose,itisappropriatetolookaheadintopossiblefuturedirectionsinChristiancounselingandpsychotherapyandidentifysomeoftheimplicationsforethicalpracticeinthisfield.First,inamoregeneralcontext,James R.Beck(2006)hasmadeseveralpredictionsabouthowtheintegrationofpsychology,includingcounselingand _Tan_Counseling_BB_mw.indd398 9/21/104:40:25PM LegalandEthicalIssuesinChristianCounselingandPsychotherapy 385 psychotherapy,andChristianfaithmaydevelopinthenextfiftyyears.Afterprovidingbriefsnapshotsofthestateofpsychology,theology,andintegrationin1956andin2006,hehascourageouslymadesnapshotpredictionsabouttheirpossiblestatein2056.Morespecificallyintheareaofintegration,Beckhasmadethefollowingpredictionsfor2056:1.Christiantherapistswillbechallengedtowidentheirunderstandingofpsychotherapytoincludeothermodalitiessuchascoaching,spiritualformation,anddiscipleship;2.Theoreticianswhoworkintheareaoftheintegrativeenterprisewillmakegreatprogressinsynthesizingwhatnowseemtobedistinctmodelsofintegration;3.Christianpsychologywilldisplayanincreasedneedforsophisticatedempiricalresearchtoundergirditseffortstodeliverqualityservices . . . ;4.Christianintegratorsmustupgradethelevelofunderstandingandutilizationofpsychologicalscience. . .intheirworkofintegration;5.Integratorsmustlikewiseupgradethesophisticationofthebiblicalandtheologicalmaterialtheyutilizeintheirwork.(J. R.Beck2006,327–28)TheneedtostayabreastofthelatestdevelopmentsinpsychologyandtheologyintheintegrationenterpriseaswellastheneedtoobtainempiricalsupportfortheeffectivenessofChristiantherapeuticapproachesandinterventionswithmoresophisticatedoutcomeresearch(seeWorthington2006)areclearethicalchallengesforintegratorsinthenextfewdecades.Second,ClintonandOhlschlager(2006)havealsomadeseveralpredictionsmorespecificallyaboutthefutureofChristiancounseling,asthefieldmatures.Theyincludethefollowingtwenty-fivetrends:1.A21stcenturycodeofethics;2.Sureadvocacyforclientandthemarginalized;3.Nationalcredentialing;4.Academicandclinicaccreditation;5.Layhelpingministry;6.Spiritualandrelationshipformation;7.Biblicalandtheologicaldepth;8.e-CounselinganduseofInternettechnologies;9.Expandingcutting-edgemodesofcare;10.Interprofessionalrelations;11.Workingwithfaith-basedinitiatives;12.Intensivecareforcounselorsandpastors;13.Distanceandon-lineeducation; _Tan_Counseling_BB_mw.indd399 9/21/104:40:26PM 386 AChristianApproachtoCounselingandPsychotherapy 14.Continuingeducationandfocusedcertificateprograms;15.DoctoralprogramsforChristiancounselingleaders;16.Heightenedmulticulturalsensitivity;17.Newandmorerefinedresearch;18.Saltandlightministry;19.Glocalization(“thinkingglobal,actinglocal”);20.Floweringintoamatureinterdisciplinaryprofession;21.Theoreticalintegrationreachingmaturity;22.Integrationwithmedicineandlaw;23.Brainimagingandneuroscience;24.Positivepsychologymovement;25.Spiritualhungerandtheemergingchurch.(seeClintonandOhlschlager2006,33–35)ThesearepossibletrendsinthefutureofChristiancounselingasitmaturesasafield.However,theneedforhighethicalandbiblicalstandardsisobviousasnewstrategies,practices,andotherinnovationsareused,especiallyintechnologicalareas.Oneexampleise-counselingortelephoneandInternettherapy,whichraisesethicalandlegalquestionsaboutissuessuchasconfidentiality,helpingsuicidalordangerousclients,andcounselingclientsfromdifferentstatesintheUnitedStates(Centore2006;seealsoMcMinn,Orton,andWoods2008).ThepositivepsychologymovementinparticularholdspromiseforfurtherdevelopmentintheChristiantherapycontext(see,e.g.,HartandHart-Weber2006;seealsoHackney2007).However,italsomustbecarefullyandbiblicallycritiqued,becauseitcanoveremphasizestrengths,virtues,andhappiness,anddownplaythehumancapacityforsinandevilandtheimportanceofgodlysorrowandrepentance(Tan2006a).ClintonandOhlschlagerhaveencouragedChristiancounselorstoseethat“thedoortothefutureiswideopentousasChristiancounselors,buttherearemanychallengesandadversaries.Wemustjoinhandsnowandgoforwardtogether”(2006, 35).Finally,CollinshassimilarlydescribedtencounselingwavesofthefuturethatapplytothefieldofChristiancounseling.Theyincludethewavesoftechnology,globalism,biotechnology,whole-brainthinking,postmodernism,changeinspirituality,changingchurches,changingprofessionalism,nontraditionaleducation,andpositivepsychology(see2007,849–61).Again,thereisaneedforclearandhighstandardsofethicsandbiblicalvaluestoguideChristiancounselorsandtherapistsintheyearsaheadastheynavigatesuchsignificantwavesofchangeinthecounselingfield.ItisinterestingtonotethattwelveemergingdirectionsforthegeneralfieldofpsychotherapyhavealsobeendescribedbyJamesProchaskaandJohnNorcrossinthefollowingareas:economicsofmentalhealthcareortheindustrializationofmentalhealthcare;evidence-basedpractice;therapyrelationship; _Tan_Counseling_BB_mw.indd400 9/21/104:40:28PM LegalandEthicalIssuesinChristianCounselingandPsychotherapy 387 technologicalapplications;self-helpresources;neuroscience;behavioralhealth;proactivetreatmentofpopulations;faith-basedpractices;positivepsychology;integrationofpsychotherapyandpharmacotherapy;andtheeffectivenessofpsychotherapy(see2010,520–32).ThefutureofChristiancounselingandpsychotherapythereforelooksbrightandpromising,asspirituallyorreligiouslyorientedtherapyingeneralcontinuestogrowanddevelopinthecomingdecades.ThechallengeforChristiancounselorsandtherapistsistoremainfaithfulandfruitfulinChrist,bythepoweroftheHolySpiritandthegraceofGod.ChristiantherapymustalwaysbeChristcentered,biblicallybased,andSpiritfilled(Tan1999b,2001b),whateverthewavesofchangemaybeinthecounselingandpsychotherapyfieldintheyearstocome.Weshouldregardthesepossiblefuturedirectionswithhumilityandsometentativeness,becauseonlyGodknowsthefuturewithcertainty.ChristiantherapymustalsobeethicallycharacterizedbyagapeorChristlikelove(Mark12:31;John13:34–35),upholdingthehighestofbiblicalvirtueethics,manifestedasthefruitoftheHolySpirit(Gal.5:22–23).RecommendedReadingsAmericanAssociationofChristianCounselors.(2004).AACCcodeofethics:TheY2004finalcode.Forest,VA:AACC.Browning,D. S.(2006).Christianethicsandthemoralpsychologies.GrandRapids:Eerdmans.Levicoff, S.(1991).Christiancounselingandthelaw.Chicago:MoodyPress.Ohlschlager,G. W.,&Clinton,T. E.(2002).Theethicalhelpingrelationship:Ethicalconformationandspiritualtransformation.InT. E.Clinton&G. W.Ohlschlager(Eds.),CompetentChristiancounseling(Vol. 1,pp.244–293,750–751).ColoradoSprings,CO:WaterBrookPress.Ohlschlager,G. W.,&Mosgofian, P.(1992).LawfortheChristiancounselor.Dallas:Word.Sanders,R. K.(Ed.).(1997).Christiancounselingethics:Ahandbookfortherapists,pastors,andcounselors.DownersGrove,IL:InterVarsity.Tjeltveit,A. C.(1999).Ethicsandvaluesinpsychotherapy.NewYork:Routledge. _Tan_Counseling_BB_mw.indd401 9/21/104:40:28PM _Tan_Counseling_BB_mw.indd402 9/21/104:40:28PM AppendixIsPsychotherapyEffective? MethodsofResearchResearchmethodsareusuallycategorizedasquantitativeorqualitative.Thequantitativeapproachhasbeenmorewidelyandtraditionallyusedthusfar.Itfocusesonmeasuringtheoutcomesofcounselingandpsychotherapyaswellastheprocessesthatoccurintherapyinteractionsthatmayberelatedtosuchoutcomes.Outcomeresearchisusedtoevaluatetheefficacyoreffectivenessoftherapy.Theterms“efficacy”and“effectiveness”areusuallyusedinterchangeably.However,inrecentyearssomeauthorshaveusedtheterm“efficacy”torefertotheresultsofscientificallycontrolledoutcomestudiesthatshowwhetheraparticulartherapeutictechniqueorinterventionworksbetterthannotreatmentoran“attention-placebo”condition.Suchstudiestypicallyinvolverandomassignmentofpatientsorclientswhomeetthediagnosticcriteriaforspecificpsychologicaldisordersandtheuseofdetailedtreatmentmanualsormanualizedtreatmentsinsystematicallyandconsistentlycarryingouttheparticulartherapeuticinterventionwhoseefficacyisbeingevaluated.Thesestudiesarealsocalledrandomizedcontrolledtrials(RCTs)byexperimentalorscientificdesignandarebasicallyquantitativeinnature.Theterm“effectiveness”hasrecentlybeenusedtorefermorespecificallytohowsuccessfulaparticulartherapyortechniqueisinreal-life,clinicalsituationsinactualpractice,andnotincarefullycontrolledscientificexperimentalstudiessuchastheRCTsoftenusedinefficacyoutcomeresearch(seeM. E. P.Seligman1995).However,mostauthorsandtextsstillusetheterms“efficacy”and“effectiveness”synonymouslyandinterchangeably,asIdointhebookyouarenowreading.Itisneverthelessimportanttoevaluatehoweffectivea389 _Tan_Counseling_BB_mw.indd403 9/21/104:40:29PM 390 Appendix particulartherapyortechniqueisinbothcarefullycontrolledscientificoutcomestudiesandinreal-lifeclinicalpractice.J. HunsleyandC. M.Lee(2007)haverecentlyreviewedthirty-fiveeffectivenessstudiesforadultdisorders(N = 21)andchildandadolescentdisorders(N = 14)andfoundthattheimprovementratesintheseeffectivenessstudieswerecomparabletothosereportedinefficacystudiesinvolvingrandomizedcontrolledtrials.Theseinitialdatathereforeprovideencouragingsupportfortheapplicationortransportabilityoftreatmentswithestablishedefficacytoreal-lifeclinicalsettings.Qualitativeresearchismoredifficulttodefineandevaluate,butitisanimportantcomplementtoquantitativeresearch.Qualitativeresearchusuallyinvolvesintensestudyofindividualcasesusingdatacollectionmethodssuchasrepeatedinterviews,questionnairesorsurveys,andtapes.Itismoreoftenusedtoinvestigatetheprocessesoftherapythatmayberelatedtotheoutcomesorefficacyandeffectivenessoftherapy.Qualitativeresearchisstillnotasvaluedaswell-controlledquantitativeresearch,buttherearealsosomesignificantproblemsandissueswithquantitativeresearchinvolvingRCTsthatwillbecoveredlaterinthisappendix(seeWesten,Novotny,andThompson-Brenner2004).Qualitativeresearchtendstobevaluedmorebyresearchersevaluatingapproachessuchaspsychodynamic,humanistic,andconstructivistictherapiesthataremorerelationalandopen-ended(ToddandBohart2006).ResultsofResearch:TheEffectivenessofCounselingandPsychotherapyIscounselingorpsychotherapyeffective,thatis,efficacious?Thisquestionisdifficulttoanswer.However,manyoutcomestudieshavenowbeendone,withsomeimportantresultseverycounselorortherapistneedstoknowanduseinhisorherclinicalpractice.ItiswellknownthatHansEysenck’soriginal1952scathingcritiqueofthe(in)effectivenessofpsychotherapyaspracticedatthattime(mainlyFreudianandRogeriantherapies)isnolongervalid.Heassertedaboutsixdecadesago(Eysenck1952)thatpsychotherapywasnotmoreeffectivethanspontaneousremissionrates(i.e.,aroundtwo-thirdsofneuroticpatientswillrecoverorsignificantlyimproveoveratwo-yearperiodwithouttherapy)foundamongno-treatmentcontrolpatients.Sincethen,moreoutcomeresearchhasbeendone,andtheresultsofsuchresearcharequitedifferentfromEysenck’searlyclaims.Forexample,BerginandLambert(1978)haveshownthatspontaneousremissionratesactuallyrangefrom43to65percentof“untreated”patients,andnotedthatratescloserto43percentwouldbemoreaccurate.Inawell-knownreviewoftherapyoutcomestudiesthatintroducedtheuseofastatisticalmethodcalledmeta-analysis,M. L.Smith,Glass,andMiller(1980)identified475studiesatthattimethatcomparedsometherapyapproachorinterventiontoacontrolgroupofsomekind.Meta-analysisisastatisticalmethodusedtocalculateaneffectsizebasedontheresultsofallavailablestud- _Tan_Counseling_BB_mw.indd404 9/21/104:40:30PM Appendix 391 ies(regardlessofthemethodologicalqualityofaparticularstudy)onasubjectofinterest,inthiscase,theeffectivenessofcounselingandpsychotherapy.Theeffectsizegivesustheaverageeffectofaspecifictreatmentthatisaboveorbetterthantheaverageeffectforthosewhodidnotreceivethetreatment.M. L.Smith,Glass,andMillerreportedthatpsychotherapyhadanoveralleffectsizeof0.85:theaveragepersonwhohadtherapydidbetterthan80percentofthosewhodidnothavetherapy,afarcryfromthenosignificantdifferencebetweentreatedanduntreatedpatientsthatEysenckhadboldlyclaimedin1952.Morerecently,Michael J.LambertandBenjamin M.Ogles(2004)havereviewedtheresultsofresearchontheeffectivenessandefficacyofpsychotherapy,includingmeta-analysesconductedsincetheonedonebyM. L.Smith,Glass,andMiller(1980).Effectsizesreportedrangefrom0.47to1.05.Despitesomeinconsistentresults,aswellasmethodologicalproblemswithmeta-analysis(e.g.,thisstatisticalproceduredoesnottakeintoconsiderationthequalityofeachoutcomestudybutlumpsallavailablestudiestogetherincalculatinganeffectsize),thecurrentconclusionisthatpsychotherapyismoderatelyeffective,tosaytheleast.LambertandOgles(2004)alsofoundthatvarioustherapiesdidnotsignificantlydifferfromoneanotherintermsoftheireffectiveness.ThisconclusionagainechoeswhatLesterLuborsky,BartonSinger,andLiseLuborsky(1975)foundoverthreedecadesago:amongthedifferenttherapiesnoparticularapproachissuperiorsincetheyareallroughlyequivalentintheireffectiveness.Therefore,theyallhavewon,andallmusthaveprizes,toparaphrasetheDodobirdinAlice’sWonderland.Thishascometobeknownasthe“DodoBirdEffect”ofnosignificantdifferenceintheeffectivenessofthevariousapproachestocounselingandpsychotherapy(seealsoWampoldetal.1997).TheDodoBirdEffect,however,hasnotbeenuniversallyacceptedbyresearchersinthisfield.Infact,ithasrecentlybeenstronglychallengedbythosewhoadvocateempiricallysupportedtreatments(ESTs)andtheuseofspecifictechniquesforparticularpsychologicaldisorders.ESTswillbediscussedinmoredetaillaterinthisappendix.Despitethegeneralconclusionthatcounselingorpsychotherapyiseffectiveoverall,itisimportanttonotetwootherfactsfromtheresearchresults:asignificantminorityofclients(5–10percent)actuallygetworseordeterioratewhileundergoingpsychotherapy(LambertandOgles2004);andabout20percentofclientsdonotimproveorrespondtotherapy(M. L.Smith,Glass,andMiller1980).UsingthisroughestimateTyTashiroandLauraMortensen(2006)haverecentlyconcludedthatabout6,273,000adultsand3,024,000childrenintheUnitedStatesannuallycontinuetohavedebilitatingsymptomsevenafterundergoingandcompletingpsychotherapy.Therapythereforedoesnothelpasignificantnumberofpeople(about20percent)andmayevenharmacertainpercentage(5–10percent)ofthem.Thereisstillmuchworktobedonetoimprovetheeffectivenessofpsychotherapyandtoreduceitspotentialharmfuleffectsonsomepeople. _Tan_Counseling_BB_mw.indd405 9/21/104:40:31PM 392 Appendix ScottLilienfeld(2007)hasrecentlyprovidedaprovisionallistofpsychologicaltreatmentsthatcancauseharm,potentiallyharmfultherapies(PHTs)(seealsoTan2008c).TheyincludethefollowingLevelIPHTsthatareprobablyharmfulforsomeclients:criticalincidentstressdebriefing(withheightenedriskforposttraumaticstresssymptoms);ScaredStraightinterventions(withriskofexacerbationofconductproblems);facilitatedcommunication(withriskoffalseaccusationsofchildabuseagainstfamilymembers);attachmenttherapies,forexample,rebirthing(withriskofdeathandseriousinjurytochildren);recoveredmemorytechniques(withriskoffalsememoriesoftrauma);dissociativeidentitydisorder–orientedtherapy(withriskofinductionof“alter”personalities);griefcounselingforclientswithnormalbereavementreactions(withriskofincreasesindepressivesymptoms);expressive-experientialtherapies(withriskofworseningofpainfulemotions);boot-campinterventionsforconductdisorder(withriskofworseningofconductproblems);andDAREprograms(withriskofincreasedintakeofalcoholandothersubstancessuchascigarettes).LevelIIPHTsthatarepossiblyharmfulforsomeclientsinclude:peer-groupinterventionsforconductdisorder(withpossibleworseningofconductproblems);andrelaxationtreatmentsforpanic-proneclients(withpossibleinductionofpanicattacks)(seeLilienfeld2007,58).Moreattentionisthereforebeingfocusedonthepotentialharmfulornegativeeffectsofpsychologicaltreatment(seeBarlow2010;Castonguay,Boswell,Constantino,Goldfried,andHill2010;DimidjianandHollon2010).TashiroandMortensen(2006)notethatresultsofclinicaloutcomeresearchshowthatabout80percentofclientsinpsychotherapydobetterthanthosewhodonotreceivetreatment(M. L.Smith,Glass,andMiller1980),andabout55–66percentofclientsintreatmentwillimprovecomparedwiththoseinactivecontrolgroups(Baskin,Tierney,Minami,andWampold2003).Yetthecausalmechanismsorprocessesresponsibleforwhypsychotherapyworksarestillunclear(Westen,Novotny,andThompson-Brenner2004).TashiroandMortensenalsopointoutthatthedose-responseresearchliteratureestimatesthatforatleast50percentofclientstoimprove,aroundthirteensessionsoftherapyareneeded;for83percentofclientstoimprove,aroundtwenty-sixsessionsarerequired(Hansen,Lambert,andForman2002).WhyPsychotherapyWorks:TheCommonFactorsApproachTheDodoBirdEffect,whenaccepted,hasledseveralresearcherstoconcludethatcounselingorpsychotherapyworksbecauseofsomecommonfactorsthatareoperativeacrossthedifferentapproachestotherapy.Thefollowingarecommontherapeuticfactorsandtheassociatedpercentageofimprovementinclientsasafunctionofsuchfactors(LambertandBarley2002):extratherapeuticchange(outsidetherapy,includingreceivinghelpfromfriends,family,clergymembers,self-helpliterature,andself-helpgroups,andclientcharacteristics _Tan_Counseling_BB_mw.indd406 9/21/104:40:32PM Appendix 393 suchasseverityandchronicityoftheclient’scondition;thepresenceofanunderlyingpersonalitydisorder;thenature,strength,andqualityofsocialsupports;andtheclient’sdiagnosis),40percent;commonfactorsorrelationshipfactors(e.g.,therapistattributesandfacilitativeconditionssuchaswarmth,empathy,andcongruenceorgenuineness,andthetherapeuticalliance),30percent;techniques(specifictherapeuticmethodsorinterventions),15percent;andexpectancy(placeboeffect),15percent(seealsoHubble,Duncan,andMiller1999;Duncan,Miller,Wampold,andHubble2010).Michael J.LambertandDean E.Barley(2002)thereforeconclude,asothershave,thatspecifictherapeutictechniquescontributemuchless(15percent)totheoutcomeofpsychotherapythanrelationshiporinterpersonalfactors(30percent)commontoalltherapies(seealsoLambertandOgles2004).However,theydoacknowledgethatafewspecializedtherapytechniqueshavebeenfoundtobesuperiorintheireffectivenesswithclientswithspecificdiagnostictypesorcategories.Thefollowingaresomeexamples:exposuretreatmentsforspecificphobias,gradualpracticewithparticularsexualdisorders,responsepreventionforobsessive-compulsivedisorders,cognitiverestructuringandexposureforagoraphobia,andusingamoresupportiveapproachininterpretationinshort-termpsychodynamictherapy,takingclientsymptomseverityintoconsideration.Otherresearchershaveputmoreemphasisonsuchtechniquesinproducingtherapeuticchange.Infact,awholemovementbeganin1995,whenthefirstlistofempiricallyvalidatedtreatmentswaspublishedbyataskforceofDivision12(SocietyofClinicalPsychology)oftheAPA.Sincethen,thelisthasbeenrelabeledempiricallysupportedtreatments(ESTs),andithasgrowntoover145(seeChamblessandOllendick2001;Tan2001a).WhyPsychotherapyWorks:EmpiricallySupportedTreatments(ESTs)ThelistofESTshasgrowntobeyondthe145well-establishedefficaciousandprobablyefficacioustreatments(108foradultsand37forchildren)listedseveralyearsagobyDiane L.ChamblessandThomas H.Ollendick(2001).Sincethen,therehavebeenmorerecentupdatesofthesetreatmentsthatwork(e.g.,NathanandGorman2007;RothandFonagy2005).ThefollowingaretheoriginalcriteriathattheTaskForceonPromotionandDisseminationofPsychologicalProceduresofDivision12ofAPAprovidedfordefiningwell-establishedefficacioustreatments(TaskForce1995;seealsoChamblessetal.1998):I.Atleasttwogoodbetween-groupdesignexperimentsdemonstratingefficacyinoneormoreofthefollowingways:A.Superior(statisticallysignificantlyso)topillorpsychologicalplaceboortoanothertreatment.B.Equivalenttoanalreadyestablishedtreatmentinexperimentswithadequatesamplesizes. _Tan_Counseling_BB_mw.indd407 9/21/104:40:33PM 394 Appendix ORII.Alargeseriesofsinglecasedesignexperiments(nineormore)demonstratingefficacy.Theseexperimentsmusthave:A.UsedgoodexperimentaldesignsandB.ComparedtheinterventiontoanothertreatmentasinIA.FurtherCriteriaforBothIandII:III.Experimentsmustbeconductedwithtreatmentmanuals.IV.Characteristicsoftheclientsamplesmustbeclearlyspecified.V.Effectsmusthavebeendemonstratedbyatleasttwodifferentinvestigatorsorteams.Probablyefficacioustreatmentsaredefinedas:I.Twoexperimentsshowingthetreatmentissuperior(statisticallysignificantlyso)toawaiting-listcontrolgroup.ORII.Oneormoreexperimentsmeetingthewell-establishedtreatmentcriteriaIAorIB,III,andIVbutnotV.ORIII.Asmallseriesofsinglecasedesignexperiments(threeormore)otherwisemeetingwell-establishedtreatmentcriteriaII,III,andIV.SomeofthesecriteriahavebeensomewhatmodifiedinattemptsbyotherstocompilesimilarlistsofESTs(seeChamblessandOllendick2001).Itshouldbenotedthatofthe145well-establishedefficaciousandprobablyefficaciousESTssummarizedbyChamblessandOllendick(2001),themajorityarebehavioral,cognitive-behavioral,andcognitiveinterventions.However,thelistofESTsalsoincludesbriefdynamictherapy,interpersonaltherapy,hypnosis,familysystemstherapy,emotion-focusedcouplestherapy,insight-orientedmaritaltherapy,systemictherapy,long-termfamilytherapy,andfunctionalfamilytherapyfordifferentdisorders(Tan2001a).AlthoughtheESTmovementhasgainedmomentum,therehavealsobeensomecriticismsofESTs.Forexample,questionshavebeenraisedaboutwhethertheyareeffectiveinreal-lifeclinicalsettingswithpatientswhohavenotbeenscreenedorpreselectedforresearchoutcomestudies(Nathan,Stuart,andDolan2000),andwhethertheyfocustoomuchontechniqueandnotenough _Tan_Counseling_BB_mw.indd408 9/21/104:40:33PM Appendix 395 onothercrucialvariablessuchastherapist,client,andrelationshipfactors(Norcross2002).AnothercriticismofESTsisthatempiricalsupportfortheirefficacywithethnicminorityclientsisstilllacking(G. C. N.Hall2001).However,thereismore-recentempiricalsupportfortheefficacyofcognitivebehavioraltherapywithadultethnicminorityclients(VossHorrell2008).Hyun-NieAhnandBruce E.Wampold(2001)didameta-analysisoftwentysevencomponentstudiesandhaveconcludedthattheoreticallybasedsignificantcomponentswerefoundnottoberesponsiblefortherapeuticeffects,thusraisingfurtherdoubtsaboutthespecificityofpsychologicaltreatments.Theyemphasizeinsteadthattheefficacyoftherapiesisduemoretocommonpathwaysfoundinallvalidtreatmentssuchasthecontextforhealing,thebeliefintheefficacyoftreatment,thetherapeuticalliance,therapeuticinterventionsconsistentwiththeclient’sperceptionofhisorherproblems,thedevelopmentofself-efficacy,andremoralization(AhnandWampold2001,255).Morerecently,DrewWesten,CatherineNovotny,andHeatherThompsonBrenner(2004)haveprovidedacriticalreviewoftheassumptionsandfindingsofRCTsusedtoprovideresearchsupportforESTs.TheyadvocatemetaanalyticstudiesasmoreappropriateandnuancedforevaluatingtreatmentefficacyratherthanadichotomousjudgmentofsupportedversusunsupportedtreatmentsinestablishingESTs.TheyalsorecommendchangesinreportingpracticestomaximizetheclinicalutilityofRCTs,describealternativemethodologiesthatmaybeusefulwhentheassumptionsunderlyingESTmethodologyareviolated,andsuggestmovingfromvalidatingtreatmentpackagestoevaluatinginterventionstrategiesandtheoriesofchangethatpractitionerscanintegrateintoempiricallyinformedtherapies(631).AspecificreactiontotheESTmovementwastheformationofanothertaskforce,thistimeofAPADivision29(Psychotherapy),commissionedbyJohnNorcrossin1999toidentify,operationalize,anddisseminateinformationaboutempiricallysupportedtherapyrelationships(ESRs).Thistaskforcefocusedmoreonpsychotherapyrelationshipsratherthanontechniquesineffectivetherapy.WhyPsychotherapyWorks:EmpiricallySupportedTherapyRelationships(ESRs)Norcross(2002)haseditedabookonpsychotherapyrelationshipsthatworksummarizingwhatwasdonebytheAPADivision29taskforce.Itfocusesontherapistcontributionsandresponsivenesstoclientsorpatients,thatis,onESRs,tocounterbalancetheemphasisonESTssince1995(seeTan2003a).Inthefinalchapteroftheeditedvolume,thesteeringcommitteeofthistaskforcemakesthefollowingconclusionsandrecommendationsregardingESRs(seeSteeringCommittee2002,441–43):Withregardtogeneralelementsofthetherapyrelationshipmainlyprovidedbythetherapist,theempiricalevidenceindicatedthatthefollowingfactorsaredemonstrablyeffective:therapeutic _Tan_Counseling_BB_mw.indd409 9/21/104:40:34PM 396 Appendix alliance,cohesioningrouptherapy,empathy,andgoalconsensusandcollaboration.Theevidencereviewedalsoindicatedthatthefollowingfactorsarepromisingandprobablyeffective:positiveregard,congruence/genuineness,feedback,repairofallianceruptures,self-disclosure,managementofcountertransference,andqualityofrelationalinterpretations.Withregardtocustomizingthetherapyrelationshiptoindividualclientsbasedontheirqualitiesorbehaviors,theempiricalevidenceindicatedthatthefollowingfactorsaredemonstrablyeffective:resistanceandfunctionalimpairment.Theevidencereviewedalsoindicatedthatthefollowingfactorsarepromisingandprobablyeffectiveasameansofcustomizingtherapy:copingstyle,stagesofchange,anaclitic/sociotropicandintrojective/autonomousstyles,expectations,andassimilationofproblematicbehaviors.Insufficientempiricalevidencewasfoundforadefinitiveconclusiontobepresentlymadeforthefollowingclientorpatientcharacteristics:attachmentstyle,gender,ethnicity,religionandspirituality,preferences,andpersonalitydisorder.Thesteeringcommitteestronglyrecommendsthattherapistsmakethecreationandcultivationofthetherapyrelationshipbasedonthefactorsfoundtobedemonstrablyandprobablyeffectiveamajorgoalintheirtherapeuticworkwithclients.ItalsosuggeststhattheconcurrentuseofbothESRsandESTstailoredtotheclient’sdisorderandcharacteristicswillleadtothebesttherapeuticoutcomes(SteeringCommittee2002,442).Anotherapproachtoansweringthequestionofwhypsychotherapyworksistomorebroadlyextractempiricallyinformedprinciplesoftreatmentselectionthatgobeyondtechniquesorsingle-theoryviewsasLarry E.Beutler(2000)hasdone(seealsoBeutler,Clarkin,andBongar2000;BeutlerandHarwood2000).Beutlersuggestseighteenguidingprinciplesfortreatingclientswithdepression,withtenbasicguidelines(e.g.,thelikelihoodofimprovementisapositivefunctionofsocialsupportlevelandanegativefunctionoffunctionalimpairment)andeightoptimalandenhancingguidelines(e.g.,therapeuticchangeismostlikelyifchangeeffortsinitiallyfocusonbuildingnewskillsanddisruptingsymptoms)(seeTan2002a).Morerecently,thisapproachhasbeenexpandedinworkdonebyyetanothertaskforcejointlysponsoredbyAPADivision12(SocietyforClinicalPsychology)andtheNorthAmericanSocietyforPsychotherapyResearch,between2002and2004.Louis G.CastonguayandLarry E.Beutler(2006b)havesummarizedwhatthistaskforcehasdoneinaneditedvolumeonprinciplesoftherapeuticchangethatworkorempiricallybasedprinciplesoftherapeuticchange(seealsoTan2007a).WhyPsychotherapyWorks:EmpiricallyBasedPrinciplesofTherapeuticChangeThetwomajorquestionsthatthetaskforcefocusingonempiricallybasedprinciplesoftherapeuticchangeattemptedtoanswerare:“(1) Whatisknownabout _Tan_Counseling_BB_mw.indd410 9/21/104:40:35PM Appendix 397 thenatureoftheparticipants,relationship,andprocedureswithintreatmentthatinducepositiveeffectsacrosstheoreticalmodelsandmethods?(2) Howdothefactorsorvariablesthatarerelatedtoparticipants,relationships,andtreatments,worktogethertoenhancechange?”(CastonguayandBeutler2006b,v–vi).CastonguayandBeutler(2006b)coverbothcommonanduniqueprinciplesoftherapeuticchangethatareempiricallybasedorgrounded,buttheyincludeonlypsychosocialtreatmentswithadultclients(withfourmajordisorders:dysphoricdisorders,anxietydisorders,personalitydisorders,andsubstanceusedisorders).Theynotethattheseprinciplesarenotempiricallysupportedbyexperimentalstudiesperse.Theseempiricallybasedprinciplesoftherapeuticchangethatworkshouldthereforebeconsideredmoreashypothesesandnotyetasestablishedfactualprocessesofchange.Gerald M.RosenandGerald C.Davison(2003)haverecentlyadvocatedthatpsychologylistempiricallysupportedprinciplesofchange(ESPs)insteadofcredentialingtrademarkedtherapiesorothertreatmentpackages.CastonguayandBeutler(2006a)havesummarizedsixty-oneempiricallybasedprinciplesoftherapeuticchangecoveringtheworkofthetaskforce.Thefollowingaresomeexamplesofthesesixty-oneprinciplesundertheirthreemajorheadings(seeTan2007a):participant(clientandtherapist)characteristics(e.g.,dropoutratesarereducedandimprovementisbetterifclientsandtherapistsarefromthesameorsimilarsocial/ethnicbackgrounds;ifclientshaveapreferenceforreligiouslyorientedtherapy,therapeuticeffectsareenhancedifthispreferenceisaccommodatedbytherapists;therapistsarelikelytoenhancetheireffectivenessiftheyhaveattitudesofflexibility,openmindedness,andcreativity,andiftheyarepatient);therapeuticrelationship(e.g.,therapytendstobehelpfulifastrongworkingallianceisformedandmaintainedduringtherapy;therapistsshouldrelatetotheirclientswithempathy;anattitudeofcongruenceorauthenticityonthepartofthetherapistislikelytopromotechange);andtechniquefactors(e.g.,therapeuticchangeislikelytooccuriftherapistsprovideastructuredtreatmentandstayfocusedintheapplicationoftheinterventions;positivetherapeuticoutcometendstooccurwhentherapistshelpclientschangetheircognitionsorthinkingandhelpthemengageinself-exploration;therapeuticchangeislikelyiftherapistshelpclientsaccept,tolerate,andevenfullyexperiencetheirfeelings).TheresearchliteraturehasthereforeincludedESTs,ESRs,andevenESPs(andPHTs).Theworkofthelatesttaskforceonempiricallybasedprinciplesoftherapeuticchangehashelpedtobroadenthefocustoincludeparticipant(clientandtherapist)characteristics,therapeuticrelationship,andtechniquefactorsthatcutacrosstheoreticalmodelsandmethods.Infact,thelatestdevelopmentinempiricallybasedcounselingandpsychotherapyistheevenbroaderconceptofevidence-basedpractice(EBP).Morespecifically,EBPthatrelatestotheclinicalpracticeofpsychologyisnowcalledevidence-basedpracticeinpsychology(EBPP). _Tan_Counseling_BB_mw.indd411 9/21/104:40:36PM 398 Appendix Evidence-BasedPracticeinPsychology(EBPP)TheempiricallybasedprinciplesoftherapeuticchangethatCastonguayandBeutler(2006a,2006b)haverecentlysummarizedareconsistentwiththelatestdevelopmentofEBPP.AnAPApresidentialtaskforce(yes,anotherone!)hasdefinedEBPPastheintegrationofthebestavailableresearchwithclinicalexpertiseinthecontextofpatientorclientcharacteristics,culture,andpreferences(APAPresidentialTaskForceonEvidence-BasedPractice2006;seealsoNorcross,Beutler,andLevant2006).EBPPisthereforebroaderthanESTs,ESRs,orevenESPs.Ittakesintoconsiderationnotonlythebestavailableresearch(fromvarioussourcesthatincludeRCTsaswellascorrelationalandqualitativestudies)butalsotheclinicalexpertiseofthetherapist,andespeciallyclientcharacteristics,culture,andpreferences,includingreligiousandspiritualvaluesandpreferences.EBPPemphasizestheapplicationofempiricallysupportedprinciplesofpsychologicalassessment,caseformulation,therapeuticrelationship,andinterventioninordertopromoteeffectivepsychologicalpracticeandenhancepublichealth(seealsoKazdin2008;LevantandHasan2008).Alan E.Kazdin(2008)hasnotedthatevidence-basedpractice(EBP)isthebroadertermthatincludesevidencebasedtreatment(EBT),whichissynonymouswithEST(seeMcHughandBarlow2010).Attimessomeauthors(e.g.,Gotham2006)haveerroneouslyusedthetermevidence-basedpractices(EBPs)torefertoESTs(orEBTs),thusconfusingEBPP(orEBP)withESTs,asRonaldF.LevantandNadiaT.Hasan(2008)havenoted.TheNationalInstituteofMentalHealth(NIMH)hasrecentlyattemptedtogenerateinnovativetreatmentsformentalorpsychologicaldisorders.Ithasspecificallytargetedtranslationalresearchforalleviatingmentalillnessasamajorpriorityforresearchfunding.TashiroandMortensen(2006)havethereforeprovidedsomehelpfulsuggestionsfortranslatingbasicsciencefromsocialpsychologyinparticularintoinnovativetreatmentsformentaldisorders.NIMHhasdefinedtranslationalresearchinthebehavioralandsocialsciencesasresearchthatdealswithhowbasicbehavioralprocessesinformthediagnosis,prevention,treatment,anddeliveryofservicesformentalillness,andalsohowknowledgeofmentalillnessincreasesourunderstandingofbasicbehavioralprocesses(seeTashiroandMortensen2006,959).ABiblicalPerspectiveonESTs,ESRs,ESPs,andEBPPESTsandtherapeuticrelationships(ESRs)aswellasprinciplesoftherapeuticchangeorESPsareallbasedongoodscientificresearch.Assuch,theycanbeappropriatelyrespectedandusedinclinicalpracticebyChristiancounselorsandtherapists.However,biblicalguidelinesforeffective,efficient,andethicaltherapymusthavefirstpriority.Forexample,weshoulduseESTs,ESRs,orESPsthatworkonlyiftheyareconsistentwithbiblicaltruth,ethics,and _Tan_Counseling_BB_mw.indd412 9/21/104:40:37PM Appendix 399 values.WhatevercontradictstheBibleanditsteachings,evenifempiricallysupported,shouldnotbeacceptedorappliedinclinicalpracticebyChristiantherapists(Tan2001a).Theprimacyofagapelove(1 Cor.13)asthefoundationandcenterofChristiancounselingandpsychotherapymeansthatESTscannotbeusedwithoutESRs,includingtheimportanceofagoodtherapeuticalliancebetweentherapistandclientbasedonempathy,whichisacrucialcomponentofagapelove(seeTan2002a,2003a).Appropriaterespectandappreciationforgoodscientificresearch,includingtheuseofRCTs,shouldchallengeChristiantherapistsandresearcherstoconductadditionalempiricaloutcomestudiesontheeffectivenessofChristiantherapeuticinterventions(Tan2001a).However,aChristianbiblicalperspectiveonoutcomeorefficacystudieswilltakeabroaderapproachtotheresearchmethodsusedinsuchstudies.WecanvalueexperimentalmethodssuchasRCTswithoutviewingthemastheonlyvalidresearchmethodstouse.More-qualitativeresearchmethodssuchasphenomenological,hermeneutical,andnarrativeapproachescanalsobevalidlyused,especiallyininvestigatingreligiousorspiritualphenomenaandexperiences(e.g.,seeVandeKemp1996;Wulff1998),evenintherapyoutcomestudies.Itisimportantnottofallintoapsychologicalreductionismthatisbasedtoomuchonlogicalpositivism,whichviewsrealityonlyinphysicalistic,naturalisticways.However,wecanstillhaveahealthyrespectforgoodsciencewithoutembracingscientism(theworshipofscienceandnaturalism)andtherebyexcludingthesupernaturalorspiritualrealm.EBPPisamorecomprehensiveapproachtousingESTs,ESRs,andESPs.EBPPnotonlystressestheneedtousethebestavailableresearchorempiricallysupportedvariablesineffectivetherapy.Italsoemphasizestheneedtousetheclinicalexpertiseofthetherapistandtoincorporatetheclient’scharacteristics,culture,andpreferences,includingreligiousandspiritualvaluesandpreferences.Thisisamorebalancedandbroad-basedapproachtoconductingeffective,efficient,andethicaltherapy.Assuch,EBPPisrelativelymoreconsistentwithabiblicalperspectiveoneffectivetherapyoraChristiancounselingapproachthataffirmsbiblicalvaluesandethics(Tan1987a,1987b,2007a).ResultsofResearch:TheEffectivenessofLayorParaprofessionalCounselingInconcludingthisdiscussiononresearchincounselingandpsychotherapy,itisimportanttonotetheresultsofdozensofoutcomestudiesthathaveevaluatedtheeffectivenessoflayorparaprofessionalcounseling(seeTan1991,1997b,2002bforreviewsoftheresearch;seealsoEgan2010).Suchcounselingisdonebyuntrainedorminimallytrainedlaycounselorswhodonothavegraduatedegreesincounselingandrelatedmentalhealthfieldsandwhothereforearenotlicensedmentalhealthprofessionals.Briefly,theresults _Tan_Counseling_BB_mw.indd413 9/21/104:40:38PM 400 Appendix ofthemajorityofoutcomestudiesthathavecomparedtheeffectivenessofprofessionalcounselorstolaycounselorshaveshownthatlaycounselorsaregenerallyaseffectiveasprofessionalcounselorsformostcommonproblems(seeAtkinsandChristensen2001;Bickman1999;ChristensenandJacobson1994;LambertandBergin1994;seealsoAli,Rahbar,Naeem,andGul2003;Neuner,Onyut,Ertl,Odenwald,Schauer,andElbert2008).However,someresultsfromresearchindicatethatprofessionallytrainedandexperiencedtherapistsorcounselorsdobetterthanparaprofessionalsinoutpatientsettingsintermsofhavingfewerclientdropouts(SteinandLambert1995).Otherresultsfavoringprofessionalexperiencehavebeenfoundinresearchontheuseofmanualizedtreatmentswithchildrenwithconductdisorders(Kendalletal.1990),inastudyofgroupcognitive-behavioraltherapyfordepressionatsixmonthfollow-up(Bright,Baker,andNeimeyer1999),andinastudyonrelaxationtrainingadministeredbyprofessionals,paraprofessionals,oraudiotapeforcancerchemotherapypatients(CareyandBurish1987).Morerecently,Barlow(2004)hasassertedthatcontrarytosomeassumptions,resultsfromrecentresearchindicatethatsignificantclinicalexpertiseandastrongtherapeuticrelationshipareessentialtomaximizetheefficacyofpsychologicaltreatments,especiallyforclientswhohavemoreseverepsychopathology(D. N.Kleinetal.2003;Norcross2002).Furthermore,therapistvariables,suchasexperience,docontributetobeneficialoutcomeinthesepsychologicalinterventions(Huppertetal.2001).Barlowthereforestronglyadvocatestheuseofhighlytrainedandexperiencedtherapistsorcounselors,preferablyapsychologist,inthetreatmentofclientswithmoreseverepsychopathology(seealsoBeutlerandKendall1995).Thesemorerecentdata,however,donottotallynegatepreviousfindingsthatlaycounselorsaregenerallyaseffectiveasprofessionaltherapists.Infact,afterbrieflyreviewingrelevantresearch,LeonardBickmanhasconcluded:“Untiladditionalresearchdemonstratesconsistentresults,weshouldconsiderthebeliefthatdegreeprogramsproducebettercliniciansamyth”(1999,971).Furtherresearchisthereforeneededbeforemore-definitiveconclusionscanbemaderegardingthegreatereffectivenessofprofessionallytrainedandexperiencedcounselorsortherapists.Itisstillfairandvalidtoconcludethatlaycounselorscangenerallybeeffectivehelpers(Tan1991,2002b).However,theempiricalevidencemorespecificallyfortheeffectivenessoflayChristiancounselingisverylimited(e.g.,TohandTan1997)withaneedforbettercontrolledoutcomestudies(GarzonandTilley2009). _Tan_Counseling_BB_mw.indd414 9/21/104:40:39PM References 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_Tan_Counseling_BB_mw.indd486 9/21/104:41:24PM NameIndex Abanes,R.,175AbuRaiya,H.,361Abzug,R.H.,106Ackerman,N.W.,285Adams,J.E.,329,330,332,334,335,336,363Addis,M.E.,220Adler,A.,60,62,79,253Ahn,H.N.,395Alberti,R.E.,221Alcorn,R.,122Alexander,J.,317–18Alford,B.A.,280Ali,B.S.,400Alicke,M.D.,151Alsdurf,J.M.,351Anderson,H.,300,301Anderson,N.T.,ix,11,325,334,339,356,361Anderson,R.S.,315,325Andersson,G.,278Ano,G.G.,331Ansbacher,H.L.,63,69Ansbacher,R.,63,69Ansley,T.N.,352Appleby,D.W.,351Arezmendi,T.G.,151Arias,B.,21Arkowitz,H.,143,152Arlow,J.A.,55,56Arnkoff,D.B.,206,207,208,209,244,248,254,258Arterburn,S.,356 Aten,J.D.,11,325,358Atkins,D.C.,294,317,400Atwood,G.E.,46Augsburger,D.,ix,11,325,337,367,370Augusta-Scott,T.,292Axline,V.M.,141Baca,C’de,J.,366Bachrach,H.,54Backus,W.,331Bade,M.K.,352Baer,R.A.,171Bagiella,E.,368Bailey,J.W.,360Bair,D.,83,101Baker,E.K.,19,400Baker,L.,288,304Baldwin,S.A.,242,290,316,317,318Balswick,J.K.,315Balswick,J.O.,315,328Bandura,A.,211,212,214,216,221,248,252Bankart,C.P.,129,132Barber,J.P.,53Barkham,M.,151Barley,D.E.,14,147,392,393Barlow,D.H.,2,3,227,245,278,352,360,392,398,400Barnes,K.L.,28Barnett,J.E.,19,27,28,29,30,31,32,383 Bartz,J.,11,281,361Baskin,T.W.,392Bassel,M.,55Bateson,G.,286Baucom,B.,294Baucom,D.H.,300,317Bauman,J.,290Baumgardner,P.,157Baxter,L.R.,245Beavers,W.R.,312Beck,A.T.,55,217,218,247,249,250,254,255,257,258,262,272,273,280,282Beck,J.R.,328,338,384,385Beck,J.S.,217,250,258,282Becker,E.,112Becker,W.W.,27Becvar,D.S.,284Becvar,R.J.,284Beebe,G.D.,368Bellack,A.S.,218Bemis,K.M.,253,254,257Benner,D.G.,150,325,341,359,360,362,367Benson,H.,224Berg,I.K.,291Bergin,A.E.,11,208,325,341,343,357,379,381,382,383,390,400Berman,J.,24,25,29,374Bernauer,F.,78,151,241Berry,J.T.,326 473 _Tan_Counseling_BB_mw.indd487 9/21/104:41:25PM 474Beutler,L.E.,13,151,177,396,397,398,400Bhar,S.S.,55Bickman,L.,400Binswanger,L.,104,108Bitter,J.R.,69,290,297–98,302,320Bjorck,J.P.,333Bloesch,D.,367Blomberg,J.,54Boa,K.,368,370,371Bohart,A.C.,9,95,96,120,121,125,133,137,142,147,151,152,174,177,311,316,317,318,390Bolsinger,T.E.,314Bongar,G.,396Book,H.E.,56Borduin,C.M.,318Boscolo,L.,286,299,304Boss,M.,104,108Boswell,J.F.,392Boszormenyi-Nagy,I.,290,299Bottome,P.,60Bowen,M.,298Bowers,K.S.,237,273Bowers,T.G.,241Bowman,C.E.,155,156Bozarth,J.D.,138,139Bracke,P.E.,117Brandchaft,B.,46Brawer,P.A.,352,360Breggin,P.R.,186,198Brenner,C.,57Breunlin,D.,302Brickell,J.,189,194,195,197Bright,J.I.,400Brock,R.T.,363,373Brotman,M.A.,217Brown,C.,292Brown,G.K.,249Brown,W.S.,328Browning,D.S.,ix,31,54,96,97,98,150,175,176,238,239,315,376,387Brugger,E.C.,328Bryant,C.,99Bucky,S.F.,28Budman,S.H.,295Bufford,R.K.,239,332,340,351,362Bugental,J.F.T.,106,114,117 _Tan_Counseling_BB_mw.indd488 NameIndexBuie,D.H.,137Bumberry,W.M.,289,298Burish,T.G.,400Burke,B.L.,152Burkett,L.,345,351,367Burns,D.,262Butler,A.C.,218,250,280Butler,C.C.,143Butman,R.E.,ix,11,53,98,99,122,124,149,158,173,176,200,202,238,239,274,302,313,316,325,384Cain,D.J.,131,132,139,146,154Calhoun,A.A.,358Calhoun,L.G.,358Callanan,P.,27,29,32,384Campbell,C.D.,ix,11,273,275,315,325,336,359,362Canter,P.H.,231Carey,M.P.,400Carkhuff,R.R.,2,137,141,335,336Carlson,D.E.,336Carlson,J.,60,69,78,79,302,303Carter,B.,302Carter,J.D.,15,326,327,336Cashwell,C.S.,325Castellani,A.M.,319Castonguay,L.G.,13,392,396,397,398Caussade,J.P.de,174,276Cautela,J.R.,254Cecchin,G.,299,304Cecchin,G.F.,286Celano,M.,283,284Centore,A.J.,386Chambless,D.L.,53,218,244,280,393,394Chan,S.,368Chang,C.,203Chapelle,W.,359Chapian,M.,331Chapman,J.E.,218,250,280Chase,S.,345Chen,S.W.-H.,236,272Chrisholm-Stockard,S.,151Christensen,A.,294,300,317,400 Christensen,O.C.,69,285Chung,W.,28Cilliers,F.,154Clark,D.A.,249Clark,L.A.,277Clarkin,J.F.,396Clinton,T.E.,ix,11,31,325,353,376,385,386,387Clum,G.,241Cockrum,J.R.,193Coe,J.H.,363,371Coelho,H.F.,231Coffman,S.J.,220,277Cohn,H.W.,112Colapinto,J.,288Collins,G.R.,ix,2,11,15,16,18,19,313,325,326,327,332,334,335,337,338,357,362,384,386Collins,P.L.,203Combs,A.W.,8,142,146Consoli,A.,177Constantino,M.J.,392Cook,S.W.,352Cooper,A.M.,57Cooper,J.W.,328Cooper,M.,107,110Cooper,T.D.,ix,54,96,97,98,150,175,176,238,239Corcoran,K.J.,328Corey,G.,ix,2,11,13,14,17,27,29,32,38,40,47,49,58,61,63,64,66,67,69,74,92,100,103,105,106,110,127,132,137,142,158,159,161,162,163,164,172,179,185,186,189,192,197,199,200,204,206,210,212,214,218,219,220,229,230,231,235,238,244,248,250,251,262,263,264,265,271,274,282,283,284,287,288,290,291,292,298,302,303,309,320,384Corey,M.,27,29,32,384Cormier,S.,223,225,229Corsini,R.J.,ix,1,35Crabb,L.J.,15,326,327,329,330,331,332,334,336,338,344,355,359,362,366 9/21/104:41:25PM 475 NameIndexCrago,M.,151Craske,M.G.,227,278Crits-Christoph,P.,56Crocket,K.,292,300Crumbaugh,J.C.,126Cuijpers,P.,278Czikszentmihalyi,M.,12Daldrup,R.J.,177Dattilio,F.M.,223,273,300Dausch,B.M.,283,284Davenport,D.S.,236,272Davidson,J.,258Davis,D.D.,249Davis,D.E.,361Davis,K.E.,382Davis,S.D.,306Davison,G.,214,223,225Davison,G.C.,245,397Day,S.X.,2,100,121,173,175,206,209,256,284DeJong,P.,291deShazer,S.,291,300,305DeCarvalho,R.J.,106Decker,E.E.,363,372Deere,J.,366DeJulio,S.S.,147,151Demarest,B.,328,338Demorest,A.,37Denney,R.,358Derlega,V.J.,77DeRubeis,R.J.,217DiClemente,C.C.,152Dimeff,L.A.,231Dimidjian,S.,220,277,294,300,392Dinkmeyer,D.C.,64,69,79Dinkmeyer,D.C.,Jr.,64Dobson,D.,258Dobson,K.S.,220,258,277,282Dodds,L.,363Dolan,S.L.,394Dolan,Y.M.,291,300Doll,B.,28Donati,R.,78,151,241Doss,A.J.,78,241Douglas,C.,80,81,82,89,90,91,92,93,99,100,101Dowd,E.T.,325,357,383Dreikurs,R.,63,64,65,66Dreikurs,R.,68 _Tan_Counseling_BB_mw.indd489 Drekstra,R.F.W.,276Drishell,J.E.,279Driskill,J.D.,344Dryden,W.,248,262,264,300Dubin,L.F.,368Dudley,R.,258,273Dueck,A.,99,327,337,384Duncan,B.L.,14,142,393Dunn,C.,152Dunn,R.L.,242Dunn,T.W.,277D’Zurilla,T.J.,254Eck,B.E.,16,325,326,338,339,359Edens,R.,202Egan,G.,137,141,336,399Elbert,T.,400Ellenberger,H.F.,36,37,74,82,83Elliott,R.,142,151,167,172,176,177,294Ellis,A.,74,247,248,251,252,253,254,255,256,257,262,264,265,273,282,355Elman,N.S.,19Emery,G.,217,249,257,258,272,273,282Emmelkamp,P.M.G.,218,229Emmons,M.L.,221Engels,G.L.,276Englar-Carlson,M.,78Engle,D.,177Entwistle,D.N.,327Epstein,N.B.,300Epston,D.,292,300Eriksen,K.,360Erikson,E.H.,44,352Ernst,E.,231Ertl,V.,400Evans,A.L.,28Evans,C.S.,123,124,275,331Eysenck,H.J.,208,209,390Fairbairn,W.R.D.,45Fairburn,C.G.,249Fall,K.A.,2,7,8,100,136,179,182,183,197,201,235,248,250,284Farber,B.A.,146Farnsworth,K.E.,326,327Farrell,W.,203 Farson,R.,130Fee,G.D.,363,373Felton,J.,356Finch,J.G.,123Finley,J.,276Finney,J.R.,344Fisher,S.,54Fishman,D.B.,206,209,244,245,288,302Fitzpatrick,D.,267Flores,N.,21Flynn,M.,345Foa,E.B.,244Foerster,F.S.,166,178Follette,V.M.,214,230,237,245,254,273,281Fonagy,P.,218,393Forman,E.M.,218,250,280,392Foster,R.J.,330,344,358,368,370Fraenkel,P.,317Frame,M.W.,325Frank,J.D.,206,372Frankl,V.,104,105,109,114,127Franks,C.M.,209,244,245Frazier,R.,360Freeman,A.,237,249Freeman,J.,248,257,258,262,273,292Freiheit,S.R.,244,280Freud,A.,45Freud,S.,36,37,53,56Friedlander,M.,318Friedman,E.H.,319Frisch,M.,281Fulton,P.R.,171Gabbard,G.O.,57Galatzer-Levy,R.M.,54Gamori,M.,290Garcia-Preto,N.,310,320Garnefski,N.,276Garzon,F.,345,351,352,367,400Gass,S.C.,352Gawrysiak,M.,220Gay,P.,37Gendlin,E.T.,131,140,141–42George,W.H.,294 9/21/104:41:25PM 476Gerber,J.,290Germer,C.K.,171Getz,G.,314Gibbons,C.J.,217Giesen-Bloo,J.,280Gilbert,M.G.,363,373Gilbert,P.,217,237,240,258,272Gilliam,A.,203Gingrich,F.C.,358Giordano,J.,310,320Gladding,S.T.,284Glaser,R.R.,317Glass,C.R.,206,207,208,209,244Glass,G.V.,78,151,176,276,390,391,392Glass,R.M.,55Glasser,C.,182,184Glasser,N.,182,197,202Glasser,W.,180,181,182,183,184,185,186,187,188,190,193,194,198,202,204,205,236Goldenberg,H.,283,284,285,286,287,292,293,296,297,298,299,300,301,302,303,304,305,306,319,320Goldenberg,I.,283,284,285,286,287,292,293,296,297,298,299,300,301,302,303,304,305,306,319,320Goldfried,M.R.,214,223,225,227,245,248,254,392Goldman,R.,164,167,172,177Goldman,R.N.,167,294Gomes-Schwartz,B.,335Gonsiorek,J.C.,376Gonzalez,J.E.,277Goodman,P.,157Goodrich,T.J.,312Goolishian,H.,301Gorman,J.M.,13,218,393Gorsuch,R.L.,360Gossett,J.T.,312Gotham,H.J.,398Gottlieb,M.,24,25,29,374Gottman,J.M.,294,295Gottman,J.S.,294,295Gould,W.B.,105 _Tan_Counseling_BB_mw.indd490 NameIndexGrant,P.,249Grawe,K.,78,151,241Green,J.B.,328Greenberg,J.R.,46Greenberg,L.S.,137,142,151,166,167,172,176,177,178,293,294Greenberg,R.L.,249Greenberg,R.P.,54Greenberger,D.,262Gregg,D.H.,16,23,345,353,358,367,369,373Greggo,S.P.,362Griffith,J.L.,325Griffith,J.W.,220Griffith,M.E.,325Grounds,V.,275,331Grudem,W.,328Gruener,D.,249Guarnaccia,C.A.,77Guernsey,D.B.,315Guevremont,D.C.,206,212,213,217,218,221,222,223,225,226,227,229,235,246,271Gul,A.,400Gurman,A.S.,283,284,295,317,318,321Guttman,D.,115Guy,J.D.,15,19,22,23Hackney,C.H.,386Haden,N.,122Haggbloom,S.J.,209,212Hahlweg,K.,242Haigh,G.,130Haley,J.,286,287,299Hall,C.S.,57Hall,G.C.N.,395Hall,M.E.L.,339Hall,T.W.,339,363,371Halligan,F.G.,272Hambright,A.B.,318,319Hamilton,J.C.,151Handelsman,M.M.,24,25,29,374Hannah,B.,83Hansen,N.B.,360,392Hardy,K.V.,310,312,320Hargrave,T.D.,290,316Harper,R.A.,1,264Harris,A.S.,83,101 Hart,A.D.,ix,11,23,325,386Hart-Weber,C.,386Harter,M.,55Hartmann,H.,45Harwood,T.M.,396Hasan,N.T.,398Hathaway,W.L.,376Hawes,C.,69Hawkins,R.,353Hawley,K.M.,78,241Hayes,S.C.,213,214,230,231,237,243,245,254,273,281,339Hayford,J.,364Hays,P.A.,236,272Hefferline,R.F.,157Heiblum,N.,318Heidegger,M.,103,104Helgeson,V.S.,358Henggeler,S.W.,318Henrion,R.,126Herman-Dunn,R.,220Hersen,M.S.,218Hesselgrave,D.,337Hettema,J.,152Hill,C.E.,392Hill,K.,125Hill,P.C.,325,338,368Hillmann,M.,115Hodges,L.,229Hoffman,E.,60Hoffman,L.,286,299,304Hoffman,L.W.,328Hoffman,M.,54Hofmann,S.G.,244Holden,J.M.,2,7,8,62,100,136,179,182,183,197,201,235,248,250,284Holdstock,L.,154Hollon,S.D.,215,218,247,254,392Holzel,L.,55Hoogduin,C.A.L.,153Hook,J.N.,361Hopko,D.R.,220Horowitz,J.D.,243Horton,M.S.,328Houston,J.,344Howard,E.B.,368,370,373Hoyt,M.F.,291,292Hubble,M.A.,14,142,393Hughes,J.P.,273 9/21/104:41:26PM 477 NameIndexHull,C.,207Humphrey,K.,158Hunsinger,D.v.D.,344Hunsley,J.,390Huppert,J.D.,400Hurding,R.F.,98,99,124,149,176,200,334,353Hurley,J.B.,326Hutchison,J.C.,353Hwang,J.G.,202Hycner,R.,163Ingersoll,R.E.,176Ingram,J.,363Iwamasa,G.Y.,236,272Jackson,D.D.,286Jacobs,L.,155,159,163,178,179Jacobson,E.,223Jacobson,N.S.,220,294,295,300,400Jaremko,M.D.,212Jarrett,R.B.,277Jeeves,M.,328Jenaro,C.,21Jewett,L.R.,55Johnson-Greene,D.,28Johnson,C.B.,344,353Johnson,E.L.,327,338,371Johnson,J.H.,279Johnson,R.B.,95Johnson,S.M.,293,294,298Johnson,W.B.,27,28,30,31,32,237,239,251,273,281,352,355,361,383Johnston,W.,99Jones,E.,36,37,57Jones,I.F.,325,334Jones,S.L.,ix,11,53,98,99,122,124,149,158,173,176,200,202,238,239,274,302,313,316,325,327,384Jones,W.H.,77Joseph,S.,12,13Jourdan,A.,151,153Jung,C.G.,81,82,83,101Kabat-Zinn,J.,231Karkkainen,V.-M.,363Kaslow,F.,319 _Tan_Counseling_BB_mw.indd491 Kaslow,N.J.,28,283,284Kazantzis,N.,273Kazdin,A.E.,214,219,220,235,241,246,252,254,271,398Keijsers,G.P.J.,153Keith,D.V.,288,289,298Kellemen,R.W.,359Kellogg,S.H.,250,258,280,281Kelly,G.,248Kelsey,M.,98,99Kendall,P.C.,215,247,253,254,257,400Kent,J.S.,21Kenward,R.,103,107,127Kernberg,O.F.,45,251Kiesler,D.V.,131,140Kim,R.J.,202King,P.E.,328Kirby,J.S.,300Kirschenbaum,H.,129,130,151,153Klaassen,D.W.,114,123,127,173,176,356Klein,D.N.,400Klein,M.,45Klein,M.H.,151Klosko,J.S.,258,280,281Klotz,M.L.,151Knapp,S.,24,25,29,374Kniskern,D.P.,295,318Koenig,H.G.,368Koerner,L.,231Kohut,H.,45Kolden,G.G.,151Korman,L.M.,142Kraft,C.H.,345Krasner,B.R.,290,299Kriston,L.,55Kruis,J.G.,334,353Kunst,J.,366Kuyken,W.,258Kwasny,J.C.,360Kyken,W.,273L’Abate,L.,195Laing,R.D.,106Lambert,M.J.,14,147,151,208,390,391,392,393,400Lane,G.,151,177Lantz,J.,117,121,127 Larson,D.B.,344,368LaTaillade,J.J.,300Lawrence,D.H.,203Lawrence,J.,326Lazar,A.,54Lazarus,A.A.,30,31,208,209,210,211,218,230,237,248,257,272,333,383Lazarus,C.N.,230Leach,M.M.,11,325Leahy,R.L.,217,237,240,249,258,271,272,282Lebow,J.L.,283,284,292,293,306,309,318,320Lee,C.,327Lee,C.M.,390Lee,R.G.,174Lee,W.Y.,288Lehman,C.L.,278Leichsenring,F.,53,55Leszcz,M.,106Levant,R.F.,283,398Levicoff,S.,25,374,387Levis,D.J.,227,228Levitt,B.E.,154Levy,K.N.,280Lewinsohn,P.M.,220Lewis,J.M.,302,303,312Liddle-Hamilton,B.,201Liese,B.S.,249Lietaer,G.,172,176,177,294Lilienfeld,S.O.,173,178,223,392Lindsley,O.R.,209,210Linehan,M.M.,214,230,231,237,243,245,254,273,278,281Linley,R.A.,12,13Linnenberg,D.,201Lints,R.,328Lobovits,D.,292Loftus,P.E.,341Lovinger,R.J.,357Luborsky,E.B.,55,56Luborsky,Lester,56,177,391Luborsky,Lise,391Lucado,M.,122Ludgate,J.W.,249Luoma,J.B.,231Lyddon,W.J.,237,273Lyubomirsky,S.,12 9/21/104:41:26PM 478MacIan,P.S.,20MacKune-Karrer,B.,302MacLaren,C.,262,282MacNutt,F.,332,351Madanes,C.,287,290Magaletta,P.R.,352,360Magyar,G.M.,331Mahoney,M.J.,22,23,248,254,258,267,268Malcolm,W.,166,167,178Malone,T.,289Malony,H.N.,ix,11,123,325,327,328,344,351,356Maniacci,M.,60,65,67,69,79Margolin,G.,294,300Markman,H.J.,242Marks,I.,372Marquis,A.,2,7,8,100,136,179,182,183,197,201,235,248,250,284Marra,T.,231Martell,C.R.,220,294,300Martin,J.E.,237,239Martinez,J.S.,352,360May,R.,106,109,111,113,117,127McCullough,M.E.,344,368McDaniel,M.A.,361McDonald,M.J.,114,123,127,173,176,356McElwain,B.,102,125McGoldrick,M.,302,310,312,320McGrath,A.,368McHugh,R.K.,398McKnight,S.,353,368,370McLean,C.,243McLemore,C.,176McMinn,M.R.,ix,11,150,273,275,315,325,327,336,351,359,362,376,380,386McMullin,R.E.,258McRay,B.,ix,325,351,380McWilliams,N.,47,57Mearns,D.,142,154Mease,A.,318Meichenbaum,D.,212,213,224,232,233,237,248,254,256,258,260,266,267,273,279,282Melnick,J.,164Menchola,M.,152 _Tan_Counseling_BB_mw.indd492 NameIndexMendelowitz,E.,107,111,116,117,125,127Merbaum,M.,248Messer,S.B.,295Michels,J.L.,151Mickel,E.,201Miller,G.,325Miller,J.C.,84Miller,K.R.,334,353Miller,P.A.,334,353Miller,S.D.,14,291,393Miller,T.I.,78,151,176,276,390,391,392Miller,W.R.,142,143,151,152,237,239,325,366,368Miltenberger,R.G.,217,218,219,220,235,246,271Minami,T.,392Minuchin,P.,288Minuchin,S.,287,288,299,302,304Miranda,J.,236,272Mischel,W.,248Mitchell,S.A.,46,57Moltmann,J.,363Monk,G.,292,300Monroe,P.G.,327,353Montgomery,L.M.,317Moon,G.W.,359,360,362Moon,K.,141Moorehead-Slaughter,O.,30Moriarty,G.L.,327Morris,P.,200Mortensen,L.,391,392,398Mosak,H.H.,60,63,65,67,71,79Mosgofian,P.,25,374,387Mosher,L.,125Moyers,T.B.,142Murphy,L.,203Murphy,N.,328Murray-Swank,N.A.,331Myers,D.G.,327Naeem,S.,400Narramore,S.B.,15,326,327Nathan,P.E.,13,218,393,394Natiello,P.,142Neimeyer,R.A.,400Nelson,A.A.,342,380Nelson,J.,325Nelson,M.L.,28 Neuner,F.,400Nevis,S.M.,164Newman,C.F.,249Nicholas,C.,220Nichols,M.P.,288,290Nicoll,W.G.,69Nielsen,S.L.,251,273,325,357,383Norcross,J.C.,ix,1,8,9,11,13,19,22,23,54,55,78,100,104,105,108,109,110,116,125,126,142,148,152,153,177,178,183,204,206,207,210,211,213,232,235,236,241,242,244,245,248,254,256,271,276,277,278,279,280,281,283,284,286,288,309,311,312,313,316,318,319,335,386,395,398,400Novotny,C.,390,392,395Nurius,P.S.,223,225,229O’Donnell,D.J.,204O’Reilly-Landry,M.,55,56Odenwald,M.,400Ogles,B.M.,147,391,393Oh,D.,244Ohlschlager,G.W.,ix,11,25,31,325,374,376,385,386,387Ollendick,T.H.,53,218,393,394Oman,D.,344Onyut,P.L.,400Orange,D.M.,46Orgler,H.,60Orsillo,S.M.,230,245,246,273,281Ortberg,J.,345,358,367Orton,J.J.,386Osborn,C.,223,225,229Osborne,G.R.,353Ososkie,J.N.,198Ost,L.G.,231Otis,K.E.,360Ouellet,M.C.,315Packer,J.I.,369Padesky,C.A.,248,250,258,262,273 9/21/104:41:27PM 479 NameIndexPaivio,S.C.,142,166,178Palmer,R.B.,28,328Paloutzian,R.F.,325Papadopolous,R.,83,101Pargament,K.I.,11,325,331,343,355,356,361,362,368,376Park,C.L.,12,325,358Parker,S.,363,365,370Parks,A.C.,12Parloff,M.B.,147,151Parrott,L.,III,2,9,11,15,18,62,66,67,74,100,105,107,109,112,132,146,156,157,163,164,172,181,182,190,192,198,206,207,216,217,218,219,235,266,271,272,284,302,303,306,309Parsons,T.D.,229Passons,W.R.,179Patterson,C.H.,2,142,273Payne,I.R.,341Payne,L.,345Pearlman,L.A.,20Peck,M.S.,356Pedersen,P.,147Pendleton,B.F.,344Penn,P.,286,299,304Perkins,B.R.,243Perls,F.,156,157,158,160,162,164,166,173,179Perls,L.,157Person,E.S.,57Persons,J.B.,228,257,258,282Peterson,A.V.,203Peterson,C.,12Peterson,E.H.,368Petra,J.R.,203Pfitzer,F.,290Philips,V.A.,312Phillips,T.R.,327Piercy,F.P.,317Pinnock,C.,363Pinsof,W.M.,318,319Plante,T.G.,11,325,343,368,376Platt,J.J.,254Plummer,R.L.,358Poloma,M.M.,344Polster,E.,160,161 _Tan_Counseling_BB_mw.indd493 Polster,M.,160,161,162,164,179Pope,K.S.,29,30,32Porter,S.L.,326,327Pos,A.E.,177,294Poser,E.G.,213Poster,E.,179Powell,L.H.,368Powers,M.B.,229,243Powers,W.T.,182Powlison,D.,326,327Prata,G.,286,299Prater,J.S.,337Prochaska,J.O.,ix,1,8,9,11,13,54,55,78,100,104,105,108,109,110,116,125,126,142,148,152,153,177,178,183,204,206,207,210,211,213,232,235,236,241,242,244,245,248,254,256,271,276,277,278,279,280,281,283,284,286,288,309,311,312,313,316,318,319,386Propst,L.R.,237,239,273,350Puffer,K.A.,328,329Pugh,J.,325,334,363,366Purves,A.,369Rabung,S.,53,55Rachman,S.,209Rachor,R.,203Radnitz,C.L.,272Radtke,L.,203Ragsdale,K.,317Rahbar,M.H.,400Rank,O.,130Rapaport,D.,45Rashid,T.,12Raskin,N.J.,141,147,149,151,153Rattner,J.,60Ray,W.A.,287Rector,N.A.,249Reese,J.B.,273Rehm,L.P.,248Reimer,K.,337Reimer,K.S.,328Reinecke,M.A.,248,257,258,262,273Renneberg,B.,55 Rennie,D.L.,142Reynolds,K.A.,358Rice,L.N.,142Richards,P.S.,11,281,325,343,357,361,376,379,381,382,383Richardson,F.,227,254Richardson,R.,345Richeport-Haley,M.,286,287Ridley,C.R.,337Ripley,J.S.,361,376Rizzo,A.A.,229Roazen,P.,37Robbins,M.S.,318,321Roberts,R.C.,315,327Roemer,L.,230,245,246,273,281Roepke,S.,55Rogers,C.R.,129,130,131,132,133,134,135,136,137,138,139,140,141,149,153,154Rogers,H.E.,129Rogers,N.,141Rogers,S.A.,341,366Rollnick,S.,142,143Rose,E.M.,352Rose,G.,143Rosen,G.M.,397Rosenfeld,E.,157Rosengren,D.B.,143Rosenthal,R.,125Rosman,B.L.,288,304Rosner,R.I.,237,273Roth,A.,218,393Rothbaum,B.O.,229Rouanzoin,C.C.,243Rubin,N.J.,28Rupert,P.A.,21Rush,A.J.,217,249,257,258,272,273,282Russell,D.,231Russell,I.,231Rychtarik,R.G.,152Ryckman,R.M.,84,85,86,87,95,99,106,134Safran,J.D.,237,240,258,272Salas,E.,279Saley,E.,154Sandage,S.J.,11,361,368Sandberg,J.G.,318 9/21/104:41:27PM 480Sandell,R.,54Sanders,P.,130,152,154Sanders,R.K.,31,376,379,387Sanford,J.A.,89Sapp,M.,203Satir,V.M.,290,297,298Saunders,T.,279Sawyer,A.T.,244Schaap,C.D.P.R.,153Schaeffer,C.M.,318Scharff,D.,297Scharff,J.,297Schauer,E.,400Schewebel,A.I.,242Schlesinger,S.E.,300Schneider,K.,107,111Schneider,K.J.,116,117,125,127Schoener,G.R.,19Schwartz,R.,302Scott,J.,249Seamands,D.,345SeeJ.D.,148Seeman,M.,368Seeman,T.E.,368Segal,Z.V.,214,231,237,240,258,272Seligman,L.,74Seligman,M.E.P.,12,248,389Sells,J.N.,11,284,286,287,288,289,290,291,292,293,296,298,301,313,314,315,321,325,362Selvini-Palazzoli,M.,286,299Selvini,M.,286Sexton,T.L.,317,318,321Shadish,W.R.,242,316,317,318Shafran,R.,243Shafranske,E.P.,11,325,344Shahabi,L.,368Shamdasani,S.,83,85Shapiro,D.,151,241Shapiro,D.A.,151,241Sharf,R.S.,ix,37,44,55,56,63,64,67,69,78,81,82,83,84,85,87,88,89,92,93,99,101,103,105,106,107,109,110,111,112,113,125,127,154,157,161,162,177,179,182, _Tan_Counseling_BB_mw.indd494 NameIndex183,188,190,194,195,202,204,206,222,248,249,262,263,264,266,311,316,318Shaw,B.F.,217,249,257,258,272,273,282Shedler,J.,55Shepard,M.,156Shepherd,I.L.,173Sherman,A.C.,368Shoham-Salomon,V.,125Shults,F.L.,368Shure,M.B.,254Shuster,M.,332Siegel,R.D.,171Silver,N.,295Silverstein,L.B.,312Simon,G.M.,288Sin,N.L.,12Singer,B.,391Skinner,B.F.,209,210,220Skolnikoff,A.,54Skovholt,T.M.,19,20,21,23Sloan,R.P.,368Smith,D.,153,252Smith,E.M.,345Smith,M.L.,78,151,176,276,390,391,392Smith,S.,231Smith,T.B.,11,281,352,360,361Smuts,J.C.,156Smyrl,T.,202Snyder,D.K.,311,319Solomon,H.C.,209,210Sommers-Flanagan,J.,2,31,72,83,85,87,92,93,96,100,132,133,135,137,138,139,140,141,151,164,165,169,182,183,187,188,258Sommers-Flanagan,R.,2,31,72,83,85,87,92,93,96,100,132,133,135,137,138,139,140,151,164,165,169,182,183,187,188,258Sorenson,R.L.,54,325Spark,G.,290,299Sperry,L.,11,64,69,79,302,303,325,344 Spiegler,M.D.,206,212,213,217,218,221,222,223,225,226,227,229,235,246,271Spivack,G.,254Sprenkle,D.H.,306,317St.Clair,M.,45,57Stampfl,T.G.,227,228Stanton,M.D.,318Steele,J.,152Steen,T.A.,12Stein,D.M.,147,151,400Stevens,A.,96Stevenson,D.H.,325,338Stewart,R.E.,244,280Stolar,N.,249Stolorow,R.D.,46Storr,A.,83,101Strawn,B.D.,54,55,328Strosahl,K.D.,231Strümpfel,U.,164,167,172,177Stuart,S.P.,394Sturkie,J.,383Sue,D.,337,382Sue,D.M.,337Sue,D.W.,337,382Suinn,R.M.,227,254Summers,R.F.,53Sweeney,T.J.,60,79Swindoll,C.R.,366Szasz,T.S.,186,198Takle,D.,353Talbot,M.R.,328Tallman,K.,142Tan,S.Y.,11,12,15,16,23,76,150,173,190,201,223,224,237,238,239,240,273,274,275,281,315,316,325,326,327,329,331,333,334,335,336,337,338,339,340,341,342,343,344,345,346,350,351,352,353,354,355,357,358,359,360,361,362,363,364,366,367,368,369,370,372,373,379,380,381,383,384,386,387,392,393,394,395,396,399,400Tang,A.,358 9/21/104:41:27PM 481 NameIndexTashiro,T.,391,392,398Tausch,R.,139,153Teasdale,J.D.,214,231Tedeschi,R.G.,358Telch,M.J.,243Terrell,C.J.,341,343,366Tharp,R.,214,229,252Thase,M.E.,249Thomas,G.,315,358,371Thombs,B.D.,55Thompson-Brenner,H.,390,392,395Thoresen,C.E.,368Thorne,B.,129,130,142,154Thorpe,C.,351Tierney.S.C.,392Tilley,K.A.,400Tillich,P.,108Tjeltveit,A.C.,31,376,387Todd,J.,9,95,96,120,121,125,147,151,174,177,311,316,317,318,390Toh,Y.M.,400Tolle,E.,174Toman,S.M.,179Tomich,P.L.,358Tompkins,M.A.,258Triggiano,P.J.,28Troskie,M.J.,273Truax,C.,2,131,140Truscott,D.,7Tuason,M.A.,318Turk,D.C.,212Turner,J.A.,21Turpin,J.O.,198Tweedie,D.,122,123,124Tyler,K.,138Tyrell,B.J.,360Ulanov,A.B.,99Unger,M.F.,368Uomoto,J.M.,337Vaihinger,H.,62VandenEerenbeemt,E.,290,291VanDragt,123VanDuerzen-Smith,E.,107,109,112,115,117VanDuerzen,E.,103,107,127VanHeusden,A.,290,291VanIngen,D.J.,244,280 _Tan_Counseling_BB_mw.indd495 VanOppen,P.,278VanStraten,A.,278VandeKemp,H.,399VandeCreek,L.,25,29Vasquez,M.J.T.,29,30,32Vining,J.K.,363,373Vittengl,J.R.,277Vitz,P.,83,98,124,149,175Vogel,D.,11,352,361vonBertalanffy,L.,296VossHorrell,S.C.,236,244,272,395Vye,C.S.,244,280Wachtel,P.L.,46,55Wade,N.G.,11,352,361Wagner,C.P.,364Waldron,S.,54Walker,D.F.,273,360Walker,G.,198Wallerstein,R.S.,54Walser,R.D.,231Walsh,F.,310,320,321,325Walsh,J.,117,121,127Walsh,R.A.,102,125Wampold,B.E.,241,391,392,393,395Wardle,T.,345Waskow,I.E.,147,151Watkins,C.E.,273Watkins,C.E.,Jr.,77Watson,D.L.,214,229,252Watson,J.C.,137,142,145,151,167,177,294Watson,W.H.,313Watts,R.E.,60,62,69,79Weakland,J.,286Webber,R.E.,368Wedding,D.,ix,1,30,35Weeks,G.R.,195,318,321Weiner,D.N.,248Weishaar,M.E.,248,249,250,255,258,262,280,281,282Weiss,B.,151Weisz,J.R.,78,151,241,243,276Welch,E.,326Weld,C.,352,360Wenzel,A.,249Westefeld,J.S.,352Westen,D.,56,390,392,395 Westra,H.A.,143Whaley,C.A.,382Wheeler,G.,179Whisman,M.A.,311Whisman,M.W.,319Whitaker,C.A.,288,289,298White,F.J.,355,357White,G.,28White,M.,292,300Whitmont,E.C.,83Whitney,D.S.,358Wiederhold,B.K.,229Wigren,J.,45,57Wilhoit,J.C.,314Willard,D.,358,368,372Williams,J.M.G.,214,231,249Williams,M.,231Willis,D.E.,360Wilson,G.T.,206,217,235,237,238,243,244,245,271,272,273Wilson,K.G.,231Wilson,W.P.,342,380Winnicott,D.W.,45,365Winslade,J.,292,300Winstead,B.A.,77Winterowd,C.,249Wise,E.H.,28Witt,A.A.,244Witty,M.C.,141,149,153Woldt,A.S.,179Wolfe,B.E.,147,151Wolitzky-Taylor,K.B.,243Wolpe,J.,208,210,216,217,218,223,225,254Wong,L.C.J.,114,123,127,173,176,356Wong,P.T.P.,114,123,127,173,176,356Woods,S.W.,386Woody,S.R.,243Worthington,E.L.,Jr.,11,316,327,352,361,362,385Wright,F.D.,249Wubbolding,R.E.,183,184,185,189,192,194,195,197,198,199,200,202,203,204,205,238Wulff,D.,399Wynne,L.C.,318,319 9/21/104:41:28PM 482Yalom,I.D.,106,111,112,114,115,117,127Yang,H.,337Yankura,J.,248Yarhouse,M.A.,ix,11,284,286,287,288,289,290,291,292,293,296,298,301,313,314,315,321,325,362Yi,J.,294,317 _Tan_Counseling_BB_mw.indd496 NameIndexYontef,G.,155,159,163,178,179Young,J.,200Young,J.E.,250,258,280,281Young,J.S.,325Youngren,J.N.,28Zimring,F.M.,139Zinbarg,R.E.,220 Zinker,J.,162Zinnbauer,B.J.,368Zuehlke,J.S.,ix,11,325,339,356,361Zuehlke,T.E.,ix,11,325,339,356,361Zunin,L.M.,193,194Zur,O.,31,383Zweben,A.,152 9/21/104:41:28PM SubjectIndex AACC.SeeAmericanAssociationofChristianCounselors(AACC)AAMFT.SeeAmericanAssociationforMarriageandFamilyTherapy(AAMFT)A-B-CtheoryofREBT,6,248,263ACA.SeeAmericanCounselingAssociation(ACA)academicdiscipline,spiritual,368acceptance.Seeregard,unconditionalpositiveacceptanceandcommitmenttherapy(ACT),231acceptance-basedcognitivebehaviortherapy,230–31accommodationstage,Gestalt,163Ackerman,Nathan,285ACT.Seeacceptanceandcommitmenttherapy(ACT)act,needto,108acting,totalbehavior,186acting“asif,”70,77actionconditions,therapeutic,141actionhomework.Seehomeworkactivation,behavioral,218–19activeimagination,Jungian,93activities,self-care,21activityscheduling,262ACTS.SeeAdoration,Confession,Thanksgiving,andSupplication(ACTS)actualizingtendency,131–32,133.Seealsoselfactualizationaddictions,positive,194Adler,Alfred,3–4,37,58–60,284–85.Seealsoindividualpsychology adolescentstage,44,88Adoration,Confession,Thanksgiving,andSupplication(ACTS),344advantages,analyzing,259–60adversity,advantageof,260adversivecontrol,219–20advice,useof,17agapeloveinChristiancounseling,335,365,376familyand,315self-actualizationand,175–76therapeuticrelationshipand,53–54,123–24,200–201,240unconditionalpositiveregardand,139,149–50aggressiveinstincts,Freudian,38aloneness,existential,108,113–14,122alternatives,examining,259ambiguity,toleranceof,17AmericanAssociationforMarriageandFamilyTherapy(AAMFT),12AmericanAssociationofChristianCounselors(AACC),12,375–79AmericanCounselingAssociation(ACA),12AmericanPsychologicalAssociation(APA),12amplification,Jungian,86analstage,Freudian,42,43analysis,behavioral,217,218–19analysisoftransference.Seetransferenceanalyticalframework,maintaining,48analyticalpsychology,4,80–101angermanagementtraining,221 483 _Tan_Counseling_BB_mw.indd497 9/21/104:41:28PM 484angst.Seeanxietyanimaandanimus,Jungian,85antecedents,conditional,214anthropology.Seehumannatureanticathexis,Freudian,39anxiety,17,39–40,108–9,227,278APA.SeeAmericanPsychologicalAssociation(APA)APAEthicsCode,26–27approaches,spiritual,370–71arbitraryinference,255archetypes,Jungian,4,80,85–87“asif,”70,77assertivenesstraining,6,207,221assessment,realitytherapy,194assessment,religious,342–43,355–56,381–82assets,Adleriananalysisof,68assimilationstage,Gestalt,163assumptions,Christiancounseling,16attachmenttherapies,392attitude,87,116,138–39,335.Seealsocognitiverestructuringauthenticdisciplines,358authenticity,existential,108–10,113,121–22,171–72authorities,religious,381–82automaticthoughts,255autonomy,44,149.Seealsoindividuation;selfactualizationavoidingthetarbaby,71awe,existential,127Bandura,Albert,211–12,215BASICI.D.,multimodal,230,333basicassumptions,255basicmistakes,67–68basicorientation,4,63,66Beck,Aaron,6,248–50,258behavior,185–87,217,218–19,222,331–32behavioralactivation,277behavioraldisciplines,spiritual,359behavioralmaritaltherapy(BMT),241–42behavioraltechniques,CBT,262,265–66behaviortherapy,5–6,206–45,277being-in,existential,108–9belonging,needfor,5,184beneficence,principleof,26Bible,useof,314,334,352–55,369bibliotherapy,262Binswanger,Ludwig,103–4birthorder,Adleriananalysisof,4,64,66–67BMT.Seebehavioralmaritaltherapy(BMT) _Tan_Counseling_BB_mw.indd498 SubjectIndexbodyboundaries,Gestalt,161bodydysmorphicdisorder,CTand,278boot-campinterventions,392Boscolo,Luigi,299Boss,Medard,104Boszormenyi-Nagy,Ivan,290–91,299boundarysettingforbeginningcounselors,17inChristiancounseling,381–83dualrelationshipsand,30–32inexistentialtherapy,114,123–24inGestalttherapy,160,161inmaritalandfamilytherapy,7,284,306Bowen,Murray,6,285–86,298Bowman,Isadore,155Breuer,Josef,36briefintegrativemaritaltherapy(BIMT).Seeintegrativecoupletherapy(ICT)Buber,Martin,103Bugental,James,106burnout,counselor,17–23CAPS.SeeChristianAssociationforPsychologicalStudies(CAPS)caranalogy,Glasser’s,186caringhabits,seven,188castrationanxiety,43catchingoneself,70cathects,Freudian,39causality,circular,296CBM.Seecognitivebehaviormodification(CBM)CBT.Seecognitivebehaviortherapy(CBT)Cecchin,Gianfranco,299chair,empty,5,93,166–67challenges,beginningcounselor,16–18change,personality,7.Seealsodevelopmentcharacteristics,counselor,14–16charismatictradition,370childhoodstage,Jungian,88choicedenialof,238–39ethicsof,27–29,122,315–16existential,113,121–22,202Seealsohumannaturechoicetheory,5,180,182,183–88choosingbehavior,186–87Christ,bodyof,76,313–14Christ,identityin,356Christensen,Andrew,294ChristianAssociationforPsychologicalStudies(CAPS),12 9/21/104:41:29PM SubjectIndexChristiancounselor,characteristicsof,15–16,23chronicpain,CTand,278church-stateboundaries,382circularcausality,systemic,296circularquestioning,304–5circumstantialspiritualdisciplines,358classicalconditioning,214–15client-centeredtherapy.Seeperson-centeredtherapyclinicalpsychologists,9CNP.Seeconstructivenarrativeperspective(CNP)CodeofEthics,AAAC,375–79cognitivebehaviorfamilytherapy,300cognitivebehaviormodification(CBM),6,232–33,256,266–68cognitivebehaviortherapy(CBT),6,9,215–16,247–82cognitivedisciplines,spiritual,359cognitiverestructuring,6,248,254,305cognitivetherapy(CT),6,8–9,255–56,258–62,277–79collaborativeempiricism,258collectiveunconscious,Jungian,85colloquialprayer,344commitment,client,17commonfactors,psychotherapy,392–93communicationskillstraining,7community,useof,313–14,337,355,381–82communityfeeling,Adlerian,63–64,76compensation,Adlerian,61,62–63compensatoryfunction,dream,91–92competence,27–28,382–83complex,Jungian,84concreteness,141,335conditionedresponse(CR),215conditionedstimulus(CS),215confession,Jungian,89–90confidentiality,27–28confluence,Gestalt,161confrontation,113,168,173,190–91,335congruence,5,133,136,139,335conjointfamilytherapy,290,297–98,318consciousness,levelsof,4,38,53,83–85consent,informed,28–29consequences,fantasized,259constellation,family,65,66–67constructivedebate,193constructivenarrativeperspective(CNP),267constructivepsychotherapy,267–68contact,Gestalt,160–61container,Jungian,89 _Tan_Counseling_BB_mw.indd499 485contemplativeprayer,344contemplativetradition,370contemporarydevelopments,psychotherapeutic.Seetrends,psychotherapeuticcontextualfamilytherapy,290–91,299contingency,existential,108contingencymanagement,232contracts,5,191controltheory.Seechoicetheorycopingdesensitization,227copingskillstherapies,6,248,254,266–68copingstrategies,counselor,21CoreConflictualRelationshipThememethod,55–56corporatespirituality,371correlatesprocess,326counseling,cycleof,188counseling,definitionsof,2counselingpsychologists,9–10counselors,counselor’s,18–19counterconditioning,232countertransference,49–50,90–91,356coupleandfamilytherapy.Seemaritalandfamilytherapy(MFT)covertmodeling,222CR.Seeconditionedresponse(CR)crises,existential,116–17criticalincidentstressdebriefing,392cross-culturaltherapy.Seeculturalsensitivitycrossings,boundary,30–31CS.Seeconditionedstimulus(CS)CT.Seecognitivetherapy(CT)culturalsensitivitybehaviortherapyand,236,238,240Christiancounselingand,333,337,357,382–83cognitivebehaviortherapyand,271–72,273–74,275existentialtherapyand,121Gestalttherapyand,174maritalandfamilytherapyand,310–12,314,320person-centeredtherapyand,146–47psychoanalytictherapyand,52realitytherapyand,198,200cycleofcounseling,188Czikszentmihalyi,Mihaly,11–12DAREprograms,392darknightofthesoul,330–31,369–70Dasein,existential,108DBT.Seedialecticalbehaviortherapy(DBT)deadlydozen,self-care,19–20 9/21/104:41:29PM 486deadlyhabits,seven,188death,anxietyand,108,112–13,122deathinstincts,Freudian,38debate,constructive,193decatastrophizing,259deciding,existential,113decisionmaking,ethical,29deepbreathing,224defensemechanisms,Freudian,40–42deflection,Gestalt,161deliverance,prayerfor,351demands,client,17demonization,332,367denial,Freudian,40–41depression,CTand,277–78dereflection,4,105,115–16desensitization,systematic,6,207,225–27deShazer,Steve,291–92despair,developmentof,44determinism.SeechoicedevelopmentAdlerian,62behavioral,216,254–56existential,109–10,116–17Freudian,42–44Jungian,87–88developmentallines,45devotionalspirituality,371dialecticalbehaviortherapy(DBT),231dialogicrelationship,Gestalt,163dichotomousthinking,255differentiationofself,298dignity,individual,27directdisputation,6,261,263direction,useof,189,336disadvantages,analyzing,259–60disciplines,spiritual,16,358–59,367,371discipling,counselingas,334–35,382,383disclosure,counselor,17discouraging,modelingas,222discoverystage,Gestalt,162–63discoverytechnique,CT,260discrepancy,therapeutic,142–43disgust,developmentof,44displacement,Freudian,41disputation,6,261,263dissociativeidentity,392distortions,cognitive,255,261distraction,261disturbances,contactboundary,161DodoBirdEffect,391doingrealitytherapy,189 _Tan_Counseling_BB_mw.indd500 SubjectIndexdomesticviolence,203,279doublebinds,therapeutic,303downwardarrowtechnique,260dread,existential.SeeanxietydreamanalysisAdlerian,4,67Freudian,3,48–49Gestalt,5,164–65Jungian,4,91–93,98Dreikurs,Rudolph,3–4drives,Freudian,37–38,39dualism,anthropological,328dualrelationships,30–32,381,383.Seealsoboundarysettingdynamics,client,66–68dynamics,spiritual,368earlychildhoodstage,Erikson’s,44earlyrecollections.Seememorieseatingdisorders,CTand,278EBPP.Seeevidence-basedpracticeinpsychology(EBPP)eclectic/integrativetherapy,8–9,275–76,336eclecticism,technical,230,336economies,token,220–21education,Jungian,90.Seealsoreorientationandreeducation,Adlerianeducators,ethicsand,378effectiveness,psychotherapy,8,389–400efficacy,measuring,389EFT.Seeemotion-focusedtherapy(EFT)ego,38–39,84egoism,ethical,98,150,175egopsychology,44–45Egyptians,spoiling,326–27Eigenwelt,existential,108Ellis,Albert,6,250–52,262elucidation,Jungian,90embodiedmeditation,116EMDR.Seeeyemovementdesensitizationandreprocessing(EMDR)emergingpersons,Rogerian,134emotionalempathy,137emotion-focusedtherapy(EFT),293,298emotivetechniques,REBT,264–65empathy,5,137–38,140–41,142,335emphasizingchoice,192empiricallysupportedprinciplesofchange(ESPs),396–97empiricallysupportedtherapyrelationships(ESRs),395–96 9/21/104:41:30PM SubjectIndexempiricallysupportedtreatments(ESTs),393–95emptychair,the,5,93,166–67enactment,304.Seealsorole-playingencouragement,Adlerian,64–65,69,76energy,Gestalt,162environment,roleof,7,337Epston,David,292Erikson,Erik,44,45Eros,Freudian,38eschatology,76,174–75,201ESPs.Seeempiricallysupportedprinciplesofchange(ESPs)ESRs.Seeempiricallysupportedtherapyrelationships(ESRs)ESTs.Seeempiricallysupportedtreatments(ESTs)ethicalconvictions,Adlerian,66ethicalegoism,98,150,175ethicscounseling,24–25,26–32,342–43,374–87situational,176,201EthicsCode,APA,26–27evangelicaltradition,370evangelism,counselingas,334–35,382,383evidence,questioning,259evidence-basedpracticeinpsychology(EBPP),398evil,Jungian,97–98.Seealsosinexaggeration,167–68,260exaggeration,Gestalt,5exchangedlifespirituality,371exercises,Gestalt,163existence,foundationof,108existentialtherapy,4,102–27.SeealsoGestalttherapy;realitytherapyexpectancy,effectivenessand,393experience,98–99,133,149,176.Seealsophenomenologyexperientialdreamwork,5,164–65experientialfamilytherapy,297–98experientialtherapy.SeeGestalttherapyexperiments,Gestalt,163–64explicitintegration,340,342–61,366–67explosivelayer,160–61expressiveboundaries,Gestalt,161expressive-experientialtherapies,392externalcontrolpsychology,183externalization,260,300–301,305extinction,219extratherapeuticchange,392–93extraversion,Jungian,87 _Tan_Counseling_BB_mw.indd501 487eyemovementdesensitizationandreprocessing(EMDR),228,242–43Eysenck,HansJürgen,208–9,390facilitatedcommunication,392facilitativeconditions,therapeutic,141facts,contextualfamilytherapy,290familiarityboundaries,Gestalt,161familyconstellation,65,66–67familylifecycle,302familysculpting,7,284,304familysystemstherapy.Seemaritalandfamilytherapy(MFT)fantasizedconsequences,259feeding,sentence,168feeling,stayingwith,168–69feeling,totalbehavior,186feelingfunction,Jungian,87fees,counseling,380fictionalfinalism,Adlerian,62fidelity,principleof,26fieldtheory,Gestalt,159figure-formationprocess,Gestalt,159finiteness,existential,108fixation,Freudian,42flooding,6,207,227–29forcefulself-dialogue,265forgiveness,needfor,316,329–30framework,analytical,48Frankl,Viktor,4,104–5,109,114–16,122–23freeassociation,3,48freedom,5,113,184–85.Seealsochoice;humannatureFreud,Anna,45Freud,Sigmund,3,35–37,82friendship,socialtaskof,63fruit,theSpirit’s,365fullyfunctioningpersons,Rogerian,5,134fun,needfor,5,185functionalassessment,217functionality,5,7,87,134,315fusion,family,298future.Seeeschatology;trends,psychotherapeuticgenerativity,developmentof,44genitalstage,Freudian,42,44genogram,7,284,306genuineness.SeecongruenceGestalttherapy,5,155–79.Seealsoexistentialtherapygifts,spiritual,16,364,369 9/21/104:41:30PM 488givens,existential,108Glasser,William,5,180–82gnosticism,Jungian,98goalsChristiancounseling,16existentialtherapy,110inindividualpsychology,62,67,76psychoanalytic,46Gottman,JohnMordecai,294–95GreatCommission,counselingand,334–35,382,383Greenberg,LeslieSamuel,6,294growthpotential,Rogerian,131–32,133.Seealsoself-actualizationguidedassociation,260guidedimagery,217guidingself-ideal,Adlerian,62guilt,developmentof,44Gurman,AlanS.,295–96habits,counseling,188Haley,JayDouglas,6,286–87harm,psychotherapyand,391–92health,spiritual.SeespiritualityHeidegger,Martin,103hierarchy,anxiety,225holinesstradition,370holism,62,158–59,332,371holynamerepetition,344HolySpiritChristiancounselingand,16,363–72ascounselor,334psychotherapyand,275,315assourceofagape,123–24homework,6,72,262,263–64,266honesty,counselor,17hope,needfor,329–30.SeealsoeschatologyhumannatureAdlerian,60–61,75–76,77inbehaviortherapy,213–14,238–40biblicalviewof,328–33incognitivebehaviortherapy,252–53,274existential,109–10,121–22existentialtherapyon,107Freudian,37–38,53,54inGestalttherapy,158,172,175Jungian,83,97–98inmaritalandfamilytherapy,296–97,315–16inperson-centeredtherapy,131–32,146–47,148–49questionof,7inrealitytherapy,183,198–99,201,202 _Tan_Counseling_BB_mw.indd502 SubjectIndexhumanrights,27humanvalidationprocessmodel,290,297–98,318humor,17,193,265ICT.Seeintegrativecoupletherapy(ICT)id,38–39idealworld,existential,109identity,42,44,315,356idiosyncraticmeaning,258–59imagery,217,224,226–27,261,264–65imaginalflooding,227–29imagination,modelingin,222imaginativeempathy,137imagoDei,53,315–16,369immediacy,69–70,335impasse,Gestalt,160impasselayer,160implicitintegration,340–42,365–66implosivelayer,160implosivetherapy,228,242incarnationalintegration,intentional,341incarnationaltradition,370incongruence.Seecongruenceindividualpsychologies,contextualfamilytherapy,290individualpsychology,3–4,58–79.SeealsoAdler,Alfredindividuation,45,88–89,98.Seealsoautonomy;self-actualizationindustrial/organizationalpsychologists,10industry,developmentof,44infancystage,Erikson’s,44inferiority,44,61,62–63,77informedconsent,28–29initiative,developmentof,44inner-healingprayer,345–51innerpicturealbum,185insightandinterpretation,Adlerian,68instincts,Freudian,37–38,39instruction,5,191integration,Christiancounseling,339–61,365–67,379–83,385integrativecoupletherapy(ICT),295integrativetherapy,8–9,275–76,336integrity,17,26,44intellectualempathy,137intellectualization,Freudian,42intention,paradoxical.Seeparadoxicalintentionintentionalincarnationalintegration,341intercessoryprayer,344 9/21/104:41:31PM SubjectIndexinterpersonaldisciplines,spiritual,359interpretation,psychoanalytic,49interpretationofreality,Adlerian,61–62intersubjectivitytheory,163interview,Adlerian,66intimacy,44,63,113–14intrapersonalintegration,357–60introceptiveexposure,227introjection,39,161,297introversion,Jungian,87intuitingfunction,Jungian,87invivoexposure,227–29isolation,developmentof,44isolation,existential,108,113–14,122Jacobson,NeilS.,294Jesusprayer,344Johnson,Susan,6,293Jung,Carl,4,37,80–83Jungiananalyst,89,101Jungiantherapy.Seeanalyticalpsychologyjustice,principleof,27Kierkegaard,Søren,103Kohut,Heinz,45–46Laing,R.D.,106–7language,changing,264latencystage,Freudian,42,43–44latentcontent,dream,48laterlifestage,Erikson’s,44laycounselors,10,399–400layers,contact,160–61Lazarus,ArnoldAllan,210–11,230learning,Rogerian,131–32,133legalissues,counseling,24–25,374–75libido,Freudian,38licensedprofessionalcounselors(LPC),11lifecycle,family,302lifeinstincts,Freudian,38lifestyle,4,63,66lifetasks,Adlerian,63–64,72,76–77limitations,awarenessof,337lines,developmental,45livemodeling,222logotherapy,4,104–5,114–16,122–23,126–27loveneedfor,5,184,329–30therapeutic,111,113–14,120,123–24LPC.Seelicensedprofessionalcounselors(LPC)lying,existential,109–10 _Tan_Counseling_BB_mw.indd503 489Madanes,Cloé,290magnification,255makingtherounds,167mandala,Jungian,86–87manifestcontent,dream,48manipulativeparadigm,326Marcel,Gabriel,103maritalandfamilytherapy(MFT),6–7,10,278–79,283–320marriage,family,andchildcounselors(MFCC),10May,Rollo,105–6,109MBCT.Seemindfulness-basedcognitivetherapy(MBCT)MBSR.Seemindfulness-basedstressreduction(MBSR)McGrath,Alister,368meaninglessness,anxietyand,108–9,114–17,122,124,176medications,psychotropic,198,199,236meditativeprayer,344Meichenbaum,Donald,6,212–13memories,67,345–51Menningerproject,54meta-analysis,390–91metaframeworks,MFT,302–3metaphors,realitytherapy,194methods,Christiancounseling,16MFCC.Seemarriage,family,andchildcounselors(MFCC)MFT.Seemaritalandfamilytherapy(MFT)MI.Seemotivationalinterviewing(MI)middleagestage,44,88MilanGroup,6,286,299mindfulness-basedcognitivetherapy(MBCT),231mindfulness-basedstressreduction(MBSR),231mindfulness,behaviortherapy,230–31minimization,255Minuchin,Salvador,6,287–88miraclequestion,305misbeliefs,mentalillnessand,331–32misperceptions,Adleriananalysisof,67mistakes,basic,67–68mistakes,counselor,17,18Mitchell,StephenA.,46Mitwelt,existential,108modeling,221–22modification,existential,4moralanxiety,40moralityprinciple,Freudian,39motivatedspirituality,371 9/21/104:41:31PM 490motivating,modelingas,222motivation,client,335motivation,counselor,18motivationalinterviewing(MI),142–43,152,153multiculturaltherapy.Seeculturalsensitivitymultigenerationaltransmissionprocess,298multimodaltherapy,211,230multiplerelationships.Seedualrelationshipsmusclerelaxation,progressive,223–24mysticism,Jungian,98–99narrativefamilytherapy,292,300–301NASW.SeeNationalAssociationofSocialWorkers(NASW)NationalAssociationofSocialWorkers(NASW),12needs,5,18,183–85,329–30negativepunishment,220negativereinforcement,219neuroticanxiety,40Nietzsche,Friedrich,103nonbeing,anxietyand,108,112–13,122nondirectivetherapy.Seeperson-centeredtherapynon-integrativeparadigm,326nonmaleficence,principleof,26non-manipulativeparadigm,326nonreductivephysicalism,328nouns,personal.Seepronouns,personalnoutheticcounseling,336now,the,159–60,168–69,171,172–73,174–75nurses,psychiatric,10nurturingspirituality,371objectiveinterpretation,dream,92objectiveinterview,Adlerian,66objectrelationspsychology,3,45,297observation,behavioral,217occupationalcounselors,10oldagestage,Jungian,88operantconditioning,210,215,219–21,239options,examining,259oralstage,Freudian,42–43organinferiority,62organism,Rogerian,132–33organismicself-regulation,159,171,175–76organismicvaluingprocess,132organizationalpsychologists,10organizations,psychotherapeutic,12.Seealsospecifictherapiesorientation,basic,4,63,66outcomeresearch,389 _Tan_Counseling_BB_mw.indd504 SubjectIndexoutreach,counselingand,337overgeneralization,67,255pain,sinand,330–31panicdisorder,CTand,278paradigms,Christianintegration,326–27paradigmspirituality,371paradoxicalintentionincognitivebehaviortherapy,260inindividualpsychology,71inlogotherapy,105,115,125inmaritalandfamilytherapy,303inrealitytherapy,194–95paraklesis,336paraprofessionalcounselors,10,399–400parentingandfamily,taskof,64Parker,Stephen,365participantmodeling,222pastoralcounselors,10pathology,psychologicaltreatmentof,2–3pathways,spiritual,371patient’srights,27patientsubstitution,313peer-groupinterventions,392penisenvy,43perceivedself-efficacy,211–12,215perception,subjective,61–62,77perfection,goalof,62perfectionism,counselor,17Perls,Frederick“Fritz,”5,155–57Perls,LauraPosner,5,155,157–58person,counselorasinanalyticalpsychology,89inbehaviortherapy,217,230,237–38biblicalviewof,327,335inChristiancounseling,337,339–40,341–43,357–60incognitivebehaviortherapy,273effectivenessand,397inexistentialtherapy,111–12,123–24importanceof,14–23inpsychoanalysis,53–54inrealitytherapy,188–89,193–94,202Rogerian,134–36,138–39,145,147–48,150theSpiritand,363–64,371–72persona,Jungian,85personality,Freudian,38–39personalitychange,7.Seealsodevelopmentpersonalitydevelopment.Seedevelopmentpersonalitydisorders,CTand,278personalitytheory,38–39,83–88,107–9,132–34personalization,255 9/21/104:41:32PM 491 SubjectIndexpersonalpronouns,using,5,165personalunconscious,Jungian,84person-centeredtherapy,4–5,128–54petitionaryprayer,344phallicstage,Freudian,42,43phenomenologicalapproach,77phenomenology,61–62,133,149,159.Seealsoexperiencephobiclayer,160phonylayer,160PHTs.Seepotentiallyharmfultreatments(PHTs)physiology,totalbehavior,186picturealbum,inner,185pitfalls,beginningcounselor,16–18placeboeffect,393planning,realitytherapy,190playingtheprojection,166pleasureprinciple,Freudian,39Poser,ErnestG.,213positiveaddictions,194positivepsychology,12positivepsychotherapy,12positivepunishment,220positiveregard,unconditional.Seeregard,unconditionalpositivepositivereinforcement,5–6,207,219posttraumaticstressdisorder(PTSD),CTand,278potentiallyharmfultreatments(PHTs),392power,5,184,364practice,psychotherapy,8–12practice,spiritual,368practitioners,mentalhealth,9–11prayer,useof,334,344–52,366–67preconscious,Freudian,38preschoolstage,Erikson’s,44prescriptions,realitytherapy,195primaryprocessthinking,Freudian,39principleethics,27principles,counseling,333–38,396–97prizing.Seeregard,unconditionalpositiveproblemsolving,6,248,254processspirituality,371professional,counseloras,14–18,20professionalcounselors.Seelicensedprofessionalcounselors(LPC)progressivemusclerelaxation,223–24projection,41,161,166prompting,modelingas,222pronouns,personal,5,165prospectivepurpose,dream,91psyche,Jungian,84 _Tan_Counseling_BB_mw.indd505 psychiatricnurses,10psychiatrists,defined,9psychoanalysts,defined,9psychoanalytictherapy,3,35–56psychoeducationalmethods,264psychologicaltreatments,defined,2–3psychologists,typesof,9–10psychosexualstages,Freudian,42–44psychosocialstages,Erikson’s,44psychotherapy,definitionsof,1–3psychotherapy,typesof,3–7psychoticdisorders,CTand,278psychotropicmedications,198,199,236PTSD.Seeposttraumaticstressdisorder(PTSD),CTandpublication,ethicsand,379punishment,219–20purpose,needfor,329–30push-buttontechnique,71qualitativeresearch,390qualities,counselor,14–16qualityworld,185quantitativeresearch,389–90question,miracle,305“Question,The,”4,66,70questioning,circular,304–5questioning,skillful,5,191–92questioningevidence,259questions,Gestaltconversionof,5,165questions,self-care,22randomizedcontrolledtrials(RCTs),389–90rationalemotivebehaviortherapy(REBT),6,247–48,255–56,262–66,276–77rationalemotiveimagery,264–65rationalization,Freudian,41rationalresponding,259RCTs.Seerandomizedcontrolledtrials(RCTs)reactionformation,Freudian,41reality,interpretationof,61–62realityanxiety,40realityprinciple,Freudian,39realitytherapy,5,180–204.Seealsoexistentialtherapyreattribution,259REBT.Seerationalemotivebehaviortherapy(REBT)reconstructsprocess,326recoveredmemorytechniques,392reducinganxiety,modelingand,222 9/21/104:41:32PM 492reeducation.Seereorientationandreeducation,Adlerianreferral,Christiancounseling,355reframing,7,195,284,303regard,unconditionalpositive,5,133–34,136–40,149–50,335regression,Freudian,41rehearsal,behavior,222reinforcement,positive,5–6,207,219rejectsprocess,326relationalethics,contextualfamilytherapy,290relationalpsychoanalysis,46,54relationalspirituality,368,370–71relationship,therapeutic.Seetherapeuticrelationshiprelationships,family,315relaxationtraining,222–24,392religiousvalues,psychotherapyand,11reorientationandreeducation,Adlerian,68–72,76.Seealsoeducation,Jungianreplacementimagery,developing,261repression,Freudian,40research,psychotherapyonanalyticalpsychology,99–100onbehaviortherapy,220,228,236,241–44onChristianityincounseling,350–52,360–61oncognitivebehaviortherapy,275,276–80effectivenessand,8,389–400existentialtherapyand,124–26onGestalttherapy,172,174,176–78onindividualpsychology,77–78onmaritalandfamilytherapy,316–19onperson-centeredtherapy,150–52onpsychoanalysis,54–55onrealitytherapy,202–3researchers,ethicsand,379resistance,analysisof,50,143,161respect.Seeregard,unconditionalpositiverespect,principleof,27respondentbehavior,214–15responding,rational,259responsibilityassumptionof,5,113,166,192principleof,26sharingof,17restructuring,cognitive.Seecognitiverestructuringretroflection,Gestalt,161reversal,Gestalt,169rights,individual,27ritualisticprayer,344Rogers,Carl,4–5,128–31 _Tan_Counseling_BB_mw.indd506 SubjectIndexRogers,Steven,341–42role,counselor,17,46,53–54.Seealsoperson,counselorasroleconfusion,developmentof,44role-playing,5,192–93,222,265,304rounds,makingthe,167SAMIC,189sandbox,Jungian,93Sartre,Jean-Paul,103Satir,Virginia,6,289–90,298scaling,260ScaredStraight,392schemas,maladaptive,255,258,280schoolcounselors,10schoolstage,Erikson’s,44Scripture,useof.SeeBible,useofsculpting,family,7,284,304secondaryprocessthinking,Freudian,39security,needfor,329–30selectiveabstraction,255self,Jungian,84,86self-acceptance,taskof,63–64self-actualization,98,149–50,175self-care,counselor,17–23self-concept,Adlerian,66self-dialogue,vigorous,265self-directedbehavior,229self-disclosure,194self-doubt,counselor,17self-efficacy,143,211–12,215self-efficacy,perceived,239self-evaluation,realitytherapy,189self-ideal,guiding,62,66self-instruction,212,260–61self-managedexposure,228self-modificationprograms,229self-monitoring,behavioral,217selfpsychology,45–46self-regard,unconditionalpositive,133–34self-regulation,organismic,159,171,175–76self-statements,REBT,264self-talk,calming,224self-theory,Rogerian,132–33selfworth,Adleriananalysisof,67.Seealsoworth,conditionsofSeligman,Martin,11–12Selvini-Palazzoli,Mara,299sensingfunction,Jungian,87sentencefeeding,Gestalt,168service,disciplinesof,358settings,psychotherapeutic,11,21,382 9/21/104:41:33PM SubjectIndexsevenhabits,counseling,188sexdrive,Freudian,38shadow,Jungian,86,97–98shameanddoubt,developmentof,44shame-attackingexercises,265Shazer,Stevede.SeedeShazer,Stevesignificance,needfor,329–30silence,understandingof,17sin,53,76–77,148–49,175,330–31SIT.Seestressinoculationtraining(SIT)situationalethics,176skillfulquestioning,5,191–92Skinner,B.F.,209–10,215slips,Freudian,48social-cognitiveapproach,215socialcognitivetheory,239socialconstructionistfamilytherapy,300socialinterest,Adlerian,63–64,76socialjusticetradition,370sociallearningtheory,215socialself,Rogerian,133–34socialskillstraining,221socialworkers,10societalcontribution,taskof,63Socraticdialog,115solitude,disciplinesof,358solution-focusedfamilytherapy,291–92soul,human,97,328specificity,141,335Spirit,the.SeeHolySpiritSpirit-filledspirituality,371spiritualityChristiancounselingand,331,355–57,367–71,380disciplineof,16,358–59,367,371psychotherapyand,11,64,201–2,275spittingintheclient’ssoup,70–71stages,development.Seedevelopmentstages,Jungiantherapeutic,89–90stagnation,developmentof,44Standards,APAEthical,27stayingwiththefeeling,168–69strategicfamilytherapy,286,299,318stressinoculationtraining(SIT),6,224,232–33,266–68,279–80structuralfamilytherapy,287,299,318structure,dream,92structure,personality,38–39structuring,5,190struggle,spiritual,330–31,369–70style,counselor,17subception,Rogerian,134 _Tan_Counseling_BB_mw.indd507 493subjectiveinterpretation,dream,92subjectiveinterview,Adlerian,66subjectiveperception,Adlerian,61–62,77SubjectiveUnitsofDiscomfortscale(SUDs),225sublimation,Freudian,41substance-abusecounselors,10substitution,patient,313SUDs.SeeSubjectiveUnitsofDiscomfortscale(SUDs)superego,38–39superiority,drivefor,61,62–63,77supernatural.Seetranscendencesupervisors,ethicsand,378support,realitytherapy,193supportsystems,useof,337,355,381–82surrender,disciplinesof,358survival,needfor,5,184symbolic-experientialfamilytherapy,297–98symbolicmodeling,222symbols,4,49,86–87synchronicity,Jungian,93systematicdesensitization,6,207,225–27systemicfamilytherapy,299systemictherapies.Seemaritalandfamilytherapy(MFT)tarbaby,avoidingthe,71targetbehaviors,217tasksetting,Adlerian,71–72,76–77teaching,modelingas,222teachingothers,264technicaleclecticism,230,336techniques,useofAdlerian,65–72beginningcounselorsand,17inbehaviortherapy,207,218–33,240,240–41inChristiancounseling,336,343–61incognitivebehaviortherapy,258–68,275effectivenessand,393,397inexistentialtherapy,111–17inGestalttherapy,163–69,172,173–74Jungian,89–93inmaritalandfamilytherapy,302–6,314–15psychoanalytic,47–50inrealitytherapy,190–95Rogerian,138–43,147teleology,Adlerian,60,62telepsychotherapy,11tenaxioms,choicetheory’s,187–88tendency,actualizing,131–32,133.Seealsoselfactualization 9/21/104:41:33PM 494 SubjectIndex tenets,CBT,253–54terminatingandsummarizing,Adlerian,72Terrell,C.Jeffrey,341Thanatos,Freudian,38theology,basic,327–28theories,psychotherapeutic,3–7,8–9therapeuticrelationshipAdlerian,65–66inbehaviortherapy,217,230,237,240inChristiancounseling,335,341–43,357–60,363–64incognitivebehaviortherapy,257–58,272effectivenessand,393,395–96,397existential,111,114,123–24Freudian,46–47,53–54inGestalttherapy,163,172Jungian,89,99inmaritalandfamilytherapy,301,310inrealitytherapy,188–89,193–94,200–201Rogerian,134–36,145,147,150therapist-directedexposure,228thinking,totalbehavior,186thinkingfunction,Jungian,87thoughtstopping,261Tillich,Paul,103timeline,healing,351tokeneconomies,220–21topdog,Gestalt,166–67totalbehavior,185–86traditions,spiritual,370transactions,contextualfamilytherapy,290–91transcendentfunction,Jungian,84transcendence,124,238–39transference,3,46,49–50,90–91,356transformation,Jungian,90transformation,spiritual,76,175transformsprocess,326transgenerationalfamilytherapy,298–99,318translationalresearch,398transmissionprocess,multigenerational,298trends,psychotherapeutic,9,11–12.Seealsospecifictherapiestriangulation,298trichotomism,anthropological,328trueself,Rogerian,133–34trust,developmentof,44truth,theSpirit’s,364–65types,dream,92types,personality,87 UCS.Seeunconditionedstimulus(UCS)Umwelt,existential,108unconditionalpositiveregard.Seeregard,unconditionalpositiveunconditionalself-acceptance(USA),264unconditionedresponse(UCR),214–15unconditionedstimulus(UCS),214–15unconscious,4,38,53,84–85underdog,Gestalt,166–67unfinishedbusiness,Gestalt,160,171–72unifiesprocess,326uniqueness,Christiancounseling,16unity,Adlerian,62USA.Seeunconditionalself-acceptance(USA)usefulsideoflife,68–69 Überwelt,109UCR.Seeunconditionedresponse(UCR) Yalom,Irvin,106youngadulthoodstage,Erikson’s,44 _Tan_Counseling_BB_mw.indd508 vacuum,existential,122,124,202,369values,67,161,382VanDuerzen,Emmy,107,109verbs,choice,186,192verticalarrowtechnique,260vigorousself-dialogue,265violations,boundary,30violence,domestic,203virtualrealityexposuretherapy,229virtualtherapy,11virtueethics,27,31,383–84vocationalcounselors,10voices,externalizationof,260Wallerstein,RobertS.,54wants,realitytherapy,189warfare,spiritual,332,369,371warmth.Seeregard,unconditionalpositiveWDEPsystem,189–90Whitaker,Carl,288–89,298White,MichaelKingsley,292–93wildanalysis,49willing,existential,113wisdom,developmentof,44wishing,existential,113Wolpe,Joseph,207–8work-settingboundaries,382world,pictureof,66worth,conditionsof,133–34.Seealsoselfworth,Adleriananalysisofwriters,ethicsand,379 9/21/104:41:34PM AbouttheAuthor S iang-YangTanservedasdirectorofthePsyD(DoctorofPsychology)programinclinicalpsychology(1989–97)andisnowprofessorofpsychologyintheGraduateSchoolofPsychologyatFullerTheologicalSeminaryinPasadena,California.HeisalicensedpsychologistwithaPhDinclinicalpsychologyfromMcGillUniversityandaFellowoftheAmericanPsychologicalAssociation(APA).Hehaspublishedarticlesonlaycounselingandlaycounselortraining,intrapersonalintegrationandspirituality,religiouspsychotherapy,theuseofspiritualdisciplinesincounselingandclinicalsupervision,cognitivebehaviortherapy,epilepsy,pain,andcross-culturalcounselingwithAsiansandHispanics,aswellasseveralbooks,includingLayCounseling:EquippingChristiansforaHelpingMinistry(Zondervan,1991),ManagingChronicPain(InterVarsity,1996),DisciplinesoftheHolySpirit(withDouglasGregg,Zondervan,1997),Rest:ExperiencingGod’sPeaceinaRestlessWorld(RegentCollege,2003),ExercisesforEffectiveCounselingandPsychotherapy(2nded.,withLesParrott III,Brooks/Cole,2003),CopingwithDepression(rev.ed.,withJohnOrtberg,BakerBooks,2004),andFullService:MovingfromSelf-ServeChristianitytoTotalServanthood(BakerBooks,2006).Hehasreceivedseveralawards,includingtheDistinguishedMemberAwardfromtheChristianAssociationforPsychologicalStudiesInternational,theGary R.CollinsAwardforExcellenceinChristianCounselingfromtheAmericanAssociationofChristianCounselors,andtheWilliamBierAwardforoutstandingandsustainedcontributionsfromDivision36(PsychologyofReligion)ofAPA.HeisassociateeditoroftheJournalofPsychologyandChristianityandservesorhasservedontheeditorialboardsoftheJournalofConsultingandClinicalPsychology,ProfessionalPsychology:ResearchandPractice,JournalofPsychologyandTheology,andJournalofSpiritualFormationandSoulCare.HewaspresidentofDivision36(PsychologyofReligion)ofAPA(1998–99).HealsoservesasseniorpastorofFirstEvangelicalChurchGlendaleinGlendale,California.OriginallyfromSingapore,henowlivesinArcadia,California,withhiswife,Angela.Theyhavetwogrownchildren,CarolynandAndrew.495 _Tan_Counseling_BB_mw.indd509 9/21/104:41:35PM E-BookInformation Year:2,011 Edition:1 Pages:513 PagesInFile:510 Language:English Identifier:9780801029660,2010026145 OrgFileSize:4,046,811 Extension:pdf Toc:Contents Prefaceix Acknowledgmentsxi 1.OverviewofCounselingandPsychotherapy:Theory,Research,andPractice 2.ThePersonoftheCounselor 3.LegalandEthicalIssuesinCounselingandPsychotherapy 4.PsychoanalyticTherapy 5.AdlerianTherapy 6.JungianTherapy 7.ExistentialTherapy 8.Person-CenteredTherapy 9.GestaltTherapy 10.RealityTherapy 11.BehaviorTherapy 12.CognitiveBehaviorTherapyandRationalEmotiveBehaviorTherapy 13.MaritalandFamilyTherapy 14.ChristianTheologyinChristianCounseling:ABiblicalPerspectiveonHumanNatureandEffectiveCounselingandPsychotherapy 15.ChristianFaithinClinicalPractice:ImplicitandExplicitIntegration 16.TheHolySpiritandChristianSpiritualityinCounselingandPsychotherapy 17.LegalandEthicalIssuesinChristianCounselingandPsychotherapy Appendix:IsPsychotherapyEffective? 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